Behavior Change & Public Health in the Developing World


John P. Elder

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    J. RickTurnerHealthComm Consulting

    Behavioral Medicine and Health Psychology brings the latest advances in these fields directly into undergraduate, graduate, and professional classrooms via individual texts that each present one topic in a self-contained manner. The texts also allow health professionals specializing in one field to become familiar with another by reading the appropriate volume, a task facilitated by their short length and their scholarly yet accessible format.

    The development of the series is guided by its Editorial Board, which comprises experts from the disciplines of experimental and clinical psychology, medicine and preventive medicine, psychiatry and behavioral sciences, nursing, public health, biobehavioral health, behavioral health sciences, and behavioral genetics. Board members are based in North America, Europe, and Australia, thereby providing a truly international perspective on current research and clinical practice in behavioral medicine and health psychology.


    William B.Applegate, M.D., University of Tennessee, Memphis
    JacquelineDunbar-Jacob, Ph.D., R.N., F.A.A.N., University of Pittsburgh
    Marc D.Gellman, Ph.D., University of Miami, Florida
    Laura L.Hayman, Ph.D., R.N., F.A.A.N., Case Western Reserve University
    Jack E.James, Ph.D., National University of Ireland, Galway
    MarieJohnston, Ph.D., University of St. Andrews, United Kingdom
    Lynn T.Kozlowski, Ph.D., Pennsylvania State University
    Laura C.Leviton, Ph.D., University of Alabama at Birmingham
    AndrewSherwood, Ph.D., Duke University
    Shari R.Waldstein, Ph.D., University of Maryland-Baltimore County

    Books in This Series

    Volume 1: Stress & Health: Biological and Psychological Interactions by William R. Lovallo

    Volume 2: Understanding Caffeine: A Biobehavioral Analysis by Jack E. James

    Volume 3: Physical Activity and Behavioral Medicine by James F. Sallis and Neville Owen

    Volume 4: Behavior Change and Public Health in the Developing World by John P. Elder

    Volume 5: Cigarettes, Nicotine, and Health: A Biobehavioral Approach by Lynn T. Kozlowski, Jack E. Henningfield, and Janet Brigham


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    To Connie Nelson Elder, for her feedback, reinforcement, and international perspective.

    Series Editor's Introduction

    Behavior Change and Public Health in the Developing World is the fourth volume in this book series. In an extremely engaging manner, Professor John Elder accomplishes two goals. First, he introduces the reader to the discipline of public health and describes the relationship between behavioral risk factors and disease. Second, he provides a powerful and moving description of how desperately the science of behavioral science is needed worldwide to fight disease and to promote health. Examples of the topics covered include tobacco use, nutrition, infectious diseases, home hygiene, family planning, breast-feeding, respiratory infections, and vaccination.

    As health psychology and behavioral medicine have matured as scientific disciplines, there has been a growing awareness in the United States and other developed countries that research findings and implications need to be appropriately disseminated, not only in academic journals to fellow professionals, but also in readily accessible ways to health policy makers and to the general public. Dr. Elder shows how this awareness needs to be taken to the global level and describes the implementation of behavioral change programs in the arena of international health.

    It is certainly true that disease exists in developed countries, and that a variety of behaviors are contributory factors. Nevertheless, stark contrasts can be made between developed and developing countries. Consider three examples. First, although generalizations are by definition never completely accurate, it is often the case that disease related to nutritional factors in developed countries is a consequence of “too much,” whereas it is a consequence of “too little” in many developing regions of the world. About 33% of American adults are obese: In contrast, 20% of the world's population does not receive an adequate daily caloric intake. Second, developing countries have different patterns of mortality than developed countries. For example, children in the poorest countries of Africa and Asia are 20 times more likely to die by their 5th birthday than children bom in the United States. Third, although AIDS is clearly a serious health problem in developed countries, its magnitude is even greater, and its threat less acknowledged by local authorities, in other regions of the world. AIDS continues to devastate Africa, and it is spreading rapidly in Asia. Behavior-change programs and public health strategies are extremely important tools in the worldwide fight against AIDS.

    Dr. Elder is professor of public health in the Graduate School of Public Health at San Diego State University. My thanks are extended to him for writing a most illuminating testimony to the power of, and the critical need for, behavior-change and public health approaches in the developing countries of our world. I have no doubt that you will find his book compelling, compassionate, and extremely instructive.

    J. RickTurnerChapel Hill, North Carolina


    The Dow Jones average had just soared 250 points on the news that U.S. unemployment was at a 30-year low. The American economy entered yet another consecutive month of unprecedented expansion. Memories of the Cold War were rapidly fading. The political “third way” espoused by the erstwhile liberal leaders of the United States, Britain, Canada, Germany, and elsewhere—socially left-of-center yet fiscally conservative—was hailed as a model not only for the industrialized democratic world but for former socialist nations and “Third World” countries, as well. Approaching the last year of his presidency with his impeachment behind him, President Clinton sought to put an international stamp of approval on his legacy. As the leader of the nation with the most powerful economy in history, he headed for Seattle to give a valedictory address to the World Trade Organization (WTO) at a meeting largely orchestrated by his advisers and allies. Everone anticipated concurrence and accolades from trade ministers and stock-trading floors around the world.

    But a funny thing happened on the way to the victory party. In what The Economist (Divan & Thorson, 1999, pp. 18–19) characterized as an “NGO (nongovernmental organization) swarm,” union activists, environmentalists, and others around the world had become increasingly concerned about the universal adoption of unfettered capitalism. By this time, the NGOs were well experienced in forcing changes on seemingly omnipotent institutions. From pushing through agreements on greenhouse gases to outlawing landmines, to boycotting Nike for its labor practices, NGOs had developed an Internet-driven knack for establishing temporary or permanent coalitions to advocate various causes. Now, the WTO was being targeted: The massive protest organized via the Internet told WTO members that they would have to learn to sustain the prosperity of rich nations and export it to poorer ones without exporting barbaric labor conditions' and environmental destruction. By the time President Clinton made his way to the convention hall, Seattle had essentially been shut down by protests and anarchy in its streets. In his speech, Clinton rapidly backed off his bolder ideas for further opening world trade. WTO delegates left the riot-torn city frustrated and empty-handed.

    Is this the new modus operandi for social change in the 21st century? Not necessarily. Some issues, such as the control of vaccine-preventable diseases, malaria, and acute respiratory infections, are not as emotionally compelling as land mines, even though these diseases kill and disable at vastly greater rates than leftover military ordnance. AIDS and tobacco-related diseases, finally being brought partially under control in wealthier nations, devastate the health and society of the planet's poorer regions at an ever-accelerating pace. Yet, the confrontation of the WTO in Seattle showed us that action can be taken to tackle some of the Earth's most intractable problems, even when the powerful establishment has to be confronted in the process. Rapid and effective communication combined with old-fashioned community organization and advocacy have revitalized efforts at effecting universal health and social change. An examination of how such change can be brought about will engage behavioral and social scientists for years to come.

    Behavior Change and Public Health in the Developing World focuses on universal public health issues, how they developed, what can be done about them, and what the future holds. The book has two intended audiences. Students, researchers, and practitioners of health psychology, health education, and other health behavior-change endeavors, who may have had limited exposure to public health issues in developing countries, comprise the first group. The second audience consists of professionals and trainees in international public health, who perhaps have had limited exposure to health behavior-change theories and applications.

    This is not a presentation of research methodologies nor of the disciplines that underpin them (epidemiology, demography, ethnography, and so forth). Rather, it emphasizes experience in behavior-change programs for the prevention and control of the world's biggest killers: malnutrition, respiratory infections, diarrhea, vaccine-preventable diseases, wasteful fertility, HIV/AIDS, and tobacco use. These programs are linked to theories and models that most typically frame them: health communications and social marketing, learning theory, media advocacy, and community self-control. Descriptions of programs and related literature presented in the book were selected essentially for how well they represent the application of a theory to a specific health or disease target.

    This eight-chapter text comprises three basic sections. The first two chapters describe the overall international health picture, draw the association between health (or illness) and behavior, and present four basic theories or models of behavior change most applicable to the context of developing countries. The next five chapters provide details with respect to five “dependent variable” areas (malnutrition, infectious diseases, family planning, HIV/AIDS, and tobacco use) and present applications of the aforementioned behavior-change theories for addressing these public health issues. The final chapter addresses the accomplishments and shortcomings of behavior-change intervention experiences to date and looks at possible directions the field could or should take in the coming decades. Each chapter finishes with a summary and suggestions for additional readings.

    The literature reviewed has been limited to that published in English- or Spanish-language (primarily peer-reviewed) journals or books that are available in university libraries. I reviewed the contents of recent editions of a wide variety of journals that frequently or exclusively present developing-country health issues. Internet sources pointed the way toward other publications, which were then tracked down by research assistants.

    Unfortunately, many of the field's most practiced experts are not heard from here. Although I have endeavored to review research done in developing countries by developing-country investigators, many journals published in Asia, Africa, or Latin America were not available or were not abstracted on the Internet. Often, valuable experiences never get archived, as staff from field projects simply do not have that as a priority, nor do they have the resources or time to communicate their results in journal or book form. In other cases, experiences are written up in reports that, although valuable, are not accessible in any systematic fashion. Although my public health experience has been substantial, I would not make any sweeping claims with respect to my expertise. With respect to regions and health problems with which I have had minimal experience, I relied relatively more on the published word, whether through archived research or technical reports that I have persuaded colleagues to share with me. I apologize in advance to international experts who feel that, in my review, I have overlooked an important project (and I look forward to hearing from them about their work). I hope that the overall message of the text, nevertheless, will come through clearly.

    The Swarm in Seattle showed that seemingly unstoppable social forces can at least be altered in form. But no one should be left with the impression that the momentum toward globalization has in any important way been weakened—indeed, it took a global effort to engineer the Seattle protest. Like economics and the media, public health has rapidly assumed an international character. As diseases refuse to respect national boundaries, neither can their prevention. Behavior Change and Public Health in the Developing World places the valuable lessons learned in chronic disease prevention in a universal context and explores new frontiers for the evolving technologies of behavior change and public health promotion.


    1. Not all protestors, of course, were necessarily selfless in motive: Many simply did not want to see jobs leave the United States and other industrialized countries for poorer nations (Krauthammer, 1999).


    This manuscript is the product of 15 years of work with numerous talented colleagues throughout the world. I owe my beginnings in international health to students and colleagues in nearby Tijuana, Mexico, most notably Rafael Laniado and Rene Salgado. For a decade, it was my honor to work with the American and international staff of the worldwide Health Communications for Child Survival (HealthCom) Project and its abundance of talent, including Bette Booth, Judy Graeff, Bill Smith, Terry Louis, Mark Rasmusson, Will Shaw, Patricio Barriga, Pepe Romero, Tom Reis, Andy Pillar, and many others. Later, I was privileged to collaborate with Lourdes Rivas, Linda Lloyd, Mark Nichter, and Gary Clark in the Yucatan on a dengue-fever control project. Many of the ideas represented in this book were initially suggested by or developed in tandem with these people and others, and I am deeply indebted to all.

    Equally valuable assistance came from other quarters as well. Jim Brace-Thompson from Sage has been a very supportive editor and got me through some of the rough spots. Jacqueline Tasch and Nevair Kabakian of Sage were also central to the editing and production process. Connie Elder, Rick Gersberg, Jim Sallis, and four anonymous reviewers arranged for by Sage provided indispensable editorial advice, helping transform a very rough draft into a finished product. Rick Gersberg and Susan Wilson also served as an important sounding board for the “Wheel of Disease” concept. Ken Bart provided critical information on immunization campaigns. Susan Zimicki updated me on some promising initiatives of the CHANGE Project. Esther Martinez, April Busic, and Sunny Choe carried out much of the library work, and Veronica Serrano, Lisa Kondrat, and Nancy Phu prepared the graphs. Jenny Offner, Nancy Phu, and Amelia Arroyo processed the manuscript into a presentable form. The excellent library resources of the Escuela Nacional de Sanidad in Madrid, Spain, proved critical for later revisions. I would like to thank Dean José María Martín Moreno and Professors Antonio Sarría and María Teresa García of the Escuela Nacional de Sanidad for hosting me during my wonderful year in Spain.

    Sabbaticals are critical times of renewal for university faculty, and I would like to express my appreciation to San Diego State University (SDSU) for granting me the 1-year leave during which I wrote this manuscript. Nevertheless, responsibilities do not simply disappear for a year, and I am indebted to many SDSU colleagues for filling in for me during my absence. Mel Hovell, Joni Mayer, Moshe Engelberg, Greg Talavera, and Terry Conway accepted most of my teaching assignments during my absence. Amelia Arroyo, Nadia Campbell, Jeanette Candelaria, Suchi Ayala, Don Slymen, and Al Litrownik, among others, had to fill in for me in various research and administrative capacities. Although I am sure some of them are thinking “He owes me!,” I never heard a word of complaint from any of them.

    This effort was, in part, inspired by many enjoyable Sunday morning conversations with Dale Daniel. A renowned surgeon with a public health soul, he never failed to speak out for peace, equality, and the protection of the environment, and he stimulated all who knew him to do the same.

    John P.ElderMadrid, Spain April 7, 2000
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    Name Index

    • Aaro, L. E., 110
    • Academy for Educational Development, 19, 20, 27, 28, 78
    • Africa AIDS crisis, 94
    • Aikens, M., 87
    • Ake, C., 110
    • Ali, M. M., 95
    • Allen, S., 16
    • Amarillo, M., 87
    • Anaya, S. J., 131
    • Anderson, A., 110
    • Anderson, E., 94, 102
    • Anderson, R., 93, 96
    • Andreasen, A., 20
    • Annest, J., 51
    • Aplasca, M. R., 100
    • Aral, S. O., 129
    • Arevalo, E., 96
    • Ashton, J., 4, 36, 120, 137
    • Asma, S., 106, 108
    • Assadpour, S., 60, 61, 62
    • Ayala, G. X.,
    • Badger, G. J., 110
    • Baer, E. C., 51
    • Bagci, T., 107
    • Baingana, G., 95
    • Balabanova, D., 107
    • Bandura, A., 27, 29
    • Banerji, D., 36
    • Baris, E., 107
    • Baron, D., 59, 60
    • Barrett, D. C., 95
    • Barro, R. J., 128
    • Barros, F., 46
    • Barrowclough, J., 46
    • Basch, P., 2, 3, 5
    • Basu, R., 74
    • Batholet, J., 94, 96
    • Becker, K. M., 113
    • Bennett, D. E., 113, 117
    • Bennett, S., 87
    • Bennett, T., 94, 95, 97
    • Berelson, B., 63
    • Beyrer, C., 101
    • Bhave, G., 98
    • Biddulph, J., 51
    • Biener, M. L., 110
    • Bilizario, V., 87
    • Black, R., 43, 44, 47, 49
    • Bloom, P. N., 19
    • Bobak, M., 107
    • Booth, E., 28
    • Boreham, J., 106, 107
    • Boyden, S., 124, 125
    • Braudel, F., 106
    • Brookfield, H., 137, 138
    • Broomberg, J., 96
    • Browder, J. O., 134
    • Brown, K., 43, 44, 45, 56
    • Brown, L., 132, 133, 134
    • Bunch, R., 36, 37, 38, 39
    • Byansi, R., 95
    • Capo-Chichi, V., 95
    • Cargill, V., 94, 102
    • Carpenter, J. H., 110
    • Cartoux, M., 100
    • Cash, R., 78
    • Celentano, D. D., 101
    • Cham, K., 87
    • Chan, A. S. 88
    • Chandiwana, S., 96
    • CHANGE Project, 52
    • Changerlayne, E., 73
    • Chapman, S., 107, 113
    • Chavez, D., 38, 137
    • Chenet, L., 107
    • Choi, K. H., 95
    • Chotpitayasunondh, T., 95
    • Chowdhury, A. M. R., 83, 84
    • Chowdhury, R., 78
    • Chowdhury, S., 83, 84
    • Cleland, J. G., 95
    • Coate, D., 113
    • Cohen, D., 16, 142
    • Conway, T., 113, 117
    • Cortés, M., 105, 106
    • Council on Economic Priorities, 139
    • Crider, S. T., 131
    • Crofton, J., 106, 107, 108, 111, 113
    • Crumble, D., 94, 102
    • Cutts, F. T., 73, 74
    • Dabis, F., 100
    • D'Alessandro, U., 87
    • Davey, S., 74, 76
    • Desai, S., 98
    • Diaz, J., 68
    • Diaz, M., 68
    • DiClemente, C. C. 18, 34
    • Divan, D.K., xiii
    • Doll, R., 106, 107
    • Dorfman, L., 31
    • Douglass, E., 32
    • Dovers, S., 124, 125
    • Dowdle, W., 72
    • Duhl, L., 35, 36
    • Dye, C., 81, 82
    • Edwards, C., 113, 117
    • Eiumtrakul, S., 101
    • Elder, J., 6, 8, 11, 18, 27, 28, 32, 47, 50, 51, 76, 78, 79, 105, 106, 113, 117
    • Emery, S., 110
    • Emri, S., 107
    • Engeland, A., 110
    • Escohotado, A., 105
    • Estey, J., 16, 79
    • Estrera, N., 51
    • Ewart, C. K., 9, 10
    • Fairchild, A., 136, 137
    • Fajans, P., 68
    • Farkas, A. J., 110
    • Farley, T., 16, 142
    • Farmer, P., 71, 129
    • Fathalla, M. F., 67
    • Fauci, A. S., 93, 94, 97
    • Fengying, Z., 64
    • Fernandes, M., 96
    • Fernandez, E. A., 88
    • Fernandez, T., 51
    • Fincancioglu, N., 65
    • FitzGerald, J. M., 82, 83
    • Flynn, B. S., 110
    • Fox-Rushby. J., 87
    • Gardner, G., 44
    • Garnett, G. P., 81, 82
    • Gehrman, C., 18
    • Geller, E. S., 6, 27, 28, 51, 76, 78
    • Gilpin, E. A., 110
    • Gleissberg, V., 82
    • Go, V. F., 101
    • Gondrie, P. C. F. M., 83
    • Gordon, A., 90
    • Gottert, P., 55
    • Graeff, J., 6, 11, 28
    • Grange, J., 82
    • Gray, G., 97
    • Greenwood, B., 87
    • Gregson, S., 96
    • Grossman, M., 113
    • Gubler, D. J., 36, 40, 84, 88, 136
    • Gueye, M., 59, 60
    • Guillot, M., 5
    • Guthrie, G., 51
    • Guthrie, H., 51
    • Gwarkin, D. R., 5
    • Hackshaw, A. K., 106
    • Hafstad, A., 110
    • Hall, P., 68
    • Halweil, B., 44
    • Hammer, J., 86
    • Harpham, T., 142
    • Hearst, N., 95, 100
    • Heath, C., 106, 107
    • Heckman, T., 94, 102
    • Heuveline, P., 5
    • Hilari, C., 38, 137
    • Him-Farley, R., 73
    • Hinman, A., 72, 73, 74
    • Hoodfar, H., 60, 61, 62
    • Hopkins, D., 72
    • Horta, B., 46
    • Hovell, M., 6, 11, 27, 28, 52, 76, 78
    • Howard, C. R., 45
    • Hudes, E., 96
    • Hudes, E. S., 98, 100
    • Hughes, V., 96
    • Hurst, R. D., 106, 107
    • Hyde, L., 97
    • Islam, A., 83, 84
    • Islam, M. N., 83, 84
    • Jacobsen, J., 63, 65, 66
    • Jaffar, S., 87
    • Jato, M., 6
    • Jelliffe, D. B., 47, 48, 49, 50, 56
    • Jelliffe, E. F. P., 47, 48, 49, 50, 56
    • Jezek, Z., 74
    • Joesoeff, R., 51
    • Johnson, C. A., 113, 117
    • Joossens, L., 108, 109, 113
    • Kanchanamayul, V., 95
    • Kane, T., 59, 60
    • Kanfer, F. H., 36, 38
    • Karakoca, Y., 107
    • Kegeles, S., 16
    • Kelly, J., 94, 102
    • Kennedy, K., 50
    • Kenney, E., 113, 117
    • Khamboonruang, C., 101
    • King, M., 2, 120
    • King, R., 16
    • Kinghorn, A., 97
    • Kosters, M., 128
    • Kotler, P., 20
    • Krieger, N., 95
    • Kuntolbutra, S., 101
    • Kwon, K. H., 66
    • Lalonde, M., 3
    • Langerock, P., 87
    • Langmark, F., 110
    • Lansang, M., 87
    • Lappe, F., 126
    • Lavis, J., 96
    • Lederberg, J., 127
    • Lee, J., 66
    • Leon, D., 107
    • Leontsini, E., 88
    • Lewin, K., 15
    • Lewitt, E. M., 113
    • Liese, B. H., 86
    • Limpitikul, W., 95
    • Lindan, C. P., 99
    • Lindman, C. P., 98
    • Linsk, J. A., 127
    • Lloyd, L., 84, 88, 91
    • Lopez, A. D., 106, 107
    • Lopez, A. S., 4, 5, 82
    • Lozano, R. C., 88
    • Lurie, P., 96
    • Lutter, C. K., 46
    • Lyles, C. M., 101
    • MacKay, J., 106, 107, 111, 113
    • Maher, D., 83
    • Malthus, T., 125
    • Mandel, J. S., 98, 99, 100
    • Marceau, L. D., 3, 4, 10, 15, 16, 120, 137, 141
    • Masland, T., 94
    • Matulessy, P., 51
    • Mayer, G. R., 28, 76
    • Mayer, J. A., 6, 27, 28, 51, 78
    • McAdam, K., 81
    • McAuliffe, T., 94, 102
    • McGuire, T., 17, 18, 19
    • McKee, M., 107
    • McKeown, T., 136
    • McKinlay, J. B., 3, 4, 10, 15, 16, 120, 141
    • Meda, N., 100
    • Menzies, D., 82, 83
    • Mercer, M., 94, 102
    • Miguel, C., 87
    • Miller, K., 63, 67, 68
    • Mills, A., 87, 96
    • Molgaard, C., 6, 11
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    About the Author

    John P. Elder is currently Professor of Public Health at San Diego State University and adjunct professor of pediatrics at the University of California—San Diego. He holds the PhD in psychology from West Virginia University and the MPH from Boston University. Prior to coming to San Diego, he was on the community medicine faculty at Brown University. Guest faculty appointments include the National School of Public Health in Spain and the Magdeburg (Germany) Polytechnic Institute. Dr. Elder has written three books and nearly 200 articles and chapters. He has worked on child survival, vector control, environmental protection, and chronic disease prevention projects in 20 countries in the Americas, the Middle East, Europe, Asia, and the Southwest Pacific.

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