Behavioural approach and ecological approach are two concepts in managing public health issues. Behavioural approach focuses on individual behaviour. Meanwhile an ecological approach is a comprehensive strategy looking at public health issues through determinants of health environmental, social/structural, cultural, individual and health service.
In terms of the malnutrition issue in NTT Province Indonesia, local authorities are strengthening the implementation program mainly by a behavioural approach. Short-term programs such as providing supplement food packages and health education are the main local government strategies. Partnership with other sectors to address the issue is not yet part of the strategies. However, malnutrition is still one of the main health issues in this region.
Because health has multi determinant factors, an ecological approach is very useful to address this issue by considering some determinants of health, such as, environmental factors, social/structural factors, cultural factors, individual factors. An ecological approach is appropriate to malnutrition in NTT Province.
INTRODUCTION
There are some public health problems in Indonesia. Malnutrition in children under five years of age is one of the public health problems. The Incidence Rate (IR) of malnutrition in children is tending to increase. For example, in 2000 the incidence rate are 26.7%, in 2001, IR: 27.3%, and in 2003 IR : 27.5%. (Hadi, 2004).
In NTT Province, malnutrition in children under 5 years has been huge problem in the last 5 years. For instance, in 2005, around 368 children in NTT Province were suffering malnutrition in categories of marasmus and kwashiorkor. In 2006, around 439 children under five years identified as suffering malnutrition, and 12 children were reported died. In 2007 a total case of malnutrition in NTT Province was 559 cases and 72 children were died in that period (IR:12,59 %, Total Fatality Rate / TFR: 12.8%). (P. H. O. NTT, 2007).
Local authorities conducted four strategies to overcome the malnutrition. Firstly, they provide food packages or food supplements for 12 months particularly for children who were identifying as marasmus and kwashiorkor. Secondly, the government provide vitamins as a supplement for children less than 5 years and pregnant women. Thirdly, the government conducted health promotion or education program, which focused on behavioural change in nutrition consumption. The Health promotion program was delivering by health promoting staff from public health centres and district health offices. The last strategy is to provide Therapeutic Feeding Centre (P. NTT, 2005). Even though the local government conducted some strategies above, malnutrition is still happening in this region.
A comprehensive study analysed policy related to an outbreak of malnutrition in eight districts in 2006 conducted by the Provincial Research and Development Body in NTT Province found some information below:
1. The local government was paying more concern to malnutrition cases, which were happening in their district. It was indicating from good knowledge related to malnutrition. However, the government did not have a comprehensive strategy to address malnutrition issues. They used the action strategy that has developed by the provincial health office. In this action strategy, consisted of technical procedures for nurses, nutritionists or managers to manage their program.
2. Governments in sub district levels did not have sufficient knowledge and awareness about malnutrition. In addition, they did not have particular strategies for malnutrition, but they totally depended on the initiative from public health centres. The data of malnutrition cases was available in public health centres. Reports from public health centres showed that other infectious diseases, such as, malaria, TBC, diarrhoea, tuberculosis, etc, also accompanied some of the malnutrition cases.
3. Cadres (community health volunteers) from community health centres (posyandu) have more understanding about malnutrition than heads of villages and other community leaders.
4. In terms of eating traditions in the family, the adult man has more priority to be serve or to be the first person who will get the food rather than the woman and children. Parents are mostly busy with their jobs and do not have enough time to take care their children. They leave the younger children or babies with their adult children in the home. Other problems at the community levels were poor sanitation, (safe water and toilet). (P. NTT, 2005).
This paper will compare the concepts behavioural change approach and the ecological public health approach to address malnutrition in NTT Province Indonesia. Thus, in the next sections, this paper will explain about the general overview of malnutrition in NTT Province. In the literature review, this paper will describe a behavioural change approach and an ecological approach. In the last sections, this paper will discuss the approach that is appropriate to address malnutrition in NTT Province.
RATIONALE
The World Health Organization (1947) defines health as a state of complete physical, mental, and social wellbeing and not merely the absence of disease and infirmity. Moreover, the World Health Organization, (1998) stated that health is a basic fundamental human right. (Chu, 2009).
Throughout the history of public health, there are some strategies to overcome the challenges or problems in public health. For example, in 19th century, public health focused on prevention medicine to protect human health. Moreover, in 1960-1970, public health focused on the individual life style or behavioural change. In this period, public health creates behavioural approach to address the public health issues. The recent concept of public health in 21st century is an ecological approach. This concept is focusing on determinants of health such as environment, social/structural, culture, lifestyle, and the health care system. (Chu, 2009).
Malnutrition in children under five years is huge problem in NTT province. The recent study indicates that malnutrition is related to low of economic conditions, culture barriers, etc. In 2005, local authorities conducted some strategies to overcome the malnutrition (as explained above) which focused on the individual approach. However, malnutrition is still happening in this province.
LITERATURE REVIEW
Health behavioral change approach
Some definitions of health behaviour is introduced by scientists as explained below. Notoatmodjo (2003) explained that health behaviour refers to the individual responses regarding illness and diseases, response to the health care system, to the food consumption behaviour and to the environment. He argues that there are four factors that influences public health they are environment, behaviour, genetics and health services. Behaviour is the more influential then other factors. By contrast, Blum (cited by Notoatmodjo, 2003) argues that, environment is the main factor to influence public health.
In the broad context, health behaviour is the actions of individuals, groups community and organizations as well-as determinants, correlate and consequences including social changes, policy development implementation, improved coping skills, and enhanced quality of life. (Parkerson and others 1993, cited by (Karen Glanz, 2002).
The health behavioural approach in public health problems has been introduced by Kurt and Lewin (1930) to develop field theory which is the form of intellectual roots of much of today’s health education practice, and also explain behaviour related to tuberculosis screening using Health the Belief Model Hocbaum (1958) in (Karen Glanz, 2002).
Generally, there are some behavioral change theories to address the public health which are Health Belief Model (HBM), reasoned action, trans theoretical model, social cognitive theory (Nancy K. Janz, 2002). The Health Belief Model is a psychological model. There are five elements of the health belief model theory, perceived susceptibility, perceived severity, perceived benefits, perceived barriers and self efficacy. (Nancy K. Janz, 2002). Those key variables explain factors that inffluence the individual behavior change. The health belief model is limited in regard to predicting on the individual behavior.
The health belief model can not predict community behavior. This theory does not cover the comprehensive community needs, and does not involve other variables around the individual such as environmental conditions, economy, and health care facilities. Behavioral based health promotion starts from the premise that in the developed countries the major killers or injuries are linked to life style, sometimes called the diseases of affluence, and that modification of the lifestyles linked to disease or injury will be of benefit to peoples health (Winkler (1986, p.270) cited by Baum (2008.).
In the case of malnutrition contexts in NTT Province, the authorities (government) were paying more attention to this model. It is indicated from the strategy that was conducted to address the issue on malnutrition. For instance to provide food packages for children directly (PMT) who were identified as marasmus and kwashiorkor for 12 month and to provide vitamins as a supplement for children less than 5 years and pregnant women and to provide health promotion or education and Therapeutic Feeding Centres (TFC) (P. NTT, 2005). All of these strategies were focusing on individual behaviour.
Integrated approach (ecological public health)
The integrated approach or ecological public health presumes that human health is caused by multi determinant factors, which are environmental factors, social/cultural factors, structural factors, individual factors, and health care system. All the determinant factors are interrelated. Therefore, it is important to consider the ecological approach to overcome the public health issues. (Chu, 2009).
Environmental determinants
Environmental factors including water supply, disposal systems, food safety and physical, chemical and biological hazards can cause a variety of communicable diseases and non-communicable diseases and traumas. In terms of malnutrition cases, lacks of water supply in the community and food safety are the main issues related to the environmental determinants.
A study in the local community in NTT province that was identifying about the relationship between environmental determinant and malnutrition found that around 72.5% of households who suffered malnutrition did not have access to clean water and only 37.5% households have water closets. (R.H. Kristina, 2006).
Social / structural determinants
Research demonstrates the strong relationship between income per capita and nutrition status in the children less than five years in NTT. (R.H. Kristina, 2006). About 67.5% of households have incomes less than Rp. 200.000 (USD$ 30) per month. Other sociological studies demonstrate that health behaviour and health outcomes are determined by social structure. Health outcomes are a reflection of one’s social position in the society as indicated by their education, income, gender, ethnic group membership, religion, and occupation.(Chu, 2008)
Culture determinants
Culture refers to the belief and system of meaning created by a group of people through their interactions over time. Cultural determinants of health include beliefs, values and norms relating to the conception of health and health behaviour. (Chu, 2008).
Based on the research in local communities in NTT it indicates that local cultures were predisposing factors. There was 67.5% of parents who argued that were particular meat and fish and egg are taboo when the females are pregnant, because they can cause allergic reactions such as itchy skin. There are 70% of household that were suffering malnutrition which indicates that the adult man (father) is the priority in getting the meal first, because father is the head of household, and the one who is looking after the family members. (P. NTT, 2005; R.H. Kristina, 2006).
Individual determinants
Individual determinants of health include genetics, biology or lifestyle factors such as poor eating habits, attitudes and values, physiological risk factors, psychological factors such as personality and behavioural risk factors such as smoking. (Chu, 2009). According to Green (1970) individual knowledge is a predisposing factor in health behaviour. Good knowledge of particular diseases results in supportive behaviour in health (Karen Glanz, 2002). Knowledge is an output of the education system. A study in local communities in NTT province found that most of the mothers who had malnourished children have lower education backgrounds (72.5%) completed or not completed primary school. A factor related to the lower education among these mothers includes lack of money to pay school fees, difficulty to access the school location and some community belief that a girl does not need a high education because they will marry.(R.H. Kristina, 2006).
Health services determinants
Health services determinants of health include whether health services are accessible and available. It also endorses that health services are sensitive to the needs of a given population and are provided in a way that is acceptable to the target population. (Chu, 2009).
Around 87.5% of children who were suffering malnutrition did not have access to health facilities to control weight and to get immunisation appropriately. It happened because of several reasons, such as lack of knowledge about the advantage of immunisation and too far to access health facilities. They needed 1-2 hours to get to health facilities by walking. The other reason is parents were busy with their activities.(P. NTT, 2005; R.H. Kristina, 2006).
DISCUSSION
The behavioral approach to address the malnutrition issue in NTT Province has some limitations, because this approach just focuses on the individual behavior, which is indicate from the government strategies above. The behavioral approach does not consider the other determinant factors such as environment, economy, health care services/facilities. This approach presumes that modification of individual life styles is linked to reducing malnutrition. This led to “blame the victim” as stated by Richmod (1999) in (Baum, 2008).
The ecological public health approach is a broad context. It is presume that human health is related to multi determinant factors, such as environmental factors, social/cultural, structural, individual, and health care system. Therefore, the Ottawa Charter concept in health promotion is appropriate to address the public health issues including malnutrition. (Chu, 2009). Ottawa charter offers some strategies, which is explains below:
a. Build a Healthy Public Policy. It means that puts health issues on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health.
b. Create Supportive Environments. It is strong relationships between humans and the environment. Creating environment with water supply system and providing public toilet are very important to support health.
c. Strengthen Community Actions. Strengthening communities are important in health programs, because communities are subjects and objects of the health programs. Strengthening community action in setting priorities, making decisions, planning strategies and implementing them to achieve better health are strengthen of community actions.
d. Develop Personal Skills. Developing personal skills in health programs can be conduct through providing information, education for health, and enhancing life skills. Developing personal skills enables people to have more control over their own health and over their environments, and to make choices conducive to health. Develops personal skills can be conducted in school, home, work and community settings.
e. Reorient Health Services. Health services have a main role in public health. Health services should be sensitive and respect individual or community culture needs. Health service should be open channels between the health sector and broader social, political, economic and physical environmental components. Reorienting health services also requires stronger attention to health research as well as changes in professional education and training.
However, McQueen has introduced a critic of the ecological approach that is concern on social determinants of health. He argues that ecological approach has been introduced in hundreds or thousands year ago, and the last was introduced by WHO in 1977. It means that they know the social determinants impact on health, but they do not adopt the approach into the action. In addition, the ecological approach is difficult to measure its effects on health and it is difficult to prove that changing social factors solve the health problems. (V.McQueen, 2009).
Based on the case study of intervention malnutrition in NTT Province and considering the two strategies above, I believe that the ecological approach is an appropriate strategy to address the issue. Based on the research, malnutrition in NTT province is relate to low economic conditions, culture barriers, lack of community knowledge related to food consumption, and lack of comprehensive strategies to address the issue. Therefore, local government should create policy that is involves some sectors to address the issue. It is also important to create supportive environment such as building transportation systems to connect with remote areas; Strengthen the community actions such as basic value systems in the local community (NTT) “Gotong Royong” means together the community to solve the problem; develop personal skills in the community level (mother/father) through training or promotion related to local foods; provide health care services such as improving the health professional skills.
CONCLUSION
Malnutrition is a serious problem in NTT Province. The government has some strategies to overcome the issue. Those strategies were similar to behavioural approach. Meanwhile, the behavioural approach has certain limitations, because it is only concerned with individuals, without considering other factors outside the individual.
Compared with the behavioural approach, the ecological public health approach is the appropriate concept to address malnutrition in NTT Province, because concerned with determinant factors of health; such as environment, social/structural, individual, health sector and economy.
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