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Crosscultural Issues in Research and Treatment of Respiratory Conditions


Culture: what one needs to know or believe in order to behave appropriately. ... Shortness of breath/gasping for air 19% Allergy symptoms (itchy eyes, eczema) 16 ... – PowerPoint PPT presentation

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Title: Crosscultural Issues in Research and Treatment of Respiratory Conditions

Cross-cultural Issues in Research and Treatment
of Respiratory Conditions
  • Anne L. Wright, PhD
  • Arizona Respiratory Center
  • The Department of Pediatrics
  • The University of Arizona
  • Tucson, Arizona, USA

Outline of todays talk
  • I. Overview What is culture?
  • II. Cultural influences in research
  • III. Cultural influences on health beliefs and
  • IV. Native American/Alaska Native perceptions of
  • Asthma among the Navajo
  • Asthma among the Yupik

I. Overview
What is culture? (1)
  • Culture what one needs to know or believe in
    order to behave appropriately.
  • Everybodys got culture!
  • Culture influences beliefs and behaviors.

What is culture? (2)
  • Cultural beliefs arbitrary based on core,
    normative values
  • Individuals vary in acceptance of cultural
  • Culture influences illness beliefs and behaviors.

Main cultures in the Southwest
  • Tohono OOdham
  • Yaqui
  • Apache
  • Navajo
  • Mexican American
  • Alternative, New Age

II. Cultural influences on research
Worldwide variation in asthma symptoms,13-14 yrs
  • Wheeze past yr. Ever asthma
  • Africa 11.7 10.2
  • Asia-Pacific 8.0 9.4
  • Latin America 16.9 13.4
  • North America 24.2 16.5
  • Northern Europe 9.2 4.4
  • ISAAC Steering Committee Eur Resp J

Main technique for studying prevalence Survey
  • Questionnaire with short questions Yes/no, fill
    in the blank
  • In the past year, did your child have a cough
    without a cold?
  • How often did your child wheeze in the past year
    Never, 1-3 times, 4-7 times, 8-12 times, etc.
  • Questions asked in a standardized way, same order

But, cultural and linguistic issues affect survey
  • How question is phrased influences answers
  • Appropriate terms in local language may have
    different connotations, so questions may not
    really be standardized in different languages
  • Classification and reporting of symptoms varies
  • Example fallen fontanelle syndrome (caida de la

Survey shared assumptions
  • What medicines do you take for your asthma?
  • Assumes
  • Shared understanding of asthma
  • Shared understanding of medicine
  • Shared health philosophy

Example High blood pressure among African
  • Medical condition Hypertension
  • Chronic, imperceptible disease
  • Genetic and lifestyle risk factors
  • Consistent taking of medicines regardless of
  • Folk illness High blood
  • Intermittent condition that can be felt by the
  • Associated with stress
  • Take medicine when feel stressed

Alternate approach Ethnographic Interviews
  • Goal to reproduce cultural reality as it is
    perceived, lived by members of a society
  • Semi-structured, open-ended
  • Start with grand tour question (Tell me about
    your health problems, asthma.)
  • Use list of topics to cover which can encompass
    symptoms, attitudes, behaviors
  • Analyzed for themes

How ethnographic interviews differ from surveys
  • Survey
  • Starts with the conceptual categories of the
  • Follows a set order
  • Asks the same questions in the same way
  • Ethnographic interviews
  • Respondent defines the terms, the domain of
  • Follow the respondents logic
  • Questions, sequence modified based on responses,
    terms used

Summary Pros and cons of ethnographic interviews
  • Advantages
  • In depth understanding of an issue that is
    consistent with how it is perceived by a
    particular group
  • Uses respondents language, categories
  • Helps understand the logic of behavior
  • Disadvantages
  • Time consuming to conduct, analyze
  • Difficult to compare across studies
  • Some standardization essential to assessing

III. Cultural influences on health beliefs and
Culture influences illness beliefs and behaviors
  • Culture influences sick role, social relations of
    treatment, communication about the illness,
    health beliefs
  • Beliefs re illness influence behavior (medicine
    taking, prevention, health service utilization)
  • Although they may appear quaint in isolation,
    there is a logic to cultural beliefs about

Hozho (harmony) Key concept in Navajo
philosophy of health
  • Health results from harmony with the natural,
    social and spiritual worlds
  • Disease is defined in terms of causes, not
  • Causes involve breach of taboo, exposure to
    powerful and malevolent forces
  • Viruses and bacteria can be agents, but they only
    affect (spiritually) vulnerable individuals
  • Only religious rituals that restore harmony can
    cure illness, although symptoms may be reduced
    with medicines

(No Transcript)
Investigating cultural influences on asthma
perceptions and behaviors among Native
Americans/Alaska Natives
  • Two projects
  • 1. Navajo (SW US) 1997 - 1998
  • 2. Yupik (Alaska) 1999 - 2001

Asthma projects among Native Americans/Alaska
  • Specific aims were to
  • Investigate perceptions of asthma and its
    treatment among families with asthmatic children
  • Identify health care utilization patterns for
    wheeze and asthma in these two groups
  • Identify any differences in presentation of
  • Investigate potential differences in labeling of
    respiratory symptoms among health care providers.
  • Funded by NIAID.

1. The Navajo study Methods
  • Semi-structured, open-ended ethnographic
  • List of topics
  • History of illness
  • Significant episodes of asthma
  • Management and prevention
  • Reasons behind patterns of medication use
  • Conducted in English or Navajo
  • Tape recorded and transcribed, analyzed for
  • 30 families with ? one asthmatic child, 5 elders
  • Van Sickle and Wright, Pediatrics, 2001

Ways to refer to asthma in Navajo
  • Dine cheeh didziih
  • Person with difficulty he breathes
  • Dine anazhil
  • Person cannot breathe out
  • Dine biyol bichi anahooti
  • Person his breath toward it a problem
  • Dine biyi hoo diitsago nididzih
  • Person internally a sound comes when he

Navajo taxonomy of Respiratory problems
  • Hayol bichi ana hootsi
  • Ones breath A problem extends to it
  • Colds Allergy
  • Dikos Taa doolee hojoola
  • Something doesnt agree with you
  • Dikos Dikos nitsaa Ajoolaii
  • Common colds Large colds Allergy
  • Asthma Asthma Asthma

Definition of asthma for Navajo respondents
  • Asthma is an acute illness, with attacks
    considered temporary episodes resulting from
    mechanical obstruction of the airways.
  • Traditional belief asthma brought upon a person
    who is vulnerable after some unfortunate event or
  • Regarded by Navajo elders as a mechanical symptom
    of an underlying spiritual disorder.
  • Asthma is often feared, because of the
    unpredictable, erratic nature of symptoms and
    apparent lack of control

Asthma symptoms reported by Navajo respondents
  • Difficulty breathing/cant breathe 56
  • Nocturnal symptoms 35
  • Wheeze 35
  • Cough 28
  • Lack of energy, lethargy 28
  • Chest tightness/congestion 23
  • Shortness of breath/gasping for air 19
  • Allergy symptoms (itchy eyes, eczema) 16
  • Throat tightness/soreness 12
  • Cyanosis/blue skin or lips 7

Explanatory models Systematic way to elicit
health beliefs
  • General and specific beliefs about
  • Cause of condition
  • Timing and triggers
  • Pathophysiology
  • Course and prognosis of the disease
  • Treatment efficacy and side effects

Cause Number citing specific causes of asthma
  • Heredity 11
  • Environment Air pollution 9
  • Local environment 6
    Weather 4 Uranium exposures
    4 Atmosphere/stuff in air
    2 Occupational exposures 2 Wood
    smoke 1
  • Traditional violations/change in traditional
    lifestyle 4
  • Individual characteristics
  • Lung infection or insult 7
  • Diet 4
  • Weight 3
  • Prematurity/birth defects 4
  • Individual constitution 3
  • Not taking care of oneself 2
  • Lack of exercise 2
  • Other (medications, low 3
    immune system)

Common beliefs about the pathophysiology of asthma
  • Involves mechanical obstruction of the lungs,
    through constriction of air passages or
    production of mucous
  • Respondents spoke of losing their breath or
    running out of breath to describe this
  • Related to infections and allergies

Perceived prognosis
  • Most parents (70) believed their children would
    outgrow asthma, and most felt the illness was
  • Adults less optimistic about their disease 14
    expressed concern that they might die from the
  • Personalized Asthma history, course and
    prognosis, and thus optimal management varies
    among individuals.

Treatment Percent using traditional healing
  • Herbs only 5 (1)
  • Prayer and herbs 10 (2)
  • Traditional ceremonies 25 (5)
  • Several different ceremonies attended

  • Do you think the traditional way . . . helps in
    a different way than medications would from the
  • I think so. Like mentally and spiritually. You
    know, the medicine man tells you that you have
    these problems, and- when you go to a physician
    they dont diagnose those things. So to me, it is
    important to do, like prayers, protection
    ceremonies and all these things.

Treatment Use of health care services for asthma
  • Number of emergency room visits None 8
    (21) One 6 (16) Multiple 24 (63)
  • Hospitalizations for asthma None 16
    (49) One 7 (21) Multiple 10 (30)
  • Percents calculated on the basis of the
    asthmatics for whom information was available.
    n38, n33

Treatment Medication use (n39)
  • Rescue meds (bronchodilators) 71
  • Controller meds
  • Inhaled steroids 23
  • Inhaled anti-inflammatories 11
  • Inhalers (unspecified) 36
  • Nebulizers 7
  • Oral or nasal steroids 4
  • Other 11

Cultural issues re use of asthma medications (1)
  • Controller meds distinguished from rescue
    medications. But
  • Preventive medications thought to work like
    rescue meds
  • Effectiveness of controller medications harder to
  • Each inhaler thought to offer unique formulation
    which is more or less compatible with a
    particular individuals constitution
  • Perception that use of medications delays bodys
    own healing
  • Concern about dependency 59 tried to endure
    episodes without medicines, to teach their body
    to handle the symptoms

Cultural issues re use of asthma medications (2)
  • Severe attacks the standard against which
    current symptoms are measured to judge when meds
    should be started.
  • Breathing treatments (nebulized medicines)
    given in the ER perceived as the strongest and
    most effective medicine
  • Child is responsible for his/her medicine taking
  • 81 of children lt18 years old (n35) had primary
    responsibility for taking their own medications
  • Responsibility began at a very young age (i.e. 3

Is asthma under-treated in this population?
  • Relatively severe symptoms reported
  • Fear of death in significant proportion of
  • Extensive use of emergency department for acute
  • Extremely high rates of hospital admission for
  • Small percentage of asthmatics on
    anti-inflammatory medications

Anti-inflammatory (AI) use in populations of
  • 36.9 mild 47.3 moderate, 56.8 of severe
    asthmatics in a California HMO (Jatulis et al.
  • 23.5 of children who presented at an
    Indianapolis ED for asthma (Leickly et al. 1998)
  • 5.3 in a school-based study among inner city
    asthmatics in Baltimore (Eggleston et al. 1998)

Patient beliefs and behaviors contribute to
  • Hesitancy to take meds in absence of symptoms as
    body must be allowed to heal itself try to wean
    from meds to see if asthma has gone away
  • Fear of dependency on medication
  • Severe attacks are the standard against which
    current symptoms are measured
  • Nebulized meds in ER considered most effective
  • Medication use cant cure the disease
  • These beliefs result in delay in use of
  • during acute attack.

Clinical implications of Navajo beliefs about
asthma meds
  • Children must be involved in treatment
  • The fear of dependency, and of reducing bodys
    ability to heal itself, must be addressed
  • Although preventive medications recognized as
    distinct, their efficacy is difficult to measure
  • Discuss problems associated with trying to wean
    from medications
  • Use of peak flow meters could provide objective
    assessment of severity of attack

(No Transcript)
Asthma among Alaska Natives
  • Earlier study examined the prevalence of asthma
    among two American Indian and Alaska Native
    (AI/AN) middle school populations
  • Used two indicators for asthma prevalence
  • symptoms
  • diagnosis
  • Stout et al. Public Health Rep 2001

Methods Stout et al. data collection
  • ISAAC -- internationally validated video and
    written survey
  • designed to compare prevalence worldwide
  • mitigate language and translation issues
  • 25 written questions - modified for regional use
  • 5 video scenarios
  • 13 year old children contacted through schools in
    three towns in the Yukon-Kuskokwim Delta region
    of Alaska (n452), and in Tacoma, Washington

Asthma diagnoses clinic visits
Stout results Summary
  • Similar reported prevalence of respiratory
    symptoms, visits
  • Metro WA sample twice as likely to report MD
    asthma diagnosis and ever had asthma
  • Among respiratory visitors, Metro WA sample 2.8x
    more likely to report ever had asthma 4.5x
    more likely to report MD diagnosis
  • Suggested that prevalence of asthma may depend
  • Diagnostic behaviors of physicians
  • Differential health care utilization
  • Cultural perceptions of illness

2. The Yupik study
  • Purpose To identify cultural factors influencing
    presentation and treatment of asthma among Yupik
    children with asthma
  • Approach
  • Ethnographic interviews with 60 asthmatic
  • Medical record review to assess visits for
    wheezing, diagnoses, medicines prescribed,
    co-morbidity (allergy, GE)
  • Ethnographic interviews with health care

Respiratory health and treatment among the Yupik
  • Published epidemiology of respiratory illness
  • Very high rates of respiratory illness in all
  • Highest rates of documented RSV infection in the
  • 10 of children have bronchiectasis, though
    virtually unknown among children in the
    industrialized world
  • Structural issues
  • Village based health care that relies on lay
    health workers
  • Use of term reactive airways disease by some MDs

(No Transcript)
Yupik philosophy of health
  • Less well articulated than the Navajo
  • Ritual cycle organized around the spirits of
    animals they hunted and fished rather than health
  • Steam has cultural salience and is commonly
    prescribed for respiratory ailments

Causes of asthma reported by Yupik families
  • Heredity 55 Mold 28
  • Dust 48 Smoking 25
  • Colds / infections 45 Childhood LRI 25
  • Allergies 44 Smoke 25
  • Cold air 36 Fumes 22
  • Passive smoke 33 Wood smoke 19
  • Pollution 30 Exercise 13 Vehicle
    exhaust 13

Yupik beliefs about asthma
  • Often denied by patients identified as asthmatic
    by MDs
  • Thought to be less serious than pneumonia
  • Main reason to see MD for wheezing fever
  • Children expected to grow out of the disease
  • Wind, Van Sickle, Wright Soc Sci Med 2004

Yupik perceptions of asthma medications
  • Most families own a nebulizer, used for any
    respiratory illness in any family member
  • Fear of dependency on the medications
  • Moral identity as physically fit, able to engage
    in subsistence activities
  • Sports, exercise thought to develop lungs

Record reviews suggest different asthma
presentation for Yupik
  • Extremely high numbers of LRIs 1.9
    episodes/child year of follow-up
  • Mean 3.4 visits for respiratory symptoms/child
    year (2.3 visits/child year for wheeze)
  • 50 of these asthmatic children have chronic lung
  • Relatively low percentage (57) with allergy
  • Question Does the altered presentation influence
    treatment for asthma?

Medication use
  • Inhaled steroids only prescribed for 38 of
    asthmatic children only 30 of those who were
    hospitalized for asthma.
  • Bronchodilators, antibiotics prescribed for all
    but one child
  • Controller medicines not available at village
  • While CLD is the main predictor of asthma
    morbidity among the Yupik, allergy is more
    strongly associated with prescriptions for
    inhaled steroids.

CLD ? asthma morbidity, severity but not steroid
  • hospitalized inhaled
  • CLD Allergic 52.6 .51
  • Non-allergic 50.5 .07
  • Total 51.7 .36
  • No CLD
  • Allergic 14.3 .18
  • Non-allergic 20.0 .03
  • Total 17.2 .10
  • Kurzius-Spencer et al. Pediatr Pulmonology, In

Summary and Conclusions
  • Morbidity due to asthma and other respiratory
    conditions is significant among Native
    Americans/Alaska Natives
  • Both traditional and biomedical concepts are used
    to explain asthma among Native American
  • Asthma appears to be under-treated in both
  • Patient beliefs and behaviors contribute to the
    under-use of asthma medications
  • Physician behavior also contributes to low use of