global mental health: globalization and hazards to women’s health

Global Mental Health: Globalization and Hazards to Women’s Health

Anne E. Becker, M.D., Ph.D., Sc.M. October 15, 2009

SW 25

Global Mental Health Delivery Challenges: Quick Reprise & Overview

Resource and allocation gaps• Suboptimal health financing and

inequitable distribution– “Clinico-centric services”

• Child mental health policy gap– Understanding their relation to

social processes and to vulnerable & “undervisible” populations (e.g., women and adolescents)

• Research & information gap– Operationalization of social

predictors of risk & resilience– Assessment of mental illness

outcomes


Limitations of quantitative assessment

• Uncertain validity of measurement

• Selection and reporting biases (method and topic-dependent)

• Perils of reductionism– Ethnocentrism, bias, and

limited local relevance


Limitations of mental health assessment

• Uncertain fit of universal nosologic categories with local worlds and relevance

• Implications for screening, prevalence estimates, relevance of interventions developed for other populations

• Not only illness, but impairment, distress, course, and outcomes may be culturally particular

Possible strategies to circumvent limitations?


Limitations of qualitative assessment of mental health data

• Disentangling signal from noise: the inherent “messiness” of field data

• Imperfect access to inner experience

• Positioned subjects• Limits to causal inference• Balance of action with

scholarship

What about globalization and mental health?

• What causal mechanisms link economic and social change to impact on health?

• Who is vulnerable?• Social processes and

associated health risks are dynamic

Why study mental health in Fiji?

• Fiji is undergoing rapid social and economic change

• Opportunity to understand impact of social adversity

How do we measure impact of socio-cultural environment on mental health?

Studies relating acculturation to eating pathology (n=29)

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Assessments

Nu

mb

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f S

tud

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Suinn-Lew Acculturation Scale (SL-ASIA)

Acculturation Rating Scale for MexicanAmericans (ARSMA)

African-American Acculturation Scale(AAAS)

Ethnic Identity Scale

East Asian Acculturation Measure

Culture Questionnaire

Acculturation Index

Minority Majority Relations Scale(MMRS)

South African Acculturation Scale

Societal, Familial and EnvironmentalAcculturative Stress Scale (SAFE)

American-International Relations Survey

Becker et al, 2009

What are relevant dimensions of acculturation?

Studies relating acculturation to eating pathology (n=29)

0 1 2 3 4 5 6

Pro

xy

Number of studies

TV ownership & exposure

Culture-specific attitudes toward eating

Comfort with living in daily Westernenvironment

Language

Perceived traditionality of parents

Length of time living in the US

Generation status in US

Parents' birthplace

Born in US?

Becker et al, 2009

Results of an exploratory factor analysis of items relating to 5 dimensions of *acculturation*

Becker et al, in press

Intercorrelations among 12 dimensions of *acculturation*

Note: *p<.05, **p<.01; ***p<.001; Traditional adherence dimensions shaded in light grey; overlapping traditional dimension cells shaded in dark grey. Note: ** p<.01; ***p<.001; Ethnic Fijian cultural dimensions are shaded in light grey; overlapping Ethnic Fijian cultural

dimension cells are in shaded in dark grey. (Becker et al, in press)

• LeGrange and colleagues (2004) investigated the validity of high EAT-26 scores among impoverished black adolescents in South Africa

Outcome misclassification

Outcome misclassification

• EDE-Q was used as a gold standard for validation and was consistent with no eating disorder diagnosis in 2 of 5 study participants

• Their response relating to food preoccupation turned out to have related to their poverty and hunger, not an eating disorder

Anorexia Nervosa without Fat Phobia

• Lee and colleagues described anorexia nervosa without fat phobia in the 1990s

• EAT-26 misclassified non fat phobic individuals as not having an eating disorder when they apparently did (Lee et al. 2002)

Eating Disorders as biosocial phenomena

Cultural diversity in aesthetic idealsand what they mean

Eating Disorders as biosocial phenomena:

Weight management behaviors are constrained by the social environment

Eating Disorders as biosocial phenomena

Cultural diversity in idioms of distress and rhetoric for self-expression

Can flexibility be built into classification?

Should ‘Non-Fat Phobic AN’ be Included in DSM-V?

Study name Outcome Statistics for each study Std diff in means and 95% CIStd diff Standard

in means error p-Value

Lee, 1993 Current BMI 0.26 0.27 0.34Lee, 1998 Current BMI 0.35 0.42 0.40Lee, 2001 Current BMI -0.17 0.31 0.58Lee, 2002 Current BMI 0.79 0.20 0.00Lau, 2006 Current BMI -0.21 0.47 0.66

0.27 0.21 0.20

-4.00 -2.00 0.00 2.00 4.00

NFP-AN > BMI AN > BMI

AN and Non-Fat-Phobic AN Have Similar BMI

Meta Analysis

(Becker, Thomas, & Pike, 2009)

d = .27, p = ns

Meta-analysis comparing AN with NFP-AN

Comparison Outcome Statistics for each study Std diff in means and 95% CI

Std diff Standard in means error p-Value

Lee, 1993 Eating Pathology Combined 0.74 0.32 0.02


Lee, 2001 Eating Pathology Bulimia 0.64 0.47 0.17


Noma, 2006 Eating Pathology EAT-26 score > 15 2.37 0.72 0.00

Lau, 2006 Eating Pathology Combined 0.07 0.47 0.88

0.65 0.21 0.00

-4.00 -2.00 0.00 2.00 4.00

NFP-AN Worse AN Worse

AN Has Greater Eating Pathology Than Non-Fat-Phobic AN

Meta Analysis

(Becker, Thomas, & Pike, 2009)

Significant difference holds even when constructs with no potential for overlap with fat phobia are excluded from the meta-analysis (d = .41, p = .04).

d = .65, p = .002

Meta-analysis comparing AN with NFP-AN

DSM-IV Eating Disorder Categories Not Useful for Classifying Potential Cases

Source and relevant discussion in: Thomas JJ, Crosby RD, Wonderlich SA, Striegel-Moore RH, Becker AE. A latent profile analysis of the typology of bulimic symptoms in an indigenous Pacific population: Evidence of cross-cultural variation in phenomenology.

Under review at Psychological Medicine.

Required reading?

Universalizing versus local classification

Etic perspective

• The “outsider” perspective

• Assumes a universal framework for illness

• Attempts to identify the “true” core illness despite variations in epiphenomena

Universalizing versus local classification

Emic perspective

• The “local” perspective

• Assumes a culturally particular and relativistic frame

• Begins from the “ground up” with indigenous nosologic categories

An indigenous perspective on food refusal: Macake

An indigenous perspective on an illness episode: Macake

Food RefusalSeizure

Peri-orbitalcellulitis

DeliriumWeight

loss

Highfever

An indigenous perspective on an illness episode: Macake

Food RefusalSeizure

Peri-orbitalcellulitis

DeliriumWeight

loss

Macake

Highfever

Bacterial meningitis

An indigenous perspective on food refusal: Macake

Cultural Norms vs. Symptoms

Is binge-eating relative to its context?

Cultural Norms vs. Symptoms

Is purging relative to its context?

So, in the universe of possible ED symptoms, where do we draw the line?

Food Refusal

Excessshapeconcer

n

Binge-eating

Purging

Weight loss

Anorexianervosa?/EDNOS?

Where do we draw the line?

Food Refusal

Excessshapeconcer

n

Binge-eating

Purging

Weight loss

Bulimianervosa?/EDNOS?

Where do we draw the line?

Food Refusal

Excessshapeconcer

n

Binge-eating

Purging

Weight loss

Macake?

Encompassing cultural diversity in DSM-V another empirical approach

Indigenous Herbs Facilitate Culturally Normative Purging

• Purging with indigenous Fijian herbs reported in focus groups

• Using herbs to induce vomiting or diarrhea, or clean out the stomach, is socially acceptable in Fiji

• Added items to EDE and EDE-Q to assess herbal purgative use

LPA Identified Two Classes with Different Methods of Purging

Multiple purging class (37%)

(Data from Thomas et al, under review)

LPA Identified Two Classes with Different Methods of Purging

Multiple purging class (37%)

Herbal purging class (63%)


F = 13.72, p< .001, error bar = SE

a b b

Herbal and Multiple Purging Classes Have Similar Levels of Eating Pathology

EDE-QGlobal


F = 5.88, p< .01, error bar = SE

a b b

Herbal and Multiple Purging Classes Have Similar Levels of Dysphoric Affect

CES-D


F = 6.12, p< .01, error bar = SE

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Non-P urging Multiple P urging Herbal P urging

a a b

CIA

Herbal Purging Class Exhibits Greater Impairment Than Multiple Purging Class


Conclusions about Eating Disorder Nosology from Fiji

• No, despite high rates of individual ED symptoms, DSM-IV categories did not detect any eating disorder cases

Are DSM-IV eating disorder categories useful for classifying potential cases in Fiji?

•Yes, latent profile analysis identified two classes associated with impairment and pathology:

• Multiple purging class• Herbal purging class

Can a more culturally sensitive and locally meaningful classification be empirically derived through latent profile analysis?

• Attunement to diverse cultural patterning of symptoms and local social norms

• Locally valid assessment of population and individual risk

• Consideration of emerging risk in populations undergoing rapid economic transition

• Emphasis of fluidity of social norms

Eating Disorders: Can the DSM V have Global Clinical Utility?

School-based study on Social change & health risk behaviors

Back story narrative: Violence and despair

• 117 (23%) girls reported seriously considering killing themselves in the past year

• 15% (80) girls reported a physical attack in the past year

Suicide

From: http://www.who.int/mental_health/prevention/suicide/evolution/en/index.html

Multivariable logistic regression model predicting suicidal ideation and behavior

Covariate p value

Physical attack 1.13 <.0001**

“Western oriented” 0.28 .019*

Television viewing .049 NS

Traditional -.16 NS

Parental support -.10 .01*

*significant to the p<.05 level

**significant to the p<.001 level

Adjusted for age, poverty, social rank, urban location, preliminary model

Suicide narratives

A1 Last SI in May after a beating at home. Frequent beatings because of her not doing work at home. Each time this occurs, she feels suicidal. She reports an especially bad episode last year (January 2006) when her mother nearly killed her and told her to kill herself.

A42 Episode of SI (week 8 of first term) when she went to games with her friend instead of going right home. Arrived home at 8; mother was angry and told her to wait up for her father. She was worried that he would beat her and she’d get hurt given that he is a soldier. So she thought about hanging herself with a wire hanger. She started to tie it but her sister came in and saw her.

F8SI occurred in February when she was in conflict with her brother (she went out with friends). She was beaten with a bridle and a rope and ran away.

F39Last SI started 2 weeks ago when her father beat her with a horse’s bridle, marking her arm and back.

beat her with a horse’s bridle

What can be done?Pragmatic and moral solutions

Can these young women be helped to navigate opportunities and backlash?

Deficits in human resources for mental health care in Fiji

Proportion of mental health

budget (% of total health budget)

Psychiatric nurses per

100,000 people

Psychiatrists per 100,000 people

New Zealand 11% 74 6.6

Australia 9.6% 53 14

USA 6% 6.5 13.7

Fiji

Jacob KS, Sharan P, Mirza I et al. Mental health systems in countries: where are we now? Lancet 2007; published online Sept 4. =2

1.7% 0 0.25

Access to care

What are the viable strategies?

Relocation and reframe

Intervention with parents?

Relocation of mental health care?

Can the schools take this on?

What is the added value of multiple research perspectives?

• Epidemiologic• Ethnographic• Clinical

Complementary signals and limitations: Epidemiologic data

Comparative prevalence of alcohol use in young women in Fiji between two assessments

20.1%

7.8%

0%

5%

10%

15%

20%

25%

GSHS NCD Steps Survey

Assessment

Per

cen

tag

e re

po

rtin

g c

urr

ent

alco

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l use

wit

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5% C

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GSHS 2007 (HEALTHY Fiji Study): ages 15-20

NCD STEPS survey 2002: ages 15-24

Complementary signals and limitations: Epidemiologic data

Data from: Cornelius M, Cecourten M, Pryor J, Saketa S, Waqanivalu T, Laqeretabua A, Chung E. Fiji Non-communicable diseases (NCD) STEPS Survey 2002. Ministry of Health: Shaping Fiji's Health 2002: 1-65.

Becker AE, Perloe A, Richards L, Roberts AL, Bainivualiku A, Khan AN, Navara K, Gilman SE, Aalbersberg W, Striegel-Moore RH for the HEALTHY Fiji Study Group Prevalence and Socio-demographic Correlates of Cigarette Smoking, Alcohol Use, and Unsafe Sexual Behavior among Ethnic Fijian Secondary Schoolgirls. Fiji Medical Journal; 2009, in press.

Complementary signals and limitations: Ethnographic data

Complementary signals and limitations: Clinical data

What is a suitable metric for mental distress?

The Interview

F35+ recurrent SI with plan of taking pesticide but no intent; no attempts. No SI current; last episode last week. in August she was caught drinking with her friends (was beaten) . . . in forms 1-5, she had been first in her class, but after that time her marks went down. She finds that the work she is asked to do at home interferes with school work,

J11 + 2 episodes of SI, both after getting a beating from her brother. Last time in June when she was beaten with an electric wire and then seen at hospital.

J66 December went to a birthday party and drank. Parents mad at her when she got home. Talked to her and beat her with a stick (first beating). She planned to hang herself, got a rope but didn’t put it around her neck, was looking for a place to hang it,

J69June 2006; beaten with an electrical cord by father for going to train in [. . . ]; left marks on her body, not seen at hospital. She felt that she would either run away or kill herself. Took a rope and sat thinking about it.

J47 With friends and parents got mad at her. She got really angry. Got rope tied it to a tree and around her neck,

J51Christmas day 2006, went to road to see a boy, stayed and talked to him x several hours. Parents very upset with her after. Whipped her with a horse’s bridle: left marks on back. Very upset. +SI with plan/intent to hang self. Got a rope and went outdoors.

What was the meta-narrative?

The meta-narrative:A co-construction?

Is this representation of experience authentic?

• No matter how much we may shrink with horror from certain situations [ . . . ] it is nevertheless impossible to feel our way into such people . . .

– Freud, Civilization and Its Discontents

• All interpretations are provisional. They are made by positioned subjects who are prepared to know some things and not others. [ . . . ] good ethnographers still have their limits, and their analyses always are incomplete.

– Rosaldo, Grief and a Headhunter’s Rage, 1984.

Or . . . focus on visibility and corrective action!

“ . . . So call a big meeting. Get everyone out.

Make every Who holler! Make every Who shout!

Make every Who scream! If you don’t, every Who

Is going to end up in a Beezle-nut stew!”

– Suess, Horton Hears a Who

Thank you

• Funding– Claneil Foundation

– NIMH K23 MH 68575 01– Harvard REG– Radcliffe Institute

• Fijian collaboration and assistance– Tui Sigatoka– Dr. Tevita Qorimasi – Dr. Lepani Waqatakirewa – Fiji Ministry of Health– Fiji Ministry of Education– Professor Bill Aalbersberg– Professor Vaula Qereti– Alumita Taganesia – Livinai Masei– Pushpa Wati Khan– Fulori Sarai – Dr. Jan Pryor – Na vuwere qenia na rara ni vuli taucoko

Thank you

Research Team & Collaborators • Jessica Agnew-Blais• Gene Beresin, M.D.• Jennifer Derenne, M.D.• Kristen Fay• Stephen Gilman, Sc.D.• Amy Heberle• Olga Levin• Alex Perloe• Jane Murphy, Ph.D.• April Opoliner• Andrea Roberts, Ph.D.• Ruth Striegel-Moore, Ph.D.• Jennifer Thomas, Ph.D.

HEALTHY Fiji Research Field Team• Asenaca Bainivualiku• Nisha Khan• Kesaia Navara• Lauren Richards• Amy Saltzman• Aliyah Shivji

global mental health: globalization and hazards to women’s health

Documents

dynamicwhy study mental

associated health risks

social processes

social change

eating disorders

impact of social adversityhow

becker et

quick reprise overviewresource