Abstract
Creativity is often enhanced when we look at a problem from different perspectives. For those of us in health promotion, looking at successful approaches to change one behavior like smoking can lead to ideas and approaches about addressing different behaviors like opioid use or physical activity. The broader our knowledge base and experiences are, the better able we are to draw from different experiences to create novel approaches to addressing challenges. One way to broaden our perspectives is to look at how other countries address health promotion.
With over 180 countries in the world, there is a lot to learn about the ways that health can be improved. With a life expectancy of 79.5 years, Americans can expect to live about 4 years less than someone living in Japan. 1 While one might think this is a genetic difference, it is important to note that Italy, Singapore, Spain, Iceland, Israel, South Korea, Canada, Chile, and several other countries enjoy longer life expectancies than the United States. 1 When many people think of international health issues, HIV/AIDS, famine, and diarrheal diseases come to mind. However, 6 of the top 7 leading causes of death globally are noncommunicable diseases including ischemic heart disease, stroke, chronic obstructive pulmonary disease, Alzheimer disease and other dementias, trachea, bronchus and lung cancers, and diabetes mellitus. 2 About half of premature deaths are preventable through health behavior change, including tobacco use, nutrition, physical activity, and alcohol use. 3 Health behaviors range widely across countries. For instance, in Ecuador, annual per capita cigarette consumption is less than 100 cigarettes per year, while in Russia it is over 2000 per year, a 10-fold increase. 4
Given the large differences in health behaviors and approaches to health promotion in different countries, an improved global understanding can improve our effectiveness in health promotion back in the United States. With the requirements post-2001 for US citizens to hold passports to travel to Mexico, Canada, and Bermuda, there has been a steady rise in the number of American citizens who hold passports. Amazingly back in 1989, only 3% of Americans had ever held a passport. 5 This had increased by 2017 to 42%. 5 Although this is an impressive increase, more than half of all Americans have never left US soil. If you are interested in gaining a global perspective, where can you start?
Travel is one of the best ways to experience different cultures. If you are new to travel, it is fine to stay close to home. Even Canada addresses health promotion issues differently than America. For my students who study abroad, I tell them to use their “public health lens” as they travel. For instance, go to a convenience store and look at a pack of cigarettes. Are they self-serve or behind the counter? How much do they cost? What does the warning label look like? Where is smoking allowed? In this brief exercise, you will learn a lot about smoking regulations in the country you are visiting. Trying this exercise in Canada, you will quickly notice that half of the package is covered in a graphic warning label. Cigarettes will also cost quite a bit more unless you live in New York, Illinois, or other states with high cigarette taxes. Next, take a walk through the city. What do you notice? Is it pedestrian and cyclist friendly? Is there bike share or green space where you are walking? Are destinations convenient? Try walking into a park. In one of my research studies in China, we found that over half of the users of parks were older adults compared to less than 10% in numerous studies across the United States. 6 What we found was that parks were designed fundamentally different. 7 Parks in the United States were designed for children and teenagers with playgrounds, basketball, and tennis courts and baseball fields. Parks in China were built for adults with water features, quiet green space, exercise equipment, and areas for dance and tai chi. Eat your meals in local restaurants. Take good notice of the menu. Are there vegetarian/vegan options? How big are the portion sizes? How often are vegetables served with the meal? On one of my trips to Ireland, I noticed that every menu item included allergen information. This is an easy way to address food allergies that has not been widely adopted in the United States.
Tourist travel is a first step toward gaining a better understanding of different global approaches to health promotion. There are several things that we can learn at home that can help us when we travel but also help us to better understand the diverse people who we work with and interact with in our daily lives. Dr David Livermore has developed an excellent course called, “Customs of the World: Using Cultural Intelligence to Adapt to Wherever You Are.” 8 This 24-lecture course provides a good overview of some of the major dimensions that differ in cultures across the world, including identity, authority, risk, achievement, time, communication, lifestyle, rules, expressiveness, and social norms. While people within certain cultures certainly differ quite a bit, these traits help to provide a framework for understanding different cultures. I traveled to China for the first time in 2004 before taking this course and experienced quite a bit of culture shock. China scores highly in a collectivist approach with a high-power differential, while the United States is highly individualistic with a low-power differential. I experienced this first hand at every meal, where all of the seating was done by academic rank from the most important to the least important and all the food was ordered family style without asking anyone what they wanted. Understanding these cultural issues are essential in any type of dietary intervention in a Chinese community. There are also several Massive On-line Open Courses in comparative health systems, cultural competence, global health, and other areas that provide a free and easy way to learn about how different countries about health care and health promotion.
The US workplace and our universities are becoming more and more global. We work with more people from diverse backgrounds that can share about the practices in their cultures and countries. At my School of Public Health at Texas A&M University, about one-third of our students come from international backgrounds. Our faculty is just as diverse coming from South Korea, China, India, Trinidad and Tobago, Ghana, Canada, and Mexico. Take time to talk to people from other countries in your organization. Learn about health promotion practices in their country. What did they notice was the most different about the United States when they came here? What were they surprised to find out? These conversations can be quite enlightening. When I teach global health, one of my first questions to the international students is what they think is the strangest thing that we do in the United States. The answers are quite varied and surprising. It helps to challenge the ideas we have about what is “normal.” Things like vacation time, maternity leave, and work schedule vary dramatically across the world. In China, I was surprised that my hosts dropped me off after lunch to take a nap. Soon, I realized this was the standard schedule and most people took a short nap after lunch. I found this in Italy too, where most businesses would close in the afternoon to accommodate a nap and are open later in the evening with dinner occurring quite late. This different pace of life across the country affects stress and coping responses in people from different countries.
One of the best ways to learn about the world is to see it like a local. As I had the conversations with my colleagues at the University of Hawaii at Manoa, I ended up talking a lot to a faculty member named Yuanan Lu. One day, Yuanan asked me if I would like to go to China with him to set up exchange agreements for the school. This was one of the best decisions I ever made. Yuanan served as a cultural bridge between me and my Chinese counterparts. He helped me to understand intricate cultural details and how to get business done. These insights have helped me have a successful career in China as a visiting faculty member at 2 Chinese universities and contributed to more than a dozen peer-reviewed articles on public health in China. In the 14 years since this trip, I have sent several faculty and dozens of students to China to live and work. Every one of them has come back changed. It is incredibly rewarding to see the amount of learning and self-awareness that occurs when someone is outside their comfort zone.
I have found both direct and indirect effects of my global perspective on my work in health promotion in the United States. This past year, Texas A&M University launched the largest dockless bike share program on any campus in the United States. My group assisted the transportation department in studying how the implementation was going. Although the program was highly successful in getting users, there was a major problem with riders parking the bikes all over campus and the surrounding community. The initial plan was to create a rack to rack system where riders would park the bikes in a bike rack. At this point, I traveled to Beijing for a business trip. I rode the bike share across the city and noticed that the bikes were neatly parked in squares painted for bike share returns. I was able to bring this idea back and help partially solve some of the bike parking issues. Another area where international experience has affected my work is in Japan. There is a strong recognition between exposure to nature and health. There is even a concept of forest bathing, where people take retreats to natural areas to restore their health and reduce stress. I have been able to work with 2 developers in the United States to include nature exposure in their developments. The first is a new housing development, which now includes miles of wooded walking trails. The second is a local wellness center, which now includes both indoor and outdoor spaces and views of the natural environment. In China, at every meeting we were served green tea or water. While this is a welcoming gesture, it is also a healthy way to keep hydrated throughout the day. At my school, I have banned school funds from being used to buy sugary beverages. When people come to visit the Dean’s office, there are offered water, coffee, or tea. In my office, I have over a dozen types of tea from my visits to China.
International work has been one of the most rewarding things that I have done in my career. It can be intimidating at first but by taking the small steps outlined here it can grow fast. There is no one current way to promote the health of populations, improving our understanding of the myriad of ways that countries and cultures address health promotion issues can make us better health promotion practitioners in our daily work. Try finding some ways that you can expand your global perspective on health promotion. You will be glad you did.