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Mainstream, VOL LX No 25, New Delhi, June 11, 2022

Network Stars in Community Education: A Study From Bihar | Aditya Raj & Papia Raj

Saturday 11 June 2022


by Aditya Raj & Papia Raj

Community education (HE) is very important today because it can create processes for appropriate health seeking behavior (HSB) and help control any public health problem. HSB, defined as any action (or, series of action) undertaken by individual and/or community which enable or prevent them from making healthy choices, in either their lifestyle behaviors or their use of medical care and treatment, is a vital component of public health. HSB is context specific and is influenced by various factors, including but not limited to, availability, accessibility, and accept-ability of health care facilities; level of awareness; cultural beliefs; and perception of health. It is a continuous sustainable measure that has long-term influence on health status. The Covid-19 pandemic has highlighted the fact that in India during initial phases there was strong unwillingness among people to get tested for the virus. Such negative HSB among people is responsible for uncontrolled spread of the virus in the community. Positive HSB must be highlighted through examples of best practices. Among others, supportive intervention of influential com-munity members can be useful as well. Either due to social status or due to a combination of other factors these “star” nodes in any community becomes important. This study identified “star” networks in a community by using social network (SN) analysis and geographic infor-mation system (GIS) mapping technologies. Thereafter, we accessed the feasibility of these “star” for health education through observation and participation (online as well in the concur-rent new normal). In this process of mapping, data collection, and analysis, we comprehended the kind of interventions (curricula of health education) that may be significant for behavioral changes required for positive HSB. First, the preliminary field study for this was conducted in Patna district where urban as well as rural milieu was studied together. The number of Covid-19 cases was high in Bihar with Patna leading the way. This research and its findings can be seen only as a pilot that can be scaled up in different communities of practice in India. The re-search highlights how specific social interventions through health education by important social agents can be instrumental to pioneer positive HSB among individuals in the community and prevent public health crisis, such as Covid-19 endemic.


The recent epidemic of Covid-19 has posed a unique condition where behavioral changes have become the norm to control spread of the virus in the community. Government had declared lockdown (and even the unlock processes had various restrictions) and had been advising peo-ple for physical distancing, self-isolation, home quarantine, use of mask and gloves at public places, importance of hand wash, etc. Despite such efforts, we are not able to control the situation as people are not adhering to these guidelines. This phenomenon points towards the importance of HSB of individuals in any community. It is about rational, context specific and timely action undertaken by individual and/or community, which enable or prevent them from making healthy choices. Therefore, to improve the situation it is most important to comprehend what factors prevent people from adopting progressive HSB and how people could be motivat-ed to develop positive HSB. Individuals are sociosyncratic, both acting and reacting to social networks in their milieu (Pescosolido 1992). Education is instrumental to initiate behavioral changes that are sustainable. WHO (2012) recognizes education as key component of health promotion and defines HE as any combination of learning experiences designed to help indi-viduals and communities. This study identified the pivotal human node that acts as pedagogue in disseminating health education suitably. Though it can be done various methods including a mean of degree centrality, closeness centrality, betweenness centrality, and Eigen vector centrality of various social networks in the community. In this study we followed the mean of degree centrality method. When the “star” was located, we tested their feasibility for contextual health education. After we had established who can act as a community teacher, then we tried to com-prehend the kind of social interventions (curricula) that can be adopted to improve HSB of the community. WHO has also recommended that sustainable social interventions will equip us to deal with the current Covid-19 pandemic.

Literature Review and Identification of Gaps

A review of research literature was done to better situate the study. Studies in India have been very disease-specific and have focused mainly on treatment seeking behavior during epidemic and not on HSB or the agency through which it can be realized. Malaria has attracted a lot of research since 2000 (Tyagi 2005, Yadav 2010, Mahapatra et al. 2017). Tuberculosis had been another popular disease to attract research on treatment seeking behaviour (Sudha et al. 2003, Sharma & Taneja 2005, Selvam et al. 2007, Samal 2016). Studies have also focused on repro-ductive health (Barua et al. 2001, Stephenson & Tsui 2003, Joshi et al. 2006, Pandey & Singh 2009, Sehgal 2013). Few studies were conducted on chikungunya (Mavalankar & Govil 2010) in Ahmedabad and leptospirosis (George 2007) in Kerala. Patil et al.’s (2016) study analyses treatment seeking behaviour at a clinic in Dharavi.

A similar trend was noticed in studies conducted at the global level with malaria topping the list (Oberlander et al 2000, Beiersmann et al. 2007, Chibwana et al 2009). Hoa et al. (2003) and Nyamvithayapong (2001) focus on tuberculosis in rural Vietnam and Thailand. Boardman et al. (2000) examines headache and self-care in Northern Ireland. Lee et al. (2014) and Maneze et al. (2015) analyse HSB among international migrant workers in Australia and Singapore, respec-tively. Gakunga et al. (2019) studied HSB among breast cancer patients in Kenya, while Grundy & Annear (2010) reviews HSB in Cambodia. Lee et al. (2006) provide a review of repro-ductive health seeking behaviour and Munguambe et al. (2016) studied pregnancy related HSB in Mozambique. Gulliver et al. (2010) provides a review about mental health seeking behaviour among young people. Latunji et al. (2018) suggest that HSB are closely linked with health status of nation. While study by Musoke et al. (2014) states that SHB can be potentially increased by strengthening community health workers’ strategy.

But, none of the major studies locates the importance of HE in HSB. Moreover, the use of net-work analysis (NA) or GIS has not been done for mapping the pivotal community leaders to act as pedagogue for better health education or the kind of interventions, which will be useful from the perspective of the community. Some studies have explored the centrality of SN in HSB, use of smart devices for SN, or relationship of SN with quality of life in old age. Studies in India are about SN and partnership among health professionals for better outcome. Since HSB varies across geographical spaces and among communities and, therefore, HE will may take different contour and be realized through different agency/star. Due to this detection rate as well as recovery rate will be fast not just for Covid 19 but also for any other case.

Objectives of The Proposed Study

Considering the research gaps, the objectives of this study were to:

1. To identify “star” network in the community.
2. To test the feasibility of using these “stars” for health education of the community and beyond.
3. To access interventions through the “stars” that can have positive impacts in the com-munity.

Design and Practice

A cross-sectional study was desired for this research, which was conducted in Patna district, the capital city of Bihar- the province that is one of the most underdeveloped in India and has shown a high rate of morbidity for Covid-19. The research design was exploratory and yet em-powering as all attempts were made to bring the voice, agency, and subjectivity of research par-ticipants in the study. Primary data is important and were collected using the best contemporary e-resources in the absence of free personal interaction. Adhering to the lockdown norms and physical distancing as a preventive measure, data were collected using online tools and re-sources as well. Mixed method approach was adopted for both data collection and analysis. Da-ta collection were in two phases. First phase of data collection was quantitative and included an online survey. Service providers, service users, and other stakeholders were considered as study participants and different sets of questionnaire was prepared specifically for each group. Questionnaire were e-mailed or sent through WhatsApp to potential research participants. Pur-posive sampling was used to select participants. An individual who is 18 years or above, i.e., who can decide about his/her health seeking behavior, was eligible to participate in the study. Steps were taken to ensure that study population is representative of the community. Drawing important themes from preliminary data analysis of the survey, second phase of data collection was qualitative and involved in-depth interviews over phone and Focused Group Discussions (FGDs) through online platforms, such as Zoom, Googlemeet or WebEx. Softwares like SPSS, NVivo, UCINET, and ArcGIS were used for analysing quantitative and qualitative data, respectively. To conclude, the research framework was emancipatory and the latest methods were used mostly through best electronic tools.

Pioneering aspect of the Study

This study considers the role of health education as an important tool to improve HSB of any given community. Improved HSB will lead to beneficial health promotion of members of the community at large. The study highlights how positive health education of any community can take place. Identification of who is the most connected in the social network among those who can make a difference- the “star”- was most significant. In some case it was a designated health worker, while for others a community leader, or even a community elder. How these “star” can make a difference by acting as a pedagogue was crucial to comprehend. Also, it was challeng-ing to design what kind of content would be useful for better education by these identified “star” in the social network. Better health education can negate the impact of regressive social norms regarding HSB as well. This process of inculcating necessary behavioural changes through health education, will be a boon by acting as a social vaccine.

Relevance of the Study

Covid-19 is an ongoing threat to public health of the nation. Population and health polices try-ing to combat the situation should be sustainable and most importantly acceptable to the community for successful implementation. This research provides a holistic understanding from perspectives of service users as to- who they consider to be facilitator for progressive HSB and what factors can motivate and encourage them to have a positive attitude towards HSB. Most importantly, based on the findings, this study suggests specific social interventions through health education for improving HSB among any community of practice. The integrated approach of incorporating health education as a part of health policy will be very instrumental to initiate behavioral changes among different contextual communities and lead to health promo-tion in the country. The present situation of Covid-19 has re-established the importance of community engagement in dealing with an epidemic situation. The society will immensely bene-fit from the findings as they would be directly involved in suggesting how to foster good be-havioral practices which has long term effect on their health status. By engaging in participatory research, the voices of the community will be incorporated in framing the future policies. Also, whose voice people in the community likes to hear and how they incorporate them is crucial to understand. Moreover, most of the interventions would not require any monetary expenditure on part of the community, which often act as a major hurdle in HSB. The central quest of this study was about learning from the community about how best to help them so that their engagement can be best utilised for their own benefit.


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(Authors: Dr. Aditya Raj and Dr. Papia Raj are Associate Professors at the Indian Institute of Technology Patna)

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