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2023 HSR&D/QUERI National Conference Abstract

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4015 — Veterans Health Administration Providers’ Perspectives on the Impact of Culture in the Diagnosis and Recognition of Anxiety

Lead/Presenter: Darius Dawson,  COIN - Houston
All Authors: Dawson DB (Houston VA HRS&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA), Chen, P (Houston VA HRS&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA), Tsao CGJ (Houston VA HRS&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA), Fletcher TL (Houston VA HRS&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA)

Objectives:
Examining the impact of culture on diagnosing anxiety is necessary to ensure equitable diagnostic processes for all patients. Research indicates that culture can impact patients’ development and expression of anxiety. As well, culture may impact providers’ accurate diagnosis of anxiety: providers may misinterpret anxiety symptoms or disregard diverse presentations of anxiety. Few studies have examined providers’ perspectives on the role culture plays in their diagnosis and recognition of anxiety.

Methods:
We conducted interviews with mental health providers on their diagnostic processes for anxiety. Our sample was drawn from a national, randomized list of providers within the Veterans Health Administration (VHA) primary care mental health integration and general mental health clinics. We asked providers: “How do you think culture impacts the expression and diagnosis of anxiety?” Responses to this question were extracted from transcripts and coded using atlas.ti software. Each response was coded and reviewed independently by two co-authors (DBD and CGT), with additional review and discussion with others (PVC, TLF) as needed. We took an inductive analytic approach, using open-coding, to allow themes to emerge organically from the data.

Results:
We conducted interviews with 32 VHA mental health providers: 20 Female, 11 Male; 1 gender-queer; 18 White, 8 Black/African American, 3 Hispanic/Latinx, 3 Other; 6 Psychiatrists, 12 Social Workers, 11 Psychologists, 1 Nurse Practitioner, 1 Physician Assistant, 1 LPC; 17 located in primary care mental health integration settings, 15 located in general mental health clinics. We identified three stances towards culture and assessment of anxiety: Impartiality toward Culture: Some providers downplayed the importance of culture in recognizing or diagnosing patients’ anxiety and did not acknowledge necessary cultural diagnostic considerations. Acknowledgment of Cultural Impact: Many providers detailed variations across different cultural communities in how patients present with anxiety symptoms, describe anxiety, and have differing levels of stigma associated with the expression and treatment of anxiety. Providers also described awareness of how their own cultural backgrounds and experiences can impact their approach to diagnosing anxiety. Culturally Integrated Practice: In addition to acknowledging the impact of patients’ and their own cultural background and experiences in the accurate diagnosis of anxiety, some providers discussed the importance of implementing culturally informed diagnostic and treatment practices. These providers described completing their own training and self-directed processing on culture and bias, shifting assessment techniques based on patients’ presentations, and providing psychoeducation to patients on anxiety and culture to account for cultural impact on anxiety.

Implications:
Findings indicate that while most providers acknowledge that culture impacts accurate diagnosis of anxiety, providers vary in how they integrate cultural information into the assessment and diagnosis of anxiety. Results also emphasize the importance of delivering culturally informed care to account for cultural differences in patients’ presentation of anxiety.

Impacts:
Results from this study highlight how mental health providers in VHA understand and integrate culture into their practice. Providers with low, limited cultural awareness potentially contribute to inequities experienced by Veterans that are burdened with stigma, mistrust, and complex treatment presentations.