Understanding Cross-Cultural Neuropsychology

Science, Testing and Challenges

Alberto Luis Fernández, Jonathan Evans, Alberto Luis Fernández, Jonathan Evans

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000551525
• Edition: 1
• Topic: Psychologie
• Subtopic: Neuropsychologie

Understanding Cross-Cultural Neuropsychology thoroughly examines the meaning of culture in the context of neuropsychology, focusing on the fundamental neuroscience underlying how different aspects of culture influence neuropsychological test performance, and how that is related to brain function. It explores in detail the relationship between brain activity and culture, and the influence of various cultural, educational, and linguistic factors on neuropsychological test performances across various cognitive domains.

Written by leadings researchers in cross-cultural neuropsychology, the book first introduces the basic concepts in the field. It goes on to focus on the influence of cultural variables on specific domains of cognition, including perception, attention, memory, language, and executive functions. It also explores the implications of cross-cultural neuropsychology in practice, including a focus on test adaptation, the use of interpreters, the influence of acculturation, and the practice of neuropsychological rehabilitation in different cultural settings.

This book is essential reading for neuropsychologists and related practitioners working with culturally diverse clients, who need a good grasp of the cultural impacts on neuropsychological test performance when assessing clients from different cultural, linguistic, and educational backgrounds. It is also valuable for neuropsychologists in countries around the world who need a means of understanding the ways in which their culture impacts the performances of their clients on tests, which have been mostly developed in the U.S. or other Western cultures.

PART I Basic concepts in cross-cultural neuropsychology

1 Challenges for neuropsychology in the global context

Aparna Dutt, Jonathan Evans, and Alberto Luis Fernández

DOI: 10.4324/9781003051497-2

Introduction

An unprecedented acceleration in the movement of people within and across national borders has led to a massive increase in cultural diversity within countries across the globe. The world's population is also aging, increasing the burden of neurological conditions such as dementia and stroke. Consequently, there is an increasing need for culturally appropriate and equitable neuropsychology services right across the world. This is a challenge for countries without an established tradition of neuropsychology research and practice who need to develop services for the majority culture, as well as for minority groups. It is also a challenge for countries with well-established neuropsychology services who need to ensure equity of service to all members of the community. Sociocultural and socioeconomic inequalities within and between nations contribute to a higher prevalence of conditions such as hypertension, diabetes, and HIV/AIDS (Corsi & Subramanian, 2019; Hajizadeh et al., 2014; Stronks et al., 2013) that affect cognitive functioning, resulting in a need for neuropsychological services (Rivera Mindt et al., 2010). However, the vast majority of the world's population lack access to neuropsychological services for a myriad of reasons (Allott & Lloyd, 2009; Joosub, 2019; Romero et al., 2009).

Providing culturally competent neuropsychological assessment is seriously challenging and there are many factors that contribute to inequalities in neuropsychological service provision. The challenges in meeting the needs for neuropsychological rehabilitation are no less prevalent across the globe (See Chapter 13).

The COVID-19 pandemic has further highlighted these challenges. There is increasing evidence of long-term neurological and neuropsychological sequelae due to severe COVID-19 infection (Kirby, 2020). Black and minority ethnic populations in western countries are disproportionately affected by COVID-19, which has also been devastating in many Low and Middle-Income Countries (LMICs). The pandemic highlights the growing and urgent need to understand, identify and effectively address the challenges in delivering culturally appropriate neuropsychological assessment and neuropsychological rehabilitation.

In this chapter, we will discuss the challenges neuropsychology is facing in the delivery of effective services to everyone in need of them globally, with a focus on neuropsychological assessment. In Chapter 14, we will discuss some practical ways to respond to the challenges.

The challenges

A complex set of interlinked and interdependent challenges involving individuals, health care systems, service providers, neuropsychological training, and neuropsychological tests contributes to inequalities in neuropsychological assessment quality and quantity. These issues affect migrants (immigrants, refugees, and asylum seekers), ethnic minorities, and indigenous groups in regions with neuropsychological services that are well-established for the ethnic majority (e.g., North America, Western Europe, Australia, and New Zealand). In countries where neuropsychology is less established, particularly LMICs, these challenges are relevant to both the ethnic majority and minority groups. A model illustrating these complex interacting factors is available at (https://drive.google.com/file/d/1HcqldEVOxcaimumk1gIAWY_KEo3Hz9nl/view?usp=sharing).

Challenges in access to neuropsychological services – the five “A's”

We suggest that the main challenges that create inequalities in access to neuropsychological services to the aforementioned groups relate to: (a) awareness, (b) acceptability, (c) availability, (d) accessibility, and (e) affordability. The interplay of these challenges leads to under-diagnosis and under-treatment of neuropsychological disorders.

Awareness and acceptability

Lack of awareness of, and stigma associated with, neurological conditions like dementia (Aghvinian et al., 2020; Kenning et al., 2017; Nielsen & Waldemar, 2016), and lack of awareness of potential benefits of neuropsychological services act as barriers to access. These barriers are particularly significant in LMICs, and to many immigrants and ethnic minority groups in countries where neuropsychology is established (Romero et al., 2009), and are likely to be evident in other marginalized populations as well. Even when migrants and people from ethnic minorities are aware of neuropsychological services, personal and environmental factors, and issues affecting the relationship between the patient and the healthcare provider can lead to poor acceptability and reduced help-seeking of neuropsychological services (Leong & Kalibatseva, 2011; Terrell & Terrell, 1983). In contrast, in many non-western countries, particularly in Asia, the acceptability of neuropsychological services is poor due to the dominance of the medical model and a lack of integration of neuropsychological services in the healthcare system (Fujii, 2011). Together, lack of awareness and poor acceptability leads to reduced help-seeking and a low rate of referral for neuropsychological assessment and rehabilitation.

Availability

Perhaps the biggest challenge is the paucity of skilled neuropsychologists across the globe (Grote & Novitski, 2016). The availability of neuropsychologists with relevant knowledge and clinical skills training is often disproportionate to the population (Kasten et al., 2021). These disparities are most evident in LMICs, especially in Asia and Africa, where no specialist training or accredited qualification exists (Ponsford, 2017) but also evident in some European (Hokkanen et al., 2020), and other High-Income Countries (HICs). There is also a severe shortage of qualified culturally and linguistically diverse neuropsychologists to work with international migrants and ethnic minorities in countries where neuropsychology is well-established, which may impede access to a fair neuropsychological assessment in this group (Rivera Mindt et al., 2010). The situation is similar in low-resourced multicultural and multilingual settings like South Africa (Laher & Cockcroft, 2017) and India.

High-level academic training programs in clinical neuropsychology are available in many HIC's (Hokkanen et al., 2020). However, lack of in-depth theoretical and supervised clinical skills training with diverse cultural groups in the training programs is another major barrier to accurate neuropsychological assessment in ethnic minority patients (Baber, 2020; Elbulok-Charcape et al., 2014; Franzen et al., 2020a).

Accessibility

Reliable neuropsychological services, even when available, may not be accessible to all segments of the population. Due to inequitable access to specialists (neurologists and psychiatrists) (Saadi et al, 2017), many immigrants and people from ethnic minorities and other socially disadvantaged groups are less likely to be referred to neuropsychologists. Access to services is also urban biased, limiting access to those from rural communities.

Affordability

Lastly, apart from a few countries where neuropsychological services are covered by health services or by health insurance, unaffordability also limits the utilization of neuropsychological services, particularly when there are differences in service provision between public and private hospital sectors in some countries like South Africa (Watts & Shuttleworth-Edwards, 2016) and India. Additionally, ethnicity-related disparities in health insurance in HICs like the U.S.A. (Rivera Mindt et al., 2010) also restrict access to neuropsychological services.

Sociocultural factors that challenge the validity of neuropsychological assessment

From the clinician's side: cultural competence

Multicultural competence is a fundamental skill for neuropsychologists working with patients in cross-cultural situations. Clinical neuropsychology is cross-cultural “when there are significant cultural or language differences between the examiner, examinee, informants, tests, and/or social context” (Judd et al., 2009). Based on this definition, multicultural competence in neuropsychology can broadly be considered as the clinician's (a) awareness, knowledge and attitude regarding the patient's culture and (b) the skills, knowledge and experience necessary to communicate effectively, understand the way the symptoms may manifest, conduct the clinical interview, tailor the neuropsychological assessment (appropriate test selection, adaptation/translation and administration of tests, accurate scoring, interpretation, and case formulation), effectively communicate the neuropsychological findings with the patient, family and relevant others, and execute neuropsychological interventions that meet the social, cultural and linguistic needs of the patient...