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					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 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‟...
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

                                                   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 = 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”

“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.
           Similarities vs. Differences in
         Human Developmental Processes

• 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).
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 categories
       b. Item Equivalence: respondents can related to items
    Statistical vs. Practical 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          2nd Generation
                                              Immigrant               Immigrant
                                            Hispanic Youth          Hispanic Youth
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
          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 Competent
Cross-Cultural Research
              Cavusgil S.T., & Das, A. (1997).
             Becoming Culturally Competent

•   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
    "The art of teaching is TOLERANCE.
    HUMBLENESS is the art of learning"
                                      BKS Iyengar
                        (1918- Indian Yoga Master)

         “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)
Barber, 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:

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,

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.

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