Medical Sociology and Anthropology

MPH Ist Year

Medical Sociology and Anthropology

Prabesh Ghimire


MPH 1st Year

Table of Contents UNIT 1: INTRODUCTION .......................................................................................................................................................... 4

General Introduction to Sociology/ Anthropology .................................................................................................... 4 Basic Terminologies in Medical Sociology/ Medical Anthropology........................................................................... 4 Historical Development of Society and Public Health ............................................................................................... 8 Definition, Nature and Scope and Historical Development of Medical Sociology and Medical Anthropology ........9 Definition, Nature and Scope of Medical Sociology.............................................................................................. 9 Definition, Nature and Scope of Medical Anthropology ..................................................................................... 11 UNIT 2: CULTURE AND HEALTH ...............................................................................................................................................14

Meaning, Definition and Characteristics of Culture Applied to Public Health ........................................................ 14 Definition of Health, Disease, Illness and Sickness Applied to Public Health .......................................................... 16 Personalistic Medical System Applied to Public Health .......................................................................................... 16 Naturalistic Medical System Applied to Public Health ............................................................................................ 17 Self-Medication/ Alternative Medication and Other Prevailing Health Care Practices and its Importance in Nepal Applied to Public Health .......................................................................................................................................... 17 Self Medication Practices in Nepal ..................................................................................................................... 17 Traditional Medicine: Alternative Medication and Other Prevailing Health Care Practices in Nepal ................19 Importance of Indigenous Health Care System and Health Care Provider with Special Reference to Nepal .........21 UNIT 3: PROVIDER-CONSUMER RELATIONSHIP .......................................................................................................................22

Meaning and Interpretation of Provider (Public Health Professional) and Consumer/ User/ Patient/ Organizational Relationship .................................................................................................................................... 22 Reciprocal and Complex Roles of Provider and Consumer/Users ........................................................................... 23 Parson’s Sick Role Model ........................................................................................................................................ 24 Szasz and Hollander’s Basic Model of Provider-Consumer Relationship ................................................................ 25 Relationship Pattern between Traditional and Public Health Professionals and Consumer/Users ........................26 Barriers in Effective Provider-Consumer Relationship ............................................................................................ 27 UNIT 4: HEALTH POLITICS .......................................................................................................................................................28

The Meaning and Interpretation of Health Politics................................................................................................. 28 Comprehensive and Selective Primary Health Care ................................................................................................ 31 Human Rights and Health Rights ............................................................................................................................. 31 Manifestoes of the Political Parties on Health Issues in Nepal ............................................................................... 33 Role of Public Health Institutions on the Existing Health Politics ........................................................................... 34 UNIT 5: RESEARCH METHODS OF SOCIOLOGY/ANTHROPOLOGY APPLIED TO PUBLIC HEALTH ................................................36

Meaning and Nature of Research ........................................................................................................................... 36

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Types of Social Research ......................................................................................................................................... 36 Research Procedures and Methods in Health System Research ............................................................................. 37 Research Procedures .......................................................................................................................................... 37 Research Methods in Medical Sociology and Anthropology .............................................................................. 39 Role and Importance of NHRC ................................................................................................................................ 42

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UNIT 1: INTRODUCTION General Introduction to Sociology/ Anthropology Differences between sociology and anthropology Basis of difference Sociology Driving question What is society, and how does it shape and reflect human nature Emphasis

Emphasis is on society and its origin and development (social class, structures, social movements)

Historical Basis Methodology

Studying western societies Predominantly quantitative (survey and sampling), viewed as harder social science

Level of Focus

Macro level focus- studies how the larger society and social trends affect individuals, families and communities

Anthropology What does it mean to be human? How do humans behave and why? Emphasis on culture and its physical and social characteristics (kinship, language, religion, gender, art, etc.) Studying non-western cultures Predominantly qualitative (ethnography), viewed as a softer social science Micro level focus- studies how individuals, families and communities engage with the larger society and social trends

Basic Terminologies in Medical Sociology/ Medical Anthropology Social Status and Roles Social Status: When analyzing any social interaction, sociologists identify the social statuses of the participating parties. Status in its abstract sense means the position of an individual in a certain social system; such as doctor and patient, a husband and a wife, a professor and a student, etc. Individuals usually occupy more than one social status. Ascribed and Achieved Status Ascribed Status - Ascribed status results from a chance; that is, individual exerts no effort to obtain them. - A person's birth order, race, national origin, sex, and age qualify as ascribed status. Achieved Status - Achieved statuses are acquired through combination of personal choice, effort, and ability. - A person's marital status (except widowhood), occupation (e.g. doctor), etc. are considered as achieved status. Roles Ralph Linton (1936) defined role as the dynamic aspect of status, contending that every status in a society has an attached role and that every role is attached to a status. Sociologists use the term role to describe the behavior, obligations and rights expected of a status in relation to another status. (for example, physician to patient, professor to student).

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Relation between status and roles: - The relationship between role and status is that people occupy statuses and enact or perform roles. Any status with it carries a variety of roles. - There is no status without a role, and no role without a status. - Example: Physician is a social status, a fixed position in a social structure. Attached to that social status is roles specifying how physicians are expected to behave toward people depending on the status (nurse, patient, colleague) they occupy. - The role of physician in relation to a patient specifies that a physician has an obligation to establish a diagnosis, treat the patient, respect privacy, etc. Ethnocentrism and Cultural Relativism When confronted with new or different cultural traditions, values, or behaviours we may fall into one of two traps: ethnocentrism or cultural relativism. Ethnocentrism Ethnocentrism adheres to a set of beliefs or attitudes that asserts that one's culture is superior while all other cultures are, by extension, inferior. - Persons gripped by ethnocentric views or opinions tend to judge, sometimes to condemn, different cultures or alternative cultural values through the lens of their own. - In doing so, they risk falling into traps of prejudgement or prejudice. A sign of this is the assertion that other cultures are primitive or backward. - This reflects a failure to frame other cultural practices without understanding their motivations, intentions or purposes. - When caring for culturally diverse groups, health care workers at first may tend to be ethnocentrism, believing that their profession, scientifically based practice are superior. - Health care provider's ethnocentrism can result in poor communication, patient alienation, and potentially inadequate treatment. Cultural Relativism - Cultural relativism adheres to the belief that cultural practices and traditions can never be judged critically. - Cultural relativism requires that we objectively consider actions, beliefs, values, norms of others within their own cultural contexts in order to understand them. - Cultural relativism asks what functions various cultural elements serve within that cultural context and how they are sustained not whether they are good or bad. - A typical example of cultural relativism in health care is than a health care provider recognizes and appreciates cultural differences and treats individual clients with respect to their cultural backgrounds Ethno-medicine Ethno-medicine is a branch of medical anthropology which termed as "those beliefs and practices relating to disease which are the products of indigenous cultural development and are not explicitly derived from the conceptual framework of modern medicine. (Rubel and Haas 1996) -

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Ethno-medicine refers to the study of traditional medical practice which is concerned with the cultural interpretation of health, diseases and illness and also addresses the health care seeking process and healing practices. It is sometimes used as a synonym for alternative medicine and the term 'Ethno-medicine' was used for medical systems of 'primitive' or non-western societies.

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However, in contemporary medical anthropology biomedicine is not uncritically privileged above other medical systems and biomedicine is also considered to be a form of ethno-medicine. The practice of ethno-medicine is a complex multi-disciplinary system constituting the use of plants, spirituality and the natural environment and has been the source of healing for people for thousands of years. Ethno-medicine concerns both art and research information to help the human body to refurbish its health and well-being. It utilizes natural treatments to trigger the immune scheme. Ethno-medical study is interdisciplinary and it concerns the methods of ethno-botany and medical anthropology. Ayurveda is one of the popular ethno-medicine practiced in Nepal. Other popular ethno-medicinal practices includes Amchi, Anthropological approaches to the study of ethno-medicine have always included not only understanding how people think about health and disease but also studying the social organization of healing practices. In the simplest sense, all ethno-medical systems have three interrelated parts:  A theory of the etiology of sickness  A method of diagnosis based on the etiological theory  The prescription of appropriate therapies based on the diagnosis

Ethno-psychiatry Ethno-psychiatry is defined as an approach aimed to understand the ethnic and cultural dimensions of mental illnesses. - The term ethno-psychiatry is normally applied to the study of psychology and behavior of non-western people - Other names used in psychiatric literature for ethnopsychiatry are cross cultural psychiatry or transcultural psychiatry. - Ethnopsychiatry refers to indigenous conceptions about mental states and mental illness in different cultures. - It studies mental illness in a cross- cultural perspective; including its definitions, classification, causality and treatment of mentally ill persons in different cultural contexts. - The term itself is ambiguous, reflecting Western assumptions about the divisibility of mind from body, and notions about a particular disciplinary approach to dealing with mental illness. - In the context of ethnopsychiatry mental health has not been an easy task to define as there is a disagreement over the boundaries of normal and abnormal behaviour. Values and Norms Values Values are the fundamental beliefs underpinning a community or society and providing general principles for human behavior. Some values are formalized as principles of law and are enforced through the formal agencies of social control. Others remain as general organizing principles for life and are fostered through the agencies of socialization. -

The values are those aspects of a culture that are held in high regard, are desirable and therefore worthy of emulation. E.g. a doctor is never commercial and business like in his dealings with patients.

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Norms While values operate as general principles, norms are specific rules that govern human behavior in particular situations. These norms may vary widely from society to society and from community to community. - Norms usually refers to principles of right and wrong actions and the rules and the laws that govern the acceptable and unacceptable behavior - E.g. illegitimate pregnancy, unsafe abortion, euthanasia, intake of alcohol and substance abuses are all considered against the norms. Cultural Lag The term 'Cultural Lag' was coined by Ogburn. Cultural lag refers to the delay on time between changes in one realm of culture, such as mental culture, and inevitable changes in related realms, such as material and normative culture (Ogburn 1922). -

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Cultural Lag suggests that a period of maladjustment occurs when the non material culture is struggling to adapt to new material conditions. Cultural lag is a useful concept for examining how social disorder and ethical dilemmas result from variable rates of social and cultural change within the larger social setting. For example, the accumulation of medical knowledge (e.g., curative theories) proceeds at a faster pace than the invention of spinoff material technologies and treatment regimens. Changing knowledge and technology make old forms of organization obsolete and call for innovation; yet social resistance to such changes causes lags in the adoption of new technologies and organizational structures. For instance, a less invasive surgical technique eliminates the need for long hospital stays, but because of delays in acceptance by physicians and delays before insurance companies agree to pay for the innovation, many years may pass before the technique is provided on an outpatient basis. Cultural lag is especially apparent in the ethical controversies created by changing medical technology, such as the moral and legal confusion surrounding the termination of life supports for moribund patients. Cultural lag theory is a meaningful approach to understanding how interests within medicine (such as professionalism and the service ethic) retard change induced by external forces (such as increasing malpractice litigation, government regulation, and consumerism)

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Historical Development of Society and Public Health SN

Types of Society Asiatic (Forest)

Means of Production Forest resource, animal hunting

Relations of Production Free labour

Health Systems

Conditions

Prospect

Situation

Remarks

Nature control

Population increased and resource limitation

Scarcity and hunger

Exploitation between human and conflict between stronger and weaker

Change

2

Slavery

As above and slaves as property

Master vs Slaves

As above

As above

As above

3

Feudalistic

Agriculture and animal husbandry

Landlord Vs Tenants

As above and magic and religion (Shamanism) As above ayurvedic and ethnomedicine

As above

As above

As above

4

SemiFeudalistic

As above and petty industries

As above and farmers, owners vs labour

As above and emergence of allopathic system

As above

As above

As above

5

Capitalistic

As above and industries

Owner vs Labour Landlord vs tenants

As above and emergence of public health

As above

As above

As above

6

Imperialistic

Colonial countries resources

Imperialist vs colonies

Above all specialization

As above with heavy exploitation

As above and nationality unity

As above and war

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Socialistic

Social cooperatives

Society and social groups

All types

Balance

Elimination of hunger

Development

8

Proposed communistic

National cooperative

Nation and citizens

Except shamanism others as above

More balance

Development

Development

1

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Definition, Nature and Scope and Historical Development of Medical Sociology and Medical Anthropology Definition, Nature and Scope of Medical Sociology Medical Sociology: It is defined as professional endeavour devoted to social epidemiology, the study of cultural factors and social relations in connection with illness, and social principles in medical organization and treatment. (Charles McIntire, 1894) -

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The medical sociology helps to identify and study social groups in their activities of maintaining and preserving health, alleviating or curing diseases. It is concerned with the social facets of health and illness, social function of health institutions and organizations, the relationship of health care delivery to other social systems and social behavior of health personnel and consumers of health care. In brief, it is the study of relationships between health phenomena and social factors. Thus, in medical sociology health, illness and medical care are studied from sociological perspectives.

Importance of Medical Sociology in relation to public health - Medical sociology has a stronger sense of engaging with mainstream sociological debates, medical sociology continues to directly contribute to improving health and well being of populations through its applied component. - Sociological tools are essential applications in a large range of important issues such as quality of life of patients, the design of clinical trials on drugs, and treatments and in the development of health policy. - Illness can be influenced by an individual’s diet, lifestyle, stress, familial duties and social environment –such as area of residence, housing, access to medical services, access to amenities, income, etc. Understanding the social causation of ill-health is the key factor in preventing illness and spread of disease. Example: many diseases such as cholera and syphilis were halted through public health measures, which emphasized the social aspect of health rather than through clinical medicine. - Identifying social inequalities in health are important to health policy and the provision of health care as it can help policy makers to consider the disparities that occur to women, ethnic groups, the elderly and the socially deprived. - Due to the key roles that social behavior and living conditions play in the onset and course of chronic diseases, medical sociologists bring more expertise to the study of health related social conditions than physicians. Secondly, medical sociologists are significant critics of public health. - Many public health research projects require the use of social research methods- such as ethnography and focus groups in exploratory research. Nature of Medical Sociology i. Medical Sociology is a social science. It is the study of the societal dimensions of health and medicine. ii. Medical Sociology is interdisciplinary. Medical Sociology overlaps with Social Epidemiology, Health Services Research, Behavioural Medicine, Social Psychiatry and Medical Anthropology. iii. Medical sociology is related to social medicine. Both of them deal with the role of social factors in the aetiology, course and management of illnesses. iv. Medical Sociology is a descriptive science v. Medical Sociology is a specialized science

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Scope/Division of Medical Sociology Robert Straus (1957) suggests that medical sociology can be divided into two areas: i. Sociology in medicine ii. Sociology of Medicine i. -

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Sociology in Medicine The sociology in medicine is one which collaborates directly with physicians and other health personnel in studying the social factors that are relevant to a particular health problem. The work of the sociologists in medicine is intended to be directly applicable to patient care and other practical uses in the area of health. Thus, sociology in medicine can be characterized as applied research and analysis primarily motivated by a medical problem rather than a sociological problem. Sociologists in medicine usually work in medical schools, nursing schools, teaching hospitals, public health agencies and other health organizations. Sociology of Medicine Sociology of Medicine deals with such factors as the organization, role relationships, norms, values and beliefs of medical practice as a form of huma behavior. The emphasis is on the social processes that occur in the medical setting and how these contribute to our understanding of medical sociology in particular and to our understanding of social life in general. The sociology of medicine shares the same goals as all other areas of sociology and may consequently be characterized as research and analysis of the medical environment from a sociological perspective.

Historical Development of Medical Sociology i. Medicine has been concerned with the treatment of disease from time immemorial past, but sociology is a product of nineteenth century thought. ii. The term “Sociology” was not coined until 1839 when Auguste Comte joined the Latin ‘Socius’ with the Greek ‘Logus’, and sociology emerged as the study of society. iii. A decade later in 1849, Rudolf Virchow identified medicine as a Social Science. iv. Thirty years later, John Shaw Billings linked public health to sociology. v. The history of medical sociology extends back to 1894 when Dr. Charles McIntire wrote an article in the Bulletin of the American Academy of Medicine entitled “The importance of the Medical Sociology”. vi. Since the Flexner report of 1910, the trend in medicine has emphasized full-time clinical faculties and basic physical science departments. vii. Until the 1930s and 1940s, the interrelations between society and health science was of no interest to sociologists. However, it was not until 1949 that the mutual interests of medicine and sociology culminated in the appointment of a sociologist to a medical faculty. viii. During the decades 1950-1960, medical sociology was increasingly given recognition as an academic area of specialization by both physicians and sociologists. ix. In the first three decades of the twentieth century, medical sociology was identified first with the field of social work and later with the field of public health. x. At present, the expansion of institutes for health and the interest of private foundations in interdisciplinary research have stimulated and supported the growth of medical sociology as an area of teaching.

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Definition, Nature and Scope of Medical Anthropology Medical Anthropology: Medical Anthropology is a subfield of anthropology that draws upon social, cultural, and linguistic anthropology to better understand those factors which influence health and well-being, the experience and distribution of illness, the prevention and treatment of sickness, healing processes, the social relations of therapy management, and the cultural importance of utilization of pluralistic medical systems. (Society of Medical Anthropology, 2015) Medical anthropology is the cross cultural study of medical systems and the study of bio ecological and socio-cultural factors that influence the incidence of health and disease now and throughout human history - Medical anthropology encompasses the study of medical phenomena as they are influenced by social and cultural factors and social and cultural phenomena as they are influenced by these medical aspects. - Another definition states that medical anthropology is concerned with the bio-cultural understanding of man and his works in relation to health and medicine. - Medical anthropology studies the relationship between human evolution and disease in the past, the biological and cultural determinants of disease, health and health care, the basis and effectiveness of traditional health care systems and suggests ways to integrate modern medicine into traditional societies. Divisions of Medical Anthropology i. Anthropology in medicine: Anthropologists work together with health professionals to solve problems that are defined by anthropology of medicine. (for example, why don't people at risk of HIV use condoms?). ii. Anthropology of medicine: Anthropologists take medicine as an object of study and define relevant topics and approach (for example, what non-medical factors influence how doctors make end-of-life decisions? History of Medical Anthropology i. The term ‘Anthropologists’ was coined by Aristotle and Anthropology emerged as the study of Man. ii. George M. Foster and Barbara Gallatin Anderson (1978) trace the development of medical anthropology to four distinct sources; the interest of early physical anthropologists in human evolution and adaptation, ethnographic interest in primitive medicine, studies of psychiatric phenomena in the culture and personality school, and anthropological work in international health. iii. William H.R. Rivers (1924), a physician, is considered the first ethnologist of non-western medical practices. iv. Early theoretical work by Forrest Clements (1932) and Erwin H. Ackerknecht (1942, 1946) also attempted to systematize primitive medical beliefs and practices. v. Paralleling theory development were early applications of anthropological principles to health problems. vi. Since the 1940s anthropologists have helped health care providers understand cultural differences in health behavior, as shown in Benjamin D. Pauf’s edited volume “Health, Culture and Community: Case Study of Public Reactions to Health Programs (1955)”, one of the first medical anthropology texts. vii. The Group of Medical Anthropology (GMA) was established in 1967 with Weidman as chairperson.

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viii. Since the mid-1960s, medical anthropology developed three major orientations; medical ecology, ethno-medicine and applied medical anthropology. ix. Alexander Alland Jr, (1970) was the first to apply the concept of adaptation in Medical Anthropology. x. During 1980s, after the development of other medical fields like nuring, public health etc., anthropologists began conducting researches on the culture and personality of people with respect to health beliefs and practices. xi. At present, international health is guided by anthropological works, interests have aroused in the research of primitive medicine and human evolution with respect to health and disease. Importance of Medical Anthropology in Relation to Public Health Medical Anthropology has been useful to public health in various diverse fields such as - Understanding the development of systems of medical knowledge and medical care - Studying of the patient-physician relationship - Integrating alternative medical systems in culturally diverse environment - Studying the interaction of social, environmental and biological factors which influence health and illness both in the individual and the community as a whole - Critically analyzing the interaction between psychiatric services and migrant populations - Identifying the impact of biomedicine and biomedical technologies in non-Western settings Nature of Medical Anthropology - Medical anthropology is a bio-cultural field. It places human sickness and health in biological and cultural evolutionary contexts - Medical anthropology is the fastest-growing applied specialty within anthropology. - Medical anthropology is interdisciplinary: It is a discipline where humanities, social, and natural sciences, health services and medical anthropology are forced to confront one another - Medical anthropology is interpretive. It focuses on how people with particular cultural beliefs and practices make sense of their suffering. The study of illness narratives is a form of interpretive medical anthropology that allows outside observers, such as biomedical specialists, to understand the perspectives of individual experiences of illness shaped by non-biomedical beliefs and practices. Scope of Medical Anthropology The scope of anthropological inquiry into issues of human health, sickness and healing is very diverse. The scope of medical anthropology can be explained based on the following five basic approaches: i. -

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Biological areas in medical anthropology Much research in biological anthropology concerns important issues of human health and illness. Many of the contributions of biological anthropologists help to explain the relationship between evolutionary processes, human genetic variation, and the different ways that humans are sometimes susceptible and other times are resistant to disease. The evolution of disease in ancient human population helps us to better understand current health trends. For example, the recent global trend of emerging and remerging infectious diseases, such as tuberculosis and AIDS, is influences by forces of natural and cultural selection that have been present throughout modern human evolution. Biological anthropology plays a central role in the field of evolutionary medicine, which considers how survival pressures over the course of evolution may have shaped human biology.

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Medical Ecology Within medical anthropology, the ecological perspective focuses on the interactions between environmental contexts and human health. An ecological approach to medical anthropology emphasizes that the total environment of the human species include the products of large-scale human activity, as well as natural phenomena, and that health is affected by all aspects of human ecology. Many ecological approaches to medical anthropology include some aspects of both cultural and political ecology. At the micro level, cultural ecology examines how cultural beliefs and practices shape human behavior, such as sexuality and residence patterns, which in turn alter ecological relationships between host and pathogen. At a broader level, political ecology examines the historical interactions of human groups and the effects of political conflict, migration and global resource inequality on diseases ecology.

iii. Ethno-medicine Anthropological approaches to the study of ethno-medicine have always included not only understanding how people think about health and disease but also studying the social organization of healing practices. - In the simplest sense, all ethno-medical systems have three interrelated parts:  A theory of the etiology of sickness  A method of diagnosis based on the etiological theory  The prescription of appropriate therapies based on the diagnosis iv. Anthropology in and of biomedicine - In recent years there has been an increased focus on studying biomedicine as an ethno-medical system of knowledge and social practice. - Although this approach has a lot in common with the study of other ethno-medicines, it has become such a large part of the subfield of medical anthropology. - The study of biomedicine sheds light on the epistemology of scientific and medical knowledge. v. -

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Experiential Approach in Medical Anthropology Anthropologists using this approach frequently put illness-related suffering-whether due to pain, disability or the awareness of one’s own mortality- at the centre of analysis. They focus on three aspects of illness, in particular:1) narrative- the stories that people tell about their illness; 2) experience- the way that people feel, perceive, and live with illness; and 3) meaning- the ways that people make sense of their illness, often linking their experience to larger moral questions. Experiential approaches often explore the links between sickness and problems in the social world.

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UNIT 2: CULTURE AND HEALTH Meaning, Definition and Characteristics of Culture Applied to Public Health Culture Culture is a pattern of ideas, customs and behaviours shared by a particular people or society. These patterns identify members as part of a group and distinguish members from other groups. Edward B Taylor, the famous English anthropologist has defined culture as that complex whole which includes knowledge, belief, art, morals, laws, custom and any other capabilities and habits acquired by man as a member of society. Characteristics of Culture i. Culture is social: Culture is social and not an individual heritage of man. It does not exist in isolation. It is the product of society and shared by all members of the society. No man can acquire culture without association with other human beings. Example, myths and misconceptions is the product of social interactions in the society. ii.

Culture is learnt: Culture is not inherited biologically, but learned socially by man. Health feeding practices, health seeking behavior, child care are all learnt and determined by the society we live in.

iii. Culture is shared: Culture involves the learned patterns of shared group behavior. These learned shared behaviours are the framework for understanding and explaining all human behavior. These include health behaviours, particularly intergroup differences in health behaviours and health beliefs. Health beliefs and health care practices, health prevention knowledge have been shared within and between two groups. iv. Culture is transmissive: Culture is transmitted vertically or horizontally and thus is a form of communication. Vertical transmission is from one group to another group within the same period. Language is the chief vehicle of culture. v.

Culture is dynamic and adaptive: Though culture is relatively stable, it is not altogether static. It is subject to slow but constant changes. Culture is also responsive to changing conditions of the physical world. It is adaptive. It also intervenes in the natural environment and helps man in his process of adjustment.

vi. Culture is consistent and integrated: Culture is an integrated system. It presents an order and systems. At the same time different parts of culture are interconnected. For example, the value system. Culture as a major determinant of Health All cultures have systems of health beliefs to explain what causes illness, how it can be cured or treated, and who should be involved in the process. Cultural issues play a major role in determining a person's health or the health of a community as a whole. i. -

Beliefs Some societies believe that illness is the result of cultural/ spiritual phenomena and promote prayers or other cultural/ spiritual interventions to counter powerful forces.

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Religious beliefs that a ‘parents cannot reach heaven without procreating son’ can also affect the reproductive health of a mother.

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Practices There are dangerous practices of applying mud and cow-dung to umbilical cord of neonates after birth. This significantly increases risks of neonatal sepsis. Harmful practices such as Chhaupadi puts women at risk of UTI, reproductive problems, mental health problems and various other risks.

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iii. Food habits - Culture influences food habit of a community in both positive and negative way and is an important determinant of health. - In many communities, offering chickens (ratobhale), jwano soup etc. to nursing mothers is a common practice. This creates positive nutrition effect on mothers. - Many food taboos result in poor diet intake and malnutrition among women and children. iv. Myths and misconceptions - Many myths and misconceptions also center on many cultural groups. For example: A myth that “use of family planning device causes sterility” discourages couples from adopting contraceptives. - Misconception that “mass drug administration against filariasis is a community trial of an untested drug” discourages people from taking chemoprophylaxis. v. -

Cultural stigma Many diseases have been stigmatized in various cultures. In some cultures, depression is a common stigma and seeing a psychiatrist may label them as being crazy. Moreover, diseases like HIV/AIDS, STIs, leprosy, epilepsy are stigmatized and thus people prefer to stay covert and in many instances they do not seek health care for fear of being stigmatized.

vi. Customs and traditions - Many customs and traditions like early marriage and early childbirth extend reproductive period of girl child affecting her reproductive and mental health. vii. Ethnocentrism - Cross-cultural differences between service providers and users are likely to result in ethnocentrism. - This affects the diagnosis, treatment and compliance with care affecting overall doctor patient relationship. viii. Material culture and health - Traditional housing design with poor ventilation increases exposure to indoor smoke affecting seriously the health of women and neonates.

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Definition of Health, Disease, Illness and Sickness Applied to Public Health Disease In the biomedical model, a disease is the product of a causative agent (pathogen) on a susceptible organism, and its biological consequences. The pathogen can be genetic, developmental, environmental, or a combination of all three. Illness An illness is the subjective, psychological experience of ill health. The illness may have a biological basic, but this is not essential. Illness refers to the subjective state of being unwell, of experiencing distress or pain. Just as organic malfunctioning or disease may not be accompanied by subjective discomfort, illness can be experienced even in the absence of disease. Where disease is a biological concept, illness is a socio-psychological one, and it includes the cultural meaning of the discomfort or pain. Sickness Sickness in contrast to disease and illness is a social concept. It refers to a social label applied by others and accepted by the individual. Sickness is the social experience of ill health – what happens when a disease or illness is acknowledge and dealt within the public sphere. Personalistic Medical System Applied to Public Health Foster (1976) defines a personalistic medical system as “one in which illness is believed to be caused by the active, purposeful interventions of a sendate agent who may be a supernatural being (a deity or god), a non human being (such as ghost, ancestor, or evil spirit), or a human being (a witch or sorcerer).” - The sick person literally is a victim, the object of aggression or punishment directed specifically against him, for reasons that concern the patient alone. - A personalistic explanation of illness is traditionally accepted by much of the non-western world. - Personalistic causality allows little room for accident or chance. Typical causes of illness in personalistic medical system i. Intrusion of foreign agent (spirit) in the body by spiritual means: - Intrusion of foreign agents is a common explanation among many cultures for internal body pains such as headaches, stomachaches, etc. - The spirits are believed to be intentionally put into an individuals by witchcraft. - The cure for such illness is the removal of spirit by shaman healers. ii. -

Susto Susto means sudden fear. Susto is believed to result from incidents that have a destabilizing effect of an individual causing the soul to leave the body. Susto are seen the results of spirit possession by action of supernatural beings or people.

iii. Bewitching/ Witchcraft - Bewitching involves the use of magical acts and supernatural powers either by humans or supernatural beings.

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It is believed that particular kind of supernatural beings can cause an illness called aire. The typical symptoms may include paralysis, twisted mouth, aching joints, etc.

iv. Sorcery v. Evil eye Naturalistic Medical System Applied to Public Health According to Foster (1976), “Naturalistic systems explain illness in impersonal, systemic terms. Disease is thought to stem, not from the machinations of an angry being, but rather from such natural forces or conditions as cold, heat, wind, dampness and above all, from an upset in the balance of the basic body elements. - Naturalistic systems conform to an equilibrium model; health prevails when the insensate elements in the body, the heat, the cold, the humans are in balance to the age and the condition of the individual in his natural and social environment. When equilibrium is disturbed, illness results. Typical cause of illness in naturalistic medical system i. Organic breakdown or deterioration (e.g., tooth decay, heart failure) ii. Obstruction (e.g., kidney stones, arterial blockage due to plaque build up) iii. Injury (e.g., broken bones, bullet wounds) iv. Imbalance (e.g., too much or too little of specific hormones and salts in the blood) v. Malnutrition (e.g. too much or too little food, not enough proteins, vitamins, or minerals) vi. Parasites (e.g., bacterial or viral infection, amoeba or worm infestation) Summary: Personalistic vs Naturalistic Medical System

Causation Illness Religion, Magic Causality Prevention Responsibility Societies

Personalistic System Active agent Special case of misfortune Intimately tied to illness Multiple levels Positive action Beyond patient control Primitive bands/tribes

Naturalistic System Equilibrium loss Unrelated to other misfortune Largely unrelated to illness Single level Avoidance Resides with patient Ancient “great traditions”

Self-Medication/ Alternative Medication and Other Prevailing Health Care Practices and its Importance in Nepal Applied to Public Health Self Medication Practices in Nepal Self-medication is the selection and use of medicines by individuals to treat self-recognized illnesses or symptoms. It is the use of a drug with therapeutic intent but without professional advice or prescription. There are many factors that are associated with self-medication like: - Socioeconomic factors and lifestyle, - Ready access to medications, - Belief of patients that they can manage certain illnesses through self-care and

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Greater availability of medicinal products. Health care costs

Benefits of self-medication - Self-medication if done correctly moves patients towards greater independence in making decision about management of minor illness thereby promoting empowerment. - It facilitates better use of clinical skills; increases access to medication and may contribute to reducing prescribed drug costs. Potential risks of self-medication Self-medication is potentially an unsafe practice with many risks that include: - Incorrect self-diagnosis - Delays in seeking medical advice when needed - Infrequent but severe adverse reactions, - Dangerous drug-drug interaction - Incorrect manner of drug administration, - Incorrect dosage - Incorrect choice of therapy, - Masking of a severe disease and - Risk of dependence and abuse. Common Sources of medicine for self medication includes: - Elderly from households (with knowledge of simple remedies for common illnesses) - Pharmacies and drug stores - Medicines stored at home - Friends and relatives - Street vendors - Advertisements (e.g. use of “sancho” during cold, cough syrup, paracetamol) Self-Medication in Nepal - Because of various reasons, most of the people in Rural as well as urban areas of Nepal are forced to turn to the private market for their health care. These consist of drug shops and various types of practitioners of traditional medicine. - Based on some knowledge available to them, the pharmacists often suggest drugs and sells medicines from their stores to the patients who prefer to consult them. - In some cases, FCHVs also prescribe drugs to patients outside their jurisdiction. Because of their door to door service practices, they are readily available for misuse of their authority. - Also in groceries, the shopkeepers sell certain types of medicines such as paracetamol, analgesic, metronidazole, antibiotics, etc. People contact them and buy these medicines for prompt reaction or recovery. - Self-medication practices are widely chosen medication practice in various areas of Nepal. To eliminate this practice is neither possible nor desirable. Thus it is better to strengthen primary health care services through educating providers and consumers in how to maximize the benefits and minimize the risks associated with self-medication.

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Traditional Medicine: Alternative Medication and Other Prevailing Health Care Practices in Nepal WHO defines Traditional/Alternative medicine as “the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures, whether explicable or not, used in the maintenance of health as well as in the prevention, diagnosis, improvement or treatment of physical and mental illness.” The traditional/ alternative medicine has been classified into Scholarly medical system, folk medicine and shamanistic medicine. A. i. -

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ii. -

Scholarly Medical System Ayurveda Since time immemorial, Ayurveda has been a major source of health care in Nepal. It is the most authentically recorded and culturally based health system. Two types of Ayurvedic practitioners exists in Nepal  Ayurveda based traditional healers  Trained ayurvedic practitioners: (Vaidya and Kabiraj) Ayurvedic health care in Nepal is provided from 2 hospitals, 14 Zonal Dispensaries, 50 Ayurvedic Health Centres, and 211 Ayurvedic Clinics. Homeopathy In homeopathic approach, rather than to target symptoms of the diseases, the priority will be on bringing the person into the right balance of body, mind and emotion. The government of Nepal has recognized homeopathic treatment in the national health system. Government runs a six-bedded Sri pashupati homeopathic hospital in Lalitpur. There are several homeopathic clinics, dispensaries and practitioners all over the nation.

iii. Tibetan Medicine - Tibetan medicine has been in vogue in the northern part of Nepal bordering Tibet since long time. - Tibetan medicine is found to be practiced in the districts such as Dolpa, Mustang, Mugu, Humla, Jumla, Manang, Surkhet, Bajhang, Solukhumbu, etc. - Amchis are the names given to Tibetan medicine doctors or practitioners. iv. -

Unani System Unani medicine has been recognized by the Government of Nepal. One government sponsore Unani dispensary is in existence in Nepal. Hakims (Unani doctors) are trained in India. Upon completion of their education, they practice in Nepal although they are extremely few in number.

B. Folk Medicine - Folk medicine employs principles and practices sourced from the indigenous cultural development in treating symptoms of illness. Plants constitute major form of medicines in such folk medicines. - Several studies have documented thousands of medicinal plants used by ethnic and indigenous groups of Nepal in traditional healing mechanisms. - Example: burnt leaves or seed powder of Mimosa pudica used in treatment of scurvy, leaf pulp of Aloe vera used for headache, pulp seed cover of Cassia fistula used for constipation, etc.

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C. Shamanistic Medicine (Faith & Spiritual Healing System) - The faith healing has been described as “a method of treating diseases by prayer and exercise of faith in god.” - Mostly thriving on the rural and traditional societies of Nepal, faith healing is still a force to consider within these societies. - In Nepal, the faith healers are of four types: Dhami-Jhankri, Jharphuke, Pubdit-Lama-Pujari-Gubhaju and Jyotish. i. -

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ii. -

Dhami-Jhankri Dhami Jhankri is a popular name of the shamans in different ethnic communities of Nepal. Jhankri is the broad name to include shamans of all communities. A kirati shaman is called mangpa; shamans are called bijuwa in the eastern part of Nepal. Some other names are Ojha, fedangwa, baidang and phukne manche. They are regarded to be the representatives of the supernatural powers and with their aid they can cast off the evil spirits that causes affliction to people. Chanting the sacred lore, beating the drum and cleaning patient’s body from the evil spirits with the broom, the Jhankri in euphoric manner travels into trance state where he communicates with god, goddess or spirit for the safe recovery of the patients. For curing the patient, the Jhankri pledges to worship these deities and sacrifice birds or even goats to satisfy these deities. In order to make sure that the spirit is thrown out from the patient’s body, at time the patients are beaten. The jhankris claim that the patient will feel no pain. Jharphuke (Sweeping and blowing healers) They also constitute spiritual healers; however, they lack the power of undergoing into trance. They use jharphuk (sweeping and blowing) for the diagnosis and treatment of the ailments. By murmuring mantras and touching and blowing the patients over the effected area, the jharphuke cures the patient. At times, they give herbal medicines prepared by themselves to the patients.

iii. Pundit-Lama-Pujari-Gubhaju - Pundit, Lama, Pujari and Gubhaju are all priests. Gubhaju are the priests of Buddhist Newars; Lamas the priests of Buddhist monasteries; and Pundit and Pujari are hindu priests. - They all diagnose and cire illness through prayers and rituals. This type of treatment is called ceremonial healing. iv. Jyotish (Astrologer) - Jyotish are also Hindu priests.They read the horoscope, palm and forehead of the patients. - They interpret the influences of the planets on the patients. By doing so, the illness of the patient will be diagnosed. - Remedies take the form of chanting vedic mantras, putting on gem stones (ratna), fasting on particular days, carrying out fire rituals (yagya), etc.

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Importance of Indigenous Health Care System and Health Care Provider with Special Reference to Nepal In countries like Nepal, indigenous health care system and traditional providers are significant resources that should be fully employed in the struggle to provide adequate health care. Examples of indigenous health service providers include herbalist, faith healers and practitioners of Chinese or Ayurvedic medicine. Indigenous healers play a significant role in a health system. Indigenous health care are significant for developing countries like Nepal because they are more accessible and affordable. They are more deep rooted within the cultural settings and therefore more socially acceptable form of health system - WHO notes that, Dhami-Jhankri or faith healers in Nepal could play a culturally appropriate and costeffective role in health promotion and family planning. It was estimated that the country has well over 100 such healers for every health worker, and they are paid only modest fees by the people for their services. - Indigenous healers have also been shown to have greater leverage in treating illnesses where behavior change is needed (i.e. STIs) because they are often integrated and accepted in the community. - Indigenous healers are influential in reaching and changing the behavior of low-status, stigmatized patients, who often avoid public providers or are neglected by the public health system. - Although the treatment methods used by indigenous healers are often criticized for being unscientific, recent studies have proved the effectiveness of indigenous herbal medicines and chanting for relieving pain and other health problems by its hypnotic effects. - More recently, indigenous healers have become interested in learning about modern medicine and using modern methods. Few years back, a project was sponsored by the government in which traditional practitioners were trained to carry out one or more primary care activities in communities. Nepalese Context: - In Nepal, a project was sponsored by the government in which traditional practitioners were trained to carry out one or more primary care activities in communities. - They involved herbalist, diviners, spiritual or faith healers, shamans, traditional Chinese doctors, ayurvedic practitioners, Unani practitioners and other types of traditional healers. - The traditional practitioners were available and willing to work in primary care when trained, and established good working relationships with other staff. - They also demonstrated the following changes in the practices of healers after they had attended training workshops:  Increased use of oral rehydration solution for children with diarrhea  Use of washbasins for cleaning hands in traditional healing clinics  Decreased use of strong purges and ememas for treating diarrhea  Construction and use of latrine in healers’ homes  Increased referrals to clinics for patients with dangerous symptoms  Increased attendance at rural clinics

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Conclusion: There are many elements in the indigenous health care system which is beneficial while many others are not. Health workers should look carefully at the beneficial resources in the traditional health sector.

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Given the major status and influence of most traditional practitioners among their own people, their role in providing sound and culturally appropriate primary health care should not be underestimated. However, it is important to clearly define the roles of indigenous healers in relation to other members of the primary health care. In countries like Nepal, where needs are great and resources scarce, traditional practitioners can play a significant role in helping people in rural communities to improve their quality of life.

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UNIT 3: PROVIDER-CONSUMER RELATIONSHIP Meaning and Interpretation of Provider (Public Health Professional) and Consumer/ User/ Patient/ Organizational Relationship Provider Consumer relationship is an emotional association (clinical encounter) between the health provider and a consumer/client which arises when health provider in a professional capacity interact with the patient. Doctor patient relationship is established when the patient makes a request for medical examination, diagnosis, opinion, advice or treatment and the doctor undertakes to provide these. The three main goals of doctor patient relationship are creating a good interpersonal relationship, facilitating exchange of information, and including patient in decision making. Significance and importance of Provider-Consumer Relationship i.

Excellent public health outcomes – in which consumers report high degree of satisfaction, work effectively with their health providers, adhere to treatment regimens or preventive behaviours, experience improvements in the conditions of concern to them and proactively manage their lives to promote health and wellness are far more likely to arise from relationship with providers that are collaborative and in which patient/client feels heard, understood, respected and included in the treatment planning. ii. Good provider-consumer communication and relationship has the potential to help regulate patient’s emotions, facilitate comprehension of public health information, and allow for better identification of consumer’s needs, perceptions and expectations. iii. Users reporting good communication with their health professionals are more likely to be satisfied with their care, and especially to share pertinent information for accurate diagnosis of the problems, follow advice, and adhere to the prescribed treatment and suggestions. iv. Poor health outcomes including non-compliance with treatment plans, complaints to oversight boards and malpractice actions tend to arise when patient/client feels unheard, disrespected, or otherwise out of partnership with their health providers. v. Better the relationship in terms of mutual respect, knowledge sharing, trust and perspectives about diseases, better will be the amount and quality of information about the service user’s health condition, enhancing accuracy of diagnosis and treatment. vi. A health provider’s better communication and interpersonal skills encompasses the ability to gather correct information in order to facilitate accurate diagnosis, counsel appropriately, give health instructions and establish caring relationships with consumers.

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Reciprocal and Complex Roles of Provider and Consumer/Users Parson’s Sick role model and Szasz and Hollander Model suggest that both health professional and consumers have vital roles and obligations to improve the quality of health care. These both models have been explained in relation to psychological and clinical approaches. Not only medicines or other drugs react for the recovery of illness, disease and problems but behavior of health professionals and patients also play a vital role. In such medical encounter, the health providers and patients exhibit reciprocal roles. It is a relationship in which the roles of both parties are defined with reference to one another. -

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Providers and consumers continually evaluate the adequacy of each other’s performance, according to their own values and expectations, and respond in a way that they feel somehow matches with, or is deserved by, the other’s behavior. The common notion of reciprocal relationship centers on things people can do for, or give to each other in a spirit of exchange. In public health encounter between health provider and consumer, a special case exists with regard to reciprocal relationship. A health provider can do things for the users, but the users can do things both for the provider and for himself or herself. Interestingly, because consumer can choose between provider directed responses and responses on their own behalf, they can hurt themselves. The health professional who is perceived as working especially hard may find the users follow the prescribed suggestions and regimen with special conscientiousness. Consumers who feel they did not receive the kind of care they expected may withhold payment of bills, boycott further services, discourage friends from going to this health provider, or even file malpractice suits. Positive statement or facial expressions by the health provider are likely to produce the same behavior in the clients. If a warm greeting pleases the client, the client also returns good feeling (warm behavior) to the health provider. Behaviours that are more task oriented in both health professional and patient/client can also show reciprocity; for example, more information giving by the provider and greater expertise produce better understanding and better service compliance. Health professionals are profoundly influenced by the demeanor, interest, expressions, comments, attitudes, and positive or negative regard expressed by their clients. That influence can return to help or to haunt the client. To an extreme case, a client who is consistently rude and irritable will almost certainly not receive the same health care as a client who conveys positive, or at least constructive, attitudes. More subtly, consumers’ expectations for how their providers are going to act will very likely come true because the expectations shape the consumer’s behavior, which, by reciprocity, is reflected back in the behavior of the health provider. Thus, relationship between health professionals and consumer is very critical, complex and reciprocal. Both parties must play their roles as partners accepting the system and situation governing health care.

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Parson’s Sick Role Model Sick role is the set of patterned expectations that defines the norms and values appropriate for individuals who are sick and for those who interact with them. Talcott Parsons (1951) According to Parsons, the sick role implies four major expectations which comprises of two rights and two duties Rights i. Sick person is temporarily exempt from ‘normal’ social roles. Depending on the nature and severity of the illness, a physician can legitimize the sick role status and permit the patient to forgo normal responsibilities. The physician’s endorsement is required so that society can maintain some control and prevent people from lingering in the sick role. ii. People who are sick are generally not held responsible for their condition (absence of blame). It is assumed that being sick is not a deliberate and knowing choice of the sick person. Sick person has a right to be taken care of Duties/Obligations i. People who are sick have an obligation to try to get well. The sick role is considered to be a temporary one that people must relinquish as soon as their condition improves sufficiently. Those who do not return to their regular activities in a timely fashion may be labeled as hypochondriacs or malingerers. ii. The sick person has an obligation to seek technically competent help from a suitably qualified professional and to cooperate in the process of trying to recover. According to Parsons, it is important for the society to maintain social control over people who enter the sick role. Physicians are empowered to determine who may enter this role and when patients are ready to exit it. When patients seek the advice of a physician, they enter into the doctor-patient relationship, which does not contain equal power of both parties. The patient is expected to follow the doctor’s orders by adhering to a treatment regime, recovering from the malady, and returning to a normal routine as soon as possible. Status Obligations

Privileges

Patient’s (Sick) Role To be motivated to get well To seek technically competent help To trust the doctor

Doctor’s (Professional) Role Act for the welfare of the patient Be guided by the rules of professional behavior Be objective and emotionally attached

To accept the competence gap between doctor and patient Exemption from performing normal social obligations

Have high degree of skills and knowledge on illness` Access to patient’s physical and personal intimacy

Exemption from responsibilities for one’s own condition

Professional autonomy Professional dominance

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Criticism: 1. Rejecting the sick role model - This model assumes that the individual voluntarily accepts the sick role. - Individual may not comply with expectations of the sick role, may not give up social obligation, may resist dependency, may avoid public sick role if their illness is stigmatized. - E.g. middle class women may not give up household works despite being sick, poor employee may continue his work to earn daily wages. 2. Doctor-patient relationship - Going to see doctor may be the end of a process of help seeking behavior. Lay person consults significant lay group first. - This model assumes ideal patient and ideal doctor roles. Differential treatment of patient and differential doctor patient relationship variations depend on social class, gender and ethnicity. - Doctor patient relationship is more complex and is reciprocal 3. Blaming the sick - Rights do not always apply. Sometimes individuals are held responsible for their illness. - For example, smokers are responsible for lung cancer, intravenous drug users are responsible for HIV/AIDS. 4. Chronic Illness - This model does not fit chronic illness as easily getting well is not an expectation with chronic illness such as cancer, heart disease, diabetes,etc. - In chronic illness, acting the sick role is less appropriate and less functional for both individuals and social system. Szasz and Hollander’s Basic Model of Provider-Consumer Relationship Thomas Szasz and Marc Hollander argue that physician-patient interaction falls into one of three possible models: activity-passivity, guidance-cooperation and mutual participation. This model is more extensive to explain the doctor-patient relationship and is based on the behavioural implications of organic symptoms. i. -

ii. -

Activity Passivity In the activity-passivity relationship the physician in active and the patient is passive. Szasz and Hollander note that such model is most appropriate for the treatment of medical emergencies (coma) or seriously ill patient (unconscious). Typically, the situation is critical as the physician works in a state of high activity to stabilize the patient’s condition. An important characteristic of this medical orientation is that decision making and power in the relationship are all on the side of the doctor and treatment takes place regardless of the patient’s contribution or active participation. Guidance-cooperation Szasz and Hollander argue that the guidance cooperation relationship is the most pervasive in ongoing medical practice. This interaction style is common in cases of acute illness (such as flu, measles), when the patient’s major concern is to find a cure for his disease so that he can resume a normal life.

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In this model, the physician tells the patient what to do, and the patient cooperates. This interaction can be seen as equivalent to the relationship between a parent and a child. In this model, treatment refers to whatever the physician does. The patient is nonetheless suffering, seeking help, and ready to cooperate. In turning to a physician, patients place themselves in a position of less power; the physician has knowledge and skills, resources the patient does not possess. The patient is expected to obey, follow orders, and comply with the medical regimen prescribed by the doctor. The guidance-cooperation model is probably identical with the doctor-centered interaction. The success of the interaction as seen by the physician is measured by the degree to which the patient complies with the physician’s advice.

iii. Mutual Participation - Mutual participation (adult to adult) is favored by patients who want to take care of themselves. - Socially and psychologically, it is the most complex of the three relationships to sustain, because both physician and patient must be aware of each other’s needs, wishes, and individuality. - Szasz and Hollander suggest that mutual participation may be most appropriate in the treatment of chronic illnesses such as diabetes mellitus and chronic heart disease, where patients are required to carry out much of the treatment program themselves with only occasional medical consultation. - Both parties bring important knowledge to the interaction, which is used to formulate strategies that will allow the patient to achieve his health goals. - This model does not suit for children, mentally retarded, illiterate or immature patients. Model Activity-Passivity

Patient’s Role Recipient- unable to respond or inert

Physician’s Role Does something for the patient

Guidance operation Mutual Participation

CooperatorObeys orders Participant partnership

Tells patient what to do Helps patient to help himself

Co-

Relationship Pattern Consumer/Users

1 2 3 4 5 6 7 8 9 10

between

in

Traditional

Modern/Professional Relationship Pattern Registration system (outdoor) Institutional system Written documents Strict on date and time Lab/Supporting alternatives Technical methods of using instruments More responsible and easy to predict Routine for follow up Patient comes to hospital or professionals Long or short term relationships depending upon nature of disease

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Clinical Application Acute trauma, delirium, unconscious state, etc. Acute infection, clinical procedures Most chronic illness, cancer, psychosocial problems

Public

Health

Prototype Parent-Infant

Parent-Child Adult-Adult

Professionals

and

Traditional Relationship Pattern Personal contact Family-individual system Verbal fixation Flexibility on date and time Sacrifice system Approximation based on healers’ decisions No any responsibility and haphazard prediction No such system but frequent use Healer goes to the patient’s house Long-tern relationship with family system

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Barriers in Effective Provider-Consumer Relationship A. Provider Related Barriers i. Deterioration of provider’s communication skills - Professional attitudes and interview styles ii. Non disclosure of information to patients iii. Provider’s avoidance behavior iv. Discouragement of collaboration - Discouraging patients from voicing their concerns and expectation as well as requests for information. v. Provider’s working environment, professional ethics, workload, etc. B. Consumer/Client Related Barriers i. Resistance by patients - Resisting monologue of information transfer from doctors - Resisting power and expert authority that society grants doctor ii. Conflict of patient’s interest - Patient interest vs society - Patient’s interest vs other patients - Problem of confidentiality iii. Illiteracy, superstition and lack of information about health care system iv. Cultural assumptions and understanding of the patients C. Other Barriers i. Socio-political barriers - Poverty, cost of medical treatment, doctor’s fee, conflicts, etc. ii. Difference in perspectives - Social class, egoism, language ethnicity, gender, clinical practice style, superior/inferior feeling, self-centered behavior iii. Personality clash between professionals, users, administrators, etc.

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UNIT 4: HEALTH POLITICS The Meaning and Interpretation of Health Politics Health Politics Politics means striving to share power or striving to influence the distribution of power, either among states or among groups within states. (Max Weber) Health Politics is the process associated with the organization and management of health care, the distribution of resources and authority in any community of people, livelihood and so on. Health Politics can be understood not only in the ways in which health is ‘made’ politically, but also in what health ‘does’, that is, its impact upon the political sphere. Health and disease give rise to interventions that are also concerned with political organization and with categories such as identity, community and sovereignty. In order to fully explain what is at stake here, health politics can be illustrated by looking at two examples: first, the connection between social medicine and the rise of governmental power; and second, the reconfiguration of social relations by medical practice. These examples allow us to begin to unpack the political dimensions of health. Importance of health politics in health system of a country Health politics is important to the health system of a country for the following main reasons: i. Health Politics influences policy formulation - Health politics has direct implication in the formulation and execution of health related policies, law, acts, plans and overall health strategies that way or the other. - Awareness of political factors such as partisanship, voters' views, public opinion, political ideology, values and belief systems, the power of entrenched interest groups, and the nature of media coverage, along with constitutional requirements and institutional arrangements is essential to understanding health policy making. ii. -

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Improving health determinants requires political action The determinants of the public's health are not limited to bacteria and viruses and other specific disease factors to which people are exposed. They also include threats that can be controlled only by concerted community action, through the political process. Environmental problems, unsafe working environments, inadequate housing policies, the absence of universal health coverage, and personal behaviors that jeopardize people's well-being—these are all determinants of health, and none, except personal behaviors, are subject to solutions by individuals. All require community action, political responses, and political will.

iii. Resource allocation to health care is a political process - Responses to health problems depend upon political decisions regarding the allocation of appropriate resources. - The overall resource management in health sector including decisions about how this sector should be funded, how much funds should be allocated and what are the sources, are all the part of a wider political exercise. iv. Political ideologies influence health sector - The health mandates raised by political parties and those incorporated in their manifestoes are likely to influence overall way the health sector is governed and health services are delivered.

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Healthcare systems organization, besides the common principle that is based on certain models, is also influenced by ideologies and politics.

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Politicization occurs in public health Health officials appointed by political leaders and government officials must define public health policy and programs within the framework of pertinent legislation and what is acceptable to the political leadership. This often leads to the politicization of public health issues and results in political debate instead of public health discourse.

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World Trends of Health Politics World health politics have been changed drastically. The first international sanitary conference convened in Paris in 1851 roughly marks the origin of world health politics. Although several efforts had been made in health sector in the past, much of the works were institutionalized only after the birth of WHO in 1948. Alma Ata Declaration on PHC is often viewed as a new chapter in the history of world health politics. Since then, the world has witnessed series of changes in health sector. Some of the noteworthy developments in world health politics have been summarized below: i. ii. -

Alma Ata Conference on PHC The international conference of primary health care was organized by the WHO, the UNICEF and the government of USSR from 6-12 Sep 1978 with participation of 134 countries and various agencies. This conference was a major turning point in world health history as the countries moved to the concept of "Health for All" through primary health care approach. The conference also reaffirmed health as a fundamental human right. Evolution of Selective Primary Health Care Immediately after the Alma-ata conference, the top ranking health experts in the west began to criticize PHC in the global context with shrinking health budget. They advocated that comprehensive approach would be too costly. If health indicators were to be improved, they argued, high risk group must be targeted with few cost effective interventions (SPHC). In 1983, UNICEF adopted Selective Primary Health Care through implementing key strategy "GOBIFFF".

iii. Structural Adjustment Programs (SAPs) - Another major political turning point in health was the introduction of Structural Adjustment Program and user financed health services by World Bank in 1980s. - It included cutbacks in public spending, freezing of wages, charging user fees, etc. - It has been considered as a major assault to primary health care approach and has been criticized around the world till date. iv. Investing in health - Another important milestone to world health politics was the World Bank's focus on "Investing in Health" by taking over third world's health policy planning. - The World Bank's policy on user financing had put the burden of health costs back on the shoulders of the poor. - Privatization of health services priced many interventions beyond the reach of those in greatest need.

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Bamako initiative In 1987, Bamako initiative was funded by WHO and UNICEF with an aim to increase access to primary health care services. Community financing was introduced to capture a fraction of the funds that households were already spending in the informal sector and combine them with government and donor funding to revitalize health services and improve their quality. The application of user fees to poor households and the principles of cost recovery seemed as a barrier for poor and marginalized communities.

Besides these changes in the health politics over several decades, many more initiatives and efforts have also been made in the health sector. Many international issues of health politics originates through international partnerships such as IHP+ and numerous international conferences and declarations. Framework Convention on Tobacco Control adopted in 2005 has also been viewed as an important milestone in health politics. Nepalese Status of Health System (Health Politics Perspectives) After the establishment of a republican system in 2006, Nepal is undergoing a period of great political and social transition. Along with political changes, Nepal has changes in its health system. Some of the noteworthy changes are listed below: - In recent years, health sector reform efforts are being exemplified by the adoption of a Nepal Health Sector Strategy and implementation of Nepal Health Sector Program Implementation Plan III (2015‐2020). The plan puts a major emphasis on a universal health coverage and quality of 'Essential Health Care Services' with a special attention to improve access for poor, vulnerable and disadvantaged groups. - Free health service which has been progressively rolled out since Dec 2006 was a major political decision in the area of health sector. - Nepal is also experiencing revitalization of primary health care with the establishment of Primary Health Care Revitalization Division. Though outcomes are yet to be tangible, it is of a great hope for revitalizing primary health care for health for all. It is also the reflection of belief that ‘health for all’ is still possible in Nepal though rest of the world stayed back from PHC already in 1980s. - New constitution of Nepal 2015 has reiterated health as a fundamental human right which was guaranteed by interim constitution in 2006. - After the piloting of community-based health insurance schemes by the Government of Nepal since 2003, first phase of the Social Health Security scheme has also been started in three districts (Kailali, Baglung, and Ilam) in 2015 with an aim to ensure universal health coverage. Major Policy debate in current Nepalese health system - The main policy level discussion on fire is about increasing the effectiveness of Social Health Security Scheme and scaling it upto 25 districts in upcoming fiscal year - The next sprouting discussion on going is approaches of mainstreaming the private sectors actors in health system. For this Nepal signed Nepal Health Development Partnership with major EDPs in 2009 and implemented sector wide approach to improve aid effectiveness. But government solely is not able to handle such mechanism. - The discussion over the human resource management is the next policy level debate over the rate of production and consumption as well. The growing interest of private sectors in human resource production and the conflict on the modality of guidelines for retention of human resources is blurring the prospect of Health for All in Nepal. The major actors in these debates are the private sectors and business houses, INGOs, NGOs and international power centers who intend to play in low and middle income countries for their interest in sustaining their leverage in global politics

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Comprehensive and Selective Primary Health Care The contrast between comprehensive and selective primary health care Characteristics

Comprehensive PHC

Selective PHC

Main aim

Improvement in overall health of the community and individuals

Reduction of specific disease

View of health

Positive well being

Absence of disease

Major Focus

Health through equity and community empowerment

Health through medical interventions

Strategies

Comprehensive strategy with curative, rehabilitative, preventive and health promotion that seeks to remove root causes of health

Focus on curative care, with some attention to prevention and promotion

Planning and strategy development

Local and reflecting community priorities; professional on tap not on top

External, often global programmes with little tailoring to local circumstances

Locus of control over health

Communities and individuals

Health professionals

Participation

Engaged participation that starts with community strengths and the community's assessment of health issues, is ongoing and aims for community control

Limited engagement, based on terms of outside experts and tending to be sporadic

Engagement with politics

Acknowledges that PHC is inevitably political and engages with local political structures

Professional and claims to be apolitical

Approach

Bottom up

Top down

Human Rights and Health Rights Nepal is governed by the new constitution of Nepal, which came into force on 2015. The constitution of Nepal guarantees every citizen the fundamental right to basic health services free of cost from the state. Likewise women's right to reproductive health and other reproductive rights have also been included in part of the constitution along with children's right to basic health services. The constitution of Nepal recognizes several health related rights as human rights. Some of the important provisions related to health have been summarized below: Part 3: Fundamental Rights and Duties Article 35; Right to health care: i. Every citizen shall have the right to seek basic health care services from the state and no citizen shall be deprived of emergency health care. ii. Each person shall have the right to be informed about his/her health condition with regard to health care services. iii. Each person shall have equal access to health care. iv. Each citizen shall have the right to access to clean water and hygiene.

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Article 38: Right of women i. Every woman shall have the right relating to safe motherhood and reproductive health. ii. There shall not be any physical, mental, sexual or psychological or any other kind of violence against women. iii. Women shall have the right to special opportunity in the spheres of education, health, employment and social security on the basis of positive discrimination. Article39: Right of children i. Every child shall have the right to education, health care nurturing, appropriate upbringing, sports, recreation and overall personality development from family and the State. ii. No child shall be subjected to child marriage, illegal trafficking, kidnapping, or being held hostage. iii. No child shall be subjected to physical, mental, or any other forms of torture. iv. Children who are helpless, orphaned, physically impaired, victims of conflict and vulnerable, shall have the right to special protection and facilities from the State. In order to address these fundamental rights, the state shall adopt the following policies: i. The State shall gradually increase necessary investment in the public health sector in order to make citizens healthy. ii. Ensuring easily available and equal access to high quality health care for all. iii. Protecting and promoting Nepal's traditional medicinal system such as the Ayurveda, natural medicines and homeopathy; iv. The State shall gradually increase investment in the health sector and make it service oriented by regulating and managing the investment of the private sector in it.

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Manifestoes of the Political Parties on Health Issues in Nepal The provisions on health in the manifestoes of three major political parties of Nepal have been presented in the table below: Topic

Nepali Congress

CPN UML

CPN Maoist

Fundamental Human Rights

- The state's fundamental aim shall be to wage a war against hunger and malnourishment - Rehabilitation, compensation and social security to citizens affected by violent conflict

- Education, health, employment and food situation shall include in fundamental right - Special privileges to conflict victims, displaced, torture victims, vulnerable, including destitute and orphans

- Assurance of fundamental rights to all citizens to education, health, employment, housing and foodsovereignty

Women and Children

- End all types of violence and discrimination - Women entitled to reproductive health rights - Nutritional food, education, basic services and social security of children guarantee

- Women entitled to reproductive health rights and divorce - Special preference to women for education, health and employment

- Women entitled to reproductive health rights

- Right of the disabled to identity, representation and protection, including education, health, employment and social protection - Free health services to disabled

- Special programs to protect and respect and respect of the differently abled

- Free basic health services shall be availed - There shall be subsidy to treatment of complexities of heart, kidney and cancer

- Implementation of health for all as fundamental right. - Free basic health services to all - Special provisions to develop allopathic, homeopathic, ayurvedic, unani and accupunture/ accupressure, natural healing and yoga therapies shall be made - There shall be allopathic, ayurvedic, natural healing centers at each VDC.

Disability

Health

- Network of public hospitals and quality improvement to easy access of people in the remote areas shall be state obligation - Increase health expenditures in private, NGO and public sectors to avail all types of services within the country - Special attention to control HIV/AIDS - Control of drug abuse and management of addicts shall be attended by the state

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Based on the review of manifestoes of major political parties, we can draw the following conclusions: Strong points - Almost all political parties seem to have consensus regarding "Health as a fundamental right". - The political manifestoes categorically address a mother and child health issue which is a very applaudable thing. - The statement about alternative medicine is very contentious in manifestoes of some political parties like CPN Maoist and MJFN. Limitations - Although the declarations on health made by political parties in their manifestoes seem welcoming, there are no much details on how such achievements will be realized. This brings little suspicion that the declarations may be limited to documents. - Many political parties have been found to use a populist tool so liberally by declaring health care to be made free in their manifestoes. Role of Public Health Institutions on the Existing Health Politics In order to understand the roles of public health institutions, it is first important to understand about health politics. Politics does not always mean ballot and bullet. It means the overall process and mechanism of making a system in the country across all sectors. Health politics includes most of the influences that have something to do with the organization and management of health care, the distribution of resources and authority in any community of people, livelihood and so and so. Therefore health politics is not a concept that can be solely equated to partisan politics. Role of Public Health Institutions i. Advocacy and lobbying in health policy formulation - One of the critical roles of public health institutions is on advocacy and lobbying with central ministers, leaders and policy makers for drafting people centered health policies, strategies and plans. - Public health institutions can identify implementation gaps, prepare recommendations and guide policy makers to define national priorities, establish necessary regulatory framework as well as allocate necessary technical and financial resources for health. ii. -

Decentralized planning and budgeting Another important focus of public health institutions is on decentralized approach to health sector planning and budgeting that is more accountable to the public and responsive to their needs. Public health institutions at district levels and below are responsible for participatory planning, budgeting and implementing their respective health plans.

iii. Rebuilding and strengthening health systems - It is a crucial role of health institutions to ensure quality health services at the point of service delivery. - For this, within overall socio-political environment focus should be on strengthening production, deployment and retention of human resources, developing and upgrading physical infrastructures, maintenance, timely procurement and efficient supply chain.

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iv. Equitable distribution and utilization of health services - Based on existing health policy and health sector strategy, the political decisions and public health institutions' work needs to be concentrated on expanding health services closer to communities and strengthening decentralized network of public health institution, particularly focusing on under-served, poor and urban communities. v. -

Improving sector management and governance Public health institutions can also play an important role in improving health aid effectiveness by espousing the principles and priorities of Nepal's Development Cooperation Policy 2014. Further, the institution can also support government's effort to strengthening current practices of financial planning, auditing and transparency with emphasis on reducing financial irregularity and improved accountability.

vi. Improving sustainability of health care financing - Public health institutions have important roles in improving mobilization of existing resources and better pooling of resources and risks. - They can also play a role in supporting government to develop Health Sector Financing strategy.

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UNIT 5: RESEARCH METHODS OF SOCIOLOGY/ANTHROPOLOGY APPLIED TO PUBLIC HEALTH Meaning and Nature of Research Research is a scientific activity undertaken to establish something, a fact, a theory, a principle or an application. Research means a set of activities designed to develop or contribute generalisable knowledge, consisting theories, principles or relationships, or the accumulation of information on which they are based, that can be corroborated by scientific methods of probing. Purpose of Research Research is largely concerned with i. Description or exposition of status of existing problem (s) or phenomena, and seek to explain them with a purpose. ii. Establishment of cause and effect relationship or association of observed events with sets of determinants, iii. Analysis of events retrospectively or prospectively with interpretation and explanations, iv. Prediction or forecasting with trend analysis of epidemiological or health or problem status v. Evaluation, assessment of effectiveness of benefits or risks or complications of technology, drug or regimen, equipment, health care system, control program, education program or Teaching/ Learning activities, environmental condition. Nature of Research - Research involves investigation of some hypothetical proposition. - Scientific research is systematic and controlled - Scientific research is empirical, i.e. it is based on larger experience of others - Research may be defined as systematic and objective analysis - Research aims towards the solution of a problem - Research is always based upon observable experience or empirical evidence - Research demands accurate observation and description - Research is carefully designed - Research requires expertise - Research involves the quest for answers to unsolved problems Types of Social Research On the basis of application or purpose, social research can be classified into two types: i. Pure/ Basic Research - According to PV Young, "gathering knowledge for knowledge sakes is termed as pure or basic research - The purpose of pure research is not to apply the findings to sole an immediate problem at hand, but rather to understand more about certain phenomena and problems that occur in several organizations and how they can be solved - This type of research is purely theoretical and is undertaken to improve our understanding of certain problems and how to solve them. - Basic research generates new ideas, principles and theories.

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ii. -

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Applied Research Applied research is conducted in response to specific problems which requires a defined and purposeful end. The major purpose of applied research is to answer practical and useful questions about policies, programmes, projects, procedures or organizations. Action research is one of the forms of applied research

On the basis of intervention i. Intervention Research Intervention research is distinguished by two features: random allocation and manipulation of key causal variables. Intervention research is not common in medical sociology and anthropology but there are some successful examples. ii. -

Non-intervention Research (Observational) Most research in medical sociology/anthropology is observational. Two broad classes of observational research includes cross-sectional and longitudinal. Although these research designs are often used in epidemiology, they are also used to varying degree in sociology and anthropology. Long-term ethnographic research is usually cross-sectional in design. Longitudinal research is usually rare in social science.

On the basis of properties of subject matter i. Qualitative Research ii. Quantitative Research On the basis of time dimension i. Cross-sectional Research ii. Longitudinal Research Research Procedures and Methods in Health System Research Research Procedures The research process is the method by which research is planned and conducted, and is essentially always the same, regardless of where and by whom the research is being conducted, or the purpose of the research. i.

-

ii.

-

Developing the research question Most research projects begin with an idea for a research problem. A researcher should have a clear and well-defined research question before he or she begins planning research The most important consideration in developing a research question is that it can be answered using the research methods and tools available to the researcher. Formulating Hypothesis and Research Objectives The research hypothesis should be stated at the beginning of the study to guide the objectives for research.

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iii.

-

iv.

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v.

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vi.

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Designing a research hypothesis is supported by a good research question and will influence the type of research design for the study. The primary objective of research should be coupled with the hypothesis of the study. The study objective is an active statement about how the study is going to answer the specific research question. Objectives can (and often do) state exactly which outcome measures are going to be used within their statements. Searching and evaluating the literature A thorough, critical review of the literature is required to determine what research has been published already and to establish what is already known about the research topic. It can also help researchers to detect any gaps in existing knowledge identified by other researchers. A literature review also helps the researcher to refine his or her research question and may help decide how to conduct the research. Selecting the Research Design The research approach or overall design of the research project is determined by the research question and the review of the literature. Some questions are best answered using a qualitative approach and others using a quantitative approach. Qualitative research adopts an inductive approach and quantitative research adopts a deductive approach. In mixed methods research, qualitative and quantitative approaches may be used either sequentially or concurrently within a single research project. It is important that the research approach adopted is determined by the research question and the subject of the research, rather than by the methodological preference of the researcher. Selecting Research Method The choice of appropriate research method is influenced by the research question, the literature review and the research approach selected. The methods selected must be appropriate to, and fit well with, the chosen research approach. For example, research using a qualitative approach often collects data through interviews, focus groups or observations. In contrast, research adopting a quantitative approach often collects numerical data, for example through direct measurement or questionnaires. Gaining access to the research site and data Before the researcher can move on from planning research to approaching participants and collecting data, he or she should obtain research ethics and governance approvals to access the research site or data. Research ethics approval should be obtained to ensure that research is conducted ethically, with regard for the safety of all those involved in the research. Research governance approval is also required from the organization with direct responsibility for the participants involved in the research.

vii. Data collection

-

Each methodological approach can employ a range of methods for collecting data from research participants. The data collection techniques used should be appropriate to the research approach selected and provide the researcher with the data he or she needs to answer the research question.

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For example, researchers undertaking qualitative and exploratory research studies may collect data through interviews and focus groups, which allow them to extract and explore textual data to describe and explain the phenomena being researched. In contrast, quantitative researcher may collect numerical data through direct observation or questionnaires.

viii. Data Analysis

-

-

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ix.

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In the penultimate stage of the research process, the researcher analyses the data collected in the previous stage. Qualitative and quantitative data are processed and analysed differently. Usually, researchers analyse quantitative data when all the data have been collected, although they may undertake an interim analysis. Quantitative data are used to test the study hypothesis and answer the research question. Qualitative data are analysed soon after collection as part of an ongoing process, constant comparison. Each analysis may influence the selection of subsequent participants and/or the way subsequent data are collected. Regardless of how data are collected, it is important that they are used to answer the research question identified in earlier stages of the research process. Dissemination and implementation Regardless of its quality, research will be proven worthless if findings are not disseminated and implemented in practice when appropriate. Research findings may be disseminated in many different ways. Common means of dissemination include publication in peer-reviewed journals and presentation at professional conferences or meetings.

Research Methods in Medical Sociology and Anthropology Some commonly used methods of research in medical sociology and anthropology includes: i.

Ethnographic method Ethnographic method is the core of anthropological research. The traditional ethnographic approach assumes that cultures are whole units and can be comprehended as such. It tries to interpret and describe the symbolic and contextual meanings of the everyday practices in their natural setting. Any anthropological research is essentially based on ethnographic fieldwork, involving mainly participant observation, case study and genealogical method.

ii. -

Participant Observation Participant observation is a qualitative method whose objective is to help researchers learn the perspectives held by study populations. The researcher engaged in participant observation tries to learn what life is like for an “insider” while remaining, inevitably, an “outsider.” While in these community settings, researchers make careful, objective notes about what they see, recording all accounts and observations as field notes in a field notebook. Informal conversation and interaction with members of the study population are also important components of the method and should be recorded in the field notes, in as much detail as possible.

-

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Participant observation is useful for gaining an understanding of the physical, social, cultural, and economic contexts in which study participants live; the relationships among and between people, contexts, ideas, norms, and events; and people’s behaviors and activities – what they do, how frequently, and with whom.

Strengths: - Allows for insights into contexts, relationships, behavior - Can provide information previously unknown to a researcher that is crucial for project design, data collection, and interpretation of other data. Limitations - Time consuming - Documentation relies on memory, personal discipline, and diligence of researcher - Requires conscious effort at objectivity because method is inherently subjective. iii. Non-Participant Observation - When the observer does not actively participate in the activities of the group and simply observes them as a total outsider, it is known as non-participant observation. - This can be conducted by the researcher either by keeping away from the group, without revealing the identity to the subjects or by being present in the group, but without involving in their activities. - They keep a record of the verbal and overt behavior of each person within the group. Strengths - Objectivity and neutrality could be maintained because of detachment with the activities of the group. - By keeping a distance from the group, it would be easier for the observer to learn the weakness as well as strength of the group. Limitations - The dangers of subjectivity are more pronounced. - Nobody would like to open their true feelings, action, attitude and opinion before a stranger, without any kind of rapport. iv. In-depth Interview - The in-depth interview is a technique designed to elicit a vivid picture of the participant's perspective on the research topic. - This type of method is appropriate for eliciting individual experiences, opinions and feelings or to address sensitive health issues. - Researchers engage with participants by posing questions in a neutral manner, listening attentively to participants’ responses, and asking follow-up questions and probes based on those responses. - They do not lead participants according to any preconceived notions, nor do they encourage participants to provide particular answers by expressing approval or disapproval of what they say. - In-depth interviews are usually conducted face-to-face and typically involve one interviewer and one participant. Strengths - Elicits in-depth response, with nuances and contradictions - Gets at interpretative perspective i.e, the connections and relationships a person sees between particular events, phenomena, and beliefs.

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Limitations - Prone to interviewer bias - Not- generalizable - Can be time intensive v. -

Case Study Case study involves intensive, comprehensive and detailed study of a social unit. It is a method of qualitative analysis which aims at obtaining a complete and detailed account of a social phenomenon or a social unit, which may be person, family, community, institution or an event. Anthropologists study the case history of a group. Case history may be obtained using a combination of different methods and techniques such as interview and participant observation.

Strengths - Suitable for collecting data pertaining to sensitive areas of a social phenomenon. - Helps to collect details regarding the diverse habits, traits and qualities of the unit under investigation. Limitations - Difficult to generalize on the basis of few cases. - Investigator's bias might distort the quality of the case study. vi. Focus Group Discussion - A focus group is a qualitative data collection method in which one or two researchers and several participants meet as a group to discuss a given research topic. - These sessions are usually tape recorded, and sometimes videotaped. - One researcher (the moderator) leads the discussion by asking participants to respond to openended questions – that is, questions that require an in-depth response. - A second researcher (the note-taker) takes detailed notes on the discussion. - A principal advantage of focus groups is that they yield a large amount of information over a relatively short period of time. - They are also effective for accessing a broad range of views on a specific topic, as opposed to achieving group consensus. vii. Visual Ethnography - The purpose of this method is to document behavior and cultural practices; elicit participants’ perspectives and encourage collaboration and co- learning. - Procedures include construction of visual record (photographs or video) using degree of structure suitable for research objectives. viii. -

Other Methods Scaling Elicitation Methods Spatial Mapping Social Network Analysis

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Role and Importance of NHRC The roles and importance of NHRC (Nepal Health Research Council) includes the following: - To do or cause to do study and research in the various fields relating to health. - To formulate National health research policy and give a definite direction for the promotion, aspects of health in Nepal. - To undertake research on health system, including, biomedical, behavioral and other related health sciences. - To undertake studies on prevention, diagnosis, treatment of disease and ailments. - To specify the priority sectors of study and research relating to health. - To provide consent for study and research in subjects related to health, to determine authenticity and recommended to Nepal government. - To co-ordinate, guide and evaluate research works related to health and make appropriate recommendation. - To publish and publicize the know-how experiences and the results of research relating national and international levels. - To keep records of research relating to health. - To strength the research capability through training. Similarities and Differences in Anthropological and Epidemiological Methods Similarities i. Vast majority of epidemiological studies are observational just as anthropological studies are participant observational ii. The most common method of data collection employed in epidemiology is the same one that is employed in anthropology that is talking with people. Epidemiologists gather data through communicating with research subjects, just as medical anthropologists do. iii. Although the interviewing techniques of epidemiology tend to be more formal than those of anthropology since they rely on standardized interview schedules, they nevertheless may be quite indepth. Differences If anthropology and epidemiology do differ methodologically, the difference may be one of scope rather than kind. i. Anthropologists tend to have a greater variety of methods to choose from than epidemiologists do, and are much less concerned than most epidemiologists in establishing normative methodological standards, ii. However, of all the methods used by epidemiologists including interviewing, archival researches, and record review, are also components of the anthropological toolkit. iii. Conversely, epidemiologists tend to deal with a larger sample size than epidemiologists do and to work with people who do not view themselves as necessarily connected in anyway. Yet, some epidemiological studies, especially in genetic epidemiology may work with a very small sample size of individuals who are often related. Thus, there are no fixed rules that divide the epidemiological and anthropological enterprises on a methodological basis, and it could be argued that their similarities are perhaps greater than their differences.

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Medical Sociology and Anthropology

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