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Crosscultural Issues in Research and Treatment of Respiratory Conditions

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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


1
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

2
Outline of todays talk
  • I. Overview What is culture?
  • II. Cultural influences in research
  • III. Cultural influences on health beliefs and
    behaviors
  • IV. Native American/Alaska Native perceptions of
    asthma
  • Asthma among the Navajo
  • Asthma among the Yupik

3
I. Overview
4
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.

5
What is culture? (2)
  • Cultural beliefs arbitrary based on core,
    normative values
  • Individuals vary in acceptance of cultural
    beliefs
  • Culture influences illness beliefs and behaviors.

6
Main cultures in the Southwest
  • Tohono OOdham
  • Yaqui
  • Apache
  • Navajo
  • Mexican American
  • Alternative, New Age

7
II. Cultural influences on research
8
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
    199812315-335

9
Main technique for studying prevalence Survey
interviews
  • 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

10
But, cultural and linguistic issues affect survey
findings
  • 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
    cross-culturally
  • Example fallen fontanelle syndrome (caida de la
    mollera)

11
Survey shared assumptions
  • What medicines do you take for your asthma?
  • Assumes
  • Shared understanding of asthma
  • Shared understanding of medicine
  • Shared health philosophy

12
Example High blood pressure among African
Americans
  • Medical condition Hypertension
  • Chronic, imperceptible disease
  • Genetic and lifestyle risk factors
  • Consistent taking of medicines regardless of
    symptoms
  • Folk illness High blood
  • Intermittent condition that can be felt by the
    patient
  • Associated with stress
  • Take medicine when feel stressed

13
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

14
How ethnographic interviews differ from surveys
  • Survey
  • Starts with the conceptual categories of the
    researcher
  • Follows a set order
  • Asks the same questions in the same way
  • Ethnographic interviews
  • Respondent defines the terms, the domain of
    thought
  • Follow the respondents logic
  • Questions, sequence modified based on responses,
    terms used

15
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
    prevalence

16
III. Cultural influences on health beliefs and
behaviors
17
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
    illness.

18
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
    symptoms
  • 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

19
(No Transcript)
20
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

21
Asthma projects among Native Americans/Alaska
Natives
  • 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
    asthma
  • Investigate potential differences in labeling of
    respiratory symptoms among health care providers.
  • Funded by NIAID.

22
1. The Navajo study Methods
  • Semi-structured, open-ended ethnographic
    interviews
  • 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
    themes
  • 30 families with ? one asthmatic child, 5 elders
  • Van Sickle and Wright, Pediatrics, 2001
    108(1)/e11

23
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
    extends
  • Dine biyi hoo diitsago nididzih
  • Person internally a sound comes when he
    breathes

24
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

25
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
    violation.
  • 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

26
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

27
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

28
Cause Number citing specific causes of asthma
(n29)
  • 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)

29
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
    situation.
  • Related to infections and allergies

30
Perceived prognosis
  • Most parents (70) believed their children would
    outgrow asthma, and most felt the illness was
    improving
  • Adults less optimistic about their disease 14
    expressed concern that they might die from the
    disease
  • Personalized Asthma history, course and
    prognosis, and thus optimal management varies
    among individuals.

31
Treatment Percent using traditional healing
practices
  • Herbs only 5 (1)
  • Prayer and herbs 10 (2)
  • Traditional ceremonies 25 (5)
  • Several different ceremonies attended

32
  • Do you think the traditional way . . . helps in
    a different way than medications would from the
    doctor?
  • 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.

33
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

34
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

35
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
    evaluate
  • 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

36
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
    years)

37
Is asthma under-treated in this population?
  • Relatively severe symptoms reported
  • Fear of death in significant proportion of
    respondents
  • Extensive use of emergency department for acute
    care
  • Extremely high rates of hospital admission for
    asthma
  • Small percentage of asthmatics on
    anti-inflammatory medications

38
Anti-inflammatory (AI) use in populations of
asthmatics
  • 36.9 mild 47.3 moderate, 56.8 of severe
    asthmatics in a California HMO (Jatulis et al.
    1998)
  • 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)

39
Patient beliefs and behaviors contribute to
under-treatment
  • 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
    treatment
  • Medication use cant cure the disease
  • These beliefs result in delay in use of
    medications
  • during acute attack.

40
Clinical implications of Navajo beliefs about
asthma meds
  • Children must be involved in treatment
    discussions
  • 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

41
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42
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
    Jan-Feb116(1)51-7

43
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
    (n159)

44
Asthma diagnoses clinic visits
45
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
    on
  • Diagnostic behaviors of physicians
  • Differential health care utilization
  • Cultural perceptions of illness

46
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
    families
  • Medical record review to assess visits for
    wheezing, diagnoses, medicines prescribed,
    co-morbidity (allergy, GE)
  • Ethnographic interviews with health care
    providers

47
Respiratory health and treatment among the Yupik
  • Published epidemiology of respiratory illness
  • Very high rates of respiratory illness in all
    ages.
  • Highest rates of documented RSV infection in the
    world.
  • 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

48
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49
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

50
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

51
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

52
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

53
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
    disease
  • Relatively low percentage (57) with allergy
  • Question Does the altered presentation influence
    treatment for asthma?

54
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
    level
  • While CLD is the main predictor of asthma
    morbidity among the Yupik, allergy is more
    strongly associated with prescriptions for
    inhaled steroids.

55
CLD ? asthma morbidity, severity but not steroid
use
  • hospitalized inhaled
    steroids
  • 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
    press

56
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
    asthmatics
  • Asthma appears to be under-treated in both
    communities
  • Patient beliefs and behaviors contribute to the
    under-use of asthma medications
  • Physician behavior also contributes to low use of
    meds.
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