The instruments used for the survey in each study location varied slightly, but for the purposes of this analysis, each study site used three key instruments -a demographic questionnaire, the Life Orientation Test (LOT-R), and the Short form 12, or SF-12. The instruments were pilot tested separately in each location, and minor modifications were made to ensure comprehension and comparability across sites. In China and Ghana, the instruments were translated into the dominant language of the region and backtranslated into English by native bi-lingual speakers. The original and back-translated versions were compared for consistency, and any inconsistencies were resolved by discussion and consensus among the research team.