Culture, Behavior, and Health

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE© Anton OR Balazh/Shutterstock DISTRIBUTION CHAPTER 2 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Culture,NOT FOR SALE OR DISTRIBUTION Behavior, andNOT FOR SALEHealth OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALESusan OR C. DISTRIBUTIONScrimshaw and Sandra D. Lane NOT FOR SALE OR DISTRIBUTION

“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 Jones new & healthBartlett habits, Learning, it is wise to LLCof adults used such treatments© Jones (NCCIH, & Bartlett 2017). Learning, The LLC ascertain the existingNOT habits, FOR how these SALE habits OR are linkedDISTRIBUTION to one global importance of thoseNOT approaches FOR SALE is evidenced 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 © Joneseople around& Bartlett the world Learning, have beliefs LLC and behav- the study© Jonesof traditional & Bartlett medicine Learning, to strengthen LLC the iors related to health and illness that stem from NOT FOR SALE OR DISTRIBUTION evidenceNOT base FOR and promote SALE quality.OR DISTRIBUTION cultural forces as well as individual experiences In the past three decades, we have moved from Pand 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 heal- found that in all 42 communities studied, people used ing approaches are valued and used, often in combina- © Jones & Bartlettboth the Learning,Western biomedical LLC system and indigenous© Jones tion & withBartlett biomedicine. Learning, At this LLC time there is increasing NOT FOR SALEpractices, OR DISTRIBUTIONincluding indigenous practitioners. Also,NOT FORrecognition SALE ORthat DISTRIBUTIONsuch approaches can and should be 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 expe- execution of health programs often falls short of the riences with alternative healing systems and short- mark. Experience has shown that when health pro- comings in the Western© Jones biomedical & Bartlett system, Learning, people LLCgrams fail to recognize© andJones work & with Bartlett indigenous Learning, LLC relied on both (Nichter,NOT FOR 2008; SALE Scrimshaw, OR DISTRIBUTION 1992). In beliefs and practices, theyNOT also FORfail to SALEreach their OR goals. DISTRIBUTION recognition of the widespread use of nonbiomedical Similarly, research to plan and evaluate health programs therapies, the U.S. National Institutes of Health estab- must take cultural beliefs and behaviors into account lished a center for the study of alternative and comple- if researchers expect to understand why programs are mentary© Jones medicine, & Bartlett which Learning, is now called LLC the National not working© Jones and determine & Bartlett what Learning, to do about LLCit. CenterNOT FORfor Complementary SALE OR DISTRIBUTION and Integrative Health ThisNOT chapter FOR SALEdraws ORon the DISTRIBUTION social sciences— (NCCIH, 2014). With a yearly budget of $124.1 mil- particularly, anthropology, psychology, and sociology— lion, the NCCIH’s mandate is to provide research evi- to 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 & Bartlettspiritual Learning,healing. The LLC popularity of complementary© Jones on & Social Bartlett Determinants Learning, of Health LLC and Health Equity NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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© Joneschapter, & Bartlett which Learning,covers social, LLC political, and economic © Joneseducation & andBartlett experiences, Learning, and as LLC conditions change forces that affect health, but does not go deeply into around them (e.g., armed conflicts, economic changes NOT FOR SALE OR DISTRIBUTION NOT FORthe culturalSALE ORcomponents DISTRIBUTION of health. This chapter begins in a country or region, political changes). This is a with some key concepts from the field of anthropol- helpful viewpoint when looking at cultural change on ogy and the subfield of medical anthropology. It con- both individual and group levels. tinues with brief descriptions of the various types of Medical anthropologists observe different cultures health belief systems and© Jones healers &around Bartlett the world.Learning, and LLC their perspectives on disease© andJones illness. & ForBartlett exam- Learning, LLC Next, some key theoriesNOT of health FOR behavior SALE and OR behav DISTRIBUTION- ple, they look at the biological andNOT the FORecological SALE aspects 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 Jones available.& Bartlett Methodological Learning, issuesLLC are Insider Versus© Jones Outsider & Bartlett Perspectives Learning, LLC presented, followed by a case study of acquired immu- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION nodeficiency syndrome (AIDS) and a commentary To understand the cultural context of health, it is on the international efforts to curb the Ebola virus essential to work with several key concepts. First, the pandemic in West Africa. Another case study exam- concepts of insider and outsider perspectives are use- ines the use of rapid assessment methods to guide the ful for examining when we are seeing things from our © Jonesintroduction & Bartlett of Learning, an improved LLC nutritional cereal for © Jonespoint of &view Bartlett and when Learning, we are trying LLC to understand NOT FORinfants SALE and ORchildren DISTRIBUTION in Ghana. The chapter concludes NOTsomeone FOR else’sSALE view OR of DISTRIBUTIONthings. The insider perspective by summarizing how all of these areas need to be con- (emic, in anthropological terminology) shows the cul- sidered in global health efforts. ture as viewed from within. It refers to the meaning that people attach to things from their cultural perspective. For example, the view that worms (Ascaris) © Jones & Bartlett Learning,in LLC children are normal and are© caused Jones by eating& Bartlett sweets Learning, LLC ▸▸ Basic ConceptsNOT from FOR MedicalSALE OR DISTRIBUTIONis a perspective found within NOTsome cultures.FOR SALE The outOR- DISTRIBUTION sider perspective (etic, in anthropological terminol- Anthropology ogy) refers to the same thing as seen from the outside. Health and illness are defined, labeled, evaluated, and Rather than meaning, it conveys a structural approach, acted upon© Jones in the context& Bartlett of culture. Learning, In the nineteenth LLC or something© as Jonesseen without & Bartlett understanding Learning, its mean LLC- century,NOT anthropologist FOR SALE Edmund OR DISTRIBUTIONTyler (1871) defined ing for a givenNOT culture. FOR The SALE outsider OR DISTRIBUTIONperspective can culture as “that complex whole which includes knowl- also convey an outsider’s meaning attached to the edge, belief, art, morals, law, custom, and any other same phenomenon. For example, this view might capabilities acquired by man as a member of society.” hold that Ascaris infection is contracted through eggs Since those early days of anthropology, there have in contaminated soil or foods contaminated by con- © Jonesbeen & Bartlett literally hundreds Learning, of definitionsLLC of culture, but © Jonestact with & that Bartlett soil; the Learning, eggs get into LLC the soil through NOT FORmost SALE have theOR following DISTRIBUTION concepts in common (Board NOTfecal FOR wastes SALE from ORinfected DISTRIBUTION individuals. The concepts on Neuroscience and Behavioral Health, 2002): of insider and outsider perspectives allow us to look 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 ■■ © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Patterns of behavior that are guided by these approaches that will work within a cultural context shared ideas, meanings,NOT and FOR values 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© Jones the experiences & Bartlett that peopleLearning, (and sometimes LLC mothers believed© Jones that worms & Bartlett are normal Learning, and are notLLC groupsNOT of people) FOR go SALE through OR as DISTRIBUTION they live their lives. a problem unlessNOT they FOR become SALE agitated. OR DISTRIBUTION In their view, 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 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC constantly changing. This concept allows for cultural agitated during the rainy season, because the thunder NOT FORchange SALE as people OR DISTRIBUTION migrate to a new setting (commu- NOTand FOR lightning SALE frighten OR DISTRIBUTIONthem. From an outsider per- nity, region, or country), as people acquire additional spective, this relationship makes sense: Sanitation is

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© Jones & Bartlettmore likely Learning, to break down LLC in the rainy season, so there© Jones &It Bartlett is also possible Learning, for someone LLC to feel ill and for is more chance of infection and more diarrheal dis- the Western biomedical system not to identify a NOT FOR SALE OR DISTRIBUTION NOT FOR SALEease, whichOR DISTRIBUTION will reveal the worms. disease. When this occurs, there is a tendency for The dilemma for the health workers, in the Gua- Western-trained healthcare providers to say that noth- temalan worms example, was to get the mothers to ing is wrong or that the person has a “psychosomatic” accept deworming medication for their children, problem. Although both of these statements can be because most of ©the Jones time worms & Bartlett were perceivedLearning, as LLCcorrect, there are several© Jonesother explanations & Bartlett for Learning, this LLC normal. If the healthNOT workers FOR triedSALE to tellOR the DISTRIBUTION mothers occurrence. One possibilityNOT is FOR that WesternSALE ORbiomed DISTRIBUTION- that their beliefs were wrong, the mothers would rea- ical science has not yet figured out how to measure a son that the health workers did not understand illness disease or disorder. Recent examples of this phenom- in a Guatemalan village and would reject their pro- enon include chronic fatigue syndrome and fibromy- posal.© Jones The &compromise Bartlett Learning,was to suggest LLC that the chil- algia: These© Jones conditions & Bartlett were labeled Learning, “psychosomatic” 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 SALE OR DISTRIBUTION to avoid the problem of agitated worms. It worked.* by biomedicine, but 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 © Jones & Bartlettis, disease Learning, is an undesirable LLC deviation from a measur© Jones- elevated & Bartlett prostaglandin Learning, levels LLC and can be helped by NOT FOR SALEable norm. OR DISTRIBUTION Deviations in temperature, white blood NOTcell FORadministration SALE OR of DISTRIBUTION a prostaglandin inhibitor. count, red blood cell count, bone density, and many oth- A more intriguing set of conditions are what ers are, therefore, seen as indicators of disease. Illness, in anthropologists have called “culture-bound syn- contrast, means “not feeling well.” Thus, it is a subjective, dromes” (Hughes, 1990; Simons, 2001; Simons & insider view. This© sets Jones up some & Bartlettimmediate Learning, dissonances LLCHughes, 1985), but that© might Jones be better& Bartlett described Learning, as LLC between the two views. It is possible to have an unde- “culturally defined syndromes.” Culturally defined syn- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION sirable deviation from a Western biomedical norm and dromes are an insider way of describing and attribut- to 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 physio- stages of diabetes are all instances where people may feel logical disease may also exist, posing a challenge to well,© Jones yet have & a Bartlettdisease. Thus, Learning, healthcare LLC providers must the health© Jones practitioner. & Bartlett For example, Learning, Rubel, LLC O’Nell, communicateNOT FOR SALEthe need OR for behaviorsDISTRIBUTION to “fix” something and Collado-ArdonNOT FOR SALE (1984) OR found DISTRIBUTION that an illness that people may not realize is wrong. called susto (“fright”) in Mexico corresponded with This potential conflict becomes even more criti- symptoms 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 & BartlettLaboratory Learning, tests can reveal LLC the potential risk of future© Jones treatment & Bartlett on the Learning, grounds that LLC the doctors obviously NOT FOR SALEdisease—for OR DISTRIBUTION example, elevated low-density lipoproNOT- FORknew SALE nothing OR about DISTRIBUTION susto. This situation was com- tein 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 dis- the symptoms with people and mention that West- ease, the patient ©might Jones be labeled & Bartlett as “high Learning, risk” and LLCern biomedicine has a treatment© Jones for & thoseBartlett symptoms Learning, LLC prescribed medicationNOT FORto take SALE daily forOR years. DISTRIBUTION Even (Rubel et al., 1984). SustoNOT may FORalso be SALE used to OR describe DISTRIBUTION among those persons with substantial education, it other sets of symptoms—for example, those of diar- is 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), well-educated© Jones & Bartlettparents represents Learning, another LLC example of zar (the© Middle Jones East & Bartlettand North Learning, Africa), brain LLC fag or theNOT power FOR of SALEinsider (ORemic DISTRIBUTION) understandings. The fail- brain fogNOT (West FOR Africa), SALE amok OR DISTRIBUTION(running amok) or ure of public health advocacy for vaccines to convince mata elap (Indonesia, Malaysia, and the Philippines), such parents of the outsider (etic) view of the safety latah (Malaysia and Indonesia), p’a leng (China), and and value of vaccines demonstrates the power of cul- ataque de nervios (Puerto Rico) (Guarnaccia et al., © Jones & Bartletttural beliefs Learning, even in the LLC face of scientific evidence.© Jones2010; & Bartlett Simons & Learning, Hughes, 1985). LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION * We are indebted to Elena Hurtado of Guatemala for this example.

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© Jones &A Bartlett recent example Learning, of what LLC appears to be a new © Jonesculture depend& Bartlett on its Learning, teaching its LLCchildren to accept culture-bound syndrome has emerged among refugee the culture and on its members feeling that it is a good NOT FOR SALE OR DISTRIBUTION NOT FORchildren SALE in SwedenOR DISTRIBUTION whose families faced deportation thing. In 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.© Jones The children& Bartlett exhibit Learning, no to LLC how we view the world is cultural© Jones relativism & Bartlett, which Learning, LLC neurologic pathology inNOT clinical FOR tests, SALE yet they OR must DISTRIBUTION be refers to the idea that the beliefs,NOT behaviors, FOR SALE and values 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© sameJones beliefs & Bartlett and behaviors. Learning, With culturallyLLC how to obtain© the Jones essentials & Bartlett of life, such Learning, as food and LLC defined syndromes, it is essential for an outsider to ask shelter; how to explain phenomena; and so on. Cul- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION about the symptoms associated with the illness and to tural relativism has been misunderstood in contem- proceed 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. © Jonescause & Bartlett of a disease Learning, or illness andLLC its symptoms. Even if © JonesFor example, & Bartlett in parts Learning, of Africa and LLC the Middle East, NOT FORthe SALEperceived OR cause DISTRIBUTION is inconsistent with the Western NOTfemale FOR infants SALE or youngOR DISTRIBUTION girls may have their genitals 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 activ- people’s beliefs about the cause. When people’s beliefs ists seeking to end the practice. Lane and Rubinstein about the cause are denied,© Jones they may & rejectBartlett prevention Learning, (1996), LLC in their analysis of the ©practice, Jones advocated & Bartlett that Learning, LLC or treatment measures entirely (Nichter, 2008). cultural relativism means that we should try to under- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The term Western biomedicine is used through- stand the cultural explanations driving the 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 sys- they 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© Jones forms. & IndigenousBartlett Learning,medical system LLC is used practice. Indeed,© Jones familiarity & Bartlett with the cultural Learning, rationale LLC to referNOT to an FOR insider—“within SALE OR theDISTRIBUTION culture”—system. of a potentiallyNOT harmful FOR practice SALE canOR beDISTRIBUTION the basis of 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 cul- and 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 Europe. Learning, In most of LLC the world, Western bio- © Jonesfrom an & epidemiologic Bartlett Learning, perspective? LLC How does one NOT FORmedicine SALE now OR coexistsDISTRIBUTION with, and often dominates, NOTdistinguish FOR SALE between OR aDISTRIBUTION “dangerous” behavior (e.g., local or indigenous systems. Because of this multi- using 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 heal- accept or even be aware© of Jones the extent & Bartlettto which indigLearning,- ing LLC ritual) and behaviors that are© Jonesmerely different & Bartlett and, Learning, LLC enous systems exist orNOT recognize FOR theirSALE importance OR DISTRIBUTION therefore, seem odd? For example,NOT BolivianFOR SALE peasants 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 is to work© Jones in multiple & Bartlett countries Learning, or cultures. LLC bad thing. The© Joneshealth workers& Bartlett then foundLearning, themselves LLC NOT FOR SALE OR DISTRIBUTION faced with increasedNOT FOR caries SALE and other OR symptoms DISTRIBUTION 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 © Jonesthat & Bartlettof ethnocentrism. Learning, Ethnocentric LLC refers to seeing © Jonesuses clay—but & Bartlett we color Learning, it pink or giveLLC it a mint flavor NOT FORyour SALE own culture OR DISTRIBUTION as “best.” Ethnocentrism is a natural NOTand FOR put it SALEin a bottle OR with DISTRIBUTION a fancy label (S. Scrimshaw, tendency, because the survival and perpetuation of a personal observation).

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© Jones & BartlettThus, Learning, there is a LLCdelicate balance between being© Jones cooked, & Bartlett but women, Learning, who did LLC the cooking, and chil- judgmental without good reason and seeking to intro- dren, who were around during cooking, were more NOT FOR SALE OR DISTRIBUTION NOT FOR SALEduce behaviorOR DISTRIBUTION change because there is real harm from likely to eat it when it was partially cooked and, there- existing behaviors. In general, it is best to leave harm- fore, still infectious. Lindenbaum and Glasse sug- less practices alone and focus on understanding and gested the disease was transmitted by cannibalism. To changing harmful behaviors. This task is more diffi- confirm their hypothesis, Gadjusek’s team inoculated cult than it might© seem, Jones because & Bartlett the concept Learning, of cul- LLCchimpanzees with brain© materialJones &from Bartlett women Learning, who LLC tural relativism alsoNOT applies FOR to SALE perceptions OR DISTRIBUTION of quality had died of kuru; the NOTanimals FOR subsequently SALE OR devel DISTRIBUTION- of life. A culture in which people believe in reincarna- oped 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© Jones briefly. & In Bartlett some cultures, Learning, loss of LLCa body organ is through© the Jones ingestion & Bartlett of brain tissue.Learning, Since then,LLC the 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 FOR SALE OR DISTRIBUTION the next life, and such surgery may be refused. Thus, has now virtually disappeared (Gadjusek, 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 © Jones & Bartlett Learning, LLC © Jonesfed & neurologic Bartlett Learning,tissue of deceased LLC cattle, called “mad NOT FOR SALE OR DISTRIBUTION NOT FORcow SALE disease” OR or DISTRIBUTION variant Creutzfeldt-Jakob disease 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© anthropologistsJones & Bartlett that looksLearning, at the LLC © Jones & Bartlett Learning, LLC broad context of whatever phenomenon is being In recent years, increasing attention has focused on NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION studied. Holism involves staying alert for unexpected another area that intersects with culture in people’s influences, because you never know what may have a ability to understand and access health care—the bearing on the program you are trying to implement. concept of health literacy. Health literacy is defined as For public health, this consideration is crucial because “the degree to which individuals have the capacity to diverse© Jones factors & mayBartlett influence Learning, health and LLC health behav- obtain, ©process, Jones and & understand Bartlett Learning, basic health LLCinforma- iorNOT (Nichter, FOR 2008). SALE OR DISTRIBUTION tion andNOT services FOR needed SALE to ORmake DISTRIBUTION appropriate health A classic example of this situation is the detective decisions” (Ratzan & Parker, 2000). Health literacy has work that went into discovering the etiology of the been most thoroughly explored in the United States, New Guinea degenerative nerve disease, kuru. Epide- and until recently was seen more as a literacy issue miologists could not figure out how people contracted than a cultural issue. A 2004 Institute of Medicine © Jones & Bartlettthe disease, Learning, which appeared LLC to have a long incuba© Jones- report & Bartlett notes the Learning, importance LLC of considering cultural NOT FOR SALEtion periodOR DISTRIBUTION and to occur more frequently in womenNOT FORissues SALE such asOR many DISTRIBUTION of those discussed in this chapter, and children than in men. Many hypotheses were and of taking a more global look at the problem and advanced, including inheritance (genetic), infection needed interventions (Nielsen-Bohlman, Panzer, & (bacterial, parasitic), and psychosomatic explanations. Kindig, 2004). Many National Academy of Medicine By the early ©1960s, Jones the most& Bartlett widely Learning,accepted of LLC(NAM) reports have followed,© Jones along & Bartlett with an NAMLearning, LLC the prevailing hypothesesNOT FOR was SALE that kuru OR wasDISTRIBUTION genet- Roundtable and discussionNOT papers FOR on SALE the topic OR (e.g., DISTRIBUTION ically transmitted. Nevertheless, this proposal did Allen, Auld, Logan, Montes, & Rosen, 2017). not explain the sex differences in infection rates in In looking at culture and health literacy, several adults but not in children, nor how such a lethal gene categories for misunderstandings between provider could persist. Working with Gadjusek of the National and patient emerge. Institutes© Jones of & Health Bartlett (NIH), Learning, cultural anthropologistsLLC First,© Jonesthere is a& difference Bartlett betweenLearning, medical LLC termi- GlasseNOT FORand Lindenbaum SALE OR used DISTRIBUTION in-depth ethnographic nologyNOT and lay FOR terminology, SALE OR which DISTRIBUTION can occur in any interviews to establish that kuru was relatively new to language or culture. What is “diastolic” or a “broncho- that region of New Guinea, as was the practice of can- dilator”? What are HDL and LDL? What are T cells? nibalism. Women and children were more likely to Second, individual and cultural differences sur- © Jones & Bartlettengage in Learning, the ritual consumption LLC of the brains of dead© Jones round & Bartlett concepts. Learning, What does LLC it mean to maintain a NOT FOR SALErelatives OR as DISTRIBUTION a way of paying tribute to them, which NOTwas FOR“moderate” SALE ORweight? DISTRIBUTION To an anxious teen who wants culturally less acceptable for men. Also, this tissue was to become a model, moderate weight might mean

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© Jonessomething & Bartlett clinically Learning, dangerously LLC low (from the © JonesU.S. federal & Bartlett government’s Learning, elaboration LLC of the Cultural outsider, health practitioner perspective). To some and Linguistically Appropriate Services (CLAS) guide- NOT FOR SALE OR DISTRIBUTION NOT FORwomen SALE from OR Latin DISTRIBUTION America or the Middle East, mod- lines to improve the 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 Jones differ. & WhileBartlett working Learning, with in-service LLC training was insufficient© Jones to make & Bartlettparticipants Learning, LLC prenatal care programsNOT in Mexico, FOR Scrimshaw’sSALE OR teamDISTRIBUTION truly competent in cultural issues.NOT From FOR this SALE critique, 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 under- identify symptoms that meant that they should seek standing and appreciation of health beliefs and behav- care. It ©turned Jones out &that Bartlett the direct Learning, translation LLC of “risk” iors in their cultural© Jones contexts & Bartlett and respectful Learning, strategies LLC to into Spanish, or riesgo, did not carry the same mean- negotiate optimal health in the context of these beliefs NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ing. When they explained the concept to women, and behaviors (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 © Jones & Finally,Bartlett language Learning, issues mayLLC affect understanding. © Jonesmay be seen& Bartlett as normal Learning, and may not LLC be defined as ill- NOT FORWhile SALE researchers OR DISTRIBUTION were investigating seizure disorders in NOTness. FOR Ascaris SALE infection OR DISTRIBUTIONin young children was previ- 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.© TheJones exact & same Bartlett word trauma Learning, had LLC it. In Egypt, where schistosomiasis© Jones was & Bartlett common Learning, LLC is used in Spanish, with the same two potential mean- and affected the blood vessels around the bladder, blood NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ings. When neurologists talked with patients who had in the urine was referred to as “male menstruation” and epilepsy and their parents from Latino cultures, the neu- was 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© Jones meaning & Bartlett and thought Learning, their child LLC had been same symptoms© Jones in adults. & MenBartlett may Learning,deny symptoms LLC traumatizedNOT psychologicallyFOR SALE ORby some DISTRIBUTION fright or shock more than womenNOT inFOR some SALE cultures, OR but DISTRIBUTION women may (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 & note Bartlett that health Learning, literacy is LLC as much a problem of the © Jones“agree” to & be Bartlett considered Learning, ill and to take LLC actions (or allow NOT FORhealthcare SALE provider OR DISTRIBUTION and health communication staff as NOTothers FOR to takeSALE actions) OR DISTRIBUTIONto define the state of his or her it is of a patient or the people in a community. If med- health, 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© as Jones “oncology,” & Bartlett “nephrology,” Learning, behaviors, LLC and seek treatment ©to Jonesget well. &By Bartlett adopting Learning, LLC and “gastroenterology” NOThave meaning FOR SALE for the OR medical DISTRIBUTION the sick role, they are viewed asNOT having FOR “permission” SALE OR to DISTRIBUTION world, but not for patients. Healthcare providers out- be exempted from usual obligations, but they are also side the United States often have a better understand- under an obligation to try to restore health. The pro- ing 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 © Jones & Bartlett Learning, LLC CulturalNOT Competence FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION A concept related to health literacy is that of cultural Belief Systems competence. Cultural competence in health care describes EXHIBIT 2-1 depicts types of insider cultural explanations “the ability of systems to provide care to patients with of disease causation. Based on the literature, it attempts diverse values, beliefs and behaviors, including tailoring to be as comprehensive as possible for cultures around © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC delivery to meet patients’ social, cultural, and linguistic the world. The exhibit consists of generalizations about NOT FORneeds” SALE (Betancourt, OR DISTRIBUTION Green, & Carrillo, 2002). The con- NOTculture-specific FOR SALE healthOR DISTRIBUTION beliefs and behaviors; these cept of cultural competence emerged, in part, from the generalizations cannot, however, be assumed to apply

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© Jones & BartlettEXHIBIT Learning, 2-1 Types ofLLC Insider Cultural Explanations ©of DiseaseJones Causation & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Body Balances Supernatural ■■ Temperature: Hot, cold ■■ Bewitching ■■ Energy ■■ Demons ■■ Blood: Loss of© blood; Jones properties & Bartlett of blood Learning, reflect LLC■■ Spirit possession © Jones & Bartlett Learning, LLC imbalance; pollutionNOT FOR from menstrual SALE ORblood DISTRIBUTION■■ Evil eye NOT FOR SALE OR DISTRIBUTION ■■ Dislocation: Fallen fontanel ■■ Offending God or gods ■■ Organs: Swollen stomach; heart; uterus; liver; ■■ Soul loss umbilicus; others ■■ Incompatibility of horoscopes Food © Jones & Bartlett Learning, LLC ■■ Properties:© Jones Hot, cold, & Bartlett heavy (rich), Learning, light LLC NOTEmotional FOR SALE OR DISTRIBUTION ■■ SpoiledNOT foods FOR SALE OR DISTRIBUTION ■■ Fright ■■ Dirty foods ■■ Sorrow ■■ Sweets ■■ Envy ■■ Raw foods ■■ Stress ■■ Combining the “wrong” foods © Jones & Bartlett Learning, LLC © Jones &(incompatible Bartlett Learning, foods) LLC NOT FOR SALEWeather OR DISTRIBUTION NOT FOR■■ Mud/claySALE OR DISTRIBUTION ■■ Winds ■■ Change of weather Sexual ■■ Seasonal disbalance ■■ Sex with forbidden person © Jones & Bartlett Learning, LLC■■ Overindulgence in sex© Jones & Bartlett Learning, LLC Vectors or OrganismsNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ■■ Worms Heredity ■■ Flies Old Age ■■ Parasites ■■ Germs © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION 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 per- © Jones & Bartlettbut the details Learning, of the system LLC will vary from country© to Jones vasive & Bartlett around theLearning, world. The LLC hot/cold balance is par- NOT FOR SALEcountry, OR from DISTRIBUTION village to village, and from individualNOT FORticularly SALE important OR DISTRIBUTION in Asian, Latin American, and 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 indi- of 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, LLC © Jones & Bartlett Learning, LLC takes. This makes the task of the culturally proficient 1972; Weller, 1983). The concept of opposites (e.g., hot healthcare providerNOT both FOR easier SALE and harder. OR DISTRIBUTIONIt means a and cold, wet and dry) alsoNOT may FOR have SALE developed OR inde DISTRIBUTION- 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© Jones that the& Bartletthot/cold beliefLearning, system LLCis important in In ©the Jones hot and & cold Bartlett belief system,Learning, a healthy LLC body MexicanNOT FOR culture SALE and beOR able DISTRIBUTION to be understanding and is seen NOTas in balance FOR SALEbetween OR the DISTRIBUTIONtwo extremes. Illness 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), eat- here. These categories are used for diagnosis and treat- ing hot or heavy foods at night, or breastfeeding while © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ment and for explaining the etiology or origin of the upset (the milk will be hot from the emotions and NOT FOR SALEillness. OR Often, DISTRIBUTION multiple categories are used. For examNOT- FORmake SALE the baby OR ill). DISTRIBUTION “Hot” does not always refer to tem- ple, emotions may be seen as causing a “hot” illness. perature, however. Often foods such as beef and pork

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© Jonesare & classified Bartlett as Learning, hot regardless LLC of temperature, whereas © Jonesin this spot & Bartlettcan be indicative Learning, of dehydration, LLC often due fish may be seen as cold regardless of temperature. to diarrheal disease. From the insider perspective, it is NOT FOR SALE OR DISTRIBUTION NOT FOR SALEWhen illnessOR DISTRIBUTION has been diagnosed, the system is referred to as a cause of the disease (caida de mollera) used to attempt to restore balance. Thus, in Central in Mexico and Central America. America, some diarrheas in children are viewed as hot, Many cultures associate illness with problems in and protein-rich “hot” foods such as meats are with- specific organs. Good and Good (1981) talk about the held, aggravating the malnutrition© Jones & that Bartlett may be Learning, pres- importance LLC of the heart for both© Jones Chinese & and Bartlett Iranian Learning, LLC ent and may be exacerbatedNOT byFOR the SALEdiarrheal OR disease DISTRIBUTION cultures. They discuss a case NOTin which FOR problems SALE ORwith DISTRIBUTION (Scrimshaw & Hurtado, 1988). An extensive literature cardiac medication were wrongly diagnosed for a Chi- exists on the topic of hot and cold illness classifica- nese woman who kept complaining about pain in her tions and treatments for them advocated by many of heart. In fact, she was referring to her grief over the the world’s© Jones cultures. & Bartlett Learning, LLC loss of her son.© TheJones Hmong & Bartlett people of Learning, Laos link many LLC Energy balance is particularly important in problems to the liver, referring to “ugly liver,” “diffi- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Chinese medicine, where it is referred to as chi. When cult liver,” “broken liver,” “short liver,” “murmuring this balance is disturbed, it creates internal problems liver,” and “rotten liver.” These terms are said to refer to of homeostasis. Foods (often following the hot/cold mental and emotional problems, and so are idiomatic theories) and acupuncture are among the strategies rather than literal (O ‘Connor, 1995, p. 92; Thao, 1986). © Jonesused & Bartlett to restore Learning,balance (Topley, LLC 1976). © JonesTopley & Bartlett(1976) mentions Learning, incompatibility LLC of horo- NOT FOR SALEBlood beliefs OR DISTRIBUTION include the concept that blood is irre- NOTscopes FOR between SALE mother OR DISTRIBUTION and child in Chinese explana- placeable; thus loss of blood—even small amounts—is tions for some children’s illnesses. 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 © Jones & Bartlett Learning,Illnesses LLC of emotional origin ©are Jones important & Bartlett in many Learning, LLC obtain blood samples until the phlebotomists were NOT FOR SALE OR DISTRIBUTIONcultures. Sorrow (as in the caseNOT of the FOR Chinese SALE woman 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 medi- girl’s smallpox infection was attributed to her sorrow cines if© it Joneswere sick, & which Bartlett in fact Learning, did occur. LLC © Jones & Bartlett Learning, LLC over the death of her father. MenstrualNOT FOR blood SALE is regarded OR DISTRIBUTION as dangerous, espe- NOT FOR SALE OR DISTRIBUTION Envy can cause illness because people with envy cially to men, in many cultures, and elaborate precau- could 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 LLCseen as causing scabies in © Jones & Bartlett Learning, LLC Latin America, has already been mentioned. In NOT FORSouth SALE India OR(Beals, DISTRIBUTION 1976, p. 189). Haitians have a partic- NOT FOR SALE OR DISTRIBUTION addition to the case of tuberculosis in adults dis- ularly elaborate blood belief system, which includes con- cussed previously, susto is a common explanation cepts such as mauvais sang (literally, “bad blood,” when for illness in children. It is also mentioned in Chi- blood rises in the body and is dirty), saisissement (rapid nese culture (Topley, 1976). heartbeat and cool blood,© due Jones to trauma), & Bartlett and faiblesses Learning, LLC © Jones & Bartlett Learning, LLC (too little blood). BloodNOT qualities FOR may SALE also be OR seen DISTRIBUTION as NOT FOR SALE OR DISTRIBUTION “opposites,” such as clean–unclean, sweet–normal, Weather bitter–normal, high–normal, heavy–weak, clotted–thin, Everything from the change of seasons to unusual and quiet–turbulent (C. Scott, personal communica- variations 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, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC be used in a current program to prevent HIV infection such as the Santa Ana in California or the Scirocco in a HaitianNOT community, FOR SALE because OR theDISTRIBUTION culture already has in the NorthNOT African FOR desert, SALE are ORalso DISTRIBUTION 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 © Jones“soft & Bartlett spot” in aLearning, baby’s head LLCwhere the bones have not © Jonesexample, & in Bartlett many areas Learning, people have LLC a greater chance NOT FORyet SALEcome together OR DISTRIBUTION in the first year or so to allow for NOTof contractingFOR SALE malaria, OR DISTRIBUTION cholera, and gastrointestinal growth. From the outsider perspective, a depression infections during the rainy season.

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© Jones & BartlettVectors Learning, or Organisms LLC © Jones &Spirit Bartlett possession Learning, is also LLC a worldwide belief, and one that is found especially frequently in African and NOT FOR SALEVectors OR or DISTRIBUTIONorganisms are blamed for illness in someNOT FOR SALE OR DISTRIBUTION cultures and represent a blend of Western biomed- Asian cultures. One of the best-known accounts of this ical and indigenous concepts. “Germs” is a catch-all phenomenon is A Spirit Catches You and You Fall Down category, as is “parasites.” Worms are seen as causing (Fadiman, 1997), a moving story of seizure disorders in a Hmong community and the misunderstandings diarrhea, whereas© flies Jones are seen & Bartlett as causing Learning, illness and, LLC © Jones & Bartlett Learning, LLC sometimes, as carrying germs. between the family and physicians. In another exam- NOT FOR SALE OR DISTRIBUTIONple, from South India, NOTBeals FOR(1976) SALE mentions OR spirit DISTRIBUTION possession in a daughter-in-law whose symptoms The Supernatural included refusing to work and speaking insultingly The supernatural is another frequently viewed source to her mother-in-law. He suggests that spirit posses- of© illness,Jones especially & Bartlett in Africa Learning, and Asia, LLC though this sion is a© “culturally Jones & sanctioned Bartlett means Learning, of psychological LLC release for oppressed daughters-in-law” (p. 188). Freed beliefNOT system FOR isSALE certainly OR not DISTRIBUTION confined to those regions. NOT FOR SALE OR DISTRIBUTION In fact, the evil eye is a widespread concept—someone and Freed (1967) discuss similar cases in other regions deliberately or unwittingly brings on illness by look- of India. In Tanzania, malaria in children is sometimes ing at someone with envy, malice, or too hot a gaze. blamed on possession by a bird spirit (Kamat, 2008). In cultures where most people have dark eyes, strang- In Haiti, spirit possession is seen as a mark of favor by © Jones & Bartletters with lightLearning, eyes may LLC be seen as dangerous. In Latin© Jones the & spirits Bartlett and isLearning, actively sought LLC out. One of the draw- NOT FOR SALEAmerica, OR aDISTRIBUTION light-eyed person who admires a child NOTcan FORbacks, SALE however, OR isDISTRIBUTION that the possessing spirits object to risk bringing evil eye to that child, but can counter the presence of foreign objects in the body; as a conse- it by touching the child. In other cultures, touching quence, some women do not want to use intrauterine the child can be unlucky, so it is important to learn devices as a means of birth control. about local customs.© Jones Frequently, & Bartlett amulets Learning, and other LLC Demons are viewed© as Jones causing & illness Bartlett in Chinese Learning, LLC culture, while offending God or gods is a problem in protective devices,NOT such FORas small SALE eyes of OR glass, DISTRIBUTION red hats, NOT FOR SALE OR DISTRIBUTION and a red string around the wrist, are worn to prevent other cultures (Topley, 1976). In South India, epidemic evil eye. These objects can be viewed as an opportu- diseases such as chickenpox and cholera (and, formerly, nity to discuss preventive health measures, because smallpox) are believed to be caused by disease goddesses. they are an indication that people are thinking about These goddesses bring the diseases to punish communi- prevention.© Jones & Bartlett Learning, LLC ties that© become Jones sinful & Bartlett (Beals, 1976, Learning, p. 187). The LLC concept NOTBewitching FOR SALE is deliberate OR DISTRIBUTION malice, done either by the of punishmentNOT FOR from SALE God is ORseen DISTRIBUTIONin a case study from individual who wishes someone ill (literally) or by a Mexico, where onchocerciasis (river blindness), which practitioner at someone else’s request. Bewitching can is caused by a parasite transmitted by the bite of a fly be countered by another practitioner or by specific that lives near streams, is often thought to be due to sins measures taken by an individual. In some regions of committed either by the victim or by relatives of the vic- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Africa, epidemics are blamed on “too many witches,” tim. These transgressions against God are punished by NOT FOR SALEand people OR DISTRIBUTION disperse to get away from them, therebyNOT FORGod SALE closing ORthe victim’s DISTRIBUTION eyes (Gwaltney, 1970). 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© beJones caused & by Bartlett sources such Learning, as fright, LLC © Jones & Bartlett Learning, LLC cause illness through its role in the hot and cold belief bewitching, evil eye, and demons. It can occur in adults NOT FOR SALE OR DISTRIBUTIONsystem; through spoiledNOT foods, FOR dirty SALE foods, OR or DISTRIBUTIONraw 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 chil- In 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 © Jones & Bartlett Learning, LLC also cause© Jones problems & ifBartlett eaten at theLearning, wrong time LLC of day, thwarted when the family would not allow him to enter such as “heavy” foods at night. An extensive literature theNOT house. FOR The SALE family ORlater DISTRIBUTIONreported that an indigenous NOT FOR SALE OR DISTRIBUTION 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 © Jones & Bartlettto the priest Learning, would have LLC allowed the soul to escape.© In Jones Sexual & Bartlett Illnesses Learning, LLC NOT FOR SALEthe Western OR DISTRIBUTION biomedical system, this child’s symptomsNOT FORIn EcuadorSALE OR in theDISTRIBUTION early 1970s, children’s illnesses would have been attributed to severe malnutrition. were sometimes blamed on affairs between one of the

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© Joneschild’s & Bartlett parents andLearning, a compadre LLC or comadre—one of the © Jonestaken to & the Bartlett clinic only Learning, for the worst LLC form of diar- child’s godparents (Scrimshaw, 1974). Such a relation- rhea, dysentery. Instead, the most common treatment NOT FOR SALE OR DISTRIBUTION NOT FORship SALE was viewed OR DISTRIBUTIONas incestuous and dangerous to the 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, storekeep- to 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© of Jones blood are& Bartlettneeded to Learning,make at LLC clinics, so that all diarrheas© were Jones more & likely Bartlett to be Learning, LLC one drop of semen, so bloodNOT loss FOR weakens SALE a man.OR DISTRIBUTIONtreated (Scrimshaw & Hurtado,NOT 1988). FOR SALE OR DISTRIBUTION In a related situation, Kendall, Foote, and Martorell Heredity and Old Age (1983) found that, when the government of Honduras did not include indigenous or “folk” terminology for Heredity is sometimes blamed for illness, early death, diarrheal disease in its mass-media messages regard- or some© types Jones of death. & Bartlett Similarly, Learning, old age may LLC be the © Jones & Bartlett Learning, LLC ing oral rehydration, people did not use ORS for diar- simple NOTexplanation FOR givenSALE for OR illness DISTRIBUTION or death. Heredity NOT FOR SALE OR DISTRIBUTION rheas attributed to indigenously defined 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 © JonesEXHIBIT 2-&2 Bartlettlists types Learning, of healers, LLCwhich range from NOT FORIllness SALE in ORVarious DISTRIBUTION Forms NOTindigenous FOR SALE practitioners OR DISTRIBUTION to Western biomedical pro- 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© mayJones be seen & Bartlett as having differLearning,- traditions LLC in their practices. © Jones & Bartlett Learning, LLC ent forms, or manifestations, with different etiologies. It As with explanations of disease, the types of heal- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION is also typical of the way in which several different expla- ers listed in Exhibit 2-2 are found in different combi- nations 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 Jones American & Bartlett diarrheal Learning, disease LLCprogram. study of health-seeking© Jones & behavior Bartlett described Learning, earlier LLC The programNOT FOR had intended SALE ORto emphasize DISTRIBUTION the distribu- found that in NOTall communities, FOR SALE people OR used DISTRIBUTION more than 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 &TABLE Bartlett 2-1 TaxonomyLearning, of Diarrhea LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION SYMPTOMS All types have watery CAUSE and frequent stools TREATMENT © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Physical activity Not breastfeeding when NOT FOR SALE OR DISTRIBUTION hotNOT FOR SALE OR DISTRIBUTION

Hot Hot foods Mother changes diet

© Jones & BartlettPregnancy Learning, LLC © Jones & BreastfeedingBartlett Learning, stops LLC Mother’s milk NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Anger Very dangerous Home, drugstore, injectionist, witch, Sadness Emotional spiritualist © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Fright NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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Does not eat on Food © Jones & Bartlett Learning,time LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Hot Quality

Cold © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTTooth FOR SALE OR DISTRIBUTION ToothNOT eruption FOR SALENone OR DISTRIBUTION Eruption

Fallen fontanel, Fallen stomach Green with mucus Folk curer © Jones & Bartlettfallen stomachLearning, LLC © Jones &Sunken Bartlett fontanel; Learning, LLC NOT FOR SALE OR DISTRIBUTIONFallen fontanel NOT FORvomiting; SALE ORgreen DISTRIBUTION in color

Evil eye Fever Folk curer

Stomach © Jones & Bartlett Learning, LLC Worms © JonesDrugstore, & home, Bartlett folk curer Learning, LLC Worms NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Cold enters From feet White in color Folk curer Stomach © Jones & BartlettFrom Learning, head LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Dysentery Blood in stools, Home, drugstore, health “urgency;” color is red post or black © 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 SALELos Angeles: OR UCLA DISTRIBUTION Latin America Center, p. 26. Reprinted with permission of the RegentsNOT of the University FOR of California. SALE OR DISTRIBUTION

Drinks Baths Enemas “Mecánicas” © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Waters Purgatives Change Message Wrapping Application NOT FOR SALE OR DISTRIBUTION positionNOT FOR SALE OR DISTRIBUTION Herbs Herbs with Soda waters Home Pharmaceuticals Rags store-bought with store- remedies Poultices medication bought medication © Jones & BartlettFIGURE 2- 1Learning, Taxonomy of LLCtreatments for diarrhea. © 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 SALEReprinted with OR permission DISTRIBUTION of the Regents of the University of California. NOT FOR SALE OR DISTRIBUTION

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© Jones EXHIBIT& Bartlett 2-2 Learning,Types of Healers LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Indigenous Western Biomedical ■■ Midwives ■■ Pharmacists ■■ Doulas ■■ Nurse–midwives ■■ Shamans © Jones & Bartlett Learning,■ ■ LLCNurses © Jones & Bartlett Learning, LLC ■■ Curers NOT FOR SALE OR DISTRIBUTION■■ Nurse practitioners NOT FOR SALE OR DISTRIBUTION ■■ Spiritualists ■■ Physicians ■■ Witches ■■ Dentists ■■ Sorcerers ■■ Other health professionals ■■ Priests ■■ Diviners© Jones & Bartlett Learning, LLC Other Medical© Jones Systems & Bartlett Learning, LLC ■■ Herbalists NOT FOR SALE OR DISTRIBUTION ■■ Chinese medicalNOT system FOR SALE OR DISTRIBUTION ■■ Bonesetters •• Practitioners ■■ Massagers •• Chemists/herbalists •• Acupuncturists Pluralistic ■■ Ayurvedic practitioners © Jones ■&■ BartlettInjectionists Learning, LLC © Jones■■ Taoist &priests Bartlett Learning, LLC NOT FOR■ ■ SALEIndigenous OR healthDISTRIBUTION workers NOT FOR SALE OR DISTRIBUTION ■■ Western-trained birth attendants ■■ Traditional chemists/herbalists ■■ Storekeepers and vendors © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION illness and seeking a cure has been referred to as “pat- well, but they are not paid for illness treatment. The 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 practi- programs in those cultures. tioner ©to Jonesanother, &crossing Bartlett from Learning, one type to LLC another For the most© Jonespart, indigenous & Bartlett practitioners Learning, do “good,” LLC type of NOThealer, FOR and not SALE always OR starting DISTRIBUTION with the simplest meaning healing.NOT Some FOR can SALE do both OR good DISTRIBUTION and evil (e.g., 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 & Bartlettuse other typesLearning, of practitioners LLC and practices. © Jonesthen be countered& Bartlett by someoneLearning, who LLC does “good” magic. NOT FOR SALEIndigenous OR practitioners DISTRIBUTION are usually members of the NOTThe FOR power SALE of belief OR is DISTRIBUTION such that if individuals believe culture and follow traditional practices. Today, they often they have been bewitched, they may need a counterac- mix elements of Western biomedicine and other tradi- tive 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,© Jones omens, or& anBartlett illness, whichLearning, woman LLC believed that she had been© Jones maleada & (cursed) Bartlett by Learning, LLC usually can be cured onlyNOT by their FOR agreement SALE to ORbecome DISTRIBUTION a a woman who was jealous of her,NOT and thatFOR this SALE curse was 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 community-based© Jones &health Bartlett promoters. Learning, In some LLCinstances, confined only© Jones to bewitching. & Bartlett One Learning, anthropologist LLC they mustNOT conceal FOR their SALE role ORas traditional DISTRIBUTION healer from working withNOT a Haitian FOR population SALE OR discovered DISTRIBUTION 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 © Jones & SomeBartlett indigenous Learning, practitioners LLC charge for their © Jones(J. Halifax-Groff, & Bartlett personal Learning, communication, LLC 1976). NOT FORservices, SALE but OR many DISTRIBUTION do not, accepting gifts instead. In NOT FORIn some SALE cultures, OR DISTRIBUTIONhealers are seen as diagnosti- 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

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© Jones & Bartlettkinds of Learning,illness to other LLC practitioners. In Haiti, both© Jones difficult & Bartlett to access Learning, in remote LLC areas. As mentioned ear- midwives and voodoo priests refer some cases to lier, if an individual believes that an illness is due to a NOT FOR SALE OR DISTRIBUTION NOT FOR SALEthe Western OR DISTRIBUTION biomedical system. Healers who com- cause explained by the indigenous system and a West- bine healing practices or who combine the ability to ern biomedical practitioner denies that cause, the indi- do 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© inJones the setting & Bartlett of Hong Learning, Kong, not- LLC As noted, there are other© Jones medical & systems Bartlett with Learning, long LLC ing that Taoist priestNOT healers FOR are SALE particularly OR DISTRIBUTION respected traditions, systematic waysNOT of training FOR SALEpractitioners, OR DISTRIBUTION and 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 fail- and© Jones self-cultivation & Bartlett of the Learning, Buddhist monk.” LLC ing to ©recognize Jones how & Bartlett many practices Learning, and medicines LLC Pluralistic healers combine Western biomedical that Western biomedicine has “borrowed” from other NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and indigenous practices. Injectionists will give an systems (e.g., quinine, digitalis, many anesthetics, aspi- injection of antibiotics, vitamins, or other drugs pur- rin, and estrogen). Elements of these systems that were chased at pharmacies or stores. Sometimes these injec- derided in the past, such as acupuncture, have now tions are suggested by the pharmacist or storekeeper; found their way into Western biomedical practice and © Jones & Bartlettat other timesLearning, they are LLC self-prescribed. Because antibi© Jones- are & being Bartlett “legitimized” Learning, by Western LLC research (Baer, 2008). NOT FOR SALEotics provedOR DISTRIBUTION so dramatically effective in curing infecNOT- FOR SALE OR DISTRIBUTION tions when Western biomedicine was first introduced in many cultures, injections are often seen as convey- ▸▸ Theories of Health Behavior ing greater healing than the same substance taken and Behavior Change orally. Thus, many© antibioticsJones & nowBartlett available Learning, orally and LLC © Jones & Bartlett Learning, LLC vitamins are injected. In today’s environment, this NOT FOR SALE OR DISTRIBUTIONThe fields of sociology,NOT psychology, FOR SALE and anthropology OR DISTRIBUTION practice increases the risk of contracting HIV or hepa- have 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 store- Ockene, & Riekert, 2009). Some theories developed keepers and vendors (many communities are too small to by sociologists and psychologists in the United States have© Jones a pharmacy), & Bartlett often sellLearning, Western biomedicalLLC medi- were developed© Jones first & Bartlett for U.S. Learning,populations LLCand only cations,NOT FOR including SALE those OR that DISTRIBUTION require a prescription in the later appliedNOT FORinternationally. SALE OR Others DISTRIBUTION 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 phar- theories of health and illness beliefs and behavior are macies, which are very important—sometimes the most © Jones & Bartlett Learning, LLC © Jonescovered & Bartlett in this section;Learning, those LLC included here have been important—sources of diagnosis and treatment in many quite influential in general or are applicable for inter- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION communities around the world. national work in particular. For more than 50 years, countries around the world have enlisted and trained indigenous health practitioners to function as part of the national or regional Health Belief Model health system. These© Jones programs & Bartlett have rangedLearning, from LLC The health belief model© suggestsJones &that Bartlett decision Learning, mak- LLC China’s “barefoot doctors”NOT FOR to the SALE education OR ofDISTRIBUTION commu- ing about health behaviorsNOT is influencedFOR SALE by fourOR DISTRIBUTIONbasic nity members in Latin America, Africa, and Asia to pro- premises—perceived susceptibility to the illness, per- vide 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- are© Jonesnow involved & Bartlett as indigenous Learning, health outreach LLC workers demographic© Jones factors & Bartlett(Rosenstock, Learning, Strecher, &LLC Becker, toNOT their FOR communities SALE (2010, OR DISTRIBUTION [email protected]). 1974). NOTIn general, FOR peopleSALE are OR seen DISTRIBUTION as weighing per- In Nepal, indigenous health workers have been enlisted ceived susceptibility (how likely they are to get the dis- in programs to address diarrheal disease and acute respi- ease) and perceived severity (how serious the disease ratory infections (Ghimire, Pradhan, & Mahesh, 2010), is) against their belief in the benefits and effectiveness © Jones & Bartlettand female Learning, Ayurvedic LLCdoctors are important resources© Jones of &the Bartlett prevention Learning, behavior theyLLC must undertake and NOT FOR SALEfor women’s OR DISTRIBUTION health (Cameron, 2010). NOT FORthe SALEcosts of OR that DISTRIBUTION behavior in terms of barriers such Western biomedical practitioners are an import- as 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

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© Jonesthe & prevention,Bartlett Learning, the more likely LLC people are to incur © Jonesefficacy & of Bartlett the cure toLearning, be sought, theLLC cost (money, time, the costs of engaging in the prevention behavior. and so on) of the cure, and their own resources to seek NOT FOR SALE OR DISTRIBUTION NOT FOR SALEThe health OR beliefDISTRIBUTION model has been extensively stud- treatment and pay 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 con- may force adoption of a more costly option. Other cern has been that this© model Jones does & notBartlett work as Learning, well studies LLC of health-seeking behavior© Jones have found & Bartlett similar Learning, LLC for chronic problems orNOT habitual FOR behaviors SALE OR because DISTRIBUTION patterns throughout the worldNOT (e.g., Kamat,FOR SALE 2008). OR DISTRIBUTION 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 Jones the& Bartlett potential Learning,for blaming LLCthe indi- Ajzen and Fishbein© Jones (1972) & Bartlettto predict Learning, an individual’s LLC vidual. The difficulty in quantifying the model for NOT FOR SALE OR DISTRIBUTION intention to engageNOT FORin a behaviorSALE OR in aDISTRIBUTION specific time research and evaluation purposes is also a problem. and place. This theory was intended to explain vir- Work by Bandura led to the inclusion of self-efficacy tually all behaviors over which people have the abil- in the model. Self-efficacyhas been defined as “the con- ity to exert self-control. Five basic constructs precede viction that one can successfully execute the behavior the performance of a behavior: (1) behavioral intent, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC required to produce the desired outcome” (Bandura, (2) attitudes and beliefs, (3) evaluations of behavioral NOT FOR1977, SALE 1989). OR The DISTRIBUTION concept of locus of control, or belief NOToutcomes, FOR SALE (4) subjective OR DISTRIBUTION norms, and (5) normative in the ability to control one’s life, also has been incor- beliefs. Behavioral intent is seen as the immediate pre- porated 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 maxi- and Swedish females with© diabetes.Jones &The Bartlett study revealed Learning, mize LLC the predictive ability of an© intention Jones &to performBartlett a Learning, LLC a stronger locus of control in the Swedish women and NOT FOR SALE OR DISTRIBUTIONspecific behavior, the measurementNOT FORof the SALEintent mustOR DISTRIBUTION more passivity toward self-care in 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 sys- oral contraceptives must include questions about when tems in the two countries—collectivism in Yugosla- a woman plans to visit a clinic and which clinic she plans via versus© Jones individualism & Bartlett in Sweden Learning, (Hjelm, LLC Nyberg, to attend. The© failure Jones to &address Bartlett action, Learning, target, context, LLC Isacsson,NOT & Apelqvist, FOR SALE 1999). OR A moreDISTRIBUTION recent example, and time in theNOT measurement FOR SALE of behavioralOR DISTRIBUTION 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, measures of past behavior were found to © Jonesshared & Bartlett cultural Learning, model of self-management LLC enhanced © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOTbe FORthe best SALE predictors OR DISTRIBUTION of intentions and attenuated the women’s confidence in their own ability to care for 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 ©up Jones well under & Bartlett scrutiny. Learning, Per- LLC © Jones & Bartlett Learning, LLC ceived barriers have theNOT strongest FOR predictive SALE OR value DISTRIBUTION of The diffusion of health innovationsNOT FOR model SALE proposes OR DISTRIBUTION the four dimensions, followed by perceived suscepti- that communication is essential for social change, and bility and perceived benefits. Perceived susceptibility that diffusion is the process by which an innovation is most frequently associated with compliance with is communicated through certain channels over time health screening exams. Perceived severity of risk among members of a social system (Rogers, 1983; has been© Jonesnoted to & have Bartlett a weaker Learning, predictive LLCvalue for Rogers & Shoemaker,© Jones 1972). & Bartlett An innovation Learning, is an idea, LLC protectiveNOT health FOR behaviors, SALE OR but isDISTRIBUTION strongly associated practice, service,NOT or FOR other SALE object thatOR isDISTRIBUTION perceived as with sick-role behaviors. new by an individual or group. Ideally, the develop- In Medical Choice in a Mexican Village, Young ment of a diffusion strategy for a specific health behav- (1981) describes a health decision-making process ior change goal will proceed through six stages: © Jonesvery & Bartlettsimilar to thatLearning, found in theLLC health belief model. In © Jones & Bartlett Learning, LLC NOT FORchoosing SALE between OR DISTRIBUTION home remedies, pharmacy, or store, NOT FOR1. SALERecognition OR DISTRIBUTIONof a problem or need and between indigenous healer or doctor, the villagers 2. Conduct of basic and applied research to weigh the perceived severity of the illness, the potential address the specific problem

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© Jones & Bartlett3. Learning,Development LLC of strategies and materials© Jones wood & Bartlett and making Learning, a fire to LLC boil the water far out- that will put the innovative concept into a weighed any perceived benefits, so water boiling was NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR formDISTRIBUTION 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 4. Commercialization of the innovation, expenditure of much additional time, energy, or other which will involve production, marketing, resources. and distribution© Jones efforts & Bartlett Learning, LLC One of the overall ©messages Jones regarding& Bartlett commu Learning,- LLC 5. DiffusionNOT and FOR adoption SALE of theOR innovation DISTRIBUTIONnicating health educationNOT and FOR promotion SALE statedOR DISTRIBUTION by 6. Consequences associated with adoption of Rogers (1973) is that mass media and interpersonal the innovation communication channels should both be used. Imple- menting both methods is of particular importance in © JonesAccording & Bartlettto classic diffusion Learning, theory, LLC a population low- and© Jonesmiddle-income & Bartlett countries Learning, (LMICs), LLC espe- targeted by an intervention to promote acceptance of cially in rural communities. Rogers emphasizes that NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION an innovation includes six groups: Innovators, early mass media deliver information to a large population adopters, early majority, late majority, late adopt- and 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 popula- people to adopt new behaviors (thereby using the © Jones & Bartletttion are mediatedLearning, by LLCa number of factors, including© Jones knowledge & Bartlett function, Learning, the persuasion LLC function, and the NOT FOR SALErelative OR advantage, DISTRIBUTION compatibility, complexity, comNOT- FORinnovation-decision SALE OR DISTRIBUTION process). In Rogers’s work and municability, observability, trialability, cost-efficiency, other work cited by him, “family planning diffusion time, commitment, risk and uncertainty, reversibil- is almost entirely via interpersonal channels” (p. 263). ity, modifiability, and emergence (see the Innovation, Notably, Rogers presents five examples in different Technology and Design© Jones chapter & Bartlettfor more informationLearning, LLCcountries (including India,© Jones Taiwan, & and Bartlett Hong Kong), Learning, LLC on scaling up health innovations). wherein interpersonal channels were the primary NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Relative advantage refers to the extent to which a source for family planning information and were the health innovation is better (faster, cheaper, more ben- motivating factors to seeking services. eficial) than an existing behavior or practice. Antibiot- The limitations of using mass media to dissemi- ics, for example, were quickly accepted in most of the nate health messages include the following issues: world© Jones because & theyBartlett were dramaticallyLearning, fasterLLC and more © Jones & Bartlett Learning, LLC ■■ Limited exposure. In LMICs, smaller audiences effective than traditional practices. NOT FOR SALE OR DISTRIBUTION haveNOT access FOR to mass SALE media. OR Radio DISTRIBUTION continues to be Compatibility is the degree to which the innova- an 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 accept- levels are another barrier. © Jones & Bartlettable in theLearning, village in LLCIndia where Marshall worked© Jones & Bartlett Learning, LLC ■■ Message irrelevancy. The content of mass-media NOT FOR SALEbecause OR injections DISTRIBUTION 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 instrumen- The degree to which an innovation is easy to incor- tal 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 easier to use than tak- © Jones & Bartlett Learning, LLC services or the positive© Jones and negative & Bartlett consequences Learning, LLC ing an iodine pill, because consuming salt is already NOT FOR SALE OR DISTRIBUTION of adapting a particularNOT health FOR behavior). 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 try- In many LMICs, radio and TV stations are run by ing© Jonesout a new & behavior.Bartlett For Learning, example, itLLC is easier to try © Jones & Bartlett Learning, LLC a government monopoly and their content may be aNOT condom FOR than SALE to be ORfitted DISTRIBUTION for a diaphragm. Observ- NOT FOR SALE OR DISTRIBUTION considered 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). © Jones & BartlettA health Learning, innovation LLC is also more likely to© be Jones & Bartlett Learning, LLC NOT FOR SALEadopted OR if DISTRIBUTION it is seen as cost-efficient. A famousNOT case FOR SALEThe diffusion OR DISTRIBUTION of innovations model focuses solely study of water boiling in a Peruvian town demon- on the processes and determinants of adoption of a strated that the cost in time and energy of gathering new behavior and does not help to understand or

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© Jonesexplain & Bartlett the maintenance Learning, of LLC behavior change. Many © Jones“Stages & ofBartlett change” Learning, LLC health behaviors require permanent or long-term Transtheoretical model of behavior change NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION changes. Also, it is important to understand whether 1 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 demon- 5 2 strated to a population ©by Jonesunrolling & the Bartlett condom Learning, over LLCMaintenance 1 © JonesContemplatio & Bartlettn Learning, LLC a banana. Women whoNOT became FOR pregnant SALE while OR DISTRIBUTIONthey Ongoing practice NOT FORThinking SALE about OR DISTRIBUTION of new, healthier 5 2 changing reported using condoms had been faithfully putting behavior them on bananas. The rapid development of information 4 3 4 3 technology—in© Jones particular, & Bartlett the useLearning, of smartphones— LLC © Jones & Bartlett Learning, LLC is revolutionizing diffusion of information and com- Action Preparation NOT FOR SALE OR DISTRIBUTION AdoptingNOT new habits FOR SALEPlanning OR for DISTRIBUTION change munication. For example, a smartphone innovation among men who have sex with men (MSM) consists FIGURE 2-2 “Stages of change” transtheoretical model of of a computer app designed to facilitate finding sexual behavior change. partners of men infected with a sexually transmitted Reproduced from Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search of how people change: Applications to addictive behaviors. American Psychologist, 47, 1102–1104. © Jonesdisease. & Bartlett This Learning,app was used LLC by the Monroe County © Jones & Bartlett Learning, LLC Health Department in Rochester, New York, to map NOT FOR SALE OR DISTRIBUTION NOTbalance, FOR (3) SALE self-efficacy, OR DISTRIBUTION (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). © Jones & Bartlett Learning,and LLC maintain behavior change.© Jones & Bartlett Learning, LLC Wearable devices range from sensors embed- NOT FOR SALE OR DISTRIBUTIONThe transtheoretical modelNOT identifies FOR SALE five stagesOR 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, indi- quantifying sports exercise, studying people’s habits, viduals express an intention to take some action to and monitoring© Jones the & elderlyBartlett (Hagthi, Learning, Thurow, LLC & Stoll, © Jones & Bartlett Learning, LLC change a negative health behavior or adopt a positive 2017). Smartphone apps, in some cases, are motivat- NOT FOR SALE OR DISTRIBUTION one within theNOT next FOR 6 months. SALE The OR preparation DISTRIBUTION 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 read- than 6 months. In the fifth stage, known as mainte- © Jonesings, & Bartlettheart rates Learning, and other healthLLC data that they and © Jones & Bartlett Learning, LLC nance, a person will have sustained a change for at NOT FORtheir SALE providers OR canDISTRIBUTION 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 medi- communication, 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,for LLC change. © Jones & Bartlett Learning, LLC health monitoring. . . .” Globally, smartphones and NOT FOR SALE OR DISTRIBUTIONDecisional balance is an NOTassessment FOR of SALE the costs OR DISTRIBUTION 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, confi- Transtheoretical© Jones & Bartlett Model Learning, LLC dence exists that© Jones one can & engage Bartlett in the Learning, new behavior. LLC NOT FOR SALE OR DISTRIBUTION Second, the NOTtemptation FOR aspect SALE of OR self-efficacy DISTRIBUTION refers Theories around the concept of stages of change to factors that can tempt one to engage in unhealthy have been evolving since the early 1950s. Currently, behaviors across different settings. the most widely accepted stage change model is the The fourth construct of the transtheoretical transtheoretical model of behavior change devel- model deals with the process of change. It includes © Jonesoped & Bartlett by Prochaska, Learning, DiClemente, LLC and Norcross © Jones10 factors & thatBartlett can influence Learning, the LLCprogression of indi- NOT FOR(1992) SALE (FIGURE OR 2-DISTRIBUTION2). This model includes five core NOTviduals FOR from SALE the precontemplation OR DISTRIBUTION stage to the main- constructs: (1) stages of change, (2) decisional tenance stage.

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© Jones & BartlettThe Harm Learning, Reduction LLC Model © JonesAn & explanatory Bartlett Learning, model is seen LLC as dynamic, and can change based on individual experiences with health, Harm reduction is a concept that emerged fromNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION with health 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 © Jones & Bartlett Learning, LLCmeaning-centered approach.© Jones This & approach Bartlett involves Learning, LLC the vast majority. It drew on the ideas of the transthe- NOT FOR SALE OR DISTRIBUTIONmutual interpretations acrossNOT systemsFOR SALE of meaning. OR DISTRIBUTION The oretical model that changing health behavior involves interpretive goal is understanding the patient’s per- several 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 influ- the harm reduction model are that (1) relapse is not ences in interpretation, behavioral expression, sever- failure© Jones and (2)& Bartlettmaking even Learning, a small stepLLC in improv- © Jones & Bartlett Learning, LLC ity, and duration. As noted earlier, it is difficult to apply ingNOT health FOR behavior SALE often OR DISTRIBUTIONleads to additional positive NOT FOR SALE OR DISTRIBUTION “codes” to culture and symptoms due 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. © Jones & Bartlett Learning, LLC © Joneswas & traditionally Bartlett Learning, strongest among LLC Puerto Rican groups NOT FOR SALE OR DISTRIBUTION NOT FORin theSALE United OR States, DISTRIBUTION but this belief has now been Explanatory Models adopted by other cultures of Latin American origin as 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, © Jones & Bartlett Learning, LLCdifferent cultures, the focus© Jones with the &meaning-centered Bartlett Learning, LLC 1988). They differ from some of the theories described approach is on the meaning of symptoms. Themedical NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION earlier in this section in that they are designed for encounter must involve the interpretation of symp- 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© Jones such & Bartlett models focusLearning, on individual LLC interac- © Jones & Bartlett Learning, LLC tionsNOT between FOR SALE physician OR or DISTRIBUTIONother staff and patients, the A numberNOT of otherFOR theories SALE canOR be DISTRIBUTION useful in looking at concepts underlying them—such as Kleinman’s nego- culture and behavior. For example, the multi-attribute tiation model—have proved useful for research and utility theory predicts behavior directly from an indi- for behavioral interventions for larger populations. vidual’s evaluation of the consequences or outcomes

Primary Principles Actions ■■ Groups vary in the specificity of their medical Practitioners must: complaints. © Jones & Bartlett Learning, LLC■■ Elicit patients’ requests,© questions, Jones and & Bartlettother Learning, LLC ■■ Groups vary inNOT their styleFOR of medicalSALE complaining.OR DISTRIBUTIONcommunications. NOT FOR SALE OR DISTRIBUTION ■■ Groups vary in the nature of their anxiety about the ■■ Elicit and decode patients’ semantic networks. meaning of symptoms. ■■ Distinguish disease and illness and develop plans for ■■ Groups vary in their focus on organ systems. managing problems. ■■ Groups vary in their response to therapeutic ■■ Elicit explanatory models of patients and families, © Jonesstrategies. & HumanBartlett illness Learning, is fundamentally LLC semantic analyze© Jones conflict with& Bartlett biomedical Learning, models, and LLC NOTor FORmeaningful SALE (it may OR have DISTRIBUTION a biological base, but is a negotiateNOT alternatives. FOR SALE OR DISTRIBUTION human experience).

Corollary © Jones & Bartlett■■ Clinical Learning, practice is inherentlyLLC interpretive. © Jones & Bartlett Learning, LLC

NOT FOR SALEAdapted OR by permission DISTRIBUTION from Springer Nature: Springer Nature, The Meaning of Symptoms:NOT A Cultural FOR Hermeneutic SALE Model for ORClinical PracticeDISTRIBUTION by B. J. Good and M. J. D. Good, Copyright 1981.

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© Jonesassociated & Bartlett with Learning, both performing LLC and not performing © Jonesand religion & Bartlett was essential Learning, to programLLC strategies a given behavior. Some models, such as social learning (Rekart, 2002). In Belize, understanding adoles- NOT FOR SALE OR DISTRIBUTION NOT FORtheory, SALE have OR been DISTRIBUTION criticized by anthropologists who cents and making sure the program met their needs argue against the notion that people are like a “black in both cultural- and age-appropriate ways was key box” into which you can pour information and expect (Martiniuk, O’Connor, & King, 2003). In Nepal, the a specific behavior change. use of indigenous workers and attention to cultural © Jones & Bartlett Learning,practices LLC helped lower the incidence© Jones and & severityBartlett of Learning, LLC NOT FOR SALE OR DISTRIBUTIONdiarrheal and respiratory infectionsNOT FOR in the SALE districts OR DISTRIBUTION ▸▸ Common Features targeted for interventions (Ghimire et al., 2010). Eval- uation of programs addressing family planning and of Successful Health HIV prevention shows that behavior-change commu- © Jones & Bartlett Learning, LLC nication increases© Jones knowledge & Bartlett and interpersonal Learning, com LLC- Communication and Health munication among audience members and motivates NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Promotion Programs positive changes in behavior (Salem, Bernstein, Sulli- van, & Lande, 2008). When applied in practice, many of the principles dis- Another example of focusing on understand- cussed in this chapter can help increase the success ing and changing cultural values around unhealthy © Jonesof & health Bartlett communication Learning, and LLC health promotion pro- © Jonesbehaviors & isBartlett found in Learning, the area of LLCsmoking cessation. NOT FORgrams. SALE In particular, OR DISTRIBUTION understanding and incorporating NOTAbdullah FOR andSALE Husten OR (2004) DISTRIBUTION set forth a framework for people’s insider cultural values, beliefs, and behaviors; public health intervention in this area that addresses a community-based approach with strong community multiple levels of society. participation; recognition of gender issues (Zamen & The need for the involvement of communities is Underwood, 2003); peer© groupJones education, & Bartlett including Learning, also LLC clearly demonstrated in the© Jonesliterature, & asBartlett literally Learning, LLC use of community-based outreach workers; and mul- hundreds of references exist on this topic. A recent NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION tilevel intervention approaches have proved essential summary article outlines many of the broad princi- to program success. ples underlying this approach, including community The Agita Sao Paulo Program in Brazil provides analysis with community participation, action plans a case study in using local culture to design both the designed with community input, and community content© and Jones the delivery & Bartlett system Learning, for a program LLC to use involvement ©in Jones implementation & Bartlett (Nguyen-Truong, Learning, LLC physicalNOT activity FOR to SALEpromote OR health DISTRIBUTION (Matsudo et al., Tang, & Hsiao,NOT 2017). FOR Community SALE OR involvement DISTRIBUTION may 2002). Just the word agita (which means to move the take the form of ongoing oversight and evaluation as body—to “agitate” in the sense of “stirring,” but also to well as the more usual modes of using community out- change) is more culturally understood and internal- reach workers (e.g., Thevos, Quick, & Yanduli, 2000), ized than a literal translation of “exercise.” In addition working through community organizations, and get- © Jonesto & representing Bartlett Learning, careful work LLC on culturally acceptable © Jonesting individuals & Bartlett involved Learning, (Bhuyan, LLC 2004). A report NOT FORways SALE of delivering OR DISTRIBUTION the message, this project provides NOTfrom FOR a recent SALE project OR inDISTRIBUTION Bolivia documents the suc- multiple culturally valued ways to increase physical cess of involving community members in everything activity, and “tailors” these options to the age, gender, from mapping the villages to priority setting for the and lifestyles of community members. program (Perry, Shanklin, & Schroeder, 2003). The In a very different© project, Jones work& Bartlett in three Learning,town- former LLC head of the United Kingdom’s© Jones National & Bartlett Health Learning, LLC ships in South Africa focusedNOT FOR on identifying SALE OR where DISTRIBUTION Service, Nigel Crisp, argues stronglyNOT FORthat the SALE quest forOR DISTRIBUTION AIDS prevention would be most effective from the global health in the twenty-first century must involve culturally appropriate, insider perspective (Weir et al., a paradigm shift in which nations, communities, and 2003). Among other things, researchers learned that indigenous peoples around the world have a much ideal prevention intervention sites varied depending greater voice in the design and implementation of on whether© Jones the central & Bartlett business Learning, district or theLLC town- health services© (Crisp,Jones 2010). & Bartlett Learning, LLC ship wasNOT the mostFOR popular SALE locationOR DISTRIBUTION for initiating new Two projectsNOT in ChicagoFOR SALE demonstrate OR DISTRIBUTION the success of sexual encounters. The type of sex (commercial ver- the community outreach worker approach. In one case, sus casual) as well as the availability of condoms var- the project focuses on intravenous drug abusers, help- ied with the site. The age of people engaging in risky ing them to reduce their HIV/AIDS-related risk behav- © Jonesbehaviors & Bartlett and riskLearning, behaviors LLC by gender also varied by © Jonesiors and to& initiateBartlett drug Learning, abuse treatment LLC programs. This NOT FORsite. SALE Again, preventionOR DISTRIBUTION programs needed to be tailored. NOTwork FOR simply SALE could ORnot haveDISTRIBUTION been accomplished without In another HIV/AIDS prevention project, the efforts of community outreach workers, all of whom this time in Vietnam, paying attention to culture are former addicts who know how and when to reach

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© Jones & Bartlettcurrent addicts. Learning, Also, theLLC outreach workers come from© Jones concepts & Bartlett referable Learning, to empirical LLC observations” (p. 22). the predominant cultural/ethnic group in each commu- The Peltos add that “if the ‘personal factor’ in anthro- NOT FOR SALE OR DISTRIBUTION NOT FOR SALEnity (Booth OR DISTRIBUTION & Wiebel, 1992; Wiebel, 1993; Wiebel et al., pology makes it automatically unscientific, then much 1996). Similarly, the Chicago Project for Violence Pre- of medical science, psychology, geography, and signif- vention involves ex-gang members as outreach work- icant 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 Jones in the & BartlettUnited States. Learning, A simi- LLC In fact, scientific research© Jones is ¬ Bartlett truly objective, Learning, LLC lar focus on peer NOTgroup FOReducation SALE in BotswanaOR DISTRIBUTION led to but rather is governed byNOT the culturalFOR SALE framework OR DISTRIBUTIONand 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 bio- McElmurray, Tlou, & Moeti, 2004). medical researchers in the United States to focus on © Jones & Bartlett Learning, LLC adult men© Jones for many & health Bartlett problems Learning, that also LLC occur in women (such as heart disease). The earlier example of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ▸▸ Methodologies for kuru also demonstrates the limitations of cultural bias. Qualitative research techniques include the Understanding Culture and following:

■ © Jones & BartlettBehavior Learning, LLC © Jones■ &Observation: Bartlett Learning, Behaviors are LLC observed and recorded. ■■ Participant observation: The researcher learns by NOT FOR SALEMany OR of theDISTRIBUTION research methodologies developedNOT in FOR SALE OR 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, © Jones & Bartlett Learning, LLC■■ Focus groups: A group© Jones of people & areBartlett asked to Learning, dis- LLC and in what they would reveal to someone from their NOT FOR SALE OR DISTRIBUTION cuss specific questionsNOT and FOR topics. 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 ask- projects© Jones and & missedBartlett interpretations, Learning, LLCand especially © Jones & Bartlett Learning, LLC ing informants to draw maps; sort cards with pic- onceNOT AIDS FOR appeared. SALE AsOR a diseaseDISTRIBUTION whose prevention is 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 conducted by individuals from the cultures being studied. A key feature of qualitative research is the use of © Jones & BartlettMore recently, Learning, the Ebola LLC pandemic of 2013–2016 rein© Jones- these & Bartlett multiple Learning,methods to LLCtriangulate, or compare, NOT FOR SALEforced OR the DISTRIBUTIONneed to understand and address behaviorsNOT FORdata SALE so as to OR ensure DISTRIBUTION accuracy. With these approaches, and beliefs as part of health interventions. the researcher does not simply rely on what is said, but The field of global health has now moved from an can observe what is actually done. Another feature is almost exclusively quantitative orientation to the rec- that the researcher spends enough time in the com- ognition that a toolbox© Jones of methodologies & Bartlett Learning,is available. LLCmunity to be able to interview,© Jones observe, & Bartlett or otherwise Learning, LLC Some of these toolsNOT may FOR be more SALE valuable OR than DISTRIBUTION others evaluate the same individualsNOT FOR or behaviors SALE ORmultiple DISTRIBUTION for some situations or questions; at other times, a mix times, thereby further ensuring the depth and accu- of several methodologies may offer the best approach. racy of the resulting data. These methodologies derive from epidemiology, sur- These techniques yield data that are descrip- vey research, psychology, anthropology, marketing tive and exploratory, and that serve to investigate (including© Jones social& Bartlett marketing), Learning, and other LLC fields. The little-understood© Jones &phenomena, Bartlett Learning,identify or LLCdiscover biggestNOT FOR disagreement SALE ORhas beenDISTRIBUTION over the relative value importantNOT variables, FOR SALE and generate OR DISTRIBUTION hypotheses for fur- of quantitative and qualitative methods. ther research. Results are often explanatory, helping The debate on the scientific value of qualitative ver- researchers to understand the social and cultural forces sus quantitative research is well summarized by Pelto causing the phenomenon and to identify plausible causal © Jones & Bartlettand Pelto Learning, (1978). They LLC definescience as the “accumu© Jones- networks. & Bartlett They Learning, also present LLCthe “voices” of the partici- NOT FOR SALElation OR of systematic DISTRIBUTION and reliable knowledge aboutNOT an FORpants, SALE and introduce OR DISTRIBUTION context and meaning into the find- aspect of the universe, carried out by empirical obser- ings. They yield themes, patterns, concepts, and insights vation and interpreted in terms of the interrelating of related to cultural phenomena. They can be particularly

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© Jonesvaluable & Bartlett for behaviors Learning, that are LLC often hidden, such as sex- © Jonescommenced. & Bartlett Murray subsequentlyLearning, LLCincluded questions ual risk taking and drug abuse (Dickson-Gomez, 2010; about perdition in a later survey, which revealed that NOT FOR SALE OR DISTRIBUTION NOT FORWiebel, SALE 1993) OR In DISTRIBUTION evaluations, they help practitioners it was apparently a cultural way of making infertility make judgments about a program, improve its effec- or subfecundity socially acceptable, as many women tiveness, and inform decisions about future program- in 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© Jones in this chapter. & Bartlett Learning,from LLC a large sample, particularly© Jones when the& Bartlett distribu- Learning, LLC The methodologicalNOT concepts FOR of SALE validity OR and DISTRIBUTION reli- tion of a variable in a populationNOT is FOR needed SALE (e.g., theOR DISTRIBUTION ability provide a common foundation for the integra- percentage 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 Joneswhich scientific & Bartlett observations Learning, measure LLC what people’s answers© Jones to questions & Bartlett about Learning,their behavior, LLC they purport to measure” (Pelto & Pelto, 1978, p. 33). motivations, perception of an event, and similar top- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION For example, in Spanish Harlem in New York City, a ics. Although 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 © Jonesused & Bartlettas the first Learning, in a series of LLC questions on family plan- © Jonesthe meaning & Bartlett of the question, Learning, or their LLC desire to please NOT FORning. SALE By not OR using DISTRIBUTION family planning terminology at the NOTthe FORinterviewer SALE with OR their DISTRIBUTION answers. Surveys also can 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!” Jones If the & BartlettNew York Learning,ques- unconsciously LLC concealed. In “Truths© Jones and & Untruths Bartlett in Learning, LLC tionnaire had been applied in Ecuador without first Village Haiti: An Experiment in Third World Survey NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION testing it through semi-structured ethnographic inter- Research,” Chen and Murray (1976) describe some of 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 Jones quantitative & Bartlett methods Learning, because LLCthey rely site for at least© Jonesa year. &This Bartlett practice Learning, is intended LLC to on multipleNOT data FOR sources, SALE including OR DISTRIBUTION direct observation ensure that theNOT findings FOR take SALE into ORaccount DISTRIBUTION the changes of behavior and multiple contacts with people over in people’s lifestyles with the changes in seasons, activ- time. Thus, they can be used to increase the validity of ities, available food, and so on. Also, the anthropolo- survey 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 scientific Learning, observations LLC can be repeated and © Jonesfor questions & Bartlett and observations. Learning, More LLC recently, a sub- NOT FORthe SALEsame results OR DISTRIBUTIONobtained. In general, this goal is best NOTset FORof anthropological SALE OR DISTRIBUTIONtools (ethnographic interview, accomplished through survey research or other quanti- participant observation, conversation, and observa- tative means. Surveys can test hypotheses and examine tion) plus the market researchers’ tool of focus groups questions generated through qualitative data. Qualita- have been combined in a rapid anthropological assess- tive methods may help us© discoverJones a& behavior Bartlett or Learning, learn ment LLC process known as the Rapid© Jones Assessment & Bartlett Proce- Learning, LLC how to ask questions aboutNOT it, FOR while SALEquantitative OR dataDISTRIBUTION dure (RAP) (Scrimshaw, Carballo,NOT Carael,FOR SALERamos, OR & DISTRIBUTION can tell us how extensive the behavior is in a popula- Parker, 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 where ©a simpleJones question—“Are & Bartlett Learning, you pregnant?”—had LLC (Chambers, 1992).© Jones Both & methods Bartlett made Learning, listening LLC to two meanings.NOT FOR Women SALE could OR be DISTRIBUTION pregnant with gros community voicesNOT FOReasier SALEfor program OR DISTRIBUTION planners and ventre (“big belly”) or could be pregnant and in perdi- healthcare providers and became frequently used tion. Perdition meant a state where a woman was preg- tools 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 © Jonesgrow. & Bartlett Perdition Learning, was attributed LLC to causes such as “cold,” © Jonesknow the & language Bartlett and Learning, much of the LLC cultural context. NOT FORspirits, SALE or ancestors. OR DISTRIBUTION Women may be in perdition for NOTSuch FOR procedures SALE haveOR DISTRIBUTIONbeen developed for many top- years, and may be separated, divorced, or widowed, ics, including AIDS, women’s health, diarrheal disease, but the pregnancy is attributed to her partner when it seizure disorders, water and health, and childhood

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© Jones & Bartlettobesity prevention. Learning, RAP LLC has become a generic con© Jones- &A Bartlett final comment Learning, on methodologyLLC is that as the cept, and has been modified for many uses. Modified social sciences are increasingly combining methodol- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION titles include RARE, ERAP, and FES (focused ethno- ogies and sharing each other’s tools, it is also important graphic study). In the past 20 years, the RAP method- to 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, used in community© Jonesparticipatory & Bartlett research. Learning, LLCcognitive issues, societal© Jonesand cultural & Bartlett context, Learning, and LLC The case studyNOT on the FOR use SALEof focused OR ethnographic DISTRIBUTION political and economic forcesNOT allFOR can SALEcontribute OR to DISTRIBUTION the methods to assess the feasibility of introducing a forti- analyses. 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 Jones use and & valueBartlett of this Learning, approach. With LLC a relatively (Rubenstein,© Jones Scrimshaw, & Bartlett & Morrissey, Learning, 2000). LLC small number of interviews, researchers were able to An example of a logic framework using this NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION establish that the cereal as constituted and packaged approach can 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 rec- © Jones & Bartlettchange the Learning, product’s likely LLC acceptability. © Jonesommendations & Bartlett Learning,for community LLC public health practice NOT FOR SALEIn OR community DISTRIBUTION participatory research, communityNOT FORbased SALE on a ORsystematic DISTRIBUTION and critical review of the evi- 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© whereJones community & Bartlett acceptance Learning, of LLCactivity, healthy sexual© behavior), Jones & specific Bartlett illnesses Learning, LLC such interventions and programs is essential for suc- (e.g., cancer, diabetes), and one overarching topic, the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION cess. It also has been found to increase the validity sociocultural environment. FIGURE 2-3 presents the (accuracy) of the data, as community members are logic framework for this topic. The outcomes of com- invested in developing programs that work. munity health (on the right side of the figure) stem

© Jones & Bartlett Learning,Societal LLC resources ©Neighborhood Jones & Bartlett living conditions Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Human, social, & financial: Opportunities for learning & • Standard of living developing capacity • Culture and history Health outcomes • Social institutions Community development & • Built environments employment opportunities Level of • Political structures community © • Economic Jones systems & Bartlett Learning,Prevailing LLC community norms, © Jones & Bartlett Learning, LLC health NOT • Technology FOR SALE OR DISTRIBUTIONcustoms & processes NOT FOR SALE OR DISTRIBUTION Social cohesion, civic engagement & collective efficacy Physical Health promotion, disease & injury environment prevention, & health care © Jones & Bartlettnatural Learning, resources LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Legend

Relationships for which evidence was sought Relationships for which © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,evidence LLC was not sought NOT FOR SALE OR DISTRIBUTION 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.

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© Jonesfrom & Bartlett factors in Learning,the physical environmentLLC and societal © Jonesof these &steps Bartlett did or did Learning, not occur LLCwas also important resources; outcomes related to equity and social justice to assess. The price of the product was pegged at the NOT FOR SALE OR DISTRIBUTION NOT FORissues SALE derive OR from DISTRIBUTION factors on the left side of the fig- amount that most 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 regard- study framework broad enough to include key vari- ing prevention and health© Jones care (Anderson, & Bartlett Fielding, Learning, ables, LLC so that they could avoid ©mistakes Jones made & Bartlett by inter- Learning, LLC et al., 2003; Anderson, NOTScrimshaw, FOR etSALE al., 2003). OR DISTRIBUTIONThis vention projects that fail to takeNOT important FOR SALE cultural, OR DISTRIBUTION approach greatly broadens the context for under- economic, access, and other factors into account. A standing and addressing the health of individuals and household perspective was chosen because the pur- of communities. chase and preparation of the cereal would be done at The© JonesCDC’s Community & Bartlett Guide Learning, can be LLCaccessed the household© level. 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 improv- food for their infants? ing community health, many of which have global ■■ Are their current expenditures providing a nutri- relevance. tionally adequate diet? © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ■■ Do households that are spending less than x NOT FOR SALE OR DISTRIBUTION NOT FORamount SALE (e.g., cents/day)OR DISTRIBUTION have the potential to shift ▸▸ Case Study: Use of a Focused their expenditures? ■■ Which other factors determine household buy- Ethnographic Study to Assess ing and/or preparation of foods for the infant or © Jones & Bartlett Learning, LLCyoung child, and would these© Jones other factors& Bartlett inter- Learning, LLC the AcceptabilityNOT FOR of a SALE Fortified OR DISTRIBUTION fere with making a switch,NOT even ifFOR the family SALE could OR DISTRIBUTION Infant Cereal in Africa†* afford it monetarily? It was also important to take into account the pos- Earlier in this chapter, qualitative methods derived sible foods for infants and young children in this envi- largely from anthropology were described as being ronment: (1) human milk, (2) home-prepared foods important© Jones tools for & Bartlettascertaining Learning, cultural facilitators LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION that are madeNOT for family FOR members SALE OR and DISTRIBUTIONare also given 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 pur- study involves a rapid (focused) ethnographic study chased for household consumption, (5) commercial © Jonesthat & Bartlettwas conducted Learning, before LLCa new infant cereal was © Jonesproducts & that Bartlett are marketed Learning, and purchased LLC exclusively NOT FORintroduced SALE toOR assess DISTRIBUTION the potential success of this cereal NOTfor FORthe infant SALE or ORyoung DISTRIBUTION child, and (6) commercial by investigating household and local market behaviors. products that are marketed for household consump- Many infants and young children (IYC) in Africa tion, but are purchased exclusively for the infant or continue to suffer from malnutrition or undernutri- young child. tion. Where mothers breastfeed exclusively for at least © Jones & Bartlett Learning, LLCThe focused ethnographic© studyJones interviewed & Bartlett key Learning, LLC six months, quality foods that complement the nutri- informants—people who had personal knowledge and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ents in human milk are important after six months experience in an area of concern to the project. Four when human milk alone is not adequate to meet nutri- different techniques were used: tional needs. In one African country, a project was devised 1. Free listing exercises. The respondent is asked to introduce© Jones a fortified & Bartlett cereal-based Learning, food thatLLC could a question© Jones or &set Bartlett of questions Learning, that elicit LLC a help contributeNOT FOR to improved SALE OR nutrition DISTRIBUTION for infants and seriesNOT of itemsFOR (objects,SALE ORevents, DISTRIBUTION issues) per- children consuming it. The aim of the focused eth- taining 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.

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© Jones & Bartlett2. Learning,Open-ended LLC interviewing, with guiding© Jones &Because Bartlett families Learning, were already LLC spending so much questions. In open-ended questions, the for these foods, there was clearly a niche for a lower-cost NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR interviewerDISTRIBUTION writes down what the respon- fortified cereal, but 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© Jonesyour baby?” & Bartlett Learning, LLCthe guidance that healthcare© Jones practitioners & Bartlett needed Learning, to LLC 3. Rating NOTand ranking FOR SALEexercises. OR Respondents DISTRIBUTION proceed with an appropriatelyNOT FOR modified SALE product, OR DISTRIBUTION and 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 © Jonespictures & Bartlett of objects Learning, to be ranked LLC and asking © Jones & Bartlett Learning, LLC them to arrange these from most to least ▸▸ Case Study: The Slim NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION important, as well as asking them to assign Disease—HIV/AIDS in the card to a slot along a continuum. (A ‡ similar technique for the latter method is Sub-Saharan Africa * the familiar scale of perceived pain.) © Jones & Bartlett4. Learning,Mapping exercises.LLC Respondents create© Jones AIDS & Bartlett changed Learning,the way in which LLC epidemiologic and NOT FOR SALE OR visualDISTRIBUTION maps on which they indicate NOTthe FORbehavioral SALE researchOR DISTRIBUTION is conducted and health inter- locations of specific features of concern ventions designed and carried out. This case study for the researcher, such as places to obtain illustrates virtually all the topics covered in this commercial foods. chapter. In this case study,© Jones there &were Bartlett two main Learning, types of LLC © Jones & Bartlett Learning, LLC key informant-respondents:NOT FOR (1)SALE women OR DISTRIBUTIONwho gave Epidemiology NOT FOR SALE OR DISTRIBUTION information from the perspective of people who take As of 2016, an estimated 36.7 million adults and chil- care of children and (2) people who gave information dren were living with HIV/AIDS worldwide (UNAIDS, from the perspective of marketing infant and young 2017). Nearly half (17.8 million) were women, and child foods. Thirty primary care givers, 10 alternate 2.1 million were children. Of the 36.7 million persons caregivers,© Jones and& Bartlett 12 sellers Learning, of these foods LLC were inter- with HIV/AIDS,© Jones 19.4& Bartlett million Learning,reside in eastern LLC and viewed.NOT FOR The SALEsellers ORwere DISTRIBUTIONdivided into street venders southernNOT Africa, FOR among SALE whom OR 59%DISTRIBUTION are women and and keepers of small shops. girls. In 2016, 77,000 new HIV infections in eastern The results of the study provided evidence to answer and southern Africa occurred in children. Per capita the key question about the potential acceptability of rates of infection rates in the United States decreased © Jones & Bartletta new fortified Learning, cereal LLC for infants and young children.© Jones by & 18% Bartlett between Learning, 2008 and 2014, LLC as a result of a combi- NOT FOR SALEThey OR revealed DISTRIBUTION that fortified cereals are, indeed,NOT used FORnation SALE of aggressive OR DISTRIBUTION use of antiretroviral therapies and and accepted, and that a relatively high proportion of prevention strategies (HIV.gov, 2017a, 2017b; WHO, the food budget for households with infants is spent on 2010). these items. Thus the key question about a dietary niche Unlike in the Western world, where AIDS was for a fortified cereal was answered affirmatively. originally associated with gay men and injection-drug Importantly, the© Jones study uncovered & Bartlett the realityLearning, that a LLCusers, in Africa the most© commonJones &route Bartlett of transmis Learning,- LLC food that must beNOT cooked, FOR however SALE briefly, OR DISTRIBUTION is unlikely sion is through heterosexualNOT FORsex. MenSALE infect OR theirDISTRIBUTION to be chosen over instant foods that do not require partners (often wives) as a result of their involvement cooking. Busy mothers will spend more money to pur- with other partners. A pregnant, HIV-positive woman chase prepared cooked cereals from street vendor or may transmit the virus to her fetus through the pla- buy© Jones small packets & Bartlett of instant Learning, cereal that LLC can be mixed centa or© to Jones her infant & Bartlett through breastfeeding Learning, .LLC withNOT water FOR rather SALE than OR cooking DISTRIBUTION a cereal themselves. Generally,NOT FOR AIDS SALE patients OR in DISTRIBUTION Africa suffer from This was extremely important guidance, as it showed intestinal infections, skin disease, tuberculosis, her- that the cereal planned for introduction would need to pes zoster, and meningitis. In the industrialized coun- be modified so that it would not require cooking if it tries, AIDS is associated with Kaposi’s sarcoma (a skin was to be a success. cancer), meningitis, and pneumonia. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ‡* This case study was developed by Isabel Martinez, MPH.

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© Jones &Why Bartlett does theLearning, same disease LLC spread so differently © Jonesand refugees. & Bartlett Women Learning, are especially LLC at risk. They are from one region of the world to another? History, pol- six times more likely to contract HIV in refugee camps NOT FOR SALE OR DISTRIBUTION NOT FORitics, SALE economics, OR DISTRIBUTIONand cultural and social environments than 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 inter- which imposed changes© on Jones the existing & Bartlett culture. Learning, Even act LLC are also affected by the epidemic© Jones (Akeroyd, & Bartlett 1997; Learning, LLC after countries becameNOT independent FOR SALE from OR Europe, DISTRIBUTION Carballo & Siem, 1996; Jok,NOT 2001, FOR 2012; SALE UNAIDS, 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© Jones hold &(Akeroyd, Bartlett 1997; Learning, Bond, Kreniske,LLC © Jones & Bartlett Learning, LLC Susser, & Vincent, 1997; Hunt, 1989; Jok, 2001). These Gender Roles and Cultural Traditions NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION factors and their association with the AIDS pandemic The African woman’s struggle with the AIDS pandemic are described in the following subsections. In addi- has been depicted often in the literature (Akeroyd, tion to illustrating the relationship between cultural 1997; Carballo & Siem, 1996; Hunt, 1989; Messer- norms, prevention and healthcare access, and disease, smith, 1991; Salopek, 2000; UNAIDS, 1999; Watkins, © Jonesthis & caseBartlett study Learning, demonstrates LLC the profound relation- © Jones2004). The & Bartlett risk to women Learning, from husbands LLC or partners NOT FORship SALE between OR the DISTRIBUTION general sociocultural, political, phys- NOTreturning FOR SALEfrom work OR in DISTRIBUTION other areas has already been ical, and economic environment and health. discussed. Another risk—sex work or prostitution by women as a means of survival—is now almost a death sentence in Africa, considering the great risk of con- Risk of AIDS Associated with Migratory Labor tracting HIV/AIDS through such employment. There The integral family structure© Jones of the& Bartlett African cultureLearning, are LLC many reasons why some African© Jones women & Bartlett find the Learning, LLC has been broken up by NOTthe migratory FOR SALE labor systemOR DISTRIBUTION in need to engage in sex work,NOT although FOR studies SALE have OR DISTRIBUTION 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,© Jones which include& Bartlett mining, Learning, railroad work, LLC plan- from female entrepreneurs© Jones & Bartlettin foreign Learning,trade having LLC to tation NOTwork, FORand primary SALE productionOR DISTRIBUTION facilities (e.g., use sexual ploysNOT to FORensure SALE business OR to DISTRIBUTIONimpoverished 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 prevent- they remain for long periods of time. This system has ing HIV infection through use of condoms, their cost © Jonesnot & onlyBartlett kept Learning,families apart, LLC but also increased the © Jonesand availability, & Bartlett combined Learning, with the LLC resistance of some NOT FORnumbers SALE of ORsex partnersDISTRIBUTION for men—in turn, giving rise NOTmales FOR to use SALE them, OR raise DISTRIBUTION barriers for the safety of these to a higher prevalence of sexually transmitted infec- women 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 Jones sex with & prostitutesBartlett Learning, close been LLC implicated in raising the risk© Jonesfor HIV for& Bartlettboth men Learning, LLC to their work sites, become infected, and eventually NOT FOR SALE OR DISTRIBUTIONand women (Helleringer, Kohlerb,NOT &FOR Kalilani-Phiric, SALE OR DISTRIBUTION return home and infect their wives, whose babies may 2009). Called “concurrency,” these practices are now a 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 some areas that© Jones having sex& Bartlett with a virgin Learning, will cure LLCan In 2017,NOT there FOR were SALE 14 major OR armed DISTRIBUTION conflicts and 29 HIV-infectedNOT man. AdolescentFOR SALE girls OR and DISTRIBUTION young women additional armed conflicts globally. Of these 43 con- are 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 © Jonesation & Bartlett in Africa Learning,has intensified LLC the impact of the AIDS © Jonescircumcision & Bartlett also places Learning, young girls LLC at risk. In both epidemic. Several populations become more vulnerable of these circumstances, the risk of contracting HIV NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION to HIV/AIDS during wartime, including those affected through sex or infected surgical instruments increases by food emergencies and scarcity, displaced persons, for adolescents (Akeroyd, 1997; Salopek, 2000).

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© Jones & BartlettAdditional Learning, Cultural LLC Beliefs © Jones1997; & Bartlett Bartholet, Learning, 2000; Salopek, LLC 2000; UNAIDS, 1999; United Nations, 1999c). Secrecy regarding HIV/AIDS is common within someNOT 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 peo- among youth. The authors of the study found that per- ple because preventive actions are not taken (Akeroyd, © Jones & Bartlett Learning, LLCceived barriers significantly© Jones interacted & Bartlett with perceived Learning, LLC 1997; Salopek, 2000; UNAIDS, 1999; United Nations, NOT FOR SALE OR DISTRIBUTIONsusceptibility and self-efficacy.NOT FOR Youth SALE who ORperceived DISTRIBUTION a 1999d). Preventive actions go beyond preventing sex- high level of susceptibility to HIV infection and a low ual transmission, to include concerns about transmis- level 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 © JonesIn some &parts Bartlett of Africa, Learning, AIDS is referred LLC to as the © Jones & Bartlett Learning, LLC of perceived barriers increased the likelihood of use “slimNOT disease” FOR SALEbecause OR of the DISTRIBUTION wasting away that occurs NOT FOR SALE OR DISTRIBUTION three times (Adih & Alexander, 1999). 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 © Jones & Bartlettin Gabon Learning, and “that other LLC thing” in Zimbabwe. HIV© Jones & Bartlett Learning, LLC and AIDS are a source of shame and denial in these Governmental Agencies and NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION African cultures. AIDS is also considered a punish- Nongovernmental 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 treat- her belief in reviving© Jones this custom & Bartlett by saying, Learning, “We have LLCment programs for other© JonesSTIs, mobilization & Bartlett of Learning,non- LLC adopted too manyNOT Western FOR things SALE without OR DISTRIBUTION thinking, governmental organizationsNOT (NGOs),FOR SALE and reductionOR DISTRIBUTION 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 © Jones & Bartlett Learning, LLC intercourse© Jones and increased & Bartlett condom Learning, use among LLC sex BarriersNOT FOR to SALEPrevention OR DISTRIBUTION or Treatment workersNOT and FORmen and SALE women OR whoDISTRIBUTION have casual sex (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 proj- Africa found that knowledge of risk and its preven- © Jones & Bartlettects that Learning, might be lessLLC crucial than those related© Jones tion & Bartlettwas important, Learning, but notLLC sufficient to change NOT FOR SALEto health. OR DISTRIBUTIONFor example, a foreign country fundedNOT a FORbehavior. SALE The OR authorsDISTRIBUTION stress the need to improve 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).© Jones & Bartlett Learning, LLCself-efficacy (Reddy, Meyer-Weitz,© Jones &van Bartlett den Borne, Learning, & LLC Changing people’sNOT healthFOR SALEbehavior OR and DISTRIBUTION address- Kok, 1999). NOT FOR SALE OR DISTRIBUTION ing cultural beliefs has also been a tough challenge The United Nations 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 abstain- communities in prevention efforts, including joining ing from some cultural rituals, can be perceived as forces to accelerate the development of experimental changing© Jones traditional & Bartlett gender Learning, roles for LLCboth men and vaccines.© JonesAcademic & institutionsBartlett Learning, have also teamed LLC up women,NOT FOR and maySALE go against OR DISTRIBUTION some religious values that with localNOT community FOR SALE and ORchurch DISTRIBUTION organizations to are part of the core for some communities. The need create prevention projects and help organize the com- to 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 © Jones & Bartlettmakes it Learning,difficult for LLC people even to discuss it,© much Jones women, & Bartlett to motivate Learning, others LLC in their communities less be tested for this infection. The stigma of HIV/ through education and increasing women’s negotia- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION AIDS needs to be removed for prevention efforts to be tion skills for safe sex or condom use (Msiza-Makhubu, more widely accepted by the African people (Akeroyd, 1997; United Nations, 1999d; WHO, 1997).

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© Jones &There Bartlett is also Learning, a growing LLCmovement in which doctors © Jones▸▸ & Bartlett Learning, LLC in Africa work with traditional healers to do outreach Ebola NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and education on AIDS. As discussed earlier, traditional The Ebola virus shares several characteristics with HIV/ healers have better access to many populations. People AIDs. First identified in 1976, Ebola is a newly emergent seek their help because of tradition and lack of adequate infection. Beginning as a zoonotic disease that infected health care (Associated Press, 2000; Green, 1994). fruit bats, nonhuman primates, and other mammals, it © Jones & Bartlett Learning,“jumped LLC species” to infect humans© Jones as a result & Bartlettof ecolog- Learning, LLC Antiretroviral TherapyNOT FOR SALE OR DISTRIBUTIONical disruption—in this case, huntingNOT FOR wild animalsSALE ORfor DISTRIBUTION 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. Pres- countries 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 European© Jones Commission; & Bartlett WHO; Learning, and the Gates LLC Foun- © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION short intervalNOT between FOR recognition SALE OR of symptomsDISTRIBUTION and 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 © Jonesthe & United Bartlett States Learning, implemented LLC the President’s Emer- © Jonessupportive & careBartlett to the Learning,infected. LLC NOT FORgency SALE Plan OR for DISTRIBUTIONAIDS Relief (PEPFAR/Emergency NOT FORThe two SALE hardest-hit OR DISTRIBUTION countries—Liberia and Sierra Plan). As of 2017, this program had provided antiret- Leone—are impoverished. Liberia ranks 182th out of roviral treatment (ART) to more than 11 million 187 countries in the United Nations Human Devel- HIV-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 (PEPFAR, 2017). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONpatterns of care for the sick andNOT dying, FOR as well SALE as care OR- DISTRIBUTION Innovative prevention programs such as the intro- ful tending of the dead in preparation for burial, were duction of male circumcision in areas where it had found to increase Ebola transmission, because con- not 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 pro- cleaning, feeding, or moving an infected person can tect against© Jones infection, & Bartlett reducing Learning, transmission LLC rates by lead to transmission© Jones (CDC, & Bartlett 2015). Learning, LLC as muchNOT as 60% FOR (Bailey SALE & Mehta,OR DISTRIBUTION 2009; Bailey et al., When AmericanNOT FOR and EuropeanSALE OR global DISTRIBUTION health per- 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 © JonesDiminished & Bartlett political Learning, and LLCeconomic support for © Jones & Bartlett Learning, LLC family members. A new psychosocial paradigm called NOT FORantiretroviral SALE OR programs DISTRIBUTION could lead to the interrup- NOT FOR SALE OR DISTRIBUTION tion of treatment of HIV/AIDS patients, which in “fear-related behaviors” in situations of mass threat is turn would provide the HIV virus with the potential now recognized as an expected reaction to disasters and to become drug resistant. Other challenges in Africa must be planned for with clear communication, cul- include a shortage of health professionals, many of tural understanding, and the close collaboration of for- whom have left their home© Jones countries & Bartlettfor better Learning,oppor- eign LLC public health workers with© localJones professional & Bartlett and Learning, LLC tunities in higher-incomeNOT countries. FOR SALE In addition, OR DISTRIBUTION a community leaders (Espinola etNOT al., 2016). FOR Viewed SALE from OR DISTRIBUTION lack of treatment literacy poses a huge challenge for this perspective, the panicked responses of the African effective antiretroviral treatment (UNAIDS, 2004b). villagers were not irrational (Richardson et al., 2016). The individual behaviors that place people at risk Beginning with the slave trade and colonialism, West- are part© ofJones the larger & Bartlett root causes Learning, of the problem LLC in ern incursions© into Jones Liberia & and Bartlett Sierra Leone Learning, have caused LLC Africa,NOT including FOR colonialism, SALE OR bigDISTRIBUTION industry’s design immense suffering.NOT FOR Further SALE complicating OR DISTRIBUTION the cultural of mass labor migration, poverty, gender inequalities, misunderstandings is the fact that Liberia has 31 separate and war. The ideal prevention and intervention strate- languages 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 services andLearning, treatment LLC options (Akeroyd, 1997; © Jonestries were & under-resourced Bartlett Learning, and overwhelmed, LLC numer- NOT FORBond SALE et al., OR1997; DISTRIBUTION Tylor, 1871; United Nations, 1999c, NOTous FOR well-meaning SALE OR multinational, DISTRIBUTION governmental, and 1999d; WHO, 1997). nongovernmental agencies rushed to the scene to help.

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© Jones & BartlettGrieving Learning,African family LLC members were not allowed© Jones intervention & Bartlett literature; Learning, and IsabelLLC Martinez and Janel to touch or kiss their dead. Rather than observing Heinrich for their assistance with the literature search, NOT FOR SALE OR DISTRIBUTION NOT FOR SALEtime-honored OR DISTRIBUTION funereal practices, they were instead for helpful comments 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 repre- notes on the various intervention theories. In addi- sented enormous© changes Jones in &cultural Bartlett practices Learning, around LLCtion, we would like to ©thank Jones and &acknowledge Bartlett Learning, Pro- LLC death and dying, NOTbut they FOR worked SALE to reduce OR DISTRIBUTION transmis- fessor Gretel Pelto and NOTDr. Margaret FOR SALE Armar-Klemesu OR DISTRIBUTION sion (Agusto, Teboh-Ewungkem, & Gumel, 2015). for permission to base the case study on the introduc- Analyses 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, demon- projects. strated© Jones that serious& Bartlett attention Learning, to clear communicationLLC © Jones & Bartlett Learning, LLC and understanding of cultural patterns are critical ele- NOT 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 ▸▸ Conclusion of a sub-Saharan African country? Which strat- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC egies would you use if you were a community NOT FOR SALEThis ORchapter DISTRIBUTION has briefly explored cultural and behavNOT- FOR SALE OR DISTRIBUTION ioral issues that influence global health. Anthropol- leader? Would the strategies used for these two ogy, sociology, and psychology have much greater perspectives differ? If so, how? How would you depth in terms of both methods and theories than address some of the cultural beliefs or traditions can be described in this chapter. A rich and exten- associated with HIV/AIDS mentioned in the sive literature exists© Jones on health & Bartlettbeliefs and Learning, behaviors, LLC case study? © Jones & Bartlett Learning, LLC environmental andNOT biological FOR SALE contexts, OR health DISTRIBUTION sys- 2. If you were enteringNOT a community FOR SALE to introduceOR DISTRIBUTION tems, and programmatic successes and failures. It a health program, who would you talk to? What is essential to take these factors into account when would you ask? Why? contemplating global health work. In addition, a pro- 3. Discuss the concepts of validity and reliability gram must consider structural factors, such as setting, in research as they apply to the use of quantita- © Jones & Bartlett Learning, LLC tive© Jones and qualitative & Bartlett methods. Learning, Next, discuss LLC the hours,NOT childFOR care, SALE and OR ambience, DISTRIBUTION as well as factors of NOT FOR SALE OR DISTRIBUTION content, such as culturally acceptable services, which same concepts as they apply to community par- includes providers who treat patients with respect and ticipatory research. understanding. 4. What is the hot/cold illness belief system? Why Research and preventive services regarding health is it important? How would you incorporate it © Jones & Bartlettbeliefs and Learning, behaviors LLCmust accept and integrate con© Jones- & Bartlettinto a maternal Learning, and child LLC health program? NOT FOR SALEcepts ORdifferent DISTRIBUTION from those held by Western biomediNOT- FOR5. SALEMany OR people DISTRIBUTION believe that healers such as mid- cine, by middle- or upper-class healthcare providers, wives and shamans are called to their profession or by healthcare providers from an ethnic or cultural by a greater spiritual power. What significance group that is different from their patients. This require- does this belief have for official health programs ment demands the ability inherent in some of the around the world? How should they address © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC anthropological methods and approaches discussed this belief? earlier—that is, theNOT ability FOR to “get SALE into someone’s OR DISTRIBUTION head” 6. If an indigenous practiceNOT FOR seems SALE peculiar OR to you,DISTRIBUTION and understand things from an insider perspective. but does no apparent harm, what should you do? There is nothing like the experience of spending time 7. How could you learn what people in a commu- with people, in their own homes or community, and nity really believe about health and illness? striving© Jones to reach & Bartlett that insider Learning, understanding. LLC 8. Based© Jones on the & theoriesBartlett of Learning,behavior change, LLC cre- NOT FOR SALE OR DISTRIBUTION ateNOT your FOR own modelSALE by OR taking DISTRIBUTION what you think is 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 & Bartlettin editing Learning, and preparing LLC the bibliography; Pamela© Jones & Bartlettrecent West Learning, African outbreak LLC with the impor- NOT FOR SALEIppoliti OR for DISTRIBUTION her editorial assistance; Susan Levy NOTand FOR SALEtance ORof addressing DISTRIBUTION the fears and panic of the John Justino for providing key examples from the population?

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References Bartholet, J. (2000, January 17). The plague years. Newsweek, © Jones & Bartlett Learning, LLC © Jones135(3). & Bartlett Learning, LLC NOT FORAbdullah, SALE A., OR& Husten, DISTRIBUTION C. (2004). Promotion of smoking NOTBeals, FOR A. R. SALE(1976). Strategies OR DISTRIBUTION of resort to curers in south India. 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.Jones & Bartlett Learning,Betancourt, LLC J. R., Green, A. R., & Carrillo,© Jones J. E. (2002).& Bartlett Cultural Learning, LLC Adih, W. K., & Alexander, C. 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de Oliveira, T., Kharsany, A., Gräf, T., Cawood, C., Khanyile, D., comparison of migrant Yugoslavian and Swedish diabetic © Jones & BartlettGrobler, Learning, A., . . . Abdool LLC Karim, S. (2017). Transmission© Jones &females. Bartlett Journal Learning, of Advanced Nursing, LLC 30(5), 1147–1159. NOT FOR SALEnetworks OR DISTRIBUTION and risk of HIV infection in KwaZulu-Natal, SouthNOT FORHughes, SALE C. (1990). OR DISTRIBUTIONEthnopsychiatry. In T. M. Johnson & C. E. Africa: A community-wide phylogenetic study. Lancet HIV, Sargent (Eds.), Medical anthropology: Contemporary theory 4(1), e41–e50. and method. (p. 131). New York, NY: Praeger. Dickson-Gomez, J. (2010). Structural factors influencing the Hunt, C. W. (1989). Migration labor and sexually transmitted patterns of drug selling and use and HIV risk in the San diseases: AIDS in Africa. Journal of Health in Social Science Salvador metropolitan© Jones area. Medical & Bartlett Anthropology Learning, Quarterly, LLC Behavior, 30, 353–373. © Jones & Bartlett Learning, LLC 24(2), 157–181. NOT FOR SALE OR DISTRIBUTIONJok, J. M. (2001). War andNOT slavery FOR in Sudan.SALE Ethnography OR DISTRIBUTION Espinola, M., Shultz, J. M., Espinel, Z., Althouse, B. M., Cooper, of Political Violence Series. Philadelphia, PA: University 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 Hmong child, & Bartlett her American Learning, doctors, and LLCthe collision of two in Africa© Jones (pp. 154–169). & Bartlett New York, Learning,NY: Routledge. LLC NOTcultures. FOR New SALE York, NY: OR Farrar, DISTRIBUTION Straus, and Giroux. Kamat, V.NOT R. (2008). FOR Dying SALE under OR the DISTRIBUTIONbird’s shadow: Narrative Foster, G. M. (1953). Relationships between Spanish and Spanish- representations 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 © Jones & Bartlettnorth IndianLearning, village. In LLC J. Middleton (Ed.), Magic, witchcraft,© Jones &for Bartlett patients’ health Learning, and fitness: LLC Internal medicine alert.Relias. NOT FOR SALEand OR curing DISTRIBUTION (pp. 295–320). Garden City, NY: Natural HistoryNOT FOR RetrievedSALE ORfrom DISTRIBUTIONhttps://www.ahcmedia.com/articles/137485 Press. -use-of-smartphone-applications-for-patients-health-and 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. construction of the© past:Jones A comparison & Bartlett of cultural Learning, consensus LLCKleinman, A. (1980). Patients© and Jones healers in& the Bartlett context of culture.Learning, LLC theory and culturalNOT schema FOR theory. SALE Ethos, 28, OR 275–319. DISTRIBUTIONBerkeley, CA: University NOTof California FOR Press. SALE OR DISTRIBUTION Ghimire, M., Pradhan, Y. V., & Mahesh, M. K. (2010). Community- Kleinman, 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,© Jones B. J., & Good,& Bartlett M. J. D. (1981). Learning, The meaning LLC of symptoms: A Lane, S.,© Lurie, Jones P., Bowser, & Bartlett B., Khan, J.,Learning, & Chen, D. (1999).LLC The cultural hermeneutic model for clinical practice. In L. Eisenberg coming of age of needle exchange. In Harrison, L. (Ed.), Harm NOT& A. KleinmanFOR SALE (Eds.), The OR relevance DISTRIBUTION of social science for medicine reductionNOT (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, © Jones & BartlettGuarnaccia, Learning, P. J., Lewis-Fernandez, LLC R., Martinez Pincay, I., Shrout,© Jones &S., Bartlett Ramachandran, Learning, T., & Amaus LLC Student Researchers. (2017). NOT FOR SALEP., ORGuo, J.,DISTRIBUTION Torres, M., . . . Alegria, M. (2010, May 1). AtaqueNOT FOR ActionSALE anthropology OR DISTRIBUTION in a free clinic. Human 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. © Jones & Bartlett Learning, LLC controlling pellagra in Mexico.© Jones Ethnomedizin, & Bartlett 4, 397–410. Learning, LLC Haghi, M., Thurow, K., & Stoll, R. (2017). Wearable devices in Long, A., Scrimshaw, S. C. M., & Hernandez, N. (1992). Transcultural medical Internet ofNOT Things: FOR Scientific SALE research OR and DISTRIBUTION commercially epilepsy services. In N. S.NOT Scrimshaw FOR & G.SALE R. Gleason OR (Eds.), DISTRIBUTION available devices. Healthcare Informatics Research, 23(1), 4–15. Rapid assessment procedures: Qualitative methodologies http://doi.org/10.4258/hir.2017.23.1.4 for planning and evaluation of health related programmes Helleringer, S., Kohlerb, H., & Kalilani-Phiric, L. (2009). (pp. 205–213). Boston, MA: International Nutrition Foundation The association of HIV serodiscordance and partnership for Developing Countries. © concurrencyJones & Bartlettin Likoma Learning, Island (Malawi). LLC AIDS, 23, Martiniuk,© A.,Jones O’Connor, & K., Bartlett & King, W. (2003).Learning, A cluster randomizedLLC NOT1285–1290. FOR SALE OR DISTRIBUTION trial NOTof a sex FOReducation SALE programme OR in DISTRIBUTION Belize, Central America. HIV.gov. (2017a, November 20). 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McSweeney, J. C., Allan, J. D., & Mayo, K. (1997). Exploring the Culture, natality, and family planning (pp. 204–218). Chapel © Jones &use Bartlett of explanatory Learning, models in nursingLLC research and practice. © JonesHill, NC: & CarolinaBartlett Population Learning, Center. LLC NOT FOR ImageSALE Journal OR of DISTRIBUTIONNursing Scholarship, 29(3), 243–248. NOTPresident’s FOR EmergencySALE OR Plan DISTRIBUTION for AIDS Relief (PEPFAR). (2017, Messersmith, L. J. (1991). The women of good times and Baba’s July 22). Home page. Retrieved from https://www.pepfar.gov/ Place: The multi-dimensionality of the lives of commercial sex Prochaska, J., DiClemente, C., & Norcross, J. (1992). In search workers in Bamako, Mali. PhD dissertation, University of of how people change: Applications to addictive behaviors. California at Los Angeles. American Psychologist, 47, 1102–1104. Msiza-Makhubu, S. B. (1997).© Peer Jones education & and Bartlett support for Learning, AIDS Ratzan, LLC S. C., & Parker, R. M. (2000).© Jones Introduction. & Bartlett In C. R. Learning, LLC prevention among womenNOT in South FOR Africa. SALE PhD dissertation, OR DISTRIBUTION Selden, M. Zorn, S. C. Ratzan, & NOTR. M. Parker FOR (Eds.), SALE National OR DISTRIBUTION University of Illinois at Chicago. Library of Medicine current bibliographies in medicine: Health Murray, G. F. (1976). Women in perdition: Ritual fertility control literacy (pp. v–vii). NLM Pub. No. CBM 2000-1. Bethesda, in Haiti. In J. F. Marshall & Polgar, P. (Eds.), Culture, natality, MD: National Institutes of Health, U.S. Department of Health and family planning (pp. 59–78). Chapel Hill, NC: Carolina and Human Services. Population Center. Reddy, P., Meyer-Weitz, A., van den Borne, B., & Kok, G. (1999). National© Center Jones for &Complementary Bartlett Learning, and Integrative LLC Health STD-related ©knowledge, Jones &beliefs Bartlett and attitudes Learning, of Xhosa- LLC (NCCIH).NOT (2014, FOR December SALE 17).OR NIH DISTRIBUTION complementary and speaking patientsNOT attending FOR SALESTD primary OR health-care DISTRIBUTION clinics integrative health agency gets new name. Retrieved from in South Africa. International Journal of Sexually Transmitted https://nccih.nih.gov/news/press/12172014 Diseases and AIDS, 10(6), 392–400. National Center for Complementary and Integrative Health Reichel-Dolmatoff, G., & Reichel-Dolmatoff, A. (1961).The people (NCCIH). (2017, September 24). Use of complementary of Aritama. London, UK: Routledge and Kegan Paul. © Jones &health Bartlett approaches Learning, in the U.S. Retrieved LLC from https://nccih.nih © JonesRekart, M. & (2002). Bartlett Sex in the Learning, city: Sexual behavior, LLC societal change, NOT FOR .gov/research/statistics/NHIS/2012/key-findingsSALE OR DISTRIBUTION NOT andFOR STDs SALE in Saigon. OR DISTRIBUTIONSexually Transmitted Infections, 78 Nguyen-Truong, C. K., Tang, J., & Hsiao, C. Y. (2017) Community (suppl I), i47–i54. Interactive Research Workshop Series: Community members Richardson, E. T., Barrie, M. B., Kelly, J. D., Dibba, Y., Koedoyoma, S., engaged as team teachers to conduct research. Progress in & Farmer, P. E. (2016). Biosocial approaches to the 2013–2016 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 Nichter, M. (2008). Global health:© Jones Why cultural & Bartlett perceptions, Learning, social LLCencyclopedia of world slavery (p.© 410).Jones Santa & Barbara, Bartlett CA: Learning, LLC representations and biopoliticsNOT matter. FOR Tucson, SALE AZ: OR University DISTRIBUTION ABC-CLIO. 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.© Jones Washington, & Bartlett DC: National Learning, Academies LLC Press. Rogers, E. M., ©& JonesShoemaker, & F.Bartlett F. (1972). Learning,Communication LLC of Norr, K., Norr, J., McElmurray, B., Tlou, S., & Moeti, M. (2004). Impact innovations (2nd ed.). New York, NY: Free Press. of peerNOT group FOR education SALE on HIV OR prevention DISTRIBUTION among women in Rosenstock, I., Strecher,NOT FOR V., & Becker, SALE M. OR(1974). DISTRIBUTION Social learning Botswana. 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Baltimore, MD: INFO Pennise, M., Inscho, R, Herpin, K, Owens, J., Jr., Bedard, B. A., Project, Johns Hopkins Bloomberg School of Public Health. Weimer,© Jones A. C., . &. . BartlettYounge, M. Learning,(2015). Using smartphoneLLC Salopek, P. (2000,© Jones January &10). Bartlett We die lyingLearning, to ourselves: LLC appsNOT in STD FOR interviews SALE to find OR sexual DISTRIBUTION partners. Public Health Part 2. ChicagoNOT FORTribune SALE. Retrieved OR fromDISTRIBUTION http://www 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. © Jones &Health, Bartlett Population, Learning, and Nutrition, LLC 21(4), 383–395. © JonesScrimshaw, & S. Bartlett C. (1974). Learning,Culture, environment, LLC and family size: Polgar, S., & Marshall, J. F. (1976). The search for culturally acceptable A study of urban in-migrants in Guayaquil, Ecuador. PhD NOT FOR fertilitySALE regulating OR DISTRIBUTION methods. In J. F. Marshall & S. Polgar (Eds.), NOT dissertation,FOR SALE Columbia OR University,DISTRIBUTION New York.

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a global approach. Collaborating Centre for International World Health Organization (WHO). (2010, June). Programmes. © Jones &Nursing Bartlett Development Learning, in Primary LLC Health Care Research. © JonesRetrieved & Bartlettfrom http://www.who.int/hiv/en/ Learning, LLC NOT FOR Geneva,SALE Switzerland: OR DISTRIBUTION Author. NOTYoung, FOR C. J.SALE (1981). ORMedical DISTRIBUTION choice in a Mexican village. New World Health Organization (WHO). (2004). Investing in a Brunswick, NJ: Rutgers University Press. comprehensive health sector response to HIV/AIDS: Scaling up Zamen, F., & Underwood, C. (2003). The gender guide for health treatment and accelerating prevention. WHO HIV/AIDS plan. communication programs. Baltimore, MD: Population Geneva, Switzerland: Author. Retrieved from http://www.who Communications Services, Center for Communications .int/entity/3by5/en/HIV_AIDSplan.pdf© Jones & Bartlett Learning, LLCPrograms, Johns Hopkins. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

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