Learning Social and Behavioral Sciences (Humanities) from People

Regulations on Competency Based Medical Education (CBME) programs have identified several wide-ranging overlapping core competencies relevant to Social and Behavioral Sciences (SBS). Critical analysis of these competencies indicates that all these are relevant to the domains of sociology, social psychology, and social and cultural anthropology (Behavioral sciences). Experience over the years indicates that the topic of SBS in most textbooks of community medicine is not dealt with adequately. Its contents are vague and not focused. Students are not able to grasp or conceptualize the application of SBS in health and disease. Faculty find it difficult and struggle hard to teach SBS. Similarly, logbooks recently introduced and prepared by various institutions do not inspire much to learn SBS. Further, the faculty of community medicine often lacks the training on SBS. With a minimum formal knowledge in social and behavioral sciences the faculty can do a great deal themselves, simply by moving out of classrooms into community and families to learn their perceived/felt needs and demands as also real healthcare needs. This is the best way to gain understanding of community organization, its way of life, human behaviors, and lifestyles and thereby learning SBS in real-life situation from people. NEW CURRICULUM BY NATIONAL MEDICAL COMMISSION (NMC) 2022 The new CBME regulations for Undergraduates (UGs) curriculum are being implemented with the objective of covering all three domains of learning—Cognitive, Affective, and Psychomotor. New regulations make a paradigm shift and reforms in learning of community medicine and redefine the role of teachers as facilitators and mentors. NMC mandates family adoption program (FAP) through village/urban outreach as a part of new course curriculum of community medicine. It has a structured FAP which begins from first professional and continues throughout the course curriculum. It allocates 78 teaching hours spread over 20 visits in various phases besides field visits under foundation course. Families are allotted to each student for longitudinal follow-up of “Family Cohort “for three years in the adopted villages/urban wards. Student maintains sustained and recurrent contacts, on a fortnightly or monthly basis with these families and the adopted community.[1] Practice of family-based/household health care model really exists in the country as developed over years of experience gained under National Rural Health Mission (NRHM). In this community-based model all households and families are empaneled by accredited social health activist (ASHA) and linked to healthcare system for providing comprehensive primary healthcare services. ASHA’s key role is to mobilize community and ensure its participation through village/urban health sanitation and nutrition committees (HSNC), hence this is the best model to learn SBS in real-life situation. This model must be demonstrated to the learner. Over 5.5 lakh village/urban HSNCs have been constituted in the country with ASHA as member secretary. They work under Panchayati Raj Institutions (PRIs). These committees are pre-eminent platform for convergent actions on health and social determinants. All the ministries, departments, and various sectors converge at the level of village; hence, the PRIs and HSNCs are best suited to ensure inter-sectoral coordination and convergent action on health and social determinants at local levels. PRIs and people are at the center of the health and development process. Village Panchayats and equivalent urban local bodies are local self-government under Panchayati Raj Act and made responsible for 29 subjects including health, family welfare, and education under the 73rd and 74th Constitutional Amendment Act. CULTIVATION OF BEHAVIOR The households and community are where healthcare practices and health-seeking behaviors are learned and supported. Health promotion and prevention typically requires behavior change that starts in households and gains support through community. Improvement in nutrition, for example, are often the result of better infant and young child feeding practices by mothers or caregivers through breastfeeding or, later, by providing diversified diet at home. Such practices must be learned at home by an individual and reinforced by the community. Children must learn to wash their hands and practice good hygiene habits that are cultivated at home, at anganwadis center, in schools, and among neighbors with peer groups and friends.[2] LEARNING FROM PEOPLE: THE LEARNER Meets with PRIs members, non-formal and opinion leaders, and members of community, greets them respectfully with a smile on their face to build a good rapport, and keeps it up throughout every visit. Actively listens to people, by engaging them in informal conversation and discussion. Listens to their perceived/felt needs and demands, not only those related to health but in general. What are their priority health needs and local resources available to meet these needs? Any outside/government help they require to solve these problems in a lasting way. Learners also listen to what is not being said, that is, observe body language and gestures, facial expression, and learn to interpret body language. TRANSACT GROUP WALK: THE LEARNER Along with local people and resident community members like ASHA and Anganwadi Worker (AWW) undertakes transact walk through the village/urban ward to capture various social life processes and dynamics of community. He/she directly observes the access to village/urban ward by all-weather roads, its topography, housing conditions, electricity (power supply), pavement of streets, sources of drinking water, waste water and garbage disposal practices-stagnant pool of water, village ponds, and garbage dumps (breeding places for mosquitoes, houseflies, and sandflies). Collects demographic data from annual household survey/village or ward health survey register maintained by ASHA to enumerate the total resident population, describes its age and sex composition to assess healthcare needs of target groups in the catchment area, prepares age and sex pyramid of population and describes its implications on health and disease.[3] Analyses the compiled household survey data of ASHA or Auxiliary Nurse Midwife (ANM) to determine sex ratio of population, sex ratio at birth of children born last year, child sex or juvenile sex ratio and describes its implications on gender inequalities, shares these data with community leaders/panchayat/nagarpalika councilors. Analyses the data of birth and death register maintained by ANM to arrive at crude birth and death rate of community for the last one year, as also describes the causes of death as recorded by health workers, describes disease burden and priority health problems in the community based on the causes of death and shares it with community to elicit their views/reactions. Attends village/urban HSNC meetings and describes its composition, frequency of meetings, and availability of untied funds and functions and responsibilities especially related to social determinants of health- nutrition, drinking water, sanitation, education, as also inter-sectoral coordination efforts. FAMILY ADOPTION PROGRAM (FAP) The learner uses the same household survey format as actually being used by ASHA to collect household information such as: ownership of house (own/rented), type of house (kacha/pakka)—number of rooms, details of amenities—availability of separate kitchen, cooking fuel used, electricity, source of drinking water, toilet, beneficiary of any health insurance/protection scheme, ration card color—green/yellow/pink—presence of mosquitoes/houseflies, rats in the house and their breeding places around the house, availability of TV/radio, refrigerator and livestock and cattle sheds, if any. Line lists all the family members in order of oldest member first and the youngest last to assess demographic profile of each individual such as age, sex, literacy, marital status, occupation, head of the household, and the decision makers in the family and women-headed households. Based on the age, classifies the individual as neonate, infant, preschool, school-going child, adolescent, eligible couple, working person, old age person and describes their health care needs and current health status. Uses community-based assessment checklist (CBAC) for risk behavior assessment in persons above 30 years of age by scoring system to identify and prioritize high-risk persons and carries out screening of common NCDs—obesity, hypertension, diabetes, oral and breast cancer, and other chronic diseases, besides raising awareness and educating the family members. The CBAC tool essentially helps to capture high-risk behaviors such as physical inactivity, sedentary lifestyle, tobacco use (smoking and consumption of smokeless tobacco gutka/khaini), consumption of alcohol, overweight, obesity and high body mass index and waist measurement. By this way, the student is able to learn behavioral risk factors for NCDs in real-life situation and promotes risk reduction measures, on behavior change and lifestyle modification to be practiced by the individual, family, and community.[4] Follows family longitudinally once a month/once in two months to maintain regular communication and contacts to observe and records occurrence of any events like marriage, pregnancy, birth, illness, death as also growth monitoring and weight gain pattern. The student also observes the gender roles assigned by family to boys and girls, men, and women to learn to gender disparity and discrimination as also behavior change if any. SOCIO-ECONOMIC STATUS The learner assesses the socio-economic status (SES) of the family by standard acceptable methods to identify deprived families, classifies the allotted family as patriarchal, matriarchal, monogamous, polygamous, polyandry, nuclear, joint, and three-generation family, elicits practice of consanguineous marriages, and risk associated with such practices, classifies the family into- above poverty line (APL), below poverty line (BPL), and extremely poor family (Antyodaya family), observes color-coded ration card available with the family which makes them entitled for several benefits. Pink card holder is extremely poor, yellow card holder is BPL, and green card holder is APL family. These cards have been issued to the families by the government based on Socio-Economic Caste Census of 2011 (using seven deprivation indicators/multi-poverty indicators), gathers information on benefits of various poverty reduction programs reached to BPL families such as health protection under PM-JAY (Pradhan Mantri Jan Arogya Yojna), food security/free ration/highly subsidized food grains, gas cylinders, electric connection, piped water supply, sanitary toilets, free elementary education for children and Mahatma Gandhi National Rural Employment Guarantee Program, affordable houses and Beti Bachao and Beti Padhao.[5,6] ASSESSMENT OF BARRIERS TO GOOD HEALTH Learner elicits and describes various barriers to good health and health-seeking behaviors such as poverty, illiteracy, cultural barriers, poor geographical access, poor quality of service, gender bias, stigma, negative experience from contact with formal healthcare facilities, lack of information, absence of health providers, timing of services, etc. HEALTH, SANITATION AND NUTRITION DAY ASHA/Anganwadi workers (AWW) are serving as bridges between the community and the formal health system to help the community identify and address their own health needs. They are part of the community and stay connected with the community by regular home visits to promote healthy practices. They maintain a good relationship of trust and confidence with the community to sustain changes in behavior once initiated. They organize regular Health Sanitation and Nutrition Day (HSND) once a month at anganwadi center hence best suited to promote healthy behavior and lifestyles in the community. ASHA facilitator, Anganwadi worker (AWW) supervisors, and health system provide supportive supervision and monitor their performance regularly. The learner gathers the information from households/community as to how often ASHA/AWW visits them and provides any health information. This way the learners assesses communication between ASHA/AWW/ANM and mothers/caregivers for behavior change. HEALTH PROMOTION/EDUCATION AND EVALUATION The learner observes and describes various behaviors/practices in the family. After observing various practices, the learner classifies these practices/behaviors into beneficial, harmful, and harmless, assesses the communication needs of the target individual and family based on observed practices, attempts to promote healthy behaviors and life styles and doing away harmful practices by behavior change communication (prepares a health message or uses a poster or pamphlet with appropriate message for behavior change communication and counselling), lists the various channels on communication available in the family, segments audience based on literacy and income, elicits the specific health messages heard, seen, and understood by family members through various available channels and changed their behavior as a result of these exposures thus evaluates the effects of the messages, interviews and informally discusses with school going children/adolescents to know health promotion messages transacted by school teachers/health ambassadors, peer educators of Rashtriya Kishor Swasthya Karyakram and acted upon these messages to change their behavior, meets the potential beneficiaries exposed to a specific health program for a long time such as prevention and control of NCDs, tobacco control and anaemia control program to elicit the self-reported behavior change as a result of exposure to the program/various channels of communication, gets the information from family members as to any health worker (ASHA, AWW, ANM) visited the family in the last three months and provided any health information, carries out exit interviews of beneficiaries attending HSND or outreach immunization to get feedback from beneficiaries on their experience and satisfaction level and any health message or information received from providers of services for action. DIETARY BELIEFS HELD BY MOTHERS The learner carefully observes and describes the common dietary beliefs held by mothers and caregivers in the family. People organize and classify the food groups into “hot and cold”, “heavy and light”, “wind producing and indigestible foods”, and make food choices, accordingly, describe food that are deliberately withheld from the diet of the infant and young children, pregnant and lactating mothers. Carefully listens to people about what they say on feeding practices of young children and observes what actually they do, elicits the history of common ceremonies, social customs performed before initiating breast feeding that delays the initiation of breast feeding, practice of pre-lacteal feeds, beliefs on discarding colostrum and drastically reduction of feeding and fluids during diarrhea, respiratory illness and fever, practice of diluting whole milk with plenty of water. Whole milk is considered too heavy for children, and the practice of withholding cereals, leafy vegetables, pulses, and ghee from the diet of infant and young child is wide spread in India. WIDER APPLICATIONS OF SBS SBS are not only restricted to domains covered and described in this article but have wider ramifications. Behavior Change Communication and community participation form essential as well as supportive elements of comprehensive primary health care and ultimately universal health care, health for all, and health in all. They form an integral part of all the National Health Programs covering reproductive, maternal, child and adolescent health, communicable and non-communicable disease control/elimination programs as well as sustainable development goals and all the national health development and planning policies.[7] Therefore, SBS along with Attitude, Ethics, and Communication Module (AETCOM) form vital and integral part of teaching, training, and learning program for UGs and PGs not only in the subject of community medicine but all the other subjects of the curriculum. CONCLUSION Sustained community contacts and Family Adoption Program (FAP) are the best approaches to learn Social and Behavioral Sciences in real-life situation. It is strongly recommended that the learner maintains sustained contacts and interactions with rural/urban community throughout the course curriculum of three years at regular interval of one month. Learner undertakes transact walk along with local community members and health workers to map various resources and depicts these on a spot map. He or she actively listens to their felt needs/demands including health care needs. The learner obtains the village coverage area profile and data of annual household survey register and prepares age and sex pyramid and describes its implications. Finally, he/she describes the characteristics of rural/urban community, its structure, organization, power, and governance—PRIs/Urban local bodies, leadership patterns, and responsibilities taken by the community for health and development in the form of a case study. The learner follows the allotted families longitudinally for three years to capture the occurrence of vital events like- marriage, pregnancy, child birth, disease, hospitalization, deaths, and migration. Learner assesses the health status of each individual by history taking of self-reported illness, by reviewing family retained health records, by anthropometric measurements (weight, height, body mass index, waist circumference), by clinical examination and point of care laboratory tests. He or she directly observes and describes the gender roles assigned by the family to boys and girls, men, and women to learn gender disparity and discrimination. The learner collects data on knowledge, attitude, beliefs, and practices related to a specific health problem observed in the family and prepares a case study to develop scientific temper and learn qualitative methods of research. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.