Cultural influences on perceived quality of life

Cultural

Influences

on Perceived Quality

of Life

Patricia A. Marshall

CIENTIFIC AND technological advances in medical care make possible the prolongation of life for a growing number of patients. The efficacy of life-sustaining therapies in thwarting the inevitability of death is unquestionable. However, the goal of survival is only one dimension of patient care. Health professionals and consumers alike are increasingly concernedabout the quality of life in the context of experiencing and adjusting to chronic or acute illness. In the last decade, quality of life has becomea factor in medical decision-making,‘J and the concept has been used in studies examining psychosocial factors, life satisfaction, and physical impairment in diverse patient populations.3-7Quality of life may refer to broad social indicators such as income, housing, and education; it also refers to an individual’s experience of emotional and physical well-being. Numerous instruments have been designed to measureboth the subjective and objective dimensions of quality of life.8,9 Investigators use various definitions of what constitutes quality of life, and there is considerablediversity in their methodological approachesto the problem. lo-i3 Although the literature on quality of life and its relationship to health and illness is increasing, there have been few systematicattemptsto examine cross-cultural aspectsof the concept.14-i7This article briefly explores cultural influences on perceived quality of life with special attention to the cultural construction of individual well-being. Problemsin the cross-cultural use of quality of life instruments in health researchare addressed,and suggestionsfor the development of culturally sensitive methodsto assessquality of life are outlined.

S

From the Medical Humanities Program, Loyola University Snitch School of Medicine, Maywood, IL. Patricia A. Marshall, PhD: Assistant Director, Medical Humanities Program. Address reprint requests to Patricia A. Marshall, PhD, Medical Humanities Program, Loyola University &itch School of Medicine, 2160 S First Ave, Maywood, IL 60153. 0 1990 by W.B. Saunders Company. 0749-2081/90/06@#-0006$0.500/0

278

CULTURE, ETHNICITY, AND ACCULTURATION DEFINED

Culture refers to learned patterns of behavior, beliefs, and values sharedby individuals in a particular social group; it implies a set of assumptions about the nature of the social and physical environment and one’s place within it. Perhaps the most important aspectof culture is that it provides human beings with a framework for understanding experience. Culture acts as an interpretive guide for the symbolic significance individuals attach to human behavior, human interactions, and the material products of human life. Geertz’* defines culture as, “an historically transmitted pattern of meaningsembodiedin symbols, a systemof inherited conceptions expressed in symbolic form by means of which men communicate, perpetuate, and develop their knowledge about and attitudes towards life.” Ethnicity is characterized by an individual’s identification as a memberof a social group with a common racial, national, tribal, religious, or linguistic background. The majority of nation states throughout the world are composedof diverse ethnic groups. Thus, it is possible to speak in broad terms about American culture or the American worldview, but most Americans will identify themselves as members of a particular ethnic group. To identify oneself as African American suggestsa life experiencequite different from that implied by an ethnic identification of, for example, Vietnamese, Italian, Polish, or Mexican. Acculturation or enculturation is the process through which one learns to be a member of a specific culture or ethnic group. This socialization process occurs within the context of family and community relationships and ensuresthat children will become skilled manipulators of their social, emotional, and physical environments. Acculturation may also refer to the process through which one ethnic group assimilatesand adaptsto another ethnic group or another culture. For example, a recent emmigrant from Mexico to the US will experience an adjusted diet, a new language, and

Seminars in Oncology Nursing, Vol 6, No 4 (November),

1990: pp 276-264

CULTURAL INFLUENCES AND QUALITY OF LIFE

new social customs, and, in time, may adopt some of the values of the dominant culture. Acculturation may be assessedby examining the extent to which one ethnic group conforms to the language and customsof another ethnicity. The key element in acculturation is the degreeto which underlying values are incorporated into individual life styles and attitudes. Many individuals are bilingual or multilingual, but a fluent grasp of language does not in itself indicate acculturation within a society or ethnic group. Some individuals are bicultural, implying an ability to understandand to function within the cultural constraintsof two particular ethnic groups, These individuals are able to masterthe social nuances suggestedby the process of acculturation, and they are more likely to accommodatetheir behavior to the cultural expectationsof particular settings and relationships. CULTURE, ILLNESS, AND QUALITY OF LIFE

Cultural and ethnic background influence every aspectof the experienceof both health and illness, including the meaning attached to physical symptoms,19-23responses to pain,24325and the identification and selection of medical care.26327 The cultural construction of AIDS in Botswana28 highlights the importance of underlying explanations of diseaseand therapeutic remedies thought to be efficacious. Boswagadi is one manifestation of m&la, a diseasethat is believed by natives of Botswana to result from the violation of sexual taboos. Symptomsinclude aching legs and general bodily pain, urinary incontinence, diarrhea, and stomach pains. Some traditional healers believe that AIDS is boswagudi. Although certain healers are cynical about their power to cure thoseafflicted with the disease, others are more optimistic. One healer said, “Of courseI can cure it. I useherbsto boil with water and give (it to) the patient to drink or inhale. ’ ’ *’ Assessmentsof quality of life, including the effect of illness, must be understoodwithin the cultural boundaries that maintain and reinforce life experience.Cultural beliefs as well as personalexperience directly influence appraisal of symptoms and stimuli and determine not only which conditions are perceived as threatening and socially or physically constraining, but also the manner in which they are discussed. In interviews with in-

dividuals suffering from chronic neurasthenia in the People’s Republic of China, Kleinman and Kleinman found that although many patients were clinically depressedand had other psychiatric disorders, their primary complaints were somatic, not psychosocial. One patient with the classic symptomsof Major Depressive Disorder believed he had a serious heart condition although he was repeatedlyreassuredthat his heart was normal and that his physical symptoms were associatedwith anxiety. The patients’ preference to discuss physical rather than psychological distress is indicative of the way in which symptom-reporting is culturally sanctioned. Thus, it was culturally appropriate for the patients with chronic neurastheniato talk about headaches,dizziness, weakness,and a lack of energy; it was not culturally sanctioned to discuss problems in personal relationships or concerns about work or finances. This type of cultural patterning in relation to idioms for psychological distress has been observed in other societies, including that of the US. Perceptions of quality of life are embeddedin cultural beliefs about what constitutes normality and health. Value structures play a crucial role in the cultural patterning of illness30*3’ and in the cultural expression of personal well-being. Body image and physical appearance,for example, are often viewed as concrete manifestations of health and wellness. However, the value attachedto specific body types vary considerably across cultures.32Although obesity is socially stigmatized in the US,33in many countries fatnessis associated with health and prosperity. The symbolic meaning attachedto physical appearancehas important clinical implications, especially for compliance with medical treatment. Lock34 cites the case of a 20month-old obesechild of a first generation Greek mother who refusedto return to a clinic after being encouragedby the pediatrician to change the baby’s diet to reduce her weight. The experience of well-being and a “good” quality of life was, in part, manifestedto the mother by the baby’s robust appearance.The doctor’s definition of obesity and its implications for a reduced quality of life for the child are indicative of a very different cultural norm. The nature and extent of family relationships have particular significance for perceived quality

PATRICIA

of life and life satisfaction generally and, more specifically, for the interpretation of physical malaise, subsequenttreatment, and coping strategies throughout an illness episode. Spinetta35 noted strong differences in family functioning in responseto canceramongMexicans and recent Vietnameseimmigrants receiving treatment at a clinic in SanDiego, CA. Mexican motherswere found to rely on one another rather than on their husbands for support in dealing with childhood cancer, and direct communication with children about their illnesswas viewed as inappropriate. Different issues arosewith the Vietnamesefamilies, who often depend on a tribal spokesmanin negotiations with members outside their community. Clinicians found that it was important to communicate, at least initially, with the tribal leader in discussing treatment concerns. This tradition is foreign to the style of direct communication between clinicians and American families. CROSS-CULTURAL USE OF QUALITY OF LIFE INSTRUMENTS

A considerabledegreeof caution is warrantedin cross-cultural examinations of issues surrounding perceived quality of life, especially in the implementation of standardized measurements.Kleinman36suggeststhat quality of life in the context of health and sickness is directly associatedwith individual meanings attached to the experience of illness: “Illness refers to the perception of symptoms, the experience of disability, the acts of labeling and communicating distress, and the coping processesdrawn on by patients and families to control, order, make sense of, and live with disorder.” Kleiurnan is critical of attemptsto evaluate quality of life that do not account for the personal significance of illness and the manner in which it is embedded and expressed in cultural norms and social relationships. Certain investigators question whether it is actually possible to quantify the diffuse experienceof quality. For example, Bergsmaand Enge13’define the concept of quality of life on four levels: macro, meso, personal, and physical. The macro and meso levels broadly refer to societal and institutional factors that influence quality of life, while the personal level is representedby individuals’ framesof referencefor health and illness. Bergsma and Engel suggestthat measurementsconfined to the level of physical activity are inadequate and

A. MARSHALL

argue that objective measures at all levels are needed. Patrick et a138note that the value orientation and cultural content of standardizedmeasuresfor assessinghealth statusare expressedin several ways including: “(1) the conceptualization of health on which the measure is based; (2) tbe different dimensionsof health described by the measure;(3) the division of each dimension into discrete statements denoting level or degree of health; and (4) the relative weighting of each statement or level within and across different categories of health states.” Translation of questionnaires into different languages adds yet another dimension to the problem of cross-cultural application. Literal translations do not necessarily addressunderlying semantic structures, idiomatic expressions, and cultural interpretations of responsecategories.39 Cultural relativity in the translation of questionnaire items relating to quality of life is an important factor to consider in researchdesign. Results of cross-cultural studies using standardizedhealth measurementscannot be understood apart from their so&cultural context. The adaptation of the Ferrans and Powers Quality of Life Index (QLI) for a non-western setting exemplifies both the problems and the potential for constructing a culturally sensitive and culturally appropriate standardized instrument.4o The Femurs and Powers QLI was designed to measurequality of life for people in good health and for those experiencing illness.i2 The instrument contains 35 items and explores 18 dimensions of life goals, stress,physical health, and life satisfaction. An important aspectof this instrument is that it measuresboth the degree of satisfaction with the specific life domain (eg, How satisfied are you with your family’s health?) and the relative importance of the domain for the individual (eg, How important is your family’s health to you?). The Ferransand PowersQLI was translatedinto Chinese and given in Taiwan to a convenience sampleof 135 men and women in a study of urban adult children caring for older parents.40The Taiwaneseversion of the Femursand PowersQLI was developed using a method of back-translation. Back-translation is a process whereby questions are first translated from one language to another and then translated back again into the original languageby independenttranslators. This process insures an accuratetranslation of the questionnaire

CULTURAL

INFLUENCES

AND QUALITY

OF LIFE

items. Ideally, the new instrument should be comparedwith instrumentspreviously validated for the culture being studied. In adapting the Ferrans and Powers QLI, the questionswere first translatedfrom English to Chinese and then back again to English by independent translators. Several items were changed to conform to cultural mores concerning particular behavioral domains. For example, the question, “How satisfied are you with your sex life?,” became “How satisfied are you with your intimacy with your spouse?” Results of analysessupported the reliability and validity of the instrument, except in the domain of the family. Since the extendedfamily plays an important social role in Taiwaneseculture, additional questions were created for the Quality of Life Index subscalein order to measure family variables. The investigators are currently in the processof retesting the instrument for internal consistency and reliability. This study calls attention to the need for measurementsthat are sensitive to cultural variation in family composition and its influence on family functioning and individual well-being. The SicknessImpact Profile (SIP) is often used in addition to other measuresof quality of life in studies assessingphysical impairment and the effect of illness on social and emotional functioning. The SIP is a standardizedinstrument composedof 136 yes/no statements.It examines physical, social, and psychological dysfunction as a result of sickness.41’42This instrument has been used in cross-cultural studies of illness.43,44 In an attempt to determine whether or not the values attachedto health statesare similar among English-speaking cultures, Patrick et a13*asked health professionals and consumers in Seattle, WA, and London, UK, to rate the severity of dysfunction described in the items contained on the SIP. Results show that judges in the two countries gave similar ratings to most items. However, agreementwas higher on items rated as more dysfunctional than on items rated as less dysfunctional. The investigators point out that, while English-speaking societies may generally agreeupon the relative values assigned to health states, the meaning of the concept of dysfunction and its salience for specific dimensions of health may vary considerably. For example, when considering the impact of sicknesson behavioral functioning, most people would prefer mobility to confinement in a

281

hospital bed or an unrestricted diet comparedwith one that restrictedfat and sodium intake. However, the meaningof behaviorandits implications for quality of life may differ acrosssocial andcultural groups despitethe use of a commonlanguage.31 The SIP was also used in a cross-cultural investigation of low-back pain among Spanish- and English-speaking patients attending a walk-in clinic in SanAntonio, TX.44 A Spanishtranslation of the SIP was developed using the procedure of backtranslation. A bilingual interviewer gave the Spanish and English versions of the SIP to 120 adults. The sample included non-Hispanic patients, Mexican Americans who usedan English version of the SIP, and Mexican Americans who used the Spanish SIP. The reliability and clinical validity of the responsesof these groups were compared, and internal consistencywas found to be excellent. However, important differences emerged when construct validity was examined by correlating SIP scores with several measuresof disease severity. While non-Hispanic responses appeared to be valid, the responsesof Mexican Americans using the Spanishversion of the SIP did not. The validity coefficients for the responses of the Mexican Americans using the English SIP were intermediate between the other two groups. The investigators suggestthat levels of Western acculturation, including educational background and familiarity with questionnaire research, could account for the differences in observedvalidity. In other words, the instrument, originally constructed in English for a North American culture, was most successful with English-speaking individuals socialized into the normative behavior and normative expectationsof North American society. The individuals for whom construct validity was the strongest spoke English fluently, and it was also their native language. Moreover, they were more likely to be educated in North American schools and to be accustomedto the questionnaire style of survey research.The results of this study point to the difficulties involved in the translation and implementation of instruments cross-culturally. Accurate measurementsof the variables investigated and effective interpretation of results dependupon the respondents’ability to understandthe language and the method of investigation. Application of other instruments measuring different dimensions of quality of life have been used with varying degreesof successin cross-cultural

PATRICIA

282

research.45-47 For example, a Chinese version of the Purpose in Life Questionnaire was given to more than 2,000 Chinese secondary school students and was found to have high internal consistency as a scale.45Investigatorsexploring the emotional well-being of elderly American Indians used the Life Satisfaction Index Z-scale, the Oars Multidimensional Functional Assessment Questionnaire, and a semistructuredinterview scheduleand found that subjective measuresof life satisfaction were more predictive of mental health than were the objective measures.47Table 1 presentsa list of cross-cultural studies in which standardizedinstruments have been usedto documentvarious aspects of perceived quality of life. METHODOLOGICAL ISSUES INFLUENCED BY CULTURE

Social, cultural, and linguistic differences between the interviewer and respondentscan bias results in studies of quality of life and health status. For example, investigators using the Hispanic Health and Nutrition Examination Survey with Mexican Americans, Puerto Ricans, and Cuban Americans found significant intragroup differences that were strongly influenced by the language in which the person was interviewed.48 Clinicians working with Mexican patients attending oncology clinics found that poorer and less educatedfamilies were uncomfortable talking freely with a bicultural, bilingual psychologist; they were more selfdisclosing with an older Mexican woman who had lost a child to cancer.35 The use of a standardizedself-report instrument assumesliteracy among the study population. In addition, an instrument with closed questions and fixed alternatives, even when it has undergone a sensitive and meaningful translation and is administered by an interviewer, may be difficult to comprehend for individuals unfamiliar with the

A. MARSHALL

structured survey approach. In a review of health interview surveys in developing countries, Kroeger49arguesthat the anonymity of survey research and the idea of answering questions by choosing from arbitrary categories is foreign to many people of the world, especially those in less developed countries. He suggeststhat the limitations of this method of questioning may be overcome by using an interview style that conforms to the mode of everyday communication. In cross-cultural investigations of quality of life, it is imperative to collect dataregarding indigenous beliefs and meaningsattachedto the variables under consideration. For example, in addition to asking about satisfactionwith recreational activities or family relations, one must also determine what constitutes social interactions or activities, what is important about them to the individual, and under what conditions they become salient. Data based on semi-structured interviews, open-ended questionnaires, and direct observation of behavior and affect greatly enhancesurvey findings. When these methods are an u&fordable luxury given the exigenciesof research,every attemptshould be made to documentunderlying sociocultural determinants in the experienceand expressionof quality of life. The developmentof culturally sensitive research instruments dependsupon a sound knowledge of the languageof the study population. When translations of English forms to other languages are required, Tripp-Roemer” recommends following the suggestions of Brislin, Lonner, and Thomdike.‘l Sentencesshould be simple and short and written at an easy level of understanding;metaphors and idiomatic expressions should be avoided; nouns should be repeatedrather than using pronouns; specific rather than general terms open to broad interpretation should be used. These are good rules to follow in questionnaire construction regardlessof the cultural background of the

Table 1. Examples of Cross-Cultural Studies Using Standardized Instruments to Measun, Dimensions of Ouallty of Life Sample

Instrument

Ferrans and Powers QLI SIP SIP Life Satisfaction Index Life Satisfaction Index Purpose in Life Questionnaire Modified Purpose in Life Questionnaire Qualitative semistructured interviews, Karnofsky scale, Glasgow Outcome scale Qualitative in-depth interviews

Study

Taiwanese American/English Anglo/Mexican American American Indian Anglo/Mexican American Chinese AmericanlTaiwanese Finnish

Ferrar# Patrick et aI= Deyo* Johnson et al4’ Cleeland et aIt6 Shep Chang4a Koivukangas and Koivukangass*

Dutch

Tymstra

et aiw

283

CULTURAL INFLUENCES AND QUALITY OF LIFE

individuals being studied, but they becomecrucial in the implementation of a cross-cultural study. SUMMARY

Cross-cultural investigations of quality of life will provide a more well-rounded picture of the multidimensional aspectsof life satisfaction and personal well-being. Careful attention must be given to the nuancesof languageand sociocultural context in the translation of questionnairesand the

implementation of cross-national research. Future explorations of the conceptof quality of life should incorporate qualitative and ethnographic data to insure an adequaterepresentation of the social and emotional context surrounding perceptionsof wellbeing and life satisfaction. A meaning-centeredapproach to the examination of quality of life will facilitate understanding of the nature of wellness and the impact of illness on individuals and families of every cultural background.

REFERENCES 1. ThomasmaDC: Quality-of-life judgements,treatmentdecision, and medical ethics. Clin Geriatr Med 2:17-27, 1986 2. PearlmanRA, JonsenA: The use of quality-of-life considerations in medical decision making. J Am Geriatr Sot 33:344-350, 1985 3. Young K, Longman A: Quality of life and personswith melanoma:A pilot study. Cancer Nuts 6:219-225, 1983 4. Padilla GV, Grant M: Quality of life as a cancer nursing outcome variable. Adv Nurs Sci 3:45-60, 1985 5. Evans RW, Mamtinen DL, GarrisonLP, et al: The quality of life of patients with end-stagerenal disease.N Engl J Med 312553, 1985 6. BremtanAF, Davis MH, Buchholz DJ, et al: Predictorsof quality of life following cardiac transplantation.Psychosomatits 11566-571, 1987 7. Lough ME, Lindsey AM, Shinn JA, et al: Impact of symptom frequency and symptom distress on self-reported quality of life in heart transplantrecipients. Heart Lung 16:193200, 1987 8. Frank-Stromborg M: Single instruments for measuring quality of life, in Frank-Stromborg M (ed): Instruments for Clinical Nursing Research.Norwalk, CT, Appleton and Lange, 1989, pp 79-95 9. Dean H: Multiple instruments for measuring quality of life, in Frank-StromborgM (ed): Instrumentsfor Clinical Nursing Research.Norwalk, CT, Appleton and Lange, 1989, 97106 10. SugarbakerPH, Barofsky I, RosenbergSA, et al: Quality of life assessmentof patients in extremity sarcomaclinical trials. Surgery 91:17-23, 1982 11. FlanaganJ: Measurementof quality of life: Current state of the art. Arch Phys Med Rehabil63:56-59, 1982 12. FermnsCE, PowersMJ: Quality of life index: Development and psychometric properties. Adv Nurs Res 8:15-24, 1985 13. ProznanskiEO, Miller E, Salguero, C, et al: Quality of life for long-term survivors of end-stagerenal disease.JAMA 23912343-2347,1978 14. Herleman H: Quality of Life in the Soviet Union. Boulder, CO, Westview Press, 1987 15. Chamberlain K: Value dimensions,cultural differences, and the prediction of perceived quality of life. Social Indicators Res 17:345-401, 1985 16. Cleeland CS, Ladinsky JL, Serlin RC, et al: Multidimensionalmeasurementof cancerpain: Comparisonof US and Vietnamesepatients. J Pain Symptom Manage 3:23-27, 1988

17. Moller V: The relevanceof personaldomain satisfaction for the quality of life in SouthAfrica. S Afr J Psycho1l&69-75, 1988 18. Geertz C: Interpretation of Cultures. New York. NY, Basic Books, 1973 19. Zola IK: Culture and symptoms:An analysis of patients presenting complaints. Am Sot Rev 31:615-630, 1966 20. Kleinman A, EisenbergL, Good B: Culture, illness and care. AM Intern Med 88~251-258,1978 21. Good B, Good MD: The meaning of symptoms: A cultural hermeneuticmodel for clinical practice, in Eisenberg L, Kleimnan A (eds): The Relevance of Social Science for Medicine, Dordrecht, The Netherlands, D. Reidel, 1981, pp 165196 22. Mechanic D: The concept of illness behavior: Culture, situation and personal predisposition. Psycholog Med 16:1-7, 1986 23. Kleimnan A, Good B: Culture and Depression: Studies in the Anthropology and Cross-Cultural Psychiatry of Affect and Disorder. Berkeley, CA, University of California Press, 1985 24. Zborowski M: Cultural componentsin responsesto pain. J Social Issues8:16-30, 1958 25. Zborowski M: People in Pain. San Francisco, CA. Jossey-Bass, 1969 26. Chrisman NJ: The health seeking process:An approach to the natural history of illness. Cult Med Psychiatry 1:351-377, 1977 27. Freidson E: Patients’ Views of Medical Practice: A Study of Subscribersto a Prepaid Medical Plan in the Bronx. New York, NY, Russell Sage Foundation, 1961 28. Ingstad B: The cultural construction of AIDS and its consequencesfor prevention in Botswana. Med Anthropol Q 4:28-40, 1990 29. Kleimnan A, Kleinman J: Somatization: The interconnections in Chinese society among culture, depressiveexperiences, and meanings of pain, in Kleinman A, Good B (eds): Culture and Depression. Berkeley, CA, University of California Press, 1985, pp 429-490 30. Kleinman A: Patientsand Healers in the Context of Culture. Berkeley, CA, University of California Press, 1980 31. Payer L: Medicine and Culture: Varieties of Treatment in the United States, England, West Germany, and France. New York, NY, Henry Holt, 1988 32. Brown PJ, Konner M: An anthropological Perspective on obesity. Ann NY Acad Sci 499:29-46, 1987

284 33. Cahmnan WJ: The stigma of obesity. Social Quarterly 91294291, 1968 34. Lock M: The relationship between culture and health or illness, in Christie-Seeley J (ed): Working with the Family in Primary Care. New York, NY, Praeger, 1984, pp 73-92 35. Spinetta J: Measurementof family function, communication, and cultural effects. Cancer 53:2330-2337,1984 36. Kleinman A: Culture, the quality of life and cancerpain: Anthropological and cross-cultural perspectives, in Ventiafridda V, van Dam S, Yancik R, Tamburini M (eds): Assessment of Quality of Life and Cancer Treatment. Amsterdam, Netherlands, Elsevier Science, 1986, pp 43-50 37. Bergsma J, Engel GL: Quality of life: Does measurement help? Health Policy 10:267-279,1988 38. Patrick DL, Sittampalam Y, Somerville SM, et al: A Cross-culturalcomparisonof health statusvalues. Am J Public Health 75:1402-1407, 1985 39. De Benedittis, Massei R, Nobili R, et al: The Italian pain questionnaire. Pain 33:53-62, 1988 40. Ferrans, C: Personalcommunication, 1989 41. Bergner M, Bobbitt RA, Kressel S, et al: The Sickness Impact Profile: Conceptual formulation and methodology for the development of a health statusmeasure.Int J Health Serv 6:393-415, 1976 42. Bemger M, Bobbitt RA, Carter W, et al: The Sickness Impact Profile: Development and tinal revision of a health status measure.Med Care 19:787-805,1981 43. Gilson BS, Erickson D, Chavez CT, et al: A Chicano version of the Sickness Impact Profile. Cult Med Psychiatry 4:137-150, 1980

PATRICIA

A. MARSHALL

44. Deyo RA: Pitfalls in measuringthe health statusof Mexican Americans: Comparative validity of the English and Spanish SicknessImpact Profile. Am J Public Health 74:569-573, 1984 45. Shek DT: Reliability and factorial structure of the Chineseversion of the Purposein Life Questionnaire.3 Clin Psychol 44384-392, 1988 46. Chang RH: The Modified Purpose in Life Scale: A cross-nationalvalidity study. Int J Aging Hum Dev 18:207217, 1984 47. JohnsonFL, Cooke E, Foxall MJ, et al: Life satisfaction of the elderly American Indian. Int J Nut-sStud 23:265-273, 1986 48. GuarnacciaPJ, Angel R, Worobey JL: The factor structure of the CES-D in the Hispanic health and examination survey: The influences of ethnicity and gender and language. Sot Sci Med 29:85-94, 1989 49. Kroeger A: Health interview surveys in developing countries:A review of the methodsand results. Int J Epidemiol 12:465-481, 1983 50. Tripp-Roemer T: Researchin cultural diversity. West J Nurs Res 6:457-458, 1984 51. Brislin R, Lonner W, Thomdike R: Cross-cultural ResearchMethods. New York, NY, Wiley, 1973 52. Koivukangas P, Koivukangas J: Role of quality of life in therapeutic strategies in brain tumors. Health Policy 10:241258, 1988 53. Tymstra J, Heyink J, Roorda J, et al: Research into quality of life: A qualitative approach in the evaluation of a liver transplant programme. Health Policy 10:231-240, 1988