How is culture relevant to digital mental health?
Healthcare across the globe is going through a monumental transformation, driven by the growth in digital health. One of the major benefits of these new technologies is the ability to reach people that do not otherwise have access to healthcare services, such as many in low- and middle-income countries (LMICs) (Wellcome 2020).
However, the expansion of any new technology into countries with diverse cultural backgrounds raises a number of important considerations. A one-size-fits-all approach clearly will not work. Culturally-specific designs of new technologies are needed to get people engaged, and for these applications to be effective. This is especially relevant in terms of mental health, as culture can be crucial in shaping people’s beliefs and therefore could dictate how experiences of mental illness and wellbeing are seen (Euromed Info, 2020).
“When your spirit leaves your body, you better start looking around for a Ngangkari (Aboriginal Australian traditional healers).”
In many Aboriginal, Indigenous (Nieuwsma et al. 2011) and Native communities (Beghtol 1988), physical and mental disorders are still identified as having a spiritual cause.
Several years ago, when I was working in a hospital in north London, I vividly remember sitting in on a psychiatric assessment in which the patient described how they were possessed by a spirit, and that the spirit was speaking to them and guiding their decisions. I was amazed at the psychiatrist’s empathy and consideration for the patient’s specific cultural background, which he integrated into their therapy. Some research has confirmed the beneficial effects of traditional spiritually-based and alternative medicines (National Center for Complementary and Integrative Health 2020), but even if not, placebo effects are well-known (Dockrill 2015) to be very powerful, and are driven by belief alone.
(Jessica Dere, Challenges and Rewards of a culturally-informed approach to mental health, TEDxUTSC) Beliefs about the causes (Kleinman et al. 1978) of mental illness are clearly very important with any therapeutic tool, but beliefs around stigma (Abdullah et al. 2011), prejudice (Carpenter-Song et al. 2010) and pride can also dictate how effective an intervention is. A lack of acceptance (Mizock et al. 2016) of mental illness in some cultures can lead to social isolation and poor support, and further intensifying suffering. Trust of new technology also varies across different cultures and backgrounds. Older generations, for example may be less familiar and more skeptical of new digital tools (Wakefield 2015). Gender hierarchies also play a pivotal role in access to technology in certain cultures (Teach Mideast 2019).
There are even culturally specific syndromes that depend completely on the socio-cultural background, such as koro (Mattelaer et al. 2007) in China, Dhat syndrome (A. Sumathipala)( in India and hikikomori (Aljazeera 2004) in Japan. Above I mention only a few of the cultural concerns that could determine how much digital mental health interventions are able to make an impact on people’s lives, but there are many more.
There is already a lot (US Department of Health and Human Services 2007) of guidance (National Institute of Health 2017) out there about learning how to take a culturally-informed approach (Euromed Info 2020) to healthcare. There is even an academic discipline in its own right that studies the relevance of culture in medical practice, namely medical anthropology (Society for Medical Anthropology 2017 ). Looking ahead, it is crucial that the pioneers of new digital mental health technologies take these issues into consideration if they want their products to be effective.
Elliot C. Brown, Ph.D.
Young Leaders for Health
Abdullah, T., Brown, T.,2011. Mental illness stigma and ethnocultural beliefs, values, and norms: An integrative review.Clinical Psychology Review.31(6),pp.934-948.
Aljazeera, 2004. "Hikikomori" is not a word that crops up too often in polite society in Japan.30th May. Japan's secret epidemic.[Online].[19 May 2020].Available from: https://www.aljazeera.com/archive/2004/05/200849143357899418.html
Sumathipala, A., Siribaddana, S., Bhugra, D., 2004. Culture-bound syndromes: The story of dhat syndrome. The British Journal of Psychiatry,184:200-209.
Beghtol , M.J.,1988. HMONG REFUGEES AND THE US HEALTH SYSTEM.March .Cultural Survival Quarterly Magazine.[Online].[19 May 2020].Available from: https://www.culturalsurvival.org/publications/cultural-survival-quarterly/hmong-refugees-and-us-health-system
Carpenter-Song, E. et al., 2010. ‘Ethno-Cultural Variations in the Experience and Meaning of Mental Illness and Treatment: Implications for Access and Utilization’, Transcultural Psychiatry, 47(2), pp. 224–251. doi: 10.1177/1363461510368906.
Dockrill, P., 2015.T he ‘Placebo Effect’ Is Getting Even Stronger With Time, Study Finds.8th October.Science Alert.[Online].[19 May 2020].Available from: https://www.sciencealert.com/the-placebo-effect-is-somehow-getting-even-better-at-fooling-patients-study-finds
Euromed Info, 2020. Doing a cultural assessment.[Online].[19 May 2020].Available from: https://www.euromedinfo.eu/doing-a-cultural-assessment.html/
Euromed Info, 2020. How culture influences health beliefs.[Online].[19 May 2020].Available from: https://www.euromedinfo.eu/how-culture-influences-health-beliefs.html/
Kleinman, A., Eisenberg, L., Good, B.,1978. Culture, illness, and care: clinical lessons from anthropological and cross-cultural research. Ann Intern Med, 88:251–88.
Mattelaer, JJ., Jilek, W., 2007. Koro—The psychological disappearance of the penis. J Sex Me, 4:1509–1515
Mizock, L., Russinova, Z., 2016. Acceptance of Mental Illness, England: Oxford.
National Center for Complementary and Integrative Health, 2020. Know the Science.[Online].[19 May 2020].Available from: https://www.nccih.nih.gov/
National Institute of Health,2017. Clear Communication - Cultural Respect.[Online].[19 May 2020].Available from: https://www.nih.gov/institutes-nih/nih-office-director/office-communications-public-liaison/clear-communication/cultural-respect
Nieuwsma et al., 2011. Indigenous perspectives on depression in rural regions of India and the United States.SAGE Journals.48(5),pp.539-568.
US Department of Health and Human Services, 2007.Outreach activities and resources. Multi-Cultural Resources for Health Information.[Online].[19 May 2020].Available from: https://sis.nlm.nih.gov/outreach/multicultural.html
Society for Medical Anthropology, 2017 .What is Medical Anthropology?.[Online].[19 May 2020].Available from: http://www.medanthro.net/about/about-medical-anthropology/
Teach Mideast, 2019. Introduction to Women and Gender Roles in the Middle East.[Online].[19 May 2020].Available from: http://teachmideast.org/articles/introduction-women-gender-roles-middle-east/
Wakefield, J., 2015. The generation that tech forgot.[Online].[19 May 2020].Available from: https://www.bbc.com/news/technology-32511489
Wellcome, 2020. Low- and middle-income countries.[Online].[19 May 2020].Available from: https://wellcome.ac.uk/funding/guidance/low-and-middle-income-countries