Disease Management & Health Outcomes

, Volume 16, Issue 6, pp 411–419 | Cite as

Health Beliefs and Culture

Essential Considerations for Outcome Measurement
  • Kamaldeep Bhui
  • Sokratis Dinos
Review Article


Culture is linked to the way emotions, mental distress, social problems, and physical illness are perceived, experienced, and expressed. Beliefs about what constitutes illness and what can be done about it vary considerably across cultures. Defining mental health and measuring mental health outcomes have been the focus of academics and mental health professionals across a number of disciplines from psychiatry and psychology to anthropology and sociology.

Mental health diagnostic constructs and subsequent treatment practices designed in developed countries are often used in the provision of care in the developing world and in care practices for ethnic minorities, asylum seekers, and refugees. However, there are concerns about the limitations of using mono-cultural outcome measures in these culturally diverse contexts. This article reviews the role of health beliefs and culture in the development and use of mental health outcome measures. Suggestions are made for criteria to improve the reliability and validity of mental health outcome measures used in multicultural contexts. In particular, the role of language in describing salience and severity of symptoms is discussed alongside a number of methodological approaches to improve the development of mental health outcomes in cross-cultural contexts.


Mental Health Ethnic Minority Mental Health Outcome Health Belief Asylum Seeker 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



No sources of funding were used to assist in the preparation of this review.

Professor K. Bhui is Principal Investigator on related projects on an outcomes compendium development for the Department of Health, UK, and Principal Investigator of MSc Transcultural Mental Healthcare. Professor Bhui and Dr Dinos have received a UK Department of Health grant to develop a compendium of outcomes measures. The authors have no other conflicts of interest that are directly relevant to the content of this review.


  1. 1.
    Kirmayer LJ. Cultural variations in the response to psychiatric disorders and emotional distress. Soc Sci Med 1989; 29: 327–39PubMedCrossRefGoogle Scholar
  2. 2.
    Lopez SR, Guarnaccia PJJ. Cultural psychopathology: uncovering the social world of mental illness. Annu Rev Psychol 2000; 51: 571–98PubMedCrossRefGoogle Scholar
  3. 3.
    Kleinman A. Rethinking psychiatry: from cultural category to personal experience. New York: Macmillan, 1988Google Scholar
  4. 4.
    Mezzich JE, Kleinman A, Fabrega H, et al. Culture and psychiatric diagnosis: a DSM-IV perspective. Washington, DC: American Psychological Association, 1996Google Scholar
  5. 5.
    Patel N, Bennet E, Dennis M, et al. Clinical psychology, ‘race’ and culture: a training manual. Leicester: British Psychological Society, 2000Google Scholar
  6. 6.
    Hays PA. Addressing cultural complexities in practice: a framework for clinicians and counselors. Washington, DC: American Psychological Association, 2001CrossRefGoogle Scholar
  7. 7.
    Vega WA, Murphy JW. Culture and the restructuring of community mental health. Westport (CT): Greenwood, 1990Google Scholar
  8. 8.
    Thornicroft G, Tansella M. Mental health outcome measures. Berlin, New York: Springer, 1996CrossRefGoogle Scholar
  9. 9.
    US Public Health Service. US Department of Health and Human Services. Mental health: culture, race and ethnicity. A supplement to mental health: a report of the Surgeon General [online]. Available from URL: [Accessed 2008 Nov 18]
  10. 10.
    Smedley BD, Stith AY, Nelson AR. Unequal treatment: confronting racial and ethnic disparities in mental health care. Institute of Medicine. Washington, DC: The National Academies Press, 1999Google Scholar
  11. 11.
    Warren RC. Preface. In: Centers for Disease Control and Prevention, editors. Use of race and ethnicity in public health surveillance: summary of the CDC/ATSDR workshop. MMWR 1993; 42 (No. RR-10)Google Scholar
  12. 12.
    Bhui K. Racism and mental health, prejudice and suffering. London: Jessica Kingsley Publishers, 2002Google Scholar
  13. 13.
    National Institute for Mental Health in England. Outcome measures for routine practice in mental health services. London: NIMHE, 2002 [online]. Available from URL: [Accessed 2008 Nov 18]Google Scholar
  14. 14.
    UK Department of Health. Delivering race equality in mental health care: an action plan for reform inside and outside services and the Government’s response to the independent inquiry into the death of David Bennett. London: Department of Health, 2005 [online]. Available from URL: [Accessed 2008 Nov 18]Google Scholar
  15. 15.
    UK Department of Health. Improving access to psychological therapies (IAPT) programme: computerised cognitive behavioural therapy (cCBT) implementation guidance. London: Department of Health, 2007 [online]. Available from URL: [Accessed 2008 Nov 18]Google Scholar
  16. 16.
    Janca A, Ustun TB, Sartorius S. New versions of World Health Organization instruments for the assessment of mental disorders. Acta Psychiat Scand 1994; 90 Suppl. 2: 73–83PubMedCrossRefGoogle Scholar
  17. 17.
    Spaniol L. Editorial. Psychosoc Rehabil J 1991; 14 Suppl. 4: 1Google Scholar
  18. 18.
    Deegan PE. Recovery: the lived experience of rehabilitation. Psychosoc Rehabil J 1988; 11 Suppl. 4: 11–9Google Scholar
  19. 19.
    Anthony W. Recovery from mental illness: the new vision of services researchers. Innovations Res 1991; 1: 13–4Google Scholar
  20. 20.
    Anthony W, Rogers ES, Farkas M. Research on evidence-based practices: future directions in an era of recovery. Community Ment Health J 2003; 39 Suppl. 2: 101–14PubMedCrossRefGoogle Scholar
  21. 21.
    Fenton S, Sadiq-Sangster A. Culture, relativism and the expression of mental distress: South Asian women in Britain. Sociol Health Illn 1996; 18 Suppl. 1: 66–85CrossRefGoogle Scholar
  22. 22.
    Blaxter M. Health and lifestyles. London: Routledge, 1990CrossRefGoogle Scholar
  23. 23.
    Kleinman A, Good B. Culture and depression. Los Angeles (CA): University of California Press, 1985Google Scholar
  24. 24.
    Duclos CW, Beals J, Novins DK, et al. Prevalence of common psychiatric disorders among American Indian adolescent detainees. J Am Acad Child Adolesc Psychiatry 1998; 37 Suppl. 8: 866–73PubMedCrossRefGoogle Scholar
  25. 25.
    Marella AJ, Friedman MJ, Gerrity ET, et al., editors. Ethnocultural aspects of posttraumatic stress disorder: issues, research, and clinical applications. Washington, DC: American Psychology Association, 1996Google Scholar
  26. 26.
    Jablensky A, Sartorius N, Ernberg G, et al. Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychol Med Monogr Suppl 1992 Nov; 22 Suppl. 4: 1–97CrossRefGoogle Scholar
  27. 27.
    Cohen A, Patel V, Thara R, et al. Questioning an axiom: better prognosis for schizophrenia in the developing world?. Schizophr Bull 2008; 34: 229–44PubMedCrossRefGoogle Scholar
  28. 28.
    McKenzie K, van Os J, Fahy T, et al. Psychosis with good prognosis in Afro-Caribbean people now living in the United Kingdom. BMJ 1995; 311: 1325–8PubMedCrossRefGoogle Scholar
  29. 29.
    Azuonye IO. Psychosis in Afro-Caribbean people: ‘Afro-Caribbean’ could have been of Chinese, Indian, European, or African extraction. BMJ 1996; 312: 1157–8PubMedCrossRefGoogle Scholar
  30. 30.
    Cochrane R, Stopes Roe M. The mental health of immigrants. New Community 1980; 8(Suppl 1 & 2): 123–8Google Scholar
  31. 31.
    Krause IB. Sinking heart: a Punjabi communication of distress. Soc Sci Med 1989; 29 Suppl. 4: 563–7PubMedCrossRefGoogle Scholar
  32. 32.
    Weiss MG, Sharma SD, Gaur RK, et al. Traditional concepts of mental disorder among Indian psychiatric patients: preliminary report of work in progress. Soc Sci Med 1986; 23 Suppl. 3: 379–86PubMedCrossRefGoogle Scholar
  33. 33.
    Broadbent E, Petrie KJ, Main J, et al. The brief illness perception questionnaire. J Psychosom Res 2006 Jun; 60 Suppl. 6: 631–7PubMedCrossRefGoogle Scholar
  34. 34.
    Bhui K, Riidell K, Priebe S. Assessing explanatory models for common mental disorders. J Clin Psychiatry 2006 Jun; 67 Suppl. 6: 964–71PubMedCrossRefGoogle Scholar
  35. 35.
    Currer C. Concepts of mental well- and ill-being: the case of Pathan mothers in Britain. In: Currer C, Stacey M, editors. Concepts of health, illness and disease: a comparative perspective. Leamington Spa: Berg, 1986Google Scholar
  36. 36.
    Sachs L. Evil eye or bacteria: Turkish migrant women and Swedish health care [dissertation]. Stockholm: University of Sweden, Department of Social Anthropology, 1983Google Scholar
  37. 37.
    Carr JE, Vitaliano PP. The theoretical implications of converging research on depression and the culture-bound syndromes. In: Kleinman A, Good B, editors. Culture and depression. Los Angeles (CA): University of California Press, 1985Google Scholar
  38. 38.
    Bhui K, Craig T, Mohamud S, et al. Mental disorders among Somali refugees: developing culturally appropriate measures and assessing socio-cultural risk factors. Soc Psychiatry Psychiatr Epidemiol 2006 May; 41 Suppl. 5: 400–8PubMedCrossRefGoogle Scholar
  39. 39.
    Incayawar M. Efficacy of Quichua healers as psychiatric diagnosticians. Brit J Psych 2008; 192: 390–1CrossRefGoogle Scholar
  40. 40.
    Bhui K, Bhugra D. Transcultural psychiatry: some social and epidemiological research issues. Int J Soc Psychiatry 2001 Autumn; 47(Suppl. 3): 1–9PubMedCrossRefGoogle Scholar
  41. 41.
    Bhugra D, Bhui K. Cross-cultural psychiatry: a practical guide. London: Arnold, 2001Google Scholar
  42. 42.
    Bhugra D, Bhui K. Textbook of cultural psychiatry. Cambridge: Cambridge University Press, 2007CrossRefGoogle Scholar
  43. 43.
    Ohio Department of Mental Health Office of Program Evaluation and Research. The Ohio mental health consumer outcomes system: procedural manual. Columbus (OH): Ohio Department of Mental Health, 2000Google Scholar
  44. 44.
    Bhui K, Warfa N, Edonya P, et al. Cultural competence in mental health care: a review of model evaluations. BMC Health Serv Res 2007; 7: 15PubMedCrossRefGoogle Scholar
  45. 45.
    Leininger M. Culture care diversity and universality: a theory of nursing. New York: National League for Nursing Press, 1991Google Scholar
  46. 46.
    Locke DC. The Locke paradigm of cross cultural counseling. Int J Adv Couns 1991; 14: 15–25CrossRefGoogle Scholar
  47. 47.
    Locke DC. Increasing multicultural understanding. Newbury Park (CA): Sage, 1992Google Scholar
  48. 48.
    Campinha-Bacote J. The process of cultural competence in the delivery of healthcare services. 3rd ed. Cincinnati (OH): Transcultural C.A.R.E. Associates, 1998Google Scholar
  49. 49.
    Campinha-Bacote J. Cultural competence in psychiatric nursing: have you “ASKED” the right questions?. J Am Psychiatr Nurses Assoc 2002; 8: 183–7CrossRefGoogle Scholar
  50. 50.
    Spector RE. Cultural diversity in health and illness. 5th ed. Upper Saddle River (NJ): Prentice Hall, 2000Google Scholar
  51. 51.
    Spector RE. Cultural diversity in health and illness. J Transcult Nurs 2002; 13 Suppl. 3: 197–9PubMedCrossRefGoogle Scholar
  52. 52.
    Srole L, Langner TS, Michael ST, et al. Mental health in the metropolis: the midtown Manhattan Study. Vol. 1. New York: McGraw-Hill, 1962CrossRefGoogle Scholar
  53. 53.
    Leighton DC, Harding JS, Macklin DB, et al. The character of danger: stifling county study. Vol. 3. New York: Basic, 1963Google Scholar
  54. 54.
    Manson SM, Shore JH, Bloom JD. The depressive experience in American Indian communities. In: Kleinman A, Good B, editors. Culture and depression. Berkeley (CA): University of California Press, 1985: 331–68Google Scholar
  55. 55.
    Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Pscyhol Measure 1977; 1: 385–401CrossRefGoogle Scholar
  56. 56.
    Kolody B, Vega W, Meinhardt K, et al. The correspondence of health complaints and depressive symptoms among Mexican Americans and Anglos. J Nervous Mental Dis 1986; 174: 221–8CrossRefGoogle Scholar
  57. 57.
    Kleinman A. Social origins of distress and disease: depression, neurasthenia, and pain in modern china. New Haven (CT): Yale University Press, 1986Google Scholar
  58. 58.
    Vega WA, Rumbaut RG. Ethnic minorities and mental health. Annu Rev Sociol 1991; 17: 351–83CrossRefGoogle Scholar
  59. 59.
    Robins LN, Heizer JE, Croughan J, et al. National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and validity. Arch Gen Psych 1981; 38: 381–9CrossRefGoogle Scholar
  60. 60.
    Lewis G, Pelosi AG, Araya R, et al. Measuring psychiatric disorder in the community: a standardized assessment for use by lay interviewers. Psychol Med 1992 May 22; (2): 465–86CrossRefGoogle Scholar
  61. 61.
    Bhui K, Bhugra D, Goldberg D, et al. Assessing the prevalence of depression in Punjabi and English primary care attenders: the role of culture, physical illness and somatic symptoms. Transcult Psychiatry 2004 Sep; 41 Suppl. 3: 307–22PubMedCrossRefGoogle Scholar
  62. 62.
    Bhui K, Stansfeld S, Hull S, et al. Ethnic variations in pathways to and use of specialist mental health services in the UK: systematic review. Br J Psychiatry 2003 Feb; 182: 105–16PubMedCrossRefGoogle Scholar
  63. 63.
    Bhui K, Bhugra D. Explanatory models in psychiatry [letter]. Br J Psychiatry 2003 Aug; 183: 170PubMedCrossRefGoogle Scholar
  64. 64.
    Bhui K, Mohamud S, Warfa N, et al. Cultural adaptation of mental health measures: improving the quality of clinical practice and research. Br J Psychiatry 2003 Sep; 183: 184–6PubMedCrossRefGoogle Scholar
  65. 65.
    Wing JK, Lelliott P, Beevor AS. Progress on HoNOS. Br J Psychiatry 2000; 176: 392–3CrossRefGoogle Scholar
  66. 66.
    Wing JK, Beevor AS, Curtis RH, et al. Health of the Nation Outcome Scales (HoNOS): research and development. Br J Psychiatry 1998; 172: 11–8PubMedCrossRefGoogle Scholar
  67. 67.
    Gowers SG, Harrington RC, Whitton A, et al. Brief scale for measuring the outcomes of emotional and behavioural disorders in children: Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). Br J Psychiatry 1999; 174: 413–6PubMedCrossRefGoogle Scholar
  68. 68.
    Gowers S, Bailey-Rogers SJ, Shore A, et al. The Health of the Nation Outcome Scales for Child and Adolescent Mental Health (HoNOSCA). Child Psychol Psychiatr Rev 2000; 5: 50–6CrossRefGoogle Scholar
  69. 69.
    Burns A, Beevor A, Lelliott P, et al. Health of the Nation Outcome Scales for Elderly People (HoNOS65+). Br J Psychiatry 1999; 174: 424–7PubMedCrossRefGoogle Scholar
  70. 70.
    Pirkis J, Burgess P, Coombs T, et al. Routine measurement of outcomes in Australian public sector mental health services. Aust New Zealand Health Policy 2005; 2: 8PubMedCrossRefGoogle Scholar
  71. 71.
    Pirkis JE, Burgess PM, Kirk PK. A review of the psychometric properties of the Health of the Nation Outcome Scales (HoNOS) family of measures. Health Qual Life Outcomes 2005; 3: 76PubMedCrossRefGoogle Scholar
  72. 72.
    Shergill SS, Shankar KK, Seneviratna K, et al. The validity and reliability of the Health of the Nation Outcome Scales (HoNOS) in the elderly. J Ment Health (UK) 1999; 8: 511–21CrossRefGoogle Scholar
  73. 73.
    Orrell M, Yard P, Handysides J, et al. Validity and reliability of the Health of the Nation Outcome Scales in psychiatric patients in the community. Br J Psychiatry 1999; 174: 409–12PubMedCrossRefGoogle Scholar
  74. 74.
    Isaac M, Chand P, Murthy P. Schizophrenia outcome measures in the wider international community. Br J Psychiatry 2007; 191 Suppl. 50: s71–7CrossRefGoogle Scholar
  75. 75.
    Kulhara P, Chakrabarti S. Culture and schizophrenia and other psychotic disorders. Psychiat Clin N Am 2001; 24: 449–64CrossRefGoogle Scholar
  76. 76.
    WHO. World Health Organization Disability Assessment Schedule II (WHODAS II). Geneva: WHO, 2000Google Scholar
  77. 77.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. Washington, DC: APA, 1987Google Scholar
  78. 78.
    Saraswat N, Rao K, Subbakrishna DK, et al. The Social Occupational Functioning Scale (SOFS): a brief measure of functional status in persons with schizophrenia. Schizophr Res 2006; 81: 301–9PubMedCrossRefGoogle Scholar
  79. 79.
    Bhui K, Bhugra D, Goldberg D. Cross-cultural validity of the Amritsar Depression Inventory and the General Health Questionnaire amongst English and Punjabi primary care attenders. Soc Psychiatry Psychiatr Epidemiol 2000 Jun; 35 Suppl. 6: 248–54PubMedCrossRefGoogle Scholar
  80. 80.
    Bhui K, Bhugra D, Goldberg D, et al. Cultural influences on the prevalence of common mental disorder, general practitioners’ assessments and help-seeking among Punjabi and English people visiting their general practitioner. Psychol Med 2001 Jul; 31 Suppl. 5: 815–25PubMedGoogle Scholar
  81. 81.
    Bhui K. Over-representation of Black people in secure psychiatric facilities [letter]. Br J Psychiatry 2001 Jun; 178: 575PubMedCrossRefGoogle Scholar
  82. 82.
    Fitzpatrick R, Davey C, Buxton MJ, et al. Evaluating patient-based outcome measures for use in clinical trials. Health Technol Asses 1998; 2 Suppl. 14: 1–74Google Scholar
  83. 83.
    Patel V, Musara T, Butau T, et al. Concepts of mental illness and medical pluralism in Harare. Psychol Med 1995 May; 25 Suppl. 3: 485–94PubMedCrossRefGoogle Scholar
  84. 84.
    Bullinger M, Alonso J, Apolone G, et al. Translating health status questionnaires and evaluating their quality: the IQOLA Project approach. J Clin Epidemiol 1998; 51 Suppl. 11: 913–23PubMedCrossRefGoogle Scholar
  85. 85.
    Leplege A, Verdier A. The adaptation of health status measures: methodological aspects of the translation procedure. In: Shumaker S, Berzon R, editors. The international assessment of health-related quality of life: theory, translation, measurement and analysis. Oxford: Rapid Communications of Oxford, 1995: 93–101Google Scholar
  86. 86.
    Hunt SM. Cross-cultural issues in the use of quality of life measures in randomised controlled trials. In: Staquet M, Hays R, Fayers P, editors. Quality of life assessment in clinical trials. Oxford: Oxford University Press, 1998: 51–68Google Scholar
  87. 87.
    Collinge A, Rudell K, Bhui K. Quality of life assessment in non-Western cultures. Int Rev of Psychiatr 2002; 14 Suppl. 3: 212–8CrossRefGoogle Scholar
  88. 88.
    WHOQOL Group. The World Health Organization quality of life assessment (WHOQOL): development and general psychometric properties. Soc Sci Med 1998; 46: 1569–86CrossRefGoogle Scholar
  89. 89.
    Marsella AJ, Sartorius N, Jablensky A, et al. Culture and depressive disorders. In: Kleinman A, Good B, editors. Culture and depression. Berkeley (CA): University of California Press, 1986: 299–324Google Scholar
  90. 90.
    Bhui K, Dinos S, Khoshaba B. Outcomes compendium: helping you select the right tools for best mental health care practice in your field [report to the Department of Health]. London: Department of Health. In pressGoogle Scholar

Copyright information

© Adis Data Information BV 2008

Authors and Affiliations

  1. 1.Centre for Psychiatry, Barts and the London School of Medicine and DentistryQueen Mary University of LondonLondonUK

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