Cultural Competence: Building Up a Knowledge Base of Cultural Observations in Medicine


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Cultural Competence: Building Up a Knowledge Base of Cultural Observations in Medicine

  1. 1. Cultural Competence: Building Up a Knowledge Base of Cultural Observations in Medicine Dr. Riccardo Colasanti Rielo Institute for Integral Development
  2. 2. Why a Knowledge Base on Medical Anthropology?
  3. 3. Cultural differences
  4. 4. Zuo-yuezi in China (Doing the month) 1. Do not wash yourself and do not wash your hair for the entire month 2. Do not go outside for the entire month 3. Do not eat any raw and any “cold” food 4. Eat chicken 5. Do not be blown on by the wind 6. Do not walk and move around 7. Do not go to other person’s home 8. Do not get sick during the month 9. Do not read or cry 10. Do not have sexual intercourse during the month 11. Do not eat at the table with the rest of the family 12. Do not burn incense Soc Sci Med. 1978 Jan;12(1B):11-22. "Doing the month": confinement and convalescence of Chinese women after childbirth. Pillsbury BL.
  5. 5. What about “Doing the month” in a migration process?
  6. 6. Sudden Unexpected Nocturnal Death Syndrome (SUNDS) Sudden Unexpected Nocturnal Death Syndrome (SUNDS) is a syndrome with different names in Japan (Pokkury) in northeast Thailand (Tai lai) and 'Bangungut in Tagalog reported in young healthy asiatic males. The syndrome consists in an unxepected nocturnal death. The survivors tell they felt a big sense of chest oppression, paralysis, nightmares. The syndrome is reported even in southAsia Males (Hmong) who migrated in USA and in Bangladesh workers living abroad. In Japan pokkury it is also related to Pokkury Dera that are Buddhist temple where people pray to receive a sudden death without passing through the pain and trouble of a long disease. An example of Pokkuri Dera is Kichidenji Temple[1] in Ikaruga. It seems that pokkuri in Japanese culture it is related to a good and peaceful death. Reference: Sudden Unexpected Nocturnal Death Syndrome among Hmong Immigrants: Examining the Role of the "Nightmare" Shelley R. Adler The Journal of American Folklore Vol. 104, No. 411 (Winter, 1991) (pp. 54-71) [2] Is sudden unexplained nocturnal death a breathing disorder? Psychiatry Clin Neurosci. 1995 May;49(2):111-4. Tanchaiswad W. Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Songkla, Thailand. [3] Pokkuri Death Syndrome; sudden cardiac death cases without coronary atherosclerosis in South Asian young males. Forensic Sci Int. 2010 Nov 15. Department of Legal Medicine (Forensic Medicine), Keio University School of Medicine, Shinanomachi 35, Shinjuku-ku, Tokyo 160-8582, Japan; Takeichi Medical Research Laboratory, 4-8-8, Shiroyama, Odawara, Kanagawa, Japan; School of Health Sciences, Faculty of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan. • [4] • • Sudden unexpected nocturnal deaths among Thai immigrant workers in Singapore. The possible role of toxigenic bacteria. Int J Legal Med. 1994;106(4):205-8. Blackwell CC, Busuttil A • Weir DM, Saadi AT, Essery SD. • [5] • Cloud, or silver linings? - Japan's changing demography; Japan's changing demography The Economist. London: Jul 28, 2007. Vol. 384, Iss. 8539; pg. 27
  7. 7. Linguistic differences
  8. 8. ஈரல் : irel The lungs, liver, spleen, and other viscera இரத்தக்க விச்சு, (irattacavicciù) Tamil terms related to health : Offensive smell of blood.
  9. 9. Foot/Leg Diversity in language Arabic Bangla -desh Turki sh Persian Tami l Malayal am Pasht o Sinhala Manda- rine Foot Riğl Qada m Pā Ayak Pā Kal (mor e com mon ) Pada m Kal Kh-pā Kakula Jiao Leg Riğl, Sāq Pā Bacak (Ayak) Pā Sāq-e pā (parte inferiore, dal tallone in sù) Kal Kal Kh-pā Kakula Gaataya Tui (De Blasio, Colasanti 2009)
  10. 10. Foot-Leg Romanian Moldovan Lingala Congo Bandund u Pular Guinea Ewe Togo Amharic Ethiopia Foot Picior Picior, Talpà Likolo Thépéré Afo Egher Leg Picior Picior Likolo Coȉghal Ata Egher (De Blasio, Colasanti 2009)
  11. 11. Two Areas in the doctor-patient relationship • Tech • Objectivity • Science Clinical • Emotional • Communication • Cultural Non Clinical
  12. 12. four competences: 1.Communicative competence 2.Cultural competence 3.Clinical competence 4.Psychological competence
  13. 13. Cultural Competence Doctor-Patient Communication, Cultural Competence, and Minority Health: Theoretical and Empirical Perspectives Perloff, Richard M; Bonder, Bette; Ray, George B; Eileen Berlin Ray; Siminoff, Laura A. The American Behavioral Scientist49. 6 (Feb 2006): 835-852.
  14. 14. What is cultural competence? There are many definitions 1. Betancourt et al. 2002 Cultural competence in health care describes the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs. Betancourt, J., Green, A. & Carrillo, E. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. The Commonwealth Fund.
  15. 15. Culture and Health • The difficulty to harness the concept of cultural competence depende on the fact that culture is a shared knowledge. For example language is shared. • It means that is meaning of concepts shared in a group that trought the time tende to separe in the syncronyc drift from the other
  16. 16. The culture of Official Medicne • Even with a well documented cultural differences in the medical institutions in different country we can say that that is a shared encyclopedia of causes, goals, ideas, meanings.
  17. 17. On the patient’s side • There is: • 1. A partly shared knowledge of the official medicine (He is a doctor) • 2. A partly shared knowledge of the traditional medicine of the group to whom the patient belongs (He is not a traditional healer) • 3. A non shared knwoledge of the private health experience and of the language to use (he doesn not know what happening to him and how to explain)
  18. 18. Sharing Culture in Health Doctor Shared Partly shared Non shared Partly shared Partly shared Patient What he feels Traditional ideas Official Medicine What he studied Cultural localizati on
  19. 19. Shared Culture in Health for the patient • Associations of Patients • Patient Communities – ( • 122,124 patients 1000+ conditions ) –
  20. 20. Some issues: 1. Synchronic Variation – Culture of a group is not well defined (who are the italians? Sicilians napolitans, Romans 2. Health Culture is partly shared 3. Diachronic Cultural Drift – (are Italians of ‘90 like italian of 2000?) 4. Reciprocal Bias 5. Cultural/non cultural swap 6. Cultural counterswap 7. Underestimation of culture 8. Multicultural influxes
  21. 21. Cultural competency. Two approches • 1. Trait Oriented (which are the health custom of Italians?) • 2. Skill Oriented (what is my sensitivity to difference?) • We need both of them
  22. 22. The Elusive Concept of Cultural Competence. • Examined agreement statistics (kappas) to assess the extent to which 2 groups of experts (those nominated by important peer scholars as having expertise in cultural competence and therapists with extensive experience and training in working with African Americans) agreed on the specific composition of constructs related to cultural competence. Using items from existing psychotherapy process measures, peer-nominated experts indicated whether each item was relevant to the construct of cultural competence. Therapists with expertise in treating African Americans indicated whether an item fit the same cultural competence categories generated through expert consensus. Peer nominated experts and therapist experts showed poor agreement (kappas) in their classification of which items were relevant to cultural competence. Despite poor overall agreement, however, the groups concurred that a small subset of items were relevant to culturally competent practice with African Americans. These results indicate the need for improved operationalization of the construct of cultural competence Cunningham P, Foster S, Henggeler S. Children's Services: Social Policy, Research & Practice [serial online]. July 2002;5(3):231-243. Available from: Academic Search Premier, Ipswich, MA. Accessed December 13, 201
  23. 23. Cultural competence + Linguistic Competence are an important part of Communication in MEDICINE Cultural Misunderstanding Lack of Linguistic Competence Empathy Poor Comprehension
  24. 24. Reciprocal Comprehension in the doctor-patient relationship • According Van Wieregen et al. (2002) in medical consultation in general practice mutual understanding was poor in 33% of consultations with ethnic-minority patient versus 13% with native-born patient Eur J Public Health. 2002 Mar;12(1):63-8. Intercultural communication in general practice. Van Wieringen JC, Harmsen JA, Bruijnzeels MA.
  25. 25. Outcomes of poor comprehension in medicine • The lack of comprehension may imply, medical misdiagnosis (false positive or false negative), erroneous prescriptions, a possible death toll
  26. 26. To improve medical comprehension We need to know: • Cultural medical models of the patient • His cultural expectative • How he/she communicates with linguistical and not-linguistical skills his/her problems • How the doctor can communicate to her/him
  27. 27. The medical incomprehension is a multilayer issue: • Pre-linguistic • Linguistic • Cultural (Different Customs in Food, Habits etc) • Philosophical and Religious (Explanatory Model of Health and Disease, Existential meaning of Life and Disease )
  28. 28. Patient Sickness Doctor Intercultural communication is very complex objectifying objectif ying subjectifying
  29. 29. Some tipical issue in Crosscultural Communication in Medicine • Gesture Ambiguity (ex.: nodding and shaking head) • Lack of grammatical precision • Hyperbolic use of deictical terms (ex. that, this) that hides the meaning in case of lack of context • Lexical Differences (Ethnoanatomy) • False Friends in the Vocabulary • The Rethorical use of Medical Language • Differences in Conceptual Schemas (Frames di Minsky) • Difference in the medical encyclopedia • Difference in Health Customs • Difference in Symbolic Values • Difference in philosophical and religious values
  30. 30. It is really necessary to constitute a knowledge base of alle the medical observations related to cultural and linguistically topics in all the culture ion the world
  31. 31. Basic Problem: Huge Dimension of the Data Base • To determine the dimension (excluding the Migration cultural Drift). • Number of Languages & Dialects x Social Stratification x Grade Education • If we speaks in term of d • Languages
  32. 32. How many cultures in the world? I we the number of cultural groups is proportional to the number of linguistic differences: In the World 2011 Languages Dialects Difference in Grammar According to Ethnologue ( 6,909 11,779 According Stephen Anderson ~109 Secondo World Christian Database http://www.worldchristiandatabase.o rg 33,000
  33. 33. Peoples Defined By Resulting List Examples Totals Language Linguistic peoples  Ethnologue ~7,000 Language / Dialect Linguistic peoples (Particularly supports language based ministry)  ROPAL (Registry of Peoples and Lang) ~11,000 Language / Dialect Ethnicity Ethno-linguistic peoples (Particularly supports language based evangelistic / discipleship outreaches)  Integrated Strategic Planning Database  World Christian Encyclopedia  Operation World peoples lists  Original Joshua Project list  ~ 13,000 Language / Dialect Ethnicity Religion Caste Culture Ethnic peoples (Particularly supports church planting outreaches)  Joshua Project  Registry of Peoples (ROP) ~ 16,600 Language / Dialect Ethnicity Religion Caste Culture Education Politics Ideology Historical enmity Customs Behavior Unimax peoples (Particularly supports church planting and all types of evangelistic / discipleship outreaches)  World Christian Encyclopedia estimates  US Center for World Mission estimates ~ 27,000 Modificato da
  34. 34. The Knowledge Base has to be • Broad • Up-to-date • Scientific • But open to Social Network of Healthcare Professionals
  35. 35. 2. Cultural Data Collection • From the scientific literature peer reviewed – Medical (Medline) – Non Medical • From the social Network of Health Care Professional
  36. 36. 3 Structural Blocks of the Knowledge Base Taxonomy • Taxonomy • Ontology/based Data • Cultural and Antropologicsl Data • From scientific literature (Medical and non medical) • From Social Network IT • Data Base • Social Network 1 2 3
  37. 37. 3. IT database • A data base to be consulted via web • Interface user friendly • A IT Social Network platform
  38. 38. 1. Taxonomy Ontology Based • Define the taxonomical tree in Medical Anthropology and in Transcultural Medicine
  39. 39. SEMANtic Web • 22 million of web pages in November 2011
  40. 40. Semantic Web: adding meta data • Machine cannot understand the meanng of documents in the web • “One possible solution is to modify the web documents, and one such modification is to add some extra data to these documents; the purpose of this extra information is to enable the computers to understand the meaning of these documents” Yu, L. (2007). Introduction to the Semantic Web and Semantic Web services. Boca Raton, FL: CRC Press. Metadata Data
  41. 41. PUBMED: 21 million citations PubMed comprises more than 21 million citations for biomedical literature from MEDLINE, life science journals, and online books. Citations may include links to full- text content from PubMed Central and publisher web sites.
  42. 42. MESH (Medical Subject Headings)
  43. 43. MESH (Vocabulary of Medline) • The MeSH Tree Structure • MeSH vocabulary is organized by 16 main branches: • Anatomy • Organisms • Diseases • Chemical and Drugs • Analytical, Diagnostic and Therapeutic Techniques and Equipment • Psychiatry and Psychology • Biological Sciences • Natural Sciences • Anthropology, Education, Sociology and Social Phenomena • Technology, Industry, Agriculture • Humanities • Information Science • Named Groups • Health Care • Publication Characteristics • Geographic Locations
  44. 44. Mesh: Geographic Locations lack of detailes! • All MeSH Categories • Geographical Locations Category • Geographic Locations • Africa • Africa South of the Sahara • Africa, Central • Cameroon • Central African Republic • Chad • Congo • Democratic Republic of the Congo • Equatorial Guinea • Gabon
  45. 45. Journal not indexed by PUBMED 1° Problem: PUBMED does not know the article Journal indexed by EBSCO
  46. 46. While this other article it is indexed in PUBMED
  47. 47. The autors
  48. 48. 2. This article is coherent with our search: cultural competency but it is not indexed in Pubmed
  49. 49. The authors define circassian as: “Adyge Peolple”
  50. 50. Where are living Adyghe people?Joshua Project - Adyghe Ethnic People in all Countries. (S.d.). Recuperato Dicembre 2, 2011, da
  51. 51. How many they are? Country Population Bulgaria 520 Egypt 11,500 Iraq 30,600 Israel 6,760 Kazakhstan 140 Russia 120,000 Serbia 2360 Syria 30,900 Turkey 308,000 Ukraine 620 United States 3,310 Uzbekistan 300 West Bank / Gaza 3,640Joshua Project - Adyghe Ethnic People in all Countries. (S.d.). Recuperato Dicembre 2, 2011, da
  52. 52. What is their name? Wikipedia Yafa Haron article Joshua Project Adyghe y y Cherkess y Adygs y Circassia n y Adyge y
  53. 53. If we consult Ethnologue
  54. 54. To fix these Problem
  55. 55. Ontologies and Taxonomies • Ontologies are the evolution of the concept of metadata • XML -> RDF -> OWL
  56. 56. What is an ontology? • A metadata that is consistently logical connected to other metadata permitting di realize inferences
  57. 57. Ontology (information science) From Wikipedia, the free encyclopedia • In computer science and information science, an ontology formally represents knowledge as a set of concepts within a domain, and the relationships between those concepts. It can be used to reason about the entities within that domain and may be used to describe the domain. • In theory, an ontology is a "formal, explicit specification of a shared conceptualisation".[1] An ontology renders shared vocabulary and taxonomy which models a domain with the definition of objects and/or concepts and their properties and relations.[2] • Ontologies are the structural frameworks for organizing information and are used in artificial intelligence, the Semantic Web, systems engineering, software engineering, biomedical informatics, library science, enterprise bookmarking, and information architecture as a form of knowledge representation about the world or some part of it. The creation of domain ontologies is also fundamental to the definition and use of an enterprise architecture framework.
  58. 58. An Ontology Editor • Protégé v. 4.1 (Stanford)
  59. 59. A simple Ontology
  60. 60. • <?xml version="1.0"?> • <!DOCTYPE Ontology [ • <!ENTITY xsd "" > • <!ENTITY xml "" > • <!ENTITY rdfs "" > • <!ENTITY rdf "" > • ]> • <Ontology xmlns="" • xml:base="" • xmlns:rdfs="" • xmlns:xsd="" • xmlns:rdf="" • xmlns:xml="" • ontologyIRI=""> • <Prefix name="xsd" IRI=""/> • <Prefix name="owl" IRI=""/> • <Prefix name="" IRI=""/> • <Prefix name="rdf" IRI=""/> • <Prefix name="OntologyDivinaCommedia" IRI=""/> • <Prefix name="rdfs" IRI=""/> • <Declaration> • <Class IRI="#Authors"/> • </Declaration> • <Declaration> • <Class IRI="#Country"/> • </Declaration> • <Declaration> • <Class IRI="#France"/> • </Declaration> • <Declaration> • <Class IRI="#Germany"/> • </Declaration> • <Declaration> • <Class IRI="#Human_Beings"/> • </Declaration> • <Declaration> • <Class IRI="#Italy"/> • </Declaration> • <Declaration> • <Class IRI="#Popes"/> • </Declaration> • <Declaration> • <Class IRI="#Synonims"/> • </Declaration> • <Declaration> • <Class IRI="#Usa"/>
  61. 61. • Using a First Order Logic I can do inferences • The Ontological Tree gives a meaningful contextual framework to every data • A Semantic Search Engine can “Understand “ what we are looking for
  62. 62. Basic Elementes of Ontologies are Classes Properties Objects That we will see in action in Protege
  63. 63. Annotating
  64. 64. A possible Workflow