Racial and ethnic differences in patient perceptions of bias and cultural competence in health care

Multilevel Influences on Black Cancer Patient Experiences With Care: A Qualitative Analysis

PURPOSE

Black patients with cancer report worse experiences with health care compared with White patients; however, little is known about what influences these ratings. The objective of this study is to explore the multilevel factors that influence global ratings of care for Black cancer survivors.

METHODS

We conducted semistructured in-depth interviews with 18 Black cancer survivors. We assessed the global ratings of their personal doctor, specialist, health plan, prescription drug plan, and overall health care, and asked patients to elaborate on their rating. We analyzed the interviews with a deductive grounded theory approach using the socioecologic model to identify the individual, interpersonal, organizational, and environmental influences on Black cancer patient experiences with global ratings of care. We used an inductive constant comparison approach to identify additional themes that emerged. Two coauthors separately coded a set of transcripts and met to refine the codebook.

RESULTS

On average, participants reported the highest mean rating for their specialist (9.39/10) and the lowest mean rating for their personal doctor (7.33/10). Emerging themes that influenced patient ratings were perceptions about their interaction with medical providers, physician communication, the doctor's expertise, and aspects of the physical facilities. Global ratings of care measures were widely influenced by patient interactions with their providers that were empathetic, nondiscriminatory, and where the doctors addressed all concerns.

CONCLUSION

This grounded theory study identifies multiple aspects of health care that intervention researchers, health care administrators, and providers may target to improve Black cancer patient experiences with care.

The Patient's Point of View: Characterizing Patient-Level Factors Associated with Perceptions of Health Care

Purpose: We explored the association between perception of care, as measured by the Interpersonal Processes of Care (IPC) survey, and patient-level factors, including (1) Trust in physicians; (2) Perceived empathy; (3) Stereotype threat; (4) Perceived everyday discrimination; and (5) Self-Reported Health. Methods: Fifty participants from diverse racial backgrounds and education levels were surveyed. We examined the associations between the five patient-level factors and each subdomain of the IPC using multiple linear regression. We added a race interaction term to assess whether associations between IPC subdomains and predictors differed by race. We tested for correlation among factors found to be significantly associated with the IPC. Results: In adjusted analyses, trust in the physician, perceived empathy from the provider, and perceived everyday discrimination were significantly associated with most subdomains of the IPC. There was no significant race interaction. Conclusion: This exploratory study suggests that empathy, trust, and perceived everyday discrimination are significantly linked to patient perception of quality care, which are linked to clinical outcomes. Results present modifiable factors that may potentially improve patient care. Practice Implications: Increased efforts to improve clinician communication of empathy and general communication skill may have a positive effect on quality of care.

The association between organizational cultural competence and teamwork climate in a network of primary care practices

BACKGROUND

A health system's commitment to delivering culturally competent care is essential in creating a culture of respect for patients, clinicians, and administrative staff. As the diversity of the health care workforce grows, gaining an understanding of the perspectives among different health care personnel and the value that they place on organizational cultural competence is a first step in developing more effective team environments.

PURPOSE

The aim of the study was to determine whether an association exists between perceptions of organizational cultural competence and teamwork climate among employees in a health system.

METHODOLOGY/APPROACH

One thousand eighty employees in a primary care network consisting of 49 ambulatory practices were surveyed on their perceptions of senior management's efforts in organizational cultural competence and teamwork climate in their own work setting using 5-point Likert scales. Linear regression models were used to evaluate the association between organizational cultural competence and teamwork climate.

RESULTS

The overall organizational response rate for the survey was 84%. Higher perception of organizational cultural competence was associated with better teamwork climate (coef. = 0.4, p <0.001) after adjusting for gender, age, years in specialty, race, and position type. The association was stronger in magnitude for support staff compared to administrators and clinicians and stronger for younger compared to older age groups.

CONCLUSIONS

Higher employee perceptions of organizational cultural competence are associated with better self-reported teamwork climate, and this relationship is magnified for support staff and younger employees.

PRACTICE IMPLICATIONS

Senior leaders of health systems should consider investment in cultural competence as a contributor toward team effectiveness. Specifically, organizations may help support cultural competence by committing resources to the following: developing a comprehensive plan that addresses patients' cultural needs, recruiting and retaining a diverse staff and leadership, collaborating with the community, recognizing and rewarding care that meets patients' cultural needs, and providing adequate diversity training.

Patient-provider communication patterns among Asian American immigrant subgroups in New York City

OBJECTIVES

Patient-provider communication is essential for patient-centered care, yet Asian American immigrant populations face barriers. We aim to describe: 1) patient-reported communication-related characteristics for 16 disaggregated Asian American subgroups; and 2) the association of patient comprehension of provider communication with socio-demographics, language proficiency and concordance, and perceived cultural sensitivity in this population.

METHODS

Descriptive statistics are presented for 1269 Asian American immigrants responding to cross-sectional, venue-sampled surveys conducted in New York City. Logistic regression models examine predictors of low comprehension of provider communication.

RESULTS

Approximately 11% of respondents reported low comprehension of provider communication: lowest among South Asians and highest among Southeast Asians. Eighty-four percent were language-concordant with their provider, 90.1% agreed that their provider understood their background and values, and 16.5% felt their provider looked down on them. Low comprehension of provider communication was significantly associated with Southeast Asian subgroup, less education, limited English proficiency, public health insurance, patient-provider language discordance, and perceived low cultural understanding.

CONCLUSION

Among our sample, language and cultural sensitivity are associated with comprehension of provider communication.

PRACTICE IMPLICATIONS

Strategies improving language access and cultural sensitivity may be important for Asian immigrant patients. These could include interpretation services, bilingual community-based providers, and cultural sensitivity training.

A Culturally Relevant Care Model to Reduce Health Disparities Among Medicaid Recipients

Health disparities among Hispanics are associated with poorer health status across multiple health conditions, greater use of high-acuity services, and lower use of care continuity and preventive services. A new integrated delivery organization (IDO) designed around culturally responsive care aims to reduce health disparities and improve health outcomes among the Hispanic community by deploying a multifeatured approach. The IDO combines the universal administration of a culturally sensitive health risk screening tool, the delivery of culturally appropriate medical, behavioral and spiritual health, and creative support of provider practices with training and informational resources, financial incentives, actionable data, technology, and cultural sensitivity training for providers and staff. The IDO further distinguishes its unique approach by partnering with a university informatics program to establish a local learning health care system destined to enrich the evidence base for culturally appropriate interventions that reduce health disparities. Longitudinal research is currently underway that focuses on the impact of culturally motivated interventions on resource utilization, retention, and quality.

Advancing Diversity, Equity, and Inclusion in Hospital Medicine

BACKGROUND

In nearly all areas of academic medicine, disparities still exist for women and underrepresented minorities (URMs).

OBJECTIVES

Develop a strategic plan for advancing diversity, equity, and inclusion (DEI); implement and evaluate the plan, specifically focusing on compensation, recruitment, and policies.

DESIGN, SETTING, PARTICIPANTS

Programmatic evaluation conducted in the division of hospital medicine (DHM) at a major academic medical center involving DHM faculty and staff.

MEASUREMENTS

(1) Development and implementation of strategic plan, including policies, processes, and practices related to key components of DEI program; (2) assessment of specific DEI outcomes, including plan implementation, pre-post salary data disparities based on academic rank, and pre-post disparities for protected time for similar roles.

RESULTS

Using information gathered from a focus group with DHM faculty, an iterative strategic plan for DEI was developed and deployed, with key components of focus being institutional structures, our people, our environments, and our core mission areas. A director of DEI was established to help oversee these efforts. Using a two-phase approach, salary disparities by rank were eliminated. Internally funded protected time was standardized for leadership roles. A data dashboard has been developed to track high-level successes and areas for future focus.

CONCLUSION

Using a systematic evidence-based approach with key stakeholder involvement, a division-wide DEI strategy was developed and implemented. While this work is ongoing, short-term wins are possible, in particular around salary equity and development of policies and structures to promote DEI.

Perceptions of Patient-Provider Communication Across the Six Largest Asian Subgroups in the USA

BACKGROUND

Asians are the fastest-growing racial/ethnic minority group in the USA and many face communication barriers when seeking health care. Given that a high proportion of Asians are immigrants and have limited English proficiency, poor patient-provider communication may explain Asians' relatively low ratings of care. Though Asians are linguistically, economically, and culturally heterogeneous, research on health care disparities typically combines Asians into a single racial/ethnic category.

OBJECTIVES

To estimate racial/ethnic differences in perceptions of provider communication among the six largest Asian subgroups.

DESIGN AND PARTICIPANTS

Using a nationally representative sample of adults from the 2014-2017 Medical Expenditure Panel Survey (N = 136,836, round-specific response rates range from 72% to 98%), we estimate racial/ethnic differences in perceptions of provider communication, adjusted for English proficiency, immigration status, and sociodemographic characteristics.

MAIN MEASURES

The main dependent variable is a 4-item scale ranging from 0 to 100 measuring how positively patients view their health care providers' communication, adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS©) program. Respondents report how often their providers explain things clearly, show respect, listen carefully, and spend enough time with them.

KEY RESULTS

Asians, overall, had less positive perceptions of their providers' communication than either Whites or Latinxs. However, only Chinese-White differences remained after differences in English proficiency and immigration status were controlled (difference = - 2.67, 95% CI - 4.83, - 0.51). No other Asian subgroup differed significantly from Whites.

CONCLUSIONS

Negative views of provider communication are not pervasive among all Asians but, rather, primarily reflect the perceptions of Chinese and, possibly, Vietnamese patients. Researchers, policymakers, health plan executives, and others who produce or use data on patients' experiences with health care should, if possible, avoid categorizing all Asians into a single group.

Sex Differences in Willingness to Participate in Research Based on Study Risk Level Among a Community Sample of African Americans in North Central Florida

This study examined the association between sex, study risks and willingness to participate in research among a community sample of African Americans. We hypothesized that African American males would be more willing to participate in studies involving both minimal and greater-than-minimal risk. The study sample was recruited through a community engagement program (HealthStreet). Interviewers obtained information on socio-demographic variables and willingness to participate in various research types. We categorized research types into minimal risk and greater- than- minimal risk based on the IRB classification. The study sample comprised 6544 African-Americans; 58.4% were females. About 92.6% of the participants were willing to participate in surveys and 58.1% in research requiring medication use. More males would participate in minimal risk studies requiring review of medical records (males 87.0% vs. females 84.2%, p = 0.0021) and studies involving giving a blood sample (males 84.2% vs. females 81.7%, p = 0.0083). Also, more males would participate in greater than minimal risk studies involving the use of medication (60.5% v. 56.3% p = 0.0007). More males were willing to participate in minimal risk studies (studies involving the review of medical records and giving blood samples) and greater-than-minimal risk study involving the use of medication.

Review article: Implicit bias towards Aboriginal and Torres Strait Islander patients within Australian emergency departments

Aboriginal and Torres Strait Islander peoples continue to suffer adverse experiences in healthcare, with inequitable care prevalent in emergency settings. Individual, institutional and systemic factors play a significant part in these persisting healthcare disparities, with biases remaining entrenched in healthcare institutions. This includes implicit racial bias which can result in stereotyping of racial minorities and premature diagnostic closure. Furthermore, it may contribute to distrust of medical professionals resulting in higher rates of leave events and hinder racial minorities from seeking care or following treatment recommendations. The aim of this review is to analyse the effect of implicit bias on patient outcomes in the ED in international literature and explore how these studies correlate to an Australian context.

Effects of an eHealth Intervention on Patient-Provider Interaction and Functional Health Literacy in Adults With Hypertension

INTRODUCTION

Hypertension is a life-limiting, chronic condition affecting millions of Americans. Modifiable factors, quality of the patient-provider interaction and functional health literacy, have been linked to effective hypertension self-management. However, there has been limited interventional research targeting these modifiable factors. Electronic hypertension self-management interventions, in particular those incorporating virtual simulation, may positively influence the quality of the patient-provider interaction and functional health literacy status of adults with hypertension. Yet there is a dearth of evidence examining the efficacy of eHealth interventions targeting these modifiable factors of hypertension self-management.

OBJECTIVE

Evaluate the effects of two electronic hypertension self-management interventions on the quality of the patient-provider interaction and functional health literacy in adults with hypertension.

METHODS

A convenience sample of community-dwelling adults (>18 years) with hypertension were recruited and randomized to an avatar-based simulation (eSMART-HTN) or a video presentation on hypertension self-management (attention control). Participants were administered questionnaires to capture demographic characteristics, the quality of the patient-provider interaction, and functional health literacy. Questionnaire data were collected at baseline, and then monthly across three months. Two separate repeated measures analysis of covariance models were conducted to assess the effects of the interventions across the time points.

RESULTS

The sample included 109 participants who were predominately middle-aged and older, nonwhite, and female. Scores for the quality of the patient-provider interaction demonstrated significant within-group changes across time. However, there were no significant differences in the quality of the patient-provider interaction or functional health literacy scores between experimental conditions while adjusting for covariates.

CONCLUSION

An avatar-based simulation (eSMART-HTN) intervention proved to have a positive effect on patient-provider interaction compared to an attention control condition. Although the results are promising, future research is needed to optimize the effectiveness of eSMART-HTN and enhance its efficacy and scalability in a larger cohort of adults with hypertension.

"Starting that Conversation Is Even Harder than Having It": Female Patients' Perceptions of Physicians' Communication Competence in Communication about Sexual Behavior

Female college students demonstrate a persistent lack of knowledge about safe sexual practices and engage in sexual behavior that puts them at risk for sexually transmitted infections and unplanned pregnancy. Physicians have an opportunity to provide accurate and timely information about safe sexual behavior to individuals in their care. However, many young people, and in particular young women, are reticent to talk to their physicians about sexual behavior because they typically consider the information to be private. Exacerbating this issue is the fact that many physicians are also uncomfortable discussing sexual topics with their patients. In this study, Communication Privacy Management (CPM) theory is used to investigate the criteria that female college students employ to negotiate the disclosure and concealment of information about sexual behavior in communication with physicians. Qualitative analysis of semi-structured interviews with female college students was used to explain their perceptions of disclosure of sexual behaviors to their physician. Specifically, the participants' perceptions of physicians' communication competence informed privacy management rules. These findings have the potential to improve communication interventions for both female college students and healthcare professionals.

Factors affecting the self-rated health of immigrant women married to native men and raising children in South Korea: a cross-sectional study

Background

Since the influx of international immigrants to South Korea (Korea) in the 1980s, the number of immigrants married to native Koreans has increased substantially over the last 30 years. This study aims to provide recent evidence on the self-rated health of immigrant women married to native men and raising children. We evaluated the self-rated health of immigrant women sorted by their country of origin and elucidated factors that affect their self-rated health.

Methods

Data were obtained from the 2015 Korean National Multi-Cultural Family Survey. From the survey, a total of 6960 Korean-Chinese, Han-Chinese, Japanese, Vietnamese, and Filipino women were identified and a series of logistic regressions was conducted to elucidate factors that affected the self-rated health of immigrant women.

Results

The majority of immigrant women in Korea perceived that they are healthy. However, the self-rated health of immigrant women varied by country of origin. Korean-Chinese and Japanese immigrants are less likely to perceive that they are healthy compared with Filipino and Vietnamese immigrants. We identified several factors at the individual, household, and community levels and found that the majority of them are likely to be ethnic dependent. However, satisfaction with husband and experience of unmet medical needs presented consistent results in the five ethnicity groups.

Conclusions

Programs that strengthen spousal relationships and policies to enhance access to healthcare could be prioritized options to improve the self-rated health of immigrant women in Korea.

Torture-survivors' experiences of healthcare services for pain: a qualitative study

Background:

Increasing numbers of torture-survivors are presenting to UK healthcare services with persistent pain. However, there is a paucity of evidence surrounding the management of persistent pain among torture-survivors and their experience of healthcare services for pain is currently unknown. This qualitative study explores their experiences of services for managing pain, to inform clinical practice and service provision.

Methods:

Thirteen participants were recruited from a specialist pain clinic for torture-survivors in the United Kingdom. Utilising an ethnographic approach, data were collected via clinic appointment observations, interviews and medical records and analysed using inductive thematic analysis.

Results:

Three themes emerged in relation to torture-survivors’ experiences of healthcare services for pain: the patient–clinician relationship; multiplicity of diagnoses and treatments; lack of service integration. Participants described limited engagement in decision-making processes regarding their care. Lack of recognition of torture experience when diagnosing and treating pain, alongside multiple unsuccessful treatments, led to confusion, frustration and hopelessness. These issues were exacerbated by the disconnect between physical and mental health services.

Conclusion:

This study provides new insight into the challenges faced by torture-survivors when accessing healthcare services for pain. Our findings suggest current service provision is not meeting their complex needs. Clinical implications include the need for integrated care systems and better recognition of the influence of torture experience on persistent pain. Strategies to engage and empower torture-survivors in the management of their pain are suggested.

Veterans' perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication

OBJECTIVES

Drawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication.

METHODS

We interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach.

RESULTS

Participants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers' fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication.

CONCLUSION

Our findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans.

PRACTICE IMPLICATIONS

We discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers' burnout.

Racial disparities in clinician responses to patient emotions

OBJECTIVE

In a previous study of patients newly enrolled in HIV care, we observed that clinicians were less likely to address emotional issues expressed by African-American patients compared to whites. We sought to verify and expand these findings in a larger group of patients established in HIV care.

METHODS

We used VR-CoDES to analyze transcripts from 342 audio-recorded medical visits in the United States. We used random intercept multilevel logistic regression to assess associations between patient and clinician characteristics and patterns of emotional talk.

RESULTS

African-American patients were less likely than others to spontaneously express emotions (OR 0.50; 95 % CI 0.29-0.85). Clinicians, who were predominantly white, were more likely to respond to emotional expressions by African-American patients explicitly (OR 1.56; 95 % CI 1.11-2.20) but less likely to offer neutral/passive responses that provide space for emotional conversation (OR 0.56; 95 % CI 0.37-0.84) and more likely to block discussion of the emotional issue (OR 2.20; 95 % CI 1.05-4.63). Emotional talk did not vary by patient age or gender.

CONCLUSION

These results confirm our prior findings, demonstrating less open emotional communication between African-American patients and their providers.

PRACTICE IMPLICATIONS

Addressing racial differences in communicating about emotions may reduce disparities in patient-clinician relationships.

Barriers impacting an individuals decision to undergo bariatric surgery: A systematic review

OBJECTIVE

Bariatric surgery is a procedure intended to control morbid obesity but it is minimally utilized in the United States. Therefore, the aim of this systematic review was to identify common barriers to proceeding and completing bariatric surgery.

METHODS

Pubmed, Medline, CINAHL, and Google Scholar were used to identify articles published between the years 2010-2020, written in English, and included adults with a BMI ≥ 35 with a desire to undergo bariatric surgery.

RESULTS

From the 10 included studies, 7 of which were conducted in the United States, the following were the most cited barriers to undergoing surgery: insurance, socioeconomic status, language spoken and ethnicity, sex, and risk of surgery. Three of the studies also noted that the reason specific ethnic groups were less likely to undergo surgery was secondary to their economic status or insurance type.

CONCLUSIONS

Undergoing bariatric surgery is highly dependent on an individual's demographics. Future research on this topic may help medical practitioners learn how to minimize or remove these barriers to make bariatric surgery more feasible for all populations.

"I Had Nobody to Represent Me": How Perceptions of Diabetes Health-Care Providers' Age, Gender and Ethnicity Impact Shared Decision-Making in Adults With Type 1 and Type 2 Diabetes

OBJECTIVES

Our aim in this study was to investigate how patients' perceptions of their diabetes health-care providers' (HCP) age, gender and ethnicity impact shared decision-making using the Theory of Planned Behaviour.

METHODS

Adult participants receiving diabetes care at community sites, primary care or specialty clinics participated in semistructured, one-on-one interviews conducted from November 2018 to January 2019. Responses were transcribed and qualitatively analyzed for emergent themes using statistical software (NVivo version 9).

RESULTS

We conducted 28 interviews with participants 34 to 81 years of age. The following themes were identified: 1) participants' gestalt of their diabetes HCP was strongly gender dependent 2) there was a hidden preference for Caucasian HCPs, 3) age evoked a less defensive response with regard to shared decision-making and 4) degree of trust in self and in their diabetes HCP directed participants' readiness to be part of the shared decision-making.

CONCLUSIONS

Participants' narrative experiences strongly suggest that they view their diabetes HCPs through a gendered and racialized lens.

The Effects of an Indigenous Health Curriculum for Medical Students

PURPOSE

Indigenous patients experience a variety of healthcare challenges including accessing and receiving needed healthcare services, as well as experiencing disproportionate amounts of bias and discrimination within the healthcare system. In an effort to improve patient-provider interactions and reduce bias towards Indigenous patients, a curriculum was developed to improve first-year medical students' Indigenous health knowledge.

METHOD

Two cohorts of students were assessed for their Indigenous health knowledge, cultural intelligence, ethnocultural empathy, and social justice beliefs before the lecture series, directly after, and 6 months later.

RESULTS

Results of paired t test analysis revealed that Indigenous health knowledge significantly improved after the training and 6 months later. Some improvements were noted in the areas of cultural intelligence and ethnocultural empathy in the second cohort.

CONCLUSIONS

It is feasible to teach and improve Indigenous-specific health knowledge of medical students using a brief intervention of lectures. However, other critical components of culturally appropriate care including social justice beliefs and actions, ethnocultural empathy, and cultural humility may require increased and immersed cultural training.

Serious Mental Illness and Smoking Cessation Treatment Utilization: the Role of Healthcare Providers

Healthcare provider barriers to cessation resources may be undercutting quit rates for smokers with serious mental illness (SMI). The study aim was to examine how providers influence cessation treatment utilization among smokers with SMI. Data were taken from a trial conducted among smokers in Minnesota Health Care Programs. The sample was split into groups of participants with SMI (n = 939) and without SMI (n = 1382). Analyses assessed whether the association between SMI and treatment utilization was mediated by healthcare provider-delivered treatment advice and healthcare provider bias. Results revealed higher rates of treatment utilization among smokers with SMI than those without SMI (45.9% vs 31.7%, p < 0.001); treatment advice and provider bias did not mediate this association. Subsequent individual regression analyses revealed positive associations between treatment advice and treatment utilization (β 0.21-0.25, p < 0.05), independent of SMI status. Strategies to increase low-income smokers' contacts with providers may reduce treatment utilization barriers among these smokers.

The Politics of Health Care: Health Disparities, the Affordable Care Act, and Solutions for Success

This article explores why racial and income health disparities continue to exist in the United States. Poverty and racism are the primary drivers of the social problem which impact social determinants of health for vulnerable populations. The theoretical frameworks of conflict theory and critical race theory contextualize the causes and provide direction for overhauling public health policy in general and the Patient Protection and Affordable Care Act (Affordable Care Act) in particular. Although the Affordable Care Act was implemented to increase health coverage, economic and racial health inequities still exist in the United States. Policy recommendations for improving the health and welfare of low-income minorities include: 1) impacting poverty itself by desegregating urban areas of concentrated poverty, and 2) impacting racial discrimination in health care by putting the voices of African-American patients in the forefront to inform culturally relevant policy and practice.

Impact of Physician Race on Patient Decision-Making and Ratings of Physicians: a Randomized Experiment Using Video Vignettes

BACKGROUND

Studies suggest that black patients have better interactions, on average, with physicians of their own race. Whether this reflects greater "cultural competence" in race-concordant relationships, or other effects of race unrelated to physician behavior, is unclear. It is also unclear if physician race influences patient decision-making.

OBJECTIVE

To determine whether physician race affects patients' ratings of physicians and decision-making, independent of physician behavior.

DESIGN

Randomized study using standardized video vignettes.

PARTICIPANTS

Primary care patients with coronary risk factors or disease.

INTERVENTIONS

Each participant viewed one of 16 vignettes depicting a physician reviewing cardiac catheterization results and recommending coronary artery bypass graft (CABG) surgery. Vignettes varied only in terms of physicians' race, gender, age, and communication style (high vs. low patient-centeredness).

MAIN MEASURES

Participants rated the video physician's communication, interpersonal style, competence, trustworthiness, likability, and overall performance (0-4 Likert scales). They also rated the necessity of CABG (0-5 scale) and whether they would undergo CABG or obtain a second opinion if they were the video patient (0-3 scales).

KEY RESULTS

Participants included 107 black and 131 white patients (72% participation rate). Black participants viewing a black (vs. white) video physician gave higher ratings on all physician attributes (e.g., overall rating 3.22 vs. 2.34, p < 0.001) and were more likely to perceive CABG as necessary (4.05 vs. 3.72, p = 0.03) and say they would undergo CABG if they were the video patient (2.43 vs. 2.09, p = 0.004). Patient-centered communication style reduced, but did not eliminate, the impact of race concordance. Physician race was not associated with any outcomes among white patients.

CONCLUSIONS

Black patients viewed the doctor in a scripted vignette more positively, and were more receptive to the same recommendation, communicated in the same way, with a black vs. white physician. Patient-centered communication reduced but did not eliminate the effect of physician race.

Patient satisfaction with primary care physician performance in a multicultural population

BACKGROUND

A key component of the quality of health care is patient satisfaction, particularly in regard to Primary Care Physician (PCP), which represents the first contact with health care services. Patient satisfaction is associated with ethnic, regional and socio-demographic differences, due to differences in service quality, patient-doctor communication, and the patient's perceptions. The aim of this study was to evaluate patients' satisfaction related to primary care physicians' (PCP) performance and to explore potential differences by ethnicity in a multicultural population.

METHODS

A national cross-sectional telephone survey was conducted, among a random sample of the Israeli population aged ≥25 years. Satisfaction level from performance of PCP was assessed using a validated questionnaire (30 items; 6 different domains).

RESULTS

The final sample included (n = 827 Jews; n = 605 Arabs, mean age 54.7(±14.9). In the adjusted logistic regression models, Arabs reported lower general satisfaction related to PCPs' performance as compared to Jews (adjusted odds ratio (AOR), 0.63; (95% CI: 0.40-0.98). Arabs reported lower satisfaction related to PCPs' performance across the following domains: communication skills (AOR, 0.42; 95% CI, 0.22-0.82); interpersonal manners (AOR, 0.37; 95% CI, 0.24-0.58); and time spent with the patients (AOR, 0.60; 95% CI, 0.43-0.85).

CONCLUSIONS

Jews and Arabs were very satisfied with PCPs' performance. However, there are ethnic differences in the extent of satisfaction level related to the performance of PCP. Satisfaction from PCPs' performance may be achieved by improving the communication skills of the PCP, encouraging interpersonal interaction between the PCP and the patient, and devoting more time to the patient during the visits.

The Role of Parental Knowledge and Attitudes about ADHD and Perceptions of Treatment Response in the Treatment Utilization of Families of Children with ADHD

The present study examined the impact of parental knowledge and attitudes about attention-deficit/hyperactivity disorder (ADHD), and parental perceptions of treatment response on the utilization of behavioral and pharmacological ADHD treatments, using data from a longitudinal treatment study designed to assess physical growth in children with ADHD. It also explored if these relations were moderated by race/ethnicity. Participants include 230 (74% Hispanic) families of treatment naïve children with ADHD (M age = 7.56, SD = 1.94; 73% male). Families were randomly assigned to receive behavior therapy (BT) or stimulant medication (MED; which also included low dose BT). After 6 months, families whose children still showed at least moderate impairment had access to either treatment for a total of 30 months. Utilization was measured using the number of BT sessions attended and total mg of MED taken over the study period. Families who reported more willingness to use medication for their child's ADHD at baseline were more likely to use MED and less likely to use BT, regardless of race/ethnicity. Parental knowledge about ADHD was only important in predicting BT utilization for White non-Hispanic families. Greater reduction in ADHD symptoms and impairment significantly predicted more MED utilization for Hispanic families. Results highlight the need to explore multiple parent (e.g., medication willingness) and child (e.g., symptom severity) factors when considering treatment utilization. Results also highlight ethnic differences in which factors affect treatment utilization.

The dual contingencies of ethnoraciality: Status-context disparities in health information sources among sexual minorities

Researchers often explore health (care) beliefs as a function of individual characteristics; yet, few consider the role of context in shaping both beliefs and the behaviors that are informed by them. As a sociopolitical construct, ethnoraciality provides a concerning source of bias in studies of health (care) beliefs because it inhabits both individual and contextual forms. This study examines whether the ethnoracial context of the residential area where sexual minorities live is associated with a particular health (care) belief - sources of trustworthy health information - and considers how ethnoracial group membership status differentiates these ecological associations drawing on mediation and moderation models. Using data from the 2010 Social Justice Sexuality Project, our analysis shows that sexual minorities who live with high concentrations of Latinos and Whites are less likely to rely exclusively on medical professionals for trustworthy health information than those who live with high concentrations of Blacks. Moreover, exclusive reliance on medical professionals for health information among Black and Latino sexual minorities is stronger in co-ethnic communities (predominately Black and Latino areas, respectively). The analysis also documents status and contextual differentials and status-context contingencies of reliance on the Internet, social networks, and multiple agents ("triangulation") as sources of health information. Findings suggest that place-based co-ethnic networks may facilitate disease prevention among Black and Latino sexual minorities by improving the quality of their relationships with sick role gatekeepers and breaking down the silos of the medical complex. The study concludes by considering the value of a place-based approach to alleviating health disparities among sexual minorities vis-à-vis the health care system.

Exploring barriers to seeking health care among Kenyan Somali women with female genital mutilation: a qualitative study

Background

Female genital mutilation/cutting (FGM/C) is a cultural practice associated with health consequences, women rights and deprivation of dignity. Despite FGM/C-related health consequences, circumcised women may encounter additional challenges while seeking interventions for reproductive health problems. Experiences of women/girls while accessing health services for reproductive health problems including FGM/C-related complications in poor, remote and hard to reach areas is poorly understood. We sought to explore barriers to care seeking among Somali women with complications related to FGM/C in public health facilities in Kenya.

Methods

We drew on qualitative data collected from purposively selected women aged 15–49 years living with FGM/C, their partners, community leaders, and health providers in Nairobi and Garissa Counties. Data were collected using in-depth interviews (n = 10), key informant interviews (n = 23) and 20 focus group discussions. Data were transcribed and analyzed thematically using NVivo version 12.

Results

Barriers were grouped into four thematic categories. Structural barriers to care-seeking, notably high cost of care, distance from health facilities, and lack of a referral system. Concerns regarding perceived quality of care also presented a barrier. Women questioned health professionals’ and health facilities’ capacity to offer culturally-sensitive FGM/C-specific care, plus ensuring confidentiality and privacy. Women faced socio-cultural barriers while seeking care particularly cultural taboos against discussing matters related to sexual health with male clinicians. Additionally, fear of legal sanctions given the anti-FGM/C law deterred women with FGM/C-related complications from seeking healthcare.

Conclusion

Structural, socio-cultural, quality of service, and legal factors limit health seeking for reproductive health problems including FGM/C-related complications. Strengthening health system should consider integration of FGM/C-related interventions with existing maternal child health services for cost effectiveness, efficiency and quality care. The interventions should address health-related financial, physical and communication barriers, while ensuring culturally-sensitive and confidential care.

Exploring the preferences of a culturally congruent, peer-based HIV prevention intervention for black men who have sex with men

Background HIV testing, treatment initiation and treatment adherence have been emphasised for Black men who have sex with men (BMSM). However, many BMSM do not get tested, obtain HIV treatment or adhere to treatment. It is essential to highlight barriers to HIV testing, treatment adherence and the ideal components for an intervention: peer mentors, socioeconomic resources and participant incentives.

METHODS

Five focus groups (n=24) were conducted among HIV-negative and HIV-positive BMSM aged ≥18 years in Los Angeles, California, USA to explore motivations and barriers to testing and treatment and the components of an ideal, culturally competent HIV testing intervention for BMSM.

RESULTS

Barriers to HIV testing included fear and stigma associated with discovering a HIV-positive status and drug use. Motivations for testing included experiencing symptoms, beginning new relationships, perceptions of risk and peer mentors.

CONCLUSIONS

Future HIV prevention and treatment efforts should consider these components to improve health outcomes among BMSM.

Oncology healthcare provider perspectives on caring for diverse patients fifteen years after Unequal Treatment

OBJECTIVE

The purpose of this study was to provide a snapshot of U.S. oncology provider perspectives on caring for diverse patients, including self-rated awareness, comfort, skills, practices, challenges, facilitators, and barriers.

METHODS

An online survey was administered to a convenience sample of multidisciplinary oncology providers. Descriptive statistics and bivariate analyses were computed for Likert-style items to investigate differences by level of past diversity training. Qualitative content analysis was conducted on open-response questions.

RESULTS

Roughly one-third (36.7%) of the 406 survey respondents reported receiving high levels of past diversity training, with statistically significant differences by training amount for self-rated skills and select awareness and practice items (p < 0.05). Key challenges qualitatively described included language barriers (n = 143) and alternative health beliefs (n = 52). Knowledge and training (n = 62), interpretation services (n = 53), and staff attitudes (n = 46) were the most frequently mentioned factors affecting culturally sensitive care.

CONCLUSION

Fifteen years after the publication of Unequal Treatment, the National Academies' landmark report on healthcare disparities, oncology healthcare providers have ongoing challenges caring for diverse patients and opportunities to implement recommendations from the report.

PRACTICE IMPLICATIONS

Content of diversity trainings should focus on identified gaps and practical challenges. Multi-level supports are needed, including resources and training for oncology providers.

Injustice Appraisal, but not Pain Catastrophizing, Mediates the Relationship Between Perceived Ethnic Discrimination and Depression and Disability in Low Back Pain

Despite growing evidence of significant racial disparities in the experience and treatment of chronic pain, the mechanisms by which these disparities manifest have remained relatively understudied. The current study examined the relationship between past experiences of racial discrimination and pain-related outcomes (self-rated disability and depressive symptomatology) and tested the potential mediating roles of pain catastrophizing and perceived injustice related to pain. Analyses consisted of cross-sectional path modeling in a multiracial sample of 137 individuals with chronic low back pain (Hispanics: n = 43; blacks: n = 43; whites: n = 51). Results indicated a positive relationship between prior discriminatory experiences and severity of disability and depressive symptoms. In mediation analyses, pain-related appraisals of injustice, but not pain catastrophizing, were found to mediate these relationships. Notably, the association between discrimination history and perceived injustice was significantly stronger in black and Hispanic participants and was not statistically significant in white participants. The findings suggest that race-based discriminatory experiences may contribute to racial disparities in pain outcomes and highlight the specificity of pain-related, injustice-related appraisals as a mechanism by which these experiences may impair physical and psychosocial function. Future research is needed to investigate temporal and causal mechanisms suggested by the model through longitudinal and clinical intervention studies. PERSPECTIVE: More frequent prior experiences of racial discrimination are associated with greater depressive symptomatology and pain-related disability in individuals with chronic low back pain. These associations are explained by the degree of injustice perception related to pain, but not pain catastrophizing, and were stronger among black and Hispanic participants.

What is needed in culturally competent healthcare systems? A qualitative exploration of culturally diverse patients and professional interpreters in an Australian healthcare setting

Background

Culturally competent health care service delivery can improve health outcomes, increasing the efficiency of clinical staff, and greater patient satisfaction. We aimed to explore the experience of patients with limited English proficiency and professional interpreters in an acute hospital setting.

Methods

In-depth interviews explored the experiences of four culturally and linguistically diverse communities with regards to their recent hospitalisation and access to interpreters. We also conducted focus group with professional interpreters working. Data were analysed using an inductive thematic approach with constant comparison.

Results

Individual interviews were conducted with 12 patients from Greek, Chinese, Dari and Vietnamese backgrounds. Focus groups were conducted with 11 professional interpreters. Key themes emerged highlighting challenges to the delivery of health care due distress and lack of advocacy in patients. Interpreters struggled due to a reliance on family to act as interpreters and hospital staff proficiency in working with them.

Conclusions

In an era of growing ethnic diversity this study confirms the complexity of providing a therapeutic relationships in contemporary health practice. This can be enhanced by training towards the effective use of professional interpreters in a hospital setting. Such efforts should be multidisciplinary and collective in order to ensure patients don’t fall through the gaps with regards to the provision of culturally competent care.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7378-9) contains supplementary material, which is available to authorized users.

A Proactive Smoking Cessation Intervention for Socioeconomically Disadvantaged Smokers: The Role of Smoking-Related Stigma

Introduction

Smoking denormalization has been paralleled by reduced smoking prevalence, but smoking rates among socioeconomically disadvantaged populations remain high. The social unacceptability of smoking has also led to increased perceptions of smoking-related stigma. By examining how smoking stigma influences cessation intervention effectiveness, we can better tailor interventions to socioeconomically disadvantaged smokers.

Aims and Methods

Data are from a randomized controlled trial evaluating the effectiveness of a proactive cessation intervention on abstinence. Current smokers enrolled in Minnesota Health Care Programs were randomized to proactive outreach (n = 1200) or usual care (n = 1206). The intervention included mailings, telephone outreach, counseling, and access to free cessation treatments. Using baseline measurements, groups with lower (n = 1227) and higher (n = 1093) perceived stigma were formed. Intervention, stigma, and their interaction term were added to a logistic regression modeling abstinence at 12 months.

Results

Lower perceived smoking-related stigma was associated with less support for quitting, lower rates of physician quitting advice, and less motivation for quitting. A logistic regression modeling abstinence found a significant intervention × stigma interaction. The proactive intervention was more effective among smokers with lower perceived smoking-related stigma (odds ratio 1.94, 95% confidence interval, 1.29 to 2.92) than those with higher perceived smoking-related stigma (odds ratio 1.04, 95% confidence interval, 0.70 to 1.55).

Discussion

Smokers with lower perceived smoking-related stigma had social environments that were conducive to smoking, received less physician advice to quit, and were less motivated to quit than higher stigma smokers. Despite these barriers, the intervention was more effective for lower stigma smokers, suggesting that proactive outreach is an efficient treatment for these hard-to-reach smokers.

Implications

Smoking denormalization has led to increased perceptions of smoking-related stigma among many smokers; however, little is known about how this stigma influences the cessation process. In the present study, smokers with lower levels of perceived smoking-related stigma lived in social environments that were more conducive to smoking and were less motivated to quit than higher stigma smokers. Despite these barriers, our proactive outreach cessation intervention was more effective for lower stigma smokers, suggesting that interventions which utilize proactive outreach to stimulate interest in quitting and offer facilitated access to free cessation treatments are an effective treatment approach for these hard-to-reach smokers. These strategies may be particularly effective for motivating smokers enrolled in government-subsidized health insurance programs to take advantage of cessation resources.

Changes in Perceptions of Discrimination in Health Care in California, 2003 to 2017

IMPORTANCE

Research in the early 2000s in California demonstrated that racial and ethnic minorities, immigrants, and those with limited English proficiency (LEP) experienced high rates of discrimination in health care. Less is known about how patients' perceptions of discrimination in health care have changed since then.

OBJECTIVE

To determine whether perceptions of discrimination in health care have changed overall and for specific vulnerable populations.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the California Health Interview Survey for state residents aged 18 years and older for 2 periods, 2003 to 2005 and 2015 to 2017. χ2 analyses and multivariate logistic regression were performed to compare recent discrimination in health care in late vs early periods controlling for race/ethnicity, poverty level, education, insurance status, usual source of care, self-reported health, and LEP. Additional subanalyses were performed by race/ethnicity, immigrant status, and LEP status. Jackknife replicate weights were provided by the California Health Interview Survey.

EXPOSURE

Survey year was dichotomized as combined 2003 to 2005 and combined 2015 to 2017.

MAIN OUTCOMES AND MEASURES

Survey respondents were identified as having experienced recent discrimination in health care if they responded "yes" to the question, "Was there ever a time when you would have gotten better medical care if you had belonged to a different race or ethnic group?" and reported that this occurred within the last 5 years.

RESULTS

There were 84 088 participants in 2003 to 2005 (51.0% female; 14.7% aged ≥65 years) and 63 242 participants in 2015 to 2017 (51.1% female; 18.0% aged ≥65 years). Rates of recent discrimination in health care decreased from 6.0% to 4.0% (difference, 2.0%; 95% CI, 1.5%-2.5%; P < .001). In adjusted analyses, perceptions of discrimination in health care decreased in 2015 to 2017 compared with 2003 to 2005 (odds ratio [OR], 0.60; 95% CI, 0.53-0.68; P < .001). There was a significant race × period interaction for Latino individuals (OR, 0.58; 95% CI, 0.40-0.83; P = .003) but not for Asian individuals (OR, 0.76; 95% CI, 0.50-1.16; P = .20) or African American individuals (OR, 1.24; 95% CI, 0.76-2.02; P = .40). There was a significant immigrant status × period interaction (OR, 0.55; 95% CI, 0.44-0.69; P < .001) and LEP status × period interaction (OR, 0.67; 95% CI, 0.51-0.89; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that perceptions of discrimination in health care in California decreased between 2003 to 2005 and 2015 to 2017 among Latino individuals, immigrants, and those with LEP. African American participants reported consistently high rates of discrimination, indicating that interventions targeting health care discrimination are still necessary.

Exploring associations between older adults' demographic characteristics and their perceptions of self-care actions for communicating with healthcare professionals in southern United States

AIMS

This study examined associations between older adults' demographic factors and their perceived importance of, desire to and ability to perform seven self-care behaviours for communicating with healthcare professionals.

DESIGN

This cross-sectional survey study analysed subset data of 123 older adults 65 years and older, living in southern United States.

METHODS

The Patient Action Inventory for Self-Care (57 items, grouped into 11 categories) was used to collect self-reported self-care data. Demographic characteristics were also collected. Descriptive statistics and logistic regression analyses were used to tests for relationships between the variables relevant to the research objective.

RESULTS

Regression findings showed that separated older adults felt less able to share ideas about their healthcare experiences compared to married older adults. Male older adults reported less desire to list issues to discuss and less desire to share ideas about their care experience with their healthcare professionals compared to their female counterparts.

Psychosocial Determinants of Communication Satisfaction in Racially Concordant and Discordant Patient-Physician Interactions

INTRODUCTION

Although socioeconomic and race-related factors both influence the quality of medical encounters, it is not known how these effects differ between racially concordant and discordant medical visits. The current study investigated psychosocial determinants of physician visit satisfaction of Black adults based on a racial concordance of the medical encounter.

MATERIALS AND METHODS

Data came from the Detroit Area Study, a community survey of adults in Michigan, United States. The current analysis included 336 Black individuals who had visited a White (n = 191) or a Black (n = 145) physician in the last year. The outcome was satisfaction with the quality of communication with the doctor. Demographics (age and gender), socioeconomic status (education and income), psychosocial factors (control beliefs and social support), race-related factors (having a close White friend, negative attitudes about Blacks, discrimination), and health status (chronic disease count, self-rated health, and distress) of the patient as well as race of the doctor were measured. We used multi-group structural equation modeling for data analysis, where the two groups were racially concordant (those who met a Black physician) and racially discordant (those who met a White physician) visits.

RESULTS

Satisfaction with physician visit was lower in racially discordant than racially concordant encounters. In racially concordant visits, high education was associated with higher satisfaction; however, racial discrimination was associated with lower satisfaction. In racially discordant visits ((i.e., with a White doctor), having a White friend as well as high sense of control were associated with higher satisfaction, while negative attitudes about Blacks was associated with a lower level of satisfaction.

CONCLUSIONS

Racially concordant and discordant visits have different satisfaction levels. Racially concordant and discordant visits also have different predictors of communication satisfaction among Black patients. Socioeconomic status as well as racial attitudes and experiences impact the quality of communication of the Black patients with their doctors; however, these effects depend on the race of the doctor.

Community members trusted by African American parents for vaccine advice

Exposure to pro-vaccination messages from nonmedical peers and others perceived to share a similar value system for society (referred to as worldview outlook) improves vaccination attitudes. Nonetheless, a minority of African American parents have friends and family members who provide them with vaccine advice. The aims of the current study were to identify the presumed worldview outlook of eight types of community figures as perceived by African American parents, and determine parents' trust in these figures for vaccine advice, and whether trust varied according to the figures' racial concordance. A cross-sectional survey was administered to 110 African American parents in 2015. Parents perceived the community figures to represent a spectrum of worldview outlooks. Although levels of trust in the community figures differed overall (p < .001), it was high in the school nurse, pediatrician, mother, father, disease survivor, and vaccine scientist. All trusted figures except the father were perceived to hold a communitarian outlook. Parents shown race-concordant figures had higher levels of trust in them than those who were shown race-discordant equivalents (p < .01). These findings suggest that vaccination campaigns geared toward African American parents may be strengthened by including other nonmedical, African American spokespersons who convey their community contributions in messages.

Differences in Perioperative Outcomes and Complications Between African American and White Patients After Total Joint Arthroplasty

BACKGROUND

Racial disparities in healthcare utilization and outcomes have been reported and have wide-reaching implications for individual patient and healthcare system; as providers we bear an ethical burden to address this disparity and provide culturally competent care. This study will examine the influence of race on length of stay, discharge disposition, and complications requiring reoperation following total joint arthroplasty (TJA).

METHODS

Single institution retrospective analysis of a consecutive series of 7208 primary TJA procedures performed between July 2013 and June 2017 was conducted. Chi-squared and t-tests were used to quantify differences between the groups and multiple logistic regression was used to identify race as an independent risk factor.

RESULTS

In total, 6182 (84.3%) white and 1026 (14.0%) African American (AA) patients were included. AA patients were younger (63.62 vs 66.84 years, P < .001), more likely female (68.8% vs 57.0%, P < .001), had a longer length of stay (2.19 vs 2.00 days, P < .001), more likely to experience septic complications (1.3% vs 0.5%, P = .002) and manipulation under anesthesia (3.9% vs 1.8%, P < .001), and less likely to discharge home (67.1% vs 81.1%, P < .001). Multiple logistic regression showed that AA patients were more likely to discharge to a facility (adjusted odds ratio 2.63, 95% confidence interval 2.19-3.16, P < .001) and experience a manipulation under anesthesia (adjusted odds ratio 1.90, 95% confidence interval 1.26-2.85, P = .002).

CONCLUSION

AA patients undergoing TJA were younger with longer length of stay and a higher rate of nonhome discharge; AA race was identified as an independent risk factor. Further study is required to understand the differences identified in this study. Targeted interventions should be developed to attempt to eliminate the disparity.

Using Values Affirmation to Reduce the Effects of Stereotype Threat on Hypertension Disparities: Protocol for the Multicenter Randomized Hypertension and Values (HYVALUE) Trial

Background

Medication nonadherence is a significant, modifiable contributor to uncontrolled hypertension. Stereotype threat may contribute to racial disparities in adherence by hindering a patient’s ability to actively engage during a clinical encounter, resulting in reduced activation to adhere to prescribed therapies.

Objective

The Hypertension and Values (HYVALUE) trial aims to examine whether a values-affirmation intervention improves medication adherence (primary outcome) by targeting racial stereotype threat.

Methods

The HYVALUE trial is a patient-level, blinded randomized controlled trial comparing a brief values-affirmation writing exercise with a control writing exercise among black and white patients with uncontrolled hypertension. We are recruiting patients from 3 large health systems in the United States. The primary outcome is patients’ adherence to antihypertensive medications, with secondary outcomes of systolic and diastolic blood pressure over time, time for which blood pressure is under control, and treatment intensification. We are comparing the effects of the intervention among blacks and whites, exploring possible moderators (ie, patients’ prior experiences of discrimination and clinician racial bias) and mediators (ie, patient activation) of intervention effects on outcomes.

Results

This study was funded by the National Heart, Lung, and Blood Institute. Enrollment and follow-up are ongoing and data analysis is expected to begin in late 2020. Planned enrollment is 1130 patients. On the basis of evidence supporting the effectiveness of values affirmation in educational settings and our pilot work demonstrating improved patient-clinician communication, we hypothesize that values affirmation disrupts the negative effects of stereotype threat on the clinical interaction and can reduce racial disparities in medication adherence and subsequent health outcomes.

Conclusions

The HYVALUE study moves beyond documentation of race-based health disparities toward testing an intervention. We focus on a medical condition—hypertension, which is arguably the greatest contributor to mortality disparities for black patients. If successful, this study will be the first to provide evidence for a low-resource intervention that has the potential to substantially reduce health care disparities across a wide range of health care conditions and populations.

Trial Registration

ClinicalTrials.gov NCT03028597; https://clinicaltrials.gov/ct2/show/NCT03028597 (Archived by WebCite at http://www.webcitation.org/72vcZMzAB).

International Registered Report Identifier (IRRID)

DERR1-10.2196/12498

The challenge of cultural competence in the workplace: perspectives of healthcare providers

Background

Cross-cultural educational initiatives for professionals are now commonplace across a variety of sectors including health care. A growing number of studies have attempted to explore the utility of such initiatives on workplace behaviors and client outcomes. Yet few studies have explored how professionals perceive cross-cultural educational models (e.g., cultural awareness, cultural competence) and the extent to which they (and their organizations) execute the principles in practice. In response, this study aimed to explore the general perspectives of health care professionals on culturally competent care, their experiences working with multi-cultural patients, their own levels of cultural competence and the extent to which they believe their workplaces address cross-cultural challenges.

Methods

The perspectives and experiences of a sample of 56 health care professionals across several health care systems from a Mid-Western state in the United States were sourced via a 19-item questionnaire. The questionnaire comprised both open-ended questions and multiple choice items. Percentages across participant responses were calculated for multiple choice items. A thematic analysis of open-ended responses was undertaken to identify dominant themes.

Results

Participants largely expressed confidence in their ability to meet the needs of multi-cultural clientele despite almost half the sample not having undergone formal cross-cultural training. The majority of the sample appeared to view cross-cultural education from a ‘cultural awareness’ perspective - effective cross-cultural care was often defined in terms of possessing useful cultural knowledge (e.g., norms and customs) and facilitating communication (the use of interpreters); in other words, from an immediate practical standpoint. The principles of systemic cross-cultural approaches (e.g., cultural competence, cultural safety) such as a recognition of racism, power imbalances, entrenched majority culture biases and the need for self-reflexivity (awareness of one’s own prejudices) were scarcely acknowledged by study participants.

Conclusions

Findings indicate a need for interventions that acknowledge the value of cultural awareness-based approaches, while also exploring the utility of more comprehensive cultural competence and safety approaches.

Lesbian, Gay, Bisexual, Transgender, and Queer Patients: Collegiate Athletic Trainers' Perceptions

CONTEXT

Research suggests that patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) are at risk for certain conditions and denied equal access to health care in physician offices compared with their heterosexual counterparts. However, little evidence exists regarding the treatment of LGBTQ student-athlete patients in the athletic training clinic and the role the athletic trainer (AT) plays in these health care experiences.

OBJECTIVE

To explore the perceptions of ATs treating LGBTQ student-athlete patients.

DESIGN

Cross-sectional study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

A total of 1077 collegiate and university ATs completed the survey (5685 e-mails distributed, 1214 surveys started, access rate = 21.4%, completion rate = 88.7%).

MAIN OUTCOME MEASURE(S)

Demographic information and level of agreement in 3 areas (approach, quality of care, and comfort) were obtained on a 5-point Likert scale. We asked ATs their likeliness of providing guidance to student-athletes about navigating their sexuality generally and as it related to athletic participation, if they thought they provided equal health care to a student-athlete who identified as LGBTQ, how comfortable they were treating LGBTQ student-athlete patients, and how comfortable they thought student-athlete patients would be seeking care from them or from providers in their clinic.

RESULTS

Overall, we found differences among groups for sexual orientation, gender, religion, and the existence of interpersonal contact with LGBTQ friends or family for approach, quality of care, and comfort. We also identified 2 main themes indicating ATs' desire for more training and education, specifically in caring for transgender student-athletes and providing patient-centered care with professionalism, regardless of gender identity or sexual orientation.

CONCLUSIONS

Although differences existed among demographic groups, ATs had a generally positive view of treating LGBTQ student-athlete patients and wanted more training and education on the specific needs of this population.

The relationship between smoking cessation and binge drinking, depression, and anxiety symptoms among smokers with serious mental illness

INTRODUCTION

Concerns about the adverse effects of smoking cessation on alcohol use and mental health are a barrier to cessation for smokers with serious mental illness (SMI). The purpose of this study is to examine how incident smoking cessation affects binge drinking and symptoms of depression and anxiety among smokers with SMI.

METHODS

The present study is a secondary analysis of the OPTIN trial, which demonstrated the effectiveness of proactive outreach for smoking cessation among Minnesota Health Care Programs enrollees. Participants with ICD-9 codes indicating schizophrenia spectrum disorders, psychotic disorders, bipolar disorders, or severe/recurrent major depressive disorder were categorized as having SMI (n = 939); remaining smokers were categorized as non-SMI (n = 1382). Multivariable regressions modeled the association between incident smoking cessation and binge drinking, PHQ-2 depression scores, and PROMIS anxiety scores in the two groups.

RESULTS

Quitting smoking was not associated with binge drinking among those with SMI, but was associated with less binge drinking among those without SMI (p = 0.033). Quitting smoking was not associated with PHQ-2 depression scores among those with or without SMI. However, quitting smoking was associated with lower mean PROMIS anxiety scores for those with SMI (p = 0.031), but not those without SMI.

CONCLUSION

Quitting smoking was not associated with heightened binge drinking or symptoms of depression and anxiety among smokers with SMI. These findings suggest that quitting smoking is not detrimental for these patients, and provide evidential support for facilitating access to cessation resources for patients with serious mental illness who smoke.

Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development

OBJECTIVE

Patients describe feelings of bias and prejudice in clinical encounters; however, their perspectives on restoring the encounter once bias is perceived are not known. Implicit bias has emerged as a target for curricular interventions. In order to inform the design of novel patient-centered curricular interventions, this study explores patients' perceptions of bias, and suggestions for restoring relationships if bias is perceived.

METHODS

The authors conducted bilingual focus groups with purposive sampling of self-identified Black and Latino community members in the US. Data were analyzed using grounded theory.

RESULTS

Ten focus groups (in English (6) and Spanish (4)) with N = 74 participants occurred. Data analysis revealed multiple influences patients' perception of bias in their physician encounters. The theory emerging from the analysis suggests if bias is perceived, the outcome of the encounter can still be positive. A positive or negative outcome depends on whether the physician acknowledges this perceived bias or not, and his or her subsequent actions.

CONCLUSIONS

Participant lived experience and physician behaviors influence perceptions of bias, however clinical relationships can be restored following perceived bias.

PRACTICE IMPLICATIONS

Providers might benefit from skill development in the recognition and acknowledgement of perceived bias in order to restore patient-provider relationships.

Health professional-patient communication practices in East Asia: An integrative review of an emerging field of research and practice in Hong Kong, South Korea, Japan, Taiwan, and Mainland China

OBJECTIVE

To provide an integrative review of literature on health communication in East Asia and detail culturally-specific influences.

METHODS

Using PRISMA model, search of PubMed, PsychInfo, Web of Knowledge, ERIC and CINAHL databases were conducted for studies between January 2000 and March 2017, using the terms 'clinician/health professional-patient', 'nurse/doctor-patient, 'communication' and 'Asia'.

RESULTS

38 studies were included: Mainland China, Hong Kong, Japan, South Korea, and Taiwan. The existing body of research on clinician patient communication in East Asia can be classified: 1) understanding the roles and expectations of the nurse, clinician, patient, and family in clinician-patient consultations: a) nurse-patient communication; b) doctor-patient communication; c) the role of family member; and 2) factors affecting quality of care: d) cultural attitudes towards death and terminal illnesses; e) communication preferences affecting trust, decision-making and patient satisfaction; f) the extent to which patient centred care is being implemented in practice; and g) communication practices in multilingual/multi-disciplinary environments.

CONCLUSION

The review detailed the complexity and heterogeneity of clinician-patient communication across East Asia. The studies reviewed indicate that research in East Asia is starting to move beyond a preference for Western-based communication practices.

PRACTICE IMPLICATIONS

There is a need to consider local culture in understanding and interpreting medical encounters in East Asia. The paper highlights the need for a specific culturally-appropriate model of health communication in East Asia which may significantly improve relationships between clinicians and patients.

Examination of cultural competence in service providers in an early intervention programme for psychosis in Montreal, Quebec: Perspectives of service users and treatment providers

AIM

To better understand cultural competence in early intervention for psychosis, we compared service users' and service providers' perceptions of the importance of providers being culturally competent and attentive to aspects of culture.

METHODS

At a Canadian early intervention programme, a validated scale was adapted to assess service user (N = 51) and provider (N = 30) perceptions of service providers' cultural competence and the importance accorded thereto.

RESULTS

Analyses of variance revealed that the importance of service providers being culturally competent was rated highest by service providers, followed by visible minority service users, followed by white service users. Providers rated themselves as being more interested in knowing about service users' culture than service users perceived them to be.

CONCLUSIONS

Service users accorded less import to service providers' cultural competence than providers themselves, owing possibly to varied socialization. A mismatch in users' and providers' views on providers' efforts to know their users' cultures may influence mental healthcare outcomes.

Racial and cultural minority experiences and perceptions of health care provision in a mid-western region

Background

Disparities across a number of health indicators between the general population and particular racial and cultural minority groups including African Americans, Native Americans and Latino/a Americans have been well documented. Some evidence suggests that particular groups may receive poorer standards of care due to biased beliefs or attitudes held by health professionals. Less research has been conducted in specifically non-urban areas with smaller minority populations.

Methods

This study explored the self-reported health care experiences for 117 racial and cultural minority Americans residing in a Mid-Western jurisdiction. Prior health care experiences (including perceived discrimination), attitudes towards cultural competence and satisfaction with health care interactions were ascertained and compared across for four sub-groups (African-American, Native American, Latino/a American, Asian American). A series of multiple regression models then explored relationships between a concert of independent variables (cultural strength, prior experiences of discrimination, education level) and health care service preferences and outcomes.

Results

Overall, racial/cultural minority groups (African Americans, Native Americans, Latino/a Americans, and Asian Americans) reported general satisfaction with current healthcare providers, low levels of both health care provider racism and poor treatment, high levels of cultural strength and good access to health care services. Native American participants however, reported more frequent episodes of poor treatment compared to other groups. Incidentally, poor treatment predicted lower levels of treatment satisfaction and racist experiences predicted being afraid of attending conventional health care services. Cultural strength predicted a preference for consulting a health care professional from the same cultural background.

Conclusions

This study provided a rare insight into minority health care expectations and experiences in a region with comparatively lower proportions of racial and cultural minorities. Additionally, the study explored the impact of cultural strength on health care interactions and outcomes. While the bulk of the sample reported satisfaction with treatment, the notable minority of participants reporting poor treatment is still of some concern. Cultural strength did not appear to impact health care behaviours although it predicted a desire for cultural matching. Implications for culturally competent health care provision are discussed within.

Supporting Accurate Interpretation of Self-Administered Medical Test Results for Mobile Health: Assessment of Design, Demographics, and Health Condition

BACKGROUND

Technological advances in personal informatics allow people to track their own health in a variety of ways, representing a dramatic change in individuals' control of their own wellness. However, research regarding patient interpretation of traditional medical tests highlights the risks in making complex medical data available to a general audience.

OBJECTIVE

This study aimed to explore how people interpret medical test results, examined in the context of a mobile blood testing system developed to enable self-care and health management.

METHODS

In a preliminary investigation and main study, we presented 27 and 303 adults, respectively, with hypothetical results from several blood tests via one of the several mobile interface designs: a number representing the raw measurement of the tested biomarker, natural language text indicating whether the biomarker's level was low or high, or a one-dimensional chart illustrating this level along a low-healthy axis. We measured respondents' correctness in evaluating these results and their confidence in their interpretations. Participants also told us about any follow-up actions they would take based on the result and how they envisioned, generally, using our proposed personal health system.

RESULTS

We find that a majority of participants (242/328, 73.8%) were accurate in their interpretations of their diagnostic results. However, 135 of 328 participants (41.1%) expressed uncertainty and confusion about their ability to correctly interpret these results. We also find that demographics and interface design can impact interpretation accuracy, including false confidence, which we define as a respondent having above average confidence despite interpreting a result inaccurately. Specifically, participants who saw a natural language design were the least likely (421.47 times, P=.02) to exhibit false confidence, and women who saw a graph design were less likely (8.67 times, P=.04) to have false confidence. On the other hand, false confidence was more likely among participants who self-identified as Asian (25.30 times, P=.02), white (13.99 times, P=.01), and Hispanic (6.19 times, P=.04). Finally, with the natural language design, participants who were more educated were, for each one-unit increase in education level, more likely (3.06 times, P=.02) to have false confidence.

CONCLUSIONS

Our findings illustrate both promises and challenges of interpreting medical data outside of a clinical setting and suggest instances where personal informatics may be inappropriate. In surfacing these tensions, we outline concrete interface design strategies that are more sensitive to users' capabilities and conditions.

Patient Choice of Nonsurgical Treatment Contributes to Disparities in Head and Neck Squamous Cell Carcinoma

Objectives

There are well-established outcome disparities among different demographic groups with head and neck squamous cell carcinoma (HNSCC). We aimed to investigate the potential contribution of patient choice of nonsurgical treatment to these disparities by estimating the rate of this phenomenon, identifying its predictors, and estimating the effect on cancer-specific survival.

Study Design

Retrospective nationwide analysis.

Settings

Surveillance, Epidemiology, and End Results Database (2004-2014).

Subjects and Methods

Patients with HNSCC, who were recommended for primary surgery, were included. Multivariable logistic regression was used to identify demographic and clinical factors associated with patient choice of nonsurgical treatment, and Kaplan Meier/Cox regression was used to analyze survival.

Results

Of 114,506 patients with HNSCC, 58,816 (51.4%) were recommended for primary surgery, and of those, 1550 (2.7%) chose nonsurgical treatment. Those who chose nonsurgical treatment were more likely to be older (67.1 ± 12.6 vs 63.6 ± 13.1, P < .01), were of Black (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.28-1.74) or Asian (OR = 1.79; 95% CI, 1.46-2.20) ethnicity, were unmarried (OR married, 0.50; 95% CI, 0.44-0.58), had an advanced tumor, and had a hypopharyngeal or laryngeal primary. Choice of nonsurgical treatment imparted a 2.16-fold (95% CI, 2.02-2.30) increased risk of cancer-specific death.

Conclusion

Of the patients, 2.7% chose nonsurgical treatment despite a provider recommendation that impairs survival. Choice of nonsurgical treatment is associated with older age, having Black or Asian ethnicity, being unmarried, having an advanced stage tumor, and having a primary site in the hypopharynx or larynx. Knowledge of these disparities may help providers counsel patients and help patients make informed decisions.

Medical Students' Implicit Bias and the Communication of Norms in Medical Education

ISSUE

Medical educators should consider how institutional norms influence medical students' perceptions of implicit bias. Understanding normative structures in medical education can shed light on why this influence is associated with students' resistance to implicit bias.

EVIDENCE

Extant research across diverse fields of study uncovers and theorizes layers of norms and normative systems and how they are related to ethical behavior. This review bridges the fields of communication, bioethics, and medical education, constructing an organized foundation and common language by which researchers can build effective educational interventions. First, the nature and effects of implicit bias are described. Second, the nature of normative systems in medical education is explicated. Concepts from the fields of education and communication are transferred to medical education. Third, the structure of the communication of norms in medical education is revealed, through theoretical research in bioethics and empirical medical education research.

IMPLICATIONS

Recommendations are provided for medical educators to improve activities intended to encourage reflection on implicit bias. These recommendations include reframing educational activities as endeavors in "personal" development and uncovering and transforming those normative structures that encourage resistance to implicit bias.