BLOCK 2

PSYCHOLOGICAL, BEHAVIOURAL AND SOCIAL

ISSUES IN PUBLIC HEALTH AND MANAGEMENT
Psychological, Behavioural,
and Social Issues in Public
Health and Management

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 Influence of Social Factors on
UNIT 5 INFLUENCE OF SOCIAL FACTORS Health and Illness

ON HEALTH AND ILLNESS*

Contents
5.0 Introduction
5.1 Defining Health
5.2 Health Disparity, Health Outcome and Health Inequality
5.3 Social Determinants of Health
5.3.1 Commission on Social Determinants of Health
5.4 Cultural Determinants of Health
5.5 Gender and Health
5.5.1 Gender Inequality in Relation to Health
5.6 Behavioural Determinants of Health
5.7 Economic Determinants of Health
5.7.1 Globalization and its Impact on Health
5.8 Summary
5.9 References
5.10 Answers to Check Your Progress
Learning Objectives
After reading this Unit, you would be able to:
Discuss broad definition of health;
Understand terms like determinants, health outcome, health disparity, health
inequality and health equity;
Understand about determinants of health with special focus on social,
psychological, cultural and economic determinants of health; and
Appreciate the role of these determinants in promoting health or ill-health
(disease) in a population.

5.0 INTRODUCTION
Health is a broad concept that includes a broad range of meanings that ranges
from narrow technical definitions to all embracing philosophical definitions.
Health is often described as “devoid of illness” and as a state of wellbeing. These
are created and maintained by a set of factors, which are known as determinants
of health. In this Unit we will discuss in detail about different determinants of
health.

Different population group has different health status, for example if we take the
case of life expectancy as an indicator of health, a person born in Japan has an
average life expectancy of 88 years where as Indian average life expectancy is
68.56 years. If you consider only Indians, then for men it is 67.3 years and

* Contributed by Dr. Lekha D Bhat, Department of Epidemiology and Public Health, Central
University of Tamilnadu, Neelakudy. 89
Psychological, Behavioural, women it is 69.6 years. Have you ever thought what factors are responsible for
and Social Issues in Public
Health and Management
these stark differences? Determinants of health will be the answer you reach at.

5.1 DEFINING HEALTH

We will begin the discussion with a positive and comprehensive definition of
health. According to World Health Organisation (WHO, 1948) “Health” is a
state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity”. In the context of Medical Anthropology, David
Landy (1997) defined health as the condition of an organism that permits it to
adapt to its environmental situation with relative minimal pain and discomfort,
achieve at least some physical and psychic gratification and possess a reasonable
probability of survival.

Health is not just the physical well-being of an individual but also the social,
emotional and cultural well-being of the whole country in which each individual
is able to achieve their full potential as a human being, thereby bringing about
the total well-being of their community (Aboriginal Health and Medical Research
Council of New South Wales, 2012).

Different medical systems conceptualise health in different ways. For example,

Ayurveda considers health as a balance between body, mind, spirit and social
wellbeing.
Box 5.1: Definitions of Health
Selective Definition Health as absence of disease
of Health Health as socio psychological adaptation or
adjustment to circumstances
Health as a functional capacity to fulfil essential
life functions.
Universal Definition Health as growth
of Health Health as independence, the exercise of
autonomy and self determination
Health as well being
Health as the realization of potential
Health as empowerment
Health as wholeness.
(Source: Procter S 2000, Caring for Health, Macmillan Press, London)

If we consider the broad comprehensive definitions of health, we can identity

that it covers not only physical health but also include mental, social and even
spiritual dimensions of well-being. Hence it is developed and maintained by a
number of determinants.

5.2 HEALTH DISPARITY, HEALTH OUTCOME

AND HEALTH INEQUALITY
A Health Disparity is a difference that is closely linked with social, economic
and or environmental disadvantage in achieving health or health outcomes. Health
disparities adversely affect group of people who have systematically experienced
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greater obstacles to health based on racial group, religion, economic, cultural, Influence of Social Factors on
Health and Illness
gender, age, sexual orientation etc.
A health disparity is the differences in the incidence and prevalence of health
conditions and health status between groups based on race, gender, socio-
economic status, disability status etc.
Health Outcome is the changes in health that results from measures or specific
health care investments or interventions. It is the change in the health of an
individual, group or community which is attributable to an intervention or a
series of interventions. For example, immunization programme has brought down
Infant mortality considerably in the last fifteen years. For example Niti Aayog
(2020) data shows that in 2000, IMR was 68 and in 2016 it is 34. Here
immunization is the medical intervention and reduction in IMR is the health
outcome.
Health Inequality is observable health differences between subgroups within a
given population; it can be measured and monitored. These are unjust and
avoidable differences in people’s health status between subgroups; health
inequalities are against the principle of social justice, because they are mostly
avoidable. Different study findings reveal that the degree of health inequalities
escalates when the rising average income levels of the population are accompanied
by rising income inequalities.
Some health inequalities are attributable to biological variations or free choice
and others are attributable to the external environment and conditions mainly
outside the control of the individuals concerned. In the first case it may be
impossible or ethically or ideologically unacceptable to change the health
determinants and so the health inequalities are unavoidable. In the second, the
uneven distribution may be unnecessary and avoidable as well as unjust and
unfair, so that the resulting health inequalities also lead to inequity in health
(WHO, 2018).

5.3 SOCIAL DETERMINANTS OF HEALTH

Social determinants of health can be defined as the conditions in the social,
physical and economic environment in which people are born, live, work and
this include access to health care. They consist of policies, programmes and
institutions and other aspects of the social structure including the government
and private sectors as well as the community factors. Social determinants affect
the health of the population through the social and physical environment (Healthy
People, 2000)
They are considered as the life-enhancing resources such as food supply, housing,
economic and social relationships, transportation, education and health care whose
distribution across the population effectively determines the length and quality
of life.
Let us see some examples on how social determinants of health increase or
decrease health inequality:
Education: Mother education emerges as the single most important determinant
of child health care utilization in India when the influences of other intervening
factors are controlled (Govindasamy and Ramesh, 1997). The empirical results 91
Psychological, Behavioural, show that a higher level of maternal education results in improved child survival
and Social Issues in Public
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because health services that effectively prevent fatal childhood diseases are used
to a greater extent by mothers with higher education than by those with little or
no education.

Sex Ratio: According to NITI Aayog Data Number of females per 100 males in
Haryana is 831 whereas for Kerala it is 967. The reason for this stark difference
is attributed to education of women, employment of women, patriarchal status
that is followed in the society etc., over all India’s sex ratio is on decline where
women are at disadvantage over the last few decades.

Figure 5.1 explains about various determinants of health in a comprehensive

manner. This model is developed by Whitehead M and Dahlgren G and first
appeared in their article titles “What can be done about inequalities in Health” in
the Lancet in 1991.

Fig. 5.1: Determinants of Health

(Source: Dahlgren, G. (1995) European Health Policy Conference: Opportunities for the Future.
Vol. 11 – Intersectoral Action for Health. Copenhagen: WHO Regional Office for Europe).

We shall discuss eight social determinants of health in detail in this section.

a) Family, Friends and Communities: Studies show that social isolation and
loneliness are associated with increase in the risk of heart disease and stroke.
People who are socially connected to their family, friends and community
are generally happier and live healthier lives with fewer physical and mental
health problems than people who are less well connected.

b) Money and Resources: An inadequate income can cause poor health because
poor access to resources bring in stress and it affects physical and mental
health. Money is essential to have access to good food, water, immunization
etc., poverty damages health.

c) Housing: Studies show children living in congested rooms and houses have
more than twice likelihood to suffer from respiratory problems rather than
children living in spacious- aired houses.
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d) Education and Skills: Good education and skills can help build strong Influence of Social Factors on
Health and Illness
foundations for support. Accessing good work, lifelong problem-solving
ability, develop lifelong healthy habits, afford good quality of life, live and
work in healthy environment all this is possible only if good education is
ensured to the people.

e) Good Work/ Employment: Employability offers stability, security and

regular income. It provides good wages and in turn ensures access to quality
health care system. Good employment ensures that the person can afford
basic living standard, ensure feel of self-esteem and worthiness, which all
in turn has impact on the health of the person.

f) Transport: A healthy transport system can provide opportunities to improve

air quality; also help people travel and access health care services like
hospitals.

g) Physical Surroundings: Clean surroundings, spaces and buildings are

essential for people’s physical and mental health. For example, well
maintained and easy to access green spaces in a city makes it easy for the
people to be physically active.

h) Access to Food: Poor diet is one of the biggest risks for ill health. Healthy
food needs to be affordable, available and accessible within the available
resources at disposal.

Figure 5.2 explains the linkages between various social determinants and how
policy formulation, interventions and health outcomes are linked with each other
in a continuously monitored and evaluated health system.

Fig. 5. 2: Action Model to Achieve Healthy People

(Source: Healthy Campus 2020: Determinants of Health and Evidence-Based Actions)

5.3.1 Commission on Social Determinants of Health

Commission on Social Determinants of Health was formed by World Health
Organization in 2003. The Commission released its final report in 2008, and this
document serves as a guiding principle to policy makers in developing countries
like India to shape health policies and programmes that acknowledge the role of
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Psychological, Behavioural, social determinants of health. It acknowledged and identified that marked
and Social Issues in Public
Health and Management
inequities in health care caused by a) Structural Determinants (for example:
unequal distribution in power, money, goods and services globally, nationally
and locally) and b) Conditions of Daily Life (for example: consequent unfairness
in the immediate conditions in people’s lives — access to school, education,
health care, conditions of work, leisure time etc.)
The Commission made three major recommendations as follows:
1) Improve daily living conditions.
2) Tackle the unequal distribution of power, money and resources.
3) Measure and understand the problem of health inequality and assess the
impact of interventions continuously.
Another Important work in this area by Micheal Marmot and his team (2010)
suggest that reducing health inequalities requires a series of objectives to be met
and they are as follows:
a) Giving every child the best possible start in life.
b) Creating job opportunities and fair working conditions for all
c) Ensuring healthy standard of living for whole of the population
d) Develops pro-healthy physical environment
e) Empowering communities
f) Strengthening disease prevention.
Exercise 5.1
1) Identify how are resources like food shops, housing, hospitals, nursing
homes distributed within your locality?
2) Compare this with the surrounding communities and see whether there
are stark differences in health outcomes?

Check Your Progress

1) Differentiate between health outcome, health disparity and health
inequality.
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2) Define Social determinants of health and discuss eight social determinants

that have impact on Health in Indian Context.
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 Influence of Social Factors on
5.4 CULTURAL DETERMINANTS OF HEALTH Health and Illness

Culture is a system of thoughts and behaviours shaped by a group of people. Our

cultural backgrounds have tremendous impact on our lives especially on our
health. Culture varies from one local group to another. It endures and evolves as
well as is valued for itself.

Anthropologists have focused on both artistic as well as behavioural dimensions.

Herskovits (1948) tells us that, “Culture is the man-made part of the environment,”
and Margaret Mead (1953) says culture “is the total shared, learned behaviour of
a society or a subgroup.” These dimensions are combined in Malinowski’s (1931)
formulation: “Culture is a well organized unity divided into two fundamental
aspects — a body of artefacts and a system of customs.”

Cultural determinants of health incorporate the cultural aspects that promote

resilience, allow a sense of identity and support good mental and physical health
for individuals, families and communities. These norms, values, beliefs, customs
and practices are shaped, supported and protected through traditional cultural
practice, art, song, dance, traditional healing etc.

United Nations Declaration on the Rights of Indigenous People considers the

following cultural determinant elements as very important to shape health culture
of the community.
a) Self Determination
b) Freedom from discrimination
c) Individual and Collective Rights
d) Freedom from assimilation and destruction of culture
e) Protection from relocation
f) Protection and promotion of traditional knowledge and indigenous
intellectual property rights.

The cultural beliefs of a community shape the health care practices and develop
locally believed ideas about illness. Any health intervention for community
members must be made sensible in the context of local beliefs and practices.
Understanding the beliefs and customs of a community is important to
acknowledge and appreciate the differences between groups of people. For
example, how Indian women understand and handle pregnancy and newborn
care is entirely different from that of women from western developed countries.

Every culture has its own customs which influences the disease pattern. It plays
important role in the matters of personal hygiene, family planning, seeking early
medical care, immunization etc. in short it has strong influence in the way of
lives of people. Not all customs and beliefs are bad. Some are based on evidences
(like rest after childbirth) where as some are harmful (like female genital
mutilation).

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Psychological, Behavioural, Box 5.2: Culture has impact on all the following areas as far as health is
and Social Issues in Public
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concerned with
1) Concept of Etiology and Cure (example, considering smallpox/ worship
of goddess Shitala)
2) Environment Protection and Sanitation (Belief that latrines are meant
for city people where there are no open fields, protecting water bodies
as part of religious beliefs)
3) Sexuality and Family Planning
4) Food Habits (vegetarian or non-vegetarian for religious reasons,
considering certain food as hot/cold, fasting on special occasions;
avoidance/consumption of certain food items in illnesses)
5) Mother and Child (prolonged breast feeding, oil bath and sun exposure
to the new born)
6) Personal hygiene (not taking haircut or cutting nails on certain days;
prohibition of haircare on certain days)

Exercise 5.2
Identify the assumptions and practices related to childbirth in your
community? And reflect upon your ideas about the following questions.
At what age is it appropriate for a woman to become mother?
To whom do children belong?
How many children should a family have?
Where should women deliver and who should be involved?
Who should be involved in child rearing thereafter?

Discuss your ideas with your fellow classmates; and analyze how the cultural
background in which you are brought up shaped your ideas/ views on pregnancy
and childbirth which is different from fellow students’ ideas.

5.5 GENDER AND HEALTH

Gender refers to the socially (as well as culturally) defined roles and
responsibilities of men and women. The gender roles are learned through
socialization in different social institutions. Gender inequality is the discrimination
based on the person’s sex in terms of opportunities in the allocation of resources/
benefits or access to the services.
Gender equality means the absence of discrimination, based on a person’s sex,
in opportunities, in the allocation of resources or benefits or in access to services.
Gender equity means fairness and justice in the distribution of benefits and
responsibilities between women and men and often requires women-specific
projects and programmes to end existing inequities.
In many societies, women systematically fail to achieve or fail to use some basic
human rights according to men. Most of the time, women’s health status and
96 problems related to affect the mortality, morbidity and disability rates.
Let us discuss three examples. Influence of Social Factors on
Health and Illness
1) Women’s subordinate status in society means that they are often in violent
relationships that are both physically and emotionally abusive. This affects
their mental health (Sharma and team 2019).
2) Women are twice likely as men to suffer from depression- largely because
of poor self-esteem (Orth and Team 2008).
3) Indian women are prone to be anaemic than their male counterparts this is
mainly because of their poor eating habits (eating all left over) and less
access to nutritious balanced diet (Imrana Qadeer 1998).
There are specific gender barriers that women face while accessing adequate
health care services. They are:
1) Limited control over sex and reproduction: In India traditionally, women
do not have the right to decide when to get married; how many children to
have; spacing between children etc. In these situations, women participation
in decision making are almost absent which consequently have tremendous
impact on women’s body and mind.
2) Time constraints: In the social-cultural contexts of Indian societies, most
often, women accord less time to their health and well-being maintenance
as household work and child rearing get the main priority both for working
or non-working women. Thus diet, personal exercise, meditation or taking
care of own health are mostly the least important aspects of women’s life.
Similarly, seeking health care services (like consulting a doctor) will be
postponed as far as possible till the symptoms become intolerable. Hence
early detection chances of various diseases are poor among women.
3) Lack of support from health care workers: Health care workers lack of
understanding about gender disparities and role gender plays in health ensures
that they do not alert women to their reproductive and sexual rights; these
gender insensitive approaches discourage many women from seeking specific
treatments.

5.5.1 Gender Inequality in Relation to Health

For Indian women the lower status/social value in the household affect their
health outcome. Cultural factors such as lack of female health providers in the
community and health facilities hinder their physical access to hospitals and
nursing homes. Lower literacy rates and reduced access to information makes
the situation worse for women. Social division of labour considers women as
informal care provider at home hence it takes toll on her physical and mental
health. Issues like violence, alcoholism, smoking and life style related problems
are having public health implications and this makes the gender based health
inequality very complicated in Indian Context.
WHO Technical Paper on gender and health (1998) cites the main criticism of
women empowerment policies as being that they continue to define women
themselves as the problem, who need welfare and special treatment if
improvements in their circumstances are to be made. The underlying reasons of
women are largely unexplored and no explanation is offered for the systematic
devaluation of their work or the continuing constraints on their access to resources. 97
Psychological, Behavioural, The following table 5.1 gives an idea about certain problems that Indian women
and Social Issues in Public
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face which has huge impact on their physical and mental health.

Table 5.1: Problems faced by Indian Women impacting their Physical and
Mental Health
Childhood Adolescence and Old Age
Adulthood
• Sex selective • Unwanted • Increase in morbidity /
abortion pregnancies, STDs problems on quality of life
• Female • Sexual harassment/ • Early years health is not
mutilation abuse taken care off; so minor
• Nutrition aliments and health
• Forced Sex
problems conditions like diabeteis
• Smoking and
substanee abuse
(Source: World Health Organisation, 2009)

As per WHO recommendations, women should: (World Health Organisation

2009).
Be able to access information on and be able to choose from a range of
methods to control their fertility (Example: use of services like contraception,
abortion etc.).
Have access to screening of different non communicable diseases including
breast and cervical cancer prevention.
Be able to decide when and with whom to have sexual relationships.
Be able to protect themselves against STI and HIV.
Be protected from harmful traditional practices such as female genital
mutilation (context of African continent).
Be able to access psycho-social counseling as a support in case of domestic
violence, sexual abuse etc.
Exercise 5.3: Reflect upon the following questions and discuss with your
mentor
• In India why sex ratio and child sex ratio becoming more unfavourable
to females over the last few decades?
• How do socioeconomic position, race, and other dimensions of social
status interact with gender to produce variations in gender inequity and
its health consequences?

5.6 BEHAVIOURAL DETERMINANTS OF

HEALTH
Behaviour is associated with health and disease. Health related behaviour of an
individual is very important to ensure good health for him/ her. For example a
person maintaining personal hygiene is health related behaviour and it affects
his/ her health. Behaviour of one individual leaves impact on another person’s
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health (for example impact of passive smoking). Behaviour of groups influence Influence of Social Factors on
Health and Illness
physical and social environment which ultimately has an impact on health. For
example, when a community decides to use car pooling system to travel to
workplace it has an impact on environment pollution and pollution levels come
down which ultimately improves our health.

Health behaviour is any behaviour that has or might have implications for health
of an individual. The actions or reactions of an individual to a situation and this
can be conscious or unconscious, voluntary or involuntary (Warwick Medical
School, 2016).

Gochman (1988) considers that the personal attributes such as beliefs,

expectations, motives, values, perceptions influence a person’s health behaviour.
Personality characteristics, actions and habits also influences a person’s health
behaviour. The Lifestyle Diseases are on rise in India, which has strong connection
with the behavioural determinants of health. Life style includes “the way that
people live reflecting a range of social values, attitudes and activities. This is
constituted of cultural and behavioural patterns and lifelong personal habits (for
example alcoholism) that are developed through the process of socialization.
Life styles are learnt through social interactions and mass media. Many of the
current health problems/ health conditions like cancer, obesity etc., are associated
with life style that the individual follows. We need to focus on the indirect
behaviour route of disease. This is because as per the study by Niaura and
Abrahams (2002). Behaviour contributes to 50% of the leading cause of disease,
which is followed by 20% causes from environment, 20% causes from biology
(genetics) and rest 10% due to poor access to health care services.
Box 5.2: Classification of Behaviour
1) Health Seeking Behaviour and Illness behaviour.
2) Adaptive Behaviour and Maladaptive behaviour.
3) Prevention Behaviour and Detection Behaviour.
4) Public Behaviour and Private behaviour.
5) Service Use Behaviour and Self Care Behaviour.

Individual behaviours vary depending upon three factors as follows:

1) Emotional Dispositions: They are the psychological processes involved in
both the experience and expression.
2) Generalized expectancies: Psychological processes involved in formulating
expectation in relation to the future outcomes (locus of control, self-efficacy
etc.).
3) Explanatory styles: psychological processes involved in explaining the
causes of negative events (optimism, attribution styles etc.).
Key Health Behaviours: Numerous studies have examined the relationship
between health behaviours and health outcomes and have demonstrated their
role in both morbidity and mortality. One of the first such studies identified seven
features of lifestyle which were associated with lower morbidity and higher
subsequent long-term survival: not smoking, moderate alcohol intake, sleeping
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Psychological, Behavioural, 7–8 hour per night, exercising regularly, maintaining a desirable body weight,
and Social Issues in Public
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avoiding snacks, and eating breakfast regularly (Belloc and Breslow 1972).
Smoking is the health behaviour most closely linked with long-term negative
health outcomes. Morbidity and mortality from coronary heart disease (CHD)
are increased among smokers. The impact of diet upon morbidity and mortality
are well established. In the Third World, the problems related to diet and health
is ones of under-nutrition; in the First World, the problems are predominantly
linked to overconsumption of food. The potential health benefits of engaging in
regular exercise include reduced cardiovascular morbidity and mortality, lowered
blood pressure, and the increased metabolism of carbohydrates and fats, as well
as a range of psychological benefits such as improved self-esteem, positive mood
states, reduced life stress and anxiety. Individuals may seek to protect their health
by participating in various screening programmes which attempt to detect disease
at an early, or asymptomatic, stage. Thus, health screening seeking is also a key
aspect of health behavior.

Box 5.3: Case Study

A woman aged 32, mother of three, after her recent childbirth is seen in a
psychiatric clinic because she feels depressed. The patient refuses to take
medicines as she feels people will corner her as “madwoman”. She feels
exhausted with double burden of role of mother and a bank employee. She
is sad about the unkind behaviour of her husband and indifferent attitude
of in-laws. She tells the counsellor that her only comfort is from prayers to
God and “the saints”.
As a part of a multi-disciplinary team in a hospital, how would you help
manage this patient’s depression considering determinants of health
framework? Before helping the woman try to answer the following
questions:
1) What is (are) the possible cause(s) of depression?
2) How do social and psychological factors influence her present state?
3) Can you suggest a plan to the psychiatrist so as to accommodate socio-
cultural influences into treatment?

5.7 ECONOMIC DETERMINANTS OF HEALTH

Different countries/continents of the world are not equally developed; this is
because of the difference in resources, differences in culture, and differences in
political and economic systems of the country. The health of a person is primarily
dependent up the level of socio-economic development. Examples are per capita
income, Gross National Product, employment and housing conditions have
tremendous impact on an individual’s life. The economic progress of many
countries has been a major factor in reducing the mortality, morbidity rates; it
also increased life expectancy, family size reduced drastically and there was a
decrease in the communicable disease rates.

Health is closely linked with the economic system of a country. Often the main
obstacles to the implementation of superior technology in health care in a country
are not technical but are economic and political hurdles.
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The economic system and economic stability of a country decides whether to Influence of Social Factors on
Health and Illness
make health care free for all or it should be charged. What per cent of Gross
Domestic Product is to be spending on public health is also dependent upon the
economic system and economic prospectus of that country. For example in the
USA, health care is predominantly based on health insurance coverage. Hence
health care is too expensive in that country. India, though devote only 1.5% of
GDP into health we have, both government and private health care coexisting
and people are free to choose from these available health care systems. Hence
health care seems to be more accessible and affordable, though technology wise
it is not as superior as in the USA.

5.7.1 Globalization and its Impact on Health

Globalization impacted on the trade relations and movements between countries.
The competition and search for new markets, technological developments and
agreements and cooperation between countries through international organizations
(World Trade Organisation, World Bank) mediations make this process a reality.

Globalization is defined as the processes that are changing the ways in which
people interact across boundaries, notably physical (such as the nation-state),
temporal (such as instantaneous communications) and cognitive (such as cultural
identity). The result is a redefining of human societies across many spheres,
economic, political, cultural, technological and so on (Lee K and his team 2002).

Health achievements are critical international development goal. Globalization

is helping to develop new knowledge and skills; promote policy coherence. This
also contributes to global public goods for health, global health funds, international
standards/ rules are developed for health.
However, some of the specific concerns in a globalized world that has direct/
indirect impact on health are:
1) Food safety
2) Environmental degradation and its impact on health
3) Access to Drugs
4) Health Care Service Availability
5) Emerging issues like Genetically Modified Food’s impact on health
6) Increasing Life Style Disease burden.
Globalization has left negative impact on local knowledge, local resources and
traditional whereby global knowledge, resources exert hegemony in the power
system. The increase in Food chains like MacDonald, KFC and its popularity
over Indian food among adolescents/ urban folks is an example to mention. This
fast food culture leave impact on health and life style diseases like PCOD and
obesity is on increase amongst this age group.

Check Your Progress

3) Discuss the role of cultural determinants on health of a community. Cite
suitable examples.
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4) “Globalization has both positive and negative impact on Health” Justify.

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5.8 SUMMARY
Many factors combine together to affect the health of individuals and
communities. These include determinants of health and his/ her biological/ genetic
characteristics. Whether people are healthy or not, is determined by their
circumstances and environment. The determinants of health include the social
and economic environment, the physical environment, and the person’s individual
characteristics and behaviours.

The context of people’s lives determines their health, and so blaming individuals
for having poor health or crediting them for good health is inappropriate (WHO,
2019). Individuals are unlikely to be able to directly control many of the
determinants of health and hence it is the responsibility of society, state and
health care workers to develop determinants of health to such a level that they
influence people’s lives in a positive way, promoting health and well-being.

5.9 REFERENCES
Dahlgren, G. (1995). European Health Policy Conference: Opportunities for the
Future. Intersectoral Action for Health, 11, Copenhagen.
Govindasamy, P., & Ramesh, B. M. (1997). Maternal Education and the Utilization
of Maternal and Child Health Services in India.
Healthy Campus (2020). Determinants of Health and Evidence-Based Actions,
Ganeva. Accessed as https://www.acha.org/HealthyCampus/HealthyCampus/
Action_Model.aspx on 12th Sep 2019.
Kleinman, A. (2004). Culture and Psychiatric Diagnosis and Treatment. The
Trimbos Lecture.Harvard University.
Kleinman, A., & Benson, P. (2006). Anthropology in the Clinic: The Problem of
Cultural Competency and How to Fix It. PLoS medicine, 3(10), e294.
Lovell, N., &Bibby, J. (2018). What makes us healthy? An Introduction to the
Social Determinants of Health. Health Foundation, New York.
Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady, M., & Geddes,
I. (2010). The Marmot Review: Fair Society, Healthy Lives. The Strategic Review
102 of Health Inequalities in England Post-2010, London.
Procter, S. (2000). Caring for Health. London: Macmillan Press. Influence of Social Factors on
Health and Illness
Smith, R. D., Beaglehole, R., Woodward, D., &Drager, N. (2003). Global Public
Goods for Health: Health Economic and Public Health Perspectives. Oxford
University Press.
K K Sharma et al (2019). Mental health effects of domestic violence against
women in Delhi: A community-based study. Journal of Family Medicine and
Primary Care. Jul; 8 (7): 2522–2527.
Orth, U., Robins, R. W., & Roberts, B. W. (2008). Low self-esteem prospectively
predicts depression in adolescence and young adulthood. Journal of personality
and social psychology, 95(3), 695. DOI: https://doi.org/10.1037/0022-
3514.95.3.695  
Qadeer, Imrana (1998) Reproductive Health: A Public Health Perspective.
Economic and Political Weekly. Oct 10, 1998. 33s(41). p.2675-2684.
World Health Organisation (2009). Women and Health: Today’s Evidence and
Tommorow’s Agenda. Ganeva. Accessed as https://www.who.int/gender/
women_health_report/full_report_20091104_en.pdf on 16th Aug 2019.
Niaura R and Abrahams DB (2002). Smoking cessation: Progress, priorities, and
prospectus. Journal of Consulting and Clinical Psychology. 70(3). 494-509.

5.10 ANSWERS TO CHECK YOUR PROGRESS

1) A Health Disparity is a particular type of health difference that is closely
linked with social, economic and or environmental disadvantage. Health
Outcome is the changes in health that results from measures or specific
health care investments or interventions. Health Inequality is observable
health differences between subgroups within a given population; it can be
measured and monitored. For details refer section 5.2.
2) Social determinants of health can be defined as the conditions in the social,
physical and economic environment in which people are born, live, work
and age and this include access to health care. The eight social determinants
that have impact on Health in Indian Context are: a) Family, Friends and
Communities; b) Money and Resources; c) Housing; d) Education and Skills;
e) Good Work/ Employment; f) Transport; g) Physical Surroundings; h)
Access to Food. For details refer section 5.3.
3) Cultural determinants of health incorporate the cultural aspects that promote
resilience, allow a sense of identity and support good mental and physical
health for individuals, families and communities. For details refer section
5.4.
4) Globalization helps to develop new knowledge and skills; promote policy
coherence and it also contributes to global public goods for health, global
health funds and in developing international standards/rules for health. On
the other hand, Globalization has left negative impact on local knowledge,
local resources and traditional whereby global knowledge, resources exert
hegemony in the power system. For details refer section 5.7.

103
Psychological, Behavioural,
and Social Issues in Public UNIT 6 THEORY AND METHODS OF
Health and Management
PUBLIC HEALTH*

Contents
6.0 Introduction
6.1 Health Behaviour and Classification
6.1.1 Definition
6.1.2 Classification of Health Behaviour
6.1.3 Characteristics of Health Behaviour
6.1.4 The Relationship between Knowledge, Values, Attitudes and Beliefs to Health
Behaviour
6.1.5 Introduction to the Theories and Models of Health Behaviour
6.2 Theories and Models of Individual Health Behaviour
6.2.1 The Health Belief Model
6.2.2 The Theory of Reasoned Action, Theory of Planned Behaviour and the Integrated
Behaviour Model
6.2.3 The Trans-Theoretical Model and Stages of Change
6.3 Theories and Models of Interpersonal Health Behaviour
6.3.1 Social Cognitive Theory (SCT)
6.3.2 Social Networks and Social Support Models
6.3.3 Stress, Coping and Health Behaviour Model
6.4 Community and Group Models of Health Behaviour Change
6.4.1 Diffusion of Innovations
6.5 Selection of Theory to Choose While Planning Health Interventions
6.6 Summary
6.7 References
6.8 Answers to Check Your Progress
Learning Objectives
After reading this Unit, you would be able to:
Discuss the importance of health behaviour theories and interventions to
improve health outcomes of a population;
Define what is a theory, model and identify various broad categorisations of
health behaviour theories;
Discuss and describe nine major theories (by explaining the key constructs,
application, advantages and challenges) that are commonly used in public
health intervention;
Identify and appreciate the relevance of various health behaviour theories
and models to address public health problems; and
Identify the most important considerations in choosing the correct theory to
address a public health problem in a given social context.

* Contributed by Dr. Lekha D Bhat, Department of Epidemiology and Public Health, Central
104 University of Tamilnadu, Neelakudy.
 Theory and Methods of
6.0 INTRODUCTION Public Health

Public health uses various methods and approaches to address public health issues.
Health behaviour modification, health promotion, outbreak investigation, health
research etc., are the important components of public health methods and
strategies.
The unit specifically deals with health behaviour theories and how these theories
can be used to improve health status of a population. The most frequent causes
of death worldwide are chronic non-communicable diseases that include heart
diseases, lung diseases and cancer (Yach et al 2004). Behavioural factors like
tobacco use, diet, alcohol consumption and avoidable injuries are among the
prominent contributors to this mortality (Schroeder 2007). At the same time, in
many parts of the world, including India, infectious diseases continue to pose
grim threats; malaria, diarrheal diseases, Tuberculosis, HIV/AIDS are major
threats to the poorest people around the world (PLoS Medicine Editors 2007).
Both communicable (infectious) and non-communicable disease burden can be
influenced by changing the important and crucial health behaviour of the people.
Positive changes in a person’s health behaviour would help to bring down
substantial suffering, premature mortality and medical costs. Reports and policy
documents of Government of India emphasises on health education and promotion
as one among the strategy to combat health problems. To promote health education
and health promotion, first, we need to develop understanding about health
behaviour, various theories, its applicability and its limitations.

6.1 HEALTH BEHAVIOUR AND CLASSIFICATION

In the simplest sense, health behaviour includes any activity undertaken for the
purpose of preventing disease or detecting disease or for improving health and
well being.

6.1.1 Definition
Gochman (1997) defined health behaviour as those personal attributes such as
beliefs, expectations, motives, values, perceptions and other cognitive elements;
personality characteristics, including affective and emotional states and traits;
and overt behaviour patterns, actions and habits that relate to health maintenance
to health restoration and to health improvement. In the broadest sense health
behaviour refers to the actions of individuals, groups and organisations, as well
as their determinants, correlates and consequences, including social change, policy
development and implementation, improved coping skills and enhanced quality
of life (Parkerson and others 1993).
Box 6.1: Some Examples of Key Health Behaviours
1) A man avoids smoking to bring down risk of lung cancer.
2) An adolescent does daily exercise to remain physically fit.
3) A middle-aged woman following a correct diet to control thyroid.
4) An elderly woman doing appropriate health screening as per the age.
5) A commercial sex worker ensures protected sexual behaviour/acts to avoid
the risk of HIV/AIDS and other sexually transmitted infections.
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Psychological, Behavioural, 6.1.2 Classification of Health Behaviour
and Social Issues in Public
Health and Management
Kasl and Cobb (1966) discuss about three categories of health behaviour. They
are:
a) Preventive health behaviour: Any activity undertaken by an individual who
believes himself (herself) to be healthy, for the purpose of preventing or
detecting an illness in an early state (example — a mother getting her
daughter immunised against cervical cancer as a preventive measure) or a
simpler example of vaccinating children against an array of diseases in
childhood (diphtheria, measles, whooping cough, Tuberculosis, encephalitis,
small pox, etc.) In the present context of COVID 19, to prevent this disease,
we are directed to cover face with mask, maintain social distancing and
wash hands frequently. This is an example of preventive health behaviour.
b) Illness behaviour: Any activity undertaken by an individual who perceives
himself/ herself to be ill, to define the state of health and discover a suitable
remedy (example — a person consulting a doctor with the fever taking it as
a symptom of tuberculosis and acting as per the instructions of doctor to
undergo further diagnosis).
c) Sick role behaviour: Any activity undertaken by an individual who considers
himself/ herself to be ill, for the purpose of getting well (example — a doctor
prescribing drugs and bed rest after being diagnosed with viral fever and
the patient follows it).

Check Your Progress

1) Define Health behaviour. Differentiate between different types of health
behaviours.
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6.1.3 Characteristics of Health Behaviour

Health Behaviour is complex in nature. This is because it is influenced by beliefs,
environment and emotional state/ traits. Further, health behaviour is strongly
influenced by psychological, cultural, social and environmental factors.

The second feature of health behaviour is its dynamic nature. That means, along
with time, place, age, social-physical environment it undergoes changes and
alterations. For example, a person does not smoke when he or she is in home
where he or she will be judged, but smokes when he or she moves out to the city
for a job.
Next, health behaviour is considered as a process, rather than discrete entity or
fixed trait. As time and circumstances changes it will evolve. For example, a
106 person does not become addicted to alcohol suddenly. But it is a gradual process
whereby he or she is introduced to alcohol, slowly increase its consumption due Theory and Methods of
Public Health
to various reasons and gradually reaches the state of addiction.

Finally, any health behaviour is motivated by a stimulus. This means, any health
behaviour, to occur needs a trigger and this trigger leads to its manifestation or
happening.

6.1.4 The Relationship Between Knowledge, Values, Attitudes

and Beliefs to Health Behaviour
As we already discussed, any health behaviour is shaped by four factors-
knowledge, attitudes, beliefs and values. Having appropriate or correct knowledge
is one important prerequisite of developing health behaviour. It refers to the
knowledge people have about health-related issues. Individuals are not always
knowledgeable about the good or bad outcomes of health behaviour. But,
imparting correct knowledge alone will not always guarantee changes in an
individual’s behaviour. This is because change of knowledge into action is
dependent on a wide range of internal and external factors, which includes attitude
beliefs and values.

Values are acquired through socialization and are those emotionally charged
beliefs which make up what a person thinks are important. A belief represents
the information a person has about an object or action. It links the object to some
attribute. Attitudes are value-ladened social judgments which possess a strong
evaluative component. Sometimes, people do not follow a good healthy behaviour
despite having correct knowledge. This knowledge-action gap can be explained
by attitudes and values that he or she upholds.

For example, in India most adults who smoke, are aware of the hazards of smoking,
but continue to smoke. This is because either their attitude, value or belief is
having more influence on the behaviour than the knowledge component.

Implication
When the health intervention strategies are planned the first and foremost thing
is imparting correct knowledge. The intervention should also focus on factors
like beliefs, attitudes and values to bring the desired change in the subject.

6.1.5 Introduction to the Theories and Models of Health

Behaviour
Theories and models of human behaviour originate from all disciplines of social
sciences. Disciplines like Anthropology, Psychology and Sociology offer
considerable insight especially in relation to the factors such as habits and rituals
having an impact on health.

Theories of behaviour change?

A theory is a set of interrelated concepts, definitions and propositions that present
a systematic view of events or situations by specifying relations among variables,
in order to explain and predict the events or situations. The notion of generality
(broad application) is important as is the testability (Kerlinger, 1986).
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Psychological, Behavioural, Theories of behaviour change are comprehensive answers to the question “why
and Social Issues in Public
Health and Management
does behaviour change”. They incorporate a variety of constructs, interventions
and methods to explain relationships or causes that influence behaviour (Michie
et al 2008).

Broad Classification
Different theories of health behaviour emphasise and focus on different aspects.
Based on the way health behaviour is conceptualised or defined the theories can
be broadly divided into three categories.

a) Theories of Individual Behaviour and Behaviour Change

A wide range of health professionals focus all or most of their efforts on
changing the health behaviour of individuals. The primary focus is on the
individual. These theories consider the behaviour as an outcome of
competing influences balanced and decided upon by the individual. ‘Health
Belief Model’, ‘The Theory of Reasoned Action’ and ‘The Theory of Planned
Behaviour’ are some examples of theories that focus on the individual himself
or herself.

b) Theories and Models of Interpersonal Health Behaviour

These models emphasise that the interpersonal interactions influence the
individual’s cognitions, beliefs and behaviours. Other people influence our
behaviour by sharing their thoughts/ ideas/ feelings and by providing
emotional and social support. Social Cognitive Theory, Community level
theories are some popular and widely accepted theories in this category.
Diffusion of Innovation theory is an example of community level theory.
Unlike the theories of individual behaviour, the second category of theories
shifts the focus from individual to the behaviour itself. These theories also
stress upon relationship between behaviour and the individual and social/
physical environment.

c) Theories and Models that Focus on Behaviour as an Outcome

The third set of theories focus on behaviour as an outcome of complex
inter-relationships and shared social practices. In these theories, environment
and object both become active in the production of particular behaviour.
‘Social Practice Theory’ is the most cited example.

6.2 THEORIES AND MODELS OF INDIVIDUAL

HEALTH BEHAVIOUR
During 1940-50s, research focused on how individuals make decisions about
health and what determines health behaviour. In 1950s in the USA American
Psychological Association studied why individuals did or did not participate in
screening programme for TB. This work led to the development of health belief
model. In the last twenty years value expectancy theories were proposed that
include both the Health Belief Model and the theory of Planned Behaviour and
the Theory of reasoned Action. The Trans theoretical Model also known as
Stages of Change model grew initially from the work of Prochaska, Diclemente
and their team of researchers during the period 1970-90.
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6.2.1 The Health Belief Model Theory and Methods of
Public Health

Health Belief Model explains people’s beliefs about the severity of a disease and
their susceptibility to it. This belief will influence their willingness to take a
preventive action. Example: a group of social psychologists trying to explain
why people do not use health services like immunisation though it is provided
free of cost and is accessible. Health Belief model, proposed by Rosenstock and
Becker in 1974, considers behaviour as an outcome of perceived susceptibility,
perceived severity, perceived barriers, perceived benefits, cues to action and self-
efficacy. Box 6.2 explains these constructs in detail and Figure 6.1 narrates the
relationship between these constructs. The major advantage of this theory is that
it is amongst the oldest theories that helped to understand health behaviour. Its
simplicity enabled researchers to identify the reasons behind many health
problems like why people do not adhere or accept public health programmes.

Box 6. 2: Major Constructs of Health Belief Model

Perceived susceptibility: The degree to which a person feels at the risk of
health problem.
Perceived Severity: The degree to which a person’s belief that the
consequences of health loss will be severe in terms of both health and societal
consequences (like loss of job etc.).
Perceived susceptibility together with the perceived severity is called as
Perceived Threat.
Perceived Benefits: The person’s beliefs regarding the benefits provided
he or she prevent or treat the disease on time.
Perceived Barriers: The negative aspects of a health action
Self-Efficacy: The conviction that one can successfully execute the behaviour
required to produce the outcome (Bandura 1997)
Cues to Action: This triggers the actual adoption of a certain (preventive)
behaviour. This might be an individual or an incident.

Fig. 6. 1: Depicting the relationship between various constructs of health belief model
(Source: Becker, M. H. & Maiman, L. A., (1975). Socio-behavioral determinants of compliance
with health and medical care recommendations. Medical Care, 134(1), 10-24. Figure 1, p. 12. 109
Psychological, Behavioural, Box 6.3: Case Study
and Social Issues in Public
Health and Management
Health Belief Model (HBM) in Breast Cancer Screening: HBM predicts
that woman will be more likely to adhere to screening tests like
mammography, if they feel perceived threat to breast cancer as high and
perceived barriers (like expenditure, accessibility of service, fear) as low.
Perceived benefits (like continuing in good health, advantages of early
detection in increasing recovery chances) etc., should also be clearly
explained. Self-efficacy of women also plays a major role in deciding the
behaviour/ action. Cues to action can be a mass campaign exposure where
women became suddenly conscious about the need to undergo a screening.
When the perceived benefits are more than the perceived barriers the person
will take the step and seek a mammography/ screening test.
Take the example of COVID 19. When the cases were initially reported
from China the perceived threat in India was low; so, people did not take
preventive steps like covering face with mask. However, as cases are reported
in India or in own state/district people become more cautious as perceived
risk is more. Government has announced that all COVID infected cases
will be treated by Government hospitals; this is to bring down the perceived
barrier level to low so that infected person will seek treatment and will
cooperate to break the chain.

Researchers cite two major limitations about HBM which are: 1) This model is
based on cognitive component and it completely ignores the emotional component
of behaviour, 2) There is no major research done about “cues to action” construct
and it’s role is not clearly explored.
Check Your Progress
2) Discuss Health Belief Model and its applicability in altering health
behaviour of alcohol addict person.
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6.2.2 The Theory of Reasoned Action, Theory of Planned

Behaviour and the Integrated Behaviour Model
The Theory of planned behaviour is the most widely cited and applied behaviour
theory in the field of public health. It adopts a cognitive approach to explain
behaviour that centres on individual attitudes and beliefs. The Theory of Planned
Behaviour (TPB) is an extension of the Theory of Reasoned Action (TRA) which
includes an additional construct called ‘perceived control over the performance
of behaviour’. The Theory of Planned Behaviour was proposed by Icek Ajzen in
1985) and later in 1986 Icek Ajzen and Madden refined it.

110
In recent years a group of psychologists led by Fishbein have further expanded Theory and Methods of
Public Health
TRA and TPB to include more components from behaviour theories and have
proposed the use of an Integrated Behaviour Model (IBM).
Theory of reasoned Action and the Theory of Planned Behaviour both argue that
the best predictor of behaviour is behavioural intention. This behavioural intention
is shaped by a) attitude towards the behaviour, and b) social-normative
perceptions. TRA used these two constructs and later TPB added a third set of
factors affecting intention as –perceived behavioural control. This is the perceived
ease or difficulty with which the individual will be able to perform or carry out
the behaviour.
How attitude towards behaviour is shaped? It is determined by the individual’s
beliefs about outcomes or attributes of performing behaviour. The health decisions
are influenced by a person’s view about that action and whether the significant
others (like family and friends) would approve it.
These models are very useful to study why some people change health behaviour
after health education programmes and why some others do not change. Figure
6.2 represents TRA and TPB thematically.
Key Constructs are:
The individual’s attitude, or personal opinion, on whether a specific behaviour
is good or bad, positive or negative, favourable or otherwise. The attitude must
be specific, since this specificity will allow the prediction in the resulting
behaviour.

*Note: Light area shows the TRA and the Entire figure shows TPB
Fig. 6.2: Representing TRA and TPB
(Source: Montano& Kazprzyk TRA , TPB and Integrated Model in the Book Health Behaviour
and Health Education Theory, Research and Practice, Ed Glanz.K ,Rimer , B. And Viswanath K,
Wiley Imprint , 2008,San Fransisco, pp.70 ) 111
Psychological, Behavioural, The prevailing subjective norms, or the social pressure arising from other people’s
and Social Issues in Public
Health and Management
expectations, as seen from the individual’s point of view. This, in turn, has two
components:
The individual’s normative beliefs, or what he perceives to be what other people
want or expect; and
The individual’s motivation, or need, to comply with what other people want or
expect.
The perceived behavioural control of the individual, or his perception of his ability
to perform a specific behaviour.
An Integrated Behavioural Model
This model integrates the constructs of the TRA and the TPB along with constructs
from some other behavioural theories. Apart from the most important component
of ‘behavioural intention’, the integrated model points out four other components
that directly affect behaviour.
They are listed as follows:
1) Even if a person has a strong behavioural intention, he or she needs
knowledge and skills to carry out that behaviour.
2) There should be no or few environment constraints.
3) Behaviour should be salient to a person.
4) Experience of performing the behaviour may make it habitual so that the
intention becomes less important.
Box 6.4: Case Study — Integrated Behavioural Model
If a woman has a strong intention to get a mammogram, it is important to
ensure that a) she has sufficient knowledge about health care system, b) No
environment constraints like lack of transportation or limited clinic hours
that prevent her from getting the tests done, c) for an action that is carried
out at longer interval (example mammography is generally performed once
in a year for screening purpose) the behaviour must also be made salient
(cued) so that the woman will remember to carry out her behaviour intention.

6.2.3 The Trans-Theoretical Model and Stages of Change

The Trans theoretical model also known as the Stages of Change (SoC) Model
was first developed by James O Prochaska in 1978. This model was first developed
based on health behaviour studies on smoking.
Assumptions:
1) Stages of behaviour Change: It’s a cognitive model of health behaviour that
divides individual between first categories that represent different “levels
of motivational readiness”. The behaviour change is a process that unfolds
over time, with progress through a series of six stages. These six stages are
(i) Pre-contemplation, (ii) Contemplation, (iii) Preparation, (iv) Action, (v)
Maintenance, and (vi) Termination.
2) The Process of Change is important in SoC model. These are the covert and
112 overt activities people use to progress through stages. (i) Consciousness
 raising, (ii) Dramatic relief (like media campaigning), (iii) Self-revaluation, Theory and Methods of
Public Health
(iv) Self-liberation, (v) Stimulus control are some of the important process
of change.
3) Decisional Balance: An individual weigh the pros and cons of change
systematically and logically before initiating a behaviour change. Self-
efficacy is also the factor that decides the behaviour change. It is the situation
specific confidence that the person has that he or she can cope with the
situation without any relapse.
4) The individuals at the same stage should face similar problems and barriers
and thus can be helped by the same type of intervention.
5) The movement or transition between these stages is driven by two key factors
— self-efficacy and decisional balance.
6) Relapse: Moving backwards through the stages is common and acceptable.

The Trans-Theoretical Model is showing good results when applied for

interventions like substance abuse control programmes. Large number of TTM
related intervention studies have focused on smoking cessation. The major
limitations of this model is it’s complete focus on the self and misses the structural,
economic, social and environment factors which affect an individual’s ability to
change the behaviour. Another limitation is that the model has not shown
promising results with children and adolescents because culture specific aspects
are not acknowledged/ taken care of.

Box 6.5: Stages of Behavioural Changes-Trans Theoretical Model

Precontemplation: It is the stage in which the person does not intend to
take any action in the near term, usually the next six months.
Contemplation: The person intends to take action soon usually within
next six months.
Perception: The person intends to take action soon usually within next
one months.
Action: The person has taken specific, overt modifications in their lifestyles
within the past six months.
Maintenance: It is the stage in which the person has made specific overt
modifications in their lifestyle and are working to prevent relapse.
Termination: In this stage the person has zero temptation to relapse and
has 100% self-confidence about this.

Box 6.6: Case Study TTM

Let us apply TTM to develop an intervention for an entire high-risk group
for cardio-vascular diseases like smokers. The intervention should identify
where the person presently located in the stages of behaviour. The programme
should help the participant to progress through the stages of change in a
systematic manner. The transition from one stage to another should be
progressive and smooth. Relapse to previous stage is commonly seen and
this should be accepted. A matching process of change should be selected
depending upon everyone’s interest.
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Psychological, Behavioural,
and Social Issues in Public 6.3 THEORIES AND MODELS OF
Health and Management
INTERPERSONAL HEALTH BEHAVIOUR
These models in general emphasize that interpersonal relationships and
interactions influence the individual’s cognitions, beliefs and in turn decide
behaviour. Contrary to the previous theories (discussed in Section 3) the focus
shifted from individual to behaviour itself and the influence of interpersonal
relations on the behaviour. We will discuss three important theories here:
1) Social Cognitive Theory (SCT)
2) Social Networks and Social Support Model
3) Stress, Coping and Health Behaviour Model

6.3.1 Social Cognitive Theory (SCT)

This theory was proposed by Albert Bandura 1960s and developed as Social
Cognitive Theory in 1986 and the key term proposed is reciprocal determinism.
The theory argues that, both individuals and their environment interact and
influence each other which he termed as reciprocal determinism. This results in
changes both at individual and social level. SCT was first known as social learning
theory (SLT), later it was renamed as SCT when concepts from cognitive
psychology were integrated to accommodate the growing understanding about
human information processing. With further developments, SCT has embraced
concepts from sociology and political science.
This theory used the following five constructs:
1) Psychological determinants of behaviour: This includes outcome
expectations and self-efficacy. People act (or behave) in a way to maximise
benefits and minimise costs. Self-efficacy is the person’s belief about his/
her capacity to influence the events that affect his or her life.
2) Observational Learning: This is the capacity of a person to observe something
and learn-repeat that behaviour. For example, access to family peer and
media models determines what behaviour a person is able to observe and
learn.
3) Environmental Determinants of Behaviour: No amount of observational
learning will lead to behaviour change unless the observers’ social and
physical environment support the new behaviour.
4) Self-Regulation: SCT emphasises the human capacity to endure short-term
negative outcomes in anticipation of important long-term positive outcomes.
Self-regulation does not depend on a person’s willpower but instead on his
or her acquisition of concrete skills for managing himself/ herself.
5) Moral Disengagement: When people learn moral standards for self-
regulation this will lead them to avoid violence and cruelty to others.

Application
Social Cognitive Theory provides a comprehensive and well supported conceptual
framework to understand many health behaviours and how to alter health
114
behaviours. SCT based intervention focuses on changing behaviour by increasing Theory and Methods of
Public Health
self-efficacy, social modelling, verbal persuasion etc., are the ways in which
self-efficacy can be improved. While designing intervention programmes
importance is given to the aspects like self-monitoring, self-reward, goal setting,
feedback and social support. The advantage is that SCT is very broad and
ambitious in that it seeks to provide explanations for virtually all human
phenomena. This, broad nature of theory also brings in the limitation that since it
is too broad it has not been tested comprehensively. Another problem with SCT
based interventions is the constructs are difficult to measure and manipulate.

6.3.2 Social Networks and Social Support Models

The social network and social support-based models assume that social
relationships have powerful influence on health behaviours, health status and
health decision-making.

Social network refers to the web of social relationships that surround individuals.
Social networks give rise to various social functions like social influence, social
control, social companionship and most importantly social support. These social
networks may or may not provide social support. Social networks, through social
support provide emotional support, instrumental support, information support
and appraisal support.

By 1990s, a new concept, social capital has been introduced. Jane Jacobs used
this term in her writings to mention about value of networks. In the late 1990s
the concept gained popularity, serving as the focus of a World Bank research
programme. It refers to certain resources and norms that arise from social
networks. Social support is provided consciously. It is always intended to be
helpful thus distinguishing it from intentional negative interactions. Enhancing
existing social linkages (like training members for skill development), developing
new social network linkages (like developing self-help groups, peer groups) and
enhancing networks using indigenous natural helpers and community health
workers are the health intervention examples based on social network and support
model.

Example: There is research evidence that shows, negative interpersonal

interactions such as those characterised by mistrust, hassles, criticisms and
domination are more strongly related to such factors as negative mood and
depression. It also accelerates risky health behaviour like substance abuse.

Check Your Progress

3) Examine the relevance of social network and social support model in
altering adolescents’ behaviour.
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Psychological, Behavioural, 6.3.3 Stress, Coping and Health Behaviour Model
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Health and Management
This model considers stress and the coping skill as the most important
determinants of health behaviour. Stress may have a negative physiological effect
on health or contribute indirectly to behaviour that are not conducive to good
health. For example, smoking might be a way for a person to cope with stress.
Interpersonal interactions and communications play a crucial role in helping
people copes with stress by providing social support potentially mitigating the
impact of stress or providing ways to cope with it.

Transactional Model of stress and coping is a framework for evaluating process

of coping with stressful events. Stressful experiences are constructed as person-
environment transactions. When faced with a stressor, a person evaluates potential
threats or harms (this is termed as primary appraisal) as well as his or her ability
to alter the situation and manage negative emotional reactions (secondary
appraisal). Actual coping efforts aimed at problem management and emotional
regulation, give rise to outcomes of the coping process. Figure 6.3 represents the
transactional model of stress and coping in more detail.

Stressor

Fig. 6.3: Represents the Transactional Model of Stress and Coping

(Source: Prochaska, J., Redding, C and Evers, K. The Trans theoretical Model and Stages of
Change, in the Book Health Behaviour and Health Education Theory, Research and Practice, Ed
Glanz. K, Rimer, B. And Viswanath K, Wiley Imprint, 2008, San Fransisco, pp.112)

116
Applicability of transactional model: The transactional model has been applied Theory and Methods of
Public Health
to public health issues such as the effect of racism on health disparities. Studies
examining relationship between perceived racism and hypertension have found
positive associations. A variety of techniques to manage stress, improve coping
and reduce deleterious effects of stressors on health have been developed.
Relaxation strategies, cognitive behavioural stress management etc., are the
approaches that are developed from transactional model.

6.4 COMMUNITY AND GROUP MODELS OF

HEALTH BEHAVIOUR CHANGE
Groups, organisations and large-scale organisations and communities play a vital
role to health improvement. The collective well-being of the communities can
be fostered by creating structures and policies that support healthy lifestyles and
by reducing or eliminating health hazards. Health concerns like substance abuse,
HIV/AIDS, obesity can’t be addressed adequately through individual or small
group interventions alone. Rather health professionals need to review and health
behaviour in the context of large communities and social institutions.

Improving health through ‘Community Organisation and Community Building’,

and ‘Diffusion of Innovations’ are the main two models in this category.

6.4.1 Diffusion of Innovations

The development of diffusion studies has emerged from works of Rogers (1995)
later developed by Wejnert (2002).
Key concepts of the Diffusion of Innovations are the following:
1) Diffusion is defined as the overall spread of an innovation. The process by
which an innovation is communicated through certain channels over the
time.
2) Five stages of Diffusion. Any innovation is diffused into a society through
five stages viz. Adoption, Implementation, maintenance, sustainability and
institutionalisation.
3) The following characteristics of innovations affect diffusion: Relative
Advantage, Compatibility, Complexity, Triability, Observability.
4) Any community has five type of people viz. Innovators, early adopters,
early majority, late majority, and laggards. The adoption of ideas and its
diffusion in the person is different in the community depending upon which
category he or she falls.

Check Your Progress

4) What are the different stages that diffusion theory proposes? Discuss.
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117
Psychological, Behavioural, Limitation of the diffusion theory is that it has stressed a lot on pro-innovation
and Social Issues in Public
Health and Management
orientation. Individual blame bias is another problem of this theory where the
individual is held responsible for the problem rather than society or community.
The application level of the theory is that when public health professionals plan
for some interventions, where the person is located in these five stages has to be
located. Similarly, for community level health interventions we need to identify
the innovators and early adapters and channelize the communication through
them.
Box 6.7: Five Types of People in a Community
Innovators: Introduction of a new idea is always picked up first by this
group. They have features like independent, adventure and risk taking. They
will come forward to accept any new health behaviour that public health
professional introduces.
Early Adopters: They are very interested in the innovation, but they are
not the first to sign up. They wait until the innovators are already involved
to make sure the innovation is useful. They will be mostly respected people
of that community.
Early Majority: They are interested in the innovation but will need external
motivation to become involved.
Late Majority: are next and it will take more time to get them involved for
they are skeptical and will not adopt an innovation until most people in the
community have done so.
Laggards: are not very interested in innovation and would be the last to
become involved. They are very traditional and are suspicious of
innovations.
Five stages of diffusion of any idea related to health:
Adoption: Uptake of the programme or innovation by the target audience.
Implementation: The active, planned efforts to implement an innovation
within a defined setting.
Maintenance: The on-going use of an innovation over time.
Sustainability: The degree to which an innovation or programmes of change
is continued.
Institutionalisation: Incorporation of the programme into the routines of
an organisation or broader policy and legislation.

6.5 SELECTION OF THEORY TO CHOOSE WHILE

PLANNING HEALTH INTERVENTIONS
After learning about various theories and models of health interventions, you
might be having this question in mind “How to pick one theory over another”?
The simple answer to this question is that there is no superior or inferior theory.
Some theories are intuitively appealing than others, matching people’s naïve
ideas of the motivators of health behaviour. Other theories are quite complex
and are applicable to specifically health domain. In the absence of a good research-
118 based evidence on which theory is better, researcher and practitioners should
select theories based on their assessment, merits and appropriateness of the Theory and Methods of
Public Health
theories to the cultural and social context of the targeted group/ community. The
readers should consider integrating theories from more than one level and using
theories to design and evaluate (and also understand) health behaviour
interventions.

6.6 SUMMARY
Theories that emphasize individual health behaviour have an important role to
play in our understanding of how to improve human health. One must nearly
always consider the social and community context to understand where beliefs
come from and to find ways to change both beliefs and external constraints.
Health professionals to consider the nature of the health problem or condition on
which they wish to intervene and select the appropriate theory, sometimes
employing multiple theories to permit intervention at multiple levels.

6.7 REFERENCES
Becker, M. H., & Maiman, L. A. (1975). Socio behavioral Determinants of
Compliance with Health and Medical Care Recommendations. Medical Care,
10-24.

Gochman, D. S. (1997). “Health Behavior Research: Definitions and Diversity.”

In D. S. Gochman (ed.), Handbook of Health Behavior Research, Vol. I. Personal
and Social Determinants. New York: Plenum Press.

Kasl, S. V., & Cobb, S. (1966). Health behavior, illness behavior and sick role
behavior: I. Health and illness behavior. Archives of Environmental Health: An
International Journal, 12(2), 246-266.

Kerlinger, F. N. (1986). Foundations of Behavioral Research. (3rd ed.) New

York: Holt, Rinehart & Winston.

Montano, D. E. & Kazprzyk, D. (2008). “TRA, TPB and Integrated Model” In

Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.). Health Behaviour and Health
Education Theory, Research and Practice, (pp. 70). San Francisco: Wiley Imprint.

Parkerson, G. R., Connis, R. T., Broadhead, W. E., Patrick, D. L., Taylor, T. R., &
Tse, C. K. J. (1993). Disease-specific versus generic measurement of health-
related quality of life in insulin-dependent diabetic patients. Medical care.

PLoS Medicine Editors. (2007). Thirty Ways to Improve the Health of the World’s
Poorest People.

Prochaska, J. O., Redding, C. A., & Evers, K. E. (2015). The Transtheoretical

Model and Stages of change. In Glanz, K., Rimer, B. K., & Viswanath, K. (Eds.).
Health Behaviour and Health Education Theory, Research and Practice, (pp.
125-148). San Francisco: Wiley Imprint.

Rogers Everett, M. (1995). Diffusion of innovations (4th ed.). New York: Free
Press.
119
Psychological, Behavioural, Schroeder, S. A. (2007). We can do better-improving the health of the American
and Social Issues in Public
Health and Management
people. New England Journal of Medicine, 357(12), 1221-1228.

Wejnert, B. (2002). Integrating models of diffusion of innovations: A conceptual

framework. Annual review of sociology, 28(1), 297-326.

Yach, D., Hawkes, C., Gould, C. L., & Hofman, K. J. (2004). The global burden
of chronic diseases: overcoming impediments to prevention and control. Journal
of the American Medical Association, 291(21), 2616-2622.

6.8 ANSWERS TO CHECK YOUR PROGRESS

1) Health behaviour refers to the actions of individuals, groups and
organisations, as well as their determinants, correlates and consequences,
including social change, policy development and implementation, improved
coping skills and enhanced quality of life. For more details refer sub-section
6.1.2.
2) Health belief model explains people’s beliefs about the severity of a disease
and their susceptibility to it. This belief will influence their willingness to
take a prevention action. For more details refer sub-section 6.2.1.
3) Social networks, through social support provide emotional support,
instrumental support, information support and appraisal support. For more
details refer sub-section 6.3.2.
4) Any innovation is diffused into a society through five stages viz. Adoption,
Implementation, maintenance, sustainability and institutionalisation. For
more details refer sub-section 6.4.1.

120
 Theory and Methods of
UNIT 7 MANAGEMENT OF HEALTH CARE Public Health

PROGRAMMES BY INDIAN
GOVERNMENT AND NGO’S*

Contents
7.0 Introduction: Health Care System in India
7.1 Health Care: Basic Concepts
7.1.1 Health Care and Public Health
7.1.2 Main Characteristics of Health Care
7.1.3 Levels of Health Care
7.1.4 Components of a Just and Efficient Health Care System
7.2 India’s Health Care System: At a Glance
7.3 National Health Programmes in India
7.3.1 National Vector Borne Disease Control Programme (NVBDCP)
7.3.2 National Leprosy Eradication Programme
7.3.3 Revised National Tuberculosis Control Programme (RNTCP)
7.3.4 National AIDS Control Programme
7.3.5 Universal Immunisation Programme
7.3.6 National Programme for Prevention and Control of Cancer, Diabetes,
Cardiovascular Diseases and Stroke (NPCDCS)
7.3.7 National Mental Health Programme
7.3.8 Reproductive, Maternal, Neonatal, Child Health and Adolescents Programme
(RMNCH +A)
7.3.9 National Health Mission (NHM)
7.4 Role of Non-Governmental Organisations in Health Sector of India
7.4.1 Understanding of NGOs
7.4.2 Functions of NGOs in the Health System
7.4.3 The Health Activities of NGOs in India
7.4.4 NGOs and Health Sector: Future
7.5 Problems, Achievements and Prospects of Indian Health System
7.6 Summary
7.7 References
7.8 Answers to Check Your Progress
Learning Objectives
After going through this Unit, you would be able to:
Understand about health care delivery in India — its structure, organisation
and functions;
Discuss various health programmes and policies implemented by the
Government of India, with focus on the post-independence era;
Understand the role of NGOs in the health sector in Indian context; and
Summarise India’s key achievements and major challenges in Public Health.

* Contributed by Dr. Lekha D Bhat, Department of Epidemiology and Public Health, Central
University of Tamilnadu, Neelakudy. 121
Psychological, Behavioural,
and Social Issues in Public 7.0 INTRODUCTION: HEALTH CARE SYSTEM IN
Health and Management
INDIA
Health is clearly not the mere absence of disease. Good health condition ensures
that the person is free from any disease and this gives him/ her ability to work
and realise his/ her full potential. Good health confers on a person or groups’ the
freedom from illness and the ability to realise one’s full potential. Health is best
understood as the indispensable basis for defining a person’s sense of well-being.
In ensuring good health, a country’s health care plays a major role. Health care
covers not merely medical care; all aspects like preventive and curative and
rehabilitative care are given due importance. It includes both public and private
sector health care institutions; health promotion-prevention of disease- curative-
rehabilitative elements is given representation in an ideal health care system.

Under the Indian Constitution, health is a state subject. Each state therefore has
its own health care delivery system in which both public and private actors operate.
While states are responsible for the functioning of their respective health care
systems, certain responsibilities fall on the federal (central) government, namely
policy making, planning, guiding, evaluating, assessing, assisting to the respective
state governments and providing funding to implement the national health
programmes. India’s health care system is characterised by multiple systems of
medicine which include not only Allopathy (western medicine) but also Ayurveda,
Sidhha, Unani, Yoga and Sowa Rigpa type of medical systems. In India, apart
from various national programmes targeting different diseases, we have both
public (Government) owned hospitals and private hospitals and clinics.

Check Your Progress

1) Discuss India’s health care system with special emphasis to its structure.
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7.1 HEALTH CARE: BASIC CONCEPTS

Health care is defined as a multitude of services rendered to individuals, families
or communities by the agency of the health services or professions, for the purpose
of promoting, maintaining, monitoring or restoring health (Park and Park, 2015).

7.1.1 Health Care and Public Health

Health care services are the set of institutions with adequate infrastructure; work
force and funding that ensure the delivery of public health facilities/programmes
in the country.
According to Monica Das Gupta (2006) public health services are conceptually
122 different from medical services. They have a key goal in reducing a population’s
exposure to diseases; for example, assuring food safety, vector control, waste Management of Health Care
Programmes by Indian
management, health education etc., are important elements of health care along Government and NGO’s
with the medical (curative) oriented facilities. Public health services produce
“public goods” of incalculable benefit for facilitating economic growth and
poverty reduction.

7.1.2 Main Characteristics of Health Care

The main characteristics of health care can be summarised as follows:
Appropriateness (relevance) i.e. whether the service is needed at all in
relation to essential human needs.
Comprehensiveness i.e. whether there is an optimum mix of preventive,
curative and promotional services.
Adequacy i.e. if the service is proportionate to the requirements like doctor-
patient ratio.
Availability i.e. ratio between the population and the health facility
Accessibility i.e. geographic, economic and cultural accessibility
Affordability i.e. expenses involved in availing the health care services.

7.1.3 Levels of Health Care

Indian Health Care Services are usually organised at three levels as follows:

Primary Health Care: This is the first level of contact between the individual/
community and the health system, where “essential” health care is provided. A
majority of prevailing health complaints, minor ailments, and common infections
along with preventive services can be satisfactorily dealt with at this level. In
India, Village Health Guides, ASHA Workers followed by the Sub-centres and
the Primary Health Centres together constitute the primary level health care
providers. Sub Centres and Primary Health Centres also provide reproductive
health/ family planning services along with immunisation for children. Most of
the vertical programmes use this level as the base of service provision.

In a PHC, a doctor along with ANM will be posted and they can handle a normal
delivery; whereas the cases that require Caesarean section will be referred to
CHC or secondary health care facility like district hospital where an Obstetrics
and Gynaecology specialist is posted and other facilities like blood transfusion
is available.

Secondary Health Care: At this level, more complex health problems are dealt
with that are not effectively dealt at the primary level. It is essentially curative
service oriented. It is provided by the district hospitals and the community health
centres. They are also the first referral level in the health system. Facilities like
X-Ray, CT/ MRI Scan, Blood bank etc., will be available and specialist doctors
will be posted here. Various departments like, Obstetrics and Gynaecology,
Ophthalmology, ENT, Oncology etc., will be functioning in these hospitals.

Tertiary Health Care: This level offers specialist and super specialist care. These
institutions also do planning, developing managerial skills and teaching/ training
the medical/ paramedical staff. Medical colleges and super speciality hospitals 123
Psychological, Behavioural, are included in this category. They are generally referral hospitals where highly
and Social Issues in Public
Health and Management
specialised treatments are available.

7.1.4 Components of a Just and Efficient Health Care System

Having a good network of health care is not adequate; but the system should be
‘Just and Efficient’ so that the services reach to the most marginalised and poor
people of the society.

Understanding health as a human right creates a legal obligation on states to

ensure access to timely, acceptable, and affordable health care of appropriate
quality as well as to providing for the underlying determinants of health, such as
safe and potable water, sanitation, food, housing, health-related information and
education, and gender equality. The right to health must be enjoyed without
discrimination on the grounds of race, age, ethnicity or any other status.

Right to Health and Components

The right to health (Article 12) was defined in General Comment 14 of the
Committee on Economic, Social and Cultural Rights – a committee of Independent
Experts, responsible for overseeing adherence to the Covenant. The following
are the components of Right to Health.
1) Availability: The health care services are available to all irrespective of the
ability to pay, caste, class, religion, gender etc.
2) Accessibility: The health care services are physically and economically
accessible to all. The accessibility to information is also part of accessibility.
3) Acceptability: Relates to respect for medical ethics, culturally appropriate,
and sensitivity to gender. Acceptability requires that health facilities, goods,
services and programmes are people-centred and cater for the specific needs
of diverse population groups and in accordance with international standards
of medical ethics for confidentiality and informed consent.
4) Quality: The services provided must be scientifically and internationally
accepted. Safety, effectiveness, efficiency and timely nature of services are
covered in this aspect.

According to Srinivasan (2006) the following four criteria are important to

consider/evaluate a health care system as Just and Efficient.
a) Universal access, access to an adequate level and access without excessive
burden.
b) Fair distribution of financial costs for access and a constant search for
improvement to a more efficient system.
c) Training providers for competence, empathy, accountability, cost-effective
use of resources etc.
d) Pay special attention to the vulnerable groups such as disabled, aged and
children.
Frieden Thomas (2014) in his work lists six components that will ensure efficiency
and success in public health care. They are:
124
a) Innovation to develop the evidence base for action. Management of Health Care
Programmes by Indian
b) A technical package of a limited number of high priorities, evidence–based Government and NGO’s
interventions that together will have a major impact.
c) Effective performance management, especially through rigorous, real time
monitoring and evaluation.
d) Partnerships and Coalitions.
e) Communication of accurate and timely information to the health community
and civil society.
f) Political commitment to obtain resources and support for effective action.

Check Your Progress

2) List out important components of a Just and Efficient Health Care System.
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7.2 INDIA’S HEALTH CARE SYSTEM: AT A

GLANCE
India’s health care system can be classified into many categories based on various
parameters.
Depending upon the function it addresses the Health Care system in India consists
of four components. They are:
Primary, secondary, tertiary institutions manned by medical and para-medical
personnel;
Medical colleges and para-professional training institutions to train the
needed manpower and give the required academic input;
Programme managers, managing on-going programmes at central, state and
district levels; and
Health management information system consisting of a two-way system of
data collection, collation, analysis and response.
Depending upon the source of funds for operation and health resources
(technology/work force) used, health care system is divided into five sectors as
follows:
Public Health Sector — Include Primary health care (Sub-Centers and Primary
Health Centres), Hospitals (Community Health Centres, Rural Hospitals, district
Hospitals, medical colleges, specialist hospitals), health insurance schemes (ESI,
Central Government Health Scheme) and other agencies health services (like
defence hospitals, railway hospitals). Private Health Sector — This includes
private hospitals, nursing homes, dispensaries, clinics etc.
125
Psychological, Behavioural, Voluntary Health Agencies – which are not-for-profit organisations working in
and Social Issues in Public
Health and Management
the field of health Depending Upon Type of Medical Systems we have
Allopathy and AYUSH services are two broad categories. Indigenous System
of Medicine consists of Ayurveda, Yoga, Unani, Siddha, Homeopathy, Sowa-
Rigpa shortly termed as AYUSH. This has a separate ministry to provide
fund, support Research and Development. Public hospitals, clinics and
private hospitals/ clinics form part of this network.
Various National Health Programmes
National Health Programmes-they are vertical programmes, planned,
developed, implemented and funded by the federal (central) government to
combat particular diseases like malaria/leprosy etc. We will be studying
more about these national programmes in detail in the following sections.

a) Public Sector Health Care in India

Primary Health Care in India forms the backbone of the health system,
especially in rural areas. At village level, it consists of Village Health Guides,
trained Dais and Anganwadi workers (From Integrated Child Development
Scheme). This is supported and supervised/coordinated by the Sub-centres
and the Primary Health Care Centres.
Accredited Social Health Activist (ASHA) is a woman who is selected from
the village itself and she is trained to work as interface between the
community and the public health system. ASHA will be a health activist in
the community who will create awareness on health and its social
determinants and mobilise the community towards local health planning
and increased utilisation and accountability of the existing health services.
She would be a promoter of good health practices and will also provide a
minimum package of curative care as appropriate and feasible for that level
and make timely referrals.
Village Health Guide: is a person who has an aptitude for social service and
he or she is not a full-time government employee. He or she serves as a link
between the community and the government health infrastructure. He or
she is selected at the village level (1 for each 1000 rural population) and
undergoes training in the nearest Primary Health Care Centre for three
months. Primary responsibility of village health guide includes, helping the
community with minor medical problems, ensure first aid, maternal-child
health care, health education and sanitation.
Trained Birth attendants: Woman from village is selected and she undergoes
a training of thirty working days at the Primary health care centre or maternal
and child health centre. After the training she is provided with delivery kits,
her main responsibility is to ensure safe delivery and promote small family
norm.
Anganwadi Worker: Under the Integrated Child Development Scheme
(ICDS) there is one Anganwadi worker employed for 1000 population. She
is trained in various aspects of health, nutrition, primary education etc. and
she plays a pivotal role in ensuring health access and health/ nutritional/
health supplements benefit to pregnant women, 0-6 year children, lactating
126 mothers and adolescents.
 Subcentre (SC): Government of India approves one SC for 5000 population Management of Health Care
Programmes by Indian
in general and in hilly / tribal areas it is one per 3000 population. Two multi- Government and NGO’s
purpose workers (shortly called as MPW — one male and one female) are
employed here. They are responsible for all health service and health
programme implementation in that area. Generally, the male MPW looks
after programmes like malaria, Tuberculosis etc., whereas the female MPW
will look after maternal and child health/ family planning services.
Primary Health Centre (PHC): One PHC is approved for 30000 population
in rural/ plains whereas it is one PHC for every 20000 population in tribal/
hilly areas. The major functions of PHC includes health education, promotion
of nutrition, sanitation, immunisation, MCH care, appropriate treatment of
common diseases/ injuries, essential drug supply, implementing and
supervising various national health programmes and referral services. PHC
will have medical officers, staff nurse, nursing assistants, pharmacists and
other supporting staff.
Angwanwadi Centers (Department of Women and Child Development):
Nutritional needs of pregnant woman, nutritional needs of 0-6 year old
children and adolescent girls’ health requirements are met through anganwadi
centers where food grains and medicines are distributed.
Secondary Level of Health Care consists of community health centres,
rural hospitals, district hospitals and speciality hospitals.
Community Health Centres (CHC): One out of four PHC in a block is
usually upgraded and recognised as a Community Health Centre (CHC). It
should have 30 beds with specialists in surgery, medicine, gynaecology/
obstetrics and paediatrics. It also should have diagnostic facilities like X
ray and laboratory facilities. One CHC usually covers a population of 80000-
120000.
Health Insurance: No universal health insurance is mandatory in our country.
However, two insurance-based programmes are well-implemented and
managed in India. They are ESI and Central Government Health scheme.
ESI was introduced in 1948 to provide medical care for people working in
industries. Central Government Health Scheme was introduced in 1954 and
it covers the employees of autonomous organisations, retired central
government servants, retired judges, MPs of Parliament and their families.
Ayushman India is a new scheme that was recently launched, and it aims to
provide universal insurance coverage to the citizens of this country.
Other Agencies: This includes medical services provided by defence forces,
through their hospitals/ medical colleges. Similarly, Indian railways also
provide health care facilities for their employees and family members.

b) Private Health Care in India

This mainly consists of private hospitals, independent clinics, nursing homes
etc. This sector is highly unorganised and is concentrated in urban areas. It
provides mainly curative and immunisation services. Medical Council of
India and Indian Medical Association regulate and control some aspects of
the private health care sector.
127
Psychological, Behavioural, c) Ministry of AYUSH and its Health Care Institutions
and Social Issues in Public
Health and Management Ministry of AYUSH (which was initially the department of AYUSH),
regulates, maintains and develop manpower, infrastructure, Research and
Development, drugs etc., for AYUSH systems (Ayurveda, Yoga, Unani,
Sidha, Homeopathy and Sowa-Rigpa). Both public sector institutions
(primary level clinics, Ayurveda hospitals, Ayurveda/ homeopathy medical
colleges) and private hospitals/clinics/colleges are under the control and
supervision of Ministry of AYUSH.

d) Voluntary Health Agencies

Voluntary health institutions are not-for-profit organisations usually
registered under the Societies Registration Act or the Trust Act. International
level organisations like Red Cross Society, World Health Organisation etc.,
are also part of this network, which provides specialised training, skill
development, R&D support to the federal (central) government. Indian
Council for Child Welfare, Voluntary Health Association of India, The All
India Blind Relief Society etc., are some other important organisations that
render their services in the area of health.

Thematic Diagrammatic Representation of Indian Health Care Sector

Indian Health Care Sector


 
Public Private


   
Ministry of Ministry of Ministry of Ministry of
Health and AYUSH Defence Railways
Family Welfare

   
Tertiary Hospitals AYUSH Dispensaries
National Health Programmes Dispensaries Base Hospitals
Medical Colleges and AYUSH Hospitals
Hospital Speciality
AYUSH Medical Hospitals
Central Government health
Colleges Armed Forces
Scheme Dispensaries
District and Sub divisional AYUSH Medical Colleges
Hospitals Independent and Research
Practitioners Institutes
Community Health Centres
Primary Health Centres

Sub Centres Non Profit
ASHA, Anganwadi Worker,

For Profit
Village Health Guide 
 Charitable Trust
Multispecialty Hospitals Dispensaries and
Hospitals
Speciality Hospitals
Nursing Homes NGO run Clinics
and Outreach
Private Clinics
Programmes

Fig. 7.1: The Indian Health Care Sector (Swedish Agency for Growth Policy Analysis (2014).
India’s Health Care System. Overview and Quality Improvements. Direct Response Report,
128 pp.13).
 Management of Health Care
7.3 NATIONAL HEALTH PROGRAMMES IN Programmes by Indian
INDIA Government and NGO’s

The federal (central) government has undertaken several measures to improve

the health of the people. Prominent among these measures are the National Health
Programmes. Various international agencies like WHO, UNICEF, UNFPA etc.,
are also providing technical-material assistance in the implementation of these
programmes. India, since independence has formulated and implemented couple
of National Health Programmes and these programmes have helped the country
to improve health status tremendously.
National Programmes has the following features in common:
Targeting one disease — usually national health programme is shaped
targeting one disease. For example, National Malaria Programme focused
specifically malaria.
Vertical in nature — i.e. each national programme has separate work force,
fund allocation and research institutes etc., and the programme is usually
not integrated with general health system. However, under the aegis of
National Health Mission (NHM) almost all the national programmes are
integrated with the general national health services.
The impact of National health Programmes is constantly monitored through
surveillance mechanism. This is to check the impact on the disease burden.
They focus both preventive and curative aspects. Programme will have both
curative and preventive elements integrated into the system.

In the following section, we will briefly discuss some of the important National
health Programmes.

7.3.1 National Vector Borne Disease Control Programme

(NVBDCP)
The NVBDCP is implemented in the States/ UTs for prevention and control of
vector borne diseases namely malaria, filariasis, Kala-Azar, Japanese Encephalitis
(JE), Chikungunya and Dengue. The Directorate of NVBDCP is the nodal agency
to implement the programme. Now the programme is integrated with the National
Health Mission (NHM). Under NVBDCP there are three strategies: a) Disease
management including early case detection, complete treatment, strengthen the
referral services and preparedness; b) integrated vector management; c) supportive
interventions like behaviour change communication and capacity building.

National Malaria Control Programme was launched in 1953. In 1958, aim was to
eradicate malaria. But in 1970s there was resurgence of malaria, and in 1999 the
programme was renamed as National Anti Malaria Programme and in 2002 this
national programme was integrated to NVBDCP.

National Filaria Control programme has been in operation since 1955. In India,
in 1978 the operational component of this programme was merged with the Urban
Malaria Scheme.

129
Psychological, Behavioural, Kala-Azar which is now endemic to 31 districts of the country especially in West
and Social Issues in Public
Health and Management
Bengal, Bihar and Uttar Pradesh received special attention, when a centrally
sponsored scheme was launched in 1990-91. World Health Organisation is also
supporting this programme by providing drugs free of cost.
Japanese Encephalitis (JE) is a disease with high mortality rate and those who
survive do so with various degrees of neurological complications. JE vaccination
is recommended for children between 1 to 15 years of ages.
Dengue in 1996 onwards often outbreaks of dengue are reported from across the
states. Strategies used to combat this disease include identification and control
of outbreak, demarcation of affected area, case management, vector control and
Information Education Communication (IEC) activities.
Chikungunya is a debilitating nonfatal viral illness, remerging in the country
after a gap of three decades. The diagnostic kits are developed and provided by
the Institute of Virology, Pune. Vector control and IEC are the other strategies
used.
All the above mentioned six diseases are vector borne and are integrated into
NVBDCP, which stands presently implemented through the National health
Services under National Health Mission (NHM).

7.3.2 National Leprosy Eradication Programme

The programme to combat leprosy was initially launched in 1955 and strategy
was early detection of cases. By 1980 Central Government resolves to eradicate
leprosy by the year 2000. In 1983, the programme was renamed as National
Leprosy Eradication Programme and since 1993, the World Bank is supporting
the programme. Decentralised, integrated leprosy services through general health
care system, capacity building, use of IEC, medical rehabilitation are the
components of the programme.

7.3.3 Revised National Tuberculosis Control Programme

(RNTCP)
National Tuberculosis Programme (NTP) has been in operation since 1962.
However, treatment success rates were unacceptably low, and death and default
rates remained high. In 1993, the programme was renamed as the Revised
National Tuberculosis Control programme and the strategy adopted DOTS
(Directly Observed Treatment Short-Course) strategy. DOTS strategy ensured
higher treatment completion rates. The organisation structure included state level
offices, District Tuberculosis Centres, DOTS providers and microscopy centres.

7.3.4 National AIDS Control Programme

National AIDS Control programme was launched in India in the year 1987,
immediately after the detection of the first case in 1986 in Chennai. National
AIDS Control organisation (NACO) was set up as a separate organisation to
plan, implement, and monitor and modify the components of the programme. At
the state level, state AIDS control societies are established to implement the
programme. The national strategy has the following components: a) establishment
130 of surveillance centres to cover the whole country; b) identification of high risk
group and their screening; c) issuing specific guidelines for blood banks; d) IEC Management of Health Care
Programmes by Indian
through mass media. Preventive, curative and rehabilitative services are provided. Government and NGO’s
ICTC (Integrated Counselling and Testing Centres) and ART centres (Anti Retro
Viral Therapy) are established integrated with general health services of the
country.

7.3.5 Universal Immunization Programme

With the support of World Health Organisation (WHO) Indian Government
launched expanded the programme on immunisation in 1974, against, six most
common, preventable childhood diseases, viz. Diphtheria, whooping cough,
tetanus, polio, tuberculosis and measles. Now UNICEF is also supporting the
programme. Apart from this JE, rotavirus, Measles –Rubella, Chikenpox
vaccinations is also available on optional-payment basis. Now, Universal
Immunisation Programme is integrated with the general health system under the
aegis of National health Mission and at Primary Health Centre level special
emphasis is provided to achieve the universal coverage.

7.3.6 National Programme for Prevention and Control of Cancer,

Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)
Cardiovascular diseases and other non–communicable diseases are surpassing
the burden of communicable diseases in India. Considering this epidemiological
risk, this programme was launched. The programme focuses on the health
promotion, capacity building including human resource management and
development, early diagnosis and management of these diseases with integration
with the primary health care system. The programme is integrated with the general
health services and is implemented through Primary Health Centres and
Community Health Centres. Non-communicable disease clinics are established
at Primary Health Centre and Community Health Centres. At district level, the
work force is trained and deployed.

7.3.7 National Mental Health Programme

National Mental Health Programme was launched in 1982 with a view to ensure
availability of mental health care services for all, especially for the risk groups
and unprivileged section of the population. The aim of national mental health
programme are: a) prevention and treatment of mental and neurological disorders
and their associated disabilities; b) use of mental health technology to improve
general services; c) application of mental health principles in total national
development to improve the quality of life; d) streamlining / modernising mental
hospitals; e) upgrading psychiatric department research and development.

7.3.8 Reproductive, Maternal, Neonatal, Child Health and

Adolescents Programme (RMNCH+A)
This is the strategy based on a continuum of care approach and defines integrated
packages of services for different stages of life. It aims to provide services from
neo-natal stage to child, adolescent group to reproductive — maternal stages in
a woman’s life. Essential obstetric care, promoting anti-natal checkups, essential
newborn care, family planning services and choices, HIV/AIDS, Sexually
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Psychological, Behavioural, transmitted Diseases (STD) support, immunisation, disease control among
and Social Issues in Public
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newborn and children, iron –calcium nutritional supply, supplementary nutrition
to the lactating mothers, registration of all pregnancies, child birth and mortalities,
adolescent health care etc., are the major components of this programme.
Reproductive and Child Health Programme was launched in 1990s and had
different phases before it is revamped and relaunched as RMNCH+A in 2013.

7.3.9 National Health Mission (NHM)

The Ministry of Health and Family Welfare is implementing various schemes
and programmes to provide universal access to health care for its citizens. As a
part of the plan to increase the efficiency of health care system, many programmes
have been brought together under the overall umbrella of National Health Mission
with National Rural Health Mission (NRHM) and National urban Health Mission
(NUHM) as its two sub-mission. The NHM was approved in 2013. The main
programmatic components include: a) health system strengthening in rural and
urban areas; b) Reproductive-maternal-New Born-Child and Adolescent Health
(RMNCH+A); c) control of communicable and non-communicable diseases.

7.4 ROLE OF NON-GOVERNMENTAL

ORGANISATIONS IN HEALTH SECTOR OF
INDIA
Apart from the federal (central) and state governments, there are other stakeholders
who are working in improving the health status of people. Non-Governmental
Organisations play an important role in reaching out to the most underprivileged
sections of the society. NGOs have long history of active involvement in the
promotion of human well-being. In particular, NGOs provide important links
between the community and government. They possess certain strengths and
characteristics that enable them to function as effective and dynamic agents in
this process. Their programmes ranging from research to community-based-
projects cover the wide spectrum of human concerns and often pioneer in the
fields of health and developments.

7.4.1 Understanding of NGOs

Non-Governmental organisations are called by various names across the world,
such as third sector organisations, non-profit organisation, voluntary organisation,
charitable organisation and community-based organisation. In India, they are
often called as not-for-profit institutions and officially defined as an organisation
that are – a) not-for-profit and ; b) by law or custom do not distribute any surplus
they may generate to those who own or control them; c) are institutionally separate
from the government; d) are self governing; e) are non-compulsory in nature.
Check Your Progress
3) NGOs play an important role in providing health care to the poor.
Comment.
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NGOs generate funds from foreign funds, government grants, corporate social Management of Health Care
Programmes by Indian
responsibility funds, NGOs own fund generating resources and other Government and NGO’s
philanthropic/ individual charitable donations. Though the nature and focus of
activities has changed over the time, NGOs have gained prominence in the wide
spectrum of social life including health care. The World Health Organisation has
acknowledged NGOs in terms of increasing recognition to complement
government programmes and creating effective people’s voice in respect of health
service requirements and expectations.

7.4.2 Functions of NGOs in the Health System

The primary focus of NGOs in the health sector can be listed as follows:
Establishing health care institutions;
Fulfilling health and social needs of groups like women, elderly and
vulnerable local communities;
Dealing with specific health issues such as AIDS, alcoholism;
Promoting Health Rights;
Performing preventive health programmes; and
Managing health finance/ funding and administration.
Some NGOs operate internationally and are concerned with global health issues.
Some NGOs in India also play an important role in providing health care at the
time of emergencies/ natural disasters.

7.4.3 The Health Activities of NGOs in India

NGO run hospitals are heterogeneous and vary in terms of ownership, financing
and costs. In recent past, in about ten health–oriented projects of Ministry of
Health and Family Welfare, NGOs have actively taken part as health service
providers. All these NGO schemes are now under the provision of flexi pools of
National Health Mission. Besides, some NGOs (especially the national counter
parts of International NGOs) have their own health financing schemes.
In India, majority of these NGOs are covered under the Societies Registration
Act or Indian Trusts Act. In addition, there are number of informal associations
working at grassroots level without being registered in the legal level. The study
by das and Kumar (PHFI, 2016) shows that one per hundred organisation primarily
or subsidiarity is involved in health activities has a hospital. An overwhelming
number of NGOs about 84% are found in outreach activities. The outreach
activities are the main health activity in which generating awareness to targeted
population is the major subcomponent of outreach for Indian NGOS.
Preventive care is the most common activity provided by the NGO sector in
India. In most states, other than Kerala and Manipur maximum funds are directed
towards preventive care. In Kerala maximum funds are spent for curative care
with preventive care being the second highest. In Manipur, health system
supportive services in terms of management and finance dominate other expenses.
Expenses for rehabilitative care are not significant except in few states like
Karnataka.
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Psychological, Behavioural, According to Monica Das Gupta (PHFI, 2016) the health activities of NGOs in
and Social Issues in Public
Health and Management
India can be broadly classified into nine groups as follows:
Medical education
Hospital services
Rehabilitative clinics
Outpatient clinics
Ancillary services like lab and X Ray
Nonclinical medical support like health system management
Health insurance for targeted population
Out-reach activities for preventive care
Engagement in medical research

7.4.4 NGOs and Health Sector: Future

In a position paper by World Federation of Public Health Associations (2015)
opined that the following are the areas in which NGOs can efficiently contribute
to India’s health care sector:
At all stages, in the development of primary health care programmes NGOs
can be more effective.
NGOs can work for greater understanding and positive attitudes towards
primary health care.
NGOs can assist national policy formation in the areas of health care and
integrate human development.
NGOs can contribute to primary health care in many ways as follows by
providing assistance to develop strengthen local capabilities; by further
extending their capacity to work with poor, disadvantage and remote located
population.

7.5 PROBLEMS, ACHIEVEMENTS AND

PROSPECTS OF INDIAN HEALTH SYSTEM
Since independence, in the last seventy years India’s health care system has
developed at an impressive rate. We have large network of integrated primary-
secondary-tertiary level services where both public and private providers co-
exist. India’s overall achievements regarding longevity and other key indicators
are impressive but it is uneven across various states. For example, in Kerala
Maternal Mortality Rate is 64 whereas national average is 165 and in states like
Uttar Pradesh, it is still above 200 (NFHS IV data, 2015).

In the past seven decades, life expectancy has increased from 45 years to 68
years (2011 census). Infant mortality rate has come down from 230 during
independence to below 40 in 2017. Crude birth rates have dropped to 26.1 and
death rates to 8.7. India also successfully managed the population problem by
effectively implementing the Family Planning Programme since 1950s. Reduction
in IMR, under five mortality rates during the last seven decades is impressive.
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Maternal Mortality Ratio reduced from 560 per 100,000 to 230 (Census 2011). Management of Health Care
Programmes by Indian
This was achieved because of a cluster of services (anti-natal care, vaccinations, Government and NGO’s
control of childhood diarrhoea and effective nutritional supply through
anganwadi). India has also developed an impressive workforce and infrastructure
in both public and private sector for health care. Further, diseases like smallpox
stands eradicated, while other diseases like polio is near the elimination stage.
Diseases like cholera, leprosy has reduced drastically. Disease burden of infectious
diseases like tuberculosis, malaria etc., has marked reduction, whereas non-
communicable diseases like cancer, hypertension, cardiovascular diseases, obesity
etc., are rising. India is facing the epidemiological transition where the burden of
communicable diseases is showing reduction whereas burden of non-
communicable diseases is increasing. Recently, new diseases like Nipah, Zika
etc., are also reported from India which is new public health threats for our country.

However, there are some limitations and challenges that the health care system
of our country is facing. Some are listed below:

According to Monica Das Gupta (2016) it has long been accepted that the most
effective approaches to improving population’s health care are those that prevent
rather than treat a disease. However, in India, public health policies and
programmes have focused largely on the provision of curative care and personal
prophylactic interventions such as immunisations; while other social determinants
of health (like food, water, and sanitation) remains relatively neglected. This
helps explain why India’s health indicators are so much poorer than many other
countries in East Asia.

The following are the reasons for the withering away of public health services in
India (Das, 2016).
Neglect of public health regulations and their implementation. Public Health
Acts which constitute the legislative framework for public health provisions
have not been updated and rationalised since the colonial era.
Diversion of funds from public health services and general reduction of
funds allotted to the public sector in health care.
Organisational changes inimical to maintaining public health. The central
government is the key actor in designing health policies and programmes
because state budgets are highly constrained. However, the central
government focuses on planning specific programmes. Therefore, the bulk
of the funds allotted by the central government are tied to specific programme
and the states are not free to reallocate the funds to the public health issues
specific to the local priority.
There is also inadequate inter-sectoral coordination. For example, health
department has limited resources if the irrigation department generates
malaria by leaving a canal half-finished and waterlogged.

The difference between rural and urban indicators of health status and the wide
inter-state disparity in the health status needs further attention. The infrastructure
and manpower developed is based completely on biomedicine (allopathy) and
other AYUSH systems are not properly integrated to our health system. In fact,
rural and tribal folk has more confidence and faith in AYUSH medical systems,
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Psychological, Behavioural, but this is not properly capitalised and the outlay for AYUSH streams was always
and Social Issues in Public
Health and Management
negligible.

However, many encouraging trends are observed in the country’s health system.
There are many reasons to be hopeful that public health may receive more attention
soon. Finance is available through large programmes; for example, National health
Mission, Swach Bharat Mission etc., have huge fund allotments. Institutions are
also being built at the local and national levels, which can play powerful roles in
public health. For example, The Panchayathi Raj Act places emphasis on building
local government and devolving health activities to them. Further recognising
the importance of AYUSH a new ministry is established to promote the R& D
and utilisation of these Indigenous Medical Systems.

Check Your Progress

4) Examine the challenges and prospects of Indian Health Care system.
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7.6 SUMMARY
Nearly 400 million people in India live on less than 1.25$ (PPP) per day and 44
per cent of all children are malnourished. Infant Mortality rate and Maternal
Mortality Rate still unacceptably high despite earnest efforts by the government.
There is a rise in infectious diseases as well as in non-infectious diseases. At the
same time India’s public spending on health is extremely low. In 2009, it amounted
to just 1.1 per cent of GDP and National health Policy 2017 directs the State to
gradually increase it up to 2.5 per cent of GDP by 2015. With a shrinking public
health system, people have become dependent on private health care providers
who currently handle 75 percent of outpatients. A country that aspires to be a
developed one needs further strengthening of public health care and closer
monitoring and regulation of private health care.

7.7 REFERENCES
Das Gupta, M. (2016). Public Health in India: An overview. Working Paper Series
3787. World Health Organisation.

Das, N. (2016). Role of Non-Governmental Organisations of India. Technical

Report. US AID India & Public Health Federation India, Delhi.

Frieden, T. R. (2014). Six components necessary for effective public health

program implementation. American Journal of Public Health, 104(1), 17-22.

Park, J. E. & Park, K. (2015). Textbook of Preventive and Social Medicine. 23rd
Edition. Jabalpur: Bhanot Publishers.
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Srinivisan, R. (2006). Healthcare in India: Vision 2020, Issues and Prospects. Management of Health Care
Programmes by Indian
New Delhi: Planning Commission. Government and NGO’s

Swedish Agency for Growth Policy Analysis (2014). India’s Health Care System.
Overview and Quality Improvements. Direct Response Report.

World Federation of Public Health Associations (1978). Non-Governmental

Organisations and Primary Health Care. Position Paper Passed by the WFPHA
General Assembly.

7.8 ANSWERS/HINTS TO CHECK YOUR

PROGRESS
1) Under the Indian Constitution, health is a state subject. Each state therefore
has its own health care delivery system in which both public and private
actors operate. For details refer section 7.0.

2) According to Srinivasan (2006) four criteria are important to consider/

evaluate a health care system as Just and Efficient. (a) Universal access (b)
Fair distribution of financial costs (c) Training (d) Special attention to the
vulnerable groups. For details refer sub-section 7.1.4.

3) Non-Governmental Organisations play an important role in reaching out to

the most underprivileged sections of the society. NGOs have long history
of active involvement in the promotion of human well-being. For details
refer section 7.4.

4) In India, public health policies and programmes have focused largely on the
provision of curative care and personal prophylactic interventions such as
immunisations; while other social determinants of health (like food, water,
and sanitation) remains relatively neglected. For details refer section 7.5

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