Expert answer:psychological needs of children with ABI, writing
Answer & Explanation:Attn: The 2nd article in the file below will be used to support the 1st article Requirement are as follows: peer-reviewed journal ( I have already selected the articles) that addresses
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ARTICLES
The Influence of Cultural Background
on Experiences and Beliefs about
Traumatic Brain Injury and their
Association with Outcome
Helen Saltapidas1 and Jennie Ponsford1,2
1 Monash
University, Australia
Rehabilitation Research Centre, Epworth Hospital, Australia
2 Monash-Epworth
he aim of the study was to compare beliefs and experiences of traumatic brain
injury (TBI) in patients with TBI from the dominant English-speaking culture in
Australia versus those from minority culturally and linguistically diverse (CALD)
backgrounds and examine the relative influence of beliefs, acculturation, along with
demographic and injury-related variables on outcome. The primary measures
included the Illness Perception Questionnaire-Revised (IPQ-R), and the Craig
Handicap Assessment and Reporting Technique (CHART). Participants were 70
individuals with mild to severe TBI, including 38 of English-speaking background
(ESB) and 32 from CALD backgrounds. Although similar to the ESB participants in
education, preinjury employment status, injury severity and experience of TBI, the
CALD participants differed significantly from ESB participants on acculturation variables. CALD participants also experienced greater negative emotions and were less
likely to have internal locus of control causal beliefs than ESB participants.
Regression analyses indicated that describing one’s value system as other than
Australian, poorer understanding of TBI and greater negative emotional reactions,
along with fewer years of education were associated with poorer outcomes on the
CHART. Thus, in treating patients from different cultural backgrounds it is important
for health professionals to understand beliefs about and responses to TBI, as they
could potentially impact on coping, emotional adjustment and long-term outcome.
T
Key words: traumatic brain injury, culture, beliefs, emotions, outcome
Numerous studies have documented the complex
range of cognitive and behavioural changes associated with TBI, which have a significant long-term
impact on vocational, social, and emotional functioning (Ponsford, Sloan, & Snow, 1995). Outcome
studies have shown that factors such as age
(Hoofien, Vakil, Gilboa, Donovick, & Barak, 2002)
and injury severity, as measured by posttraumatic
amnesia (PTA) duration and Glasgow Coma Scale
(GCS) scores, are relatively strong predictors of
outcome, but account for less than 30 percent of the
variance in outcomes (Ponsford, Olver, Curran, &
Ng, 1995). Other studies have demonstrated that
coping style, social factors (Moore & Stambrook,
1992; Moore, Stambrook, & Wilson, 1991; Snead
& Davis, 2002) and motivation for and participation
in rehabilitation (Cavallo & Saucedo, 1995;
Gallaher & Hough, 2001; Wallace & Bogner, 2000)
may also influence outcome. These factors may be
influenced, in turn, by illness beliefs and cultural
background. However, the documentation of the
problems and experiences of individuals with TBI
has been largely confined to patients of Western
English-speaking backgrounds, and the perceptions
and experiences of TBI among people from different cultural groups remain poorly understood.
Address for correspondence: Professor Jennie Ponsford, Department of Psychology, Epworth Rehabilitation Centre,
Epworth Hospital, 89 Bridge Road, Richmond VIC 3121, Australia. E-mail: jennie.ponsford@med.monash.edu.au
BRAIN IMPAIRMENT
VOLUME
9 NUMBER 1 MAY 2008 pp. 1–13
1
HELEN SALTAPIDAS AND JENNIE PONSFORD
The term ‘culture’ can refer to groups of people
on the basis of ethnicity, gender, religion, social
class, and sexual orientation (Harley, Feist-Price, &
Alston, 1996). Cultural norms and values guide
beliefs about what is considered healthy (Brown,
Ballard, & Gregg, 1994), how physical symptoms
should be interpreted, appropriate illness behaviour
and expression of symptoms (Gallaher & Hough,
2001), treatment norms and outcomes of illness or
injury (Banja, 1996; Fitzgerald, 1992). Attitudes to
illness and disability, coping style and utilisation of
supports are also said to be shaped by cultural
norms and values (Gallaher & Hough, 2001). When
examining health beliefs and practices in multicultural societies, it is important to assess the degree to
which patients identify with and retain their own
customs and their acceptance of host cultures; that
is, their degree of acculturation (Berry, 1980; Berry,
1997). While research investigating acculturation
and health beliefs and practices has yielded inconsistent findings, some authors have found that certain aspects of health seeking and utilisation are
impacted upon by level of acculturation (Sue &
Sue, 1990; Suinn, Ahuna, & Khoo, 1992).
People with a chronic illness are said to create
cognitive representations of the illness in order to
understand and cope with the associated difficulties (Heijmans & deRidder, 1998; Weinman,
Petrie, Moss-Morris, & Horne, 1996). A theoretical framework explaining these illness representations has been developed by Leventhal and
colleagues (as cited in Heijmans & deRidder,
1998; Weinman et al., 1996), known as the SelfRegulation Model. According to this framework,
illness is represented in four themes: illness identity (symptoms and labels patients associate with
illness), cause (personal ideas about etiology),
timeline (perceived duration of the illness), and
consequence (expected effects and outcomes).
Lau and Hartman (as cited in Heijmans &
deRidder, 1998) proposed cure/control (whether
the illness is curable or manageable) as a further
dimension. This same framework of understanding chronic illness could arguably be applied to
the understanding and experience of TBI, which
often results in chronic sequelae. Illness representations have been shown to impact on coping, psychosocial functioning (e.g., return to work) and
compliance with medical advice (Heijmans &
deRidder, 1998; Moss-Morris, Weinman, Petrie,
Horne, Cameron et al., 2002). It has been suggested that these representations of illness are
shaped by cultural beliefs (Gallaher & Hough,
2001). However the extent to which this is the
case following TBI has not been investigated.
2
Another construct of relevance in this context
is that of illness locus of control (LOC). Some
studies have suggested that LOC may vary
according to cultural background, and that LOC
can impact on the experience of and beliefs about
illness and injury, potentially influencing coping
style and acceptance of disability. In some cultures, LOC is externalised so that the ill individual
is not seen as responsible for his or her symptoms
(Stanhope, 2002). On the other hand, in Western
cultures, LOC tends to be internalised, meaning
that the ill individual is thought to exercise some
degree of control over his or her environment,
resulting in a sense of responsibility or ownership
of symptoms (Stanhope, 2002). Bates and RankinHill (1994) found that LOC was related to cultural
identity, both of which were associated with adaptation to chronic pain. Moore and colleagues
(1992, 1991) investigated the impact of LOC
beliefs and coping style on outcome following
TBI. They found that those with higher external
LOC and a more negative, less self-controlling
coping style showed poorer outcomes than those
with a more internal LOC and a positive, self-controlling coping style. In a sample of patients with
TBI, Snead and Davis (2002) found an association
between positive attitudes towards disability and
acceptance of one’s own disability, which in turn
was associated with better quality of life, mental
health and community integration. Thus, it
appears that LOC is a potentially important component of the experience of illness/injury that may
vary according to acculturation.
It is important to acknowledge that beliefs and
perceptions about TBI might also reflect sociodemographic differences between some cultural
groups, which have been shown to impact upon
health care utilisation and may also influence
functional outcome. These include lower levels of
preinjury education and employment and lower
socioeconomic status (SES; Armengol, 1999;
Blackmer & Marshall, 1999; Rosenthal, Dijkers,
Harrison-Felix, Nabors, Witol et al., 1996; Sherer,
Nick, Sander, Hart, Hanks et al., 2003).
There has been little research directly examining beliefs about TBI among individuals from culturally diverse backgrounds and minority groups
in Western societies (Ferrari, Obelieniene,
Russell, Darlington, Gervais et al., 2001).
Symptom expectation following mild TBI was
investigated by Ferrari et al. (2001) in a sample of
Canadian and Lithuanian nationals, and by
Ferrari, Constantoyiannis and Papadakis (2001) in
a sample of Canadian and Greek nationals who
had not sustained a brain injury. While the
Canadian, Lithuanian, and Greek groups showed
INFLUENCE OF CULTURAL BACKGROUND AND TBI
similar expectations regarding acute symptoms
following TBI, in both studies the Canadians were
more likely than the other two groups to expect
chronic symptoms, with the Greek participants
‘largely unaware of the possibility of chronic
sequelae after minor head injury’ (Ferrari et al.,
2001, p. 258).
In an Australian study by Simpson, Mohr and
Redman (2000), a small sample of Italian,
Lebanese and Vietnamese TBI patients reported
physical, cognitive and psychosocial difficulties
that were consistent with findings from previous
TBI outcome studies, irrespective of cultural background. However, differences were evident in their
expectations and understanding of rehabilitation
(Simpson et al., 2000). The patients’ cultural communities were reportedly perceived as supportive,
although many patients and their families felt
ashamed and withdrew from their communities,
arguably because of the belief that social wrongdoing brought on the injury (particularly in the
Vietnamese sample) or their perception that brain
injury was associated with madness (Simpson et
al., 2000). However, the extent to which these
beliefs differed from those of Anglo–Australians
with TBI was not examined in this study.
Saltapidas and Ponsford (2007) compared
motivation for and participation in rehabilitation,
outcomes and attitudes to role changes following
TBI in two groups of patients, one from the dominant English-speaking culture in Australia and
the other from minority culturally and linguistically diverse (CALD) backgrounds. Although
both groups had similar education and preinjury
employment status, similar length of inpatient
rehabilitation, similar levels of rehabilitation participation and positive attitudes towards rehabilitation, CALD participants showed poorer
outcomes in several domains, including postinjury
employment, cognitive independence, mobility
and social integration on the Craig Handicap
Assessment and Reporting Technique (CHART;
Mellick, Walker, Brooks, & Whiteneck, 1999;
Walker, Mellick, Brooks & Whiteneck, 2003;
Whiteneck, Charlifue, Gerhart, Overholser, &
Richardson, 1992) and showed greater distress
about changes in ability to perform certain life
roles. These findings suggested that differences in
outcome and levels of distress over role changes
may occur in those from CALD backgrounds following TBI, independent of socioeconomic background and access to rehabilitation. It was
concluded that there was a need to further investigate possible reasons for this, including beliefs
and emotional response to injury.
Study Rationale and Objectives
The present study represented an extension of the
study by Saltapidas and Ponsford (2007) aiming
to compare beliefs about core symptoms, causes,
chronicity, consequences and recovery following
TBI, between people from majority Englishspeaking background (ESB) and minority CALD
groups in Australia who were less discrepant in
SES status and who had more equitable access to
rehabilitation. A second aim was to examine the
relative influence of beliefs, acculturation, demographic and injury-related variables on outcome.
On the basis of the available literature suggesting
cultural differences in beliefs and experiences of
illness and injury, it was hypothesised that there
would be differences in beliefs about core symptoms, causes, chronicity, consequences, and
recovery following TBI including locus of control, between people from majority ESB and
minority CALD backgrounds when demographic
and injury related variables were controlled for.
Second, it was hypothesised that injury beliefs and
acculturation, along with demographic and injury
severity variables, would make a unique contribution to outcome, measured on the CHART.
Method
Participants
The patient group was the same as that included in
the study by Saltapidas and Ponsford (2007).
Patients with mild to severe TBI were recruited
from the database of all patients with head injuries
who had been referred for rehabilitation. All participants were treated, in a comprehensive multidisciplinary inpatient and outpatient rehabilitation
program, in the context of a statewide no-fault
accident compensation system. All had been discharged from inpatient rehabilitation, and were
deemed cognitively capable of giving informed
consent and of comprehending the questionnaires
with or without the aid of an interpreter by their
treating neuropsychologist. Exclusion criteria
included neurological disorder apart from TBI or
any psychiatric disturbance, including drug or
alcohol abuse, requiring treatment. On the basis of
available information from the database, approximately 16.8% (n = 151) of Epworth Hospital TBI
patients treated within the previous 8 years were
born overseas, with 13.1% (n = 118) of those born
in a non-English speaking country, thus being
classified as CALD. All CALD patients who met
inclusion criteria were consecutively sampled
from the database, beginning with those who had
sustained their injury between the years of 1998
and 2001, and 2002 and 2004. Patients from ESB
3
HELEN SALTAPIDAS AND JENNIE PONSFORD
backgrounds were also consecutively sampled from
the same time periods until a group of similar size
and demographic background to that of the CALD
group had been recruited. Sixty-five ESB patients
and 75 from CALD backgrounds were contacted.
Of those, 58.5% (n = 38) of ESB and 42.7% (n =
32) of CALD patients participated, 9.23% (n = 6)
of ESB and 17.3% (n = 13) of CALD patients
declined, and for 21.5% (n = 14) of ESB and 25.3%
(n = 19) of CALD patients, contact details were
incorrect or had changed, or patients were medically unwell. A further 10.7% (n = 7) of ESB
patients were excluded from the study because they
were born in an English-speaking country other
than Australia, and 14.7% (n = 11) of CALD were
excluded from the study because they were later
identified as second generation CALD patients
(i.e., born in Australia, with parents born in nonEnglish-speaking countries). It was felt that this
was necessary in order to more clearly delineate the
ESB and CALD groups.
A total of 70 participants were recruited, with
38 participants (22 male, 16 female) categorised
as ESB, and 32 participants (15 male, 17 female)
CALD, having been born overseas in non-English
speaking countries. This grouping was necessary
due to the small numbers of participants from
each country of birth. The majority of those born
overseas were from China (15.6%), Vietnam
(12.5%), Greece (12.5%), and Italy (9.4%), with
two participants each from Hong Kong, Malta,
and India, and one each from Czechoslovakia,
Croatia, Germany, Lebanon, Singapore, Slovenia,
Sri Lanka, Thailand, Ukraine, and Uruguay.
English was the first language for 12.5% of
CALD participants. Ten CALD participants
(31.3%) indicated that they were unable to communicate in English and required the assistance of
an interpreter. Interpreters from the same cultural
background were hired through an interpreting
service and were sent a questionnaire package
prior to the meeting with the participants.
Questionnaires were translated verbatim orally via
interview. In all instances the psychologist conducting the interviews endeavoured to ensure that
participants understood the concepts being discussed. All ESB participants indicated that they
spoke only English.
The participants recruited were aged between
17 and 72 years (M: 39.06, SD: 14.85) and had sustained TBI an average of 2.25 years previously
(range = 4–89 months). Table 1 gives the means
and standard deviations of demographic, treatment
and injury-related variables for ESB and CALD
participants, and results of t tests comparing the
two samples. ESB and CALD participants did not
4
differ significantly on any of these variables. In
terms of injury severity, 29.2% of the sample sustained an injury with PTA < 7 days, 25.7% had PTA
lasting 7–14 days and 40% of patients had PTA
duration > 15 days, PTA duration having been
determined by prospective monitoring using the
Westmead PTA Scale (Shores, 1989).
There was no statistically significant difference between the groups in terms of SES, measured by the Daniel Occupation Prestige Scale
(Daniel, 1983). There were also no statistically
significant group differences in terms of preinjury
employment status, with 79% of the ESB participants and 75.4% of CALD participants working or
studying prior to injury. However, as reported by
Saltapidas and Ponsford (2007), significantly
fewer CALD participants were in open employment postinjury, CALD participants showed
poorer outcomes on the cognitive independence,
social integration and mobility subscales and
poorer overall scores on the CHART (Whiteneck
et al., 1992) and greater distress about changes in
ability to perform the life roles of parent and
homemaker (Sherer et al., 2003).
Measures
Demographic Information
and English Proficiency
Demographic information was obtained using a
questionnaire. With participants’ permission,
injury and treatment details were obtained from
medical records and the relevant funding agencies. The reading subtest (word reading) of the
Wide Range Achievement Test (3rd ed.;
Wilkinson, 1993) was used to measure English
language proficiency. Postinjury employment
status was categorised according to whether the
person was employed on a full-time or part-time
basis or not employed (due to being medically
unfit for work or unemployed, being a homemaker
or retired). The Daniel Occupational Prestige
Scale (Daniel, 1983) was used as a measure of
preinjury SES status.
Acculturation
The Brief Acculturation Scale (BAS; Paniagua,
1998) was used to measure acculturation. It provided a brief assessment of generation, preferred
language and social activity, which are thought to
be three significant variables in the process of
acculturation (Suinn, Ahuna, & Khoo, 1992). The
BAS allows for measurement of acculturation
across different cultural groups, allowing for
modification of items according to the cultural
INFLUENCE OF CULTURAL BACKGROUND AND TBI
TABLE 1
Means, Standard Deviations and t Test Results for Demographic and Injury-Related Variables
Injury related variables
Age (years)
Education (years)
Inpatient stay (days)
Duration of PTA (days)
Time postinjury (months)
ESB
CALD
M
SD
M
SD
t
p
36.58
12.77
51.06
17.08
23.42
13.37
1.66
36.75
15.42
17.44
42.00
12.40
44.17
18.90
32.59
16.15
3.07
26.67
20.04
21.58
–1.54
.569
.881
–.416
–1.93
.129
.555
.382
.678
.058
groups being studied (Paniagua, 1998). In the present study, item 1 (measuring generation) was not
modified, although an explanation was added to
assist participants. For item 2 (preferred language
used) the phrase ‘native language other than
English’ was added to distinguish between participants whose native language was English. The
word ‘ethnic’ was added to item 3, examining
socialisation preferences, in order to distinguish
between socialising within one’s own ‘ethnic’
racial group (indicative of low acculturation), or
within a nonethnic racial group; that is, with
Australians or those from other English-speaking
countries (thought to represent high acculturatio …
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