Health Psychology in Global Perspective

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Frances E. Aboud

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  • Cross-Cultural Psychology Series

    SERIES EDITORS

    Walter J. Lonner

    Western Washington University

    John W. Berry

    Queens University

    Many of the basic assumptions contained in standard psychology curricula in Western universities have been uncritically accepted for many years. The volumes in the Cross-Cultural Psychology series present cultural perspectives that challenge Western ways of thinking in the hope of stimulating informed discussions about human behavior in all domains of psychology.

    Cross-Cultural Psychology offers brief monographs describing and critically examining Western-based psychology and its underlying assumptions. The primary readership for this series consists of professors who teach, and students who take, the wide spectrum of courses offered in upper-division and graduate-level psychology programs in North America and elsewhere.

    EDITORIAL BOARD

    • John Adamopoulos

      United States

    • Fanny Cheung

      Hong Kong

    • Pierre R. Dasen

      Switzerland

    • Rolando Diaz-Loving

      Mexico

    • Cigdem Kagitcibasi

      Turkey

    • Yoshihisa Kashima

      Australia

    • Kwok Leung

      Hong Kong

    • Bame Nsamenang

      Cameroon

    • Ype Poortinga

      The Netherlands

    • T. S. Saraswathi

      India

    • Gisela Trommsdorff

      Germany

    • Fons van de Vijver

      The Netherlands

    Books in this series:

    • Methods and Data Analysis for Cross-Cultural Research, Fons van de Vijver and Kwok Leung
    • Health Psychology in Global Perspective, Frances E. Aboud
    • Masculinity and Femininity: The Taboo Dimension of National Cultures, Geert Hofstede

    Copyright

    View Copyright Page

    Dedication

    This book is dedicated to my partner in life, Charles, and to the children who make our life exciting, Charles and Leila.

    Series Editors' Introduction

    The comparative study of thought and behavior across cultures has been one of the most interesting and productive developments in psychology during the past quarter century. We believe, as do many others, that psychology can mature into a valid and global discipline only to the extent that it incorporates paradigms, perspectives, and data from an ever-widening circle of both cultures and ethnic groups. That was the general guiding philosophy behind the Cross-Cultural Research and Methodology series that was started in 1975, in which 20 volumes were published. Like the CCRM series, this new series offers books describing and critically examining Western-based psychology and its underlying assumptions. Most of the basic assumptions contained in standard psychology curricula in the many universities of the highly industrialized Western world have been unchallenged. The volumes in this new series present cultural elements that challenge Western ways of thinking in the hope of stimulating informed discussions about human behavior in all domains of psychology. Books in this series are written for use as core texts or as supplements, depending on the instructor's requirements. We believe that the cumulative totality of books in this series will contribute to the development of a much more inclusive psychology and will lead to the formation of the interesting, testable hypotheses about the complex relationships between culture and behavior.

    As series editors, we are fortunate to have an international panel of experts in cross-cultural psychology to help guide us in the selection and evaluation of manuscripts. The 14 members of the editorial board represent 11 different countries and many of the domains within psychology.

    This volume in the series is written by a cross-cultural social psychologist who has spent her professional career teaching and studying the topics included in the book. Using McGill University as her base, Frances Aboud has been involved in social psychological applications to health and education, with an interest in countries in the developing world. She is particularly knowledgable about Ethiopia, where she has been involved for many years in a variety of research projects. An energetic and creative researcher, her passionate interest in health psychology is timely and efforts like hers are sorely needed throughout the world. Covering critical areas such as family planning, nutrition for proper child growth and development, uses and abuses of alcohol, and mental health and illness, the breadth of the book will be of great interest to psychologists, many in medical fields, educators, and others who are interested in the parameters of international health. The book also contains solid material on certain methodological procedures and perspectives that are critical to the gathering of reliable data.

    All things considered, the scope and tone of this volume make it attractive as a text for classroom use, as a guide for research, and as solid background material for a wide assortment of field projects. We are pleased that it appears in the Cross-Cultural Psychology series, and we believe it will become an influential book in an interesting and growing field. We thank Frances E. Aboud for writing it with her characteristic clarity and unbridled enrhusiasm.

    Walter J.Lonner
    John W.Berry

    Preface

    The title of this book combines global health and psychology, two disciplines that have come together in my life. As a psychologist, teaching and researching in Ethiopia, I tried to bring all my understanding of human existence to bear on the health problems of rural people. Fortunately, there were many colleagues, students, and acquaintances willing to fill me in on the details of health and illness in a developing country. I hope to pass on to you, the reader, what I learned from them.

    The field of international health attracts many people, each with his or her own motivation and own orientation: the medical profession, the social scientists, the humanitarians. Professional and academic writings are full of their contributions as well as their quarrels. Each has a unique contribution to make, but it can best be made by working closely with others. Community health work, in particular, demands a collaborative effort. My experience and my nature tend to be inclusive, to avoid fights over who can and can't do what. Regardless of your major discipline, I am sure you can learn to develop a qualitative and a quantitative measure or help develop an intervention for a health problem.

    I have taken a biopsychosocial approach to international health by discussing the biological, psychological, and social contributions to health and illness. As a social and developmental psychologist, my strength lies in explaining the middle factor, without excluding the other two. Although there is a thriving group of health psychologists, they have not been particularly visible in developing countries, where people are more likely to recognize the social science work of anthropologists. However, the field of psychology includes topics that range from physiological and developmental mechanisms to social and educational applications. It also has developed and used a wide range of measurement techniques not only to assess personality but also to examine learning, attitudes, and group problem solving, to name but a few. My work in cross-cultural psychology has taught me that a different nation or cultural group sometimes sees their lives from a different perspective, although we all have much in common. I know that there are many right ways to reach our common goals of health and development, and I hope we will explore these together through discussions generated by my text. Without glossing over the differences, I have taken a broad psychological perspective while including the published ideas and research of people from other disciplines. Whatever region of the world you live in, and whatever your particular interest in health, I hope this book provides some impetus for pursuing your own personal and collective goals.

    Acknowledgments

    I would like to thank colleagues and students from the following places for their intellectual and financial support: the McGill-Ethiopia Community Health Project, the International Development Research Center, the Canadian International Development Agency, the Jimma Institute of Health Sciences, Addis Ababa University, Concordia University, and especially McGill University. I am grateful to colleagues who gave me feedback on earlier versions of chapters: Will Boyce, Judith Graeff, Catherine Hankins, Morton Mendelson, Joyce Pickering, Robert Pihl, and Lisa Serbin.

    I am grateful to Dr. Michaela Hynie, a psychologist, for writing the complete chapter on AIDS and HIV (Chapter 4) and to Dr. Charles P. Larson, an epidemiologist and physician, for writing the epidemiology section in Chapter 1.

    Copyright permission was granted by the following:

    • The Canadian University Consortium for Health in Development for extensive borrowing from my chapter in their book, Health Research for Development: A Manual, edited by Joyce Pickering, for Chapter 2 here.
    • Carfax Publishing Ltd., P.O. Box 25, Abingdon, Oxfordshire OX14 3UE, United Kingdom, for Table 7.1, which was adapted from an article by Saunders, Aasland, Amundsen, and Grant in the journal Addictions, 1993, 88, 349–362.
    • The Guardian Weekly for referencing in Chapter 4 an article from the March 25, 1997, issue by P. Brown titled “And Now for the Bad News About AIDS.”
    • The Washington Post for quoting from two articles published in the Washington Post section of the Guardian Weekly: The quote in Chapter 3 was written by B. Vobejda in an article titled “U.S. Aid Cut ‘Will Increase Abortions’ “in the March 17, 1996, issue of the Guardian Weekly; the quote in Chapter 9 was written by J. Mathews in an article titled “Population Control That Really Works” in the April 10, 1994, issue of the Guardian Weekly.
    • UNAIDS for the rates and numbers shown in Figure 4.1, which were taken from their web site http://www.us.unaids.org.
  • A Final Note: Where Do You Go from Here?

    Forward-looking enthusiasm, tempered with caution and realistic expectations, has spiced this overview of international health. The enthusiasm to try harder is what motivates people who work in developing countries. Yet it is all too easy to pack a few facts in your head and some money in your pocket and launch a new campaign to eradicate ill health and poverty. As one of my colleagues tactfully put it to me, “Be careful you don't just fire up another wave of idealistic workers to go out and press contraceptives on reluctant women.” I hope we have realized that problems and solutions are not as simple as they appear at first glance.

    The catchphrase of UNICEF and other international agencies is “local problems generating global solutions.” Problems, such as not enough food and exposure to HIV, are experienced at a local level—within the person, the family, and the community—with variations at each level. While recognizing that people have different emotional reactions to these problems, ranging from anger to acceptance, the community health approach focuses on their common experiences. People who share a culture often experience health and illness similarly. So it is reasonable to generate solutions within a cultural community. But, although we like to think of ourselves and our culture as unique, we share many health-related practices and problems with other cultures. The evil eye, attraction to injections, food taboos, withholding food and fluid from a sick child, and myths about condoms and AIDS are common across cultures. For this reason, it is important to learn about problems and solutions in other cultures, and to build on them and modify them when developing solutions for our own. Global solutions, such as the child immunization program and oral rehydration salts, have many components that are universal while allowing for cultural flexibility at the community level.

    Other solutions have no universal appeal because they have not worked at the local level in many countries, although they might have worked in some. The system of community health workers has not worked in many places, although we have been able to learn lessons from these failures. We have learned that the health workers need regular and frequent supervision and a resource such as drugs to make them gain respectability in their communities. Community participation is a promising activity, but as implemented in many countries, it has not increased the use of health services. Many health education projects have not had the impact they hoped for because they changed knowledge but not behavior. From these experiences, we learn that change does not come about easily. Some people are receptive to the innovative practices proposed, but many others are not convinced enough to change their habits. Basic primary school education seems to be the one common resource that makes a difference. But even this is not universally acceptable in its present form.

    Where you go from here depends on the kind of expertise you can offer. Several routes appear to be more promising than others. One route is with NGOs who work at the grassroots level. They can make a difference by promoting change through community involvement. NGOs often have job openings for people who are good at helping groups to organize and make decisions. Changes at the community level are sustainable if they are institutionalized through training managers, forming decision-making structures, and identifying sources of funds and human resources. Another route is work within local health and educational institutions and government structures to train people. Governments usually have a clear idea of the kinds of skills they are lacking, and these are most often at the mid-and lower level health worker positions. Specialists are not likely to be their priority.

    NOTE: DIGITAL RIGHTS HAVE NOT BEEN CLEARED.

    A final route is by working with governments to bring about policy changes. A recent headline in the Guardian Weekly read, “Foreign Aid ‘Has No Impact’” (Blustein, 1997). Reviewing an upcoming World Bank report, the article pointed out that billions of dollars in foreign aid have produced no appreciable impact on the overall economic performance of the Third World because governments have not developed and implemented new policies aimed at reforming old practices. Some countries, such as Ghana, have used aid to support policy reform, but many others have not. Good government, quality education, and involved communities are three important catalysts for change.

    The most important lesson we have learned and relearned is that people and problems cannot be stereotyped. After reading Lewis Aptekar's (1988) book on street children, I realized that I had a stereotype of street children as forlorn, frightened, homeless boys. This description fits some, but not all, of them. Many are very competent and confident, and grow up to be productive, satisfied members of their society. Through research, we learn about the way different cultures give meaning to health and illness, as well as the way they raise their children. We may see problems in the way other people conduct their lives. Our ethno-centrism often hinders us from realizing that there are many different routes to the same goal of well-being.

    I hope this book has helped you become informed about health problems and solutions in an international perspective. Research and personal experience have informed my own awareness. Only when we give others the research tools to inform themselves can we hope to achieve a workable partnership.

    Glossary

    • Absolute poverty level: The income level below which a minimum nutritionally adequate diet plus essential nonfood requirements is not affordable.
    • Acceptability: People's satisfaction with the health service in question.
    • Access to adequate sanitation: Percentage of the population that has household waste disposal facilities such as a latrine and garbage pit.
    • Access to health services: Percentage of the population that can reach appropriate local health services by the local means of transportation in no more than 1 hour; sometimes a distance of 10 km is used. Documents usually provide separate figures for urban and rural populations because of the disparity.
    • Access to safe water: Percentage of the population that can reach a protected source of drinking water that is uncontaminated by parasites and bacteria.
    • Acute respiratory infection: An infection of the tract from the nose to the lungs. The most fatal, pneumonia, is an infection of the lungs.
    • Adult literacy rate: Percentage of persons aged 15 and over who can read and write. This probably requires 4 years of formal schooling.
    • Affordability: The total cost to a client, including payment for service and transportation to the service.
    • Aid: Emergency, life-saving interventions that are not intended to be sustained; 80% of donor funds and resources are used for aid.
    • Alcohol abuse or harmful use: Harmfully excessive and recurrent use of alcohol resulting in physical, personal, or social problems. One or more of the following alcohol-related problems are experienced within a 12-month period: (a) failure to fulfill major role obligations at work, school, or home; (b) recurrent use in physically hazardous situations such as when using industrial equipment or driving an automobile; (c) legal problems such as arrests; and (d) continued use despite persistent social or interpersonal problems exacerbated by the effects of alcohol.
    • Alcohol dependency: Excessive and prolonged drinking, which affects the person at many levels and creates physiological dependency that manifests as withdrawal (symptoms of nonuse such as seizures and tremors) and tolerance (needing more alcohol to have an effect), craving alcohol, and curtailing normal activities so as to obtain alcohol.
    • Alcohol intoxication: A temporary state due to the recent consumption of alcohol resulting in maladaptive behavioral or psychological changes such as aggressive or argumentative behavior, disinhibition, and impaired social or occupational functioning. Other signs such as slurred speech and uncoordinated movements are apparent. Legal levels of intoxication may be under 0.10% blood alcohol concentration (BAC), which means 100 parts of alcohol per 10,000 parts of blood, or 100 mg of alcohol per 100 ml of blood.
    • Alcoholism: The excessive and regular use of alcohol leading to alcohol-related problems.
    • Attitudes: Predispositions to respond in a positive or negative manner toward a person, object, or event.
    • Autonomy: Having the resources necessary to think, decide, and act independently, using but not needing input from others.
    • Availability: The number of health workers serving 1,000 people.
    • Behavioral diagnosis of a health problem: The process by which we look at the causes of a health problem and find out whether human behavior is involved in its prevention or treatment.
    • Biopsychosocial framework: A systematic approach that seeks to understand health and illness in terms of three components: biological, psychological, and social.
    • Births attended by a trained health worker: Percentage of deliveries made by someone trained in obstetric care as opposed to deliveries made by relatives or traditional attendants who do not follow sterile procedures.
    • Breast-feeding: Percentage of children who are exclusively breast-fed from 0 to 3 months, breast-fed along with solid food (6–9 months), and breast-fed for up to 2 years (20–23 months).
    • Children reaching grade 5 of primary school: Percentage of the children entering the first grade of primary school who eventually reach grade 5. The difference from 100% is the dropout rate. Note that some children may not even enter first grade.
    • CIDI-SAM: The Composite International Diagnostic Interview's Substance Abuse Module:, which assesses whether a person has a serious problem of substance abuse and dependency, including alcohol abuse and dependency.
    • Cognition: Interpreting the world, memory, learning, thinking, reasoning, problem solving, and knowledge.
    • Communication: The transmission of a message from one person to another. It can be face to face or mass media, auditory and visual; it can be informative and emotional and persuasive; it can be positive (what to do and the benefits) and negative (what not to do and the disadvantages).
    • Community health workers (CHW): People who are selected by their communities and given some training in health so that they can serve their community by performing basic preventive and curative services.
    • Community participation: A social process whereby specific groups with shared needs living in a defined geographic area actively pursue identification of their needs, make decisions, and establish mechanisms to meet these needs.
    • Conduct disorder: A childhood mental health problem, comparable to the term antisocial personality: used for people 18 years and older. It describes people who are aggressive, destructive of property, deceitful, or who frequently violate rules.
    • Contraceptive prevalence rate: Percentage of married women aged 15–49 years currently using contraception.
    • Coping: Cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person. Coping strategies include, among others, social support seeking, planful problem solving, and escape/avoidance.
    • Coverage: The proportion of the population that received a particular health service, such as immunization or antenatal care.
    • Crude birth rate: Annual number of births per 1,000 population.
    • Crude death rate: Annual number of deaths per 1,000 population.
    • Dehydration: A loss of water and dissolved salts from the body that occurs, for instance, as a result of diarrhea.
    • Dependency ratio: The number of people under 15 years and over 49 years of age divided by the number of people aged 15 to 49 years.
    • Dependent population: Percentage of the population 0 to 15 years of age.
    • Development: Interventions that are intended to be sustainable, such as skill training and resource building; 20% of donor funds and resources are used for development. Health development activities are only one part of overall development, which also includes agriculture and education.
    • Diagnostic and Statistical Manual (DSM-IV): for mental disorders: The classification system used in North America. It covers organic mental disorders, substance-related disorders, schizophrenia, mood disorders, anxiety disorders, somatoform disorders, sexual disorders, eating and sleep disorders, personality disorders, and developmental disorders.
    • Diarrheal diseases: An illness of the digestive system, caused by many microorganisms, the most common of which are rotavirus and Escherichia coli. A child with diarrhea passes three or more loose, watery stools in one day, and this continues for several days.
    • Disability adjusted life years (DALYs) lost: The product of two indicators. The first is the number of years lost, calculated by subtracting the age of death or onset of disability from the life expectancy of a healthy person, usually set between 65 and 75. The second is a value from 0 to 1, representing the degree of functional disability; death receives a maximum value of 1 and minor disabilities are closer to 0.
    • Effectiveness: An indicator of how well the service worked, such as the percentage of children who recovered from diarrhea after receiving ORT.
    • Emic-etic dilemma: Two extreme ways of incorporating cultural differences in a measure. Emic is the strategy of including items derived from and relevant to a particular culture with no intention of comparing responses from another culture. Etic is the strategy of importing a measure developed in one culture to another culture, for the sake of comparability. There are strategies in between these two extremes, for example, maintaining some constancy in the underlying concepts while varying the surface expression.
    • Emotion: States of affect (e.g., happiness, anger, fear), moods (a brief positive or negative emotion), and attitudes (long-term evaluations of people, objects, and events).
    • Empowerment: The gaining of power, influence, and control over one's life at personal, interpersonal, and community levels.
    • Endemic: A situation in which a disease commonly exists at very high levels in a particular locality.
    • Epidemic: A situation in which a disease that is normally not common experiences an outbreak and becomes very prevalent.
    • Episodic heavy drinking: Having six or more drinks per occasion at least weekly, similar to regular binge drinking.
    • Estimate: A close approximation of the true value of a variable based on the partial information available from a representative sample of the population.
    • Focus group: A method of collecting information on people's perceptions and opinions. A group of people with similar backgrounds are brought together to talk about a specific topic of interest under the guidance of a moderator.
    • Fully immunized 1-year-old children: Percentage of all 1-year-old children who have been immunized for tuberculosis, diphtheria, pertussis, tetanus, polio, and measles. More than 120 million babies born each year need to receive vaccinations on five occasions during their first year.
    • GNP and GDP: Gross national product and gross domestic product reflect the amount of money spent and earned on goods and services, which reflects the economic activity of a country.
    • Goiter rate: Percentage of children aged 6–11 with palpable or visible goiter. This is an indicator of iodine deficiency, which causes mental retardation.
    • Habit: A set of actions that has become automatic, fixed, and easily and effortlessly carried out as a result of repetition.
    • Hazardous consumption: Operationally defined as an average daily consumption of six or more drinks in a typical month for men and four or more drinks for women.
    • Health: Physical, mental, and social well-being—an important resource for a satisfying and productive life.
    • Health behaviors: Actions that directly influence one's own and others' health. They include behaviors that promote physical well-being, prevent illness, and manage or eliminate illness, and also those that demote or reduce health.
    • Health education: A process with intellectual, psychological, and social dimensions relating to activities that increase the abilities of people to make informed decisions affecting their personal, family, and community well-being. This process, based on scientific principles, facilitates learning and behavioral change in both health personnel and consumers, including children and youth.
    • Health locus of control: Generalized expectancies that either self (internal), powerful others (P), or chance (C) determine one's health and illness. A fourth source of health and illness for some cultures may be powerful spirits.
    • Health promotion: Political, social, and educational action that enhances public awareness of health, fosters healthy lifestyles and community action in support of health, and empowers people to exercise their rights and responsibilities in shaping environments, systems, and policies that are conducive to health and well-being.
    • Incidence: A measure of the occurrence of new cases over a specified time interval (frequently 1 year).
    • Infant mortality rate: Number of deaths of infants under 1 year of age per 1,000 live births.
    • International Classification of Disease (ICD-10):: Classification system for all disorders developed by the World Health Organization, which covers organic mental disorders, substance-related disorders, schizophrenia, mood disorders, anxiety disorders, somatoform disorders, sexual disorders, eating and sleep disorders, personality disorders, and developmental disorders.
    • International health: A multidisciplinary field of study that takes a multination perspective on the state of people's health, seeking knowledge and effective action strategies through a systematic examination of health problems, their determinants, and their solutions around the world.
    • KAP questionnaire: A structured set of questions that assess knowledge, attitudes, and practices relevant for a particular health problem. The items should be answered in the reverse order—PAK—so that describing what you do is not influenced by hearing the knowledge items.
    • Key informant interviews: Unstructured questioning of informed individuals to collect information quickly about events and people in a community or to gain a deeper understanding of how community members think about an event. A key informant has wide contacts, good communication skills, and a reflective attitude.
    • Knowledge: All the information possessed by a person or group, however it was acquired (i.e., a form of cognition).
    • Kwashiorkor: A form of malnutrition due to insufficient protein in one's diet. The child's legs and sometimes face are swollen with edema; the skin becomes flaky and the hair turns a red color.
    • Leadership style: The task-oriented or relation-oriented style one uses to influence and motivate other people.
    • Learning: The process of acquiring a relatively permanent mental or behavioral response as a result of rewarded practice or observation of someone performing the behavior. The reward may take the form of a biologically satisfying object or it may be social approval and recognition. The observed model is likely to be a parent, older sibling, or teacher.
    • Leprosy: A disease caused by the Mycobacterium leprae. A mild form results in depigmentation of a patch of skin that spontaneously heals, whereas a more severe form results in damage to nerves, bones, and muscles.
    • Lessons learned: A phrase that refers to reasons for a failure, which we identify after much reflection and evaluation and hope not to repeat in subsequent attempts.
    • Level of confidence: A numerical value that describes an interval within which one is certain the estimate exists. A narrow interval indicates certainty and unlikelihood of error.
    • Life expectancy at birth: The number of years newborn children would live if subject to the mortality risks prevailing for the cross section of population at the time of their birth.
    • Locus of control: In terms of health, it is the expectation that either oneself or others or chance factors determine one's health and illness.
    • Low birth weight infants: Newborns weighing less than 2,500 gm. If the child is a full-term newborn, the low birth weight is attributed to intrauterine growth retardation.
    • Malaria: An infection due to a parasite that is carried by the Anopheles mosquito. The main symptom is a fever.
    • Malnutrition: A state of deficiency in energy, protein, or other micro-nutrients such as vitamin A, iodine, and iron.
    • Marasmus: An extreme form of malnutrition, the result of insufficient calories due to diet or illness. The child's body lacks the layer of fat normally seen under the skin, and the muscles are wasted.
    • Maternal depletion: The decline in a woman's health as a result of giving birth to many children in countries where women experience ill health, malnutrition, and closely spaced births.
    • Maternal mortality: The number of women who die in pregnancy and childbirth is usually expressed as the number of deaths from pregnancy-related causes per 100,000 live births (which is a proxy for the number of pregnancies).
    • McGill Pain Questionnaire: Measures the subjective perception of tissue injury, extreme temperature, or pressure in terms of sensory and emotional experiences.
    • Measles: A very contagious viral disease transmitted from person to person through simple respiration. The main symptoms are rash and fever.
    • Mental disorders: Behavioral or psychological syndromes (groups of associated features) that are associated with one or more of the following: present distress, impairment in one or more important areas of functioning, a significantly increased risk of suffering death, pain, or disability.
    • Mental health: Satisfactory functioning in cognitive, emotional, and social domains.
    • Motivation: Energized, goal-directed behavior, influenced by need, value of the goal, and expectations of reward.
    • Neonatal tetanus: A disease acquired when the tetanus bacteria, present in the soil and dust, enter an open wound. In the case of newborns, the bacteria enter from unsterile razors or other sharp objects used to cut the umbilical cord or from improper dressing or cleaning of the stump. Tetanus manifests with rigidity of the mouth and lips and, finally, death.
    • Nongovernmental organizations (NGOs): Organizations or institutions that conduct activities in one or more countries on the basis of a written agreement with the host country. They are generally nonprofit groups that raise money from donors and government agencies in their own countries. Their goals are to promote development and training, and they often work at the grassroots level with local communities.
    • Number of radio and television sets per 1,000 population: Indicates the amount of public information received by a population.
    • Official development assistance (ODA): Annual amount of grants, in U.S. dollars, received from donor governments to be used for development. A target level of 0.7% of the donor's GNP was set in 1969, but few countries now meet this standard. This figure is also expressed as a percentage of the recipient country's GNP.
    • Oral rehydration salts (ORS): Specifically, the standard WHO/UNICEF-recommended formula, which consists of four constituents: sodium chloride, trisodium citrate (or sodium bicarbonate), potassium chloride, and glucose. Dissolved in 1 liter of clean drinking water, it is given to children to prevent or correct dehydration resulting from diarrhea.
    • Oral rehydration therapy (ORT): The administration of fluid by mouth to prevent or correct the dehydration that is a consequence of diarrhea, including use of porridge, drinks, and ORS.
    • ORT use rate: Percentage of all cases of diarrhea in children under 5 years of age treated with oral rehydration salts (the UNICEF sachet) or an appropriate household solution of salt, sugar, water, and sometimes porridge.
    • Pandemic: A situation in which a disease becomes common and spreads to many locations.
    • Participant observation: An in-depth case study of group life from the perspective of someone who has a prolonged, intense involvement in that life, that is based on naturalistic observations and information intentionally solicited.
    • Per capita alcohol consumption: An estimate of the amount of alcohol consumed in a country per person (sometimes excluding abstainers). Figures are usually based on what is commercially produced in the country plus whatever is imported minus whatever is exported during that year. The amounts are usually converted to quantities of 100% ethanol per capita population 15 years and over.
    • Personality: Relatively enduring ways of behaving, thinking, and feeling that characterize a person and that to a certain extent distinguish that person from others.
    • Poliomyelitis: A viral infection; only 1% of those infected have symptoms. Muscles may become sore and lower limbs paralyzed. In time, the paralyzed limb becomes wasted from lack of use and the person may need crutches.
    • Population doubling time: The number of years it will take for the population to double its current numbers, estimated by dividing the crude growth rate (as a percentage) into 75.
    • Positive consequences: The social, emotional, or material benefits that follow from an action, for example, receiving approval, social recognition, or any other rewarding event.
    • Prevalence: The proportion of the population currently ill; a crude measure of the burden of disease in a population.
    • Primary health care (PHC): Essential health care made available at a cost that countries and communities can afford with methods that are practical, scientifically sound, and socially acceptable. It is the first line of health service and includes promotive, preventive, and curative services. There are eight components, following the acronym MEDECINS.
    • Primary school enrollment ratio (gross): The total number of children enrolled in primary school, whether or not they are of the age for that level, expressed as a percentage of the total number of children of that age. This indicates how many eligible children are enrolled in primary school. Figures are also available for secondary school enrollment:.
    • Protective factors: Characteristics of people or their environments that are associated with health in the presence of adversity and that therefore decrease the likelihood that these people will suffer from illness.
    • Qualitative methods: Ways of collecting rich descriptive information about a community or about individuals, usually accompanied by information about the context in which they function. Examples are focus group discussion, participant observation, and key informant interviews.
    • Quantitative methods: Ways of collecting information that can be given a numerical value for the purpose of estimating prevalence or average tendencies, or to conduct statistical analyses of the association between different variables. Examples are nonparticipant observation and structured survey questionnaires.
    • Relational: Actual interactions with other people that involve participation in friendship, family, and community life as well as the mental processes involved in relationships with others, such as emotional attachments and realistic interpretations of others.
    • Risk factors: Characteristics of people or their environments that are associated with illness and therefore increase the likelihood that people with the characteristics will suffer from illness.
    • Salt and sugar solution: The salt and sugar added to water to make a homemade fluid for oral rehydration.
    • Sampling: The procedure of selecting from a population those who will become participants in a survey or other method of data collection. Representative sampling means that the sample will have the same proportions of people from different age and sex groups as the general population from which they were selected, accomplished through random or systematic sampling.
    • Self-efficacy: Confidence that one can perform the actions considered necessary for the role (e.g., leader, organizer, health educator) or for the outcome (e.g., to persuade people to give resources).
    • Self-esteem: (or self-confidence): A person's perception of his or her worth generally and in specific domains such as family, social, and work.
    • Self-Reporting Questionnaire: A 24-item measure of adult mental health problems developed by experts from the WHO and intended for use in developing countries.
    • Skills: Capacities for carrying out complex, well-organized patterns of behavior smoothly and adaptively to achieve a goal.
    • Social Readjustment Rating Scale: Measure of the psychological impact of major life events experienced in the past year.
    • Stress: An internal state of tension or disequilibrium that results from repeated or intense stressors.
    • Stressor: An aspect of the environment that is perceived as threatening or that requires adaptation.
    • Structured self-report measures: Usually an interview instrument that includes a standard set of questions about a person's health behavior, attitudes, beliefs, or whatever, the answers to which can be quantified and summed to create a composite score. The questions are written and read in the same way to all respondents.
    • Stunting: An index of chronic or long-term malnutrition because it implies that insufficient protein for bone growth (and energy) has existed for months or years. Children who are below minus two standard deviations from the median height for their age and gender reference population (formerly 90% of the median height for their age) are considered moderately to severely stunted.
    • Subjective norm: The perception that significant other people will approve of the action. In other words, it is one's view of the unwritten social rules specifying acceptable behaviors.
    • Systematic observation: Planned, methodical, objective observation of events in their sequence and in their natural context. The observations can be coded and quantified.
    • Total fertility rate: The number of children who would be born to a woman if she were to live to the end of her childbearing years and bear children at each age in accordance with prevailing age-specific fertility rates.
    • Traditional birth attendants (TBA): Usually women who serve as the midwife in their community and who are given extra training so that they can care for women during pregnancy and during the delivery of their babies. If given extra training, they are called trained traditional birth attendants (TTBA).
    • Tuberculosis: A disease caused by the bacillus Mycobacterium tuberculosis, which is transmitted from one person to another through coughing or sneezing. This infects the lungs.
    • Under-5 mortality rate: Number of deaths of children under 5 years of age per 1,000 live births. This is the probability of dying between birth and exactly 5 years of age, and it is one of the most important indicators of the health of a nation's children because it reflects many inputs from nutrition, immunization, use of oral rehydration solution, mothers' knowledge, and access to health services.
    • Underweight: Moderately and severely underweight children weigh less than two standard deviations below the median weight for their age. In the past, some definitions were stated in terms of weighing less than 80% of the median.
    • Utilization of health services: Percentage of the population that uses preventive or curative services offered by a local clinic or a community health worker.
    • Values: Relatively enduring preferences for certain end states such as health and social recognition and the means for achieving them such as through self-control or obedience. Rokeach measured the values of a person and culture by asking people to rank in the importance to them a list of 18 values. A traditional culture is one that values ways of living that have been passed down through many generations.
    • Verbal autopsy: A technique for identifying the cause of death by asking structured questions of an adult who cared for the deceased before death.
    • Wasting: Moderate and severe wasting refers to weighing less than two standard deviations below the median weight for that height (previously less than 80% of the median).
    • Ways of Coping Questionnaire: A 66-item questionnaire to measure cognitive and behavior efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of that person.
    • Weaning foods: The semisolid foods that are given to children from 6 to 24 months of age, along with breast milk, to provide extra energy and other nutrients.

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    Author Index

    About the Author

    Frances E. Aboud is Professor in the Department of Psychology at McGill University in Montreal, Canada. She has been teaching there for 22 years, offering courses on personality and social psychology, social development, and international health psychology. She has conducted research on the development of ethnic prejudice in children and ways of reducing it, and has published a book on this topic called Children and Prejudice. For several years, she worked in Ethiopia as a member of the McGill-Ethiopia Community Health Project. At that time, she taught a behavioral science course to master's students in the public health program at the University of Addis Ababa and the Jimma Institute of Health Sciences. In collaboration with staff and students, she conducted and published research on malnutrition in children, mental illness, mothers' management of children's diarrhea, and community health workers.

    About the Contributors

    Micheala Hynie is currently Assistant Professor of psychology at York University in Toronto, Canada. She received her PhD from McGill University, where she conducted research on social psychological aspects of women's sexuality. In addition to continuing this research, she teaches community mental health and social psychology.

    Charles P. Larson is Associate Professor in the Department of Epider-miology and Biostastics and the Department of Pediatrics at McGill University. He was Director of the McGill-Ethiopia Community Health Project and has been involved with projects in Vietnam and Russia. He has published extensively on topics related to public health in developing countries, some of which include randomized field trials of family planning promotion, functional status of community health workers, and oral rehydration therapies. He is currently co-chair of the Canadian Society for International Health.


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