Apart from changing its site, the study of primary care psychiatry in non-European countries will raise an important methodological issue—that of cultural equivalents of the disease concepts and thus the validity of measuring instruments. The traditional approach to the cross-cultural approach will be the 'etic', which involves the application of an internationally agreed classificatory system using appropriately translated standardized instruments. Data obtained in this way are comparable across all countries of the world. Its value was demonstrated by the WHO multicentre study. (11) However, critics of the etic approach claim that it relies on untested assumptions—that mental illness, as described in Euro-American countries, occurs everywhere, that the syndromes show the same core features, and that the current classificatory arrangements are useful. Thus there is a danger of labelling culturally distinct behaviours as psychopathology, if they appear to the outsider to have similarities with a typical Euro-American pattern (e.g. depression or anxiety). Secondly, both patient and physician are making judgements of normality and deviance when either consulting or responding to a consultation. These two concepts underlying clinical judgement are not uniform. Thirdly, the assumption that mental disorders, as set out in an international classification, exist everywhere predisposes to a biological viewpoint, i.e. the cause of the disorder lies in the human substrate. However, accepting that concepts of illness will vary between cultures will allow study of social influences that make some individuals perceive themselves and be perceived as in need of help. (H1)
In contrast with the etic, the 'emic' aims to evaluate phenomena from within a culture to describe local models of illness without imposing Euro-American diagnoses.(!!2) Data are gathered through open-ended unstructured interviews of local informants. Inevitably, such research tends to be small scale and the data are open to bias in both the recording and interpretation. Furthermore, cross-cultural comparisons are not possible because of the idiosyncrasy of local concepts. Thus, more recently, there have been calls for a new cross-cultural psychiatry, in which value is given to both folk beliefs about mental illness and biomedical concepts. (113) The elucidation of patients' explanatory models of illness is an important step—how patients understand their problems, the origins, and the consequences. These data are traditionally obtained through lengthy semistructured interviews. The Short Explanatory Model Interview ( SEMI), based upon Kleinman's original concepts, has now been developed to allow explanatory model variables to be included in quantitative analyses and large field samples. This interview takes 15 to 20 minutes to deliver and provides both quantitative and qualitative data. Lloyd et al.(11i) compared responses to the SEMI in four culturally diverse groups of patients attending primary care, each meeting case criteria for common mental disorders in etic terms. The patients' explanation of their symptoms and the expectations from the consultations with the primary care physician, showed marked differences, even though the patients suffered from (in Euro-American diagnostic terms) the same disorder. It may be that explanatory model measures will be useful to further primary care psychiatry research in predicting frequency of consultation with different agencies, compliance with proposed treatment, and even responses that to treatment.
Another approach that has aimed to bring together both emic and etic approaches in the field has been the development of culturally sensitive screening questionnaires for common mental disorders. An example of this comes from Harare, Zimbabwe. Focus groups of local health-care professionals and traditional/religious healers were set up, and a list of symptoms of what were called 'idioms of distress', used by the Shona people, were developed. (115) Forty-seven such symptoms were assembled into a questionnaire and, after field trials, were reduced to a 14-item questionnaire with good discriminatory power to detect cases of common mental disorder. The gold standard in this study was both etic (the use of the Clinical Interview Schedule) and emic (the care-provider judgement that mental disorder was present). The final questionnaire contained some items that are recognizable in etic terms (tearfulness, poor sleep, anhedonia, tiredness, stomach ache, poor concentration, difficulty in decisions, irritability), but some that would not be (thinking too much, disturbing dreams, and visual/perceptual abnormalities). This questionnaire was then used to detect common mental disorders amongst representative samples of attenders in primary care of all types in Harare—GP, nurse-led primary care clinic, and traditional healers. Fifty per cent of consecutive attenders were deemed probable cases. Caseness was associated with disability, poverty, and adverse events/!1,6) Patients attending the traditional healer tended to have longer duration of illness, and were likely to believe in witchcraft as the cause and to complain of 'thinking too much'. The agreement between the emic caseness (as defined locally by the care provider, whether GP, nurse, or traditional healer) and by a standard diagnosis was 55 per cent (k = 0.1), (11Z) and similar figures were found in the WHO study. It seemed that the emic criteria tended to be more inclusive; these providers identified as cases those who were poorly educated, unemployed, female, with long-standing social problems, and who provided a spiritual explanation for their difficulties. Otherwise, the emic cases tended to show higher scores on the etic measures, except for phobias, which were more common in emic non-cases. This study was an important step in introducing emic symptomatology and models of causation into essentially epidemiological inquiry in primary care. The important findings were that idioms of distress did have some distinct local features and that local care providers took spiritual explanations and social factors into account when deciding caseness. An outcome study that reassessed those who were cases at cross-section 2 and 12 months later, showed that 49 per cent had recovered by 2 months and remained well, but that 28 per cent remained continuously unwell for full year. (H8) The persistent cases were much more disabled and had the most disability and economic deprivation of the whole group. Explanatory models tended to have some power to predict 2-month outcome, but lost significance by the 12-month follow-up. Recognition by the local health care provider improved outcome. The outcome was similar whether the patients with common mental disorder attended medical or traditional forms of primary care. This study, which is the first of its type, provides support for some similarity for concepts of common mental disorder across cultures, but has shown that there are some local aspects which must be taken into account. These would be particularly important for training primary care providers (whether doctors, nurses, or traditional healers) in recognition and introducing some form of treatment.
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