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What is the key to culturally competent care: Reducing bias or cultural tailoring?

Adolfo G. Cuevasa,c*, Kerth O’Briena and Somnath Sahab

aDepartment of Psychology, Portland State University, Portland, OR, USA; bPortland Veterans Affairs Medical Center, Public Health & Preventive Medicine, Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA; cDepartment of Social

and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA

(Received 28 July 2016; accepted 15 January 2017)

Objective: To gain a better understanding as to whether disparities in patient– provider relationships arise from ethnic minority patients being treated differently than European American patients while they would prefer to be treated the same, or whether disparities arise when ethnic minority patients are treated the same as European American patients while they would prefer to be treated differently. Method: African-American, Latina/Latino and European American community members were recruited to participate in one of 27 focus group discussions. Topics included what made a good or bad relationship with a doctor and what led one to trust a doctor. A thematic analysis was conducted using NVivo 10. Results: Patients of all groups described experiences that reflected the concepts of patient-centred care, such as wanting a clinician who is attentive to patients’ needs. African-American patients reported experiences they viewed as discriminatory. Some African-American patients felt it was appro- priate to racially/ethnically contextualise their care, and most Latina/Latino patients preferred language/culturally concordant clinicians. Conclusion: Health care disparities might be reduced through a patient- centred approach to cultural competency training, general knowledge of the cultural context of clinicians’ patient population, and attention to the effects of racial bias and discrimination among both clinicians and non-clinical staff.

Keywords: clinician–patient relationships; patient-centred care; cultural competency; health care disparities; ethnic minorities; focus groups

Introduction

Despite efforts through community interventions and health care training programmes, health care disparities persist for African-Americans and Latinas/Latinos (National Center for Health Statistics, 2016; Shi et al., 2013; Smedley, Stith, & Nelson, 2003). Although these disparities have many sources, they result at least in part from patients’ experiences in clinician–patient relationships. For example, in comparison to European American patients, African-American patients see themselves as being in worse health and receiving lower quality of care (Smedley et al., 2003). They are more likely to visit

*Corresponding author. Email: [email protected]

© 2017 Informa UK Limited, trading as Taylor & Francis Group

Psychology & Health, 2017 Vol. 32, No. 4, 493–507, http://dx.doi.org/10.1080/08870446.2017.1284221

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What is the key to culturally competent care: Reducing bias or cultural tailoring?

Abstract Objective:

Method:

Results:

Conclusion:

Keywords:

Introduction

Email: [email protected]

the emergency department and they have fewer physician visits per year (Brown et al., 2012; Smedley et al., 2003). In the clinician’s office, for example, physicians are more verbally dominant and engage in less patient-centred communication with African- American patients than with White patients (Johnson, Roter, Powe, & Cooper, 2004). Along with African-Americans, Latinas/Latinos report greater perceived discrimination compared to European Americans and these perceptions are associated with lower rat- ings of quality of care (Sorkin, Ngo-Metzger, & De Alba, 2010). These perceptions may be amplified when Latinas/Latinos face language barriers. For example, limited English proficient (LEP) Latinas/Latinos with language-discordant physicians are more likely to have poor glycemic control than LEP Latinas/Latinos with language-concor- dant physicians (Fernandez et al., 2010). This finding suggests that language concor- dance is an important component to trust-building, medication comprehension, and overall receipt of quality of care for LEP Latinas/Latinos (Diamond & Jacobs, 2010).

There is debate over the principal underlying sources of these disparities in clini- cian–patient relationships. Lower quality clinician–patient relationships for minority patients may arise from clinicians treating patients differently based on race/ethnicity. Clinicians may deliver higher quality, more patient-centred care to White patients due to cultural insensitivity, racial bias, or discriminatory treatment (Betancourt & Green, 2010; Blair et al., 2013; Cooper et al., 2012; Penner et al., 2013). Alternatively, lower quality clinician–patient relationships for minority patients may arise from racial or eth- nic differences between clinicians’ and patients’ preferences, beliefs, and values. Clini- cians may deliver the same care to White and minority patients with the result that minority patients perceive lower quality care due to a lack of cultural tailoring (Betan- court & Green, 2010; Saha, Beach, & Cooper, 2008; Weech-Maldonado et al., 2012).

Cultural competency training has been adopted as health professionals’ primary approach to addressing racial and ethnic disparities in health care, but currently such training varies widely. In the US some programmes focus on reducing provider bias and equalising the care provided to patients of varied ethnic groups, while other pro- grammes focus on improving provider awareness and responsiveness to varying cultural norms and differentiating care for patients of colour vs. European American patients (Betancourt & Green, 2010; Blair, Steiner, & Havranek, 2011; Lie, Lee-Rey, Gomez, Bereknyei, & Braddock, 2010; Penner et al., 2013). Patients’ own voices, however, have been largely missing from the debate about how to improve clinician–patient rela- tionships for minority patients and thus to reduce disparities in health care quality. In this study, we sought to understand the degree to which disparities in clinician–patient relationships arise from African-American and Latina/Latino patients being treated dif- ferently from European American patients when they would prefer to be treated the same vs. being treated the same when they would prefer to be treated differently. To accomplish this we used focus groups to explore the experiences and perspectives of African-American, Latina/Latino and European American patients on their clinician– patient relationships.

Method

The study, known as Project EQUALED (Exploring the Quality of African American and Latina/Latino Experiences with Doctors), aimed to determine what constitutes good or bad relationships with clinicians from the perspectives of patients across three broad

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Method

cultural groups comprised of African-Americans, Latinas/Latinos and European Americans. Employing several principles of community-based participatory research (CBPR; Israel, Schulz, Parker, & Becker, 1998), our research team included two com- munity liaisons as active research team members meeting weekly with academic project staff during the formative phases of the project. We also enlisted the guidance of a com- munity advisory board which provided input into recruitment approaches as well as revisions of the focus group discussion guide. The advisory board also provided input into the design of study recruitment flyers. Word-of-mouth invitations from advisory board members and from initial research participants helped the research team to involve the participation of community members in the focus groups. Research team members conducted the focus groups in community settings including public libraries and a locally-owned coffee shop.

Participant recruitment

We wanted to hear the experiences and views of adult community residents who were diagnosed with diabetes and/or hypertension because people living with these illnesses are seen routinely in primary care. We posted study flyers in a variety of venues, including restaurants, stores, barber and beauty shops, and we enrolled people during community events in Portland (African-American participants) and Silverton, Oregon (Latina/Latino participants). To recruit for the European American groups we posted study flyers widely in predominately European American neighbourhoods of Portland, Oregon. We limited our efforts recruiting European American participants to neighbour- hoods of modest socio-economic status in order that our comparisons across ethnicity would not be conflated with socio-economic differences. We avoided clinics and hospi- tals as recruitment sites because we wanted the sample to be truly community-based, not clinic-based, and because we did not want to oversample from any particular health care facility. We also asked participants and potential participants to talk about the study with other possibly eligible persons in their personal networks. The advertising flyers said that the project involved group discussion pertaining to the experiences that com- munity members with diabetes, hypertension, or both of these, have with their doctors.

Upon telephoning the research office, interested community members were screened for eligibility (ethnicity and diabetes and/or hypertension diagnosis). Participants were told what some of the key questions would be in the focus group discussions (e.g. ‘Tell us about a good experience you had with a doctor’) and were briefed on key points that would be covered in the informed consent paperwork.

Focus groups

In keeping with principles of CBPR, moderators for the African-American and Latina/ Latino focus groups were recruited from these respective communities. Potential focus group moderators were first identified by community advisory board members and other community members. Potential moderators underwent an initial eight-hour training ses- sion addressing principles of focus group research, and including moderator practice as well as human subjects training. Moderators also received coaching throughout the study period. Each moderator also received an individual copy of the volume Moderat- ing Focus Groups (Krueger, 1997). Focus groups with European American participants

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Participant recruitment

Focus groups

were moderated by European American members of the research team with assistance from another European American moderator.

Focus groups were segmented by ethnicity and gender, with moderators matched to discussion participants on these key characteristics. Typically one co-moderator asked questions and led discussion while the other co-moderator took notes and monitored the discussion to ensure balanced participation. The interviews were semi-structured in order to allow moderators the freedom to probe interesting topics that arose during the sessions (Tong, Sainsbury, & Craig, 2007). All focus groups with Latina/Latino commu- nity members were conducted in Spanish. Simultaneous translation using a remote microphone was used in order to allow research team members to follow the focus group discussions in real time (Esposito, 2001).

Focus groups began 15 to 20 min or so after the first participants arrived so that almost all participants had time to meet the members of the research team. Each place setting at the discussion table included informed consent paperwork that participants were able to review at their own pace before the discussion began; team members also answered individual participants’ questions about the study.

The focus group guide employed by the moderators was intended to solicit partici- pants’ actual experiences in the health care system with particular attention to their interactions with physicians, including participants’ values and preferences relating to these interactions. The guide included questions about participants’ most recent visit to the doctor, their good experiences with doctors (and what makes a good experience), their bad experiences with doctors (and what would have made for a better experience), their experiences and preferences if any regarding a physician’s race/ethnicity, their per- spectives on important relationship dimensions such as trust and respect, and their advice to doctors for improving the way doctors work with patients. Focus group partic- ipants were compensated $40 for their time. Study procedures were approved by the Oregon Health & Science University Institutional Review Board.

Analysis

The focus group discussions were audiorecorded. All dialogue was transcribed and tran- scriptions were placed into Microsoft Word documents. Documents were then imported into the qualitative software, NVivo 10, and each focus group was given its own file. The academic research team employed a thematic analysis approach in the analysis of transcripts, including six phases: familiarising with data, generating initial codes, search- ing for themes among codes, reviewing themes, defining and naming themes, and pro- ducing the final report (Braun, Clarke, & Terry, 2014). Because the goal of the project was to report patients’ experiences and preferences regarding the patient–clinician rela- tionship in patients’ own terms, the team adopted a realist framework for data analysis (Braun & Clarke, 2006).

In the first phase of analysis, three team members read the transcripts to become familiar with the content and discuss potential patterns that might exist in the data. In the second phase two team members independently coded 25% of the transcripts. Coders also kept notes (or memos) on issues on which they anticipated a need for clari- fication. All three team members then met to compare codes, to discuss areas of diver- gence and to reach agreement on coding and organisation. In these discussions, team members took care to keep codes close to the transcript content, not yet identifying

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Analysis

themes. After code agreement was reached, one team member (the first author) coded the remainder of the transcripts, applying a common set of codes and sub-categories across all transcripts. During the third and fourth phases, the team members met fre- quently to discuss codes, particularly any newly emerging codes, and to reach agree- ment on the codes and sub-categories. They then reviewed the codes to develop themes capturing the essence of the given data. The team then discussed relationships between subthemes and the overarching themes. The team then examined patterns of difference and similarity across the three participant ethnic groups. During this process, the three team members were mindful of the different perspectives they brought to this analysis due to their backgrounds, with one investigator being a scholar of Latina/Latino and African-American descent, two being social scientists, and one being a practicing pri- mary care physician. Throughout the process, the research team reviewed analytic mem- os, discussed discrepancies of thinking, and reached agreement on analytic findings.

Results

A total of 142 adults participated in 27 focus groups segmented by ethnicity and gen- der, including five groups of African-American women, five groups of African-Ameri- can men, five groups of Latina women, four groups of Latino men, four groups of European American women and four groups of European American men.

Appendix 1 presents our summary of thematic findings, including both commonali- ties and differences among the three ethnic groups. In general we found substantially more commonalities than differences in patients’ preferences for care and in how they described good and bad experiences. Patients of all groups described experiences that reflected the concepts of patient-centred care. Across the three groups, patients wanted a personable provider who listened to their comments and paid attention to their prob- lems. Patients also expressed their desire to be more participatory in the interactions with their providers and be more involved in their own care. Supplementary to these preferences, they wanted their clinicians to be attentive and sensitive to their needs. The following quote from one of the African-American men participating in the study illus- trates the common themes of open communication, listening, and valuing a patient’s perspective on the treatment regimen that were expressed by members in all three ethnic groups.

[What I would like from a doctor is] open communication. Being able to give and receive information. Being attentive to the patient’s needs. Taking recommendations from the patient, you know, vs. always just on the tell and tell and tell, because the bottom line, you know your body better than anybody else. Now, the doctor’s there to help you understand what’s going on, but like the gentleman was saying down here, when he was in Alabama, all he knew, his foot was hurting. And then he came and told the doctor what was going on. He had to give him the information. And the doctor had to be able to listen to that, and then when he listened to that, then he was able to do what he was supposed to do. So it has to be open communication on both ends.

Ethnic difference in preferences

While the three groups shared similar criteria for good patient–provider relationships, there were some differences in preferences across ethnic groups.

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Results

Ethnic difference in preferences

Acknowledging patients’ racial/ethnic background

Some African-American patients felt it was important for clinicians to consider the patient’s race in providing health care. For example, this patient felt clinicians should consider his racial/ethnic identity in working with him and formulating a treatment plan:

I expect him just to be polite and nice to me, and not just treat me as just another patient, another piece of my income, you know, you’re just another patient, another income. Treat me like, yes, this is a Black man, this is a Black man with diabetes, this is a Black man with diabetes and high blood pressure. I know that we have a problem with this as a race. I’ve learned other things being a Black man, about this particular problem that we have, and I’m going to inform him a little better than other people or, if I’m not going to inform him better than other people, I’m going to get him somebody that can.

Preference for ethnic and language concordance

African-Americans varied in their preferences regarding the race of their physicians. Many African-Americans said they did not care whether their doctor was African-Amer- ican or not as long as the doctor was competent. Similarly, European American patients reported indifference about physicians’ race. They wanted a clinician who showed respect and attentiveness during the interaction. Unlike the European Americans and many of the African-Americans, most Latinas/Latinos preferred an ethnic- or language- concordant provider. Some did not have a preference for an ethnic-concordant provider as long as the provider knew Spanish, while others preferred a Latina/Latino provider, believing that Latina/Latino providers understand Latina/Latino experiences. The patients believed that language-concordant providers and ethnic-concordant providers communicate effectively with patients, enabling patients to understand their providers’ recommendations and allowing physicians to understand their patients’ explanations of their symptoms. For example, this Latino male participant preferred

Latina/Latino clinicians because he felt patient and clinician would understand each other better:

I think the, the majority of us try to look for Latino doctors, because first of all the com- munication that I think more than anything that’s really indispensable. Just understanding each other. And by understanding each other, the results of the doctor will be better, because they know exactly the problem we have. At least I, where I go, they’re all Hispanic. And I feel good, I feel good going there.

Some Latinas/Latinos preferred that clinicians be knowledgeable about complementary and alternative medicine and spoke about their own use of alternative medicine to com- plement medicines obtained by prescription. Because they were concerned that the alter- native medicine might cause complications, Latinas/Latinos wanted providers to be informed and to have better connections with herbalists. As this Latina participant said:

I would like my doctor to speak Spanish, but I would like them to know more about alter- native medicine, like herbs, cause I use that a lot. I use a lot of Chinese medicine and herbs. I would like them to ask me about going to a curandero …

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Acknowledging patients� racial/ethnic background

Preference for ethnic and language concordance

There’s a lot of people nowadays that use that kind of medicine and therapy. I would like for them to ask me that question … [I want them] to study more about alternative medi- cine, so they can have an intelligent conversation with the patients and know that that doesn’t coincide with the medicine he wants to give me. Not just say, ‘No, don’t take it.’

Ethnic difference in experience

Perceived discrimination among African-Americans

Some African-American participants had experienced negative events before they saw the clinician, including long waits in the waiting or exam room. While some patients did not know whether the long waits were based on their ethnic background or not; these ambiguous events negatively influenced their health care experience prior to see- ing the clinician. African-American patients also spoke about the personable welcomes they sometimes observed European American patients receiving from non-medical staff compared to the cold, business-like greetings they themselves received and indicated that this negatively affected their mood. One woman shared her experience about the unequal treatment she received from non-medical staff.

Well, um, my primary care doctor, doctor of internal medicine, is very helpful towards me, and she goes out of her way to help me, but I notice … when I’m in the receptionists’ area, the receptionists seem more willing to chit-chat with the white clients that come through than they are with me. They’ll have them standing there talking to them and laugh- ing and joking, and when I step up and make a comment, you know, it’s all business. I feel (laughs), I feel like they’re prejudiced.

In the clinician’s office, African-Americans often perceived unfair treatment from their clinicians. Many African-Americans felt that clinicians did not provide them with pain medication because clinicians perceived them as drug users. For example, this African- American woman shared her experience dealing with pain and how she felt she did not receive medication because clinicians see African-Americans as drug addicts.

When I flare all up, I take something, you know, so I like to have something just because my pain goes from my toes all the way up to my neck and shoulders sometimes. I can hardly function, and I need something, and that’s why I’ve been saying, give me something or tell me something I can do. I need help and that’s my biggest gripe. I think it’s because I’m a Black woman I don’t get no medication or no kind of other kind of treatment because we got a reputation of being drug addicts and stuff.

Discrimination based on health insurance coverage

African-Americans perceived discrimination within the health care system based on the insurance they had or lacked. They felt they would receive better treatment if they had better insurance coverage. For example, this patient mentioned that he felt that the health care staff treats patients better if they have insurance. He believed that hospitals are businesses that give preferential treatment to those with insurance.

And this is a good example of how when, you know, even though, in the medical, in the medical field, it still, the overarching … the denominator is dollars and cents. If you have insurance, they will treat you … they will roll out the red carpet. If you don’t, I mean, it’s challenging. And so [they] rush me out the hospital … Unfortunately, the hospital is a

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Ethnic difference in experience

Perceived discrimination among African-Americans

Discrimination based on health insurance coverage

business, I mean, it’s a business, and at the end of the day, they sitting down seeing … Well, that’s our life.

Similar to African-Americans, European Americans felt their lack or availability of insurance played a role in the health care service they received. For example, this patient described her experience of being refused service because of her lack of health care insurance.

I lived in another city and I had some very serious heart problems, so they sent me to Port- land and I was admitted to this hospital and they started running all these tests … I went in to the doctor to make the arrangements and he said, ‘I’m going to have to send you home.’ My husband says ‘You’re going to send her home, why?’ And this doctor says, ‘Because you have no insurance.’ And my husband says ‘Are you sending her home to die?’ and he says ‘Yes, basically that’s what I’m doing,’ and I got up and walked out the door. They called me back, they told my husband that 3 more minutes and I would have been dead. And I had a 2-way bypass, but I was refused at one of the hospitals in Portland because of no insurance.

Discussion

We explored the degree to which disparities in the quality of clinician–patient relation- ships arise from ethnic minority patients being treated differently than European Ameri- can patients when those minority patients would prefer to be treated the same as European American patients, vs. the ethnic minority patients being treated the same as European American patients when preferring to be treated differently. Although we found evidence for both, our findings suggest that in general, patients have similar pref- erences but receive unequal treatment. There were substantially more commonalities than differences in patients’ preferences for care and in how they described good and bad experiences. Patients of all groups described preferences reflecting the concepts of patient-centred care (Epstein & Street, 2011), in that patients wanted a personable provi- der who listened to their comments and was attentive and sensitive to their needs. Patients also expressed their desire to be more involved in their own care.

While preferences for care were mostly similar across groups, experiences differed in ways that patients, particularly African-American patients, perceived as discrimina- tory. Long waits in the waiting room or exam room made many wonder whether the delay was a response to their racial or ethnic background, negatively influencing their health care experience prior to seeing the clinician. During the wait, many felt that the non-medical staff treated them differently than European American patients. They per- ceived the interaction between office staff and European American patients as warm and welcoming, and their own interaction with office staff as cold and business-like. African-Americans also often perceived unfair treatment from the clinicians themselves. Many African-Americans felt that clinicians did not provide them with pain medication because clinicians perceived them as drug users.

There were some differences in preferences within and across ethnic groups. Some African-American patients felt clinicians should take patients’ race/ethnicity into account when discussing their health. They felt that clinicians may be able to deliver better care if the patients’ race were acknowledged. Some Latinas/Latinos preferred ethnic- or language-concordant providers. They believed that these providers were more

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Discussion

proficient communicators who helped them understand the treatment regimen and allowed them to share their perspectives about their own health. Lastly, some Latinas/ Latinos who used alternative medicines (e.g. herbs and roots) wanted providers to be more knowledgeable of alternative medicine and discuss how it may or may not com- plement their current treatment regimen. It is not surprising that Latina/Latino patients preferred ethnic- or language-concordant providers. The extant literature shows that Latinas/Latinos report health care problems pertaining to cultural issues, language, and lack of culturally-matched health care providers (González, Vega, & Tarraf, 2010; Timmins, 2002). However, we were surprised that many African-American patients were indifferent on the question of race-concordant physicians. Upon further reflection we believe that African-American patients may not view the clinician’s race as impor- tant as other dimensions of the clinician’s characteristics, such as communication style (Dale, Polivka, Chaudry, & Simmonds, 2010). Sacks (2013) also did not find a uniform preference for race concordant providers among African-American female patients. She found that the environmental constraints in health care (e.g. wait times, quality of inter- personal interactions) were more important for the patients than having a race concor- dant clinician. Based on our findings as well, most African-Americans did not believe that having race concordant clinicians would in itself assure the delivery of quality health care. In contrast, Latinas/Latinos in our study felt that having culturally-matched providers would assure good quality of care. Because this was a salient issue for them, the need felt by Latinas/Latinos for an ethnically concordant clinician may have kept Latinas/Latinos from mentioning other barriers that also affect their health care experi- ences. In sum, our findings indicate that racial or ethnic concordance is not always identified by patients themselves as important; even so, improving access to culturally- sensitive health care may help address many concerns of minority patients.

Using focus groups, Tucker et al. (2003) found that African-Am

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