Depressed patients’ desire for culturally competent providers differs by race, ethnicity
People from historically underrepresented groups with depression symptoms more often expressed wanting a provider who shared or understood their culture, according to a retrospective, population-based, cross-sectional study in Lancet Psychiatry.
“Assessment of access to culturally competent care, in terms of importance placed on access and disparities in access, might identify ways to decrease health care disparities,” Hatice Nur Eken, BS, of Vanderbilt University School of Medicine in Nashville, Tennessee, and colleagues wrote. “Although engendering cultural competence is not the only solution that can address inequities in health care, it might mitigate some of the health consequences of racial discrimination.”
Eken and colleagues collected questionnaire information from 3,910 adults (median age, 52 years; 60.9% women) who participated in the 2017 U.S. National Health Interview Survey (NHIS), the only year for which questions on cultural competence were available. Researchers examined responses to cultural competency, anxiety and depression questions.
Participants identifying as Black or African American, Asian American or mixed race were more likely to say that providers sharing or understanding their culture was “very important” or “somewhat important” compared to those identifying as white (Black vs. white, adjusted OR, 2.54; 95% CI, 1.86–3.48; Asian American vs. white, aOR, 2.57; 95% CI, 1.66–3.99; mixed race vs. white, aOR, 1.69; 95% CI, 1.01–2.82). Hispanic participants were more likely to report the same compared with non-Hispanic participants (56.9% vs. 35.6%; aOR, 2.69; 95% CI, 2.03–3.6).
Adjusting for demographics and whether they saw a mental health specialist within the last year, individuals from underrepresented populations were also less likely to have access to providers who shared their culture than white and non-Hispanic participants.
Additionally, 49.6% of participants with depressive symptoms reported that having their provider share or understand their culture was important, while 37.7% of participants without depression or anxiety said the same (aOR, 1.57; 95% CI, 1.13–2.19). However, patients with depressive symptoms were less likely to have a provider who shared their culture compared to those without depression or anxiety (aOR, 0.63; 95% CI, 0.41–0.96).
These correlations were not present in patients with anxiety or with comorbid depression and anxiety, the researchers wrote.
Women were more likely than men to place importance on a provider sharing or understanding their culture, and participants with the highest levels of poverty were most likely to want a culturally competent provider.
“To our knowledge, our findings are among the first to show patient preference for cultural competence in individuals with depression and anxiety symptoms and highlight the importance of incorporating culturally competent and humble interactions in psychiatric care,” Eken and colleagues wrote. “Although previous studies have investigated racial and ethnic differences and implicit biases in patient–provider interactions, our study contributes to the existing literature by highlighting the importance of taking patient perspectives into account, especially in patients with common psychiatric conditions.”
Limitations included classification of depression and anxiety, how access to mental health care was assessed, small sample sizes of some racial groups and use of NHIS’s definition of culture.
"Future efforts to rectify racial disparities in mental health should emphasize cultural competence and humility in training as a mandatory skill, given the lack of diversity in the current mental health workforce," Ayana Jordan, MD, PhD, of Yale University School of Medicine's department of psychiatry, told Healio Psychiatry. "This level of sophistication to articulate the cultural and structural phenomena at play along with the biological illness, especially among those from historically excluded populations, can indeed impact overall treatment outcomes.
"Therefore, research that highlights best practices in teaching cultural and structural competence must be studied as a means to replicate those behaviors that prove successful," Jordan added. "The gravity of the pandemic has demonstrated that natural disasters leading to environmental stressors can disproportionately affect racial and ethnic minoritized groups, so having an understanding of the underlying cause of these disparities is more important than ever to successfully intervene and improve outcomes."