Lecture 7: Case study: Understanding HIV risk in the aids Pandemic's Epicentre

The epicentre: eastern/southern Afrika. 10% of the world population lives there. 75% of all people infected with HIV and 75% of newly infected people live there. 

Differences between psychology and anthropology

Anthropology: how individuals’ behaviour is shaped more by group norms and values, but they have been too focused on group norms. They studied only the cultures and took themselves as the norm and the other as needed of explanation. We still see this today. But, our own point of view needs explanation too. The individual perspective of a culture lacked, not everyone in a culture is the same. The lay people still see their own culture as the norm and that everyone within a culture thinks the same. 

  • The cultural difference within nations and cultural similarity across nations. 
  • People think that the way they learned it, is the way it should be/ it ought to be. 

Cultural relativism: becoming aware that we are also trained to see the world a certain way. The opposite of ethnocentrism. Differences between groups of people are not biological but cultural (‘man-made’/ taught). Franz Boas: "civilization is not something absolute, but is relative, and our ideas and conceptions are true only so far as our civilization goes”. cultural relativism has consequences for data collection. 

Cross-cultural research (speciality of anthropologists) 

Data collection: it suggests that the data is out there, has a form/shape, regardless of who finds it. That's not true, data is not easy to find. A lot of the time people just ask what they want to know, but when asked sensitive questions (about HIV for example), people don't always answer honestly. Also, our concepts of things/situations aren't always the same. For example, marriage is very different in the West, then in Afrika. 

Ethnographic research: a qualitative research method centred upon direct and sustained, naturalistic interaction with people in the context of their daily lives in an attempt to grasp the world from their perspective.

  • Etic/outsiders’ perspective: e.g. In ‘experience-distant’, biomedical concepts 
  • Emic/insiders’ perspective: ‘experience-near’, locally meaningful concepts and classifications

How to gain the trust of a culture: participate in the daily lives, activities. Trying to bond with the people. Bodily experiencing helps to understand the people.  

Differences in world views: Gender

Malawi: you squat down when talking to someone older. Social hierarchy is much more related to age/seniority than gender. Gender not a universal social stratifier in that society. In Malawi, you have words for a younger and older sibling, instead of brother or sister. 

Cultural differences in health

Everywhere people try to make sense of health problems and seek ways to prevent and cure these. So many profound differences about what health attains and how you can achieve this. 

  • When is a body alive/dead/healthy/ill?
  • Body-mind division
  • Individual vs social body
  • Naturalistic vs personalistic causes of illness 

Health & illness explanations worldwide 



Illness explained as caused by natural elements

Cause located in individual body or natural environment 

Explanatory models are restricted to illnesses 

Illness explained as caused by a purposeful act of an agent 

‘Real’ cause located in social or spiritual world 

Part of larger explanatory models of misfortune 

Prevention: Avoid natural forces or conditions that may directly disrupt bodily functions 


Prevention: Follow moral, social, religious guidelines.

NB Prevention at other levels may be considered futile! 

Treatment: Find out WHAT caused illness 

Treatment: Finding out WHO caused illness and WHY 

NB Treating the body without addressing ‘real cause’ is senseless... 


Biomedical ‘belief’ system is very superficial. The biomedical doctor says take this pill and your body will be restored. This system is a belief system too. Have you seen a virus? We have been told that it works like that, and believe it. 

HIV/aids in the pandemic’s epicentre southern Africa 

Telling people is not enough.

HIV is not a very contagious virus; you need a lot of the virus and it should be released in the bloodstream. Probabilities of getting HIV when having unprotected sex: women: 1 in 500; men: 1 in 1000. Only when semen can get in the bloodstream (wound). Not everyone gets it. The campaigns say: everybody can get HIV, but it is not the reality that people see. 

Problem: HIV continues to spread despite the high levels of awareness. 

What makes this epidemic so extraordinary, why so many people there and not here, so demographically different?

Biological explanations: were there any biological difference, no. 

Cultural explanations: the claimed: stimulation of sex, uncontrolled sexual drive of African women/man. Lineage family. More freedom, not only sex with the husband.

--> it was a comfort for other people: it's them, not us. 

--> then, more epidemics. The cultural explanation did not hold anymore. 

Dr. Paul Farmer: vulnerability approach: “Real cause of most diseases is not in the biological body, but in the social context.” If people have structural deficiencies, it will affect people's health. = ’Structural violence’: social/political/economic structures or institutions which harm people by preventing them from meeting their basic needs. 

Structural vulnerabilities approach to HIV infection (paper Parker 2001)

Marginalization & impoverishment: Malnourished bodies are more susceptible to any kind of infection, including HIV. Also, low-quality living circumstance, health care services, education, infrastructure etc. If you don't have access to medication/healthcare, that will also increase the infection rates. High-risk survival strategies (migration, transactional sex) - pushing men to migrate, which leads to more short-term sexual relationships, when they migrate back, they spread the disease. 

Gender inequality: “women most disadvantaged!” -  the only thing that women have, is their body to survive. Women are especially disadvantaged in poverty. Women receive something for sex, in the West we interpret that as prostitution, but it is not like that. 

The ‘Transactional Sex’ paradigm: Assumption that low social and economic status forces women to direct exchanges of sex for resources needed for survival. It underlies much of the current thinking on African women’s persistent engagement in risky sexual practices. It leads to the conclusion that women must be economically empowered to halt AIDS pandemic. --> focus right now: Women, make them independent. Give them the choices that we think they want to make. 

The sexual and partnership choices are very risky: 

  • Quick acceptance of proposals, even from unknown men, they form relationships extremely quick (for example within one day); 
  • Both men and women have extramarital relationships, relationships are quite short (frequent partner change); 
  • Low condom use, the use of condoms is connected to HIV/Aids, so if someone suggests the use of condoms, it is directly connected to HIV. 
  • Also, people with HIV will die soon and cannot reciprocate help she gets. Or she will not get help because she will die soon. 

Men and women really need each other. Men do all the work (build houses, get food, get soap etc.). Women can’t do it; it is looked down on. A single woman is seen as strange, people will not help them, especially if she declined a husband. 

Sexual norms & values in southern Malawi:

  • Elaborate initiation rites for sexual instruction, especially of girls 
  • Sex is almost a sacred undertaking, to be performed with the utmost care, very powerful forces come with it. There are a lot of sexual rituals (for example the death of a partner). 
  • Vital for personal health, relationship stability, and community survival 
  • Should be enjoyable for both partners, there is a very positive attitude towards sex. 

But what is ’safe’ sex? What do professionals think of sex?

“Risky” sex in Mudzi (Malawi)?

Physical risk 

Social risk

    • HIV infection 
    • Losing a ‘good’ husband (e.g. best are those working abroad...) 
    • Losing community support (e.g. being single, not accepting proposal) 
    • Remaining childless 

In the social risk perspective, condom use and abstinence are risky. 

Intersecting forces that causes HIV to spread. 

  • Biological vulnerability - women are more at risk (vaginal skin tears easily)
  • Structural economic deprivation
  • Cultural sex & gender & health/illness constructs 

--> Individual perceptions of risk and efficacy (etc) shaped by these wider societal, cultural and material factors! None of these can be meaningfully disentangled from the others. 

Reasons for sexual relationship: Gendered division of tasks: men provide extra’s, build house etc / Conformation to ideal of being married = respectable status, community inclusion, safety net / Sex is vital for good health & community survival (only through children can one become a real woman) / Lust & love  

So... Women’s decision to engage in (high-risk) sexual relationships partly instigated by the desire for direct material benefit. But that is rather a result of cultural constructs than the difference between male wealth/female poverty. Additional motivations are not directly related to material support that a man might provide. 

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Lecture 8: Problems and treatment of traumatized refugees in Western countries 

Lecture 8: Problems and treatment of traumatized refugees in Western countries 

ARQ: organization helping people after traumas.

Who are refugees? Because conflict or persecution they have to flee their country. No longer in their own country, having to cross borders and it is not possible to go back home safely. Countries have a legal obligation to help refugees and are not allowed to send them back if it is not safe. When do you stop being a refugee: when they can go back? When they integrate in their new country?

2017: 14.716 new asylum application. Mostly from Syria (2.202) and Eritrea (1.095). 14.490 people reunited with their families in the Netherlands. 


Syrians are the largest group of refugees in the Netherlands. 40% of male and 45% of female recognised refugees have psychological complaints (anxiety, depression, PTSD).  

The refugee (mental) burden:

  • War, organized crime, persecution 
  • Leaving everything behind
  • Fleeing
  • Asylum procedure: very stressful
  • Integration 
  • Loss of status: for example, when you were a doctor in your home country and have to be a cleaner in the new country. 
  • Takes a long time to be reunited with your family 
  • Conflict in the home country is ongoing, they keep checking the news, very stressful. 

Posttraumatic stress disorder 

  1. Exposure to actual or threatened death, serious injury, or sexual violence
  2. Intrusion symptoms(need 1 for diagnosis) 
    1. Intrusive memories: the memory keeps the same vividness. 
    2. Destressing dreams
    3. Dissociative reactions 
    4. Cued psychological distress
    5. Cued physiological reactions
  3. Avoidance symptoms(need 1 for diagnosis) 
    1. Avoidance of memories, thoughts, feeling 
    2. Avoidance of external reminders
  4.  Cognitions and mood symptoms(need 2 for diagnosis)
    1. Inability to recall important aspect of event
    2. Exaggerated negative beliefs or expectations
    3. Distorted cognitions leading to blame 
    4. Persistent negative emotional state
    5. Diminished interest or participation in activities
    6. Detachment or estrangement from others
    7. Persistent inability to experience positive emotions
  5. Arousal and reactivity symptoms(need 2 for diagnosis) 
    1. Irritable behaviour and angry outburst
    2. Reckless or self-destructive behaviour
    3. Hypervigilance (extremely alert) 
    4. Exaggerated startle response
    5. Problems with concentration 
    6. Sleep disturbance
  6. Dissociative symptoms
    1. Depersonalization
    2. Derealization 

Complicated grief (persistent complicated bereavement disorder)

Complicated grief is unusually severe and prolonged, and it impairs function in important domains. Characteristic symptoms include intense yearning, longing, or emotional pain, frequent preoccupying thoughts and memories of the deceased person, a feeling of disbelief or an inability to accept the loss, and difficulty imagining a meaningful future without the deceased. Complicated grief affects about 2 to 3% of the population worldwide and is more likely after the loss of a child or a life partner and after a sudden death by violent means. 

PTSD prevalence

  • Dutch general population: 7,4% 
  • Displaced people worldwide: 30,6%
  • Refugees in Western countries: 9%, 5% major depression 
  • Treatment seeking refugees: 14-95%

Predicting PTSD in refugees

Elements that predict PTSD: 

  • 23,6% torture
  • 10% cumulative number of traumatic experiences
  • 10% time since conflict 
  • 3,5% level of political terror in country of origin 
  • I.e. 1/3 predicted by traumatic experiences 

Prediction depression in refugees

  • 22% cumulative number of traumatic experiences
  • 21.9% time since conflict
  • 11.4% torture
  • 5.0% residency status


Guideline for PTSD treatment in adults

  • Trauma-focused cognitive-behavioural treatment (TF-CBT)
  • Eye Movement Desensitization and Reprocessing (EMDR)

Discussion in refugees: should we follow the treatment guidelines in refugees? We have to stabilise them instead of focusing on the PTSD, but now a lot of research is done, and we know it is not true. There is no reason to wait.  

TFT in refugees

  • Narrative Exposure Therapy (NET) is effective 
  • Culturally-Adapted Cognitive Behavioural Therapy (CA-CBT) is effective 
  • TFT is more effective than multimodal treatment
  • TFT reduces PTSD severity and depression

Narrative Exposure Therapy: 

  • Protocol with 10-12 sessions 
  • Laying a lifeline (rope) on the floor, for different memories they put a rock or a flower down. 
  • The other sessions are used for narrative (imaginary) exposure, reliving the memories. 
  • The narrative is also written document, in this way they can give it to someone (children, lawyers). 

EMDR - helps to lose information and boil it down. 

  1. Activating memory, putting it in the working memory
  2. Focus on the event 
  3. Rapidly moving the fingers across the eyes (burden the working memory)
  4. A lot of information has to be processed by the working memory
  5. The memory will become blurry, fewer emotions

If the memory is in the working memory, then it can be changed. 

EMDR study - Discussion


Acceptability of EMDR significantly lower than of stabilisation → For a subgroup of refugees, acceptability needs to be a focus of treatment.  


EMDR and stabilisation equally safe → EMDR may be offered earlier in treatment and to a broader range of refugee patients. 


EMDR and stabilisation equally efficacious → Efficacy of EMDR with refugees needs to be increased. 

  • With a subgroup of refugee patients?
  • Greater number of sessions?
  • More attention to match in explanatory models? 
  • Phased or multimodal treatment?  

Explanatory model: culturally adapted psychotherapy is more effective than unadapted, bona fide psychotherapy for primary measures of psychological functioning. Adaptation of the illness myth was the sole moderator of superior outcomes via culturally adapted psychotherapy. 

Lecture 6: Cultural Aspects of Clinical Neuropsychology

Lecture 6: Cultural Aspects of Clinical Neuropsychology

Culture and Clinical Neuropsychology: Theory

How can culture affect neuropsychological function?

Neuropsychology: study of the relationship between behaviour, emotion and cognition on one hand, and brain function on the other. 

Clinical neuropsychology(NP): assessing and cognitive, emotional and behavioural function after suspecting brain damage for diagnosis and potential treatment. 

Brain damage after trauma, vascular accidents, tumours, toxicity, infections, also (neurodegenerative) diseases, or just ageing. 

NP assessment: 'imperfect index of brain function'

Physical differences: brain - Brain plasticity can be affected by: specialized skill acquisition, enrichment, deprivation, education, health, stress, correlates of differing cognitive mechanisms, experience more generally. 

Cultural neuroscience: field with focus on factors that affect biologicals and psychological processes that reciprocally shape beliefs and norms shared by groups of individuals. 

Physical differences: genetics - Core of nature/nurture interactions!

Heredity: passing on characteristics from parents to children based on genetic material. Although about 99% of genes are fixed, 1% differs across individuals. Genes can have effects that depend on external variables.

Epigenetics: environmental factors cause genes to switch on or off without modification of the DNA sequence. Chemical tags can control genes in specific cells. Epigenetic tags can result from lifestyle choices or specific experience. Some epigenetic tags are hereditary! Part of our genetics that only become available in certain circumstances.

Physiological approach is relatively new! Questions:

  • How can the same physiological characteristics lead to different outcomes depending on one's culture?
  • How can the same culture lead to different outcomes depending on one's physiological characteristics?

The relation between biology and behaviours may depend on the cultural meaningsof behaviours, rather than on the actual behaviours. 

How does culture influence neuropsychological assessment?

Measuring brain function: NP assessment: intelligence; memory; verbal abilities; executive functions; visuo-spatial functions; attention; syndrome-related combinations; general batteries. The scores will be compared to normative data, sometimes with correlations for age or education level. 

Culture and NP assessment: Normative data based on very limited subsample WEIRD patients: which is partial and biased. 

There are several thousands of cultures, and over 6800 language spoken! Relative differences may vary. Biggest commonality is driven by schooling, science and technology (useful information spreads fast!)  

Why would culture affect NP assessment?

Values and meaning: no general agreement on merit responses (what is the right response): eg in the Raven's, do you go for aesthetics or for rules? Attitudes, eg are animals pets or food. 

Modes of knowing: individual task vs collective endeavour: why would it matter what I know when I'm part of a collective?

Conventions of communication: interaction: one-way questions, authority; and the type of questions (both in content and way of asking).

Patterns of abilities: Culture prescribes what should be learned, at what age, and by which gender. Results in culture-specific clusters of skills or abilities that 'belong' with a stage of life or role. Tests need to be appropriate for subject's learning opportunities and contextual experiences. 

Cultural values: culture dictates what is or is not situationally relevant and significant, or even appropriate. Based on values that are not necessarily shared! 

  • One-to one testing relationship with a stranger 
  • Background authority: why follow orders? 
  • Best performance: why try to get a high score?
  • Isolated environment: unusual social situation
  • Special type of communication: unusual language 
  • Speed: why trade off speed for accuracy? 
  • Private, embarrassing or subjective issues 
  • Specific testing materials and strategies


Testing situation: being tested is part of school culture! 

Attitudes that facilitate good performance: motivation, purpose

Elements used in testing: eg objects, situations, stories: animals, foods, plants, natural phenomena. 

Strategies needed to solve task: eg spelling is an artificial task in language with a phonological writing system; eg cardinal direction (north, south, east, west) not used in all cultures.

Language: Linguistic relativity: Whorfian hypothesis: language influences thought. Language use and the meaning differs with a cultural and subcultural background. Correlates strongly with education level, testing language often formal. Important to make test instructions understandable and appropriate!

Education: Accounts for up to 50% of variance in IQ tests, 0.6-38% in NP tests! Double role: increases knowledge of test content; increases familiarity with testing setting and strategies. Schooling increases test performance, smaller increases with each year of schooling. 


Illiteracy: not being able to read or write 

Functional illiteracy: reading and writing is inadequate "to manage daily living and employment tasks that require reading skills beyond a basic level".

Literacy is generally higher in men than in women. 2/3 of illiterates are women. In Europe, North-America and Australia, literacy is closely tied to poverty: functional illiteracy can be high in specific groups!

Research in other countries: US, Canada, Mexico, Bermuda, Italy, Norway, and Switzerland. Investigated function: document literacy, prose literacy, numeracy and problem solving. All countries have significant numbers of people with low skills: between 1/3 and 2/3 do not attain minimum level demanded by increasingly complex knowledge economy. Especially the US and Italy show a large range in skills. Lower document literacy and numeracy also associated with poorer health. Interpreted as causing difficulties to navigate the health care system. Proportionally similar health rating between countries. 

Learning to read reinforces certain cognitive abilities, such as verbal memory, phonological awareness, and visuospatial discrimination. Illiterate individual show lower scores on: naming tasks, verbal fluency, verbal memory, visuo-perceptual abilities, conceptual functions and numerical abilities. 

Illiteracy: More difficulty copying nonsense figures or words. Concrete, real-life situations much easier to process! True for all kinds of tasks: naming, memory, visuospatial, etc. Standard test materials put illiterates at a disadvantage!

Effects of being in a minority group 

Minorities within a culture: different ethnic groups in one country; after migration (especially first-generation); groups with no country. In NP assessment, testing is approached from a majority culture perspective!  

Six potentially distinguishing variables: 

  • Nationality and legality 
  • Relative culture distance to majority culture 
  • Relative language distance to majority language 
  • Normality: how ‘strange’ is the minority culture perceived by the majority? 
  • Reference group: how big is the minority group? 
  • Social image: positive or negative attitudes of the majority group towards a minority group  

Necessity for specific tests and norms - Indication of functional level depends on relative scores. But: not clear hoe specific this needs to be: for each language? Cultural region? Educational level? SES level? Depends on cognitive function in question! Understanding the underlying variables is at least as important as having assess to specific norms. 

Potential psychological consequences of being a member of a minority group:

  • Homesickness – tends to start after 2-3 years and recurs even after long periods of time 
  • Frustration – difficulty in dealing with the environment, discrimination 
  • Isolation 
  • Cultural solitude – lack of understanding 
  • Decreased self-esteem – perceived as foolish or childish 
  • Paranoia – feeling different from everyone else 
  • Anger 
  • Depression 
  • Feelings of failure and/or success – minor successes can be perceived as very significant, also by other group members 


Strong identification with host culture

Weak identification with host culture

Strong identification with heritage culture


Positive attitudes toward host and heritage culture; participate in host culture while maintaining traditions of heritage culture; most successful strategy - least prejudice and greatest social support. 



Weak identification with heritage culture




Negative attitudes toward host and heritage culture; no effort to engage with host and heritage cultures; rare and lest successful strategy; may characterize third culture kids

Discrimination and othering - Stereotypes and prejudice can lead to discrimination, which can be a large problem in contexts where there is intercultural interaction. Discrimination can affect the acculturation process in two ways: 

  1. Identity denial—questioning someone’s cultural identity because he or she does not match the prototype of the culture 
  2. Stereotype threat—anxieties about one’s group’s negative stereotypes lead one to confirm those stereotypes 

Discrimination has a range of negative effects on (mental) health, including High blood pressure; Heart problems; Low birth weight; Depression; Somatization; Risky behaviours such as smoking and alcohol use. 

Discrimination is very hard to study. It can be very subtle (othering). Incidents may not always be remembered or interpreted as discrimination. Effects may be moderated by coping and social support. Still an active research field, but many studies now point in this same direction of discrimination as a health risk. 

Summary part 1 - Neuropsychological assessment aims to provide an index of brain function. Physical differences may emerge based on hereditary and experiential factors. Culture can affect NP assessment in multiple ways: Patterns of abilities, cultural values, familiarity, language, education. Illiteracy affects the development of cognitive abilities. Being a member of a minority group can affect various aspects of well-being: Discrimination and other affect mental and physical health. 

Culture and Clinical Neuropsychology: Practice - clinical aspects

Implications for clinical practice

Neuropsychological practice in a multi-cultural society              Social aspects and care needs

MCI and dementia: how to diagnose?                                         What are the obstacles? 

Prevalence in different cultural groups                                      Solutions: culture-fair screenings 

Aging, prevalence of MCI and dementia

Aging - Cognitive functions decline with age. Not all! Memory and executive functions deteriorate more than vocabulary and world knowledge. Risk of mild cognitive impairment (MCI) and dementia increases with age.  

MCI - Mild cognitive impairment: Cognitive changes that are serious enough to be noticed, but not severe enough to interfere with daily life or independent function. Most common subtype of MCI first presents as memory impairment. Progression to dementia in 10 to 15% of afflicted persons per year. MCI as a precursor for dementia.  

DementiaUmbrella term for symptoms caused by neural disorders, especially cognitive symptoms. Most common causes of dementia:

  • Alzheimer’s disease: 50-80% 
  • Vascular dementia: 20% 
  • Dementia with Lewy bodies 15% 
  • Frontotemporal dementia 5% 

Each have own most prominent symptoms, all interfere with everyday activities. Data come from Western sample! 

How do we screen for dementia? - MMSE: Mini-Mental Screening Exam (Maximum score=30, dementia is indicated for scores below 24) --> screening, not diagnosing! Kinds of items: orientation to time and place; naming; registration (responding to prompts); attention and calculation; recall; repetition; complex command (figure). 

DSM 5 name for dementia: Major neurocognitive disorder 

Obstacles to good diagnosis

Prevalence - MCI prevalence = 3.0 - 19.0%, with a risk of developing dementia of 11-33% within 2 years. Dementia prevalence = 5.4 - 6.4% (≥60 years). Not the same everywhere! Related to wealth! Higher prevalence MCI and dementia described for immigrant populations in USA and UK 

More dementia in poorer countries: the predictions are that the proportion of people with dementia will increase under low- and middle-income countries.  

Migrant groups in the Netherlands - In the Netherlands, 11.1% of the population in 2010 consisted of migrants (8.5% from outside the EU). Turkish, Moroccan and Surinamese people make up 65% of all non-western immigrants in NL (i.e. born abroad to foreign parents). First-generation non-western immigrants are aging: 4% of population in 2013, to 15% in 2039. Native Dutch older group grows a bit less fast: 18% to 28%. Older immigrants in the US show a higher prevalence of risk factors for dementia. Diabetes, cardiovascular disease, obesity, smoking, hypertension, high cholesterol, low SES.

Care experts - Among European dementia experts, 64% find it more challenging to assess dementia in patients from ethnic minorities. Reported problems include: Language proficiency (88%); Presentation of symptoms (84%); Educational level (84%); Lacking assessment tools (68%); Lacking cultural knowledge (44-56%). 

Over- and underdiagnoses - Accurate diagnosis: High sensitivity(good true detection) and high specificity(low false detection). 

Findings from Denmark: Belief: dementia is underdiagnosed in migrant groups; Finding: in general health care, immigrant groups show different rates of diagnosis than native Danish. Turkish, Pakistani and Ex-Yugoslavian groups (no difference!). Finding: Age effect: overdiagnosis for younger people (<60y) and underdiagnoses for older people. Belief supported, but only for the older group! 

Reasons for over and underdiagnoses? 

Differences in help-seeking behaviour 

  • Stigma on illness, especially dementia 
  • More inclined to solve problems within the family 
  • Insufficient knowledge of dementia 

Difficulty with the health care system 

  • Language barrier 
  • Literacy skills 

Assessment and diagnosis 

  • Language & literacy 
  • Test-wiseness   

Examples of culture-fair diagnostic tool: CCD

Culture-fair diagnosis - From the first week: culture-fair testing! From the previous part: need to account for cultural values, familiarity, language, different education levels, interpretation of norms, etc 

Daily practice in a memory clinic: 

  • In which province are we? (MMSE) 
  • Who is our prime minister? (CST) 
  • Read and follow this instruction (MMSE) 
  • What is this? 

Cross-cultural dementia screening (CCD): Developed in Amsterdam, Validated in 2009, norm data from 2013. Instructions in own language; Culture-free/fair items; Nonverbal as much as possible. Domains: Memory, mental speed, executive function 

CCD tasks:

Memory: Objects testremember objects among distractors 

  • Household items shown in coloured pictures 
  • Immediate and delayed recognition 

Mental speed and divided attentionDots test: connect objects in order of increasing numbers 

  • Adjusted Trail-Making Test, looks like dominoes 
  • Using black and white dominoes instead of numbers and 

Mental speed and inhibitionSun-moon test: cross-name pictures in own language 

  • Adjusted Stroop task using only pictures 
  • Takes speed and accuracy into account 

Interpreters - CCD developed in 6 languages: Dutch, Turkish, Moroccan- Arabic, Moroccan-Tarifit, Sranantongo, Sarnámi-Hindustani. Interpreters that are not family are preferred. Shameful for patient, covering up by interpreter. Native testers are ideal! Interpreters no longer covered by Dutch insurance since 2012. 

CCD evaluation- Total battery:

  • Sensitivity (true detection of dementia): 85% 
  • Specificity (true detection of no dementia): 89% 

(MMSE: sensitivity=76%, specificity=.83)

All subtests showed good individual sensitivity and specificity. Strongest predictors of dementia: Objects test B (delayed) and Sun-Moon test B (Interference). 

Dementia research in migrant groups - Evidence on dementia prevalence is rare in many regions 

  • Denmark: Turkish immigrants show a higher prevalence of dementia than native Danish (13.5% vs 7.0%)
  • Netherlands: SYMBOL study(SYstematic Memory testing Beholding OLder Migrants)

Symbol study - Aim: to assess the prevalence of MCI and dementia in community-dwelling migrants ≥ 55yrs, and to map their and their caregivers’ health care use and care needs. Hypothesis: prevalence

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