What can we learn from a cross-national study of somatic distress?

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Abstract

Objective

To examine the extent of cross-national variations in the rates and correlates of somatic distress and determine whether this can be ascribed to cultural differences.

Methods

A two-stage survey in primary care across 15 sites in 14 countries. Screening with the 12-item General Health Questionnaire (GHQ-12) was followed with detailed diagnostic assessment with the Composite International Diagnostic Interview. Self-rating of overall health and evaluation of disability days were also conducted (N=5438). Twelve months later, 3204 of the patients completed follow-up interviews.

Results

Somatic distress (different definitions of somatization and of hypochondriasis as well as persistent pain disorder) varied in its occurrence across sites. However, other than elevated rates in Latin America, variation tends to be complex and does not lend itself to a neat cultural explanation. The nature of patient–doctor relationship is related to this variation.

Conclusion

Cross-national differences occur in somatic distress. The pattern of these differences does not follow clear cultural lines even though the role of culture cannot be excluded.

Introduction

Even though the literature is replete with reports describing association of culture with various aspects of somatization [1], [2], [3], [4], there is little empirical evidence that observed variations in, for example, the occurrence of the disorders across countries lend themselves to obvious cultural explanations [5], [6].

To draw reliable inferences in regard to cross-national variations in somatoform disorders, studies need to meet a set of conditions. One, it is important that cross-national comparisons be drawn from data that utilize identical ascertainment procedure in the countries of interest. Two, the assessment tools should be developed in such a way that they allow for the inclusion of symptoms that may be peculiar to study sites. Third, the assessment should be comprehensive, allowing not just for examination of the frequency of somatic distress but also its correlates in regard to demographic attributes and impact. When differences are obtained in these areas, attempts could thereafter be made to examine whether such differences bear associations with study sites in a manner that may suggest plausible cultural explanation.

The study Psychological Problems in General Health Care (PPGHC), a World Health Organization collaborative project that was conducted in 15 centers in 14 countries located in four continents [7], provides an opportunity to address the following questions: To what extent do differences in the experience of somatic distress across countries lend themselves to cultural interpretations? Are there factors related to the nature of patient–doctor interaction that may be associated with the reporting of somatization symptoms?

Section snippets

Aims and methods

The aims of the PPGHC were to investigate the nature, impact, and course of common psychological problems presenting in primary care settings. Designed as a two-stage cross-cultural epidemiological survey of people contacting general health settings, the study was conducted in Ankara (Turkey), Athens (Greece), Berlin and Mainz (Germany), Bangalore (India), Ibadan (Nigeria), Groningen (the Netherlands), Manchester (United Kingdom), Nagasaki (Japan), Paris (France), Rio de Janeiro (Brazil),

Results

Across the sites, the samples were composed of predominantly young to middle-aged people with a mean age of 40±14 years. Patients in Ankara, Bangalore, and Ibadan, with respective mean ages of 32±13, 31±13, and 33±11 years, tended to be younger in keeping with the age structures of these countries. Patients from developing countries (Ankara, Bangalore, Rio de Janeiro, Santiago, and Ibadan) also had lower means of education than those from more developed ones (Athens, Paris, and Seattle): 5–7

Discussion

The results of the PPGHC, a project conducted in primary care settings in 15 countries drawn from five continents and with the use of identical ascertainment procedures, showed that there is a wide variability in the occurrence of somatoform disorders across the cultures studied [7], [8]. This variability was true of both prevalence and incidence over a 12-month period. On the other hand, associations of somatization with demographic attributes with health perception were generally less

Acknowledgements

The data reported in this paper were collected as part of a World Health Organization's Psychological Problems in General Health Care project. Participating investigators include Orhan Ozturk, MD and Murat Rezaki, MD, Ankara, Turkey; Costas Stefanis, MD and Venetsanos Mavreas, MD, PhD, Athens, Greece; S. M. Channabasavanna, MB, BS, MD and T. G. Sriram, MB, BS, MD, Bangalore, India; Hanfried Helmchen, MD and Michael Linden, PD, Berlin; Wim van den Brink, MD and Bea Tiemens, PhD, Groningen, The

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