CHAPTER 2 Culture , Behavior , and Health

© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION CHAPTER 2 © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Anton Balazh/Shutterstock NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Culture, Behavior, and Health © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Susan C. DISTRIBUTION Scrimshaw and Sandra D. Lane NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR “If you wish to help a community improve its health, you must and integrative approaches was demonstrated by a learn to think like the people of that community. Before asking U.S. nationwide survey, demonstrating that 33.2% a group of people to assume new health habits, it is wise to © Jones & Bartlett Learning, LLCof adults used such treatments © Jones & Bartlett LLC (NCCIH, 2017).Learning, The ascertain the existingNOT habits,FOR how these habitsOR are linked to one global importance of those is evidenced SALE DISTRIBUTION NOTapproaches FOR SALE OR DISTRIBUTION another, what functions they perform, and what they mean to by the World Health Organization’s (WHO) major those who practice them” (Paul, 1955, p. 1). report, WHO Traditional Medicine Strategy 2014– 2023, and the establishment of 21 regional centers for eople around the world have beliefs and behavthe study of traditional medicine to strengthen the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC iors related to health and illness that stem from evidence base and promote quality. NOTcultural FOR SALE OR DISTRIBUTION FOR SALE ORwe DISTRIBUTION forces as well as individual experiences In NOT the past three decades, have moved from and perceptions. A 16-country study of community rejecting traditional health beliefs and practices to perceptions of health, illness, and primary health care understanding that culturally rooted, traditional healfound that in all 42 communities studied, people used ing approaches are valued and used, often in combinaboth the Western biomedical system and indigenous tion biomedicine. At this time there is increasing © Jones & Bartlett Learning, LLC © Jones & with Bartlett Learning, LLC practices, including indigenous practitioners. Also, recognition that such approaches can and should be NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION there were discrepancies between which services the rigorously evaluated. Nevertheless, appreciation for governmental agencies said existed in the community cultural knowledge and behaviors in the planning and and what was really available. Due to positive expeexecution of health programs often falls short of the riences with alternative healing systems and shortmark. Experience has shown that when health pro© Jones & Bartlett Learning, Jones Bartlett Learning, LLC comings in the Western biomedical system, people LLCgrams fail to recognize©and work&with indigenous NOT FOR OR DISTRIBUTION NOT ORgoals. DISTRIBUTION relied on both (Nichter, 2008;SALE Scrimshaw, 1992). In beliefs and practices, they also FOR fail to SALE reach their recognition of the widespread use of nonbiomedical Similarly, research to plan and evaluate health programs therapies, the U.S. National Institutes of Health estabmust take cultural beliefs and behaviors into account lished a center for the study of alternative and compleif researchers expect to understand why programs are mentary medicine, which is now called the National not working and determine whatLearning, to do about LLC it. © Jones & Bartlett Learning, LLC © Jones & Bartlett Center for Complementary and Integrative Health This chapter social sciences— NOT FOR SALE OR DISTRIBUTION NOT FORdraws SALEon ORthe DISTRIBUTION (NCCIH, 2014). With a yearly budget of $124.1 milparticularly, anthropology, psychology, and sociology— lion, the NCCIH’s mandate is to provide research evito examine the cultural and behavioral parameters dence of efficacy for nonbiomedical treatments, such that are essential to understanding global health as acupuncture, herbal preparations, meditation, and efforts. It complements the Understanding and Acting © Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLC and Health Equity spiritual healing. The popularity of complementary on&Social Determinants of Health P NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 43 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 44 Chapter 2 Culture, Behavior, and Health chapter, which covers social, political, and economic education and experiences, and as conditions change © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, forces that affect health, butLLC does not go deeply into around them (e.g., armed conflicts, economic changes SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the cultural components of health. This chapter begins NOT in aFOR country or region, political changes). This is a with some key concepts from the field of anthropolhelpful viewpoint when looking at cultural change on ogy and the subfield of medical anthropology. It conboth individual and group levels. tinues with brief descriptions of the various types of Medical anthropologists observe different cultures health belief systems and healers & around the world. their perspectives on disease illness. exam- Learning, LLC © Jones Bartlett Learning,and LLC © and Jones & For Bartlett Next, some key theoriesNOT of health behavior behavple, they look at the biological and theFOR ecological aspects FOR SALEand OR DISTRIBUTION NOT SALE OR DISTRIBUTION ioral and cultural change are described and discussed. of disease, the cultural perspectives, and the ways in Issues of health literacy and health communication which cultures approach prevention and treatment. are then addressed, along with the myriad health promotion strategies available. Methodological issues are Insider Versus Outsider Perspectives © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC presented, followed by a case study of acquired immuNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR To understand the cultural context ofDISTRIBUTION health, it is nodeficiency syndrome (AIDS) and a commentary essential to work with several key concepts. First, the on the international efforts to curb the Ebola virus concepts of insider and outsider perspectives are usepandemic in West Africa. Another case study examful for examining when we are seeing things from our ines the use of rapid assessment methods to guide the point of & view and when we are trying an improved nutritional cereal for © Jones © Jonesintroduction & BartlettofLearning, LLC Bartlett Learning, LLCto understand someone else’s view of things. The insider perspective infants and OR children in Ghana. The chapter concludes NOT FOR SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION (emic, in anthropological terminology) shows the culby summarizing how all of these areas need to be conture as viewed from within. It refers to the meaning sidered in global health efforts. that people attach to things from their cultural perspective. For example, the view that worms (Ascaris) © Jones & Bartlett Learning,inLLC Jones & Bartlett children are normal and are©caused by eating sweets Learning, LLC ▸ NOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION is a perspective found within NOT some cultures. The outsider perspective (etic, in anthropological terminology) refers to the same thing as seen from the outside. Rather than meaning, it conveys a structural approach, Health and illness are defined, labeled, evaluated, and or something© as Jones seen without understanding its meanacted upon in the context of culture. In the nineteenth © Jones & Bartlett Learning, LLC & Bartlett Learning, LLC ing for a given culture. The outsider perspective can century, anthropologist Edmund Tyler (1871) defined NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION also convey an outsider’s meaning attached to the culture as “that complex whole which includes knowlsame phenomenon. For example, this view might edge, belief, art, morals, law, custom, and any other hold that Ascaris infection is contracted through eggs capabilities acquired by man as a member of society.” in contaminated soil or foods contaminated by conSince those early days of anthropology, there have tact with&that soil; theLearning, eggs get into the soil through © Jonesbeen & Bartlett Learning, LLC © Jones Bartlett LLC literally hundreds of definitions of culture, but fecal wastes from infected individuals. The concepts NOT FOR SALE ORfollowing DISTRIBUTION most have the concepts in common (Board NOT FOR SALE OR DISTRIBUTION of insider and outsider perspectives allow us to look on Neuroscience and Behavioral Health, 2002): at health, illness, and prevention and treatment sys■ Shared ideas meanings and values tems from several vantage points; to analyze the dif■ Socially learned, not genetically transmitted ferences between these perspectives; and to develop ■ Patterns of behavior that are&guided by Learning, these © Jones Bartlett LLC © Jones & Bartlett approaches that will work within a cultural context Learning, LLC shared ideas, meanings, and values NOT FOR SALE OR DISTRIBUTION (Scrimshaw & Hurtado, 1987).NOT FOR SALE OR DISTRIBUTION ■ Often exists at an unconscious level To continue the example, in Guatemalan vil■ Constantly modified through “lived experiences” lages where the previously mentioned insider beliefs The last of these concepts—lived experiences— about Ascaris prevailed, researchers learned that some comprises the experiences that people (and sometimes mothers believed that worms are normal and are not © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC groupsNOT of people) through they live their lives. a problem unless become agitated. In their view, FORgo SALE ORasDISTRIBUTION NOTthey FOR SALE OR DISTRIBUTION These experiences modify their culturally influenced worms live in a bag or sac in the stomach and are beliefs and behaviors (Garro, 2000; Mattingly & Garro, fine while so confined. Agitated worms get out and 2000). As a consequence, culture is not static on either appear in the feces or may be coughed up. Mothers the group or the individual level; rather, people are also believed that worms are more likely to become © Jonesconstantly & Bartlett Learning, LLC allows for cultural © Jones Bartlett Learning, LLC the thunder changing. This concept agitated & during the rainy season, because NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION change as people migrate to a new setting (commuand lightning frighten them. From an outsider pernity, region, or country), as people acquire additional spective, this relationship makes sense: Sanitation is Basic Concepts from Medical Anthropology © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Basic Concepts from Medical Anthropology more likely to break down in the rainy season, so there 45 It is also possible for someone to feel ill and for Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC and more diarrheal © is more chance of infection disthe Western biomedical system not to identify a NOT FOR SALE OR this DISTRIBUTION NOT FOR SALE OR DISTRIBUTION disease. When occurs, there is a tendency for ease, which will reveal the worms. Western-trained healthcare providers to say that nothThe dilemma for the health workers, in the Guaing is wrong or that the person has a “psychosomatic” temalan worms example, was to get the mothers to problem. Although both of these statements can be accept deworming medication for their children, other explanations this because most of © theJones time worms were perceived as LLCcorrect, there are several & Bartlett Learning, © Jones & BartlettforLearning, LLC occurrence. One possibility that Western biomednormal. If the health workers to tell mothers NOT FOR tried SALE ORthe DISTRIBUTION NOTisFOR SALE OR DISTRIBUTION ical science has not yet figured out how to measure a that their beliefs were wrong, the mothers would readisease or disorder. Recent examples of this phenomson that the health workers did not understand illness in a Guatemalan village and would reject their proenon include chronic fatigue syndrome and fibromyposal. The compromise was to suggest that the chilalgia: These conditions were labeled “psychosomatic” © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC dren be dewormed just before the rainy season, so as at one time, and remain incompletely understood NOT FOR SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION to avoid the problem of agitated worms. It worked.* by biomedicine, butSALE now are defined by measurable The insider–outsider approach leads to another deviations from a biological norm. Similarly, painful set of concepts. According to the Western biomedical menstruation was labeled “subconscious rejection of definition, disease is the outsider perspective—that femininity” in the past, but is now associated with is, diseaseLearning, is an undesirable elevated prostaglandin levels and can be helped by © Jones & Bartlett LLC deviation from a measur© Jones & Bartlett Learning, LLC able norm. Deviations in temperature, white blood NOT cell FOR administration a prostaglandin inhibitor. NOT FOR SALE OR DISTRIBUTION SALE ORofDISTRIBUTION count, red blood cell count, bone density, and many othA more intriguing set of conditions are what ers are, therefore, seen as indicators of disease. Illness, in anthropologists have called “culture-bound syncontrast, means “not feeling well.” Thus, it is a subjective, dromes” (Hughes, 1990; Simons, 2001; Simons & insider view. This sets up some immediate dissonances Hughes, 1985), but that might be better described as © Jones & Bartlett Learning, LLC“culturally defined syndromes. © Jones & Bartlett Learning, LLC between the two views. It is possible to have an unde” Culturally defined synNOT FOR SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION sirable deviation from a Western biomedical norm and dromes are an insider way of describing andOR attributto feel fine. Hypertension, early stages of cancer, human ing a set of symptoms. They often refer to symptoms immunodeficiency virus (HIV) infection, and early of a mental or psychological problem, but a physiostages of diabetes are all instances where people may feel logical disease may also exist, posing a challenge to well, yet have a disease. Thus, healthcare providers must the health practitioner. For example, Rubel,LLC O’Nell, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, communicate the needOR for behaviors to “fix” something and Collado-Ardon (1984)OR found that an illness NOT FOR SALE DISTRIBUTION NOT FOR SALE DISTRIBUTION that people may not realize is wrong. called susto (“fright”) in Mexico corresponded with This potential conflict becomes even more critisymptoms of tuberculosis in adults. If people were cal when we think about the role of risk factors and told there was no such thing as susto and that they prevention in contemporary biomedical practice. had tuberculosis, they rejected the diagnosis and the © Jones & Bartlett Learning, LLC the potential risk of future © Jones & Bartlett Learning, LLC Laboratory tests can reveal treatment on the grounds that the doctors obviously NOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORabout DISTRIBUTION disease—for example, elevated low-density lipoproknew nothing susto. This situation was comtein cholesterol (LDL) level, which may be predictive plicated by the fact that tuberculosis was viewed as of an increased possibility of future cardiac or arterial serious and stigmatizing. The solution was to discuss disease. To reduce the possibility of such future disthe symptoms with people and mention that Westease, the patient © might be labeled as “high risk” and symptoms Jones & Bartlett Learning, LLCern biomedicine has a treatment © Jonesfor & those Bartlett Learning, LLC prescribed medication to take daily for years. Even (Rubel et al., 1984). Susto may also be used to describe NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION among those persons with substantial education, it other sets of symptoms—for example, those of diaris difficult to understand how to interpret risk and rheal disease in children (Scrimshaw & Hurtado, probability when one feels well and does not have a 1988). Other examples of culture-bound syndromes disease. The widespread rejection of vaccines by some include evil eye (Latin America, the Mediterranean), © Jones & Bartlett Learning, LLC JonesEast & Bartlett LLC well-educated parents represents another example of zar (the©Middle and NorthLearning, Africa), brain fag or NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the power of insider (emic) understandings. The failbrain fog (West Africa), amok (running amok) or ure of public health advocacy for vaccines to convince mata elap (Indonesia, Malaysia, and the Philippines), latah (Malaysia and Indonesia), p’a leng (China), and such parents of the outsider (etic) view of the safety ataque de nervios (Puerto Rico) (Guarnaccia et al., and value of vaccines demonstrates the power of cul2010; Simons &Learning, Hughes, 1985). tural beliefs even in the face of scientific evidence. © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION * We are indebted to Elena Hurtado of Guatemala for this example. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 46 Chapter 2 Culture, Behavior, and Health A recent example of what appears to be a new culture depend on its teaching its children to accept © Jones & Bartlett Learning, LLC © Jones & Bartlett syndrome Learning, culture-bound hasLLC emerged among refugee the culture and on its members feeling that it is a good FOR OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION children in Sweden whose families faced deportation NOT thing. In SALE the context of cross-cultural understand(Aviv, 2017). Uppgivenhetssyndrom, or resignation ing, ethnocentrism poses a barrier if people approach syndrome, afflicting hundreds of children on the eve a culture with the attitude that it is inferior to their of their families’ deportation, involves loss of speech own culture. One of anthropology’s key contributions and voluntary movement. The children exhibit no toLLC how we view the world is cultural relativism, which Learning, LLC © Jones & Bartlett Learning, © Jones & Bartlett neurologic pathology inNOT clinical tests,SALE yet theyOR must be refers to the idea that the beliefs, behaviors, and values FOR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION fed, washed, and turned in bed by caregivers, as if they of each culture make sense within that culture. From are comatose. this perspective, each culture has developed its own Not all individuals within a group will necessarily ways of solving the problems of how to live together; have the same beliefs and behaviors. With culturally how to obtain the essentials of life, such as food and © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC defined syndromes, it is essential for an outsider to ask shelter; how to explain phenomena; and so on. CulNOT FOR SALE OR DISTRIBUTION NOT SALE OR DISTRIBUTION about the symptoms associated with the illness and to tural relativism has FOR been misunderstood in contemproceed with diagnosis and treatment on the basis of porary discourse as implying that we should not hold those symptoms. This is good practice in any event, beliefs about “right” and “wrong,” especially about because people often make a distinction between the culturally patterned practices that may cause harm. of a disease or illness and For example, in partsLearning, of Africa and the Middle East, © Jonescause & Bartlett Learning, LLCits symptoms. Even if © Jones & Bartlett LLC the SALE perceived is inconsistent with the Western NOT female infants or young girls may have their genitals NOT FOR ORcause DISTRIBUTION FOR SALE OR DISTRIBUTION biomedical system, a disease can be diagnosed and partially or completely amputated, which is sometimes treated based on the symptoms without challenging called “female genital mutilation” by Western activpeople’s beliefs about the cause. When people’s beliefs ists seeking to end the practice. Lane and Rubinstein about the cause are denied, they may reject prevention (1996), in their analysis of the practice, advocated that © Jones & Bartlett Learning,cultural LLC relativism means that© Jones & Bartlett Learning, LLC or treatment measures entirely (Nichter, 2008). we should try to underNOT FOR SALE OR DISTRIBUTION NOT FORthe SALE OR DISTRIBUTION The term Western biomedicine is used throughstand the cultural explanations driving practice out this chapter because a term like modern medicine and the context in which it occurs. At the same time, would deny the fact that there are other medical systhey emphasize that understanding why and how this tems, such as Chinese and Ayurvedic medicine, that behavior occurs does not mean that we condone the have modern forms. Indigenous medical system is used practice. Indeed, familiarity with the cultural rationale © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC to referNOT to anFOR insider—“within culture”—system. of a potentially harmful the basis of SALE ORthe DISTRIBUTION NOT FORpractice SALE can OR be DISTRIBUTION Thus, Western biomedicine is an indigenous medical effective intervention against it. system in some countries, such as the United States The importance of seeking to understand a culand Canada, but it may exist side by side with other tural practice can be a major challenge when global indigenous systems, even in the United States and health is considered. What if a behavior is “wrong” © JonesWestern & Bartlett Learning, Bartlett Learning, LLC Europe. In most ofLLC the world, Western bio- © Jones from an&epidemiologic perspective? How does one NOT FOR SALEnow OR coexists DISTRIBUTION FOR SALE OR aDISTRIBUTION medicine with, and often dominates, NOT distinguish between “dangerous” behavior (e.g., local or indigenous systems. Because of this multiusing an HIV-contaminated needle, swimming in plicity of systems, and because of class differences, a river with snails known to carry schistosomiasis, physicians and policy makers in a country may not ingesting a powder with lead in it as part of a healaccept or even be aware©ofJones the extent to which indigritual) and behaviors that are merely different and, Learning, LLC & Bartlett Learning,ingLLC © Jones & Bartlett enous systems exist orNOT recognize their importance therefore, seem odd? For example, Bolivian peasants FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (Cameron, 2010). Also, many countries are home to traditionally used very fine clay in a drink believed to peoples with multiple cultures and multiple languages. be good for digestion and stomach ailments. Health The cross-cultural principles discussed in this chapter workers succeeded in discouraging this practice in may be just as important to work within a country as it some communities because “eating dirt” seemed like a © Jones & Bartlett Learning, LLC © health Jones & Bartlett Learning, LLC is to work in multiple countries or cultures. bad thing. The workers then found themselves NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION faced with increased caries and other symptoms of calcium deficiency in these same communities. Analysis Ethnocentrism revealed that the clay was a key source of calcium for Another key concept from medical anthropology is these communities. It turns out that biomedicine also that of ethnocentrism. Ethnocentric refers to seeing uses clay—but we color it pink or give © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLCit a mint flavor your own culture as “best.” Ethnocentrism is a natural and put it in a bottle with a fancy label (S. Scrimshaw, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tendency, because the survival and perpetuation of a personal observation). © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Basic Concepts from Medical Anthropology Thus, there is a delicate balance between being 47 cooked, but women, who did the cooking, and chil- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC judgmental without good reason and seeking to introdren, who were around during cooking, were more NOT FOR SALE DISTRIBUTION NOT FOR SALE OR DISTRIBUTION duce behavior change because there is real harm from likely to eat OR it when it was partially cooked and, thereexisting behaviors. In general, it is best to leave harmfore, still infectious. Lindenbaum and Glasse sugless practices alone and focus on understanding and gested the disease was transmitted by cannibalism. To changing harmful behaviors. This task is more difficonfirm their hypothesis, Gadjusek’s team inoculated cult than it might©seem, because the concept of cul- LLCchimpanzees with brain from womenLearning, who Jones & Bartlett Learning, © material Jones & Bartlett LLC tural relativism also applies perceptions of quality had died of kuru; the NOT animals subsequently NOT FORtoSALE OR DISTRIBUTION FOR SALE ORdevelDISTRIBUTION of life. A culture in which people believe in reincarnaoped the disease. The disease, initially thought to be tion may approach death with more equanimity, and a slow virus, was subsequently identified as caused may not embrace drastic procedures that prolong life by prions, which are mis-folded proteins transmitted only briefly. In some cultures, loss of a body organ is through the ingestion of brain tissue. Since then, the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC viewed as impeding the ability to go to an afterlife or practice of cannibalism has declined and the disease NOT FOR SALE OR DISTRIBUTION NOT FORdisappeared SALE OR(Gadjusek, DISTRIBUTION the next life, and such surgery may be refused. Thus, has now virtually Gibbs, & it is important in global health for cultural outsiders Alpers, 1967; Lindenbaum, 1971). The research on to be cautious about making statements about what is kuru led scientists to discover a similar pattern of good for someone else. disease caused by the ingestion of beef that had been fed&neurologic tissue of deceased © Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLC cattle, called “mad cowSALE disease” variant Creutzfeldt-Jakob disease NOT FOR SALE OR DISTRIBUTION NOT FOR ORorDISTRIBUTION Holism (Collinge et al., 2006). The concept of holism is also useful in looking at health and disease cross-culturally. Holism is an Health Literacy approach used by anthropologists that looks at the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC In recent years, increasing attention has focused on broad context of whatever phenomenon is being NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION another area that intersects with culture in people’s studied. Holism involves staying alert for unexpected ability to understand and access health care—the influences, because you never know what may have a concept of health literacy. Health literacy is defined as bearing on the program you are trying to implement. “the degree to which individuals have the capacity to For public health, this consideration is crucial because obtain,© process, and basic health LLC informadiverse factors may influence health and health behav© Jones & Bartlett Learning, LLC Jones &understand Bartlett Learning, tion and services make appropriate health ior (Nichter, NOT FOR2008). SALE OR DISTRIBUTION NOT FORneeded SALEtoOR DISTRIBUTION decisions” (Ratzan & Parker, 2000). Health literacy has A classic example of this situation is the detective been most thoroughly explored in the United States, work that went into discovering the etiology of the and until recently was seen more as a literacy issue New Guinea degenerative nerve disease, kuru. Epidethan a cultural issue. A 2004 Institute of Medicine miologists could not figure out how people contracted © Jones & Bartlett Learning, LLC to have a long incuba© Jones & Bartlett Learning, report notes the importanceLLC of considering cultural the disease, which appeared NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION issues such as many of those discussed in this chapter, tion period and to occur more frequently in women and of taking a more global look at the problem and and children than in men. Many hypotheses were needed interventions (Nielsen-Bohlman, Panzer, & advanced, including inheritance (genetic), infection Kindig, 2004). Many National Academy of Medicine (bacterial, parasitic), and psychosomatic explanations. along with an NAM By the early © 1960s, the most widely accepted of Jones & Bartlett Learning, LLC(NAM) reports have followed, © Jones & Bartlett Learning, LLC Roundtable and discussion papers on the topic (e.g., the prevailing hypotheses was that kuru was genetNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Allen, Auld, Logan, Montes, & Rosen, 2017). ically transmitted. Nevertheless, this proposal did In looking at culture and health literacy, several not explain the sex differences in infection rates in categories for misunderstandings between provider adults but not in children, nor how such a lethal gene and patient emerge. could persist. Working with Gadjusek of the National © Jones & Bartlett Learning, LLC © Jones Bartlettbetween Learning, LLC First, there is a&difference medical termiInstitutes of Health (NIH), cultural anthropologists NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION nology and lay terminology, which can occur in any Glasse and Lindenbaum used in-depth ethnographic language or culture. What is “diastolic” or a “bronchointerviews to establish that kuru was relatively new to dilator”? What are HDL and LDL? What are T cells? that region of New Guinea, as was the practice of canSecond, individual and cultural differences surnibalism. Women and children were more likely to round concepts. What doesLLC it mean to maintain a engage in the ritual consumption of the brains of dead © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, “moderate” weight? To an anxious teen who wants relatives as a way of paying tribute to them, which was NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to become a model, moderate weight might mean culturally less acceptable for men. Also, this tissue was © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 48 Chapter 2 Culture, Behavior, and Health something clinically dangerously low (from the U.S. federal government’s elaboration of the Cultural © Jones & Bartlett Learning, LLC © Jones & Bartlett outsider, healthLearning, practitionerLLC perspective). To some and Linguistically Appropriate Services (CLAS) guideSALEthe OR DISTRIBUTION NOT FOR SALE DISTRIBUTION women fromOR Latin America or the Middle East, mod- NOT linesFOR to improve care of diverse populations (Office erate weight will be heavier than U.S. norms, whereas of Minority Health, 2016). Healthcare institutions began a U.S. woman who fears she weighs too much might using the CLAS standards to design cultural competence be viewed as dangerously thin in those cultures. trainings for their staff. It became clear, however, that Third, meanings may differ. While workingLearning, with in-service to make&participants © Jones & Bartlett LLC training was insufficient © Jones Bartlett Learning, LLC prenatal care programsNOT in Mexico, truly competent in cultural issues. critique, FOR Scrimshaw’s SALE OR team DISTRIBUTION NOTFrom FORthis SALE OR DISTRIBUTION struggled with communicating the concept of risk in scholars have suggested that cultural humility is a more pregnancy as they developed materials to help women realistic framework, because it promotes the underidentify symptoms that meant that they should seek standing and appreciation of health beliefs and behavcare. It turned out that the direct translation of “risk” iors in their cultural contexts and respectful strategies to © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC into Spanish, or riesgo, did not carry the same meannegotiate optimal health in the context of these beliefs NOT FOR SALE OR DISTRIBUTION FOR&SALE OR DISTRIBUTION ing. When they explained the concept to women, and behaviorsNOT (Tervalon Murray-García, 1998). To they said, “Oh, you mean peligro.” Peligro translates achieve this goal, we must understand our own biases. directly as “danger” (Alcalay, Ghee, & Scrimshaw, Cultures vary in their definitions of health and of 1993; Scrimshaw et al., 1990). illness. A condition that is endemic in a population language issues may may be seen as normal and may not be defined as ill© Jones & Finally, Bartlett Learning, LLCaffect understanding. © Jones & Bartlett Learning, LLC While researchers were investigating seizure disorders in NOT ness. Ascaris infection in young children was previNOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION adolescents from three cultures, it became clear that the ously mentioned as a perceived “normal” condition in word “trauma” has two different meanings. It can mean many populations. Similarly, malaria is seen as normal psychological shock, or it can mean physical trauma, in some parts of Africa, because everyone has it or has such as a blow to the head. The exact same word trauma had it. In Egypt, where schistosomiasis was common © Jones & Bartlett Learning,and LLC © Jones & Bartlett Learning, LLC is used in Spanish, with the same two potential meanaffected the blood vessels around the bladder, blood NOT FOR SALE OR DISTRIBUTION NOTmenstruation” FOR SALEand OR DISTRIBUTION ings. When neurologists talked with patients who had in the urine was referred to as “male epilepsy and their parents from Latino cultures, the neuwas seen as normal. These definitions may also vary by rologists used the word “trauma” as a cause of seizures to age and by gender. In most cultures, symptoms such mean a blow to the head. The Latino parents heard the as fever in children are seen as more serious than the psychological meaning and thought their child had been same symptoms in adults. may Learning, deny symptoms © Jones & Bartlett Learning, LLC © Jones & Men Bartlett LLC traumatized by some fright or shock more than women someSALE cultures, women may NOT psychologically FOR SALE OR DISTRIBUTION NOT in FOR ORbut DISTRIBUTION (Long, Scrimshaw, & Hernandez, 1992). do the same in others. Often, adult denial of symptoms Lane and her colleagues (2017) found that is due to the need to continue working. health literacy can be compromised at times even for Sociologist Talcott Parsons (1948) first discussed well-educated individuals. It is particularly important the concept of the sick role, wherein an individual must © Jonesto& Bartlett Learning, Learning, LLC note that health literacy isLLC as much a problem of the © Jones “agree” to&beBartlett considered ill and to take actions (or allow NOT FOR SALEprovider OR DISTRIBUTION FOR SALE OR DISTRIBUTION healthcare and health communication staff as NOT others to take actions) to define the state of his or her it is of a patient or the people in a community. If medhealth, discover a remedy, and do what is necessary ical “jargon” is used, no amount of education short of to become well. Individuals who adopt the sick role experience in medicine or nursing will help someone neglect their usual duties, may indulge in dependent understand. Terms such©asJones “oncology, ” “nephrology, ” to Jones get well. & ByBartlett adopting Learning, LLC & Bartlett Learning,behaviors, LLC and seek treatment © and “gastroenterology” have meaning for the medical the sick role, they are viewed as having “permission” to DISTRIBUTION NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR world, but not for patients. Healthcare providers outbe exempted from usual obligations, but they are also side the United States often have a better understandunder an obligation to try to restore health. The proing of this issue than their U.S. counterparts. cess of seeking to remain healthy or to restore health is discussed in more detail later in this chapter. © Jones & Bartlett Learning, LLC Cultural Competence NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Belief Systems A concept related to health literacy is that of cultural EXHIBIT 2-1 depicts types of insider cultural explanations competence. Cultural competence in health care describes of disease causation. Based on the literature, it attempts “the ability of systems to provide care to patients with to be as comprehensive as possible for cultures around diverse values, beliefs and behaviors, including tailoring © Jonesdelivery & Bartlett LLC & The Bartlett LLC the world. exhibitLearning, consists of generalizations about to meetLearning, patients’ social, cultural, and linguistic © Jones NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION culture-specific health beliefs and behaviors; these needs” (Betancourt, Green, & Carrillo, 2002). The concept of cultural competence emerged, in part, from the generalizations cannot, however, be assumed to apply © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Basic Concepts from Medical Anthropology 49 JonesCausation & Bartlett Learning, LLC © Jones & Bartlett Learning, EXHIBIT 2-1 Types ofLLC Insider Cultural Explanations © of Disease NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Supernatural Body Balances ■ ■ ■ ■ ■ ■ ■ Bewitching Temperature: Hot, cold ■ Demons Energy Blood: Loss of© blood; properties of blood reflect Jones & Bartlett Learning, LLC■ Spirit possession © Jones & Bartlett Learning, LLC ■ Evil eye imbalance; pollution from menstrual bloodDISTRIBUTION NOT FOR SALE OR NOT FOR SALE OR DISTRIBUTION ■ Offending God or gods Dislocation: Fallen fontanel ■ Soul loss Organs: Swollen stomach; heart; uterus; liver; umbilicus; others Incompatibility of horoscopes Food © Jones & Bartlett Learning, LLC Emotional NOT FOR SALE OR DISTRIBUTION ■ ■ ■ ■ Fright Sorrow Envy Stress © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Weather ■ ■ ■ Winds Change of weather Seasonal disbalance © Jones & Bartlett Learning, LLC Properties: Hot, cold, heavy (rich), light NOT FOR SALE OR DISTRIBUTION Spoiled foods ■ Dirty foods ■ Sweets ■ Raw foods ■ Combining the “wrong” foods © Jones &(incompatible Bartlett Learning, LLC foods) NOT FOR SALE OR DISTRIBUTION ■ Mud/clay ■ ■ Sexual ■ Sex with forbidden person Overindulgence in sex © Jones © Jones & Bartlett Learning, LLC Vectors or Organisms NOT FOR SALE OR DISTRIBUTION Heredity ■ Worms ■ ■ ■ ■ Flies Parasites Germs & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Old Age © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION to every individual from a given culture. We can learn Body Balances about the hot/cold balance system of Latinos, Asians, Within body balances (opposites) belief systems, the and Middle Easterners, explained in the next section, concepts of “hot” and “cold” are among the most perbut the details of the system will vary from country to vasive around the world. TheLLC hot/cold balance is par© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, country, from village to village, and from individual ticularly important in Asian, Latin American, and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to individual. When someone walks in the door of a Mediterranean cultures. Hot and cold beliefs are part clinic, you cannot know whether he or she as an indiof what is referred to as “humoral medicine,” which is vidual adheres to the beliefs described for his or her thought to have derived from Greek, Arabic, and East culture and what shape the individual’s belief system Indian pre-Christian traditions (Foster, 1953; Logan, Jones Bartlett Learning, Jones Bartlett Learning, LLC takes. This makes©the task of&the culturally proficient LLC1972; Weller, 1983). The© concept of & opposites (e.g., hot NOT OR DISTRIBUTION NOT FOR ORindeDISTRIBUTION healthcare provider bothFOR easierSALE and harder. It means a and cold, wet and dry) also may haveSALE developed practitioner working with a Mexican population does pendently in other cultures (Rubel & Haas, 1990). For not have to memorize which foods are hot and which example, in the Chinese medical tradition, hot is referred are cold in Mexico, but the practitioner does need to to as yin and cold as yang (Topley, 1976). know that the hot/cold belief system is important in In © theJones hot and&cold belief system, a healthy © Jones & Bartlett Learning, LLC Bartlett Learning, LLCbody Mexican culture and be to be understanding and is seen NOT as in balance betweenOR the DISTRIBUTION two extremes. Illness NOT FOR SALE ORable DISTRIBUTION FOR SALE responsive when people bring up the topic. may be brought on by violating the balance, such as The beliefs held by cultures around the world are washing the hair too soon after childbirth (cold may classified into various categories, which are discussed enter the body, which is still “hot” from the birth), eathere. These categories are used for diagnosis and treating hot or heavy foods at night, or breastfeeding while © Jones & Bartlett LLC & Bartlett ment andLearning, for explaining the etiology or origin of © theJones upset (the milkLearning, will be hotLLC from the emotions and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION illness. Often, multiple categories are used. For exammake the baby ill). “Hot” does not always refer to temple, emotions may be seen as causing a “hot” illness. perature, however. Often foods such as beef and pork © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 50 Chapter 2 Culture, Behavior, and Health are classified as hot regardless of temperature, whereas in this spot can be indicative of dehydration, often due © Jones & Bartlett Learning, LLC © Jones &may Bartlett LLC of temperature. to diarrheal disease. From the insider perspective, it is fish be seenLearning, as cold regardless NOT FORtoSALE ORofDISTRIBUTION NOT FOR SALE OR DISTRIBUTION referred as a cause the disease (caida de mollera) When illness has been diagnosed, the system is in Mexico and Central America. used to attempt to restore balance. Thus, in Central Many cultures associate illness with problems in America, some diarrheas in children are viewed as hot, specific organs. Good and Good (1981) talk about the and protein-rich “hot” foods such as meats are withimportance of the heart for both Chinese&and Iranian Learning, LLC held, aggravating the malnutrition may beLearning, pres© Jones &that Bartlett LLC © Jones Bartlett cultures. They discuss a case in which problems ent and may be exacerbated the SALE diarrheal disease NOT by FOR OR DISTRIBUTION NOT FOR SALEwith OR DISTRIBUTION cardiac medication were wrongly diagnosed for a Chi(Scrimshaw & Hurtado, 1988). An extensive literature nese woman who kept complaining about pain in her exists on the topic of hot and cold illness classificaheart. In fact, she was referring to her grief over the tions and treatments for them advocated by many of loss of her son. The Hmong people of Laos link many the world’s cultures. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC problems to the liver, referring to “ugly liver,” “diffiEnergy balance is particularly important in NOT FOR SALE OR DISTRIBUTION NOT FOR OR ”DISTRIBUTION cult liver,” “broken liver,” SALE “short liver, “murmuring Chinese medicine, where it is referred to as chi. When liver,” and “rotten liver.” These terms are said to refer to this balance is disturbed, it creates internal problems mental and emotional problems, and so are idiomatic of homeostasis. Foods (often following the hot/cold rather than literal (O ‘Connor, 1995, p. 92; Thao, 1986). theories) and acupuncture are among the strategies Topley (1976) mentions incompatibility of horoto restoreLearning, balance (Topley, © Jonesused & Bartlett LLC1976). © Jones & Bartlett Learning, LLC scopes between and child in Chinese explanaBlood beliefs include the concept that blood is irre- NOT NOT FOR SALE OR DISTRIBUTION FOR SALEmother OR DISTRIBUTION tions for some children’s illnesses. placeable; thus loss of blood—even small amounts—is perceived as a major risk. Adams (1955) describes a nutritional research project in a Guatemalan village Emotional Illnesses where this belief inhibited the researcher’s ability to areJones important in many Learning, LLC © Jones & Bartlett Learning,Illnesses LLC of emotional origin © & Bartlett obtain blood samples until the phlebotomists were cultures. Sorrow (as in the caseNOT of theFOR Chinese woman NOT FOR SALE OR DISTRIBUTION SALE OR DISTRIBUTION instructed to draw as little blood as possible. Also, mentioned previously), envy, fright, and stress are villagers were told that the blood would be examined often seen as causing illnesses. In a Bolivian village in to see if it was “sick” or “well” (another belief about 1965, for example, Scrimshaw was told that a young blood) and they would be informed and given medigirl’s smallpox infection was attributed to her sorrow cines if©it Jones were sick,&which in fact did occur. LLC Bartlett Learning, © Jones & Bartlett Learning, LLC over the death of her father. Menstrual bloodSALE is regarded as dangerous, espeNOT FOR OR DISTRIBUTION OR DISTRIBUTION Envy canNOT causeFOR illnessSALE because people with envy cially to men, in many cultures, and elaborate precaucould cast the “evil eye” on someone they envy, even tions are taken to avoid contamination with it (Buckley unwittingly, or the envious person can become & Gottlieb, 1988). As seen in the Guatemalan example, ill from the emotion (Reichel-Dolmatoff & blood may have many properties that both diagnose and Reichel-Dolmatoff, 1961). Fright, called susto in © Jonesexplain & Bartlett illness. Learning, Bad blood is LLC seen as causing scabies in © Jones & Bartlett Learning, LLC Latin America, has already been mentioned. In NOT FOR SALE DISTRIBUTION South India OR (Beals, 1976, p. 189). Haitians have a partic- NOT FOR SALE OR DISTRIBUTION addition to the case of tuberculosis in adults disularly elaborate blood belief system, which includes concussed previously, susto is a common explanation cepts such as mauvais sang (literally, “bad blood,” when for illness in children. It is also mentioned in Chiblood rises in the body and is dirty), saisissement (rapid nese culture (Topley, 1976). heartbeat and cool blood, to trauma), and faiblesses ©due Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC (too little blood). BloodNOT qualities may also be seen as FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Weather “opposites,” such as clean–unclean, sweet–normal, bitter–normal, high–normal, heavy–weak, clotted–thin, Everything from the change of seasons to unusual and quiet–turbulent (C. Scott, personal communicavariations within seasons (too warm, too cold, too tion, 1976). It is easy to see how these concepts could wet, too dry) can be blamed for causing illness. Winds, & program BartletttoLearning, © Jones & California Bartlett Learning, LLC be used©inJones a current prevent HIVLLC infection such as the Santa Ana in or the Scirocco NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION in a Haitian community, because the culture already has in the North African desert, are also implicated as ways of describing problems with blood. sources of illness in many cultures. From the outsider Dislocation of body parts may occur with organs, perspective, changes in seasons can be associated but also with a physical aspect, such as the fontanel or with increases in risk and incidence of disease. For “soft spot” in a baby’s head where the bones have not example,&inBartlett many areas people have a greater chance © Jones & Bartlett Learning, LLC © Jones Learning, LLC yet come together in the first year or so to allow for of contracting malaria, cholera, and gastrointestinal NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION growth. From the outsider perspective, a depression infections during the rainy season. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Basic Concepts from Medical Anthropology 51 Spirit possession is also a worldwide belief, and VectorsLearning, or Organisms © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC one that is found especially frequently in African and Vectors or organisms are blamed for illness in some NOT FOR SALE OROne DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Asian cultures. of the best-known accounts of this cultures and represent a blend of Western biomedphenomenon is A Spirit Catches You and You Fall Down ical and indigenous concepts. “Germs” is a catch-all (Fadiman, 1997), a moving story of seizure disorders category, as is “parasites.” Worms are seen as causing in a Hmong community and the misunderstandings diarrhea, whereas flies are seen as causing illness and, between the family and©physicians. another exam© Jones & Bartlett Learning, LLC Jones &InBartlett Learning, LLC sometimes, as carrying germs. ple, from South India, NOT Beals FOR (1976)SALE mentions NOT FOR SALE OR DISTRIBUTION ORspirit DISTRIBUTION possession in a daughter-in-law whose symptoms The Supernatural included refusing to work and speaking insultingly to her mother-in-law. He suggests that spirit possesThe supernatural is another frequently viewed source sion is a “culturally sanctioned means of psychological of©illness, especially in Africa and Asia, though this Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC release for oppressed daughters-in-law” (p. 188). Freed belief system is certainly not confined to those regions. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORcases DISTRIBUTION and Freed (1967) discuss similar in other regions In fact, the evil eye is a widespread concept—someone of India. In Tanzania, malaria in children is sometimes deliberately or unwittingly brings on illness by lookblamed on possession by a bird spirit (Kamat, 2008). ing at someone with envy, malice, or too hot a gaze. In Haiti, spirit possession is seen as a mark of favor by In cultures where most people have dark eyes, strangthe&spirits and isLearning, actively sought out. One of the draw© Jones & Bartlett Learning, © Jones Bartlett LLC ers with light eyes mayLLC be seen as dangerous. In Latin backs, however, that the possessing spirits object to America, light-eyed person who admires a child NOT can FOR NOT FOR SALE OR aDISTRIBUTION SALE OR isDISTRIBUTION the presence of foreign objects in the body; as a conserisk bringing evil eye to that child, but can counter quence, some women do not want to use intrauterine it by touching the child. In other cultures, touching devices as a means of birth control. the child can be unlucky, so it is important to learn Demons are viewed as causing illness in Chinese about local customs. Frequently, amulets and other © Jones & Bartlett Learning, LLCculture, while offending©God Jones & Bartlett Learning, LLC or gods is a problem in protective devices, such as small eyes of glass, red hats, NOT FOR SALE OR DISTRIBUTION NOT FOR DISTRIBUTION other cultures (Topley, 1976). In SouthSALE India, OR epidemic and a red string around the wrist, are worn to prevent diseases such as chickenpox and cholera (and, formerly, evil eye. These objects can be viewed as an opportusmallpox) are believed to be caused by disease goddesses. nity to discuss preventive health measures, because These goddesses bring the diseases to punish communithey are an indication that people are thinking about ties that©become sinful (Beals, 1976, p. 187). TheLLC concept © Jones & Bartlett Learning, LLC Jones & Bartlett Learning, prevention. of punishment fromSALE God is OR seen DISTRIBUTION in a case study from Bewitching is deliberate malice, done either by the NOT FOR SALE OR DISTRIBUTION NOT FOR Mexico, where onchocerciasis (river blindness), which individual who wishes someone ill (literally) or by a is caused by a parasite transmitted by the bite of a fly practitioner at someone else’s request. Bewitching can that lives near streams, is often thought to be due to sins be countered by another practitioner or by specific committed either by the victim or by relatives of the vicmeasures taken by an individual. In some regions of © Jones & Bartlett Learning, © Jones & These Bartlett Learning, LLCGod are punished by tim. transgressions against Africa, epidemics are LLC blamed on “too many witches, ” NOT FOR SALE OR DISTRIBUTION NOT FOR DISTRIBUTION GodSALE closing OR the victim’s eyes (Gwaltney, 1970). and people disperse to get away from them, thereby reducing the critical population density that had previously sustained the epidemic (Alland, 1970). Food Belief in soul loss is widespread throughout the In many cultures, food is perceived as being able to world. Soul loss can caused&byBartlett sources such as fright, LLC © be Jones Learning, Jones LLC cause illness through its© role in the & hotBartlett and cold Learning, belief bewitching, evil eye, and demons. It can occur in adults NOT FOR SALE OR DISTRIBUTION NOT FOR SALE system; through spoiled foods, dirty foods,OR or DISTRIBUTION raw and children. Soul loss is serious and can lead to death. foods; and by combining the wrong foods. Sweets are It must be treated through rituals to retrieve the soul. implicated as a cause of worms in children, and chilIn Bolivia, for example, a village priest complained to dren who eat mud or dirt may become ill. Foods may Scrimshaw that his attempt to visit a sick child was also cause problems eaten at the wrong time of day, © Jones & Bartlett LLC © Jones & ifBartlett Learning, LLC thwarted when the familyLearning, would not allow him to enter such asNOT “heavy” foods at night. An extensive literature NOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION the house. The family later reported that an indigenous describes food beliefs and practices worldwide, which healer was performing a curing ritual at the time, and has important implications for public health practice. the soul was flying around the house as they were trying to persuade it to reenter the child. Opening the door Sexual Illnesses to the priest would have allowed the soul to escape.©InJones © Jones & Bartlett Learning, LLC & Bartlett Learning, LLC the Western biomedical system, this child’s symptoms In Ecuador in the early 1970s, children’s illnesses NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION would have been attributed to severe malnutrition. were sometimes blamed on affairs between one of the © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 52 Chapter 2 Culture, Behavior, and Health child’s parents and a compadre or comadre—one of the taken to the clinic only for the worst form of diar- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC child’s godparents (Scrimshaw, 1974). Such a relationrhea, dysentery. Instead, the most common treatment SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION shipSALE was viewed as incestuous and dangerous to the NOT for FOR diarrhea consisted of fluids in the form of herbal child. In India, sex is sometimes viewed as weakening teas or sodas with medicines added. Often, storekeepto the man, so overindulgence is considered a cause of ers and pharmacists were consulted. It made sense to weakness. To return to the concept of blood beliefs, it provide the ORS at stores and pharmacies as well as is thought that 30 drops©ofJones blood are needed to Learning, make atLLC clinics, so that all diarrheas©were more&likely to be Learning, LLC & Bartlett Jones Bartlett one drop of semen, so blood weakens treated (Scrimshaw & Hurtado, 1988). NOTloss FOR SALEa man. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION In a related situation, Kendall, Foote, and Martorell (1983) found that, when the government of Honduras Heredity and Old Age did not include indigenous or “folk” terminology for Heredity is sometimes blamed for illness, early death, diarrheal disease in its mass-media messages regardor some©types of death. Similarly, old age may be the Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ing oral rehydration, people did not use ORS for diarsimple NOT explanation forOR illness or death. Heredity FOR given SALE DISTRIBUTION NOT FOR SALEdefined OR DISTRIBUTION rheas attributed to indigenously causes. as noted here is expressed as an insider view, but is also part of the Western biomedical body of evidence on the causation or risk for many diseases. Healers © Jones & Bartlett Learning, LLC Illness in OR Various Forms NOT FOR SALE DISTRIBUTION EXHIBIT 2-2 lists typesLearning, of healers, LLC which range from © Jones & Bartlett indigenous practitioners to Western biomedical proNOT FOR SALE OR DISTRIBUTION TABLE 2-1 illustrates the way in which some of these viders. Pluralistic healers are those who mix the two beliefs are used to explain a particular illness—in this traditions, although some Western biomedical healers case, diarrheal disease in Central America. It is typical of and those from other medical systems may also mix the way in which an illness may be seen as having differtraditions in their practices. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ent forms, or manifestations, with different etiologies. It As with explanations of disease, the types of healNOT FOR SALE OR DISTRIBUTION NOTinFOR SALE OR DISTRIBUTION is also typical of the way in which several different explaers listed in Exhibit 2-2 are found different combinations may be put forth for one set of symptoms. nations in different cultures. There is always more than In this case, Table 2-1 and FIGURE 2-1 (the diagram one type of healer available to a community, even if of treatments) were key in expanding the orientation members have to travel to seek care. The 16-country of the © Central American diarrheal disease program. study of health-seeking earlier Jones & Bartlett Learning, LLC © Jones &behavior Bartlettdescribed Learning, LLC The program had intended emphasize the distribufound that inNOT all communities, people more than NOT FOR SALE to OR DISTRIBUTION FOR SALE ORused DISTRIBUTION tion of oral rehydration solutions (ORS) in the clinics, one healing tradition, and usually more than one type but the insider perception was that a child should be of healer (Scrimshaw, 1992). The process of diagnosing © Jones & Bartlett Learning, LLC TABLE 2-1 Taxonomy of Diarrhea NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION SYMPTOMS All types have watery and frequent stools CAUSE © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC OR DISTRIBUTION Physical activity Hot foods Not breastfeeding when hotNOT FOR SALE Hot © Jones & Bartlett Learning, LLC Pregnancy NOT FOR SALE OR DISTRIBUTION Mother’s milk Anger Mother changes diet © Jones & Breastfeeding Bartlett Learning, LLC stops NOT FOR SALE OR DISTRIBUTION Very dangerous Sadness © Jones & Bartlett Learning, LLC Fright NOT FOR SALE OR DISTRIBUTION Emotional TREATMENT Home, drugstore, injectionist, witch, spiritualist © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Basic Concepts from Medical Anthropology 53 Bad food© Jones &Flatulence, Bartlett Learning, LLCfolk curer feeling of Home, NOT FORfullness SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Excess Does not eat on Food © Jones & Bartlett Learning, LLC time NOT FOR SALE OR DISTRIBUTION Hot © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Quality Cold © Jones & Bartlett Learning, LLC NOT ToothFOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC FOR SALENone OR DISTRIBUTION ToothNOT eruption Eruption Fallen fontanel, Fallen stomach fallen stomach Bartlett Learning, LLC Green with mucus Folk curer Sunken fontanel; © Jones & Bartlett Learning, LLC vomiting; green in NOT FORcolor SALE OR DISTRIBUTION © Jones & Fallen fontanel NOT FOR SALE OR DISTRIBUTION Evil eye Fever Folk curer © Jones & Bartlett Learning, LLC Worms NOT FOR SALE OR DISTRIBUTION Stomach Worms Cold enters Stomach From feet © Jones &home, Bartlett Learning, LLC Drugstore, folk curer NOT FOR SALE OR DISTRIBUTION White in color © Jones & Bartlett Learning, LLC From head NOT FOR SALE OR DISTRIBUTION Folk curer © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Dysentery Blood in stools, “urgency;” color is red or black Home, drugstore, health post © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Courtesy of Scrimshaw, S. C. M., & Hurtado, E. (1987). Rapid assessment procedures for nutrition and primary health care: Anthropological approaches to improving program effectiveness (RAP). NOT FOR SALE ORUCLA DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Los Angeles: Latin America Center, p. 26. Reprinted with permission of the Regents of the University of California. © Jones & Bartlett Learning, LLC Treatments for diarrhea © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Home remedies Drinks Baths © Jones & Bartlett WatersLearning, LLCPurgatives NOT FOR SALE OR DISTRIBUTION Herbs Herbs with Soda waters store-bought with storemedication bought medication Pharmaceuticals Enemas Home Pharmaceuticals remedies “Mecánicas” © Jones & Bartlett Learning, LLC Application OR DISTRIBUTION Change Message Wrapping NOT FOR SALE position Rags Poultices FIGURE 2-1Learning, Taxonomy ofLLC treatments for diarrhea. © Jones & Bartlett © Jones & Bartlett Learning, LLC Courtesy of Scrimshaw, S. C. M., & Hurtado, E. (1987). Rapid assessment procedures for nutrition and primary health care: Anthropological approaches to improving program effectiveness (RAP). Los Angeles: UCLA Latin America Center, p. 26. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Reprinted with permission of the Regents of the University of California. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 54 Chapter 2 Culture, Behavior, and Health © Jones EXHIBIT & Bartlett LLC 2-2 Learning, Types of Healers NOT FOR SALE OR DISTRIBUTION Indigenous © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Western Biomedical ■ Pharmacists Midwives ■ Nurse–midwives Doulas ■ Shamans Nurses © Jones & Bartlett Learning,■ LLC © Jones & Bartlett Learning, LLC ■ Curers ■ Nurse practitioners NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■ Spiritualists ■ Physicians ■ Witches ■ Dentists ■ Sorcerers ■ Other health professionals ■ Priests ■ Diviners Other Medical Systems © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■ Herbalists NOT FOR SALE OR DISTRIBUTION NOTsystem FOR SALE OR DISTRIBUTION ■ Chinese medical ■ Bonesetters • Practitioners ■ Massagers • Chemists/herbalists • Acupuncturists Pluralistic ■ Ayurvedic practitioners © Jones ■& Bartlett © Jones Bartlett Learning, LLC ■ Taoist & priests InjectionistsLearning, LLC NOT FOR■ SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Indigenous health workers ■ Western-trained birth attendants ■ Traditional chemists/herbalists ■ Storekeepers and vendors ■ ■ © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION FOR SALEThe OR DISTRIBUTION illness and seeking a cure has been referred to as “patwell, but they are not paid forNOT illness treatment. terns of resort,” a descriptor that is now favored over duty of the practitioner in those cases is to keep people the older term “hierarchy of resort” (Scrimshaw & well, which argues for the acceptability of prevention Hurtado, 1987). People may zigzag from one practiprograms in those cultures. tioner © to Jones another, & crossing from one type to another For the most part, indigenous practitioners do “good, ” Bartlett Learning, LLC © Jones & Bartlett Learning, LLC type of NOT healer,FOR and not alwaysOR starting with the simplest meaning healing. Some canSALE do bothOR goodDISTRIBUTION and evil (e.g., SALE DISTRIBUTION NOT FOR and cheapest, but with the one they can best afford shamans, sorcerers, and witches in many cultures). A few and who they believe will be most effective, given the in these categories practice only evil or negative rituals, severity of the problem. Even middle- and upper-class which aim to cause harm—for example, for revenge or to individuals, who can afford Western biomedical care, counteract the good fortune of a rival. Their work must © Jonesmay & Bartlett Learning, LLC and practices. © Jones & Bartlett Learning, use other types of practitioners then be countered by someone whoLLC does “good” magic. NOT FOR SALE ORpractitioners DISTRIBUTION OR Indigenous are usually members of the NOT TheFOR powerSALE of belief is DISTRIBUTION such that if individuals believe culture and follow traditional practices. Today, they often they have been bewitched, they may need a counteracmix elements of Western biomedicine and other traditive ritual, even if the Western biomedical system detects tional systems. In many instances, they are “called” to their and treats a specific disease. In Guayaquil, Ecuador, one profession through dreams, omens, or an illness, which maleada&(cursed) by Learning, LLC © Jones & Bartlett Learning,woman LLC believed that she had been © Jones Bartlett usually can be cured only by their agreement to become a a woman who was jealous of her, and that this curse was NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION practitioner. Most learn through apprenticeship to other making her and her children ill. A curandera (curer) was healers, although some are taught by dreams. Often, they brought in to do a limpia (ritual cleansing) of the house will take courses in Western practices in programs such and family to remove the curse (Scrimshaw, 1974). as those developed to train Chinese “barefoot doctors” or The importance of the power of belief is not © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC community-based health promoters. In some instances, confined only to bewitching. OneLearning, anthropologist NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION they must conceal their role as traditional healer from working with a Haitian population discovered that a those running the training programs. The incorporation Haitian burn patient made no progress until she went of some Western biomedical knowledge and skills often to a Houngan (voodoo priest) on the patient’s behalf enhances a practitioner’s prestige in the community. and had the appropriate healing ritual conducted Some indigenous practitioners charge for their (J. Halifax-Groff, personal communication, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 1976). services, but many do not, accepting gifts instead. In In some cultures, healers are seen as diagnostiNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION a few traditions (including some Chinese cultures), cians, while others do the treatment (Alland, 1970). practitioners are paid as long as family members are Other healers may handle both tasks, but refer some © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Theories of Health Behavior and Behavior Change kinds of illness to other practitioners. In Haiti, both 55 difficult to access in remote areas. As mentioned ear- © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC midwivesLearning, and voodoo priests refer some cases to lier, if an individual believes that an illness is due to a NOT FOR SALE OR by DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the Western biomedical system. Healers who comcause explained the indigenous system and a Westbine healing practices or who combine the ability to ern biomedical practitioner denies that cause, the indido both diagnosis and treatment are viewed as more vidual may not return to that practitioner but rather powerful than other types. Topley (1976, pp. 259–260) seek help elsewhere (Kamat, 2008; Nichter, 2008). discusses this issue the setting of HongLearning, Kong, not- LLC As noted, there are other medical&systems withLearning, long © in Jones & Bartlett © Jones Bartlett LLC ing that Taoist priest healers particularly respected traditions, systematic ways of training practitioners, and NOT FORareSALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION in that area. They are seen as both priest and doctor well-established diagnostic and treatment procedures. and “claim to combine the ethics of Confucianism, the Until recently, Western biomedical practitioners totally hygiene and meditation of Taoism, and the prayers rejected both these and indigenous systems, often failand self-cultivation of the Buddhist monk.” ing to recognize how many practices and medicines © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Pluralistic healers combine Western biomedical that Western biomedicine has “borrowed” from other NOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION and indigenous practices. Injectionists will give an systemsNOT (e.g., quinine, digitalis, many anesthetics, aspiinjection of antibiotics, vitamins, or other drugs purrin, and estrogen). Elements of these systems that were chased at pharmacies or stores. Sometimes these injecderided in the past, such as acupuncture, have now tions are suggested by the pharmacist or storekeeper; found their way into Western biomedical practice and at other times they areLLC self-prescribed. Because antibiare&being “legitimized” by Western © Jones & Bartlett Learning, © Jones Bartlett Learning, LLCresearch (Baer, 2008). otics proved so dramatically effective in curing infecNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tions when Western biomedicine was first introduced in many cultures, injections are often seen as convey▸ ing greater healing than the same substance taken orally. Thus, many antibiotics now available orally and © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC vitamins are injected. In today’s environment, this The fields of sociology, psychology, anthropology NOT FOR SALE OR DISTRIBUTION NOT FORand SALE OR DISTRIBUTION practice increases the risk of contracting HIV or hepahave developed many theories to explain health beliefs titis if sterile or new needles and syringes are not used. and behaviors and behavior change (Schumacher, Traditional chemists and herbalists, as well as storeOckene, & Riekert, 2009). Some theories developed keepers and vendors (many communities are too small to by sociologists and psychologists in the United States have a pharmacy), often sell Western biomedical medi© Jones & Bartlett Learning, LLC © Jonesfirst & Bartlett Learning, and LLConly were developed for U.S. populations cations, including thoseOR thatDISTRIBUTION require a prescription in the NOT FOR SALE NOT FOR SALE OR DISTRIBUTION later applied internationally. Others were developed United States and Western Europe. While prescriptions with international and multicultural populations in may be “legally” required in many countries, the laws are mind from the beginning. Only a few of the many not always rigorously enforced. This is also true for phartheories of health and illness beliefs and behavior are macies, which are very important—sometimes the most covered in this section; those included here have been © Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC important—sources of LLC diagnosis and treatment in many quite influential in general or are applicable for interNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR communities around the world. national work in DISTRIBUTION particular. For more than 50 years, countries around the world have enlisted and trained indigenous health practiHealth Belief Model tioners to function as part of the national or regional decision Learning, makhealth system. These programs have ranged from LLCThe health belief model©suggests © Jones & Bartlett Learning, Jones that & Bartlett LLC China’s “barefoot doctors” to the education of commuing about health behaviors is influenced by four basic NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION nity members in Latin America, Africa, and Asia to propremises—perceived susceptibility to the illness, pervide preventive care and triage. These efforts have nearly ceived severity of the illness, perceived benefits of the disappeared in some areas (e.g., China) and reemerged prevention behavior, and perceived barriers to that in others. For example, in Australia, indigenous people behavior—as well as by other variables, such as socio© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC are now involved as indigenous health outreach workers demographic factors (Rosenstock, Strecher, & Becker, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to their communities (2010, [email protected]). 1974). In general, people are seen as weighing perIn Nepal, indigenous health workers have been enlisted ceived susceptibility (how likely they are to get the disin programs to address diarrheal disease and acute respiease) and perceived severity (how serious the disease ratory infections (Ghimire, Pradhan, & Mahesh, 2010), is) against their belief in the benefits and effectiveness and female Ayurvedic doctors are important resources of & theBartlett prevention behavior they © Jones & Bartlett Learning, LLC © Jones Learning, LLCmust undertake and for women’s health (Cameron, 2010). the costs of that behavior in terms of barriers such NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Western biomedical practitioners are an importas time, money, and aggravation. The more serious ant source of care, but they may also be expensive or the disease is believed to be, and the more effective Theories of Health Behavior and Behavior Change © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 56 Chapter 2 Culture, Behavior, and Health the prevention, the more likely people are to incur efficacy of the cure to be sought, the cost (money, time, © Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLC the&costs of engaging in the prevention behavior. and so on) of the cure, and their own resources to seek FOR SALE DISTRIBUTION NOT FOR SALE ORbelief DISTRIBUTION The health model has been extensively stud- NOT treatment and pay OR the cost as they make their decision. ied, critiqued, modified, and expanded to explain The simplest, least costly treatment is always the first people’s responses to symptoms and compliance with choice, but the severity of illness and efficacy issues healthcare regimens for diagnosed illnesses. One conmay force adoption of a more costly option. Other cern has been that this©model does work asLearning, well studies have found similar Learning, LLC Jones & not Bartlett LLC of health-seeking behavior © Jones & Bartlett for chronic problems or habitual because patterns throughout the worldNOT (e.g., Kamat, 2008). OR DISTRIBUTION NOT FORbehaviors SALE OR DISTRIBUTION FOR SALE people learn to manage their behaviors or the healthcare system. Also, it has been accused of failing to take Theory of Reasoned Action environmental and social forces into account, which The theory of reasoned action was first proposed by in turn increases the potential for blaming the indiAjzen and Fishbein (1972) to predictLearning, an individual’s © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC vidual. The difficulty in quantifying the model for intention to engage in a behavior in aDISTRIBUTION specific time NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR research and evaluation purposes is also a problem. and place. This theory was intended to explain virWork by Bandura led to the inclusion of self-efficacy tually all behaviors over which people have the abilin the model. Self-efficacy has been defined as “the conity to exert self-control. Five basic constructs precede viction that one can successfully execute the behavior the performance of a behavior: (1) behavioral intent, to produce the desired © Jonesrequired & Bartlett Learning, LLCoutcome” (Bandura, © Jones & Bartlett Learning, LLC of behavioral (2) attitudes and beliefs, (3) evaluations 1977, 1989).OR TheDISTRIBUTION concept of locus of control, or belief NOT NOT FOR SALE FOR SALE OR DISTRIBUTION outcomes, (4) subjective norms, and (5) normative in the ability to control one’s life, also has been incorbeliefs. Behavioral intent is seen as the immediate preporated into this model. An example of this concept dictor of behavior. Factors that influence behavioral can be found in a comparison of migrant Yugoslavian choices are mediated through this variable. To maxiand Swedish females with diabetes. The study revealed the predictive ability of an to perform © Jones & Bartlett Learning,mize LLC ©intention Jones & Bartletta Learning, LLC a stronger locus of control in the Swedish women and specific behavior, the measurement of the intent FOR OR DISTRIBUTION NOT FOR SALEmust OR DISTRIBUTION more passivity towardNOT self-care in SALE the Yugoslavian closely reflect the measurement of the behavior. For women, who also had a lower self-efficacy. The authors example, measurement of the intention to begin to take attributed these findings to the different political sysoral contraceptives must include questions about when tems in the two countries—collectivism in Yugoslaa woman plans to visit a clinic and which clinic she plans via versus individualism in Sweden (Hjelm,LLC Nyberg, © Jones & Bartlett Learning, Jones & Bartlett LLC to attend. The©failure to address action,Learning, target, context, Isacsson, & Apelqvist, 1999).OR A more recent example, NOT FOR SALE DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and time in the measurement of behavioral intention among impoverished HIV-positive women in Kenya, will undermine the predictive value of the model. found that the women preferred to use indigenous In a test of this theory’s ability to predict condom treatments to manage their symptoms, rather than use intentions in a national sample of young people taking available antiretroviral therapy. The women’s in England, measuresLearning, of past behavior © Jonesshared & Bartlett LLC & Bartlett LLCwere found to culturalLearning, model of self-management enhanced © Jones be the best predictors of intentions and attenuated NOT FOR DISTRIBUTION FOR SALE OR DISTRIBUTION the SALE women’sOR confidence in their own ability to care for NOT the effects of attitude and subjective norms (Sutton, themselves rather than take the Western biomedical McVey, & Glanz, 1999). drugs (Copeland, 2017). The value of the four basic premises of the health Diffusion of Health Innovations Model belief model has held © upJones well under scrutiny.Learning, Per& Bartlett LLC © Jones & Bartlett Learning, LLC The diffusion of health innovations model proposes ceived barriers have theNOT strongest predictive value of FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION that communication is essential for social change, and the four dimensions, followed by perceived susceptithat diffusion is the process by which an innovation bility and perceived benefits. Perceived susceptibility is communicated through certain channels over time is most frequently associated with compliance with among members of a social system (Rogers, 1983; health screening exams. Perceived severity of risk © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Rogers & Shoemaker, 1972). An innovation is an idea, has been noted to have a weaker predictive value for NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION practice, service, or other object that is perceived as protective health behaviors, but is strongly associated new by an individual or group. Ideally, the developwith sick-role behaviors. ment of a diffusion strategy for a specific health behavIn Medical Choice in a Mexican Village, Young ior change goal will proceed through six stages: (1981) describes a health decision-making process similar to that found in the health belief model. In © Jones & Bartlett Learning, LLC © Jonesvery & Bartlett Learning, LLC 1. Recognition of a problem or need choosing between home remedies, pharmacy, or store, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2. Conduct of basic and applied research to and between indigenous healer or doctor, the villagers address the specific problem weigh the perceived severity of the illness, the potential © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Theories of Health Behavior and Behavior Change 3. Development of strategies and materials 57 wood and making a fire to boil the water far out- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, that will putLLC the innovative concept into a weighed any perceived benefits, so water boiling was NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR form DISTRIBUTION that will meet the needs of the target seldom adopted (Wellin, 1955). Successful health population innovations are likely to be those that do not require Commercialization of the innovation, expenditure of much additional time, energy, or other which will involve production, marketing, resources. and distribution commu© Jonesefforts & Bartlett Learning, LLC One of the overall ©messages Jones regarding & Bartlett Learning, LLC 5. Diffusion andFOR adoption of the innovation nicating health education and promotion by NOT SALE OR DISTRIBUTION NOT FOR SALE stated OR DISTRIBUTION 6. Consequences associated with adoption of Rogers (1973) is that mass media and interpersonal the innovation communication channels should both be used. Implementing both methods is of particular importance in According to classic diffusion theory, a population low- and middle-income countries (LMICs), espe© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC targeted by an intervention to promote acceptance of cially in rural communities. Rogers emphasizes that NOT FOR SALE OR DISTRIBUTION NOTdeliver FOR information SALE OR to DISTRIBUTION an innovation includes six groups: Innovators, early mass media a large population adopters, early majority, late majority, late adoptand add knowledge to the general knowledge base, ers, and laggards. The rapidity and extent to which but interpersonal contacts are needed to persuade health innovations are adopted by a target populapeople to adopt new behaviors (thereby using the tion are mediated by LLC a number of factors, including knowledge function, the persuasion © Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC function, and the relative compatibility, complexity, cominnovation-decision process). In Rogers’s work and NOT FOR SALE ORadvantage, DISTRIBUTION NOT FOR SALE OR DISTRIBUTION municability, observability, trialability, cost-efficiency, other work cited by him, “family planning diffusion time, commitment, risk and uncertainty, reversibilis almost entirely via interpersonal channels” (p. 263). ity, modifiability, and emergence (see the Innovation, Notably, Rogers presents five examples in different Technology and Design chapter for more information countries (including India, Taiwan, and Hong Kong), © Jones & Bartlett Learning, LLCwherein interpersonal ©channels Jones were & Bartlett Learning, LLC on scaling up health innovations). the primary NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR Relative advantage refers to the extent to which a source for family planning information and wereDISTRIBUTION the health innovation is better (faster, cheaper, more benmotivating factors to seeking services. eficial) than an existing behavior or practice. AntibiotThe limitations of using mass media to dissemiics, for example, were quickly accepted in most of the nate health messages include the following issues: world because were dramatically © Jones & they Bartlett Learning, faster LLC and more © Jones & Bartlett Learning, LLC ■ Limited exposure. In LMICs, smaller audiences effective than SALE traditional NOT FOR ORpractices. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION have access to mass media. Radio continues to be Compatibility is the degree to which the innovaan important mass-media tool, but social media tion is congruent with the target population’s existing via cell phones and other modes of Internet access set of practices and values. Polgar and Marshall (1976) are now a key way to reach people. Low literacy point out that injectable contraceptives were acceptare another barrier.LLC © Jones & Bartlett Learning, © Jones &levels Bartlett Learning, able in the village in LLC India where Marshall worked ■ Message irrelevancy. The content of mass-media NOT FOR SALE ORinjections DISTRIBUTION because were viewed so positively due toNOT the FOR SALE OR DISTRIBUTION messages may be of no practical use for many rural success of antibiotics. and “non-elite” populations. Often instrumenThe degree to which an innovation is easy to incortal information—“how to” information—is not porate into existing health regimens may also affect included in the messages (e.g., where to receive rates of diffusion.© Iodized salt&is Bartlett easier to use than tak- LLC Jones Learning, © Jones & Bartlett Learning, LLC services or the positive and negative consequences ing an iodine pill, because consuming salt is already NOT FOR SALE OR DISTRIBUTION of adapting a particular NOThealth FORbehavior). SALE OR DISTRIBUTION a habit. Health innovations are also more likely to be ■ Low credibility. For people to accept and believe adopted quickly and by larger numbers of individuals the messages being diffused, trustworthiness if the innovation itself can be easily communicated. needs to exist between the sender and the receiver. The concept of trialability involves the ease of tryIn © many LMICs, radio and TV stations are run by © Jones & behavior. BartlettFor Learning, Jones & Bartlett Learning, LLC ing out a new example, itLLC is easier to try a government monopoly and their content may FOR SALE NOT FOR SALE OR DISTRIBUTIONbe aNOT condom than to be OR fittedDISTRIBUTION for a diaphragm. Observconsidered to be government propaganda by the ability refers to role models, such as village leaders receivers. Radio and TV in Nigeria, Pakistan, and volunteering to be the first recipients in a vaccination other African and Asian countries, for example, campaign. are controlled by the government (Rogers, 1973). A health innovation © Jones & Bartlett Learning, LLCis also more likely to©beJones & Bartlett Learning, LLC The diffusion of innovations model focuses solely adopted if it is seen as cost-efficient. A famous case NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION on the processes and determinants of adoption of a study of water boiling in a Peruvian town demonnew behavior and does not help to understand or strated that the cost in time and energy of gathering 4. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 58 Chapter 2 Culture, Behavior, and Health explain the maintenance of behavior change. Many “Stages of change” © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Transtheoretical model of behavior change health behaviors require permanent or long-term NOT FOR SALE ORit DISTRIBUTION 1 changes. Also, is important to understand whether NOT FOR SALE OR DISTRIBUTION Precontemplation a new behavior is being carried out appropriately, No recognition of need consistently, or at all. One salient example involves for or interest in change condom use, which healthcare practitioners demon5 2 1 © Jones strated to a population © by Jones unrolling&the condomLearning, over Bartlett LLC & Bartlett Learning, LLC Contemplation Maintenance Ongoing practice Thinking aboutOR DISTRIBUTION a banana. Women whoNOT became pregnant they FOR SALEwhile OR DISTRIBUTION NOT2 FOR SALE 5 of new, healthier changing reported using condoms had been faithfully putting behavior them on bananas. 3 The rapid development of information 4 4 3 technology—in particular, the use of smartphones— © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Preparation Action is revolutionizing diffusion of information and comAdopting new habits Planning forDISTRIBUTION change NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR munication. For example, a smartphone innovation among men who have sex with men (MSM) consists FIGURE 2-2 “Stages of change” transtheoretical model of behavior change. of a computer app designed to facilitate finding sexual Reproduced from Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search of how people change: Applications to addictive partners of men infected with a sexually transmitted behaviors. American Psychologist, 47, 1102–1104. This app was usedLLC by the Monroe County © Jones & Bartlett Learning, LLC © Jonesdisease. & Bartlett Learning, Health Department in Rochester, New York, to map NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION balance, (3) self-efficacy, (4) processes of change, and the spread of several sexually transmitted infections (5) maintenance. Interventions relying on this model among this group, to document their sexual networks, are expected to include all four constructs in the and to advise sexual partners that they may have been development of strategies to communicate, promote, exposed to an infection (Pennise et al., 2015). maintain behavior change. © Jones & Bartlett Learning,and LLC © Jones & Bartlett Learning, LLC Wearable devices range from sensors embedThe transtheoretical model identifies five stages NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ded in clothing to glasses to computerized watches of change. The first is precontemplation, in which and health-related wrist units. These devices have individuals have no intention to take action within multiple applications, including fall risk assessment, the next 6 months. In the contemplation stage, indiquantifying sports exercise, studying people’s habits, viduals express an intention to take some action to and monitoring (Hagthi, Thurow,LLC & Stoll, © Jonesthe & elderly Bartlett Learning, © Jones Bartlett Learning, LLC change a negative health&behavior or adopt a positive 2017). NOT Smartphone apps, inOR some cases, are motivatFOR SALE DISTRIBUTION NOT FOR SALE OR DISTRIBUTION one within the next 6 months. The preparation stage ing people to engage in more physical activity or eat refers to the intent to make a change within the next healthier—for example, by tracking their daily steps 30 days. The action stage involves the demonstration or completing a food diary (Karpman, 2016). Others of an overt behavior change for an interval of less allow patients to upload their blood glucose readthan 6 months. In the fifth stage, LLC known as mainte© Jonesings, & Bartlett LLC data that they and © Jones & Bartlett Learning, heart ratesLearning, and other health nance, a person will have sustained a change for at NOT FOR OR can DISTRIBUTION theirSALE providers monitor over time. Hagthi et al. NOT FOR SALE OR DISTRIBUTION least 6 months. The model helps healthcare provid(2017) note that “Based on consultation with expert ers, including those working in health education and scientists in environmental engineering and medicommunication, to develop appropriate strategies cine, we believe that, motion trackers, gas detectors, for reaching people at the various stages of readiness and vital signs are the©most important elements in Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC forLLC change. health monitoring. . . NOT .” Globally, smartphones and FOR SALE OR DISTRIBUTION FORofSALE OR DISTRIBUTION Decisional balance is an NOT assessment the costs wrist or belt units are the most likely to be relevant for and benefits of changing, which will vary with the health-related applications in the near future. stage of change. Self-efficacy is divided into two concepts within the transtheoretical model. First, confidence exists that one can&engage in the new behavior. © Jones & Bartlett © Jones Bartlett Learning, LLC Transtheoretical Model Learning, LLC Second, the temptation aspect of self-efficacy refers NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to factors that can tempt one to engage in unhealthy Theories around the concept of stages of change behaviors across different settings. have been evolving since the early 1950s. Currently, The fourth construct of the transtheoretical the most widely accepted stage change model is the model deals with the process of change. It includes transtheoretical model of behavior change devel© Jonesoped & Bartlett Learning, LLC & that Bartlett Learning, LLC 10 factors can influence the progression of indiby Prochaska, DiClemente, and Norcross © Jones NOT FOR SALE OR 2-2). DISTRIBUTION FOR SALE OR DISTRIBUTION viduals from the precontemplation stage to the main(1992) (FIGURE This model includes five core NOT tenance stage. constructs: (1) stages of change, (2) decisional © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Theories of Health Behavior and Behavior Change 59 An explanatory model is seen as dynamic, and can The Harm Reduction © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLCModel change based on individual experiences with health, Harm reduction is a concept that emerged from NOT FOR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION withSALE health OR information, or with the illness in ques- chemical dependency treatment programs, in which tion (McSweeney, Allan, & Mayo, 1997). researchers realized that expecting those persons who EXHIBIT 2-3 adapts and summarizes concepts were addicted to substances to become abstinent in one from Good and Good’s (1981) description of the single step, without any relapse, was not possible for This & approach involves © Jones & Bartlett Learning, LLCmeaning-centered approach. © Jones Bartlett Learning, LLC the vast majority. It drew on the ideas of the transthemutual interpretations across systems of meaning. The NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION oretical model that changing health behavior involves interpretive goal is understanding the patient’s perseveral steps (contemplation, planning, action) and spective. The underlying premise is that disorders vary may also involve relapse. The important insights of profoundly in their psychodynamics, cultural influthe harm reduction model are that (1) relapse is not ences in interpretation, behavioral expression, severfailure and (2) making even a small step © Jones & Bartlett Learning, LLCin improv© Jones & Bartlett Learning, LLC ity, and duration. As noted earlier, it is difficult to apply ing health behavior to additional positive NOT FOR SALEoften OR leads DISTRIBUTION FOR SALE OR due DISTRIBUTION “codes”NOT to culture and symptoms to factors such as changes (Lane, Lurie, Bowser, Kahn, & Chen 1999). individual variations, groups assimilating or changing, The harm reduction model has been integrated into and groups adding beliefs and behaviors from other obesity-reduction programs, smoking cessation, and cultures. For example, belief in espiritismo (spiritism) teen pregnancy prevention. was strongest among © Jones & Bartlett Learning, LLC © Jones &traditionally Bartlett Learning, LLCPuerto Rican groups in the United but this belief has now been NOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORStates, DISTRIBUTION adopted by other cultures of Latin American origin as Explanatory Models well. Thus, instead of trying to provide “formulas” for Explanatory models were initially proposed by the understanding health and illness belief systems within physician-anthropologist Kleinman (1980, 1986, different cultures, the focus with the meaning-centered Jones Learning, © Jones & Bartlett Learning, LLC 1988). They differ©from some& ofBartlett the theories described LLCapproach is on the meaning of symptoms. The medical earlier in this section thatSALE they are designed for NOT in FOR OR DISTRIBUTION NOT FOR SALE of ORsympDISTRIBUTION encounter must involve the interpretation multicultural settings. They include models such toms and other relevant information. as the meaning-centered approach to staff–patient negotiation described by Good and Good (1981). Other Theories Although such models focus on individual interac© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC A number of other theories can be useful in looking at tions between physician or other staff and patients, the NOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION cultureNOT and behavior. For example, the multi-attribute concepts underlying them—such as Kleinman’s negoutility theory predicts behavior directly from an inditiation model—have proved useful for research and vidual’s evaluation of the consequences or outcomes for behavioral interventions for larger populations. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION EXHIBIT 2-3 Meaning-Centered Approach to Clinical Practice Primary Principles Actions Practitioners must: Groups vary in the specificity of their medical Jonesand & Bartlett Learning, LLC complaints. © Jones & Bartlett Learning, LLC■ Elicit patients’ requests,© questions, other ■ Groups vary in their style of medical complaining. communications. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■ Groups vary in the nature of their anxiety about the ■ Elicit and decode patients’ semantic networks. ■ Distinguish disease and illness and develop plans for meaning of symptoms. ■ Groups vary in their focus on organ systems. managing problems. ■ Groups vary in their response to therapeutic ■ Elicit explanatory models of patients and families, © Jones & Human Bartlett Learning, LLCsemantic © Jones & Bartlett strategies. illness is fundamentally analyze conflict with biomedicalLearning, models, and LLC meaningful (it may a biological base, but is a negotiate NOTorFOR SALE ORhave DISTRIBUTION NOTalternatives. FOR SALE OR DISTRIBUTION human experience). ■ Corollary ■ Clinical practice is inherently interpretive. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION Adapted by permission from Springer Nature: Springer Nature, The Meaning of Symptoms: A Cultural Hermeneutic Model forOR Clinical Practice by B. J. Good and M. J. D. Good, Copyright 1981. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 60 Chapter 2 Culture, Behavior, and Health associated with both performing and not performing and religion was essential to program strategies © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC a given behavior. Some models, such as social learning (Rekart, 2002). In Belize, understanding adolesFOR NOT FOR SALE DISTRIBUTION makingOR sureDISTRIBUTION the program met their needs theory, haveOR been criticized by anthropologists who NOT cents and SALE in both cultural- and age-appropriate ways was key (Martiniuk, O’Connor, & King, 2003). In Nepal, the use of indigenous workers and attention to cultural and&severity of Learning, LLC © Jones & Bartlett Learning,practices LLC helped lower the incidence © Jones Bartlett diarrheal and respiratory infections in the districts NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION targeted for interventions (Ghimire et al., 2010). Eval▸ uation of programs addressing family planning and HIV prevention shows that behavior-change communication increases knowledge and interpersonal com© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC munication among audience members and motivates NOT FOR SALE OR DISTRIBUTION NOT FOR SALE ORBernstein, DISTRIBUTION positive changes in behavior (Salem, Sullivan, & Lande, 2008). Another example of focusing on understandWhen applied in practice, many of the principles dising and changing cultural values around unhealthy cussed in this chapter can help increase the success behaviors found inLearning, the area of LLC smoking cessation. communication health promotion pro- © Jones © Jonesof&health Bartlett Learning,and LLC & isBartlett Abdullah Husten set forth a framework for grams. In particular, understanding and incorporating NOT NOT FOR SALE OR DISTRIBUTION FOR and SALE OR(2004) DISTRIBUTION public health intervention in this area that addresses people’s insider cultural values, beliefs, and behaviors; multiple levels of society. a community-based approach with strong community The need for the involvement of communities is participation; recognition of gender issues (Zamen & also clearly demonstrated in the literature, as literally Underwood, 2003); peer group education, including © Jones & Bartlett Learning,hundreds LLC of references exist © Jones & Bartlett Learning, LLC on this topic. A recent use of community-based outreach workers; and mulNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION summary article outlines many of the broad princitilevel intervention approaches have proved essential ples underlying this approach, including community to program success. analysis with community participation, action plans The Agita Sao Paulo Program in Brazil provides designed with community input, and community a case study in using local culture to design both the involvement ©inJones implementation content©and the delivery system for a program to use Jones & Bartlett Learning, LLC & Bartlett(Nguyen-Truong, Learning, LLC Tang, & Hsiao, 2017). Community involvement may physical activity to SALE promoteOR health (Matsudo et al., NOT FOR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION take the form of ongoing oversight and evaluation as 2002). Just the word agita (which means to move the well as the more usual modes of using community outbody—to “agitate” in the sense of “stirring,” but also to reach workers (e.g., Thevos, Quick, & Yanduli, 2000), change) is more culturally understood and internalworking through community organizations, and getized than a literal translation of “exercise.” In addition © Jonesto&representing Bartlett Learning, & Bartlett Learning, LLC ting individuals involved (Bhuyan, 2004). A report careful workLLC on culturally acceptable © Jones NOT FOR OR DISTRIBUTION FOR SALE OR in DISTRIBUTION from a recent project Bolivia documents the sucwaysSALE of delivering the message, this project provides NOT cess of involving community members in everything multiple culturally valued ways to increase physical from mapping the villages to priority setting for the activity, and “tailors” these options to the age, gender, program (Perry, Shanklin, & Schroeder, 2003). The and lifestyles of community members. National Health Learning, LLC In a very different © project, work in three townJones & Bartlett Learning,former LLC head of the United Kingdom’s © Jones & Bartlett Service, Nigel Crisp, argues strongly that the quest for ships in South Africa focused on identifying where NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION global health in the twenty-first century must involve AIDS prevention would be most effective from the a paradigm shift in which nations, communities, and culturally appropriate, insider perspective (Weir et al., indigenous peoples around the world have a much 2003). Among other things, researchers learned that greater voice in the design and implementation of ideal prevention intervention sites varied depending © Jones & Bartlett Learning, LLC © (Crisp, Jones2010). & Bartlett Learning, LLC health services on whether the central business district or the townNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Two projects in Chicago demonstrate the success of ship was the most popular location for initiating new the community outreach worker approach. In one case, sexual encounters. The type of sex (commercial verthe project focuses on intravenous drug abusers, helpsus casual) as well as the availability of condoms varing them to reduce their HIV/AIDS-related risk behavied with the site. The age of people engaging in risky iors and to drugLearning, abuse treatment behaviors and risk behaviors by gender also varied by © Jones & Bartlett Learning, LLC © Jones & initiate Bartlett LLCprograms. This work simply could not have been accomplished without site. Again, prevention programs needed to be tailored. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the efforts of community outreach workers, all of whom In another HIV/AIDS prevention project, are former addicts who know how and when to reach this time in Vietnam, paying attention to culture argue against the notion that people are like a “black box” into which you can pour information and expect a specific behavior change. Common Features of Successful Health Communication and Health Promotion Programs © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Methodologies for Understanding Culture and Behavior current addicts. Also, the outreach workers come from 61 concepts referable to empirical observations” (p. 22). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the predominant cultural/ethnic group in each commuThe Peltos add that “if the ‘personal factor’ in anthroSALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION nity (Booth & Wiebel, 1992; Wiebel, 1993; Wiebel etNOT al., FOR pology makes it automatically unscientific, then much 1996). Similarly, the Chicago Project for Violence Preof medical science, psychology, geography, and signifvention involves ex-gang members as outreach workicant parts of all disciplines (including chemistry and ers. Both programs have been adopted internationally physics) are unscientific” (p. 23). as well as in other©cities in the United States. A simi- LLC In fact, scientific research is not truly objective, Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC lar focus on peerNOT groupFOR education in Botswana led to but rather is governed by the cultural framework and SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION increased knowledge and prevention behaviors among theoretical orientation of the researcher. One example women at risk for HIV/AIDS infection (Norr, Norr, of this bias can be found in the past tendency of bioMcElmurray, Tlou, & Moeti, 2004). medical researchers in the United States to focus on adult men for many health problems that also occur in © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC women (such as heart disease). The earlier example of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION kuru also demonstrates the limitations of cultural bias. ▸ Qualitative research techniques include the following: Methodologies for Understanding Culture and Behavior © Jones & Bartlett Learning, LLC ■ Observation: Behaviors are observed and recorded. © Jones & Bartlett Learning, LLC ■ Participant observation: The researcher learns by ManyOR of the research methodologies developedNOT in FOR SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION participating in cultural events and practices. the United States do not translate easily, literally, ■ Interviews: Both open-ended and semi-structured or figuratively to international settings. Differences queries are possible, usually based on interview in linguistic nuances, in the meanings of words and guides or checklists. concepts, in what people would reveal to a stranger, ■ of people asked toLearning, dis© Jones & Bartlett Learning, LLC Focus groups: A group © Jones & are Bartlett LLC and in what they would reveal to someone from their cuss specific questions andFOR topics. NOT FOR SALE OR DISTRIBUTION NOT SALE OR DISTRIBUTION community have all complicated the application of ■ Document analysis: Existing documents and prior the quantitative methodologies used by sociologists, research are evaluated. psychologists, and epidemiologists. The realization of ■ Systematic data collection: This technique ranges these problems came about gradually, through failed widely, from photography and videotaping to askprojects and& missed interpretations, and especially © Jones Bartlett Learning, LLC Jones &toBartlett Learning, ing©informants draw maps; sort cards LLC with piconce appeared. whose prevention is NOTAIDS FOR SALE As ORa disease DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tures, words, or objects; answer questions based still largely behavioral, and with which many hidden on scales; and many more (Bernard, 2013; Pelto & or taboo behaviors are involved, AIDS highlighted Pelto, 1978; Scrimshaw & Hurtado, 1987). the need for qualitative research and for research conA key feature of qualitative research is the use of ducted by individuals from the cultures being studied. © Jones & Bartlett Learning, LLC © Jones & Bartlett these multiple Learning, methods to LLC triangulate, or compare, More recently, the Ebola pandemic of 2013–2016 reinNOT FOR SALE NOT FOR DISTRIBUTION dataSALE so as toOR ensure accuracy. With these approaches, forcedOR the DISTRIBUTION need to understand and address behaviors the researcher does not simply rely on what is said, but and beliefs as part of health interventions. can observe what is actually done. Another feature is The field of global health has now moved from an that the researcher spends enough time in the comalmost exclusively quantitative orientation to the recobserve, or otherwise ognition that a toolbox of methodologies is available. © Jones & Bartlett Learning, LLCmunity to be able to interview, © Jones & Bartlett Learning, LLC evaluate the same individuals or behaviors multiple Some of these tools may be more valuable than others NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION times, thereby further ensuring the depth and accufor some situations or questions; at other times, a mix racy of the resulting data. of several methodologies may offer the best approach. These techniques yield data that are descripThese methodologies derive from epidemiology, surtive and exploratory, and that serve to investigate vey research, psychology, anthropology, marketing © Jones social & Bartlett Learning, LLCfields. The © Jones & Bartlett Learning, little-understood phenomena, identify or LLC discover (including marketing), and other NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR important variables, and generateDISTRIBUTION hypotheses for furbiggest disagreement has been over the relative value ther research. Results are often explanatory, helping of quantitative and qualitative methods. researchers to understand the social and cultural forces The debate on the scientific value of qualitative vercausing the phenomenon and to identify plausible causal sus quantitative research is well summarized by Pelto networks. They Learning, also present the “voices” of the particiand Pelto (1978). They define science as the “accumu© Jones & Bartlett Learning, LLC © Jones & Bartlett LLC pants, and introduce context and meaning into the findlation of systematic and reliable knowledge about an NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ings. They yield themes, patterns, concepts, and insights aspect of the universe, carried out by empirical obserrelated to cultural phenomena. They can be particularly vation and interpreted in terms of the interrelating of © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 62 Chapter 2 Culture, Behavior, and Health valuable for behaviors that are often hidden, such as sex- commenced. Murray subsequently included questions © Jones & Bartlett Learning, LLC © Jones Bartlett Learning, LLC ual&risk taking and drug abuse (Dickson-Gomez, 2010; about perdition in a later survey, which revealed that FOR SALE OR DISTRIBUTION NOT FOR SALE ORInDISTRIBUTION Wiebel, 1993) evaluations, they help practitioners NOT it was apparently a cultural way of making infertility make judgments about a program, improve its effecor subfecundity socially acceptable, as many women tiveness, and inform decisions about future programin perdition fell into these categories. ming, as illustrated in the case study on acceptability of Surveys are effective tools for collecting data an infant cereal found later in this chapter. when the distribu- Learning, LLC © Jones & Bartlett Learning,from LLCa large sample, particularly © Jones & Bartlett The methodologicalNOT concepts validityOR and DISTRIBUTION relition of a variable in a population needed (e.g., the FORofSALE NOTisFOR SALE OR DISTRIBUTION ability provide a common foundation for the integrapercentage of women who obtain prenatal care) or tion of quantitative and qualitative techniques. Validity when rarely occurring events must be assessed (e.g., refers to the accuracy of scientific measurement—“the neonatal deaths). Surveys are also used to record degree to which scientific observations measure what people’s answers to questions about their behavior, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC they purport to measure” (Pelto & Pelto, 1978, p. 33). motivations, perception of an event, and similar topNOT FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION For example, in Spanish Harlem in New York City, a ics. AlthoughNOT surveys are carefully designed to collect study using the question “¿Sabe como evitar los hijos?” data in the most objective manner possible, they often (“Do you know how to avoid [having] children?”) suffer inaccuracies based on respondents’ perceptions elicited responses on contraceptive methods and was of their own behavior, their differing interpretations of as the firstLearning, in a series of LLC questions on family plan- © Jones the meaning of the question, or their desire to please © Jonesused & Bartlett & Bartlett Learning, LLC ning. By notOR using family planning terminology at the NOT the FOR interviewer answers. Surveys also can NOT FOR SALE DISTRIBUTION SALEwith ORtheir DISTRIBUTION outset, the study was able to avoid biasing respondents encounter difficulty in uncovering motives (i.e., why (Scrimshaw & Pasquariella, 1970). The same phrase in individuals behave as they do), and they are not apt Ecuador, however, produced reactions like “I would to uncover behaviors that may be consciously or never take out [abort] a child!” If the New York quesunconsciously concealed. In “Truths and Untruths in © Jones & Bartlett Learning,Village LLC Haiti: An Experiment©inJones & Bartlett Learning, LLC tionnaire had been applied in Ecuador without first Third World Survey NOT FOR SALE OR DISTRIBUTION NOT FOR SALE testing it through semi-structured ethnographic interResearch,” Chen and Murray (1976) describe someOR of DISTRIBUTION views, the same words would have produced answers these problems. to what was, in fact, a different question (Scrimshaw, The traditional anthropological approach involves 1974). Qualitative methods often provide greater one person or a small team who remain at the research validity©than quantitative methods because LLC they rely site for at least a year. & This practiceLearning, is intended LLC to Jones & Bartlett Learning, © Jones Bartlett on multiple sources, including direct observation ensure that the findings into account the changes NOTdata FOR SALE OR DISTRIBUTION NOT FORtake SALE OR DISTRIBUTION of behavior and multiple contacts with people over in people’s lifestyles with the changes in seasons, activtime. Thus, they can be used to increase the validity of ities, available food, and so on. Also, the anthropolosurvey research. gist often needs time to learn a language or dialect and Reliability refers to replicability—the extent to learn enough about the culture to provide a context © Joneswhich & Bartlett LLC & Bartlett Learning, LLC scientificLearning, observations can be repeated and © Jones for questions and observations. More recently, a subNOT FOR OR DISTRIBUTION SALE OR DISTRIBUTION the SALE same results obtained. In general, this goal is best NOT set FOR of anthropological tools (ethnographic interview, accomplished through survey research or other quantiparticipant observation, conversation, and observatative means. Surveys can test hypotheses and examine tion) plus the market researchers’ tool of focus groups questions generated through qualitative data. Qualitahave been combined in a rapid anthropological assesstive methods may help us discover a behavior or learn Assessment Proce- Learning, LLC © Jones & Bartlett Learning,ment LLCprocess known as the Rapid © Jones & Bartlett how to ask questions about it, while quantitative data dure (RAP) (Scrimshaw, Carballo, Carael, Ramos, & DISTRIBUTION NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR can tell us how extensive the behavior is in a populaParker, 1992; Scrimshaw, Carballo, Ramos, & Blair, tion and which other variables are associated with it. 1991; Scrimshaw & Hurtado, 1987). Murray (1976) describes just such a discovery RAP evolved around the same time as Rapid during qualitative research in a Haitian community, Rural Appraisal was developed by rural sociologists Jonesquestion—“Are & Bartlett Learning, LLC © Jones Bartlettmade Learning, where © a simple you pregnant?”—had (Chambers, 1992). Both&methods listeningLLC to NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION two meanings. Women could be pregnant with gros community voices easier for program planners and ventre (“big belly”) or could be pregnant and in perdihealthcare providers and became frequently used tion. Perdition meant a state where a woman was pregtools for program development and evaluation. RAP nant, but the baby was “stuck” in utero and refused to is designed to involve local researchers who already grow. Perdition was attributed to causes such as “cold, ” know the&language much of the cultural context. © Jones & Bartlett Learning, LLC © Jones Bartlettand Learning, LLC Such procedures have been developed for many topspirits, or ancestors. Women may be in perdition for NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ics, including AIDS, women’s health, diarrheal disease, years, and may be separated, divorced, or widowed, seizure disorders, water and health, and childhood but the pregnancy is attributed to her partner when it © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Methodologies for Understanding Culture and Behavior obesity prevention. RAP has become a generic con- 63 A final comment on methodology is that as the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC cept, and has been modified for many uses. Modified social sciences are increasingly combining methodolNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION titles include RARE, ERAP, and FES (focused ethnoogies and sharing each other’s tools, it is also important graphic study). In the past 20 years, the RAP methodto share theoretical approaches. Where methodology ologies have been embraced by community members, is concerned, this leads to using multilevel approaches researchers, and funders alike and have been broadly to research, in which environment, biological factors, © Jones & Bartlett © Jones & Bartlett LLC used in community participatory research.Learning, LLCcognitive issues, societal and cultural context,Learning, and The case study on the use of focused ethnographic political and economic forces can SALE contribute the NOT FOR SALE OR DISTRIBUTION NOT all FOR ORtoDISTRIBUTION methods to assess the feasibility of introducing a fortianalyses. This should take place at least to the extent fied infant cereal in an African country, which appears that an examination is made of data one step above in the next section of this chapter, is a good example and one step below the phenomenon being explained of the use and value of this approach. With a relatively (Rubenstein, Scrimshaw, & Morrissey, 2000). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC small number of interviews, researchers were able to An example of a logic framework using this NOT FOR SALE OR DISTRIBUTION NOT SALE OR DISTRIBUTION establish that the cereal as constituted and packaged approach can FOR be found in the work of the Centers for would be unlikely to succeed. Minor modifications Disease Control and Prevention (CDC) task force that (i.e., a cereal that did not require cooking and was developed and maintains the Guide to Community packaged in small amounts) were recommended to Preventive Services—a series of evidence-based recchange the product’s likely ommendations for community public health practice © Jones & Bartlett Learning, LLCacceptability. © Jones & Bartlett Learning, LLC community participatory research, community based on a OR systematic and critical review of the eviNOT FOR SALEInOR DISTRIBUTION NOT FOR SALE DISTRIBUTION members become involved in the design, conduct, dence. Topics considered in the guide include major and interpretation of research. This approach has been risk behaviors (e.g., tobacco use, alcohol abuse and used most often for health intervention and behavior misuse, other substance abuse, nutrition, physical change programs where community acceptance of activity, healthy sexual behavior), specific illnesses © Jones & Bartlett Learning, LLC(e.g., cancer, diabetes), and © Jones & Bartlett Learning, LLC such interventions and programs is essential for sucone overarching topic, the NOT FOR SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION cess. It also has been found to increase the validity sociocultural environment. FIGURE SALE 2-3 presents the (accuracy) of the data, as community members are logic framework for this topic. The outcomes of cominvested in developing programs that work. munity health (on the right side of the figure) stem Health determinants LLC © Jones & Bartlett Learning, NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Equity and social justice Intermediate outcomes © Jones & Bartlett Learning, LLCresources Societal NOT FOR SALE OR DISTRIBUTION ©Neighborhood Jones & Bartlett Learning, LLC living conditions NOT FOR SALE OR DISTRIBUTION Opportunities for learning & Human, social, & financial: developing capacity • Standard of living • Culture and history Community development & • Social institutions employment opportunities • Built environments • Political structures © Jonessystems & Bartlett Learning,Prevailing LLC community norms, • Economic customs & processes • Technology NOT FOR SALE OR DISTRIBUTION Health outcomes Level of community © Jones & Bartlett Learning, LLC health NOT FOR SALE OR DISTRIBUTION Social cohesion, civic engagement & collective efficacy Physical environment natural resources Bartlett Learning, © Jones & LLC NOT FOR SALE OR DISTRIBUTION Health promotion, disease & injury prevention, & health care © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Legend © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION Relationships for which evidence was sought Relationships for which evidenceLLC was not sought Learning, © Jones & Bartlett NOT FOR SALE OR DISTRIBUTION FIGURE 2-3 The Guide to Community Preventive Services’ social environment and health model. Reproduced from Anderson L. M., Scrimshaw S. C., Fuillilove M. T., et al. (2003). The community guide’s model for linking the social environment to health. American Journal of Preventive Medicine, 24(35), p. 13. Reprinted with permission from Elsevier. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 64 Chapter 2 Culture, Behavior, and Health from factors in the physical environment and societal of these steps did or did not occur was also important © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC resources; outcomes related to equity and social justice to assess. The price of the product was pegged at the NOT FORthat SALE DISTRIBUTION NOT FOR SALE OR DISTRIBUTION issues derive from factors on the left side of the figamount most OR urban families, even the poor, could ure. The immediate outcomes, which are listed in the afford to spend per day for a cereal. middle of the figure, range from neighborhood living It was important to the researchers to make the conditions to prevailing community norms regardstudy framework broad enough to include key variing prevention and health care (Anderson, Fielding, mistakes by inter- Learning, LLC © Jones & Bartlett Learning,ables, LLCso that they could avoid © Jonesmade & Bartlett et al., 2003; Anderson, NOT Scrimshaw, al., 2003). This vention projects that fail to take cultural, FOR et SALE OR DISTRIBUTION NOTimportant FOR SALE OR DISTRIBUTION approach greatly broadens the context for undereconomic, access, and other factors into account. A standing and addressing the health of individuals and household perspective was chosen because the purof communities. chase and preparation of the cereal would be done at The CDC’s Community Guide can be accessed the household level. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC through the following website: www.thecommunity Research questions included the following items: NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION guide.org. That website and related publications listed ■ How much are households currently spending on there provide evidence-based guidelines for improvfood for their infants? ing community health, many of which have global ■ Are their current expenditures providing a nutrirelevance. tionally adequate diet? © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ▸ © Jones Bartlett that Learning, LLC less than x ■ Do & households are spending NOT FOR SALE OR DISTRIBUTION amount (e.g., cents/day) have the potential to shift their expenditures? Case Study: Use of a Focused Which other factors determine household buying and/or preparation of foods for the infant or Ethnographic Study to Assess young child, and would these other factors inter- Learning, LLC © Jones & Bartlett Learning, LLC © Jones & Bartlett the Acceptability of a Fortified fere with making a switch, even if the family could NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION † afford it monetarily? Infant Cereal in Africa * ■ It was also important to take into account the posEarlier in this chapter, qualitative methods derived sible foods for infants and young children in this envilargely from anthropology were described as being ronment: (1)©human milk, (2) home-prepared foods © Jones & Bartlett Learning, LLC Jones & Bartlett Learning, LLC important tools for ascertaining cultural facilitators that are made for family members and are also given NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and impediments to behavior changes that lead to to the infant or young child, (3) home-prepared foods improved health. As discussed then, these tools have that are made exclusively for the infant or young child, been adapted for use in rapid assessment. This case (4) commercial products that are marketed and purstudy involves a rapid (focused) ethnographic study chased for household consumption, (5) commercial was conducted before a new infant cereal was products&that are marketed and purchased © Jonesthat & Bartlett Learning, LLC © Jones Bartlett Learning, LLC exclusively introduced to assess the potential success of this cereal for the infant or young child, and (6) commercial NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION by investigating household and local market behaviors. products that are marketed for household consumpMany infants and young children (IYC) in Africa tion, but are purchased exclusively for the infant or continue to suffer from malnutrition or undernutriyoung child. tion. Where mothers breastfeed exclusively for at least The focused ethnographic study interviewed key © that Jones & Bartlett Learning,informants—people LLC © Jones & Bartlett Learning, LLC six months, quality foods complement the nutriwho had personal knowledge and ents in human milk are important after six months NOT FOR SALE OR DISTRIBUTION NOT SALEFour OR DISTRIBUTION experience in an area of concern to FOR the project. when human milk alone is not adequate to meet nutridifferent techniques were used: tional needs. In one African country, a project was devised 1. Free listing exercises. The respondent is asked to introduce a fortified cereal-based food that could a question or set of questions that elicit a © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC help contribute to improved nutrition for infants and series of items (objects, events, issues) perNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION children consuming it. The aim of the focused ethtaining to a particular cultural domain. For nographic study was to determine whether families example, the interviewer can ask, “What are would purchase the food if available and, if the product all the different places where a person can was purchased, who actually consumed it. Why each get food for infants or young children?” © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION †* This case study is based on Pelto, G. H., & Armar-Klemesu, M. (2010). Focused ethnographic study to assess the potential of a commercial complementary food. Report prepared for the Global Alliance for Improved Nutrition, Geneva, Switzerland. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Case Study: The Slim Disease—HIV/AIDS in Sub-Saharan Africa 2. Open-ended interviewing, with guiding 65 Because families were already spending so much © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC questions. In open-ended questions, the for these foods, there was clearly a niche for a lower-cost NOT FOR SALE OR but DISTRIBUTION NOT FOR SALE OR interviewer DISTRIBUTION writes down what the responfortified cereal, it must be instant and available dent says in response to a question without in small packets to be a financially viable option for using precoding. Questions can be broad or families. The findings of this study were valuable in narrow—for example, “How do you prepare planning a program to introduce the cereal, providing cereal for your baby?” practitioners needed to © Jones & Bartlett Learning, LLCthe guidance that healthcare © Jones & Bartlett Learning, LLC 3. Rating NOT and ranking exercises. Respondents proceed with an appropriately modified product, and FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION are asked to rate and rank items such as to avoid spending time and money on something that foods and sources of health care. Methods would not work. include handing respondents’ cards with pictures of objects to be ranked and asking © Jonesthem & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ▸ to arrange these from most to least NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION important, as well as asking them to assign the card to a slot along a continuum. (A ‡ similar technique for the latter method is the familiar scale of perceived pain.) AIDS changed Learning, the way in which 4. Mapping exercises. Respondents create © Jones & Bartlett Learning, LLC © Jones & Bartlett LLC epidemiologic and behavioral research is conducted and health intermaps on which they indicate NOT the FOR NOT FOR SALE OR visual DISTRIBUTION SALE OR DISTRIBUTION ventions designed and carried out. This case study locations of specific features of concern illustrates virtually all the topics covered in this for the researcher, such as places to obtain chapter. commercial foods. Case Study: The Slim Disease—HIV/AIDS in Sub-Saharan Africa * In this case study, there &were two main types of LLC © Jones Bartlett Learning, © Jones & Bartlett Learning, LLC Epidemiology key informant-respondents: (1) women who gave NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION As of 2016, an estimated 36.7 million adults and chilinformation from the perspective of people who take dren were living with HIV/AIDS worldwide (UNAIDS, care of children and (2) people who gave information 2017). Nearly half (17.8 million) were women, and from the perspective of marketing infant and young 2.1 million were children. Of the 36.7 million persons child foods. Thirty primary care givers, 10 alternate © Jones & Bartlett Learning, LLC © Jones 19.4 & Bartlett LLCand with HIV/AIDS, million Learning, reside in eastern caregivers, and 12 sellers of these foods were interNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION southern Africa, among whom 59% are women and viewed. The sellers were divided into street venders girls. In 2016, 77,000 new HIV infections in eastern and keepers of small shops. and southern Africa occurred in children. Per capita The results of the study provided evidence to answer rates of infection rates in the United States decreased the key question about the potential acceptability of by&18% betweenLearning, 2008 and 2014, as a result of a combia new fortified cereal for infants and young children. © Jones & Bartlett Learning, LLC © Jones Bartlett LLC nation of aggressive use of antiretroviral therapies and They revealed that fortified cereals are, indeed, used NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION prevention strategies (HIV.gov, 2017a, 2017b; WHO, and accepted, and that a relatively high proportion of 2010). the food budget for households with infants is spent on Unlike in the Western world, where AIDS was these items. Thus the key question about a dietary niche originally associated with gay men and injection-drug for a fortified cereal was answered affirmatively. © Jones & Bartlett Learning, ©common Jones & Bartlett Learning, LLC route of transmisImportantly, the study uncovered the reality that a LLCusers, in Africa the most sion is through heterosexual sex. Men infect food that must beNOT cooked, however briefly, is unlikely FOR SALE OR DISTRIBUTION NOT FOR SALE ORtheir DISTRIBUTION partners (often wives) as a result of their involvement to be chosen over instant foods that do not require with other partners. A pregnant, HIV-positive woman cooking. Busy mothers will spend more money to purmay transmit the virus to her fetus through the plachase prepared cooked cereals from street vendor or centa or her infant through breastfeeding. buy small packets of instant cereal that can be mixed © Jones & Bartlett Learning, LLC ©toJones & Bartlett Learning, LLC Generally, AIDS patients in Africa suffer from with water rather than cooking a cereal themselves. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION intestinal infections, skin disease, tuberculosis, herThis was extremely important guidance, as it showed pes zoster, and meningitis. In the industrialized counthat the cereal planned for introduction would need to tries, AIDS is associated with Kaposi’s sarcoma (a skin be modified so that it would not require cooking if it cancer), meningitis, and pneumonia. was to be a success. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION ‡* This case study was developed by Isabel Martinez, MPH. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 66 Chapter 2 Culture, Behavior, and Health Why does the same disease spread so differently and refugees. Women are especially at risk. They are © Jones & Bartlett Learning, LLC © Jones & Bartlett from one regionLearning, of the worldLLC to another? History, polsix times more likely to contract HIV in refugee camps SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION itics,SALE economics, and cultural and social environments NOT thanFOR women in populations that reside outside such influence the course of a disease in a society. In the case camps. In addition, women are often victims of rape as of Africa, traditional family, social, and environmental a weapon of war by the enemy side. Armed forces and structures were disrupted by European colonization, the commercial sex workers with whom soldiers interwhich imposed changes©on the existing culture.Learning, Even actLLC are also affected by the epidemic (Akeroyd, 1997; Learning, LLC Jones & Bartlett © Jones & Bartlett after countries becameNOT independent fromOR Europe, Carballo & Siem, 1996; Jok,NOT 2001,FOR 2012;SALE UNAIDS, FOR SALE DISTRIBUTION OR DISTRIBUTION their political, ecological, and economic structures 1999; United Nations, 1999a; Uppsala Conflict Data remained disrupted and often unstable. Many of these Program, n.d.; Wallensteen & Harbom, 2009). factors contributed to an environment in which AIDS easily took hold (Akeroyd, 1997; Bond, Kreniske, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Gender Roles and Cultural Traditions Susser, & Vincent, 1997; Hunt, 1989; Jok, 2001). These NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The African woman’s struggle with the AIDS pandemic factors and their association with the AIDS pandemic has been depicted often in the literature (Akeroyd, are described in the following subsections. In addi1997; Carballo & Siem, 1996; Hunt, 1989; Messertion to illustrating the relationship between cultural smith, 1991; Salopek, 2000; UNAIDS, 1999; Watkins, norms, prevention and healthcare access, and disease, 2004). The risk to women from husbands studyLearning, demonstrates the profound relation- © Jones © Jonesthis & case Bartlett LLC & Bartlett Learning, LLC or partners returning from work in other areas has already been shipSALE between theDISTRIBUTION general sociocultural, political, phys- NOT FOR SALE OR DISTRIBUTION NOT FOR OR discussed. Another risk—sex work or prostitution by ical, and economic environment and health. women as a means of survival—is now almost a death sentence in Africa, considering the great risk of conRisk of AIDS Associated with Migratory Labor tracting HIV/AIDS through such employment. There © Jones & Bartlett Learning,areLLC © Jones & Bartlett The integral family structure of the African culture many reasons why some African women find the Learning, LLC FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION has been broken up by NOT the migratory labor system in need to engage in sex work, although studies have eastern, central, and southern Africa. This system was linked most of these reasons to a political economy historically part of the region’s industrial development context. Sex in exchange for favors, material goods, and colonization by European powers. These large or money is conducted in all socioeconomic levels, industries, which include mining, railroad work, planfrom female entrepreneurs in foreignLearning, trade havingLLC to © Jones & Bartlett Learning, LLC © Jones & Bartlett tation work, and primary production facilities (e.g., use sexual ploys to ensure business to impoverished NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION oil refineries), have absorbed a massive labor influx young women needing money to support themselves from rural areas. Men typically leave their homes and and their families (Swidler & Watkins, 2007). Even if travel outside their communities to work sites, where women in sex work are knowledgeable about preventthey remain for long periods of time. This system has ing HIV infection through use of condoms, their cost kept Learning, families apart, but also increased the © Jones © Jonesnot & only Bartlett LLC & Bartlett Learning, and availability, combined with theLLC resistance of some numbers of sex partners for men—in turn, giving rise males to use them, raise barriers for the safety of these NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to a higher prevalence of sexually transmitted infecwomen and play a part in further transmission of the tions (STIs) and later AIDS. In many African cultures, disease (Akeroyd, 1997; Messersmith, 1991). regular sex is believed essential to health. Men in the Having multiple sexual partners has increasingly migratory labor system have sex with prostitutes close been implicated in raising the risk for HIV for both men © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC to their work sites, become infected, and eventually and women (Helleringer, Kohlerb, & Kalilani-Phiric, FORwhose SALEbabies OR may DISTRIBUTION NOTpractices FOR SALE return home and infect NOT their wives, 2009). Called “concurrency,” these are nowOR a DISTRIBUTION in turn become infected (Hunt, 1989; Salopek, 2000). major focus of intervention efforts (Shelton, 2009). Other cultural factors that place young women at greater risk for HIV infection include a superstition in War © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, some areas that having sex with a virgin will cureLLC an In 2017, thereFOR wereSALE 14 major armed conflicts and 29 HIV-infectedNOT man. Adolescent girlsOR andDISTRIBUTION young women NOT OR DISTRIBUTION FOR SALE additional armed conflicts globally. Of these 43 conare placed at higher risk of exposure to HIV due to the flicts, 21 occurred in Africa. A country at war typically behavioral practices of engaging in sex with older men faces a weakening of its political system, and this situ(Tulio de Oliveira et al., 2017). The practice of female ation in Africa has intensified the impact of the AIDS circumcision also places young girls at risk. In both © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC epidemic. Several populations become more vulnerable of these circumstances, the risk of contracting HIV NOT FOR SALE OR DISTRIBUTION NOT FORsex SALE OR DISTRIBUTION to HIV/AIDS during wartime, including those affected through or infected surgical instruments increases by food emergencies and scarcity, displaced persons, for adolescents (Akeroyd, 1997; Salopek, 2000). © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Case Study: The Slim Disease—HIV/AIDS in Sub-Saharan Africa 67 1997; Bartholet, 2000; Salopek, 2000; UNAIDS, 1999; Additional CulturalLLC Beliefs © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, United Nations, 1999c). Secrecy regarding HIV/AIDS is common within some NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION One project in Ghana used both the health belief sub-Saharan cultures. Denying that AIDS is affecting model and social learning theory to examine the one’s community or that one is infected increases the determinants of condom use to prevent HIV infection chances that the virus will be transmitted to other peoamong youth. The authors of the study found that perple because preventive actions are not taken (Akeroyd, interacted with perceived © Jones & Bartlett Learning, LLCceived barriers significantly © Jones & Bartlett Learning, LLC 1997; Salopek, 2000; UNAIDS, 1999; United Nations, susceptibility and self-efficacy. YouthSALE who perceived a NOT FOR SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION 1999d). Preventive actions go beyond preventing sexhigh level of susceptibility to HIV infection and a low ual transmission, to include concerns about transmislevel of barriers to condom use were almost six times sion during treatment of ill individuals and during as likely to have used condoms at last intercourse. A funeral practices. high level of perceived self-efficacy and a low level In some & parts of Africa, AIDS is referred © Jones Bartlett Learning, LLC to as the © Jones & Bartlett Learning, LLC of perceived barriers increased the likelihood of use “slim becauseOR of the wasting away that occurs NOTdisease” FOR SALE DISTRIBUTION NOT(Adih FOR& SALE OR1999). DISTRIBUTION three times Alexander, as a result of the infections. Because of this belief, men prefer sex with plump women, believing that they are not infected. AIDS is called “white man’s disease” Prevention Efforts by Community and in Gabon and “that other thing” in Zimbabwe. HIV © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, Governmental AgenciesLLC and and AIDS are a source of shame and denial in these NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION African cultures. AIDS is also considered a punishNongovernmental Organizations ment for overindulgence of the body. One sangoma In the 1990s, Uganda and Senegal reduced their HIV (faith healer), who has helped revive an ancient Zulu infection rates through aggressive public education custom of virginity testing of young girls, supported and condom promotion campaigns, expanded treather belief in reviving this custom by saying, “We have LLCment programs for other © Jones & Bartlett Learning, © Jones & BartlettofLearning, LLC STIs, mobilization nonadopted too many Western without thinking, NOT FORthings SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION governmental organizations (NGOs), and reduction and we lost respect for our bodies. This has allowed of stigma for people with HIV/AIDS. Health officials things like AIDS to come torture us” (Akeroyd, 1997; believe the education efforts surrounding AIDS have Hunt, 1989; Salopek, 2000; UNAIDS, 1999). contributed to women delaying the onset of sexual intercourse and increased condom use among © Jones & Bartlett Learning, LLC sex workersNOT and FOR men and women who have casual sex SALE OR DISTRIBUTION (UNAIDS, 1999; United Nations, 1999a). of HIV/AIDS The theory of self-efficacy has proved useful in Barriers to prevention of HIV/AIDS include lack of addressing AIDS. For example, one study in South financial resources and allocation of funds to projAfrica found that knowledge of risk and its preven© Jones & Bartlett LLCcrucial than those related © Jones & Bartlett Learning, LLCsufficient to change ects thatLearning, might be less tion was important, but not to health. For example, a foreign country funded a behavior. The authors stress the need to improve NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION multimillion-dollar hospital in Zambia, even though personal autonomy in decision making about sexual the rural clinics where the majority of the population behavior and condom use for both men and women live are often not even stocked with aspirin (Bartholet, through skills development programs that promote 2000; Salopek, 2000). self-efficacy (Reddy, Meyer-Weitz, van den Borne, & © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Changing people’s health behavior and addressKok, 1999). NOT SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION ing cultural beliefs has FOR also been a tough challenge The United NationsNOT and its specialized agencies when it comes to prevention efforts. Promoting safe have created major programs to assist countries and sex and the use of contraception, as well as abstaincommunities in prevention efforts, including joining ing from some cultural rituals, can be perceived as forces to accelerate the development of experimental © Jonestraditional & Bartlett Learning, © Jones & institutions Bartlett Learning, LLC up changing gender roles forLLC both men and vaccines. Academic have also teamed women, and may go against some religious values that with local andOR church organizations to NOT FOR SALE OR DISTRIBUTION NOTcommunity FOR SALE DISTRIBUTION are part of the core for some communities. The need create prevention projects and help organize the comto hide or look away from the problem of HIV/AIDS munities to reach more of the public. These efforts stems from the disgrace attached to the disease, which have assisted in empowering many volunteers, mostly makes it difficult for people even to discuss it, much women, to motivate others in their communities © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC less be tested for this infection. The stigma of HIV/ through education and increasing women’s negotiaNOT FOR SALE OR DISTRIBUTION NOT FOR AIDS needs to be removed for prevention efforts to be tionSALE skills forOR safeDISTRIBUTION sex or condom use (Msiza-Makhubu, more widely accepted by the African people (Akeroyd, 1997; United Nations, 1999d; WHO, 1997). © Jones & Bartlett Learning, LLC Barriers to SALE Prevention or Treatment NOT FOR OR DISTRIBUTION © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 68 Chapter 2 Culture, Behavior, and Health There is also a growing movement in which doctors Ebola © Jones & Bartlett Learning, LLC ▸ © Jones Bartlett LLC in & Africa work Learning, with traditional healers to do outreach FOR SALE OR DISTRIBUTION NOT FOR OR and SALE education onDISTRIBUTION AIDS. As discussed earlier, traditional NOT The Ebola virus shares several characteristics with HIV/ healers have better access to many populations. People seek their help because of tradition and lack of adequate health care (Associated Press, 2000; Green, 1994). AIDs. First identified in 1976, Ebola is a newly emergent infection. Beginning as a zoonotic disease that infected fruit bats, nonhuman primates, and other mammals, it © Jones & Bartlett Learning,“jumped LLC species” to infect humans © Jones & Bartlett as a result of ecolog- Learning, LLC ical disruption—in this case, hunting wild animals for DISTRIBUTION NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR Antiretroviral Therapy food or what is called “bush meat.” An Ebola pandemic Donor agencies/organizations such as the Global in 2013–2016 that was centered in the West African Fund to Fight AIDS, TB, and Malaria; the U.S. Prescountries of Liberia, Sierra Leone, and Guinea infected ident’s Plan for AIDS Relief; the World Bank; the some 17,145 individuals, among whom 6,070 died. The © Jones & Bartlett LLC © Jones & Bartlett Learning, LLC European Commission; WHO;Learning, and the Gates Founshort interval between recognition of symptoms and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION dation have aggressively provided testing for HIV/ death of 6–16 days, the appalling fatality rate of 25% to AIDS and antiretroviral (ARV) therapy during the 90%, and the lack of effective antimicrobial agents and past eight years, and infection rates have come down preventive vaccines produced panic that often impeded (UNAIDS, 2004a; WHO, 2004). Beginning in 2003, global health strategies to reduce infection and provide States implemented the President’s Emer- © Jones © Jonesthe&United Bartlett Learning, LLC & care Bartlett LLC supportive to the Learning, infected. gency Plan for AIDS Relief (PEPFAR/Emergency The two hardest-hit countries—Liberia and Sierra NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Plan). As of 2017, this program had provided antiretLeone—are impoverished. Liberia ranks 182th out of roviral treatment (ART) to more than 11 million 187 countries in the United Nations Human DevelHIV-infected people and supported HIV testing and opment Index; Sierra Leone comes in at 180 (United counseling (HTC) for more than 56.7 million people Nations Development Programme, 2017). Cultural © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC (PEPFAR, 2017). patterns of care for the sick and dying, as well as careNOT FOR SALE ORintroDISTRIBUTION NOT FOR SALEwere OR DISTRIBUTION Innovative prevention programs such as the ful tending of the dead in preparation for burial, duction of male circumcision in areas where it had found to increase Ebola transmission, because connot been practiced are also helping to reduce infection tact with body fluids—even sweat—in the context of rates. Male circumcision has been found to help procleaning, feeding, or moving an infected person can tect against infection, reducing transmission rates by lead to transmission (CDC, 2015). Learning, LLC © Jones & Bartlett Learning, LLC © Jones & Bartlett as much as 60% (Bailey & Mehta, 2009; Bailey et al., When American and European global health perNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2007; Tobian et al., 2009; Westercamp & Bailey, 2007). sonnel first arrived to help fight the epidemic, in many cases they were greeted with fear and even violence by Antiretroviral Treatment Challenges villagers, who, upon seeing the Westerners in hazmat suits, resisted their approach and often hid their sick and economic support for © JonesDiminished & Bartlettpolitical Learning, LLC © Jones & Bartlett Learning, LLC family members. A new psychosocial paradigm called antiretroviral programs could lead to the interrupNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION “fear-related behaviors” in situations of mass threat is tion of treatment of HIV/AIDS patients, which in now recognized as an expected reaction to disasters and turn would provide the HIV virus with the potential must be planned for with clear communication, culto become drug resistant. Other challenges in Africa tural understanding, and the close collaboration of forinclude a shortage of health professionals, many of public health workers with professional and Learning, LLC © Jones & for Bartlett Learning,eign LLC © local Jones & Bartlett whom have left their home countries better opporcommunity leaders (Espinola et al., 2016). Viewed from tunities in higher-income countries. In addition, a NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION this perspective, the panicked responses of the African lack of treatment literacy poses a huge challenge for villagers were not irrational (Richardson et al., 2016). effective antiretroviral treatment (UNAIDS, 2004b). Beginning with the slave trade and colonialism, WestThe individual behaviors that place people at risk ern incursions into Liberia and Sierra Leone have caused are part of the larger root causes of the problem in © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC immense suffering. Further complicating the cultural Africa, including colonialism, big industry’s design NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION misunderstandings is the fact that Liberia has 31 separate of mass labor migration, poverty, gender inequalities, and war. The ideal prevention and intervention stratelanguages and Sierra Leone has 25 (Rodriguez, 1997). gies would address health behavior changes as well as With Ebola deaths mounting and the evidence that economic and community barriers to the provision of the health systems of the affected West African coun© Jonessocial & Bartlett Learning, &under-resourced Bartlett Learning, LLC services and treatmentLLC options (Akeroyd, 1997; © Jones tries were and overwhelmed, numerBond et al., OR 1997;DISTRIBUTION Tylor, 1871; United Nations, 1999c, NOT ousFOR well-meaning multinational, governmental, and NOT FOR SALE SALE OR DISTRIBUTION 1999d; WHO, 1997). nongovernmental agencies rushed to the scene to help. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. Discussion Questions Grieving African family members were not allowed 69 intervention literature; and Isabel Martinez and Janel © Jones & Bartlett Learning, LLC © Jones & Bartlett to touch Learning, or kiss theirLLC dead. Rather than observing Heinrich for their assistance with the literature search, NOT FOR SALE comments OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION time-honored funereal practices, they were instead for helpful on the chapter, and, in particu- obliged to place their deceased loved ones in plastic lar, for preparing and revising the case study on AIDS. bags, to be buried with chloride disinfectant. Those Appreciation also goes to Carole Chrvala for sharing and other measures to prevent transmission reprenotes on the various intervention theories. In addisented enormous© changes in & cultural practices around LLCtion, we would like to © thank and & acknowledge ProJones Bartlett Learning, Jones Bartlett Learning, LLC death and dying, NOT but they worked to reduce transmisfessor Gretel Pelto and NOT Dr. Margaret Armar-Klemesu FOR SALE OR DISTRIBUTION FOR SALE OR DISTRIBUTION sion (Agusto, Teboh-Ewungkem, & Gumel, 2015). for permission to base the case study on the introducAnalyses of the Ebola pandemic, and the behavioral tion of a fortified infant cereal on one of their recent changes that led to decreases in transmission, demonprojects. strated that serious attention to clear communication © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC and understanding of cultural patterns are critical eleNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ments of responses to outbreaks and disasters. Discussion Questions 1. Which prevention strategies for AIDS would you develop if you were the minister of health ▸ of a sub-Saharan African country? Which strat© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, egies would you use ifLLC you were a community This chapter has briefly explored cultural and behavNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION leader? Would the strategies used for these two ioral issues that influence global health. Anthropolperspectives differ? If so, how? How would you ogy, sociology, and psychology have much greater address some of the cultural beliefs or traditions depth in terms of both methods and theories than associated with HIV/AIDS mentioned in the can be described in this chapter. A rich and extencase study? © Jones & Bartlett © Jones & Bartlett Learning, LLC sive literature exists on health beliefs andLearning, behaviors, LLC 2. If you were entering a community to introduce environmental and biological contexts, sysNOT FOR SALE ORhealth DISTRIBUTION NOT FOR SALE OR DISTRIBUTION a health program, who would you talk to? What tems, and programmatic successes and failures. It would you ask? Why? is essential to take these factors into account when 3. Discuss the concepts of validity and reliability contemplating global health work. In addition, a proin research as they apply to the use of quantitagram must consider structural factors, such as setting, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the tive and qualitative methods. Next, discuss hours, child care, and ambience, as well as factors of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION same concepts as they apply to community parcontent, such as culturally acceptable services, which ticipatory research. includes providers who treat patients with respect and 4. What is the hot/cold illness belief system? Why understanding. is it important? How would you incorporate it Research and preventive services regarding health into a maternal and child health program? beliefs and behaviors LLC must accept and integrate con© Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC 5. Many people believe that healers such as midcepts different from those held by Western biomediNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION wives and shamans are called to their profession cine, by middle- or upper-class healthcare providers, by a greater spiritual power. What significance or by healthcare providers from an ethnic or cultural does this belief have for official health programs group that is different from their patients. This requirearound the world? How should they address ment demands the ability inherent in some of the © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC this belief? anthropological methods and approaches discussed 6. If an indigenous practice seemsSALE peculiar to you, NOT FOR SALE OR DISTRIBUTION NOT FOR OR DISTRIBUTION earlier—that is, the ability to “get into someone’s head” but does no apparent harm, what should you do? and understand things from an insider perspective. 7. How could you learn what people in a commuThere is nothing like the experience of spending time nity really believe about health and illness? with people, in their own homes or community, and 8. Based on the theories of behavior change, crestriving to reach that insider understanding. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ate your own model by taking what you think is NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the best content from existing theories. Explain Acknowledgments your reasoning. Susan Scrimshaw would like to thank Carolyn Cline, 9. How would you balance the need to interrupt Rose Grignon, and Lisa Brainard for their assistance Ebola transmission in a situation such as the © Jones & Bartlett Learning, LLC the bibliography; Pamela © Jones & Bartlett Learning, LLC with the imporin editing and preparing recent West African outbreak Ippoliti her editorial assistance; Susan Levy NOT and FOR SALE tance OR of addressing the fears and panic of the NOT FOR SALE ORforDISTRIBUTION DISTRIBUTION John Justino for providing key examples from the population? Conclusion © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 70 Chapter 2 Culture, Behavior, and Health References © Jones & Bartlett Learning, LLC Abdullah, A., OR & Husten, C. (2004). Promotion NOT FOR SALE DISTRIBUTION Bartholet, J. (2000, January 17). The plague years. Newsweek, © Jones 135(3).& Bartlett Learning, LLC Beals, A. R. SALE (1976). Strategies of resort to curers in south India. NOT FOR OR DISTRIBUTION of smoking cessation in developing countries: A framework for urgent In C. Leslie (Ed.), Asian medical systems: A comparative study public health interventions. Thorax, 59, 623–630. (pp. 184–200). Berkeley, CA: University of California Press. Adams, R. N. (1955). A nutritional research program in Guatemala. Bernard, R. (2013). Social research methods: Qualitative and In B. D. Paul (Ed.), Health, culture, and community (pp. 435–458). quantitative approaches (2nd ed.). London, UK: Sage. New York, NY: Russell Sage Foundation. Betancourt, J. E. (2002). Cultural Learning, LLC © Jones & Bartlett Learning, LLC J. R., Green, A. R., & Carrillo, © Jones & Bartlett Adih, W. K., & Alexander, C. S. (1999). Determinants of condom competence in health care: Emerging frameworks and practical NOT FOR SALE ORJournal DISTRIBUTION NOT FOR SALE OR DISTRIBUTION use to prevent HIV infection among youth in Ghana. approaches. New York, NY: Commonwealth Fund. of Adolescent Health, 24(1), 63–72. Bhuyan, K. (2004). Health promotion through self-care and Agusto, F. B., Teboh-Ewungkem, M. I., & Gumel, A. B. (2015). community participation: Elements of a proposed programme in Mathematical assessment of the effect of traditional beliefs the development countries. BMC Public Health, 4, 11. Retrieved and customs on the transmission dynamics of the 2014 Ebola from http://www.biomedcentral.com/1471-2458/4/11 outbreaks. BMC Medicine,13, 96. Learning, LLC © Jones & Bartlett © Jones BartlettHealth, Learning, Board on Neuroscience and&Behavioral Institute LLC of Ajzen, I.,NOT & Fishbein, M. (1972). and normative beliefs as Medicine. (2002), on Communication for Behavior FOR SALEAttitudes OR DISTRIBUTION NOTCommittee FOR SALE OR DISTRIBUTION factors influencing behavioral intentions. Journal of Personality Change in the 21st Century: Improving the health of diverse and Social Psychology, 21(1), 1–9. populations. Speaking of health: Assessing health communication Akeroyd, A. V. (1997). Sociocultural aspects of AIDS in Africa: strategies for diverse populations. Washington, DC: National Occupational and gender issues. In G. C. Bond, J. Kreniske, I. Academy Press. Susser, & J. Vincent (Eds.), AIDS in Africa and the Caribbean Bond, G. & C., Bartlett Kreniske, J.,Learning, Susser, I., & Vincent, © Jones &(pp. Bartlett Learning, LLC © Jones LLC J. (1997). The 11–32). Boulder, CO: Westview Press. anthropology of AIDS in Africa and the Caribbean. In NOT FOR SALE ORA.,DISTRIBUTION FOR SALE OR DISTRIBUTION Alcalay, R., Ghee, & Scrimshaw, S. C. M. (1993, May–June). NOT G. C. Bond, J. Kreniske, I. Susser, & J. Vincent (Eds.), AIDS Designing prenatal care messages for low-income Mexican in Africa and the Caribbean (pp. 3–9). Boulder, CO: Westview women. Public Health Reports, 108(3), 354–362. Press. Alland, A. (1970). Adaptation in cultural evolution: An approach Booth, R., & Wiebel, W. (1992). Effectiveness of reducing needle to medical anthropology. New York, NY: Columbia University related risk for HIV through indigenous outreach to injection Press. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC drug users. American Journal of Addictions, 1, 227–287. Allen, M., Auld, E., Logan, R., Montes, J. H.,SALE & Rosen,OR S. (2017). Buckley, T., & Gottlieb, A. (Eds.). (1988). magic. Berkeley, NOT FOR DISTRIBUTION NOTBlood FOR SALE OR DISTRIBUTION Improving collaboration among health communication, health CA: University of California Press. education, and health literacy. NAM Perspectives. Discussion Cameron, M. (2010). Feminization and marginalization? Women Paper. Washington, DC: National Academy of Medicine. Ayurvedic doctors and modernizing health care in Nepal. Retrieved from https://nam.edu/improving-collaboration Medical Anthropology Quarterly, 24(1), 42–63. -among-health-communication-health-education-and Carballo, M., &©Siem, H. (1996). Migration,Learning, migration policy © Jones & Bartlett Learning, LLC Jones & Bartlett LLC -health-literacy and AIDS. In M. Knipe & R. Rector (Eds.), Crossing borders: NOT SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Anderson, L. M.,FOR Fielding, J. E., Fullilove, M. T., Scrimshaw, S. C., Migration, ethnicity and AIDS (pp. 31–48). London, UK: Taylor Carande-Kulis, V. G., & Task Force on Community Preventive and Francis. Services. (2003, April). Methods for conducting systematic Centers for Disease Control and Prevention (CDC). (2015, July reviews of the evidence of effectiveness and economic efficiency 22). Ebola: Transmission. Retrieved from https://www.cdc of interventions to promote healthy social environments. .gov/vhf/ebola/transmission/index.html Journal of PreventiveLLC Medicine, 24(3S), 25–31. Chambers,&R.Bartlett (1992). Rapid but relaxed LLC and particularly rural © Jones &American Bartlett Learning, © Jones Learning, Anderson, L. M., Scrimshaw, S. C., Fullilove, M. T., Fielding, J. E., appraisal: Towards applications in health and nutrition. In NOT FOR &SALE OR on DISTRIBUTION FOR SALE OR DISTRIBUTION Task Force Community Preventive Services. (2003, NOT N. S. Scrimshaw & G. R. Gleason (Eds.), Rapid assessment April). The community guide’s model for linking the social procedures: Qualitative methodologies for planning and environment to health. American Journal of Preventive Medicine, evaluation of health related programmes (pp. 295–305). Boston, 24(3S), 12–20. MA: International Nutrition Foundation for Developing Aviv, R. (2017, April 3). The apathetic: Why are refugee children Countries. Jones LLC © Jones & untruths Bartlett falling unconscious. New© Yorker, 68-77.& Bartlett Learning, Chen, K.-H., & Murray, G. F. (1976). Truths and in Learning, LLC Baer, H. (2008). The emergence of integrative medicine in NOT FOR SALE OR DISTRIBUTION NOTWorld FOR SALE OR DISTRIBUTION village Haiti: An experiment in Third survey research. Australia: The growing interest of biomedicine and nursing In J. F. Marshall & S. Polgar (Eds.), Culture, natality, and family in complementary medicine in a southern developed society. planning (pp. 241–262). Chapel Hill, NC: Carolina Population Medical Anthropology Quarterly, 22(1), 52–66. Center. Bailey, R. C., & Mehta, S. (2009). Circumcision’s place in the Collinge, J., Whitfield, J., McKintosh, E., Beck, J., Mead, S., vicious cycle between HSV-2 andLearning, HIV. Journal ofLLC Infectious Thomas, D. J., Alpers, M.&P. Bartlett (2006). KuruLearning, in the 21st century: © Jones & Bartlett ©&Jones LLC Diseases, 199, 923–925. An acquiredNOT humanFOR prion disease with veryDISTRIBUTION long incubation NOT FOR SALE OR DISTRIBUTION SALE OR Bailey, R. C., Moses, S., Parker, C. B., Agot, K., Maclean, I., Krieger, periods. Lancet, 367(9528), 2068–2074. J. N., . . . Ndinya-Achola, J. O. (2007). Male circumcision for Copeland, T. (2017, May). Self-managing HIV/AIDS: Cultural HIV prevention in young men in Kisumu, Kenya: A randomised competence and health among women in Nairobi, Kenya. Anthropology and Medicine, 1–15. doi:10.1080/13648470.2017 controlled trial. Lancet, 369, 643–656. .1285002 Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: © Jones &Prentice Bartlett © Jones Bartlett LLCdown: The search Crisp, N. & (2010). TurningLearning, the world upside Hall. Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION for global health in the 21st century. London, UK: Hodder Bandura, A. (1989). Human agency in social cognitive theory. Education. American Psychologist, 44, 1175–1184. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. References de Oliveira, T., Kharsany, A., Gräf, T., Cawood, C., Khanyile, D., 71 comparison of migrant Yugoslavian and Swedish diabetic © Jones &females. Bartlett LLC 30(5), 1147–1159. © Jones & Bartlett LLCKarim, S. (2017). Transmission JournalLearning, of Advanced Nursing, Grobler,Learning, A., . . . Abdool Hughes, C. (1990). Ethnopsychiatry. In T. M. Johnson & C. E. networks and risk of HIV infection in KwaZulu-Natal, South NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Sargent (Eds.), Medical anthropology: Contemporary theory Africa: A community-wide phylogenetic study. Lancet HIV, and method. (p. 131). New York, NY: Praeger. 4(1), e41–e50. Hunt, C. W. (1989). Migration labor and sexually transmitted Dickson-Gomez, J. (2010). Structural factors influencing the diseases: AIDS in Africa. Journal of Health in Social Science patterns of drug selling and use and HIV risk in the San Salvador metropolitan area. Medical Anthropology Quarterly, © Jones & Bartlett Learning, LLC Behavior, 30, 353–373. © Jones & Bartlett Learning, LLC Jok, J. M. (2001). War and slavery in Sudan. Ethnography 24(2), 157–181. NOT FOR SALE OR DISTRIBUTIONof Political Violence Series. NOTPhiladelphia, FOR SALE OR DISTRIBUTION PA: University Espinola, M., Shultz, J. M., Espinel, Z., Althouse, B. M., Cooper, J. L., Baingana, F., . . . Rechkemmer, A. (2016). Fear-related of Pennsylvania Press. behaviors in situations of mass threat. Disaster Health, 3(4), Jok, J. M. (2012). Negotiating security: Gender, violence, and the 102–111. rule of law in post-war South Sudan. In H. Stein & A. Fadlalla Fadiman, A. (1997). A spirit catches you and you fall down: Hassan (Eds.), Gendered insecurities, health and development © AJones & Bartlett Learning, © Jones & Bartlett Hmong child, her American doctors, and LLC the collision of two in Africa (pp. 154–169). New York, Learning, NY: Routledge. LLC cultures. NewSALE York, NY:OR Farrar, Straus, and Giroux. Kamat, V. R. (2008). underOR the DISTRIBUTION bird’s shadow: Narrative NOT FOR DISTRIBUTION NOT FORDying SALE Foster, G. M. (1953). Relationships between Spanish and Spanishrepresentations of degedege and child survival among the American folk medicine. Journal of American Folklore, 66, Zaramo of Tanzania. Medical Anthropology Quarterly, 22(1), 201–217. 67–93. Freed, S. A., & Freed, R. S. (1967). Spirit possession as illness in a Karpman, H. L. (2016, March 6). Use of smartphone applications north Indian village. InLLC J. Middleton (Ed.), Magic, witchcraft, patients’ health and fitness: LLC Internal medicine alert. Relias. © Jones & Bartlett Learning, © Jones &forBartlett Learning, and curing (pp. 295–320). Garden City, NY: Natural History Retrieved from https://www.ahcmedia.com/articles/137485 NOT FOR SALE OR DISTRIBUTION NOT FOR-use-of-smartphone-applications-for-patients-health-and SALE OR DISTRIBUTION Press. Gadjusek, D. C., Gibbs, C. J., & Alpers, M. (1967). Transmission -fitness and passage of experimental “kuru” to chimpanzees. Science, Kendall, C., Foote, D., & Martorell, R. (1983). Anthropology, 155, 212–214. communications, and health: The mass media and health practices Garro, L. (2000). Remembering what one knows and the program in Honduras. Human Organization, 42, 353–360. © past: Jones & Bartlett Learning, Jones Bartlett Learning, LLC construction of the A comparison of cultural consensus LLCKleinman, A. (1980). Patients©and healers in&the context of culture. theory and cultural schema theory. Ethos, 28, 275–319. of California NOT FOR SALE OR DISTRIBUTIONBerkeley, CA: University NOT FORPress. SALE OR DISTRIBUTION Ghimire, M., Pradhan, Y. V., & Mahesh, M. K. (2010). CommunityKleinman, A. (1986). Social origins of distress and disease. New based interventions for diarrhoeal diseases and acute respiratory Haven, CT: Yale University Press. infections in Nepal. Bulletin of the World Health Organization, Kleinman, A. (1988). The illness narratives. New York, NY: Basic 88, 216–221. Books. Good, B. J., & Good, M. J. D. (1981). The meaning of symptoms: A Lane, S.,© Lurie, P., Bowser, B., Khan, J., & Chen, D. (1999). © Jones & Bartlett Learning, LLC Jones & Bartlett Learning, LLC The cultural hermeneutic model for clinical practice. In L. Eisenberg coming of age of needle exchange. In Harrison, L. (Ed.), Harm NOT FOR SALE OR DISTRIBUTION NOT & A. Kleinman (Eds.), The relevance of social science for medicine reduction (pp.FOR 47–68).SALE London,OR Sage.DISTRIBUTION (pp. 165–196). Dordrecht, Netherlands: Reidel. Lane, S. D., & Rubinstein, R. A. (1996). Judging the other: Green, E. (1994). AIDS and STDs in Africa: Bridging the gap Responding to traditional female genital surgeries. Hastings between traditional healing and modern medicine. Boulder, Center Report, 26(3), 31–40. CO: Westview Press. Lane, S. D., Rubinstein, R. A. Keefe, R. H., Satterly, L. B., Huntington, Guarnaccia,Learning, P. J., Lewis-Fernandez, Ramachandran, T., & Amaus Student Researchers. (2017). © Jones & Bartlett LLC R., Martinez Pincay, I., Shrout, © Jones &S.,Bartlett Learning, LLC P., Guo, J., Torres, M., . . . Alegria, M. (2010, May 1). Ataque Action anthropology in a free clinic. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTIONHuman Organization, de nervios as a marker of social and psychiatric vulnerability: 76(4), 336–347. Results from the NLAAS. International Journal of Social Lindenbaum, S. (1971). Sorcery and structure in fore society. Psychiatry, 56(3), 298–309. Oceania, 41, 277–287. Gwaltney, J. L. (1970). The thrice shy. New York, NY: Columbia Logan, M. H. (1972). Humoral folk medicine: A potential aid in University Press. controlling pellagra in Mexico. Ethnomedizin, 4, 397–410. Bartlett Learning, ©Hernandez, Jones N. &(1992). Bartlett Learning, LLC Haghi, M., Thurow, © K., Jones & Stoll, R.&(2017). Wearable devices in LLC Long, A., Scrimshaw, S. C. M., & Transcultural SALE DISTRIBUTIONepilepsy services. In N. 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Retrieved from https://www.hiv.gov/federal-response/pepfar Matsudo, V., Matsudo, S., Andrade, D., Araujo, T., Andrade, -global-aids/global-hiv-aids-overview E., de Oliveira, L., & Braggion, G. (2002). Promotion of HIV.gov. (2017b, February 14). New HIV infections drop 18 physical activity in a developing country: The Agita São Paulo percent in six years. Retrieved from https://www.hiv.gov/blog experience. Public Health Nutrition, 5(1A), 253–261. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLCNarrative and the cultural /new-hiv-infections-drop-18-percent-in-six-years Mattingly, C., & Garro, L. (Eds.). (2000). NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Hjelm, K., Nyberg, P., Isacsson, A., & Apelqvist, J. (1999). Beliefs construction of illness and healing. Berkeley, CA: University of about health and illness essential for self-care practice: A California Press. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 72 Chapter 2 Culture, Behavior, and Health McSweeney, J. C., Allan, J. D., & Mayo, K. (1997). Exploring the Culture, natality, and family planning (pp. 204–218). Chapel & Carolina Bartlett Learning, © Jones &useBartlett Learning, LLC research and practice. © Jones Hill, NC: Population Center. LLC of explanatory models in nursing President’s Emergency Plan for AIDS Relief (PEPFAR). Image Journal of Nursing Scholarship, 29(3), 243–248. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (2017, July 22). Home page. Retrieved from https://www.pepfar.gov/ Messersmith, L. J. (1991). The women of good times and Baba’s Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search Place: The multi-dimensionality of the lives of commercial sex of how people change: Applications to addictive behaviors. workers in Bamako, Mali. PhD dissertation, University of American Psychologist, 47, 1102–1104. California at Los Angeles. Ratzan, Introduction. In C. R. Learning, LLC Msiza-Makhubu, S. B. (1997).©Peer education and support for AIDS Jones & Bartlett Learning, LLCS. C., & Parker, R. M. (2000). © Jones & Bartlett Selden, M. Zorn, S. C. Ratzan, & R. M. Parker (Eds.), National prevention among women in South Africa. PhD dissertation, NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Library of Medicine current bibliographies in medicine: Health University of Illinois at Chicago. literacy (pp. v–vii). NLM Pub. No. CBM 2000-1. Bethesda, Murray, G. F. (1976). Women in perdition: Ritual fertility control MD: National Institutes of Health, U.S. Department of Health in Haiti. In J. F. Marshall & Polgar, P. (Eds.), Culture, natality, and Human Services. and family planning (pp. 59–78). Chapel Hill, NC: Carolina Reddy, P., Meyer-Weitz, A., van den Borne, B., & Kok, G. (1999). Population Center. Jones Bartlett Learning, LLC Jones & Bartlett Learning, LLC STD-related ©knowledge, beliefs and attitudes of XhosaNational©Center for & Complementary and Integrative Health speaking patients STD primary clinics (NCCIH). complementary and NOT(2014, FORDecember SALE 17). ORNIH DISTRIBUTION NOTattending FOR SALE ORhealth-care DISTRIBUTION in South Africa. International Journal of Sexually Transmitted integrative health agency gets new name. Retrieved from Diseases and AIDS, 10(6), 392–400. https://nccih.nih.gov/news/press/12172014 Reichel-Dolmatoff, G., & Reichel-Dolmatoff, A. (1961). The people National Center for Complementary and Integrative Health of Aritama. London, UK: Routledge and Kegan Paul. (NCCIH). (2017, September 24). Use of complementary Rekart, Sex in the city: Sexual behavior, health approaches in the U.S. Retrieved from https://nccih.nih © Jones & Bartlett Learning, LLC © JonesM.&(2002). Bartlett Learning, LLC societal change, and STDs in Saigon. Sexually Transmitted Infections, 78 .gov/research/statistics/NHIS/2012/key-findings NOT FOR SALE OR DISTRIBUTION FORI),SALE i47–i54. OR DISTRIBUTION Nguyen-Truong, C. K., Tang, J., & Hsiao, C. Y. (2017) Community NOT (suppl Richardson, E. T., Barrie, M. B., Kelly, J. D., Dibba, Y., Koedoyoma, S., Interactive Research Workshop Series: Community members & Farmer, P. E. (2016). Biosocial approaches to the 2013–2016 engaged as team teachers to conduct research. Progress in Community Health Partnerships,11(2), 215–221. doi:10.1353 Ebola pandemic. Health and Human Rights Journal, 1(18), 1–13. /cpr.2017.0026 Rodriguez, J. P. (1997). Oppression of Liberia. In The historical © Jones & Bartlett LLC © 410). Jones Bartlett Nichter, M. (2008). Global health: Why cultural perceptions,Learning, social encyclopedia of world slavery (p. Santa&Barbara, CA: Learning, LLC representations and biopolitics AZ:OR University ABC-CLIO. NOTmatter. FORTucson, SALE DISTRIBUTION NOT FOR SALE OR DISTRIBUTION of Arizona Press. Rogers, E. M. (1973). Communication strategies for family planning. Nielsen-Bohlman, L., Panzer, A. M., & Kindig, D. (Eds.); New York, NY: Free Press. Committee on Health Literacy, Board on Neuroscience and Rogers, E. M. (1983). Diffusion of innovations (3rd ed.). New York, Behavioral Health. (2004). Health literacy: A prescription to NY: Free Press. end confusion. Washington, DC: National Academies Press. Rogers, E. M., © & Jones Shoemaker,&F.Bartlett F. (1972). Learning, CommunicationLLC of © Jones & Bartlett Learning, LLC Norr, K., Norr, J., McElmurray, B., Tlou, S., & Moeti, M. (2004). Impact innovations (2nd ed.). New York, NY: Free Press. NOT SALE OR DISTRIBUTION NOT FOR SALE DISTRIBUTION of peer groupFOR education on HIV prevention among women in Rosenstock, I., Strecher, V., & Becker, M.OR (1974). Social learning Botswana. Health Care for Women International, 25, 210–226. theory and the health belief model. Health Education O’Connor, B. (1995). Healing traditions. Philadelphia, PA: Monograph, 2, 328–386. University of Pennsylvania Press. Rubel, A. J., & Haas, M. R. (1990). Ethnomedicine. In T. M. Johnson Office of Minority Health, U.S. Department of Health and & C. D. Sargent (Eds.), Medical anthropology, contemporary Services. (2016). National theory & andBartlett method (pp.Learning, 115–131). NewLLC York, NY: Praeger. © Jones &Human Bartlett Learning, LLCStandards for Culturally © Jones and Linguistically Appropriate Services (CLAS) in health and Rubel, A. J., O’Nell, C. W., & Collado-Ardon, R. (1984). Susto: A NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION health care. Retrieved from https://www.thinkculturalhealth folk illness. Berkeley, CA: University of California Press. .hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf Rubinstein, R. A., Scrimshaw, S. C., & Morrissey, S. (2000). Parsons, T. (1948). Illness and the role of the physician. In C. Classification and process in sociomedical understanding Kluckholm & H. Murray (Eds.), Personality in nature, society, towards a multilevel view of sociomedical methodology. In and culture (pp. 609–617). New York, NY: Alfred A. Knopf. G. L. Albrecht, R. Fitzpatrick, & S. C. Scrimshaw (Eds.), The © Jones & Bartlett LLC © Jones & (pp. Bartlett Paul, B. D. (Ed.). (1955). Health, culture, and community.Learning, (p. 1). handbook of social studies in health & medicine 36–49). Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION New York, NY: Russell Sage Foundation. London UK: Sage. Pelto, P. J., & Pelto, G. H. (1978). Anthropological research: The Salem, R. M., Bernstein, J., Sullivan, T. M., & Lande, R. structure of inquiry. New York, NY: Cambridge University (2008, January). Communication for better health. Population Press. Reports, Series J, No. 56, 28 pages. Baltimore, MD: INFO Pennise, M., Inscho, R, Herpin, K, Owens, J., Jr., Bedard, B. A., Project, Johns Hopkins Bloomberg School of Public Health. Weimer, A. C., . & . . Bartlett Younge, M. Learning, (2015). Using smartphone Salopek, P. (2000, January & 10).Bartlett We die lying to ourselves: © Jones LLC © Jones Learning, LLC appsNOT in STDFOR interviews to findOR sexual partners. Public Health Part 2. Chicago Tribune.SALE Retrieved http://www SALE DISTRIBUTION NOT FOR OR from DISTRIBUTION Reports, 130(3), 245–252. .chicagotribune.com/news/chi-060826salopek2-story-story Perry, H. Shanklin, D., & Schroeder, D. (2003). Impact of a .html community-based comprehensive primary healthcare Schumacher, S. A., Ockene, J. K., & Riekert, K. A. (2009). The programme on infant and child mortality in Bolivia. Journal of handbook of health behavior change. New York, NY: Springer. Health, Population, and Nutrition, 21(4), 383–395. Scrimshaw, S. C. (1974). Culture, environment, and family size: © JonesPolgar, & Bartlett Learning, LLC & ofBartlett Learning, LLC Ecuador. PhD S., & Marshall, J. F. (1976). The search for culturally acceptable © Jones A study urban in-migrants in Guayaquil, NOT FOR fertility SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION regulating methods. In J. F. Marshall & S. Polgar (Eds.), dissertation, Columbia University, New York. © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. References Scrimshaw, S. C. M. (1992). Adaptation of anthropological 73 and syphilis. New England Journal of Medicine, 360(13), © Jones &1298–1309. Bartlett Learning, LLC © Jones & Bartlett Learning, methodologies to rapidLLC assessment of nutrition and primary Topley, M. (1976). traditional etiology and methods of health care. In N. S. Scrimshaw & G. R. Gleason (Eds.), NOT FOR SALE OR Chinese DISTRIBUTION NOT FOR SALE OR DISTRIBUTION cure in Hong Kong. In C. Leslie (Ed.), Asian medical systems: Rapid assessment procedures: Qualitative methodologies A comparative study (pp. 243–265). Berkeley, CA: University for planning and evaluation of health related programmes of California Press. (pp. 25–49). Boston, MA: International Nutrition Foundation Tylor, E. B. (1871). Primitive culture. London, UK: J. Murray. for Developing Countries. update: December 1999. Geneva, Scrimshaw, S. C. M., Carballo, M., Carael, M., Ramos, L., & Parker, LLCUNAIDS. (1999). AIDS epidemic © Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC Switzerland: World Health Organization. R. G. (1992). HIV/AIDS rapid assessment procedures: Rapid NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION UNAIDS. (2004a). 2004 report on the global HIV/AIDS epidemic: anthropological approaches for studying AIDS related beliefs, 4th global report. Geneva, Switzerland: Author. Retrieved attitudes and behaviours. Monograph. Tokyo, Japan: United from http://files.unaids.org/en/media/unaids/contentassets Nations University. /documents/unaidspublication/2004/GAR2004_en.pdf Scrimshaw, S. C. M., Carballo, M., Ramos, L., & Blair, B. A. (1991). UNAIDS. (2004b). AIDS epidemic update: 2004. Geneva, The AIDS rapid anthropological assessment procedures: A © tool Jones & Bartlett LLC © Jones & Bartlett LLC Switzerland: Author. Retrieved Learning, from https://reliefweb.int for health education Learning, planning and evaluation. Health /report/world/aids-epidemic-update-2004 Education Quarterly, NOT FOR SALE18(1), OR111–123. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION UNAIDS. (2017). Fact sheet: Latest statistics on the status of the Scrimshaw, S. C., & Hurtado, E. (1987). Rapid assessment procedures AIDS epidemic. Retrieved from http://www.unaids.org/en for nutrition and primary health care: Anthropological /resources/fact-sheet approaches to improving program effectiveness (RAP). Tokyo, Japan: United Nations University. United Nations. (1999a). Acting early to prevent AIDS: The case of Scrimshaw,Learning, S. C., & Hurtado, Geneva, Switzerland: Author. © Jones & Bartlett LLC E. (1988). Anthropological © Jones &Senegal. Bartlett Learning, LLC involvement in the Central American diarrheal disease control United Nations. (1999b, June). Sexual behavioral change for HIV: NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION project. Social Science and Medicine, 27(1), 97–105. Where have the theories taken us? Geneva, Switzerland: Author. Scrimshaw, S. C., & Pasquariella, B. G. (1970). Obstacles to (English original, text by Rachel King). sterilization in one community. Family Planning Perspectives, United Nations, Wellcome Trust Centre for the Epidemiology 2(4), 40–42. of Infectious Disease. (1999d). Trends in HIV incidence and Scrimshaw, S. C. M., Zambrana, R. E., Alcalay, R., Estupinan, S., prevalence: Natural course of the epidemic or results of behavioral & Bartlett Learning, © Jones Luna, R., & Rivera,© H.Jones (1990). Prenatal health behaviors in Mexico LLC change? Geneva, Switzerland: Author. & Bartlett Learning, LLC and mass communication/education strategies for improvement. United Nations Development (2017). NOT FOR SALE OR DISTRIBUTION NOTProgramme. FOR SALE ORHuman DISTRIBUTION Washington, DC: International Center for Research on Women. development reports: Human development data (1990–2015). Shelton, J. (2009, August 1). Why multiple sexual partners? Lancet, Retrieved from http://hdr.undp.org/en/data 374, 367–368. Uppsala Conflict Data Program. (n.d.). UCDP database, Uppsala Simons, R. C. (2001, November 1). Introduction to culture-bound University. Retrieved from www.ucdp.uu.se syndromes. Psychiatric Times, 18(11). Retrieved from http:// Wallensteen, P., & Harbom, L. (2009). Armed conflict, 1946–2008. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC web.mnstate.edu/robertsb/306/Intro%20to%20Culture%20 Department of Peace and Conflict Research. Harbom Journal NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Bound%20Syndromes.pdf of Peace Research, 46(4), 577–587. Simons, R. C., & Hughes, C. C. (Eds.). (1985). The culture-bound Watkins, S. C. (2004, December). Navigating the AIDS epidemic syndromes: Folk illnesses of psychiatric and anthropological in rural Malawi. Population and Development Review, 30(4), interest. Dordrecht, Netherlands: D. Reidel. 673–705. Sutton, S., McVey, D., & Glanz, A. (1999). A comparative test Weir, S. S., Pailman, C., Mahalela, X., Coetzee, N., Meidany, F., & of the theory of reasoned action and the theory of planned J. T. (2003). From people © Jones & Bartlett Learning, LLC © Jones &Boerma, Bartlett Learning, LLCto places: Focusing AIDS behavior in the prediction of condom use intentions in a prevention efforts where it matters most. AIDS, 17(6), 895–903. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION national sample of English young people. Health Psychology, Weller, S. C. (1983). New data on intracultural variability: The hot– 18(1), 72–81. cold concept of medicine and illness. Human Organization, 42, Swidler, A., & Watkins, S. C. (2007). AIDS and transactional sex 249–257. in rural Malawi. Studies in Family Planning, 38(3), 147–162. Wellin, E. (1955). Water boiling in a Peruvian town. In B. D. Paul Tervalon, M., & Murray-García, J. (1998). Cultural humility versus (Ed.), Health, culture, and community (pp. 71–103). New York, © Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC cultural competence: A critical distinction in defining physician LLC NY: Russell Sage Foundation. FOR SALE OR DISTRIBUTION NOT FORAcceptability SALE OR training outcomesNOT in multicultural education. Journal of Health Westercamp, N., & Bailey, R. C. (2007). of DISTRIBUTION male Care for the Poor and Underserved, 9(2), 117–125. circumcision for prevention of HIV/AIDS in sub-Saharan Thao, X. (1986). Hmong perception of illness and traditional ways Africa: A review. AIDS and Behavior, 11(3), 341–355. of healing. In G. L. Hendricks, B. T. Downing, & A. Deinard Wiebel, W. (1993). The indigenous leader outreach model: (Eds.), The Hmong in transition (pp. 365–378). New York, NY: Intervention manual. DHHS Publication 93-3581.Washington, for & Migration Studies of New York LLC & Southeast Asian DC: © National Institute on Drug Abuse, National Institutes © Center Jones Bartlett Learning, Jones & Bartlett Learning, LLC of Refugee Studies ProjectOR of theDISTRIBUTION University of Minnesota. Health, U.S. Department of Health Human Services. NOT FOR SALE NOT FOR SALE ORand DISTRIBUTION Thevos, A. K., Quick, R. E., & Yanduli, V. (2000). Motivational Wiebel, W., Jimenez, A., Johnson, W., Oulette, L., Jovanovic, B., interviewing enhances the adoption of water disinfection Lampinen, T., . . . Utne O’Brien, M. (1996). Risk behavior and practices in Zambia. Health Promotion International, 15(3), HIV seroincidence among out of treatment injection drug users: 207–214. A four-year prospective study. Journal of Acquired Immune Tobian, A., Serwadda, D., Quinn, T., Kigozi, G., Gravitt, P., Deficiency Syndromes and Human Retrovirology, 12, 282–289. © Jones & Bartlett Learning, © Jones & Bartlett Learning, LLC Laeyendecker, O., . . LLC . Gray, R. (2009, March 26). Male World Health Organization (WHO). (1997). Women and HIV/ NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION circumcision for the prevention of HSV2 and HPV infections AIDS prevention training manual: Peer education program, © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. 74 Chapter 2 Culture, Behavior, and Health a global approach. Collaborating Centre for International Care Research. © Jones &Nursing Bartlett Learning, LLC Health Development in Primary Geneva, Switzerland: Author. NOT FOR SALE OR DISTRIBUTION World Health Organization (WHO). (2010, June). Programmes. © Jones & Bartlett Learning, LLC Retrieved from http://www.who.int/hiv/en/ Young, C. J. (1981). Medical choice in a Mexican NOT FOR SALE OR DISTRIBUTION village. New Brunswick, NJ: Rutgers University Press. World Health Organization (WHO). (2004). Investing in a Zamen, F., & Underwood, C. (2003). The gender guide for health comprehensive health sector response to HIV/AIDS: Scaling up communication programs. Baltimore, MD: Population treatment and accelerating prevention. WHO HIV/AIDS plan. Communications Services, Center for Communications Geneva, Switzerland: Author. 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