A MUNDOS patient

When Yakeel Quiroz, PhD, Co-Director, MUNDOS, joined the Psychology Assessment program at Mass General in 2011, she worried when she noticed that some of the test questions given to Latino patients did not seem to be culturally appropriate.

Quiroz, from Colombia herself, recognized that asking non-English speakers who didn’t grow up in the US who the first or second president of the US was — things they would have never learned in school — couldn’t accurately assess their true cognitive ability. Although cultural differences are recognized in the field of neuropsychology, they can be difficult to address with existing measures.  For example, patients who are bilingual are generally evaluated in English, and it can be difficult to determine the impact that learning English as a second language had on their test performance.
Also a Mass General Neurology Department faculty member and the Director of the Clinical Neuroscience and Neuropsychology of Aging Lab at Mass General, Quiroz was familiar with research showing that despite the prevalence of diseases like Diabetes and Alzheimer’s among Latinos, due to limited cultural competence of some medical providers, among other reasons, Latinos are more likely to receive diagnosis at later stages of disease and less likely to access and benefit from early interventions or available treatments. 

To find ways to more accurately assess how cognitive deficits present in Latino patients and to ultimately provide Latino patients with more adequate health services — Quiroz, together with Janet Sherman, PhD, a neuropsychologist at Mass General since 1989 and the clinical director of the Psychology Assessment Center since 1991, established MUNDOS — a multicultural neuropsychology program in 2014, with the goal of providing culturally sensitive testing for Latino patients.

How Cultural Differences Skew Test Results
One of the biggest obstacles for Latino patients during a neuropsychological assessment is that often it can be the first test they’ve taken — in their life.

“In Latino communities, many people are not familiar with testing.  It’s done more often now in Latino American countries — but older Latino patients with low education may have never taken a test, and those with higher education may have just taken one test during their entire academic career — at the end of high school,” says Quiroz.  “Test taking for the first time ever – it is definitely anxiety provoking.  Also, the cultural differences can impact the way that individuals from different cultures approach a testing situation.”

Another disadvantage for the Latino community is that some neuropsychology assessments require reading and writing skills that many Latino patients from a low socio-economic status with no formal education do not have.

Patients from different cultures can also present with different cultural beliefs and awareness of these differences can be important in understanding a patient’s presentation. One patient, recalled Quiroz, believed he could speak to the dead.  This patient was from the Caribbean, a Latin American area known to be more superstitious than others.  “Without knowing about this cultural influence, many might assume the patient may be suffering from a psychiatric or neurologic disease, when it could actually be a normal part of their daily experience,” says Quiroz.

Another cultural norm inherent in the Latino community is that patients and their families do not want to bother people with their problems, especially their doctor.  Even simple questions from their physician, like how they’ve been feeling, can make Latino patients uncomfortable.  “Many will say, ‘Fine, I’m fine,’ and keep their symptoms to themselves,” says Quiroz.  “This can make it harder to appreciate symptoms that individuals may be having and delay treatment.

Personalized Testing Changes Outcomes
Today MUNDOS, a multi-cultural program, offers culturally sensitive clinical services, including neuropsychological assessments, support groups and psycho-education.  For patients with little to no formal education who can’t read or write, Quiroz and her team get creative in order to establish a baseline, and how far the patient is now from it.  “We speak to family members to see how their behavior has changed, or maybe ask the patient occupation related questions,” says Quiroz.  “How has their function changed, is it the same now as it was a few years ago?”

Another benefit for Latino patients – MUNDOS offers testing in the patient’s primary language.  “Referring doctors are very excited about the possibility of having cognitive testing done in the patient’s first language,” says Quiroz.  “Although the Psychology Assessment Center utilizes interpreters when patients do not speak English, this was a barrier for patients and for referring physicians.” Not surprisingly, in the past year, the number of referrals to MUNDOS from primary care clinicians has doubled. 

MUNDOS is also undertaking clinical research, investigating how environment, culture and beliefs can shape cognition and brain function.  Quiroz and Sherman have also developed a training program, recently creating a predoctoral internship and postdoctoral fellowship that focuses on multicultural neuropsychology. 

Future plans for MUNDOS include offering cognitive rehabilitation services to facilitate relearning cognitive skills that have been lost or impacted, or if relearning is not possible, teaching patient new skills to compensate for deficits.  Future clinical research includes test development and developing new neuropsychological instruments appropriate for non-English speakers and bilingual populations.

For more information about MUNDOS, please visit our website.