Culture and measurement Flashcards
What does the evidence suggest on the dichotomy of body and mind across cultures?
Most cultures differentiate illnesses of the spirits and illnesses of the body
- mental distress vs. somatic
How are illnesses of the spirit / mental distress categorised in most cultures?
- Causation: external/internal
- ancestors, witchcraft, god-given, hereditary, alcohol - Phenomenology: external/internal
- type and severity of behavioural disturbance
What does the phenomenology of mental illnesses (illnesses of the spirit) refer to?
The type and severity of behavioural disturbance
What do causation and phenomenology of illnesses of the spirit / mental distress determine in all traditions?
- Illness beliefs/prognosis
- Help-seeking
- Treatment
What does Kleinmann’s explanatory models (1980) propose?
Service users, clinicians and policymakers operate in cultural settings AND hold their explanatory models of illness
What is the purpose of Kleinmann’s explanatory models (1980)?
Useful to explain influence of culture on mental illness experience
What did Kleinmann’s explanatory models (1980) mark in history?
- A great leap forward for cross-cultural psychiatry
- Beginning of documenting and accounting for cultural differences in experiences of illness
What was the purpose of the questionnaire in Kleinmann’s explanatory models (1980)?
Reveal labels and cultural idioms in experiences of illness
- related beliefs about aetiology
- causation and relevant health-seeking behaviours
What was particular to panic disorder and PTSD in Khmer refugees?
Autonomic symptoms (e.g. dizziness and palpitations) interpreted as blocked wind - "Kyol Goeu" = 'wind overload'
- wind is essential to Khmer psychophysiology
- they believe small vessels carry blood and wind through the body
- symptoms of blockage associated to death if no intervention
What did the study on panic disorder and PTSD in Khmer refugees illustrate?
Challenges associated with understanding mental health and diagnoses across cultures
- Khmer refugees interpreted autonomic symptoms as blocked wind (“Kyol Goeu” - ‘wind overload’)
What are the implications of the challenges associated with understanding mental health and diagnoses across cultures?
> Need to develop cultural phenomenology of illness experience
> Clinicians and researchers should understand cultural syndromes
- how they relate to cognitions, experiences and MH outcomes
> It’s important in order to quantify burden of disease
> Also important when developing health services, systems and models of care
What did Francis Galton put forward about measurement?
It’s an essential component of scientific research (natural, social, health)
What was the purpose of objective (or close to objective) measurement according to Francis Galton?
- Lab/tissue -> basis for diagnosis
- Determine if patient has / does not have the disease
- Appropriate amount of time after disaster: count survivors
In which cases does measurement create challenges in mental health?
- Subjective states (e.g. quality of life)
- Conditions without biomarkers (e.g. mental disorders)
What is the place of diagnostic criteria (e.g. DSM, ICD)?
> Diagnosis relies on report or observations of behaviour and internal mental states
- important for quantification of burden and impact of disease
> We use diagnostic criteria which we believe represent the latent structures of disorders
What is the aim of diagnostic criteria?
To obtain optimum validity and reliability
What is validity in diagnosis?
A diagnosis reflects the disorder it is designed to identity
What is reliability in diagnosis?
Diagnosis works in the same way
- among different people
- in different settings
- over time in same patient
What does the DSM and ICD represent in mental illnesses?
They represent categories based on phenomenology, NOT aetiology
What are the criticisms of the DSM and ICD?
> Pharma companies have too much influence over categorisations
> Labels are unhelpful for clinicians
> Labels stigmatise patients
> Categorisation pathologist problems of everyday life
> DSM and ICD are based upon research and clinical experience from Western countries (not rest of the world)
What would be the consequences if the Western basis of the DSM and ICD results in bias?
> Symptoms that are important in particular parts of the world would be missed from DSM or ICD
> Some symptoms included in criteria might not be reported in particular populations / cultural groups
What did Haroz and colleagues (2016) identify in the experience of depression around the world?
Important signs of bias:
- features such as social isolation, crying, anger and pain are not part of DSM criteria
- problems like concentration, agitation and slowing which are part of DSM criteria were not commonly mentioned in studies
What do the signs of bias in the DSM diagnostic criteria regarding mental illness experience around the world reveal?
Need for a review of content of standard instruments
- beyond the focus on DSM diagnostic criteria
- AND beyond regional variation and instruments
- to reflect local variation in presentation of symptoms
What constitutes the universalist approach to mental illness?
= Etic approach:
- mental illness is similar around the world
- psychiatric taxonomies, measuring instruments and models of healthcare designed in the West are globally applicable
What constitutes the relativist approach to mental illness?
= Emic approach:
- evaluation of phenomena from within culture and its context
- aiming to understand significance with other intra-cultural elements
What is the criticism of the universalist (etic) approach?
This approach is an imposition of universality and of Western ideas
- seeking to impose homogeneity when the reality is heterogeneity
What is the criticism of the relativist (emic) approach?
- It negates what is shared cross-culturally
- It does not facilitate any kind of cross-cultural comparative research and learning
What has been happening over the last 25 years regarding the universalist (etic) and relativist (emic) approaches?
- Increasing recognition of importance of both approaches
- integration of emic and etic approaches is now characteristic of cross-cultural psychiatry
What are the two aims of measurement in global mental health?
- To adapt our approach to measurement to ensure we understand the ‘true’ burden and impact of disease
- To remove effects of Western bias upon results, whilst accepting shared core symptoms of mental disorder across different cultural settings
What does the validity of measurement refer to?
Does the measurement capture what it is supposed to measure?
What is a construct validity?
A way of comparing performance of a measure to that of ‘gold standard’ in identifying cases and non cases
What do criterion and convergent validity refer to?
Does the measure perform as expected in relation to other variables?
What does the reliability of measurement refer to?
Is the measure consistent over time and across different people?
What is the inter-observer reliability?
Degree of agreement between observers
What is the test-retest reliability?
Agreement between observations on the same patient, separated by interval of time
What is an internal consistency in measurement?
Degree to which different items in questionnaire are related to each other
What does the ethnocentric approach to measurement propose?
- Conceptual and psychometric equivalence
- Instruments can be used across cultures
What does the derived emic approach to measurement propose?
- Conceptual overlap across cultures
- Psychometric properties are not significantly altered
- Conceptual limitations exist but are not marked
- > Limited adaptation of measures necessary
What does the integrated emic and etic approach to measurement propose?
- Little conceptual overlap
- > adaptation cannot guarantee conceptual/psychometric equivalence
- Indigenous instrument alongside translated questionnaire (e.g. Patel et al., 1997)
What does the emic approach to measurement propose?
- Without conceptual overlap, translation and validation is impossible
What was the aim of the Shona symptom questionnaire (Patel et al., 1997)?
To develop an indigenous measure of common mental disorders
early example of integrated emic+etic approach
What constituted the Shona symptom questionnaire (Patel et al., 1997)?
Qualitative research + WHO Self-Reporting Questionnaire
- Cases: symptoms of common mental disorder
- Non-cases: no symptoms of common mental disorder
What was the etic gold standard for the Shona symptom questionnaire (Patel et al., 1997)?
A standardised clinical interview instrument
What was the emic gold standard for the Shona symptom questionnaire (Patel et al., 1997)?
A clinical judgment of a care provider
What did the Shona symptom questionnaire (Patel et al., 1997) show?
Cultural idioms of distress at the least overlap with Western notions of depression
- more than 80% of primary care attenders were cases
- symptoms represented in items of SSQ were identical with or similar to symptoms in Western instrument
- analysis of main symptom scores showed that anxiety and depression were strongly related
What are the five steps to produce the translation of a mental disorder measure instrument?
- Translation
- of the concept behind each item
- incorporating local idioms of distress - Back translation (re-translate) to original language
- Comparison
- of the two versions
- resolve discrepancies - Critical review
- bilingual mental health specialists critically review final instrument - Pilot
- pilot test with people with similar characteristics to study group
What is the consensus method process in the translation of a measure instrument?
Structured discussions:
1. Panel of local bilingual speakers with medical and/or mental health experience
- Independent translations of the instrument
- independent rating by all members of the group
- Translations achieving the most endorsement from group members will be taken forward to second round
- Discussion -> most satisfactory translations to be included in final questionnaire
What is the benefit of using the consensus method to translate a mental disorder measure instrument?
Avoids the pitfalls of a single back translation, which can reflect individual idiosyncrasies of language
How do you optimise cross-cultural validity in practice?
- Recruitment of sample sufficient to enable analysis of psychometric properties of instrument (e.g. n = 200)
- Research interview including the instrument as well as background contextual information
- Participants also undergo a gold standard semi-structured diagnostic interview with mental health specialist
- Subsample (n = 50) will be re-interviewed using the instrument within 2 weeks of initial research interview
What are the 7 practical steps to ensure cross-cultural validity?
- Consider culture and language at early stage
- Review range of local and international instruments to identify candidate instruments
- Consider your approach (etic/emic)
- Conduct qualitative work to explore the meaning of constructs
- Ensure careful translation and modification of existing instruments
- focusing on conceptual and semantic equivalence - Carry out pilot study and further modification accordingly
- Carry out validity study
- describe psychometric properties of scale
- choose appropriate sampling strategy and adequate sample size to compare new method with ‘gold standard’
What is the main focus of a cross-cultural validity analysis?
To compare the performance of the new instrument with ‘gold standard’
