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The Explanatory Models Approach

This is an excerpt from Patient-Centered Care in Sports Medicine by Rene R Shingles,Lorin A Cartwright.

The Explanatory Models Approach, Outline for Cultural Formulation, and Cultural Formulation Interview

One way to elicit information from the patient’s perspective is to use the explanatory models approach, introduced by Arthur Kleinman (Kleinman and Benson, 2006; Kleinman et al., 1978). The approach is the specific set of questions designed to elicit the patient’s explanation for their condition (see the following sidebar). For example, does the patient believe the problem was caused by fate, bad luck, an accident, or punishment by God?

The questions asked to determine a patient’s explanatory model are just one part of cultural formulation, a means for systematically reviewing, evaluating, and reporting a patient’s cultural background and the effect of the cultural context on their signs and symptoms (American Psychiatric Association, 2000). The Outline for Cultural Formation (OCF), originally appearing in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV), is a list of topics used to assess the patient’s cultural context. It consists of five components:

1. Cultural identity of the individual
2. Cultural conceptualizations of distress
3. Psychosocial stressors and cultural features of vulnerability and resilience
4. Cultural features of the relationship between the individual and the clinician
5. Overall cultural assessment (American Psychiatric Association, 2000)

In 2013, the Cultural Formulation Interview (CFI) was developed and added to the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) to provide guidance in addressing and implementing the OCF consistently (Aggarwal et al., 2013). The full interview is not printed here, but can be found online by searching for the Cultural Formulation Interview. The purpose is to obtain pertinent information from the patient’s own perspective regarding their individual experiences and the social and cultural contexts in which the experiences occurred (American Psychiatric Association, 2013a). The CFI comprises 16 questions, grouped into four domains:

1. Cultural definition of the problem
2. Cultural perceptions of cause, context, and support
3. Cultural factors affecting self-coping and past help seeking
4. Cultural factors affecting current help seeking (American Psychiatric Association, 2013)

The OCF and CFI were developed for mental health evaluations (Aggarwal at al., 2015). However, we posit there may be relevancy and applicability for use in athletic training and sports medicine as well. The CFI tools should be used at the beginning of the assessment process, when taking the oral history. By understanding what is important to the patient at the outset, the athletic trainer can integrate the appropriate information when conducting the remainder of the physical assessment. The athletic trainer should also use the information obtained when negotiating the clinical diagnosis, treatment, or rehabilitation goals and plans. The athletic trainer should consider the topics presented to provide a cultural context for physical assessment, diagnosis, and treatment.

We can now return to the case study from the beginning of the chapter to illustrate how the CFI might be used in an athletic training setting. Questions 1 to 3 (cultural definition of the problem) reveal Sade has low back pain, which she describes as dull and achy. She is troubled because she is unable to bend properly while praying, and because she does not want to worry her parents. In questions 4 to 10 (cultural perceptions of cause, context, and support), the patient discloses to Camila that bad things are happening in her life right now, and the injury is one of them. Sade has not told her family about what is happening, therefore, there is currently no family support. The family expects she will do well in school, and she does not want to disappoint them, but she is struggling in one class. Sade tells Camila that she emigrated from Nigeria as a young child and practices Islam but chooses not to wear the hijab while at college, which her mother does not like. However, she does practice modesty, thus the long-sleeved top and pants. As a result of the back pain, she is experiencing difficulty when trying to pray five times daily, and the inability to pray is distressing.

Questions 11 to 13 (cultural factors affecting self-coping and past help seeking) reveal Sade has only talked to her friends about her problems. She has been praying (with difficulty). As a student, she has a job on campus, but because of back pain, she is unable to work. The inability to work is also distressing, because she does not want to be a financial burden to her family, and a job helps to offset the cost of attending college. Lastly, Sade discloses in questions 14 to 16 (cultural factors affecting current help seeking) that her friends suggested she seek help at the clinic, which is why she is there. Because of past experiences, she was initially concerned the health care professional would be male, but she is satisfied her provider is female. However, given the apparent open floor plan of the clinic, she is still concerned about modesty and whether her back will be exposed to others during the evaluation and treatment.

The CFI is patient centered, allowing for the patient and support network to provide their own explanations about the problem and its cultural significance, thus potentially avoiding stereotyping (American Psychiatric Association, 2013a). In the case presented, because of physical appearance, Camila might have presumed the patient was African American rather than Nigerian and that she was Christian rather than Muslim. If Camila had acted on her presumptions, she may have missed crucial information about Sade’s needs and the importance of restoring range of motion to allow for praying. Camila might too have missed the significant stress that not being able to pray or work was having on the patient.

The standardized format has been reported as a barrier to using the CFI (Aggarwal et al., 2013). However, according to Diáz et al. (2017), the CFI can help provide an understanding of patients’ social and cultural needs when used regularly as part of the intake process or patient evaluation. The CFI may help identify specific group needs as well.

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