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© 2003 American Public Health Association
LETTER |
Lonnie R. Snowden, PhD, Center for Mental Health Services Research, 120 Haviland Hall, University of California, Berkeley, 94720-7400 (e-mail: snowden{at}uclink4.berkeley.edu).
Cabassa highlights the importance of cultural factors, including culture-based differences in the expression of distress, in a comprehensive account of racial and ethnic disparities in mental health. Indeed, because "culture counts,"1 I have published studies investigating the African American idiom of distress2,3 and investigating the cross-cultural validity of a widely used assessment instrument, the BASIS-32.4 Helpfully, Cabassa cites key references that provide excellent reviews of work in the area and give strong conceptual guidance.
I would also call attention to a promising approach that remains largely unexploited, that of applying to cross-cultural analysis theories and methods for understanding cognitive processes underlying interview and questionnaire responses (e.g., Warnecke et al. 5). With Martha Shumway of the University of California, San Francisco, I have begun to pursue such an approach.
Owing to space limitations, I was unable in my February article to fully consider the many factors that are likely to contribute to disparities. Thus, much more remains to be said, not only about culture, but also about the design of mental health programs, treatment financing, and many other barriers to care. My focus was on bias. I mentioned decisionmakers who might exhibit bias and decision points where it might occur, and, by touching on a wide range of possible explanations for disparities to which bias contributes, I intended to frame bias in a larger explanatory context.
References
1. Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services; 2001.
2. Heurtin-Roberts S, Snowden L, Miller L. Expressions of anxiety in African Americans: ethnography and the epidemiological catchment area studies. Cult Med Psychiatry.1997;21:337–363.[Web of Science][Medline]
3. Snowden LR. African American folk idiom and mental health service use. Cultural Diversity Ethn Minority Psychol.1999;5:364–370.
4. Chow J, Snowden LR, McConnell W. A confirmatory factor analysis of the BASIS-32 in racial and ethnic samples. J Behav Health Serv Res.2001;28:400–411.[Web of Science][Medline]
5. Warnecke RB, Johnson TP, Chavez N, et al. Improving question wording in surveys of culturally diverse populations. Ann Epidemiol.1997;7:334–342.[Web of Science][Medline]
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