Improving health, worldwide

A serious shortage of health-care providers threatens well-being around the world. With the planet's population soaring, the global health crisis stands to get even worse. According to the World Health Organization, 57 countries have fewer than 23 health workers for every 10,000 citizens, and 13 low- and middle-income countries have fewer than one hospital per million people.

Those proportions are expected to deteriorate by 2045, when the world's population is predicted to swell to 9 billion, from 7 billion today.

Clearly, there's work to be done to meet the world's burgeoning health-care needs, especially within the developing world. But more medicine and more doctors aren't the only answers. Most global health concerns—including HIV, obesity, malnutrition and sanitation—have a behavioral component, says Robert Balster, PhD, a psychologist at Virginia Commonwealth University and currently a Jefferson science fellow at the U.S. Agency for International Development (USAID). As a result, he says, "focusing on behavior change would have huge benefits."

"Regardless of the kind of health-care intervention, psychology needs to be at the table," adds Chris Stout, PsyD, who directs the Center for Global Initiatives and is a clinical professor at the College of Medicine, University of Illinois, Chicago. "Psychologists are probably better trained than any other health-care professional to have cultural awareness and sensitivity, and that queues us up to be really helpful when we deal with global health issues."

Psychologists are gradually becoming more tuned into global health, says Merry Bullock, PhD, senior director of APA's Office of International Affairs. The International Congress of Psychology, scheduled to be held in Cape Town, South Africa, in July, features health as a central topic and will include a symposium on models of health care around the world, organized by APA's Senior Science Advisor Ellen Garrison, PhD, Bullock says. And APA President Suzanne Bennett Johnson, PhD, serves on a committee for the International Council of Science, which recently issued a global call for research on a systems approach to global health issues. Those collaborations, Bullock says, "make opportunities available for broader international exchange."

Psychological perspective

Among the greatest threats to human life is infectious disease. In 2010, malaria alone killed 655,000 people—a tragedy made even more heartbreaking by the fact that the disease is both preventable and curable.

In the poverty-stricken regions where malaria is endemic, however, prevention and treatment are hard to come by. Most malaria-carrying mosquitoes bite at night, and insecticide-treated bed nets are one of the most effective and affordable defenses against the deadly disease. "[Bed nets] are a very cheap intervention and they're quite available," says Balster. "The trick is to get people to use them, and use them properly."

To do that, health workers have implemented a variety of behavior-change initiatives in countries throughout Africa, Balster says. USAID-supported behavior-change workers took steps to make it easy for people to obtain bed nets, encouraged local leaders to endorse their use and recruited community health workers to go door-to-door distributing nets and explaining how to use them. They distributed pamphlets, broadcast radio campaigns, held town hall meetings, and led community workshops. The efforts paid off. In nine countries where baseline data are available, bed net ownership more than doubled from 2004 to 2010, Balster says, with corresponding improvement in malaria rates. In Ethiopia, for instance, villages that received malaria prevention and treatment programs saw malaria cases fall by 73 percent between 2005 and 2010.

Educating communities about the importance of bed nets is one thing. Health workers face bigger hurdles when trying to convince people to change their sexual behavior. HIV/AIDS infects some 34 million people worldwide. Much of the effort to control AIDS focuses on biomedical advances such as vaccines and anti-retroviral medications. Those are clearly important, says Balster. "[But] an equally important and effective use of resources is in prevention."

Among the psychologists applying their talents to AIDS prevention is Kathleen Sikkema, PhD, a professor of psychology and neuroscience at the Duke Global Health Institute. Sikkema, who studies HIV prevention and mental health in South Africa and other developing nations, argues that mental health treatment should be a key element in any HIV prevention program (AIDS and Behavior, 2010). After all, she says, researchers have compiled strong evidence of the link between HIV transmission risk and mental health. A person with a poor mental health status is more likely to engage in risky sexual behaviors and less likely to adhere to drug treatment protocols that could minimize the spread of the disease.

To address these issues, Sikkema and her colleagues are developing and testing a number of HIV interventions in South Africa and elsewhere. One project promotes adaptive coping among HIV-positive men and women with a history of childhood sexual abuse. Another teaches coping skills to young children of HIV-positive mothers, while a third aims to reduce risky behavior among women who drink alcohol in informal drinking establishments where gender-based violence is prevalent. With these projects, she and her colleagues hope to identify effective techniques to ultimately reduce the spread of HIV.

Of course, infectious diseases such as malaria and HIV make up just one subset of the global health agenda. Worldwide, rates of chronic, non-communicable diseases such as heart disease, lung disease, diabetes and cancer have been rising sharply alongside skyrocketing obesity (The Lancet, 2011). Many people think of obesity and related diseases as plights of prosperity, but in fact, nearly 80 percent of deaths from chronic, non-communicable diseases occurred in low- and middle-income countries in 2008, according to the WHO.

With primary risk factors such as poor diet, tobacco use and inactivity, those diseases have a clear behavioral component. And that's where psychologists like Gary Bennett, PhD, also at the Duke Global Health Institute, can help. Bennett has developed obesity interventions in the United States, and is now working to adapt some of those successful interventions for China. It's a good place to start. "There are more than 1.5 billion overweight people in the world, and at least a quarter of them are in China," he says.

He's testing an innovative project that provides tailored diet and exercise goals to participants via text message. In China, as in many other countries around the world, nutrition labeling on food is inconsistent. And as the country becomes more prosperous, eating out is becoming much more popular. As a result, he says, "counting calories is a real challenge." The text message program provides accessible, understandable goals that ultimately help people reduce their caloric intake and increase their activity levels—even if they aren't charting every calorie they swallow.

Bennett is still testing the intervention, but he's hopeful that it can be adapted to communities and cultures around the world. Access to technology is growing at a rapid pace. "Cell phone towers are now found in most remote parts of the world," he says. Unfortunately, the same cannot be said for psychologists. "Obesity and other health behaviors present major opportunities for psychology," he says. "I think, frankly, we need many more psychologists focusing on these issues."

Another important area where psychologists are making a difference is at the intersection of early nutrition and behavior, says Maureen Black, PhD, a psychologist at the University of Maryland School of Medicine. Scientists have learned a lot about the relationship between psychology and nutrition over the last decade, Black says. Maternal depression, for instance, puts children at risk of nutritional deficiencies, poor growth and cognitive delays (Bulletin of the World Health Organization, 2011). On the flip side, maternal education and protective factors such as breastfeeding and early cognitive and socio-emotional opportunities can reduce a child's future health risks, as Susan Walker, PhD, at the University of the West Indies, with Black and other colleagues from the Global Child Development Group, reported last fall (The Lancet, 2011). Together with economists, psychologists have shown that ensuring early child development puts children on a positive trajectory to benefit from educational opportunities, become productive citizens and enhance the social capital of the society, Black says.

Such findings now form a basis for global policy recommendations, she says, and international agencies such as the WHO, the World Bank and UNICEF are incorporating a psychological angle into their strategies to promote early childhood development and nutrition.

Mental health experts can also help improve people's use of health-care services, says Balster. People in resource-poor regions may not take advantage of opportunities such as vaccination and prenatal care. As experts in behavior, psychologists can help identify and address the underlying reasons to help people make the most of health-care resources. "It's one thing to have medicines," Balster says, "but people have to take them properly."

Local knowledge

When working in other countries, the best approaches aren't always the most intuitive. Sometimes it makes sense to adapt models from the United States to fit the needs of a developing country or community. In other instances it's better to create a program from scratch for a particular place and culture. "Understanding cultural context and adaptation to the local community are essential for interventions to be effective," Sikkema says.

As health workers implement behavior-change programs, they must also ensure their strategies are good for the long haul, Balster says. "Historically, there's been too much of Western nations coming in, dumping a lot of money on a problem and disappearing when the money runs out." Fortunately, that appears to be changing, he says.

Stout, who works with communities around the world through the Center for Global Initiatives, has also witnessed a growing emphasis on involving locals to create sustainable programs. Drawing on local experience just makes sense, he says. "Natural healers in South Africa provide services that you and I would see as pretty close to counseling," he points out. "In Cambodia and Vietnam, midwives become the de facto medical responders." When global health workers collaborate with these local sources of knowledge, they stand to reach more people and continue to benefit communities well into the future, he says.

Nevertheless, the psychology angle still sometimes gets short shrift among global health initiatives. That's gradually changing, Stout says, as researchers continue to demonstrate the value of psychology to global health. Black adds that, in her view, most global health agencies and organizations are happy to include the psychological perspective—especially when that perspective includes a preventive point of view. "I think psychologists would be much better positioned to have a global impact if they took their theories, which are strong and effective in promoting positive behavioral changes, and put them in a public health perspective," she adds. "Don't wait until the problem has occurred. Think about prevention, or better yet, health promotion."

Ultimately, Balster adds, psychologists are poised to make an important contribution to global health. "There are associations of psychology in most every country of the world," he notes. "Psychology has the wherewithal to be an organized global presence."

Kirsten Weir is a writer in Minneapolis.