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

Activating Community Health Center Patients in Developing Question-Formulation Skills

The authors developed and delivered a brief patient activation intervention (PAI) that sought to facilitate physician–patient communication. The intervention was designed to assist low-income, racial/ethnic minority users of community health centers in building skills and confidence asking questions. The PAI takes 8 to 10 minutes to deliver and consists of five steps that can be carried out by individuals with minimal formal medical training. A total of 252 patients waiting to see their physician participated in the intervention and completed the follow-up semistructured interview after their health care visit. The authors describe the intervention and the results of their qualitative evaluation of patient’s responses. Overall, the PAI was valued by patients, appeared to add to patients’ satisfaction with the health care they received, and was feasible to implement in the primary care setting. Furthermore, findings from this study provide indirect insight regarding factors that influence minority patient’s question-asking behavior that include patient’s attitudes, social factors, and patient’s self-efficacy in question formulation.

Patient-provider communication differs for black compared to white HIV-infected patients

Poor patient-provider interactions may play a role in explaining racial disparities in the quality and outcomes of HIV care in the United States. We analyzed 354 patient-provider encounters coded with the Roter Interaction Analysis System across four HIV care sites in the United States to explore possible racial differences in patient-provider communication. Providers were more verbally dominant in conversations with black as compared to white patients. This was largely due to black patients' talking less than white patients. There was no association between race and other measures of communication. Black and white patients rated their providers' communication similarly. Efforts to more effectively engage patients in the medical dialogue may lead to improved patient-provider relationships, self-management, and outcomes among black people living with HIV/AIDS.

An interactional approach to conceptualising small talk in medical interactions

In medical interactions, it may seem straightforward to identify 'small talk' as casual or social talk superfluous to the institutional work of dealing with patients' medical concerns. Such a broad characterisation is, however, extremely difficult to apply to actual talk, and more specificity is necessary to pursue analyses of how small talk is produced and what it achieves for participants in medical interactions. We offer an approach to delineating a subgenre of small talk called topicalised small talk (TST), derived on the basis of conversation analytically-informed analyses of routine consultations involving orthopaedic surgeons and older patients. TST is a line of talk that is referentially independent from their institutional identities as patients or surgeons, oriented instead to an aspect of the personal biography of one (or both), or to some neutral topic available to interactants in any setting (e.g. weather). Importantly, TST is an achievement of both patient and surgeon in that generation and pursuit of topic is mutually accomplished. In an exploratory but systematic analysis, when this approach was applied to a purposive sample of surgeon-patient interactions, TST was much more prevalent in visits with White than African American patients. Accounts for possible ethnic differences in TST are suggested.

Do recently diagnosed black breast cancer patients find questions about cancer fatalism acceptable? A preliminary report

Socio-cultural factors such as cancer fatalism have been understudied in cancer patients. Women from two cancer centers completed a structured phone survey and an open-ended cognitive interview. Socio-cultural variables of fatalism, hope, and spiritual coping were measured using standardized scales. Older women had significantly higher fatalism scores compared to younger women (p < 0.01). Fatalism rates were low. Ratings of hope and collaborative religious coping were high (m = 20, m = 35, respectively). Qualitative comments confirmed the overall low acceptability of the fatalism measures. Further research is needed to identify measures that are acceptable to newly diagnosed patients.

The association of optimism and perceived discrimination with health care utilization in adults with sickle cell disease

OBJECTIVE

We evaluated the effect of perceived discrimination, optimism, and their interaction on health care utilization among African American adults with sickle cell disease (SCD).

METHODS

Measures of optimism and perceived discrimination were obtained in 49 African American SCD patients. Multiple regression analyses controlling for sex and age tested effects of optimism and perceived discrimination on the number of emergency department visits (ED) and number and duration of hospitalizations over the past year.

RESULTS

A perceived discrimination-optimism interaction was associated with number of emergency departments visits (b = .29, p = .052), number of hospitalizations (b = .36, p = .019), and duration of hospitalizations (b = .30, p = .045) such that those with high perceived discrimination/high optimism had the greatest health care utilization.

CONCLUSIONS

African American SCD patients with high perceived discrimination/high optimism had greater health care utilization than patients who reported either low perceived discrimination or low optimism. This study suggests that patient personality and coping styles should be considered when evaluating the effects of stress on SCD-related outcomes.

Migrants’ Mental Health Perceptions and Barriers to Receiving Mental Health Services

This article addresses the various perceptions people from other cultures have regarding mental health and mental illness and the unique coping mechanisms they use based on their cultural beliefs and values. The various barriers to receiving mental health services and the reasons for such barriers are also discussed. In addition, the article stresses the importance of using and implementing culturally appropriate and sensitive assessments and therapeutic interventions.

Does health care setting matter in reports of discrimination?

We investigated the associations between the health care setting types that California adults report as their regular source of care, socioeconomic status, and perceived racial/ethnic medical care-related discrimination. Data were analyzed from the 2005 California Health Interview Survey (n = 36,694). Adults who identified clinics/health centers/hospital clinics or "other settings" as their usual source of health care had increased odds for perceived racial/ethnic discrimination compared with those who utilized private and health maintenance organizations doctors' offices, although this was true only for middle, but not lower or higher, socio-economic respondents. We suggest several explanations for these findings and improvements for assessing health care-based racial discrimination.

Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States

BACKGROUND

To identify sources of race/ethnic differences related to post-traumatic stress disorder (PTSD), we compared trauma exposure, risk for PTSD among those exposed to trauma, and treatment-seeking among Whites, Blacks, Hispanics and Asians in the US general population.

METHOD

Data from structured diagnostic interviews with 34 653 adult respondents to the 2004-2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were analysed.

RESULTS

The lifetime prevalence of PTSD was highest among Blacks (8.7%), intermediate among Hispanics and Whites (7.0% and 7.4%) and lowest among Asians (4.0%). Differences in risk for trauma varied by type of event. Whites were more likely than the other groups to have any trauma, to learn of a trauma to someone close, and to learn of an unexpected death, but Blacks and Hispanics had higher risk of child maltreatment, chiefly witnessing domestic violence, and Asians, Black men, and Hispanic women had higher risk of war-related events than Whites. Among those exposed to trauma, PTSD risk was slightly higher among Blacks [adjusted odds ratio (aOR) 1.22] and lower among Asians (aOR 0.67) compared with Whites, after adjustment for characteristics of trauma exposure. All minority groups were less likely to seek treatment for PTSD than Whites (aOR range: 0.39-0.61), and fewer than half of minorities with PTSD sought treatment (range: 32.7-42.0%).

CONCLUSIONS

When PTSD affects US race/ethnic minorities, it is usually untreated. Large disparities in treatment indicate a need for investment in accessible and culturally sensitive treatment options.

Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States

BACKGROUND

To identify sources of race/ethnic differences related to post-traumatic stress disorder (PTSD), we compared trauma exposure, risk for PTSD among those exposed to trauma, and treatment-seeking among Whites, Blacks, Hispanics and Asians in the US general population.

METHOD

Data from structured diagnostic interviews with 34 653 adult respondents to the 2004-2005 wave of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were analysed.

RESULTS

The lifetime prevalence of PTSD was highest among Blacks (8.7%), intermediate among Hispanics and Whites (7.0% and 7.4%) and lowest among Asians (4.0%). Differences in risk for trauma varied by type of event. Whites were more likely than the other groups to have any trauma, to learn of a trauma to someone close, and to learn of an unexpected death, but Blacks and Hispanics had higher risk of child maltreatment, chiefly witnessing domestic violence, and Asians, Black men, and Hispanic women had higher risk of war-related events than Whites. Among those exposed to trauma, PTSD risk was slightly higher among Blacks [adjusted odds ratio (aOR) 1.22] and lower among Asians (aOR 0.67) compared with Whites, after adjustment for characteristics of trauma exposure. All minority groups were less likely to seek treatment for PTSD than Whites (aOR range: 0.39-0.61), and fewer than half of minorities with PTSD sought treatment (range: 32.7-42.0%).

CONCLUSIONS

When PTSD affects US race/ethnic minorities, it is usually untreated. Large disparities in treatment indicate a need for investment in accessible and culturally sensitive treatment options.

Adherence to cardiovascular disease medications: does patient-provider race/ethnicity and language concordance matter?

BACKGROUND

Patient-physician race/ethnicity and language concordance may improve medication adherence and reduce disparities in cardiovascular disease (CVD) by fostering trust and improved patient-physician communication.

OBJECTIVE

To examine the association of patient race/ethnicity and language and patient-physician race/ethnicity and language concordance on medication adherence rates for a large cohort of diabetes patients in an integrated delivery system.

DESIGN

We studied 131,277 adult diabetes patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient and physician race/ethnicity and language on adherence to CVD medications, after controlling for patient and physician characteristics.

RESULTS

Ten percent of African American, 11 % of Hispanic, 63% of Asian, and 47% of white patients had same race/ethnicity physicians. 24% of Spanish-speaking patients were linguistically concordant with their physicians. African American (46%), Hispanic (49%) and Asian (52%) patients were significantly less likely than white patients (58%) to be in good adherence to all of their CVD medications (p<0.001). Spanish-speaking patients were less likely than English speaking patients to be in good adherence (51% versus 57%, p<0.001). Race concordance for African American patients was associated with adherence to all their CVD medications (53% vs. 50%, p<0.05). Language concordance was associated with medication adherence for Spanish-speaking patients (51% vs. 45%, p<0.05).

CONCLUSION

Increasing opportunities for patient-physician race/ethnicity and language concordance may improve medication adherence for African American and Spanish-speaking patients, though a similar effect was not observed for Asian patients or English-proficient Hispanic patients.

Looking beyond "affordable" health care: cultural understanding and sensitivity-necessities in addressing the health care disparities of the U.S. Hispanic population

Health disparities are pervasive in the United States; but among Hispanics, access to health care is encumbered by poverty, lack of insurance, legal status, and racial or minority status. Research has identified certain aspects of Hispanic culture, values, and traditions contributing to the nature of the Hispanic patient-doctor relationship and the quality of the health care service. Current educational efforts by nonprofit organizations, government, health professionals, and pharmaceutical manufacturers fail to address the needs for accessible and appropriately culture-sensitive information when approaching the diverse Hispanic community. Understanding Hispanics' consumptive practices and expectations surrounding medications is critical to the success of many treatment regimens. Recommendations are presented to address this health care issue.

The importance of examining movements within the US health care system: sequential logit modeling

BACKGROUND

Utilization of specialty care may not be a discrete, isolated behavior but rather, a behavior of sequential movements within the health care system. Although patients may often visit their primary care physician and receive a referral before utilizing specialty care, prior studies have underestimated the importance of accounting for these sequential movements.

METHODS

The sample included 6,772 adults aged 18 years and older who participated in the 2001 Survey on Disparities in Quality of Care, sponsored by the Commonwealth Fund. A sequential logit model was used to account for movement in all stages of utilization: use of any health services (i.e., first stage), having a perceived need for specialty care (i.e., second stage), and utilization of specialty care (i.e., third stage). In the sequential logit model, all stages are nested within the previous stage.

RESULTS

Gender, race/ethnicity, education and poor health had significant explanatory effects with regard to use of any health services and having a perceived need for specialty care, however racial/ethnic, gender, and educational disparities were not present in utilization of specialty care. After controlling for use of any health services and having a perceived need for specialty care, inability to pay for specialty care via income (AOR = 1.334, CI = 1.10 to 1.62) or health insurance (unstable insurance: AOR = 0.26, CI = 0.14 to 0.48; no insurance: AOR = 0.12, CI = 0.07 to 0.20) were significant barriers to utilization of specialty care.

CONCLUSIONS

Use of a sequential logit model to examine utilization of specialty care resulted in a detailed representation of utilization behaviors and patient characteristics that impact these behaviors at all stages within the health care system. After controlling for sequential movements within the health care system, the biggest barrier to utilizing specialty care is the inability to pay, while racial, gender, and educational disparities diminish to non-significance. Findings from this study represent how Americans use the health care system and more precisely reveals the disparities and inequalities in the U.S. health care system.

Barriers to blood pressure control as reported by African American patients

PURPOSE

To understand African American patients' opinions as to barriers to hypertension treatment.

METHODS

Focus groups (n=3) were led by a trained African American moderator of African American patients with hypertension (n=26) who receive their care from a large primary care network. Discussions were transcribed verbatim. Information was displayed in a data matrix and analyzed for emerging themes. Descriptive statistics were used to enhance the content validity of lifestyle modification efforts planned as part of this ongoing research.

RESULTS

Most participants were female (n=20), and the mean age was 49 years. All participants were at least high school graduates. Four major levels of influence emerged from data analysis: (1) the health care system, (2) the community, (3) the family, and (4) the individual. The most prevalent concerns about hypertension centered on sodium, diet, neighborhoods, mistrust, and denial. Of great concern was lack of provider trust and a fatalistic, hopeless mindset. To improve trust, our participants suggested developing a hypertension education program and providing patients with culturally specific materials.

CONCLUSIONS

Culturally sensitive materials need to be designed and tested to improve blood pressure control. Community input regarding cultural issues is essential for designing effective and successful programs for reducing health disparities.

Understanding racial disparities in treatment intensification for hypertension management

BACKGROUND

Disparities in blood pressure (BP) control may be a function of disparities in treatment intensification (TI).

OBJECTIVE

To examine racial differences in TI, understand modifiable factors that may mediate this relationship, and explore the relative effects of TI and race on blood pressure.

DESIGN

Prospective cohort study.

PARTICIPANTS

Participants were 819 black and white patients with hypertension from an urban, safety-net hospital

MAIN MEASURES

We sequentially explored the effects of patient race, sociodemographic and clinical characteristics, beliefs about BP/medications, perceptions of provider/discrimination, sodium intake, medication adherence, and provider counseling on TI, performing a series of random effects analyses. To assess the effects of race and TI on BP, we performed linear regressions, using systolic BP (SBP) as the outcome.

KEY RESULTS

Unadjusted analyses and those including sociodemographic and clinical characteristics revealed that black patients had less TI than whites (-0.31 vs.-0.24, p < 0.001), but adjustment for patient beliefs and experiences eliminated the effects of race (beta =-0.02, p = 0.5). Increased patient concerns about BP medications were related to lower TI, as was more provider counseling (beta =-0.06, p = 0.02 and beta = -0.01, p = 0.001, respectively). In the unadjusted analysis, black race was a significant predictor of SBP (134 mm/Hg for blacks vs. 131 mm/Hg for whites, p = 0.009), but when both race and TI were included in the model, TI was a significant predictor of SBP (final SBP 2.0 mm/Hg lower for each additional therapy increase per 10 visits, p < 0.001), while race was not (Blacks 1.6 mm/Hg higher than whites, p = 0.17).

CONCLUSIONS

Improved patient-provider communication targeted towards addressing patient concerns about medications may have the potential to reduce racial disparities in TI and ultimately, BP control.

Nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology: understanding the gap between guidelines and practice

BACKGROUND

Clinical decision making in dermatology is a complex process and might be influenced by a wide range of nonclinical factors.

OBJECTIVES

The aim of this study was to explore the role of nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology.

METHODS

Semi-structured qualitative interviews were conducted with 46 clinicians working in departments of dermatology of nine different hospitals in Wales. Interviews were audio-recorded and later transcribed and their contents analysed.

RESULTS

Nonclinical factors influencing patient management decisions in dermatology that were identified related to patients, clinicians and practice characteristics. Patient-related factors included place of residence, socioeconomic circumstances, education and intelligence, ethnicity, age, treatment adherence, expectations from treatment, quality of life, concerns and worries, difficult patients, and family members or friends. Clinician-related factors included time constraints in clinic, clinicians' personal circumstances, relationship with colleagues, and relationship with pharmaceutical companies. Practice-related factors included working in private practice, cost of treatment to the National Health Service (NHS), prescribing bureaucracy, and availability of treatment service in the work place. There was a difference between the consultants' views and those of the other clinicians over the impact of pharmaceutical companies on clinicians' prescribing and the awareness of treatment costs to the NHS. Most of the factors identified could potentially influence the clinicians' decision-making process subconsciously. Some clinicians highlighted that these factors are untaught in the medical curriculum, and are usually ignored in clinical guidelines, and therefore represent a challenge to the practice of evidence-based medicine.

CONCLUSIONS

This study has described one aspect of the reality of medical decision making beyond the conventional evidence-based guidelines approach. Proper understanding of nonclinical influences on decision making is of paramount importance for the best patient-centred treatment outcomes.

Differences in patient-provider communication for Hispanic compared to non-Hispanic white patients in HIV care

BACKGROUND

Hispanic Americans with HIV/AIDS experience lower quality care and worse outcomes than non-Hispanic whites. While deficits in patient-provider communication may contribute to these disparities, no studies to date have used audio recordings to examine the communication patterns of Hispanic vs. non-Hispanic white patients with their health care providers.

OBJECTIVE

To explore differences in patient-provider communication for English-speaking, HIV-infected Hispanic and non-Hispanic white patients.

DESIGN

Cross-sectional analysis.

SETTING

Two HIV care sites in the United States (New York and Portland) participating in the Enhancing Communication and HIV Outcomes (ECHO) study.

SUBJECTS

Nineteen HIV providers and 113 of their patients.

MEASUREMENTS

Patient interviews, provider questionnaires, and audio-recorded, routine, patient-provider encounters coded with the Roter Interaction Analysis System (RIAS).

RESULTS

Providers were mostly non-Hispanic white (68%) and female (63%). Patients were Hispanic (51%), and non-Hispanic white (49%); 20% were female. Visits with Hispanic patients were less patient-centered (0.75 vs. 0.90, p = 0.009), with less psychosocial talk (80 vs. 118 statements, p < 0.001). This pattern was consistent among Hispanics who spoke English very well and those with less English proficiency. There was no association between patient race/ethnicity and visit length, patients' or providers' emotional tone, or the total number of patient or provider statements categorized as socioemotional, question-asking, information-giving, or patient activating. Hispanic patients gave higher ratings than whites (AOR 3.05 Hispanic vs. white highest rating of providers' interpersonal style, 95% CI 1.20-7.74).

CONCLUSION

In this exploratory study, we found less psychosocial talk in patient-provider encounters with Hispanic compared to white patients. The fact that Hispanic patients rated their visits more positively than whites raises the possibility that these differences in patient-provider interactions may reflect differences in patient preferences and communication style rather than "deficits" in communication. If these findings are replicated in future studies, efforts should be undertaken to understand the reasons underlying them and their impact on the quality and equity of care.

Influence of culture and discrimination on care-seeking behavior of elderly African Americans: a qualitative study

In this study, the influence of culture and discrimination on care-seeking behavior of elderly African Americans was explored. This was a qualitative phenomenological study that involved in-depth interviews with 15 African American men and women aged 60 and older in Alabama. The sample size of 15 was adequate for the phenomenological method of this study. While this was a small exploratory study and was not intended for any generalizations, it did provide a unique opportunity to hear the voices, the concerns, and the stories of elderly African Americans, which have often been overlooked in the literature. The following themes emerged from the analysis of data: (1) perception of health as ability to be active, (2) reluctance toward prescription medicine use, (3) lack of trust in doctors, (4) avoidance of bad news, (5) race of doctors, (6) use of home remedies, and (7) importance of God and spirituality on health, illness, and healing.

Racial/ethnic discrimination in health care: impact on perceived quality of care

BACKGROUND

Racial/ethnic minorities are more likely to report receipt of lower quality of health care; however, the mediators of such patient reports are not known.

OBJECTIVES

To determine (1) whether racial disparities in perceptions of quality of health care are mediated by perceptions of being discriminated against while receiving medical care and (2) whether this association is further mediated by patient sociodemographic characteristics, access to care, and patient satisfaction across racial/ethnic groups.

RESEARCH DESIGN

A cross-sectional analysis of a population-based sample of California adults responding to the 2003 California Health Interview Survey. Multivariable logistic regression was used to examine the relationship between perceived discrimination and perceived quality of health care after adjusting for patient characteristics and reports of access to care.

MAIN RESULTS

A total of 36,831 respondents were included. African Americans (68.7%) and Asian/Pacific Islanders (64.5%) were less likely than non-Hispanic whites (72.8%) and Hispanics (74.9%) to rate their health care quality highly. African Americans (13.1%) and Hispanics (13.4%) were the most likely to report discrimination, followed by Asian/Pacific Islanders (7.3%) and non-Hispanic whites (2.6%). Racial/ethnic discrimination in health care was negatively associated with ratings of health care quality within each racial/ethnic group, even after adjusting for sociodemographic variables and other indicators of access and satisfaction. Feeling discriminated against fully accounted for the difference in low ratings of quality care between African Americans and whites, but not for other racial/ethnic minorities.

CONCLUSIONS

Patient perceptions of discrimination may play an important, yet variable role in ratings of health care quality across racial/ethnic minority groups. Health care institutions should consider how to address this patient concern as a part of routine quality improvement.

Are racial differences in patient-physician cancer communication and information explained by background, predisposing, and enabling factors?

Research shows that African Americans tend to have poorer and less informative patient-physician communication than Whites. We analyzed survey data from 248 African American and 244 White cancer patients to examine whether this disadvantage could be explained by race variability on several other variables commonly reported to affect communication. These variables were organized into background, enabling, and predisposing factors, based on the Precede-Proceed Model. Multivariate regressions were used to test whether race differences in communication and information variables persisted after successively controlling for background, enabling, and predisposing factors. African American patients had higher interpersonal communication barriers than Whites, but this difference did not persist after controlling for background factors. African Americans also had higher unmet information needs and were less likely to receive the name of a cancer expert. These differences persisted after controlling for all other factors. Future research should focus on the informational disadvantages of African American patients and how such disadvantages may affect cancer treatment decisions.

Specialty care use in US patients with chronic diseases

Despite efforts to eliminate health disparities, racial, ethnic, and geographic groups continue lag behind their counterparts in health outcomes in the United States. The purpose of this study is to determine variation in specialty care utilization by chronic disease status. Data were extracted from the Commonwealth Fund 2006 Health Care Quality Survey (n = 2475). A stratified minority sample design was employed to ensure a representative sample. Logistic regression was used in analyses to predict specialty care utilization in the sample. Poor perceived health, minority status, and lack of insurance was associated with reduced specialty care use and chronic disease diagnosis.

Psychosocial correlates of medical mistrust among African American men

The current study proposed and tested a conceptual model of medical mistrust in a sample of African American men (N = 216) recruited primarily from barbershops in the Midwest and Southeast regions of the United States. Potential psychosocial correlates were grouped into background factors, masculine role identity/socialization factors, recent healthcare experiences, recent socioenvironmental experiences (e.g., discrimination), and healthcare system outcome expectations (e.g., perceived racism in healthcare). Direct and mediated relationships were assessed. Results from the hierarchical regression analyses suggest that perceived racism in healthcare was the most powerful correlate of medical mistrust even after controlling for other factors. Direct effects were found for age, masculine role identity, recent patient-physician interaction quality, and discrimination experiences. Also, perceived racism in healthcare mediated the relationship between discrimination experiences and medical mistrust. These findings suggest that African American men's mistrust of healthcare organizations is related to personal characteristics, previous negative social/healthcare experiences, and expectations of disparate treatment on the basis of race. These findings also imply that aspects of masculine role identity shape the tone of patient-physician interactions in ways that impede trust building processes.

Patient race/ethnicity and patient-physician race/ethnicity concordance in the management of cardiovascular disease risk factors for patients with diabetes

OBJECTIVE Patient-physician race/ethnicity concordance can improve care for minority patients. However, its effect on cardiovascular disease (CVD) care and prevention is unknown. We examined associations of patient race/ethnicity and patient-physician race/ethnicity concordance on CVD risk factor levels and appropriate modification of treatment in response to high risk factor values (treatment intensification) in a large cohort of diabetic patients. RESEARCH DESIGN AND METHODS The study population included 108,555 adult diabetic patients in Kaiser Permanente Northern California in 2005. Probit models assessed the effect of patient race/ethnicity on risk factor control and treatment intensification after adjusting for patient and physician-level characteristics. RESULTS African American patients were less likely than whites to have A1C <8.0% (64 vs. 69%, P < 0.0001), LDL cholesterol <100 mg/dl (40 vs. 47%, P < 0.0001), and systolic blood pressure (SBP) <140 mmHg (70 vs. 78%, P < 0.0001). Hispanic patients were less likely than whites to have A1C <8% (62 vs. 69%, P < 0.0001). African American patients were less likely than whites to have A1C treatment intensification (73 vs. 77%, P < 0.0001; odds ratio [OR] 0.8 [95% CI 0.7-0.9]) but more likely to receive treatment intensification for SBP (78 vs. 71%, P < 0.0001; 1.5 [1.3-1.7]). Hispanic patients were more likely to have LDL cholesterol treatment intensification (47 vs. 45%, P < 0.05; 1.1 [1.0-1.2]). Patient-physician race/ethnicity concordance was not significantly associated with risk factor control or treatment intensification. CONCLUSIONS Patient race/ethnicity is associated with risk factor control and treatment intensification, but patient-physician race/ethnicity concordance was not. Further research should investigate other potential drivers of disparities in CVD care.

Understanding contributors to racial disparities in blood pressure control

BACKGROUND

Racial disparities in blood pressure (BP) control are well documented but poorly understood; prior studies have only included a limited range of potential explanatory factors. We examined a comprehensive set of putative factors related to blood pressure control, including patient clinical and sociodemographic characteristics, beliefs about BP and BP medications, medication adherence, and experiences of discrimination, to determine if the impact of race on BP control remains after accounting for such factors.

METHODS AND RESULTS

We recruited 806 white and black patients with hypertension from an urban safety-net hospital. From a questionnaire administered to patients after their clinic visits, electronic medical record and BP data, we assessed an array of patient factors. We then examined the association of patient factors with BP control by modeling it as a function of the covariates using random-effects logistic regression. Blacks indicated worse medication adherence, more discrimination, and more concerns about high BP and BP medications, compared with whites. After accounting for all factors, race was no longer a significant predictor of BP control.

CONCLUSIONS

Results suggest that equalizing patients' health beliefs, medication adherence, and experiences with care could ameliorate disparities in BP control. Additional attention must focus on the factors associated with race to identify, and ultimately intervene on, the causes of racial disparities in BP outcomes.

Role of acculturation research in advancing science and practice in reducing health care disparities among Latinos

An impressive body of public health knowledge on health care disparities among Latinos has been produced. However, inconclusive and conflicting results on predictors of health care disparities remain. We examined the theoretical assumptions and methodological limitations of acculturation research in understanding Latino health care disparities, the evidence for socioeconomic position as a predictor of health care disparities, and the effectiveness of cultural competency practice. Persistent use of culture-driven acculturation models decenters social determinants of health as key factors in health disparities and diminishes the effectiveness of cultural competency practice. Social and economic determinants are more important predictors than is culture in understanding health care disparities. Improvements in the material conditions of low-income Latinos can effectively reduce health care disparities.

Preliminary outcomes of a model program for increasing treatment access for African American women who use crack cocaine and are at risk for contracting HIV

In the United States, the threat of HIV/AIDS to African American women's health has become the focus of much concern. This paper describes a federally funded community-based program that provides services to African American women at risk for HIV/AIDS in Nashville, Tennessee. The program provides a culturally relevant set of interventions specific to crack cocaine users aimed at reducing substance use and HIV/AIDS risk behaviors. The model is important for the continued development of culturally relevant interventions aimed at reducing the disproportionate rates of HIV/AIDS within the African American community by ensuring treatment access to all populations.

Disparities in cancer care: an operative perspective

BACKGROUND

Health disparities in cancer care have been described and stem from a complex interplay of patient, provider, and instutional factors.

METHODS

A review of the literature describing disparities in aspects of cancer care was performed.

RESULTS

Disparities in outcomes including overall survival for minority populations have been demonstrated to exist for race, age, and socioeconomic status.

CONCLUSION

Disparities in cancer care and outcomes clearly exist for many poorly understood reasons. After a diagnosis of cancer, barriers to care may develop at multiple points along the course of the patient's disease.

Building community-based participatory research partnerships with a Somali refugee community

BACKGROUND

The U.S. has become home to growing numbers of immigrants and refugees from countries where the traditional practice of female genital cutting (FGC) is prevalent. These women under-utilize reproductive health care, and challenge healthcare providers in providing culturally appropriate care.

PURPOSE

This study examined Somali immigrant women's experiences with the U.S. healthcare system, exploring how attitudes, perceptions, and cultural values, such as FGC, influence their use of reproductive health care.

METHODS

A mixed-method community-based participatory research (CBPR) collaboration with a Somali refugee community was conducted from 2005 to 2008 incorporating surveys, semi-structured focus groups, and individual interviews. Providers caring for this community were also interviewed to gain their perspectives and experiences.

RESULTS

The process of establishing a partnership with a Somali community is described wherein the challenges, successes, and lessons learned in the process of conducting CBPR are examined. Challenges obtaining informed consent, language barriers, and reliance on FGC self-report were surmounted through mobilization of community social networks, trust-building, and the use of a video-elicitation device. The community partnership collaborated around shared goals of voicing unique healthcare concerns of the community to inform the development of interventional programs to improve culturally-competent care.

CONCLUSIONS

Community-based participatory research using mixed-methods is critical to facilitating trust-building and engaging community members as active participants in every phase of the research process, enabling the rigorous and ethical conduct of research with refugee communities.

Perceived racial discrimination in health care: a comparison of Veterans Affairs and other patients

OBJECTIVES

We compared rates of perceived racial discrimination in health care settings for veteran and nonveteran patients and for veterans who used the Veterans Affairs health care system and those who did not.

METHODS

Data were drawn from the 2004 Behavioral Risk Factor Surveillance System. We used logistic regression to examine whether perceived racial discrimination in health care was associated with veteran status or use of Veterans Affairs health care, after adjusting for patient characteristics.

RESULTS

In this sample of 35,902 people, rates of perceived discrimination were equal for veterans and nonveterans (3.4% and 3.5%, respectively; crude odds ratio [OR] = 1.00; 95% confidence interval [CI] = 0.77, 1.28; adjusted OR = 0.92; 95% CI = 0.66, 1.28). Among veterans (n = 3420), perceived discrimination was more prevalent among patients who used Veterans Affairs facilities than among those who did not (5.4% vs 2.7%; OR = 2.08; 95% CI = 1.04, 4.18). However, this difference was not significant after adjustment for patient characteristics (OR = 1.30; 95% CI = 0.54, 3.13).

CONCLUSIONS

Perceived racial discrimination in health care was equally prevalent among veterans and nonveterans and among veterans who used the Veterans Affairs health care system and those who did not.

Patients' perceptions of discrimination during hospitalization

OBJECTIVE

To identify sources of perceived discrimination during hospitalization and examine the relationship of perceived discrimination to patient and hospital stay characteristics, and to patient ratings of care.

BACKGROUND

Patient experiences of discrimination within the health-care system are associated with delays in care seeking, non-adherence to medical advice and poorer health status. Most research to date has focused on race and ethnicity-based discrimination, and few studies have included hospitalized patients.

METHODS

Questions about patients' experiences of discrimination were added to a regular patient opinion survey conducted at the Geneva University Hospitals. Participants were 1537 adult residents of Switzerland discharged from the hospital between 15 February and 15 March 2007.

RESULTS

A total of 171 (11.1%) respondents reported at least one source of discrimination. Most (93, 54.4%) reported a single cause of discrimination. The most frequent causes of discrimination were language, age, nationality and having a disease that is viewed negatively by others. Fifteen percentage of non-European respondents reported at least one of the following types of discrimination: language, nationality, religion and skin colour. Reporting discrimination from any cause was associated with higher Picker Patient Experience problem scores, and patients who reported discrimination were less likely to describe their care as very good or excellent and less likely to recommend the hospital to others.

CONCLUSIONS

Patient experiences of discrimination during hospitalization are relatively frequent and are associated with lower patient ratings of care. Collection of data on patient experiences of discrimination may contribute to the development of interventions aimed at ensuring respectful, quality care for all patients.

Beyond literacy and numeracy in patient provider communication: focus groups suggest roles for empowerment, provider attitude and language

Background

Although the number of people living in the United States with limited English proficiency (LEP) is substantial, the impact of language on patients' experience of provider-patient communication has been little explored.

Methods

We conducted a series of 12 exploratory focus groups in English, Spanish and Cantonese to elicit discussion about patient-provider communication, particularly with respect to the concerns of the health literacy framework, i.e. ability to accurately understand, interpret and apply information given by providers. Within each language, 2 groups had high education and 2 had low education participants to partially account for literacy levels, which cannot be assessed consistently across three languages. Eighty-five (85) adults enrolled in the focus groups. The resulting video tapes were transcribed, translated and analyzed via content analysis.

Results

We identified 5 themes: 1) language discordant communication; 2) language concordant communication; 3) empowerment; 4) providers' attitudes; 5) issues with the health care system. Despite efforts by facilitators to elicit responses related to cognitive understanding, issues of interpersonal process were more salient, and respondents did not readily separate issues of accurate understanding from their overall narratives of experience with health care and illness. Thematic codes often appeared to be associated with education level, language and/or culture.

Conclusion

Our most salient finding was that for most of our participants there was no clear demarcation between literacy and numeracy, language interpretation, health communication, interpersonal relations with their provider and the rest of their experience with the health care system.

Demanding patient or demanding encounter?: A case study of a cancer clinic

This paper explores the sociological relevance of demanding encounters between doctors and patients. Borrowing from Potter and McKinlay's [(2005). From a relationship to encounter: an examination of longitudinal and lateral dimensions in the doctor-patient relationship. Social Science & Medicine, 61, 465-479] reconceptualization of the doctor-patient relationship, we suggest an analytic shift away from 'demanding patients' toward 'demanding encounters'. Such a shift places provider-patient conflict within a broader socio-cultural context, emphasizing constraints facing both doctor and patient as they interact in a clinical setting. Specifically, through an ethnographic study of doctor-patient interactions at the oncology clinic of a US University Hospital, we examine the respective influences of new information technologies and patient consumerism in the production of demanding encounters in oncology. Findings suggest that these interconnected socio-cultural realities, in tandem with patient tendencies to challenge physician judgment or expertise, play a role in demanding encounters. We conclude by considering the implications of demanding encounters for doctors, patients and healthcare organizations.

Culturally specific interventions for African American smokers: an efficacy experiment

This pilot study sought to dismantle the efficacy of culturally specific print materials for smoking cessation. Two-hundred sixty-one African American smokers were randomized into 1 of 2 conditions: standard booklet or culturally specific booklet. The content and length of the interventions were identical yet varied in their degree of cultural specificity. Three-month follow-up assessments were completed by 70% (N = 183) of participants. Dependent variables included content evaluation, readiness to quit smoking, and actual behavior change. Evidence suggested that the culturally specific material was more effective at capturing attention, providing encouragement and gaining interest compared to standard materials; however, greater credibility was found for standard materials. In addition, greater readiness to quit and more 24-hour quit attempts were found in the standard condition. No differences were found in abstinence rates. In conclusion, culturally specific interventions may be preferred over standard approaches among African American smokers. Culturally specific approaches, however, may not result in greater behavior change. Implications for written interventions and cultural specificity are discussed.

Racial segregation and disparities in health care delivery: conceptual model and empirical assessment

OBJECTIVE

This study examines two dimensions of racial segregation across hospitals, using a disease for which substantial disparities have been documented.

DATA SOURCES

Black (n=32,289) and white (n=244,042) patients 67 years and older admitted for acute myocardial infarction during 2004-2005 in 105 hospital markets were identified from Medicare data. Two measures of segregation were calculated: Dissimilarity (i.e., dissimilar distribution by race across hospitals), and Isolation (i.e., racial isolation within hospitals). For each measure, markets were categorized as having low, medium, or high segregation.

STUDY DESIGN

The relationship of hospital segregation to residential segregation and other market characteristics was evaluated. Cox proportional hazards regression was used to evaluate disparities in the use of revascularization within 90 days by segregation level.

RESULTS

Agreement of segregation category based on Dissimilarity and Isolation was poor (kappa=0.12), and the relationship of disparities in revascularization to segregation differed by measure. The hazard of revascularization for black relative to white patients was lowest (i.e., greatest disparity) in markets with low Dissimilarity, but it was unrelated to Isolation.

CONCLUSIONS

Significant racial segregation across hospitals exists in many U.S. markets, although the magnitude and relationship to disparities depends on definition. Dissimilar distribution of race across hospitals may reflect divergent cultural preferences, social norms, and patient assessments of provider cultural competence, which ultimately impact utilization.

Association between prior experiences of discrimination and patients' attitudes towards health care providers collecting information about race and ethnicity

BACKGROUND

Previously, we reported a high level of comfort among Californians for collecting race/ethnicity information by health care providers (HCPs). However, minorities were less comfortable providing race/ethnicity information and were more worried than non-Hispanic whites about the potential misuse of this information.

OBJECTIVE

To determine if perceived experiences of discrimination (both in general and in medical care) were associated with comfort providing race/ethnicity information, and conversely, to worry about providing the information.

DESIGN AND PARTICIPANTS

Telephone survey of 480 Californians, including 101 whites, 98 Asians, 173 Hispanics, 82 blacks, and 26 multiracial individuals.

MEASUREMENTS

Comfort level giving HCPs information about race/ethnicity (measured on a 1-10 scale, with text anchors of "very uncomfortable" at 1 and "very comfortable" at 10), worry that the information could be used to discriminate against patients, and worry that the information could be used to find undocumented immigrants. Worry was measured using a four-point Likert scale- not worried at all, a little worried, somewhat worried, and very worried. Respondents were also asked about perceived discrimination in general and perceived discrimination in medical care.

RESULTS

Compared to whites, Hispanics (Beta-coefficient (BC) = -1.16, SE = 0.51) and Mandarin/Cantonese-speaking Asians (BC = -1.40, SE = 0.65) reported significantly less comfort giving HCPs information about their race/ethnicity, while blacks (BC = 0.70, SE = 0.16), Hispanics (BC = 0.91, SE = 0.18), and multiracial individuals (BC = 0.63, SE = 0.24) were significantly more worried that race/ethnicity information could be used to discriminate against them. Adjusting for perceived experiences of discrimination in general and in medical care partially explained the higher discomfort and worry among minorities.

CONCLUSIONS

Perceived experiences of discrimination are associated with greater discomfort and worry about providing race/ethnicity data. Health care institutions should consider how they can address the public's concerns about possible misuses of data.

Racial/ethnic disparities and culturally competent health care among youth and young men

Racial/ethnic disparities in health and health care are receiving increasing national attention from the fields of public health and medicine. Efforts to reduce disparities should adopt a life-span approach and recognize the role of gender. During adolescence, young people make increasingly independent decisions about health-related behavior and health care, while developing gender identity. Little is known about how cultural context shapes gender identity and gender identity's influence on health-related behavior and health care utilization. The authors review disparities in health status and health care among adolescents, especially young men, by reviewing health care access, clinical services, and issues related to culture, identity, and acculturation. Significant differences in health status by gender exist in adolescence, with young men faring worse on many health markers. This article discusses gaps in research and offers recommendations for improving health care quality and strengthening the research base on gender and disparities during adolescence.

The Experience of Discrimination and Black-White Health Disparities in Medical Care

The current study of Black patients focuses on how discrimination contributes to racial disparities in health. The authors used a longitudinal methodology to study how perceived past discrimination affects reactions to medical interactions and adherence to physician recommendations. In addition, they explored whether these reactions and/or adherence mediate the relationship between discrimination and patients' health. The participants in this study were 156 Black patients of low socioeconomic status at a primary care clinic. Patients completed questionnaires on their current health, past adherence, and perceived past discrimination. Then, they saw a physician and rated their reactions to the visit. Four and 16 weeks later they reported on their adherence to physician recommendations and overall health. Perceived discrimination was significantly and negatively associated with patient health, reactions to the physician, and adherence. Path analyses indicated that adherence mediated the relationship between discrimination and patient health, but patient reactions to the interaction did not.

Physician cultural competence and patient ratings of the patient-physician relationship

OBJECTIVE

To determine the association of patients' ratings of the patient-physician relationship with physicians' self-reported cultural competence (CC).

METHODS

Physicians completed a survey assessing their CC in three domains: motivation to learn about other cultures (motivation attitudes), awareness of white privilege and acceptance of a racial group's choice to retain distinct customs and values (power assimilation attitudes), and clinical behaviors reflective of CC. Their African-American and white patients completed interviews assessing satisfaction with the medical visit, trust in their physician, perceptions of their physician's respect for them and their participation in care. We conducted regression analyses to explore the associations between CC and patient ratings of the relationship.

RESULTS

Patients of physicians reporting more motivation to learn about other cultures were more satisfied (OR = 2.1, 95% CI = 1.0-4.4), perceived their physicians were more facilitative (beta = 0.4, p = 0.02) and reported seeking and sharing more information during the medical visit (beta = 0.2, p = 0.03). Physicians' power assimilation attitudes were associated with patients' ratings of physician facilitation (beta = 0.4, p = 0.02). Patients of physicians reporting more frequent CC behaviors were more satisfied (OR = 3.1, 95% CI = 1.4-6.9) and reported seeking and sharing more information (beta = 0.3, p = 0.04).

CONCLUSIONS

Attitudinal and behavioral components of CC are important to developing higher quality, participative relationships between patients and their physicians.

Racial differences in hospital use after acute myocardial infarction: does residential segregation play a role?

This study compares the likelihood of admission to high-mortality hospitals for black and white Medicare patients in 118 health care markets, and whether admission patterns vary if residential racial segregation is greater in the area. Risk of admission to high-mortality hospitals was 35 percent higher for blacks than for whites in markets with high residential segregation. Moreover, blacks were more likely than whites to be admitted to hospitals with high mortality, even in analyses limited to patients who lived closest to lower-mortality hospitals. Eliminating health care disparities may require policies that address social factors leading to segregation.

Client satisfaction in a breast and cervical cancer early detection program: the influence of ethnicity and language, health, resources, and barriers

OBJECTIVES

Satisfaction is a critical outcome for the healthcare system and an important influence on subsequent interactions with that system, yet findings have been inconsistent. This paper examined satisfaction as a multidimensional construct and focused on the interrelated influences of ethnicity and language, the potential confounding effects of economic resources and health status, and the possible role of perceived barriers to service delivery.

METHODS

The study was based on a phone survey conducted in 2005 of a stratified random sample of 207 Massachusetts patients in the National Breast and Cervical Cancer Early Detection Program, which used case managers to increase the rates of diagnostic testing among uninsured women at risk of breast or cervical cancer. Ethnicity, primary language, economic resources, and health status were each related to particular dimensions of patient satisfaction, but mostly independent of perceived barriers to program participation.

RESULTS

The findings indicated that adequate evaluation of public health programs must conceptualize and measure satisfaction as multidimensional and supported the prediction of "segmented assimilation theory" that satisfaction can decline with time in the U.S.

Discrimination and health among Asian American immigrants: disentangling racial from language discrimination

We examined whether self-reported discrimination based on race and language was associated with the number of chronic health conditions among Asian American immigrants. We also examined whether these relationships were moderated by years in the United States. Data are from adults participating in an Asian American supplement to the 2001 Health Care Quality Survey. Language and racial discrimination in seeking health care were independently associated with increased number of chronic health conditions after controlling for age, sex, education, family income, health insurance, primary language, nativity, and ethnicity. Language discrimination was significantly associated with health conditions even with the presence of racial discrimination in the statistical model. Racial discrimination did not show a significant association in the full analytic model. The relationship between language discrimination and chronic conditions was stronger for Asian immigrants living in the USA 10 years or more compared to more recently arrived immigrants. Language discrimination may be an understudied type of discrimination associated with chronic illness among Asian Americans.

Caring for African-American patients in private practice: disparities and similarities in dental procedures and communication

OBJECTIVE. Disparities in oral health care among racial and low socioeconomic groups have been reported. The authors compared the communication behaviors and dental services to African-American and white patients in private dental offices.

METHODS

and Subjects. The investigators directly observed office visits of 292 black and 1,552 white patients in 64 practices by using standardized checklists for the frequency of services provided and frequency and time of communication behaviors. From patient surveys, they constructed three communication scales and a patient satisfaction score. They examined the effects of provider-patient racial concordance on dental services and observed and perceived communication behaviors by using multiple regression analyses.

RESULTS

Groups of black and white patients had similar demographic characteristics. Dental procedures were similar for black and white patients in offices with white providers. Compared with white patients, black patients with white providers reported lower ratings for how well the dentist knew them (P = .001), but patients' satisfaction with their providers was high and not affected by provider-patient racial concordance. After multivariate adjustment, odds of chatting were significantly lower between black patients and white providers than between racially concordant patients and providers (odds ratio = 0.38; P < .001), whereas odds of negotiation were lower among black patients regardless of the race of the provider.

CONCLUSIONS

In this study sample, the investigators did not observe overt disparities in dental services on the basis of race. They noted that some communication behaviors were influenced by dentist-patient racial concordance, which suggests the possibility of more subtle disparities than usually are considered.

CLINICAL IMPLICATIONS

Dental professionals could benefit from understanding their patients' perceptions of a range of interactions that occur during a typical dental visit.

Impact of patient race on patient experiences of access and communication in HIV care

BACKGROUND

Patient-centered care--including the domains of access and communication--is an important determinant of positive clinical outcomes.

OBJECTIVE

To explore associations between race and HIV-infected patients' experiences of access and communication.

DESIGN

This was a cross-sectional survey.

PARTICIPANTS

Nine hundred and fifteen HIV-infected adults receiving care at 14 U.S. HIV clinics.

MEASUREMENTS

Dependent variables included patients' reports of travel time to their HIV care site and waiting time to see their HIV provider (access) and ratings of their HIV providers on always listening, explaining, showing respect, and spending enough time with them (communication). We used multivariate logistic regression to estimate associations between patient race and dependent variables, and random effects models to estimate site-level contributions.

RESULTS

Patients traveled a median 30 minutes (range 1-180) and waited a median 20 minutes (range 0-210) to see their provider. On average, blacks and Hispanics reported longer travel and wait times compared with whites. Adjusting for HIV care site attenuated this association. HIV care sites that provide services to a greater proportion of blacks and Hispanics may be more difficult to access for all patients. The majority of patients rated provider communication favorably. Compared to whites, blacks reported more positive experiences with provider communication.

CONCLUSIONS

We observed racial disparities in patients' experience of access to care but not in patient-provider communication. Disparities were explained by poor access at minority-serving clinics. Efforts to make care more patient-centered for minority HIV-infected patients should focus more on improving access to HIV care in minority communities than on improving cross-cultural patient-provider interactions.

Discussion of maternal stress during pediatric primary care visits

OBJECTIVE

To determine whether the discussion of maternal stress in pediatric primary care is associated with the mother's satisfaction with her child's provider.

METHODS

Children ages 5-16 and their mothers (N=747) were recruited from the waiting rooms of 13 geographically diverse pediatric primary care sites from 2002 to 2005. Directly after the visit, the mother reported her satisfaction with the attention that the provider gave to her and her child's problems and also reported whether the provider understood the problems that she wanted to discuss during the visit. The mother also reported whether the visit included discussion of her "stresses and strains" and the discussion of child mood or behavior.

RESULTS

Thirty-five percent of mothers discussed their stresses and strains with their child's provider. The mother was more likely to be "completely" satisfied with the attention that she and her child received from the provider (odds ratio [OR] 2.43, 95% confidence interval [95% CI], 1.43-4.11) and to agree "strongly" that the provider understood the problems she wanted to discuss (OR 1.95, 95% CI, 1.32-2.93) when the visit included the discussion of maternal stress after controlling for the reason for the visit, number of previous visits, provider specialty (family practice or pediatrics), youth mental health status, whether the visit included the discussion of child mood or behavior, and maternal distress measured with a standard screening tool.

CONCLUSIONS

The mother was more satisfied with her child's primary care provider when maternal stress was discussed during the visit. This finding should somewhat alleviate fears that mothers will react negatively to discussion of their stress during pediatric visits.

Patient centeredness, cultural competence and healthcare quality

Cultural competence and patient centeredness are approaches to improving healthcare quality that have been promoted extensively in recent years. In this paper, we explore the historical evolution of both cultural competence and patient centeredness. In doing so, we demonstrate that early conceptual models of cultural competence and patient centeredness focused on how healthcare providers and patients might interact at the interpersonal level and that later conceptual models were expanded to consider how patients might be treated by the healthcare system as a whole. We then compare conceptual models for both cultural competence and patient centeredness at both the interpersonal and healthcare system levels to demonstrate similarities and differences. We conclude that, although the concepts have had different histories and foci, many of the core features of cultural competence and patient centeredness are the same. Each approach holds promise for improving the quality of healthcare for individual patients, communities and populations.