1. Cultural Competence: Building Up a
Knowledge Base of Cultural
Observations in Medicine
Dr. Riccardo Colasanti
colasanti@rieloinstitute.org
Rielo Institute for Integral Development

2. Why a Knowledge Base on
Medical Anthropology?

3. Cultural differences

5. Zuo-yuezi in China (Doing the month)
1. Do not wash yourself and do not wash your hair for the entire month
2. Do not go outside for the entire month
3. Do not eat any raw and any “cold” food
4. Eat chicken
5. Do not be blown on by the wind
6. Do not walk and move around
7. Do not go to other person’s home
8. Do not get sick during the month
9. Do not read or cry
10. Do not have sexual intercourse during the month
11. Do not eat at the table with the rest of the family
12. Do not burn incense
Soc Sci Med. 1978 Jan;12(1B):11-22. "Doing the month": confinement and convalescence of Chinese women
after childbirth. Pillsbury BL.

6. What about “Doing the month” in a
migration process?

9. Sudden Unexpected Nocturnal Death
Syndrome (SUNDS)
Sudden Unexpected Nocturnal Death Syndrome (SUNDS) is a syndrome with
different names in Japan (Pokkury) in northeast Thailand (Tai lai) and
'Bangungut in Tagalog reported in young healthy asiatic males. The syndrome
consists in an unxepected nocturnal death. The survivors tell they felt a big
sense of chest oppression, paralysis, nightmares. The syndrome is reported
even in southAsia Males (Hmong) who migrated in USA and in Bangladesh
workers living abroad.
In Japan pokkury it is also related to Pokkury Dera that are Buddhist temple
where people pray to receive a sudden death without passing through the
pain and trouble of a long disease. An example of Pokkuri Dera is Kichidenji
Temple[1] in Ikaruga. It seems that pokkuri in Japanese culture it is related to
a good and peaceful death.
Reference:
Sudden Unexpected Nocturnal Death Syndrome among Hmong Immigrants: Examining the Role of the "Nightmare" Shelley R. Adler The Journal of American Folklore Vol. 104, No. 411 (Winter,
1991) (pp. 54-71) [2]
Is sudden unexplained nocturnal death a breathing disorder?
Psychiatry Clin Neurosci. 1995 May;49(2):111-4. Tanchaiswad W. Department of Psychiatry, Faculty of Medicine, Prince of Songkla University, Songkla, Thailand. [3]
Pokkuri Death Syndrome; sudden cardiac death cases without coronary atherosclerosis in South Asian young males. Forensic Sci Int. 2010 Nov 15.
Department of Legal Medicine (Forensic Medicine), Keio University School of Medicine, Shinanomachi 35, Shinjuku-ku, Tokyo 160-8582, Japan; Takeichi Medical Research Laboratory, 4-8-8,
Shiroyama, Odawara, Kanagawa, Japan; School of Health Sciences, Faculty of Medicine, Gunma University, 3-39-22 Showa-machi, Maebashi, Gunma 371-8511, Japan.
• [4]
•
• Sudden unexpected nocturnal deaths among Thai immigrant workers in Singapore. The possible role of toxigenic bacteria. Int J Legal Med. 1994;106(4):205-8. Blackwell CC, Busuttil A
• Weir DM, Saadi AT, Essery SD.
• [5]
• Cloud, or silver linings? - Japan's changing demography; Japan's changing demography The Economist. London: Jul 28, 2007. Vol. 384, Iss. 8539; pg. 27

10. Linguistic
differences

11. ஈரல் : irel The lungs, liver, spleen, and
other viscera
இரத்தக்க
விச்சு,
(irattacavicciù)
Tamil terms related to health :
Offensive smell of blood.

12. Foot/Leg Diversity in language
Arabic Bangla
-desh
Turki
sh
Persian Tami
l
Malayal
am
Pasht
o
Sinhala Manda-
rine
Foot Riğl
Qada
m
Pā Ayak Pā Kal
(mor
e
com
mon
)
Pada
m
Kal Kh-pā Kakula Jiao
Leg Riğl,
Sāq
Pā Bacak
(Ayak)
Pā
Sāq-e pā
(parte
inferiore,
dal
tallone in
sù)
Kal Kal Kh-pā Kakula
Gaataya
Tui
(De Blasio, Colasanti 2009)

13. Foot-Leg
Romanian Moldovan Lingala
Congo
Bandund
u
Pular
Guinea
Ewe
Togo
Amharic
Ethiopia
Foot Picior Picior,
Talpà
Likolo Thépéré Afo Egher
Leg Picior Picior Likolo Coȉghal Ata Egher
(De Blasio, Colasanti 2009)

14. Two Areas in the doctor-patient
relationship
• Tech
• Objectivity
• Science
Clinical
• Emotional
• Communication
• Cultural
Non
Clinical

15. four competences:
1.Communicative competence
2.Cultural competence
3.Clinical competence
4.Psychological competence

16. Cultural Competence
Doctor-Patient Communication, Cultural Competence, and Minority Health:
Theoretical and Empirical Perspectives
Perloff, Richard M; Bonder, Bette; Ray, George B; Eileen Berlin Ray; Siminoff,
Laura A. The American Behavioral Scientist49. 6 (Feb 2006): 835-852.

17. What is cultural competence?
There are many definitions
1. Betancourt et al. 2002 Cultural competence
in health care describes the ability of systems to
provide care to patients with diverse values,
beliefs and behaviors, including tailoring
delivery to meet patients’ social, cultural, and
linguistic needs.
Betancourt, J., Green, A. & Carrillo, E. (2002). Cultural competence in health care:
Emerging frameworks and practical approaches. The Commonwealth Fund.

18. Culture and Health
• The difficulty to harness the concept of
cultural competence depende on the fact that
culture is a shared knowledge. For example
language is shared.
• It means that is meaning of concepts shared in
a group that trought the time tende to separe
in the syncronyc drift from the other

19. The culture of Official Medicne
• Even with a well documented cultural
differences in the medical institutions in
different country we can say that that is a
shared encyclopedia of causes, goals, ideas,
meanings.

20. On the patient’s side
• There is:
• 1. A partly shared knowledge of the official
medicine (He is a doctor)
• 2. A partly shared knowledge of the traditional
medicine of the group to whom the patient
belongs (He is not a traditional healer)
• 3. A non shared knwoledge of the private health
experience and of the language to use (he doesn
not know what happening to him and how to
explain)

21. Sharing Culture in Health
Doctor
Shared
Partly shared
Non shared
Partly shared
Partly shared
Patient
What he
feels
Traditional
ideas
Official
Medicine
What he
studied
Cultural
localizati
on

22. Shared Culture in Health for the
patient
• Associations of Patients
• Patient Communities
– (http://www.patientslikeme.com/
• 122,124 patients 1000+ conditions )
– http://www.dailystrength.org/

23. Some issues:
1. Synchronic Variation
– Culture of a group is not well defined (who are the
italians? Sicilians napolitans, Romans
2. Health Culture is partly shared
3. Diachronic Cultural Drift
– (are Italians of ‘90 like italian of 2000?)
4. Reciprocal Bias
5. Cultural/non cultural swap
6. Cultural counterswap
7. Underestimation of culture
8. Multicultural influxes

24. Cultural competency. Two
approches
• 1. Trait Oriented (which are the health custom
of Italians?)
• 2. Skill Oriented (what is my sensitivity to
difference?)
• We need both of them

25. The Elusive Concept of Cultural
Competence.
• Examined agreement statistics (kappas) to assess the extent to which 2
groups of experts (those nominated by important peer scholars as having
expertise in cultural competence and therapists with extensive experience
and training in working with African Americans) agreed on the specific
composition of constructs related to cultural competence. Using items
from existing psychotherapy process measures, peer-nominated experts
indicated whether each item was relevant to the construct of cultural
competence. Therapists with expertise in treating African Americans
indicated whether an item fit the same cultural competence categories
generated through expert consensus. Peer nominated experts and
therapist experts showed poor agreement (kappas) in their classification
of which items were relevant to cultural competence. Despite poor overall
agreement, however, the groups concurred that a small subset of items
were relevant to culturally competent practice with African Americans.
These results indicate the need for improved operationalization of the
construct of cultural competence
Cunningham P, Foster S, Henggeler S.
Children's Services: Social Policy, Research & Practice [serial online]. July 2002;5(3):231-243. Available from: Academic Search Premier, Ipswich, MA. Accessed December 13,
201

26. Cultural competence + Linguistic
Competence are an important part of
Communication in MEDICINE
Cultural
Misunderstanding
Lack of Linguistic
Competence
Empathy
Poor
Comprehension

27. Reciprocal Comprehension in
the doctor-patient relationship
• According Van Wieregen et al. (2002) in
medical consultation in general practice
mutual understanding was poor in 33% of
consultations with ethnic-minority patient
versus 13% with native-born patient
Eur J Public Health. 2002 Mar;12(1):63-8.
Intercultural communication in general practice.
Van Wieringen JC, Harmsen JA, Bruijnzeels MA.

28. Outcomes of poor comprehension in
medicine
• The lack of comprehension may imply,
medical misdiagnosis (false positive or
false negative), erroneous prescriptions,
a possible death toll

29. To improve medical comprehension
We need to know:
• Cultural medical models of the patient
• His cultural expectative
• How he/she communicates with linguistical
and not-linguistical skills his/her problems
• How the doctor can communicate to her/him

30. The medical incomprehension
is a multilayer issue:
• Pre-linguistic
• Linguistic
• Cultural (Different Customs in Food,
Habits etc)
• Philosophical and Religious
(Explanatory Model of Health and
Disease, Existential meaning of Life
and Disease )

31. Patient
Sickness
Doctor
Intercultural communication is very complex
objectifying
objectif
ying subjectifying

32. Some tipical issue in Crosscultural
Communication in Medicine
• Gesture Ambiguity (ex.: nodding and shaking head)
• Lack of grammatical precision
• Hyperbolic use of deictical terms (ex. that, this) that hides the meaning in case of
lack of context
• Lexical Differences (Ethnoanatomy)
• False Friends in the Vocabulary
• The Rethorical use of Medical Language
• Differences in Conceptual Schemas (Frames di Minsky)
• Difference in the medical encyclopedia
• Difference in Health Customs
• Difference in Symbolic Values
• Difference in philosophical and religious values

33. It is really necessary to constitute a
knowledge base of alle the medical
observations related to cultural and
linguistically topics in all the culture ion
the world

34. Basic Problem: Huge Dimension of the
Data Base
• To determine the dimension (excluding the
Migration cultural Drift).
• Number of Languages & Dialects x Social
Stratification x Grade Education
• If we speaks in term of d
• Languages

35. How many cultures in the world?
I we the number of cultural groups is proportional
to the number of linguistic differences:
In the World 2011 Languages Dialects Difference in
Grammar
According to
Ethnologue
(http://www.ethnologue.com/)
6,909 11,779
According Stephen
Anderson
~109
Secondo World
Christian Database
http://www.worldchristiandatabase.o
rg
33,000

36. Peoples Defined By Resulting List Examples Totals
Language Linguistic peoples  Ethnologue ~7,000
Language / Dialect Linguistic peoples
(Particularly supports
language based
ministry)
 ROPAL (Registry of Peoples and Lang) ~11,000
Language / Dialect
Ethnicity
Ethno-linguistic peoples
(Particularly supports
language based
evangelistic /
discipleship
outreaches)
 Integrated Strategic Planning Database
 World Christian Encyclopedia
 Operation World peoples lists
 Original Joshua Project list
 PeopleGroups.org
~ 13,000
Language / Dialect
Ethnicity
Religion
Caste
Culture
Ethnic peoples
(Particularly supports
church planting
outreaches)
 Joshua Project
 Registry of Peoples (ROP)
~ 16,600
Language / Dialect
Ethnicity
Religion
Caste
Culture
Education
Politics
Ideology
Historical enmity
Customs
Behavior
Unimax peoples
(Particularly supports
church planting and all
types of evangelistic /
discipleship
outreaches)
 World Christian Encyclopedia estimates
 US Center for World Mission estimates
~ 27,000
Modificato da http://www.joshuaproject.net/how-many-people-groups.php

38. The Knowledge Base has to be
• Broad
• Up-to-date
• Scientific
• But open to Social Network of Healthcare
Professionals

39. 2. Cultural Data Collection
• From the scientific literature peer
reviewed
– Medical (Medline)
– Non Medical
• From the social Network of Health Care
Professional

40. 3 Structural Blocks of the Knowledge
Base
Taxonomy
• Taxonomy
• Ontology/based
Data
• Cultural and
Antropologicsl
Data
• From scientific
literature
(Medical and
non medical)
• From Social
Network
IT
• Data Base
• Social Network
1 2 3

41. 3. IT database
• A data base to be consulted via web
• Interface user friendly
• A IT Social Network platform

42. 1. Taxonomy Ontology Based
• Define the taxonomical tree in Medical
Anthropology and in Transcultural Medicine

43. SEMANtic Web
• 22 million of web pages in November 2011

44. Semantic Web: adding meta data
• Machine cannot understand the meanng of
documents in the web
• “One possible solution is to modify the web
documents, and one such modification is to add
some extra data to these documents; the purpose
of this extra information is to enable the
computers to understand the meaning of these
documents”
Yu, L. (2007). Introduction to the
Semantic Web and Semantic Web
services. Boca Raton, FL: CRC
Press.
Metadata Data

53. PUBMED: 21 million citations
PubMed comprises more
than 21 million citations
for biomedical literature
from MEDLINE, life
science journals, and
online books. Citations
may include links to full-
text content from
PubMed Central and
publisher web sites.

54. MESH (Medical Subject Headings)

55. MESH (Vocabulary of Medline)
• The MeSH Tree Structure
• MeSH vocabulary is organized by 16 main branches:
• Anatomy
• Organisms
• Diseases
• Chemical and Drugs
• Analytical, Diagnostic and Therapeutic Techniques and Equipment
• Psychiatry and Psychology
• Biological Sciences
• Natural Sciences
• Anthropology, Education, Sociology and Social Phenomena
• Technology, Industry, Agriculture
• Humanities
• Information Science
• Named Groups
• Health Care
• Publication Characteristics
• Geographic Locations

57. Mesh: Geographic Locations
lack of detailes!
• All MeSH Categories
• Geographical Locations Category
• Geographic Locations
• Africa
• Africa South of the Sahara
• Africa, Central
• Cameroon
• Central African Republic
• Chad
• Congo
• Democratic Republic of the Congo
• Equatorial Guinea
• Gabon

62. Journal not
indexed by
PUBMED
1° Problem:
PUBMED
does not know the
article
Journal
indexed by
EBSCO

63. While this other article it is indexed in PUBMED

64. The autors

65. 2. This article is coherent with
our search: cultural
competency but it is not
indexed in Pubmed

66. The authors define circassian as:
“Adyge Peolple”

68. Where are living Adyghe
people?Joshua Project - Adyghe Ethnic People in all Countries. (S.d.). Recuperato
Dicembre 2, 2011, da http://www.joshuaproject.net/peoples.php?peo3=10161

69. How many they are?
Country Population
Bulgaria 520
Egypt 11,500
Iraq 30,600
Israel 6,760
Kazakhstan 140
Russia 120,000
Serbia 2360
Syria 30,900
Turkey 308,000
Ukraine 620
United States 3,310
Uzbekistan 300
West Bank / Gaza 3,640Joshua Project - Adyghe Ethnic People in all Countries. (S.d.). Recuperato
Dicembre 2, 2011, da
http://www.joshuaproject.net/peoples.php?peo3=10161

70. What is their name?
Wikipedia Yafa Haron
article
Joshua
Project
Adyghe y y
Cherkess y
Adygs y
Circassia
n
y
Adyge y

71. If we consult Ethnologue

72. To fix these Problem

73. Ontologies and Taxonomies
• Ontologies are the evolution of the concept of
metadata
• XML -> RDF -> OWL

74. What is an ontology?
• A metadata that is consistently logical
connected to other metadata permitting di
realize inferences

75. Ontology (information science)
From Wikipedia, the free encyclopedia
• In computer science and information science, an ontology formally
represents knowledge as a set of concepts within a domain, and the
relationships between those concepts. It can be used to reason
about the entities within that domain and may be used to describe
the domain.
• In theory, an ontology is a "formal, explicit specification of a shared
conceptualisation".[1] An ontology renders shared vocabulary and
taxonomy which models a domain with the definition of objects
and/or concepts and their properties and relations.[2]
• Ontologies are the structural frameworks for organizing information
and are used in artificial intelligence, the Semantic Web, systems
engineering, software engineering, biomedical informatics, library
science, enterprise bookmarking, and information architecture as a
form of knowledge representation about the world or some part of
it. The creation of domain ontologies is also fundamental to the
definition and use of an enterprise architecture framework.

76. An Ontology Editor
• Protégé v. 4.1 (Stanford)

78. A simple Ontology

79. • <?xml version="1.0"?>
• <!DOCTYPE Ontology [
• <!ENTITY xsd "http://www.w3.org/2001/XMLSchema#" >
• <!ENTITY xml "http://www.w3.org/XML/1998/namespace" >
• <!ENTITY rdfs "http://www.w3.org/2000/01/rdf-schema#" >
• <!ENTITY rdf "http://www.w3.org/1999/02/22-rdf-syntax-ns#" >
• ]>
• <Ontology xmlns="http://www.w3.org/2002/07/owl#"
• xml:base="http://www.semanticweb.org/ontologies/2011/11/6/OntologyDivinaCommedia.owl"
• xmlns:rdfs="http://www.w3.org/2000/01/rdf-schema#"
• xmlns:xsd="http://www.w3.org/2001/XMLSchema#"
• xmlns:rdf="http://www.w3.org/1999/02/22-rdf-syntax-ns#"
• xmlns:xml="http://www.w3.org/XML/1998/namespace"
• ontologyIRI="http://www.semanticweb.org/ontologies/2011/11/6/OntologyDivinaCommedia.owl">
• <Prefix name="xsd" IRI="http://www.w3.org/2001/XMLSchema#"/>
• <Prefix name="owl" IRI="http://www.w3.org/2002/07/owl#"/>
• <Prefix name="" IRI="http://www.semanticweb.org/ontologies/2011/11/6/OntologyDivinaCommedia.owl#"/>
• <Prefix name="rdf" IRI="http://www.w3.org/1999/02/22-rdf-syntax-ns#"/>
• <Prefix name="OntologyDivinaCommedia" IRI="http://www.semanticweb.org/ontologies/2011/11/6/OntologyDivinaCommedia.owl#"/>
• <Prefix name="rdfs" IRI="http://www.w3.org/2000/01/rdf-schema#"/>
• <Declaration>
• <Class IRI="#Authors"/>
• </Declaration>
• <Declaration>
• <Class IRI="#Country"/>
• </Declaration>
• <Declaration>
• <Class IRI="#France"/>
• </Declaration>
• <Declaration>
• <Class IRI="#Germany"/>
• </Declaration>
• <Declaration>
• <Class IRI="#Human_Beings"/>
• </Declaration>
• <Declaration>
• <Class IRI="#Italy"/>
• </Declaration>
• <Declaration>
• <Class IRI="#Popes"/>
• </Declaration>
• <Declaration>
• <Class IRI="#Synonims"/>
• </Declaration>
• <Declaration>
• <Class IRI="#Usa"/>

80. • Using a First Order Logic I can do inferences
• The Ontological Tree gives a meaningful
contextual framework to every data
• A Semantic Search Engine can “Understand “
what we are looking for

81. Basic Elementes of Ontologies are
Classes
Properties
Objects
That we will see in action in Protege

82. Annotating

83. A possible Workflow