SEIDEL’S GUIDE TO
PHYSICAL
10TH EDITION
EXAMINATION
AN INTERPROFESSIONAL APPROACH
JANE W. BALL, DrPH, RN, CPNP BARRY S. SOLOMON, MD, MPH
Chief Nursing and Content Officer Professor of Pediatrics
Triaj, Inc. Chief, Division of General Pediatrics
Havre de Grace, Maryland Assistant Dean for Medical Student Affairs
The Johns Hopkins University
JOYCE E. DAINS, DrPH, JD, APRN, School of Medicine
FNP-BC, FNAP, FAANP, FAAN Baltimore, Maryland
Professor and Chair (ad interim)
Department of Nursing ROSALYN W. STEWART, MD, MS,
Executive Director for Advanced Practice MBA
The University of Texas MD Anderson Cancer Professor of Medicine and Pediatrics
Center The Johns Hopkins University
Houston, Texas School of Medicine
Baltimore, Maryland
JOHN A. FLYNN, MD, MBA, MEd
Professor of Medicine
Department of Medicine
The University of Chicago
Chicago, Illinois
, CHAPTER
Cultural Competency 1
A chieving cultural competence is a learning process
that requires self-awareness, reflective practice, and
knowledge of core cultural issues. It involves recognizing
activated when an individual is categorized into a social
group. When this occurs, the beliefs and feelings (prej-
udices) come to mind about what members of that par-
one’s own culture, values, and biases and using effective ticular group are like. Over time, this first phase occurs
patient-centered communication skills. A culturally com- without effort or awareness. In the second phase, people
petent healthcare provider adapts to the unique needs of use these activated beliefs and feelings when they interact
patients of backgrounds and cultures that differ from their with the individual, even when they explicitly deny these
own. This adaptability, coupled with a genuine curiosity stereotypes. Multiple studies have shown that healthcare
about a patient’s beliefs, values, and lived experience, lay providers activate these implicit stereotypes, or uncon-
the foundation for a trusting patient-provider relationship. scious biases, when communicating with and providing
care to minority patients (FitzGerald and Hurst, 2017).
With this in mind, you can begin learning cultural com-
A Definition of Culture petence by acknowledging your implicit, or unconscious,
Culture, in its broadest sense, reflects the whole of human biases toward patients based on physical characteristics.
behavior, including ideas and attitudes, ways of relating At the same time, this does not minimize the value of
to one another, manners of speaking, and the material understanding the cultural characteristics of groups, nor
products of physical effort, ingenuity, and imagination. does this deny the interdependence of the physical with
Language is a part of culture. So, too, are the abstract the cultural. Genotype, for example, precedes the devel-
systems of belief, etiquette, law, morals, entertainment, opment of the intellect, sensitivity, and imagination that
and education. Within the cultural whole, different popu- leads to unique cultural achievements, such as the creation
lations may exist in groups and subgroups. Each group of classical or jazz music. Similarly, a person’s phenotype,
is identified by a particular body of shared traits (e.g., a such as skin color, precedes most of the experience of life
particular art, ethos, or belief; or a particular behavioral and the subsequent interweaving of that phenotype with
pattern) and is rather dynamic in its evolving accommo- cultural experience. Although commonly used in clinical
dations with internal and external influences. Any indi- practice, the use of phenotypic traits to classify an individ-
vidual may belong to more than one group or subgroup, ual’s race is problematic. The term race has been used to
such as ethnic origin, religion, gender, sexual orientation, categorize individuals based on their continent or subcon-
occupation, and profession. tinent of origin (e.g., Asian, Southeast Asian). However,
there is ongoing debate about the usefulness of race, con-
sidering the degree of phenotypic and genetic variation of
Distinguishing Physical Characteristics individuals from the same geographic region (Relethford,
The use of physical characteristics (e.g., anatomy or skin 2009). In addition, the origins of race date back to the 17th
color) to distinguish a cultural group or subgroup is inap- century, long before scientists identified genetic similari-
propriate. There is a significant difference between dis- ties. Over time, beliefs about particular racial groups were
tinguishing cultural characteristics and distinguishing shaped by economic and political factors, and many be-
physical characteristics. Do not confuse the physical with lieve race is a social construct (Richeson and Sommers,
the cultural or allow the physical to symbolize the cul- 2016). Racism, defined as discrimination directed against
tural. To assume homogeneity in the beliefs, attitudes, and a person or people of a particular racial or ethnic group,
behaviors of all individuals in a particular group leads to has been shown to negatively impact health over the life
misunderstandings about the individual. The stereotype, a course. This occurs through inequitable access to resourc-
fixed image of any group that denies the potential of origi- es and opportunities, such as education and healthcare,
nality or individuality within the group, must be rejected. and stressful experiences that result in altered physiologic
People can and do respond differently to the same envi- responses and changes in health behavior (Williams et al.,
ronment or situation. Stereotyping occurs through two 2019). Historically, the American healthcare system has
cognitive phases. In the first phase, a stereotype becomes discriminated against racial and ethnic minorities in edu-
1
, 2 CHAPTER 1 Cultural Competency
cation, research, and direct patient care. Structural racism genomics and other molecular technologies with data shar-
remains an ongoing problem within the healthcare sys- ing, advanced data analytics, and digital health platforms
tem and is reflected in well-documented health disparities (Ginsburg and Phillips, 2018). As healthcare providers learn
and inequities. As healthcare providers, you will encoun- to integrate precision medicine into their clinical practice,
ter patients impacted by racism on a daily basis. After ex- direct-to-consumer genetic testing continues to evolve and
Cultural Competency
amining your own biases, you can strive to create a safe has become more affordable and accessible to our patients.
space for dialogue with patients, provide support, and re- Healthcare providers in all disciplines will need to become
fer to resources when appropriate (Trent et al., 2019). fluent in the language of genomics and learn how to dis-
cuss risks and benefits of genetic testing with their patients
Genomics and Precision Medicine and families (Calzone et al., 2013; Demmer and Waggoner,
A growing body of research examines genomics, the study 2014). With this new emphasis, it may be even more impor-
of multiple genes and their interactions with environmen- tant to acknowledge unconscious biases and seek to under-
tal determinants, in predicting disease susceptibility and stand the patient’s unique cultural and personal health
response to medical treatment. An explosion of genome- beliefs and expectations.
wide association studies (GWASs) has linked genomic loci,
or single-nucleotide polymorphisms (SNPs) with common
Cultural Competence
diseases such as rheumatoid arthritis, type 1 and type 2
diabetes mellitus, Crohn disease, and schizophrenia (Viss- Culturally competent care requires that healthcare provid-
cher et al., 2017). Personalized medicine is a term used to ers be aware of and responsive to patients’ background
describe patient care that considers an individual’s genetic and cultural experiences, including their preferences, val-
susceptibility in preventing and treating disease. In 2015, ues, language, and traditions, among other things (Stubbe,
the Precision Medicine Initiative was launched by the 2020). Many models have been proposed to teach cul-
US Department of Health and Human Services to bring tural competence. Most include the domains of acquiring
researchers, policymakers, and technology innovators knowledge (e.g., understanding the meaning of culture),
together with the goal of developing individualized care. shaping attitudes (e.g., respecting differences of individu-
Precision medicine is defined as “an emerging approach als from other cultures), and developing skills (e.g., elicit-
for disease treatment and prevention that takes into account ing patient’s cultural beliefs about health and illness) (Saha
individual variability in genes, environment, and lifestyle for et al., 2008). Some of these domains overlap with core
each person” (Garrido et al., 2018). Many believe precision aspects of the patient-centered care model (Fig. 1.1). Seele-
medicine will transform healthcare delivery by leveraging man et al. (2009) have proposed a framework for teaching
Patient-Centered Care • Understands and is
• Curbs hindering interested in the patient as
behavior such as unique person Cultural Competence
technical language, • Uses a biopsychosocial model • Understands the
frequent interruptions, • Explores and respects patient meaning of culture
or false reassurance beliefs, values, meaning of • Is knowledgeable
• Understands illness, preferences, and needs about different cultures
transference/ • Builds rapport and trust • Appreciates diversity
countertransference • Finds common ground • Is aware of health
• Understands the stages • Is aware of own biases/ disparities and
and functions of a assumptions discrimination affecting
medical interview • Maintains and is able to convey minority groups
• Attends to health unconditional positive regard • Effectively uses
promotion/disease • Allows involvement of friends/ interpreter services
prevention family when desired when needed
• Attends to physical • Provides information and
comfort education tailored to patient’s
level of understanding
FIG. 1.1 Overlapping concepts of patient-centered care and cultural competence. (From Saha et al.,
2008.)
, CHAPTER 1 Cultural Competency 3
cultural competence that emphasizes an awareness of the conditions, may affect the provision of specific health-
social context in which specific ethnic groups live. Assess- care services to certain groups and subgroups in the
ing the social context includes inquiring about stressors and United States. Poverty and inadequate education dis-
support networks, sense of life control, and literacy. Health- proportionately affect various cultural groups (e.g.,
care providers need to be flexible and creative in working ethnic minorities and women); socioeconomic dispari-
Cultural Competency
with patients. Campinha-Bacote’s (2011) Process of Cultural ties negatively affect the health and medical care of
Competence Model is another approach and includes five individuals belonging to these groups. Although death
cultural constructs: encounters, desire, awareness, knowl- rates have declined overall in the United States over the
edge, and skill. Box 1.1 defines these five constructs. past 50 years, the poorly educated and those in poverty
still die at higher rates from the same conditions than
those who are better educated and economically advan-
Cultural Humility taged. Morbidity, too, is greater among the poor. Data
Cultural humility involves the ability to recognize one’s from the 2013 Centers for Disease Control and Preven-
limitations in knowledge and cultural perspective and tion (CDC) Health Disparities and Inequalities Report
be open to new perspectives. Rather than assuming all reveal a variety of healthcare disparities. Hispanic and
patients of a particular culture fit a certain stereotype,
healthcare providers should view patients as individu-
als. In doing so, cultural humility helps to equalize the he Influence of Age, Race, Ethnicity,
T
imbalance in the patient- provider relationship (Borkan BOX 1.2
Socioeconomic Status, and Culture
et al., 2008). A provider may know many specific details
Age, gender, race, ethnic group, and, with these variables, cultural
about a patient’s particular cultures, yet not show cul-
attitudes, regional differences, and socioeconomic status influ-
tural humility. Cultural humility involves self-reflection ence the way patients seek medical care and the way clinicians
and self-critique with the goal of having a more balanced, provide care. For example, consider the ethnic and racial differ-
mutually beneficial relationship. It involves meeting ences in the treatment of depression in the United States. The
patients “where they are” without judgment to avoid the prevalence of major depressive disorders is similar across groups;
development of stereotypes. Attaining cultural humility however, compared with White Americans, Black and Latino pa-
is an ongoing process shaped by every patient encounter tients are less likely to receive treatment. Although some of the
that involves openness, partnership, and genuine interest disparity is related to differing patient attitudes and perceptions of
in understanding our patients’ belief systems and lives counseling and medication, there is growing evidence suggesting
(Fahlberg et al., 2016). clinician communication style and treatment recommendations
differ on the basis of patient race and ethnicity (Shao et al., 2016).
Similarly, in the pediatric population, Black and Latino children
The Impact of Culture in the United States also experience health disparities, including
lower overall health status and lower receipt of routine medical
The information in Box 1.2 suggests that racial and care and dental care compared with White children. Flores and
ethnic differences, as well as social and economic colleagues (2010), in a systematic literature review, demonstrated
that, compared with White children, Black children have lower
rates of preventive and population healthcare (e.g., breast-feeding
BOX 1.1 Dimensions of Cultural Competence and immunization coverage), higher adolescent health risk behav-
CULTURAL ENCOUNTERS—The continuous process of interacting iors (e.g., sexually transmitted infections), higher rates of asthma
with patients from culturally diverse backgrounds to validate, emergency visits, and lower mental health service use. There is a
refine, or modify existing values, beliefs, and practices about a clear need to better understand why these differences exist more
cultural group and to develop cultural desire, cultural awareness, globally, but removing cultural blindness at the individual patient
cultural skill, and cultural knowledge. level is an important first step.
CULTURAL DESIRE—The motivation of the healthcare professional to Furthermore, the possible beneficial and harmful effects of many
“want to” engage in the process of becoming culturally compe- culturally important herbal medicines, which are used but not always
tent, not “have to.” acknowledged, must be understood and, in trusting relationships, re-
CULTURAL AWARENESS—The deliberate self-examination and ported to us if we are to guide their appropriate use. Crossing the
in-depth exploration of one’s biases, stereotypes, prejudices, cultural divide helps, but skepticism is a barrier. For example, many
assumptions, and “isms” that one holds about individuals and allopathic medical providers question the notion that complementary
groups who are different from them. and alternative medicine might be a helpful adjuvant therapy for the
CULTURAL KNOWLEDGE—The process of seeking and obtaining a prevention and treatment of acute otitis media. However, in several
sound educational base about culturally and ethnically diverse randomized controlled studies, xylitol, probiotics, herbal ear drops,
groups. and homeopathic treatments have been shown, compared with
CULTURAL SKILL—The ability to collect culturally relevant data placebo, to have a greater effect in reducing pain duration and de-
regarding the patient’s presenting problem, as well as accurately creasing the use of antibiotics. Although skepticism can be put aside,
performing a culturally based physical assessment in a culturally evidence-driven guidance is still essential. Cultural competence is
sensitive manner. entirely consistent with that.
From Campinha-Bacote (2011). Data from Bukutu et al. (2008); Flores (2010); and Shao et al. (2016).
PHYSICAL
10TH EDITION
EXAMINATION
AN INTERPROFESSIONAL APPROACH
JANE W. BALL, DrPH, RN, CPNP BARRY S. SOLOMON, MD, MPH
Chief Nursing and Content Officer Professor of Pediatrics
Triaj, Inc. Chief, Division of General Pediatrics
Havre de Grace, Maryland Assistant Dean for Medical Student Affairs
The Johns Hopkins University
JOYCE E. DAINS, DrPH, JD, APRN, School of Medicine
FNP-BC, FNAP, FAANP, FAAN Baltimore, Maryland
Professor and Chair (ad interim)
Department of Nursing ROSALYN W. STEWART, MD, MS,
Executive Director for Advanced Practice MBA
The University of Texas MD Anderson Cancer Professor of Medicine and Pediatrics
Center The Johns Hopkins University
Houston, Texas School of Medicine
Baltimore, Maryland
JOHN A. FLYNN, MD, MBA, MEd
Professor of Medicine
Department of Medicine
The University of Chicago
Chicago, Illinois
, CHAPTER
Cultural Competency 1
A chieving cultural competence is a learning process
that requires self-awareness, reflective practice, and
knowledge of core cultural issues. It involves recognizing
activated when an individual is categorized into a social
group. When this occurs, the beliefs and feelings (prej-
udices) come to mind about what members of that par-
one’s own culture, values, and biases and using effective ticular group are like. Over time, this first phase occurs
patient-centered communication skills. A culturally com- without effort or awareness. In the second phase, people
petent healthcare provider adapts to the unique needs of use these activated beliefs and feelings when they interact
patients of backgrounds and cultures that differ from their with the individual, even when they explicitly deny these
own. This adaptability, coupled with a genuine curiosity stereotypes. Multiple studies have shown that healthcare
about a patient’s beliefs, values, and lived experience, lay providers activate these implicit stereotypes, or uncon-
the foundation for a trusting patient-provider relationship. scious biases, when communicating with and providing
care to minority patients (FitzGerald and Hurst, 2017).
With this in mind, you can begin learning cultural com-
A Definition of Culture petence by acknowledging your implicit, or unconscious,
Culture, in its broadest sense, reflects the whole of human biases toward patients based on physical characteristics.
behavior, including ideas and attitudes, ways of relating At the same time, this does not minimize the value of
to one another, manners of speaking, and the material understanding the cultural characteristics of groups, nor
products of physical effort, ingenuity, and imagination. does this deny the interdependence of the physical with
Language is a part of culture. So, too, are the abstract the cultural. Genotype, for example, precedes the devel-
systems of belief, etiquette, law, morals, entertainment, opment of the intellect, sensitivity, and imagination that
and education. Within the cultural whole, different popu- leads to unique cultural achievements, such as the creation
lations may exist in groups and subgroups. Each group of classical or jazz music. Similarly, a person’s phenotype,
is identified by a particular body of shared traits (e.g., a such as skin color, precedes most of the experience of life
particular art, ethos, or belief; or a particular behavioral and the subsequent interweaving of that phenotype with
pattern) and is rather dynamic in its evolving accommo- cultural experience. Although commonly used in clinical
dations with internal and external influences. Any indi- practice, the use of phenotypic traits to classify an individ-
vidual may belong to more than one group or subgroup, ual’s race is problematic. The term race has been used to
such as ethnic origin, religion, gender, sexual orientation, categorize individuals based on their continent or subcon-
occupation, and profession. tinent of origin (e.g., Asian, Southeast Asian). However,
there is ongoing debate about the usefulness of race, con-
sidering the degree of phenotypic and genetic variation of
Distinguishing Physical Characteristics individuals from the same geographic region (Relethford,
The use of physical characteristics (e.g., anatomy or skin 2009). In addition, the origins of race date back to the 17th
color) to distinguish a cultural group or subgroup is inap- century, long before scientists identified genetic similari-
propriate. There is a significant difference between dis- ties. Over time, beliefs about particular racial groups were
tinguishing cultural characteristics and distinguishing shaped by economic and political factors, and many be-
physical characteristics. Do not confuse the physical with lieve race is a social construct (Richeson and Sommers,
the cultural or allow the physical to symbolize the cul- 2016). Racism, defined as discrimination directed against
tural. To assume homogeneity in the beliefs, attitudes, and a person or people of a particular racial or ethnic group,
behaviors of all individuals in a particular group leads to has been shown to negatively impact health over the life
misunderstandings about the individual. The stereotype, a course. This occurs through inequitable access to resourc-
fixed image of any group that denies the potential of origi- es and opportunities, such as education and healthcare,
nality or individuality within the group, must be rejected. and stressful experiences that result in altered physiologic
People can and do respond differently to the same envi- responses and changes in health behavior (Williams et al.,
ronment or situation. Stereotyping occurs through two 2019). Historically, the American healthcare system has
cognitive phases. In the first phase, a stereotype becomes discriminated against racial and ethnic minorities in edu-
1
, 2 CHAPTER 1 Cultural Competency
cation, research, and direct patient care. Structural racism genomics and other molecular technologies with data shar-
remains an ongoing problem within the healthcare sys- ing, advanced data analytics, and digital health platforms
tem and is reflected in well-documented health disparities (Ginsburg and Phillips, 2018). As healthcare providers learn
and inequities. As healthcare providers, you will encoun- to integrate precision medicine into their clinical practice,
ter patients impacted by racism on a daily basis. After ex- direct-to-consumer genetic testing continues to evolve and
Cultural Competency
amining your own biases, you can strive to create a safe has become more affordable and accessible to our patients.
space for dialogue with patients, provide support, and re- Healthcare providers in all disciplines will need to become
fer to resources when appropriate (Trent et al., 2019). fluent in the language of genomics and learn how to dis-
cuss risks and benefits of genetic testing with their patients
Genomics and Precision Medicine and families (Calzone et al., 2013; Demmer and Waggoner,
A growing body of research examines genomics, the study 2014). With this new emphasis, it may be even more impor-
of multiple genes and their interactions with environmen- tant to acknowledge unconscious biases and seek to under-
tal determinants, in predicting disease susceptibility and stand the patient’s unique cultural and personal health
response to medical treatment. An explosion of genome- beliefs and expectations.
wide association studies (GWASs) has linked genomic loci,
or single-nucleotide polymorphisms (SNPs) with common
Cultural Competence
diseases such as rheumatoid arthritis, type 1 and type 2
diabetes mellitus, Crohn disease, and schizophrenia (Viss- Culturally competent care requires that healthcare provid-
cher et al., 2017). Personalized medicine is a term used to ers be aware of and responsive to patients’ background
describe patient care that considers an individual’s genetic and cultural experiences, including their preferences, val-
susceptibility in preventing and treating disease. In 2015, ues, language, and traditions, among other things (Stubbe,
the Precision Medicine Initiative was launched by the 2020). Many models have been proposed to teach cul-
US Department of Health and Human Services to bring tural competence. Most include the domains of acquiring
researchers, policymakers, and technology innovators knowledge (e.g., understanding the meaning of culture),
together with the goal of developing individualized care. shaping attitudes (e.g., respecting differences of individu-
Precision medicine is defined as “an emerging approach als from other cultures), and developing skills (e.g., elicit-
for disease treatment and prevention that takes into account ing patient’s cultural beliefs about health and illness) (Saha
individual variability in genes, environment, and lifestyle for et al., 2008). Some of these domains overlap with core
each person” (Garrido et al., 2018). Many believe precision aspects of the patient-centered care model (Fig. 1.1). Seele-
medicine will transform healthcare delivery by leveraging man et al. (2009) have proposed a framework for teaching
Patient-Centered Care • Understands and is
• Curbs hindering interested in the patient as
behavior such as unique person Cultural Competence
technical language, • Uses a biopsychosocial model • Understands the
frequent interruptions, • Explores and respects patient meaning of culture
or false reassurance beliefs, values, meaning of • Is knowledgeable
• Understands illness, preferences, and needs about different cultures
transference/ • Builds rapport and trust • Appreciates diversity
countertransference • Finds common ground • Is aware of health
• Understands the stages • Is aware of own biases/ disparities and
and functions of a assumptions discrimination affecting
medical interview • Maintains and is able to convey minority groups
• Attends to health unconditional positive regard • Effectively uses
promotion/disease • Allows involvement of friends/ interpreter services
prevention family when desired when needed
• Attends to physical • Provides information and
comfort education tailored to patient’s
level of understanding
FIG. 1.1 Overlapping concepts of patient-centered care and cultural competence. (From Saha et al.,
2008.)
, CHAPTER 1 Cultural Competency 3
cultural competence that emphasizes an awareness of the conditions, may affect the provision of specific health-
social context in which specific ethnic groups live. Assess- care services to certain groups and subgroups in the
ing the social context includes inquiring about stressors and United States. Poverty and inadequate education dis-
support networks, sense of life control, and literacy. Health- proportionately affect various cultural groups (e.g.,
care providers need to be flexible and creative in working ethnic minorities and women); socioeconomic dispari-
Cultural Competency
with patients. Campinha-Bacote’s (2011) Process of Cultural ties negatively affect the health and medical care of
Competence Model is another approach and includes five individuals belonging to these groups. Although death
cultural constructs: encounters, desire, awareness, knowl- rates have declined overall in the United States over the
edge, and skill. Box 1.1 defines these five constructs. past 50 years, the poorly educated and those in poverty
still die at higher rates from the same conditions than
those who are better educated and economically advan-
Cultural Humility taged. Morbidity, too, is greater among the poor. Data
Cultural humility involves the ability to recognize one’s from the 2013 Centers for Disease Control and Preven-
limitations in knowledge and cultural perspective and tion (CDC) Health Disparities and Inequalities Report
be open to new perspectives. Rather than assuming all reveal a variety of healthcare disparities. Hispanic and
patients of a particular culture fit a certain stereotype,
healthcare providers should view patients as individu-
als. In doing so, cultural humility helps to equalize the he Influence of Age, Race, Ethnicity,
T
imbalance in the patient- provider relationship (Borkan BOX 1.2
Socioeconomic Status, and Culture
et al., 2008). A provider may know many specific details
Age, gender, race, ethnic group, and, with these variables, cultural
about a patient’s particular cultures, yet not show cul-
attitudes, regional differences, and socioeconomic status influ-
tural humility. Cultural humility involves self-reflection ence the way patients seek medical care and the way clinicians
and self-critique with the goal of having a more balanced, provide care. For example, consider the ethnic and racial differ-
mutually beneficial relationship. It involves meeting ences in the treatment of depression in the United States. The
patients “where they are” without judgment to avoid the prevalence of major depressive disorders is similar across groups;
development of stereotypes. Attaining cultural humility however, compared with White Americans, Black and Latino pa-
is an ongoing process shaped by every patient encounter tients are less likely to receive treatment. Although some of the
that involves openness, partnership, and genuine interest disparity is related to differing patient attitudes and perceptions of
in understanding our patients’ belief systems and lives counseling and medication, there is growing evidence suggesting
(Fahlberg et al., 2016). clinician communication style and treatment recommendations
differ on the basis of patient race and ethnicity (Shao et al., 2016).
Similarly, in the pediatric population, Black and Latino children
The Impact of Culture in the United States also experience health disparities, including
lower overall health status and lower receipt of routine medical
The information in Box 1.2 suggests that racial and care and dental care compared with White children. Flores and
ethnic differences, as well as social and economic colleagues (2010), in a systematic literature review, demonstrated
that, compared with White children, Black children have lower
rates of preventive and population healthcare (e.g., breast-feeding
BOX 1.1 Dimensions of Cultural Competence and immunization coverage), higher adolescent health risk behav-
CULTURAL ENCOUNTERS—The continuous process of interacting iors (e.g., sexually transmitted infections), higher rates of asthma
with patients from culturally diverse backgrounds to validate, emergency visits, and lower mental health service use. There is a
refine, or modify existing values, beliefs, and practices about a clear need to better understand why these differences exist more
cultural group and to develop cultural desire, cultural awareness, globally, but removing cultural blindness at the individual patient
cultural skill, and cultural knowledge. level is an important first step.
CULTURAL DESIRE—The motivation of the healthcare professional to Furthermore, the possible beneficial and harmful effects of many
“want to” engage in the process of becoming culturally compe- culturally important herbal medicines, which are used but not always
tent, not “have to.” acknowledged, must be understood and, in trusting relationships, re-
CULTURAL AWARENESS—The deliberate self-examination and ported to us if we are to guide their appropriate use. Crossing the
in-depth exploration of one’s biases, stereotypes, prejudices, cultural divide helps, but skepticism is a barrier. For example, many
assumptions, and “isms” that one holds about individuals and allopathic medical providers question the notion that complementary
groups who are different from them. and alternative medicine might be a helpful adjuvant therapy for the
CULTURAL KNOWLEDGE—The process of seeking and obtaining a prevention and treatment of acute otitis media. However, in several
sound educational base about culturally and ethnically diverse randomized controlled studies, xylitol, probiotics, herbal ear drops,
groups. and homeopathic treatments have been shown, compared with
CULTURAL SKILL—The ability to collect culturally relevant data placebo, to have a greater effect in reducing pain duration and de-
regarding the patient’s presenting problem, as well as accurately creasing the use of antibiotics. Although skepticism can be put aside,
performing a culturally based physical assessment in a culturally evidence-driven guidance is still essential. Cultural competence is
sensitive manner. entirely consistent with that.
From Campinha-Bacote (2011). Data from Bukutu et al. (2008); Flores (2010); and Shao et al. (2016).
