Abstract
OBJECTIVES: To determine: 1) whether racial and ethnic differences exist in patients’ perceptions of primary care provider (PCP) and general health care system-related bias and cultural competence; and 2) whether these differences are explained by patient demographics, source of care, or patient-provider communication variables.
DESIGN: Cross-sectional telephone survey.
SETTING: The Commonwealth Fund 2001 Health Care Quality Survey.
SUBJECTS: A total of 6,299 white, African-American, Hispanic, and Asian adults.
MEASUREMENTS AND MAIN RESULTS: Interviews were conducted using random-digit dialing; oversampling respondents from communities with high racial/ethnic minority concentrations; and yielding a 54.3% response rate. Main outcomes address respondents’ perceptions of their PCPs’ and health care system-related bias and cultural competence; adjusted probabilities (Pr) are reported for each ethnic group. Most racial/ethnic differences in perceptions of PCP bias and cultural competence were explained by demographics, source of care, and patient-physician communication variables. In contrast, racial/ethnic differences in patient perceptions of health care system-wide bias and cultural competence persisted even after controlling for confounders: African Americans, Hispanics, and Asians remained more likely than whites (P<.001) to perceive that: 1) they would have received better medical care if they belonged to a different race/ethnic group (Pr 0.13, Pr 0.08, Pr 0.08, and Pr 0.01, respectively); and 2) medical staff judged them unfairly or treated them with disrespect based on race/ethnicity (Pr 0.06, Pr 0.04, Pr 0.06, and Pr 0.01, respectively) and how well they speak English (Pr 0.09, Pr 0.06, Pr 0.06, and Pr 0.03, respectively).
CONCLUSION: While demographics, source of care, and patient-physician communication explain most racial and ethnic differences in patient perceptions of PCP cultural competence, differences in perceptions of health care system-wide bias and cultural competence are not fully explained by such factors. Future research should include closer examination of the sources of cultural bias in the US medical system.
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References
Mayberry RM, Mili F, Ofili E. Racial and ethnic differences in access to medical care. Med Care Res Rev. 2000;57(suppl 1):108–45.
Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2003.
Cooper LA, Roter DL. Patient-Provider Communication. The Effect of Race and Ethnicity on Process and Outcomes of Healthcare. In: Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academy Press; 2003:552–93.
Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583–9.
Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 1999;159:997–1004.
Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Stange KC. Patient satisfaction with time spent with their physician. J Fam Pract. 1998;47:133–7.
Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. J Gen Intern Med. 1999;14:82–7.
Malat J. Social distance and patients’ rating of healthcare providers. J Health Soc Behav. 2001;42:360–72.
Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients perceive physician communication regarding cardiac testing. Med Care. 2002;40(suppl 1):I27-I34.
Collins KS, Hughes DL, Doty MM, Ives BL, Edwards JN, Tenney K. Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. Findings from The Commonwealth Fund 2001 Health Care Quality Survey. New York: The Commonwealth Fund; 2002.
Blendon RJ, Scheck AC, Donelan K, et al. How white and African-Americans view their health and social problems. J Am Med Assoc. 1995;273:341–6.
Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340:618–26.
van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50:813–28.
Taylor JS. Confronting ‘culture’ in medicine’s ‘culture of no culture’. Acad Med. 2003;78:555–9.
Kagawa-Singer M, Kassim-Lakha S. A strategy to reduce cross-cultural miscommunication and increase the likelihood of improving health outcomes. Acad Med. 2003;78:577–87.
Wear D. Insurgent multiculturalism: rethinking how and why we teach culture in medical education. Acad Med. 2003;78:549–54.
van Ryn M, Fu SS. Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health? Am J Public Health. 2003;93:248–55.
Health Resources and Services Administration Bureau of Health Professions, USDHHS. BHPR — Other Definitions of Cultural Competence. Available at: http:/bhpr.hrsa.gov/diversity/cultcomp.htm. Accessed August 21, 2003.
Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118:293–302.
United States Department of Health and Human Services, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care Final Report, March 1 2001. United States Department of Health and Human Services, OPHS, Office of Minority Health; 2001.
Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Available at: http://www.lcme.org/functions2003july.pdf. Accessed January 19, 2004.
Dolhun EP, Munoz C, Grumbach K. Cross-cultural education in U.S. medical schools: development of an assessment tool. Acad Med. 2003;78:615–22.
Cooper LA, Hill MN, Powe NR. Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med. 2002;17:477–86.
Stata Statistical Software. College Station, Tex: Stata Corporation; 2001.
Betancourt JR, Green AR, Carrillo JE. Cultural competence in Health Care. Emerging Frameworks and Practical Approaches, 10-1-2002. The Commonwealth Fund. Quality of Care for Underserved Populations Field Report.
Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 1999;130:829–34.
Campinha-Bacote J. A model and instrument for addressing cultural competence in health care. J Nurs Educ. 1999;38:203–7.
Zweifler J, Gonzalez AM. Teaching residents to care for culturally diverse populations. Acad Med. 1998;73:1056–61.
Lurie N, Yergan J. Teaching residents to care for vulnerable populations in the outpatient setting. J Gen Intern Med. 1990;5(suppl 1):S26-S34.
Berlin EA, Fowkes WC Jr. A teaching framework for cross-cultural health care. Application in family practice. West J Med. 1983;139:934–8.
Ngo-Metzger Q, Massagli MP, Clarridge BR, et al. Linguistic and cultural barriers to care. J Gen Intern Med. 2003;18:44–52.
Tucker CM, Herman KC, Pedersen TR, Higley B, Montrichard M, Ivery P. Cultural sensitivity in physician-patient relationships. Perspectives of an ethnically diverse sample of low-income primary care patients. Med Care. 2003;41:859–70.
Stewart AL, Napoles-Springer A, Perez-Stable EJ, et al. Interpersonal processes of care in diverse populations. Milbank Q. 1999;77:305–39, 274–339.
Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(suppl 1):181–217.
Keeter S. Estimating telephone noncoverage bias with a telephone survey. Public Opin Q. 1995;59:196–217.
Williams DR, Neighbors HW, Jackson JS. Racial/Ethnic discrimination and health: findings from community studies. Am J Public Health. 2003;93:200–8.
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This work was supported by a research grant from the Common-wealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund, its directors, officers, or staff.
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Johnson, R.L., Saha, S., Arbelaez, J.J. et al. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J GEN INTERN MED 19, 101–110 (2004). https://doi.org/10.1111/j.1525-1497.2004.30262.x
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DOI: https://doi.org/10.1111/j.1525-1497.2004.30262.x