The Journal of Primary Prevention, Vol. 15, No. 4, 1995
Cross.Cultural Prevention Program Transfer: Questions Regarding Developing Countries Norman D. Sundberg, 1,5 Johana P. Hadiyono, 2 Carl A. Latkin, 3 and Jesus Padilla 4
To prevent mental illness and promote psychological health, developing countries might learn from demonstrated successes in other countries. This exploratory qualitative project involved interviewing 27 informants knowledgeable about both the United States and selected developing countries of Asia and South America. Informants reviewed five preventive programs shown to be effective in North America and then evaluated the programs as to their applicability in the other country. In general the programs were seen as not very transferrable, and in some cases not needed. Among transfer problems identified were funding, training, cultural traditions and higher priorities for other things in impoverished countries. The primary recommendation is that prevention programs be developed in other countries based on their needs and cultural characteristics and using indigenous human resources. Such programs could be informed by general principles and evaluation procedures developed in Western prevention programs. Informants noted that there are also important things for Americans to learn from the developing countries, such as family closeness and greater acceptance and relaxation about stresses of life.
Developing countries are in danger of producing mental health problems as they industrialize, urbanize and change family relations. American and 1Department of Psychology, University of Oregon. 2Faculty of Psychology, Gadja Mada University. 3School of Public Health, The Johns Hopkins University. 4Department of Psychology, University of Oregon. 5Address correspondence and reprint requests to Norman Sundberg, Dept. of Psychology, University of Oregon, Eugene, OR 97403. 361 9 1995HumanSciencesPress,Inc.
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European societies have elaborate professional procedures and personnel for treatment, but still mental health problems persist ranging from excessive stress in everyday living to severe and chronic mental illness. No physical health problem has been effectively solved by treatment; it is only through programs of education, sanitation and immunization that major impacts have been made. Can similar preventive programs be applied in the area of mental health? Psychopathology and psychological stress clearly exist in developing countries as well as in highly developed ones. Research has shown that schizophrenia, depression, and other severe mental illnesses exist in many countries throughout the world, but that these may be partially products of industrialization and the severity of disorders may be worse in modernized countries (Draguns, 1990). Societies vary a great deal in their attitudes and care for the severely mentally ill. Among less severe disorders, there is much variation among countries in such behavioral problems as reported anxiety and depression, antisocial disorders and health-related lifestyles. The process of development and modernization typically refers to the transfer of industrial technology from the West. Modernization also involves transfer of training and professional systems, including health and mental health procedures, concepts and attitudes. Some mental health professionals (e.g., Higginbotham, 1984, Higginbotham & Connor, 1989, Torrey, 1986) point out the dangers of wholesale importation of the West's psychiatric professional system in the Third World and the need to base mental health treatment on indigenous mores and resources. In order to combat the problems of psychosocial breakdowns often accompanying the intrusion of Western ways, the best strategy might be to develop prevention programs in the area of mental health. The history of the transfer of public health preventive programs to developing countries, especially with regard to sanitation and immunization has some spectacular successes (e.g., Hume, 1986). However, the emphasis on the decline in mortality related to infectious diseases has not been balanced by a concern for behavioral and social problems resulting from global industrial transformation (Sugar, Kleinman & Heggenhougen, 1991). There are some good examples of preventive and promotive programs in mental health in the United States. These have been carefully evaluated as successful in their original settings (e.g., Price, Cowen, Lotion & Ramos-McKay, 1988), but there are few studies showing successful dissemination to other places (Bauman, Stein & Kreys, 1991). Obviously, it is difficult to transfer a program to another culture, especiaUy ones as different as those in the developing countries of Asia and Latin America. South and Southeast Asian traditional cultures contrast sharply with the American culture. Prominent features include being largely
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agricultural (although there are strong industrializing and urbanizing features), having an orientation toward group and extended family (in contrast with American individualism), and having strong and different philosophical and religious influences and organizations (especially Hindu, Muslim, Buddhist, animist, and "nativized Catholicism"). (See Table III for a summary of differences frequently mentioned in the literature.) The heterogeneity among and within these nations also needs consideration for transfer and appropriateness of prevention technology and theory. Latin America shares more European cultural traditions with the U.S. than does Asia, but there are also strong differences, especially those arising from Native American cultures.
AN EXPLORATORY PROJECT
Intrigued by the problem of cross-cultural prevention program "transfer," we developed an exploratory project that might later be useful for research and application. Our purposes were to identify important questions and issues about transfer of preventive programs to developing countries and to propose criteria or guidelines that might be used in considering possibilities for application of programs in other cultures. The methods for approaching this problem involved (1) the selection of a limited number of exemplary prevention programs, (2) formulation of an interview guide based on preliminary hypotheses about issues and problems of program transfer to South and Southeast Asia and Latin America, (3) interviews with informants knowledgeable about selected countries, and (4) formulation of guidelines for cross-cultural research and development of prevention programs. The exemplary American programs we chose were five from 14 Ounces of Prevention (Price, Cowen, Lorion & Ramos-McKay, 1988), a book sponsored by the American Psychological Association, the National Council of Community Mental Health Centers and the Pew Memorial Trust. This book reported model prevention programs winnowed out of approximately 300 submissions resulting from a nation-wide search for well researched and evaluated prevention efforts. The five we chose covered different age levels. They were as follows (slightly retitled): A. The Prenatal and Early Infancy Program (by David Olds): A training program for poor, unwed mothers in caring for their babies. B. The Preschool Child-Initiated Learning Program (the High/Scope Perry Preschool Program by Lawrence Schweinhart and David
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W e i k a r t ) : A c l a s s r o o m p r o g r a m in e x p l o r a t i o n and self-development for 3 and 4 year olds. C. The Interpersonal Cognitive Problem-Solving Program (by Myrna Shure and George Spivack): A teacher and parent training program for thinking about others' feelings and relationships with children about 5 years old. D. Preventing Adolescent Substance Abuse Through Life Skills (by Gilbert Botvin and Stephanie Tortu): Teacher training to improve independent thinking, see short-range effects, and resist peer and media influence toward smoking and alcohol and other substance abuse with children about 12 to 15 years old. E. Community-wide Heart Disease Prevention Program (the Stanford Heart Disease program by Nathan Maccoby and David Altman): An extensive effort in three communities (one a control) to promote health education through better nutrition, smoking cessation, exercise, etc. using media and other means largely aimed at adults. The interview consisted of general questions about prevention, and a major section for which interviewees read a paragraph summarizing each of these programs and answered questions about their applicability in the target country. We consider the interviewees, not as subjects, but as knowledgeable informants as in anthropological research. All of the informants had lived extensively in the target country and the United States (at least one year in both). The informants were either faculty members or graduate students, nearly all in the social sciences. For each country we interviewed at least one male and one female, believing that gender might be an element in perceptions of mental health conditions. For each region, we had a primary set of informants--at least three from the selected countries--and a secondary set of additional interviewees numbering one or two from several other countries. Each interview lasted one to two hours. The primary South and Southeast countries chosen in this exploratory investigation were India, Indonesia, the Philippines, and Thailand, for each of which we interviewed a minimum of three people. One additional interviewee had done research in villages in two of the countries. Of the total of 13 informants, 10 were native to the four chosen countries, and three were American professors specializing in those countries. In addition, we interviewed five informants from Burma, Malaysia, Pakistan, and Singapore, making a total of 18 from South and Southeast Asia. The primary Latin American countries were Mexico and Chile, about which we interviewed three informants each. In addition we interviewed two from Ecuador and one from Panama, for a total of 9 from Latin America.
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The completed interview information was summarized and compiled under each of the topics or questions for each of the four countries. These topics then could provide the basis for discussion among the authors leading to interpretation and suggestions for research and guidelines for applications of preventive programs in other cultures.
OBTAINED INFORMATION
The following items give a brief summary of some of the information collected from the 27 informants and some exemplary quotations: 1. Media attention to mental health and illness: All the informants agreed there was much more media attention to health in the U.S. than in the comparison countries and more concern in developing countries for physical health than mental health. Recently there have been campaigns against AIDS and drug abuse in most counties. Special events, such as the cholera epidemic in Ecuador, result in advertising campaigns. In general in these developing countries there is little attention to mental problems. 2. Psychological treatment services: For rich and educated people, in most of these developing countries, a few private mental health services similar to those in the U.S. exist, and rich people can also hire servants to take care of their severely disturbed relatives. However, the poor have nothing except a few mental hospitals reserved for only the severest cases. There is a social stigma against mental hospitals, mental illness and going to mental health professionals. However, there is some sympathy and tolerance of disorders in small communities; for instance the Mexican term, los loquitos (little crazy ones) implies a kind of caring. Because of the cultural focus on the family and because of lack of money, most families take care of their own troubled family members. In contrast, about the U.S. one informant said, "Here psychiatrists and psychologists are everywhere; with any stress people feel they can go to them." 3. Alternative helpers: All informants mentioned the primary importance of family and friends for mental problems. Many emphasized the importance of religious people, priests and monks. All mentioned possible help from such traditional helpers as astrologers, fortune tellers, spiritualists, paranormals, sorcerers, and herbalists. These serve as resources for people with health and mental health problems in developing countries, especially among the poor. In most countries there are basically two health cultures-- one made up of those who go to traditional healers and another of those who go for Western-type medical assistance. In Mexico, it is common to go to a curandero. In some countries, even wealthy people will seek
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the traditional help first. There are also community "advice-givers" (often old women or men) known for their wisdom in helping with decisions and problems. (Such alternative care-givers might be enlisted in training programs for prevention.) 4. Existing prevention programs: Informants knew of few or no such programs in the target countries, except those about drug abuse and AIDS. There were also some health-promoting programs for new mothers of babies, and some television and poster programs about family planning. In Thailand, two informants saw the revival of Buddhism as related to promotion of mental health. 5. Rankings of the five American prevention programs: See Tables IA and IB. A rank of 1 was highest, e.g., most needed in the target country, and 5 the lowest. We did not carry out statistical checks of significance because we see this as preliminary and exploratory for formulating some hypotheses. (Arbitrarily, it seems useful to hypothesize about differences when group means are more than one point.) In the tables, averages are given only for the primary countries (with at least 3 informants each). The additional interview results with 4 other Asian countries and 2 other Latin American countries with fewer than three interviewees per country are simply listed in raw form to generate further speculation. Need: First we asked informants to rank the five programs as to need in the developing countries. In general, about Asian countries, there was little unanimity or enthusiasm regarding need for these programs. An average rank more than one point above 3 was given only in India for the Prenatal/Early Infancy program, in Indonesia and Thailand for the Adolescent Substance Abuse program, and in Thailand for the Community Heart program. In the two Latin American countries, only the Adolescent Substance Abuse program is highly ranked for need. Feasibility: The primary Asian and Latin American informants were also not dearly sure about feasibility, and interviews revealed skepticism. Only the Adolescent Substance Abuse program attained an average rank of less than 2 for economic and political feasibility. Among individual Asian countries, in India the prenatal program was perceived as quite feasible (but the answers there assumed that the women were married, since being an unwed mother is socially unacceptable in India). For Indonesia, informants perceived the Community Heart program as highly feasible. Other than that there were only a few average ratings at 2 or less. Looking at total averages for the primary countries, we see that programs related to physical health were generally more acceptable than those clearly related to mental health and educational improvement. On many rankings of needs and feasibility, the Asian and Latin American countries were perceived as fairly close. The largest differences
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Table IA. Mean Rankings (1, highest) of the Five U.S. Prevention Programs for Need and Economic, Political, Cultural, and General Feasibility in Asian Countries [I = India; Is = Indonesia; P = Philippines; T = Thailand] Need
Feasibility Econ.
A. Prenatal early inf.
I* Is: P:
Total: 4 Other Asian Co.** B. Preschool learning
I: Is: P: T:
Total: 4 Other Asian Co.**
1.7 3.6 3.3 2.8 2.8 (1, 2, 5, 1, 2)(3, 4,
1.7 3 2.6 2.5 2.4 3, 1, 3)
2.3 3 3.6 3.6 3 3 4.___22 3..__88 3.3 3.4 (3, 5, 1, 4.5, 1)(3, 4,5, 4.5, 1)
C. Interpers. Prob-Solv. I: Is: P: Total 4 Other Asian Co.**
2.5 2.5 2.6 4.3 2.6 4.3 3.8 4.__33 2.9 3.8 (5, 4, 2, 4.5, 5)(3, 5, 3, 4.5, 4)
D. Adol. Substance Ab. I: Is" P: T: Total: 4 Other Asian Co.** (2, 1, E. Commun. Heart Prob.
Total: 4 Other Asian Co.**
4.5 2 1.7
4.2 3.7 1.3 2.5 2.6 2.9 3, 3, 3)(4, 1, 2, 2, 5)
Pol.
Cult.
General
2 3 2 2.2 2.3
1.3 3.3 2.6 3.__22 2.6
1.8 2.3 3 2.2 2.3 (1, 1, 5, 1, 3)
2 3.6 2.3 2..__66 2.9
3 3.6 2.6 2._44 2.9
2.2 3.6 3 3.___66 3.0 (1, 4, 1, 4, 2)
3 4 3.3 2.__.44 3.2
4 4.3 4 3.._99 4.0
3 4.3 4 4.__.44 4.2 (4, 5, 2, 4, 5)
4 3.7 3 3.5 3.6
4 2.7 2 3 2.9
4.8 2.7 1.7 3.2 3.1 (1, 2, 4, 4, 1)
I:
3
2.8
3
2.7
3.5
Is: P:
3 4.7
1.3 2.7
1.3 4
1.7 3.7
1.7 3.3
~
~
2.5
~
2.7
2.5
3.2 2.2 (4, 3, 4, 2, 4)(4, 2, 1, 3, 2)
2.5 2.8 (1, 3, 3, 2, 4)
*Assuming girl is married. **Individual ratings for Need, Economic and General Feasibility from one or two informants in 4 other Asian countries: In order, Burma, 2 from Malaysia, Pakistan, Singapore
between them (at least one point) showed up on the ratings for programs in the Preschool Learning (Asians higher on need), Interpersonal ProblemSolving (Asians higher on the average across feasibility ratings) and Substance Abuse (Latin Americans higher on need and feasibility). Because N's for each country were small (2 to 4 ratings in each category), not much
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Table 113. Mean Rankings (1, highest) of the Five U.S. Prevention Programs for Need and Economic, Political, Cultural, and General Feasibility in Latin American Countries [C = Chile; M = Mexico] (with Asian means from Table IA) Need
Feasibility Econ.
A. Prenatal early inf.
2.7 2.__55 2.8 2.4 (3, 1, 3)
3 3 3 2.3 (3, 5, 3)
4.3 1._._/7 3 2.6 (2, 4, 5)
2.7 2._33 2.5 2.3 (3, 4, 3)
C: M:
4 4.7 4.4 3.3 (3, 4, 3)
3.3 4.__.33 3.8 3.4 (5, 2, 4)
3.3 4..__.00 3.6 2.9 (5, 2, 4)
2 4 3 2.9 (4, 2, 4)
3 4.7 3.8 3.0 (4, 5, 4)
C: M:
3 _3 3 2.9 (5, 3,4)
3 4 3.5 3.8 (2, 5,1)
2.7 4._._33 3.5 3.2 (4,4,5)
2.7 4._._77 3.7 4.0 (5, 4, 3)
3.7 4.__.-3 4 4.2 (5, 2, 5)
C: M:
1.3 1.___77 1.5 2.6 (1, 2, 2)
2.3 _1 1.6 2.9 (1, 4, 2)
2.7 1 1.8 3.6 (1, 3, 1)
2.7 2 2.4 2.9 (1, 1, 2)
3.7 1.7 2.7 3.1 (1, 1, 1)
C: M:
3 2.7 2.8 3.2 (4, 5, 5)
3.3 3.'/ 3.5 2.2 (4, 3, 5)
3.3 3.__77 3.5 2.7 (2, 5, 2)
3.3 2.-/ 3 2.5 (3, 3,1)
3 2 2.5 2.8 (2, 3, 2)
Lat. Am. Total Asian Total: 2 O t h e r L . A. Co.* D. Adol. Substance Ab. Lat. Am. Total Asian Total: 2 O t h e r L . A. Co.* E. Commun. Heart Prob. Lat. Am. Total Asian Total: 2 O t h e r L . A. Co.*
General
2.7 3._.0 2.8 2.8 (2, 1, 1)
Lat. Am. Total Asian Total: 2 Other L. A. Co.* C. Interpers. Prob-Solv..
Cult.
C: M:
Lat. Am. Total Asian Total: 2 O t h e r L . A. Co.* B. Preschool learning
Pol.
*Ratings from informants regarding 2 other Latin American countries: In order, 2 from Ecuador, 1 from Panama.
r e l i a n c e c a n b e p l a c e d o n t h e m , b u t it is c l e a r t h a t t h e r e w a s n o t u n a n i m i t y among the judges and the average ranks were seldom above the middle. 6. T h e A l b e e " F o r m u l a " f o r p r e v e n t i o n : G e o r g e A l b e e (1984) h a s m e n t i o n e d six f a c t o r s t o b e c o n s i d e r e d in p l a n n i n g p r o g r a m s f o r p r e v e n t i o n of psychopathology. (See Table II.) Informants were asked to indicate w h e t h e r e a c h f a c t o r w o u l d b e high, m e d i u m o r l o w in i m p o r t a n c e f o r a
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Table II. Ratings (High, Medium, Low) on the Albee Prevention Factors and Weighted A:
Total
India
LA:
Totals (W.T) Indonesia Philippines Thailand Chile Mexico
W.T
Organic problems (basic health): A: M,H,H L, L, H, H LA: M,H,H
M,M,M L,L,L M,H,H
2.0 1.3
Stress of ordinary living:: A: L, L, H M, H, H, H LA: H,H,H
L, M, M L, H, H H,H,H
1.6 1
Exploitation and powerlessness of certain groups A: H, H, H M, H, H, H A: H,H,H
H, H, H, L, H, H, H H,H,H
1.4 1
Competence & Coping Skills: A: H,H,? M, H, H, H LA: H,H,H
M,M,? H,H, H H H,H,H
1.2
Self Esteem A: LA:
M, ?, ?
M, H, H, H H,H,H
M, M, ? M, H, H H,H,H
1.5
Social Support: A: LA:
L, L, L
H, H, H H,L,L
H, H, H L, M, H H,H,H
1
1 1.8
1.7
program in the given country. On the table, the Weighted Total average is given by counting high as "1" etc. Both for Asia and Latin America almost all Albee factors tend to be rated medium or high. Some Asian informants indicated that some programs already were in existence (e.g., basic health in Thailand) or that stress was less in Asian societies than in the West. The mixture of ratings for Asian countries on Social Support was clarified in the interview; some informants saw little need to be concerned about that since family and group support are already strong, whereas others emphasized the importance of social support because of the danger of losing it as the country modernizes. 7. Major cultural differences from the U.S.: All informants identified many differences. Frequently mentioned for all countries were these: Strong family relationships and support in the developing countries, strong religious influences on daily life and a more relaxed life style in contrast with the competitive individualism in America. Training children to be self-directed and autonomous, as in the Interpersonal Problem-Solving program,
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would not be seen as desirable in most other countries. There were numerous other differences. Comparing the different countries some characteristics stood out as different from others; for instance, violence was mentioned as common in the Philippines and machismo as important in Mexico. Gender inequality and taboos on relations between the sexes are prominent in some countries; in India, interviewees said that a girl getting pregnant before marriage would be ostracized by her family, even killed. Some respondents noted that the U.S. had a strong cultural and media influence, especially in Panama and Mexico. Informants noted the difficulty of disentangling cultural differences from socio-economic status; poverty and low levels of education in other countries make for enormous contrasts with American lifestyles. As already suggested, some respondents pointed out that there are two cultures within these countries: The rich, educated elites and the poor, more traditional majority, often living in rural settings, but also in urban slums. 8. Problems with applying the five programs in the other countries: Numerous problems were mentioned. Most prominent among them was need for funding. Others were the lack of education, staff training, knowledge about the problems, government bureaucracy, corruption, and traditional attitudes. For example, cigarette smoking is usually not seen as a health problem because it is so widely accepted and in some countries is even promoted by the government monopoly on tobacco. A problem with school programs is the large size of classes--40 or 50 in a room m and the lack of supplies and technology. There is little training or interest in evaluating effectiveness of programs. 9. Resources for possible application of these programs: Informants also pointed out some help for prevention programs. In most countries, religious institutions might be helpful; some middle-class people, especially women, might provide volunteer help; and the health and welfare infrastructure might be enlisted in programs with proper funding. The existence of socialized medicine in some countries affects needs and feasibility; in Myanmar (Burma), for instance, clinics or health personnel, though trained at a low level, operate throughout the country and can be mobilized for prevention programs. International organizations like UNICEF and nongovernmental organizations probably could help. Those programs related to physical health would be the easiest to start. 10. What could Americans leam from these developing countries? This question was enthusiastically welcomed by the informants. Frequent answers were strong family bonds, community neighborliness, and a greater acceptance of life with its joys and problems. "We have mental peace more than Americans." "Hardly anyone is alone." Americans need to "loosen up," reduce stress, be more involved in group and family living. Some re-
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spondents said that in other countries people have a greater acceptance and care for unfortunates such as retarded people and the homeless.
DISCUSSION AND CONCLUSIONS In general, we found this exploratory effort very rewarding. We recognized our reach was very b r o a d - - 27 interviews covering 12 countries-and our methods qualitative and preliminary. However, some ideas emerged suggesting directions for further work. In the American literature on dissemination of mental health programs to other sites, there is a debate between extremes--those who advocate close fidelity to the original program and those who say programs should be re-invented for each new place (Bauman et al., 1991). It was clear that a simple transfer of a prevention program from the U.S. to a developing country in Asia or Latin America is nearly impossible. Cultural, economic and socio-political structures are too complexly different. Affecting everything else is the economic situation in these developing countries. For instance, poverty influences such things as the availability of children for the pre-school and school programs; they are needed for work to help improve the family income. As Maslow's need hierarchy postulates, the primary needs for existence--food, shelter, physical h e a l t h - - m u s t come first before higher needs such as enjoying life and actualizing oneself. So some of the programs (e.g., Interpersonal Problem-Solving) are of questionable priority for the mass of the population. Some of these programs would be of interest and appropriate for the small sector that is wealthy and educated. Along with poverty, the population p r o b l e m - - h u g e and increasing --affects every other variable in such programs. Perhaps, prevention of further population increases should be of highest priority, but we did not address this behavioral problem in our interviews. Needs, goals and ideals about positive mental health vary across countries. Draguns (1990) notes mental health implications from the general cultural dimensions found in Hofstede's research on 40 countries, namely the four dimensions of power distance, uncertainty avoidance, individualism/collectivism, and masculinity/femininity. In an European study, Minsel, Becker and Korchin (1991) found that a less developed country placed higher values on behavioral control and adaptation and less emphasis on self-actualization than more developed countries. Even within the United States, as Goggin and associates (Goggin, 1987; Goggin, Bowman, Lester & O'Toole, 1990) have shown, considerable effort is needed to identify local needs and attitudes and to assure participation in implementing community
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Table HI. Contrasting Cultural Characteristics Affecting Mental Health Work Traditional (S & SE Asian) vs. "Modem" (Western/No. Amer.) Religion, Philosophy, Folk beliefs
Hinduism, Buddhism, Islam, Filipino Catholicism, animism, spirit possession, casting spells, astrology, ancester worship, acceptance/fatalism
Judeo-Christian beliefs, determinism, scientism, pragmatism, materialism, innovation, "maker of one's fate"
Social relations:
Groupism, collectivism, familism, conformity, interdependence, hierarchical, status rigidity, holistic (whole person)
Individualism, autonomy, competition, independence, status flexibility, fragmented roles
Environmental relations:
Harmony with nature, dependence on nature, close to nature
Dominance over nature, exploitation, technical, distant from nature
Orientation to time:
Cyclical, relaxed about clocks & appointments
Linear, clock awareness, fast paced, concern for future, "time is money"
Cognitive approach:
Synthetic, multilectic, harmony-seeking (both-and)
Analytic, dialectic, critical (either-or)
Communication:
Passive,indirect, control of emotions
Active, direct, expression of emotions
Goals:
Harmony with family & environment, Enlightenment (Hinduism/Buddhism) Gaining merit by giving Submission to authorities
Self-reliance, Salvation/Adjustment Material "success" Equality, doubting authority
Self:
Defined by relation to others, especially in family relations
Defined by self, identity in accomplishments
Cause of mental illness:
Physical & mental closely related, caused by karma, spells & charms, spirits, cosmic imbalance, etc.
Compartmentalization, genetics, socialization, unconscious motives, etc.
Expectations:
Rapid cure, physical/med, treatment, authoritative prescription
Talking cure, joint participation
Disorders of Organic connection, so Thought & Emotion organic treatment
Mental causes, so talking helps
Responsibilities for Change
Family-centered
Person-centered
Self-disclosure
Low to non-family
High to helper
Relation with helper Distant
Intimate
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"lhble lII. Continued Traditional (S & SE Asian) vs. "Modem" (Western/No. Amer.) Acceptance of problem
Suffering expected, Exercise will-power
Pain can be helped
Mode of treatment
Physical or meditation
Verbal, "talking cure"
change. Torrey (1986, p. 91) points out that ideas of prevention exist in many societies, but they may take the form of an amulet worn around the neck; he notes that physicians' prescriptions are sometimes placed in amulets. As an exercise in anticipating cultural differences in developing prevention programs, Table III lists traditional (largely Asian) versus modern (largely U.S. & European) contrasts that might affect mental health work. Obviously, there are great differences between and within countries; for instance, compare affluent and internationally competitive Singapore with poor and isolated Myanmar (Burma). Table III oversimplifies, but it does suggest the exploration of hypotheses stemming from literature on cultural differences. Underlying the concept of prevention is a concern for the future. The anthropologist, Robert Textor (1991) has labeled and analyzed the widespread problem of tempocentrism, or failure in anticipating the future, in many cultures. Sippanondha Ketudat and Textor (1990) have shown ways of increasing future thinking through a method entitled Ethnographic Futures Research. Sippanondha illustrates by openly exploring optimistic, pessimistic and most probable scenarios for Thailand. A body of knowledge and training methods is developing which might be used for prevention program planning (Sundberg, 1985). As mentioned earlier, prevention researchers argue about maintaining fidelity to original programs or re-inventing them for other places. Bauman and her associates (1991) suggest a compromise: Make use of the basic program theory and adapt to local characteristics. In our interviews, it appeared that the Albee prescription for prevention, the six causative factors of psychopathology, are relevant to other countries. Keeping those in mind in designing a program should be helpful. In conclusion, we can list some general guidelines for applying prevention programs in another cultural context (especially in developing countries in Asia and Latin America):
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1. Basic principles: Many of the usual principles of program development and evaluation may apply at a general or abstract level. The six Albee factors--organic problems, stress, group exploitation, competence, self-esteem, and social supports--will provide useful guidelines for program design. In addition many of the procedures developed for prevention programs are applicable, e.g., needs assessment, identifying at-risk groups, consciousness raising, incorporating influential leadership, and program evaluation. 2. Cost~benefit analyses: In poor countries, preparatory research needs to include the costs of a prevention program relative to other possible uses of scarce funds. Long-term benefits, through perhaps not very apparent, are important. Costs and benefits also relate to population pressures, which underlie many problems in developing countries. Analyses must address issues of family planning, gender employment differences, and the effects on family structure and dynamics as change comes. Data on social indicators for developing countries are sparse. Suntaree Komin (1989) has presented thought-provoking data on social dimensions of industrialization in Thailand. The World Bank (1990) and UNESCO (1992) have begun to produce some indices of social development in addition to the usual economic development information. 3. Cultural resources: One needs to identify local resources and build on those. For instance, traditional healers and religious leaders may be trained and involved in prevention activities. The preventionist needs to find out who are influential people in the community. Often temples or churches are resources in Asia and Latin America. Some informants suggested that sports figures, radio singers and movie stars would be excellent to promote knowledge and practices about prevention in the media. Also of relevance are indigenous philosophies and sayings which might be used to promote mental health, such as rnai pen rai, the Thai idea of acceptance meaning "never mind" and "don't worry" (Hollinger, 1965). A similar idea of non-attachment, anasakti, may be useful in India (Pande & Naidu, 1992). 4. Appropriate technology: It is important to search for and develop the mental health equivalents of "appropriate technology" such as using existing communication networks, making small modifications of existing services, and offering training that is simple and pays off as immediately as possible. An interesting suggestion from informants was the possibility of illustrating mental health suggestions and how to cope with stress in popular comic books. Other vehicles for preventive education and programs are temples, mosques and other religious organizations. Some religious leaders, such as Buddhadasa in Thailand, are able to demonstrate the compatibility between science and Buddhism, the religion of 95% of the Thais (Jackson, 1988).
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5. Community sensitivity: Each developing country is different from other countries and has much heterogeneity within its borders; so programs must be specifically planned. We have not emphasized differences among these chosen Asian and Latin American countries very much but they were quite obvious. For instance, there was much concern about AIDS prevention in Thailand where prostitution has a long history, but not much concern about it for India. Gender roles differ in different cultures, seclusion and suppression of women being particularly strong in some Muslim countries. The perception of high incidence to violence was strongest in the Philippines. Substance abuse was seen as a great problem in the Philippines, Chile and Mexico but not in India. Distinctions need to be made in program planning between resources and needs of the urban elites, the urban poor and the rural populace. Program developers need to be aware of the differential readiness for programs, building on acceptable practices. In developing countries, there is hope for prevention of undue stress and psychopathology, if only their citizens and Western friends can (a) understand how to make use of and maintain strengths now in existence and (b) learn from problems and successes in other countries. For the future it seems highly likely that rapid urbanization, migration from villages, industrialization, and adopting of Western materialistic values will destroy many current social supports and indigenous helping systems. If the history of Western mental health system is blindly followed, these countries will wind up with an over-dependence on highly trained and expensive professionals, while not avoiding the disorders and stresses of modernization. ACKNOWLEDGMENTS Earlier forms of this paper were presented at the First Annual Convention of the American Association of Applied and Preventive Psychology, June 16, 1991, Washington, D.C. and the Fourth Annual Conference of the Northwest Regional Consortium for Southeast Asian Studies, Nov. 9, 1991, Eugene, OR. The authors wish to thank the 27 informants who must, however, remain nameless here.
REFERENCES Albee, G. W. (1984). Prologue: A model for classifying prevention programs. In J. M. Joffe, G. W. Albee, & L. D. Kelly (Eds.) Readings in primary prevention of psychopathology: Basic concepts. (pp. ix-xvii) Hanover, NH: University Press of New England. Bauman, L. J., Stein, R. E. K., & Ireys, H. T (1991). Reinventing fidelity: The transfer of social technology among settings. American Journal of Community Psychology, 19, 619-639.
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Draguns, J. G. (1990). Applications of cross-cultural psychologyin the field of mental health. In R. W. Brislin (Ed.) Applied cross-cultural psychology (pp. 302-324). Newbury Park, CA: Sage. Goggin, M. L. (1987). Policy design and the politics of implementation--the case of child health in the American states. Knoxville: Univ. of Tennessee Press. Goggin, M. L., Bowman, A. O., Lester, J. P. & O'Toole, L. J. (1990). Implementation theory and practice: Toward a third generation. Glenview, IL: Scott, Foresman/Little Brown. Higginbotham, H. N. (1984). Third world challenge to psychiatry: Culture accommodation and mental health care. Honolulu: Univ. of Hawaii Press. Higginbotham, H. N. & Connor, L. (1989). Professional ideology and the construction of western psychiatry in Southeast Asia. International Journal of Health Services, 19, 63-78. Higginbotham, H. N. & Marsella, A. S. (1988). International consultation and the homogenization of psychiatry in Southwest Asia. Social Science and Medicine, 27, 553-561. Hollinger, C. (1965). Mai pen rai means never mind. Boston: Houghton Mifflin. Hume, J. C. (1986). Colonialism and sanitary medicine: The development of preventive health policy in the Punjab, 1860 to 1900. Modem Asian Studies, 20, 703-724. Jackson, P. A. (1988). Buddahasa: A Buddhist thinker for the modem world. Bangkok: The Siam Society. Minsel, B., Becker, P., & Korchin, S. J. (1991). A cross-cultural view of positive mental health: Two orthogonal main factors replicable in four countries. Journal of Cross-Cultural Psychology, 22, 157-181. Pande, N. & Naidu, R. K. (1992). Anasakti and health: A study of nonattachment. Psychology and Developing Societies, 4, 89-104. Price, R. H., Cowen, E. L., Lorion, R. E, & Ramos-McKay, J. (Eds.) (1988). 14 ounces of prevention: A casebook for practitioners. Washington, DC: American Psychological Association. Sippanondha Ketudat & Textor, R. B. (1990). The middle path for the future of Thailand: Technology in harmony with culture and environment. Honolulu: East-West Center. Sugar, J. A., Kleinman, A. & Heggenhougen, K. (1991). Development's "downside": Social and psychological pathology in countries undergoing social change. Health Transition Review, 1, 211-220. Sundberg, N. D. (1985). The use of future studies in training for prevention and promotion of mental health. Journal of Primary Prevention, 6, 98-114. Suntaree Komin (1989). Social dimensions of industrialization in Thailand. Bangkok: National Institute of Development Administration. Textor, R. B. (1991, Oct.) Tempocentrism: A universal phenomenon with cultural variations. Paper presented at the Symposium for the Cultural Environment of Psychology in Honor of Ernest E. Boesch. Merlingen, Switzerland. Torrey, E. E (1986). Witchdoctors and psychiatrists: The common roots of psychotherapy and its future. New York: Harper & Row. United Nations Development Programme (1992). Human development report, 1992. New York: Oxford University Press. World Bank (1990). World Development report, 1990. New York: Oxford University Press.
Cross.Cultural Prevention Program Transfer: Questions Regarding Developing Countries Norman D. Sundberg, 1,5 Johana P. Hadiyono, 2 Carl A. Latkin, 3 and Jesus Padilla 4
To prevent mental illness and promote psychological health, developing countries might learn from demonstrated successes in other countries. This exploratory qualitative project involved interviewing 27 informants knowledgeable about both the United States and selected developing countries of Asia and South America. Informants reviewed five preventive programs shown to be effective in North America and then evaluated the programs as to their applicability in the other country. In general the programs were seen as not very transferrable, and in some cases not needed. Among transfer problems identified were funding, training, cultural traditions and higher priorities for other things in impoverished countries. The primary recommendation is that prevention programs be developed in other countries based on their needs and cultural characteristics and using indigenous human resources. Such programs could be informed by general principles and evaluation procedures developed in Western prevention programs. Informants noted that there are also important things for Americans to learn from the developing countries, such as family closeness and greater acceptance and relaxation about stresses of life.
Developing countries are in danger of producing mental health problems as they industrialize, urbanize and change family relations. American and 1Department of Psychology, University of Oregon. 2Faculty of Psychology, Gadja Mada University. 3School of Public Health, The Johns Hopkins University. 4Department of Psychology, University of Oregon. 5Address correspondence and reprint requests to Norman Sundberg, Dept. of Psychology, University of Oregon, Eugene, OR 97403. 361 9 1995HumanSciencesPress,Inc.
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European societies have elaborate professional procedures and personnel for treatment, but still mental health problems persist ranging from excessive stress in everyday living to severe and chronic mental illness. No physical health problem has been effectively solved by treatment; it is only through programs of education, sanitation and immunization that major impacts have been made. Can similar preventive programs be applied in the area of mental health? Psychopathology and psychological stress clearly exist in developing countries as well as in highly developed ones. Research has shown that schizophrenia, depression, and other severe mental illnesses exist in many countries throughout the world, but that these may be partially products of industrialization and the severity of disorders may be worse in modernized countries (Draguns, 1990). Societies vary a great deal in their attitudes and care for the severely mentally ill. Among less severe disorders, there is much variation among countries in such behavioral problems as reported anxiety and depression, antisocial disorders and health-related lifestyles. The process of development and modernization typically refers to the transfer of industrial technology from the West. Modernization also involves transfer of training and professional systems, including health and mental health procedures, concepts and attitudes. Some mental health professionals (e.g., Higginbotham, 1984, Higginbotham & Connor, 1989, Torrey, 1986) point out the dangers of wholesale importation of the West's psychiatric professional system in the Third World and the need to base mental health treatment on indigenous mores and resources. In order to combat the problems of psychosocial breakdowns often accompanying the intrusion of Western ways, the best strategy might be to develop prevention programs in the area of mental health. The history of the transfer of public health preventive programs to developing countries, especially with regard to sanitation and immunization has some spectacular successes (e.g., Hume, 1986). However, the emphasis on the decline in mortality related to infectious diseases has not been balanced by a concern for behavioral and social problems resulting from global industrial transformation (Sugar, Kleinman & Heggenhougen, 1991). There are some good examples of preventive and promotive programs in mental health in the United States. These have been carefully evaluated as successful in their original settings (e.g., Price, Cowen, Lotion & Ramos-McKay, 1988), but there are few studies showing successful dissemination to other places (Bauman, Stein & Kreys, 1991). Obviously, it is difficult to transfer a program to another culture, especiaUy ones as different as those in the developing countries of Asia and Latin America. South and Southeast Asian traditional cultures contrast sharply with the American culture. Prominent features include being largely
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agricultural (although there are strong industrializing and urbanizing features), having an orientation toward group and extended family (in contrast with American individualism), and having strong and different philosophical and religious influences and organizations (especially Hindu, Muslim, Buddhist, animist, and "nativized Catholicism"). (See Table III for a summary of differences frequently mentioned in the literature.) The heterogeneity among and within these nations also needs consideration for transfer and appropriateness of prevention technology and theory. Latin America shares more European cultural traditions with the U.S. than does Asia, but there are also strong differences, especially those arising from Native American cultures.
AN EXPLORATORY PROJECT
Intrigued by the problem of cross-cultural prevention program "transfer," we developed an exploratory project that might later be useful for research and application. Our purposes were to identify important questions and issues about transfer of preventive programs to developing countries and to propose criteria or guidelines that might be used in considering possibilities for application of programs in other cultures. The methods for approaching this problem involved (1) the selection of a limited number of exemplary prevention programs, (2) formulation of an interview guide based on preliminary hypotheses about issues and problems of program transfer to South and Southeast Asia and Latin America, (3) interviews with informants knowledgeable about selected countries, and (4) formulation of guidelines for cross-cultural research and development of prevention programs. The exemplary American programs we chose were five from 14 Ounces of Prevention (Price, Cowen, Lorion & Ramos-McKay, 1988), a book sponsored by the American Psychological Association, the National Council of Community Mental Health Centers and the Pew Memorial Trust. This book reported model prevention programs winnowed out of approximately 300 submissions resulting from a nation-wide search for well researched and evaluated prevention efforts. The five we chose covered different age levels. They were as follows (slightly retitled): A. The Prenatal and Early Infancy Program (by David Olds): A training program for poor, unwed mothers in caring for their babies. B. The Preschool Child-Initiated Learning Program (the High/Scope Perry Preschool Program by Lawrence Schweinhart and David
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W e i k a r t ) : A c l a s s r o o m p r o g r a m in e x p l o r a t i o n and self-development for 3 and 4 year olds. C. The Interpersonal Cognitive Problem-Solving Program (by Myrna Shure and George Spivack): A teacher and parent training program for thinking about others' feelings and relationships with children about 5 years old. D. Preventing Adolescent Substance Abuse Through Life Skills (by Gilbert Botvin and Stephanie Tortu): Teacher training to improve independent thinking, see short-range effects, and resist peer and media influence toward smoking and alcohol and other substance abuse with children about 12 to 15 years old. E. Community-wide Heart Disease Prevention Program (the Stanford Heart Disease program by Nathan Maccoby and David Altman): An extensive effort in three communities (one a control) to promote health education through better nutrition, smoking cessation, exercise, etc. using media and other means largely aimed at adults. The interview consisted of general questions about prevention, and a major section for which interviewees read a paragraph summarizing each of these programs and answered questions about their applicability in the target country. We consider the interviewees, not as subjects, but as knowledgeable informants as in anthropological research. All of the informants had lived extensively in the target country and the United States (at least one year in both). The informants were either faculty members or graduate students, nearly all in the social sciences. For each country we interviewed at least one male and one female, believing that gender might be an element in perceptions of mental health conditions. For each region, we had a primary set of informants--at least three from the selected countries--and a secondary set of additional interviewees numbering one or two from several other countries. Each interview lasted one to two hours. The primary South and Southeast countries chosen in this exploratory investigation were India, Indonesia, the Philippines, and Thailand, for each of which we interviewed a minimum of three people. One additional interviewee had done research in villages in two of the countries. Of the total of 13 informants, 10 were native to the four chosen countries, and three were American professors specializing in those countries. In addition, we interviewed five informants from Burma, Malaysia, Pakistan, and Singapore, making a total of 18 from South and Southeast Asia. The primary Latin American countries were Mexico and Chile, about which we interviewed three informants each. In addition we interviewed two from Ecuador and one from Panama, for a total of 9 from Latin America.
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The completed interview information was summarized and compiled under each of the topics or questions for each of the four countries. These topics then could provide the basis for discussion among the authors leading to interpretation and suggestions for research and guidelines for applications of preventive programs in other cultures.
OBTAINED INFORMATION
The following items give a brief summary of some of the information collected from the 27 informants and some exemplary quotations: 1. Media attention to mental health and illness: All the informants agreed there was much more media attention to health in the U.S. than in the comparison countries and more concern in developing countries for physical health than mental health. Recently there have been campaigns against AIDS and drug abuse in most counties. Special events, such as the cholera epidemic in Ecuador, result in advertising campaigns. In general in these developing countries there is little attention to mental problems. 2. Psychological treatment services: For rich and educated people, in most of these developing countries, a few private mental health services similar to those in the U.S. exist, and rich people can also hire servants to take care of their severely disturbed relatives. However, the poor have nothing except a few mental hospitals reserved for only the severest cases. There is a social stigma against mental hospitals, mental illness and going to mental health professionals. However, there is some sympathy and tolerance of disorders in small communities; for instance the Mexican term, los loquitos (little crazy ones) implies a kind of caring. Because of the cultural focus on the family and because of lack of money, most families take care of their own troubled family members. In contrast, about the U.S. one informant said, "Here psychiatrists and psychologists are everywhere; with any stress people feel they can go to them." 3. Alternative helpers: All informants mentioned the primary importance of family and friends for mental problems. Many emphasized the importance of religious people, priests and monks. All mentioned possible help from such traditional helpers as astrologers, fortune tellers, spiritualists, paranormals, sorcerers, and herbalists. These serve as resources for people with health and mental health problems in developing countries, especially among the poor. In most countries there are basically two health cultures-- one made up of those who go to traditional healers and another of those who go for Western-type medical assistance. In Mexico, it is common to go to a curandero. In some countries, even wealthy people will seek
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the traditional help first. There are also community "advice-givers" (often old women or men) known for their wisdom in helping with decisions and problems. (Such alternative care-givers might be enlisted in training programs for prevention.) 4. Existing prevention programs: Informants knew of few or no such programs in the target countries, except those about drug abuse and AIDS. There were also some health-promoting programs for new mothers of babies, and some television and poster programs about family planning. In Thailand, two informants saw the revival of Buddhism as related to promotion of mental health. 5. Rankings of the five American prevention programs: See Tables IA and IB. A rank of 1 was highest, e.g., most needed in the target country, and 5 the lowest. We did not carry out statistical checks of significance because we see this as preliminary and exploratory for formulating some hypotheses. (Arbitrarily, it seems useful to hypothesize about differences when group means are more than one point.) In the tables, averages are given only for the primary countries (with at least 3 informants each). The additional interview results with 4 other Asian countries and 2 other Latin American countries with fewer than three interviewees per country are simply listed in raw form to generate further speculation. Need: First we asked informants to rank the five programs as to need in the developing countries. In general, about Asian countries, there was little unanimity or enthusiasm regarding need for these programs. An average rank more than one point above 3 was given only in India for the Prenatal/Early Infancy program, in Indonesia and Thailand for the Adolescent Substance Abuse program, and in Thailand for the Community Heart program. In the two Latin American countries, only the Adolescent Substance Abuse program is highly ranked for need. Feasibility: The primary Asian and Latin American informants were also not dearly sure about feasibility, and interviews revealed skepticism. Only the Adolescent Substance Abuse program attained an average rank of less than 2 for economic and political feasibility. Among individual Asian countries, in India the prenatal program was perceived as quite feasible (but the answers there assumed that the women were married, since being an unwed mother is socially unacceptable in India). For Indonesia, informants perceived the Community Heart program as highly feasible. Other than that there were only a few average ratings at 2 or less. Looking at total averages for the primary countries, we see that programs related to physical health were generally more acceptable than those clearly related to mental health and educational improvement. On many rankings of needs and feasibility, the Asian and Latin American countries were perceived as fairly close. The largest differences
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Table IA. Mean Rankings (1, highest) of the Five U.S. Prevention Programs for Need and Economic, Political, Cultural, and General Feasibility in Asian Countries [I = India; Is = Indonesia; P = Philippines; T = Thailand] Need
Feasibility Econ.
A. Prenatal early inf.
I* Is: P:
Total: 4 Other Asian Co.** B. Preschool learning
I: Is: P: T:
Total: 4 Other Asian Co.**
1.7 3.6 3.3 2.8 2.8 (1, 2, 5, 1, 2)(3, 4,
1.7 3 2.6 2.5 2.4 3, 1, 3)
2.3 3 3.6 3.6 3 3 4.___22 3..__88 3.3 3.4 (3, 5, 1, 4.5, 1)(3, 4,5, 4.5, 1)
C. Interpers. Prob-Solv. I: Is: P: Total 4 Other Asian Co.**
2.5 2.5 2.6 4.3 2.6 4.3 3.8 4.__33 2.9 3.8 (5, 4, 2, 4.5, 5)(3, 5, 3, 4.5, 4)
D. Adol. Substance Ab. I: Is" P: T: Total: 4 Other Asian Co.** (2, 1, E. Commun. Heart Prob.
Total: 4 Other Asian Co.**
4.5 2 1.7
4.2 3.7 1.3 2.5 2.6 2.9 3, 3, 3)(4, 1, 2, 2, 5)
Pol.
Cult.
General
2 3 2 2.2 2.3
1.3 3.3 2.6 3.__22 2.6
1.8 2.3 3 2.2 2.3 (1, 1, 5, 1, 3)
2 3.6 2.3 2..__66 2.9
3 3.6 2.6 2._44 2.9
2.2 3.6 3 3.___66 3.0 (1, 4, 1, 4, 2)
3 4 3.3 2.__.44 3.2
4 4.3 4 3.._99 4.0
3 4.3 4 4.__.44 4.2 (4, 5, 2, 4, 5)
4 3.7 3 3.5 3.6
4 2.7 2 3 2.9
4.8 2.7 1.7 3.2 3.1 (1, 2, 4, 4, 1)
I:
3
2.8
3
2.7
3.5
Is: P:
3 4.7
1.3 2.7
1.3 4
1.7 3.7
1.7 3.3
~
~
2.5
~
2.7
2.5
3.2 2.2 (4, 3, 4, 2, 4)(4, 2, 1, 3, 2)
2.5 2.8 (1, 3, 3, 2, 4)
*Assuming girl is married. **Individual ratings for Need, Economic and General Feasibility from one or two informants in 4 other Asian countries: In order, Burma, 2 from Malaysia, Pakistan, Singapore
between them (at least one point) showed up on the ratings for programs in the Preschool Learning (Asians higher on need), Interpersonal ProblemSolving (Asians higher on the average across feasibility ratings) and Substance Abuse (Latin Americans higher on need and feasibility). Because N's for each country were small (2 to 4 ratings in each category), not much
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Table 113. Mean Rankings (1, highest) of the Five U.S. Prevention Programs for Need and Economic, Political, Cultural, and General Feasibility in Latin American Countries [C = Chile; M = Mexico] (with Asian means from Table IA) Need
Feasibility Econ.
A. Prenatal early inf.
2.7 2.__55 2.8 2.4 (3, 1, 3)
3 3 3 2.3 (3, 5, 3)
4.3 1._._/7 3 2.6 (2, 4, 5)
2.7 2._33 2.5 2.3 (3, 4, 3)
C: M:
4 4.7 4.4 3.3 (3, 4, 3)
3.3 4.__.33 3.8 3.4 (5, 2, 4)
3.3 4..__.00 3.6 2.9 (5, 2, 4)
2 4 3 2.9 (4, 2, 4)
3 4.7 3.8 3.0 (4, 5, 4)
C: M:
3 _3 3 2.9 (5, 3,4)
3 4 3.5 3.8 (2, 5,1)
2.7 4._._33 3.5 3.2 (4,4,5)
2.7 4._._77 3.7 4.0 (5, 4, 3)
3.7 4.__.-3 4 4.2 (5, 2, 5)
C: M:
1.3 1.___77 1.5 2.6 (1, 2, 2)
2.3 _1 1.6 2.9 (1, 4, 2)
2.7 1 1.8 3.6 (1, 3, 1)
2.7 2 2.4 2.9 (1, 1, 2)
3.7 1.7 2.7 3.1 (1, 1, 1)
C: M:
3 2.7 2.8 3.2 (4, 5, 5)
3.3 3.'/ 3.5 2.2 (4, 3, 5)
3.3 3.__77 3.5 2.7 (2, 5, 2)
3.3 2.-/ 3 2.5 (3, 3,1)
3 2 2.5 2.8 (2, 3, 2)
Lat. Am. Total Asian Total: 2 O t h e r L . A. Co.* D. Adol. Substance Ab. Lat. Am. Total Asian Total: 2 O t h e r L . A. Co.* E. Commun. Heart Prob. Lat. Am. Total Asian Total: 2 O t h e r L . A. Co.*
General
2.7 3._.0 2.8 2.8 (2, 1, 1)
Lat. Am. Total Asian Total: 2 Other L. A. Co.* C. Interpers. Prob-Solv..
Cult.
C: M:
Lat. Am. Total Asian Total: 2 O t h e r L . A. Co.* B. Preschool learning
Pol.
*Ratings from informants regarding 2 other Latin American countries: In order, 2 from Ecuador, 1 from Panama.
r e l i a n c e c a n b e p l a c e d o n t h e m , b u t it is c l e a r t h a t t h e r e w a s n o t u n a n i m i t y among the judges and the average ranks were seldom above the middle. 6. T h e A l b e e " F o r m u l a " f o r p r e v e n t i o n : G e o r g e A l b e e (1984) h a s m e n t i o n e d six f a c t o r s t o b e c o n s i d e r e d in p l a n n i n g p r o g r a m s f o r p r e v e n t i o n of psychopathology. (See Table II.) Informants were asked to indicate w h e t h e r e a c h f a c t o r w o u l d b e high, m e d i u m o r l o w in i m p o r t a n c e f o r a
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Table II. Ratings (High, Medium, Low) on the Albee Prevention Factors and Weighted A:
Total
India
LA:
Totals (W.T) Indonesia Philippines Thailand Chile Mexico
W.T
Organic problems (basic health): A: M,H,H L, L, H, H LA: M,H,H
M,M,M L,L,L M,H,H
2.0 1.3
Stress of ordinary living:: A: L, L, H M, H, H, H LA: H,H,H
L, M, M L, H, H H,H,H
1.6 1
Exploitation and powerlessness of certain groups A: H, H, H M, H, H, H A: H,H,H
H, H, H, L, H, H, H H,H,H
1.4 1
Competence & Coping Skills: A: H,H,? M, H, H, H LA: H,H,H
M,M,? H,H, H H H,H,H
1.2
Self Esteem A: LA:
M, ?, ?
M, H, H, H H,H,H
M, M, ? M, H, H H,H,H
1.5
Social Support: A: LA:
L, L, L
H, H, H H,L,L
H, H, H L, M, H H,H,H
1
1 1.8
1.7
program in the given country. On the table, the Weighted Total average is given by counting high as "1" etc. Both for Asia and Latin America almost all Albee factors tend to be rated medium or high. Some Asian informants indicated that some programs already were in existence (e.g., basic health in Thailand) or that stress was less in Asian societies than in the West. The mixture of ratings for Asian countries on Social Support was clarified in the interview; some informants saw little need to be concerned about that since family and group support are already strong, whereas others emphasized the importance of social support because of the danger of losing it as the country modernizes. 7. Major cultural differences from the U.S.: All informants identified many differences. Frequently mentioned for all countries were these: Strong family relationships and support in the developing countries, strong religious influences on daily life and a more relaxed life style in contrast with the competitive individualism in America. Training children to be self-directed and autonomous, as in the Interpersonal Problem-Solving program,
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would not be seen as desirable in most other countries. There were numerous other differences. Comparing the different countries some characteristics stood out as different from others; for instance, violence was mentioned as common in the Philippines and machismo as important in Mexico. Gender inequality and taboos on relations between the sexes are prominent in some countries; in India, interviewees said that a girl getting pregnant before marriage would be ostracized by her family, even killed. Some respondents noted that the U.S. had a strong cultural and media influence, especially in Panama and Mexico. Informants noted the difficulty of disentangling cultural differences from socio-economic status; poverty and low levels of education in other countries make for enormous contrasts with American lifestyles. As already suggested, some respondents pointed out that there are two cultures within these countries: The rich, educated elites and the poor, more traditional majority, often living in rural settings, but also in urban slums. 8. Problems with applying the five programs in the other countries: Numerous problems were mentioned. Most prominent among them was need for funding. Others were the lack of education, staff training, knowledge about the problems, government bureaucracy, corruption, and traditional attitudes. For example, cigarette smoking is usually not seen as a health problem because it is so widely accepted and in some countries is even promoted by the government monopoly on tobacco. A problem with school programs is the large size of classes--40 or 50 in a room m and the lack of supplies and technology. There is little training or interest in evaluating effectiveness of programs. 9. Resources for possible application of these programs: Informants also pointed out some help for prevention programs. In most countries, religious institutions might be helpful; some middle-class people, especially women, might provide volunteer help; and the health and welfare infrastructure might be enlisted in programs with proper funding. The existence of socialized medicine in some countries affects needs and feasibility; in Myanmar (Burma), for instance, clinics or health personnel, though trained at a low level, operate throughout the country and can be mobilized for prevention programs. International organizations like UNICEF and nongovernmental organizations probably could help. Those programs related to physical health would be the easiest to start. 10. What could Americans leam from these developing countries? This question was enthusiastically welcomed by the informants. Frequent answers were strong family bonds, community neighborliness, and a greater acceptance of life with its joys and problems. "We have mental peace more than Americans." "Hardly anyone is alone." Americans need to "loosen up," reduce stress, be more involved in group and family living. Some re-
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spondents said that in other countries people have a greater acceptance and care for unfortunates such as retarded people and the homeless.
DISCUSSION AND CONCLUSIONS In general, we found this exploratory effort very rewarding. We recognized our reach was very b r o a d - - 27 interviews covering 12 countries-and our methods qualitative and preliminary. However, some ideas emerged suggesting directions for further work. In the American literature on dissemination of mental health programs to other sites, there is a debate between extremes--those who advocate close fidelity to the original program and those who say programs should be re-invented for each new place (Bauman et al., 1991). It was clear that a simple transfer of a prevention program from the U.S. to a developing country in Asia or Latin America is nearly impossible. Cultural, economic and socio-political structures are too complexly different. Affecting everything else is the economic situation in these developing countries. For instance, poverty influences such things as the availability of children for the pre-school and school programs; they are needed for work to help improve the family income. As Maslow's need hierarchy postulates, the primary needs for existence--food, shelter, physical h e a l t h - - m u s t come first before higher needs such as enjoying life and actualizing oneself. So some of the programs (e.g., Interpersonal Problem-Solving) are of questionable priority for the mass of the population. Some of these programs would be of interest and appropriate for the small sector that is wealthy and educated. Along with poverty, the population p r o b l e m - - h u g e and increasing --affects every other variable in such programs. Perhaps, prevention of further population increases should be of highest priority, but we did not address this behavioral problem in our interviews. Needs, goals and ideals about positive mental health vary across countries. Draguns (1990) notes mental health implications from the general cultural dimensions found in Hofstede's research on 40 countries, namely the four dimensions of power distance, uncertainty avoidance, individualism/collectivism, and masculinity/femininity. In an European study, Minsel, Becker and Korchin (1991) found that a less developed country placed higher values on behavioral control and adaptation and less emphasis on self-actualization than more developed countries. Even within the United States, as Goggin and associates (Goggin, 1987; Goggin, Bowman, Lester & O'Toole, 1990) have shown, considerable effort is needed to identify local needs and attitudes and to assure participation in implementing community
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Table HI. Contrasting Cultural Characteristics Affecting Mental Health Work Traditional (S & SE Asian) vs. "Modem" (Western/No. Amer.) Religion, Philosophy, Folk beliefs
Hinduism, Buddhism, Islam, Filipino Catholicism, animism, spirit possession, casting spells, astrology, ancester worship, acceptance/fatalism
Judeo-Christian beliefs, determinism, scientism, pragmatism, materialism, innovation, "maker of one's fate"
Social relations:
Groupism, collectivism, familism, conformity, interdependence, hierarchical, status rigidity, holistic (whole person)
Individualism, autonomy, competition, independence, status flexibility, fragmented roles
Environmental relations:
Harmony with nature, dependence on nature, close to nature
Dominance over nature, exploitation, technical, distant from nature
Orientation to time:
Cyclical, relaxed about clocks & appointments
Linear, clock awareness, fast paced, concern for future, "time is money"
Cognitive approach:
Synthetic, multilectic, harmony-seeking (both-and)
Analytic, dialectic, critical (either-or)
Communication:
Passive,indirect, control of emotions
Active, direct, expression of emotions
Goals:
Harmony with family & environment, Enlightenment (Hinduism/Buddhism) Gaining merit by giving Submission to authorities
Self-reliance, Salvation/Adjustment Material "success" Equality, doubting authority
Self:
Defined by relation to others, especially in family relations
Defined by self, identity in accomplishments
Cause of mental illness:
Physical & mental closely related, caused by karma, spells & charms, spirits, cosmic imbalance, etc.
Compartmentalization, genetics, socialization, unconscious motives, etc.
Expectations:
Rapid cure, physical/med, treatment, authoritative prescription
Talking cure, joint participation
Disorders of Organic connection, so Thought & Emotion organic treatment
Mental causes, so talking helps
Responsibilities for Change
Family-centered
Person-centered
Self-disclosure
Low to non-family
High to helper
Relation with helper Distant
Intimate
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"lhble lII. Continued Traditional (S & SE Asian) vs. "Modem" (Western/No. Amer.) Acceptance of problem
Suffering expected, Exercise will-power
Pain can be helped
Mode of treatment
Physical or meditation
Verbal, "talking cure"
change. Torrey (1986, p. 91) points out that ideas of prevention exist in many societies, but they may take the form of an amulet worn around the neck; he notes that physicians' prescriptions are sometimes placed in amulets. As an exercise in anticipating cultural differences in developing prevention programs, Table III lists traditional (largely Asian) versus modern (largely U.S. & European) contrasts that might affect mental health work. Obviously, there are great differences between and within countries; for instance, compare affluent and internationally competitive Singapore with poor and isolated Myanmar (Burma). Table III oversimplifies, but it does suggest the exploration of hypotheses stemming from literature on cultural differences. Underlying the concept of prevention is a concern for the future. The anthropologist, Robert Textor (1991) has labeled and analyzed the widespread problem of tempocentrism, or failure in anticipating the future, in many cultures. Sippanondha Ketudat and Textor (1990) have shown ways of increasing future thinking through a method entitled Ethnographic Futures Research. Sippanondha illustrates by openly exploring optimistic, pessimistic and most probable scenarios for Thailand. A body of knowledge and training methods is developing which might be used for prevention program planning (Sundberg, 1985). As mentioned earlier, prevention researchers argue about maintaining fidelity to original programs or re-inventing them for other places. Bauman and her associates (1991) suggest a compromise: Make use of the basic program theory and adapt to local characteristics. In our interviews, it appeared that the Albee prescription for prevention, the six causative factors of psychopathology, are relevant to other countries. Keeping those in mind in designing a program should be helpful. In conclusion, we can list some general guidelines for applying prevention programs in another cultural context (especially in developing countries in Asia and Latin America):
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1. Basic principles: Many of the usual principles of program development and evaluation may apply at a general or abstract level. The six Albee factors--organic problems, stress, group exploitation, competence, self-esteem, and social supports--will provide useful guidelines for program design. In addition many of the procedures developed for prevention programs are applicable, e.g., needs assessment, identifying at-risk groups, consciousness raising, incorporating influential leadership, and program evaluation. 2. Cost~benefit analyses: In poor countries, preparatory research needs to include the costs of a prevention program relative to other possible uses of scarce funds. Long-term benefits, through perhaps not very apparent, are important. Costs and benefits also relate to population pressures, which underlie many problems in developing countries. Analyses must address issues of family planning, gender employment differences, and the effects on family structure and dynamics as change comes. Data on social indicators for developing countries are sparse. Suntaree Komin (1989) has presented thought-provoking data on social dimensions of industrialization in Thailand. The World Bank (1990) and UNESCO (1992) have begun to produce some indices of social development in addition to the usual economic development information. 3. Cultural resources: One needs to identify local resources and build on those. For instance, traditional healers and religious leaders may be trained and involved in prevention activities. The preventionist needs to find out who are influential people in the community. Often temples or churches are resources in Asia and Latin America. Some informants suggested that sports figures, radio singers and movie stars would be excellent to promote knowledge and practices about prevention in the media. Also of relevance are indigenous philosophies and sayings which might be used to promote mental health, such as rnai pen rai, the Thai idea of acceptance meaning "never mind" and "don't worry" (Hollinger, 1965). A similar idea of non-attachment, anasakti, may be useful in India (Pande & Naidu, 1992). 4. Appropriate technology: It is important to search for and develop the mental health equivalents of "appropriate technology" such as using existing communication networks, making small modifications of existing services, and offering training that is simple and pays off as immediately as possible. An interesting suggestion from informants was the possibility of illustrating mental health suggestions and how to cope with stress in popular comic books. Other vehicles for preventive education and programs are temples, mosques and other religious organizations. Some religious leaders, such as Buddhadasa in Thailand, are able to demonstrate the compatibility between science and Buddhism, the religion of 95% of the Thais (Jackson, 1988).
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5. Community sensitivity: Each developing country is different from other countries and has much heterogeneity within its borders; so programs must be specifically planned. We have not emphasized differences among these chosen Asian and Latin American countries very much but they were quite obvious. For instance, there was much concern about AIDS prevention in Thailand where prostitution has a long history, but not much concern about it for India. Gender roles differ in different cultures, seclusion and suppression of women being particularly strong in some Muslim countries. The perception of high incidence to violence was strongest in the Philippines. Substance abuse was seen as a great problem in the Philippines, Chile and Mexico but not in India. Distinctions need to be made in program planning between resources and needs of the urban elites, the urban poor and the rural populace. Program developers need to be aware of the differential readiness for programs, building on acceptable practices. In developing countries, there is hope for prevention of undue stress and psychopathology, if only their citizens and Western friends can (a) understand how to make use of and maintain strengths now in existence and (b) learn from problems and successes in other countries. For the future it seems highly likely that rapid urbanization, migration from villages, industrialization, and adopting of Western materialistic values will destroy many current social supports and indigenous helping systems. If the history of Western mental health system is blindly followed, these countries will wind up with an over-dependence on highly trained and expensive professionals, while not avoiding the disorders and stresses of modernization. ACKNOWLEDGMENTS Earlier forms of this paper were presented at the First Annual Convention of the American Association of Applied and Preventive Psychology, June 16, 1991, Washington, D.C. and the Fourth Annual Conference of the Northwest Regional Consortium for Southeast Asian Studies, Nov. 9, 1991, Eugene, OR. The authors wish to thank the 27 informants who must, however, remain nameless here.
REFERENCES Albee, G. W. (1984). Prologue: A model for classifying prevention programs. In J. M. Joffe, G. W. Albee, & L. D. Kelly (Eds.) Readings in primary prevention of psychopathology: Basic concepts. (pp. ix-xvii) Hanover, NH: University Press of New England. Bauman, L. J., Stein, R. E. K., & Ireys, H. T (1991). Reinventing fidelity: The transfer of social technology among settings. American Journal of Community Psychology, 19, 619-639.
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Draguns, J. G. (1990). Applications of cross-cultural psychologyin the field of mental health. In R. W. Brislin (Ed.) Applied cross-cultural psychology (pp. 302-324). Newbury Park, CA: Sage. Goggin, M. L. (1987). Policy design and the politics of implementation--the case of child health in the American states. Knoxville: Univ. of Tennessee Press. Goggin, M. L., Bowman, A. O., Lester, J. P. & O'Toole, L. J. (1990). Implementation theory and practice: Toward a third generation. Glenview, IL: Scott, Foresman/Little Brown. Higginbotham, H. N. (1984). Third world challenge to psychiatry: Culture accommodation and mental health care. Honolulu: Univ. of Hawaii Press. Higginbotham, H. N. & Connor, L. (1989). Professional ideology and the construction of western psychiatry in Southeast Asia. International Journal of Health Services, 19, 63-78. Higginbotham, H. N. & Marsella, A. S. (1988). International consultation and the homogenization of psychiatry in Southwest Asia. Social Science and Medicine, 27, 553-561. Hollinger, C. (1965). Mai pen rai means never mind. Boston: Houghton Mifflin. Hume, J. C. (1986). Colonialism and sanitary medicine: The development of preventive health policy in the Punjab, 1860 to 1900. Modem Asian Studies, 20, 703-724. Jackson, P. A. (1988). Buddahasa: A Buddhist thinker for the modem world. Bangkok: The Siam Society. Minsel, B., Becker, P., & Korchin, S. J. (1991). A cross-cultural view of positive mental health: Two orthogonal main factors replicable in four countries. Journal of Cross-Cultural Psychology, 22, 157-181. Pande, N. & Naidu, R. K. (1992). Anasakti and health: A study of nonattachment. Psychology and Developing Societies, 4, 89-104. Price, R. H., Cowen, E. L., Lorion, R. E, & Ramos-McKay, J. (Eds.) (1988). 14 ounces of prevention: A casebook for practitioners. Washington, DC: American Psychological Association. Sippanondha Ketudat & Textor, R. B. (1990). The middle path for the future of Thailand: Technology in harmony with culture and environment. Honolulu: East-West Center. Sugar, J. A., Kleinman, A. & Heggenhougen, K. (1991). Development's "downside": Social and psychological pathology in countries undergoing social change. Health Transition Review, 1, 211-220. Sundberg, N. D. (1985). The use of future studies in training for prevention and promotion of mental health. Journal of Primary Prevention, 6, 98-114. Suntaree Komin (1989). Social dimensions of industrialization in Thailand. Bangkok: National Institute of Development Administration. Textor, R. B. (1991, Oct.) Tempocentrism: A universal phenomenon with cultural variations. Paper presented at the Symposium for the Cultural Environment of Psychology in Honor of Ernest E. Boesch. Merlingen, Switzerland. Torrey, E. E (1986). Witchdoctors and psychiatrists: The common roots of psychotherapy and its future. New York: Harper & Row. United Nations Development Programme (1992). Human development report, 1992. New York: Oxford University Press. World Bank (1990). World Development report, 1990. New York: Oxford University Press.
