http://tcn.sagepub.com/Journal of Transcultural Nursing

http://tcn.sagepub.com/content/early/2012/08/17/1043659612453745The online version of this article can be found at:

 DOI: 10.1177/1043659612453745

published online 20 August 2012J Transcult NursRobin Whittemore

Susan Caplan, Javier Escobar, Manuel Paris, Jennifer Alvidrez, Jane K. Dixon, Mayur M. Desai, Lawrence D. Scahill andCultural Influences on Causal Beliefs About Depression Among Latino Immigrants

  

Published by:

http://www.sagepublications.com

On behalf of: 

  Transcultural Nursing Society

can be found at:Journal of Transcultural NursingAdditional services and information for    

  http://tcn.sagepub.com/cgi/alertsEmail Alerts:

 

http://tcn.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

What is This? 

- Aug 20, 2012OnlineFirst Version of Record >>

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from

Journal of Transcultural NursingXX(X) 1 –10© The Author(s) 2012Reprints and permission: sagepub.com/journalsPermissions.navDOI: 10.1177/1043659612453745http://tcn.sagepub.com

Introduction

By 2050, Hispanics will comprise an estimated 29% of the population of the United States (Pew Hispanic Center, 2008), more than half of whom will be foreign born (U.S. Census Bureau, 2004). Disparities in mental health care among Hispanics, compared with non-Hispanic Whites, have been well documented and are particularly egregious among immigrants (Alegria et al., 2008; Cabassa, Zayas, & Hansen, 2006). These disparities cannot be fully explained by lack of insurance and language barriers, but they may also reflect cultural and religious values and lack of provider understanding of these values. Values that emphasize over-coming adversity (sobreponerse) and self-reliance may influence health care utilization and illness outcomes (Berdahl & Torres Stone, 2009; Institute of Medicine, 2003). However, little is known of the underlying values that influence beliefs about the causes of mental illness and depression (Arcia, Sanchez-LaCay, & Fernandez, 2001; Baez & Hernandez, 2001).

Causal Beliefs About DepressionAs discussed in Caplan, Paris, et al. (2010), Hispanic illness causation beliefs incorporate historical and migratory

influences. After Spanish colonization of the Americas, indigenous religious beliefs were comingled with Iberian humoral medicine, which emphasized the importance of equilibrium within the body. Illness was attributed to a loss of balance and harmony in life, emotions that are too strong, too much heat or cold, or experiences that might cause severe fright (susto; Glazer, Baer, Weller, de Alba, & Liebowitz, 2004; Weller & Baer, 2001). Other syncretic religious practices in the Caribbean and some parts of Central and South America suffused indigenous and Catholic traditions with African and Haitian influences such as Santeria and Espiritismo (Applewhite, 1995; Baez & Hernandez, 2001; Guarnaccia, Martinez, & Acosta, 2005). Syncretic beliefs among some Latinos encompass the attribution of mental illness to supernatural forces, control

453745 TCNXXX10.1177/1043659612453745Journal of Transcultural Nursing 24(1)Caplan et al.

1Rutgers–The State University of New Jersey, Newark, NJ, USA2 University of Medicine and Dentistry of New Jersey, New Brunswick, NJ, USA

3Yale University, New Haven, CT, USA4National Institutes of Health, Bethesda, MD, USA

Corresponding Author:Susan Caplan, Rutgers–The State University of New Jersey, Ackerson Hall, 180 University Avenue, Newark, NJ 07102, USA Email: susan.caplan@rutgers.edu

Cultural Influences on Causal Beliefs About Depression Among Latino Immigrants

Susan Caplan, PhD, MSN1, Javier Escobar, MD, MSc2, Manuel Paris, PsyD3, Jennifer Alvidrez, PhD4, Jane K. Dixon, PhD3, Mayur M. Desai, PhD, MPH3, Lawrence D. Scahill, PhD3, and Robin Whittemore, PhD, APRN, FAAN3

Abstract

Purpose: This study describes causal beliefs about depression among Dominican, Colombian, and Ecuadorian immigrants. The authors describe participants’ narratives about how particular supernatural or religious beliefs may contribute to or alleviate depression. Method: Latino primary care patients (n = 177) were interviewed with the Beliefs About Causes of Depression Scale, a list of 35 items rated from not at all important to extremely important. Participants had the option of expanding on responses using an informal conversational approach. Underlying themes of these explanatory comments were derived from narrative and content analysis. Results: Major themes that emerged were Psychosocial and Religious and Supernatural causal beliefs. A third theme emerged that represented the integration of these categories in the context of the immigrant experience. Discussion and Conclusions: This article adds to the understanding of cross-cultural beliefs about depression. Psychosocial stressors related to the immigrant experience and adverse life events were highly endorsed, but the meaning of these stressors was construed in terms of religious and cultural values. To provide culturally appropriate services, nurses should be aware of and discuss the patient’s belief systems, illness interpretations, and expectations of treatment.

Keywords

causal beliefs, depression, Latinos/Hispanics, immigrants, illness perceptions

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from

2 Journal of Transcultural Nursing XX(X)

of one’s mind, and communication with the spirit world (Baer, Clark, & Pederson, 1998; Baez & Hernandez, 2001). Chronic, serious mental illness might be the result of mal puesto, hechizos, and brujeria (spells, hexes, and witch-craft; Falicov, 1999; Viladrich, 2007).

Current qualitative research studies have offered primar-ily psychosocial explanations for depression among Latinos, such as interpersonal problems, stressful life events and ill-ness; economic difficulties; discrimination; substance abuse; and lack of emotional support or social isolation (Berkman, Guarnaccia, Diaz, Badger, & Kennedy, 2005; Cabassa, Lester, & Zayas, 2007; Heilemann, Coffey-Love, & Frutos, 2004, Lackey, 2008; Martinez-Pincay & Guarnaccia, 2007). In most of the qualitative studies cited above, focus groups and open-ended interviews were used to assess causal beliefs. These approaches may account for the relative absence of less socially desirable responses, such as super-natural causal beliefs about depression. In a study of Mexican Americans, Applewhite (1995) found that direct ethnographic interviewing on the subject of witchcraft elicited unease and an unwillingness to respond. Because of the potential stigma of volunteering nonbiomedical beliefs in a conversation or interview, the use of Likert-type scale questionnaires may enhance the validity of responses to religious or supernatural causal belief items (Landrine & Klonoff, 1994). Through questionnaires to assess causal beliefs, strong endorsement for religious and supernatural beliefs was found in research studies of culturally diverse college-educated students (Landrine & Klonoff, 1994), Mexican Americans in California (Rivera, 2001), and East Asians in the United Kingdom (Sheikh & Furnham, 2000). In this research, the use of questionnaires was combined with qualitative interviews, thus obtaining the “best of both worlds” in terms of the facilitation of discussion of stigma-tized items and the ability to derive rich data from partici-pants’ elaborated responses.

Beliefs About Efficacy of TreatmentFatalism, or a belief that illness and misfortune are beyond a person’s control reflect God’s will, luck, or destiny, is often cited as a core Latino cultural belief (Añez, Paris, Bedregal, Davidson, & Grilo, 2005; Falicov, 1999). In a survey of reli-gious beliefs in approximately 2,000 Latinos, the majority endorsed that “God wills good health to all believers who have enough faith” (Pew Hispanic Center and the Pew Forum on Religion & Public Life, 2006). Fatalistic beliefs are cited as a cultural barrier to preventive care and help-seeking behaviors (Chavez, Hubbell, & Mishra, 1997). However, other researchers have questioned the validity of the construct of fatalism and its conflagration with religiosity (Florez et al., 2009; Neff & Hoppe, 1993). Religiosity may counteract fatalism by enhancing physical and mental well-being, providing a coping mechanism and source of social

support and affirming individual action (Florez et al., 2009; Neff & Hoppe, 1993). Religious practices may also serve as alternative treatments for depression (Florez et al., 2009; Loue & Sajatovic, 2008). In several studies, Hispanics were more likely than non-Hispanic Whites to believe that prayer or faith in God can help relieve depression (Cabassa et al., 2007; Givens, Houston, Van Voorhees, Ford, & Cooper, 2007). Although, there is a body of knowledge about reli-gious practices and mental illness among Latinos, there is little empirical data about religious interpretations of causal beliefs or how cultural beliefs and values form part of the social capital of immigrants that might mitigate against depression.

The purpose of this study was to examine psychosocial and religious causal beliefs about depression among Latino immigrants in primary care. We described participants’ nar-ratives about how particular life experiences and religious and cultural beliefs are believed to contribute to or alleviate depression

MethodResearch Design

A nested qualitative design within a primary cross-sectional descriptive survey was used (Miller & Crabtree, 1994).

ProceduresThe sample for this study consisted of a convenience sample of self-identified Latino immigrants (N = 177), recruited from the waiting room of the practice. There was an equitable selection of participants since all patients were approached to enter the study upon registering for their appointments or while seated in the waiting room. Patients were approached with a brief introduction about the investigator, the purpose of the study, and eligibility criteria and were given a bilingual flyer providing contact information. Eligible participants endorsed that they were Latino, aged 18 or older, and born either outside of the United States or in Puerto Rico.

The refusal rate varied greatly throughout the duration of the study from approximately 90% initially to about 10% by the end of the study. Initially, participants were wary of the investigator and, per staff report, believed that the investigator was from the Immigration and Naturalization Service. To counter this initial mistrust, the investigator employed a culturally syntonic methodology similar to the plática methodology, recommended for Latino populations by Valle and Mendoza (1978), which relied on staff mem-bers familiar to the participants to sanction the research purposes and provide a personal recommendation of the researcher. By the end of the study, when the investigator was well known to the patients, some of whom had already participated in the study, the refusal rate was minimal.

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from

Caplan et al. 3

The study received internal review board approval from a university-based institutional review board. Informed con-sent was obtained from individuals who expressed interest in participating in the study. Participants were interviewed by the principal investigator in Spanish or English according to their preference, in a private room to ensure confidentiality. Because there was presumed to be a sizeable percentage of subjects who had low literacy, the instruments were read aloud to participants. Participants had the option of expand-ing on Likert-type responses to the Beliefs About Causes of Depression Scale, and their explanatory comments were recorded verbatim. In conjunction with the structured inter-view, an in-depth informal interview technique elicited spon-taneous, informal conversation and permitted further clarification of responses (Cohen & Crabtree, 2006; Valle & Mendoza, 1978). Participants were introduced to the study with the following statement “we’re interested in hearing about your opinions and experiences; there are no right or wrong answers to the questions so feel free to elaborate on your responses to any of the questions.” Interviews lasted between 1 and 2 hours.

Setting. The study took place at one of the family practice sites of Privileged Care, Inc., in Corona, Queens, New York. Corona, Queens, has an urban population of 99,000. Approx-imately two thirds of the population is Hispanic; of these 62% are foreign born (U.S. Census Bureau, 2003).

Measures. The Beliefs About Causes of Depression Scale is a list of 35 possible explanations for illness causa-tion with a 5-point rating from not at all important to extremely important (Alvidrez, 1999). This version was based on the original scale by Landrine and Klonoff (1994) and was designed to elicit underlying values that contrib-ute to health beliefs. The original scale was validated by comparison with subject-generated causes in response to open-ended questions about illness causation and experi-menter-generated causes of depression. The Causal Beliefs About Depression scale was adapted for depression and translated into Spanish by Alvidrez (1999). The 35 items were factor analyzed, using principle components analysis. For Latinos, the total scale had an alpha of .92 and there was no difference by language of interview. A detailed description of translation and psychometrics of all mea-sures and quantitative analysis are described in Caplan, Paris, et al. (2010).

Data analysis. We used univariate analyses to describe the psychosocial and clinical characteristics of the sample and the responses to the Causal Beliefs About Depression Scale using SAS Version 9.1. We examined differences between the mean scores on the continuous demographic variable, age at migration, by country of origin variables using analysis of variance and Duncan’s test for pairwise comparisons. We examined the differences in distributions of psychosocial, demographic, and clinical/treatment categorical variables first, between the following groups by country of origin: Dominican, Central and South American, Ecuadorian, and

Colombian using the chi-square test or Fisher’s exact test depending on cell size.

An exploratory analysis was conducted to examine differ-ences in each item of the causal beliefs scale by country of origin. The .05 significance level was applied for the above analyses.

Both narrative (Mueller, 1999) and content analysis (Bernard & Ryan, 2009) were used to examine narratives and explanatory comments to derive underlying themes (Graneheim & Lundman, 2004; Holsti, 1969) in the context of cross-cultural inquiry (Leventhal, Diefenbach, & Leventhal, 1992, Spradley, 1979). Categories of the scale included (a) Psychosocial/Biomedical, (b) Religion/Supernatural/Personal Transgressions, and (c) The Immigration Experience. The first two categories corresponded to the theoretical distinction between Western biomedical causation beliefs and traditional or religious and supernatural causation beliefs (Kleinman, 1977). Within these categories, 12 subthemes were identified in this analysis (discussed below).

ResultsSample Characteristics

Sociodemographic and clinical characteristics of the 177 participants in the sample have been presented in greater detail in Caplan, Paris, et al. (2010) and are shown in Table 1. The largest ethnic group in this sample was of Dominican origin (51%), followed by those of Ecuadorian (16%) and Colombian nativity (14%).

The majority of the sample (78%) had an income of less than $20,000 annually, with 39% earning less than $10,000 a year. About half of the sample was employed either part-time or full-time, and approximately one third of the sample was unemployed. The majority of the sample was monolingual Spanish speaking or spoke very little English (85%). One fourth of the population had probable depression according to the Patient Health Questionnaire criteria (Kroenke, Spitzer, & Williams, 2001).

Eighty percent of the sample (n = 142) described them-selves as Catholic. Ten percent (n = 18) identified themselves as members of other Christian denominations, either Church of God, Pentecostal, or Jehovah’s Witnesses, and 9% (n = 16) stated that they had no religion. One person identified her religion as Yoruba. Approximately 52% (n = 92) of the sample attended services once a week or more, whereas only 28% (n = 50) attended services less than once a month. Seventy-eight percent (n = 138) of the sample reported using religion/spirituality as a coping mechanism almost all of the time. Other Central and South Americans were more likely to have no religion and less likely to be Catholic than the other groups, whereas Ecuadorians and Colombians had the largest percentages of Evangelicals among their groups. However, the numbers within these groups were too small to make meaningful comparisons.

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from

4 Journal of Transcultural Nursing XX(X)

There were very few other demographic and/or psychoso-cial differences by country of origin. A greater percentage of Dominicans were in the lowest income group (49%), com-pared with Ecuadorians, Colombians, and other Central and South Americans. Dominicans also had the lowest percentage of their group in the highest income category. Correspondingly, Dominicans were the least likely to have an educational level beyond eighth grade; 70% of Dominicans had less than a high

school education, compared with approximately 50% of Ecuadorians and Colombians and one third of other Central and South Americans. Dominicans are more likely than the other groups to speak only Spanish, whereas Ecuadorians and other Central and South Americans have a greater likelihood of being bilingual than Colombians or Dominicans. The mean age at migration was 29. Colombians migrated to the United States at an older age than the other groups, perhaps because

Table 1. Description of the Sample by Country of Origin (N = 177)

Variable n (%)

Dominican, n = 91 (51%)

Other Central and South American,

n = 33 (19%)

Ecuadorian, n = 28 (16%)

Colombian, n = 25 (14%) pa

Age at migration, mean (SD), years 29 (12.0) 30 25 27 34 .048Demographics Age 18-50 years 90 (51) 41 (45) 21 (64) 18 (64) 10 (40) NS Gender NS Female 129 (73) 69 (76) 21 (64) 23 (82) 16 (64) Income level (US$) <10,000 63 (39) 42 (49) 8 (28) 5 (21) 8 (33) .036 10,000-19,999 64 (39) 31 (36) 15 (52) 11 (46) 7 (29) ≥$20,000 36 (22) 13 (15) 6 (21) 8 (33) 9 (36) Educational level .002 Eighth grade or less 45 (25) 33 (36) 7 (21) 5 (18) 1 (4) Some high school 56 (31) 31 (34) 4 (12) 9 (32) 12 (48) GED/high school/technical

school38 (21) 16 (18) 10 (30) 5 (18) 6 (24)

Some college to graduate school

38 (21) 11 (12) 12 (36) 9 (32) 6 (24)

Work status NS Full-time 60 (34) 26 (29) 15 (45) 11 (39) 8 (32) Part-time 29 (16) 12 (13) 8 (24) 6 (21) 3 (12) Out of work force (retired,

student, disability)34 (19) 24 (26) 4 (12) 3 (11) 3 (12)

Unemployed 54 (31) 29 (32) 6 (18) 8 (29) 11 (44) Religious affiliation Catholic 142 (80) 79 (87) 22 (67) 21 (75) 20 (80) .004 None 16 (9) 8 (8) 7 (21) 1 (4) 0 (0) Pentecostal, fundamentalist 18 (10) 4 (4) 4 (12) 5 (19) 5 (20) Acculturation variables Number of years in country NS 0-10 30 (17) 13 (14) 6 (18) 5 (18) 6 (24) 11-20 52 (30) 28 (31) 7 (21) 9 (32) 8 (32) >20 94 (53) 49 (54) 20 (61) 14 (50) 11 (44) Language usage .013 Spanish only 38 (42) 6 (18) 8 (29) 8 (29) 4 (16) Mostly Spanish (some Eng.) 43 (47) 18 (55) 15 (54) 15 (54) 19 (76) Spanish and English about the

same9 (10) 6 (18) 5 (18) 5 (18) 2 (8)

Mostly English to English only 1 (1) 3 (9) 0 (0) 0 (0) 0 (0) Clinical variables Above threshold on PHQb 22 (24) 10 (30) 9 (32) 4 (16) NS

a. p Value for analysis of variance F test (continuous variable) or χ2 or Fisher’s exact test (categorical variables).b. Primary Health Questionnaire. Threshold score ≥5 (mild depression).

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from

Caplan et al. 5

of rising unemployment among the middle class, which had motivated professionals to leave the country, or perhaps, as many people explained, their motivation to leave at an older age was because of rampant age discrimination in the work-place, which had negatively affected professionals older than 30 years.

Anecdotal Responses for How Particular Beliefs Contribute to DepressionPsychosocial/Biomedical. Items pertaining to psychosocial causes were the most highly endorsed (see Table 2). Explan-atory responses indicated a strong religious/supernatural jus-tification underlying many of these items. Items such as sexual abuse, drug, and alcohol abuse were considered mor-ally wrong (eso es malo) and, therefore, were associated causally with depression. Listed below are items that gener-ated the highest endorsement or the greatest frequency of explanatory responses and the accompanying narratives that exemplified latent content.

Sexual abuse and domestic violence. These were the most highly endorsed items of the entire scale, with 89% and 90%, respectively, ranking these items as very to extremely impor-tant. A number of women reported histories of sexual abuse or domestic violence to which they attributed their own depression. One woman stated of her experiences of sexual abuse, “Me ha marcado” (it has branded me). Another woman reported that she fled a physically abusive husband in Colombia, but she was forced to leave her children behind. “nunca se borran de la mente estos recuerdos, no tenia ayuda de nadie, uno se siente traumatizado, por eso me vine a este país” (these memories can never be erased from my mind, I didn’t have help from anyone, one feels traumatized, because of this, I came to this country). Of the 14 women who volunteered histories of domestic violence or sexual abuse, only 1 had ever discussed this experience with a pri-mary care provider. Participants also volunteered that they knew physical and sexual abuse were problems that would most definitely result in depression because they had heard about it on Spanish-language talk shows. There were no gen-der differences in level of endorsement on these items.

Trauma and loss of loved ones. Participants cited September 11, 2001, and the crash of the American Airlines Flight 587, en route to the Dominican Republic, also in 2001; political violence; and torture as significantly traumatic experiences that would definitely result in depression. One man from the Dominican Republic cited being tortured as a high school student for supporting an unsuccessful attempt to overthrow Trujillo. Another man from Chile, during the regime of Pino-chet, told about being placed in front of a firing squad when he was 5 years old to coerce a confession from his mother as to the whereabouts of his father.

Eighty-four percent ranked “loss of loved ones” as very to extremely important. There was a sense of injustice related to loss, particularly when it was the result of unnatural causes,

such as murder, suicide, or infections resulting from medical procedures. This sense of unfairness can be summarized in the proverb “a Dios rogando y con el mazo dando”—to God we go begging and he gives us the mallet. Among the 16% who endorsed this item to a lesser degree, some indicated that death was a part of life and not necessarily a cause of depression. Nevertheless, the majority of people who had sought treatment for depression reported that it was precipi-tated by loss of a loved one.

Table 2. Mean Scores of Items in the Causal Beliefs About Depression Scalea (N = 177)

Item label Mean (SD)

Psychosocial/biomedical category 1. Sexual abuse 4.24 (0.91) 2. Physical abuse/domestic

violence4.24 (0.81)

3. Death of loved ones 4.10 (0.84) 4. Drug abuse 4.01 (0.99) 5. Financial 3.94 (0.97) 6. A difficult childhood 3.79 (0.96) 7. Problematic relations 3.76 (0.96) 8. Traumatic events 3.75 (1.01) 9. Worry 3.57 (0.95 10. Physical illness 3.56 (1.00) 11. Alcohol drinking 3.43 (1.20) 12. Lack of rest 3.24 (1.10) 13. Lack of harmony with others 3.11 (1.15) 14. Exhaustion 2.88 (1.21) 15.Lack of harmony with nature 2.75 (1.20) 16. Heredity/genes 2.68 (1.33) 17. Diet 2.45 (1.29) 18. Climate 2.05 (1.12)Religious/supernatural/personal transgressions 1. Lack of faith 3.39 (1.22) 2. Strong emotions 3.15 (1.10) 3. Weak character 2.98 (1.24) 4. Ambition 2.90 (1.30) 5. Lack of personal hygiene 2.89 (1.37) 6. Anger 2.85 (1.22) 7. Sinful thoughts 2.82 (1.38) 8. Sinful acts 2.79 (1.27) 9. Envy 2.72 (1.34) 10. Sex 2.64 (1.28) 11. Punishment from God 2.22 (1.41) 12. The Evil Eye 1.90 (1.23) 13. Spells/witchcraft 1.84 (1.24)The immigration experience 1. Loneliness 3.93 (1.03) 2. Bad luck 2.33 (1.38) 3. Destiny 2.09 (1.30) 4. Payback for the sins of others 2.45 (1.38)

Note. Items in boldface are discussed further in text.a. Range of responses: 1 = not at all important to 5 = extremely important.

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from

6 Journal of Transcultural Nursing XX(X)

Heredity/genes. Heredity had the largest amount of people responding “I don’t know.” Forty-eight percent felt that heredity had little or nothing to do with depression.

Religious/Supernatural/Personal Transgressions. Exam-ples of items under personal transgression included “weak character,” “ambition,” “envy,” “sinful acts.” Supernatural items included witchcraft and the Evil Eye. Religious items included lack of faith in God and punishment from God.

Weak character. The majority of people (67%) felt that a weak character was somewhat to very important as a cause of depression. If one is weak, one could be easily taken advantage of and bad things would befall you; depression was a consequence of not confronting life’s dilemmas (no enfrentan los problemas de la vida). Moreover if one is strong, one can overcome adversity (sobrevivir) and not suc-cumb to depression.

Ambition. Too much ambition, not being satisfied with one’s life’s circumstances (conforme) was seen as a some-what to very important source of depression and stress by the majority of people. This was seen as particularly true for those who would never succeed in obtaining their ambitions.

Punishment from God. This item generated the most responses, with many people informing the investigator that “God does not punish.” At least half of the people responded not at all important to this item.

Lack of faith in God. Faith in God was believed to be very important; 77% endorsed lack of faith as somewhat to very important.

The Evil Eye. The Evil Eye (mal de ojo) is a widespread belief in Latin American and other parts of the world. It is a belief that the glances of an envious person can cause harm to one’s child (Baer & Bustillo, 1993). Forty-four percent of the participants endorsed the Evil Eye to some degree. A number of participants had personally experienced the Evil Eye, “A mi me lo han hecho” (they have done this to me). One man described how when his daughter was a baby, one of the neighbors said how beautiful she was, and the next day she became seriously ill and had to be hospitalized.

The Evil Eye described to the investigator is the “uninten-tional” Evil Eye. In this interpretation of the Evil Eye, the bearer of the Evil Eye is unaware of his or her own powers and the victim of the Evil Eye does not know the perpetrator. Only one participant stated that the bearer of the Evil Eye was identified by the community, a rural village in the Dominican Republic, and, in that case, that person was ostracized.

Witchcraft/spells. Thirty-seven percent of the population endorsed this item to some extent and 28% at a level of somewhat important to extremely important. Most partici-pants stated that they had not personally been involved with witchcraft but knew of people who were involved with it. Other people felt that since God exists, the Devil must also exist, and therefore, this kind of evil was real. Still others

were more ambivalent. For example, several people stated “put a little, just in case.”

One 75-year-old Dominican male discussed his experi-ences with a practitioner of witchcraft. He related that he had been a police officer in the Dominican Republic, when he was assigned to the job of arresting a brujo or witch doctor.

And this witch doctor was very evil because he has over 100 clients, and he was really stealing their money and killing people, because the people would not seek medical care from the hospital. In front of a whole crowd of people the witch cursed me and threatened me, but I stood up to him and arrested him anyway.

Subsequently, when asked about el Mal de Ojo (The Evil Eye),” the man responded, “Esto es bien importante” (this is very important). He further explained that this belief was related to his personal experiences.

The most fervent denouncers of witchcraft and the super-natural were among the 10% of the sample who belonged to Fundamentalist Christian denominations. One Mexican woman said she used to believe in “La Llorona” and other supernatural forces, but when she became a Christian, she learned to have faith in the Lord and not in superstitions.

The Immigration ExperienceMany of the explanations for what causes depression reflected the new environment, strong cultural values, and exposure to a different culture.

Loneliness. For those who knew of people who came to the United States without family members, this item was partic-ularly relevant. Loneliness was endorsed by 79% as very or extremely important in causing depression.

Bad luck and destiny. The majority of people, 51% and 65%, respectively, felt that destiny and bad luck had nothing or only a little to do with causing depression. “Uno se lo hace a si mismo,” “one makes their own bad luck,” “no one can know their destiny or one makes their own destiny,” were frequently heard expressions. This militant self-determinism was exemplified in the personal story of one Dominican woman who came here with a second-grade education and 30 dollars in her pocket. She came to New York on a Friday, and five days later, she was working full-time for the Union, 32BJ, cleaning corporate offices. She raised four children on her own, put them all through college, and helped her sister and mother buy their homes.

Payback for the sins of others. Sixty-one percent endorsed this item to some extent, 47% at the level of “somewhat or greater.” The origins of this belief are religious in nature, but in a contemporary context, this high level of endorsement appears to be an acknowledgement of the injustices that affect people’s lives on a day-to-day basis. As one participant explained, “Jesus died for the sins of others; it’s like if your

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from

Caplan et al. 7

family member gets shot in a drug shoot-out and never did drugs, that would be an example of El Pagar por los Peca-dos de Otros.”

DiscussionThe initial quantitative survey approach provided entrée for the discussion of stigmatized issues in a nonthreatening manner. Once rapport was established, participants did not confine themselves solely to Likert-type scale responses but felt comfortable discussing sensitive issues. Researchers working with Latino populations have suggested an inter-view technique that employs spontaneous, informal conver-sation, which is congruent with cultural values in the establishment of trust (confianza), respect (respeto), friend-ship (amistad), and mutual sharing (personalismo; Añez et al., 2005; Applewhite, 1995; Valle & Mendoza, 1978).

This culturally syntonic approach provided an under-standing of the context of participants’ beliefs. Although the study’s participants represented people from diverse coun-tries of origin, they were considered as a whole because of the significant commonalities among them, including lan-guage usage and preference; their immigrant status and the number of years they have resided in the United States, which was predominantly more than 20; their socioeconomic status; place of residence and neighborhood context; and some cultural traditions. These similarities were reflected in the consistency of responses to the 35 causal beliefs items. Only 3 items showed significant differences by country of origin. Ecuadorians rated the importance of the item “Envy” as significantly less important as a cause of depression than the other three groups (p = .029), and Colombians were sig-nificantly less likely than the other three groups to believe that the Evil Eye was an important cause of depression (p = .048). For the item “Payback for the Sins of Others,” Dominicans perceived this as having greater importance as a cause of depression than Colombians or other Central and South Americans (p = .016). Given the small sample sizes, it is very difficult to interpret these findings; however, the lat-ter finding leads to some interesting speculation. Payback for the Sins of Others was explained by a number of participants as a kind of social injustice. Some participants cited, as an example, being sent to jail for a crime one had not committed. Perhaps the greater level of poverty among Dominicans, relative to the other groups, contributed to this feeling of injustice. An alternative hypothesis is that although Dominicans share a similar Spanish heritage as the other groups, a much greater percentage of their population are descendants of African slaves and perhaps this has led to greater perceived discrimination and greater perceived social injustice. However, this is a subject for future research.

In accordance with previous research (Berkman et al., 2005; Cabassa et al., 2007; Heilemann et al., 2004), some of the most strongly endorsed causal beliefs reflect the daily hardships in the lives of this immigrant sample: loneliness,

financial stressors, and worry. Nevertheless, it would be wrong to conclude that acculturative and immigrant-related stressors are perceived to be the root source of depression. The most highly endorsed items were physical and sexual abuse, which were universal experiences that were often an influential factor in migration, as well as an oft-cited source of depression postmigration.

This study reveals an interesting question about the influ-ence of acculturative stress on mental health outcomes. The concept of acculturative stress symbolizes the losses that occur when adjusting to or integrating a new system of beliefs, routines, and social roles (Hovey, 2000; Salgado de Snyder, Cervantes, & Padilla,1990). Stressful life events are common to immigrants (Perez & Fortuna, 2005) and have been found to be a strong predictor of subsequent psychiat-ric disorders (Holman, Silver, & Waitzkin, 2000). However, although there exists a well-defined body of literature related to the process of acculturation, little and inconsistent research exists that defines acculturation in terms of primary care and health outcomes (Finch & Vega, 2003, Lewis-Fernandez, Das, Alfonso, Weissman, & Olfson, 2005). This study suggests that adverse life experiences such as physical and sexual abuse and personal losses are perceived to be a more salient cause of depression than experiences related to acculturation. It is also possible that the negative appraisals associated with depression might influence causal beliefs, which could be an area of future research.

Spiritual beliefs were a foundation of Latino immigrants’ causal beliefs about depression. The assumption of diminish-ing prevalence of spiritual belief systems by number of years in the country was not born out in this research. Contextual factors, such as living in an ethnic enclave, may have a cultur-ally protective effect, particularly for immigrants who have entered the country as adults (Schwartz, Pantin, Sullivan, Prado, & Szapocznik, 2006). This sample was obtained from an area that is ethnically diverse but predominantly monolin-gual Spanish speaking, which fosters maintenance of the cul-ture of origin. However, there has also been a general erosion of more traditional beliefs because of Dominican and other Latino groups’ participation in a formalized Catholic Church in the United States (Levitt, 1998). The homogenizing effect of the pan-Latino Catholic Church in urban communities (Levitt, 1998) is evidenced by the absence of significant dif-ferences among the ethnic groups in the endorsement of reli-gious and supernatural causal beliefs. Exposure to Western biomedical concepts has the potential to change causal beliefs about depression among immigrants (Sheikh & Furnham, 2000). The experience of the elderly Dominican man who did not believe in witchcraft but did believe in the Evil Eye is an illustration of cultural syncretism, or a melding of Western biomedical beliefs and traditional belief systems, similar to other research findings (Lopez, 2005; Padilla, Gomez, Biggerstaff, & Mehler, 2001; Viladrich, 2007).

As discussed by Caplan (2009), in this study the evidence for fatalistic beliefs is mixed and supports the idea (also

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from

8 Journal of Transcultural Nursing XX(X)

discussed in the recent qualitative work of Florez et al., 2009) of a more complex conceptualization of fatalismo. Although items indicating an external locus of control, such as witchcraft and the Evil Eye, are endorsed by about one third of the study sample, they were still ranked among the least important causes of depression. Perhaps, because the study sample comprised Latino immigrants, who by the act of immigration are affirming the belief in their own self-effi-cacy, the majority of this sample did not endorse “bad luck” or destiny as a cause of depression. The coping mechanism of controlarse (self-containment or conscious control) was evidenced by the very high endorsement of the items “Strong Emotions” and “Weak Character” as causes of depression. The idea of sobreponerse (to overcome; Añez et al., 2005) was repeatedly echoed in people’s statements that one had to overcome life’s adversities. Similar to the findings among 95 predominantly Mexican immigrants (Cabassa et al., 2007), in this study, the vast majority of participants felt that there was effective treatment for depression, but “hay que poner de su parte,” or “you have to help yourself.” The totality of these beliefs does not conform to the concept of fatalism, attributed to Latinos in general. These findings caution against making inferences about health behaviors based on broad cultural generalizations.

For many of the elderly and least formally educated par-ticipants in this sample, there was a sense of relativism about causes of depression (Caplan, Paris, et al., 2010). With the exception of physical and sexual abuse, almost everything should cause only a little depression, which can be overcome; “It all depends on how you look at it and one can survive anything.” This cognitive restructuring of events evokes the expression by William Shakespeare (1601/1897), in Hamlet, “Things are neither good nor bad but thinking makes it so.”

The strong endorsement of “Lack of Faith” as a cause of depression is not evidence of passive accommodation to life’s misfortunes or external locus of control beliefs but rather might be construed as an active coping mechanism. Faith in God, in spite of adversity, is necessary to “sobrevivir,” or sur-vive, and similar to the findings of Loue and Sajatovic (2008), religion provided a source of hope and strength. The frequent comment that “God does not punish” was often followed by descriptions similar to Florez et al. (2009) of a warm, benefi-cent spiritual being that served as a protector and friend.

The evidence of a profoundly held faith in this population creates a necessity for nurses and other health care providers to assess for spiritual and religious beliefs that may influence causal beliefs about mental health and illness (Loue & Sajatovic, 2008), and moreover, the results of this investiga-tion suggest that it is appropriate and acceptable to talk about these beliefs with patients. Discussion of patients’ beliefs can help providers understand why some patients may be reluctant to talk about depressive symptoms, prefer some treatment approaches over others, and may have difficulty seeking help or receiving social support around their treatment (Caplan, Alvidrez, et al., 2010).

Study Limitations

The study population targeted a predominantly Dominican immigrant primary care population in Corona, Queens, New York, and cannot be assumed to be representative of all Latino immigrant primary care populations in the United States. Although there was little evidence of differences among study’s participants’ causal beliefs by country of ori-gin, the sample sizes may have been too small to conduct meaningful subgroup analyses.

The study employed primarily quantitative methodology, and the qualitative component was added to provide a more detailed description of causal beliefs and to enhance the comprehension of the quantitative data results (Curry, Nembhard, & Bradley, 2009). Credibility of the findings was enhanced by this multimethod analysis, the concordance of the findings with prior research, and the input from a multi-disciplinary research team. The informal data collection strategy and a lack of a purposive sampling strategy may have compromised the dependability of results. Comments represented only those participants who chose to elaborate on their responses and may not have reflected the diversity of the population. However, nearly all participants chose to elaborate on at least one of the items in this questionnaire. The interviews were conducted in conjunction with a pri-mary care appointment, so because of time constraints, some interviewees may have not chosen to elaborate on responses. Moreover, because of the transient nature of a primary care sample, it was not possible to validate these conclusions with participants in a second interview.

ConclusionsOf prime importance in understanding the Latino immigrant experience is how immigrants have social, political, and religious beliefs that meld attitudes of both the United States and their countries of origin. Latino immigrants’ causal beliefs about depression are a direct reflection of their cur-rent life’s circumstances, which are interpreted through the lens of deeply held, cultural, religious, and spiritual beliefs. To provide culturally congruent care, it is important for nurses to have a good understanding of a client’s cultural background and assess for their understanding of symptoms, as well as their migration and traumas, spirituality/religion, acculturative stressors, and support system, which are all areas of potential importance.

This study is one of the few to examine the perceived importance of supernatural and religious causation beliefs, which might contribute to a reluctance to fully accept medi-cal interventions. Data from this study inform providers of types of mental health beliefs among Latino immigrants.

Acknowledgments

Special thanks to Joshua Farkovits, Privileged Care, Inc.; Tatiana Castrillon; Monica Diaz; Enrique Malamud, MD; Marta Miguez;

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from

Caplan et al. 9

Jasmine Ramos; Gabriela Garcia Rosas, MD; Romana Suero, MA; and Johanna Tudino.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was partially supported by a the Sigma Theta Tau International Honor Small Research grant, Indianapolis, Indiana.

References

Alegria, M., Chatterji, P., Wells, K., Cao, Z., Chen, C., Takeuchi, D., . . . Meng, X. L. (2008). Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatric Services, 59, 1264-1272.

Alvidrez, J. (1999). Ethnic variations in mental health attitudes and service use in low-income African American, Latina, and European American young women. Community Mental Health Journal, 35, 515-530.

Añez, L. M., Paris, M. J., Bedregal, L. E., Davidson, L., & Grilo, C. M. (2005). Application of cultural constructs in the care of first generation Latino clients in a community mental health setting. Journal of Psychiatric Practice, 11, 221-230.

Applewhite, S. L. (1995). Curanderismo: Demystifying the health beliefs and practices of elderly Mexican Americans. Health & Social Work, 20, 247-253.

Arcia, E., Sanchez-LaCay, A., & Fernandez, M. (2001). When worlds collide: Dominican mothers and their Latina clinicians. Transcultural Psychiatry, 39, 74-96.

Baer, R.D. & Bustillo, M. (1993). Susto and Mal de Ojo among Flor-ida Farmworkers. Medical Anthropology Quarterly, 17, 90-100.

Baer, R., D, Clark, L., & Pederson, C. (1998). Folk illnesses. In Loue, S. (Ed.), Handbook of immigrant health (pp.183-202). New York, NY: Plenum Press.

Baez, A., & Hernandez, D. (2001). Complementary spiritual beliefs in the Latino community: The interface with psychotherapy. American Journal of Orthopsychiatry, 71, 408-415.

Berdahl, T. A., & Torres Stone, R. A. (2009). Examining Latino differences in mental healthcare use: The roles of acculturation and attitudes towards healthcare. Community Mental Health Journal, 45, 393-403.

Berkman, C. S., Guarnaccia, P. J., Diaz, N., Badger, L. W., & Kennedy, G. J. (2005). Concepts of mental health and men-tal illness in older Hispanics. In M. J. Gonzales & G. Gon-zalez-Ramos (Eds.), Mental health care for new Hispanic immigrants: Innovative approaches in contemporary clinical practice (pp. 161-189). Binghamton, NY: Hayworth Press.

Bernard, H.R. & Ryan, G.W.(2009). Analyzing Qualitative Data: Systematic Approaches (pp. 287-310). Thousand Oaks, CA: Sage.

Cabassa, L. J., Lester, R., & Zayas, L. H. (2007). “It’s like being in a Labyrinth:” Hispanic immigrants’ perceptions of depression

and attitudes toward treatments. Journal of Immigrant Health, 9, 1-16.

Cabassa, L. J., Zayas, L. H., & Hansen, M. C. (2006). Latino adults’ access to mental health care: A review of epidemiologi-cal studies. Administration and Policy in Mental Health and Mental Health Services Research, 33, 316-330.

Caplan, S. (2009, September). An exploratory analysis of spiri-tual, supernatural and psychological causal beliefs about depression among Latino immigrants in primary care. Paper presented at the International Conference of the Society for Medical Anthropology on Medical Anthropology at the Intersections: Celebrating 50 Years of Interdisciplinarity, New Haven, CT.

Caplan, S., Alvidrez, J., Paris, M., Escobar, J., Desai, M., Whittemore, R., . . . Scahill, L. (2010). Subjective versus objective: An explor-atory analysis of Latino primary care patients who have self- perceived depression, but do not fulfill PRIME-MD Patient Health Questionnaire (PHQ-9) criteria for depression. The Primary Care Companion to the Journal of Clinical Psychiatry, 12(5), e1-e12. doi:10.4088/PCC.099m00899blu

Caplan, S., Paris, M., Whittemore, R., Desai, M., Dixon, J., Alvidrez, J., . . . Scahill, L. D. (2010). Correlates of religious, supernatural and psychosocial causal beliefs about depression among Latino immigrants in primary care. Mental Health, Religion & Culture, 13, 1469-9737. doi:10.1080/13674676.2010.497810

Chavez, L. R., Hubbell, F. A., & Mishra, S. I. (1997). The influ-ence of fatalism on self-reported use of Papanicolaou smears. American Journal of Preventive Medicine, 13, 418-424.

Cohen, D., & Crabtree, B. (2006). Qualitative Research Guidelines Project. Retrieved from http://www.qualres.org/index.html

Curry, L. A., Nembhard, I. M., & Bradley, E. H. (2009). Qualitative and Mixed Methods Provide Unique Contributions to Outcomes Research. Circulation 2009;119;1442-1452.

Finch, B. K., & Vega, W. A. (2003). Acculturation stress, social support, and self-rated health among Latinos in California. Journal of Immigrant Health, 5, 109-117.

Falicov, C. J. (1999). Religion and spiritual folk traditions in immigrant families: Therepeutic resources with Latinos. In F. Walsh (Ed.), Spiritual resources in family therapy (pp. 104-120). New York, NY: Guilford Press.

Florez, K. R., Aguirre, A. N., Viladrich, A., Céspedes, A., DeLa Cruz, A. A., & Abraído-Lanza, A. F. (2009). Fatalism or destiny? A qualitative study and interpretative framework on Dominican women’s breast cancer beliefs. Journal of Immigrant and Minority Health, 11, 291-301.

Givens, J. L., Houston, T. K., Van Voorhees, B. W., Ford, D. E., & Cooper, L. A. (2007). Ethnicity and preferences for depression treatment. General Hospital Psychiatry, 29, 182-191.

Glazer, M., Baer, R. D., Weller, S. C., de Alba, J. E. G., & Liebowitz, S. W. (2004). Susto and soul loss in Mexicans and Mexican Americans. Cross-Cultural Research: Journal of Comparative Social Science, 38, 270-288.

Graneheim, U. H., & Lundman, B. (2004). Qualitative con-tent analysis in nursing research: Concepts, procedures and

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from

10 Journal of Transcultural Nursing XX(X)

measures to achieve trustworthiness. Nurse Education Today, 24, 105-112.

Guarnaccia, P. J., Martinez, I., & Acosta, H. (2005). Mental health in the Hispanic immigrant community: An overview. In M. J. Gonzales & G. Gonzalez-Ramos (Eds.), Mental health care for new Hispanic immigrants: Innovative approaches in contemporary clinical practice (pp. 161-189). Binghamton, NY: Hayworth Press.

Heilemann, M. V., Coffey-Love, M., & Frutos, L. (2004). Perceived reasons for depression among low income women of Mexican descent. Archives of Psychiatric Nursing, 18, 185-192.

Holman, E., Silver, R. C., & Waitzkin, H. (2000). Traumatic life events in primary care patients. A study in an ethnically diverse sample. Archives of Family Medicine, 9, 802-810.

Holsti, O. (1969). Content analysis for the social sciences and humanities. Reading, MA: Addison-Wesley.

Hovey, J. D. (2000). Acculturative stress, depression, and suicidal ideation in Mexican immigrants. Cultural Diversity & Ethnic Minority Psychology, 6, 134-151.

Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in healthcare. Washington, DC: National Academies Press.

Kleinman, A. (1977). Depression, somatization and the “new cross-cultural psychiatry.” Social Science & Medicine, 11, 3-10.

Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Jour-nal of General Internal Medicine, 16, 606-613. doi:10.1046/j.1525-1497.2001.016009606.x

Lackey, G. F. (2008). “Feeling blue” in Spanish: A qualitative inquiry of depression among Mexican immigrants. Social Science & Medicine, 67, 228-237.

Landrine, H., & Klonoff, E. A. (1994). Cultural diversity in causal attributions for illness: The role of the supernatural. Journal of Behavioral Medicine, 17, 181-193.

Leventhal, H., Diefenbach, M., & Leventhal, E. A. (1992). Illness cognition: Using common sense to understand treatment adher-ence and affect cognition interactions. Cognitive Therapy and Research, 16, 143-163.

Levitt, P. (1998). Local-level global religion: The case of U.S.-Dominican migration. Journal for the Scientific Study of Religion, 37, 74-89.

Lewis-Fernandez, R., Das, A. K., Alfonso, C., Weissman, M. M., & Olfson, M. (2005). Depression in US Hispanics: Diagnostic and management considerations in family practice. Journal of the American Board of Family Practice, 18, 282-296.

Lopez, R. A. (2005). Use of alternative folk medicine by Mexican American women. Journal of Immigrant Health, 7, 23-31.

Loue, S., & Sajatovic, M. (2008). Auditory and visual hallucinations in a sample of severely mentally ill Puerto Rican women: An examination of the cultural context. Mental Health, Religion & Culture, 11, 597-608.

Martinez-Pincay, I. E., & Guarnaccia, P. J. (2007). “It’s like going through an earthquake”: Anthropological perspectives on depression among Latino immigrants. Journal of Immigrant Health and Minority Health, 9, 17-28.

Miller, W. L., & Crabtree, B. F. (1994). Clinical research. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 340-352). Thousand Oaks, CA: Sage.

Mueller, J. H. (1999). “Narrative approaches to qualitative research in primary care.” In B. F. Crabtree & W. L. Miller (Eds.), Doing qualitative research (2nd ed., pp. 221-238). Thousand Oaks, CA: Sage.

Neff, J. A., & Hoppe, S. K. (1993). Race/ethnicity, acculturation, and psychological distress: Fatalism and religiosity as cultural resources. Journal of Community Psychology, 21, 3-20.

Padilla, R., Gomez, V., Biggerstaff, S. L., & Mehler, P. S. (2001). Use of Curanderismo in a public health care system. Archives of Internal Medicine, 161, 1336-1340.

Perez, M. C., & Fortuna, L. (2005). Psychosocial stressors, psychi-atric diagnosis, and utilization of mental health services among undocumented immigrant Latinos. Journal of Immigrant & Refugee Services, 3, 107-123.

Pew Hispanic Center. (2008). U.S. population projections: 2005-2050. Retrieved from http://pewhispanic.org/files/reports/85 .pdf

Pew Hispanic Center and the Pew Forum on Religion & Public Life. (2006). Changing faiths: Latinos and the transformation of American religion. Retrieved from http://pewhispanic.org/files/reports/75topline.pdf

Rivera, S. V. (2001). Latino cultural beliefs of the causes of a medi-cal and a psychological illness. Dissertation Abstracts Interna-tional: Series B: The Sciences and Engineering, 62(2B), 1096.

Salgado de Snyder, V. N., Cervantes, R. C., & Padilla, A. M. (1990). Gender and ethnic differences in psychosocial stress and gener-alized distress among Hispanics. Sex Roles, 22, 441-453.

Schwartz, S. J., Pantin, H., Sullivan, S., Prado, G., & Szapocznik, J. (2006). Nativity and years in the receiving culture as markers of acculturation in ethnic enclaves. Journal of Cross-Cultural Psy-chology, 37, 345-353.

Shakespeare, W. (1897). Hamlet (Act II, Scene II). London, Eng-land: S. Paul & Co. (Original work written 1601)

Sheikh, S., & Furnham, A. (2000). A cross-cultural study of mental health beliefs and attitudes towards seeking professional help. Social Psychiatry & Psychiatric Epidemiology, 35, 326-334.

Spradley, J. R. (1979). The ethnographic interview (pp. 199-201). New York, NY: Hold, Rinehart & Winston.

U.S. Census Bureau. (2003). Census 2000. Retrieved from http://factfinder.census.gov/servlet/BasicFactsServlet

U.S. Census Bureau. (2004). Interim projections by age, sex, race, and Hispanic origin. Retrieved from http://www.census.gov/ipc/www/usinterimproj/natprojtab01a.pdf

Valle, R., & Mendoza, L. (1978). The elder Latino. San Diego, CA: Campanile Press.

Viladrich, A. (2007). From “shrinks” to “urban shamans”: Argentine immigrants’ therapeutic eclecticism in New York City. Culture, Medicine, and Psychiatry, 3, 307-328.

Weller, S. C., & Baer, R. D. (2001). Intra- and intercultural variation in the definition of five illnesses: AIDS, diabetes, the common cold, empacho, and mal de ojo. Cross-Cultural Research: Journal of Comparative Social Science, 35, 201-226.

at RUTGERS UNIV on August 25, 2012tcn.sagepub.comDownloaded from