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

Modifiable risk factors for suboptimal control and controller medication underuse among children with asthma

OBJECTIVES

Our aims were (1) to describe rates of suboptimal control and controller medication underuse in a diverse population of children with asthma and (2) to identify potentially modifiable parental behaviors and beliefs associated with these outcomes.

METHODS

We conducted telephone interviews with parents of 2- to 12-year-old children with persistent asthma, in a Medicaid plan and a large provider group. Suboptimal control was defined as >or=4 symptom days, >or=1 symptom night, or >or=4 albuterol use days in the previous 2 weeks. Controller medication underuse was defined as suboptimal control and parent report of <6 days/week of inhaled steroid use. Multivariate analyses identified factors that were independently associated with suboptimal control and controller medication underuse.

RESULTS

Of the 754 study children, 280 (37%) had suboptimal asthma control; this problem was more common in Hispanic children (51%) than in black (37%) or white (32%) children. Controller medication underuse was present for 133 children (48% of those with suboptimal asthma control and 18% overall). Controller medication underuse was more common among Hispanic (44%) and black (34%) children than white (22%) children. In multivariate analyses, suboptimal control was associated with potentially modifiable factors including low parental expectations for symptom control and high levels of worry about competing household priorities. Controller medication underuse was associated with potentially modifiable factors including parental estimation of asthma control that was discordant with national guidelines and no set time to administer asthma medications.

CONCLUSIONS

Deficiencies in asthma control and controller medication use are associated with potentially modifiable parental beliefs, which seem to mediate racial/ethnic and socioeconomic disparities in suboptimal control and controller medication underuse.

So much to do, so little time: care for the socially disadvantaged and the 15-minute visit

There is so much to do in primary care, and so little time to do it. During 15-minute visits, physicians are expected to form partnerships with patients and their families, address complex acute and chronic biomedical and psychosocial problems, provide preventive care, coordinate care with specialists, and ensure informed decision making that respects patients' needs and preferences. This is a challenging task during straightforward visits, and it is nearly impossible when caring for socially disadvantaged patients with complex biomedical and psychosocial problems and multiple barriers to care. Consider the following scenario.

Perceived discrimination in health care and health status in a racially diverse sample

BACKGROUND

Despite the surge of recent research on the association between perceived discrimination and health-related outcomes, few studies have focused on race-based discrimination encountered in health care settings. This study examined the prevalence of such discrimination, and its association with health status, for the 3 largest race/ethnic groups in the United States.

METHODS

Data were drawn from the 2004 Behavioral Risk Factor Surveillance System survey. The primary variables were perceived racial discrimination in health care and self-reported health status. Multivariable logistic regression was used to compare the prevalence of perceived discrimination for whites, African Americans, and Hispanics, and to examine the association between perceived discrimination and health status, controlling for sex, age, income, education, health care coverage, affordability of medical care, racial salience, and state.

RESULTS

Perceived discrimination was reported by 2%, 5.2%, and 10.9% of whites, Hispanics, and African Americans, respectively. Only the difference between African Americans and whites remained significant in adjusted analyses [odds ratio (OR) = 3.22, 95% confidence interval (CI) = 2.46-4.21]. Racial/ethnic differences in perceived discrimination depended on income, education, health care coverage, and affordability of medical care. Perceived discrimination was associated with worse health status for the overall sample (OR = 1.71, 95% CI = 1.35-2.16). Stratified analyses revealed that this relationship was significant for whites (OR = 2.00, 95% CI = 1.45-2.77) and African Americans (OR = 1.95, 95% CI = 1.39-2.73), but not for Hispanics (OR = 0.55, 95% CI = 0.24-1.22).

CONCLUSIONS

Perceived racial discrimination in health care is much more prevalent for African Americans than for whites or Hispanics. Furthermore, such discrimination is associated with worse health both for African Americans and for whites.

Care of HIV-infected Latinos in the United States: a description of calls to the National HIV/AIDS Clinicians' Consultation Center

HIV disproportionately affects the Latino population in the United States. Little is known about clinicians who provide HIV care to the Latino community or the types of issues they face. This report presents descriptive analyses of calls made by clinicians who care for HIV-infected Latinos to two lines of the National HIV/AIDS Clinicians' Consultation Center, the National HIV Telephone Consultation Service (Warmline) and the National Perinatal HIV Consultation and Referral Service (Perinatal HIV Hotline). Separate analyses of data from Latino clinicians are also presented. The majority of Warmline calls about Latino patients (81.0%) concerned antiretroviral treatment strategies or HIV-related conditions. More than half (54.3%) of perinatal-specific calls concerned HIV management during pregnancy and the care of HIV-exposed infants. Latino clinicians most frequently called about minority patients. This descriptive study adds to the growing literature about the care of the Latino HIV-infected patient. The Warmline and Perinatal HIV Hotline are resources for HIV care providers in the nursing and medical care of Latinos.

Perceptions of race/ethnicity-based discrimination: a review of measures and evaluation of their usefulness for the health care setting

BACKGROUND

To assess discrimination in health care, reliable, valid, and comprehensive measures of racism/discrimination are needed.

OBJECTIVE

To review literature on measures of perceived race/ethnicity-based discrimination and evaluate their characteristics and usefulness in assessing discrimination from health care providers.

METHODS

Literature review of measures of perceived race/ethnicity-based discrimination (1966-2007), using MEDLINE, PsycINFO, and Social Science Citation Index.

RESULTS

We identified 34 measures of racism/discrimination; 16 specifically assessed dynamics in the health care setting. Few measures were theoretically based; most assessed only general dimensions of racism and focused specifically on the experiences of African American patients. Acceptable psychometric properties were documented for about half of the instruments.

CONCLUSIONS

Additional measures are needed for detailed assessments of perceived discrimination in the health care setting; they should be relevant for a wide variety of racial/ethnic groups, and they must assess how racism/discrimination affects health care decision making and treatments offered.

Service utilization differences for Axis I psychiatric and substance use disorders between white and black adults

OBJECTIVE

Although studies have shown disparities between black and white populations in service utilization for mental disorders, little information exists on whether such disparities apply equally across disorders. The objective of this study was to examine racial differences in lifetime prevalence of service utilization for mood and anxiety disorders and for alcohol and drug use disorders, with controls for predisposing, enabling, and need-for-service variables unequally distributed between racial-ethnic groups.

METHODS

Data were from a face-to-face epidemiologic survey of 32,752 non-Hispanic white or black adults ages 18 and older residing in households and group quarters in the United States. Main outcome measures were treatment for mood, anxiety, and alcohol and drug use disorders.

RESULTS

White adults were consistently more likely than black adults to have had treatment for mood disorders (odds ratio [OR]=2.16, 95% confidence interval [CI]=1.80-2.59) and anxiety disorders (OR=1.77, 95% CI=1.43-2.19) after adjustment for predisposing and enabling factors and need for service (severity of disorder). In contrast no evidence of lower service utilization for treatment of alcohol use disorders emerged among black respondents (OR=.87, 95% CI=.69-1.10). Moreover, white respondents with drug use disorders were significantly less likely than black respondents to receive treatment for a drug problem (OR=.64, 95% CI=.47-.88).

CONCLUSIONS

Differences in treatment between black and white adults depended on the specific disorder and type of treatment considered. Prevention and intervention strategies should address disorder-specific disparities in services received.

Racial/ethnic disparities in knowledge about risks and benefits of breast cancer treatment: does it matter where you go?

OBJECTIVE

To evaluate the association between provider characteristics and treatment location and racial/ethnic minority patients' knowledge of breast cancer treatment risks and benefits.

DATA SOURCES/DATA COLLECTION

Survey responses and clinical data from breast cancer patients of Detroit and Los Angeles SEER registries were merged with surgeon survey responses (N=1,132 patients, 277 surgeons).

STUDY DESIGN

Cross-sectional survey. Multivariable regression was used to identify associations between patient, surgeon, and treatment setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast conserving surgery with radiation.

PRINCIPAL FINDINGS

Half (51 percent) of respondents had survival knowledge, while close to half (47.6 percent) were uncertain regarding recurrence knowledge. Minority patients and those with lower education were less likely to have adequate survival knowledge and more likely to be uncertain regarding recurrence risk than their counterparts (p<.001). Neither surgeon characteristics nor treatment location attenuated racial/ethnic knowledge disparities. Patient-physician communication was significantly (p<.001) associated with both types of knowledge, but did not influence racial/ethnic differences in knowledge.

CONCLUSIONS

Interventions to improve patient understanding of the benefits and risks of breast cancer treatments are needed across surgeons and treatment setting, particularly for racial/ethnic minority women with breast cancer.

Healthcare providers' perceptions of the factors contributing to infant obesity in a low-income Mexican American community

PURPOSE

To examine healthcare professionals' perceptions of Mexican American infant feeding practices and obesity.

DESIGN AND METHODS

Five provider focus groups (n = 38 providers) were conducted in two agencies in the Denver area on the topic of contributors to childhood obesity in the Mexican American community.

RESULTS

Healthcare providers believe obesity in Mexican American infants is related to: (a) a chubby baby being a healthy baby, (b) introducing complementary foods early, (c) extended family members' infant feeding practices, (d) offering infants high-calorie foods, and (e) prolonged bottle feeding and sweet beverages. Providers reported ambivalence regarding their role in addressing infant obesity.

PRACTICE IMPLICATIONS

Healthcare providers working with Mexican American families should deliver consistent, culturally specified messages regarding infant feeding and activity practices.

Older patients' unexpressed concerns about orthopaedic surgery

BACKGROUND

As the U.S. population ages, orthopaedic surgeons will increasingly be required to counsel older patients about major surgical procedures. Understanding patient concerns or worries about surgery could help orthopaedic surgeons to assist their patients in making these decisions. The objectives of this study were to explore the nature of patient concerns regarding orthopaedic surgery and to describe how patients raise concerns during visits with orthopaedic surgeons and how orthopaedic surgeons respond.

METHODS

As part of a study involving audiotaping of 886 visits between patients and orthopaedic surgeons, fifty-nine patients sixty years of age or older who were considering surgery were recruited to participate in semistructured telephone interviews at five to seven days and one month after the visit. Patients were asked about their perceptions of the visit and how they made their decision about surgery. These interviews were analyzed to identify patients' concerns with the use of qualitative content analysis and then compared with the audiotaped visits to determine whether these concerns were actually raised during the visit and, if so, how well the orthopaedic surgeons responded. Analyses based on patient race (black or white) were also performed.

RESULTS

One hundred and sixty-four concerns pertaining to (1) the surgery (anticipated quality of life after the surgery, the care facility, the timing of the operation, and the patient's capacity to meet the demands of the surgery) and (2) the surgeons (their competency, communication, and professional practices) were identified. Patients raised only 53% of their concerns with the orthopaedic surgeons and were selective in what they disclosed; concerns about the timing of the operation and about the care facility were frequently raised, but concerns about their capacity to meet the demands of the surgery and about the orthopaedic surgeons were not. Orthopaedic surgeons responded positively to 66% of the concerns raised by the patients. Only two concerns were raised in response to direct surgeon inquiry.

CONCLUSIONS

Patients raised only half their concerns regarding surgery with orthopaedic surgeons. Orthopaedic surgeons are encouraged to fully address how patients' capacity to meet the demands of the surgery, defined by their resources (such as social support, transportation, and finances) and obligations (to family members, employers, and religion), may impinge on their willingness to accept recommended surgery.

Disparities and distrust: the implications of psychological processes for understanding racial disparities in health and health care

This paper explores the role of racial bias toward Blacks in interracial relations, and in racial disparities in health care in the United States. Our analyses of these issues focuses primarily on studies of prejudice published in the past 10 years and on health disparity research published since the report of the US Institute of Medicine (IOM) Panel on Racial and Ethnic Disparities in Health Care in 2003. Recent social psychological research reveals that racial biases occur implicitly, without intention or awareness, as well as explicitly, and these implicit biases have implications for understanding how interracial interactions frequently produce mistrust. We further illustrate how this perspective can illuminate and integrate findings from research on disparities and biases in health care, addressing the orientations of both providers and patients. We conclude by considering future directions for research and intervention.

Nativity status and patient perceptions of the patient-physician encounter: results from the Commonwealth Fund 2001 survey on disparities in quality of health care

BACKGROUND

Although racial and ethnic differences in healthcare have been extensively documented in the United States, little attention has been paid to the quality of health care for the foreign-born population in the United States.

OBJECTIVES

This study examines the association between patient perceptions of the patient-physician interaction and nativity status.

RESEARCH DESIGN

Cross-sectional telephone survey.

SUBJECTS

A total of 6674 individuals (US-born = 5156; foreign-born = 1518) 18 years of age and older.

MEASURES

Seven questions measuring the quality of patient-physician interactions.

RESULTS

Of the 7 outcome variables examined in the unadjusted logistic regression model, only 2 remained statistically significant in the fully adjusted model. For both the total sample and for Asians only, compared with US-born, foreign-born individuals were at greater odds [total sample, odds ratio (OR) = 1.43; 95% confidence interval (CI) = 1.01-2.04; Asians, OR = 3.25; 95% CI = 1.18-8.95] of reporting that their physician did not involve them in their care as much as they would have liked. Compared with US-born Asians, foreign-born Asians were at greater odds of reporting that their physician did not spend as much time with them as they would have liked (OR = 4.19; 95% CI = 1.68-10.46).

DISCUSSION

Findings from our study suggest that we should not only track disparities by race and ethnicity but also by nativity status.

Unequal burden of head and neck cancer in the United States

BACKGROUND

Black Americans are adversely affected by many types of malignancies.

METHODS

We reviewed data from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program to evaluate racial disparities in head and neck cancer incidence, mortality, and survival.

RESULTS

Head and neck cancer incidence is greater in the black population and peaks at a younger age. The incidence disparity is decreasing over time and is less for cancers of the oral cavity/pharynx (OCP) than for cancers of the larynx. The disparity in survival after diagnosis is substantial for both sites and is increasing over time because of improvement in survival for the white population, but not for the black population. Some, but not all, of the survival disparity is due to more advanced stage at the time of diagnosis within the black population. The age-adjusted mortality rate for black men is approximately twice the rate for white men.

CONCLUSION

Black Americans clearly bear a greater burden from head and neck cancer. The underlying causes are largely unknown, but are most likely due to a complex interplay of differences in access to health care, quality of medical care, biologic/genetic factors, incidence of comorbid conditions, exposure to carcinogens, diet, and cultural beliefs. Prospective studies are needed to define the relative importance of these factors and to inform intervention strategies.

Receiving advice about child mental health from a primary care provider: African American and Hispanic parent attitudes

BACKGROUND

Primary care providers (PCPs) play a critical role in the identification and treatment of child and adolescent mental health problems but few studies have examined parents' attitudes on receiving advice about child mental health from a PCP and whether attitudes are associated with race or ethnicity.

OBJECTIVE

To determine if race and ethnicity were associated with parents' attitudes on receiving advice about child mental health from a PCP.

SUBJECTS

Data were collected during 773 visits to 54 PCPs in 13 diverse clinics. Families were 56.5% white, 33.3% African American, and 10.1% Hispanic.

MEASURES

The parent reported attitudes associated with receiving advice about child mental health from the PCP. The parent completed the Strengths and Difficulties Questionnaire to report youth mental health. PCPs completed measures of psychosocial orientation, confidence in mental health treatment skills, and the accessibility of mental health specialists.

RESULTS

Hispanics were more likely than Non-Hispanics to agree that PCPs should treat child mental health and were more willing to allow their child to receive medications or visit a therapist for a mental health problem if recommended by the PCP. African Americans were significantly less willing than whites and Hispanics to allow their child to receive medication for mental health but did not differ in their willingness to visit a therapist.

CONCLUSIONS

Race and ethnicity were associated with parents' attitudes on receiving advice about child mental health from a PCP. Primary care may be a good point of intervention for Hispanic youth with mental health needs.

Correlates of hepatitis B testing among Chinese Americans

Chinese Americans are 10 times more likely to be diagnosed with hepatocellular carcinoma (HCC) than their white counterparts. About 80% of HCC's among Asian immigrants are associated with hepatitis B virus (HBV) infection. We used data from in-person interviews of Chinese residents in Seattle to examine factors associated with HBV testing. The survey was completed by 206 men and 236 women (cooperation rate: 58%). Less than one-half (48%) of respondents had been tested for HBV. Factors associated (p < 0.01) with ever having tested in bivariate comparisons included knowing that Chinese are more likely to be infected with HBV than Whites; individuals can be infected with HBV for life; HBV infection can cause liver cancer; not believing that HBV can be prevented by having a positive attitude; having a family member, friend, or medical doctor recommend testing; asking for testing from a medical doctor; and not needing interpreter services. In multiple regression analyses, the following factors were independently associated with testing: believing that Chinese were more likely than Whites to get HBV (p = 0.004), having a doctor recommend testing (p Collapse

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Voices of Asian American youth: important characteristics of clinicians and clinical sites

OBJECTIVE

The purpose of this work was to explore clinician and site characteristics that are important to Chinese and Vietnamese immigrant and first-generation youth.

METHODS

A 3-stage mixed qualitative-quantitative design consisting of exploratory focus groups, a survey, and explanatory focus groups was used to ensure that all of the ideas were generated, prioritized, and explained by youth. Adolescents of Chinese and/or Vietnamese descent and aged 13 to 18 years were recruited in community centers and schools. In stage 1, 55 adolescents in 8 focus groups shared their views on factors that attract or deter them from seeking care. In stage 2, youth responded to a survey including 27 teen-generated items regarding clinicians and sites. In stage 3, 87 teens in 11 groups explained the top-rated items and offered suggestions on how to meet their needs. All of the stages were conducted in English, Mandarin Chinese, and Vietnamese.

RESULTS

Most of the 245 survey respondents (77%) were born in Asia, and 70% had lived in the United States for <3 years. The 27 items were divided into 6 priority ranks by the marginal homogeneity test. Clinician cleanliness and experience shared first rank. Second rank was shared by Asian teens being treated like other teens, site cleanliness, clinician honesty, and clinician friendliness and attitude. The third rank was shared by respect, privacy, completeness, clinicians explaining their actions, and lower health care costs. Interspersed among ranks 5 and 6 were items specific to the needs of Asian youth: the clinician would offer more explanation because Asian families might not ask questions; the clinician would not assume that Asian teens are drug and sex free; the clinician would understand that Asian families may use traditional healing; the clinician would not assume that Asians do not know English; adolescents would not translate for parents; and the teen would be able to choose an Asian clinician. There was little variation in ratings by age, gender, ethnicity, or socioeconomic status. However, 11 of 27 items differed by acculturation. Examples include the greater importance ascribed by more acculturated youth to not being judged, to not having to translate, and to the clinician addressing behavioral issues. Acculturation also affected the youths' views regarding confidentiality and translation.

CONCLUSIONS

Asian American adolescents value the same concerns as all adolescents: respect, honesty, competency, cleanliness, privacy, and nonjudgmental service. However, they also have unique perspectives, and youth at varying levels of acculturation differ in some of their views.

Disparities in health: perspectives of a multi-ethnic, multi-racial America

This 2006 survey of 4,157 randomly selected U.S. adults compared perceptions of health care disparities among fourteen racial and ethnic groups to those of whites. Findings suggest that many ethnic minority groups view their health care situations differently and, often, more negatively than whites. A substantial proportion perceived discrimination in receiving health care, and many felt that they would not receive the best care if they were sick. Most differences remained when socioeconomic characteristics were controlled for. The variety of responses across racial groups demonstrates the importance of examining ethnic subgroups separately rather than combined into a single category.

Differences in the quality of the patient-physician relationship among terminally ill African-American and white patients: impact on advance care planning and treatment preferences

BACKGROUND

Little is known about the quality of the patient-physician relationship for terminally ill African Americans.

OBJECTIVE

To compare the quality of the patient-physician relationship between African-American and white patients and examine the extent to which relationship quality contributes to differences in advance care planning (ACP) and preferences for intensive life-sustaining treatment (LST).

DESIGN

Cross sectional survey of 803 terminally ill African-American and white patients.

MEASUREMENTS

Patient-reported quality of the patient-physician relationship (degree of trust, perceived respect, and joint decision making; skill in breaking bad news and listening; help in navigating the medical system), ACP, preferences for LST (cardiopulmonary resuscitation, major surgery, mechanical ventilation, and dialysis).

RESULTS

The quality of the patient-physician relationship was worse for African Americans than for white patients by all measures except trust. African Americans were less likely to have an ACP (adjusted relative risk [aRR] = 0.66, 95%CI = 0.52-0.84), and were more likely to have a preference for cardiopulmonary resuscitation and dialysis (aRR = 1.28, 95%CI = 1.03-1.58; aRR = 1.25, 95%CI = 1.07-1.47, respectively). Additional adjustment for the quality of the patient-physician relationship had no impact on the differences in ACP and treatment preferences.

CONCLUSIONS

Lower reported patient-physician relationship quality for African-American patients does not explain the observed differences between African Americans and whites in ACP and preferences for LST.

Impact of socioeconomic status and distance from treatment center on survival in patients receiving remission induction therapy for newly diagnosed acute myeloid leukemia

BACKGROUND

While socioeconomic status (SES) and the distance patients travel to a treatment center (DTC) impact survival of certain solid tumors, little is known of their influence in acute myeloid leukemia (AML).

METHODS

We retrospectively reviewed patients receiving remission induction therapy for AML at the Cleveland Clinic between January 1997 and December 2005. Demographic data were obtained from medical records. Income and DTC were determined using online databases. Known prognostic factors (age, WBC count at diagnosis, cytogenetics, AML etiology) were collected and controlled for in Cox proportional hazards analysis.

RESULTS

Induction chemotherapy was administered to 281 patients; 91% were Caucasian (C), 8% were African American (AA), and 1% were neither (non-AA non-C). The median DTC was 24 miles (range, 0.9-2058), and median annual household income was USD 38,972 (range, USD17,496-143,220). With a median follow up of 22.6 months, the median overall survival (OS) was 11.3 months. In multivariable analyses, age >or=60 years, unfavorable cytogenetics, initial WBC count and secondary AML significantly influenced survival (p<0.001, p<0.001, p=0.035, and p=0.010, respectively). OS was similar for AAs and non-AA non-Cs compared to Cs (HR=1.12, 95% CI=.61-2.07, p=.71, and HR=0.87, CI=0.21-3.62, p=.84, respectively). Neither DTC (HR=1.00, 95%CI=0.98-1.01, p=.96 per 20 mile increment) nor SES (HR=1.02, 95%CI=0.92-1.13, p=.77 per USD10,000 annual income increase) had an impact on OS.

CONCLUSION

Unlike with many solid tumors, SES and DTC are not predictive of outcome in AML patients.

Primary care resident perceived preparedness to deliver cross-cultural care: an examination of training and specialty differences

OBJECTIVE

Previous research has shown that resident physicians report differences in training across primary care specialties, although limited data exist on education in delivering cross-cultural care. The goals of this study were to identify factors that relate to primary care residents' perceived preparedness to provide cross-cultural care and to explore the extent to which these perceptions vary across primary care specialties.

DESIGN

Cross-sectional, national mail survey of resident physicians in their last year of training.

PARTICIPANTS

Eleven hundred fifty primary care residents specializing in family medicine (27%), internal medicine (23%), pediatrics (26%), and obstetrics/gynecology (OB/GYN) (24%).

RESULTS

Male residents as well as those who reported having graduated from U.S. medical schools, access to role models, and a greater cross-cultural case mix during residency felt more prepared to deliver cross-cultural care. Adjusting for these demographic and clinical factors, family practice residents were significantly more likely to feel prepared to deliver cross-cultural care compared to internal medicine, pediatric, and OB/GYN residents. Yet, when the quantity of instruction residents reported receiving to deliver cross-cultural care was added as a predictor, specialty differences became nonsignificant, suggesting that training opportunities better account for the variability in perceived preparedness than specialty.

CONCLUSIONS

Across primary care specialties, residents reported different perceptions of preparedness to deliver cross-cultural care. However, this variation was more strongly related to training factors, such as the amount of instruction physicians received to deliver such care, rather than specialty affiliation. These findings underscore the importance of formal education to enhance residents' preparedness to provide cross-cultural care.

Race and Ethnic Disparities in Valuing Health

Objective. Patient preferences are often cited as a possible explanation for disparities in treatment. However, no prior studies have examined whether there are racial and ethnic differences in preferences for health states in a general population sample. Methods. Data from 21,362 adult respondents to the 2002 Medical Expenditure Panel Survey were used to study variations in valuations of health states. Respondents' health states were valued based on the self-rated Visual Analogue Scale (VAS) and the Euro-Qol—5D using the US and UK societal scoring algorithms. Regression analyses determined whether valuations in health states varied by race or Hispanic origin, controlling for socioeconomic status and place of residence. Results. Race and ethnicity were not associated with differences in valuations of health states. However, there were systematic differences in characteristics that were controlled, such as health status, age, poverty status, and region of the country. Blacks and Hispanics had slightly higher VAS scores than whites. The negative influence of pain/ discomfort on the VAS score was greater for blacks and Hispanics. Conclusions. Racial and ethnic differences in treatment preferences probably do not result from differences in health state valuations. Future research should explore whether differences in preferences for other attributes of treatment account for differences in treatment decisions. Cost-utility researchers using the EuroQol—5D or VAS need not account for blacks' and Hispanics' systematically valuing health states differently than whites do. However, caution may be warranted when considering interventions designed to manage pain or discomfort, because blacks and Hispanics gave greater weight to that domain of health status in their valuations.

The Latino mental health project: a local mental health needs assessment

In this article, we present the results of a local needs assessment of the mental health experiences, service needs, and barriers to treatment-seeking of the Latino population in Worcester, Massachusetts. Overall, participants reported relatively high rates of experiences with symptoms of mental health problems, they indicated using a range of both formal and alternative mental health services, and they noted a variety of instrumental, attitudinal, and culturally-specific barriers to seeking mental health services. Findings are discussed with regards to the role that community-driven research can play in advancing efforts to provide relevant services to underserved populations.

Interpersonal processes of care survey: patient-reported measures for diverse groups

OBJECTIVE

To create a patient-reported, multidimensional physician/patient interpersonal processes of care (IPC) instrument appropriate for patients from diverse racial/ethnic groups that allows reliable, valid, and unbiased comparisons across these groups. DATA SOURCE/DATA COLLECTION: Data were collected by telephone interview. The survey was administered in English and Spanish to adult general medicine patients, stratified by race/ethnicity and language (African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino whites) (N=1,664).

STUDY DESIGN/METHODS

In this cross-sectional study, items were designed to be appropriate for diverse ethnic groups based on focus groups, our prior framework, literature, and cognitive interviews. Multitrait scaling and confirmatory factor analysis were used to examine measurement invariance; we identified scales that allowed meaningful quantitative comparisons across four race/ethnic/language groups.

PRINCIPAL FINDINGS

The final instrument assesses several subdomains of communication, patient-centered decision making, and interpersonal style. It includes 29 items representing 12 first-order and seven second-order factors with equivalent meaning (metric invariance) across groups; 18 items (seven factors) allowed unbiased mean comparison across groups (scalar invariance). Final scales exhibited moderate to high reliability.

CONCLUSIONS

The IPC survey can be used to describe disparities in interpersonal care, predict patient outcomes, and examine outcomes of quality improvement efforts to reduce health care disparities.

Dismantling institutional racism: theory and action

Despite a strong commitment to promoting social change and liberation, there are few community psychology models for creating systems change to address oppression. Given how embedded racism is in institutions such as healthcare, a significant shift in the system's policies, practices, and procedures is required to address institutional racism and create organizational and institutional change. This paper describes a systemic intervention to address racial inequities in healthcare quality called dismantling racism. The dismantling racism approach assumes healthcare disparities are the result of the intersection of a complex system (healthcare) and a complex problem (racism). Thus, dismantling racism is a systemic and systematic intervention designed to illuminate where and how to intervene in a given healthcare system to address proximal and distal factors associated with healthcare disparities. This paper describes the theory behind dismantling racism, the elements of the intervention strategy, and the strengths and limitations of this systems change approach.

Health disparities and culturally specific treatment: perspectives and expectancies of African American smokers

Researchers suggest that culturally specific (CS) interventions are important in addressing smoking-related health disparities. Yet, little research has examined the perspectives of African American smokers regarding these efforts. This qualitative study sought to gain insight into perceptions related to (a) the smoking prevalence among African Americans, (b) smoking-related health disparities, (c) expectancies for CS interventions, (d) methods of recruiting research participants, and (e) key intervention components. Six focus groups were conducted with 41 African American smokers (aged 21-64) at a community health center. Content analyses revealed several themes, including the perception that smoking is normative among African Americans, limited knowledge of racial health disparities, mixed perceptions regarding race as a risk factor for illness, and mixed expectancies for the efficacy of CS interventions. In conclusion, individual differences, such as smoking norms, knowledge of health disparities, and intervention expectations may influence receptivity to CS treatments. Implications for tobacco interventions among African Americans are discussed.

Communication patterns in medical encounters for the treatment of child psychosocial problems: does pediatrician-parent concordance matter?

This study examined how pediatrician-parent social status concordance related to communication patterns in medical encounters during which children received treatment for psychosocial problems indicating attention deficit disorder or attention deficit hyperactivity disorder. Using data from 28 pediatric medical encounters occurring in a large southeastern metropolitan city during 2003, we focused on concordance according to race, gender, and education, and its relation to laughter, concern, self-disclosure, question asking, and information-giving utterances, and patient-centeredness. Results indicated that race-concordant pediatricians and parents frequently laughed, whereas parents asked many biomedical questions in gender-concordant encounters. Education-concordant pediatricians and parents expressed concern repeatedly, exchanged biomedical information freely, and shared communication control. Pediatricians also self-disclosed when interacting with college-educated parents.

Is there a language divide in pap test use?

OBJECTIVE

We sought to determine whether primary language use, measured by language of interview, is associated with disparities in cervical cancer screening.

DATA SOURCES

We undertook a secondary data analysis of a pooled sample of the 2001 and 2003 California Health Interview Surveys. The surveys were conducted in English, Spanish, Cantonese, Mandarin, Korean, and Vietnamese.

STUDY DESIGN

The study was a cross-sectional analysis of 3-year Pap test use among women ages 18 to 64, with no reported cervical cancer diagnosis or hysterectomy (n = 38,931). In addition to language of interview, other factors studied included race/ethnicity, marital status, income, educational attainment, years lived in the United States, insurance status, usual source of care, smoking status, area of residence, and self-rated health status.

DATA COLLECTION/EXTRACTION METHODS

We fit weighted multivariate logit models predicting 3-year Pap test use as a function of language of interview, adjusting for the effects of specified covariates.

PRINCIPAL FINDINGS

Compared with the referent English interview group, women who interviewed in Spanish were 1.65 times more likely to receive a Pap test in the past 3 years. In contrast, we observed a significantly reduced risk of screening among women who interviewed in Vietnamese (odds ratio [OR] 0.67; confidence interval [CI] 0.48-0.93), Cantonese (OR 0.44; 95% CI 0.30-0.66), Mandarin (OR 0.48; 95% CI 0.33-0.72), and Korean (OR 0.62; 0.40-0.98).

CONCLUSIONS

Improved language access could reduce cancer screening disparities, especially in the Asian immigrant community.

Alcohol and other drug disorders, comorbidty and violence in rural African American women

African-American women report less alcohol and drug (AOD) use than Caucasian women. However, African-Americans disproportionately experience negative health and social consequences of AOD use. This is especially true for rural women, many of whom live in poverty and have debilitating co-morbid psychiatric disorders that go undiagnosed and treated. It is imperative that health professionals be knowledgeable about AOD use, co-morbid disorders, and how to screen for them. This manuscript is focused on examining rural African American women (n = 142) with and without AOD disorders on the following variables: drugs of abuse, Axis I psychiatric disorder, and adult and childhood victimization.

An overview of posttraumatic stress disorder in African Americans

While several studies have found high rates of trauma exposure there is limited information on posttraumatic stress disorder (PTSD) and its relationship to depression in the African American population. The prevalence and/or expression of psychiatric disorders can differ between racial/ethnic groups. The authors review literature addressing trauma exposure, prevalence, and expression of PTSD in the African American population. Risk factors that may be of specific significance to the development of PTSD in African Americans are also reviewed. Additionally, treatment issues and potential directions for future research of PTSD in the African American population are discussed.

Differences in self-management behaviors and use of preventive services among diabetes management enrollees by race and ethnicity

We assessed the degree that managed care organization (MCO) enrollees used preventive services and engaged in diabetes self-management behaviors by race/ethnicity. A 40-item selfadministered survey was mailed to 19,483 diabetic MCO enrollees. The survey measured use of eight preventive services and engagement in four self-management behaviors among enrollees who self-identified as black, white, or Hispanic. Of the 6,035 surveys analyzed, 4,623 respondents (76.6%) were white, 984 (16.3%) were black, and 428 (7.0%) were Hispanic. Black and Hispanic respondents reported more healthcare visits (mean of 7.0 and 6.5, respectively) in the past year compared to whites (mean, 5.7; p < 0.0001). However, compared to whites, blacks had significantly lower utilization of five of the eight preventive services measured, and Hispanics had significantly lower utilization of seven of the eight preventive services (p < 0.005). With regard to self-management behaviors, blacks were significantly less likely than whites to monitor their diet (65.9% vs. 73.7%, p < 0.0001), exercise (46.4% vs. 52.8%; p = 0.0004) and not smoke (85.1% vs. 89.3%; p = 0.0002); while Hispanics were less likely to monitor their diet (67.3% vs. 73.7%, p = 0.0051). All racial/ethnic groups had low levels of selfmanagement behaviors. Further research is warranted to identify why disparities remain in settings where services are universally available, and to find practical ways to eliminate disparities in a group with routine healthcare encounters.

Immigrant Perceptions of Discrimination in Health Care

BACKGROUND

U.S. healthcare disparities may be in part the result of differential experiences of discrimination in health care. Previous research about discrimination has focused on race/ethnicity. Because immigrants are clustered in certain racial and ethnic groups, failure to consider immigration status could distort race/ethnicity effects.

OBJECTIVES

We examined whether foreign-born persons are more likely to report discrimination in healthcare than U.S.-born persons in the same race/ethnic group, whether the immigration effect varies by race/ethnicity, and whether the immigration effect is "explained" by sociodemographic factors.

RESEARCH DESIGN

The authors conducted a cross-sectional analysis of the 2003 California Health Interview Survey consisting of 42,044 adult respondents. Logistic regression models use replicate weights to adjust for nonresponse and complex survey design.

OUTCOME MEASURE

The outcome measure of this study was respondent reports that there was a time when they would have gotten better medical care if they had belonged to a different race or ethnic group.

RESULTS

Seven percent of blacks and Latinos and 4% of Asians reported healthcare discrimination within the past 5 years. Immigrants were more likely to report discrimination than U.S.-born persons adjusting for race/ethnicity. For Asians, only the foreign-born were more likely than whites to report discrimination. For Latinos, increased perceptions of discrimination were attributable to sociodemographic factors for the U.S.-born but not for the foreign-born. Speaking a language other than English at home increased discrimination reports regardless of birthplace; private insurance was protective for the U.S.-born only.

CONCLUSIONS

Immigration status should be included in studies of healthcare disparities because nativity is a key determinant of discrimination experiences for Asians and Latinos.

Depression care for the elderly: reducing barriers to evidence-based practice

This paper provides an overview of five key bodies of evidence identifying: (1) Characteristics of depression among older adults -- its prevalence, risk factors and illness course, and impact on functional status, mortality, use of health services, and health care costs; (2) Effective Interventions, including pharmacologic, psychotherapies, care management, and combined intervention models; (3) Known Barriers to depression care including patient, provider and service system barriers; (4) Effective Organizational and Educational Strategies to reduce barriers to depression care; and (5) Key Factors in Translating Research into Practice. There is strong empirical support for implementing strategies to improve depression care for older adults.

Culture, language, and patient safety: making the link

It has been well recognized internationally that hospitals are not as safe as they should be. In order to redress this situation, health care services around the world have turned their attention to strategically implementing robust patient safety and quality care programmes to identify circumstances that put patients at risk of harm and then acting to prevent or control those risks. Despite the progress that has been made in improving hospital safety in recent years, there is emerging evidence that patients of minority cultural and language backgrounds are disproportionately at risk of experiencing preventable adverse events while in hospital compared with mainstream patient groups. One reason for this is that patient safety programmes have tended to underestimate and understate the critical relationship that exists between culture, language, and the safety and quality of care of patients from minority racial, ethno-cultural, and language backgrounds. This article suggests that the failure to recognize the critical link between culture and language (of both the providers and recipients of health care) and patient safety stands as a 'resident pathogen' within the health care system that, if not addressed, unacceptably exposes patients from minority ethno-cultural and language backgrounds to preventable adverse events in hospital contexts. It is further suggested that in order to ensure that minority as well as majority patient interests in receiving safe and quality care are properly protected, the culture-language-patient-safety link needs to be formally recognized and the vulnerabilities of patients from minority cultural and language backgrounds explicitly identified and actively addressed in patient safety systems and processes.

Damage compounded: disparities, distrust, and disparate impact in end-of-life conflict resolution policies

For a little more than a decade, professional organizations and healthcare institutions have attempted to develop guidelines and policies to deal with seemingly intractable conflicts that arise between clinicians and patients (or their proxies) over appropriate use of aggressive life-sustaining therapies in the face of low expectations of medical benefit. This article suggests that, although such efforts at conflict resolution are commendable on many levels, inadequate attention has been given to their potential negative effects upon particular groups of patients/proxies. Based on the well-documented tendency among many African Americans to prefer more aggressive end-of-life medical interventions, it is proposed that the use of institutional policy to break decision making impasse in cases for which aggressive treatment is deemed "medically inappropriate" will fall disproportionately on that group. Finally, it is suggested that the development and application of institutional conflict-resolution policies should be evaluated in the context of historical and current experiences of marginalization and disempowerment, lest such policies exacerbate that experience.

Cancer communication patterns and the influence of patient characteristics: disparities in information-giving and affective behaviors

OBJECTIVE

To examine whether patient characteristics are associated with communication patterns between oncologists and breast cancer patients.

METHODS

The study was conducted at 14 practices with 58 oncologists with 405 newly diagnosed patients with no prior history of breast cancer. The initial consultation between oncologist and patient was audiotaped and a detailed communication analysis performed. Interviews were conducted with patients and physicians immediately before and after consultations.

RESULTS

Disparities were found across all patient demographics. Younger patients asked more questions as did those who were white had more than a high school education and when they reported an income that was high or medium income, compared to low (p<0.01). Patient proactive behavior, such as volunteering information to the physician unasked, was similarly related with all demographic predictors as was physician tendency to ask patients questions. Despite the inherently emotional nature of this encounter, there was surprisingly little overt discussion about how the patient felt about her diagnosis and how she was coping. Both patients and physicians spent time trying to establish an interpersonal relationship with each other, although patients spent more time. Patients differed in the number of relationship building utterances by age, education and income and physicians spent more time engaged in relationship building with white than non-white patients (p<0.01) and more educated and affluent patients (p<0.05).

CONCLUSION

This study indicates that patient demographic factors, such as race, income level, education and age seem to influence the amount of time physicians spend in almost all communication categories with patients. One recurring difference across most communication categories was race. Racial differences occurred in almost every one of the communication categories examined. White patients had many more utterances in almost every communication category than their non-white counterparts. These differences may mean a less adequate decision-making process for patients who are members of racial or ethnic minorities, patients who are less affluent, older, and have less education.

PRACTICE IMPLICATIONS

This study found that providers communicate differently with patients by age, race, education and income. These differences in communication may lead to disparities in patient outcomes. Communication skills training should explicitly train clinicians to recognize these tendencies. Patients with different demographics characteristics may also required education that is tailored to them.

Health insurance coverage, health care-seeking behaviors, and genital chlamydial infection prevalence in sexually active young adults

BACKGROUND

Genital chlamydial infection remains prevalent in young adults. Differential access to health care and thus the opportunity for testing, treatment, sexual partner services, and risk reduction counseling may be among the factors contributing to variation in chlamydial prevalence.

GOAL

We investigated associations of health insurance coverage and health care-seeking behaviors, both indicators of healthcare access, to chlamydial infection in a nationally representative sample of young adults.

METHODS

Weighted logistic regression techniques were used to examine associations between indicators of healthcare access and chlamydial infection as determined using Chlamydia trachomatis ligase chain reaction among a subset of sexually active young adults ages 18 to 27 interviewed at wave III of the National Longitudinal Study of Adolescent Health (N = 9347). Analyses were stratified by gender and controlled for age and race/ethnicity.

RESULTS

Having continuous health insurance coverage in the preceding 12 months was associated with a lower risk of chlamydial infection in both men and women. Usual site of health care was also associated with chlamydial infection. Men who reported emergency rooms as their usual site of care had a higher risk of infection, whereas women who used school clinics had a lower risk compared with those seen in primary care settings. Having seen a provider in the preceding 12 months was associated with a lower risk of chlamydial infection for men only. These associations remained even after adjusting for racial/ethnic differences in health insurance coverage and health care-seeking behaviors.

CONCLUSIONS

Independent of race/ethnicity, indicators of healthcare access are associated with chlamydial infection in young adults. Furthermore, our analyses reveal differences in these associations by gender. Improved healthcare access for young people could help reduce chlamydia-associated reproductive health morbidity potentially through access to chlamydial screening, treatment, sex partner services, and risk reduction counseling.

Racial Differences in Prevalence of Coronary Obstructions Among Men With Positive Nuclear Imaging Studies

OBJECTIVES

The purpose of this research was to compare coronary obstruction between clinically similar African Americans (AA) and white persons undergoing coronary angiography.

BACKGROUND

African Americans have higher rates of coronary death than whites, but are less likely to undergo coronary revascularization. Although differences in coronary anatomy do not explain racial difference in revascularization rates, several studies of clinically diverse persons undergoing coronary angiography have found less obstructive coronary disease in AA than clinically similar whites.

METHODS

We studied 52 AA and 259 white male veterans who had both a positive nuclear perfusion imaging study and coronary angiography within 90 days of that study in five Department of Veterans Affairs hospitals. We used chart review and patient interview to collect demographics, clinical characteristics, and coronary anatomy results. Before angiography, we asked physicians to estimate the likelihood of coronary obstruction.

RESULTS

The treating physicians' estimates of coronary disease likelihood were similar for AA (79.5%) and whites (83.0%); AA were less likely to have any coronary obstruction (63.5% vs. 76.5%, p = 0.05) and had significantly less severe coronary disease (p = 0.01) than whites. African Americans continued to be less likely to have coronary obstruction in analyses controlling for clinical features, including the physician's estimate of the likelihood of coronary obstruction.

CONCLUSIONS

These results suggest that AA have less coronary obstruction than apparently clinically similar whites. Further studies are required to confirm our findings and better understand the paradox that AA are less likely to have obstructive coronary disease and more likely to suffer mortality from coronary disease.

Common Use in the General Population of Sexual Enrichment Aids and Drugs to Enhance Sexual Experience

BACKGROUND

We describe the prevalence of ever and current use of sexual enrichment aids and of using drugs to enhance the sexual experience, and correlates of that usage.

STUDY POPULATION

Participants in a random-digit dial survey conducted in the Seattle area between 2003 and 2004 among residents age 18 to 39 years of age with fluency in the English language.

RESULTS

Use of sexual enrichment aids and drugs to enhance sexual experience during a typical 4-week period were reported by 27% and 13%, respectively, of participants. Among those reporting using a drug to enhance their sexual experience, the most commonly used drugs were alcohol (83.7%), marijuana (34.7%), ecstasy or "sextasy" (ecstasy combined with sildenafil) (8.2%), and sildenafil (7.5%). Persons reporting use of sexual enrichment aids and drugs to enhance sexual experience were more likely to engage in sexual behaviors associated with a higher risk of acquiring and transmitting a sexually transmitted infection (STI),such as having nonmonogamous partnerships and multiple partners in the previous 12 months and sexual repertoire.

CONCLUSION

Whether use of sexual enrichment aids and drugs to enhance sexual experience is causally associated with STI risk or merely an additional marker of high-risk behavior or sensation seeking cannot be discerned from a single cross-sectional survey. However, these behaviors occurred frequently, and usage was common across all age, gender, ethnic, sexual, and income groups. Further studies in STI and other populations are required.

Emerging trends and future directions in patient communication skills training

Despite several reviews of research on the effects of patient communication skills interventions, relatively few new studies on the topic have been published recently. The purpose of this article is to identify areas of needed research into patient communication skills training, with the intent of stimulating further investigation. Several topics are discussed, including longitudinal research, issues for studying underserved populations, the role of patients' preference for involvement with their health care, and the assessment of the effects of patient communication skills training on health outcomes.

Delving below the surface. Understanding how race and ethnicity influence relationships in health care

There is increasing evidence that racial and ethnic minority patients receive lower quality interpersonal care than white patients. Therapeutic relationships constitute the interpersonal milieu in which patients are diagnosed, given treatment recommendations, and referred for tests, procedures, or care by consultants in the health care system. This paper provides a review and perspective on the literature that explores the role of relationships and social interactions across racial and ethnic differences in health care. First, we examine the social and historical context for examining differences in interpersonal treatment in health care along racial and ethnic lines. Second, we discuss selected studies that examine how race and ethnicity influence clinician-patient relationships. While less is known about how race and ethnicity influence clinician-community, clinician-clinician, and clinician-self relationships, we briefly examine the potential roles of these relationships in overcoming disparities in health care. Finally, we suggest directions for future research on racial and ethnic health care disparities that uses a relationship-centered paradigm.

Hispanic women's perceptions of patient-centeredness during prenatal care: a mixed-method study

BACKGROUND

Assessing the quality of prenatal care received by Hispanic women is particularly important, given the rapidly growing Hispanic population in the United States. The purpose of this study was threefold: to assess the prevalence of Hispanic mothers who perceived their prenatal care to be patient-centered, to determine whether Hispanic mothers were less likely to perceive their prenatal care to be patient-centered than non-Hispanic mothers, and to better understand Hispanic women's perceptions of the patient-centeredness of their prenatal care.

METHODS

Semistructured interviews were conducted with a proportionate, stratified random sample of 359 women initiating prenatal care in their first trimester and 68 women initiating prenatal care in their third trimester who delivered at 10 Palm Beach County, Florida, maternity hospitals between May and December 2003. Interviews assessed three aspects of patient-centered prenatal care using quantitative and qualitative methods.

RESULTS

Hispanic mothers were less likely than non-Hispanic mothers to perceive that doctors and nurses treated them with respect during their prenatal care appointments (adjusted OR, 0.29; 95% CI, 0.10-0.86), and to perceive that office staff treated them with respect during their prenatal care appointments (adjusted OR, 0.29; 95% CI, 0.12-0.73). Hispanic mothers were more likely to experience language or communication problems than non-Hispanic mothers (adjusted OR, 3.30; 95% CI, 1.40-7.76). Qualitative analyses found that lack of patient-centered care limited Hispanic mothers' ability to understand information given during prenatal visits, ability to ask questions about their prenatal care, and desire to return for subsequent appointments.

CONCLUSIONS

Hispanic women could benefit from prenatal care that is more culturally and linguistically competent as well as care that is responsive to the group's cultural norms. One recommendation is the use of group prenatal care, which encourages groups of women with similar gestational ages to articulate and discuss cultural norms and attitudes about pregnancy during structured prenatal care sessions.

Explaining US racial/ethnic disparities in health declines and mortality in late middle age: the roles of socioeconomic status, health behaviors, and health insurance

Pervasive health disparities continue to exist among racial/ethnic minority groups, but the factors related to these disparities have not been fully elucidated. We undertook this prospective cohort study to determine the independent contributions of socioeconomic status (SES), health behaviors, and health insurance in explaining racial/ethnic disparities in mortality and health declines. Our study period was 1992-1998, and our study population consists of a US nationally representative sample of 6286 non-Hispanic whites (W), 1391 non-Hispanic blacks (B), 405 Hispanics interviewed in English (H/E), and 318 Hispanics interviewed in Spanish (H/S), ages 51-61 in 1992 in the Health and Retirement Study. The main outcome measures were death; major decline in self-reported overall health (SROH); and combined outcome of death or major decline in SROH. Crude mortality rates over the 6-year study period for W, B, H/E and H/S were 5.8%, 10.6%, 5.8%, and 4.4%, respectively. Rates of major decline in SROH were 14.6%, 23.2%, 22.1% and 39.4%, for W, B, H/E and H/S, respectively. Higher mortality rates for B versus W were mostly explained by worse baseline health. For major decline in SROH, education, income, and net worth independently explained more of the disparities for all three minority groups as compared to health behaviors and insurance, reducing the effect for B and H/E to non-significance, while leaving a significant elevated odds ratio for H/S. Without addressing the as-yet undetermined and pernicious effects of lower SES, public health initiatives that promote changing individual health behaviors and increasing rates of insurance coverage among blacks and Hispanics will not eliminate racial/ethnic health disparities.