Lee M. Pachter

Culture and Clinical Care: Folk Illness Beliefs and Behaviors and Their Implications for Health Care Delivery

This article presents an approach to the evaluation of patient-held beliefs and behaviors that may not be concordant with those of biomedicine. Physicians and patients often hold discrepant models of health and illness that may affect the effectiveness of communication during the clinical visit. An extreme example of such a discrepancy exists when the patient feels that he or she has an illness that is not defined within the biomedical paradigm. These are commonly referred to as folk illnesses. An example of such an illness is provided in order to discuss the effects of folk beliefs on patient-held perceptions of health and sickness, treatment-seeking behavior, clinical care, and physician-patient communication. Guidelines for addressing clinical issues surrounding folk beliefs and behaviors in a culturally sensitive way are discussed.

Do Parenting and the Home Environment, Maternal Depression, Neighborhood, and Chronic Poverty Affect Child Behavioral Problems Differently in Different Racial-Ethnic Groups?

OBJECTIVE. To determine whether the processes through which parenting practices, maternal depression, neighborhood, and chronic poverty affect child behavioral problems are similar or different in minority and nonminority children in the United States. METHODS. Data from 884 white, 538 black, and 404 Latino families with children who were 6 to 9 years of age in the National Longitudinal Survey of Youth were analyzed. The outcome, child behavioral problems, was measured using the Behavior Problems Index externalizing and internalizing subscales. The effects of chronic poverty, neighborhood, maternal depression, and parenting on the outcome were analyzed using multigroup structural equation modeling. RESULTS. Chronic poverty affected child behavioral problems indirectly through the other variables, and parenting practices had direct effects in each racial/ethnic group. The effects of maternal depression were partially mediated through parenting in the white and Latino samples but were direct and unmediated through parenting practices in the black sample. Neighborhood effects were present in the white and black samples but were not significant for the Latino sample. CONCLUSIONS. Chronic poverty, neighborhood, maternal depression, and parenting practices have effects on child behavioral problems in white, black, and Latino children, but the processes and mechanisms through which they exert their effects differ among the groups. The differences may be related to social stratification mechanisms as well as sociocultural differences in family and childrearing practices.

Adverse Childhood Experiences Expanding the Concept of Adversity

INTRODUCTION Current knowledge of Adverse Childhood Experiences (ACEs) relies on data predominantly collected from white, middle- / upper-middle-class participants and focuses on experiences within the home. Using a more socioeconomically and racially diverse urban population, Conventional and Expanded (community-level) ACEs were measured to help understand whether Conventional ACEs alone can sufficiently measure adversity, particularly among various subgroups. METHODS Participants from a previous large, representative, community-based health survey in Southeast Pennsylvania who were aged ≥18 years were contacted between November 2012 and January 2013 to complete another phone survey measuring ACEs. Ordinal logistic regression models were used to test associations between Conventional and Expanded ACEs scores and demographic characteristics. Analysis was conducted in 2013 and 2014. RESULTS Of 1,784 respondents, 72.9% had at least one Conventional ACE, 63.4% at least one Expanded ACE, and 49.3% experienced both. A total of 13.9% experienced only Expanded ACEs and would have gone unrecognized if only Conventional ACEs were assessed. Certain demographic characteristics were associated with higher risk for Conventional ACEs but were not predictive of Expanded ACEs, and vice versa. Few adversities were associated with both Conventional and Expanded ACEs. CONCLUSIONS To more accurately represent the level of adversity experienced across various sociodemographic groups, these data support extending the Conventional ACEs measure.

Racism and Child Health: A Review of the Literature and Future Directions

Objective: Racism is a mechanism through which racial/ethnic disparities occur in child health. To assess the present state of research into the effects of racism on child health, a review of the literature was undertaken. Methods: A MEDLINE review of the literature was conducted between October and November 2007. Studies reporting on empirical research relating to racism or racial discrimination as a predictor or contributor to a child health outcome were included in this review. The definition of “child health” was broad and included behavioral, mental, and physical health. Results: Forty articles describing empirical research on racism and child health were found. Most studies (65%) reported on research performed on behavioral and mental health outcomes. Other areas studied included birth outcomes, cardiovascular and metabolic diseases, and satisfaction with care. Most research has been conducted on African-American samples (70%), on adolescents and on older children, and without a uniformly standardized approach to measuring racism. Furthermore, many studies used measures that were created for adult populations. Conclusions: There are a limited number of studies evaluating the relationship between racism and child health. Most studies, to date, show relationships between perceived racism and behavioral and mental health. Future studies need to include more ethnically diverse minority groups and needs to consider studying the effects of racism in younger children. Instruments need to be developed that measure perceptions of racism in children and youth that take into account the unique contexts and developmental levels of children, as well as differences in the perception of racism in different ethnocultural groups. Furthermore, studies incorporating racism as a specific psychosocial stressor that can potentially have biophysiologic sequelae need to be conducted to understand the processes and mechanisms through which racism may contribute to child health disparities.

Variation in Asthma Beliefs and Practices Among Mainland Puerto Ricans, Mexican-Americans, Mexicans, and Guatemalans

This study reports on community surveys of 160 representative Latino adults in Hartford, CT; Edinburg, TX; Guadalajara, Mexico; and in rural Guatemala. A 142-item questionnaire covered asthma beliefs and practices (e.g., causes, symptoms, and treatments). The cultural consensus model was used to analyze the agreement among respondents within each sample and to describe beliefs. Beliefs were then compared across the four samples. Analysis of the questionnaire data shows that there was overall consistency or consensus regarding beliefs and practices among individuals at each site (intraculturally) and to a lesser extent across respondents of all four different Latino cultural groups (i.e., interculturally). This pattern of response is indicative of a shared belief system among the four groups with regard to asthma. Within this shared belief system though, there is systematic variation between groups in causes, symptoms, and treatments for asthma. The most widely recognized and shared beliefs concerned causes of asthma. Notable differences were present between samples in terms of differences in beliefs about symptoms and treatments. The biomedical model is shown to be a part of the explanatory model at all sites; in addition to the biomedical model, ethnocultural beliefs such as the humoral (“hot/cold”) aspects and the importance of balance are also evident. The Connecticut Puerto Ricans had a greater degree of shared beliefs about asthma than did the other three samples (p<0.00005). It was concluded that the four Latino groups studied share an overall belief system regarding asthma, including many aspects of the biomedical model of asthma. In addition, traditional Latino ethnomedical beliefs are present, especially concerning the importance of balance in health and illness. Many beliefs and practices are site-specific, and caution should be used when using inclusive terms such as “Hispanic” or “Latino,” since there is variation as well as commonality among different ethnic groups with regard to health beliefs and practices.

A Cross-Cultural Approach to the Study of the Folk Illness Nervios

To systematically study and document regional variations in descriptions of nervios, we undertook a multisite comparative study of the illness among Puerto Ricans, Mexicans, Mexican Americans, and Guatemalans. We also conducted a parallel study on susto (Weller et al. 2002, Culture, Medicine and Psychiatry 26(4): 449– 472), which allows for a systematic comparison of these illnesses across sites. The focus of this paper is inter- and intracultural variations in descriptions in four Latino populations of the causes, symptoms, and treatments of nervios, as well as similarities and differences between nervios and susto in these same communities. We found agreement among all four samples on a core description of nervios, as well as some overlap in aspects of nervios and susto. However, nervios is a much broader illness, related more to continual stresses. In contrast, susto seems to be related to a single stressful event.

Acculturation and compliance with medical therapy

ABSTRACT. Lack of compliance with medical therapy is a major clinical problem. We undertook a study to determine whether degree of acculturation to mainland U.S. culture was predictive of compliance in Puerto Rican families having a child with asthma. A questionnaire was administered to parents of Puerto Rican asthmatic children attending an asthma clinic and taking oral theophylline as part of their medical management. The questionnaire included items concerning medical, socioeconomic, and cultural variables, as well as a standardized instrument devised to measure degree of acculturation. Compliance was measured by a serum theophylline level obtained at the time of the visit. Families were divided into compliant (n = 15) and noncompliant (n = 13) groups based on their childs serum theophylline determination. There was a significant difference in mean acculturation scores between compliant and noncompliant groups (p = .008). Those in the compliant group had scores indicative of a style of acculturation that integrated aspects of both “Anglo‘’ and Puerto Rican lifestyles. Those in the noncompliant group had scores indicative of a less acculturated lifestyle. The findings of this study show that degree of acculturation is a predictor of compliance with medical therapy in mainland Puerto Ricans. Additional studies with other cultural groups are needed, as well as other studies incorporating acculturation into a multivariate model of compliance. J Dev Behav Pediatr 14:163–168, 1993. Index terms: compliance, acculturation, ethnicity, Hispanic, asthma, children.

Regional variation in Latino descriptions of susto.

Susto, a folk illness notrecognized by biomedical practitioners as adisease, is now formally part of the diagnosticclassification system in psychiatry as a“culture-bound syndrome.” Susto has beenreported among diverse groups of LatinAmericans, but most of those reports areseveral decades old and many were conducted inIndian communities. This study focuses oncontemporary descriptions of susto anduses a cross-cultural, comparative design todescribe susto in three diverse Latinopopulations. Mestizo/ladino populations wereinterviewed in Guatemala, Mexico, and southTexas. An initial set of open-ended interviewswas conducted with a sample of “key” informantsat each site to obtain descriptive informationabout susto. A structured interviewprotocol was developed for use at all threesites, incorporating information from thoseinitial interviews. A second set of structuredinterviews was then conducted with arepresentative sample at each site. Resultsindicate a good deal of consistency in reportsof what susto is: what causes it, itssymptoms, and how to treat it. There appear tobe, however, some notable regional variationsin treatments and a difference between pastdescriptions and contemporary reports ofetiology.

Research ArticleAdverse Childhood Experiences: Expanding the Concept of Adversity

INTRODUCTION Current knowledge of Adverse Childhood Experiences (ACEs) relies on data predominantly collected from white, middle- / upper-middle-class participants and focuses on experiences within the home. Using a more socioeconomically and racially diverse urban population, Conventional and Expanded (community-level) ACEs were measured to help understand whether Conventional ACEs alone can sufficiently measure adversity, particularly among various subgroups. METHODS Participants from a previous large, representative, community-based health survey in Southeast Pennsylvania who were aged ≥18 years were contacted between November 2012 and January 2013 to complete another phone survey measuring ACEs. Ordinal logistic regression models were used to test associations between Conventional and Expanded ACEs scores and demographic characteristics. Analysis was conducted in 2013 and 2014. RESULTS Of 1,784 respondents, 72.9% had at least one Conventional ACE, 63.4% at least one Expanded ACE, and 49.3% experienced both. A total of 13.9% experienced only Expanded ACEs and would have gone unrecognized if only Conventional ACEs were assessed. Certain demographic characteristics were associated with higher risk for Conventional ACEs but were not predictive of Expanded ACEs, and vice versa. Few adversities were associated with both Conventional and Expanded ACEs. CONCLUSIONS To more accurately represent the level of adversity experienced across various sociodemographic groups, these data support extending the Conventional ACEs measure.

Culture and child behavior and psychosocial development

This paper provides an overview of the relationship between cultural beliefs, values, practices, behavior, and psychosocial development. A framework for analyzing this relationship is presented, illustrated with studies from the cross-cultural literature. We then present a review of the literature concerning the cultural influences on one specific behavioral issue, temperament. We conclude with a critical discussion of the unique methodological issues encountered in the study of child behavior and psychosocial development in a cross-cultural and/or culturally diverse perspective. J Dev Behav Pediatr 17:191–198, 1996. Index terms: culture, ethnic groups, child development, psychosocial behavior.