Cross-Cultural Perspective in Health Care:

When Culture Matters!

Cross-Cultural Perspective in Health Care:

When Culture Matters!

Elizabeth Trejos-Castillo, Ph.D.

TTU Human Development & Family Studies

--“Previously, men could be divided the learned and the ignorant, those more or less the one, and those more or less the other. But your SPECIALIST SPECIALIST cannot be brought in under either of these two categories. He is not learned, for he is formally ignorant of all that does not enter into his specialty; but neither is he ignorant, because he is ‘a scientist’, and ‘knows’ very well his own tiny portion of the universe.

We shall have to say that he is a ‘Learned Ignoramus’Learned Ignoramus’... a person who is ignorant, not in the fashion of the ignorant man, but with all the petulance of one who is learned in his own special line.”—

José Ortega & Gasset “The Revolt of the Masses” (1930)

--“Previously, men could be divided the learned and the ignorant, those more or less the one, and those more or less the other. But your SPECIALIST SPECIALIST cannot be brought in under either of these two categories. He is not learned, for he is formally ignorant of all that does not enter into his specialty; but neither is he ignorant, because he is ‘a scientist’, and ‘knows’ very well his own tiny portion of the universe.

We shall have to say that he is a ‘Learned Ignoramus’Learned Ignoramus’... a person who is ignorant, not in the fashion of the ignorant man, but with all the petulance of one who is learned in his own special line.”—

José Ortega & Gasset “The Revolt of the Masses” (1930)

The Greatest Sin of Specialists: Knowledge Bias

“Emic” (insider) vs. “Etic” (outsider) views in Health Care

“Disease”, “Illness”, “Social Constructionism”

or or “Sickness”? “Biological Reductionism”

Disease-Illness-SicknessDisease = bio-medical definition of a pathology (physical)

Illness = subjective feelings of not feeling “well” (psychological)

Sickness = social interpretation of a personal condition (social well-being)

Health is a state of complete Physical, Psychological, & Social well-being” (WHO, 1948)

“How we communicate about our health problems, the manner in which we present our symptoms, when and to

whom we go for care, how long we remain in care, and how we evaluate that care are all affected by cultural beliefs”

(Kleinman, Eisenberg, Good, 2006, p.251)

““Understanding Pain”Understanding Pain”

““Understanding Pain”Understanding Pain”

“Thus, while the stimulation of pain fibers to tell the brain that something is wrong is the same among all human beings, the perceptions and control of pain vary from society to society.” (Moore-Free, 2002, p. 143)

“While individual scholars conduct studies and issue reports on the phenomena of pain and its control, it is simply impossible for clinicians to understand all of these differences and societal belief systems. What is possible for clinicians and is important and comforting to patients is to ask them about their belief systems.” (Moore-Free, 2002, p. 144)

• Universal View: Developmental processes (patterns of association between predictors and outcomes) are highly similar across ethnic/racial, cultural, immigrant, and national groups (Barber & Harmon, 2002; Dmitrieva et al., 2004).

• Differential View: Developmental processes vary due to specific characteristics of a group of individuals and how cultural patterns in such groups and social networks impact individual development and behaviors (Kagitçibasi, 2003; Kwak, 2003).

Similarities vs. Differences in Similarities vs. Differences in

Human Developmental Human Developmental ProcessesProcesses

Trejos-Castillo, E., & Vazsonyi, A.T. (In-press)

Diversity = True Multiculturalism?...

Common Design Flaws in Multi-Cultural Research

Unequal percentages of participants across groups

Mostly Between-group comparisons

Assuming within-group homogeneity (generational differences?)

Mostly quantitative methods

Measurement assumptions:a. Response Consistency: similar use of response categoriesb. Item Equivalence: respondents can related to items

Statistical vs. Statistical vs. Practical SignificancePractical Significance

• “The Sizeless Stare of Statistical Significance” (Ziliak & McCloskey, 2007)

• How “BIG” is “big” in practical/clinical terms? (sample size and “true effects”)

• Better Practice: Clinically “Meaningful” Statistical Significance

Is it possible? What are the Costs? To Whom?

Table 2. Mean Level Comparisons of T1 Parenting Processes and T2 Risky Sexual Behaviors by Immigration Status

1st Generation Immigrant

Hispanic Youth

2nd Generation Immigrant

Hispanic Youth

Items Parenting Processes (T1) (range) M SD M SD p

Autonomy Granting 7 (0-7) 2.49 1.75 2.19 1.57 .614

Support 5 (5) 4.43 .585 4.39 .680 .915

Communication 4 (0-4) 1.80 1.30 1.94 1.28 .872

Risky Sexual Behaviors (T2) 6 (0-6) .663 .883 .717 .950 .499

1st Generation Immigrant

Hispanic Youth

1st Generation Immigrant

Hispanic Youth

2nd Generation Immigrant

Hispanic Youth

2nd Generation Immigrant

Hispanic Youth

Items Parenting Processes (T1) (range) M SD M SD p

Autonomy Granting 7 (0-7) 2.49 1.75 2.19 1.57 .614

Support 5 (5) 4.43 .585 4.39 .680 .915

Communication 4 (0-4) 1.80 1.30 1.94 1.28 .872

Risky Sexual Behaviors (T2) 6 (0-6) .663 .883 .717 .950 .499

Trejos-Castillo, E., & Vazsonyi, A.T. (In-press)

Where is the Culture in Where is the Culture in

Cross-Cultural Translation?Cross-Cultural Translation?

Translation Back-Translation

Culturally Sensitive Instruments

A Zebra is a ZEBRA not a Black & White Striped Horse!...

“Translation process should be focused not merely on language transfer but also

—and most importantly—on cultural transposition.”

(Karamanian, 2002)

Becoming Culturally CompetentBecoming Culturally Competent

Cavusgil S.T., & Das, A. (1997).

Cross-Cultural Research

• Generating Comparative Knowledge

• “Medicine” in many cultural groups is not clearly differentiated from that of religion, politics, and the rest of social life…

• Beliefs and health practices “go together”

• Raising awareness, tolerance, and respect

Becoming Culturally CompetentBecoming Culturally Competent

“If we are to achieve a richer culture, rich in contrasting values, we must recognize

the whole gamut of human potentialities, and so weave a less arbitrary social fabric,

one in which each diverse human gift will find a fitting place.”

Margaret Mead (1901-1978 American Anthropologist)

“If we are to achieve a richer culture, rich in contrasting values, we must recognize

the whole gamut of human potentialities, and so weave a less arbitrary social fabric,

one in which each diverse human gift will find a fitting place.”

Margaret Mead (1901-1978 American Anthropologist)

"The art of teaching is TOLERANCETOLERANCE. HUMBLENESSHUMBLENESS is the art of learning"

BKS Iyengar

(1918- Indian Yoga Master)

"The art of teaching is TOLERANCETOLERANCE. HUMBLENESSHUMBLENESS is the art of learning"

BKS Iyengar

(1918- Indian Yoga Master)

ReferencesBarber, B. K., & Harmon, E. L. (2002). Violating the self: Parental psychological control of children and adolescents. In B. K.

Barber (ed.), Intrusive Parenting: How Psychological Control Affects Children and Adolescents (pp. 15-52). Washington, DC: APA.

Cajan, S. (2001). Statistical significance is not a "Kosher Certificate" for observed effects: A critical analysis of the two-step approach to the evaluation of empirical results. Educational Researcher, 29, 31-34.

Cavusgil S.T., & Das, A. (1997). Methodology issues in cross-cultural sourcing research - A primer. Marketing Intelligence & Planning, 5, 213-220.

Dmitrieva, J., Chen, C., E., Greenberger, E., & Gil-Rivas, V. (2004). Family relationships and adolescent psychosocial outcomes: Converging findings from Eastern and Western cultures. Journal of Research on Adolescence, 14(4), 425-447.

Kagitçibasi, C. (2005). Autonomy and relatedness in cultural context: Implications for self and family. Journal of Cross-Cultural Psychology 36 (4), 403-422.

Karamanian, A.P. (2002). Translation and culture. Journal of Translation, 6(1), 1-3.

Kleinman, A. Eisenberg, L. & Good, B. (2006). Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research. American Psychiatric Association, Focus 4:140-149.

Kwak, K. (2003). Adolescents and their parents: A review of intergenerational family relations for immigrant and non-immigrant families. Human Development, 46, 115-136.

Maturo, A. (2007). "Integrating the Triad Disease-Illness-Sickness: The Concept of “Sickscape”.  Paper presented at the annual meeting of the American Sociological Association, New York, NY.

Moore Free, M. (2002). Cross-cultural conceptions of pain and pain control. Baylor University Medical Center Proceedings, 15:143–145.

Trejos-Castillo, E., & Vazsonyi, A.T. (In-press). Risky sexual behaviors in first and second generation Hispanic immigrant youth. Journal of Youth and Adolescence. Special Issue: The Place of Race and Ethnicity in Adolescent Development.

WHO (2003). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.