The impact of context processing deficits on task-switching performance in schizophrenia.

The prefrontal cortex (PFC) has been described as important for maintaining and implementing contextual information in the service of goal-oriented behavior. Accordingly, impairments in context processing are thought to underlie cognitive deficits associated with schizophrenia, a clinical disorder that has been linked to PFC dysfunction (Servan-Schreiber et al., 1996). However, task switching, a cognitive ability linked to PFC function, has not been consistently impaired in schizophrenia. In this experiment, we assessed whether task-switching performance would be selectively impaired for patients when context demands were high. In the rule-switching condition, a switch required the updating of the relevant task response rules whereas perceptual switching did not entail a switching of contextual information. Instead, a perceptual switch entailed a shift of visuospatial attention to the relevant feature. A second goal was to determine whether potential deficits in context switching would be observed in schizophrenia even in situations when these patients do not need to overcome a prepotent response. Studies of context processing have typically required patients with schizophrenia to use contextual rules to overcome prepotent response tendencies whereas our switching paradigm did not require the inhibition of a competing response. Patients were much slower to switch tasks than controls when contextual rules switched from one trial to the next whereas their performance was intact when the switch occurred between different feature sets and contextual demands were low. Our results demonstrate that context processing deficits are observable in schizophrenia even when there is no prepotent response tendency to inhibit. Moreover, our results suggest that PFC impairments influence performance primarily when patients are required to switch the application of one explicit rule to another.

Hmong/medicine interactions: improving cross-cultural health care.

BACKGROUND AND OBJECTIVES: There are now more than 100,000 Hmong (Southeast Asian) refugees in the United States. This study examined interactions between Hmong patients and their health care providers and identified specific factors that either enable or obstruct health care delivery. METHODS: We used semistructured interview techniques to investigate patients' and providers' experiences, looking for attitudes, ideas, or behaviors that could be modified to improve health care delivery. Interviews with 23 Hmong patients, 18 health care providers, and six translators were audiotaped, transcribed, and analyzed by a multidisciplinary team. Methods included text analysis, theme identification, rank ordering, participant observation, immersion-crystallization, and open-ended discussion. RESULTS: Hmong patients and their US-trained health care providers have different health belief systems. Both linguistic and cultural translation were seen as problematic. Additionally, an overwhelming number of patients identified kindness, caring, and a positive attitude as important provider characteristics. Providers noted difficulties in understanding Hmong conceptions of acute versus chronic diseases, illness prevention, and pain, both physical and psychological. Many respondents gave suggestions for improvement: 1) learn more about each other's cultures, 2) be patient, kind, and positive, 3) avoid negative statements or predictions, 4) improve translation quality, 5) explain medical terms using visual aids, 6) respect Hmong family-centered decision making, 7) increase the time allotted for translated clinical encounters, and 8) train Hmong health care providers. CONCLUSIONS: Many basic issues in relations between clinicians and Hmong patients must be addressed to improve health care communication.