Cultural Competence in Health Care: A Guide for Professionals

Cultural Competence in Health Care: A Guide for Professionals

by Wen-Shing Tseng, MD, and Jon Streltzer, MD. Springer, New York, NY, 2008, 138 pages, $59.95.

Cultural Competence in Health Care is a short, readable book written by 2 professors of psychiatry at the University of Hawaii Medical School for health care providers and mental health professionals. Dr Tseng is a cultural psychiatrist who is an author or editor of about 50 books in English and Chinese, mostly on culture and various aspects of mental health care. Dr Streltzer is a consultation-liaison psychiatrist, former residency training director, and author of 4 books and more than 65 journal articles and book chapters on psychosomatic medicine, pain, and cultural psychiatry.

The book is divided into 9 chapters, the longest of which is 22 pages. Topics covered are the relationships of culture to medical practice, clinical assessment, medical diseases and mental disorders, medical care, and special medical problems. Cultural beliefs of people of different ethnicities as they affect health care are discussed, and an initial chapter nicely defines culture, race, ethnicity, minority, and social class and discusses such issues as disease versus illness, folk concepts of illness, and traditional healing. Various important aspects of the relationship between patients and health care providers are elaborated, such as their cultural experience, privacy and confidentiality, and the need for cultural competence on the part of medical providers.

The first chapter is particularly useful. Culture is defined on page 1 as "the unique behavioral patterns and lifestyles shared by a group of people that distinguishes that group from others" and is expressed through "customs, etiquette, taboos, or rituals," as well as through language. The importance of illness behavior in various cultures is explained, and various natural and supernatural beliefs as causes for illness are discussed. Chapter 2 addresses issues of cultural competence by physicians, nurses, social workers, and physical therapists. The meaning and importance of food are also highlighted. Chapter 3 discusses culture and clinical assessment. This discussion includes ways different cultures may express symptoms of depression, use of interpreters, and how subjects such as sexual behavior and orientation, birth and care of children, and death are regarded in different ways by different cultures. Chapter 4 outlines health care issues and beliefs of several major cultural groups in the United States, including blacks, Native Americans, Muslims, Arab Americans, Asian Americans, Hispanic Americans, and subgroups of white Americans such as the Irish, Jewish, and Amish communities. Chapter 5 discusses the relationship of different cultural beliefs in assessing and treating various medical illnesses such as cancer (especially breast cancer), leprosy, epilepsy, malaria, dementia, coronary heart disease, and obesity. How psychiatric problems are defined in both clinical and cultural ways is discussed in Chapter 6, and the importance of somatic complaints that mask psychiatric symptoms is highlighted. Discussion of the ways that various cultures view suicide, substance abuse, and other mental illnesses is useful, and presentation of some culture-related specific syndromes is instructive. Varying acceptance and effectiveness of medications and "talk therapy" in various cultures is also discussed. Chapter 7 discusses the relationship of culture to various aspects of the medical care system, eg, hospitalization, being a patient, consent, taking medications, and dealing with referrals including psychiatric referrals. Complex issues related to involvement of families in patient health care across various cultures are also discussed. Special medical issues and their relationship to various cultures are addressed in Chapter 8. The list of issues is long and includes circumcision, child and sexual abuse, pain management, abortion, and difficult issues such as euthanasia, infanticide, and autopsies. The final chapter discusses the characteristics of a culturally sensitive provider and makes some suggestions for obtaining and improving this sensitivity. Suggestions include knowing the value of cultural sensitivity, having an attitude of "wanting to learn," and obtaining specific cultural knowledge via books and by consulting with persons from a specific culture. Recognizing the importance of the concept that quality health care involves knowledge about the culture of both patient and provider is key.

The strengths of this book are that it is well-written and covers a wide range of cultural issues related to both patients and providers that are often not considered. For psychiatric issues, the focus on somatization of depressed and anxious feelings is particularly useful. One of the book’s limitations is that several important cultural issues are not discussed adequately. For example, the special discussion of the role and input of traditional healers is confined to less than a page. Traditional healers are not mentioned in the discussion of Native American cultural issues; we are told that alternative practices "should be considered" for Hispanic patients, but specific guidance is not offered. Native American and Hispanic cultures often attribute major healing powers to their traditional healers, whose methods are often highly effective and should be considered complementary to Western healing practices. References and case examples in the book are generally effective, but the work of well-known cultural researchers (eg, Spero M. Manson, PhD, and his colleagues at the University of Colorado’s National Center for American Indian and Alaska Native Mental Health Research) is not mentioned or referenced. In addition, the issue of involving families as a cultural practice in relation to the limitations imposed by the American medical system on sharing confidential and private information is not discussed. The increasing prevalence and resistance of tuberculosis strains should have been mentioned in the discussion on tuberculosis.

Overall, while the book has some limitations and cultural biases and emphases that are based on the authors’ experiences, it is overall very helpful in conveying and expanding comprehensive cultural knowledge and increasing the cultural sensitivity of practitioners in the health care system, including mental health professionals.

Scott H. Nelson, MD, MPH

Author affiliation: Psychiatric consultant to American Indian mental health programs, Santa Fe, New Mexico. Potential conflicts of interest: None reported.

J Clin Psychiatry 2010;71(5):657

Volume: 71

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