Sm. Sci. Med. Vol. 23, No. 3. pp. 277-281. 1986 Printed in @eat Britain

0277-9536186 53.00 + 0.00 Pcrgamon Journals Ltd

PSYCHIATRIC RESEARCH INSTRUMENTS IN THE TRANSCULTURAL SETTING: EXPERIENCES IN

INDIA AND BRAZIL

BISWAJIT SEN and JAIR DE JESUS MARI General Practice Research Unit, Institute of Psychiatry, De Crespigny Park, London SE5 8AF, England

Abstract-Some of the issues concerned with the application of standardized psychiatric research instruments in settings other than the one in which they are developed are discussed in the light of the authors’ experiences in India and Brazil. The authors contend that in spite of the divergent manifestations of mental disorders across cultures, there is an inner core of human suffering which can be reliably detected by suitably modified instruments developed in the West. It is contended that the research worker should be as familiar with the cultural setting where the instrument is to be applied as the language in which the instrument has been developed.

Key words-interview schedules, somatization, conceptual equivalence, cultural divergence

INTRODIJCI’ION

Within the last two decades, a number of standard- ized and semi-standardized scales for measuring symptomatic behaviour have emerged. Some of them have been applied in cross-cultural studies of psychiatric phenomena, e.g. the Present State Exam- ination (PSE) [l], the General Health Questionnaire (GHQ) 121, and more recently the Clinical Interview Schedule (CIS) [3]. These scales undoubtedly repre- sent an advance over the clinically sensitive, but unpredictable and individualized opinions of the clin- ician. However, transcultural applications of these instruments have posed a new set of problems which have raised controversy. The aim of this paper will be to compare and contrast the problems encountered in the use of such psychiatric instruments in two devel- oping countries: India, which has many different languages and a heterogeneous cultural distribution and Brazil, where the overwhelming majority of people speak Portuguese and where the subcultural differences within the country are less prominent. The paper is not intended to be, in any sense, a general review of transcultural variations in clinical psychiatry.

BACKGROUND

India has a population of 750 million, speaking more than a score of different languages and several hundred dialects. There are roughly 1000 qualified psychiatrists in the country at present, i.e. 1 psychiatrist per 750,000 inhabitants. There are sig- nificant cultural and subcultural variations between different parts of the country and often between different districts of the same state. Slightly less than half the population live below the poverty line and less than two-thirds can read and write. Over three- quarters of the population live in rural areas. The infant mortality rate is 127 per 1000 and about five million children die every year from diarrhoea, mal- nutrition and other communicable diseases. 80% of

the population are Hindu, who accept the concept of rebirth and explain human suffering partially in terms of expiation of accumulated sins in the former incarnations.

Brazil has a population of approx. 130 million inhabitants. Although there are some differences in the Portuguese spoken in different areas (mainly accent and wording), in general, any form of the language can be understood all over the country. There are roughly 3.2 psychiatrists per 100,000 inhab- itants but most of the psychiatrists are concentrated in urban areas and they spend a considerable part of their practice in private clinics. The ‘official’ religion of the majority of people is Roman Catholic but the religious centres (places for worship and spiritual healing) of African origin, Umbanda and Kar- decismo, are also distributed fairly extensively. There are approx. 6 of these centres per 100,000 inhabitants [4] and it is widely known that psychiatric patients and their families resort to them very often. The infant mortality rate is around 80 per 1000.

LINGLTSTIC AND CONCEF’TL’AL EQUIVALENCE

Probably the most important problem in the trans- cultural application of psychiatric research instru- ments is the area of linguistic and conceptual equiv- alence. It has been stated that back-translation, consultation with experts, and resolution of contro- versies in committees are essential to maximize the chances of obtaining equivalent versions of an instru- ment [S]. What has been less adequately realized is that this strategy may not be feasible except at a national or multinational level, and then only if the population to be studied is linguistically and cul- turally homogeneous (although these problems are less important for Brazil than for India). The time and expense involved in such a formal stepwise procedure often preclude research workers from adopting that course. This is especially true of re- search workers in developing countries.

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278 Bnwur SE% and JAIR DE JESUS MARI

Throughout India, under- and postgraduate medi- cal education is in English. Case histories are written in English and clinical conferences and case dis- cussions are mostly in English. However, clinical interviews are, of course, held in the vernacular. It is almost second nature to Indian clinicians to translate mentally their psychiatric metaphors, idioms and concepts instantaneously from the original English into the vemacuIar and back translate most of the patient’s replies into English again for the case history record. And these verbal translations vary between patients, due less to human error than to the varying demographic characteristics, and hence, to the varying capacities of understanding of psycho- logical language, of the patients.

In the field of linguistic equivalence in India, it may be difficult if not almost impossible to arrive at a translation uniformly understandable to all and people may be imagined as distributed along a continuum, at one end of which would lie those with little, if any, formal education, clinging to their traditional beliefs, superstitions and values and at the other end those who are extremely ‘Westernized’. To the latter it is the translated version which may sometimes give rise to confusion especially with ques- tions like “Do you get the feeling that everything around you seems unreal”, whereas the original English promptly elicits an answer. Depending on whether the subject comes from an urban or rural background, has had a good or poor education, belongs to a high or low caste, there is considerable variation in the metaphors employed to elicit depres- sion, anxiety or delusions. No level of sophistication in translation can convey, at the same time, all the different nuances of language which a skilled clinician must have in his repertoire when dealing with patients from all walks of life. This problem particularly applies to translatability of adjectives and metaphors referring to personal and emotional states.

In Bradl, by contrast, medical education is mostly in Portuguese and so are most of the textbooks. Portuguese is well understood by the majority of the population and it has also a wide and relatively uniform vocabulary to describe cognitive experience of emotion and differentiating affects. Thus, trans- lation into Portuguese is easier to achieve and the back-translation is more IikeIy to be similar to the original language. Thus, for any psychiatric research instrument translation is mandatory and back- translation can be an important procedure to achieve conceptual equivalence. However, even here, the in- terviewer applying the instrument should be familiar with the subcultural nuances of the Brazilian setting, e.g. an understanding of the differential and com- bined influence of the various religions in their interpretation of questions in the questionnaire or interview schedule.

While translation and back-translation (and con- sultations to reach agreement) are deemed necessary for linguistic equivalence, conceptual equivalence probably depends more on the extent of the inter- viewer’s familiarity with the socio-cultural back- ground of the population under study than anything that translation can achieve. In the Indian context especially, back-translation, which is held to be an important check for conceptual equivalence, appears

to be of limited value in this respect. For example, in_ the CIS, while there is no difficulty in translating the question “How many hours sleep do you think that you miss on a bad night?” in the Bengali language, the reply of an average Bengali is likely to be misleading as his sense of time is, at best, rather elastic. Furthermore, a substantial proportion will not be able to answer at all as many perceive time by the movement of the sun and moon and not by the clock. Similarly, the question “Do you find it difficult to concentrate!” can be easily translated but will carry different connotations to, say, a schoolboy, a youth who practises yoga, and an illiterate housewife. To the last named especially, the question would convey little or no meaning. If instead she is asked whether she can satisfactorily complete a chore after beginning it, the desired reply is more likely to be elicited. A literal back-translation of these questions may result in, not one but several sub-cultural ver- sions of the original questions, some of which may well prove to be conceptually confusing in the West.

The ‘ability to concentrate’ also caused some prob- lems in the application of, the GHQ-30 version and the CIS in a pilot study in the city of Sao Paulo in Brazil [6]. This question was understood by some respondents to mean preparation to receive the holy spirits, probably amongst those strongly influenced by the African religions. However, the shorter version of the questionnaire (GHQ-12) was successfully applied in a later study [7].

Gillis et al. (81, working with the PSE among the Xhosa speaking people in the Cape Province of South Africa mentions that the “biggest problem lies in getting an understanding of the intent of the question which often has to be put in the spirit of the enquiry rather than the prescribed letter” of the questionnaire or the interview schedule (italics ours). Orley and Wing [9] have similarly emphasised the importance of getting at the “concept behind each item”. Close familiarity with the cultural setting of the community being studied appears to be a sine qua non for this endeavour.

The wide divergence of cultural norms across the world, differing extents of ‘somatization’ of psycho- logical distress, and the existence of culture-bound syndromes have heen held to be important reasons for the inadequacy of psychiatric research instru- ments originally developed in the West and con- sequently the reasons favouting the development of culture-specific research instruments. These perspec- tives shall now be discussed briefly in turn in the light of the authors’ experiences in India and Brazil.

CULTURAL DIVERGENCE

It has been stated that the very concept of mental disorder may be quite different in widely divergent cultures (10). Kapur et al. [l 1, 121 state that the schedules developed in the West do not pay adequate attention to possession states, symptoms of sexual inadequacy, and the variety of somatic symptoms so commonly encountered in the Indian setting. They therefore developed two structured interview sched- ules, the Indian Psychiatric Interview Schedule (IPIS) and the Indian Psychiatric Survey Schedule (IPSS) which were ‘free from (these) defects’. These sched-

Psychiatric research instruments in the transcultural setting ‘79

ules were “designed to investigate the presence of absence of 125 psychiatric symptoms, with special emphasis on those encountered in an Indian set- ting . . . . The IPSS enquires about symptoms only; no attempt has been made to combine the symptoms into psychiatric syndromes” [lo]. In so doing, they left no opportunity for any other research worker using a generally accepted system of classification of mental illness in India or elsewhere, to compare his findings to those of theirs.

What is more to the point, however, is that the IPIS ‘-when translated into English looks almost identical to questionnaires deveioped in the West” [ 131. Leff attributes this somewhat surprising result to the bias, on the part of the authors, “resulting from the selection of patients attending a Western-style facility” and having their complaints-used as the basis for constructing the two schedules-recorded by professional staff [13]. However, another expla- nation for the phenomenon, one to which the authors subscribe, suggests itself. It is that, in India, patients with psychiatric problems contacted either in a com- munity survey or in the hospital setting present with few, if any, complaints which reflect psycho- pathological states which are not readily categorised in known systems of classification.

There is growing evidence that cross-cultural in- struments (e.g. (141) to detect major mental disorders can be applied equally reliably in Western as well as other cultures. They are not appreciably different from other instruments developed and applied else- where (e.g. the PSE). A number of recent studies carried out in developing countries also illustrate the point that human suffering, though manifesting in different idioms across cultures has a common basis and can be detected reliably by research instruments developed in another culture, suitably modified if necessary [8, 15, 161. As Jablensky and Sanorius [ 171 pointed out, culture can often be used to mask socio-economic, biological, political and demo- graphic differences that might be associated with psychological disturbance.

Transcultural studies, if they are to be of interest internationally, e.g. in comparing the differential effects of socio-demographic factors on psychiatric morbidity, have to be conducted in a manner which leads to replicability and comparability with other studies in and out of the culture concerned. Only then can the cause of epidemiological investigations of psychiatric disorders be adequately served. To deny the validity of international comparisons in psychiatric epidemiology because of cultural diver- gence will be, we believe, a case of “throwing the baby out with the bath water”!

SOMATIZATION

It is now generally accepted that people all over the world express much of their psychological distress in somatic symptomatology. In this connection, Kir- mayer [18] has stated that the ability to differentiate between unpleasant emotional states in cognitive terms is restricted to ‘an educated urban minority’. In the Indian context too, this phenomenon has been well substantiated [lo, 1%221. Chakrabarti and

Sandel [23] have argued that somatization is a ‘nor- mal coping mechanism’ for Indians. However it has also been established that, at least in North India, patients are also capable of emotional differentiation and expressing themselves in psychological language [131.

In India, a psychiatrist who is unfamiliar with the patterns of somatic symptomatology, and indeed, some psychological symptoms as well, by which the patients express their distress, may well fail to detect states of mild anxiety or depression. This is especially so as most of these complaints occur commonly in conditions which are largely or entirely physical in nature. Symptoms such as weakness, feverishness, tiredness, dizziness, headache, leucorrhoea, ‘lack of peace’, are frequently the concomitants of bacterial infection, parasitic infestation, malnutrition or a combination of these factors. On the other hand these symptoms are frequently, in various combinations, the presenting complaints of psychiatric states, notably depression. Clinicians who have a cultural background similar to that of their patients and who, it may be expected, are familiar with the clinical picture of common physical disorders in that environ- ment are less likely to overlook underlying psycho- pathology when it is present.

In Brazil, vague somatic symptoms like fatigue and weakness has been speculated to be part of a depres- sive picture and that this ‘tendency to concentrate attention on body parts’ would be ‘more character- istic’ of the poorly educated [24]. Schedules used in transcultural studies (e.g. PSE and CIS) either list the majority of somatic symptoms met with in other cultures, or have provisions for their inclusion. GoId- berg and Huxley [25] have reviewed several general practice surveys, carried out in the U.K. and U.S.A., in which the GHQ and the CIS have been reliably used to ascertain psychiatric morbidity in a patient population which largely expressed their problems in somatic terms. It is the contention of the present authors that with suitable modifications [26, 151, in- struments such as the GHQ and CIS may be used in transcultural settings without significant loss in re- liability or validity, provided the research worker administering the instrument is familiar with the environment-medically as well as socially-in which he is using it.

CULTURE-BOUND SYNDROMES

The problem of culture-bound syndromes is different and worthy of close attention. A substantial body of literature exists in this subject [13,271. The clinical manifestations of some of these syndromes are so different from patterns recognised in the West that it has been suggested by several authorities that these syndromes cannot be fitted into universal cate- gories [28,29] and, by inference, are unlikely to be detected by standardized psychiatric interviews used across cultures. In the authors’ experience of their own countries, such unusual behavioural patterns are not common and hence do not support the claims for developing new research instruments for the purpose. Moreover, the apparent uniqueness in clinical mani- festation of some of these syndromes often resolve

280 BISWAJIT SEX and JAM DE JESUS .MARI

into a familiar pattern of distress signals, usually an admixture of anxiety and depression, occasionally complicated by dissociative states. Some observations from India in this context can be briefly discussed here.

In a study of fifteen patients exhibiting symptoms of ‘possession states’, Teja and Khanna [30] diag- nosed seven as hysteria, six as schizophrenia, and two as mania. Typically, the patient was a female in her twenties, of low education and income, presenting with altered states of consciousness in which she behaved as if possessed by a spirit of a dead neigh- bour or relative or more rarely a god. These authors have suggested that the hysterical cases be given the diagnosis of ‘hysterical psychosis’. Most psychiatrists in India are currently of the opinion that possession states, in general, are culture-specific manifestations of dissociative reactions. In the Indian context, there- fore, it is doubtful whether possession states should be considered to be a psychiatric syndrome in its own right [31].

Venkoba Rao [22] has reviewed various forms of sexual neurosis originating from cultural beliefs that are prevalent in India. Known amongst others, by the names of Ascetic Syndrome and Dhat Syndrome, these neuroses have in common a morbid concern over control of sexual impulses or fear of loss of semen by voluntary or involuntary means. These syndromes give rise to anxiety (often severe), hypo- chondriasis and impotence. Chakrabarty and Ban- nerji [32,33] describe the syndrome of Suchi-bai (or ‘purity mania’), related to a fear of contamination and a desire to remain clean. Although there is an absence or denial of internal resistance in many of these cases, the authors consider this syndrome to be a form of obsessive-compulsive neurosis as grossly compulsive behaviour, socially labelled as abnormal, commonly occurs without verbal admission of inter- nal resistance.

Brody [24] randomly selected 20 first-admissions from a psychiatric hospital in Rio de Janeiro to investigate how many had sought a religion centre and the reasons for such procedure: 14 patients turned out to have attended religious sessions at least once largely because either the patient or a relative believed that spirits were causing the psychiatric condition. These patients were however interviewed by a research psychiatrist who apparently had no difficulty in ascribing a psychiatric diagnosis to them. It may be interesting in this connection that pos- session states as such are rarely, if ever, delineated as a syndrome by Brazilian psychiatrists.

This is not, however, to deny the validity of the observations of those experts across the globe who have described culture-specific manifestations which are difficult to understand in terms of standard diagnostic criteria [31]. As Murphy [34] pointed out, culture does affect psychiatric research either as a distortion or as an object of inquiry. The available research instruments for psychiatric epidemiological studies have no provision for diagnosing these culture-bound syndromes. As Kirmayer [ 181 suggests, a detailed study of the epidemiology of these syn- dromes with culture-specific interviews and self re- port scales is a necessity for meaningful cross-cultural comparisons with international accepted diagnostic

categories. This, in its own right, is an important area of research which has not so far been investigated in any great detail.

On the other hand, as the available evidence from India shows, the majority of these can be reclassified for the present in accordance with the International Classification of Diseases. With suitably modified instruments, as mentioned previously, not many of these cases would be missed, provided of course, the interviewer concerned is familiar with the cultural and subcultural variations. This admittedly inefficient method will have to suffice for the time being, as it has till the present, for general epidemiological pur- poses. Important aetiological and. perhaps, ther- apeutic clues may be lost thereby and the investigator should be aware of these shortcomings in his meth- odology. What has also to be remembered in this connection, however, is that the culture-bound syn- dromes so far detected form only a tiny proportion of the entire range of mental disorders.

CONCLUSION

Notwithstanding that the manifestations of mental disorders vary between cultures, it is gradually be- coming clear that there is an inner core of human suffering, which, even in its widely varying neurotic manifestations across cultures, can be detected re- liably with suitably modified instruments originally developed elsewhere. There is much to be said for indigenous research instruments being developed in cultures which markedly differ from those for which commonly used psychiatric research instruments, e.g. GHQ and PSE were developed. However, they need to be comparable to and compatible with the instru- ments already in existence.

In India, for transcultural studies, it is our con- tention that it is the interviewer, perhaps more than the instruments he uses, who needs to be ‘standard- ized’ for reliability. One of the ways in which that can be done is for several interviewers (preferably clin- icians) belonging to the cultural background that is to be studied, independently co-rate a group of patients who are heterogeneous with regard to their subcultures, with the chosen questionnaire or inter- view schedule till acceptable levels of reliability are achieved. Once this has been done, it is our hypoth- esis that-assuming that they are clinicians-if they use the instrument both in their original English or the translated version their measures of agreement will be very similar. It is only when the interviewer himself is not well conversant with the English lan- guage that translation and back-translation achieve their proper value.

In Brazil, it is our view that, in principle, the psychiatric instruments should be translated into Portuguese. The back-translation technique would be important to compare the linguistic and conceptual similarity between the original instrument and the Portuguese version since the wording as well as the glossary definition should not neglect the Brazilian cultural context. A reliability study of the Portuguese version should be conducted to evaluate if all definitions can adequately be applied in the local setting. The findings of this evaluation might thus delineate which symptoms would be more likely to

Psychiatric research instruments in the tranxultural setting 281

cause misleading interpretations if cross-cultural ‘comparisons are to be made. For instance, very low reliability was found for ‘histrionic behaviour’ as it is defined in the CIS [35].

Although it has been suggested that ‘minor’ emo- tional disorders are more likely to raise transcultural difficulties than psychotic phenomena [36,37,9], there has not so far been any study comparing patterns of symptomatology of such emotional states in different countries. The nature and extent of any possible differences has yet to be investigated. It is our impression that existing differences of symptom- atology between cultures (and they should not be neglected) are not as important as the existing similarities.

Acknowledgements-We would like to acknowledge our gratitude to Professor Michael Shepherd and Dr Paul Williams for their encouragement, criticisms and advice. Biswajit Sen is supported by a scholarship from the Stromme Memorial Foundation in Norway. J. J. Mari has been supported by the ‘CNPq-Conselho National de Pesquisa’ and ‘FAPESP-Fundacao de Amparo a Pesquisa do Estado de Sao Paulo’.

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