Assessing the impact of cultural and contextual influences on psychiatric disorders and service use may require both conceptual and methodological approaches that take into account the uniqueness of the different ethnic and racial groups that may affect data collection and the interpretation of results. Considering the uniqueness of ethnic and racial groups may allow us to identify factors that are significant in shaping the expression of psychiatric disorders and the culture-specific processes linked to differences found between groups. To address the conceptual and methodological questions related to psychiatric illness and service use, we briefly outline below some of NLAAS strategies: 1) rigorous approaches used to translate and adapt survey instruments; 2) incorporation of cultural idioms of distress (e.g., “ataque de nervios” and neurasthenia) as part of the prevalence estimates of psychiatric disorders; 3) allowing respondents to be interviewed in more than English or in their native language; 4) an experiment to assess the impact of language on prevalence rates of psychiatric disorders; and 5) an instrumentation experiment to test the effect of survey conditioning on service use rates. A series of separate papers describes these approaches and the results in more detail. The methods emphasize language, cultural matching of interviewers to respondents and formal survey experiments of response effects.
The Spanish and Asian versions of the CIDI went through an intensive process of translation and adaptation (for a detailed description, see Alegria et al., in this same issue). Translation and cultural relevancy adaptation were necessary for an instrument that had not been previously tested among ethnic groups under study. The model used to translate and adapt these diagnostic measures was based on cross-cultural equivalency in the following domains (described by Bravo, Canino et al., 1991
): semantic (ensures that instruments are accurately translated into different languages), content (ensures that content of instruments is relevant to the study population), technical equivalence (ensures that similar layouts are used for instruments across cultures, and that the measuring strategies implemented obtain a similar effect across cultures) and criterion/conceptual equivalence (ensures that the same theoretical construct is evaluated in each culture, and that the interpretation of the results is similar when evaluated in accordance with the norms of each culture) (Flaherty, 1987
; Gaviria et al., 1985
; Bravo & Canino, 1993
; Matias et al., 2003
). The CIDI was translated into a common Spanish by an International Team of bilingual Latino investigators from different Latino-subgroups including Spain, Latin America and South America. We also included several measures to better understand variations among Asian and Latino ethnic groups in disease prevalence and service use. Details of the process of translation and adaptation of our survey measures are provided in the second article by Alegria et al., 2004 in this same issue.
One major difference between the NCS-R or NSAL, which conduct all of their interviews in English, and the NLAAS is that the NLAAS is designed to interview in Tagalog, Vietnamese, Chinese, Spanish or English. Multilingual interviewers employed in the NLAAS were certified to be fluent in both English and the other language (Spanish for Latinos, and Chinese, Tagalog, or Vietnamese for Asian Americans). This design allowed for the inclusion of the large percentage of Latinos and Asian Americans who are first generation immigrants with limited English fluency. Surveys restricted to English eliminate large segments of both ethnic categories from the national survey, and require others to respond to sensitive and complex questions in a language they understand poorly. For example in the NLAAS, 48% of the Latino respondents indicated that they only spoke Spanish or Spanish and some English, and 34% of Asian Americans responded that they only spoke an Asian language or and Asian language and some English. In addition, 50% of Latinos and 35% of Asian Americans in the NLAAS rated their English proficiency as fair or poor, potentially excluding them from an English only diagnostic assessment. NLAAS broadens the inclusion of who can be represented in psychiatric epidemiology studies at a national level.
At the same time, Latino and Asian American ethnic categories encompass a wide range of national backgrounds, social classes, races, legal status, and levels of acculturation, migration histories and literacy in English, among other distinctions. In the past, researchers typically thought of Asian Americans or Latinos as homogeneous groups, and this categorization has constrained analyses of ethnic differences in mental disorder patterns (Zane & Sasao, 1992
). One consequence of this deficiency is that insufficient data is available about whether Latino and Asian American subgroups differ in the prevalence of psychiatric disorders and service use and the explanations for the potential differences. Furthermore, although previous epidemiological data suggested an effect of acculturation on the risk for psychiatric morbidity (Ortega et al, 2001
), this effect could not be studied in depth since most epidemiological studies (NCS, ECA) did not assess acculturation or only included a few items in their survey instruments. The NLAAS sample design includes representation of eight sub-ethnic groups (Mexicans, Puerto Ricans, Cubans, Other Latinos, Chinese, Vietnamese, Filipinos, and Other Asians) for performing intra-ethnic comparisons among Latino and Asian American subgroups, with various levels of acculturation assessed by several measures. There are fundamental scientific reasons for focusing on these subgroups of Latinos and Asian Americans. They come from different social, cultural and historical circumstances that lead to some interesting comparisons about the factors associated with psychiatric disorders and service use. For example, among Asian Americans, on average, Chinese Americans have higher socioeconomic status (SES) than Filipino Americans. When examined closely, however, Chinese Americans have a SES distribution that is bimodal with representations at the high and low ends of the SES continuum. Conversely, there is considerable geographic variation in the SES distribution of Filipino Americans. Filipino Americans in Hawaii, on average, have lower SES levels than Filipino Americans in Northern California. As compared to Mexicans, Cubans and other Latinos, Puerto Ricans are more likely to be U.S. citizens, to have two parents born in the U.S., to have a higher ratio of years in the U.S., to report greater English proficiency, and to live in the Northeast. Mexicans are younger, with less education and less household income, more likely to be married and to be living in the West and the South as compared to the other Latino groups. We will test whether these variations in social and contextual circumstances are correlated to potential intra-ethnic differences in psychiatric disorders and service use.
The interpretation of “ethnic” effects in the context of psychiatric disorders and service use is an area that has consistently been unclear. When a variable representing a Latino or Asian American category is identified as important in a regression that explains psychiatric illness or use of services, the finding fails to enlighten us about the reason for the association. To identify this statistical association requires the measurement of other constructs (such as cultural values, citizenship, English proficiency, discrimination, or region) that may be correlated with the ethnic category. An example is the concept of acculturation, a complex multidimensional construct which refers to the process whereby immigrants change their behavior and attitudes toward the host society. Some claim that change in attitudes and values refers to assimilation (See Escobar & Vega, 2000
). Acculturated Latinos of different nationalities evidence increased likelihood for both psychiatric and substance disorders than their less acculturated counterparts (Ortega et al., 2000
), but it is less clear why this association occurs. NLAAS goes beyond the use of ethnic and racial typical categories (e.g. white, Latino, Asian or African American) to address which dimensions of ethnicity/race may be associated with psychiatric disorders and service use. In the NLAAS, investigating the role of social position, environmental context and psychosocial factors may help identify the mechanisms that link acculturation to psychiatric illness and mental health service use. In examining differences in the prevalence rates of psychiatric disorders and service use rates, we can evaluate whether the differences across ethnicity/racial subgroups relate to dimensions that encompass language preference, language proficiency, ethnic and racial affiliation, behaviors and attitudes congruent with the person’s ethnic/race culture (e.g. familism, spirituality), citizenship, time living in the U.S., ethnic density in the region of residency, or exposure to discrimination. By adopting a multidimensional construct of race/ethnicity, this work begins clarifying the meaning of “ethnic/race” effect, and eventually leads us to understand how ethnicity, race, culture change, and social stress may be related to psychiatric illness and service use.
Not considering the cultural background of individuals as well as cultural change can result in either incorrect inferences of pathology, or failure to recognize existing disorder (Favazza & Oman, 1984
; Kleinman, 1988
; Westermeyer & Janca, 1997
). There is persistent evidence that a patient’s cultural background colors every facet of illness experience, from linguistic structure and content of delusions (Karno & Jenkins, 1993
; Ribeiro, 1994
) to the unique meaning of expressed emotion (Kleinman, 1988
; Lewis-Fernandez, 1996
). Several approaches used in the NLAAS test artifactual explanations for the observed rates of psychiatric disorders and service use patterns in Latinos and Asians. For example, we test whether there are potential exclusions of symptomatology of certain disorders that may lead to the underestimation of psychiatric disorder rates. Ethnic minority groups may present symptoms that are not part of the established nosology, whereby there is only a partial overlap of the diagnostic construct being assessed, what has been label construct bias. While neurasthenia has virtually disappeared from the range of diagnoses that most psychiatrists identify in their patients, it remains a problem strongly related to major depression identified among Asians in clinical settings (Zhang, 1989
). Similarly, “ataque de nervios” is an idiom of distress prominent among Latinos that may appears to be part of the symptom repertoire of depression. Approximately, 16% of a representative sample of Puerto Ricans reported experiencing this problem (Guarnaccia et al., 1989
). We evaluate whether these syndromes are part of the expression of certain psychiatric illnesses for either Latinos or Asians and how including them changes the 12-month prevalence of certain psychiatric disorders. The measurement of these syndromes allow us to test whether Latinos and Asians, especially those who are less acculturated, are more likely to express specific psychiatric illness with these cultural idioms.
Another approach used to evaluate potential construct bias influencing the prevalence rates of certain psychiatric disorders was the expansion of the screener probes that entered respondents into specific psychiatric disorder batteries in the NLAAS. If screener probes are less recognized as depicting symptoms of a particular disorder for Asians or Latinos, they may fail to convey the equivalent conceptual meaning of the question, thereby increasing the likelihood of a negative endorsement by Latino or Asian respondents and artificially lowering prevalence rates for the population of interest. Based on the extensive qualitative work performed to refine the translation and adaptation of the NLAAS instrument, we asked respondents to offer alternative screener probes that reflected similar symptoms or behaviors as well as articulate how they understood the original probes. Using this information, we generated one additional probe for entry into each of the following disorders that was only asked if the respondent had negatively endorsed all other probes for that disorder (what would have been negative cases): depression, panic disorder, generalized anxiety disorder, and mania. The use of these additional probes entered an additional number of negative cases into the respective diagnostic batteries: 0.8% of Latinos and 2.4% of Asian Americans into the panic disorder battery, 21.3% of Latinos and 14.5% of Asian Americans into the depression disorder battery, 11.6% of Latinos and 6.5% of Asian Americans into the mania battery; and 6.4% of Latinos and 5.5% of Asian Americans into the generalized anxiety disorder battery.
These additional probes will allow us to compare prevalence rates of the disorder, excluding and including the extra cases that entered through these additional screener probes, and explore potential sources of construct bias in diagnostic assessment. We will supplement the analyses by conducting qualitative evaluations of the audiotaped diagnostic assessments conducted as part of the clinical reappraisal. The NLAAS clinical re-appraisal of the Spanish CIDI involved re-interviewing 195 subjects from the Latino sample who met criteria for nine psychiatric disorders, met criteria for a sub-threshold disorder, or were negative cases. Interviews were conducted by telephone by expertly trained bilingual bicultural clinicians who administered the Structured Clinical Diagnostic Interview (SCID). We expect the clinical re-appraisal to provide further information of whether the sub threshold or negative cases of several disorders may be associated to problems of construct bias in diagnostic batteries for Latino populations.
Analyses being conducted in the NLAAS also test how translation and cross-cultural adaptation of structured mental health interviews impact the results of psychiatric epidemiological surveys. Even when bilingual translators reach consensus on different language versions of a diagnostic instrument, it is still possible that respondents will have dissimilar interpretations of words or response alternatives in the translated version. In the NLAAS, we conducted a language experiment to evaluate whether translation effects influence the prevalence of psychiatric disorders. Bilingual participants were randomly assigned to either the English or Spanish version of the survey interview. By comparing the prevalence of mental disorders reported by the randomly equivalent language groups, we can determine if the choice of words influences the reporting process, and consequently the prevalence rates. The results of these analyses are described in a manuscript by Dr. Patrick Shrout and other NLAAS collaborators currently under preparation.
The NLAAS also included an instrumentation experiment to test the effect of survey conditioning on service use rates. The investigators hypothesized that the responses to survey items placed in the latter portion of the survey instrument would be influenced by experience gained from the earlier portion of the survey. The general assumption was that if the respondent learned in the earlier part of the survey that positive responses to certain service stem questions lead to additional inquiries, they might respond negatively to other similar stem questions encountered later in the survey to avoid the burden. Several investigators (Jensen, Watanabe and Richters, 1999
; Vega, 1998
) had previously shown that there could be symptom attenuation within the same administration. Following this same rationale, we conducted a randomized trial as part of NLAAS to examine the potential impact of attenuation on reported mental health service use. In order to allow for comparisons between NLAAS service use data with NCS-R and NSAL, 75% of the NLAAS sample was assessed using the traditional format with each stem question of a specific service, (e.g., use of a psychiatrist), followed by the corresponding detailed service questions for that same provider (psychiatrist) before presenting the next stem question for the second type of service provider (e.g. general health provider) in the service use assessments. The other 25% of the NLAAS sample was assessed using a modified instrument to reduce the potential impact of attenuation, placing stem questions for all of the assessed services up front in the battery (immediately after the psychiatric symptoms screeners) and then following the respondent’s previous positive endorsements to each service sector during the detailed questioning later in the battery. The two sub-samples (the 75% under the traditional instrument and the 25% under the modified instrument) were then compared to assess survey conditioning and attenuation effects. For each service use measure, we compared the presence versus the absence of service use reported under the two versions of the instrument, using the χ2
test for the two-way cross-tabulation of instrument version by service use status. We replicated these analyses using logistic regression models that controlled for additional covariates. All of those analyses are described in a manuscript under preparation by Dr. Naihua Duan and other collaborators.