Journal of Health Psychology17(4) 490 –499© The Author(s) 2011 Reprints and permission: sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1359105311419269hpq.sagepub.com

Introduction

Despite the fact that migration is not only a inherent characteristic of the “modern era”, it is currently receiving a great deal of urgent atten-tion in a variety of contexts, demonstrating that migration has many practical and theoretical implications that need to be studied. In particu-lar, Fortier and Bishop (2003) suggested that there is a need to compare, using cross-cultural studies (Berry, Poortinga, Segall, & Dasen, 2002), the consequences posed by the fact that many individuals are living in foreign contexts, and there is a need to find for ways of working together with other cultures (Ward, 2004).

According to this perspective, well-being and the connected concepts of health and illness are an important area in which the effects of the

growth of multiculturalism can be evaluated and studied. The theory of SRs (SRs) was intro-duced by Moscovici (1961/1976), who defined SRs as networks of ideas, metaphors and images which social groups use to categorize new pro-cesses and experiences. Health and illness have been central topics in the research on SR. Two pioneering qualitative studies, which focused

Representations of health and illness by Eastern European, South American and Italian care workers: a qualitative study

Cecilia Serena Pace1, Patrizia Velotti2 and Giulio Cesare Zavattini1

AbstractThis qualitative research examined the representations of health and illness presented by 30 individuals who work as care workers, from three different locations: Eastern Europe, South America and Italy. We led three focus groups for people who came from the same geographical area (intra-ethnic) and two for those from ‘mixed’ areas (inter-ethnic). From our content analyses, certain similarities and differences between the conceptualizations of health and illness emerged: in the intra-ethnic focus groups, Eastern Europeans focused on ‘inner strengths’, South Americans on ‘love’ and Italians on ‘personal autonomy’. These peculiar traits were levelled in the inter-ethnic focus groups.

Keywordscare workers, focus group, health and illness, migrants, qualitative research, social representations

1Sapienza, University of Rome, Italy2University of Genoa, Italy

Corresponding author:Cecilia Serena Pace, Sapienza, University of Rome, Department of Dynamic and Clinical Psychology, via degli Apuli 1, Rome 00185, Italy. Email: ceciliapace@fastwebnet.it

419269 HPQXXX10.1177/1359105311419269Pace et al.Journal of Health Psychology

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Pace et al. 491

on the conceptions of health and illness (Herzlich, 1969/1973), as well as on mental ill-ness (Jodelet, 1991), showed the way in which these SRs influenced daily life. Several more recent studies (Bowen & Gonzalez, 2008; Dixit, Mishra, & Sharma, 2008; Jovchelovitch & Gervais, 1999; Moodley, 2000) have already investigated the similarities and differences in the ways in which different cultures conceptual-ize health and illness, focusing specifically on the conceptions created by ethnic minorities, in order to increase the effectiveness of interven-tion programmes and to respond adequately to the health-related needs of migrants.

In fact, the trans-cultural model of nursing, based on the study of diversity and universality of culture care (Leininger, 1991), has highlighted that we need to have doctors and medical staff who take into account the standards and values of their patients’ cultures—including individu-als’ perceptions regarding their experience of illness—and who will plan interventions that are ‘culturally consistent’ (Leininger & McFarland, 2002). In order to improve their cultural compe-tence, medical staff should have knowledge of the cultural traditions, beliefs and values which affect their patients’ attitudes towards health and illness (Kurman & Ronene-Eilon, 2004).

In recent years, migrants have become not only health service users, but health service workers as well. In Italy there has been a mas-sive recruitment of migrants into care services in order to satisfy the demand for care workers for the elderly and sick living at home (Velotti & Zavattini, 2008). The XX Italian Report on Immigration (Caritas/Migrantes, 2010) indi-cated that in Italy there were 4.235.059 migrants coming from Europe (53.6%), Africa (22%), Asia (16.2%) and the Americas (8.1%). Rome and Milan, respectively, with nearly 270,000 and 200,000 foreign residents, are the quantita-tively most relevant cities. Specifically, migrants who work as care workers are generally women, and they are primarily from two large geograph-ical areas: Eastern Europe (49%) and South America (23%) (Caritas/Migrantes, 2010).

Studies on cultural differences in formal and informal care (Dilworth-Anderson, Williams,

Gibson, & 2002; Li & Fries, 2005; Wallhagen & Yamamoto-Mitani, 2006; Watson, 2003; Wells, Cagle, Bradley, & Barnes, 2008) have demonstrated that the most common problems that these workers must address are not only the difficulties concerning language, but also the complexity of cultural differences in terms of the meanings attributed to health, illness and care, and in prevention programmes and differ-ent perceptions of risk. Therefore, it would appear that SRs of health and illness (Flick, 2000) need further elaboration.

According to this view, an investigation of the concepts of health and illness among care workers from different countries may be of par-ticular interest within the study of cultural dif-ferences, not only for matters related to the different conceptualizations, but also in terms of the ways in which different cultural groups consider the meaning of ‘providing care’ (Stewart, 2009). The main purpose of this quali-tative research is to understand and analyse the meanings that care workers from different countries attribute to SRs of health and illness.

Method

Participants

The sample for this study consisted of 30 adult care workers. Of these, 10 (33%) were born in Italy, 9 (30%) were born in South America (Peru, Ecuador, Argentina and Columbia) and 11 (37%) were born in Eastern Europe (Romania, Poland, Ukraine, Moldova and Siberia). These last two categories are the ethnic groups that comprise the most number of migrant care workers in Italy (Caritas/Migrantes, 2010).

The sample comprised 27 females (90%), a figure which is in line with the characteristics of care work as profession, which is largely domi-nated by women. The age of the participants ranged from 26 to 59 years old (M = 45.2 years, SD = 8.84). The Italian (M = 47.7 years, SD = 6.82) and Eastern European (M = 48.18 years, SD = 8.15) participants were quite similar in age, while the South American care workers were younger (M = 38.78 years, SD = 9.02).

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All participants were found in Rome, one of the cities with the largest number of migrant residents. The participants were recruited using the ‘snowball technique’ (Stewart & Shamdasani, 1990): we contacted cultural associations and institutional services through which we could meet adults who worked as care workers; then, having met with some of these people, we asked them to contact their colleagues who also came from one of the aforementioned cultural areas. The organizations involved were: the Roman office of Caritas, the largest Catholic institution that deals with migrants in Italy, the Municipalities of Rome, which provide training for care workers of all nationalities, and the Andolfi Foundation, a Roman associa-tion that offers consultancy services to foreign families.

Measure

Focus group. We chose the focus group tech-nique because it is a method which is considered to be useful when studying SRs (Jovchelovitch, 2004) and for ‘exploring people’s own meanings and understandings of health and illness’ (Wilkin-son, 1998). We conducted a total of five focus group meetings, each lasting about two hours, as follows:

1. Three ‘intra-ethnic’ focus groups were carried out according to participants’ eth-nic background: one focus group with the 11 Eastern European care workers, one with the 10 Italians and finally one with the nine South American care work-ers. In this first phase, the more substan-tial questions were intentionally broad, and addressed to representations of health and illness with specific reference to the participants’ cultural background.

2. Two ‘mixed’ or ‘inter-ethnic’ focus groups were carried out, each with a similar num-ber of care workers: each included four, five or six participants from each of the three different geographical areas, with a total of 15 adults in each focus group. In

this second phase, the more substantial questions, planned on the basis of the ‘intra-ethnic’ focus groups, focused on the roles of family and social conditions, as well as on resources and difficulties in managing illness.

All the meetings were always run by the same two moderators, both of whom were psycholo-gists trained to conduct focus groups. All focus group meetings were video-recorded in their entirety and then transcribed verbatim by two members of the research team in order to ana-lyse their contents.

Procedure

The care workers were first interviewed by tel-ephone in order to gather some brief biographi-cal information (age, level of education, years in Italy) and to test their knowledge of the Italian language. This criterion was an uncondi-tional requirement in order to facilitate commu-nication among the three groups, especially in the inter-ethnic focus groups. Thus, the prior phone interview to all participants was con-ducted to make sure that the East European and South American care workers had an adequate knowledge of the Italian language; to maintain uniformity of procedure, we decided to also interview the Italian care workers by telephone. All participants were found to have an adequate knowledge of the language.

Participants were told that the present research involved intra-ethnic and inter-ethnic focus groups in order to explore their ideas about health and illness. At the beginning of the study, all of the participants signed an informed consent sheet, written on the basis of the rights and limits set out in Law 675/96: “Privacy of the person and other aspects with respect to the handling of personal data”.

Data analysis

In order to analyse the transcripts of the focus group meetings, we used the Grounded Theory

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approach (Strauss & Corbin, 1994). This approach is particularly useful in new fields in which there is little theory available to describe a phenomenon; it avoids the risk of excessive quantification of decontextualized words and themes, typical for thematic analysis. At the same time, it is more appropriate to give sense to the large amount of information emerging from focus groups, compared to discourse analysis, which is better for the analysis of indi-vidual productions such as semi-structured interviews and stories (Gee, 2005).

The advantage of this approach is that it pro-vides an opportunity to ‘let the data speak’ and to simultaneously make use of observation and the-ory, which become involved in an ongoing, circu-lar and recursive interaction. We used Atlas.ti software in order to examine and encode all of the data, making it easier to utilize an inductive approach, which is a characteristic of Grounded Theory. As the literature suggests (Douglas, 2003; Goulding, 2002; Locke, 2001), analysis proceeds in the collecting and interpreting of data about a particular category and its relationship to the other category; the end of data collection —saturation—is reached when no new or relevant data, as evaluated by two coders, seem to emerge with regard to a category (Charmaz, 2003).

Interpersonal reliability. Two members of the research team coded, blind, the 1.047 quota-tions, attributing to them 169 codes, which identified the more general concepts, and in doing so created the Codebook. The estimate of the interpersonal reliability of the Codebook was very high (Neuendorf, 2002) with 1.039 agreements and only nine disagreements.

Results

Similarities and differences in the SRs of health and illness emerging in intra-ethnic groups of care workers

Similarities. With regard to representations of health, a general framework with similar mean-ings was highlighted by the three cultural

groups. All of the participants chose similar labels to define health: they labeled it both as general psycho-physical well-being and as a lack of illness, using phrases such as: “Good health for me is a sense of well-being of … do not feel any kind of pain, of anxiety” (by the Eastern-European group), or “The health is a good … I think it is our good mental condition of soul and body, all together” (by the South-American group). In addition, the care workers provided similar definitions of “what deter-mines health”, using generic attributions of external causality (see Table 1). In other words, health seems to be considered as something that is, for the most part, subject to the laws of chance, and of which human beings cannot have full knowledge or complete control. Therefore, health cannot be fully explained or understood, using phrases such as: “Often it can happen that life takes it away or puts you in a different physical condition than before …” (by the Italian group). With regard to the deter-minants that contribute to health, participants identified four main themes—Psyche, Soma, Individual and Context—with regard to which, even if shared between the three groups, there emerged differences regarding the intensity with which a particular theme that has been linked to health by participants.

Regarding the representation of illness, all of the participants put forward similar ideas about ‘what illness is’: they considered illness mainly to be a lack of health and autonomy, in perfect opposition to the definitions they put forward for health. Moreover, all of the cross-cultural care workers were not able to describe ‘illness’ in one word: illness can exist in different types and in varying degrees of severity and have dif-ferent causes (see Table 1). Finally, all of the participants qualified illness in negative terms, emphasizing its negative impact on human existence; illness is considered to be something of unknown, which suddenly bursts into the lives of individuals, subverting their sense of balance. It is something that simply “happens or does not happen”. As the participants’ own words affirm: “You never know what the illness

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will be …” (by the South American group); “It is the illness itself … You do not know … that is something strange” (by the Italian group).

Differences. When comparing the content pro-vided by the three cultural groups, differences between groups emerged predominantly with regard to the determinants that contribute to health and illness. These differences were often related to the diverse weight of a theme that is differently accentuated by the three groups, while some content was specific only to certain groups.

Among the Eastern European care workers, psychological aspects (Psyche theme) were considered to be more crucial to the determina-tion of health and illness when compared to somatic aspects. Psychological aspects were frequently connected to representations of health in a two-way system: on the one hand, some psychological and temperamental traits of individuals (personal strength, resilience, cop-ing strategies, etc.) were seen as capable of pro-moting health and well-being; “If you have the strength, you go ahead … if you do not have the strength … the health also goes away, so what I think …” On the other hand, the participants outlined the way in which a person’s health

affects their psychological stance (good mood, serenity, etc.). For the Eastern European care workers, the psychological characteristic con-sidered the most dominant and influential in terms of an individual’s health was ‘inner strength’. This characteristic was cited more often by the Eastern Europeans than the other cultural sub-groups during the intra-ethnic and inter-ethnic focus groups.

With regard to the Eastern European sub-group, individual psychological aspects were also frequently linked to representations of ill-ness: illness appears to be considered exclu-sively ‘psychological’. Depression was therefore considered to be the principal ‘psychological ill-ness’, and also the most dangerous, according to the collective view which emerged from the dis-cussion, “ … I can also feel good with all my organs, but my mind is not right!”. The concept of ‘inner strength’ with regard to representations of illness appeared in opposition to the afore-mentioned representations of health: a lack of this essential psychological feature is what makes people sick. “I think how … as a person … a person gets sick if he doesn’t have the strength to go forward”. Among these care workers, the Soma theme, in relation to the

Table 1. Similarities and differences of health and illness conceptions in Eastern European, South American and Italian care workers.

EastEuropean

SouthAmerican

Italian

psychologicalaspects

→ “innerstrength”

Health Illness

interactionbetween

person andcontext

→ “love”

efficiency,personal

autonomy,independence

psycho-physical wellbeing-lack of illness-external causality

Sim

ilari

ties

on

defin

ito

nD

iffer

ence

s an

d st

ress East

EuropeanSouth

AmericaItalian

Differences and stress

lack of health and autonomydifferent types/ degrees of severity/ causes

psychologicalillness

→ “depression”

individualbehaviours

→ unhealthylifestyles

negative (andpositive)effects of

illness

Conceptions of

Sim

ilaritieso

n definiton

Pace et al. 495

illness, is never addressed in the speech, even in reference to the fact that the illness may relate specifically to this component.

Both somatic and psychological aspects (Psyche and Soma themes) were important fea-tures in relation to concepts of health and illness for the group of care workers from South America. Regarding the representation of health, two themes specifically emerged in the discussions with this sub-group. First, they fre-quently reported the idea that health depends on the ‘love’ that a person receives, and that this ‘love’ was considered to be the basis of indi-vidual well-being, “Is it always love, no? And is it always love that makes you feel good, I believe, no?” Second, they stressed the interac-tion between the two elements of ‘person’ and ‘context/environment’ (Individual and Context themes). The ways in which adults interact with their surrounding context and their strategies for coping with and managing the continuous challenges that arise from their environment can influence their personal health and well-being. The existence of this important link between the individual and his or her context was highlighted exclusively by this ethnic sub-group. Regarding representations of illness, the care workers from South America consistently conceived illness as a negative condition that could affect both the somatic and psychological aspects of a person. In their opinion, psycho-logical illness is usually poorly diagnosed and is generally underestimated, because it has fewer ‘clear’ characteristics than physical ill-ness. This ethnic subgroup focused much more than the others on the role of ‘individual behav-iours’ in terms of unhealthy lifestyles that could be considered as a trigger for the occurrence of illness (smoking, alcohol, hyper-caloric diet, sedentary lifestyle, etc.): “The health is influ-enced by many things … and by our behav-iours, by the way we eat … For example if we smoke or don’t smoke, if we do physical exer-cise or do not do physical exercise”.

From the Italian care workers emerged a quantitative difference between representations of health and illness. Regarding the concept of

health, the Italian sub-group put forward sig-nificantly fewer ideas, thoughts and definitions than the other two ethnic subgroups. Moreover, well-being was strongly associated with indi-vidual ‘efficiency’, ‘personal autonomy’ and ‘independence’ by the Italian care workers: “The health is physical and mental efficiency, it is the ability to satisfy by themselves the needs of daily life”. Conversely, the representation of illness in this sub-group appeared to be more complex and complete than in the other two ethnic sub-groups; it was discussed in detail and with reference to many themes and sub-themes. They shared with the South American care workers the idea that illness was a condition that could selectively affect physical and psy-chological aspects of a person. In addition, the Italian care workers emphasized the effects that an illness is capable of producing, and they described and listed a great number of them. The effects which were listed were usually con-sidered to be negative (i.e., becoming weak, being selfish, complaining all the time, etc.), although the idea that illness could also activate ‘positive’ changes—e.g., allowing the patient to re-evaluate themselves, and having a positive and indirect influence on the character and per-sonality of patients—was presented exclusively by the Italian sub-group (see Table1).

Differences between the SRs of health and illness of care workers emerging in inter-ethnic groups

Opportunities arose for each participant to dis-cuss and debate these themes in an inter-ethnic group. This enhanced the possibility of a thor-ough analysis of the themes that emerged among intra-ethnic groups in relation to health and illness in the second stage of research, as all participants perform the same profession in the same country, but come from different geo-graphical areas. One of the most easily recog-nizable aspects of the debate is represented by the attempt to highlight the many differences between characteristics, habits and life patterns in different cultures. This type of contribution

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to the discussion is made mostly by migrants, through the numerous comparisons they made between life in their country of origin prior to migration and life in Italy, the host country.

Migrant care workers underlined that the ‘scarcity of financial resources’ of their country of origin, together with a different organization of health systems, which do not involve any intervention to support the medical expenses of the citizen, are continually compared with Italian economic well-being. An Eastern Europe partici-pant said: “In Romania we have no money, we love our parents, but there is no money to take care … as in Italy. However, we do what we can … but in Italy if not have money … however … a solution is found!” A South American partici-pant affirmed: “The really big difference I’ve seen here … is that here you could see a person who is 83 years old, 90 years old, and this person physically appear fine … But in our country a person of 80 years is … is … they didn’t exists … why are they not there!? They died first!”

Moreover, the migrant care workers com-pared the “lack of ability to make prevention” in their country of origin with the special atten-tion that Italians show for prevention and con-stant monitoring of their medical condition. A South American participant affirmed “When we feel a pain, we do not say ‘I’ll go to the doctor’ … We wait, maybe if it goes well … if it do not go well … Patience! (laughing) … We do not have this care of ourselves as the people have here in Italy, where people really take care of herself”. Participants also said that, living in Italy, they had absorbed many of these behav-iours and learned from the Italians to pay more attention to their health through the implemen-tation of preventive controls and the changing of some unhealthy eating habits.

A critical comparison emerged regarding this “different practice in order to take care of the elderly in the families”: migrants distanced themselves from the practice in Italy of ‘aban-doning’ the old relatives (grandfather, grand-mother, etc.), not letting him or her live in the family, and delegating all the task structures of management and care. An East European

participant affirmed: “We have more love for our older … We don’t leave them in a place where someone cares for them, we do not … We have more love for them and until they die, they stay at home”. Italian care workers responded, also using the methods of compari-son. They recalled that until recently in Italy there were the same values of family unity and respect for the elderly but that, over time, with the change of some conditions they have unfor-tunately been lost: “In the past there was a son, with his wife and grandfather, grandmother, grandchildren …”.

Given the assumption of a strong influence that the discussion groups have on individual representations (Echabe & Castro, 1999), we would expect in such inter-ethnic focus groups a change in ideas about health and illness, as compared to what emerged in the previous intra-ethnic focus groups.

Thus, in the analysis we considered this aspect, trying to find whether and what changes had taken place in the transition from intra to inter-ethnic focus groups. The changes observed were mainly considering the frequencies in which different codes were taken: in fact, the frequencies of concepts which differentiated intra-ethnic focus groups appeared to level off when participants from the three groups have the opportunity to discuss topics together in the inter-ethnic focus groups. It is as if each partici-pant, when he/she interacts with colleagues from different cultures, tried to understand his/her own experience and decipher what is being argued by the other, narrowing the differences in an attempt to refer to a common basis.

For example, this is particularly evident with regard to the intra-ethnic emphasis on the psy-chological aspects in health and illness, where the role of ‘inner strength’ in the East-European group has been often stressed; in inter-ethnic focus groups, this stress becomes much less marked by the same group. Meanwhile, how-ever, the important role of a ‘fighting spirit’, which helps to move forward in the face of dif-ficulties and illness, is recognized and shared by participants from all three ethnic groups.

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Discussion

This qualitative research aimed to provide in-depth knowledge of the representations related to the topics of health and illness that care workers from different cultures have devel-oped. According to the literature (Fortune et al., 2004; Leventhal, Leventhal, & Cameron, 2001) individuals evaluate the health of themselves and others using an implicit or ‘common sense’ representation of the health and illness based, among other things, on the individual’s cultural context. Following this line of thought, we took the opportunity to explore the representations of care workers in order to adapt training to address specific barriers for the optimal man-agement of people who need care.

Results from this study indicate a potential dif-ference between the representations of health and illness. In fact, it is interesting to note that some common definitions were present in all ethnic groups regarding what health is. Two main types of definitions emerged: health was represented as a ‘good thing’ or as a ‘lack of one negative phe-nomenon’. These definitions appear consistent with the findings of Herzlich (1973) and her defi-nitions of health as ‘equilibrium’ and ‘reserve of health’, but also as ‘health in a vacuum’. In fact, in all three cultural groups, definitions seemed to emerge in which health involves the presence of some positive indicators, such as a general state of mental well-being, or the conditions of auton-omy and efficiency which are required in order to perform daily activities. On the other hand, another definition was also evident, which is characterized by the words ‘lack of illness’, as if health is something not easily definable in itself, but which can only be defined in relation to its opposite, and then considered exclusively as the absence of illness. These results seem to indicate the possibility that in the current community, composed of individuals belonging to different cultures, key concepts will become ‘globalised’ leading towards a process of homogenisation, which some authors consider to be a risky result-ing characteristic of the modern multi-cultural identity (Montreuil & Bouhris, 2001).

Second, when assessing the three inter-eth-nic focus groups, we highlighted some general reflections as well as some specific ones for each area of origin:

1) The idea of ‘inner strength’ and the atti-tudes towards psychological aspects of health, illness and care held by East European care workers: “Even if you do not have time to eat breakfast … but that is not a point, with the first point to be healthy … that is why you cannot eat, and you’re good anyway! Health depends on the psychology of person …”.

2) The emphasis placed on the importance of some aspects relating to interpersonal relationships and the affective-motiva-tional dimension (‘love’) by South American workers: “For me it is! It is a collection of things like love, family har-mony, love all together … I believe that health is composed of all this love”.

3) The issue of “personal autonomy” as put forward by Italian workers: “It is healthy when you don’t need something or someone. That allows you to live independently”.

Further investigations could focus on these factors—“inner strength”, “love”, and “personal autonomy”—which have been explored here at a more generic level, and which need to be better understood. These results show interesting evidence that “health and illness are socially constructed in different contexts” (Flick, 2000).

The discussions of inter-ethnic focus groups and the positive climate generated in these con-texts between the three ethnic groups have also certainly been an important exchange and shar-ing of experience for the participants. Analysing the contents of these focus groups and compar-ing them with the concepts that each group had separately expressed, it was possible to observe how those representations characteris-tic of each ethnic group appeared more nar-rowed even compared to the content created by other groups. Moreover, this mechanism of

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“mitigation” has been observed in relation to other aspects (e.g., the role of socio-economic conditions). Despite the fact that the findings may have been modulated by the type of stim-uli offered or by a general trend or “conform-ity” of the participants in a group context, this data seems provide a confirmation of the importance of providing similar opportunities for dialogue and discussion, so that their fields can enrich the representational diversity of others. This study allows us to obtain more rich and detailed data in the form of compre-hensive descriptions of health and illness representations, such as “photographs”. Nevertheless, as supported by different authors (Dilworth-Anderson, Williams & Gibson, 2002; Velotti & Zavattini, 2008), results seem to indicate that the question of ‘caring’, in association with the study of aspects of cultural diversity, is a subject in which there is a need for further investigation.

Two important potential limitations of this qualitative research can certainly be identified. The group context may have led participants to say not what they really think, but what they believe to be socially desirable and appropriate responses, developing a possible tendency towards ‘conformity’. The second limitation of qualitative research concerns the fact that we considered the two groups of Eastern Europe and South American care workers as homoge-neous groups, while they were composed of people with different national backgrounds (e.g., South American participants came from Perù, Ecuador, Argentina and Columbia). However, despite these issues, this experi-ence—which sought to explore the SRs of health and illness in a general view, without emphasis on ‘locals’ (national) concepts of them—could provide a new starting point for conducting studies on this topic with more spe-cific cultural backgrounds.

Finally, this qualitative research could have a role in promoting communication and integra-tion among care workers with different ethnic backgrounds, who often work in isolation and sometimes in a condition of social invisibility.

AcknowledgementThis research was part of research project entitled “Comparing culture care: Differences as a resource for building a shared professional identity”, which was supported by PRIN-COFIN 2006-2008 funds – Italian Research Programs of Relevant National Interest, co-financed by the Ministry of Education and La Sapienza University.

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