[Book] Principles of Modern Medicine and Health Science                                    

Chapter 2

Health Behavior through Cultural Context and Behavior Change Models in Myanmar (pp. 33 - 56)

Abstract

Health behaviors are influenced by culture, beliefs, and access to healthcare. Myanmar is a deeply spiritual and traditional location; therefore, health behavior needs to be understood through a cultural lens. This chapter discusses the health behavior influenced by culture and psychological models of health behavior including the Health Belief Model (HBM), and COM-B (Capability, Opportunity, Motivation—Behavior). The chapter is based on real world experience working in healthcare community in Myanmar and illustrates how cultural practices impact decisions to seek health care-including delaying care, complex relationships with hearing the health messages, and the continued importance upon individuals accepted practices that came from ancestors. A HBM is reviewed to demonstrate the beliefs about susceptibility and severity of being unwell or ill including the behavioral comprehend, perceived barriers, and self-efficacy to behave differently to seek care, and the COM-B model used for the areas of opportunities, and how (using the HBM and COM-B as an integrated model for guiding theory) capability and motivation were all used to alter attitudes and behaviors strategically for sustainable change through different community capacity building methods. Examples are provided including intervention examples or in real-life scenarios and local strategies through culturally sensitive language adaptation, and indirectly through community dialogue with traditional healers, storytelling, and culturally relevant education methods. The chapter ends with suggestions to use to promote the importance of integrating culturally competent care and traditional practices while incorporating evidence-based practices with implications intended for future projects.

1. Introduction

Health behavior in culturally rich communities such as Myanmar, must be considered in ways that transcend applying universal health models or standardized public health approaches. As a cultural backdrop, culture doesn't function as a mere passive determinant of health; it acts as a determinant that shapes people's understanding of symptoms, assessment of treatment options, and engagement with health systems (Handtke et al., 2019; EuroMed Info, 2019). In Myanmar, where they adhere and understand the deep connections between religious beliefs, communal beliefs, and traditional knowledge systems, cultural determinants need to be included in health behavior models for health interventions to be efficacious.

In rural and peri-urban contexts in Myanmar, for example, individuals may defer engaging with a formal health service because of being influenced by social constructions of illness as related to a spiritual cause or taking on circumstance associated with karmic actions in one's sob. This influences not only the individual's treatment choices, but also when they engage with the health care service, and how much they trust biomedical service providers to ameliorate their health. Furthermore, health education messages that do not respect these cultural frames are rejected outright by individuals as foreign or irrelevant no matter how science-based they are.

The purpose of this chapter is to examine the intersections of culture and health behavior through a synthesis of the lessons learned from fieldwork in Myanmar and several theoretical models such as the Health Belief Model (HBM) (Ogden, 2019) and the COM-B model (Capability, Opportunity, Motivation—Behavior) (Michie et al., 2011). These models offer structured pathways for exploring how beliefs, capabilities, social contexts, and motivations affect health decisions. Ultimately, through consideration of both models in situ with the lived realities of Myanmar communities, this chapter discusses culturally adaptive, sustainable, and respectful strategies that may be employed to effect public health outcomes as well.

2. Cultural Influences on Health Behavior in Myanmar

The culture of Myanmar is not one monolithic idea; it is influenced by Theravāda Buddhism, indigenous spiritual paths, family hierarchy, and oral story. The framework provided by these cultural components influences how people understand health, illness, and healing (EuroMed Info, 2019; Mews et al., 2018). While biomedical paradigms view health, illness, and sometimes healing as distinct areas of treatment or consideration, most communities in Myanmar view health and illness holistically. Illness is often clarified as an imbalance of some spiritual, environmental, or physical force. This worldview frames many people's interpretation of how to treat illnesses, as well as what it means to frame the illness and any possible response to it.

The need for traditional health authority, herbalists, and Buddhist monks to serve as health advisers reflects the cultural attitude toward health and healing. Many people see traditional authority figures for health advice before a doctor or clinic—many families with limited access to formal healthcare or people living in a rural area may not trust western medicine. When someone chooses to seek biomedicine, it is often done in conjunction with traditional paths of spiritual offering, family advice, or herbal remedies.

To use public health intervention strategies that are both accepted and effective, we must understand these cultural frameworks. Disregarding or discounting traditional health practices risks alienating communities and significantly limiting the uptake of important health services. Culturally respectful relationship-building with communities (for example, engaging community elders in the intervention process and including traditional health concepts in educational materials) creates an opportunity for us as health practitioners to mediate between biomedicine and cultural belief systems.

2.1 Traditional Beliefs and Practices

Health traditions in Myanmar are not simply alternative options, but may, in fact, be the primary health options of choice for many. In Myanmar, healing is often understood as a spiritual endeavor rather than purely physiological. For example, anyone with chronic fatigue may feel they have "bad karma" or spirit imbalance, rather than a diagnosable medical condition (e.g., anemia, depression).

These beliefs lead people to spiritual responses such as merit-making, chanting and meditation, or discussions with monks or spirit mediums. Traditional healers may use herbal remedies or perform diagnostic rituals to identify the metaphysical cause of illness. Traditional approaches are deeply ingrained in values and often transmitted orally through generations (EuroMed Info, 2019).

By recognizing and engaging in these practices, health workers can build trust and improve culturally competent care. This might occur most profoundly, for example, by including trusted traditional healers around health initiatives in their community to enhance community buy-in and improve results, particularly in areas such as maternal health, mental health, and chronic disease management.

2.2 Language and Health Literacy Barriers

In Myanmar, language diversity, with over 100 ethnic groups, can be both a strength and a hindrance to healthcare access. Several ethnic minorities including Shan, Karen, Chin, and Kachin speak languages or dialects that differ from the national language, Burmese. This diversity makes a real difference in communication barriers between healthcare providers and patients, especially in locations where medical staff are indigenous and generally unable to communicate in local languages (Wright et al., 2012).

Low health literacy adds to the difficulty. Even patients intending- to comply may not recognize medical words or follow health instructions if health providers cannot explain it in relatable terms. As such, the task of following instructions, such as using medications or care and prevention instructions or chronic diseases generally is greatly hindered.

2.2.1 Translation and Interpretation Service

Providing clinical translation and interpretation is an essential part of equitable and culturally competent forms of healthcare delivery in Myanmar. Considering the country’s extraordinary ethnic and linguistic diversity (more than 100 spoken languages), language barriers to healthcare access, adherence, and patient satisfaction (Handtke et al., 2019) are significant problems. The potential consequences of these barriers include misdiagnoses, misunderstanding medical recommendations or instructions, and a decreased willingness to engage in preventative health behaviors.

Appropriate translation services do not simply translate words from one language into another. Additionally, culturally responsive communication may include how regional dialects, idioms, and symbols reflect the specificity of different ethnic communities. For example, health materials translated into the Shan or Karen languages should include metaphors and terms that are culturally meaningful and familiar to the target community (EuroMed Info, 2019) to promote organic recognition. This is significant for comprehension and for building an alliance in biomedical health services that are often viewed with suspicion in communities that have customary and traditional systems of healing.

In clinical care settings, real-time interpretation is especially important in consultations and explaining diagnoses and treatment plans and medication. Health centers, when feasible, should use bilingual community health workers or professional interpreters in the local ethnic community. Community health workers and professional interpreters facilitate communication with clients and are cultural brokers or mediators that bridge different worldviews (i.e., the provider's and the client's; Mews et al., 2018). Community health workers and interpreters can reduce anxiety, uncertainty, and ambiguity, and enhance feelings of respect and belonging.

In developing multilingual promotional health materials (e.g., brochures, posters, educational videos, and digital health apps), practitioners should adopt a participatory approach. This means working with community members for the design and testing of the health materials so that they are culturally appropriate, correct across languages, relevant, and commonplace in people's lives. An example is nutrition leaflets that included foods from the local area and habitual meals that made it easier for clients to adjust and change their dietary behaviors (Ogden, 2019).

These strategies are also consistent with the Health Belief Model and the COM-B model insofar as they enhance capability by broadening understanding and educational capacity, reduce barriers by limiting miscommunication, and support motivation by reaffirming and respecting cultural identity (Michie et al., 2011; Deng & Stauffer, 2006). Ultimately, translation and interpretation services are fundamentally important to deliver effective, ethical, and inclusive healthcare in multi-lingual societies such as Myanmar.

2.2.2 Storytelling as Health Communication

In Myanmar, storytelling is a vital component of the cultural heritage and is a useful tool for sharing health education. Story is a well-documented form of oral tradition, which has been important in Myanmar, primarily, for the dissemination of knowledge, values, and societal expectations, not just leisure and entertainment. "In Myanmar, stories are tools of education and inspiration, and models of expected behavior" (EuroMed Info, 2019). Stories often carry spiritual, moral, and social messages that reflect a culturally embedded worldview, making those stories ideal for embedding public health information.

Health practitioners in Myanmar can take advantage of this tradition, by embedding culturally appropriate health messages into stories. Story narratives can include culturally recognized figures, names, and community members, like wise elders, monks, and village leaders, and develop relevant scenarios related to the lived experience of the audience. A well-told story with a respected elder managing type 2 diabetes through dietary change and supported exercise by community members has the potential to inspire and create expectations of healthy behavior in a relevant and respectful way (Ogden, 2019; Wright et al., 2012).

Sharing stories in alternative spaces such as community theaters, radio dramas, puppet shows, and school plays makes it more accessible and engaging emotionally. This fits with health communication, which is based on adapting our messages to audiences' interests and cultural contexts so they can grasp the meaning and impact of the message (Handtke et al., 2019) and when we are using storytelling as a cue to action, based on the Health Belief Model (HBM), we can also change how audiences perceive their susceptibility and severity, decrease their perceived barriers, and generate self-efficacy in working towards healthy behaviors (Michie et al., 2011).

And, from a behavior change perspective, storytelling also plays a role in motivation from the COM-B (Capability, Opportunity, Motivation-) framework (Michie et al., 2011). Storytelling in fact is great at inducing an emotive trigger, which research shows is vital in influencing health behavior choices (Mews et al., 2018). In health education, when education is culturally recognizable and at least in some minor way emotionally provoking, audiences are more likely to engage with the message and internalize the message and engage in action. For that reason, this approach isn't just educational, it is transformative in that it is culturally competent, creating both understanding and motivation (Taylor et al., 2021).

 3.  The Health Belief Model (HBM)

The Health Belief Model (HBM) is one of the most utilized theoretical models in health psychology and public health. It was developed to assist in understanding why people adopt—or not adopt—health promoting behaviors, particularly those that are considered preventative in nature (Ogden, 2019, pp. 13–14). The model claims that health behaviors are a function of personal beliefs about health conditions and beliefs about the perceived usefulness of undertaking certain actions to either prevent or address those conditions.

Within Myanmar, a context steeped in traditional cultural values, spiritual beliefs, and variability in access to modern health care services, the relevance of the HBM is particularly noteworthy. Traditional ideas within Myanmar, such as karma, astrology, or the merit-making religious practices, can influence how people think about illness, and interact with this as either complementary or antagonistic to a biomedical approach to health. Thus, developing an understanding of HBM components can aid in creating effective and culturally sensitive health communications and behavior change interventions.

3.1 Key Constructs in Detail

• Perceived Susceptibility: This is the individual's belief regarding the likelihood of experiencing a health problem; in Myanmar, many people may assume illness is a result of fate or karma from a past life, rather than due to a modifiable risk. Such beliefs will lead to underestimating their own risk. For example, smokers would not believe they had lung cancer risk based on their knowledge of others who smoke and maintain their health (Ogden, 2019, p. 14).
• Perceived Severity: This is the extent to which the individual believes their health problem and its consequences are dangerous. Because a health problem does not have palpable symptoms (e.g., hypertension), it may elicit a disregard for its severity. Chronic diseases (e.g., hypertension, type 2 diabetes) may not even be perceived as serious until complications arise. The biomedical model may be so foreign to some population segments that such diseases do not resemble illnesses to them, nor do they understand their severities (Ogden, 2019, p. 14).
• Perceived Barriers: These are characteristics that inhibit a person from engaging in health behavior. In Myanmar, perceived barriers include financial limits, transportation, limited access to healthcare, and language or literacy problems. Moreover, stigma may also inhibit people from using mental health services or revealing chronic conditions such as tuberculosis or HIV (Ogden, 2019, p. 14).
• Self-Efficacy: This is the belief in one's capacity to engage in a health action. Low self-efficacy can come from: prior failures, social norms, or lack of support. Developing self-efficacy with skill development initiatives, peer mentoring and support of environments is essential for motivating and helping people change health behaviors for the long-term (Ogden, 2019, p. 14).
• Cues to Action: These can be internal or external cues that ignite health behavior. In Myanmar, cues to action can include advice from respected elders, religious obligations to care for oneself, or public health campaigns in the community. Cues to action can also include seeing someone else recover after lifestyle changes, and public service announcements in their local dialect (Ogden, 2019, p. 14).

3.2 Application for Smoking Cessation: Case Study

Mr. KS is a pseudonym for 35-year-old male from a peri - urban area outside Mandalay. He began smoking while in his teenage years when he picked up the habit to socially affiliate and because social norms linked masculinity and smoking. Over the years that have passed since he first started smoking, he developed a reasonable dependency and never considered he was "at risk" from smoking tobacco. However, because of the smoking information, stories, and images that the health fair provided, He perceived his susceptibility (because he was smoking) and the severity (because he saw powerful evidence from tobacco survivors who developed throat cancer and chronic lung disease) of the smoking risks increased (Aung et al., 2025).

At a free health screening conducted at the charity clinic, Mr. KS's health screening results showed he had high blood pressure. One of the health for a healthcare worker explained cardiovascular disease in terms of smoking and reinforced how quitting could save him from the current problems he had with his blood pressure. With help, Kyaw Swar also began attending peer support groups and started accepting nicotine replacement therapy guidance. Program options helped to reduce the barriers toward quitting smoking and increase his self-efficacy. Kyaw Swar also experienced regular follow-ups to the fine events in the community recognition program for remaining smoke-free as cues to actions. Kyaw Swar's journey expresses the use of integrated and synergistic elements of HBM to support sustainable behavior change (Ogden, 2019, pp. 13 - 14). 

4. Applying the COM-B Model to Obesity in Myanmar

The COM-B model that Michie et al. (2011) created is an effective model for implementing behavior change that focuses on Capability, Opportunity, and Motivation. In relation to Myanmar, this model is especially useful, as the country faces a growing obesity issue compounded by rapid urbanization increased sedentary lifestyles, and the easy availability of ultra-processed food. Urban areas and peri-urban areas of the country are especially impacted by the globalization of dietary and physical activity behaviors, leading to rising weight and obesity.

Drawing on ten years of clinical experience as a registered nurse provide strong support for obesity as a substantial, and growing, health concern in Myanmar. Much of the adult population is overweight or obese. Globally 9.0% of adult women and 5.3% of adult men are obese, according to the Global Nutrition Report (Myanmar Nutrition Profile - Global Nutrition Report, n.d.). The prevalence of obesity in Myanmar reflects that this is an issue that is serious in nature, although it is slightly lower than this wider regional average. To target this obesity issue in Myanmar, culturally appropriate interventions are required that take into consideration the broader social, environmental and behavioral determinants of healthy and unhealthy dietary and activity behaviors.

4.1 Enhancing capability

Capability refers to the psychological and physical capability of the individual to perform the behavior. Capability is more than just having the knowledge and skills to perform a behavior, it must involve confidence and having practice within your daily life to transfer those knowledge and skills effectively (Bandura, 1986; Michie et al., 2011).

4.1.1 Nutrition Education and Health Literacy

In Myanmar, the lack of reliable health information or culturally located health information contributes to poor dietary decision-making. Most people have very little knowledge about the nutrition content of the foods they eat regularly, particularly processed foods high in sugar, salt, and fat. Moreover, hazards related to poor nutrition like chronic diseases (e.g., obesity, hypertension, type 2 diabetes) are underappreciated or misunderstood (Myanmar Nutrition Profile, n.d.; Chobanian et al., 2003).

Nutrition education must be situated and conducted locally in their language with messages that are easy to understand and culturally relevant. Messages could include pictures, posters, pictograms and graphic storyboards, that aid understanding, especially in communities with low literacy. Practical demonstrations, such as community cooking demonstrations using locally grown and affordable foods could also help families prepare nutritious meals in a way that respects the traditional tastes and preparation processes. The demonstrations can also provide guidance about portion sizes and suggest ways of reducing unhealthy ingredients while keeping the food culturally relevant.

In addition, health literacy means being able to engage critically with food promotional messages and nutritional labels when they exist. Community health workers and schoolteachers, share strong communication channels, can be agents for communicating this knowledge and building awareness and self-efficacy (Handtke et al., 2019; Rosenstock, 1974).

4.1.2 Physical Activity Skills and Community Exercise

Physical capacity provides a core enablement for adopting an active lifestyle, but many people - and particularly in urban Myanmar - lack the fitness, skills or motivation to support integrated physical movement into their daily lives. Cities are becoming more urbanized, and work is being sedentary. Local, spontaneous forms of movement, like walking to work or working on the farm, continue to decrease.

Structured programs could build physical competence and build people’s confidence to engage with movement. Some initiatives might include school-based physical education that is inclusive of all skill levels, and adult exercise programs through community centers or religious compounds. Examples might include early morning community group walking, participating in traditional Myanmar dance, low-impact aerobics classes for older adults, etc.

Sustainability is reliant on community buy-in and engagement. If  local volunteers were trained as representatives to be exercise to be ambassadors (with fitness education) or peer trainers, where community members might be influenced positively to participate and be ‘active’ together in and associated with many physical activity domains, this would wholly increase not only an individual person’s capacity to engage, but ultimately a sense of social (and communal) motivation (Prochaska & DiClemente, 1983; Ajzen, 1991).

In addition, where physical activity skills have been included into routine health program delivery (which would be valid for community health programs aimed at smoking cessation or hypertension management) physical activity would provide integrated capacity to provide a cumulative series of changes for behavioral change (Taylor et al., 2021; WHO, 2024).

4.2 Expanding Opportunity

Opportunity encompasses all outside factors—physical and social—that determine whether a behavior is possible or called for. This includes availability of resources, environmental design, cultural influences, and social support structures. Even individuals with motivation and capability are unlikely to adopt and maintain healthy behaviors on their own in the absence of supportive environments (Michie et al., 2011).

4.2.1 Environmental Access to Healthy Foods

Access to healthy foods (availability and affordability) is a major obstacle to healthy eating in Myanmar, particularly for people living in low-income urban and peri-urban areas. Fresh fruits, vegetables, and whole grain foods are often more expensive than calorie-dense, processed foods, are advertised heavily, and are easy to prepare (Myanmar Nutrition Profile, n.d.)

Addressing this gap requires multi-sectoral action. Health sectors can work with local markets, local vendors, and the agricultural development sector to subsidize healthy staples and promote other nutrient-rich alternatives. For example, establishing food labeling schemes can help consumers choose healthier options compared to calorie-dense foods. Establishing vendor incentives (such as cancelling fees to sell fresh fruits and vegetables) in local markets with no cost to the vendor can encourage sales of fresh produce.

Additionally, community-supported agriculture programs (CSAs), rooftop gardens, and urban agriculture initiatives can increase access to healthy foods (by increasing local food production) and reduce reliance on imported foods, build food sovereignty and promote resilience in the community where consumers are gathered (Mews et al., 2018). Schools and centers of faith can also be the main instigators of programs to promote healthy eating when they adopt systems of healthy food production (urban gardens, food programs) in an institutionalized way or when they reach young children, so that good eating habits were established from an early age.

4.2.2 Physical Activity Infrastructure

The physical environment (built and natural) is important in shaping exercise behaviors, as many areas of Myanmar have inadequate and limited public spaces, like parks, sidewalks, and community facilities, to allow for safe and consistent physical activity, and this is often more pronounced for women, children, and the elderly population.

Urban planning needs to incorporate health-promoting infrastructure such as walking and cycling paths, children's playgrounds, and “fitness corners” in residential areas. In circumstances where physical infrastructure cannot be established permanently, “pop-up” infrastructures (Deng & Stauffer, 2006), as an example, stationing street closures for exercise groups on weekends or providing mobile fitness facilities, can be made available to encourage physical activity.

Local governments, in collaboration with public health authorities, have the option of utilizing a “Healthy Cities” model to create environments that encourage active living. Investment in infrastructure enhances community physical activity levels and well-being but also builds community connection and reduces social isolation (WHO, 2024).

4.2.3 Cultural and Social Soiling

Social opportunity is largely culturally bound too through cultural values, social expectations, and peer influences. In Myanmar, for example, while body size and shape may be linked to indicators of wealth and health (EuroMed Info, 2019; Handtke et al., 2019), weight loss efforts are often challenged by the stronger cultural belief that being less than thin could indicate socio-economic disadvantage or ill health and thus make for less fit populations. Similarly, interventions focused on weight management are likely to also be met with different levels of resistance and availability of services, due to cultural values placed on physical activity, engagement of youth's parents and monitoring their impact, leading us back again, to problems of mediated white moralities in environments of ease in simple but direct when considering available alternatives of meaning in a local and historical sense. By changing social opportunities, it is hoped to change cultural beliefs and social norms in children and adults. This involves prioritizing culturally sensitive messaging through trusted and known local collectivities and representatives (monks, teachers, community elders, and local personalities) to reflect and can create ideas reflecting trends of social engagement. Noticing and acknowledging healthy role models with fun, health, and life engagement over thinness should be role modeled through culturally competent messaging also.

 Further to this, the media, particularly radio and television services, can reach even rural level communities as 96% of Myanmar's populations have access to a working radio (MMR, 2020) and developed nations' creation of accessible media usage having paved a way to develop messages best suited to local people's perception and meaning. Schools, religious services, and community clubs may facilitate discussions relating to health, wellbeing, and body image, enabling youth in developing inclusive conversations and collective opinions on health, thereby lessening visibility of social norms (HEATHERTON et al., 1991). The development of social support groups, particularly women, to share and received feedback on case study and help them lessen stigma of gaining confidence in managing and modifying their lifestyles can also play a significant role in reducing the conditions that contribute to feel stigmatized by others and increase levels of support to pursue lifestyle changes (Wright et al., 2012; Ogden, 2019).

4.3 Strengthening Motivation

Motivation consists of internal processes that energize, direct, and sustain behaviors. Motivation includes reflective or conscious motivation (goals, beliefs, evaluations), and automatic motivation (emotions, impulses, habits, and social identity) (Michie et al., 2011; Bandura, 1986). Strengthening motivation is essential for overcoming inertia, particularly for health behaviors that involve sustained effort, such as a change to your diet or increasing your activity.

4.3.1 Emotional Engagement through Storytelling

Narratives are a way of influencing behavior in a variety of ways, because they draw on emotional responses, values, and social identity. Stories can be informed by local context, culture, and history. In the context of Myanmar, where storytelling is a culturally rich tradition in oral storytelling, Buddhist teachings or philosophies, and community theatre, we can effectively apply these assets in health promotion campaigns to demonstrate real experiences of people changed through adopting a healthier lifestyle, especially if they are of similar ethnic, linguistic, or socio-economic backgrounds (Ogden, 2019).

To demonstrate the value of storytelling in health promotion, we could use testimonies of parents that switched from continuous consumption of processed snack foods to home cooked family meals, or older people that have maintained physical activity by walking daily to engender some mobility. These stories can be delivered at the community level through gatherings, illustrated poster presentations, air on local radio stations, or via Facebook or Instagram. This is useful, because these narratives offer relatable, humanized examples that can afford both an emotional and cognitive connection to real life experiences (Prochaska & DiClemente, 1983).

Storytelling is also relevant because it fits Bandura's (1986) social cognitive theory, and the most relevant aspect of his theory is that we learn through seeing others--when we see 'someone like us' succeed we develop feelings of self-efficacy an important pre-condition of self-efficacy is to identify with the peer success that was observed; this is 'self-efficacy', which is a primary antecedent effecting sustained behavior change.

4.3.2 Incentives and Recognition

Motivation is derived from both intrinsic rewards (like personal appreciation, greater quality of life) and extrinsic incentives (like public praise for success, prizes). Recognition programs (like health champions of the month, fitness challenge milestones, or healthy meal preparation competitions) can engage and foster friendly competition for interest groups, communities, schools, or villages.

In addition, initial participation can also be provided by financial or material incentives such as discounted gym membership to sign up, free health screening, or discount on the purchase of healthy foods. More importantly, symbolic rewards like certificates, badges, or public praise during community events may be perceived as equivalently worthy in collectivist culture (like in Myanmar) wherein social status and community approval are powerful motivators (Ajzen, 1991; Rosenstock, 1974). Events, including "Healthy Village Festivals" or healthy competitions among townships on weight reduction or steps, could also lead to group participation and pride in group accomplishments.

4.3.3 Peer Support and Modelling

Social networks can influence individual behavior. In Myanmar, communal living, strong family ties, and a respect for elders present a strong opportunity for peer-based interventions. A peer support group would be established by a trained community health worker or other local role model and the support group would provide emotional support, group problem-solving, and the measure of accountability needed for sustainable behavior change (Wright et al., 2012).

Peer support groups are especially helpful for populations facing barriers to participation, such as women with caregiving roles, or older adults who may need help getting to the support group meetings. Learning and sharing new recipes and group exercise helps give participants a sense of belonging and promote encouragement among participants.

Modelling is also important. If local leaders, teachers, or even religious leaders demonstrate and engage in (and therefore model) healthy behaviors such as drinking water instead of sugary drinks and walking instead of taking transportation, these behaviors could be anchored in local social norms and changes can also be validated. As Bandura (1986) suggested, the likelihood of adopting a behavior is greatest when it is modelled by a person deemed credible and one that is perceived as similar by the person observing.

5. Strategy Focus: Motivation First

Motivation is the driving force in the COM-B model that converts knowledge and opportunity into action. Motivation reflects an individual's underlying values, which are heavily influenced by cultural, religious, and community factors. Therefore, health decisions, including health behaviors, are more than just an individual decision. They involve social expectations regarding personal and family actions, spiritual beliefs, and long-standing family obligations and roles.

5.1 Cultural Motivation

In Myanmar, when individuals become sick, they often attribute their ill health to karma or spiritual imbalance. Therefore, even when it comes to the motivation to adopt healthy behaviors, the motivation may not be based purely on medical advice, but rather the duty to their family, a desire to protect their spiritual wellbeing, or cultural expectations. Local leaders, including monks, often have more influence over health decisions than a health professional.

5.2 Storytelling as a Motivational Tool

Stories are a powerful motivation for change in Myanmar. Health messages, conveyed through stories from the community, examples, and personal circumstances, have a strong resonance with the audience. For example, a local story about someone's individual recovery from diabetes through changes in their lifestyle is likely to motivate individuals to change their behaviors more than facts and figures. Storytelling in local dialects, utilizing characters that they know, or that they can relate to, lessens the distance between recommendation and action. 

5.3 Applying Motivational Interviewing

Nurses and educators can utilize motivational interviewing (MI) as a strategy that engages patients and clients in a familiar, respectful, supportive manner. In MI, clients explore "their" reasons for change. This is especially useful in the Myanmar context, where patients may be shy, or have deference to authority figures. MI can foster trust, particularly when it is carried out in a culturally sensitive and compassionate way.

5.4 Peer and Community Influence

When people feel supported by their community, it becomes a motivational force. Peer-led hospice groups, such as walking clubs or smoking cessation groups, are useful in helping to solidify positive habits. In much of Myanmar, the spread of health behaviors is based on social networks, and social support in groups and public recognition are important in maintaining change.

5.5 Practical Recommendations

Strategies to assist in elevating and sustaining motivation in Myanmar include:

• Culturally linked motivators: Health messages that appeal to cultural beliefs, values, and norms, including mindfulness, karma, and family responsibility
• Apply storytelling: Use of true, local stories in educational materials and campaigns
• Training in MI: Network in your nurses or volunteer group to learn (or polish) a skill in MI to help support motivation in patterns
• Peer support: Encourage group processes, where gains and losses can be reviewed together
• Celebration of successes: Public praise and minor rewards can be helpful in keeping motivation levels up. 

6. Integration and Recommendations 

The combination of the Health Belief Model (HBM) and the COM-B framework usefully addresses the environmental contexts and identification of belief systems involved in behavior (HBM) as well as the structures related to these which enable actions or inhibit actions (the COM-B framework). By using HBM and COM-B framework together they provide powerful planning options for project planners to design culturally sensitized, multidimensional health promotion interventions.

To apply this in Myanmar:

• Include Traditional Healers and Monks in Health Promotion: Traditional healers and monks have a form of credibility that can be significant in helping to change behaviors (Wright et al., 2012, p. 60).
• Provide Health Education in local languages and symbols: Abstract concepts can become associated with the local language and become immediately relevant by way of Oral storytelling narration, songs and metaphors. For example, the idea of balance in a diet considered through a Buddhist lens of the Middle way in Buddhism (Wright et al., 2012, p. 62).
• Provide Emotionally and Culturally Engaging 'Consumption': Health promotion communication can include idioms, humor, and aspirational role models which are relevant to local consumption (Wright et al., 2012, p. 64).
• Communication Between Biomedical and Traditional Models of Health: By situating the spiritual beliefs of individuals and aligning them with the wider public health effort, health professionals can initially build rapport with the community and engage people more widely (Ogden, 2019, pp. 13–14).
• Foster Interdisciplinary and Community-Based Research: Continued collaboration among researchers, local providers, and community stakeholders is critical to ensure the interventions are culturally relevant and effective. Community-based participatory research (CBPR), allows for a more granular understanding of local beliefs and barriers that may have been excluded from outside researchers, improving program design and future sustainability (Mews et al., 2018; Handtke et al., 2019).

Table 1. Key Constructs of the Health Belief Model (HBM) and Their Relevance in the Myanmar Context

Note. This table summarizes the constructs of the Health Belief Model (HBM) and their cultural interpretations in Myanmar. Examples illustrate how traditional beliefs and healthcare infrastructure impact perceived health risks and actions.

Declaration of Interest

The authors declare that there are no conflicts of interest. They have no financial, personal, or professional relationships with any organizations or individuals that could be perceived to have influenced the content or outcomes of this book chapter. All aspects of the research and writing were conducted independently and without external influence.

Funder Statement

This book chapter did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors conducted this work independently without external financial support.

Author Contributions

• Htet Lin Aung led the conceptualization and drafting of the book chapter. He was responsible for compiling, editing, and preparing the final version of the manuscript.
• Htay Thiri contributed to write § 3 in the chapter.
• Nway Yee Win wrote § 4 of the chapter.
• All authors participated in the review and approval of the definitive version of the chapter.

ABOUT THE AUTHORS

Htet Lin Aung is a Clinical and Health Science Research Fellow affiliated with Harvard Medical School in Boston, United States. He is also connected with the Department of Health Science at the University of the People in Pasadena, United States. His academic and research interests include clinical research, public health, neurology, and evidence-based healthcare education with a commitment to global health equity, he focuses on advancing inclusive digital learning and improving access to healthcare knowledge for underserved populations.

Htay Thiri is a former instructor at the Nursing Training School in Falam, Myanmar. She is a graduate of the University of Nursing, Yangon, and has played a key role in training nursing students in both theoretical instruction and hands-on clinical experience. Her work has centered on improving healthcare education in  Myanmar, with a strong emphasis on building the capacity of young healthcare professionals and promoting quality nursing standards in challenging settings.

Nway Yee Win is a registered nurse with more than 10 years of professional experience in both hospital-based and community health settings. She is also a graduate of the University of Nursing, Yangon, and has contributed significantly to maternal and child health, community health outreach, and health education programs. Her dedication to patient-centered care and grassroots health promotion reflects her strong commitment to improving public health outcomes and empowering local communities through nursing leadership.