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Struggling for clarity: cultural context, gender and a concept of depression in general practice
Umeå University, Faculty of Medicine, Public Health and Clinical Medicine, Family Medicine.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Many depressed patients attend primary health care, and minority-group patients often see general practitioners for depressive symptoms. The diagnosis and classification criteria of depression and guidelines for management are based on symptoms. However,expressions of depression can vary with culture and gender but the diagnostic tools and guidelines are not adapted to gendered or cultural context and have shown to be poorly applicable in clinical practice. The purpose of this thesis was to analyse how socio-cultural factorswith focus on gender and ethnicity and their intersections- could influence the concept of depression from the perspectives of the patient and patient descriptions, of medical experts as well as general practitioners. By viewing these different perspectives I have tried to illustrate how depressive symptoms are expressed and interpreted in different gendered socio-cultural contexts and how they become a disease entity. Furthermore, I want, in particular, to illustrate a variety of difficulties that GPs may face during the process of care when meeting and treating men and women from different countries showing symptoms which may indicate depression.

Study I. The aim of the study was to explore the reasons for and patterns of attendance among Roma women in primary health care and to shed light on health problems of the Roma. Four Roma women were interviewed in-depth. The data were audiotaped and analysed according to Grounded Theory. The resuIts showed that the daily life of women was characterized by marked hierarchical order and rules formed by gender, age and the collective culture. Young women had most rules to follow and if the rules were broken it was easy to end up outside the collective and display depressive symptoms or pain. The gendered, collective culture could both construct and/or form the concept of illness among the Roma women.

Study II. The aim of the study was to highlight the gendered representations of lay persons´ experiences of depression by drawing on personal stories of depression that appeared in Swedish newspapers. The data were then subjected to a Qualitative Content Analysis. The mediated accounts of depression both upheld and challenged traditional gender stereotypes. The women’s stories were more detailed, relational, emotionally oriented, and embodied. The portrayal of men was less emotional and expressive, reflecting hegemonic patterns of masculinity. The media representations of gendered healthrelated beliefs and behaviours may influence the way patients, physicians and other health care professionals understand and communicate about issues of mental health and depression.

Study III. The aim of the study was to explore how authors of medical articles wrote about different symptoms and expressions of depression in men and woman from various ethnic groups as well as to analyse the meaning of gender and ethnicity for expressions of depression. Through a search in the medical database PubMed 30 scientific articles were identified and included in the analysis. The result and the discussion section of each article was analysed with Qualitative Content Analysis. The analysis showed that culture and gender formed the expressions of depression, how depression was interpreted and the diagnosis of depression. The analysis of the articles identified a western point of view, which could lead to “cultural or gender gaps” and which could also influence the diagnosis of depression.

Study IV. The aim of the study was to make a qualitative analysis of medical research articles in order to get a broader view of explanations of depression in men and women in various ethnic groups. Through a search in the medical database PubMed 60 scientific articles were identified and included in the analysis. The result and the discussion section of each article was analysed with Qualitative Content Analysis. The explanations for depression in our study have a strong emphasis on socio-cultural causes with focus on depressed persons from non-western minority groups. Even so, discussion about cultural or gendered explanations for depression was almost missing. We interpreted that the view of minority groups in the articles could be described as a view of “others”. The view of “othering” increases risks for cultural and gender gaps, such as biased scientific knowledge, medicalization of social problems, cultural stereotypes, risk for misdiagnosis of men´s depression, and affects the quality and care of depressed patients.

Studv V. The aim of the study was to explore and analyse how GPs think and deliberate when seeing and treating patients from foreign countries who display potential depressive symptoms. The data were collected in focus group and individual interviews with GPs in northern Sweden and analysed by Qualitative Content Analysis. The study showed that patients’ early life events of importance were often unknown which blurred the accuracy. Reactions to trauma, cultural frictions and conflicts between the new and old gender norms made the diagnostic process difficult. The patient-doctor encounter comprised misconceptions, and social roles in meetings were sometimes confused. GPs based their judgement mainly on clinical intuition. Tools for management and adequate action were diffuse. There is a need for tools for multicultural, general practice care. It is also essential to be aware of the GPs’ own conceptions to avoid stereotypes and not to under-or overestimate the occurrence of depressive symptoms.

Conclusion: The concept of depression is always situated. The gendered socio-cultural norms, beliefs and behaviours can both construct the concept of illness and influence patients’ experiences and expressions of depression as well as form the patient-doctor encounter. The knowledge of medical “experts” is based on a dominating, western view of knowledge, which defines diagnosis and classification criteria of depression as well as guidelines for management. GPs are struggling for clarity between the medical and the clinical practice. The multicultural appearances of depressive symptoms are a challenge for GPs but it is a challenge for society to improve the life circumstances which can lead to a depressed mood and suffering.

Place, publisher, year, edition, pages
Umeå: Umeå university , 2009. , 54 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1296
Keyword [en]
depression, gender, ethnicity, qualitative research, general practice
National Category
Family Medicine
Research subject
Family Medicine
Identifiers
URN: urn:nbn:se:umu:diva-26189ISBN: 978-91-7264-869-2 (print)OAI: oai:DiVA.org:umu-26189DiVA: diva2:240760
Distributor:
Allmänmedicin, 901 87, Umeå
Public defence
2009-10-23, E04, Umeå Universitet, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2009-10-06 Created: 2009-09-29 Last updated: 2010-01-18Bibliographically approved
List of papers
1. Health, attitude to care and pattern of attendance among gypsy women: a general practice perspective
Open this publication in new window or tab >>Health, attitude to care and pattern of attendance among gypsy women: a general practice perspective
2001 (English)In: Family Practice, ISSN 0263-2136, Vol. 18, no 4, 445-448 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: There is a lack of knowledge about health and attitude to care among gypsies.

OBJECTIVES: The aim of this study was to explore the reasons for and patterns of attendance among gypsy women in primary health care and to shed light on health problems of gypsies.

METHODS: Four gypsy women, frequently attending a primary health care centre, were interviewed in depth. Data were analysed according to grounded theory. Additional facts were received from record files.

RESULTS AND CONCLUSIONS: The gypsy women seldom approached the health centre alone but paid a visit together with relatives or friends. The women usually presented the same type of symptoms, often pain, headache and depression, and obtained the same type of diagnosis and treatment. The symptoms had an acute character and the women wanted immediate access. A collective pattern, a hierarchical order and a strict rule system characterized the gypsy life and coloured the relation to health and illness. Young women were especially vulnerable and could easily end up outside the collective and display symptoms.

Place, publisher, year, edition, pages
Oxford: Oxford University Press, 2001
Identifiers
urn:nbn:se:umu:diva-26179 (URN)11477054 (PubMedID)
Available from: 2009-09-29 Created: 2009-09-29 Last updated: 2009-10-06Bibliographically approved
2. Gendered portraits of depression in Swedish newspapers
Open this publication in new window or tab >>Gendered portraits of depression in Swedish newspapers
Show others...
2008 (English)In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 18, no 7, 962-973 p.Article in journal (Refereed) Published
Abstract [en]

Mass media are influential mediators of information, knowledge, and narratives of health and illness. In this article, we report on an examination of personal accounts of illness as presented in three Swedish newspapers, focusing on the gendered representation of laypersons' experiences of depression. A database search identified all articles mentioning depression during the year 2002. Twenty six articles focusing on personal experiences of depression were then subjected to a qualitative content analysis. We identified four themes: displaying a successful facade, experiencing a cracking facade, losing and regaining control, and explaining the illness. We found both similarities and differences with regard to gendered experiences. The mediated accounts of depression both upheld and challenged traditional gender stereotypes. The women's stories were more detailed, relational, emotionally oriented, and embodied. The portrayal of men was less emotional and expressive, and described a more dramatic onset of depression, reflecting hegemonic patterns of masculinity.

Place, publisher, year, edition, pages
Newbury Park, Calif.: Sage Publications, 2008
Keyword
depression, experiences, gender, illness and disease, media
Identifiers
urn:nbn:se:umu:diva-10126 (URN)10.1177/1049732308319825 (DOI)
Available from: 2008-06-18 Created: 2008-06-18 Last updated: 2011-04-11Bibliographically approved
3. "The Western gaze": An analysis of medical research publications concerning the expressions of depression, focusing on ethnicity and gender
Open this publication in new window or tab >>"The Western gaze": An analysis of medical research publications concerning the expressions of depression, focusing on ethnicity and gender
Show others...
2010 (English)In: Health Care for Women International, ISSN 0739-9332, E-ISSN 1096-4665, Vol. 31, no 2, 100-112 p.Article in journal (Refereed) Published
Abstract [en]

Our aim of this study was to explore how authors of medical articles wrote about different symptoms and expressions of depression in men and women from various ethnic groups as well as to analyze the meaning of gender and ethnicity for expressions of depression. A database search was carried out using PubMed. Thirty articles were identified and analyzed using qualitative content analysis. Approaches differ with regard to how depression is described and interpreted in different cultures in relation to illness complaints, illness meaning, and diagnosis of depression. Articles often present issues based on a Western point of view. This may lead to “cultural or gender gaps,” which we refer to as “the Western gaze,” which may in turn influence the diagnosis of depression.

Identifiers
urn:nbn:se:umu:diva-22879 (URN)10.1080/07399330903067861 (DOI)000275687500001 ()
Available from: 2009-05-19 Created: 2009-05-19 Last updated: 2010-12-07Bibliographically approved
4. "The others": a qualitative analysis of explanations of depression in research publications focusing on ehtnicity and gender
Open this publication in new window or tab >>"The others": a qualitative analysis of explanations of depression in research publications focusing on ehtnicity and gender
Show others...
(English)Article in journal (Other academic) Submitted
Identifiers
urn:nbn:se:umu:diva-26182 (URN)
Available from: 2009-09-29 Created: 2009-09-29 Last updated: 2010-02-10Bibliographically approved
5. Recognition of depression in people of different cultures: a qualitative study
Open this publication in new window or tab >>Recognition of depression in people of different cultures: a qualitative study
2009 (English)In: BMC Family Practice, ISSN 1471-2296, Vol. 10, 53- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Many minority group patients who attend primary health care are depressed. To identify a depressive state when GPs see patients from other cultures than their own can be difficult because of cultural and gender differences in expressions and problems of communication. The aim of this study was to explore and analyse how GPs think and deliberate when seeing and treating patients from foreign countries who display potential depressive features.

METHODS: The data were collected in focus groups and through individual interviews with GPs in northern Sweden and analysed by qualitative content analysis.

RESULTS: In the analysis three themes, based on various categories, emerged; "Realizing the background", "Struggling for clarity" and "Optimizing management". Patients' early life events of importance were often unknown which blurred the accuracy. Reactions to trauma, cultural frictions and conflicts between the new and old gender norms made the diagnostic process difficult. The patient-doctor encounter comprised misconceptions, and social roles in the meetings were sometimes confused. GPs based their judgement mainly on clinical intuition and the established classification of depressive disorders was discussed. Tools for management and adequate action were diffuse.

CONCLUSION: Dialogue about patients' illness narratives and social context are crucial. There is a need for tools for multicultural, general practice care in the depressive spectrum. It is also essential to be aware of GPs' own conceptions in order to avoid stereotypes and not to under- or overestimate the occurrence of depressive symptoms.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-26181 (URN)10.1186/1471-2296-10-53 (DOI)19635159 (PubMedID)
Available from: 2009-09-29 Created: 2009-09-29 Last updated: 2012-05-31Bibliographically approved

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