JURNAL YG DIPAKE

Illness perceptions and personality traits ofpatients with mental disorders: the impact ofethnicity

Franz M, Salize HJ, Lujic C, Koch E, Gallhofer B, Jacke CO. Illnessperceptions and personality traits of patients with mental disorders: theimpact of ethnicity.

Objective: To identify dierences and similarities between immigrantsof Turkish origin and native German patients in therapeuticallyrelevant dimensions such as subjective illness perceptions andpersonality traits.Method: Turkish and native German mentally disordered in-patientswere interviewed in three psychiatric clinics in Hessen, Germany. TheRevised Illness Perception Questionnaire (IPQ-Revised) and theNeuroticism-Extraversion-Openness Five-Factor Inventory (NEO-FFI)were used. Dierences of scales and similarities by k-means clusteranalyses were estimated.Results: Of the 362 total patients, 227 (123 immigrants and 104 nativeGermans) were included. Neither demographic nor clinical dierenceswere detected. Socioeconomic gradients and dierences on IPQ-R scaleswere identified. For each ethnicity, the cluster analysis identified fourdierent patient types based on NEO-FFI and IPQ-R scales. Thepatient types of each ethnicity appeared to be very similar in theirstructure, but they diered solely in the magnitude of the cluster meanson included subscales according to ethnicity.Conclusion: When subjective illness perceptions and personality traitsare considered together, basic patient types emerge independent of theethnicity. Thus, the ethnical impact on patient types diminishes and aconvergence was detected.

M. Franz1, H. J. Salize2,C. Lujic3, E. Koch4, B. Gallhofer5,C. O. Jacke21Clinic for Psychiatry and Psychotherapy, Vitos ClinicKurhessen, Bad Emstal, Germany, 2Central Institute ofMental Health, Medical Faculty Mannheim, University ofHeidelberg, Heidelberg, Germany, 3Rabenstein Clinic,Bad Salzhausen, Germany, 4Clinic for Psychiatry andPsychotherapy, Vitos Clinic Marburg, Germany and5Centre for Psychiatry, Justus Liebig University, Giessen,Germany

Key words: behaviour; public mental health;transcultural psychiatry; treatment; psychoeducation

Christian O. Jacke, Central Institute of Mental Health,Health Service Research Group, Medical FacultyMannheim, University of Heidelberg, Square J5,Mannheim 68159, Germany.E-mail: [email protected]

Accepted for publication March 5, 2013

Signicant outcomes

There are socioeconomic dierences between native and immigrant patients who utilize the samepsychiatric care.

There are systematic dierences between native and immigrant patients on the scales related to sub-jective illness perceptions.

For each ethnicity, four salient patient types based on subjective illness perception scales and person-ality trait scales could be identified, which (i) are similar across ethnicities but (ii) dierent in themagnitude of cluster means on included subscales.

Limitations

The study concerns a population of healthcare utilizers that is always susceptible to selection biases. The patient types are based on the diagnosis groups included in this study. This study is unable todetermine the types relevance for other diagnosis groups.

Additional cross-cultural methods and confirmative analyses, based on measurements at severalpoints following in-patient treatment, will be needed to assess whether these exploratory results arerelevant for treatment outcomes.

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Acta Psychiatr Scand 2014: 129: 143155 2013 John Wiley & Sons A/S. Published by John Wiley & Sons LtdAll rights reservedDOI: 10.1111/acps.12134

ACTA PSYCHIATRICA SCANDINAVICA

Introduction

Health is considered by all cultures to be more thanthe mere absence of disease (1). When disease doesdisrupt health, however, people develop certain per-ceptions and assumptions about the origins andtreatment of their illness (2). Immigrants are an espe-cially vulnerable group in Western, developed coun-tries. Not only because diseases tend to be moreprevalent in immigrant populations, but also becausethese populations show poorer therapeutic results forpsychological and psychosomatic disorders and tendto face more barriers to access appropriate healthcare compared to the native population (36). Com-paring dierent illness-associated factors for immi-grant patients to those of native patients can help uslearn more about these patient groups itself. Further-more, it can help us to develop a deeper understand-ing of how patientdoctor relationships, includingcommunicative and informational needs, could beimproved by better understanding the factors under-lying ethnic dierences. Finally, the relevance of thistopic emerges with the increasing significance ofimmigrants on the macro level concerning the publicsocial insurance systems owing to the wake of demo-graphic transitions in developed countries. In the fol-lowing, native patients refer to Germans andimmigrant patients refer to Turkish patients. TheTurkish population is by far the largest immigrantcommunity in Germany with 1.6 million people in2010 (7). Moreover, Turkish immigrants are repre-sented in most European countries and belong to thelargest immigrant group in Scandinavia and theNetherlands.

Subjective illness perceptions

The term illness-associated factors refers both topatients subjective perceptions of their illness andto their personality traits. Patients subjective ill-ness perceptions are taken to include their percep-tions and assumptions concerning their diseasessymptoms, causes, consequences, and duration;the ecacy of their treatment; their own self-e-cacy as well as their own emotional representationsof their illness. These factors are linked together ina common-sense model and are modeled with ref-erence to medical results, while taking coping strat-egies into account (810). Subjective illnessperceptions are highly relevant for treatmentbecause they influence compliance with medica-tion, the eectiveness of treatment, as well as thecourse of the illness (1117). Many studies founddierences in subjective illness perceptions (e.g.,neuroticism scale) when comparing groups withdierent ethnic origin (18).

Personality traits

Patients personality traits are associated with theirsubjective illness perceptions (19, 20). For measur-ing personality traits, continuous scales are gener-ally preferred over dichotomous indicators becausethey allow personality traits to be more graduallyand individually graded (21). As for the number ofrelevant and meaningful personality dimensions,there are as many dierent opinions as there aredierent approaches to personality research,although five dimensions, in particular opennessto experience, conscientiousness, extraversion,agreeableness, and neuroticism the so-called bigfive, are especially common in current personalityresearch (22, 23). These personality traits arehighly relevant for treatment because they havebeen shown to be empirically associated withpatients health-related behaviour, health con-sciousness, as well as the ecacy of their treatment(2435). The cultural universality of this five-factorpersonality structure has been confirmed in manyintercultural studies. Although when comparingaverage values of the personality trait scales, it isshown that there is more variance within a singleculture than between dierent cultures (34, 36, 37).Subjective illness perceptions are considered

learnable, changeable, and culture specific (2, 4, 5,3840), while personality traits are regarded to beinheritable, universal, and more consistent overtime than subjective illness perceptions (33, 41).Deducing from this, we can expect (i) immigrantsillness perceptions to be dierent from those ofpeople who were born and still live in the countryand (ii) immigrants personality traits to be similarto natives.

Aims of the study

The explorative approach taken in this study ismeant to compare immigrant and native patientgroups to confirm dierences in subjective illnessperceptions scales and similarities on the personal-ity trait scales. Both scales are analyzed together todevelop typical patient types respective profilesfor each ethnicity. Then, in a cross-cultural com-parison of these profiles, dierences and similari-ties of the ethnical taxonomies are furtheridentified and described.

Material and methods

Setting

This multicenter study on Germans and Turk-ish immigrants illness-relevant constructs was

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conducted on in-patients at the Clinic for Psy-chiatry and Psychotherapy at the UniversityHospital of Giessen and Marburg (UKGM), theCenter for Social Psychiatry in Marburg, andthe Sudpark Clinic in Bad Nauheim, all locatedin Germany (39). All these clinics specialize inmental health; the Sudpark Clinic additionallyprovides psychosomatic rehabilitation treatmentsfor coronary heart diseases.

Study design

The comparative cross-sectional survey comparesTurkish and German patients. Turkish patientswere born in Turkey, immigrated between19512000 to Germany, and since then resided inGermany. The German patients were born andresided in Germany. Females and males of bothethnicities were included. They received care fromthe three participating clinics, were between theages of 20 and 70, and had been definitively diag-nosed, according to ICD-10 criteria, with at leastone of the following disorders: schizophrenia(F.2), depression (F.3), or neurotic stress disorderand somatoform disorder (F.4). Patients with men-tal retardation (F.7), organically caused mentaldisorders (F.0), and patients who were not fit to beinterviewed were excluded from the study. Addi-tionally, patients with coronary diseases(I.20I.25) were excluded from all analyses toobtain homogeneous patient and diagnosis groupsfrom the medical point of view.

Recruiting and sampling procedure

All patients were recruited within three days afterbeing admitted to the in-patient treatment (T0)and were interviewed again in the three days priorto their discharge (T1), which occurred betweenFebruary 2005 and June 2007. The doctor respon-sible for treatment informed patients about thecontent and objectives of the study and alsoobtained their informed consent.Sociodemographic data and details about

patients illness were obtained from the patientsfiles, doctors records, and the patients basic medi-cal documentation, both prior to the first interview(T0), and again before the second interview (T1).Primary data collection was carried out by stu-dents who had completed a training course oninterviewing and who had been given a trainingmanual. The pool of interviewers consisted of stu-dents of both German and Turkish native speakersso that all standardized interviews could be con-ducted in the patients respective mother tongue.The training courses, for both the German and

Turkish interviewers, were conducted by a psy-chologist together with a bilingual doctoralstudent.

Questionnaires, scales, and variables

The used questionnaires were the Illness Percep-tion Questionnaire Revised (IPQ-R) and the NEOFive-Factor Inventory (NEO-FFI) (42, 43). TheGerman and the Turkish versions of both ques-tionnaires have been shown to be valid (39, 4446).The IPQ-R was used for the first interview, at

T0, and measured 64 items on the following ninescales: perceived symptoms, associations betweensymptoms and illness (identity), possible causes ofillness, illness timeline (acute vs. chronic, cyclicalvs. periodic), negative consequences (severity aswell as consequences for patients physical, social,and mental functioning), personal control and per-ceived possibility to gain control or influence onthe disease (self-ecacy), treatment control andestimated influence to alter the disease progression(treatment ecacy), patients understanding oftheir own illness (coherence), as well as emotionalrepresentations of any kind related to the disease.Scores for the individual scales were calculatedadditively according to the manual (47).For the second interview, at T1, we used the

NEO-FFI, which includes 60 items in fivedimensions of 12 items each, to measure keypersonality traits (42, 48). The dimension open-ness to experience concerns ones interest in andcuriosity about new experiences. The dimensionconscientiousness concerns a persons ability tobe organized, thorough, eective, responsible,reliable, reasonable, and to plan for the future.Extraversion concerns ones level of excitementseeking (surgency) and ones level of activity,ranging from extraverted to introverted. Agree-ability is a distinctive indicator that includesaltruistic, empathetic, and pro-social behaviour(as opposed to antagonistic, egocentric, andcompetitive behaviour). The neuroticism dimen-sion includes the experience of negative emotionsand the resulting emotional stability or instabil-ity. Scores for the individual scales were calcu-lated additively according to the manual (48).

Descriptive statistics

Dierences in German and Turkish patients soci-odemographic characteristics were tested using achi-squared test or the non-parametric KruskalWallis H-test, the former was applied in cases withdichotomous variables and the latter in cases withcategorical variables. In cases with metric

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variables, the dierences were tested with indepen-dent t-tests or the abovementioned non-parametrictest in case of non-normal distributed variables.Both the IPQ-R and the NEO-FFI scores wereentered into a one-factor ANOVA model, whichallowed further post hoc tests on the dierencesbetween German and Turkish patients. All posthoc tests were chosen in such a way that the alphaerror would not exceed 5%.

Cluster analysis

The IPQ-R and NEO-FFI scale values were alsoentered into additional analyses to group similarpatients into homogeneous groups. We chose theexplorative cluster-analysis method for its abilityto uncover unknown structures and to reducethe quantity of data (49). We opted for anobject-oriented approach, that is, groups weredefined across the rows (patients) and not thecolumns (variables) of a matrix. All variableswere z-standardized so that they would generatedimensionless characteristics (mean = 0, standarddeviation = 1). Finally, we calculated the dis-tances between the individual means (rows) overtheir values in variables (columns) using thesquared Euclidean distance formula. Those indi-viduals who were the closest to each other werecombined into one data object using thek-means procedure (fusion algorithm), a processthat was repeated until at the end there was onlya single group left. This k-means cluster analysiswas conducted separately for the Turkish andGerman patients. SPSS software was used.

Number of group-test statistics

The k-means procedure does not oer any clueabout the number of groups. Therefore, we esti-mated the number of relevant homogenousgroups per ethnicity. The coecients g2c , thePREc-measure, and the F-Maxc value were cal-culated as test statistics dependent on the num-ber of clusters c (50). The coecient g2crepresents the percentage of the varianceexplained by the number of clusters c, while thePREc-measure represents the relative improve-ment of the cluster c + 1 in comparison with thecluster solution number c. Compared to the g2cvalue, the F-Maxc value is adjusted for the num-ber of clusters itself. These three measures werecalculated for the cluster solutions 110, whichhelped us to determine the appropriate numberof clusters to be used (cluster configuration 1).These test statistics were calculated separatelyfor the Turkish and German patients.

Stability analysis

The results of k-means cluster analysis may beinfluenced by its starting partition (49). The k-means cluster configuration 1 was obtained by arandom starting partition. This starting partitionwas alternated by the Ward method to provide analternative starting partition (49). This methodproduced a second k-means solution by a Wardstarting partition for each ethnicity. We obtained acluster configuration 2 per ethnicity, which wasused for stability analysis. The latter compares themembership of each individual (and ethnicity) tothe cluster configuration one and two. This proce-dure allows the estimation of kappa coecients,which informs about conformities between the twocluster solutions. In this way, the reproducibilityand thus the statistical stability were estimated.

Results

Sampling

Data were collected for 362 patients, of which 227were included in the analyses. We excluded 101patients because of an underlying coronary heartcondition. Another 34 patients were excludedbecause of insucient scores of the questionnairecompletion on the NEO-FFI scales. Of the 34excluded patients, 12 were Turkish and 22 wereGerman. A few dierences between the includedpatients and these excluded patients in terms ofsocioeconomic and clinical variables were detected.However, it seems rational to assume that gravedistortions of statistical results could not haveoccurred. The demographic, socioeconomic, andclinical characteristics of the included study partici-pants are shown in Table 1.

Descriptive statistics

Of the 227 patients included in the analysis, 54%(N = 123) were Turkish and 46% (N = 104) wereGerman, 79% (N = 179) were treated in a clinicfor rehabilitation and psychosomatic medicine,12% (N = 28) in a social psychiatric hospital, and9% (N = 20) in the psychiatry department of auniversity hospital. More Turkish men than Turk-ish women were included. The mean age at time ofimmigration was 17.4 (SD = 6.2), and at the meantime, the Turkish patients had lived in Germanywas 28.9 years (SD = 7.5). The Turkish andGerman patients did not exhibit systematic dier-ences in demographic and clinical characteristics.In contrast, socioeconomic gradients were detectedand salient dierences in the number of disability

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days in the previous year, the subjectively per-ceived reduction in earning capacities, and thenumber of psychiatric diagnoses were observed(Table 1).

Ethnic gradients for subjective illness perceptions and personalitytraits

There were significant dierences between Turkishand German patients after adjusting for multiplecomparisons on the scale for subjective illness per-ceptions. This concerned the scales symptoms,symptoms and illness, timeline, timeline cyclical,consequences for personal relationships, andemotional representations, for which Turkishpatients scored significantly higher (Table 2). Incontrast, on the IPQ-R scales personal control,treatment control, and coherence, the Turkishpatients showed significantly lower values thanGerman patients. On the NEO-FFI personalitytrait scales, German patients scored significantlyhigher than Turkish patients. Only on the neuroti-

Table 1. Demographic, socioeconomic, and clinical characteristics of includedpatients

VariableParameter orcategory

Included patients

Turkish(N = 123)

German(N = 104)

Age at admission Average (SD) 45.5 (7.9) 46.2 (9.0)Gender (%) Females 41.0 50.0

Males 59.0 50.0Age at migration Average (SD) 17.4 (6.2) Year ofmigration (%)

19511960 0.8 19611970 14.2 19711980 65.8 19811990 11.7 19912000 7.5

Maritalstatus (%)

Single 2.4 18.3Married 73.2 56.7Separated 5.7 3.8Divorced 15.4 16.3Living ina Partnership

0.8 1.9

Widowed 2.4 2.9Religion (%)* Protestant 41.7

Catholic 0.8 42.7Muslim 97.6 None 1.6 15.5

Highest level ofeducationcompleted (%)*

None completed 17.9 3.8Primary school(4th grade)

53.7 0

School for mentallyhandicappedchildren

0 4.8

Secondary school(9th grade)

2.4 57.7

Secondary school(10th grade)

14.6 23.1

Secondary school(12th/13th grade),with universityentrancequalification

10.6 10.6

Other 0.8 0Highest level ofvocationalqualification (%)*

None completed 22.8 18.3Tertiary education 17.1 74.0University degree 1.6 3.8No vocationalqualification

58.5 3.8

Occupationalactivity (%)*

Full time 44.6 58.7Part time 9.9 18.3Not employed (e.g.,domesticwork only)

5.8 5.8

Unemployed 30.6 7.7Retired 3.3 2.9Other 5.8 6.7

Householdincome (%)*

< 500 euros 8.1 3.95001000 euros 26.0 16.510001500 euros 33.3 24.315002000 euros 21.1 19.420002500 euros 9.8 17.5>2500 euros 1.6 18.4

Sources ofincome (%)

Salary/Wages 53.5 70.3Retirement Pensions 4.7 4.7Fringe Benefits 34.9 10.9Family Aid 2.3 10.9Others 4.7 3.1

Table 1. (Continued)

VariableParameter orcategory

Included patients

Turkish(N = 123)

German(N = 104)

Diagnoses (%) F3 38.2 36.5F4 61.0 61.5F3 and F4 0.8 1.9

Number ofchildren*

Average (SD) 2.7 (1.3) 1.4 (1.2)

Persons perhousehold*

Average (SD) 2.7 (1.6) 1.8 (1.4)

Days of disabilityin the previousyear*

Average (SD) 152 (125) 69 (93)

Reduction inearningcapacity (%)*

Yes 39.0 18.0No 61.0 82.0

Duration ofdisease

Average (SD) 363 (363) 355 (439)

Disease-relatedin-patient stays

Average (SD) 1.9 (1.5) 2.2 (2.5)

Disease-relatedin-patient days

Average (SD) 70.3 (76.1) 91.2 (145.8)

Number ofadditionaldiagnoses

Average (SD) 1.7 (1.5) 1.4 (1.6)

Number ofpsychiatricdiagnoses*

Average (SD) 1.8 (0.9) 1.5 (0.7)

Number ofsomaticdiagnoses

Average (SD) 1.3 (1.3) 1.1 (1.4)

Length of stay Average (SD) 38.8 (8.3) 37.3 (11.5)

F3, Affective disorders; F4, Neurotic stress-related and somatoform disorders; SD,Standard deviation; , No data.*P < 0.05 difference for included patients.

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cism scale, the Turkish patients score higher (notsignificant).

Number of cluster diagnostics for k-means cluster analysis

The IPQ-R and NEO-FFI scales were entered intothe cluster analysis according to ethnicity using thek-means method, which was first computed on thebasis of a random partition. For Turkish patients,the percentages of explained variance g24 = 0.31and g27 = 0.40 point toward a four- and seven-clus-ter solution respectively. The PRE measure con-firms this assumption, whereas the F-Max4 valueof 17.7 favors a four-cluster solution. For Germanpatients, the percentages of explained varianceg24 = 0.31, g

25 = 0.37, and g

29 = 0.43 point toward a

four-, six-, or nine-cluster solution respectively.While PRE values for the German patients sup-ported also the 4-cluster options, the value of theadjusted F-Max statistic tipped the scale towardthe 4-cluster solution. The test statistics can befound in Table 3.The cluster analysis was repeated, separately for

each ethnic group, for the four patient groupsusing Wards method. The resumed cluster-center

means were again entered into the k-means clusteranalysis as alternative starting partitions. The finalcluster centers can be found in Table 4. To facili-tate interpretation, they can also be found inFig. 1(ad), which show the similarities betweenthe patient profiles of Turkish and German patientprofiles. These graphical representations supportedthe development of concise labels for each cluster,which were inferred from salient characteristics ofeach profile respective patient type.

Labeling of cluster A

Cluster A represents for Turkish and Germanpatients high means on the scale of emotional rep-resentations and a high number of perceived symp-toms, which are related to personal and socialconsequences. These patients only know littleabout their illnesses and do not expect high eec-tiveness, either from themselves or from their treat-ment (personal control and treatment control).Their personality traits suggested low levels of con-scientiousness, open-mindedness, and agreeability.Individuals from Cluster A can be describedas symptom-sensitive, emotionally introverted

Table 2. Average differences in scores on dimensions of illness perceptions (IPQ-R) and personality traits (NEO-FFI)

Score Nationality NArithmeticmean SD SE

Meandifference

Dimensions of subjective illness perceptionsSymptoms Turkish 123 9.5 2.7 0.24 2.1*

German 104 7.4 2.7 0.26Symptoms and Illness Turkish 123 8.2 3.3 0.30 2.3*

German 104 5.9 2.6 0.26Timeline Turkish 123 18.3 3.7 0.33 2.4*

German 104 15.8 3.9 0.39Timeline cyclical Turkish 123 14.6 2.5 0.22 1.5*

German 104 13.1 2.6 0.26Consequences Turkish 123 20.0 2.8 0.25 2.9*

German 104 17.1 3.9 0.38Personal control Turkish 123 11.1 2.9 0.26 !2.6*

German 104 13.6 3.0 0.29Treatment control Turkish 123 12.8 2.6 0.24 !1.9*

German 104 14.7 2.2 0.22Coherence Turkish 123 15.8 3.7 0.33 !1.8*

German 104 17.6 3.9 0.38Emotional representations Turkish 123 20.2 3.4 0.31 3.0*

German 104 17.2 4.1 0.40Dimensions of personality traitsOpenness to experience Turkish 123 25.5 5.3 0.5 !1.5*

German 104 27.0 4.7 0.5Agreeableness Turkish 123 28.1 4.0 0.4 !1.7*

German 104 29.8 4.0 0.4Conscientiousness Turkish 123 29.9 6.3 0.6 !2.8*

German 104 32.7 5.7 0.6Extraversion Turkish 123 22.5 6.4 0.6 !2.4*

German 104 24.9 6.4 0.6Neuroticism Turkish 123 27.9 5.6 0.5 1.8

German 104 26.1 7.8 0.8

*P < 0.05 after adjusting for multiple tests; differences are independent of educational level, vocational qualification, occupational activity, household income, and number ofpsychiatric diagnosis.

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patients who are convinced that their locus of con-trol is internal, who have little faith in their ownpersonal control respective self-ecacy, and whotend to assume their illness to be cyclical and of aprolonged duration.

Labeling of cluster B

Cluster B represents patients who recognize a highnumber of symptoms related to their illness. Thetime horizon of the disease and treatment areexpected to be short. The patients of type Bdevelop a high level of understanding of theirsymptoms. Hence, they expect therapeutic eects,not only from their treatment, but also from them-selves (treatment control and personal control).Cognitive aspects regarding the disease, treatment,and personal control are strongly emphasized withhigh values on average. On the other side, thesepatients exhibit low levels of emotional representa-

tions and emotional stability respective neuroti-cism. Their personality traits tend to suggest lowlevels of conscientiousness, open-mindedness, andagreeability. Individuals from Cluster B can bedescribed as symptom-sensitive, cognitively extra-verted and as patients with a strong belief in theirown personal control, and who assume that theirillness will be temporary.

Labeling of cluster C

Cluster C represents a group of patients who expe-rience almost no symptoms and assume that boththeir illness and treatment will end quickly. Theydo not expect their illness to have any impact ontheir personal relationships with others. They haveextensive knowledge about their illness, a trait thatis associated with high expectations concerningboth personal control (self-ecacy) and treatmentecacy. They are emotionally stable and exert low

Table 3. Test statistics for k-means cluster analysisbased on a random starting partition for Turkishand German patients Coefficient

Number of clusters1 2 3 4 5 6 7 8 9 10

Turkish patientsg2 0 0.20 0.26 0.31 0.34 0.36 0.40 0.41 0.42 0.44PRE 0.20 0.08 0.06 0.04 0.04 0.05 0.03 0.00 0.05F-Max 29.9 21.3 17.7 15.0 13.2 12.7 11.5 10.1 10.0

German patientsg2 0.00 0.16 0.25 0.31 0.32 0.37 0.39 0.38 0.43 0.46PRE 0.16 0.10 0.08 0.02 0.08 0.03 !0.02 0.08 0.04F-Max 19.6 16.7 15.0 11.7 11.7 10.4 8.5 9.1 8.8

, No data or parameter estimated.

Table 4. Final cluster centers for Turkish andGerman patients across illness perceptionsdimensions and personality traits dimensions

Scales

German patient groups resp. clusters(GER)

Turkish patient groups resp. clusters(TUR)

GER_AN = 27

GER_BN = 32

GER_CN = 22

GER_DN = 23

TUR_AN = 42

TUR_BN = 36

TUR_CN = 21

TUR_DN = 24

Dimension of illness perceptionSymptoms 0.47 0.47 !0.91 !0.35 0.52 0.33 !1.16 !0.39Symptoms and illness 0.30 0.58 !0.93 !0.26 0.55 0.33 !1.01 !0.57Timeline 0.18 !0.40 !0.67 0.98 0.71 !0.71 !0.89 0.60Timeline, cyclical 1.04 !0.24 !0.94 0.01 0.24 0.28 !0.80 !0.15Consequences 0.40 0.06 !1.22 0.60 0.38 0.23 !1.14 !0.01Personal control !0.03 0.66 0.17 !1.04 !0.57 0.61 0.56 !0.42Treatment control 0.14 0.40 0.51 !1.21 !0.71 0.52 0.81 !0.26Coherence !0.61 0.54 0.31 !0.34 !0.56 0.13 0.49 0.35Emotional representations 0.72 !0.07 !1.13 0.33 0.70 !0.04 !1.03 !0.26

Dimension of personality traitsOpenness to experience 0.05 0.21 0.14 !0.48 !0.71 0.19 0.54 0.47Conscientiousness !0.27 0.00 0.54 !0.20 !0.64 0.41 0.50 0.06Extraversion !0.31 0.24 0.50 !0.44 !0.67 0.48 0.70 !0.16Agreeableness 0.39 !0.31 0.15 !0.16 !0.21 0.40 0.01 !0.24Neuroticism 0.20 0.14 !0.87 0.39 0.72 !0.19 !0.81 !0.26

A = Symptom-sensitive, emotionally introverted patients; B = Symptom-sensitive, cognitively extraverted patients;C = Symptom-repressing, cognitively ruled patients; D = Symptom-repressing, emotionally unstable patients;N = Number of patients of each cluster, k-means cluster analysis based on z-standardized values and Wards method(4 clusters), which defined the starting partition; GER, German patients; TUR, Turkish patients; resp., Respective.

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levels of expressed emotions. Their personalitytraits tend to suggest high levels of conscientious-ness, open-mindedness, and agreeability. Individu-als from Cluster C can be described as symptom-repressing, cognitively ruled patients who assumethat their illness will be short lived.

Labeling of cluster D

Cluster D represents a group of patients who,although experiencing symptoms less often,nonetheless assume that their illness will be pro-longed and cyclically recurring. For this type ofpatient, the personal or treatment controls are ofreduced magnitude. Hence, personal and socialconsequences become apparent for these individ-uals. This eect may be boosted owing to theobservation that these patients have little knowl-

edge of their illness (coherence) triggering moreemotional representations and neuroticism scoreson average. Their other personality traits tend tosuggest low levels of conscientiousness, open-mindedness, and agreeability. Individuals fromCluster D can be described as symptom-repress-ing, emotionally unstable patients who assumethat their illness will be prolonged.

Statistical stability

To check for statistical stability, we used theassignments of individuals to groups that had beendefined by the solutions to the k-means clusteranalyses. The random start partition and its clustersolution 1 as well as the Ward-based start partitionand its cluster solution 2 for each ethnicity wereapplied. For each ethnicity, the individual assign-

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Fig. 1. Profiles of Turkish and German in-patients across illness perceptions dimensions and personality traits dimensions. (a)symptom-sensitive, emotionally introverted profiles of Cluster A. (b) symptom-sensitive, cognitively extraverted profiles of ClusterB. (c) symptom-repressing, cognitively ruled profiles of Cluster C. (d) symptom-repressing, emotionally unstable profiles of ClusterD.

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Ayu Gina

ments to groups of solution 1 and 2 were com-pared. The conformities between both cluster con-figurations were jtur = 0.53 for Turkish patientsand jgar = 0.47 for German patients (P < 0.001for both). The assignment of patients to clusterscan thus be considered as stable.

Discussion

Sociodemographic gradients

This study was conducted on Turkish immigrantsand German patients with mental disorders (ICD-10:F.2F.4), who had been admitted to in-patienttreatment and whose demographic and clinicaldata (duration of illness, length of in-patient treat-ment, and number of psychiatric or somatic diag-noses) did not dier systematically. This was,however, not the case from the socioeconomicpoint of view. Even after having lived an averageof 28.9 years in Germany, the Turkish immigrantssocioeconomic situations still diered from theGerman patients. The immigrant group also had ahigher inability to work, less earning potential, andmore psychiatric diagnoses. In such contexts ofpoor health outcomes and potentially inadequateservice delivery, integrating subjective illness per-ceptions into the therapeutic approach in a tar-geted way, while also taking personality traits intoaccount, can help to ensure personalized carewithin established health insurance systems.

Ethnic gradients on scales

On the level of subjective illness perceptions, Turk-ish patients systematically show lower mean valueson the subscales that address emotional, illness-specific (i.e., symptoms, etc.), and time-related top-ics, as well as for subscales addressing the conse-quences for their interpersonal relationships. Incontrast to the Turkish patients emotionalresponses, the German patients showed signifi-cantly higher values on the subscales that representthe verbalizing and cognitive skills necessary tounderstand the illness itself and that allow both thepersonal control (self-ecacy) and the treatmentcontrol to be realistically assessed. This dualismbetween the emotional and the verbalizing-cogni-tive ends of the subjective illness perception spec-trum, which can be seen in the data, is in line withearlier findings on intercultural dierences betweenTurkish and German patients (4, 5, 3840, 51).There is also a similar dualism on the level of per-sonality traits. The Turkish patients have higherscores on the neuroticism scale, while Germanpatients deem to score lower. Instead, German

patients have higher values on subscales, related tointerpersonal behaviour (extraversion, agreeable-ness, and openness to new experiences) and consci-entiousness. This is an important finding, becauseneuroticism in particular has been associated withincreased illness severity in the context of depres-sion and bipolar disorders (52, 53), a finding thathas been confirmed in particular for Turkishpatients (54). In this respect, the findings of thepresent study are consistent with earlier results (33,41). However, it cannot be excluded that such dif-ferences might be caused or increased by languagebarriers or lesser familiarity with the health system(access).

Cluster analysis and ethnicity-independent patient profiles

Unlike earlier studies, the present study goesbeyond merely describing dierences in scale rat-ings and patients utilization of healthcare services(3, 5557). As both, immigrants and ethnicGermans, experience processes of inclusion andexclusion to various extents, it makes sense to gobeyond simple dierences between two ethnicgroups on various scales and use cluster analysisinstead. This approach allows to identify similari-ties and dierences between German and Turkishpatients, in this case, on subjective illness percep-tion scales and personality traits. This methodshowed four basic patient types, common to boththe German and Turkish patients. This resultcould not have been achieved through an isolated,point-by-point consideration of the subscales. Theshapes of the patient profiles for Clusters ADwere similar for both ethnicities although the mag-nitude of cluster means on included subscales didvary according to ethnicity. These dierent patienttypes could thus form the basis for useful treat-ment approaches that could be implemented inde-pendent of the patients ethnicity.Subjective illness perceptions (such as strongly

pessimistic and external illness convictions) can beinfluenced through systematic education, psycho-education, and psychotherapy (40, 58), while per-sonality traits tend to be more resistant to change.However, personality traits can be used as a start-ing point for targeted patient-centered communica-tion, with the goal of modifying subjective illnessperceptions. As a result, improved therapeutic out-comes are expected to be achieved (40, 58). In con-trast to Broadbent et al. (58), the typologyidentified here allows to individually modify singledimensions respective subscales of patients subjec-tive illness perceptions according to each patientprofile. This approach allows for a more targeteduse of psychoeducative interventions. Taking per-

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sonality traits into account in treatment alwaysallows one to increase patients satisfaction levels,change their health-related behaviour, andimprove their compliance, thus leading to bettertherapeutic results (1117).

Models of care for different patient profiles

In this vein, dierentiating between patient typescan independent of their ethnicity and on theo-retical grounds so far help to adapt long-termcare models other than the most resource-intensivein-patient models. If a number of conditions apply(5963), patients of clusters B or C could poten-tially receive both acute treatment and/or long-term rehabilitation (out-patient psychotherapy,home treatment, and assertive community treat-ment) owing to their emotional stability (lowscores on neuroticism scales and emotional repre-sentation scales) and emphasized cognitive dimen-sions (scores on personal and treatment controlscales and coherence scales). These attributes maybe favorable for treatment adherence, expectedoutcomes, and costs. On the opposite, it may bereasonable to assume that more in-patient treat-ments, but within shorter time intervals forpatients with higher scores on neuroticism or emo-tional representations (such as cluster profiles A orD), may be more recommendable owing to its pre-ventive and stabilizing character. Hence, shorterin-patient stays replace fewer but longer and costly(in-patient) episodes in theory. However, the adap-tion of patient profiles to models of care wouldrequire an uninterrupted, quality-assured healthservice chain between in-patient and out-patientfacilities. This continuity of care is rarely observedin health care systems, especially in Germany (64).The high drop-out rates from mental treatmentamong patients with native or migratory back-grounds (65) are proof of the prevailing problemsin other existing health service infrastructures.Therefore, it remains a challenging task to inte-grate the isolated treatment options to one uninter-rupted health service chain.

Impact of ethnicity on patient profiles vs. culture-sensitivetreatment

The patient profiles developed in this study arenot contradictory or inconsistent with earlier find-ings on culture-sensitive care (6669). Without adoubt, there is a need for cultural specificity andsensitivity in communication, that is, when estab-lishing contact with patients and building physi-cianpatient relationships, during anamnesis anddiagnosis with a patient, and during the shared

decision-making process over the course of thetreatment (6870). Thus, the patient profiles devel-oped in this study would not be of any help forphysicians if they do not understand a migrantpatient adequately. Knowledge about culture-spe-cific characteristics of communication is necessaryfor adequate treatment (39, 68), which comprises,for example, religious and disease-related termsand metaphors. It is the physicians task to recog-nize these peculiarities and interpret them cor-rectly, but nevertheless use them to assign patientsto one of the four patient profiles. This approachfacilitates, independently of the ethnicity, a partic-ipatory decision-making process (71) that achievesproven therapeutic eects in the development ofsubjective illness perceptions (7274).

Strengths

This study was based on an extensive databaseof German and Turkish patients who utilizehealthcare services. The data were collected inroutine everyday care settings by trained inter-viewers whose mother tongue was the same asthe respondents. Especially, the Turkish patientcould choose the language for all interviews.From a statistical point of view, the distributionof patients with Turkish and German nationalitywas balanced, and significant or systematic dif-ferences between included and the excludedpatients were detected. The cluster analysisincludes the relatively seldom-reported g2, PRE,and F-Max values for a four-part cluster solu-tion per ethnicity. This solution oers a content-based and feasible interpretation and, again froma statistical perspective, is both reproducible andstable. Both of the resulting kappa coecients ofjtur = 0.53 and jger = 0.47 (for Turkish and Ger-man patients respectively) show systematic con-formity between the two estimation methods.This conformity was beyond a commonlydefined threshold of j = 0.45 (75).

Limitations

The data are based on a population of health careutilizers for which selective errors can always occur(7678). Owing to a lack of a comparison group, itis impossible to quantify these errors or determinewhether they are positive or negative. However,the possible impact of any selection bias to thecluster analysis deems to be low as the number ofpatients of each cluster is relatively high. Hence,the impact of any potential selection bias on theclusters is of limited influence (49). The study isalso unable to dierentiate between first- and sec-

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ond-generation Turkish immigrants. This dieren-tiation could be relevant (79). Dierent period orcohort eects may be related with subjective illnessperceptions and personality traits. However, in thisstudy, it should not be of certain concern becausethe immigrants included in this study had lived inGermany for an average of 28.9 years. During thisperiod, possible period- or cohort-specific illnessperceptions and personality traits may have beenaected by acculturation processes and the degreeof societal inclusion. But this study exhibits gravesocioeconomic gradients whose impact remainsrather unclear toward the observed dierences insubjective illness perceptions and personality traits.Additionally, one has to bear in mind that theresults of cluster analyses are very sensitive to thedistance measurements, the fusion algorithmsapplied, as well as the number of clusters selected.Small changes in these analytical decisions cancause sharp divergences in the analysis results andinterpretations (49, 50). To oset this drawback,we used two dierent methods during the explor-atory phase and should be replaced by latent classmodels (80) if the identified patient profiles showclinical relevance. At this point, one should alsokeep in mind that this study is based on Germanand Turkish patients who immigrated to Germany,who belong to the ICD-10 diagnostic groupsF.2F.4 only. Therefore, it is beyond the scope ofthis study to check for the relevance concerningother ethnicities in other countries or other diag-nostic groups. Finally, it is completely reasonableto argue that classifying patients into four set typesdisregards the individuality and complexity notonly of the diverse group of patients, but of theirunique illnesses. This argument is, however, dia-metrically opposed to the central result of thisstudy. Far from suggesting that there is only onetype of immigrant or ethnically German patient,this study shows that there are at least four distinctpatient profiles, each transcending ethnicity. Theabstract statistical model considered here in noway purports to provide a complete reflection ofreality in all its details.

Future perspectives

According to our results, the focus on cultural dif-ferences could be overestimated and should bereconsidered in favor of various types appearing inmigration processes as well as in patients livingwithin their native country. Future studies willneed to make an even stronger eort to understandthe culture-specific aspects of subjective illness per-ceptions and personality traits in this context, oftheir importance for the field of individualized and

personalized medicine (81). Naturally, this con-cerns not only the patientdoctor relationship, butalso the institutional and organizational aspects(69). Moreover, future studies should analyze theinfluence of the migration processes (acculturation)on the development and change of the abovemen-tioned types, within and between the two ethnici-ties and their occurrence in other ethnicities. Theresults of this study are exploratory and will needto be validated in future studies.

Acknowledgements

This work was supported by an unrestricted grant from thePitzer Foundation. We would like to thank Professor BerndWusten and the sta of the Klinik am Sudpark, as well as theVitos Klinik, Marburg, for their organizational support. Wealso thank the anonymous reviewer for the thoughtful support.

Declaration of interest

M Franz received financial support and sponsoring for oralpresentations and for symposia from Lundbeck, Janssen-Cilag,Novartis, Lilly, Astra Zeneca, Pfizer, Servier, Bristol-MyersSquibb, and GlaxoSmithKline. HJ Salize, C Lujic, and E Kochhave no conflict of interest. B Gallhofer received consultanciesfees, lecturing honoraria, andor research funding from Astra-Zeneca, Janssen-Cilag, Servier, Sanofi-Aventis, Lundbeck,Bristol-Myers Squibb, Novartis, Eli Lilly, and Wyeth. COJacke has no conflict of interest.

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