WHO cross-cultural applicability research on diagnosis … cross-cultural applicability research...

Addiction (1996) 91(2), 199-220

RESEARCH REPORT

WHO cross-cultural applicability research ondiagnosis and assessment of substance usedisorders: an overview of methods andselected results

R. ROOM, A. JANCA/ L. A. BENNETT,' L. SCHMIDT^& N. SARTORIUS^

Addiction Research Foundation, Toronto,- ^Division of Mental Health, World HealthOrganization, Geneva; ^Department of Anthropology, Memphis State University, Memphis;^Alcohol Research Group, Berkeley & '^Department of Psychiatry, University of Geneva,Geneva, Switzerland

With: J. Blaine (NIDA, Washington DC); C. Campillo (Mexico City, Mexico);C.R. Chandrashekar (Bangalore, India); D. Dawson (NIAAA, Washington DC); A. Gogus(Ankara, Turkey); B. Grant (NIAAA, Washington DC); O. Gureje (Ibadan, Nigeria);Ho Young Lee (Seoul, Republic of Korea); V. Mavreas (Athens, Greece); J. Rolf (Baltimore,Maryland); L. Towle (NIAAA, Washington DC); R. Trotter, III (Flagstaff, Arizona);T.B. tJstun (WHO, Geneva); J.L. Vazquez-Barquero (Santander, Spain) & R. Vrasti Qebel,Romania)

AbstractThe cross-cultural applicability of criteria for the diagnosis of substance use disorders and of instruments usedfor their assessment were studied in nine cultures. The qualitative and quantitative methods used in the studyare described. Equivalents for English terms and concepts were found for all instrument items, diagnosticcriteria, diagnoses and concepts, although often there was no single term equivalent to the English in thelanguages studied. Items assuming self-consciousness about feelings, and imputing causal relations, poseddifficulties in several cultures. Single equivalent terms were lacking for some diagnostic criteria, and criteriawere sometimes not readily differentiated from one another. Several criteria—narrowing of the drinkingrepertoire, time spent obtaining and using the drug, and tolerance for the drug—were less easy to use incultures other than the United States. Thresholds for diagnosis used by clinicians often differed. In mostcultures, clinicians were more likely to make a diagnosis of drug dependence than of alcohol dependencealthough behavioural signs were equivalent. The attitudes of societies to alcohol and drug use affects the useof criteria and the making of diagnoses.

Responsible project officer: Dr A. Janca, Mental Health Division, World Health Organization, 1211 Geneva 27,Switzerland.

Correspondence to: Robin Room, Addiction Research Foundation, 33 Russell Street, Toronto, Ontario,Canada M5S 2S1.

0965-2140/96/020199-22 $8.00 © Society for the Study of Addiction to Alcohol and other Drugs

Carfax Publishing Company

200 R. Room et al.

IntroductionThe WHO/NIH Joint Project on diagnosis andclassificationDevelopment of cross-culturally applicable diag-nostic criteria and instruments for the assess-ment of mental disorders in different cultureshas been one of the major goals in the WHO/NIH Joint Project on Diagnosis andClassification of Mental Disorders, Alcohol- andDrug-related Problems. This reflects the com-mitment of the World Health Organization(WHO) to the development of a "common lan-guage" (Sartorius, 1989) which will allow mentalhealth professionals and others concerned withthe management of mental health and psychoso-cial problems to understand one another andwork together.

The Joint Project started in 1979 as a collabo-rative endeavour between WHO and three USNational Institutes, the National Institute ofMental Health (NIMH), the National Instituteon Alcohol Abuse and Alcoholism (NIAAA) andthe National Institute on Drug Abuse (NIDA)—formerly parts of the Alcohol, Drug Abuse andMental Health Administration (ADAMHA) andnow research institutes within the National Insti-tutes of Health (NIH). In a series of workshopsorganized at the beginning of the project expertsfrom different countries, different cultures and avariety of clinical and social science traditionswere invited to define problems and recommendactivities which could lead to the development ofcrossculturally applicable instruments for the as-sessment of various aspects of mental and be-havioural disorders, to the formulation of criteriafor their diagnosis, and to the adoption of sci-entifically and practically useful internationalclassifications (Sartorius, 1989).

More than 100 centres from all over the worldhave been participating in the various activitiesof the WHO/NIH Joint Project. Major achieve-ments of this fruitful international collaborationhave been related to the development of clinicaland research diagnostic criteria for the ICD-10Classification of Mental and Behavioural Disor-ders (WHO, 1992aj 1993) and instruments fortheir assessment. The Composite InternationalDiagnostic Interview (CIDI) (Robins et al., 1989;WHO, 1990), and the Schedules for ClinicalAssessment in Neuropsychiatry (SCAN) (Winget al., 1990; WHO, 1992b), are members of thefamily of instruments developed within theWHO/NIH Joint Project.

77ie international diagnostic instrumentsSCAN is a semi-structured diagnostic instru-ment primarily designed for use in diagnosingdisorders and syndromes by clinicians, particu-larly psychiatrists and clinical psychologists; itmay be administered by other health profession-als with appropriate training. It offers consider-able freedom for interviewers to frame questionsabout a particular symptom, and requests thatthey make a judgement about the presence orabsence of a symptom defined in the SCANglossary. Stemming from the tradition of thePresent State Examination (PSE) developed atMaudsley Hospital in London, the SCAN hasbeen developed as a clinical assessment tool forthe assessment of a broad range of psychiatricsymptoms, syndromes and disorders listed in thecurrent classification systems (for details seeWing et al., 1990).

CIDI is a highly structured interview schedulewhich is designed to be administered by trainedlay interviewers. The instrument consists of fullyspelt-out questions, fixed coding options and aclearly specified probing system that allow theinterviewer to determine the severity and likelypsychiatric significance of a positive symptom.The instrument is designed for adult respon-dents with varying educational and culturalbackgrounds. Stemming from the Diagnostic In-terview Schedule (DIS) which was developed atthe Washington University, St Louis and appliedin the US Epidemiological Catchment Areastudies (Robins & Regier, 1991), the CIDI isprimarily intended for epidemiological studies ofmental disorders in different cultures and set-tings (for details, see Robins et al, 1989).

The traditions from which the CIDI andSCAN stem have been distinguished by a com-mitment to the operationalization of diagnosticconcepts and categories in a reliable form. Foreach diagnosis, a set of operational criteria weredeveloped which were in principle objectivelyand reliably measurable. The reliability of anoperational measure—the degree to which itcould be reproduced by an application of thesame measure a second time or by a seconddiagnostician—became a key criterion of its ac-ceptability. With the issuance of the Uiird Re-vision of the Diagnostic and Statistical Manual ofthe American Psychiatric Association (DSM-III), this approach gained general acceptance inthe United States, and increasingly also in othercountries. Its influence is strong in the mental

Cross-cultural applicability of diagnoses 201

disorders chapter of the new version of the Inter-national Classification of Diseases, ICD-10.With the advent of ICD-lO's Classification ofMental and Behavioural Disorders (WHO,1993), it might truly be said that the emphasison operationalizability as the sine qua non ofdiagnosis of mental disorders has become aworld standard.

The application of alcohol and drug concepts anddiagnostic instruments cross-culturallyOperationalization is necessary for major studiesin psychiatric epidemiology and in clinical trials.It may also be helpful to clinical practice; but itis not without hazards. This is particularly truewhen the resulting measures are to be used tocompare rates or trends across cultures and soci-eties, while the operational criteria are based onmaterial dravsni from a narrow cultural range.The application of culturally specific descriptionsand symptomatologies to other cultures may leadto inappropriate diagnoses and conclusions(Klausner & Foulks, 1982, Chapter 16; Room,1984).

There has already been an object lesson in thisdanger in the history of the concept of alco-holism. In the late 1940s and early 1950s, as"alcoholism" became the main alcohol-relatedpsychiatric disorder, it was defined in ratherculturally specific terms—in terms, in fact, of theexperience of an emerging US-centred mutualhelp group. Alcoholics Anonymous. Thus theclassic description of alcoholism by the leadingalcohol scholar of the time, E. M. Jellinek(1952), was based on the results of question-naires about symptomatology developed by andcirculated among Alcoholics Anonymous mem-bers in the United States. Only when Jellinekhad acquired a wider experience in the field byworking as a consultant to the World HealthOrganization in Geneva did he develop the ideathat there were a number of culturally influenced"species" of alcoholism, with different symp-tomatologies Qellinek, 1960a, b). Jellinek's dif-ferent species, distinguished by Greek letters,mapped onto the very different denotations hefound that "alcoholism" had among health pro-fessionals in different cultures—"gamma" for the"Anglo-Saxon" variety he had earlier described,"delta" for the French variety, "epsilon" for theFinnish variety.

Despite the possible pitfalls, there has been an

increasing interest in applying clinical instru-ments developed in one culture in another cul-tural situation. Applying the Munich AlcoholismTest (MALT) developed in Germany to samplesin Spain and Ecuador, Gorenc et al. (1984)found that five of the 31 items were "relativelyfiree of cultural differences" by their criteria, butthe authors added that when used in Ecuadornone of the items passed all five of the filtersused to screen out items in the original Germanstudy.

The most ambitious effort in this direction waswell under way before the CAR project started(Helzer & Canino, 1992). The effort was aserendipitous by-product of the wide inter-national use of the DIS, an instrument originallydeveloped for use in the United States. In gen-eral, the DIS was applied without adaptation.Since the analysis is primarily at the level ofdiagnoses, findings about the cross-cultural ap-plicability of the instrument are mainly in theform of side-comments. An example of this is thenotation that whether the "period of heavydrinking" required for a dependence diagnosishad to last 2 weeks or 4 weeks made an import-ant difference in how many received the diag-nosis among American Indians in the UnitedStates, given a "well-defined cultural pattern ofbinge or episodic heavy drinking" (Helzer &Canino, 1992, p. 126).

An earlier WHO study also analysed the cross-cultural applicability of alcohol dependencesymptomatology (Hall et al, 1993). Using data-sets from six divergent countries which com-bined together drinkers among generalhealth-service patients and clinical alcoholics,the study found a strong general factor for 13dependence-related items in factor analysingeach country's data. This was interpreted assupporting the cross-cultural generalizability ofthe alcohol dependence syndrome, althoughalternative interpretations are possible for afinding of a general factor for symptomatic itemsin factor analyses in different societies.

The genesis and material of the Cross-CulturalApplicability (CAR) StudyOver the past 10 years both CIDI and SCANwere field-tested in more than 20 centres world-wide, and were found to be generally appropriateand reliable for use across cultures and settings(Wittchen et al., 1991). However, the field tests

202 R. Room et al.

did not include large numbers of alcohol anddrug users, so that the modifications of the sub-stance use disorders sections of the instrumentshad not been field-tested in different culturalsettings.

Accordingly, in September 1990 an advisorygroup recommended a substantial programme ofresearch on the cross-cultural applicability of thealcohol and drug sections of the internationaldiagnostic instruments. The programme wasconceived as having two phases: a study of themeanings and interpretations of alcohol and druguse and problems in different cultures, and oftheir implications for creating uniform diagnosticstandards and international instruments appli-cable across cultures; and a cross-cultural studyof the reliability and validity of the instruments.The present report is concerned with the first ofthese phases, known as the Cross-Cultural Ap-plicability Research (CAR) study. The secondphase of the programme of research is underway.

The CAR study was thus carried out in ninesites world-wide, selected for their cultural andlinguistic diversity: Ankara, Turkey; Athens,Greece; Bangalore, India; Flagstaff, Arizona(Navajo); Ibadan, Nigeria; Jebel, Romania; Mex-ico City, Mexico; Santander, Spain; and Seoul,South Korea. The proximal aim of the study wasto test and as necessary improve the cross-cultural applicability of two existing internationaldiagnostic instruments—the CIDI and theSCAN. Our task was simplified by the fact thatfor alcohol and drug conditions, the SCAN wasclearly derivative from the CIDI, so that only fora few special topics was it necessary to cover twodifferent approaches.

The study's design included five substudieswith diverse data collection techniques and sam-pling frames, including a translation and back-translation study, key informant interviews andfocus groups with cultural informants, self-ad-ministered questionnaires filled out by local clin-icians, and trials of diagnostic schedules with"reference cases" in alcohol and drug treatmentfacilities. The findings of the study were plannedto be used in: (a) future work improving of thediagnostic instruments and developing guidelinesand instructions for their use in different cul-tures, (b) making the final adjustments for thelarge-scale testing of these instruments for re-liability and validity in population-based sam-ples, (c) analysing of the cross-cultural

applicability of concepts, criteria and symptomsof substance use disorders and their operational-izations, and (d) producing recommendationsconcerning cross-cultural research in the field ofalcohol, drug use and mental health.

In the present paper we give an outline of theCAR project and its findings on the applicabilityin different cultural circumstances of items, cri-teria, diagnoses and concepts particularly rel-evant to four major alcohol diagnoses in ICD-10:acute intoxication, harmful use of alcohol, thealcohol withdrawal syndrome and the alcoholdependence syndrome.

Our analysis is primarily based on English-lan-guage reports of findings from the collaboratingteams of investigators at each study site. As eachcomponent of the study was finished, the investi-gators at each site prepared a report in Englishon the results. In addition, each site prepared anoverall report on the findings from that site forinclusion as a chapter in a book on the study (L.Betinett et al.. Use and Abuse of Alcohol and Drugsin Different Cultures: A Nine-Country Study, inpreparation). The present paper is based onthese reports, and quotes from them as appropri-ate.

Premises of the studyAs we have described, the central purpose of theCAR project was to study the cross-cultural ap-plicability of the alcohol and drug portions of theCIDI and SCAN instruments. Early in the proj-ect it was concluded that this required a studywith a broader reach than simply settling theissue of whether CIDI or SCAN items could betranslated and understood in different languagesand cultures. Behind the items lay the diagnosticcriteria they were designed to measure, and be-hind the diagnostic criteria lay the diagnosesthemselves and the conceptualizations on whichthey were based. A full understanding of cross-cultural applicability and comparability requiredinvestigating the cultural relevance of and vari-ation in the diagnoses and criteria as well as inthe instrument items.

The CIDI and SCAN specifically measurethree ICD-10 diagnoses: the Dependence Syn-drome, Withdrawal State and Harmful Use. Theinstruments also measure the DSM-III-R's ver-sion of the first two diagnoses, along with theDSM Alcohol/Drug Abuse diagnosis. While eachof these diagnoses is given a technical meaning

Cross-cultural applicability of diagnoses

Table 1. ICD-10 substance use diagnoses and their conceptual location

203

Diagnoses

Acuteintoxication

**Harmfuluse

•Withdrawalstate

Dependencesyndrome:

Criteria

1. Strong desire,compulsion

2. Impaired capacityto control

*3. Withdrawal/use to relievewithdrawal

4. Tolerance5. Neglect of alternative

pleasures & activities''*6. Harmful use

(use despite physicalor psychological harm)

X. Narrowing of repertoire

Contrasting(non-diagnostic)

states

Vs. intoxication,not medicallysignificant

Vs. normal use

Vs. hangover

Vs. hangover

Vs. normal use

Related &lay

concepts

Abuse

Alcoholism,addiction

Craving,compulsion

Loss of control

Abuse

•Withdrawal state is both a diagnosis and an element in a criterion for the dependencesyndrome

**Harmful use is both a diagnosis and a criterion for the dependence syndrome

and specific criteria in the nosologies, we mayexpect their practical use to be influenced bydiagnostic concepts which are widely recognizedin lay as well as professional circles—such con-cepts as alcoholism, addiction, withdrawal andabuse. Several of the component criteria for theDependence Syndrome themselves also tap intowell-recognized diagnostic concepts. Besideswithdrawal, these include increased tolerance,compulsion, impairment or loss of control andcraving. Associated with each diagnosis or diag-nostic criterion in the ICD-10 and DSM nosol-ogies is one or more characterizations orsymptoms; in a more or less direct fashion, theseare translated into items or subitems in the CIDIand SCAN.

The CAR study therefore set out to measurethe cross-cultural applicability of terms and for-mulations which fell at each of four distinguish-able conceptual levels: at the level of typificationsor characterizations of problems related to drink-ing or drug use; at the level of diagnoses; at thelevel of diagnostic criteria; and at the level ofinstrument items. As we shall describe, covering

this terrain required the use of several method-ologies in a series of substudies.

Across the various methods and substudies,our general approach has been comparative andcontrastive. The fundamental comparison of thestudy, of course, is berween the nine culturesand eight primary languages of the study. In eachsite, data were collected systematically for al-cohol and for one other drug class of interest,allowing contrasts of the application of conceptsand diagnoses to alcohol and to the drug class.The data also allow for comparisons within eachculture, such as comparisons of professional andlay terminology related to each diagnostic con-cept. Thus respondents were asked for their ownways of describing behaviour covered by suchterms as intoxication, withdrawal, tolerance andharmful use, as well as about their understandingof the meanings of diagnostic terms—both thosein the nosologies and those in popular use, suchas alcoholism and addiction (see Table 1).

In addition to our interest in differences in themeaning of terms and concepts cross-culturally,across drug classes and between experts, profes-

204 R. Room et al.

sionals and lay people, we were also particularlyinterested in differences in the scope of applicationof the terms and concepts. For example, whilethe ideal-type definition of alcoholism given byrespondents from difiFerent cultures might bequite similar, there could still be vast differencesin the threshold of problem severity at whichthey would apply the term alcoholism to a par-ticular case. This question of the scope of appli-cation is as significant as the meaning assigned toa diagnosis in determining the diagnostic processin a given culture. We thus asked respondentsthemselves to compare and differentiate betweenstates which were and were not of diagnosticsignificance (see Table 1). One such set of con-trasts was between "normal" use of a particulardrug, abuse of the drug and harmful use. An-other was between simple intoxication and in-toxication which merited medical attention(assuming the latter to correspond to the AcuteIntoxication diagnosis of ICD-10). Yet anotherwas between a hangover (or the equivalent fordrugs other than alcohol) and the withdrawalstate. In one of the substudies (SARS), theboundaries of application of dependence con-cepts were also explored, with questions con-cerning whether a hypothetical person withparticular symptoms or clusters of symptomsshould be considered addicted or alcoholic.

The study sites and the place of alcohol anddrugs in their culturesNine centres from different cultures and repre-senting different language groups participated inthe CAR study: Ankara, Turkey; Athens,Greece; Bangalore, India; Flagstaff, Arizona,USA; Ibadan, Nigeria; Jebel, Romania; MexicoCity, Mexico; Santander, Spain; and Seoul,South Korea. The sites were selected to assure awide range of diversity in language-groups ofthe main language and in cultural patterns ofdrinking and drug use. The availability on site ofexpert investigators with a command of Englishand an ability to mount a substantial projectwas also a practical consideration. As Table 2summarizes, the nine sites include substantialvariation in dominant religions. They are also atdifferent levels of economic development andgeographically widely dispersed.

In each site, the main emphasis of the studywas on the predominant local culture. In manycases the predominant local culture was also the

main national ethnicity and people living therespoke the dominant national language. In othercases, the cultural and linguistic situation wasmore complex. In Bangalore the emphasis wason Kannada, the local language and ethnicity,and similarly in Ibadan the emphasis was onYoruba, but in both places some data were col-lected in English, which is in widespread use asa lingua franca. In Flagstaff the emphasis was onNavajo, an American Indian nation with its ownlanguage, but all data were collected in English,since English is known to nearly all and is theusual language of therapeutic and official com-munication, while not all Navajos understandspoken Navajo. The inclusion of both San-tander, Spain and Mexico City allowed a com-parison of two very diverse cultures sharing acommon language.

The sites included in the CAR study not onlyrepresented a diversity of language groups, butalso varied greatly in terms of the place of al-cohol in the culture. The position of alcohol in agiven culture is often discussed in terms of arough dimension of greater or less "wetness"(Pittman, 1967; Room, 1989, 1992; Levine,1992). In the ideal type of a wet culture nearlyeverybody drinks nearly every day; alcohol is adomesticated and indeed banalized part of dailylife. Heavy drinking is thus an extension of socialdrinking; the norm for the heavy drinker, indeed,is to keep drunken behaviour as much like soberbehaviour as possible. As described by thestudy's investigators and respondents, the studysites in Santander, Spain and Athens, Greeceprobably come as close as anywhere to embody-ing this "wet" type. Jebel, Romania would alsoapproach this end of the continuum, but with theharsher economic conditions enforcing less regu-larity in drinking, and perhaps also with heavydrinking seen somewhat more as "time out".

At the "dry" end of the continuum, as it iscommonly discussed, are cultures in whichdrinking is set apart from daily life, on fiestas orweekends, and in which there are many abstain-ers. Drinking is "time out" behaviour, anddrunkenness can serve as an explanation of badbehaviour (MacAndrew & Edgerton, 1969). In afurther extension of this, indeed, extreme drunk-enness to the point of passing out can take on apositive value for some in the culture. Amongour study sites extremely heavy drinking is well-established in the culture in Flagstafif, Arizona(see also Kunitz & Levy, 1994) and Seoul,

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206 R. Room et al.

South Korea, even though only a substantialminority of the population engages in it. Theother four study sites all show a pattern whereabstention is common, and drinking is defined aspotentially disinhibiting. In Ankara, Turkey andBangalore, India, indeed, most adults are ab-stainers, and in Bangalore any drinking at allmay be problematized and seen by the drinker'sfamily as causing bad behaviour.

The per capita consumption figures shown inTable 1 confirm the places of Athens, Santanderand Jebel at the "wetter" end of the drinkingspectrum, and the status of Ankara, Bangaloreand Mexico City as located in societies withmuch lower consumption. The relatively highper capita consumption in South Korea, how-ever, alerts us that a differentiation in terms ofthe drama surrounding drinking is not only amatter of the level of consumption. The level ofdrinking in South Korea has risen dramatically inthe last three decades, but the cultural patterningof drinking, with an emphasis on ostensive drink-ing bouts, is far removed from the banalizedpattern of everyday drinking in a wine culture.The cultural variation to be found among the"dryer" cultures in the CAR study material sug-gests, in fact, that a single "wet/dry" continuumdoes not adequately capture the dimensions ofcultural variation in the position of drinking.

Limits on resources meant that data collectionwas limited to covering alcohol and one otherdrug class at each site. The other drug or class ofdrugs covered at each site was chosen as havingthe highest apparent prevalence of harmful usethere. In Ankara, Athens and Santander heroinwas chosen as the most significant drug, whilecannabis was the choice in Bangalore, Flagstaff,Ibadan and Mexico City. In Jebel the choice wassedative medications, and in Seoul am-phetamines. In most sites, use of the other drugcovered by the study was seen as substantiallymore culturally alien than drinking alcoholicbeverages. However, in Jebel the use of sedativesis somewhat normalized in the culture, while inBangalore drinking alcoholic beverages may beat least as marginalized as using carmabis.

Study methodsThe study represented a multi-disciplinary en-deavour of psychiatrists, anthropologists, sociol-ogists, epidemiologists, psychologists and

linguists, with the lead provided at most centresby psychiatrists and their staff. All the partici-pants listed at the head of this article, and someothers as well, were involved in the design of thestudy and in an intense phase of writing, testingand refining the new or revised instruments usedin the study. Since the study's use of qualitativeand ethnographic methods in the context of amulti-national effort in psychiatric epidemiologyrepresented a new departure, considerable effortwent into training in and demonstration of themethods. In addition to demonstrations as partof the meetings of investigators two trainingcourses were organized for investigators and in-terviewers, covering CIDI and SCAN adminis-tration as well as key informant interview andfocus group techniques.

The study consisted of five core components,designed to complement each other vsdth differ-ent methods, study populations and focal con-cerns, A strength of the study's design is itsdiversity of data collection methods, which al-lowed for some convergent validation of findingsfi-om different substudies.

Due to the compressed timetable and limitedresources of the study not all components werecompleted at each site, and there was also vari-ation between sites, as we shall describe, in theextent to which the fiall design of a componentwas carried out. Overall, the completion of thegreater pan of the full design is a tribute to thecommitment and perseverance of the site investi-gators.

Bilingual expert consultation and exploratory trans-lation/back-translationA bilingual expert group was formed at each site,consisting of individuals conversant both withthe native language and with English who couldbe considered experts in the alcohol and drugfield. The bilingual expert group conducted aspecific protocol of translation and back-transla-tion of the CIDI and SCAN questionnaires, aswell as of the other questiormaires and materialsused in the CAR study.

The experts were selected on the basis of theirability to elicit information firom monolingualinformants and served as liaisons between inves-tigators, interviewers and other members of thestudy teams. For the translation study, a mono-lingual group of people knowledgeable in thealcohol and drug field was also formed, as a


group which could register the comprehensibilityof the study materials (as translated and editedby the bilingual group) for study subjects whodid not possess a knowledge of English.

The exploratory translation and back-transla-tion exercise was viewed as a substudy in its ownright, contributing to the understanding of thecross-cultural applicability of concepts and theiroperationalization. In addition to assessing thecomprehensibility of CIDI and SCAN questionsin the particular culture, the exercise exploredcultural obstacles related to concepts of sub-stance abuse which should be taken into accountin the instruments. The translation process wasalso seen as a source of data on cultural andlinguistic meanings of terms and concepts andwas a necessary step in undertaking other com-ponents of the CAR study.

The steps followed in the translation andback-translation of instruments and interviewschedules were as follows: (i) the translationfrom English into the target language was pre-pared by one or more translators who were notpsychiatrists or other mental health profession-als; (ii) the translated version was discussed bythe bilingual expert group to identify areas oflikely difficulty and to agree on issues to beexplored in the monolingual groups; (iii) themembers of the bilingual group discussed thetranslated version with the monolingual group;(iv) after reviewing the translation in question,the monolingual group leaders reported back tothe bilingual group regarding whether the ques-tions were comprehensible, whether there werecultural obstacles to responding to the questions,and whether there were other important prob-lems related to specific symptoms which shouldbe added to questions in CIDI and/or SCAN; (v)the bilingual expert group discussed these re-ports and decided whether there were majorproblems which would require a second revisionof the translation to be passed in the same waythrough the monolingual group; (vi) the transla-tion was back-translated by another (non-pro-fessional) individual; and (vii) the bilingualgroup prepared a summary report specifying par-ticular areas which needed in-depth explorationand addressing in the final report of the study.Typically, the bilingual expert groups discussedthe results of each component of the study as itwas completed and made summary remarks forthe final report.

In the case of Flagstaff, an early finding of the

study was that translating all the study instru-ments into Navajo would not be a sensiblechoice, given that Navajo is primarily a spokenand not a written language, and given the bi-lingual patterning of daily life, with health andsocial service interactions commonly conductedin English. However, a translation of the CIDIwas prepared in oral form on audiotape, andextensive lists of translations of terms intoNavajo were made and drawn on for the findingsof the study. The translation/back-translationstudy was completed in each of the other eightsites.

Key informant interviewsThe major objective of the key informant sub-study was to elicit information about how differ-ent types of people living in each society thoughtabout the main concepts which are used in thediagnosis of alcohol and drug disorders. Infor-mants were encouraged to answer as spokespeo-ple for the culture as a whole, rather than as anindividual. Investigators were trained to usesemi-structured interviewing techniques, follow-ing an interview schedule which elicited largelyopen-ended answers. The interview was conduc-ted in a conversational style, starting with open-ended, general questions about what words orphrases the informant might use to describe aparticular behaviour or state related to drinkingor drug use. Subsequently, more specific ques-tions asked about the meaning of particular con-ceptual or diagnostic terms, and how people inthe culture might distinguish them from otherterms. The schedule included optional probes tofollow up answers to the main questions. De-tailed information was provided to the investiga-tors and interviewers regarding the intent of eachquestion and guidelines to follow in asking ques-tions.

Each centre was asked to interview at least 20informants concerning concepts and terms usedfor alcohol, and 20 informants concerning con-cepts and diagnoses used for the other drug typestudied at that centre. The aim was to tap bothlay and professional constituencies with substan-tial knowledge concerning drinking or drug use,but reaching well beyond the narrow and oftencosmopolitan circles of specialist expertise. Itwas suggested that each centre include withinthe 20 informants for each drug three healthworkers working in the area of alcohol or drug

208 R. Room et al.

problems, seven other health or social serviceworkers in regular contact with alcohol or drugproblems, five heavy users of alcohol or the drugand five family members of heavy users. In mostcases, the heavy users and families were drawnfrom clinical cases and their families. In usingthe relatively limited resources of the study thechoice was thus not to expend resources oninterviewing members of the general populationwho might have only a distant and hazy knowl-edge concerning alcohol or drug matters, butrather to elicit information from knowledgeableconstituencies, lay and professional.

With minor variations, each centre collectedthe key informant data in accordance with thesuggested methods and sampling. Besides thewritten record of the interview, most or all in-formant interviews were tape-recorded in all cen-tres other than Jebel. Participating centres wereable to put much effort into carrying out thesubstudy well, since it was the first major datacollection effort of the study, and one which wascharacterized by the Jebel team, for instance, as"the real core of the research".

Focus groupsAs the CAR study was designed, the focus groupsubstudy was intended to allow a more extendeddiscussion among members of different socialconstituencies of concepts and terms identifiedas problematic in the translation and the keyinformant substudies. Group discussion of con-ceptual meanings and differences, it was felt,would help clarify ways of thinking in the cultureand perhaps also areas where there was no clearcultural consensus.

Each focus group addressed a relatively smallnumber of general questions:

• what is normal and abnormal use of the sub-stance (alcohol or drug);

• what are the meanings of the various diagnos-tic terms related to the concept of alcohol/drugdependence;

• what are the similarities and differences be-tween alcohol and drug abuse and addiction;and

• which prevention and intervention strategiesare most likely to be effective against alcohol-or drug-related problems in the culture?

The focus group interview technique usedaimed to facilitate interaction among group

members and to allow free expression of theopinions of group members. In the course offocus groups, the interviewers/researchers hadseveral tasks: to moderate, to listen, to observeand to analyse discussions. There was no press-ure on the moderator to have the group reachconsensus. These group discussions were meantto provide more information on how alcohol anddrug problems are seen in each culture, how thequestions about these problems can be formu-lated in a culturally appropriate way, and howwell diagnostic criteria and concepts of substanceuse disorders apply in each culture.

Focus groups were organized as discussionswith seven to 10 participants. Study sites wereasked to convene separate focus groups for eachof five categories of participants: (a) psychiatristsand other professionals with alcohol or drugdiagnostic experience; (b) other health profes-sionals such as family physicians, social workersor nurses; (c) other community workers whodealt with alcohol and drug problems, such aspolicemen, judges or priests, (d) members of theculture who used alcohol or drugs heavily, and(e) family members of heavy alcohol or drugusers.

All sites convened at least two focus groupsbut the limited resources, the backbreaking CARfieldwork schedule, and in some cases thedifficulty of finding members of a constituency,limited the extent of the focus group substudy.As for the key informant interviews, the study bydesign concentrated data-collection efforts onrelatively knowledgeable constituencies, lay andprofessional. All sites conducted a focus groupwith heavy alcohol users (usually clinical or re-covering cases; including some drug users inFlagstaff); most sites conducted a separate focusgroup with heavy drug users (not Jebel orFlagstaff); most sites conducted one or moregroups with psychiatrists and other health pro-fessionals (not Mexico City or Seoul); and Ban-galore, Flagstaff, Ibadan and Jebel conductedgroups with family members of alcohol or drugclients.

Self-administered Rating Schedule (SARS)The SARS substudy was primarily focused onobtaining views from treatment providers con-cerning the cultural applicability of particularCIDI and SCAN items and their appropriate-ness as indicators of diagnostic criteria. Thequestions asked in it were pitched at a lower level


of generality from the preceding substudies,namely that of the individual SCAN or CIDIitem. Tbe precoded SARS questionnaires aimed(i) to elicit data in a systematic way on tbe extentto wbicb various symptom-items or question-items represented diagnostic criteria in a particu-lar culture and tbeir cultural appropriateness; (ii)to assess wbicb item or subset of items repre-sented tbe minimum set to represent or coveradequately and completely a diagnostic criterion;(iii) to explore tbe cultural appropriateness ofindicators of barmful use, abuse and dependencein difiFerent cultures; and (iv) to obtain sugges-tions on alternative or additional symptoms orcriteria tbat are needed to better represent con-cepts of alcobol and drug abuse and dependenceacross tbe cultures.

Five separate questionnaires were used in tbeSARS substudy. Tbe SARS Cultural Appropri-ateness (SARS-CA) questionnaires, one for al-cobol and one for drugs, were intended to befilled out by social and bealtb workers dealingwitb alcobol and drug-related problems, but notnecessarily scbooled in diagnostic concepts andtecbniques, wbile tbe SARS Diagnostic (SARS-DX) questionnaires for alcobol and for drugswere intended to be filled out by bealtb profes-sionals familiar witb psycbiatric diagnostic sys-tems. A Slang/Street Name Drug Supplement(SARS-SDS) questionnaire was also developedfor tbe identification of culturally appropriateterminology for various types of drugs at eacbsite.

Fieldwork on tbe SARS substudy was carriedout on an expedited timetable, since tbe sub-study was a late addition to tbe CAR study, andin several sites required extensive translation. Intbe event, botb tbe CA and DX versions wereprimarily administered to expert staff close atband to tbe investigators; overall, 66% of tbosefilling out tbe DX and 46% of tbose filling outtbe CA were psycbiatrists, and over balf of tbosefilling out eacb form bad iobs wbicb includedresearcb work in tbe alcobol field. At least 15responses to eacb of tbe four forms were gatb-ered in eacb of seven sites: Ankara (n = 106 CAor DX forms completed), Atbens (n = 66), Ban-galore (n = 154), Ibadan (n = 60), Jebel (n = 61),Mexico City (n = 67) and Santander (n = 60).

Reference cases

Tbe reference cases component of tbe CAR

study was designed to focus on tbe actual formu-lation and wording of alcohol- and drug-relatedquestions in tbe diagnostic instruments, as tbeywere administered to individuals known to bavealcohol and/or alcohol problems ("referencecases"). As tbe study was designed, subjects wereto be first interviewed witb tbe alcobol and drugsections of CIDI or SCAN, and tben questionedin a semi-structured exploratory interview abouttbe meaning of, and concrete details bebind,tbeir answers to CIDI and SCAN questions. Tbedraft scbedule also included alternative formula-dons of items and follow-up questions to askrespondents about tbeir views and understandingof specific items (e.g. "You mentioned tbat youfound it difficult to stop drinking before youbecame completely intoxicated. Please describeto me wbat it means to you to be completelyintoxicated. Wbat are tbe signs of complete intoxi-cation?").

In tbe design of tbe reference cases componenta minimum of 24 cases per centre were to beassessed, including substance users witb mildproblems and tbose witb severe problems (butwitbout serious cognitive impairments). Half oftbe cases were to be patients wbo bad receivedtreatment for alcobol- or drug-related problems;tbe otber balf bad not received any treatment. Intbe selection of subjects, botb alcobol and drugusers were to be included, drawn from varyingsocio-demograpbic groups.

Tbe timetable tied to tbe study's fundingmeant tbat work on tbis component bad to beconsiderably curtailed; it was decided in tbecourse of tbe study tbat tbe component would beoptional. Four of tbe sites collected data from21-24 cases (Bangalore, Ibadan, Jebel and Mex-ico City), wbile Santander collected 10 cases,Atbens 15 and Ankara 32. Tbe semi-structuredfollow-up was dropped and in almost all casesdata collection was limited to asking tbe CIDIalcobol and drug schedules, and comparing theresults in a case conference witb expert diag-noses.

Study limitationsAmong tbe limitations inberent to tbe CAR proj-ect's researcb design, four are of particular rel-evance to tbis report. First, as we have noted,tbere is some unevenness in tbe data collected,due to limited resources and tbe inberentdifficulty of collecting data simultaneously in

210 R. Room et al.

nine geographically dispersed sites, and this lim-its the scope of the cross-cultural analysis. Sec-ondly, cross-cultural analysis is also limited bythe fact that the second drug class, besides al-cohol, considered in the project varied by studysite. This is in part simply a reflection of reality:commonly used drugs vary considerably by cul-tural setting. It also reflected that in-depth infor-mation could only manageably be collected onone other drug class besides alcohol. Conse-quently, while we draw on the drug findings inthe present report, we focus on conceptions ofalcohol-related problems, since it is for these thatthe most comprehensive cross-cultural data areavailable.

Thirdly, the scope of the study inevitably lim-ited the depth of data collected on particulartopics in particular cultures. A whole study, forexample, might well be focused on the meaning-fulness and boundaries between terms for hang-over and withdrawal in Korean, and anethnographer or other researcher doing such astudy would undoubtedly be able to collectdeeper and richer data than could be done in thepresent study (for an example of such a study,see Taipale, 1979). On the other hand, thecross-cultural design of the CAR study allowedan explicit comparative framing which is unusualin detailed studies, and indeed in the literature.The present study offers a rich lode of tentativeobservations and conclusions to be tested andrefined in more detailed studies.

Fourthly, the CAR project relied on the exten-sive cooperation of treatment professionals, andparticularly of psychiatrists, who served both asinvestigators and as respondents in various facetsof the research. Many of these professionals re-ceived training in the United States or Britishpsychiatric and nosological traditions, and thismay have influenced their perception and de-scription of indigenous concepts and terminol-ogy. Furthermore the respondents to the study,lay and professional, were by design more knowl-edgeable about alcohol or drugs than the averageperson in their culture. Concepts and perspec-tives may thus be more sharply defined in thestudy results than they would be in general dis-course in the culture.

It should be recognized that the results re-ported here are derived from interpretation, intwo different senses of the term. In the firstplace, we are relying on summaries in English ofwhat informants and respondents had to say.

mostly in another language. To get these state-ments and thoughts into a cross-cultural com-parative frame, they have had to pass throughtranslation—a methodological limitation in-herent in comparative research across languages.In the second place, these summaries have beenprepared and organized by very special culturalrepresentatives—in most sites, bilingual researchpsychiatrists. On the one hand, the special exper-tise and cultural position of the site investigatorshas been essential to the study; but on the otherhand, it is possible that their familiarity withinternational concepts and terms has pulled thestudy material closer to those concepts and termsthan would otherwise have been the case.

Selected results from cross-cultural analysisA full discussion of the results of the study ispresented elsewhere (L. Bennett et al.. Use andAbuse of Alcohol and Drugs in Different Cultures: ANine-Country Study, in preparation). Thefindings described here serve as an illustration ofthe wealth of data collected and of some of thepossible ways of using it.

At the level of instrument itemsThe findings of the CAR study generally supportthe feasibility of translating instruments such asCIDI and SCAN into a diversity of languages invery different cultural circumstances and gettingback meaningful and usable answers. At themost concrete level of analysis, then, the overallfindings of the study are encouraging of cross-cultural work on diagnostic instruments in thealcohol and drug arena.

The findings also suggest substantial cautionboth in the translation and interview proceduresof such studies and in the interpretation of theirresults. At the item level, some of the difficultieshave obvious solutions: for instance, to ask aboutamount of drinking in terms of customary bever-ages and container sizes, and to substitute localmodes of transportation as appropriate for"bicycle, car or boat". However, not all of theproblems can be solved so simply. The meaningor underlying assumptions built into a CIDIitem may be quite foreign to the language orculture.

An overarching finding, in fact, is that thediagnostic criteria and their operationalizationsassume a self-consciousness about feelings.


knowledge and consciousness which is foreign tothe folk traditions of some cultures. Here aresome examples of problems of this sort in trans-lating the study materials for use in differentsites:

• In Kannada, "feel emotionally" was translatedto "mental state", with the explanation thatthere was no simple word for emotion in Kan-nada; the only available word was seen as"bookish", that is, not in the common ver-nacular language. "Feel" after drinking wastranslated with a word which also means ex-perience. Positive and negative feelings be-came good/pleasant and bad/unpleasantexperiences.

• "Anxiety" is a new term in Romanian and noteasily distinguished from the sensation of fear.

• In Korea, "many people cannot distinguishfeelings from thinking". The word that con-notes feeling is rarely used in conversation,and is more comfortably used for physicalsensations (do you feel this pin-prick?) than foraffective states (how do you feel about this?).Korean "has many adjectives and expressions,but they are not well differentiated in terms ofemotions, thoughts and sensations".

• In Yoruba, the term "emotion" was difficult toconvey.

The CIDI items often also have built-in attri-butional, causal and other relational assumptionswhich are not customary in some languages andcultures. Such language as "trouble because ofdrinking", "after you had realized it had causedyou...", "where it increased your chances ofgetting hurt" presume both self-consciousnessand a style of causal attribution which is un-recognizable in some cultures. Some items alsobuild in assumptions about intentionality whichdo not travel well; thus it was reported that inAnkara respondents found vague and inscrutablethe idea of intention at the beginning of a drink-ing occasion, as in drinking "for a longer periodof time than you intended to".

Some of the language in the items which causedifficulty is not part of the main meaning of theitem, but instead is derived from a well-estab-lished English-language style of question-itemconstruction which uses introductory phrasessuch as "did you ever find" or "did you ever feel"as a way of sofrening items which might soundaccusatory and making them more colloquial.These difficulties are amenable to solution. The

translation can drop the "find" and the "feel",for instance, from such constructions. However,this leaves open the question of whether the itemreally offers a comparable stimulus without thesoftening effect of such phrases.

While discrepancies and difficulties in the cul-tural translation of individual items can some-times be resolved through rewording, in somecases our analysis suggested that the problems intranslation were symptomatic of deeper prob-lems with how well particular concepts travelledacross cultural boundaries.

At the level of criteriaAs finally adopted the ICD-10 dependence syn-drome has six criteria, three of which must havebeen exhibited or experienced to make the diag-nosis. Two of the criteria—withdrawal or use torelieve withdrawal, and using despite harmfulconsequences—relate to phenomena, withdrawaland harmful use, which are ICD-10 diagnoses intheir own right, and will be discussed in the nextsection. Other criteria cover craving or compul-sion; loss or impairment of control; tolerance;and neglect of pleasures or interests or increasedtime spent seeking or using (see Table 1). In thetext of ICD-10 concerning the dependence syn-drome in the "clinical descriptions and diagnos-tic guidelines" (WHO, 1992a), although not inthe diagnostic criteria for research (WHO,1993), two other aspects which had originallybeen proposed as criteria are mentioned: rapidreinstatement, and narrowing of the repertoire ofuse. Rapid reinstatement had already beendropped from the ICD-10 list of criteria by theinception of the CAR study, but narrowing ofthe repertoire was included in the study. Thefindings on the responses of key informants ateach site concerning the applicability of the al-cohol dependence syndrome criteria are summa-rized in Table 3.

In a majority of cultural situations, narrowingof the repertoire was felt to be neither clearlydefinable nor an appropriate indicator of alcoholdependence. In some cases this was because thetraditional cultural repertoire of patterns of usewas narrow for all: in Santander, for instance,"the consumption pattern is socially established,and heavy consumers tend to adopt the sociallyaccepted pattern", and in Bangalore, the concept

212 R. Room et al.

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is "rather alien...insofar as there is not a widerepertoire to begin with".

All sites recognized phenomena related to tol-erance, though only in a minority of the sites wasthere a specific term for the concept in ordinaryuse. The idea of tolerance for alcohol often elic-ited responses indicating that this state was notviewed in the culture as a symptom of pathology,or as associated with problematic drinkingj of-ten, indeed, it had positive associations. In awetter cultural context such as Santander, theconnotation was of an ability to drink withoutbehavioural change. In a context such as Seoul,where behavioural change with drinking was ex-pected, the connotation was of endurance orimmunity; here it was declining rather than in-creasing tolerance which was seen as a markerfor alcoholism. The terms used in Ankara con-note being able to hold one's liquor as a signal ofmanhood, while in Bangalore and Jebel the term"tolerance" was frequently assigned such mean-ings as being indulgent, accustomed to or at-tracted to.

In several sites tolerance was understood in itstechnical meaning for the drug type included inthe study but not for alcohol. This was an exam-ple of a wider phenomenon encountered in thestudy, where the relative novelty of drug use inthe culture had brought with it technical andloan-words, while the understanding of alcoholdisorders remained organized around older con-cepts and traditional language. For instance, inJebel both professional and lay people use pri-marily pejorative words describing drinking be-haviour and social reactions to drinking, wordssuch as etilic (heavy ethanol user), betiv (drunk-ard) and alcoolic (alcoholic), rather than pro-fessional terms. But:

in contrast to the language used in the alcoholfield, Romanians have adopted the modemlanguage of professionals when describing theuse of drugs such as benzodiazepines or hyp-notics. Drug users and lay people frequentlyuse words such as intoxication, dependence,abuse, tolerance, etc., the very words whichthey reject for the alcohol field.

In all sites except Bangalore, there was a ten-dency to see drug use in more clinical terms thanalcohol use.

Concepts and terms around compulsion or crav-

ing were recognized in most of the sites, but themeaning was often not differentiated from loss orimpairment of control or from dependence moregenerally. In Bangalore, for instance, the conceptof craving was recognized, but it was equatedwith loss of control. In some sites, the usualterminology was closer to "having a desire orurge", and it took some explanation to convey torespondents the connotation of an irresistibleurge. In Cantabria, Spain, the best equivalentterm was a local word unlisted in Spanish dic-tionaries; the term was unknown in Mexico City.

Impaired control of drinking was a recognizableconcept everywhere, though its meaning variedbetween cultural settings. In Athens it referred toincompetent drinking, the drinker's failure tokeep behaviour appropriate to the context andcircumstances, while in Bangalore the emphasiswas on a generalized craving taking over thedrinker's whole life. In some places (Athens,Jebel and Mexico City) impaired control wasseen as the characteristic which distinguishedalcoholics from others. In the Key Informantsubstudy respondents were asked whether theythought the amount people drink was controlledby availability or by people's self-control. InIbadan and Bangalore most respondents saw thecontrol as external—that drinkers had no in-herent self-control over their consumption. InSeoul, losing control was not seen as problematicor unusual but rather as the purpose of drinking.Along with respondents in Flagstaff, where thequestions tapped into the Navajo cultural valueon personal autonomy, Seoul respondentsshowed the strongest commitment to the ideathat control of drinking was always a matter ofpersonal choice.

Neglect of alternative pleasures or increased timeseeking or using proved to be a difficult criterionto understand in some cultural situations. Inseveral sites, including Santander and Ibadan,alcohol was so easily available that time spentprocuring made no sense to informants as anindicator of anything. In Bangalore, time was notviewed as a scarce or expendable commodity, sothat time devoted to drinking or drug use wasnot seen as a problem, except if the time wassubtracted from work time. The notion of alter-nate pleasures also caused trouble: in Romania,it was remarked: "almost all pleasures are relatedto alcohol consumption". Giving up social orrecreational activities for drinking was not seenas much of a problem in Ibadan, since drinking

214 R. Room et al.

Table 4. Signs of intoxication, when help is needed, and when medical attention is needed

Signs of intoxication mentioned

tJncooordinated Aggressive Quiet, sad When medical attention seen as necessary

SantanderAthens

JebelIbadan

AnkaraMexico

BangaloreSeoulFlagstaff

00

00

00

0

0*

0

0

0

Lxjss of consciousnessLlnconscious, nonstop vomiting, very serious

aggressivenessComa, seizures, fitsSustained injuries, endless vomiting,

unconsciousBlackoutDisturbance of consciousness, violence,

physical illnessHead injury, unconsciousComa, almost dead, seizures, severe illnessBleeding, DTs, seizures

+ Mentioned as a sign® Mentioned as a sign, and outside help is seen as necessary*"Outside help must be requested"

"could in itself be the social or recreational ac-tivity of the individual". The criterion was morecommonly recognized as a problem with respectto drug use.

In responses to the SARS self-rating substudy,elements of three criteria stood out in all sites asamong the lowest-rated in terms of their"cultural appropriateness" (how understandableand how acceptable they were) as "alcohol-re-lated symptom items": narrowing of the reper-toire, time spent obtaining and tolerance whendefined as the ability to function at doses whichwould impair the casual user (Dawson, Grant &Towle, 1993). While withdrawal, drinking torelieve withdrawal and continued use despitesocial problems ranked highest overall across theseven participating sites in their "cultural appro-priateness" as items, there was substantial vari-ation between sites in their ranking.

These results partially converge vsdth the re-sults from the qualitative substudies, but themessage we are getting from the key informantinterviews is probably mixed. In part we arebeing informed about the recognizability of theconcept and terminology in a particular culturalframe. Also included in the message, we maysuspect, is a judgement about how much thebehaviour or state referred to is or should beconsidered a problem in a particular culturalsituation—^both as a problem in itself, and as apotential indicator of dependence/alcoholism.From these mixed perspectives, narrowing of thedrinking repertoire, tolerance and time spent or

pleasures given up are all quite widely seen asquestionable criteria, particularly when appliedto a culturally entrenched drug such as alcohol.

At the level of concepts and diagnosesAs noted above, we took the distinction betweenthe acute intoxication diagnosis of ICD-10 andother intoxication as being that the former re-quired medical attention. In line with this, re-spondents in the Key Informant study wereasked about signs of drunkenness, about whatsigns would indicate that the drinker is in need ofhelp from others, and about what signs wouldindicate a need for medical attention. In severalsites there was no exact equivalent of intoxi-cation, as a semi-technical term in English. Theequivalent term in Spanish would indicate poi-soning, while the most common term in Greek,methi, has positive connotations, being also usedas a metaphor to indicate extreme happiness.

Table 4 shows the signs of alcohol intoxicationmentioned in each of the sites, with the sitesarranged in rough order of descending"wetness". Respondents at most sites mentionlack of coordination, and this is the primaryindication that help from others wUl be needed.Aggression is also commonly mentioned as a signof intoxication; only in Santander and Athens isbeing quiet or sad mentioned as a sign. Despitethe major differences between the sites in drink-ing culture there is strong agreement on when


medical attention is seen as necessary: basically,this is when the drinker has lost consciousness oris suffering seizures. "Ordinary" drunkenness,short of serious central nervous system (CNS)disturbance, is thus clearly defined as not requir-ing medical attention.

The existence of withdrawal symptoms wasrecognized everywhere, although in most sitesthere was no single commonly understood termfor the phenomena. In Romanian, for instance,professionals used the term sevraj (weaning), butthis was not understood by lay people, who usedwords meaning to renounce, abstain or stoponeself. In Ankara, withdrawal was sometimesconfused with craving: "these two states cannotbe differentiated easily and clearly. Alcoholic pa-tients and some family members often used theterm 'crisis' instead of either of these terms".

In several of the study sites there was no cleardistinction for alcohol between the withdrawalsyndrome and a hangover (see Table 5). InSantander, for instance, one-third of the keyinformants mentioned the word for hangoverwhen trying to describe the concept of with-drawal. In Athens, "the transition from hangoverto withdrawal was defined as the point when theperson starts drinking in order to cover up theunpleasant experiences of hangover".

Mexican respondents distinguished between amoral and a physical hangover, and in severalother sites, too, regret and guilt were describedas part of a hangover. Feelings of guilt wereprominent among the descriptions of a hangoverin Athens, but were not included in the descrip-tions of withdrawal. In Ibadan, "while most re-spondents emphasized regret as an importanteffect of hangover,...only one key informantmentioned regret as a hallmark of withdrawal".The Ibadan investigators suggest that the re-spondents may have felt that those who hadprogressed to withdrawal are beyond feeling re-morse, but it is possible too that withdrawal, asa concept more within the medical and technicalsphere, attracts fewer moralized connotations.

Study sites with marijuana as the other drugstudied reported either no withdrawal syndromefrom cannabis or a much less clearly definedcluster of symptoms than for alcohol. There was,if anything, even less distinction between hang-over and withdrawal.

In lay usage there was little distinction at anysite between harmful use and abuse. Harmful usewas understood to include social, economic and

family problems as well as physical and psychichealth problems; the intention in ICD-10 toconfine the terms to harm to health will clearlybe hard to realize. For illicit drugs many sitesreported that lay respondents made no distinc-tion between use and abuse or harmful use.Many Navajo respondents also denied that therewas a normal drinking pattern for Navajo people,distinguishable from harmful use. In Bangalore,too, some respondents maintained that there wasno such thing as normal use of alcohol—that alluse is harmful and will lead to addiction (see alsoBennett et al., 1993).

Terms for alcoholism and addiction were wellrecognized at all sites, but dependence or itsequivalent was a new term to many respondents.Respondents in Seoul equated the term withintoxication. In Romanian, dependence carried amain meaning of subjugation or subordination.In Athens and elsewhere no clear distinction wasmade between dependence, on the one hand,and addiction or alcoholism, on the other. Themain features described for alcoholism variedquite widely by site. Respondents at the"wettest" sites did not mention amount or pat-tern of drinking as a sign of alcoholism, whilecharacterizations in terms of loss of control orillness, as well as drinking behaviour, were com-mon at sites where drinking is more problema-tized.

There are clearly substantial variations fromone site to another in the threshold for identify-ing and defining dependence or addiction,whether the definition is in global terms or interms of qualifying with a certain number ofdependence criteria. For alcohol dependence anilluminating extreme can be found in Bangalore,a cultural situation in which only a minority ofmen drink at all and almost no women drink.Table 6 summarizes the responses to CIDI ques-tions of four Bangalore non-clinical "referencecases", none of whom met a local clinician'sstandards for a dependence diagnosis, but eachof which met three or more dependence criteriafrom their answers to CIDI questions. A Banga-lore drinker who consumed the equivalent of twoEuropean bottles of beer (a total of 700 ml) onceevery 2 months, and had never drunk more thanthis, nevertheless qualified for three criteria ofdependence: he reported that drinking has lesseffect on him than it used to; his family andfriends objected to his drinking, but he contin-ued to drink, and when he had had tuberculosis

216 R. Room et al.

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Table 6. Drinking and dependence in Bangalore, India: four nonclinical cases meeting formal criteria for dependence

Occupation age, and drinkingpattern of respondent

Drinkingdespite social

Tolerance consequences

Drinkingdespitephysical

harm(bicycle

injury,TB,stomachdisease)

Difficultystopping.cuttingdown

Irresistibledesire

Police constable, age 40 years700 ml beer (two bottles)once in 2 months

Attendant at hospital, age 36 years1000 ml beer (three bottles)1-3 days a month

Staff nurse, age 33 years700-1000 ml beer (2-3 bottles)1—3 times a month

Farm worker, age 55 years90 ml arrack (30 gm alcohol~ three drinks)once or twice a week

his doctor had advised him to stop (he hadindeed stopped for a few months but thenstarted again); and he had wanted to stop or cutdown drinking but could not. Other respondentswho drank only a little more than this qualifiedfor a dependence diagnosis. For instance, a re-spondent who accompanied his wife when shecame to the hospital for treatment reported thefollowing pattern of positive items: drinking theequivalent of three bottles of beer 1-3 days amonth, and never drinking more; objectionsfrom friends, doctor, or clergy; trouble drivingbecause of drinking; the same amount of alcoholhaving less effect than before; and having hadsuch a strong desire to urge to drink that hecould not resist it. Clearly, in a cultural situationwhere there is much disapproval of drinking thethreshold for positive responses to precodedquestions has been set very low, so that a mech-anical application of scoring algorithms for de-pendence would result in inappropriatediagnosis.

ConclusionThe goal and promise of a valid and usefulcross-cultural epidemiology of alcohol and drugconditions remains before us, in no way invali-dated by the results of the CAR study. But theresults do highlight the challenges inherent inthis endeavour. The CAR study's results suggestthat more than translation is involved in adapting

concepts and instruments developed in a par-ticular cultural frame for use in other cultures.Most centrally, they underline that the fact thatapparently meaningful answers to items can beelicited with instruments that are a simple trans-lation—and that respondents will answer thesame way the next time—does not necessarilymean that the instruments are yielding valid oruseful diagnoses.

The CAR study started from an already exist-ing structure of diagnostic interview items, diag-nostic criteria and diagnoses, and studied theirapplicability in nine disparate societies. Thestudy's methodologies and time-frame allowedus to acquire a broad picture in each society andto set it in a cross-cultural comparative frame,but it did not allow us to match the level of detailthat might be found in an in-depth study in aparticular culture. Also, given the study's pur-poses, it did not give us a full picture of anyalternative, non-diagnostic conceptualizations ofalcohol and drug problems which might beprevalent in a given society.

The study's findings suggest that, at the levelof diagnostic interview items, cross-culturallycomparable formulations can usually be found.However, the task is not straightforward. Thedifficulties start at the level of cultural differencesin ways of thinking about subjective states. Manyof the items in instruments like CIDI assumethat the respondent can report on individuatedfeelings and states of mind in a detached way.

218 R. Room et al.

which is not a way of thinking used in all cul-tures. The CIDI items assume what has beencalled a "modem self standing outside and sep-arate from feelings and sensations, a self that canevaluate, describe, and sometimes even controlsubjective states (Toulmin, 1990). The itemsthus reflect a post-Enlightenment Eurocentrictradition in which individuals have feelingswhich they can express in words—not only sen-sations, but also emotional states. In this world-view, individuals may focus on and talk aboutthese feelings; and it is conceivable that relievingthose feelings might be a reason for taking adrink or a pill.

There are also difficulties at the level of directtranslation. Ofren there is no equivalent in com-mon use for English terms, for example for with-drawal and tolerance. The English term may beborrowed or a direct translation may be used,but this may have little meaning, or a very differ-ent meaning, for a lay respondent. Even wherethe denotations of a term or concept seem simi-lar, two cultures may differ in where they drawthe threshold for applying it. The Korean termfor "hangover", for instance, has a highthreshold, connoting that the drinker still hassubstantial alcohol in the blood the next mom-ing. On the other hand. Bangalore respondentsreport experiencing tolerance and difficulty cut-ting down on the basis of a drinking pattern thatwould seem to a respondent from a Mediter-ranean wine culture to be homeopathic doses ofalcohol.

The study's findings suggest that comparabil-ity is also an issue at the levels of criteria andconcepts. Some criteria used in diagnostic sys-tems appear to be culture-bound, depending fortheir force on specific cultural ideas about theuse of time, about "alternative pleasures", aboutself-control, or about customary patterns of sub-stance use (e.g. narrowing of the repertoire).Also, while cultures readily borrow concepts andterms for behaviours that are seen as alien—asdrug use is in many places—they may be quiteresistant to applying new medical terminology towhat is seen as mundane and familiar, e.g. winedrinking in Mediterranean societies.

Perhaps the most problematic aspect of thefindings for cross-cultural comparisons concernscultural differences in the perceived linkage be-tween items or criteria, on the one hand, anddiagnoses on the other. An epidemiological studymay get usable and reliable answers to interview

items in a culture, but if the culture does notaccept the diagnostic connections built into aninternational scoring algorithm, the algorithm islikely to yield a diagnosis which would be seen asinappropriate and even wrong within that so-ciety. For most of the ICD-10 criteria for thealcohol dependence syndrome, indeed, the keyinformants from one or another of the study sitesreported that, while the criterion was recogniz-able to them, it was seen as a commonplace oreven admirable quality in their culture, andwould not be recognized as diagnostic of depen-dence or addiction.

The CAR study findings thus pose for nosolo-gists the question of whether the six criteriadesignated in ICD-10 are the most appropriateway to characterize dependence as a disorder indifferent cultures. There are three main altema-tive solutions to this question. One choice wouldbe to decide that the validity of a criterion ofdependence in a given society does not dependon whether it is accepted as symptomatic of adisorder in the society. A second choice forfuture nosologists would appear to be to returnto a culturally differentiated definition of depen-dence, as in Jellinek's Greek-letter typology or inthe earliest World Health Organization definitionof alcoholism as use going beyond "the socialdrinking customs of the whole community con-cemed" (WHO, 1951). A third choice would beto undertake a search for new criteria or forreformulations of criteria which would be univer-sally validated as diagnostic of dependence.

Along with the issue of cultural differences inconceptual linkages, there is also an issue ofcultural differences in the threshold for positiveresponses to items or criteria. The Bangalorereference cases described above alert us to thepossibility of overdiagnosis, particularly with arigidly structured schedule and scoring pro-cedure, as is commonly used in epidemiologicalstudies, in cultural situations where there ismuch social disapproval of any use. In the localcircumstances of Bangalore, formulations suchas the CIDI question about whether there wereever any objections about the respondent'sdrinking, as the Bangalore investigators noted,are likely to be answered positively by anydrinker. In an environment where drinking isrelatively infrequent and limited by finances andsocial disapproval, respondents may also give alevel of attention to their desires and to theeffects and possible consequences of drinking


which those from a "wetter" cultural environ-ment might find exaggerated.

These data from a culture where drinking isdisapproved of remind us that the same kinds ofproblems of overdiagnosis could well arise withrespect to dependence on other drugs in cultureswhere use of the drugs is strongly socially disap-proved of. The disapproval results not only inhigh rates of social and interactional problemsfrom use, but also in increasing the perceivedpower of the drug to take over one's life andactions, and in encouraging users to introspectcarefully concerning variations in the psychoac-tive effects of the drug (tolerance) and in feelingsand urges concerning use.

One other aspect of the findings deserves acomment. The field of alcohol and drug prob-lems has many terms—such as alcoholism oraddiction—which originate from medical usagebut which have passed into common usage inmany languages. Often such terms were orig-inally put forward with the aim of removing themoral judgements imputed by the terms theyreplaced. The CAR study findings remind us invivid terms, however, how much the diagnosis ofalcohol and drug disorders depends on themores in a society, and how quickly and easilynew medical terminology can take on the samemoralizing tones as the old.

The findings of this study provide a fertileground for future comparative and collaborativeresearch on these disorders. The network of cen-tres and experts created in this study is a poten-tial asset for this research, and its coming intoexistence is undoubtedly one of the study's mostimportant results.

AcknowledgementsThis project was supported by funds from theUS federal government under a cooperativeagreement (5U01 MH35883) from the NationalInstitutes of Health (formerly the Alcohol, Drugand Mental Health Administration). Support forparticipation was also drawn from collaboratinginstitutions at each site. The views expressed inthis paper are the collective views of an inter-national group of researchers and do not necess-arily express the views or policy of the WorldHealth Organization or supporting agencies.

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