Text for Figures and Slides in TB Behavioral
and Social Science Research Forum Proceedings
KEYNOTE SESSION
WHEN SACRED COWS BECOME THE TIGER’S BREAKFAST: DEFINING A ROLE FOR
THE SOCIAL SCIENCES IN TUBERCULOSIS CONTROL
Jessica Ogden, Ph.D.
Technical Specialist
International Center for Research on Women
Slide #1: ICRW logo
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Slide #2: When sacred cows becomes the
tiger’s breakfast:
towards defining a role for the social and behavioral sciences in TB
control
Jessica Ogden
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Slide #3: Acknowledgements
- John Porter, London School of Hygiene & Tropical Medicine
- Mukund Uplekar, Communicable Diseases Cluster (Stop TB), WHO
- Sheela Rangan, Maharashtra Association of Anthropological Sciences
- Varinder Singh, Lala Ram Swarup Institute of TB and Allied Diseases
- Christian Lienhardt, Institute Research du Developpment, Senegal
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Slide #4: Overview of Presentation
- Situating a social science perspective
- Defining our roles:
- Who are we not? orientations and contributions of the medical
sciences in public health/TB control
- Sacred cows whose time has come
- Who are we instead? Strengths (and limitations) of social/behavioral
science approaches (and another ‘sacred cow’)
- Proposed (draft) framework
- Key questions a multi-disciplinary approach can answer
- Some principles to guide our way forward
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Slide #5: Classical Public Health Paradigms:
‘elimination of disease’ orientation
Addressing the microbe in relation to an individual or population
Establishing foundations for diagnosis & treatment
- Epidemiology: interactions between infectious agent, the host and
the environment:
- identify source of infection; interrupt transmission
- Microbiology & genetics
- understanding the bacteria and developing new drugs
- Immunology & molecular biology
- refining response to infection and developing new vaccines
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Slide #6: Sacred Cow #1: the Broad Street
pump handle
- Cholera epidemic in London,1854
- John Snow identifies source of infection (water supply)
- John Snow removes pump handle (interrupts transmission)
- Cholera epidemic ends
- Theory of disease transmission proved
- Deaths prevented
- Community empowered?
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Slide #7: Sacred Cow #2: TB and the limits
of ‘control’
- Control in the community
- May lead to neglect of wider social realities: ordinary life,
poverty, health care system constraints
- Power and Agency: who has them and who does not?
- Who has the power to determine success? Who ‘should’
have it?
- Are people able to take the actions we suggest?
- Are people willing to take these actions?
- Questions of trust: does the control paradigm foster or challenge
efforts to build trust?
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Slide #8: Those of us involved in TB
would do well to consider a shift in paradigm - a shift from a focus on
control to a focus that privileges care.
- Attentive to Trust
- Fostering Partnership
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Slide #9: Social Science Paradigm: wellbeing
orientation
“the production of health”
Understanding how the person and the disease interact in context of everyday
life
- Health outcomes understood in terms of context
- People’s responses to ill health made intelligible
- Individual ‘nested’ within layers of social context
- influencing whether individuals are able and willing
to obtain, maintain and complete treatment
- Relating the individual to the local, national
and the global
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Slide #10: This figure graphically
illustrates how a patient is “nested” within layers of social
context. The drawing consists of concentric layering of the various influences
that bear upon a patient, with the patient in the center, surrounded by
household, community, health and social services, and, on the outermost
layer, policy.
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Slide #11: Sacred Cow #3: ‘beliefs’
and ‘behaviors’
Study of ‘beliefs’ and ‘behaviors’ alone will
not answer our questions
- what people think and what people do mediated by elements
of culture but also by elements of social structure (e.g. poverty)
- affects availability, accessibility
and acceptability of health care options
- impacts on agency - freedom/ability to make choices
within a range of options, or the ability to take action according
to belief
Does not account for global and local power relations that produce
and shape sickness and health
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Slide #12: Social structures within household,
community, policy determine
- Who can adopt the sick role, and when
- Range of treatment options available
- Extent to which a given person has access to Rx
- Extent to which a given person will obtain diagnosis
& Rx
- Extent to which a given person can adhere to Rx
These are all aspects to which research and policy can respond
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Slide #13: This figure illustrates the overlap
among five multidisciplinary levels, including patients (interviews, case
studies); programs (focus group discussion, key informant interviews);
Community and Households (mapping, participant observation, field diaries,
semi-structured questionnaires, key informant interview, ethnographic
survey, focus group discussions, informal interviews); Health Services—Providers
(semi-structured, open-ended interviews, pre-coded questionnaires, non-participant
observation, facility assessment, workshops with practitioners, involvement
of NGOs); Donors and Policy Makers (stakeholder analysis, semi-structured
interviews).
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Slide #14: Multi-disciplinary Approach
- Combines strengths of medical sciences and social/behavioral sciences
- Answering the ‘why’ questions
- Why don’t patients come for treatment?
- Why do they only come when it’s too late?
- Why don’t they complete their therapy?
- Answering the ‘how’ questions
- How can we make our programs accessible and acceptable?
- How can we meet health needs of community?
- How can communities be involved as participants in their own health?
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Slide #15: Closing graphic of tiled ICRW logos
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