Detecting cross-cultural differences in somatization.

N umerous studies indicate cross-cultural differences in the symptom reporting in a variety of domains, including menopausal symptoms, somatic symptoms, sexual functioning, and mental health. These differences may occur for multiple reasons. First, cross-cultural differences in symptom reporting may reflect differences in biologic factors, such as environment or region, lifestyle behaviors, and physiology, which are themselves linked to symptom occurrence. For example, vasomotor symptom frequency may vary cross-culturally because of regional temperature differences, variations in endogenous estrogen concentrations, or lifestyle behaviors such as body composition, smoking, diet, and physical activity. Second, even when symptoms occur, there may be cultural differences in perception and subsequent reporting of these symptoms. As summarized in Warnecke et al, symptom reporting entails multiple steps, any of which may be influenced by culture: (1) interpretation of the question; (2) retrieval of the relevant information from memory, which can be affected by factors such as attitudes toward the topic; (3) forming a judgment about the recalled information to respond, which is influenced in part by the topic’s saliency; and (4) response editing, which may reflect conversational norms or perceptions of social acceptability. Using vasomotor symptoms (VMS) as an illustration, the interpretation of a survey question may differ by culture (eg, if completeness of ascertainment varies); for example, Mexican Americans have been found to use multiple terms for VMS; thus, the use of a single term may underestimate VMS occurrence. Furthermore, attitudes toward menopause differ by culture, with more negative attitudes among European and European American women; as a result, VMS may be more memorable and thus more likely to be recalled. Finally, cultural norms may discourage mentioning VMS; for instance, focus group data suggest that menopause and its symptoms are commonly discussed by women in the United States but not in traditional Chinese culture. All of these differences may lead to cultural variation in VMS reporting, even in the absence of cultural differences in actual VMS occurrence. The article by Sievert and Obermeyer in this month’s issue of Menopause points to possible health-related consequences from these issues of perception and reporting. In particular, they note that reporting of somatic symptoms may reflect somatization, where underlyingVbut possibly unperceived or unexpressedVemotional or psychosocial difficulties are reported instead in terms of physical symptoms. Previous research indicates that somatization is common and leads to delay in diagnosis and treatment of depression. Sievert and Obermeyer posit that the extent of somatization, as well as the links between individual somatic symptoms and particular aspects of psychosocial distress, may vary cross-culturally; hence, the occurrence of reported somatic symptoms serving as proxies for unreported mental health problems such as depression and anxiety may also differ by culture. Given the possible cultural differences in the steps involved in perception and reporting of symptoms, it is important to explore this hypothesis. Taking anxiety as an example, a survey instrument may not query the respondent in a culturally appropriate way, perhaps using unfamiliar terms. Alternatively, cultural conversational norms may discourage discussion of this topic, and mentioning somatic symptoms may be a more socially acceptable substitute response. Sievert and Obermeyer’s work informs these questions first by comparing responses from close-ended questions on symptoms with open-ended responses, with a comparison of agreement across four different countries: Beirut, Lebanon; Rabat, Morocco; Madrid, Spain; and central Massachusetts, United States. Inclusion of open-ended questions facilitates the assessment of cultural differences, including the ability to measure any symptoms not captured adequately in a list of close-ended items. Despite cross-country differences in the prevalences of reported symptoms, each country exhibited generally high consistency between symptom reporting from openand close-ended items, as well as a substantial overlap in the symptoms on the checklist and self-reported symptoms, suggesting that close-ended items can be used effectively in well-done cross-cultural studies, particularly in those using uniform methodology throughout. Second, the authors assessed the clustering of somatic and psychosocial or emotional complaints using both standard factor analysis of close-ended responses and textual analysis of open-ended responses, with the latter analysis suggesting how women themselves group symptoms or attribute emotional symptoms to physical conditions. Both sets of analyses indicated cultural differences in links between somatic and emotional symptoms, as well as some within-country differences in associations identified from factor analysis and women’s self-identified associations. Their findings suggested that psychosocial or emotional symptoms still may be occurring even if not explicitly endorsed or mentioned by a participant. This was particularly true in Lebanon and Morocco but less so in central Massachusetts and Madrid. Moreover, the somatic Bproxies[ for emotional or psychosocial distress varied by countryVfatigue in Lebanon and Morocco