The influence of culture on neuropsychological testing in Zambia

A research project, the Zambia Neurobehavioural (ZNB) study aimed at developing normative data for a Neuropsychological neurobehavioural test battery was started. The test battery is sensitive to HIV neurocognitive defects and it is hoped that it can be used for clinical practice (for diagnostic and prognostic purposes) and further research in HIV in Zambia. However, none of the test components of the ZNB test battery were developed in Zambia, or indeed Africa. Literature shows that when tests that are developed in one culture are administered in another one, the validity and reliability of the results is compromised because of the influence of cultural differences. The Zambian situation is no different. In my research, I did a phenomenological study seeking to identify and describe the cultural influences on NP testing in Zambia through semi-structured questionnaire administration and in-depth interviews with test-takers and focus group discussion with test-administrators.

Five major themes emerged from the results. (1) Use of English as a language of instruction and testing may have given rise to underestimates of the cognitive competence of participants most of whom had limited knowledge of English, and this effect was probably intensified by the use of a type of English that is not quite familiar in Zambia. (2) Use of computer tests in a population that is relatively computer ‘naïve’ gave rise to distraction, such that much of what was assessed may have been skills and attitudes towards computers per se rather than the cognitive functions the tests were supposed to measure. (3) Use of geometrical forms and graphical representation for the assessment of visual-spatial memory may have given rise to underestimates of the cognitive competence of participants most of whom had limited experience with those media. (4) The emphasis of speed in some of the tests may have given rise to underestimates of the cognitive competence of participants in a culture where people seem to pay more attention to how well something is done rather than how quickly it can be completed. (5) Inclusion of some activities of daily living that were not, in some aspects, culturally relevant, in the questionnaire designed to assess participants’ level of functioning may have generated misleading results. Based on these findings, it is recommended that tests be adapted to be relevant to the Zambian culture.