International Journal ofOffender Therapy andComparative .docx

International Journal of
Offender Therapy and
Comparative Criminology
2017, Vol. 61(8) 919 –937
© The Author(s) 2015
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DOI: 10.1177/0306624X15608823
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Article
Selecting a Method of Case
Identification to Estimate
the Involvement of People
With Mental Illnesses in the
Criminal Justice System:
A Research Note
Melissa S. Morabito1 and Amy Blank Wilson2
Abstract
Arrest and incarceration are a pervasive reality for people with
mental illnesses.
Wide variation, however, exists in the estimates of the
percentage of people with
mental illnesses who become involved in the criminal justice
system. Researchers

and practitioners need a variety of methods in their toolbox to
maximize their
ability to identify mental illness depending on available
resources and needs. Yet, the
benefits and costs of utilizing these different approaches have
yet to be explored in
the criminal justice literature. To begin exploring the utility of
the different methods
of case identification, we review the most commonly used
approaches to identifying
people with mental illnesses and end with a detailed
examination of the use of
behavior health records. The use of behavioral health records is
a case identification
method that has gained emerging support in criminal justice
research in recent years.
Keywords
mental illness, measurement, behavioral health
Arrest and incarceration are a pervasive reality for people with
mental illnesses
(Ditton, 1999; James & Glaze, 2006; Steadman, Osher, Robbins,
Case, & Samuels,
2009; Teplin, 1984). However, wide variation exists in the
estimates of the percentage
1University of Massachusetts Lowell, USA
2University of North Carolina at Chapel Hill, USA
Corresponding Author:
Melissa S. Morabito, School of Criminology and Justice
Studies, University of Massachusetts Lowell, 113
Wilder St., Lowell, MA 01854, USA.
Email: [email protected]
608823 IJOXXX10.1177/0306624X15608823International

Journal of Offender Therapy and Comparative
CriminologyMorabito and Wilson
research-article2015
mailto:[email protected]
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920 International Journal of Offender Therapy and Comparative
Criminology 61(8)
of people with mental illnesses who become involved in the
criminal justice system.
Some variation in estimates is understandable because different
segments of the sys-
tem have contact with varying subsets of this population. For
example, police officers
interact with a much broader subset of the population than
prosecutors or correctional
officers. Nevertheless, unexplained differences exist across
estimates made within the
same component of the criminal justice system and within the
same geographic areas
(see Ditton, 1999; Steadman et al., 2009). These differences
make measurement and
planning challenging for practitioners and policy makers.
One of the first researchers to question this inconsistency in
estimates identified
two methodological issues as potential causes for the variation:
(a) the definition of
mental illness used in research and (b) the methods used to
identify cases for study
(Teplin, 1983). Since Teplin’s initial work, researchers have

begun to address how the
lack of a standardized definition can affect estimates of those
with mental illnesses
who become involved in the criminal justice system (hereafter,
justice-involved per-
sons with mental illnesses; Draine, Wilson, & Pogorzelski,
2007; Roesch, Ogloff, &
Eaves, 1995; Teplin, 1990). However, the criminal justice
literature has not yet exam-
ined other issues affecting estimates of this population,
including the different meth-
ods of case identification used to formulate estimates of the rate
of mental disorders in
justice-involved populations, or a cost-benefit analysis of each
method.
To fill this gap, this article explores the utility of different
methods of case identifi-
cation, reviewing the case identification methods most
commonly used to identify
justice-involved persons with mental illnesses within the
different criminal justice set-
tings (e.g., police, courts, corrections). These case
identification methods include
diagnostic interviews, participant observation, and self-report
surveys.
Case Identification Methods Commonly Used to Establish
Estimates
Criminal justice agencies must identify people with mental
illnesses under their super-
vision or jurisdiction for two main reasons. First, it is
imperative to have a general
estimate of the proportion of individuals in their care with
mental illness to make deci-

sions about the allocation of resources. Second, the estimates of
the number of indi-
viduals with specific mental health diagnoses is also crucial,
because it facilitates
communication and coordination with the community-based
public mental health sys-
tem, which is responsible for treating people with the most
serious mental illnesses. To
identify justice-involved persons with mental illnesses in
various criminal justice set-
tings, researchers and policy makers must first establish a
protocol for defining mental
illness. A critical component of this decision-making process
centers on the research-
er’s selection of the diagnoses or behaviors included in this
definition. For example,
academic researchers whose interest is in understanding the
scope of issues facing
prison populations might include a broad range of mental health
diagnoses in their
definition of mental illness. In contrast, jail administrators who
want to effectively
target the jail’s limited resources might establish a narrow
definition of mental illness
that includes only those diagnoses that will identify inmates
with the most serious and
Morabito and Wilson 921
persistent mental illnesses. Once a definition of mental illness
is established, research-
ers must then select a method for identifying people who meet
the criteria established
by the definition (i.e., a case identification method).

Table 1 provides a comparison of the three case identification
methods most fre-
quently used to establish rates of justice-involved persons with
mental illnesses by
some of the most cited studies in the literature.1 The first two
columns organize the
three methods by the criminal justice setting, and the rows
document some of the most
frequently cited estimates of the rates of justice involvement
among people with seri-
ous mental illnesses, organized by setting and case
identification method. The third
column compares the rates of mental illness. As illustrated by
this table, substantial
variation exists between both between- and within-case
identification methods. As
previously noted, some variation in estimates is to be expected
because of differences
in the volume of contact and nature of involvement in different
criminal justice set-
tings. However, Table 1 shows that considerable variation also
exists in estimates gen-
erated using the same case identification methods, within the
same criminal justice
setting. This point is best illustrated in the differences in
estimates associated with
Steadman et al. (2009), Teplin (1990), and Teplin, Abram, and
McClelland (1996).
These studies used diagnostic interviews to identify individuals
with the most severe
forms of mental illness. Yet, when compared, these estimates
show a difference of 16
Table 1. Case Identification Methods.

Criminal
justice setting
Case identification
method
% of population
with mental illness Source
Police Police contacts
Observational 5.90 Teplin (1984)
Observational 3.60 Engel and Silver (2001)
2.70
Jail Jail detainees
Diagnostic interview 6.36 (men with
current diagnosis)
Teplin (1990)
9.48 (men with
lifetime disorder)
Diagnostic interview 15.0 (women with
current diagnosis)
Teplin, Abram, and
McClelland (1996)
18.5 (women with
lifetime disorder)
Self-report survey 16.0 Ditton (1999)
Self-report survey 64.20 James and Glaze (2006)
Diagnostic interview 14.50 (men) Steadman, Osher, Robbins,

Case, and Samuels (2009)
31.0 (women)
Prison Prison inmates
Self-report survey 16.20 Ditton (1999)
Self-report survey 56.20 James and Glaze (2006)
Criminology 61(8)
percentage points in the number of women with a current mental
health diagnosis in
the two studies and a difference of 7 percentage points among
men.
The literature contains a growing number of explanations for
these variations in
rates. Some explanations focus on the lack of precision in
certain case identification
methods, such as self-report surveys. Other explanations focus
on variability in the
definitions of what factors are considered as indicators of
mental illness in the case
identification process (Steadman et al., 2009; Teplin, 1983).
Other explanations have
pointed to the possibility that estimates deviate, given the
naturally occurring temporal
and geographic variations that occur within the populations
being studied (Steadman
et al., 2009). The accuracy of these proffered explanations
cannot be established
because the existing data do not provide answers as to the
extent of variation in rates
of involvement is attributable to the factors described above.

However, the fact remains
that policy makers and program developers need estimates of
the number of justice-
involved persons with mental illnesses that are stable and
consistent (i.e., reliable).
Reliable estimates of both those generally involved in criminal
justice as well as esti-
mates of those under the jurisdiction of localities are required to
develop programs of
appropriate scale and with adequate resources to meet the needs
of this population. In
addition, due to the focus on people with the most severe and
persistent mental ill-
nesses (i.e., schizophrenia spectrum and major affective
disorders), in the United
States’s public mental health system, these estimates will be
most useful if they are
also diagnostically specific. Given that none of the case
identification methods in cur-
rent use offers a guarantee of a reliable estimate (see Table 1),
we examine the strengths
and weaknesses of each method.
Diagnostic Interview
The diagnostic interview is commonly used in psychiatric
research to identify people
with mental illnesses for research purposes. The wide
acceptance of this approach as
one the most empirically defensible ways to estimate the rate of
mental illnesses has
led to the diagnostic interview being regarded as the gold
standard in research involv-
ing psychiatric diagnoses (Draine et al., 2007; Nordgaard,
Revsbech, Saebye, &
Parnas, 2012). The instruments used for diagnostic interviews in

research settings are
structured, empirically validated instruments intended to
identify mental health diag-
noses in study populations.
One of the most widely cited studies that used a diagnostic
interview to identify
justice-involved persons with mental illnesses was conducted by
Teplin and her asso-
ciates in Chicago during the 1980s. This study yielded several
publications that exam-
ined the rate of men and women with serious mental illnesses in
the jail system (Teplin,
1990; Teplin et al., 1996). The researchers drew a random
sample of individuals
admitted to the Cook County Correctional Facility in Chicago
and then used the
National Institute of Mental Health Diagnostic Interview
Schedule, Version III, a
structured diagnostic assessment tool designed specifically to
identify people with a
range of psychiatric disorders (Robins, Helzer, Croughan, &
Ratcliff, 1981). As Table 1
illustrates, Teplin and colleagues found that approximately
9.5% of men and 18.5% of
women entering this correctional facility met the diagnostic
criteria of having a severe
mental illness during their lifetime2 (Teplin, 1990; Teplin et al.,
1996).
One of the more recent studies to use the structured diagnostic

interview to investi-
gate rates of mental disorders in the criminal justice population
was conducted by
Steadman et al. (2009), using samples of inmates recently
admitted in five county jails
in Maryland and New York. These samples of inmates were
screened for mental disor-
ders using the SCID—Structured Clinical Interview for the
Diagnostic and Statistical
Manual of Mental Disorders (4th ed.; DSM-IV; American
Psychiatric Association
[APA], 1994; First, Gibbon, Spitzer, & Williams, 2001), which
is a revised version of
the instrument used by Teplin and colleagues (1996). Steadman
et al. found that 14.5%
of the men and 31% of the women had a current serious mental
illness.
Using structured clinical interviews as a method of case
identification poses limita-
tions because different diagnostic interviews are available, and
each require substantial
resources and have different levels of precision and diagnostic
accuracy (Rogers,
Sewell, Ustad, Reinhardt, & Edwards, 1995; Teplin & Swartz,
1989). The SCID (First
et al., 2001) has been used in numerous studies and found to be
an accurate measure of
psychiatric diagnoses (Basco et al., 2000; Fennig, Craig,
Lavelle, Kovasznay, &
Bromet, 1994; Lobbestael, Leurgans, & Arntz, 2010). The SCID
is designed to provide
diagnostic information related to the full range of Axis I (i.e.,
schizophrenia and major
depressive disorder) diagnoses. This diagnostic tool has
recently been updated to ensure

alignment with the diagnostic categories found in the
Diagnostic and Statistical Manual
of Mental Disorders (5th ed.; DSM-5; APA, 2013). There is also
a separate version of
this diagnostic tool, called the SCID-II that assesses Axis II
(anti-social personality
disorder or paranoid personality disorder) diagnoses that are
present in DSM-IV (APA,
1994). The SCID-II is currently being revised to ensure
alignment with the DSM-5 and
is expected to be available in fall of 2015 (www.scid4.org). To
use any of the SCID
interviews, staff must purchase and complete training developed
specifically for this
diagnostic interview. The SCID was developed for use with
clinicians and other mental
health professionals (www.scid4.org). It can also be
administered by research assis-
tants, without prior clinical experience; however, these
individuals are likely to require
more training before they can begin using this interview
(www.scid4.org).
Diagnostic interviews provide the diagnostic specificity needed
to identify people
in the justice system with a wide range of psychiatric disorders,
while also providing
the information needed to identify the subset of individuals with
psychiatric disorders
who will need services from the public mental health system.
However, this precision
comes at an expense. Diagnostic instruments, such as the SCID,
represent a time-
consuming, resource-intensive method of case identification.
For example, the SCID
is administered as a one-on-one interview that requires an

average of 90 min to com-
plete (Lecrubier et al., 1997). Moreover, it is recommended that
interviewers adminis-
tering the SCID complete SCID-specific training that takes at
least 20 hr to complete
(http://www.scid4.org/faq/scidfaq.html).
The Mini-International Neuropsychiatric Interview (MINI;
Lecrubier et al., 1997)
is a short diagnostic interview that was designed to be an
alternative to longer diagnos-
tic interviews such as the SCID (Sheehan et al., 1998). It is
reported to be one of the
www.scid4.org
www.scid4.org
www.scid4.org
www.scid4.org
Criminology 61(8)
most widely used psychiatric diagnostic assessment tools
(Medical-outcomes.com).
The accuracy rates of the MINI have been found comparable
with those of longer
diagnostic interviews such as the SCID (Lecrubier et al., 1997).
However, two major
differences exist between the MINI and other longer diagnostic
interviews such as the
SCID: administration time and diagnostic range. The MINI is
completed in 15 to 20
min (Lecrubier et al., 1997). However, as compared with the
SCID’s capacity to assess
all DSM’s major mental health diagnoses, the MINI assesses a

smaller range of diag-
noses, with the capacity to identify only 17 psychiatric and
substance use diagnoses
(Lecrubier et al., 1997). The MINI’s diagnostic range does
include major affective
disorders and schizophrenia. In addition, the MINI has not been
updated to align with
the diagnostic categories in the DSM-5, and its diagnostic
capacity is largely limited to
current disorders, rather than a comprehensive assessment of
current and lifetime dis-
orders. Despite these limitations, the relatively shorter format
of the MINI makes it a
more feasible and readily administered diagnostic instrument in
many situations.
Similar to the SCID and other diagnostic instruments, the MINI
requires face-to-
face interviews conducted by researchers who are trained in the
administration of the
MINI. However, despite its shortened length, conducting
diagnostic interviews of any
type can exceed the available time, expertise, and financial
resources of many criminal
justice agencies.3 Even when such resources are available,
diagnostic interviews might
not be a feasible method of case identification, especially in
settings where even short
interviews might not be possible because the person with a
suspected mental illness is
not interested in being interviewed and cannot be compelled to
stay because he or she
is not in police custody (e.g., police stations, courts). This
limitation suggests that
using diagnostic interviews to identify justice-involved persons
with mental disorders

will be restricted to a few well-funded studies in sites that can
accommodate interview
formats (e.g., jails, prisons).
Participant Observation
Participant observation is one of the more popular methods used
to identify police
interactions involving people with mental disorders (Denzin,
1989). In studies using
this method, researchers with diagnostic training accompany
police officers on patrol
and observe and track the number and context of police–citizen
interactions that
involve people with mental disorders (Engel & Silver, 2001;
Novak & Engel, 2005;
Teplin, 1984). In Teplin’s (1984) seminal study of people with
mental illnesses
involved in police–citizen interactions, the observers used a
structured clinical check-
list designed to identify behaviors associated with diagnosable
mental disorders. This
checklist enabled the trained observers to make a clinically
informed assessment of
mental illness independent of the officers’ determination of
mental illness status.
Results indicated that 5.9% of police–suspect encounters
involved a person with a
serious mental illness (Teplin, 1984).
In a test of Teplin’s (1984) research, Engel and Silver (2001)
examined police–citizen
interactions involving people with mental illness. Engel and
Silver’s study included a
reanalysis of data collected in two earlier studies: the Project on
Policing Neighborhoods

(POPN; see Parks, Mastrofski, & DeJong, 1999) and the Police
Services Study (Engel
& Silver, 2001). These studies examined police–citizen
interactions in five metropoli-
tan areas, and both studies used trained observers who
accompanied officers during
their shift (Parks et al., 1999). However, in the studies analyzed
by Engel and Silver,
the observation method differed from the method used in other
studies. Rather than
identifying suspects with mental illnesses, the intent of the
observations in these stud-
ies was to identify situations in which officers were likely to
perceive of the suspects
as mentally ill. Therefore, rather than a clinical-diagnostic
checklist, these observers
used a rating sheet to identify behaviors generally considered
indicative of a mental
illness (Engel & Silver, 2001). The analytic results showed that
3.6% of police con-
tacts in the POPN Study and 2.7% of contacts in the Police
Services Study involved a
suspect with a mental illness.
These participant-observation studies have greatly advanced the
field, in increasing
knowledge of the rates of contact between police and people
with mental illnesses.
However, these studies also vary widely in their estimates of the
number of people
with mental illnesses involved in the criminal justice system.

Even the researchers
noted that the variation in estimates across studies was likely
explained by the diverse
methods used to identify mental illness (Engel & Silver, 2001).
The small number of
contacts involving persons with mental illness found in both
studies (2.7%-3.6%;
Engel & Silver, 2001; Teplin, 1984; 5.9%) questions whether
future efforts should use
these resource-intensive methods of case identification.
The use of trained observers for identification is both a strength
and weakness. As
compared with relying on police officers’ assessments of a
suspect’s mental status, the
trained observers can increase the number of contacts correctly
identified as involving
a person with mental illness. The observers’ training enables
them to identify nuances
in symptomatic behavior that are likely to be overlooked by
police officers without
this specialized training. However, even trained observers tend
to under-identify cases
because the symptoms of mental illness are cyclical, meaning
those with mental ill-
nesses might not be symptomatic at the time of a police
encounter. Furthermore, men-
tal illness may be masked by substance abuse—a difficult
relationship for untrained
observers to untangle. Another weakness associated with the use
of trained observers
is the significant expense incurred. Similar to the resource-
intensive diagnostic inter-
view, the costs associated with participant-observation
techniques for case identifica-
tion typically restrict this method to large-scale publically

funded studies investigating
various aspects of police behavior (Engel & Silver, 2001; Novak
& Engel, 2005).
Survey
Survey methods have also been applied to case identification to
generate estimates of
the number of justice-involved persons with mental illnesses
(Ditton, 1999; James &
Glaze, 2006). For example, a study conducted by James and
Glaze (2006) with two
nationally representative samples used a survey to assess the
rates of mental health
problems among jail and prison inmates. To identify inmates
with mental health prob-
lems, the survey included items from a structured clinical
interview organized into a
Criminology 61(8)
self-administered questionnaire. The survey items asked inmates
about mental health
symptoms they had experienced over the past 12 months but did
not collect data on
symptom severity or duration. Moreover, the survey did not
collect data that would
allow researchers to rule out symptoms caused by issues other
than mental illness,
such as substance use or other medical conditions (Steadman et
al., 2009). James and
Glaze found that 56% of state prisoners and 64% of local jail
inmates had mental

health problems.
Although James and Glaze (2006) found that more than half of
prison and jail
inmates had mental health problems, an earlier study conducted
by Ditton (1999)
reported a significantly lower rate of mental illness among
inmates. Similar to James
and Glaze’s study design, Ditton’s study also used a self-report
survey with a nation-
ally representative sample of jail and prison inmates, but found
that only 16% of the
sample reported a mental illness. The difference in the estimates
between these two
studies is likely the result of the different methods used to
identify mental illness.
James and Glaze used self-reports of symptoms (but did not
account for duration or
severity or symptom-related issues, such as substance use or
medical conditions),
whereas Ditton’s survey assessed presence of mental illness
based on inmates’ self-
reports of mental or emotional problem or an overnight stay in a
psychiatric facility.
Ditton’s survey has been criticized by scholars who consider the
items to be an overly
broad indicator of serious mental illness (Draine et al., 2007).
Self-reported data collected through surveys are a relatively
inexpensive way to
estimate the rates of involvement of persons with mental
illnesses in the criminal jus-
tice system. As compared with diagnostic interviews and
observational methods, the
survey method requires fewer resources to collect data. For
example, using self-

administered surveys does not require trained interviewers to
administer the survey,
thus, this method substantially reduces costs associated with
data collection. In turn,
the lower costs of the survey method allow researchers to assess
larger study samples
in shorter periods.
Nevertheless, surveys have substantial limitations. Surveys
must rely on less accu-
rate and often overly broad indicators of mental illness because
the interview format
of the survey does not allow for clinically based assessments of
specific mental health
disorders (Teplin, 1983). This lack of clinical precision in case
identification will skew
the estimates of mental illness in ways that are difficult to
predict. Surveys could use
brief screening tools, such as the Symptom Checklist–90 (SCL-
90; Derogatis & Unger,
2010), to identify people who are present with symptoms that
may be associated with
mental illness. However, screening tools are designed to act as
triage tools that identify
individuals who require further evaluation. Even when used in
conjunction with other
indicators such as receipt of outpatient treatment or a stay in a
psychiatric hospital,
these indicators lack the diagnostic specificity needed to
identify individuals with the
mental health disorders that are the focus of most treatment in
the criminal justice and
mental health system. In addition, self-report survey data are
often rife with missing
data, which further degrades the quality of information
collected. Therefore, although

surveys offer a less expensive and more expedient method of
case identification, the
overly broad indicators of mental illness and missing data
associated with this case
identification method make the use of this method problematic
in differentiating the
most serious and entrenched forms of mental illness from
behaviors associated with
situational or personality problems.
Using Behavioral Health Records (BHR) in the Case
Identification Process
In recent years, researchers have increasingly used BHR to
identify justice-involved
persons with mental illness (Baillargeon et al., 2010; Draine,
Blank Wilson, Metraux,
Hadley, & Evans, 2010; Morrissey, Cuddeback, Cuellar, &
Steadman, 2007; Morrissey
et al., 2006; Wilson, Draine, Hadley, Metraux, & Evans, 2011).
The BHR used in these
studies have typically involved insurance reimbursement claims
or treatment records
compiled during routine treatment. The steps involved in this
method of case identifi-
cation are outlined in Table 2. This table shows that this method
of case identification
involves a two-step process. Each step includes an outline of
key decisions that need
to be addressed when engaging this case identification method,
which are discussed

further in the text below. However, this method of visual
display is not meant to imply
that these decisions are sequential in nature. Rather, as the
discussion below shows,
many decisions are inter-related and so need to be dealt with
accordingly.
Establish a Pool of Potential Cases
As outlined in Table 2, the first step of this case identification
method involves
developing a pool of potential cases. In this case identification
method, administra-
tive records are used to develop the pool by identifying
individuals who have
involvement with both the criminal justice and mental health
systems. To develop
Table 2. The Case Identification Process Using BHR.
1. Establish a pool of
potential cases
Select data files that can identify individuals who are involved
in
both the criminal justice system and mental health services.
Define the window of observation that will be used for each
data
file during the matching process.
Select a matching procedure to identify individuals who are
present in both data files.
2. Identify cases where
individuals have a

mental illness
Select BHR that can identify individuals with qualifying
mental health diagnoses from the pool of potentially eligible
cases.
Identify specific mental health diagnoses that will be searched
for
in the behavior health records.
Define the window of observation that BHR will be searched
for
qualifying mental health diagnoses.
Develop procedures to address situations where individuals
have
multiple mental health diagnoses.
Note. BHR = behavioral health records.
Criminology 61(8)
the pool, researchers must have access to two types of records:
criminal justice con-
tact (e.g., police, courts, or jail/prison records) and BHR. At
this step, in the case
identification process, it is important to consider that the
matching process is most
feasible when both data files are stored in electronic format and
include at least one
common unique identifier for each person (e.g., social security
number, the person’s
first and last names).

Researchers must also define the window of observation that
will be used when
comparing records between data files. This involves
determining the specific time
period that data will be extracted from each file for the
matching process. For example,
researchers could use police records for all arrests that occurred
in 2010 in a particular
jurisdiction and Medicaid eligibility files for all individuals
enrolled in Medicaid dur-
ing the same time period. However, if researchers are concerned
that a person’s pres-
ence in one data set is related in some way to their presence in
the second data set, the
time periods of observation for each data set could vary to
account for this problem.
For example, admission to jail or prison can affect a person’s
eligibility for Medicaid.
So, if a researcher was using records of jail admissions in the
matching process, they
could choose to vary the time periods used in the window of
observation for each data
set to account for this potential problem. In this example, the
study team might decide
to use all jail admissions in 2010 and Medicaid eligibility
records for 2009.
The other important decision that researchers need to make
during this step in the
case identification process is the type of matching procedure
that will be used to com-
pare records across data files. There are two matching
procedures that are generally
used in this process: deterministic and probabilistic matching
procedures. Deterministic

matching procedures identify individuals across multiple data
sets by comparing cases
using a unique identifier, such as social security number, in
each data set. In this
method, the unique identifier must be exactly the same in both
data sets for a match to
be identified. Probabilistic matching procedures identify
individuals across multiple
data sets by comparing cases using multiple unique identifiers
in each data set. During
this matching process, an algorithm is used to assign each
unique identifier with a
weight that indicates how closely the unique identifier matches
in the two data sets. A
sum of these weights is then used to indicate the likelihood that
a match exists between
the two records.
Deterministic matching procedures are an expedient method for
matching
records; however, this method of matching cases can encounter
challenges when
used with criminal justice records because these records often
have inaccurate or
missing data. However, recent studies have overcome this
problem by incorporating
probabilistic matching procedures into the case identification
process. For example,
the Link King program (http://www.the-link-
king.com/download.html; Campbell,
Deck, & Krupski, 2008), which is a public domain software,
increases the accuracy
of the matching process by using a combination of deterministic
and probabilistic
matching procedures. The inclusion of probabilistic matching
procedures in the case

identification process allows programs such as Link King to
address missing data,
misspellings, or other errors in data entry, as well as the use of
aliases or nicknames
(Campbell et al., 2008).
http://www.the-link-king.com/download.html
Identifying Case Where Individuals Have a Mental Illness
Once the researcher has established a pool of potential cases by
executing the match-
ing process described above, the next step in the case
identification process focuses on
identifying cases where a mental illness is present. This step in
the case identification
process involves a number of key decision points that require
consideration. Chief
among these decisions is locating a record source that contains
the diagnostic informa-
tion needed to identify people with qualifying mental health
diagnoses.
Several different types of BHR can be used during this step in
the case identifica-
tion process. For example, Medicaid reimbursement claims for
mental health services
have been used, as have prison treatment records documenting
evaluations conducted
as follow-up with all inmates whose intake screeners indicated
that they were in need
of a mental health evaluation.

Although some scholars have expressed concerns regarding the
reliability of diag-
noses obtained from administrative records, research has
demonstrated a comparable
reliability of diagnoses in records, such as Medicaid insurance
claims and diagnoses
obtained in routine clinical practice (Rothbard, Kuno, Hadley,
& Dogin, 2004).
However, much remains unknown about the consistency and
accuracy of the mental
health diagnoses recorded in other BHR, such as those
maintained by correctional
facilities.
In addition to selecting a record source to identify cases that
have mental health
diagnoses, it is also necessary to specify what mental health
diagnoses are being
searched for in these records. When selecting mental health
diagnoses, it is important
to work with individuals who have knowledge of the record
source and how it is used
in practice, so that the study team understands the range of
diagnostic information
contained in the records. Once this information is obtained, the
number of diagnoses
included in the definition has little impact on the time involved
in extracting this infor-
mation from the records, so the team can include as many or as
few diagnoses as they
need at this stage in the case identification process.
As in the previous step, it is also necessary to identify the
window of observation
that will be used to extract diagnostic information from the
identified record sources.

Establishing this window requires that the specific time period
that the records will be
searched for diagnostic information will be defined ahead of
time. Similar to the selec-
tion of mental health diagnoses, it is important for researchers
to work with individuals
with a working knowledge of the record source to ensure that
there is equivalence of
diagnostic information contained in the records during the time
period that the records
are being searched.
It is also important for researchers to try and identify any
contextual or situational
factors that need be considered when selecting the time period
for observation. For
example, researchers may consider selecting a window of
observation that falls before
the time period used in the first step of the case identification
process to ensure that
mental health diagnoses identified during this step were
received before the person’s
contact with the criminal justice used in the first step of the
case identification
process.
Criminology 61(8)
In this method of case identification, researchers also have
flexibility in how they
set the beginning and end date for the window of observation.
This can be useful when
trying to identify populations of consumers who may have

sporadic contact with the
service provider completing the BHR. In cases such as this, a
longer window of obser-
vation may be used to adjust for gaps in service. However, in
other cases when a
record source such as prison classification records are being
used, a shorter window of
observation may be used because diagnostic information is
being pulled from records
related to a more systematic and reliable evaluation process.
The last important decision that has to be made during this step
in case identifica-
tion process is how to address situations where individuals have
more than one quali-
fying mental health diagnosis in their record. Researchers have
not yet reached
consensus on how to address this issue. Some studies address
the issue of dual or
multiple diagnoses by collapsing individual mental health
diagnoses of interest into a
broader indicator variable such as serious mental illnesses. This
variable includes all
individuals whose treatment records indicate at least one of the
qualifying diagnoses
(Draine et al., 2010; Morrissey et al., 2007; Morrissey et al.,
2006; Wilson et al.,
2011). Although this approach avoids supplanting clinical
judgment as to which diag-
nosis is “primary,” it comes at the expense of organizing people
into mutually exclu-
sive categories based on specific mental health diagnoses.
Other methods have been developed to address the issue of
individual cases with
multiple diagnoses. For example, some studies have used the

most frequently occur-
ring diagnosis as the diagnosis of record (Becker, Andel, Boaz,
& Constantine, 2011),
whereas others have relied on the diagnosis assigned during a
stay in an inpatient
psychiatric hospital (McCabe et al., 2012). Still, other
researchers have chosen to use
the diagnosis recorded during the prison intake screening and
classification process
(Baillargeon, Binswanger, Penn, Williams, & Murray, 2009;
Baillargeon et al., 2010;
Baillargeon, Williams, et al., 2009). Currently, no data are
available to assess the rela-
tive reliability of the different approaches to assigning
diagnoses during the case iden-
tification process. However, at a minimum, the different ways
in which diagnostic
information is dealt with during the case identification process
has implications for the
comparability of these estimates that must be considered in
future research efforts.
Strengths and Weaknesses of the BHR Case Identification
Method
The relatively low cost of using BHR to identify justice-
involved persons with mental
illnesses is a particular strength of this method, hereafter
referred to as the BHR case
identification. Unlike the case identification methods
traditionally used to estimate the
rates of mental illnesses in criminal justice settings, BHR case
identification is the
only method that does not use primary data collection. Instead,
BHR case identifica-
tion uses existing data, requiring only that the data be

abstracted, coordinated, and
formatted for analysis. The BHR case identification method
substantially reduces the
time involved in generating data. However, this method requires
not only that project
personnel have substantive knowledge of the data used in
identification process but
also that project personnel have the computing capabilities to
abstract and organize the
data for analysis. Even so, the overall time and resources
needed for BHR case identi-
fication are far lower than those associated with the methods
involving primary data
collection.
As mentioned previously, the levels of accuracy in BHR case
identification are
commensurate with traditional clinical interviews conducted by
service providers. The
recent development of techniques such as the Link King
algorithm have strengthened
the accuracy and comprehensiveness of BHR case identification
by lessening the
potential for undercounts that can occur when deterministic
matching procedures are
used alone with administrative data (Campbell et al., 2008).
Equally important, the BHR case identification method is
associated with other
strengths that aid the case identification process. By using
existing data sets (e.g.,

criminal justice records, insurance claims, other health records),
the BHR case identi-
fication method allows researchers and policy makers to
capitalize on the growing
volume of data stored in digital formats. For example, the
Patient Protection and
Affordable Care Act (ACA; 2010) requires the use of electronic
health care records,
and a provision in the American Recovery and Reinvestment
Act (ARRA; 2009)
funded the conversion of many existing health records to
electronic format. These
policies have created access to unprecedented levels of
electronic health records,
which enable researchers to include service-use analyses with
case identification
efforts at little to no additional costs. Furthermore, BHR case
identification provides
flexibility in the type and number of mental health diagnoses
used to identify cases
without increasing the costs. The cost-savings represents a
significant advantage over
primary data collection methods (e.g., diagnostic interviews), in
which each diagnos-
tic module increases the time and costs of obtaining the data.
Despite these appealing strengths, BHR case identification also
has limitations that
must be considered. First, this method provides estimates only
of persons with an iden-
tified mental illness. Relying on BHR means that the estimates
include only those per-
sons who have received treatment for mental illness. People
who have not received
behavioral health services or who have private insurance are not
included in the esti-

mates; therefore, this method can potentially produce an
undercount of those with men-
tal illnesses. Some researchers have sought to address this issue
by using longer “look
back” periods when examining BHR as a way of including cases
with sporadic or low
levels of receipt of mental health services (Draine et al., 2010;
Wilson et al., 2011).
Nevertheless, even these larger data windows cannot account
for people who have not
received any type of formal diagnosis or treatment or those with
private insurance.
Next, the BHR case identification method has variable utility
for different criminal
justice agencies. This approach may be more prohibitive for
some agencies such as
police because it requires a great deal of resources and could
not be done as often. It is
more feasible for other agencies with available records. For
example, jail and prison
personnel could use the BHR method to get estimates and last
known diagnoses for
current inmates. This information could guide the use of
resources and current treat-
ment planning. For police, however, who deal with many people
with mental illnesses
in short interactions, the BHR method would not be feasible for
immediate planning.
This approach could provide retrospective data for policing and
help paint a picture of
Criminology 61(8)

the populations with which they interact which could be useful
for future planning.
Although police are competent at identifying mental illness
when a citizen is symptom-
atic (Fry, O’Riordan, & Geanellos, 2002), they may be
undercounting interactions with
this population because people with mental illnesses are not
symptomatic all the time.
Another limitation of BHR case identification is related to the
security and privacy
concerns that must be addressed when matching criminal justice
data with BHR. For
example, legislation such as the Health Insurance Portability
and Accountability Act
(HIPPA; 1996) strictly controls the sharing of health records.
University researchers have
worked through their institutional review boards to address the
privacy concerns when
dealing with protected health data. However, initiatives such as
the National Institutes of
Health (NIH) Big Data Knowledge project (BD2K; NIH, n.d.)
are developing mecha-
nisms that will allow localities to share protected data both
within and across systems.
Initiatives such as BD2K are also creating new funding
opportunities that researchers and
policy makers can capitalize on to develop the data and resource
infrastructure needed to
use electronic records in the case identification process (NIH,
n.d.). Finally, it is possible
that states’ efforts to move Medicaid populations into private
sector managed care cover-
age, could decrease the accessibility of Medicaid data.
However, at least two of the stud-

ies cited in this article were conducted in states that had already
transitioned the
management of Medicaid to managed care entities (Becker et
al., 2011; Blank Wilson,
Draine, Hadley, & Metraux, 2011), thus it is reasonable to
expect that even in this sce-
nario, private corporations will still be required to submit these
data to the state.
Discussion
Within the criminal justice field, there is near universal
agreement that people with
mental illnesses are overrepresented in the criminal justice
system (e.g., see Ditton,
1999; James & Glaze, 2006; Steadman et al., 2009). However,
the same research
shows that the extent of involvement varies. Even estimates of
the rates of involve-
ment of people with mental illnesses in the criminal justice
system formulated using
the most rigorous method of case identification (i.e., diagnostic
interview) vary based
on geographic locations where the estimates were made
(Steadman et al., 2009). This
point underscores the critical importance of formulating
estimates of the justice-system
involvement of people with mental illnesses that are specific to
the locality that will
provide and develop services for this population.
Until recently, developing locally specific estimates of justice-
involved persons
with mental illnesses was beyond the reach of most localities
because of the high
expense and high level of research expertise needed to

accomplish the task. However,
the BHR case identification method offers practitioners and
policy makers a viable
method for examining rates of involvement on a local level.
Although this method has
limitations—particularly that it excludes people who were
previously undiagnosed
and those with private insurance, BHR case identification offers
the benefit of provid-
ing estimates of justice-system involved populations with
mental illnesses that are
derived from provider-reported diagnostic data, and at a fraction
of the cost of con-
ducting diagnostic interviews.
We hope the discussion of the methods presented in this article
will guide practitioners
and policy makers who are considering the use of BHR in the
case identification process.
For practitioners, using systematic, data-driven methods to
determine local rates of
involvement of people with mental illnesses maximizes the
chances of services and
resources being appropriately distributed. For example, police
departments must decide
which partnerships to pursue and trainings to use, correctional
institutions must determine
which medication and treatment services will be available to
inmates, and reentry person-
nel must link newly released offenders with the appropriate
mental health services.
Personnel, access, and service availability are all based on

estimates of the number of
people in need of these services. This approach is not the
answer for every agency in
every situation but may be useful for some. For some criminal
justice agencies, this may
be the only way to screen large populations such as arrestees
and jail inmates.
Researchers have taken diverse approaches to identifying people
with mental ill-
ness who are involved in various criminal justice settings.
Given the nature of police
work, including the brevity of many police–citizen encounters,
researchers have relied
on trained observers to identify which of these encounters
involved a person with
mental illness (Engel & Silver, 2001; Teplin, 1984). Although
the courts and jail set-
tings have provided researchers with better access to justice-
involved populations,
these research efforts have lacked a standardized definition of
mental illness and used
multiple methods to identify people with mental illness,
resulting in wide variability in
estimated numbers of this population. However, the recent
societal-level investments
in digitizing medical records (American Recovery and
Reinvestment act (ARRA:
2009) combined with the new mandate to use electronic records
in health care settings
(ACA, 2010) are creating volumes of digital data that can be
used to identify individu-
als across all levels of involvement in the criminal justice
system. The availability of
these new data sources has coincided with significant public
investment in developing

technological resources to mine these data resources; this
intersection of data access
availability of new methods will create opportunities for
researchers to explore the
involvement of people with mental illnesses at all points of the
criminal justice system.
Although a discussion of the full range of implications of the
“big data revolution” on
research with justice-involved people with mental illnesses is
beyond the scope of this
article, the resources generated by these efforts address
limitations of the case identi-
fication methods that have prohibited use of big data in the past.
The criminal justice field is entering a research era that is likely
to be defined by the
big data revolution, wherein large administrative data sources
will become the primary
data source for many studies, especially research on health and
health care services use
(NIH, n.d.). However, this data revolution also offers criminal
justice practitioners and
policy makers the infrastructure needed to use existing data to
guide real-time decisions
regarding mental health services that require additional
development and testing. Part
of such exploration should involve tests of the accuracy of the
BHR case identification
method as reliable information is needed, but for it to be useful
for service planning in
the public mental health system, it also has to be diagnostically
specific. However,
these tests should involve real-world considerations—such as
cost-benefit analysis of
increased accuracy or improved diagnostic precision—compared
across case

Criminology 61(8)
identification methods to enable practitioners and policy makers
to use the data to make
the best decisions possible based on the needs and resources
present in their specific
localities. Finally, these are not always mutually exclusive
methods. The best way to
capture the rate of mental illness including the previously
undiagnosed may be some
combination of these approaches. For example, it may be useful
to merge jail and prison
classification records with BHR or to conduct a brief survey of
inmates to identify the
undiagnosed. It is true that only direct screening can catch the
undiagnosed and the
truly unidentified, but given the resources required to conduct
diagnostic interviews,
this method cannot be used in a wide-scale manner. A
combination of these methods
could widen the net and include more people who are in need of
treatment.
Conclusion
Researchers and practitioners must consider the positive and
negative aspects of every
method of case identification. Estimates of mental illness in
criminal justice popula-
tions are crucial to making public policy decisions regarding
funding for programs
such as Crisis Intervention Teams (CIT), mental health courts,

and reentry programs.
Such programs and the criminal justice knowledge base would
benefit significantly if
the same method was used to measure the extent of involvement
of people with mental
illnesses at all points in the criminal justice system. Although
every police–citizen
encounter does not lead to an arrest and jail time, and every jail
detainee is not sen-
tenced to prison, some overlap does exist among these
populations.
We have demonstrated the wide variation that exists in
estimates of mental illness
within some criminal justice settings. Notably, even the most
conservative rates dem-
onstrate that a large number of people with mental illnesses
become involved with the
criminal justice system, and such involvement occurs at
disproportionately higher
rates than community samples (Teplin, 1990; Teplin et al.,
1996). Thus, it is important
for local jurisdictions to understand the size of the population
they are trying to
address, especially given that recent estimates have been shown
to vary substantially
across local jurisdictions (Steadman et al., 2009).
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship,
and/or publication of this article.
Funding

The author(s) received no financial support for the research,
authorship, and/or publication of
this article.
Notes
1. Based on Google Scholar counts, the studies that had the
most citations of rates of involve-
ment were included in the table. This list is not meant to be
inclusive of all studies that esti-
mated rates of involvement of mental illness in criminal justice
populations. These studies
are not meant to be the most recent or most rigorous in the
field, rather they are indicative of
the research that is most utilized in the field.
2. For serious mental illnesses, a diagnosis at any point in the
lifetime of the individual will be
important information for criminal justice personnel because
individuals with these diagno-
ses require ongoing treatment to support the management of
these disorders and alleviation
of symptoms during active stages of the disorders.
3. Ideally, a mental health clinician with training in interpreting
these measures would conduct
these interviews or would supervise non-mental health
professionals.
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10. Journal of Clinical Psychiatry, 59(Suppl. 20), 22-33; quiz
34-57.
Steadman, H., Osher, F., Robbins, P. C., Case, B., & Samuels,
S. (2009). Prevalence of serious men-
tal illness among jail inmates. Psychiatric Services, 60, 761-

765. doi:10.1176/appi.ps.60.6.761
Teplin, L. A. (1983). The criminalization of the mentally ill:
Speculation in search of data.
Psychological Bulletin, 94, 54-67. doi:10.1037/0033-
2909.94.1.54
Teplin, L. A. (1984). Criminalizing mental disorder: The
comparative arrest rate of the mentally
ill. American Psychologist, 29, 794-803. doi:10.1037/0003-
066X.39.7.794
Teplin, L. A. (1990). The prevalence of severe mental disorder
among male urban jail detainees:
Comparison with the Epidemiologic Catchment Area program.
American Journal of Public
Health, 80, 663-669. doi:10.2105/AJPH.80.6.663
Teplin, L. A., Abram, K. M., & McClelland, G. M. (1996).
Prevalence of psychiatric disorders
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505-512. doi:10.1001/archpsyc.1996.01830060047007
Teplin, L. A., & Swartz, J. (1989). Screening for severe mental
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doi:10.1016/j.ijlp.2011.07.004

Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Transcultural Health Care
Haitian Americans
Larry Purnell, PhD, RN, FAAN
*
4th Edition
OverviewHaiti shares the Island of Hispaniola with the
Dominican Republic. Dominican Republic and Haiti have little
in common culturally.Haiti is the poorest country in the
Western hemisphere with a per capita income of less than $450.
*
4th Edition
Overview ContinuedOver 500,000 Haitians live in the United

States, with more arriving after the Haitian earthquake in 2010.
Their numbers may exceed 1.5 million. Most live in NYC, FL,
Boston, Chicago, and CAMost come here for better economic
opportunities and political freedom
*
4th Edition
Overview ContinuedHaitians are a mix of Arawak Indian,
Spanish, French, and African Black resulting in sharp class
stratification and color consciousness1791 ended slavery in
Haiti
*
4th Edition
Communications Languages are primarily Creole (for the poor)
and French (wealthier) and English although many speak all
three languagesBlack, mulatto, or white and colors in-
betweenMost Blacks are poor and underprivileged
*

4th Edition
OverviewEarly immigration to the United States was the
wealthier groups for education, followed by general
immigration after 1920 and the United States occupation of
HaitiAfter 1964, Duvalier became president for life, mass
exodus because of oppression politically and economically
*
4th Edition
Overview Continued1980 immigration with the Mariel Boat Lift
from Cuba brought first legal and then the Boat People from
Haiti. Many had left Haiti to Cuba in previous generations and
this group joined in coming to the United States.Resulted in
Cuban-Haitian entrant: status pending
*
4th Edition
Overview ContinuedFrench model of education with liberal arts,
philosophy, classics, and languages—Latin and Greek and de-
emphasizes technical and vocational training and the social and
physical sciences Educated Haitians are multilingualOnly 15%
to 20% receive an education—high illiteracy rates

*
4th Edition
CommunicationsFrench and Creole official languages15% speak
French, 100% speak CreoleOral communication patterns to pass
on culture through proverbs and storytellingSmile timidly to
hide lack of education and understandingNod of the head does
not mean “I understand”
*
4th Edition
Communications ContinuedMost are private individuals who do
not want friends or family to interpret for them Traditional
Haitians do not usually maintain eye contactTouching is
commonWomen may hold hands while walking in public
*
4th Edition

Communications ContinuedMost are present oriented out of
necessity, the past is cherished and the future is predetermined
—many remain rather fatalisticPunctuality is not valued—
flexible time is the norm
*
4th Edition
Communications ContinuedFirst and middle name are usually
hyphenatedWoman takes her husband’s name upon marriageLast
names are usually French or Arabic in originFormality in name
is the norm
*
4th Edition
Family RolesMatriarchal or shared decision-making is the
norm—although there are variationsMale is the primary
breadwinner Concept of machismo prevailsNot uncommon to
have more than one mistress or for women male partners
*

4th Edition
Family Roles ContinuedChildren are valued and expected to be
well behaved—otherwise physical punishment may be usedMost
feel US society is too permissiveBoys are given more freedom
and permissive behaviorGirls cannot go out alone until age 17+
*
4th Edition
Family Roles ContinuedNuclear, consanguine, and affinal
relatives are the normFamily lineage is what denotes respect,
not moneyChildren expected to care for parents when self-care
is a concern
*
4th Edition
Family Roles ContinuedSingle parenting is well
acceptedHomosexuality is taboo—if known, total denial from
both sidesMistress supports her children with little to no
financial help
*

4th Edition
ClickerCheck
The nurse is providing insulin injection instructions to Mrs.
Paul, a 44-year-old Haitian. When the nurse asks her if she
understands the instructions, she nods. To assure understanding,
the nurse should
Ask her to repeat the instructions.
Give her written instruction to ensure.
Have her demonstrate an injection.
Give the instructions to a family member.
*
4th Edition
Correct Answer
Correct answer: C
The best way to assure understanding is for the patient to
demonstrate the injection.
*
4th Edition

Health ConditionsCholera, parasitosis, and malaria without
malaria control measuresHepatitis, tuberculosis, venereal
disease have high ratesMost test positive for TBC because of
Bacille bilie de Calmette-Guerin vaccinationsHigh rates of
diabetes and hypertension
*
4th Edition
NutritionFor many, food means survivalPrefer eating at home
and dislike fast foodWhen hospitalized, many prefer to fast
rather than eat hospital foodDislike yogurt, runny eggs, and
cottage cheeseStaples are rice and beans, plantains, salad
*
4th Edition
Nutrition ContinuedLists of foods are in the Haitian--American
chapterFoods are classified as cold (fret) and hot (cho), acid and
non-acid, and heavy and lightMust balance fret and cho foods or
illness occurs
*

4th Edition
Nutrition ContinuedCough medicines are hot, laxatives are
coldAvoid citrus, causes acneAfter ironing do not open
refrigerator doorDo not shower when you are hotDo not put
warm feet directly on the cold floor
*
4th Edition
Nutrition ContinuedDiet high in carbohydrates and fatBeing
overweight is seen as positiveMajor portion of meat protein is
given to men
*
4th Edition
PregnancyPregnancy is not an illness so why seek prenatal
careSpicy foods will cause the fetus to be irritableVegetables
and red fruits build blood for the fetusIncreased salivation—
“use a spit cup”

*
4th Edition
Pregnancy ContinuedPrefer natural childbirth, although
changing somewhat in the United StatesMen usually not present
during labor—female family members are preferredDress
warmly and stay in bed 2 to 3 days after birth and use an
abdominal binder to close the bones so cold air does not enter
and cause illness
*
4th Edition
PostpartumThree baths postpartum, more difficult in the United
StatesAvoid food believed to increase vaginal discharge—lima
beans, okra, mushroomsOther foods are strength
foodsBreastfeeding is encouragedAll infants receive lok to help
meconium pass
*
4th Edition

ClickerCheck
Most Haitians practice the hot and cold dichotomy of foods.
This is know in Haitian Creole as
a. Yin and yang.
b. Calor y frio.
c. Fret and cho.
d. Am and duong.
*
4th Edition
Correct Answer
Correct answer: C
Fret and cho are the Haitian Creole words for hot and cold.
*
4th Edition
Death RitualsPrefer to die at homeDeath watch by family who
brings religious pictures and have bedside prayerMale kinsman
responsible for funeral arrangements, notifying all family
members, and coordinating the servicePreburial veye to
celebrate deceased’s life
*

4th Edition
Death Rituals ContinuedSeven consecutive days of prayer in the
home to help the passage of the soul into the next lifeBelieve in
resurrection so no cremationAutopsy may relieve fear of
deceased becoming a zombie
*
4th Edition
SpiritualityFamily is the center of lifeCatholicism is the
primary religion of HaitiReligious practices combined with
voodooismLoa, the gods or spirits, believed to receive powers
from God can provide protection and wealth
*
4th Edition
Healthcare PracticesGood health is balance between hot and
cold, eat well, be plump, pray, be free of pain, eat and sleep
right, and exerciseIllness is seen as punishment and comes of
two types—natural and supernaturalNatural illnesses of two

types—short duration caused by environmental factors
*
4th Edition
Healthcare Practices ContinuedNatural longer term illness due
to disequilibria between hot and cold and bone
displacementSupernatural illnesses are caused by angry spirits,
which are placated by ceremonial feastsGas is a major cause of
illness and can be in any part of the body
*
4th Edition
Healthcare Practices ContinuedCertain foods can dispel
gasPostpartum more susceptible to gasTraditional Haitians have
a low pain (doule) threshold and is difficult to assess because of
vague terms used to describe painInjections are preferred to oral
medications
*

4th Edition
Healthcare Practices ContinuedCondition is deemed very
serious if oxygen is neededSpecial diet for physical weakness—
vitamins, liver, pigeon meat, leafy green vegetables, and cow’s
feetSezisman, similar to susto or magical fright, is caused by
unexpected bad news and fright
*
4th Edition
Healthcare Practices ContinuedStrong stigma with mental
illnessSelf-treat and self-medicate or take friends medicineMay
bring medicines from HaitiCultural bound illness—oppression
*
4th Edition
Barriers Delay seeking care because of self-careNo health
insuranceView that Western medicine does not understand
voodooismLanguage difficultiesVery reluctant to receive blood
transfusions or engage in organ donation
*

4th Edition
Healthcare PractitionersUse traditional and Western practices
simultaneouslyRespectful of Western healthcare providersMay
have limited understanding of Western healthcare providers and
their functions and capabilities
*
4th Edition
Copyright © 2013 F.A. Davis Company
Iranian
Larry Purnell, PhD, RN, FAAN
*
4th Edition
Overview/HeritageOver 400,000 in the United States with about
½ living in CaliforniaCurrently about 76 million in Iran with

75% under the age of 30Much diversity in Iran (Persia) among
its inhabitants and also much diversity among Iranians in the
United States
*
4th Edition
Overview/Heritage ContinuedThe reform institutions of current
Iran are colored by religious traditions and ideology of
Islam.Current industrialization of Iran has been from the
outside, not from the inside and is due to the oil production
industry.Political instability continues with clashes between
conservatives and liberals.
*
4th Edition
Overview/Heritage ContinuedFirst wave of immigration
between 1950 and 1970 were mostly students and professionals
from the social elite and many stayed in the United
States.Second wave between 1970 and 1978 were varied in their
background, but most were still affluent and urban and came for
education and to be with family.
*

4th Edition
Overview/Heritage ContinuedNot a major influence in the
United States because they did not live in ethnic enclaves and
assimilated into the United States culture easilyThe third wave
of immigration began in 1979 at the time of the Islamic
revolution and included voluntary and involuntary political
exiles and others who come for economic and personal security
*
4th Edition
Overview/Heritage ContinuedThe hostage crisis between 1979
and 1981 increased ethnic tension of Iranians in the United
StatesMany are unable to find work in the United States that is
compatible with their education in IranMost highly educated
immigrant group in the United States
*
4th Edition
CommunicationsFarsi (Persian) is the national language of Iran

but half speak another language with the educated group
speaking three or more languages, including EnglishInvasions
by numerous other nations have caused a mistrust and suspicion
of foreigners resulting in not sharing one’s feeling with
strangers
*
4th Edition
Communications ContinuedTell stories rather than being blunt
and to the point in conversations leading to politeness and
sometimes disguised as modestyHierarchical relationships
dictate politeness and social communication resulting in a
public self and a personal self
*
4th Edition
Communications ContinuedFamily affairs remain within the
familySelf-control is valued and therefore do not show anger or
emotionsMen can show affection for men and women for women
in public, but not men and womenStand close in conversations,
regardless of social status between conversants
*

4th Edition
Communications ContinuedMaintain intense eye contact
between intimates, but avoid eye contact with superiors and
eldersExpressive gesturingBalance in temporalityClock time is
meaningless, even with appointments unless well acculturated
*
4th Edition
Communications ContinuedFormality in addressing each other
unless close friendsMore traditional men do not mention their
wives’ names in publicMan should wait for woman to extend
her hand for a greeting
*
4th Edition
Name FormatOrder of the name is the same as the Western
method with the given name followed by the
surname.Traditional women do not take their husband’s last
name although some in the United States and elsewhere may

upon immigration.
4th Edition
Family RolesSociety is patriarchal and hierarchicalOldest son
takes over if father is not present or unable to carry out
decision-makingMale children are more desirable than female
children—true in other cultures as well
*
4th Edition
Family Roles ContinuedMen deal with finance and matters
outside the home.Women care for the home and children.Before
1960s social reform, women were legally expected to be
obedient and submissive to their husbands.
*
4th Edition
Family Roles ContinuedMarry early and have children. New law

says women cannot marry until age 14—was 12 and marriages
may still be arranged, but less so in the United StatesRespect
elders and never speak rudely to themChildren rarely left with
babysitters
*
4th Edition
Family Roles ContinuedTraditional do not allow dating; women
are expected to remain virgins until married, but not menStrong
intergenerational ties and family life together or nearbyMay
dress conservatively outside the home but less so while at home
*
4th Edition
Family Roles ContinuedDivorce uncommon in Iran and carries a
stigma—if divorce, it is the woman’s fault, never the man’s—
varies in the United StatesPregnancy before marriage can have
devastating outcomes and is not talked about, it does not
happen—it is just taken care ofGay and lesbianism highly
stigmatized and is a capital crime punishable by death in Iran
*

4th Edition
Biocultural EcologyWide variations in skin color, hair color,
and eye color and depends on heritage from previous
domination by other countries and culturesCommon illnesses in
Iran include malaria, hypertension, meningitis, hookworms, and
parasitosis
*
4th Edition
Biocultural Ecology ContinuedGreat numbers with genetic
disorders brought on by close sanguinity marriages resulting in
blindness, epilepsy, anemias, hemophiliasGlucose-6-phosphate
dehydrogenase deficiency —fava bean allergies can cause
hemolytic crisis
*
4th Edition
Nutrition Food is a symbol of hospitality; serve the best food
for guests who are expected to eat several servings.Polite to
refuse snacks and beverages when first offered—accept it on the

third offeringRarely eat fast food; fresh food is greatly
preferred, and many hours are spent preparing meals
*
4th Edition
Nutrition ContinuedStrict Muslims avoid pork and alcohol and
meat must be prepared with ritual slaughter called halal.Food
should be eaten with the right hand (clean hand) and food
should be passed with the right hand or both hands.Traditional
prefer family to bring food from home if hospitalized.
*
4th Edition
Nutrition ContinuedBalance food between garm (hot) and sard
(cold) —if balance does not occur, one may become “chilled” or
“overheated.”Women are more susceptible to these conditions
than are men.Newer immigrants may have protein and vitamin
deficiencies.
*

4th Edition
Childbearing FamilyMenstruating women are not allowed to
touch holy objects, have intercourse, exercise, or shower.Iran is
changing from openly discouraging birth control to now
cautiously and secretly encouraging birth control because of the
population explosion.
*
4th Edition
Childbearing Family ContinuedCravings must be satisfied
because the fetus needs the craved foodAvoid fried foods or
foods that cause gasEat lots of fruits and vegetablesBalance
garm and sard foodsPregnant woman should not work after the
sixth month
*
4th Edition
Childbearing Family ContinuedThe father should not be present
at birth in the traditional family30- to 40-day postpartum period
where other women are to care for the new motherRitual bath
after this period so religious obligations can continueEat
different foods if a boy baby versus girl babyEat an herbal

extract (taranjebin) to have a boy
*
4th Edition
Death RitualsOkay to begin life support, but usually not okay to
end life supportMultiple family members come to bedside of the
dying person and recite/read prayersBed should be turned to
face MeccaMore traditional want to return to Iran to die
*
4th Edition
Death Rituals ContinuedEven though death is seen as a
beginning, not an end, mourning and grief are displayed openly
and even dramatically to encourage letting goAfter death,
relatives and friends gather on days 3, 7, and 40 to pray and
grieve with family and friends
*
4th Edition

Death Rituals ContinuedAll wear black for mourning and
women should not wear makeupOn the anniversary of the death,
family and friends again gather to express grief and pay respect
to their loved one
*
4th Edition
Death Rituals ContinuedRitual body washing by another Muslim
after death and dressed in a white shroud; body orifices stuffed
with cotton and ritual prayers said during the cleansingIf non-
Muslim, touch the body only with glovesNo embalming in Iran
nor is cremation practiced
*
4th Edition
Spirituality Specific Muslim practices include praying 5 times
each day and need privacy and ritual washing before
prayerDuring Ramadan, fasting from sunup to sundown unless
pregnant or illFamily relationships and friendships are primary
sources of strength
*

4th Edition
Spirituality ContinuedSadness is valued and a sad person is
considered to be deep, thoughtful, and sensitiveGod’s Will and
power over one’s fate fosters passivity and dependence
*
4th Edition
ClickerCheck
A 76 year old Iranian, Muslim male is in the process of dying
after a long debilitating illness. The nurse would
Have his Imam visit.
Make sure no one touches him with bare hands.
Turn him to face Mecca.
Place him in a supine position.
*
4th Edition
Correct Answer
Correct answer: C

At the time of death, the dying person should be positioned to
face Mecca. This can be accomplished by moving the bed or at a
minimum of turning the patient’s face towards Mecca.
*
4th Edition
Healthcare PracticesCombination of humoral medicine, Islam,
and biomedical practicesHumoral medicine—illness is caused
from an imbalance in wet and dry and hot and cold forcesSacred
men are able to healEvil eye is alive and well
*
4th Edition
Healthcare Practices ContinuedGood health is a daily way of
lifeSeek care immediately and shop around for the right
treatmentUse traditional herbs and over-the-counter medicine to
relieve symptoms and seek care provider to determine the
cureAble to purchase a wide variety of drugs over-the-counter
in Iran and bring them to the United States
*

4th Edition
Healthcare Practices ContinuedNarahati—general term to
express unpleasant emotional or physical illnesses and
somatization is common and accepted and can be treated
religiously or medically, depending on what the cause might
beGhalbam gerefteh—distress of the heart—is an expression of
emotional turmoil or homesickness
*
4th Edition
Healthcare Practices ContinuedVarious remedies for the evil
eye and dependent on the age and family of the person
afflictedLanguage can be a barrier to care for someDescriptions
of conditions may be different from the US descriptionMany do
not have health insurance
*
4th Edition
Healthcare Practices ContinuedConcept of insurance may not be
known to someUsually very expressive with pain and
discomfortMental illness is highly stigmatized and may hinder

other family members from marriagePrefer drugs, the stronger
the better, and prefer IV over IM, and IM over pillsThe more
invasive, the better
*
4th Edition
Healthcare PractitionersOrgan donations and transplantations
may be seen as a business transactionFolk or religious
practitioner used for narahatisMost respected biomedical
practitioner is a middle-aged male with a title and white
hairFirm believers in high technology
*
4th Edition
Healthcare Practitioners ContinuedNurses are usually afforded
little respect—partially because of trainingPhysicians are on
top—all other healthcare providers take a lesser position If self-
care is encouraged, it may be seen as non-caring
*

4th Edition
ClickerCheck
Mrs. Said is brought to the nurse practitioner by her daughter
because she has naharati. The nurse recognizes this condition as
Equivalent to congestive heart failure.
Generalized distress.
Generalized weakness of aging.
Abdominal pain.
*
4th Edition
Correct Answer
Correct answer: B
Naharati is generalized distress that can be brought on by stress,
anxiety, homesickness, or other things that can cause emotional
turmoil.
*

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