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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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