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Relationship of multicultural interactions to healthcare providers' cultural sensitivity and cultural competence

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Relationship of multicultural interactions to healthcare providers' cultural sensitivity and cultural competence
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Hackshaw, Rhonda L
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Ethnicity ( jstor )
Health care industry ( jstor )
Medical personnel ( jstor )
Minority groups ( jstor )
Multiculturalism ( jstor )
Professional competence ( jstor )
Self reports ( jstor )
Social interaction ( jstor )
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Thesis (Ph. D.)--University of Florida, 2005.
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Includes bibliographical references.
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Vita.
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by Rhonda L. Hackshaw.

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RELATIONSHIP OF MULTICULTURAL INTERACTIONS TO HEALTHCARE
PROVIDERS' CULTURAL SENSITIVITY AND CULTURAL COMPETENCE








By

RHONDA L. HACKSHAW


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE
UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2005












ACKNOWLEDGEMENTS

First and foremost, I would like to thank my parents, Brian and Fleurette

Hackshaw, for their unwavering, staunch and loving support throughout this long

journey. I could not have accomplished this without them. I likely would not have

pushed myself so hard if I had not been trying to keep up with my "big brothers,"

Patrick and Simon Hackshaw. I thank them for the motivation. My sister in spirit if

not in blood, Jennifer Hackshaw, exemplifies grace and courage to me. She is

the wife and mother I hope one day to be. My nieces, Zoe Rune and Kalina

Colibri, give me hope for the future. There were days when only thoughts of their

smiles and laughter bore me past the obstacles I encountered. I carried their

pictures everywhere to remind me of the joy life has to offer.

Jim Carter is my daily sunshine and my strength. I would still be

foundering around in the dreary dissertation quagmire without him. He sustained

and inspired me to keep walking one foot in front of the other towards the

wonderful opportunities that lie ahead. He believed in me unceasingly and helped

me to believe in myself. I am grateful for and humbled by his sweet love and

support. Katey Sellers and Sara Theiss taught me the true meaning of friendship

and to trust that we will be there for each other in the best and worst of times.

Most importantly, they taught me that distance means nothing if we carry each

other in our hearts. Leslie Ziegenhorn, my twin, and Sam Park, my hero, were

the best of cheering sections. Their mentorship and faith in me held me in good






stead and gave me the backbone I needed during some very difficult times. I am

honored to keep professional company with them and doubly privileged to call

them my friends. Sagey and Solly shed fur and sat upon every page of every

draft, and I have delighted in every minute of our long life spent together in

adoration of each other.

Dr. Carloyn Tucker was my mentor and guide throughout this process.

She helped me to find strength I never knew I had and to reach constantly for

excellence. I am a better person because of all that I have learned from her over

the years. I am very grateful to Dr. Greg Neimeyer, Dr. Robert Ziller, Dr. Heather

Hausenblas, Dr. Pete Giacobbi, and Dr. Ken Rice for everything they have

contributed to making this experience a success and for being such gracious

peers. I would like to thank the Behavioral Medicine Team at the University of

Florida for their hard work and incredible dedication to the cultural sensitivity

research and to the patients and healthcare providers who were the inspiration

for this project.













TABLE OF CONTENTS

page


ACKNOW LEDGEM ENTS .............................................................................................. i

LIST OF TABLES ........................................................................................................ v

ABSTRACT .............................................................. ................................................ vi

CHAPTER

1 INTRODUCTION .................................................................................................

Statement of the Problem........................................................................................ 1
Purpose of the Study.............................................................................................. 5
Hypotheses............................................................................................................. 6

2 REVIEW OF THE LITERATURE ................................................ ..................... 9

Contemporary Issues in Healthcare.................................................................. 9
Culture, M ulticulturalism and Healthcare .................................................. .......... 11
M multicultural Counseling and Therapy Theory ..................................... ........... 16
Culture, Illness and Healthcare Provision M odels ................................... ........... 21
Need for Culturally Sensitive Healthcare ............................................ .......... .... 24
M ulticulturalism and Research Design........................... ................................ 30
Researching Cultural Sensitivity .......................................................................... 37

3 M ETHODOLOGY .................................................................................................... 44

Participants .......................................................................................................... 44
Instruments ................................................................................................................ 44
Procedure ............................................................................................................. 50

4 RESULTS .................................................................................................................. 53

Descriptive Data for the M ajor Variables of Interest ............................................. 53
Preliminary Data Analysis.................................................... ............................. 54
Hypotheses.............................................................................. ................................ 60
Hypothesis One ............................................................................................. 60
Hypothesis Two ............................................................................................ 67



iii







Hypothesis Three ............................................ .............................................. 70
H hypothesis Four.................................................................. .. ................. ....... 75
Post H oc A analyses ..................................................................................................... 78

5 D ISC U SSIO N ............................................................................................................ 83

Summary and Interpretation of the Results ...................................................... 84
Multicultural Interactions and Cultural Sensitivity.................................... .. 88
Multicultural Interactions and Cultural Competence ......................................... 93
Overall Trends Among Study Findings...................................... .................. 98
Theoretical and Practical Implications ...................................................................... 99
Lim itations........................................... .................................. .... ........................... 102
Future Research .......................................... ................ 105
C conclusion ................. ........................................................................... ............. 106

APPENDIX

A HEALTHCARE PROFESSIONAL DEMOGRAPHIC DATA QUESTIONNAIRE
......... .............. .... ................ .............. ..... ........ ..............................108

B TUCKER-CULTURALLY SENSITIVE HEALTHCARE INVENTORY FOR
PHY SICIAN S ..................................... ................................................ ............ 112

C TUCKER-CULTURALLY SENSITIVE HEALTHCARE INVENTORY FOR
HEALTHCARE PROVIDERS .................................... .............. 118

D CULTURAL COMPETENCE SELF-ASSESSMENT QUESTIONNAIRE -
SERVICE PROVIDER VERSION ...................................................................... 124

E MARLOWE-CROWNE SOCIAL DESIRABILITY SCALE SHORT FORM...... 142

F HEALTHCARE PROFESSIONAL INVITATION COVER LETTER................ 144

BIOGRAPHICAL SKETCH .................................................................................. 153












LIST OF TABLES

3.1. Characteristics of Study Participants................................................. .............. 45

4.1. Descriptive Statistics for Major Variables of Interest.............................................. 54

4.2 Correlation Matrix showing Intercorrelations among Major Variables of Interest.... 56

4.3. Prediction of Cultural Sensitivity by Multicultural Professional and Social
Interactions with People of an Ethnic Minority Group ........................................... 62

4.4. Prediction of Cultural Sensitivity by Multicultural Professional and Social
Interactions with People of an Ethnic Group Different from that of the Participant. 64

4.5.Prediction of Cultural Sensitivity by Multicultural Social Interactions.................. 68

4.6. Prediction of Cultural Competence by Multicultural Professional and Social
Interactions with People of an Ethnic Minority Group ........................................... 71

4.7. Prediction of Cultural Competence by Multicultural Professional and Social
Interactions with People of an Ethnic Group Different from that of the Participant. 73

4.8. Prediction of Cultural Competence by Multicultural Professional Interactions........ 77

4.9. Multivariate and Univariate Analyses of Variance Examining Influence of
Participants' Gender and Ethnicity on Major Variables of Interest ...................... 80












Abstract of Dissertation Presented to the Graduate School of the University of
Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of
Philosophy

RELATIONSHIP OF MULTICULTURAL INTERACTIONS TO HEALTHCARE
PROVIDERS' CULTURAL SENSITIVITY AND CULTURAL COMPETENCE


By

Rhonda L. Hackshaw

August 2005

Chair: Carolyn M. Tucker
Major Department: Psychology

This study was conducted to examine the relationship between healthcare

providers' self-reported experience in multicultural interactions, and these

providers' self-reported levels of cultural sensitivity and cultural competence.

Study participants were 22 physicians and 10 other healthcare providers (19

females, 13 males; 75% Caucasian, 25% Non-Caucasian) recruited from two

primary care clinics in Florida. The instruments constituting each assessment

battery obtained data on or measured the following: demographic variables,

multicultural interactions (social and professional), and self-reported cultural

sensitivity and cultural competence in healthcare provision.

Study data were analyzed using multiple regression models. Contrary to

what was hypothesized, the analyses revealed that multicultural professional

interactions, when measured as providing healthcare to patients of an ethnic






minority group, were a significant positive predictor of provider self-reported

cultural sensitivity. As expected, the analyses also revealed that multicultural

professional interactions, when measured as providing healthcare to patients of

an ethnic group different from that of the provider, were not a significant positive

predictor of provider self-reported cultural sensitivity. Contrary to what was

hypothesized, multicultural social interactions were not a significant predictor of

self-reported cultural sensitivity, regardless of whether interactions were

measured as social experience with people of an ethnic minority group or as

social experience with people of an ethnic group different from that of the

participant.

As hypothesized, multicultural professional interactions were a significant

positive predictor of self-reported cultural competence, both when interactions

were measured as providing healthcare to patients of an ethnic group different

from that of the provider and when measured as healthcare provision to patients

of an ethnic minority group. Also, as expected, multicultural social interactions

were not a significant predictor of self-reported cultural competence, regardless

of how they were measured.

The study findings suggest that healthcare organizations would benefit

from focusing the content of future training on facilitating an increase in

healthcare providers' professional interactions with patients from ethnic minority

groups and with patients from ethnic groups different from that of the individual

provider in order to increase providers' cultural sensitivity and cultural

competence in healthcare provision.












CHAPTER 1
INTRODUCTION

Statement of the Problem

Upon graduation, many medical students take a modern version of the

oath coined by Hippocrates, the father of medicine, swearing to fulfill to the best

of their ability and judgment principles held sacred by most doctors today. While

these ideals include providing the best quality of care possible, preserving patient

confidentiality, and emphasizing prevention as well as cure, there is one line that

reads: "I will remember that there is art to medicine as well as science, and that

warmth, sympathy, and understanding may outweigh the surgeon's knife or the

chemist's drug" (NOVA online, 2001). Even as these principles are perpetuated

in modern medicine, there is recognition in the oath's ancient origins of the

essential interpersonal connection between provider and patient.

The quality of the relationship between the healthcare provider and the

patient is critical for several reasons. When receiving services, a positive

perception of this relationship leads to increased satisfaction for the patient

(Safran et al., 1998) and, likely greater practical and personal satisfaction for the

provider in the delivery of these services. Improved patient satisfaction is then

strongly associated with enhanced treatment compliance and better treatment

outcomes (DiPalo, 1997; Safran et al., 1998). For example, a patient who trusts

the recommendations of the healthcare provider will be far more likely to follow







the proposed medical regimen, resulting in superior health outcomes.

Accordingly, both clinicians and researchers have expressed considerable

interest in better understanding and improving relationships between providers

and patients.

One aspect of this patient-healthcare provider relationship that has gained

recent increased attention is the interplay of cultural components within the

interaction. This is due in part to the rapid rate of ethnic diversification in the U.S.

(U.S. Census Bureau, 1998) and the undeniable fact that healthcare providers

will continue to experience escalating diversity in the populations they serve. In

addition, the sharpened focus on culture has come about due to the documented

nationwide racial and ethnic disparities in access to care, quality of healthcare,

and health outcomes (Beal, 2003); patients from minority populations report

prejudice in the healthcare process, experience a decreased quality of care, and

do not enjoy as many positive health outcomes as do patients from the majority

population (Beal, 2003; Stewart et. al, 1999). As a result, the Department of

Health and Human Services, medical schools, minority health advocates, and

many others have issued urgent calls for health care that takes into account

multicultural issues (Huff & Kline, 1999).

Multicultural Counseling and Therapy (MCT) theory (Sue, Ivey, &

Pedersen, 1996) has addressed the influence of cultural values on the

relationship between healthcare providers and patients. Specifically, the

contribution of culture to the quality of the relationship goes beyond simply

considering the culture of the patient and that of the provider; the totality and







interrelationships between each one's cultural milieu is of the utmost importance.

Also, the provider's self-awareness of her/his own cultural background is as

critical as possessing knowledge of the patient's culture. Further, regardless of

cultural differences or similarities, because there frequently exists an acute

power differential between the patient and the provider, it is arguably the

responsibility of the provider, who occupies the more authoritative role, to

steward the quality of the relationship. Finally, a multicultural approach to

healthcare requires consideration of how congruent treatment recommendations

and treatment goals are with the cultural values and life experiences of the

patient.

The importance of integrating multiculturalism in healthcare has been

further advanced by the research on the constructs of cultural competence and

cultural sensitivity (Tucker et al., 2001; Tucker et al., unpublished manuscript).

The first construct, cultural competence, involves having the knowledge, skills,

experiences, and awareness needed to provide healthcare that is respectful of

and takes into account a patient's culture. The second construct, cultural

sensitivity in healthcare, involves communicating or displaying culture-related

knowledge, skills, experiences, and awareness in ways that make patients feel

that their culture is respected and that make them feel comfortable with and

trusting of the healthcare that they receive. Each construct makes its own

essential contribution to a multicultural approach in the delivery of healthcare

services. Cultural competence offers the extensive knowledge base of the myriad

cultural specifics accumulated by experts and researchers in the field, while







cultural sensitivity reflects the manner in which the knowledge is applied during

the healthcare process. An exciting outgrowth of research on the two constructs

is the recognition that they involve knowledge and skills that can be taught and

developed over time.

Unquestionably, healthcare providers will benefit from the acquisition of

knowledge about and an appreciation for the worldviews of culturally diverse

patients. A contemporary challenge is to assist in the training of healthcare

providers to take a multicultural approach in the delivery of medical science. This

training can be adequately guided by the research on cultural competence and

cultural sensitivity, and by the implications of MCT theory. The training should

include psychoeducation about attitudes, beliefs, knowledge and skills as it

relates to professional experiences, i.e., providing healthcare to patients of

different ethnicities and cultures. Also, this training should incorporate an

understanding of how to convey these attitudes, beliefs, knowledge and skills in a

culturally sensitive fashion. According to MCT theory, "besides traditional 'book

learning,' experiential training that integrates the cognitive, affective, and

behavioral experiences must be tapped" (Sue, Ivey, & Pedersen, 1996, p. 50).

This theory proposes the crucial nature of the learning experience provided by

immersion in culturally different groups and points to the importance of social

multicultural interactions in order to develop a sensitivity to cultural issues.

However, much is still unknown about how multicultural interactions affect

the development of cultural sensitivity and growth of cultural competence among

healthcare providers. First, research is required to help define what types of




5

multicultural interactions are related to cultural sensitivity and cultural

competence. Specifically, there is a need to explore the weight of multicultural

professional experiences during service delivery versus multicultural contact

during social interactions on the development of the provider. Second, it is

unclear what makes an interaction a multicultural one. Is it sufficient to interact

with people of an ethnic minority or is it equally necessary to have exposure to

people whose ethnicity is different from one's own? Third, it is not understood

how the ethnicity of the healthcare provider influences the development of

cultural competence and cultural sensitivity. Filling these gaps in knowledge is

critical to the training of providers to become culturally competent and culturally

sensitive. Once more has been articulated about these issues in multicultural

healthcare provision, we can then indicate and advocate which variables should

receive the greatest focus to accomplish improved training and experiential

learning.

Purpose of the Study

The purpose of this present study was to investigate how self-reported

multicultural experiences and interactions are related to self-reported levels of

cultural sensitivity and cultural competence among healthcare providers. The

definition of healthcare provider included physicians, nurses, physician assistants

and other allied healthcare professionals. Specifically, the study examined two

types of multicultural interactions experienced by healthcare providers: 1) amount

of self-reported experience providing healthcare to African Americans,

Hispanic/Latino(a) Americans, and Caucasian Americans; and 2) amount of self-







reported social experience those providers have had as an adult with the same

populations. These two types of multicultural interactions, professional and

social, were measured in two ways: amount of self-reported experience with

people of an ethnic minority group and amount of self-reported experience with

people of an ethnic group different from that of the healthcare provider. Thus, in

this study, amount of experience healthcare providers reported they had had

providing healthcare and amount of experience socially as an adult providers

reported they had had were independent variables, and these providers' levels of

self-reported cultural sensitivity and cultural competence were dependent

variables.

Hypotheses

The present study tested the following four hypotheses:

1) The amount of experience healthcare providers self-report having had in

multicultural social interactions will be a significant positive predictor of providers'

self-reported cultural sensitivity, whereas the amount of experience providers

self-report having had in multicultural healthcare provision (multicultural

professional interactions) will not be a significant positive predictor of their self-

reported cultural sensitivity. The direction of this hypothesis was based upon

MCT theory's implied importance of social immersion in culturally different groups

in developing sensitivity to multicultural issues (Sue, Ivey, & Pedersen, 1996).

2) The predictive relationship between the amount of experience healthcare

providers self-report having had in multicultural social interactions and these

providers' self-reported cultural sensitivity will be stronger for multicultural social







interactions with people of an ethnic group different from that of the healthcare

provider rather than for multicultural social interactions with people of an ethnic

minority group. MCT theory suggests that there is tremendous value in social

immersion with people of cultures different from the self. Therefore, it was

proposed that providers' self-reported levels of cultural sensitivity will be higher

when multicultural social experience is defined as exposure the provider has had

socially to people who are culturally different rather than as social exposure to

people who are of an ethnic minority group.

3) The amount of experience healthcare providers self-report having had in

multicultural healthcare provision (multicultural professional interactions) will be a

significant positive predictor of providers' self-reported cultural sensitivity,

whereas the amount of experience providers self-report having had in

multicultural social interactions will not be a significant positive predictor of their

self-reported cultural sensitivity. The direction of this hypothesis was based upon

the research on cultural competence, which indicates that it is composed of

attitudes, knowledge, skills, and behaviors. The more experience providers have

had ostensibly demonstrating these aspects in the delivery of multicultural

healthcare, the higher their perceptions of self-reported cultural competence are

likely to be.

4) The predictive relationship between the amount of experience healthcare

providers have had in multicultural healthcare provision (multicultural

professional interactions) and the providers' self-reported cultural competence

will be stronger for multicultural professional interactions with patients of an




8


ethnic minority group rather than for multicultural professional interactions with

patients of an ethnicity different from that of the healthcare provider. Since

cultural competence represents having a knowledge base specific to various

ethnicities, it is likely that the more experience providers have had providing

healthcare to people of ethnic minority groups, the larger the body of culturally

competent knowledge they will perceive themselves as possessing.












CHAPTER 2
REVIEW OF THE LITERATURE

Contemporary Issues in Healthcare

At no other time has the issue of racial disparities in clinical care and

health outcomes been more at the forefront of public health concerns; the

elimination of such disparities is a priority in the Healthy People 2010 goals

developed by the Institute of Medicine (1999) as part of the recommended

national public health policy. In 2002, The Commonwealth Fund published

findings from the national Health Care Quality Survey, which documented racial

and ethnic disparities in access to care, quality of healthcare, and experienced

health outcomes. Specifically, access to healthcare is severely limited for

patients who lack health insurance and Hispanic and African American adults are

those who most frequently are without insurance. Members of minority

populations are the least likely to be under the care of a regular doctor, have

fewer options in terms of where they can go to receive care, and are those most

likely to utilize emergency departments as their primary healthcare provision site.

Differences in healthcare quality can also be seen among various minority

groups. "Healthcare quality is often measured by receipt of preventive care

services and management of chronic disease" ( Beal, 2003, p. 4). Certain

preventive services (e.g., physical exams, cholesterol and blood pressure

checks, tests that screen for cancer) have been reported to be more often







received by Caucasian and African American men and women than by Hispanic

and Asian American men and women (Beal, 2003).

Other recent studies have documented the existence of racial and ethnic

disparities when measuring healthcare quality for patients with diabetes, heart

disease, and mental illness, and in the screening of women for breast cancer; on

every aspect of quality of care assessed, African American patients were rated

more poorly than Caucasian patients (Schnieder, Zaslavsky, & Epstein, 2002).

These disparities are exacerbated when the patient's native language is

considered. Support for this assertion is the following finding of Beal (2003):

Sixteen percent of white patients report a communication problem with their

providers while 23 percent of African American patients and 33 percent of

Hispanic patients have difficulties with communication. However, for those

patients who spoke Spanish at home, 43 percent reported issues of

communication with their healthcare providers. For minority patients, these and

other experiences lead to less confidence in the healthcare system.

Patient dissatisfaction, often associated with low healthcare quality, can

be extremely impactful on the patient/provider relationship. In a recent study, 15

percent of African Americans and 13 percent of Hispanics endorsed the belief

they would have received better care if they had been of a different race or

ethnicity, while only 1 percent of Caucasians reported a similar belief (Beal,

2003). Minority patients are significantly more likely to report that they have been

treated disrespectfully during the healthcare process; thus, they may be less

likely to return or follow through with necessary healthcare (Beal, 2003). Beal







(2003) reported finding that 16 percent of African American patients and 18

percent of Hispanic patients believed they had been treated disrespectfully

during a recent healthcare visit. Beal (2003) concluded that minority patients are

less confident than majority patients that they will be the recipients of quality

healthcare in the future.

It stands to reason, however, that if patient dissatisfaction and lack of

confidence can and does negatively affect the patient/provider relationship,

follow-up care and health outcomes, interventions that cultivate patient

satisfaction and trust in providers, will likely positively impact the healthcare

process, particularly for minority patients. Research to develop such interventions

seems especially needed given census data indicating that 29 percent of the

population is composed of minority individuals and that by the year 2050, nearly

half the population of the U.S. will be people of color (U.S. Census Bureau,

1998).

Culture, Multiculturalism and Healthcare

The term "culture" has had myriad definitions over the years and remains

today without a universally accepted denotation. Kagawa-Singer and Chung

(1994) depict culture as "a tool that defines reality for its members" (p. 198); in

other words, a person's life purpose unfolds through an emergent process as he

or she is socialized by and within the culture, and learns the accepted beliefs,

values, and behaviors common to that society. Accordingly, culture serves both

functional and integrative purposes; it allows for the transmission of beliefs and

values that determine the rules of behavior members of a culture must follow to







ensure the society's survival and contributes to a sense of identity for the

individual (Huff & Kline, 1999).

However, it is important to remember that cultural parameters are

essentially only possibilities for an individual's actions; every person can and

does choose from, deselect, and/or modify a given society's values, beliefs, and

behaviors. For example, one must consider the impact of acculturation, or the

degree to which a person deselects the traits of her or his original culture and

adopts those of the dominant culture in which she or he resides (Huff & Kline,

1999). Additionally, assimilation, or the integration of the social, economic, and

political specifics of a intact culture into the mainstream society where it is

situated (Huff & Kline, 1999), often mediates in what might otherwise become the

direct adoption of the original group's values, beliefs, and behaviors.

The understanding of culture becomes even more complex when the

concepts of race and ethnicity are examined. Although the terms are frequently

used interchangeably, they have very discrete and distinct meanings. Race is

ostensibly a biological descriptive that classifies members of an ethnic group

according to physical characteristics such as the color of a person's skin, and the

shape of the eyes, nose and mouth (Montague, 1964). In actual fact though,

race is much more a sociocultural derivative whereby genetics are ignored, and

racial stratifications are made to promote agendas of power and control (Nelson

& Jurmain, 1988). On the other hand, ethnicity deals more with the "sense of

identity an individual has based on common ancestry and national, religious,

tribal, linguistic, or cultural origins" (Huff & Kline, 1999, p. 8). A claim of shared







ethnicity often indicates shared values, lifestyles, beliefs, and norms. Yet,

similarly to race, ethnicity classifications are also used for the purposes of

stereotyping people's differences and frequently to justify ignoble actions.

Two other important aspects of culture are the notions of diversity and

multiculturalism that are receiving unprecedented attention in today's scientific

inquiry on a wide variety of topics (Robinson & Howard-Hamilton, 2000).

Specifically, diversity is the condition of a multitude of differential variables (e.g.,

gender, race, ethnicity, culture, sexual orientation, age, able-bodiedness,

nationality, etc.) existing within a single social, political, and environmental space.

However, one does not have to look far to see that these variables have been

ascribed values by societal construction and are not weighted as equally

favorable. In the United States, dominant social discourses center around

majority race (White/Caucasian American), traditional male sex roles, able-

bodiedness, youth, middle to upper class status, higher socioeconomic status,

heterosexuality, etc. (Robinson & Howard-Hamilton, 2000). The end product of

these privileged discourses is to relay the hierarchical structure of social value

where the "other" is marginalized; ultimately, systems of racism, sexism, able-

bodiedism, ageism, classism, and homophobia are effected on individual and

organizational levels (Robinson & Howard-Hamilton, 2000).

As a result, institutions such as the health care system are predicated

upon patriarchal and other value-laden beliefs (Brown, 1994, 2000). Through the

lens of a systems approach, the presence of these value-laden beliefs at a macro

level can be seen at the following micro level indices, which vary according to







gender, ethnicity and income level: rates of adherence to medical regimens, who

makes use of the health care system and at what rates, differential treatment and

outcomes, levels of patient satisfaction, and the prevalence of certain types of

diseases (Lewis, 2002; Ratcliff, 2002). Rather than giving mere lip service to

diversity, Robinson and Howard-Hamilton (2000) advocate a privileging of

multiculturalism in which the various inter- and intra-levels of diversity peacefully

coexist in egalitarian relationships, and are given equal attention and value in

terms of social discourse.

Ethnocentrism is the erroneous assumption a person makes that her or

his system of beliefs, values, and behaviors is both correct and preferred

(Ferguson, 1991), and it pervades all levels of intrapersonal and interpersonal

relationships. On an organizational level, within the healthcare system, this can

lead to interactions in which the healthcare provider "may directly or indirectly

discount or ignore the client's cultural orientation and belief system, considering

them unimportant, incorrect, or in conflict with the practitioner's own perceptions

or worldview of how best to treat the client's health problem or issue" (Huff &

Kline, 1999, p. 7). In addition, the provision of healthcare takes place within a

dyad; that is, most clinical encounters involve an interaction between two or more

cultures, the culture of the patient and the culture of Western medicine and/or

some other culture in which the provider is indoctrinated (Pachter, 1994). The

Western medical model is only one of several possible explanatory models of

illness and health. Finally, the healthcare provider is the product of her or his

own cultural blend of ethnicity, assimilation, and/or acculturation, and brings







these values, beliefs, and behaviors to her or his health care provision role. If we

were to integrate multiculturalism in healthcare provision, the cultures of all

participants would be sensitively attended to as would the interaction of various

cultural specifics. The outcome would be a more informed, collaborative and

likely satisfactory encounter for both the patient and the healthcare professional.

With regard to health and illness, the worldview of many healthcare

providers is informed by the medical model and prevailing culture of North

American medical schools and practice. This worldview often assumes a position

of its own centrality, if not exclusivity, in the worldview of the patient. However,

the worldview of the provider may function on the periphery of the patient's

conceptual framework of health and illness. It may even be usurped by the

patient's worldview as it is informed by family dynamics and multigenerational

cultural heritage. There is a tendency to color the cultural precepts of the etiology

and maintenance of health and of the predicating factors of illness as folksy or

even false (i.e., "old wives' tales"). There may even be polemic opposition of

diverse cultural beliefs about health and illness and the tenets of Western

medicine, where the latter is seen as hard science and the former is seen as

culturally quaint. This can subtly or dramatically affect patients' experience within

the healthcare system, recovery from illness, and maintenance of health.

In actuality, Western medicine arose in traceable steps from its own rich

source of culture and tradition, just as did indigenous practices of healing. It can

no more be fully extracted and made distinct from its own cultural background

than can the hot toddy cure for the common cold be unlinked from the







grandmother who passed that knowledge to the mother who divested it to her

child. Systems such as these may often be self-perpetuating but they are always

the product of what came before; the practice of Western medicine is no

exception nor should it strive to be so. Practitioners and the beneficiaries of that

practice alike should simply seek to be informed about the cultural bases and

assumptions thereof in order to achieve the greatest health outcomes.

The same is true of counseling, as is highlighted by Wood and

Mallinckrodt's (1990) discussion of how the therapist's choice of an intervention

is always value laden.

In making this choice, the therapist cannot escape his or her own culture,
which includes the "culture of psychology" that has been imparted during
training. The dominant culture and the culture of psychology have deemed
certain ... behaviors to be appropriate. This valuing of... behavior may
lead therapists to adopt a 'let's fix the minority' approach that blinds them
to other possible alternatives including the alternative in which the client
rejects the values of the dominant culture. (Wood & Mallinckrodt, 1990,
p.6)

Ultimately, all healthcare providers and patients would benefit from specific

guidelines to meet the goal of facilitating better health outcomes through

culturally sensitive service provision.

Multicultural Counseling and Therapy Theory

There is ever-increasing criticism that contemporary theories of counseling

and psychotherapy are culture bound (Sue, Ivey, & Pedersen, 1996). More

specifically, many experts in the field have described these theories and related

courses as ethnocentric, monocultural, and without a conceptual framework that

establishes culture as a central concept for the therapeutic relationship (Sue,

Ivey, & Pedersen, 1996). In addition, they "fail to make clear or explicit the







cultural basis and assumptions of the various theories" (Sue, Ivey, & Pedersen,

1996, p. 3). Being culturally bound is a limiting factor that contributes to the

assertion that "current theories of counseling and psychotherapy inadequately

describe, explain, predict, and deal with the richness and complexity of a

culturally diverse population" (Sue, Ivey, & Pedersen, 1996, p. 3).

In order to incorporate the variable of cultural diversity into developing

culture-specific healthcare delivery interpersonal behaviors and approaches, the

present study is utilizing Sue, Ivey, and Pedersen's (1996) Multicultural

Counseling and Therapy (MCT) theory as its framework. According to MCT

theory, counseling with culturally different individuals in a culturally appropriate

manner necessitates culturally relevant knowledge, experiences, awareness, and

skills that are gained in a large degree through social contact with, or social

emersion in, the cultures of individuals similar to those to whom counseling is

provided. Counseling is just one form of healthcare delivery and this theory has

much to offer its sister disciplines of medicine and similar others that strive for

health, both mental and physical.

As the U.S. population continues its unprecedented rates of diversification,

the limitations of culture-bound theories will become increasingly unacceptable

and they will be less justifiable for application to members of a multicultural

society. Accordingly, the level of preparedness of mental health professionals to

successfully and ethically manage service delivery to such a population is

questionable at best (Sue, Ivey, & Pederson, 1996). Mental health professionals

have largely been responsible for developing the science on cultural diversity and







promoting multiculturalism in practice, including recommending specific

efficacious interventions and behaviors in the mental health field and in other

healthcare professions within Western medicine. Psychologists continue to have

a vital role in assisting in the process of training other healthcare providers to

take a culturally sensitive approach in the delivery of medical science. Thus, the

criticisms of current mental health practice when working with culturally diverse

clients are often applicable to the medical practice of other healthcare providers

with culturally diverse patients; too, there is much that is analogous between the

role of the mental health professional and other healthcare practitioners.

Alternatively, the implications for practice of a well-articulated theory of

multicultural counseling and therapy like Sue, Ivey and Pedersen's (1996) would

benefit both mental health and other healthcare professionals such as

physicians, registered nurses, physician assistants and those with direct patient

contact and responsibilities for care.

If, as Pedersen (1991) has noted, existing theories of counseling and

psychotherapy are not able to be easily adapted to a variety of cultures, there is

a great need for a theory of multicultural counseling and therapy to be elucidated

for people in the helping professions. Sue (1995) argued that utilizing the

perspective of multiculturalism in counseling in terms of both theory and

application is most appropriate to resolve this issue of adaptability to diverse

peoples. Over time, multiculturalism has come to be known as "the fourth force in

psychology," bearing out the importance of the development of a metatheory of

multicultural counseling and therapy (MCT) as presented by Sue, Ivey and







Pedersen (1996). These authors claim that the six propositions and related

corollaries of MCT theory are grounded in the available research on and theory

of multiculturalism.

The first proposition that underlies MCT theory is that it represents a

metatheory of counseling and psychotherapy. It is described as a theory about

theories that offers an organizational and conceptual framework for

understanding the variety of helping approaches developed by different cultures.

Every theory is therefore a representation of a different worldview, accompanied

by an inherent value within that worldview (Sue, Ivey, & Pedersen, 1996). The

second proposition states that the identities of the helping professional and her or

his client are formed and embedded within multiple layers of experiences

(individual, group, and universal) and contexts (individual, family, and cultural).

MCT theory emphasizes the vital nature of focusing on the totality and

interrelationships of these diverse experiences and contexts (Sue, Ivey, &

Pedersen, 1996). The third proposition of MCT theory is that the "development of

cultural identity is a major determinant of counselor and client attitudes toward

the self, others of the same group, others of a different group, and the dominant

group. These attitudes are strongly influenced not only by cultural variables but

also by the dynamics of a dominant-subordinate relationship among culturally

different groups" (Sue, Ivey, & Pedersen, 1996, p. 25).

The fourth proposition of MCT theory asserts that the effectiveness when

applying MCT theory is most augmented when the helping professional employs

modalities and articulates goals that are consistent with the life experiences and







cultural values of the client (Sue, Ivey, & Pedersen, 1996). This reinforces the

importance of eliciting these experiences and values in a sensitive manner from

the client and simultaneously being aware of one's own life experiences and

cultural values, and further, how they interrelate with those of the client. Only

then will the most collaborative goals be defined and the greatest chance of

bringing them to fruition be realized.

The fifth proposition of MCT theory emphasizes the influence of various

helping roles that have emerged in many culturally different groups and societies.

"Besides the one-on-one encounter aimed at remediation in the individual, these

roles often involve larger social units, systems intervention, and prevention" (Sue,

Ivey, & Pedersen, 1996). In Western medicine, this requires recognition of the

impact not only from physicians but also registered nurses, physician's

assistants, and other hospital or clinic staff. It also requires recognition by the

aforementioned medical personnel of the roles played by family, friends, and

other community members, including other types of indigenous, alternative, or

complementary healers and spiritual advisers.

The sixth and final proposition of MCT theory sets forth the goal of

liberation of one's consciousness as it relates to multiculturalism in healthcare

and other helping professions. Implicit in this is the importance of the

psychoeducational component of MCT theory where the role of counselor often

incorporates teaching the client about the relevance of cultural dimensions to the

current issues being tended to within the helping relationship (Sue, Ivey, &

Pedersen, 1996). Further, the client of the counselor is frequently a member of







the healthcare field; often the role of the counselor is to act as a consultant to

other healthcare providers and to conduct this psychoeducational component as

it relates to the healthcare provider's own role in appreciating and effectively

managing the underlying cultural dimensions in their own work with patients.

There are many implications for the practice of healthcare provision that

arise from Multicultural Counseling and Therapy theory including the need to

consider the culturally appropriateness of responses and recommendations by

the healthcare provider. Also, MCT theory calls for the empowerment of

healthcare providers to first, consider and second, to impact, the social and

environmental forces in the lives of their patients. "Multicultural specialists assert

that the first step in any effective ... training is to help would-be Healthcaree)

professionals recognize their own culture" (Sue, Ivey, & Pedersen, 1996, p. 45).

Advocates for MCT theory in the field of psychology can develop training whose

aim is to have healthcare providers "become more culturally aware of their own

values, biases, stereotypes, and assumptions about human behavior" (p.45).

Thus, they can integrate an understanding of the self-in-context during the

delivery of healthcare in multicultural interactions.

Culture, Illness and Healthcare Provision Models

The human population is comprised of myriad culturally diverse groups

whose worldviews encompass health and illness as fluid, dynamic and

continuous manifestations of the long-term and fluctuating relationships and

dysfunctions each group member maintains with her or his family, community,

and environment (Landrine & Klonoff, 1992). The health concepts and definitions







of many of these cultural groups have interwoven macrolevel, interpersonal, and

supernatural agents of illness, disease, and health causality. When a person

who is loyal to her or his culturally based explanatory model of health and illness

seeks Western medical treatment, she or he runs the risk of being labeled as a

poor historian, a difficult patient, or a mentally ill somaticizer; this transaction

goes awry because the patient cannot provide or describe her or his symptoms in

the precise, clinical terms that the Western medical healthcare provider can

readily treat (Landrine & Klonoff, 1992). Obviously this interaction will prove less

than optimal for both the provider and the patient, and frequently, for treatment

outcome and patient satisfaction. Thus, there is a need to consider the best fit of

current healthcare provision models with the implications offered by Multicultural

Counseling and Therapy (MCT) theory.

In order to begin to resolve the complex interrelationships among gender,

culture, race, societal value, and health, one must attend to epistemologies. For

the last three hundred years, the biomedical model has organized the

development and implementation of health care (Taylor, 1999). However, this

model has many liabilities: 1) it is reductionistic, breaking illness down to lowest

level processes such as chemical imbalances and cellular disorder; 2) it is a

single factor model' putting all its cause-and-effect eggs into a biological basket;

3) it deals with illness as a binary concept either present or not, neglecting health

as an included or differentiated construct; 4) it is dualistic with the mind and the

body as separate entities; 5) it cannot account for social and psychological

variants in the development and outcome of any illness (Taylor, 1999).







Accordingly, the biopsychosocial model has been proposed as an alternative

theoretical orientation for exploring and meeting the needs of culturally diverse

patients.

The biopsychosocial model, initially proposed by Engel in 1977, explains

illness in terms of the interplay between the biological (cellular disorder), the

psychological (depression, optimism), and the social (interpersonal support)

factors. Moreover, this model incorporates, indeed, centralizes, the state of

health and does not privilege only the absence of acute or chronic illness. Also,

the mind and body are viewed as interconnected and inextricable. Health is

holistic, necessitating biological treatment via surgery and medication, but also

requiring the consideration of lifestyle factors, alternative and complementary

medicine such as massage and acupuncture, and patient co-responsibility for

health status (Taylor, 1999). Historically, there has been the hegemony of expert

knowledge as the property of the healthcare provider and denial of the patient's

expertise on her or his body. To the contrary, a biopsychosocial model like that

found in the science and application of health psychology, lobbies for a co-expert

model, egalitarian patient-provider relationship, and recognition of the patient's

autonomy and power in treatment options and health care seeking behaviors

(Brown, 2000; Tang & Anderson, 1999; Taylor, 1999; Tegtmeyer, 1997).

According to the propositions of Multicultural Counseling and Therapy theory

(Sue, Ivey, & Pedersen, 1996), the biopsychosocial model of healthcare

provision most closely approximates the theory's call for an organizational and

conceptual framework for understanding the variety of helping approaches







developed by different cultures and features multiculturalism with the necessary

centrality.

Need for Culturally Sensitive Healthcare

A preponderance of literature supports that ethnic minority patients

experience a lower quality of healthcare as compared to patients from the ethnic

majority. More than 14% of African American patients report experiencing

prejudice as healthcare recipients while only 1% of Caucasian American patients

report similar discrimination (Stewart et al., 1999). This type of discrimination can

have severe repercussions in terms of medical outcomes. In an article in The

New England Journal of Medicine, the authors reported that there is race and sex

bias in physicians' recommendations to patients with heart disease for more

advanced treatment (i.e., cardiac catherization) (Schulman et al., 1999); the

practice of such discrimination puts African Americans and women at higher risk

for a decreased health status.

Differences in attributions of causality of patient complaints have also

been documented. Roter et al. (1997) found that primary care physicians focus

more on biomedical than psychosocial aspects of their patients' illnesses,

particularly when the patients were African Americans and were of a low

socioeconomic status; this minimized focus on psychosocial facets of patients'

complaints was associated with decreased patient satisfaction. Patient

satisfaction is one outcome variable where gaps between ethnic minority and

majority patients are particularly salient.







Research findings have strongly demonstrated that patient satisfaction is

positively associated with adherence to medical regimens, superior health

outcomes, and continuous participation in the healthcare process (DiPalo, 1997).

Safran et al. (1998) conducted a study with 6,094 ethnically diverse primary care

patients, including Hispanic/Latino(a) American patients and African American

patients. The authors concluded that patient satisfaction with their healthcare

was tied to healthcare providers' communication behaviors, knowledge of the

patient, continuity of care, and coordination of the healthcare services. Further,

the patient's trust in the provider and the provider's knowledge of the patient

were strong predictors of treatment adherence (Safran et al., 1998).

Another example of differences in healthcare beliefs that are specific to a

patient's ethnicity is Pedersen & Tucker's (2000) findings that among pediatric

renal transplant patients, trust and comfort with the physician and belief that God

or the Holy Spirit helps one take her/his medications were predictive of the

African American patients' self-reported medication adherence. However, only

comfort with the physician predicted Caucasian American patients' self-reported

medication adherence (Pedersen & Tucker, 2000). Leppert et al. (1996) reported

that many of the obstacles to disadvantaged Latina women receiving healthcare

were physician behaviors such as not taking these women's complaints seriously

and not spending enough time with them.

Interest in multiculturalism is at an all-time high, and science, including
proponents of both the biomedical and biopsychosocial models of health
and illness, is paying more attention to the impact that variables such as
race and ethnicity have upon patterns of illness, suitability of treatment,
and satisfactory outcome (Taylor, 1999). For healthcare providers whose
aim is to incorporate multiculturalism into their practice and to deliver







culturally sensitive care, there is a need to understand how gender and
ethnicity combine to create particular issues for minority women. Those
involved in the healthcare system are experiencing consciousness-raising
around the integral role women play in the manner in which the system is
utilized. Boeke (2000) notes that despite the difficulties experienced by
women in accessing healthcare, they are the primary healthcare
provider/seeker and related decision maker for their families.

Salganicoff's et al. (2002) research showed that 6 out of 10 women (60%)
participants were the primary decision-makers while 22% more made the
healthcare decisions for their family jointly with their partner. Female
Internet users rocketed up 35% in 2000 alone and the topics of interest
were overwhelmingly healthcare for self and family, community resources,
and childcare (Boeke, 2000). Despite this vital role women play in helping
to direct the healthcare choice of themselves, their partners, children, and
family, detrimental and differential observations can be easily made
regarding the health and illness of both non-majority and female patients.

Salganicoff et al. (2002) conducted a survey of 4000 nonelderly women in

order to examine the impact of the variables of ethnicity and financial status on

healthcare outcomes. These researchers oversampled women who were

Hispanic/Latina or African American, uninsured, of a low socioeconomic status,

and who were on Medicaid. The survey findings showed significant high

correlations among negative health outcomes, underutilization of services, levels

of patient dissatisfaction, delay of treatment, discontinuity of care, lack of

insurance, and perceptions of overall health as "fair/poor" and "limited activity."

Additionally, being a woman was significantly correlated with unfavorable

healthcare outcomes; being a non-majority woman was even more strongly

correlated with unfavorable healthcare outcomes. Finally, being a poor non-

majority women had the highest correlations with unfavorable healthcare


outcomes (Salganicoff et al., 2002).







When looking at participant subgroups by age in Salganicoff et al's (2002)

research, it is important to note that negative health outcomes, underutilization of

services, levels of patient dissatisfaction, delay of treatment, discontinuity of care,

lack of insurance, and perceptions of overall health as "fair/poor" and

characterized by "limited activity" were more frequent for older women. In this

study, women of a low socioeconomic status as compared to women of a high

socioeconomic status also reported more illness and resulting activity limitations.

Health differentials by race were also documented: Latinas reported more

fair/poor health status, and African Americans reported experiencing more

activity limitations. Women also stated that they had difficulty communicating

with their healthcare providers, which was worse when they had a fair/poor

health status or were Hispanic/Latina. Latina patients had more healthcare

barriers than patients of other ethnicities, and were the least likely to have visited

their healthcare service organizations in the last year. Latinas and African

American women were more likely to use primarily hospital clinics and health

centers for their medical care than were women in the sample who were of the

majority race. Overall, women received fewer screening tests for disease and

illnesses when compared to a similar sample of male patients, putting women

more at risk for poor health. In sum, barriers to healthcare were worse for the

women who need it most. For such women, overcoming these healthcare

barriers was more challenging for those who could not easily afford the cost of

care, who had difficulty with transportation, and/or who had to arrange for

childcare in order to utilize these services.







Research on sex-based differences in healthcare reveal that a) physicians

report preferring male patients to female patients, b) women's complaints of

illness are far more likely to be attributed to psychosomatic origins or stress, c)

women receive less follow-up care and tests than men, and d) women are

prescribed more medication than are their male counterparts (Taylor, 1999). In

addition, sex-role socialization can exacerbate this process. In a study where

physicians were presented with the identical case of a woman patient with

cardiac complaints, except for greater emotiveness and gesticulation on the part

of the patient in one of the two conditions, cardiac workups were recommended

53% of the time for the emotive patient and 93% of the time for the non-emotive

patient (Lewis, 2002). Androcentric value around marginalized sex-role feminine

traits can obviously be hazardous to a woman's health (Brown, 2000; Ratcliff,

2002).

Robinson and Howard-Hamilton (2000) discuss the concept of dual

minority for individuals who are both female and of an ethnic minority, and there

are detrimental differences to be observed in the health of, and healthcare

provision to, ethnic minority women patients. Salganicoff's et al. (2002) findings

of reduced health outcomes for non-majority women concurred with others who

found that minority status is correlated with poorer health outcomes (e.g., ethnic

minority status as compared to majority status was associated with being sicker

more often and for longer periods of time, and with higher mortality rates from

illness) (Lewis, 2002; Taylor, 1999). For example, it has been found that ethnic

minority women have higher and more fatal rates of HIV/AIDS and are diagnosed







later on in the disease process, partially due to the underutilization of health care

services by minority patients as alluded to earlier (Lewis, 2002). Research has

also revealed that physicians' coercive use of power in determining treatment

course is highest with ethnic minority women. One documented example of such

coercive power is recommending and/or pushing for hysterectomies against the

wishes of ethnic minority female patients (Ratcliff, 2002). Clearly, when an

individual is both female and of a non-majority race, her status as a dual minority

presents a risk factor that must be further examined via research and thoroughly

attended to by health care providers (Lewis, 2002).

Without a biopsychosocial model of medical training that includes a focus

on communication, interpersonal skills, and the art of the interview, the provider

will have much more difficulty soliciting patient cooperation in regimen

adherence, a less likelihood of favorable medical outcomes, and perhaps a

greater likelihood of malpractice suits (Taylor, 1999). Participants in the

healthcare system (patients, providers, and researchers) must consider the

interplay of such factors in health and illness, especially when multiple diversity

variables are relevant to an individual (e.g., an ethnic minority woman). An

egalitarian, collaborative approach will likely serve to distribute more equitably

and effectively the responsibility of a truly multicultural healthcare system among

all participants, and subsequently, improve indices of favorable healthcare

outcomes.







Multiculturalism and Research Design

Multicultural Counseling and Therapy (MCT) theory indicates that past

research on culturally diverse populations is culturally bound and "at best, leads

to an extremely narrow view of the meaning and importance of culture in the

helping process" (Sue, Ivey, & Pedersen, 1996, p. 31). In addition, it advocates

for beginning all counseling research with the premise that culture is a constant

presence in how questions about the human condition are asked and answered.

In a review of counseling research, Ponterotto and Casas (1991) concluded that

investigators continue to use culturally biased measures and seemingly do not

employ cultural sensitivity when interpreting results. These researchers also

concluded that only a fraction of studies published in counseling journals have

attended to race, ethnicity, or culture and that fewer still incorporated these

variables as independent variables. Further, Ponterotto and Casas (1991) made

recommendations for future multicultural counseling research that included

focusing on the racial, cultural, and/or ethnic issues of majority people (white) as

well as those of minority people, developing assessments appropriate to minority

populations, and balancing attention to emic (culture specific) and etic (culturally

universal) aspects of the helping process.

MCT theory has important implications for practice that are consistent with

the culture-centered approach to healthcare that is endorsed by the study being

proposed. These implications include a broadening of the perspective of the

healthcare provider's helping role, an expansion of the repertoire of culturally

appropriate helping responses available to healthcare providers, and







identification of alternative roles that empower healthcare providers to influence

the social and/or environmental forces acting on the lives of their patients (Sue,

Pedersen, & Ivey, 1996).

Another implication of MCT theory is that in order to overcome limitations

of past research and to develop a truly multicultural approach to the helping

profession, a variation in the paradigmatic approach to medical science is

warranted. Indeed, the positivistic scientific method (Heppner, Kivlighan, &

Wampold, 1999) does not easily allow for patient participation in the healthcare

process. By contrast, qualitative research designs in healthcare allow exploration

of the complexity and richness of the human experiences (e.g., patients'

experiences related to health, healthcare and illness), gleaned from the

participants' words and explicated meaning (Heppner, Kivlighan, & Wampold,

1999; Morrow & Smith, 2000). Furthermore, in qualitative research, the focus is

on a science of discovery and understanding, not of theory verification leading to

prediction and control (Borgen, 1992). Most of the research thus far on the

healthcare needs of culturally diverse patients has used a qualitative design (i.e.,

Salganicoff et al., 2002) of a type such as narrative, conversation analysis, case

study, or grounded theory.

Strauss and Corbin's (1990) grounded theory qualitative analysis is

particularly appropriate for exploration of the healthcare needs of culturally

diverse patients. This design incorporates an inductive approach where a)

investigators and participants interact with each other as the researchers

immerse themselves into the participants' world, b) participants often function as







co-researchers and analysts of data, and c) a theory emerges from the data itself

through an emphasis on discovery, thick description, and participant meaning

(Morrow & Smith, 2000; Strauss & Corbin, 1990). Data from participants

collected via such procedures as focus groups then undergo open, axial, and

selective codings to flesh out properties of categories, relationships among

categories, and overall core schemas. Results of these procedures are then put

to a constant comparison analysis against extant data as new data continue to

emerge. Once no new properties emerge from theoretical sampling from the

population of interest, the core category can be considered saturated and

presented to the audience. Rigor is determined by coherence of the data,

structural corroboration via internal category consistency and comparisons to

new data for goodness of fit, and ecological applicability as judged by the

audience (Morrow & Smith, 2000; Strauss & Corbin, 1990).

An example of this type of design is Anderson's et al. (2001) 18 focus

group study on the meaning of women's health and perceptions of need. Female

patients stratified by age and race participated in focus groups to detail their

meaning of women's health and criteria for satisfaction with health care providers

and the health care system. Overall, women wanted healthcare that was holistic

or, attending to physical, emotional, and psychological needs (consistent with the

biopsychosocial model). They wanted a treatment model that included traditional

surgery and medications plus alternative/complementary treatments, and a

premium was placed on continuity and personalization of care. They desired a

focus on family and women's issues such as nutrition, chronic illness prevention







(e.g., prevention of osteoporosis, and resolution of the fragmented healthcare

system that led to their experience of lack of coordination of care (Anderson et

al., 2001).

Important dimensions of healthcare identified by patients through the

qualitative analysis in Anderson's et al. (2001) research included a) efficient

access (i.e., clinic hours) that is tailored to women's unique roles as caregiver to

children and partners, b) privacy and comfort (i.e., remaining fully clothed while

having pre-exam discussion with the healthcare provider), c) care coordination

and cohesiveness (i.e., timely notification of test results whether positive or

negative, opportunity for consultation with the provider), and d) education on their

illness and preventative care. Women wanted a provider who acted in

partnership with them and worked as an advocate on their behalf in areas such

as insurance reimbursement. Anderson et al. (2001) concluded that healthcare

should be unique to the patient, focusing not just on her medical status but also

on her life circumstances and on exploration of barriers to treatment (e.g.,

treatment cost and availability of transportation). This was particularly important

with ethnic minority patients who might have cultural beliefs regarding home

remedies that are at odds with biomedical practice and who tend to utilize lay

referral networks within their collectivistic community. (Anderson et al., 2001).

Tucker's et al. (2003) research suggests that culturally diverse patients,

rather than healthcare providers or administrators, are the true experts at

identifying the behaviors that make patients feel comfortable and trusting, and

feel that their culture is respected in the healthcare process. Yet, inadequate







numbers of low income and minority patients have been asked to carry out this

crucial task of elucidating the facets of culturally sensitive healthcare. In a large

federally funded grant study, which the present principal investigator helped

conduct, focus groups of African American, Hispanic/Latino(a) American, and

Caucasian American primary care patients at community healthcare clinics

identified the knowledge, behaviors, attitudes, and experiences that constitute

culturally sensitive healthcare (Tucker et al., 2003). This research attempted to

define culturally sensitive healthcare from the patients' perspective rather than

from the perspective of experts as usually occurs. Twenty focus groups were

conducted separately by race and gender to explore the views of low income,

culturally diverse primary care patients as to provider behaviors and healthcare

characteristics that constitute culturally sensitive healthcare. Patient participants

were 52 adult African American patients, 45 Hispanic/Latino(a) American

patients, and 38 Caucasian American patients. Specifically, these patients were

asked to identify provider behaviors and attitudes that made them feel

comfortable with, trusting of and respected by their providers, and clinic

characteristics that made them feel comfortable and a sense of belonging at their

healthcare clinic. The focus group interviews were recorded, transcribed, and

analyzed using the constant comparative method from ground theory analysis.

Tucker et all's (2003) research produced several universal themes to the

responses of the three ethnic groups. Some of the themes indicating culturally

sensitive healthcare delivery by physicians included people skills, individualized

treatment, effective communication, and technical competence. Also, some







ethnic group-specific themes were demonstrated. African American patients

indicated the importance of trustworthiness of their physician and the physician's

acknowledgement of the patient's fear of being used as a "guinea pig."

Hispanic/Latino(a) American patients stressed the importance of sharing a

common language with their physician. Caucasian American patients

emphasized the development of a collaborative relationship with their physician.

The findings from this research suggest that healthcare provider training may

need to include a focus on learning patient-defined culture-specific healthcare

delivery interpersonal behaviors and approaches.

The characteristics of culturally sensitive healthcare as have been

identified by ethnic minority patients suggest that healthcare providers need to

have good counseling skills such as listening attentively, engaging in good eye

contact that builds trust, and respecting patients' views, values, and traditions.

The research of Tucker et al. (2003) and Tucker et al. (unpublished manuscript)

bolster the growing consensus that a) healthcare requires addressing the

physical and psychological aspects of illness, health, and well-being, and b)

related differences and similarities in these aspects that exist among ethnically

diverse patients should also be considered in the healthcare delivery process.

Accordingly, this present study utilized data from the research of Tucker et

al. (2003) research which included both qualitative and quantitative

methodologies as is recommended by the authors of MCT theory. Using this

combination of research designs, ethnically diverse patients identified the

knowledge, behaviors, attitudes, and experiences that constitute culturally







sensitive healthcare from their own perspective rather than from the perspective

of healthcare professionals. This data was used to construct ethnicity specific

Tucker-Culturally Sensitive Healthcare Inventories (T-CUSHCIs), that have been

demonstrated to have good test-retest reliabilities and internal consistencies.

These T-CUSHCIs (Tucker et al., unpublished manuscript) include versions for

patients to evaluate the cultural sensitivity of their providers and versions for

providers to self-evaluate their cultural sensitivity (the T-CUSHCI Physician

Form (PF) and the T-CUSHCI Health Care Provider (HCP) Form; see

Appendices B & C, respectively).

In the present study, healthcare providers self-reported levels of patient-

defined cultural sensitivity using an appropriate T-CUSHCI, (i.e., the T-CUSHCI -

Physicians Form or the T-CUSHCI Health Care Providers) and they self-

reported their expert-defined cultural competence using the Cultural Competence

Self-Assessment Questionnaire Service Provider Version (CCSQ-SPV),

developed by Mason (1995). By exploring and comparing these self-reports, this

research invoked what Sue, Pedersen, and Ivey (1996) term the "third presence"

of culture within the relationship between the healthcare provider and the patient,

and met the primary training goal implied by MCT theory of having those in

helping professions "become more culturally aware of their own values, biases,

stereotypes, and assumptions about human behavior" (p. 45). Inviting and

integrating the patient's perspective in the healthcare planning and delivery

processes by healthcare providers represents a collaborative approach to

providing culturally sensitive healthcare an approach that can lead to improved







healthcare satisfaction and better health outcomes among patients, especially

those who are ethnic minorities.

Researching Cultural Sensitivity

Ridley et al. (1994) conducted a critical examination of the construct of

cultural sensitivity as it is presently conceptualized in the counseling literature

and highlighted limitations of the current definition of cultural sensitivity. The

limitations include 1) definitional variance; 2) inadequate descriptors of indicators

of cultural sensitivity; 3) lack of theoretical grounding; and 4) lack of

measurements and research designs.

The limitation of definitional variance refers to the fact that cultural

sensitivity has many different, overlapping definitions; it is often interchanged

with other constructs such as cultural competence, cross-cultural expertise,

cross-cultural effectiveness, cultural responsiveness, and cultural awareness,

resulting in many unclear constructs with indeterminate meanings. Also, the

complexity with which cultural sensitivity is usually defined is compounded by the

inclusion of definitions with multiple components; this exacerbates the difficulty in

achieving agreement among the experts on a single definition of the construct.

The present research directly addressed this concern of Ridley et al. (1994)

regarding investigations of the construct of cultural sensitivity. Cultural sensitivity

is simply and specifically defined, and the issue of whether its definition is

confounded with that of cultural competence is directly addressed. Cultural

competence is defined as having the knowledge, skills, experiences, and

awareness necessary to engage in healthcare that is respectful of patients'







cultural heritage. Cultural sensitivity in healthcare has three defining

characteristics (Tucker et al., 2003). It involves 1) communicating or displaying

culture-related knowledge, skills, and awareness in ways that make people feel

that their culture is respected and that make them feel comfortable with and

trusting of the healthcare they receive; 2) embracing the view that culturally

diverse patients are the experts at identifying the behaviors/attitudes and

healthcare environment variables that are indicators of culturally sensitive

healthcare; and 3) engaging in specific provider and staff behaviors and

provider/staff-patient interactions as well as promoting physical healthcare

environments that encourage patient trust in, comfort with, and feelings of being

respected by healthcare providers and staff (Tucker et al., 2003).

The limitation of having inadequate descriptors of the indicators of cultural

sensitivity as mentioned by Ridley et al. (1994) is particularly noteworthy. These

researchers break down known indicators of cultural sensitivity into a three-

category continuum, which includes 1) prerequisites of culturally responsive

behavior such as cognitive abilities, knowledge, and awareness; 2) culturally

responsive behaviors, including expression of one's own values and setting

culturally relevant treatment goals; and 3) the effects of culturally responsive

behaviors, such as high client satisfaction. However, very few investigators have

provided specific examples of these behaviors, and there are virtually no actual

samples of cognitive indicators of cultural sensitivity. The present study utilized a

measure of patient-defined cultural sensitivity (e.g., the T-CUSHCI-HCP and the

T-CUSHCI-PF for providers to self-report their cultural sensitivity) that includes







specific behaviors, attitudes, and knowledge of providers that mostly low income

African American, Hispanic/Latino(a), and Caucasian American primary care

patients consider to be indicators of cultural sensitivity by their providers. Among

these indicators are those specific to the African Americans, Hispanic/Latino(a)

Americans or Caucasian Americans who generated these indicators (i.e., emic

indicators) and those which are common across the three ethnic groups that

generated these indicators (i.e., etic indicators).

The third limitation of the construct of cultural sensitivity identified by

Ridley et al. (1994) is a lack of theoretical grounding. According to these

researchers, the term cultural sensitivity is used to encompass a complicated

network of distinct variables that interact to produce the desired effect of

providing culturally sensitive care to culturally diverse clients. These researchers

claim that cultural sensitivity is often described by others as essential to

therapeutic success without explaining how to achieve it or why it is necessary

(Ridley et al., 1994).

The foundational research for the present study (i.e., the research of

Tucker et al., 2003) is based on Wilde's et al. (1993) theory of quality of care.

This theory asserts that there are four dimensions of healthcare that inform the

construct of culturally sensitive healthcare: 1) the medical-technical competence

of the healthcare providers; 2) the physical-technical conditions of the service

organization; 3) the identity-orientation of the providers' attitudes and behaviors;

and 4) the sociocultural ambience of the service organization (Wilde et al., 1993).







The former two dimensions are reminiscent of the traditional Western

medical model of healthcare while the latter two dimensions resemble the

psychosomatic model of healthcare wherein the value of psychological and

emotional facets of illness and health are recognized and appreciated (Glaser &

Strauss, 1967; Wilde et al., 1993). Specifically, identity-orientation refers to

"patients' desire for care with a human face in relation to the caregivers" (Wilde et

al., 1993, p. 116). An identity-oriented approach includes the provider's showing

interest in and commitment to the patient's situation, demonstrating respect and

trustworthiness, utilizing an approachable personal style characterized by

honesty, sincerity, and empathy, and working to minimize the power differential

between provider and patient through soliciting patient collaboration in the

provision of her or his healthcare. The sociocultural ambience of the service

organization refers to an environment that is reminiscent of a home rather than

an institution, "where the wishes and needs of the patients have priority over

fixed routines, ... where the patient has the opportunity for self-chosen seclusion

and/or self-chosen socializing whenever he or she wishes", and where providers

"listen and help the patient in the way that he or she wants" (Wilde et al., 1993, p.

117). The T-CUSHCIs (Physician Form and Health Care Provider Form),

measures that were used in the present study to assess providers' self-reports of

the degree to which they engage in the provision of patient-defined culturally

sensitive healthcare, relate specifically to the third aspect of Wilde's et al. quality

of care theory the identity-orientation of the providers' attitudes and behaviors.

Implicit in these inventories and in their use in this present research is the view







that patients are the experts on culturally sensitive healthcare and should be

empowered partners in promoting such care.

Finally, the assertion of Ridley et al. (1994) that measurement and

research design limitations plague the construct of cultural sensitivity is important

to note. Until the recent development of the T-CUSHCIs, there were no published

instruments that specifically measured cultural sensitivity as a distinct construct.

There are existing inventories for measuring cross-cultural competence, but in

these instruments cultural sensitivity is not patient-defined and appears

confounded with cross-cultural competence. Past research gives few details

about the specific behaviors that constitute culturally sensitive behavior. The

present study utilized the T-CUSCHIs Physician Form and Health Care

Provider Form, the first inventories for providers to self-report the degree to

which they engage in the provision of patient-defined culturally sensitive

healthcare, and a measure of cultural competence the Cultural Competence

Self-Assessment Questionnaire Service Provider Version (CCSQ-SPV) (see

Appendix D).

In summary, the present study investigated how multicultural social and

professional interactions are related to self-reported cultural sensitivity and

cultural competence among healthcare professionals. Healthcare provider

participants self-reported levels of patient-defined cultural sensitivity using the

appropriate T-CUSHCI (Tucker et al., 2003); they also self-reported their expert-

defined cultural competence using the CCSQ-SPV (Mason, 1995). Specifically,

the present study examined two types of self-reported multicultural interactions:







1) amount of self-reported experience that providers have providing healthcare to

African Americans, Hispanic/Latino(a) Americans, and Caucasian Americans;

and 2) amount of self-reported experience socially as an adult with the same

populations. These two types of multicultural interactions, professional and

social, were measured in two ways: the amount of experience healthcare

providers self-report having spent with people of an ethnic minority group and the

amount of self-reported experience providers have had with people of an ethnic

group different from that of the individual healthcare provider. Thus, in this study,

the amount of self-reported experience healthcare providers have had providing

healthcare and the amount of self-reported experience socially providers have

had as adults were independent variables, and these providers' self-reported

cultural sensitivity and cultural competence were dependent variables.

Four hypotheses were tested: 1) The amount of experience healthcare

providers' self-report having had in multicultural social interactions will be a

significant positive predictor of providers' self-reported cultural sensitivity,

whereas the amount of experience providers self-report having had in

multicultural healthcare provision (multicultural professional interactions) will not

be a significant positive predictor of their self-reported cultural sensitivity; 2) The

predictive relationship between the amount of experience healthcare providers

self-report having had in multicultural social interactions and these providers'

self-reported cultural sensitivity will be stronger for multicultural social

interactions with people of an ethnic group different from that of the healthcare

provider rather than for multicultural social interactions with people of an ethnic







minority group; 3) The amount of experience healthcare providers' self-report

having had in multicultural healthcare provision (multicultural professional

interactions) will be a significant positive predictor of providers' self-reported

cultural sensitivity, whereas the amount of experience providers self-report

having had in multicultural social interactions will not be a significant positive

predictor of their self-reported cultural sensitivity; and 4) The predictive

relationship between amount of experience healthcare providers self-report

having had in multicultural healthcare provision (multicultural professional

interactions) and the providers' self-reported cultural competence will be stronger

for multicultural professional interactions with patients of an ethnic minority group

rather than for multicultural professional interactions with patients of an ethnic

group different from that of the healthcare provider.












CHAPTER 3
METHODOLOGY

This chapter presents descriptions of the participants, assessment battery,

and procedure.

Participants

The final sample of 32 healthcare providers who participated in the study

included 22 physicians and 10 other healthcare providers (19 females, 13

males). Table 3.1 provides additional demographic description of the participant

sample. All participants were recruited from Eastside Health Center and

Gainesville Family Medical Group Practice as part of a larger study of culturally

sensitive healthcare.

Instruments

Each participant completed an Assessment Battery consisting of the

following: (1) the Healthcare Professional Demographic Data and Cultural

Experiences Questionnaire (HCP-DDQ); (2) the appropriate Tucker-Cultural

Sensitivity Healthcare Inventory (T-CUSHCI), either the Physician Form (PF) or

the Healthcare Provider Form (HCP) to assess healthcare providers' self-

evaluations of patient-defined cultural sensitivity; (3) the Cultural Competence

Self-Assessment Questionnaire Service Provider Version (CCSQ-SPV) to

assess healthcare providers' self-evaluations of non-patient or "expert"-defined

culturally competent healthcare provision; and (4) the Marlowe-Crowne Social







Table 3.1. Characteristics of Study Participants
Characteristic N %

Professional Role

Physician 22 68.8
Other Healthcare Professional 10 31.3

Gender

Female 19 59.4
Male 13 40.6

Ethnicity

African American/Black American 3 9.4
Asian American/Pacific Islander 1 3.1
Caucasian/White American 24 75.0
Latino(a)/Hispanic American 3 9.4
Other (Indian) 1 3.1
Nationality

U.S.A. 25 78.1
Non-U.S.A. 7 21.9

Native/First Language

English 28 87.5
Spanish 3 9.4
Other (Hindi) 1 3.1

Fluency in Non-English Language

None 25 78.1
Spanish 3 9.4
Other 4 12.5







Table 3.1. Continued.
Characteristic N %

Time in direct patient care 32 61.56
in the 12 months prior

M SD Min Max

Age 37.70 11.64 26.00 60.00

Years in clinical practice 9.50 11.41 .00 38.50

Professional interactions with 4.38 .71 2.00 5.00
African American patients

Professional interactions with 3.66 .94 2.00 5.00
Hispanic/Latino(a) patients

Professional interactions with 4.59 .56 3.00 5.00
Caucasian American patients

Social interactions with 3.28 1.14 1.00 5.00
African Americans

Social interactions with 3.25 .98 2.00 5.00
Hispanic/Latino(a) Americans

Social interactions with 4.47 .72 2.00 5.00
Caucasian Americans

Note. Professional and social interactions were measured on a scale from 1 to 5,
with higher ratings indicating a greater amount of experience in these self-
reported interactions.

Desirability Scale, short-form (M-CSDS-SF) to assess the degree to which

participants responded in a socially appropriate manner.

A Healthcare Professional Demographic Data and Cultural Experiences

Questionnaire (HCP-DDQ; see Appendix A) was used to ascertain information

about the participants, including age, gender, nationality, race/ethnicity, time

spent in clinical practice, time spent as an employee at her/his current healthcare







provision site, estimation of the percentage of time s/he spent in direct patient

care in the last twelve months, native/first language, the experience s/he has had

in providing healthcare to three different ethnic groups (African American,

Hispanic/Latino(a) American, and Caucasian American patients), and the

experience, as an adult, s/he has had socially with three different ethnic groups

(African Americans, Hispanic/Latino(a) Americans, and Caucasian Americans).

The Tucker-Cultural Sensitivity Healthcare Inventories (T-CUSHCIs; see

Appendices B & C) was used to assess healthcare providers' self-reports of

patient-defined cultural sensitivity. Specifically, the following two T-CUSHCIs

were used: the T-CUSHCI- Physician Form (PF) and the T-CUSHCI- Health Care

Provider Form (HCP). These instruments were developed by Tucker et al. (2001)

in a study with 134 primary care patients (52 African Americans, 38 Caucasian

Americans, and 45 Hispanic Americans). Twenty focus groups were conducted

separately by race and gender to explore these patients' experiences with

cultural sensitivity in their relationship with their primary care provider. Focus

group interviews were recorded, transcribed, and analyzed using the constant

comparative method from ground theory analysis. Responses were then grouped

into primary and secondary features, which indicated several universal features

of cultural sensitivity in healthcare as well as features specific to the three ethnic

groups. A T-CUSHCI was developed from raw data-based patient responses

taken from the focus group transcripts for each of the three ethnicities of the

focus group members, African American (AA), Caucasian American (CA), and

Hispanic American (HA): T-CUSHCI- AA, T-CUSHCI-CA, and T-CUSHCI-HA.







The next stage of instrument development encompassed a

demographically similar group of 221 of primary care patients (82 African

American, 94 Caucasian American, and 45 Hispanic American patients) who

rated the importance of each behavior and attitude that the focus group patients

had identified as important to have displayed by their physician or other

healthcare provider as indicators of culturally sensitive healthcare. The focus

group generated items were organized into five groups: 1) provider trust

behaviors, 2) provider comfort behaviors, 3) provider respect behaviors, 4) clinic

staff behaviors, and 5) clinic environment characteristics. The new group of 221

primary care patients then rated the importance of these items on a five-point

rating scale where 1 = not at all important, 3= important, and 5= extremely

important. The items rated as 3, 4, or 5 were then used to construct the final

three ethnicity/race specific inventories, T-CUSHCI- AA, T-CUSHCI-CA, and T-

CUSHCI-HA.

To construct the healthcare provider versions of the T-CUSHCls (i.e., T-

CUSHCI-Physician Form and T-CUSCHI-Health Care Provider Form), items from

the three final ethnicity/race specific inventories were combined to form the

measures for healthcare providers to self-report their patient-defined cultural

sensitivity (see Appendices B & C). Any item that was mentioned by more than

one of the three ethnicities was only included one time on the provider versions.

The content of the items and the response formats of the T-CUSCHI-Physician

Form and the T-CUSCHI-Health Care Provider Form are identical except that

they are differentiated by the use of the term "physician" versus "health care







provider" as is appropriate. Sample items from the T-CUSHCI-PF/HCP include:

1) I am honest and direct with my patients; 2) I am compassionate with my

patients; and 3) I am respectful of my patients' religious beliefs. Studies of

reliability and validity of the T-CUSHCls indicate that these measure appear to be

reliable and valid inventories for assessing the level of perceived cultural

sensitivity in healthcare received (patient forms) and healthcare provided

(provider forms). Reliability was examined in several ways. For the patient forms

of the T-CUSHCI, internal consistency ranged from .92 to .99, split-half reliability,

from .77 to .96, one-month test-retest reliability, from .92 to .99, and five-month

test-retest reliability, from .98 to .99. For the physician and healthcare provider

forms of the T-CUSCHI, internal consistency ranged from .52 to .98, split-half

reliability, from .68 to .82, and test-retest reliability, from .70 to .74.

The Cultural Competence Self-Assessment Questionnaire Service

Provider Version (CCSQ-SPV; see Appendix D) was used to assess the

healthcare providers' self-evaluations of non-patient or "expert"-defined culturally

competent healthcare provision. This reliable (alpha coefficients of .80 or higher

for the majority of subscales) and valid measure was developed by the Research

and Training Center on Family Support and Children's Mental Health (Mason,

1995). The CCSQ-SPV is an 80-item inventory that is designed to assess the

cultural competence training needs of mental health and human service

professionals, including healthcare providers (see Appendix D). It includes the

following subscales: a) healthcare providers' knowledge of communities; b)

personal involvement with ethnic minority groups; c) service delivery and







practice, and d) reaching out to communities; While the CCSQ-SPV includes

three additional subscales (resources and linkages with the healthcare providers'

service clinics to ethnic minority groups; clinic staffing; and organizational policies

and procedures), these three subscales were eliminated from the analyses as

their content was not related the direct service practice of the healthcare

providers. Sample items from the CCSQ-SPV include: 1) How well are you able

to describe the communities of color in your service are; 2) Do you know the

cultural-specific perspectives of mental health/illness as viewed by the groups of

color in your area; and 3) Do you discuss racial/cultural issues with consumers in

the treatment process.

The Marlowe-Crowne Social Desirability Scale, short-form (M-CSDS-SF;

see Appendix E) by Marlowe and Crowne (1964) was used to measure the

participants' tendency to respond to questions in a culturally appropriate manner.

The short form is a 20-item inventory designed to assess whether or not

respondents give socially desirable answers as opposed to accurate ones.

Sample items on the M-CSDS short form include: "I can remember 'playing sick'

to get out of something", and "There have been occasions when I felt like

smashing things." Higher scores on the M-CSDS-SF indicate a more socially

desirable response set. Fraboni and Cooper (1989) found a .80 to .84 test-retest

reliability for adults.

Procedure

Healthcare providers (e.g., physicians, nurses, physician assistants, and

other allied healthcare professionals) were recruited via a letter to and staff







meetings at two local participating community healthcare clinics Eastside Health

Center and Gainesville Family Medical Group Practice to be participants in the

present research (see Appendix F). The letter was signed by the administrators

of the two participating clinics (co-investigators for the project), and by the

principal investigator of the larger study of cultural sensitivity of which the present

study is a sub study. It was explained via letter and at the staff meetings that

participation in this research would involve spending approximately 60 minutes

anonymously completing a set of questionnaires (the Assessment Battery) within

one week of receiving the packet of questionnaires. Additionally, it was explained

that signing an informed consent form giving written consent to participate was

required, that the consent form was the first in the questionnaire packet to be

completed, and that the completed set of materials was to be returned via a

locked box in a secure location in each healthcare clinic. The Clinic Secretary at

each participating clinic distributed the Assessment Battery to the healthcare

providers

Further, it was explained that participation in this study is voluntary, that

participants can discontinue participation at any time, and that refusal to

participate would in no way affect their employment status. Participants were

informed that at no point would any clinic administrative personnel have access

to individual responses or individual study data. To ensure confidentiality of

responses, participants were asked to not place their names on the

questionnaires but to rather, generate a healthcare professional private

identification number, which they placed on each questionnaire. Additionally,




52

participants were asked to place the informed consent form in a separate lock-

box from all other measures, and the informed consent form was stored

separately from all other measures. Participants were also informed that they

would receive three Continuing Medical Education credits for completion of the

research questionnaires and, at a later date, for attending a 3-hour workshop on

patient-defined culturally sensitive healthcare that is part of the larger study of

which the present research is a sub-study.












CHAPTER 4
RESULTS

This chapter addresses the results of the analyses to test the study

hypotheses.

Descriptive Data for the Major Variables of Interest

Table 4.1 provides descriptive data for the major variables of interest: (a)

amount of self-reported experience in Multicultural Professional Interactions with

people of an Ethnic Minority Group (MPI-EMG), (b) amount of self-reported

experience in Multicultural Professional Interactions with people of an Ethnic

Group Different from that of the participant (MPI-EGD), (c) amount of self-

reported experience in Multicultural Social Interactions with people of an Ethnic

Minority Group (MSI-EMG), (d) amount of self-reported experience in

Multicultural Social Interactions with people of an Ethnic Group Different from

that of the participant (MSI-EGD), (e) level of self-reported Cultural Sensitivity

(CS), (f) level of self-reported Cultural Competence (CC), and (g) Social

Desirability (SD). The results show that participants reported a wide range of

scores for each of the major variables of interest, indicating the appropriateness

of parametric statistical approaches. In addition, measures of skewness were

within normal limits, suggesting that transformation of scores (e.g., log-linear)

was not necessary.







Table 4.1. Descriptive Statistics for Major Variables of Interest


Study variable M SD Min Max Skewness

MPI-EMG 8.03 1.43 4.00 10.00 .59

MPI-EGD 8.34 1.68 4.00 12.00 .07

MSI-EMG 6.53 1.72 4.00 10.00 .31

MSI-EGD 6.72 2.29 4.00 13.00 1.35

CS 3.18 .30 2.75 3.72 .40

CC 2.38 .42 1.79 3.29 .59

SD 9.71 4.87 1.00 20.00 .14


Note. MPI-EMG = Amount of self-reported experience in multicultural
professional interactions with people of an ethnic minority group; MPI-EGD =
Amount of self-reported experience in multicultural professional interactions with
people of an ethnic group different from that of the participant; MSI-EMG =
Amount of self-reported experience in multicultural social interactions with people
of an ethnic minority group; MSI-EGD = Amount of self-reported experience in
multicultural social interactions with people of an ethnic group different from that
of the participant; CS = Level of self-reported cultural sensitivity; CC = Level of
self-reported cultural competence; SD = Social desirability.

Preliminary Data Analysis

A preliminary Pearson Product Moment Correlation analysis was

conducted to examine the relationships among the major variables of interest in

the study. Results of this analysis are displayed in Table 4.2. The preliminary

correlation analysis was completed to determine if the major variables of interest

were related, whether participants' responses were influenced by social

desirability, how the major variables of interest were related, and the necessity

and appropriateness of planned subsequent analyses to test the hypotheses set


forth in the study.







The first question of interest in reviewing the results of this preliminary

correlation analysis was whether the variables level of self-reported Cultural

Sensitivity (T-CUSHI mean scores) and level of self-reported Cultural

Competence (CCSQ-SPV mean scores) were significantly correlated. The

answer to this question would determine whether these variables should be

examined separately or together in subsequent analyses. The analysis revealed

that levels of self-reported Cultural Sensitivity and Cultural Competence were not

significantly correlated, r= -.04, p = .82. Thus, these variables were considered

unrelated, indicating the appropriateness of examining these variables separately

in subsequent analyses in which levels of self-reported Cultural Sensitivity and

Cultural Competence were criterion variables.

The second question of interest when reviewing the results of the

preliminary correlation analysis was whether participants' scores were

significantly related to Social Desirability as measured by the Marlowe-Crowne

Social Desirability Scale-Short Form (M-CSDS-SF). As shown in Table 4.2,

Social Desirability was not significantly correlated with any of the major variables

of interest. Specifically, there was no significant correlation between Social

Desirability and level of self-reported Cultural Sensitivity, r= .21, p = .27, and no

significant correlation between Social Desirability and level of self-reported

Cultural Competence, r = .07, p = .71.








Table 4.2 Correlation Matrix showing Intercorrelations among Major Variables of
Interest

Study variable 1 2 3 4 5 6 7


1. MPI-EMG .75** .34 .17 .38* .50** -.10

2. MPI-EGD .49** .63** .30 .45** -.03

3. MSI-EMG .86** .04 .40* .22

4. MSI-EGD -.03 .32 .17

5. CS -.04 .21

6. CC .07

7.SD


Note. MPI-EMG = Amount of self-reported experience in multicultural
professional interactions with people of an ethnic minority group; MPI-EGD =
Amount of self-reported experience in multicultural professional interactions with
people of an ethnic group different from that of the participant; MSI-EMG =
Amount of self-reported experience in multicultural social interactions with people
of an ethnic minority group; MSI-EGD = Amount of self-reported experience in
multicultural social interactions with people of an ethnic group different from that
of the participant; CS = Level of self-reported cultural sensitivity; CC = Level of
self-reported cultural competence; SD = Social desirability.
*p < .05 (2-tailed). **p < .01 (2-tailed).

In addition, Social Desirability was found to have a nonsignificant

relationship with (a) amount of self-reported experience in Multicultural

Professional Interactions with people of an Ethnic Minority Group (MPI-EMG), r=

-.10, p = .61, (b) amount of self-reported experience in Multicultural Professional

Interactions with people of an Ethnic Group Different from that of the participant

(MPI-EGD), r= -.03, p = .86, (c) amount of self-reported experience in

Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-







EMG), r= .22, p = .25, and (d) amount of self-reported experience in Multicultural

Social Interactions with people of an Ethnic Group Different from that of the

participant (MSI-EGD), r= .17, p = .37. These findings suggest that the

participants' scores on the major variables of interest were not systematically

influenced by Social Desirability, and that additional statistical approaches to

account for this potential influence (i.e., analyses of covariance) were not

warranted in subsequent analyses addressing the study hypotheses.

The final question of interest in reviewing the results of the preliminary

correlation analysis was to examine the relationships among the major variables

of interest. As seen in Table 4.2, there were several significant relationships

among the major variables of interest. The variable level of self-reported Cultural

Sensitivity was significantly correlated with amount of self-reported experience in

Multicultural Professional Interactions with people of an Ethnic Minority Group

(MPI-EMG), r = .38, p = .03. None of the other variables were significantly

correlated with level of self-reported Cultural Sensitivity. Specifically, level of self-

reported Cultural Sensitivity was found to have a nonsignificant relationship with

(a) amount of self-reported experience in Multicultural Professional Interactions

with people of an Ethnic Group Different from that of the participant (MPI-EGD), r

= .30, p = .10, (b) amount of self-reported experience in Multicultural Social

Interactions with people of an Ethnic Minority Group (MSI-EMG), r= .04, p = .82,

and (c) amount of self-reported experience in Multicultural Social Interactions

with people of an Ethnic Group Different from that of the participant (MSI-EGD), r

= -.03, p = .86.







The variable level of self-reported Cultural Competence was found to have

a significant positive correlation with the following major variables of interest: (a)

amount of self-reported experience in Multicultural Professional Interactions with

people of an Ethnic Minority Group (MPI-EMG), r= .50, p < .01, (b) amount of

self-reported experience in Multicultural Professional Interactions with people of

an Ethnic Group Different from that of the participant (MPI-EGD), r = .45, p = .01,

and (c) amount of self-reported experience in Multicultural Social Interactions

with people of an Ethnic Minority Group (MSI-EMG), r= .40, p = .02. The variable

level of self-reported Cultural Competence was found to have a nonsignificant

relationship with amount of self-reported experience in Multicultural Social

Interactions with people of an Ethnic Group Different from that of the participant

(MSI-EGD), r = .32, p = .08. The presence of some significant correlations

among the major variables of interest justifies planned additional regression

models to test the hypotheses in the study.

Results from the preliminary correlation analysis revealed several

significant relationships among the following four major variables of interest: (a)

amount of self-reported experience in Multicultural Professional Interactions with

people of an Ethnic Minority Group (MPI-EMG), (b) amount of self-reported

experience in Multicultural Professional Interactions with people of an Ethnic

Group Different from that of the participant (MPI-EGD), (c) amount of self-

reported experience in Multicultural Social Interactions with people of an Ethnic

Minority Group (MSI-EMG), (d) amount of self-reported experience in

Multicultural Social Interactions with people of an Ethnic Group Different from







that of the participant (MSI-EGD). Amount of self-reported experience in

Multicultural Professional Interactions with people of an Ethnic Minority Group

(MPI-EMG) was significantly correlated with amount of self-reported experience

in Multicultural Professional Interactions with people of an Ethnic Group Different

from that of the participant (MPI-EGD), r = .75, p < .01. None of the other major

variables of interest were significantly correlated with amount of self-reported

experience in Multicultural Professional Interactions with people of an Ethnic

Minority Group (MPI-EMG). Specifically, amount of self-reported experience in

Multicultural Professional Interactions with people of an Ethnic Minority Group

(MPI-EMG) was found to have a nonsignificant relationship with (a) amount of

self-reported experience in Multicultural Social Interactions with people of an

Ethnic Minority Group (MSI-EMG), r = .34, p = .06, and (b) amount of self-

reported experience in Multicultural Social Interactions with people of an Ethnic

Group Different from that of the participant (MSI-EGD), r= .17, p = .35.

Additionally, it was found that amount of self-reported experience in

Multicultural Professional Interactions with people of an Ethnic Group Different

from that of the participant (MPI-EGD) was significantly correlated with (a)

amount of self-reported experience in Multicultural Social Interactions with people

of an Ethnic Minority Group (MSI-EMG, r = .49, p < .01, and (b) amount of self-

reported experience in Multicultural Social Interactions with people of an Ethnic

Group Different from that of the participant (MSI-EGD), r = .63, p < .01. Amount

of self-reported experience in Multicultural Social Interactions with people of an

Ethnic Minority Group (MSI-EMG) was significantly correlated with amount of







self-reported experience in Multicultural Social Interactions with people of an

Ethnic Group Different from that of the participant (MSI-EGD), r = .86, p < .01.

The presence of significant correlations among these four major variables of

interest indicates the need to examine collinearity in subsequent regression

models.

Hypotheses

Hypothesis One

Hypothesis One was as follows: 1) Healthcare providers' self-reports of

the amount of experience in multicultural social interactions (as measured by

sub-scores on the HCP-DDQ) will be a significant positive predictor of self-

reported Cultural Sensitivity (as measured by mean scores on the T-CUSHCI-

Physician Form or Health Care Provider Form), whereas healthcare providers'

self-reports of the amount of experience in multicultural professional interactions

(as measured by sub-scores on the HCP-DDQ) will not be a significant positive

predictor of Cultural Sensitivity. The direction of this hypothesis was based upon

Multicultural Counseling and Therapy theory's implied importance of social

immersion in culturally different groups in developing sensitivity to multicultural

issues (Sue, Ivey, & Pedersen, 1996).

Hypothesis One was tested using two forced-entry stepwise multiple

regression models. In the first model, amount of self-reported experience in

Multicultural Professional Interactions with people of an Ethnic Minority Group

(MPI-EMG) and amount of self-reported experience in Multicultural Social

Interactions with people of an Ethnic Minority Group (MSI-EMG) were the two

predictor variables. In the second model, amount of self-reported experience in







Multicultural Professional Interactions with people of an Ethnic Group Different

from that of the participant (MPI-EGD) and amount of self-reported experience in

Multicultural Social Interactions with people of an Ethnic Group Different from

that of the participant (MSI-EGD) were the two predictor variables. Healthcare

providers' self-reports of Cultural Sensitivity were the criterion variable in both

regression models. Hypothesis One was only minimally supported by the study

findings.

Table 4.3 describes the results of the first forced-entry stepwise multiple

regression analysis using MPI-EMG (i.e., amount of self-reported experience in

Multicultural Professional Interactions with people of an Ethnic Minority Group)

and MSI-EMG (i.e., amount of self-reported experience in Multicultural Social

Interactions with people of an Ethnic Minority Group) as predictor variables. The

overall model fit was significant at the first step, but not at the second step. At the

first step of forced-entry with the first predictor variable (MPI-EMG) in the model,

MPI-EMG accounted for 14.4% of the variance. This overall R2 value at this first

step was significant (F(1,30) = 5.03, p = .03). At the second step of forced-entry

with both predictor variables (MPI-EMG and MSI-EMG) in the model, the

variance accounted for was 15.2%. This overall R2 value at the second step was

not associated with a significant overall model fit (F(2,29) = 2.59, p = .09).








Table 4.3. Prediction of Cultural Sensitivity by Multicultural Professional and
Social Interactions with People of an Ethnic Minority Group


Variable R2 AR2 B SEB p sr2



Step 1 .14* .14*

MPI-EMG .08 .04 .38* .14*



Step 2 .15 .01

MPI-EMG .09 .04 .41* .15*

MSI-EMG -.02 .03 -.10 .01


Note. MPI-EMG = Amount of self-reported experience in multicultural
professional interactions with people of an ethnic minority group; MSI-EMG =
Amount of self-reported experience in multicultural social interactions with people
of an ethnic minority group.
*p < .05.

In regards to individual predictors, at the first step, MPI-EMG was a

significant positive predictor of Cultural Sensitivity (b = .08, t = 2.24, p = .03). At

the second step of forced-entry, MPI-EMG remained a significant positive

predictor of Cultural Sensitivity (b = .09, t = 2.27, p = .03). However, adding MSI-

EMG at the second step only accounted for an additional 1% of variance and

MSI-EMG was not a significant predictor of Cultural Sensitivity (b = -.02, t = -.53,

p = .60). Thus, for the predictor variables that focused on multicultural

professional and social interactions with people of an ethnic minority group, the

results did not support the first hypothesis. In fact, the results were opposite than







what was predicted in that amount of self-reported experience in multicultural

social interactions was not a significant predictor of healthcare providers' self-

reported Cultural Sensitivity, whereas amount of experience in multicultural

professional interactions was a significant positive predictor of providers' self-

reported Cultural Sensitivity.

The next set of analyses addressing the first hypothesis replicates the first set of

analyses, except that multicultural professional interactions and multicultural

social interactions examined as predictors were with people of an ethnic group

different from that of the participant instead of with people of an ethnic minority

group. Table 4.4 describes the results of the second forced-entry stepwise

multiple regression analysis using MPI-EGD (i.e., amount of self-reported

experience in Multicultural Professional Interactions with people of an Ethnic

Group Different from that of the participant) and MSI-EGD (i.e., amount of self-

report experience in Multicultural Social Interactions with people of Ethnic Group

Different from that of the participant) as predictor variables. The overall model fit

was not significant at the first or second step. At the first step of forced-entry with

the first predictor variable (MPI-EGD) in the model, MPI-EGD accounted for 9.0%

of the variance. This overall R2 value at this first step was not significant (F(1,30)

= 2.97, p = .10). At the second step of forced-entry with both predictor variables

(MPI-EGD and MSI-EGD) in the model, the variance accounted for was 17.1%.

This overall R2 value at the second step was not associated with a significant

overall model fit (F(2,29) = 3.0, p = .07).







Table 4.4. Prediction of Cultural Sensitivity by Multicultural Professional and
Social Interactions with People of an Ethnic Group Different from that of
the Participant


Variable R2 AR2 B SEB p sr2



Step 1 .09 .09

MPI-EGD .05 .03 .30 .09

Step 2 .17 .08

MPI-EGD .10 .04 .53* .17*

MSI-EGD -.05 .03 -.37 .08


Note. MPI-EGD = Amount of self-reported experience in multicultural
professional interactions with people of an ethnic group different from that of the
participant; MSI-EGD = Amount of self-reported experience in multicultural social
interactions with people of an ethnic group different from that of the participant.
*p < .05.

In regards to individual predictors, at the first step, MPI-EGD was not a

significant predictor of Cultural Sensitivity (b = .05, t = 1.72, p = .10). However, at

the second step of forced-entry, MPI-EGD was a significant positive predictor of

Cultural Sensitivity (b = .10, t = 2.44, p = .02). Adding MSI-EGD at the second

step accounted for an additional 8.1% of the variance and MSI-EGD was not a

significant predictor of Cultural Sensitivity (b = -.05, t = -1.69, p = .10). Thus, for

the predictor variables that focused on multicultural professional and social

interactions with people of an ethnic group different from that of the participant,

the results only partially supported the first hypothesis. As predicted, amount of

self-reported experience in multicultural professional interactions was not a







significant predictor of Cultural Sensitivity. However, contrary to what was

predicted, amount of self-reported experience in multicultural social interactions

was not a significant predictor of healthcare providers' self-reported Cultural

Sensitivity.

The change in significance from the first to the second step for the

individual predictor (MPI-EGD) may be due to the presence of significant

multicolinearity (tolerance = .60) and the noted problems associated with

multicolinearity and the stability of the regression coefficients (Stevens, 2002).

The substantial intercorrelation of the two predictor variables of MPI-EGD and

MSI-EGD (r = .63, p < .01) as well as the fairly low measure of tolerance (.60)

may explain the change in significance for MPI-EGD when the second predictor

variable of MSI-EGD was added to the regression model. Another potential

explanation for this change in significance for MPI-EGD may be that this is the

result of a possible suppressor effect caused by adding the second predictor

variable (MSI-EGD) to the model at the second step of forced-entry. Cohen et al.

(2003) documented

the counterintuitive occurrence of a variable that has a zero, or close to
zero, correlation with the criterion leads to improvement in prediction when
it is included in a multiple regression analysis. This takes place when the
variable in question is correlated with one or more of the predictor
variables ... the inclusion in the equation of a seemingly useless variable,
so far as prediction of the criterion is concerned, suppresses, or controls
for, irrelevant variance, that is, variance that it shares with the predictors
and not with the criterion, thereby ridding the analysis of irrelevant
variation, or noise- hence the name suppressor variable. (Cohen et al.,
2003, p.186).

In examining the zero-order correlation of the predictor variables of MPI-

EGD and MSI-EGD and the criterion variable of Cultural Sensitivity, there was a







positive and significant correlation between MPI-EGD and Cultural Sensitivity (r=

.30, p = .05), and a negative and nonsignificant correlation between MSI-EGD

and Cultural Sensitivity (r = -.03, p = .43). Therefore, it is possible that the

addition of the second predictor variable (MSI-EGD) to the model suppresses, or

controls for, the variance it shares with the first predictor variable (MPI-EGD).

Support for this interpretation can be observed in that the semipartial correlation

for the first predictor variable (MPI-EGD) is larger than its corresponding zero-

order correlation (sr = .41, zero-order correlation = .30), once the second,

potentially suppressing predictor variable (MSI-EGD) has been added to the

model, as noted by Horst (1941).

Therefore, the analyses revealed that Hypothesis One was only minimally

supported by the study findings. Contrary to the hypothesis, healthcare providers'

self-reports of the amount of experience in multicultural social interactions were

not found to be a significant positive predictor of self-reported Cultural Sensitivity.

Also contrary to the hypothesis, healthcare providers' self-reports of the amount

of experience in Multicultural Professional Interactions with people of an Ethnic

Minority Group were found to be a significant positive predictor of self-reported

Cultural Sensitivity. However, consistent with the hypothesis was the finding that

healthcare providers' self-reports of the amount of experience in Multicultural

Professional Interactions with people of an Ethnic Group Different from that of the

participant were not found to be a significant predictor of self-reported Cultural

Sensitivity.







Hypothesis Two

Hypothesis Two was as follows: The predictive relationship between

healthcare providers' self-reports of amount of experience in multicultural social

interactions (measured by sub-scores on the HCP-DDQ) and these providers'

self-reported Cultural Sensitivity (measured by mean scores on the T-CUSHCI-

PF or HCP) will be stronger for Multicultural Social Interactions with people of an

Ethnic Group Different from that of the participant rather than for Multicultural

Social Interactions with people of an Ethnic Minority Group (as measured by the

respective sub-scores on the HCP-DDQ). MCT theory suggests that there is

tremendous value in social immersion with people of cultures different from the

self in terms of developing sensitivity to multicultural issues (Sue, Ivey, &

Pedersen, 1996). Therefore, it was proposed that providers' social exposure to

people who are culturally different from themselves would account for more

variance in the criterion variable of Cultural Sensitivity than would social

exposure to people who are of an ethnic minority group. Hypothesis Two was not

supported by the study findings.

Hypothesis Two was tested using a forced-entry stepwise multiple

regression model. Amount of experience in Multicultural Social Interactions with

people of an Ethnic Minority Group (MSI-EMG) and amount of experience in

Multicultural Social Interactions with people of an Ethnic Group Different from

that of the participant (MSI-EGD) were the two predictor variables. Healthcare

providers' self-reports of Cultural Sensitivity were the criterion variable in the

regression model.







Table 4.5 describes the results of the forced-entry stepwise multiple

regression analysis using MSI-EMG (i.e., amount of self-reported experience in

Multicultural Social Interactions with people of an Ethnic Minority Group) and

MSI-EGD (i.e., amount of experience in Multicultural Social Interactions with

people of an Ethnic Group Different from that of the participant) as predictor

variables. The overall model fit was not significant at the first or second step. At

the first step of forced-entry with the first predictor variable (MSI-EMG) in the

model, MSI-EMG accounted for 0.2% of the variance. The overall R2 value at this

first step was not significant (F(1,30) = .05, p = .82). At the second step of forced-

Table 4.5.Prediction of Cultural Sensitivity by Multicultural Social Interactions


Variable R2 AR2 B SEB fp sr2



Step 1 .00 .00

MSI-EMG .01 .03 .04 .00

Step 2 .02 .02

MSI-EMG .05 .06 .26 .02

MSI-EGD -.03 .05 -.26 .02



Note. MSI-EMG = Amount of self-reported experience in multicultural social
interactions with people of an ethnic minority group; MSI-EGD = Amount of self-
reported experience in multicultural social interactions with people of an ethnic
group different from that of the participant.







entry with both predictor variables (MSI-EMG and MSI-EGD) in the model, the

variance accounted for was 1.9%. This overall R2 value at the second step was

not associated with a significant model fit (F(2,29) = .28, p = .76).

In regards to individual predictors, at the first step, MSI-EMG was not a

significant predictor of Cultural Sensitivity (b = .01, t = .227, p = .82). At the

second step of forced-entry, MSI-EMG remained a nonsignificant predictor of

Cultural Sensitivity (b = .05, t = .73, p = .47). Adding MSI-EGD to the second step

accounted for an additional 1.7% of the variance and MSI-EGD was not a

significant predictor of Cultural Sensitivity (b = -.03, t = -.71 p = .48). Thus, for the

predictor variables that focused on multicultural social interactions, neither of the

two individual predictors was significant. Amount of self-reported experience in

multicultural social interactions was not a significant predictor of healthcare

providers' self-reported Cultural Sensitivity, whether they were social interactions

with people of an ethnic minority group or social interactions with people of an

ethnic group different from that of the healthcare provider.

Therefore, the analyses revealed that Hypothesis Two was not supported by

the study findings. The predictive relationship between healthcare providers' self-

reports of amount of experience in multicultural social interactions and the

providers' self-reported Cultural Sensitivity was not stronger for amount of

experience socially with people of an ethnic group different from that of the

healthcare provider versus for amount of experience socially with people of an

ethnic minority group was considered.







Hypothesis Three

Hypothesis Three was as follows: Healthcare providers' self-reports of the

amount of experience in multicultural professional interactions (as measured by

sub-scores on the HCP-DDQ) will be a significant positive predictor of self-

reported Cultural Competence (as measured by mean scores on the CCSQ-

SPV), whereas healthcare providers' self-reports of the amount of experience in

multicultural social interactions (as measured by sub-scores on the HCP-DDQ)

will not be a significant positive predictor of Cultural Competence. The direction

of this hypothesis was based upon the research on Cultural Competence, which

indicates that it is composed of attitudes, knowledge, skills, and behaviors. The

more experience healthcare providers had had ostensibly demonstrating these

aspects in the delivery of multicultural healthcare, the higher their self-reports of

Cultural Competence were hypothesized to be.

Hypothesis Three was tested using two forced-entry stepwise multiple

regression models. In the first model, amount of self-report experience in

Multicultural Professional Interactions with people of an Ethnic Minority Group

(MPI-EMG) and amount of self-report experience in Multicultural Social

Interactions with people of an Ethnic Minority Group (MSI-EMG) were the two

predictor variables. In the second model, amount of self-report experience in

Multicultural Professional Interactions with people of an Ethnic Group Different

from that of the participant (MPI-EGD) and amount of self-report experience in

Multicultural Social Interactions with people of an Ethnic Group Different from

that of the participant (MSI-EGD) were the two predictor variables. Healthcare

providers' self-reports of Cultural Competence were the criterion variable in both







regression models. Hypothesis Three was partially supported by the study

findings.

Table 4.6 describes the results of the first forced-entry stepwise multiple

regression analysis using MPI-EMG (i.e., amount of self-report experience in

Multicultural Professional Interactions with people of an Ethnic Minority Group)

and MSI-EMG (i.e., amount of self-report experience in Multicultural Social

Interactions with people of an Ethnic Minority Group) as predictor variables. The

overall model fit was significant at both the first and second step. At the first step

Table 4.6. Prediction of Cultural Competence by Multicultural Professional and
Social Interactions with People of an Ethnic Minority Group


Variable R2 AR2 B SEB p s2



Step 1 .25* .25*

MPI-EMG .15 .05 .50* .25*

Step 2 .32* .06

MPI-EMG .12 .05 .42* .15*

MSI-EMG .07 .04 .27 .06


Note. MPI-EMG = Amount of self-reported experience in multicultural
professional interactions with people of an ethnic minority group; MSI-EMG =
Amount of self-reported experience in multicultural social interactions with people
of an ethnic minority group.
*p < .05.

of forced-entry with the first predictor variable (MPI-EMG) in the model, MPI-

EMG accounted for 25.4% of the variance. This overall R2 value at this first step

was significant (F(1,30) = 10.24, p < .01). At the second step of forced-entry with







both predictor variables (MPI-EMG and MSI-EMG) in the model, the variance

accounted for was 31.7%. This overall R2 value at the second step was

associated with a significant model fit (F(2,29) = 6.72, p < .01).

In regards to individual predictors, MPI-EMG was a significant positive

predictor of Cultural Competence (b = .15, t = 3.20, p < .01). At the second step

of forced-entry, MPI-EMG remained a significant positive predictor of Cultural

Competence (b = .12, t = 2.55, p = .02). Adding MSI-EMG at the second step

accounted for an additional 6.2% of the variance and MSI-EMG was not a

significant predictor of Cultural Competence (b = .07, t = 1.63, p = .12). Thus, for

the predictor variables that focused on multicultural professional and social

interactions with people of an ethnic minority group, the results supported the

third hypothesis. As predicted, amount of self-reported experience in multicultural

professional interactions was a significant positive predictor of healthcare

providers' self-reported Cultural Competence, whereas amount of self-reported

experience in multicultural social interactions was not a significant predictor of

providers' self-reported Cultural Competence.

The next set of analyses addressing the third hypothesis replicates the

first set of analyses, except that multicultural professional interactions and

multicultural social interactions examined as predictors were with people of an

ethnic group different from that of the participant instead of with people of an

ethnic minority group. Table 4.7 describes the results of the second forced-entry

stepwise multiple regression analysis using MPI-EGD (i.e., amount of self-

reported experience in Multicultural Professional Interactions with people of an







Ethnic Group Different from that of the participant) and MSI-EGD (i.e., amount of

self-reported experience in Multicultural Social Interactions with people of an

Ethnic Group Different from that of the participant) as predictor variables. The

Table 4.7. Prediction of Cultural Competence by Multicultural Professional and
Social Interactions with People of an Ethnic Group Different from that of
the Participant


Variable R2 AR2 B SEB p sr



Step 1 .20* .20*

MPI-EGD .11 .04 .45* .20*

Step 2 .21* .00

MPI-EGD .11 .05 .42 .10

MSI-EGD .01 .04 .05 .00


Note. MPI-EGD = Amount of self-reported experience in multicultural
professional interactions with people of an ethnic group different from that of the
participant; MSI-EGD = Amount of self-reported experience in multicultural social
interactions with people of an ethnic group different from that of the participant.
*p < .05.

overall model fit was significant at both the first and second steps. At the first

step of forced-entry with the first predictor variable (MPI-EGD) in the model, MPI-

EGD accounted for 20.4% of the variance. This overall R2 value at this first step

was significant (F(1,30) = 7.69, p = .01). At the second step of forced-entry with

both predictor variables (MPI-EGD and MSI-EGD) in the model, the variance

accounted for was 20.6%. This overall R2 value at the second step was

associated with a significant model fit (F(2,29) = 3.76, p = .04).







In regards to individual predictors, at the first step, MPI-EGD was a

significant positive predictor of Cultural Competence (b = .11, t = 2.77, p = .01).

However, at the second step of forced-entry, MPI-EGD was not a significant

predictor of Cultural Competence (b = .11, t = 1.96, p = .06). Adding MSI-EGD to

the second step only accounted for an additional 0.2% of variance and MSI-EGD

was not a significant predictor of Cultural Competence (b = .01, t = .25, p = .80).

Thus, for the predictor variables that focused on interactions with people of an

ethnic minority group different from that of the participant, the results supported

the third hypothesis. As predicted, amount of self-reported experience in

multicultural professional interactions was a significant positive predictor of

healthcare providers' self-reported Cultural Competence and amount of self-

reported experience in multicultural social interactions was not a significant

predictor of providers' self-reported Cultural Competence.

The change in significance from the first to the second step for the

individual predictor (MPI-EGD) may be the result of significant multicolinearity

(tolerance = .60) and the noted problems associated with multicolinearity and the

stability of the regression coefficients (Stevens, 2002). The substantial

intercorrelation of the two predictor variables of MPI-EGD and MSI-EGD (r = .63,

p< .01) as well as the fairly low measure of tolerance (.60) may explain the

change in significance for MPI-EGD when the second predictor variable of MSI-

EGD was added to the regression model.

Therefore, the analyses revealed that Hypothesis Three was supported by

the study findings. Healthcare providers' self-reports of the amount of experience







in multicultural professional interactions were found to be a significant positive

predictor of self-reported Cultural Competence, whereas healthcare providers'

self-reports of the amount of experience in multicultural social interactions were

not found to be a significant predictor of self-reported Cultural Competence.

Hypothesis Four

Hypothesis Four was as follows: The predictive relationship between

healthcare providers' self-reports of amount of experience in multicultural

professional interactions (as measured by sub-scores on the HCP-DDQ) and the

providers' self-reported Cultural Competence (as measured by mean scores on

the CCSQ-SPV) will be stronger for Multicultural Professional Interactions with

people of an Ethnic Minority Group rather than for Multicultural Professional

Interactions with people of an Ethnic Group Different from that of the participant.

Since Cultural Competence represents having a knowledge base specific to

various ethnicities, it was hypothesized that the more experience providers have

providing healthcare to patients from ethnic minority groups, the larger the body

of culturally competent knowledge they would perceive themselves as

possessing. In other words, it was proposed that healthcare provision to people

who are of an ethnic minority group would account for more variance in the

criterion variable of Cultural Competence than would healthcare provision to

people who are of an ethnic group different from that of the provider.

Hypothesis Four was tested using a forced-entry stepwise multiple

regression model. Amount of self-reported experience in Multicultural

Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) and

amount of self-reported experience in Multicultural Professional Interactions with







people of an Ethnic Group Different from that of the participant (MPI-EGD) were

the two predictor variables. Healthcare providers' self-reports of Cultural

Competence were the criterion variable in the regression model. Hypothesis Four

was supported by the study findings.

Table 4.8 describes the results of the forced-entry stepwise multiple

regression analysis using MPI-EMG (i.e., amount of self-reported experience in

Multicultural Professional Interactions with people of an Ethnic Minority Group)

and MPI-EGD (i.e., amount of self-reported experience in Multicultural

Professional Interactions with people of an Ethnic Group Different from that of the

participant) as predictor variables. The overall model fit was significant at both

the first and second steps. At the first step of forced-entry with the first predictor

variable (MPI-EMG) in the model, MPI-EMG accounted for 25.4% of the

variance. This overall R2value at this first step was significant (F(1,30) = 10.24, p

< .01). At the second step of forced-entry with both predictor variables (MPI-EMG

and MPI-EGD) the variance accounted for was 26.7%. This overall R2value at

the second step was associated with a significant model fit (F(2,29) = 5.27, p =

.01).

In regards to individual predictors, at the first step, MPI-EMG was a

significant positive predictor of Cultural Competence (b = .15, t = 3.2, p < .01).

However, at the second step of forced-entry, MPI-EMG was not a significant

predictor of Cultural Competence (b = .11, t = 1.57, p = .13). Adding MPI-EGD to

the second step only accounted for an additional 1.2% of the variance and MPI-

EGD was not a significant predictor of Cultural Competence (b = .04, t = .69, p =







.49). Thus, for the predictor variables that looked at multicultural professional

interactions, only one of the individual predictors (MPI-EMG) was significant.

Amount of experience in multicultural professional interactions was a significant

predictor of healthcare providers' self-reported Cultural Competence when they

were professional interactions with people of an ethnic minority group. Amount of

experience in multicultural professional interactions was not a significant

predictor of providers' self reported Cultural Competence when they were

professional interactions with people of an ethnic group different from that of the

provider.

Table 4.8. Prediction of Cultural Competence by Multicultural Professional
Interactions


Variable R2 AR2 B SEB f sr2



Step 1 .25* .25*

MPI-EMG .15 .05 .50* .25*

Step 2 .27* .01

MPI-EMG .11 .07 .38 .06

MPI-EGD .04 .06 .17 .01


Note. MPI-EMG = Amount of self-reported experience in multicultural
professional interactions with people of an ethnic minority group; MPI-EGD =
Amount of self-reported experience in multicultural professional interactions with
people of an ethnic group different from that of the participant.
*p < .05.

The change in significance from the first to the second step for the

individual predictor (MPI-EMG) may be the result of significant multicolinearity







(tolerance = .44) and the noted problems associated with multicolinearity and the

stability of the regression coefficients (Stevens, 2002). The substantial

intercorrelation of the two predictor variables of MPI-EMG and MPI-EGD (r = .75,

p < .01) as well as the low measure of tolerance (.44) may explain the change in

significance for MPI-EMG when the second predictor variable of MPI-EGD was

added to the regression model.

Therefore, the analyses revealed that Hypothesis Four was supported by

the study findings. The predictive relationship between healthcare providers' self-

reports of amount of experience in multicultural professional interactions and the

providers' self-reported Cultural Competence was stronger for amount of

experience in healthcare provision to people of an ethnic minority group than for

amount of experience providing care to people of an ethnic group different from

that of the healthcare provider.

Post Hoc Analyses

Post hoc analyses were conducted to determine whether the major

variables of interest differed significantly according to gender and ethnicity of the

participants. The influence of gender and ethnicity of the participants was

examined on a post hoc basis because prior research has suggested that female

and non-majority group healthcare providers are more sensitive to multicultural

issues within healthcare provision (Lauerman, 2000; Ratcliff, 2002; Robins, et al.,

2001; Taylor, 1999). The influence of gender and ethnicity of the participants

was examined using multivariate analyses of variance (MANOVAs) because at

least some of the major variables of interest were significantly related (see Table







4.2). In addition, univariate analyses (ANOVAs) were conducted to further

elucidate any significant results found with MANOVAs.

Table 4.9 shows the results of the MANOVAs and ANOVAs. The

MANOVA examining the influence of the interaction between gender and

ethnicity of the participants was not significant, indicating the appropriateness of

further analysis of the influence of gender and ethnicity separately. The

MANOVA examining the influence of gender of the participants was not

significant, F(6,31) = .49, p = .81. Therefore, the results of the ANOVAs

examining the influence of gender of the participants on each of the major

variables of interest were not further considered. For the influence of ethnicity of

the participants, the MANOVA was significant, F(6,31) = .5.48, p < .01. Because

the MANOVA was significant for influence of ethnicity of the participants, each of

the ANOVAs was considered as well. The ANOVAs examining the influence of

ethnicity of the participants were not significant for: (a) Self-reported Cultural

Sensitivity, F(1,32) = .70, p = .41; (b) Self-reported Cultural Competence, F(1,32)

= .00, p = .95; (c) Amount of self-reported experience in Multicultural Professional

Interactions with people of an Ethnic Minority Group, F(1,32) = .06, p = .81; and

(d) Amount of self-reported experience in Multicultural Professional Interactions

with people of an Ethnic Group Different from that of the participant, F(1,32) =

2.89, p = .10. However, the ANOVA examining the influence of ethnicity of the

participants was significantly related to amount of self-reported experience in

Multicultural Social Interactions with people of an Ethnic Minority Group, F(1,32)

= 14.18, p < .01.







Table 4.9. Multivariate and Univariate Analyses of Variance Examining Influence
of Participants' Gender and Ethnicity on Major Variables of Interest


ANOVA


MANOVA MPI- MPI- MSI- MSI-
CS CC EMG EGD EMG EGD

Variable F(6,31) F(1,32) F(1,32) F(1,32) F(1,32) F(1,32) F(1,32)


Gender (G) .49 .45 .83 .58 2.17 .22 .85

Ethnicity (E) 5.48** .70 .00 .06 2.89 14.18** 11.27**

G x E .98 .27 .52 .98 2.89 .97 .02


Note. F ratios are Wilks' Lambda approximation of Fs. MANOVA =

Multivariate analysis of variance; ANOVA = Univariate analysis of variance; CS =

Self-reported cultural sensitivity; CC = Self-reported cultural competence; MPI-

EMG = Amount of self-reported experience in multicultural professional

interactions with people of an ethnic minority group; MPI-EGD = Amount of self-

reported experience in multicultural professional interactions with people of an

ethnic group different from that of the participant; MSI-EMG = Amount of self-

reported experience in multicultural social interactions with people of an ethnic

minority group; MSI-EGD = Amount of self-reported experience in multicultural

social interactions with people of an ethnic group different from that of the

participant.

**p <.01.







The mean value of amount of self-reported experience in Multicultural Social

Interactions with people of an Ethnic Minority Group was higher for participants of

an ethnic minority group (M = 8.25) than for participants of the ethnic majority

group (M = 5.96). In addition, the ANOVA examining the influence of ethnicity of

the participants on amount of self-reported experience in Multicultural Social

Interactions with people of an Ethnic Group Different from that of the participant

was significant F(1,32) = 11.27, p < .01. Similarly, the mean value of amount of

self-reported experience in Multicultural Social Interactions with people of an

Ethnic Group Different from that of the participant was higher for participants of

an ethnic minority group (M = 9.00) than for participants of the ethnic majority

group (M = 5.96).

Because of the uneven distribution of participants' ethnicity (75%

Caucasian, 25% non-Caucasian), Levene's test for equality of variances was

conducted for each comparison examining the influence of ethnicity of the

participants. Variances among ethnicity of the participants were only found to be

unequal for the variable amount of self-reported experience in Multicultural Social

Interactions with people of an Ethnic Group Different from that of the participant,

F = 6.30, p < 05. However, the difference in scores for amount of self-reported

experience in Multicultural Social Interactions with people of an Ethnic Group

Different from that of the participant remained significant even when equal

variances were not assumed, t (8.33) = 2.91, p <.05, suggesting that uneven

distribution of ethnicity of the participants did not inflate this finding.







In sum, the post hoc analyses revealed that scores on the variables of

levels of self-reported Cultural Competence and Cultural Sensitivity did not vary

systematically in relation to gender or ethnicity of the participants. In addition, no

significant gender differences were found for the other major variables of interest.

For ethnicity of the participants, no significant differences were found for the

major variables of interest pertaining to multicultural professional interactions, but

significant differences were found for major variables of interest pertaining to

multicultural social interactions. As would be expected, participants of an ethnic

minority group reported having had significantly more experience socially with

people of an ethnic minority group and with people of an ethnic group different

from their own than did participants of the ethnic majority group. This finding

suggests that participants' ethnicity and amount of self-reported experience in

multicultural social interactions are related.












CHAPTER 5
DISCUSSION

This chapter will include a summary and interpretation of the results,

theoretical and practical implications of the study, limitations of the study, and

future research directions. The results from this study provide further

understanding about how multicultural social interactions and multicultural

professional interactions relate to healthcare providers' self-reported levels of

Cultural Sensitivity and Cultural Competence. These findings are discussed

within the context of Multicultural Counseling and Therapy (MCT) theory (Sue,

Ivey, & Pedersen, 1996). In addition, the results raise important questions about

the definitions of multicultural interactions, which warrant further investigation.

The differential predictive ability of multicultural interactions on Cultural

Sensitivity and Cultural Competence in healthcare delivery, based upon how the

multicultural interactions were operationalized, has important implications for the

training of physicians and other healthcare providers in the provision of culturally

sensitive and culturally competent healthcare. Specifically, the study findings

suggest that healthcare organizations would benefit from focusing the content of

future training on facilitating an increase in healthcare providers' professional

interactions with patients from ethnic minority groups and with patients from

ethnic groups different from that of the individual provider.







Summary and Interpretation of the Results

The present study examined physicians and other healthcare providers'

self-reports of their levels of engagement in or, display of, patient-identified

knowledge, behaviors, attitudes, and experiences that patients at community-

based primary care clinics identify as indicators of culturally sensitive healthcare

(i.e., self-reports of their level of engagement in patient-defined culturally

sensitive healthcare as measured either by the T-CUSHCI Physician Form or by

the T-CUSHCI Health Care Provider Form, as was appropriate). Also, it

examined healthcare providers' self-reports of their levels of engagement in or,

display of, non-patient or "expert"-identified knowledge, behaviors, attitudes, and

experiences that experts have identified as indicators of culturally competent

healthcare (i.e., self-reports of their level of engagement in culturally competent

healthcare as measured by the CCSQ-SPV). Further, it determined if

participating healthcare providers' self-reported levels of Cultural Sensitivity and

Cultural Competence are significantly associated with their self-reported amounts

of experience in multicultural social interactions and healthcare provision to

African Americans, Hispanic/Latino(a) Americans, and Caucasian Americans.

Preliminary Analysis

The preliminary analysis revealed that the two criterion variables

examined in the study (Cultural Sensitivity and Cultural Competence) were not

significantly correlated with each other, providing support that these variables

were separate and independent constructs (see Table 4.2). This finding is

important because it demonstrates that these are separate skills, both of which






are necessary for providers to appropriately address multicultural issues in the

delivery of healthcare. This then has implications for those developing training

to answer the urgent call for healthcare that satisfactorily takes into account

multicultural issues (Huff & Kline, 1999); both Cultural Competence and Cultural

Sensitivity should be included in these training and the various factors that

promote growth of these two different but essential skills must be researched and

addressed accordingly.

Cultural Competence is defined as having the knowledge, skills,

experiences, and awareness needed to provide healthcare that is respectful of

and takes into account a patient's specific culture (Tucker et al., 2001). Cultural

sensitivity in healthcare has three defining characteristics (Tucker et al., 2003). It

involves 1) communicating or displaying culture-related knowledge, skills, and

awareness in ways that make people feel that their culture is respected and that

make them feel comfortable with and trusting of the healthcare they receive; 2)

embracing the view that culturally diverse patients are the experts at identifying

the behaviors/attitudes and healthcare environment variables that are indicators

of culturally sensitive healthcare; and 3) engaging in specific provider and staff

behaviors and provider/staff-patient interactions as well as promoting physical

healthcare environments that encourage patient trust in, comfort with, and

feelings of being respected by healthcare providers and staff (Tucker et al.,

2003). Another way to differentially conceptualize these two constructs is to

regard Cultural Competence as a set of knowledge, skills, experiences, and

awareness defined by experts, and Cultural Sensitivity as the effective display of







this expert-defined set of knowledge, skills, experiences, and awareness in ways

that facilitate patients' awareness/experience of this knowledge, skills,

experiences, and awareness. When participants were asked to report

perceptions of their own Cultural Competence, they were in essence asked to

report how extensive they perceived this expert-defined set of knowledge, skills,

experiences, and awareness to be within themselves. Alternatively, when

participants were asked to report perceptions of their own Cultural Sensitivity,

they were in essence asked to report how well they perceived themselves to be

engaging in the behaviors and displaying the knowledge, skills, experience, and

awareness that culturally diverse patients have reported to be important. The

findings from this study support that these two variables, Cultural Competence

and Cultural Sensitivity, are separate constructs and support their treatment as

such in the study discussion.

Constantine (2000) discussed how Social Desirability is a primary concern

associated with instruments that utilize self-report to measure multicultural

competence, and Sodowsky (1996) recommended that studies requiring

completion of such instruments also include a measure of Social Desirability. It

was expected that participants would likely be concerned with the potential

impact their participation in the study and their self-reports of Cultural Sensitivity

and Cultural Competence could have on professional evaluations of themselves

as healthcare providers. While the many steps taken to ensure confidentiality

were explained to participants during the recruitment phase (e.g., voluntary

participation, use of a healthcare professional private identification number,







confidentiality of individual response sets, separation of identifying information

from all other measures, etc.), it was anticipated that fear of the consequences of

participant data identification might bias the responses on the assessment

battery. Thus, the Marlowe-Crowne Social Desirability Scale, short-form (M-

CSDS-SF) by Marlowe and Crowne (1964) was used to measure the participants'

tendency to respond to questions in a socially desirable manner. The purpose of

including the M-CSDS-SF was to determine if Social Desirability was significantly

correlated with any of the major variables of interest, and if necessary, to then

control for any observed influence of Social Desirability on the major variables of

interest.

Table 4.2 describes the study findings indicating that there was no

relationship between scores on the M-CSDS-SF and any of the study variables:

(a) level of self-reported Cultural Sensitivity (CS), (b) level of self-reported

Cultural Competence (CC), (c) amount of self-reported experience in Multicultural

Professional Interactions with people of an Ethnic Minority Group (MPI-EMG), (d)

amount of self-reported experience in Multicultural Professional Interactions with

people of an Ethnic Group Different from that of the participant (MPI-EGD), (e)

amount of self-reported experience in Multicultural Social Interactions with people

of an Ethnic Minority Group (MSI-EMG), and (f) amount of self-reported

experience in Multicultural Social Interactions with people of an Ethnic Group

Different from that of the participant (MSI-EGD). Thus, the data suggest that

Social Desirability did not play a role in participants' responses to the measures

in the assessment battery. Consequently, Social Desirability was not used as a







control variable in any of the subsequent analyses to test the investigated

hypotheses or in any of the post hoc analyses.

Multicultural Interactions and Cultural Sensitivity

Hypothesis One was as follows: 1) Healthcare providers' self-reports of

the amount of experience in multicultural social interactions will be a significant

positive predictor of self-reported Cultural Sensitivity, whereas healthcare

providers' self-reports of the amount of experience in multicultural professional

interactions will not be a significant positive predictor of self-reported Cultural

Sensitivity. The direction of this hypothesis was based upon Multicultural

Counseling and Therapy theory's implied importance of social immersion in

culturally different groups in developing sensitivity to multicultural issues (Sue,

Ivey, & Pedersen, 1996). Hypothesis One was only minimally supported by the

study findings.

Consistent with the first hypothesis was the finding that for this participant

sample, healthcare providers' self-reports of the amount of experience in

Multicultural Professional Interactions with people of an Ethnic Group Different

from that of the participant was not found to be a significant predictor of self-

reported Cultural Sensitivity. Contrary to the first hypothesis, healthcare

providers' self-reports of the amount of experience in Multicultural Professional

Interactions with people of an Ethnic Minority Group were found to be a

significant positive predictor of self-reported Cultural Sensitivity. Although this

finding contradicted the original study hypothesis, one potential explanation of

this finding is that the experience of providing healthcare within multicultural

interactions is a sub-type of the social immersion described by Sue, Ivey, and







Pedersen (1996) as being necessary for the development of sensitivity to cultural

issues. The healthcare provider-patient interaction is often an intimate one with

complex interrelationships, necessitating that the provider seek self-awareness of

her/his own culture while facilitating the patient's expression of important cultural

issues that may affect the relationship, treatment adherence, and medical

outcomes. The professional interaction also allows for feedback to be given to

the provider about the patient's perceptions of the provider's Cultural Sensitivity

via several avenues: direct feedback from the patient, feedback extrapolated

from the provider's perceptions of the interaction, the patient's treatment

adherence, keeping of follow-up appointments, and satisfaction levels with

medical outcomes.

In particular, this study investigated self-reported patient-defined Cultural

Sensitivity, involving 1) communicating or displaying culture-related knowledge,

skills, and awareness in ways that make people feel that their culture is

respected and that make them feel comfortable with and trusting of the

healthcare they receive; 2) embracing the view that culturally diverse patients are

the experts at identifying the behaviors/attitudes and healthcare environment

variables that are indicators of culturally sensitive healthcare; and 3) engaging in

specific provider and staff behaviors and provider/staff-patient interactions as

well as promoting physical healthcare environments that encourage patient trust

in, comfort with, and feelings of being respected by healthcare providers and staff

(Tucker et al., 2003). It is probable that the therapeutic alliance many healthcare

providers strive to achieve in order to successfully deliver healthcare allows for







much learning about the diverse cultural contexts within which patients and

providers operate, which may then contribute to the development of patient-

defined Cultural Sensitivity. As providers gain greater amounts of experience in

Multicultural Professional Interactions with patients from an Ethnic Minority

Group, they may then perceive themselves to have higher levels of patient-

defined Cultural Sensitivity, or the ability to effectively communicate a set of

culturally relevant knowledge, skills, experiences, and awareness in a manner

that patients perceive as culturally sensitive.

In addition, it is interesting to consider how the definition of the amount of

experience in multicultural professional interactions influenced the predictive

relationship with self-reported Cultural Sensitivity. For this participant sample, as

expected, healthcare providers' self-reports of the amount of experience in

Multicultural Professional Interactions with people of an Ethnic Group Different

from that of the participant were not found to be a significant predictor of self-

reported Cultural Sensitivity, whereas contrary to what was expected, healthcare

providers' self-reports of the amount of experience in Multicultural Professional

Interactions with people of an Ethnic Minority Group were found to be a

significant positive predictor of self-reported Cultural Sensitivity. A possible

explanation for this finding is that in order for an individual to perceive that s/he

manifests patient-defined Cultural Sensitivity in the delivery of healthcare, it is

salient that the individual recognizes that the person with whom s/he is having

the multicultural professional interaction is of an ethnic minority group versus of

an ethnic majority group or of an ethnic group different from that of the provider.







This recognition of the patient's membership in an ethnic minority group may

then contribute to the provider's stored knowledge about interactions with

members of that group and further the perception that s/he (the provider) is

cumulatively more culturally sensitive because of that interaction. This is a critical

study finding because the indication that experience providing healthcare to

patients from ethnic minority groups is important in increasing self-reports of

Cultural Sensitivity has direct implications for healthcare organizations that seek

to increase the Cultural Sensitivity of their staff.

Contrary to Hypothesis One, healthcare providers' self-reports of the

amount of experience in multicultural social interactions were not found to be a

significant positive predictor of self-reported Cultural Sensitivity, regardless of

whether that experience was measured as Multicultural Social Interactions with

people of an Ethnic Minority Group or Multicultural Social Interactions with people

of an Ethnic Group Different from that of the participant. This finding did not

support the original study hypothesis based upon MCT theory's implied

importance of social immersion in culturally different groups in developing

sensitivity to multicultural issues (Sue, Ivey, & Pedersen, 1996).

A possible explanation for this negative finding is that regardless of the

operationalization of multicultural social interactions, this variable is not related to

self-reported Cultural Sensitivity. An alternative explanation for this finding may

lie with the study's reliance on self-report data. Participants' perceptions of

displayed Cultural Sensitivity may not be synonymous with the perceptions of

other observers such as the patients of these providers or a third-party rater.







Before ruling out the influence of experience in multicultural social interactions in

terms of predicting displayed Cultural Sensitivity within a healthcare provider-

patient interaction, it would be useful to conduct further research that correlates

both provider and patient assessments of Cultural Sensitivity with the provider's

self-reported experience in multicultural social interactions.

Pope-Davis et al. (2001) points out that much of the body of research

dealing with how appropriately healthcare providers address the needs of the

diverse community they serve focuses on the perceptions of the healthcare

providers and not on the perspectives of their clients. The authors discuss the

importance of integrating the perspective of clients into the research on

multiculturalism by gathering data on client preferences and expectations. Wood

and Mallinckrodt (1990) state that when attempting to bridge the gap of cultural

understanding, those providing the training in Cultural Sensitivity must be sure

that the skills presented are valued by the client, not just by the healthcare

provider. The inventory used in the present study to assess Cultural Sensitivity,

the T-CUSHCI, takes this vital step forward called for by Pope-Davis et al. (2001)

and Wood and Mallinckrodt (1990) by allowing providers to make self-reports of

their level of engagement in culturally sensitive healthcare as defined by patients.

However, it would be even further illuminating to collect mirror image reports by

the patients of the same interactions and establish the level of correlation

between the two sets of perceptions by patients and providers.

Hypothesis Two was as follows: The predictive relationship between

healthcare providers' self-reports of amount of experience in multicultural social




Full Text

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RELATIONSHIP OF MULTICULTURAL INTERACTIONS TO HEALTHCARE PROVIDERS' CULTURAL SENSITIVITY AND CULTURAL COMPETENCE By RHONDAL HACKSHAW A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2005

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ACKNOWLEDGEMENTS First and foremost I would like to thank my parents, Brian and Fleurette Hackshaw for their unwavering, staunch and loving support throughout this long journey I could not have accomplished this without them. I likely would not have pushed myself so hard if I had not been trying to keep up with my big brothers ," Patrick and Simon Hackshaw I thank them for the motivation My sister in spirit if not in blood Jennifer Hackshaw exemplifies grace and courage to me She is the wife and mother I hope one day to be My nieces Zoe Rune and Kalina Colibri give me hope for the future. There were days when only thoughts of their smiles and laughter bore me past the obstacles I encountered I carried their pictures everywhere to remind me of the joy life has to offer Jim Carter is my daily sunshine and my strength. I would still be foundering around in the dreary dissertation quagmire without him. He sustained and inspired me to keep walking one foot in front of the other towards the wonderful opportunities that lie ahead He believed in me unceasingly and helped me to believe in myself I am grateful for and humbled by his sweet love and support Katey Sellers and Sara Theiss taught me the true meaning of friendship and to trust that we will be there for each other in the best and worst of times Most importantly they taught me that distance means nothing if we carry each other in our hearts Leslie Ziegenhorn my twin and Sam Park my hero were the best of cheering sections Their mentorship and faith in me held me in good

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stead and gave me the backbone I needed during some very difficult times I am honored to keep professional company with them and doubly privileged to call them my friends. Sagey and Solly shed fur and sat upon every page of every draft and I have delighted in every minute of our long life spent together in adoration of each other. Dr Carloyn Tucker was my mentor and guide throughout this process She helped me to find strength I never knew I had and to reach constantly for excellence I am a better person because of all that I have learned from her over the years I am very grateful to Dr Greg Neimeyer Dr Robert Ziller Dr. Heather Hausenblas Dr. Pete Giacobbi and Dr Ken Rice for everything they have contributed to making this experience a success and for being such gracious peers. I would like to thank the Behavioral Medicine Team at the University of Florida for their hard work and incredible dedication to the cultural sensitivity research and to the patients and healthcare providers who were the inspiration for this project. II

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TABLE OF CONTENTS ACKNOWLEDGEMENTS ............. .................. ..... .... ... ............... ... ..... .. ....... .. ..... .. ........ . i LIST OF TABLES ...................... ......... .. ................................... .................. .. .................... V ABSTRACT ...................................................................................................................... vi CHAPTER 1 INTRODUCTION .......................................................................................... ............ 1 Statement of the Prob l em ........... ..... ................ ... ... .............. .. ...................................... 1 Purpose of th tudy .............................................................................................. .. .. 5 Hypotheses ................. .................................... .. ... ......... ......... ..... .. ... ......... .. .......... .. 6 2 REVIEW OF THE LITERATURE ....................................................... .. ............... ... 9 Contemporary Issues in Healthcare ............................. ....... ................... .......... ........ 9 Culture Multiculturalism and Healthcare ............ .. ................................ . ...... .. . .. ... 11 Multicultura l Counseling and Therapy Theory .. ... ...... ......... .. .................... ... ... . ..... 16 Cu ltur e Illness and Healthcare Provision Models .... .. .............................. . ......... ..... 21 Need for Culturally Sen itiv e Healthcare .................... ....................... . ................... 24 Multiculturalism and R searc h Design ................................................. .................... 30 Researching ultural ensitivity ............................................................................... 37 3 METHODOLOGY ....................... ................. .. .. .... ... ............. ..... .... .... ....... ........ .. 44 Participants ... ... ... ................. ................................................................. ..... ... ......... 44 Instruments .. . ...... .............. .... .......... .. .................... .. ....... ......... .... ............... . .... ...... 44 Procedure ............................ ...................................................................................... 50 4 RESULTS ..... .. ... ........ ..... .... . ...... ....... ....... ... .......................................................... 53 Descriptive Data for the Major Variables of Interest .......... ................................... . 53 Preliminary Data Analysis ........... ........ .. .... .. .... ..................................... .. ... ..... .... . .... 54 Hypotheses .............................................. .. .......... .. .......... . .............. .......................... 60 Hypothesis One ..... .. .. .... ... .. ................................................. ............... .... ........ 60 Hypothesis Two ... .. ... ......... .......... ... ... ...... .. ... . .... .. ........... ... ....... ..... .. ..... . ...... .. 67 lll

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Hypo th is Tluee . .... . .... ... .. .. ... ........................... ....... ...... . .... . ...................... 70 Hypoth is Four .................... ....... . ... .............. ... ...... ......... .. ...... ....... ... ...... . ...... 75 Post Hoc Analys s ..................................................................................................... 78 5 DI USSION ........ ... ....... ... ....... ... ........ .... ...................... .......... ..... ... ................... 83 ummary and Int e rpretation of the R es ults .... ... .... . ... ... ............ ... ..... ....... . ... .... .. . 84 Multicultural Int e raction and ultural Sensitivity ............................................ 88 Multicultural Int racti n and ultural ompetenc ........ .. ........... .... ........... .... 93 Overall Trends Among tudy Findings .............................................................. 98 Th oretical and Practical Implications ..... ...... .. ... .. .................... . ...... .. ..... ... .. ..... .... .. 99 Limitations ............................................................................................................... 102 Future Research .. ... ........ ......... .. ....... ........ ...... ... ..... .. ..... . . . .... .... ... .. .. .......... 105 onclusion ... . .. ....... ... .... ........ . ... .... ... ... ...... .. ... ..... ... .. ........... .. .... .............. .......... 106 APP NDIX A HEALTH ARE PROFE SIONAL DEMOGRAPHI DATA QUESTIONNAIRE ..... ..... .................... ... ................ ...... ...... .... ... ......... .. ....................... ... ................... 108 B TU KER-CULTURALLY SENSITIVE HEAL TH CARE INVENTORY FOR PHYSICIANS .......................................................................................................... 112 C TUCKER-CULTURALLY SENSITIVE HEALTHCARE INVENTORY FOR HEAL TH CARE PROVIDERS ..... .. .. .... ... ... .......... . .. ... . . . ... ..... ..... ............. .. .... 118 D CULTURAL COMPETEN E SELF-ASSESSMENT QUESTIONNAIRE ERVICE PROVIDER VERSION ... .. ..... .......... .. ....... ..... ..... ....... ... ......... . ........ 124 E MARLOWE-CROWNE OCIAL DESIRABILITY ALE SHORT FORM ...... 142 F HEALTHCARE PROFE IONAL INVITATION OVER L ETTE R .... .... ... .... 144 BIOGRAPH! AL KETCH ......... .. .... ....... ....... . ..... ......... . ... ............ ......................... 153

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LIST OF TABLES 3.1. Characteristics of Study Participants ....... .. ............... .............................................. 45 4.1. Descriptive Statistics for Major Variables oflnterest.. ..................................... .. .... ... 54 4.2 Correlation Matrix showing Intercorrelations among Major Variables of Interest .... 56 4.3. Prediction of Cu ltural Sensitivity by Multicultural Professional and Social Interactions with People of an Ethnic Minority Group ............................................. 62 4.4. Prediction of ultural ensitivity by Multicultural Professional and ocial Interactions with People of an Ethnic Group Different from that of the Participant. 64 4.5.Prediction of Cultural ensitivity by Multicultural ocial Interactions ............. .. ... . 68 4.6. Prediction of Cultural Comp tence by Multicultural Professional and Social Interactions with People of an Ethnic Minority Group .... .......... ...................... ...... 71 4.7. Prediction of Cu ltmal Competence by Multicultural Professional and Social Interactions with People of an Ethnic Group Different from that of the Participant. 73 4.8. Prediction of ultural ompetence by Multicultural Professional Interactions .. . . . 77 4.9. Multivariate and Univariate Analyses of Variance Examining Influence of Participants Gender and Ethnicity on Major Variables of Interest ....... .. ............ .... 80 V

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Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy RELATIONSHIP OF MULTICULTURAL INTERACTIONS TO HEALTHCARE PROVIDERS' CULTURAL SENSITIVITY AND CULTURAL COMPETENCE By Rhonda L. Hackshaw August 2005 Chair : Carolyn M Tucker Major Department: Psychology This study was conducted to examine the relationship between healthcare providers self-reported experience in multicultural interactions and these providers self reported levels of cultural sensitivity and cultural competence. Study participants were 22 physicians and 10 other healthcare providers (19 females 13 males ; 75% Caucasian 25% Non-Caucasian) recruited from two primary care clinics in Florida The instruments constituting each assessment battery obtained data on or measured the following : demographic variables multicultural interactions (social and professional) and self-reported cultural sensitivity and cultural competence in healthcare provision Study data were analyzed using multiple regression models Contrary to what was hypothesized the analyses revealed that multicultural professional interactions when measured as providing healthcare to patients of an ethnic

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minority group were a significant positive predictor of provider self-reported cultural sensitivity As expected the analyses also revealed that multicultural professional interactions when measured as providing healthcare to patients of an ethnic group different from that of the provider were not a significant positive predictor of provider self-reported cultural sensitivity Contrary to what was hypothesized multicultural social interactions were not a significant predictor of self-reported cultural sensitivity regardless of whether interactions were measured as social experience with people of an ethnic minority group or as social experience with people of an ethnic group different from that of the participant. As hypothesized multicultural professional interactions were a significant positive predictor of self-reported cultural competence both when interactions were measured as providing healthcare to patients of an ethnic group different from that of the provider and when measured as healthcare provision to patients of an ethnic minority group Also as expected multicultural social interactions were not a significant predictor of self-reported cultural competence regardless of how they were measured The study findings suggest that healthcare organizations would benefit from focusing the content of future trainings on facilitating an increase in healthcare providers professional interactions with patients from ethnic minority groups and with patients from ethnic groups different from that of the individual provider in order to increase providers cultural sensitivity and cultural competence in healthcare provision V ll

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CHAPTER 1 INTRODUCTION Statement of the Problem Upon graduation many medical students take a modern version of the oath coined by Hippocrates the father of medicine swearing to fulfill to the best of their ability and judgment principles held sacred by most doctors today While these ideals include providing the best quality of care possible, preserving patient confidentiality and emphasizing prevention as well as cure there is one line that reads : I will remember that there is art to medicine as well as science and that warmth, sympathy and understanding may outweigh the surgeon's knife or the chemist's drug (NOVA online 2001) Even as these principles are perpetuated in modern medicine there is recognition in the oath s ancient origins of the essential interpersonal connection between provider and patient. The quality of the relationship between the healthcare provider and the patient is critical for several reasons When receiving services a positive perception of this relationship leads to increased satisfaction for the patient (Safran et al. 1998) and likely greater practical and personal satisfaction for the provider in the delivery of these services Improved patient satisfaction is then strongly associated with enhanced treatment compliance and better treatment outcomes (DiPalo 1997 ; Safran et al. 1998 ). For example a patient who trusts the recommendations of the healthcare provider will be far more likely to follow

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2 the proposed medical regimen resulting in superior health outcomes. Accordingly both clinicians and researchers have expressed considerable interest in better understanding and improving relationships between providers and patients One aspect of this patient-healthcare provider relationship that has gained recent increased attention is the interplay of cultural components within the interaction. This is due in part to the rapid rate of ethnic diversification in the U S (U S Census Bureau 1998) and the undeniable fact that healthcare providers will continue to experience escalating diversity in the populations they serve In addition the sharpened focus on culture has come about due to the documented nationwide racial and ethnic disparities in access to care quality of healthcare and health outcomes (Beal 2003) ; patients from minority populations report prejudice in the healthcare process experience a decreased quality of care and do not enjoy as many positive health outcomes as do patients from the majority population (Beal 2003 ; Stewart et. al 1999) As a result the Department of Health and Human Services medical schools minority health advocates and many others have issued urgent calls for health care that takes into account multicultural issues (Huff & Kline 1999) Multicultural Counseling and Therapy (MCT) theory (Sue Ivey & Pedersen 1996) has addressed the influence of cultural values on the relationship between healthcare providers and patients Specifically the contribution of culture to the quality of the relationship goes beyond simply considering the culture of the patient and that of the provider ; the totality and

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3 interrelationsh i ps between each one s cultural milieu is of the utmost importance Also the provider s self awareness of her/his own cultural background is as critical as possessing knowledge of the patient s culture Further regardless of cultural differences or similarities because there frequently exists an acute power differential between the patient and the provider it is arguably the responsibility of the provider who occupies the more authoritative role to steward the quality of the relationship Finally a multicultural approach to healthcare requires consideration of how congruent treatment recommendations and treatment goals are with the cultural values and life experiences of the patient. The importance of integrating multiculturalism in healthcare has been further advanced by the research on the constructs of cultural competence and cultural sensitivity (Tucker et al. 2001 ; Tucker et al. unpublished manuscript). The first construct cultural competence involves having the knowledge skills experiences and awareness needed to provide healthcare that is respectful of and takes into account a patient's culture The second construct cultural sensitivity in healthcare involves communicating or displaying culture-related knowledge skills experiences and awareness in ways that make patients feel that their culture is respected and that make them feel comfortable w i th and trusting of the healthcare that they receive Each construct makes its own essential contribution to a multicultural approach in the delivery of healthcare services Cultural competence offers the extensive knowledge base of the myriad cultural specifics accumulated by experts and researchers i n the f i e l d wh i le

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4 cultural sensitivity reflects the manner in which the knowledge is applied during the healthcare process An exciting outgrowth of research on the two constructs is the recognition that they involve knowledge and skills that can be taught and developed over time Unquestionably healthcare providers will benefit from the acquisition of knowledge about and an appreciation for the worldviews of culturally diverse patients A contemporary challenge is to assist in the training of healthcare providers to take a multicultural approach in the delivery of medical science. This training can be adequately guided by the research on cultural competence and cultural sensitivity and by the implications of MCT theory. The training should include psychoeducation about attitudes beliefs knowledge and skills as it relates to professional experiences i.e ., providing healthcare to patients of different ethnicities and cultures Also this training should incorporate an understanding of how to convey these attitudes bel i efs knowledge and skills in a culturally sensitive fashion According to MCT theory bes i des traditional book learning ,' experiential training that i ntegrates the cognitive affective and behavioral experiences must be tapped (Sue Ivey & Pedersen 1996 p. 50). This theory proposes the crucial nature of the learning experience provided by immersion in culturally different groups and points to the importance of social multicultural interactions in order to develop a sensitivity to cultural issues However much is still unknown about how multicultural interactions affect the development of cultural sensitivity and growth of cultural competence among healthcare providers First research is required to help define what types of

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5 multicultural interactions are related to cultural sensitiv i ty and cultural competence Specifically there is a need to explore the we i ght of multicultural professional experiences during service delivery versus multicultural contact during social interactions on the development of the provider Second it is unclear what makes an interaction a multicultural one Is it sufficient to interact with people of an ethnic minority or is it equally necessary to have exposure to people whose ethnicity is different from one s own? Third it is not understood how the ethnicity of the healthcare provider influences the development of cultural competence and cultural sensitivity Filling these gaps in knowledge is critical to the training of providers to become culturally competent and culturally sensitive Once more has been articulated about these issues in multicultural healthcare provision we can then indicate and advocate which variables should receive the greatest focus to accomplish improved training and experiential learning Purpose of the Study The purpose of this present study was to investigate how self-reported multicultural experiences and interactions are related to self-reported levels of cultural sensitivity and cultural competence among healthcare providers The definition of healthcare provider included physicians nurses physician ass i stants and other allied healthcare professionals Specifically the study examined two types of multicultural interactions experienced by healthcare providers : 1) amount of self-reported experience providing healthcare to African Amer i cans Hispanic/Lat i no ( a ) Americans and Caucasian Americans ; and 2 ) amount of se l f

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6 reported social experience those providers have had as an adult with the same populations These two types of multicultural interactions, professional and social, were measured in two ways: amount of self-reported experience with people of an ethnic minority group and amount of self-reported experience with people of an ethnic group different from that of the healthcare provider. Thus in this study amount of experience healthcare providers reported they had had providing healthcare and amount of experience socially as an adult providers reported they had had were independent variables and these providers levels of self-reported cultural sensitivity and cultural competence were dependent variables Hypotheses The present study tested the following four hypotheses : 1) The amount of experience healthcare providers self report having had in multicultural social interactions will be a sign i ficant positive predictor of providers self-reported cultural sens i tiv i ty whereas the amount of experience providers self-report having had in multicultural healthcare provision (multicultural professional interactions) will not be a significant positive predictor of their self reported cultural sensitivity The direction of this hypothesis was based upon MCT theory s implied importance of social immersion in culturally different groups in developing sensitiv i ty to multicultural issues (Sue Ivey & Pedersen 1996) 2) The predictive relationship between the amount of experience healthcare providers self-report having had in multicultural social interactions and these providers self-reported cultural sensitivity will be stronger for multicultural social

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7 interactions with people of an ethnic group different from that of the healthcare provider rather than for multicultural social interactions with people of an ethnic minority group MCT theory suggests that there is tremendous value in social immersion with people of cultures different from the self Therefore it was proposed that providers' self-reported levels of cultural sensitivity will be higher when multicultural social experience is defined as exposure the provider has had socially to people who are culturally different rather than as social exposure to people who are of an ethnic minority group. 3) The amount of experience healthcare providers self-report having had in multicultural healthcare provision (multicultural professional interactions) will be a significant positive predictor of providers self-reported cultural sensitivity whereas the amount of experience providers self-report having had in multicultural social interactions will not be a significant positive predictor of their self-reported cultural sensitivity The direction of this hypothesis was based upon the research on cultural competence which indicates that it is composed of attitudes knowledge skills and behaviors The more experience providers have had ostensibly demonstrating these aspects in the delivery of multicultural healthcare the higher their perceptions of self-reported cultural competence are likely to be 4) The predictive relationship between the amount of experience healthcare providers have had in multicultural healthcare provision (multicultural professional interactions) and the providers self-reported cultural competence will be stronger for multicultural professional interactions with patients of an

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8 ethnic minority group rather than for multicultural professional interactions with patients of an ethnicity different from that of the healthcare provider Since cultural competence represents having a knowledge base specific to various ethnicities it is likely that the more experience providers have had providing healthcare to people of ethnic minority groups the larger the body of culturally competent knowledge they will perceive themselves as possessing

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CHAPTER 2 REVIEW OF THE LITERATURE Contemporary Issues in Healthcare At no other time has the issue of racial disparities in clinical care and health outcomes been more at the forefront of public health concerns ; the elimination of such disparities is a priority in the Healthy People 2010 goals developed by the Institute of Medicine (1999) as part of the recommended national public health policy In 2002 The Commonwealth Fund published findings from the national Health Care Quality Survey which documented racial and ethnic disparities in access to care quality of healthcare and experienced health outcomes. Specifically access to healthcare is severely limited for patients who lack health insurance and Hispanic and African American adults are those who most frequently are without insurance Members of minority populations are the least likely to be under the care of a regular doctor have fewer options in terms of where they can go to receive care and are those most likely to utilize emergency departments as their primary healthcare provision site Differences in healthcare quality can also be seen among various minority groups Healthcare quality is often measured by receipt of preventive care services and management of chronic disease ( Beal 2003 p 4 ) Certain preventive services (e g ., physical exams cholesterol and blood pressure checks tests that screen for cancer ) have been reported to be more often 9

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10 received by Caucasian and African American men and women than by Hispanic and Asian American men and women (Beal 2003) Other recent studies have documented the existence of racial and ethnic disparities when measuring healthcare quality for patients with diabetes heart disease and mental illness and in the screening of women for breast cancer ; on every aspect of quality of care assessed African American patients were rated more poorly than Caucasian patients (Schnieder Zaslavsky & Epstein, 2002) These disparities are exacerbated when the patient's native language is considered. Support for this assertion is the following finding of Beal (2003) : Sixteen percent of white patients report a communication problem with their providers while 23 percent of African American patients and 33 percent of Hispanic patients have difficulties with communication However for those patients who spoke Spanish at home 43 percent reported issues of communication w i th their healthcare providers For minority pat i ents these and other experiences lead to less confidence in the healthcare system Patient dissatisfaction often associated with low healthcare quality can be extremely impactful on the patient/provider relationship In a recent study 15 percent of African Americans and 13 percent of Hispanics endorsed the belief they would have received better care if they had been of a different race or ethnicity while only 1 percent of Caucasians reported a similar belief (Beal 2003) Minority patients are significantly more likely to report that they have been treated disrespectfully during the healthcare process ; thus they may be less likely to return or follow through with necessary healthcare (Beal 2003) Beal

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11 (2003) reported finding that 16 percent of African American patients and 18 percent of Hispanic patients believed they had been treated disrespectfully during a recent healthcare visit. Beal (2003) concluded that minority patients are less confident than majority patients that they will be the recipients of quality healthcare in the future It stands to reason however that if patient dissatisfaction and lack of confidence can and does negatively affect the patient/provider relationship follow-up care and health outcomes interventions that cultivate patient satisfaction and trust in providers will likely positively impact the healthcare process particularly for minority patients Research to develop such interventions seems especially needed given census data indicating that 29 percent of the population is composed of minority individuals and that by the year 2050 nearly half the population of the U S will be people of color (U S Census Bureau 1998) Culture, Multiculturalism and Healthcare The term culture has had myriad definitions over the years and remains today without a universally accepted denotation Kagawa-Singer and Chung (1994) depict culture as a tool that defines reality for its members (p 198) ; in other words a person s life purpose unfolds through an emergent process as he or she is socialized by and within the culture and learns the accepted beliefs values and behaviors common to that society Accordingly culture serves both functional and integrative purposes ; it allows for the transmission of beliefs and values that determine the rules of behavior members of a culture must follow to

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1 2 ensure the society s survival and contributes to a sense of identity for the individual (Huff & Kline 1999) However it is important to remember that cultural parameters are essentially only possibilities for an individual s actions ; every person can and does choose from deselect and/or modify a given society s values beliefs and behaviors. For example one must consider the impact of acculturation or the degree to which a person deselects the traits of her or his original culture and adopts those of the dominant culture in which she or he resides (Huff & Kline 1999). Additionally assimilation or the integration of the social economic and political specifics of a intact culture into the mainstream society where it is situated (Huff & Kline 1999) often mediates in what might otherwise become the direct adoption of the original group s values beliefs and behaviors The understanding of culture becomes even more complex when the concepts of race and ethnicity are examined. Although the terms are frequently used interchangeably they have very discrete and distinct meanings Race is ostensibly a biological descriptive that classifies members of an ethnic group according to physical characteristics such as the color of a person s skin and the shape of the eyes nose and mouth (Montague, 1964 ) In actual fact though race is much more a sociocultural derivative whereby genetics are ignored and racial stratifications are made to promote agendas of power and control (Nelson & Jurmain 1988) On the other hand ethnicity deals more with the sense of identity an individual has based on common ancestry and national religious tribal linguistic or cultural origins (Huff & Kline 1999 p 8) A claim of shared

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13 ethnicity often indicates shared values lifestyles beliefs, and norms. Yet similarly to race ethnicity classifications are also used for the purposes of stereotyping people s differences and frequently to justify ignoble actions. Two other important aspects of culture are the notions of diversity and multiculturalism that are receiving unprecedented attention in today's scientific inquiry on a wide variety of topics (Robinson & Howard-Hamilton 2000) Specifically diversity is the condition of a multitude of differential variables (e.g. gender race ethnicity culture, sexual orientation age, able-bodiedness nationality etc ) existing within a single social political and environmental space However one does not have to look far to see that these variables have been ascribed values by societal construction and are not weighted as equally favorable In the United States dominant social discourses center around majority race (White/Caucasian American) traditional male sex roles able bodiedness youth middle to upper class status higher socioeconomic status heterosexuality etc. (Robinson & Howard-Hamilton 2000) The end product of these privileged discourses is to relay the hierarchical structure of social value where the "other" is marginalized ; ultimately systems of racism sexism able bodiedism ageism classism and homophobia are effected on individual and organizational levels (Robinson & Howard-Hamilton 2000) As a result institutions such as the health care system are predicated upon patriarchal and other value-laden beliefs (Brown 1994 2000) Through the lens of a systems approach the presence of these value-laden beliefs at a macro level can be seen at the following micro level indices which vary according to

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14 gender ethnicity and income level: rates of adherence to medical regimens, who makes use of the health care system and at what rates differential treatment and outcomes levels of patient satisfaction and the prevalence of certain types of diseases (Lewis 2002 ; Ratcliff 2002) Rather than giving mere lip service to diversity Robinson and Howard-Hamilton (2000) advocate a privileging of multiculturalism in which the various interand intra-levels of diversity peacefully coexist in egalitarian relationships and are given equal attention and value in terms of social discourse Ethnocentrism is the erroneous assumption a person makes that her or his system of beliefs values and behaviors is both correct and preferred (Ferguson 1991 ) and it pervades all levels of intrapersonal and interpersonal relationships On an organizational level within the healthcare system this can lead to interactions in which the healthcare provider may directly or indirectly discount or ignore the client's cultural orientation and belief system considering them unimportant incorrect or in conflict with the practitioner s own perceptions or worldview of how best to treat the client s health problem or issue (Huff & Kline, 1999 p 7). In addition the provision of healthcare takes place within a dyad ; that is most clinical encounters involve an interaction between two or more cultures the culture of the patient and the culture of Western medicine and/or some other culture in which the provider is indoctrinated (Pachter 1994) The Western medical model is only one of several possible explanatory models of illness and health Finally the healthcare provider is the product of her or his own cultural blend of ethnicity assimilation and/or acculturation and brings

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1 5 these values beliefs and behaviors to her or his health care provision role If we were to integrate multiculturalism in healthcare provision the cultures of all participants would be sensitively attended to as would the interaction of various cultural specifics The outcome would be a more informed collaborative and likely satisfactory encounter for both the patient and the healthcare professional. With regard to health and illness the worldview of many healthcare providers is informed by the medical model and prevailing culture of North American medical schools and practice. This worldview often assumes a position of its own centrality if not exclusivity in the worldview of the patient. However the worldview of the provider may function on the periphery of the patient s conceptual framework of health and illness It may even be usurped by the patient s worldview as it is informed by family dynamics and multigenerational cultural heritage. There is a tendency to color the cultural precepts of the etiology and maintenance of health and of the predicating factors of illness as folksy or even false (i.e. old wives tales ). There may even be polemic opposition of diverse cultural beliefs about health and illness and the tenets of Western medicine where the latter is seen as hard science and the former is seen as culturally quaint. This can subtly or dramatically affect patients' experience within the healthcare system recovery from illness and maintenance of health In actuality Western medicine arose in traceable steps from its own rich source of culture and tradition just as did indigenous practices of healing It can no more be fully extracted and made distinct from its own cultural background than can the hot toddy cure for the common cold be unlinked from the

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16 grandmother who passed that knowledge to the mother who divested it to her child Systems such as these may often be self-perpetuating but they are always the product of what came before; the practice of Western medicine is no exception nor should it strive to be so. Practitioners and the beneficiaries of that practice alike should simply seek to be informed about the cultural bases and assumptions thereof in order to achieve the greatest health outcomes. The same is true of counseling as is highlighted by Wood and Mallinckrodt's (1990) discussion of how the therapist s choice of an intervention is always value laden. In making this choice the therapist cannot escape his or her own culture which includes the culture of psychology that has been imparted during training. The dominant culture and the culture of psychology have deemed certain ... behaviors to be appropriate. This valuing of . behavior may lead therapists to adopt a let's fix the minority approach that blinds them to other possible alternatives including the alternative in which the client rejects the values of the dominant culture (Wood & Mallinckrodt 1990 p 6) Ultimately all healthcare providers and patients would benefit from specific guidelines to meet the goal of facilitating better health outcomes through culturally sensitive service provision Multicultural Counseling and Therapy Theory There is ever-increasing criticism that contemporary theories of counseling and psychotherapy are culture bound (Sue Ivey & Pedersen 1996). More specifically many experts in the field have described these theories and related courses as ethnocentric monocultural and without a conceptual framework that establishes culture as a central concept for the therapeutic relationship (Sue, Ivey & Pedersen 1996) In addition they fail to make clear or explicit the

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1 7 cultural basis and assumptions of the various theories (Sue Ivey & Pedersen 1996, p 3) Being culturally bound is a limiting factor that contributes to the assertion that current theories of counseling and psychotherapy inadequately describe, explain predict and deal with the richness and complexity of a culturally diverse population (Sue Ivey & Pedersen 1996 p 3) In order to incorporate the variable of cultural diversity into developing culture-specific healthcare delivery interpersonal behaviors and approaches the present study is utilizing Sue Ivey, and Pedersen's (1996) Multicultural Counseling and Therapy (MCT) theory as its framework. According to MCT theory counseling with culturally different individuals in a culturally appropriate manner necessitates culturally relevant knowledge experiences awareness and skills that are gained in a large degree through social contact with or social emersion in the cultures of individuals similar to those to whom counseling is provided Counseling is just one form of healthcare delivery and this theory has much to offer its sister disciplines of medicine and similar others that strive for health both mental and physical. As the U S. population continues its unprecedented rates of diversification the limitations of culture-bound theories will become increasingly unacceptable and they will be less justifiable for application to members of a multicultural society Accordingly the level of preparedness of mental health professionals to successfully and ethically manage service delivery to such a population is questionable at best (Sue, Ivey & Pederson 1996) Mental health professionals have largely been responsible for developing the science on cultural diversity and

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18 promoting multiculturalism in practice, including recommending specific efficacious interventions and behaviors in the mental health field and in other healthcare professions within Western medicine. Psychologists continue to have a vital role in assisting in the process of training other healthcare providers to take a culturally sensitive approach in the delivery of medical science. Thus the criticisms of current mental health practice when working with culturally diverse clients are often applicable to the medical practice of other healthcare providers with culturally diverse patients ; too there is much that is analogous between the role of the mental health professional and other healthcare practitioners Alternatively the implications for practice of a well-articulated theory of multicultural counseling and therapy like Sue Ivey and Pedersen s (1996) would benefit both mental health and other healthcare professionals such as physicians registered nurses physician assistants and those with direct patient contact and responsibilities for care If as Pedersen (1991) has noted existing theories of counseling and psychotherapy are not able to be easily adapted to a variety of cultures there is a great need for a theory of multicultural counseling and therapy to be elucidated for people in the helping professions. Sue (1995) argued that utilizing the perspective of multiculturalism in counseling in terms of both theory and application is most appropriate to resolve this issue of adaptability to diverse peoples. Over time multiculturalism has come to be known as the fourth force in psychology ," bearing out the importance of the development of a metatheory of multicultural counseling and therapy (MCT) as presented by Sue, Ivey and

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1 9 Pedersen (1996) These authors claim that the six propositions and related corollaries of MCT theory are grounded in the available research on and theory of multiculturalism The first proposition that underlies MCT theory is that it represents a metatheory of counseling and psychotherapy It is described as a theory about theories that offers an organizational and conceptual framework for understanding the variety of helping approaches developed by different cultures Every theory is therefore a representation of a different worldview accompanied by an inherent value within that worldview (Sue Ivey & Pedersen 1996). The second proposition states that the identities of the helping professional and her or his client are formed and embedded within multiple layers of experiences (individual group and universal) and contexts (individual family and cultural) MCT theory emphasizes the vital nature of focusing on the totality and interrelationships of these diverse experiences and contexts (Sue Ivey & Pedersen 1996) The third proposition of MCT theory is that the development of cultural identity is a major determinant of counselor and client attitudes toward the self others of the same group others of a different group and the dom i nant group These attitudes are strongly influenced not only by cultural variables but also by the dynamics of a dominant-subordinate relationship among culturally different groups (Sue Ivey & Pedersen 1996 p 25) The fourth proposition of MCT theory asserts that the effectiveness when applying MCT theory is most augmented when the help i ng professional employs modalities and articulates goals that are consistent with the life experiences and

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2 0 cultural values of the client (Sue Ivey & Pedersen 1996). This reinforces the importance of eliciting these experiences and values in a sensitive manner from the client and simultaneously being aware of one's own life experiences and cultural values and further how they interrelate with those of the client. Only then will the most collaborative goals be defined and the greatest chance of bringing them to fruition be realized The fifth proposition of MCT theory emphasizes the influence of various helping roles that have emerged in many culturally different groups and societies Besides the one-on-one encounter aimed at remediation in the individual these roles often involve larger social units systems intervention and prevention (Sue Ivey & Pedersen 1996) In Western medicine this requires recognition of the impact not only from physicians but also registered nurses physician s assistants and other hospital or clinic staff It also requires recognition by the aforementioned medical personnel of the roles played by family friends and other community members i ncluding other types of indigenous alternative or complementary healers and spiritual advisers The sixth and final proposition of MCT theory sets forth the goal of liberation of one s consciousness as it relates to multiculturalism in healthcare and other helping professions Implicit in this is the importance of the psychoeducational component of MCT theory where the role of counselor often incorporates teaching the client about the relevance of cultural dimensions to the current issues being tended to within the helping relationship (Sue Ivey & Pedersen 1996) Further the client of the counselor is frequently a member of

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2 1 the healthcare field ; often the role of the counselor is to act as a consultant to other healthcare providers and to conduct this psychoeducational component as it relates to the healthcare provider s own role in appreciating and effectively managing the underlying cultural dimensions in their own work with patients There are many implications for the practice of healthcare provision that arise from Multicultural Counseling and Therapy theory including the need to consider the culturally appropriateness of responses and recommendations by the healthcare provider Also MCT theory calls for the empowerment of healthcare providers to first consider and second to impact the social and environmental forces in the lives of their patients Multicultural specialists assert that the first step in any effective ... training is to help would-be (healthcare) professionals recognize their own culture (Sue Ivey & Pedersen 1996 p 45) Advocates for MCT theory in the field of psychology can develop trainings whose aim is to have healthcare providers become more culturally aware of their own values biases stereotypes and assumptions about human behavior (p.45) Thus, they can integrate an understanding of the self-in-context during the delivery of healthcare in multicultural interactions Culture, Illness and Healthcare Provision Models The human population is comprised of myriad culturally diverse groups whose worldviews encompass health and illness as fluid dynamic and continuous manifestations of the long-term and fluctuating relationships and dysfunctions each group member maintains with her or his family community and environment ( Landrine & Klonoff 1992 ). The health concepts and definitions

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22 of many of these cultural groups have interwoven macrolevel, interpersonal and supernatural agents of illness disease, and health causality When a person who is loyal to her or his culturally based explanatory model of health and illness seeks Western medical treatment she or he runs the risk of being labeled as a poor historian a difficult patient or a mentally ill somaticizer ; this transaction goes awry because the patient cannot provide or describe her or his symptoms in the precise clinical terms that the Western medical healthcare provider can readily treat (Landrine & Klonoff 1992) Obviously this interaction will prove less than optimal for both the provider and the patient and frequently for treatment outcome and patient satisfaction Thus there is a need to consider the best fit of current healthcare provision models with the implications offered by Multicultural Counseling and Therapy (MCT) theory In order to begin to resolve the complex interrelationships among gender culture race societal value and health one must attend to epistemologies For the last three hundred years the biomedical model has organized the development and implementation of health care (Taylor 1999) However this model has many liabilities : 1) it is reductionistic breaking illness down to lowest level processes such as chemical imbalances and cellular disorder ; 2) it is a single factor model putting all its cause-and-effect eggs into a biological basket ; 3) it deals with illness as a binary concept either present or not neglecting health as an included or different i ated construct ; 4) it is dualistic with the mind and the body as separate entities ; 5) it cannot account for social and psychological variants in the development and outcome of any illness (Taylor 1999)

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23 Accordingly, the biopsychosocial model has been proposed as an alternative theoretical orientation for exploring and meeting the needs of culturally diverse patients The biopsychosocial model initially proposed by Engel in 1977 explains illness in terms of the interplay between the biological (cellular disorder) the psychological (depression optimism) and the social (interpersonal support) factors Moreover this model incorporates indeed centralizes the state of health and does not privilege only the absence of acute or chronic illness. Also, the mind and body are viewed as interconnected and inextricable Health is holistic, necessitating biological treatment via surgery and medication but also requiring the consideration of lifestyle factors alternative and complementary medicine such as massage and acupuncture and patient co-responsibility for health status (Taylor 1999) Historically there has been the hegemony of expert knowledge as the property of the healthcare provider and denial of the patient's expertise on her or his body To the contrary a biopsychosocial model like that found in the science and application of health psychology lobbies for a co-expert model egalitarian patient provider relationship and recognition of the patient's autonomy and power in treatment options and health care seeking behaviors (Brown 2000 ; Tang & Anderson 1999 ; Taylor 1999 ; Tegtmeyer 1997). According to the propositions of Multicultural Counseling and Therapy theory (Sue Ivey & Pedersen 1996) the biopsychosocial model of healthcare provision most closely approximates the theory s call for an organ i zational and conceptual framework for understanding the variety of helping approaches

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24 developed by different cultures and features multiculturalism with the necessary centrality. Need for Culturally Sensitive Healthcare A preponderance of literature supports that ethnic minority patients experience a lower quality of healthcare as compared to patients from the ethnic majority More than 14% of African American patients report experiencing prejudice as healthcare recipients while only 1 % of Caucasian American patients report similar discrimination (Stewart et al. 1999) This type of discrimination can have severe repercussions in terms of medical outcomes In an article in The New England Journal of Medicine the authors reported that there is race and sex bias in physicians recommendations to patients with heart disease for more advanced treatment (i.e cardiac catherization) (Schulman et al. 1999) ; the practice of such discrimination puts African Americans and women at higher risk for a decreased health status Differences in attributions of causality of pat i ent complaints have also been documented Roter et al. (1997) found that primary care physicians focus more on biomedical than psychosocial aspects of their patients illnesses particularly when the patients were African Americans and were of a low socioeconomic status ; this minimized focus on psychosocial facets of patients complaints was associated with decreased patient satisfaction Patient satisfaction is one outcome variable where gaps between ethnic minority and majority patients are particularly salient.

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25 Research findings have strongly demonstrated that patient satisfaction is positively associated with adherence to medical regimens superior health outcomes and continuous participation in the healthcare process (DiPalo 1997). Safran et al. (1998) conducted a study with 6 094 ethnically diverse primary care patients including Hispanic/Latino(a) American patients and African American patients The authors concluded that patient satisfaction with their healthcare was tied to healthcare providers communication behaviors knowledge of the patient continuity of care and coordination of the healthcare services. Further the patient s trust in the provider and the provider's knowledge of the patient were strong predictors of treatment adherence (Safran et al. 1998) Another example of differences in healthcare beliefs that are specific to a patient's ethnicity is Pedersen & Tucker's (2000) findings that among pediatric renal transplant patients trust and comfort with the physician and belief that God or the Holy Spirit helps one take her/his medications were predictive of the African American patients self-reported medication adherence However, only comfort with the physician predicted Caucasian American patients self-reported medication adherence (Pedersen & Tucker 2000) Leppert et al. (1996) reported that many of the obstacles to disadvantaged Latina women receiving healthcare were physician behaviors such as not taking these women s complaints seriously and not spending enough time with them Interest in multiculturalism is at an all-time high and science including proponents of both the biomedical and biopsychosocial models of health and illness is paying more attention to the impact that variables such as race and ethnicity have upon patterns of illness suitability of treatment and satisfactory outcome (Taylor, 1999) For healthcare providers whose a i m is to incorporate multiculturalism into the i r practice and to del i ver

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26 culturally sensitive care there is a need to understand how gender and ethnicity combine to create particular issues for minority women. Those involved in the healthcare system are experiencing consciousness-raising around the integral role women play in the manner in which the system is utilized Boeke (2000) notes that despite the difficulties experienced by women in accessing healthcare, they are the primary healthcare provider/seeker and related decision maker for their families Salganicoff s et al. (2002) research showed that 6 out of 10 women (60%) participants were the primary decision-makers while 22% more made the healthcare decisions for their family jointly with their partner. Female Internet users rocketed up 35% in 2000 alone and the topics of interest were overwhelmingly healthcare for self and family community resources and childcare (Boeke 2000). Despite this vital role women play in helping to direct the healthcare choice of themselves their partners children and family detrimental and differential observations can be easily made regarding the health and illness of both non-majority and female patients Salganicoff et al. (2002) conducted a survey of 4000 nonelderly women in order to examine the impact of the variables of ethnicity and financial status on healthcare outcomes These researchers oversampled women who were Hispanic/Latina or African American uninsured of a low socioeconomic status and who were on Medicaid The survey findings showed significant high correlations among negative health outcomes underutilization of services levels of patient dissatisfaction delay of treatment discontinuity of care lack of insurance and perceptions of overall health as "fair/poor" and "limited activity ." Additionally being a woman was significantly correlated with unfavorable healthcare outcomes ; being a non-majority woman was even more strongly correlated with unfavorable healthcare outcomes Finally being a poor non majority women had the highest correlations with unfavorable healthcare outcomes (Salganicoff et al. 2002).

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27 When looking at participant subgroups by age in Salganicoff et al's (2002) research it is important to note that negative health outcomes underutilization of services levels of patient dissatisfaction delay of treatment discontinuity of care lack of insurance and perceptions of overall health as "fair/poor" and characterized by "limited activity were more frequent for older women In this study, women of a low socioeconomic status as compared to women of a high socioeconomic status also reported more illness and resulting activity limitations Health differentials by race were also documented : Latinas reported more fair/poor health status, and African Americans reported experiencing more activity limitations Women also stated that they had difficulty communicating with their healthcare providers which was worse when they had a fair/poor health status or were Hispanic/Latina Latina patients had more healthcare barriers than patients of other ethnicities, and were the least likely to have visited their healthcare service organizations in the last year Latinas and African American women were more likely to use primarily hospital clinics and health centers for their medical care than were women in the sample who were of the majority race. Overall, women received fewer screening tests for disease and illnesses when compared to a similar sample of male patients putting women more at risk for poor health. In sum barriers to healthcare were worse for the women who need it most. For such women overcoming these healthcare barriers was more challenging for those who could not easily afford the cost of care who had difficulty with transportation and/or who had to arrange for childcare in order to utilize these services

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28 Research on sex-based differences in healthcare reveal that a) physicians report preferring male patients to female patients b) women's complaints of illness are far more likely to be attributed to psychosomatic origins or stress, c) women receive less follow-up care and tests than men and d) women are prescribed more medication than are their male counterparts (Taylor 1999) In addition sex-role socialization can exacerbate this process. In a study where physicians were presented with the identical case of a woman patient with cardiac complaints except for greater emotiveness and gesticulation on the part of the patient in one of the two conditions cardiac workups were recommended 53% of the time for the emotive patient and 93% of the time for the non emotive patient (Lewis 2002) Androcentric value around marginalized sex-role feminine traits can obviously be hazardous to a woman's health (Brown 2000 ; Ratcliff 2002) Robinson and Howard-Hamilton (2000) discuss the concept of dual minority for individuals who are both female and of an ethnic minority and there are detrimental differences to be observed in the health of and healthcare provision to ethnic minority women patients Salganicoff s et al. (2002) findings of reduced health outcomes for non-majority women concurred with others who found that minority status is correlated with poorer health outcomes (e.g. ethnic minority status as compared to majority status was associated with being sicker more often and for longer periods of time and with higher mortality rates from illness) (Lew i s 2002 ; Taylor 1999) For example it has been found that ethnic minority women have higher and more fatal rates of HIV/AIDS and are diagnosed

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29 later on in the disease process partially due to the underutilization of health care services by minority patients as alluded to earlier (Lewis 2002) Research has also revealed that physicians' coercive use of power in determining treatment course is highest with ethnic minority women One documented example of such coercive power is recommending and/or pushing for hysterectomies against the wishes of ethnic minority female patients (Ratcliff 2002). Clearly when an individual is both female and of a non-majority race her status as a dual minority presents a risk factor that must be further examined via research and thoroughly attended to by health care providers (Lewis 2002). Without a biopsychosocial model of medical training that includes a focus on communication interpersonal skills and the art of the interview the provider will have much more difficulty soliciting patient cooperation in regimen adherence a less likelihood of favorable medical outcomes and perhaps a greater likelihood of malpractice suits (Taylor 1999) Participants in the healthcare system (patients, providers and researchers) must consider the interplay of such factors in health and illness especially when multiple diversity variables are relevant to an individual (e g ., an ethnic minority woman) An egalitarian collaborative approach will likely serve to distribute more equitably and effectively the responsibility of a truly multicultural healthcare system among all participants and subsequently improve indices of favorable healthcare outcomes

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30 Multiculturalism and Research Design Multicultural Counseling and Therapy (MCT) theory indicates that past research on culturally diverse populations is culturally bound and at best leads to an extremely narrow view of the meaning and importance of culture in the helping process (Sue Ivey & Pedersen 1996 p 31 ). In addition it advocates for beginning all counseling research with the premise that culture is a constant presence in how questions about the human condition are asked and answered In a review of counseling research Ponterotto and Casas (1991) concluded that investigators continue to use culturally biased measures and seemingly do not employ cultural sensitivity when interpreting results. These researchers also concluded that only a fraction of studies published in counseling journals have attended to race ethnicity or culture and that fewer still incorporated these variables as independent variables Further Ponterotto and Casas (1991) made recommendations for future multicultural counseling research that included focusing on the racial cultural and/or ethnic issues of majority people (white) as well as those of minority people developing assessments appropriate to minority populations and balancing attention to emic (culture specific) and etic (culturally universal) aspects of the help i ng process MCT theory has important implications for practice that are consistent with the culture-centered approach to healthcare that is endorsed by the study being proposed These implications include a broadening of the perspective of the healthcare provider s helping role an expansion of the repertoire of culturally appropriate helping responses available to healthcare providers and

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3 1 identification of alternative roles that empower healthcare providers to influence the social and/or environmental forces act i ng on the lives of their patients ( Sue Pedersen & Ivey 1996) Another implication of MCT theory is that in order to overcome limitations of past research and to develop a truly multicultural approach to the helping profession a variation in the paradigmatic approach to medical science is warranted Indeed the positivistic scientific method (Heppner Kivlighan & Wampold 1999) does not easily allow for patient participation in the healthcare process By contrast qualitative research designs in healthcare allow exploration of the complexity and richness of the human experiences (e g ., patients experiences related to health, healthcare and illness) gleaned from the participants' words and explicated meaning (Heppner Kivlighan & Wampold, 1999 ; Morrow & Smith 2000). Furthermore in qualitative research the focus is on a science of discovery and understanding not of theory verification leading to prediction and control (Borgen 1992) Most of the research thus far on the healthcare needs of culturally diverse patients has used a qualitative design ( i. e ., Salganicoff et al. 2002) of a type such as narrative conversation analysis case study or grounded theory Strauss and Corbin's (1990) grounded theory qualitative analysis is particularly appropriate for exploration of the healthcare needs of culturally diverse patients This design incorporates an inductive approach where a) i nvestigators and participants interact with each other as the researchers immerse themselves into the participants' world b ) participants often function as

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32 co-researchers and analysts of data and c) a theory emerges from the data itself through an emphasis on discovery thick description and participant meaning (Morrow & Sm i th 2000 ; Strauss & Corbin 1990) Data from participants collected via such procedures as focus groups then undergo open axial and selective codings to flesh out properties of categories relationships among categories and overall core schemas Results of these procedures are then put to a constant comparison analysis against extant data as new data continue to emerge Once no new properties emerge from theoretical sampling from the population of interest the core category can be considered saturated and presented to the audience R i gor is determined by coherence of the data structural corroboration via internal category consistency and comparisons to new data for goodness of fit and ecological applicability as judged by the audience (Morrow & Smith 2000 ; Strauss & Corbin 1990). An example of this type of design is Anderson s et al. (2001) 18 focus group study on the meaning of women's health and perceptions of need Female patients stratified by age and race participated in focus groups to detail their meaning of women's health and criteria for satisfaction with health care providers and the health care system Overall women wanted healthcare that was holistic or attending to physical emotional and psychological needs (consistent with the biopsychosocial model) They wanted a treatment model that included traditional surgery and medications plus alternative/complementary treatments and a premium was placed on continuity and personalization of care They desired a focus on family and women's issues such as nutrition chronic illness prevention

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33 (e g ., prevention of osteoporosis and resolution of the fragmented healthcare system that led to their experience of lack of coordination of care (Anderson et al. 2001) Important dimensions of healthcare identified by patients through the qualitative analysis in Anderson s et al. (2001) research included a) efficient access (i.e ., clinic hours) that is tailored to women's unique roles as caregiver to children and partners b) privacy and comfort (i.e ., remaining fully clothed while having pre-exam discussion with the healthcare provider) c) care coordination and cohesiveness (i.e ., timely notification of test results whether positive or negative opportunity for consultation with the provider) and d) education on their illness and preventative care. Women wanted a provider who acted in partnership with them and worked as an advocate on their behalf in areas such as insurance reimbursement. Anderson et al. (2001) concluded that healthcare should be unique to the patient focusing not just on her medical status but also on her life circumstances and on exploration of barriers to treatment (e g ., treatment cost and availability of transportation) This was particularly important with ethnic minority patients who might have cultural beliefs regarding home remedies that are at odds with biomedical practice and who tend to utilize lay referral networks within their collectivistic community (Anderson et al. 2001) Tucker s et al. (2003) research suggests that culturally diverse patients rather than healthcare providers or administrators are the true experts at identifying the behaviors that make patients feel comfortable and trusting and feel that their culture is respected in the healthcare process Yet inadequate

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34 numbers of low income and minority patients have been asked to carry out this crucial task of elucidating the facets of culturally sensitive healthcare In a large federally funded grant study which the present principal investigator helped conduct, focus groups of African American, Hispanic/Latino(a) American, and Caucasian American primary care patients at community healthcare clinics identified the knowledge behaviors attitudes and experiences that constitute culturally sensitive healthcare (Tucker et al. 2003) This research attempted to define culturally sensitive healthcare from the patients' perspective rather than from the perspective of experts as usually occurs Twenty focus groups were conducted separately by race and gender to explore the views of low income, culturally diverse primary care patients as to provider behaviors and healthcare characteristics that constitute culturally sensitive healthcare. Patient participants were 52 adult African American patients 45 Hispanic/Latino(a) American patients and 38 Caucasian American patients Specifically these patients were asked to identify provider behaviors and attitudes that made them feel comfortable with trusting of and respected by their providers and clinic characteristics that made them feel comfortable and a sense of belonging at their healthcare clinic. The focus group interviews were recorded transcribed and analyzed using the constant comparative method from ground theory analysis Tucker et al s (2003) research produced several universal themes to the responses of the three ethnic groups Some of the themes indicating culturally sensitive healthcare delivery by physicians included people skills, individualized treatment effective communication and technical competence Also some

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35 ethnic group-specific themes were demonstrated African American patients indicated the importance of trustworthiness of their physician and the physician s acknowledgement of the patient s fear of being used as a guinea pig ." Hispanic/Latino(a) American patients stressed the importance of sharing a common language with their physician Caucasian American patients emphasized the development of a collaborative relationship with their physician The findings from this research suggest that healthcare provider training may need to include a focus on learning patient-defined culture-specific healthcare delivery interpersonal behaviors and approaches The characteristics of culturally sensitive healthcare as have been identified by ethnic minority patients suggest that healthcare providers need to have good counseling skills such as listening attentively engaging in good eye contact that builds trust and respecting patients' views values and traditions The research of Tucker et al. (2003) and Tucker et al. (unpublished manuscript) bolster the growing consensus that a) healthcare requires addressing the physical and psychological aspects of illness health and well-being and b) related differences and similarities in these aspects that exist among ethnically diverse patients should also be considered in the healthcare delivery process Accordingly this present study utilized data from the research of Tucker et al. (2003) research which included both qualitative and quantitative methodologies as is recommended by the authors of MCT theory Using this combination of research designs ethnically diverse patients identified the knowledge behaviors attitudes and experiences that constitute culturally

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36 sensitive healthcare from their own perspective rather than from the perspective of healthcare professionals This data was used to construct ethnicity specific Tucker-Culturally Sensitive Healthcare Inventories (T-CUSHCls), that have been demonstrated to have good test-retest reliabilities and internal consistencies These T-CUSHCls (Tucker et al. unpublished manuscript) include versions for patients to evaluate the cultural sensitivity of their providers and versions for providers to self-evaluate their cultural sensitivity (the T-CUSHCI Physician Form (PF) and the T-CUSHCI Health Care Provider (HCP) Form ; see Appendices B & C respectively) In the present study healthcare providers self-reported levels of patient defined cultural sensitivity using an appropriate T-CUSHCI (i.e ., the T-CUSHCI Physicians Form or the T-CUSHCI Health Care Providers) and they self reported their expert-defined cultural competence using the Cultural Competence Self-Assessment Questionnaire Service Provider Version (CCSQ-SPV) developed by Mason (1995) By exploring and comparing these self-reports this research invoked what Sue Pedersen and Ivey (1996) term the third presence" of culture within the relationship between the healthcare provider and the patient and met the primary training goal implied by MCT theory of having those in helping professions become more culturally aware of their own values biases stereotypes and assumptions about human behavior (p 45) Inviting and integrating the patient s perspective in the healthcare planning and delivery processes by healthcare providers represents a collaborative approach to providing culturally sensitive healthcare an approach that can lead to improved

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3 7 healthcare satisfaction and better health outcomes among patients espec i ally those who are ethnic minorities Researching Cultural Sensitivity Ridley et al. (1994) conducted a critical examination of the construct of cultural sensitivity as it is presently conceptualized in the counseling literature and highlighted limitations of the current definition of cultural sensitivity The limitations include 1) definitional variance ; 2) inadequate descriptors of indicators of cultural sensitivity ; 3) lack of theoretical grounding ; and 4) lack of measurements and research designs The limitation of definitional variance refers to the fact that cultural sensitivity has many different overlapp i ng definitions ; it is often interchanged with other constructs such as cultural competence cross-cultural expertise cross-cultural effectiveness cultural responsiveness and cultural awareness resulting in many unclear constructs with indeterminate meanings Also the complexity with which cultural sensitivity is usually defined is compounded by the inclusion of definitions with multiple components ; this exacerbates the difficulty in achieving agreement among the experts on a single definition of the construct. The present research directly addressed this concern of Ridley et al. ( 1994 ) regarding investigations of the construct of cultural sensit i vity Cultural sens i tivity is simply and specifically defined and the issue of whether its definition is confounded with that of cultural competence is directly addressed Cultural competence i s defined as having the knowledge skills experiences and awareness necessary to engage i n healthcare that is r espectful of pat i ents

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3 8 cultural heritage Cultural sensitivity in healthcare has three defining characteristics (Tucker et al. 2003) It involves 1) communicating or displaying culture-related knowledge skills and awareness in ways that make people feel that their culture is respected and that make them feel comfortable with and trusting of the healthcare they receive ; 2) embracing the view that culturally diverse patients are the experts at identifying the behaviors/attitudes and healthcare environment variables that are indicators of culturally sensitive healthcare ; and 3) engaging in specific provider and staff behaviors and provider/staff-patient interactions as well as promoting physical healthcare environments that encourage patient trust i n comfort with and feelings of being respected by healthcare providers and staff (Tucker et al. 2003) The limitation of having inadequate descriptors of the indicators of cultural sensitivity as mentioned by Ridley et al. (1994) is particularly noteworthy These researchers break down known indicators of cultural sensitivity into a three category continuum which includes 1) prerequisites of culturally responsive behavior such as cognitive abilities knowledge and awareness ; 2) culturally responsive behaviors including expression of one's own values and setting culturally relevant treatment goals ; and 3) the effects of culturally responsive behaviors such as high client satisfaction However very few investigators have provided specific examples of these behaviors and there are virtually no actual samples of cognitive indicators of cultural sensitivity The present study utilized a measure of patient-defined cultural sensitivity (e g ., the T-CUSHCI-HCP and the T CUSHCI-PF for providers to self report their cultural sensitivity) that includes

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39 specific behaviors, attitudes and knowledge of providers that mostly low income African American Hispanic/Latino(a) and Caucasian American primary care patients consider to be indicators of cultural sensitivity by their providers Among these indicators are those specific to the African Americans Hispanic/Latino(a) Americans or Caucasian Americans who generated these indicators (i.e ., emic indicators) and those which are common across the three ethnic groups that generated these indicators (i.e ., etic indicators) The third limitation of the construct of cultural sensitivity identified by Ridley et al. (1994) is a lack of theoretical grounding According to these researchers the term cultural sensitivity is used to encompass a complicated network of distinct variables that interact to produce the desired effect of providing culturally sensitive care to culturally diverse clients These researchers claim that cultural sensitivity is often described by others as essential to therapeutic success without explaining how to achieve it or why it is necessary (Ridley et al. 1994) The foundational research for the present study (i.e ., the research of Tucker et al. 2003) is based on Wilde's et al. (1993) theory of quality of care This theory asserts that there are four dimensions of healthcare that inform the construct of culturally sensitive healthcare : 1) the medical-technical competence of the healthcare providers ; 2) the physical-technical conditions of the service organization ; 3) the identity-orientation of the providers attitudes and behaviors ; and 4) the sociocultural ambience of the service organization (Wilde et al. 1993 ).

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40 The former two dimensions are reminiscent of the traditional Western medical model of healthcare while the latter two dimensions resemble the psychosomatic model of healthcare wherein the value of psychological and emotional facets of illness and health are recognized and appreciated (Glaser & Strauss 1967; Wilde et al. 1993) Specifically identity-orientation refers to "patients' desire for care with a human face in relation to the caregivers (Wilde et al. 1993 p. 116) An identity-oriented approach includes the provider's showing interest in and commitment to the patient's situation demonstrating respect and trustworthiness utilizing an approachable personal style characterized by honesty sincerity and empathy and working to minimize the power differential between provider and patient through soliciting patient collaboration in the provision of her or his healthcare. The sociocultural ambience of the service organization refers to an environment that is reminiscent of a home rather than an institution where the wishes and needs of the patients have priority over fixed routines . where the patient has the opportunity for self-chosen seclusion and/or self-chosen socializing whenever he or she wishes ", and where providers "listen and help the patient in the way that he or she wants (Wilde et al., 1993 p. 117) The T-CUSHCls (Physician Form and Health Care Provider Form), measures that were used in the present study to assess providers self-reports of the degree to which they engage in the provision of patient-defined culturally sensitive healthcare relate specifically to the third aspect of Wilde s et al. quality of care theory the identity-orientation of the providers attitudes and behaviors Implicit in these inventories and in their use in this present research is the view

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4 1 that patients are the experts on culturally sensitive healthcare and should be empowered partners in promoting such care Finally the assertion of Ridley et al. (1994) that measurement and research design limitations plague the construct of cultural sensitivity is important to note Until the recent development of the T-CUSHCls there were no published instruments that specifically measured cultural sensitivity as a distinct construct. There are existing inventories for measuring cross-cultural competence but in these instruments cultural sensitivity is not patient-defined and appears confounded with cross-cultural competence Past research gives few details about the specific behaviors that constitute culturally sensitive behavior The present study utilized the T-CUSCHls Physician Form and Health Care Provider Form, the first inventories for providers to self-report the degree to which they engage in the provision of patient-defined culturally sensitive healthcare and a measure of cultural competence the Cultural Competence Self-Assessment Questionnaire Service Provider Version (CCSQ-SPV) (see Appendix D). In summary, the present study investigated how multicultural social and professional interactions are related to self-reported cultural sensitivity and cultural competence among healthcare professionals Healthcare provider participants self-reported levels of patient-defined cultural sensitivity using the appropriate T CUSHCI (Tucker et al. 2003) ; they also self-reported their expert defined cultural competence using the CCSQ-SPV (Mason 1995). Specifically the present study examined two types of self-reported multicultural interactions :

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42 1) amount of self-reported experience that providers have providing healthcare to African Americans, Hispanic/Latino(a) Americans, and Caucasian Americans; and 2) amount of self-reported experience socially as an adult with the same populations. These two types of multicultural interactions, professional and social were measured in two ways: the amount of experience healthcare providers self-report having spent with people of an ethnic minority group and the amount of self-reported experience providers have had with people of an ethnic group different from that of the individual healthcare provider. Thus in this study the amount of self-reported experience healthcare providers have had providing healthcare and the amount of self-reported experience socially providers have had as adults were independent variables and these providers' self-reported cultural sensitivity and cultural competence were dependent variables Four hypotheses were tested: 1) The amount of experience healthcare providers self-report having had in multicultural social interactions will be a significant positive predictor of providers self-reported cultural sensitivity whereas the amount of experience providers self-report having had in multicultural healthcare provision (multicultural professional interactions) will not be a significant positive predictor of their self-reported cultural sensitivity ; 2) The predictive relationship between the amount of experience healthcare providers self-report having had in multicultural social interactions and these providers self-reported cultural sensitivity will be stronger for multicultural social interactions with people of an ethnic group different from that of the healthcare provider rather than for multicultural social interactions with people of an ethnic

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43 minority group ; 3) The amount of experience healthcare providers self-report having had in multicultural healthcare provision ( multicultural professional interactions) will be a significant positive predictor of providers self-reported cultural sensitivity whereas the amount of experience providers self-report having had in multicultural social interactions will not be a significant positive predictor of their self-reported cultural sensitivity ; and 4) The predictive relationship between amount of experience healthcare providers self-report having had in multicultural healthcare provision (multicultural professional interactions) and the providers self-reported cultural competence will be stronger for multicultural professional interactions with patients of an ethnic minority group rather than for multicultural professional interactions with patients of an ethnic group different from that of the healthcare provider.

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CHAPTER 3 METHODOLOGY This chapter presents descriptions of the participants assessment battery and procedure. Participants The final sample of 32 healthcare providers who participated in the study included 22 physicians and 10 other healthcare providers (19 females, 13 males) Table 3.1 provides additional demographic description of the participant sample All participants were recruited from Eastside Health Center and Gainesville Family Medical Group Practice as part of a larger study of culturally sensitive healthcare Instruments Each participant completed an Assessment Battery consisting of the following : (1) the Healthcare Professional Demographic Data and Cultural Experiences Questionnaire (HCP-DDQ) ; (2) the appropriate Tucker-Cultural Sensitivity Healthcare Inventory (T-CUSHCI) either the Physician Form (PF) or the Healthcare Provider Form (HCP) to assess healthcare providers' self evaluations of patient-defined cultural sensitivity ; (3) the Cultural Competence Self-Assessment Questionnaire Service Provider Version (CCSQ-SPV) to assess healthcare providers self-evaluations of non-patient or expert "defined culturally competent healthcare provision ; and (4) the Marlowe-Crowne Social 44

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45 Table 3 1 Characteristics of Study Partici~ants Characteristic N % Professional Role Physician 22 68 8 Other Healthcare Professional 10 31 3 Gender Female 19 59.4 Male 13 40 6 Ethnicity African American/Black American 3 9.4 Asian American/Pacific Islander 1 3 1 Caucasian/White American 24 75 0 Latino(a)/Hispanic American 3 9.4 Other (Indian) 1 3 1 Nationality U S.A. 25 78 1 Non-U.S A. 7 21 9 Native/First Language English 28 87.5 Spanish 3 9.4 Other ( Hindi) 1 3 1 Fluency in Non-English Language None 25 78 1 Spanish 3 9.4 Other 4 12 5

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46 Table 3.1 Continued Characteristic N % Time in direct patient care 32 61.56 in the 12 months prior M so Min Max Age 37 70 11.64 26.00 60.00 Years in clinical practice 9.50 11.41 00 38 50 Professional interactions with 4.38 .71 2 00 5 00 African American patients Professional interactions with 3.66 94 2 00 5 00 Hispanic/Latino(a) patients Professional interactions with 4 59 56 3 00 5 00 Caucasian American patients Social interactions with 3 28 1 14 1 00 5 00 African Americans Social interactions with 3 25 98 2 00 5 00 Hispanic/Latino(a) Americans Social interactions with 4.47 72 2 00 5 00 Caucasian Americans Note. Professional and social interactions were measured on a scale from 1 to 5 with higher ratings indicating a greater amount of experience in these self reported interactions Desirability Scale short-form (M-CSDS-SF) to assess the degree to which participants responded in a socially appropriate manner. A Healthcare Professional Demographic Data and Cultural Experiences Questionnaire (HCP-DDQ; see Appendix A) was used to ascertain information about the participants including age gender nationality race/ethnicity time spent in clinical practice time spent as an employee at her/his current healthcare

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47 provision site estimation of the percentage of time s/he spent in direct patient care in the last twelve months native/first language the experiences/he has had in providing healthcare to three different ethnic groups (African American Hispanic/Latino(a) American and Caucasian American patients) and the experience, as an adult s/he has had socially with three different ethnic groups (African Americans Hispanic/Latino(a) Americans and Caucasian Americans) The Tucker-Cultural Sensitivity Healthcare Inventories (T-CUSHCls ; see Appendices B & C) was used to assess healthcare providers' self-reports of patient-defined cultural sensitivity Specifically the following two T CUSHCls were used : the T-CUSHCIPhysician Form (PF) and the T-CUSHCIHealth Care Provider Form (HCP) These instruments were developed by Tucker et al. (2001) in a study with 134 primary care patients (52 African Americans 38 Caucasian Americans and 45 Hispanic Americans) Twenty focus groups were conducted separately by race and gender to explore these patients' experiences with cultural sensitivity in their relationship with their primary care provider Focus group interviews were recorded transcribed and analyzed using the constant comparative method from ground theory analysis Responses were then grouped into primary and secondary features which indicated several universal features of cultural sensitivity in healthcare as well as features specific to the three ethnic groups A T-CUSHCI was developed from raw data-based patient responses taken from the focus group transcripts for each of the three ethnicities of the focus group members African American (AA ) Caucasian American ( CA) and Hispanic American (HA) : T-CUSHCIAA T-CUSHCI-CA and T-CUSHCI-HA

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48 The next stage of instrument development encompassed a demographically similar group of 221 of primary care patients (82 African American 94 Caucasian American and 45 Hispanic American patients) who rated the importance of each behavior and attitude that the focus group patients had identified as important to have displayed by their physician or other healthcare provider as indicators of culturally sensitive healthcare. The focus group generated items were organized into five groups: 1) provider trust behaviors 2) provider comfort behaviors 3) provider respect behaviors 4) clinic staff behaviors and 5) clinic environment characteristics The new group of 221 primary care patients then rated the importance of these items on a five-point rating scale where 1 = not at all important 3= important and 5= extremely important. The items rated as 3 4 or 5 were then used to construct the final three ethnicity/race specific inventories T-CUSHCIAA T-CUSHCI-CA and CUSHCI-HA To construct the healthcare provider versions of the T-CUSHCls (i.e ., CUSHCI-Physician Form and T-CUSCHI-Health Care Provider Form) items from the three final ethnicity/race specific inventories were combined to form the measures for healthcare providers to self-report their patient-defined cultural sensitivity (see Appendices B & C) Any item that was mentioned by more than one of the three ethnicities was only included one time on the provider versions The content of the items and the response formats of the T-CUSCHI-Physician Form and the T-CUSCHI-Health Care Provider Form are identical except that they are differentiated by the use of the term physician versus "health care

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49 provider as is appropriate Sample items from the T-CUSHCI-PF/HCP include : 1) I am honest and direct with my patients ; 2) I am compassionate with my patients ; and 3) I am respectful of my patients religious beliefs Studies of reliability and validity of the T-CUSHCls indicate that these measure appear to be reliable and valid inventories for assessing the level of perceived cultural sensitivity in healthcare received (patient forms) and healthcare provided (provider forms). Reliability was examined in several ways. For the patient forms of the T-CUSHCI internal consistency ranged from 92 to 99 split-half reliability from .77 to 96 one-month test-retest reliability from 92 to 99 and five-month test-retest reliability from 98 to .99 For the physician and healthcare provider forms of the T-CUSCHI internal consistency ranged from 52 to 98 split-half reliability from 68 to .82 and test-retest reliability from 70 to 74 The Cultural Competence Self-Assessment Questionnaire Service Provider Version (CCSQ-SPV ; see Appendix D) was used to assess the healthcare providers' self-evaluations of non-patient or expert -defined culturally competent healthcare provision This reliable (alpha coefficients of 80 or higher for the majority of subscales) and valid measure was developed by the Research and Training Center on Family Support and Children s Mental Health (Mason 1995) The CCSQ SPV is an 80-item inventory that is designed to assess the cultural competence training needs of mental health and human service professionals including healthcare providers (see Appendix D) It includes the following subscales : a) healthcare providers knowledge of communities ; b) personal involvement with ethnic minority groups ; c) service delivery and

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50 practice, and d) reaching out to communities ; While the CCSQ-SPV includes three additional subscales (resources and linkages with the healthcare providers' service clinics to ethnic minority groups ; clinic staffing; and organizational policies and procedures) these three subscales were eliminated from the analyses as their content was not related the direct service practice of the healthcare providers. Sample items from the CCSQ-SPV include : 1) How well are you able to describe the communities of color in your service are ; 2) Do you know the cultural-specific perspectives of mental health/illness as viewed by the groups of color in your area ; and 3) Do you discuss racial/cultural issues with consumers in the treatment process. The Marlowe-Crowne Social Desirability Scale short-form (M-CSDS-SF ; see Appendix E) by Marlowe and Crowne (1964) was used to measure the participants' tendency to respond to questions in a culturally appropriate manner. The short form is a 20-item inventory designed to assess whether or not respondents give socially desirable answers as opposed to accurate ones. Sample items on the M-CSDS short form include: I can remember playing sick to get out of something ", and There have been occasions when I felt like smashing things ." Higher scores on the M-CSDS-SF indicate a more socially desirable response set. Fraboni and Cooper (1989) found a 80 to .84 test-retest reliability for adults Procedure Healthcare providers (e g. physicians nurses physician assistants and other allied healthcare professionals) were recruited via a letter to and staff

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5 1 meetings at two local participating community healthcare clinics Eastside Health Center and Gainesville Family Medical Group Practice to be participants in the present research (see Appendix F). The letter was signed by the administrators of the two participating clinics (co investigators for the project) and by the principal investigator of the larger study of cultural sensitivity of which the present study is a sub study. It was explained via letter and at the staff meetings that participation in this research would involve spending approximately 60 minutes anonymously completing a set of questionnaires (the Assessment Battery) within one week of receiving the packet of questionnaires Additionally it was explained that signing an informed consent form giving written consent to participate was required that the consent form was the first in the questionnaire packet to be completed and that the completed set of materials was to be returned via a locked box in a secure location in each healthcare clinic The Clinic Secretary at each participating clinic distributed the Assessment Battery to the healthcare providers Further it was explained that participation in this study is voluntary that participants can discontinue participation at any time and that refusal to participate would in no way affect their employment status. Participants were informed that at no point would any clinic administrative personnel have access to individual responses or individual study data To ensure confidentiality of responses participants were asked to not place their names on the questionnaires but to rather generate a healthcare professional pr i vate identification number which they placed on each questionnaire Additionally

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5 2 participants were asked to place the informed consent form in a separate lock box from all other measures and the informed consent form was stored separately from all other measures Participants were also informed that they would receive three Continuing Medical Education credits for completion of the research questionnaires and at a later date for attending a 3-hour workshop on patient-defined culturally sensitive healthcare that is part of the larger study of which the present research is a sub-study

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CHAPTER 4 RESULTS This chapter addresses the results of the analyses to test the study hypotheses Descriptive Data for the Major Variables of Interest Table 4.1 provides descriptive data for the major variables of interest: (a) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) (b) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant (MPI-EGD) (c) amount of self reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-EMG) (d) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI-EGD) (e) level of self-reported Cultural Sensitivity (CS) (f) level of self-reported Cultural Competence (CC) and (g) Social Desirability (SD) The results show that participants reported a wide range of scores for each of the major variables of interest indicating the appropriateness of parametric statistical approaches. In addition measures of skewness were within normal limits suggesting that transformation of scores ( e g log linear) was not necessary 53

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54 Table 4 1 Descriptive Statistics for Major Variables of Interest Study variable M so Min Max Skewness MPI-EMG 8.03 1.43 4 00 10 00 .59 MPI-EGD 8 34 1 68 4 00 12 00 07 MSI-EMG 6 53 1 72 4 00 10 00 31 MSI-EGD 6 72 2.29 4 00 13 00 1 35 cs 3 18 30 2 75 3.72 .40 cc 2.38 .42 1 79 3.29 59 SD 9.71 4 87 1 00 20.00 14 Note MPI-EMG = Amount of self-reported experience in multicultural professional interactions with people of an ethnic minority group; MPI-EGD = Amount of self-reported experience in multicultural professional interactions with people of an ethnic group different from that of the participant ; MSI-EMG = Amount of self-reported experience in multicultural social interactions with people of an ethnic minority group ; MSI-EGD = Amount of self-reported experience in multicultural social interactions with people of an ethnic group different from that of the participant ; CS = Level of self-reported cultural sensitivity ; CC = Level of self-reported cultural competence ; SD = Social desirability Preliminary Data Analysis A preliminary Pearson Product Moment Correlation analysis was conducted to examine the relationships among the major variables of interest in the study. Results of this analysis are displayed in Table 4 2 The preliminary correlation analysis was completed to determine if the major variables of interest were related whether participants responses were influenced by social desirability how the major variables of interest were related and the necessity and appropriateness of planned subsequent analyses to test the hypotheses set forth in the study.

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55 The first question of interest in reviewing the results of this preliminary correlation analysis was whether the variables level of self-reported Cultural Sensitivity (T-CUSHI mean scores) and level of self-reported Cultural Competence (CCSQ-SPV mean scores) were significantly correlated The answer to this question would determine whether these variables should be examined separately or together in subsequent analyses The analysis revealed that levels of self-reported Cultural Sensitivity and Cultural Competence were not significantly correlated r = 04 p = 82 Thus these variables were considered unrelated indicating the appropriateness of examining these variables separately in subsequent analyses in which levels of self-reported Cultural Sensitivity and Cultural Competence were criterion variables The second question of interest when reviewing the results of the preliminary correlation analysis was whether participants scores were significantly related to Social Desirability as measured by the Marlowe-Crowne Social Desirability Scale-Short Form (M-CSDS-SF) As shown in Table 4 2 Social Desirability was not significantly correlated with any of the major variables of interest. Specifically there was no significant correlation between Social Desirability and level of self-reported Cultural Sensitivity r = 21 p = 27 and no significant correlation between Social Desirability and level of self-reported Cultural Competence r = .07 p = 71

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56 Table 4.2 Correlation Matrix showing lntercorrelations among Major Variables of Interest Study variable 1 2 3 4 5 6 7 1 MPI-EMG 75** 34 17 38* 50** -.10 2 MPI-EGD .49 ** 63 * 30 .45** 03 3. MSI-EMG 86 ** .04 .40* 22 4 MSI-EGD 03 .32 17 5. cs 04 21 6. cc 07 7 SD Note MPI-EMG = Amount of self-reported experience in multicultural professional interactions with people of an ethnic minority group ; MPI-EGD = Amount of self-reported experience in multicultural professional interactions with people of an ethnic group different from that of the participant ; MSI-EMG = Amount of self-reported experience in multicultural social interactions with people of an ethnic minority group ; MSI-EGD = Amount of self-reported experience in multicultural social interactions with people of an ethnic group different from that of the participant ; CS = Level of self-reported cultural sensitivity ; CC = Level of self-reported cultural competence ; SD = Social desirability *p < .05 (2-tailed). ** p < 01 (2-tailed) In addition Social Desirability was found to have a nonsignificant relationship with (a) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) r = 10 p = 61 (b) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant (MPI-EGD) r = -.03 p = .86 (c) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI

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57 EMG) r = .22 p = 25 and (d) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI-EGD) r = 17 p = 37. These findings suggest that the participants scores on the major variables of interest were not systematically influenced by Social Desirability and that additional statistical approaches to account for this potential influence (i e ., analyses of covariance) were not warranted in subsequent analyses addressing the study hypotheses. The final question of interest in reviewing the results of the preliminary correlation analysis was to examine the relationships among the major variables of interest. As seen in Table 4 2 there were several significant relationships among the major variables of interest. The variable level of self-reported Cultural Sensitivity was significantly correlated with amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) r = .38 p = .03 None of the other variables were significantly correlated with level of self-reported Cultural Sensitivity Specifically level of self reported Cultural Sensitivity was found to have a nonsignificant relationship with (a) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant (MPI-EGD) r = 30 p = .10 (b) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-EMG) r = 04 p = 82 and (c) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI-EGD) r = 03 p = 86

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58 The variable level of self-reported Cultural Competence was found to have a significant positive correlation with the following major variables of interest: (a) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) r = 50 p < 01 (b) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant (MPI-EGD), r = .45 p = 01 and (c) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-EMG) r = .40 p = 02 The variable level of self-reported Cultural Competence was found to have a nonsignificant relationship with amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI-EGD) r = 32 p = 08 The presence of some significant correlations among the major variables of interest justifies planned additional regression models to test the hypotheses in the study Results from the preliminary correlation analysis revealed several significant relationships among the following four major variables of interest: (a) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG), (b) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant (MPI-EGD), (c) amount of self reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-EMG) (d) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from

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59 that of the participant (MSI-EGD) Amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) was significantly correlated with amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant (MPI-EGD) r = 75 p < .01 None of the other major variables of interest were significantly correlated with amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) Specifically, amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) was found to have a nonsignificant relationship with (a) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-EMG) r= 34 p = .06 and (b) amount of self reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI-EGD) r = .17, p = .35 Additionally it was found that amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant (MPI-EGD) was significantly correlated with (a) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-EMG r = .49 p < 01 and (b) amount of self reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI-EGD) r = 63 p < 01 Amount of self-reported experience i n Multicultural Social Interactions with people of an Ethnic Minority Group (MSI EMG) was significantly correlated with amount of

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60 self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI-EGD), r = 86, p < .01. The presence of significant correlations among these four major variables of interest indicates the need to examine collinearity in subsequent regression models. Hypotheses Hypothesis One Hypothesis One was as follows : 1) Healthcare providers self-reports of the amount of experience in multicultural social interactions (as measured by sub-scores on the HCP-DDQ) will be a significant positive predictor of self reported Cultural Sensitivity (as measured by mean scores on the T-CUSHCI Physician Form or Health Care Provider Form) whereas healthcare providers self-reports of the amount of experience in multicultural professional interactions (as measured by sub-scores on the HCP-DDQ) will not be a significant positive predictor of Cultural Sensitivity The direction of this hypothesis was based upon Multicultural Counseling and Therapy theory s implied importance of social immersion in culturally different groups in developing sensitivity to multicultural issues (Sue Ivey & Pedersen 1996) Hypothesis One was tested using two forced-entry stepwise multiple regression models In the first model amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) and amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-EMG) were the two predictor variables In the second model amount of self-reported experience in

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6 1 Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant (MPI-EGD) and amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI-EGD) were the two predictor variables. Healthcare providers self-reports of Cultural Sensitivity were the criterion variable in both regression models. Hypothesis One was only minimally supported by the study findings Table 4 3 describes the results of the first forced-entry stepwise multiple regression analysis using MPI-EMG (i e ., amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group) and MSI-EMG (i e ., amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group) as predictor variables The overall model fit was significant at the first step but not at the second step At the first step of forced-entry with the first predictor variable (MPI-EMG) in the model MPI-EMG accounted for 14.4% of the variance This overall R2 value at this first step was significant (F(1 30) = 5 03 p = 03) At the second step of forced-entry with both predictor variables (MPI-EMG and MSI-EMG) in the model the variance accounted for was 15.2% This overall R2 value at the second step was not associated with a significant overall model fit (F(2 29) = 2 59 p = 09)

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62 Table 4 3 Prediction of Cultural Sensitivity by Multicultural Professional and Social Interactions with People of an Ethnic Minority Group Step 1 Step 2 Variable MPI-EMG MPI-EMG MSI-EMG 14 14 15 01 B SEB /3 sr2 08 04 38* 14 09 04 .41 15 02 03 10 01 Note. MPI-EMG = Amount of self-reported experience in multicultural professional interactions with people of an ethn i c minority g r oup ; MSI-EMG = Amount of self-reported experience in mult i cultural social interactions w i th people of an ethnic minority group *p < .05 In regards to individual predictors at the first step MPI-EMG was a significant positive predictor of Cultural Sensitivity (b = 08 t = 2.24, p = 03 ). At the second step of forced-entry MPI-EMG remained a significant positive predictor of Cultural Sensitivity (b = 09 t = 2 27 p = 03) However adding MSI EMG at the second step only accounted for an additional 1 % of variance and MSI-EMG was not a significant predictor of Cultural Sensitivity (b = 02 t = 53 p = 60) Thus for the predictor variables that focused on multicultural professional and social interactions with people of an ethnic minority group the results did not support the first hypothesis. In fact the results were opposite than

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63 what was predicted in that amount of self-reported experience in multicultural social interactions was not a significant predictor of healthcare providers self reported Cultural Sensitivity whereas amount of experience in multicultural professional interactions was a significant positive predictor of providers self reported Cultural Sensitivity. The next set of analyses addressing the first hypothesis replicates the first set of analyses except that multicultural professional interactions and multicultural social interactions examined as predictors were with people of an ethnic group different from that of the participant instead of with people of an ethnic minority group Table 4.4 describes the results of the second forced-entry stepwise multiple regression analysis using MPI EGD (i.e ., amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant) and MSI-EGD (i.e. amount of self report experience in Multicultural Social Interactions with people of Ethnic Group Different from that of the participant) as predictor variables The overall model fit was not significant at the first or second step. At the first step of forced-entry with the first predictor variable (MPI-EGD) in the model MPI-EGD accounted for 9.0% of the variance This overall R 2 value at this first step was not significant (F(1 30) = 2.97 p = 10) At the second step of forced-entry with both predictor variables (MPI EGD and MSI EGD) in the model the variance accounted for was 17 1 %. This overall R 2 value at the second step was not associated with a significant overall model fit (F(2 29) = 3 0 p = 07)

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64 Table 4.4. Prediction of Cultural Sensitivity by Multicultural Professional and Social Interactions with People of an Ethnic Group Different from that of the Participant Step 1 Step 2 Variable MPI-EGD MPI-EGD MSI-EGD .09 09 17 08 B SEB /3 sr2 05 03 30 .09 10 04 53 17 -. 05 .03 37 08 Note MPI-EGD = Amount of self-reported experience in multicultural professional interactions with people of an ethnic group different from that of the participant ; MSI-EGD = Amount of self-reported experience in multicultural social interactions with people of an ethnic group different from that of the participant. p < 05 In regards to individual predictors at the first step MPI-EGD was not a significant predictor of Cultural Sensitivity ( b = 05 t = 1 72 p = 10) However at the second step of forced-entry MPI-EGD was a s i gnificant positive predictor of Cultural Sensitivity (b = 10 t = 2.44 p = 02) Adding MSI-EGD at the second step accounted for an additional 8 1 % of the variance and MSI-EGD was not a significant predictor of Cultural Sensitivity (b = -.05 t = -1 69 p = 10) Thus for the predictor variables that focused on multicultural professional and social interactions with people of an ethnic group different from that of the participant the results only partially supported the first hypothesis As predicted amount of self-reported experience in multicultural professional interactions was not a

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65 significant predictor of Cultural Sensitivity However contrary to what was predicted amount of self-reported experience in multicultural social interactions was not a significant predictor of healthcare providers self-reported Cultural Sensitivity The change in significance from the first to the second step for the individual predictor (MPI-EGD) may be due to the presence of significant multicolinearity (tolerance = 60) and the noted problems associated with multicolinearity and the stability of the regression coefficients (Stevens 2002). The substantial intercorrelation of the two predictor variables of MPI-EGD and MSI-EGD (r = 63 p < .01) as well as the fairly low measure of tolerance (.60) may explain the change in significance for MPI-EGD when the second predictor variable of MSI-EGD was added to the regression model. Another potential explanation for this change in significance for MPI-EGD may be that this is the result of a possible suppressor effect caused by adding the second predictor variable (MSI-EGD) to the model at the second step of forced-entry Cohen et al. (2003) documented the counterintuitive occurrence of a variable that has a zero or close to zero correlation with the criterion leads to improvement in prediction when it is included in a multiple regression analysis This takes place when the variable in question is correlated with one or more of the predictor variables .. the inclusion in the equation of a seemingly useless variable so far as prediction of the criterion is concerned suppresses or controls for irrelevant variance that is variance that it shares with the predictors and not with the criterion thereby ridding the analysis of irrelevant variation, or noisehence the name suppressor variable (Cohen et al. 2003 p 186) In examining the zero-order correlation of the predictor variables of MPI EGD and MSI-EGD and the criterion variable of Cultural Sensitivity there was a

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66 positive and significant correlation between MPI-EGD and Cultural Sensitivity (r = 30, p = 05), and a negative and nonsignificant correlation between MSI-EGD and Cultural Sensitivity (r = 03 p = .43). Therefore it is possible that the addition of the second predictor variable (MSI-EGD) to the model suppresses or controls for, the variance it shares with the first predictor variable (MPI-EGD) Support for this interpretation can be observed in that the semipartial correlation for the first predictor variable (MPI-EGD) is larger than its corresponding zero order correlation (sr = .41 zero-order correlation = 30) once the second potentially suppressing predictor variable (MSI-EGD) has been added to the model as noted by Horst (1941 ) Therefore the analyses revealed that Hypothesis One was only minimally supported by the study findings Contrary to the hypothesis healthcare providers' self-reports of the amount of experience in multicultural social interactions were not found to be a significant positive predictor of self-reported Cultural Sensitivity Also contrary to the hypothesis healthcare providers self-reports of the amount of experience in Multicultural Professional Interactions with people of an Ethnic Minority Group were found to be a significant positive predictor of self-reported Cultural Sensitivity However consistent with the hypothesis was the finding that healthcare providers self-reports of the amount of experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant were not found to be a significant predictor of self-reported Cultural Sensitivity

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67 Hypothesis Two Hypothesis Two was as follows : The predictive relationship between healthcare providers self-reports of amount of experience in multicultural social interactions (measured by sub-scores on the HCP-DDQ) and these providers' self-reported Cultural Sensitivity (measured by mean scores on the T-CUSHCI PF or HCP) will be stronger for Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant rather than for Multicultural Social Interactions with people of an Ethnic Minority Group (as measured by the respective sub-scores on the HCP-DDQ) MCT theory suggests that there is tremendous value in social immersion with people of cultures different from the self in terms of developing sensitivity to multicultural issues (Sue Ivey & Pedersen, 1996) Therefore it was proposed that providers social exposure to people who are culturally different from themselves would account for more variance in the criterion variable of Cultural Sensitivity than would social exposure to people who are of an ethnic minority group Hypothesis Two was not supported by the study findings Hypothesis Two was tested using a forced-entry stepwise multiple regression model. Amount of experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-EMG) and amount of experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI EGD) were the two predictor variables Healthcare providers self-reports of Cultural Sensitivity were the criterion variable in the regression model.

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68 Table 4.5 describes the results of the forced-entry stepwise multiple regression analysis using MSI-EMG (i.e., amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group) and MSI-EGD (i.e. amount of experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant) as predictor variables The overall model fit was not significant at the first or second step At the first step of forced-entry with the first predictor variable (MSI-EMG) in the model, MSI-EMG accounted for 0 2% of the variance The overall R 2 value at this first step was not significant (F(1 30) = 05 p = 82) At the second step of forced Table 4 5.Prediction of Cultural Sensitivity by Multicultural Social Interactions Step 1 Step 2 Variable MSI-EMG MSI-EMG MSI-EGD 00 00 02 02 B SEB /3 sr2 01 03 04 00 .05 .06 .26 .02 03 05 26 .02 Note. MSI-EMG = Amount of self-reported experience in multicultural social interactions with people of an ethnic minority group ; MSI-EGD = Amount of self reported experience in multicultural social interactions with people of an ethnic group different from that of the participant.

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69 entry with both predictor variables (MSI-EMG and MSI EGD) in the model the variance accounted for was 1 9% This overall R 2 value at the second step was not associated with a significant model fit (F(2 29) = 28 p = 76). In regards to individual predictors at the first step MSI-EMG was not a significant predictor of Cultural Sensitivity (b = 01 t = 227 p = 82) At the second step of forced entry MSI-EMG remained a nonsignificant predictor of Cultural Sensitivity (b = 05 t = 73 p = .47) Adding MSI-EGD to the second step accounted for an additional 1 7% of the variance and MSI-EGD was not a significant predictor of Cultural Sensitivity (b = -.03 t = -. 71 p = .48) Thus, for the predictor variables that focused on multicultural social interactions neither of the two individual predictors was significant. Amount of self-reported experience in multicultural social interactions was not a significant predictor of healthcare providers' self-reported Cultural Sensitivity whether they were social interactions with people of an ethnic minority group or social interactions with people of an ethnic group different from that of the healthcare provider. Therefore the analyses revealed that Hypothesis Two was not supported by the study findings The predictive relationship between healthcare providers self reports of amount of experience in multicultural social interactions and the providers self-reported Cultural Sensitivity was not stronger for amount of experience socially with people of an ethnic group different from that of the healthcare provider versus for amount of experience socially with people of an ethnic minority group was considered

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70 Hypothesis Three Hypothesis Three was as follows : Healthcare providers self-reports of the amount of experience in multicultural professional interactions (as measured by sub-scores on the HCP-DDQ) will be a significant positive predictor of self reported Cultural Competence (as measured by mean scores on the CCSQ SPV), whereas healthcare providers self-reports of the amount of experience in multicultural social interactions (as measured by sub-scores on the HCP-DDQ) will not be a significant positive predictor of Cultural Competence The direction of this hypothesis was based upon the research on Cultural Competence which indicates that it is composed of attitudes knowledge skills and behaviors The more experience healthcare providers had had ostensibly demonstrating these aspects in the delivery of multicultural healthcare the higher their self-reports of Cultural Competence were hypothesized to be Hypothesis Three was tested using two forced-entry stepwise multiple regression models In the first model amount of self-report experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) and amount of self-report experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-EMG) were the two predictor variables In the second model amount of self-report experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant (MPI-EGD) and amount of self-report experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI-EGD) were the two predictor variables. Healthcare providers self-reports of Cultural Competence were the criterion variable in both

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71 regression models Hypothesis Three was partially supported by the study findings Table 4 6 describes the results of the first forced-entry stepwise multiple regression analysis using MPI-EMG (i.e ., amount of self-report experience in Multicultural Professional Interactions with people of an Ethnic Minority Group ) and MSI-EMG (i.e ., amount of self-report experience in Multicultural Soc i al Interactions with people of an Ethnic Minority Group) as predictor variables The overall model fit was significant at both the first and second step At the first step Table 4 6 Prediction of Cultural Competence by Multicultural Professional and Social Interactions with People of an Ethnic Minority Group Step 1 Step 2 Variable MPI-EMG MPI-EMG MSI-EMG 25 25 32 06 B SEB /3 s ? 15 05 50 25 12 05 .42 15 07 04 27 06 Note MPI EMG = Amount of self reported experience in multicultural professional interactions with people of an ethnic minor i ty group ; MSI-EMG = Amount of self-reported exper i ence in multicultural soc i al interactions with people of an ethnic minority group p < .05 of forced entry with the first p r edictor var i able (MPI EMG ) in the model MPI EMG accounted for 25.4 % of the variance This overall R 2 value at th i s first step was significant ( F ( 1 3 0 ) = 1 0 24 p < 0 1 ) At the second step of for c ed-entry w i th

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7 2 both predictor variables (MPI-EMG and MSI-EMG) in the model, the variance accounted for was 31.7%. This overall R 2 value at the second step was associated with a significant model fit (F(2 29) = 6 72 p < 01 ) In regards to individual predictors MPI-EMG was a significant positive predictor of Cultural Competence (b = 15 t = 3 20 p < 01 ). At the second step of forced-entry MPI-EMG remained a significant positive predictor of Cultural Competence (b = 12 t = 2 55 p = .02) Adding MSI-EMG at the second step accounted for an additional 6.2% of the variance and MSI-EMG was not a significant predictor of Cultural Competence (b = 07 t = 1 63 p = 12) Thus for the predictor variables that focused on multicultural professional and social interactions with people of an ethnic minority group the results supported the third hypothesis As predicted amount of self-reported experience in multicultural professional interactions was a significant positive predictor of healthcare providers self-reported Cultural Competence whereas amount of self-reported experience in multicultural social interactions was not a significant predictor of providers self-reported Cultural Competence The next set of analyses addressing the third hypothesis replicates the first set of analyses except that multicultural professional interactions and multicultural social interactions examined as predictors were with people of an ethnic group different from that of the participant instead of with people of an ethnic minority group Table 4 7 describes the results of the second forced entry stepwise multiple regression analysis using MPI-EGD (i.e ., amount of self reported experience in Multicultural Professional Interactions with people of an

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7 3 Ethnic Group Different from that of the participant) and MSI-EGD (i.e ., amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant) as predictor variables The Table 4 7 Prediction of Cultural Competence by Multicultural Professional and Step 1 Step 2 Social Interactions with People of an Ethnic Group Different from that of the Participant Variable MPI-EGD MPI-EGD MSI-EGD .20 .20 21 .00 B .11 11 01 SEB /3 sr2 04 .45 20 05 .42 10 04 05 00 Note MPI-EGD = Amount of self-reported experience in multicultural professional interactions with people of an ethnic group different from that of the participant ; MSI-EGD = Amount of self-reported experience in multicultural social interactions with people of an ethnic group different from that of the participant. *p < 05 overall model fit was significant at both the first and second steps At the first step of forced entry with the first predictor variable (MPI-EGD) in the model MPI EGD accounted for 20.4% of the variance This overall R 2 value at this first step was significant (F(1 30) = 7 69 p = .01 ) At the second step of forced-entry with both predictor var i ables ( MPI-EGD and MSI-EGD) in the model the variance accounted for was 20 6 %. This overall R 2 value at the second step was associated with a sign i ficant model fit (F ( 2 29 ) = 3 76 p = 04 ).

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74 In regards to individual predictors at the first step MPI-EGD was a significant positive predictor of Cultural Competence (b = .11, t = 2 77 p = 01 ). However at the second step of forced-entry MPI-EGD was not a significant predictor of Cultural Competence (b = 11 t = 1 96 p = 06) Adding MSI-EGD to the second step only accounted for an additional 0 2% of variance and MSI-EGD was not a significant predictor of Cultural Competence (b = 01 t = .25 p = .80). Thus for the predictor variables that focused on interactions with people of an ethnic minority group different from that of the participant the results supported the third hypothesis. As predicted amount of self reported experience in multicultural professional interactions was a significant positive predictor of healthcare providers self-reported Cultural Competence and amount of self reported experience in multicultural social interactions was not a significant predictor of providers self-reported Cultural Competence The change in significance from the first to the second step for the individual predictor (MPI-EGD) may be the result of significant multicolinearity (tolerance= 60) and the noted problems associated with multicolinearity and the stability of the regression coefficients (Stevens 2002) The substantial intercorrelation of the two predictor variables of MPI-EGD and MSI EGD (r = 63 p< .01) as well as the fairly low measure of tolerance ( 60) may explain the change in significance for MPI-EGD when the second predictor variable of MSI EGD was added to the regression model. Therefore the analyses revealed that Hypothesis Three was supported by the study findings Healthcare providers self-reports of the amount of experience

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7 5 in multicultural professional interactions were found to be a significant positive predictor of self-reported Cultural Competence whereas healthcare providers self-reports of the amount of experience in multicultural social interactions were not found to be a significant predictor of self-reported Cultural Competence Hypothesis Four Hypothesis Four was as follows : The predictive relationship between healthcare providers self-reports of amount of experience in multicultural professional interactions (as measured by sub-scores on the HCP-DDQ) and the providers self-reported Cultural Competence (as measured by mean scores on the CCSQ-SPV) will be stronger for Multicultural Professional Interactions with people of an Ethnic Minority Group rather than for Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant. Since Cultural Competence represents having a knowledge base specific to various ethnicities it was hypothesized that the more experience providers have providing healthcare to patients from ethnic minority groups the larger the body of culturally competent knowledge they would perceive themselves as possessing In other words it was proposed that healthcare provision to people who are of an ethnic minority group would account for more variance in the criterion variable of Cultural Competence than would healthcare provision to people who are of an ethnic group different from that of the provider. Hypothesis Four was tested using a forced-entry stepwise multiple regression model. Amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG) and amount of self-reported experience in Multicultural Professional Interactions with

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7 6 people of an Ethnic Group Different from that of the participant (MPI-EGD) were the two predictor variables Healthcare providers self-reports of Cultural Competence were the criterion variable in the regression model. Hypothesis Four was supported by the study findings Table 4 8 describes the results of the forced-entry stepwise multiple regression analysis using MPI-EMG (i e amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group) and MPI-EGD (i.e ., amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant) as predictor variables. The overall model fit was significant at both the first and second steps. At the first step of forced-entry with the first predictor variable (MPI-EMG) in the model MPI-EMG accounted for 25.4% of the variance This overall R 2 value at this first step was significant (F(1 30) = 10 24 p < .01 ). At the second step of forced entry with both predictor variables (MPI-EMG and MPI-EGD) the variance accounted for was 26 7 %. This overall R2 value at the second step was associated with a significant model fit (F(2 29) = 5 27 p = 01 ) In regards to individual predictors at the first step MPI-EMG was a significant positive predictor of Cultural Competence (b = 15 t = 3 2 p < 01 ) However at the second step of forced-entry MPI-EMG was not a significant predictor of Cultural Competence (b = 11 t = 1.57 p = 13) Adding MPI-EGD to the second step only accounted for an additional 1 2% of the variance and MPI EGD was not a significant predictor of Cultural Competence (b = .04 t = 69 p =

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77 .49). Thus for the predictor variables that looked at multicultural professional interactions only one of the individual predictors (MPI-EMG) was significant. Amount of experience in multicultural professional interactions was a significant predictor of healthcare providers self reported Cultural Competence when they were professional interactions with people of an ethnic minority group Amount of experience in multicultural professional interactions was not a significant predictor of providers self reported Cultural Competence when they were professional interactions with people of an ethnic group different from that of the provider. Table 4 8 Prediction of Cultural Competence by Multicultural Professional Interactions Step 1 Step 2 Variable MPI-EMG MPI-EMG MPI-EGD 25* 25* 27 01 B SEB /3 s? 15 05 50* 25 11 07 .38 06 04 06 17 .01 Note. MPI-EMG = Amount of self-reported experience in multicultural professional interactions with people of an ethnic minority group ; MPI-EGD = Amount of self-reported experience in multicultural professional interactions with people of an ethnic group different from that of the participant. *p < 05 The change in significance from the first to the second step for the individual predictor (MPI-EMG) may be the result of significant multicolinearity

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78 (tolerance = .44) and the noted problems associated with multicolinearity and the stability of the regression coefficients (Stevens 2002) The substantial intercorrelation of the two predictor variables of MPI-EMG and MPI-EGD (r = 75, p < 01) as well as the low measure of tolerance (.44) may explain the change in significance for MPI-EMG when the second predictor variable of MPI-EGD was added to the regression model. Therefore the analyses revealed that Hypothesis Four was supported by the study findings. The predictive relationship between healthcare providers self reports of amount of experience in multicultural professional interactions and the providers self-reported Cultural Competence was stronger for amount of experience in healthcare provision to people of an ethnic minority group than for amount of experience providing care to people of an ethnic group different from that of the healthcare provider. Post Hoc Analyses Post hoc analyses were conducted to determine whether the major variables of interest differed significantly according to gender and ethnicity of the participants The influence of gender and ethnicity of the participants was examined on a post hoc basis because prior research has suggested that female and non-majority group healthcare providers are more sensitive to multicultural issues within healthcare provision (Lauerman 2000; Ratcliff 2002 ; Robins et al. 2001 ; Taylor 1999). The influence of gender and ethnicity of the participants was examined using multivariate analyses of variance (MANOVAs) because at least some of the major variables of interest were significantly related (see Table

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7 9 4.2) In addition univariate analyses (ANOVAs) were conducted to further elucidate any significant results found with MANOVAs Table 4 9 shows the results of the MANOVAs and ANOVAs The MANOVA examining the influence of the interaction between gender and ethnicity of the participants was not significant indicating the appropriateness of further analysis of the influence of gender and ethnicity separately The MANOVA examining the influence of gender of the participants was not significant F(6 31) = .49, p = 81. Therefore the results of the ANOVAs examining the influence of gender of the participants on each of the major variables of interest were not further considered For the influence of ethnicity of the participants the MANOVA was significant F(6 31) = 5.48 p < 01 Because the MANOVA was significant for influence of ethnicity of the participants each of the ANOVAs was considered as well. The ANOVAs examining the influence of ethnicity of the participants were not significant for : (a) Self-reported Cultural Sensitivity F(1 32) = 70, p = .41 ; (b) Self-reported Cultural Competence F(1 32) = 00 p = .95 ; (c) Amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group F(1 32) = 06 p = 81 ; and (d) Amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant F(1 32) = 2 89 p = .10. However the ANOVA examining the influence of ethnic i ty of the participants was significantly related to amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group F ( 1 32) = 14 18 p < 01

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80 Table 4.9 Multivariate and Univariate Analyses of Variance Examining Influence of Participants Gender and Ethnicity on Major Variables of Interest MANOVA Variable F(6 31) Gender (G) .49 Ethnicity (E) 5.48 ** GxE 98 cs cc ANOVA MPI EMG MPI EGD MSI EMG MSI EGD F(1 32) F(1 32) F(1 32) F(1 32) F(1 32) F(1 32) .45 70 27 83 00 52 58 06 98 2 17 22 85 2 89 14.18 ** 11 27 ** 2 89 97 02 Note F ratios are Wilks Lambda approximation of Fs. MANOVA = Multivariate analysis of variance ; ANOVA = Univariate analysis of variance ; CS = Self-reported cultural sensitivity ; CC = Self-reported cultural competence ; MPI EMG = Amount of self-reported experience in multicultural professional interactions with people of an ethnic minor i ty group ; MPI-EGD = Amount of self reported experience in multicultural professional i nteractions with people of an ethnic group different from that of the participant ; MSI EMG = Amount of self reported experience in multicultural social interactions with people of an ethnic minority group ; MSI-EGD = Amount of self-reported experience in multicultural social interactions with people of an ethnic group different from that of the participant. *p < 01

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The mean value of amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group was higher for participants of an ethnic minority group (M = 8 25) than for participants of the ethnic majority group (M = 5 96) In addition the ANOVA examining the influence of ethnicity of the participants on amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant was significant F(1,32) = 11 27 p < 01 Similarly the mean value of amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant was higher for participants of an ethnic minority group (M = 9 00) than for participants of the ethnic majority group (M = 5 96) Because of the uneven distribution of participants' ethnicity (75% Caucasian 25% non-Caucasian) Levene's test for equality of variances was conducted for each comparison examining the influence of ethnicity of the participants. Variances among ethnicity of the participants were only found to be unequal for the variable amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant F = 6 30 p < 05 However the difference in scores for amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant remained significant even when equal variances were not assumed t (8 33) = 2 91 p < 05 suggesting that uneven distribution of ethnicity of the participants did not inflate this finding

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8 2 In sum the post hoc analyses revealed that scores on the variables of levels of self-reported Cultural Competence and Cultural Sensitivity did not vary systematically in relation to gender or ethnicity of the participants. In addition no significant gender differences were found for the other major variables of interest. For ethnicity of the participants no significant differences were found for the major variables of interest pertaining to multicultural professional interactions but significant differences were found for major variables of interest pertaining to multicultural social interactions As would be expected participants of an ethnic minority group reported having had significantly more experience socially with people of an ethnic minority group and with people of an ethnic group different from their own than did participants of the ethnic majority group This finding suggests that participants ethnicity and amount of self-reported experience in multicultural social interactions are related

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CHAPTER 5 DISCUSSION This chapter will include a summary and interpretation of the results theoretical and practical implications of the study, limitations of the study and future research directions The results from this study provide further understanding about how multicultural social interactions and multicultural professional interactions relate to healthcare providers self-reported levels of Cultural Sensitivity and Cultural Competence. These findings are discussed within the context of Multicultural Counseling and Therapy (MCT) theory (Sue Ivey & Pedersen, 1996) In addition the results raise important questions about the definitions of multicultural interactions, which warrant further investigation The differential predictive ability of multicultural interactions on Cultural Sensitivity and Cultural Competence in healthcare delivery, based upon how the multicultural interactions were operationalized has important implications for the training of physicians and other healthcare providers in the provision of culturally sensitive and culturally competent healthcare. Specifically the study f i ndings suggest that healthcare organizations would benefit from focusing the content of future trainings on facilitating an increase in healthcare providers professional interactions with patients from ethnic minority groups and with patients from ethnic groups different from that of the individual provider 8 3

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84 Summary and Interpretation of the Results The present study examined physicians and other healthcare providers self-reports of their levels of engagement in or display of, patient-identified knowledge behaviors attitudes and experiences that patients at community based primary care clinics identify as indicators of culturally sensitive healthcare (i.e. self-reports of their level of engagement in patient-defined culturally sensitive healthcare as measured either by the T-CUSHCI Physician Form or by the T-CUSHCI Health Care Provider Form as was appropriate) Also it examined healthcare providers' self-reports of their levels of engagement in or display of non-patient or expert -identified knowledge behaviors attitudes and experiences that experts have identified as indicators of culturally competent healthcare (i e ., self-reports of their level of engagement in culturally competent healthcare as measured by the CCSQ-SPV) Further it determined if participating healthcare providers self-reported levels of Cultural Sensitivity and Cultural Competence are significantly associated with their self-reported amounts of experience in multicultural social interactions and healthcare provision to African Americans Hispanic/Latino(a) Americans and Caucasian Americans. Preliminary Analysis The preliminary analysis revealed that the two criterion variables examined in the study (Cultural Sensitivity and Cultural Competence) were not significantly correlated with each other, providing support that these variables were separate and independent constructs (see Table 4.2) This finding is important because it demonstrates that these are separate skills both of which

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85 are necessary for providers to appropriately address multicultural issues in the delivery of healthcare This then has implications for those developing trainings to answer the urgent call for healthcare that satisfactorily takes into account multicultural issues (Huff & Kline, 1999) ; both Cultural Competence and Cultural Sensitivity should be included in these trainings and the various factors that promote growth of these two different but essential skills must be researched and addressed accordingly Cultural Competence is defined as having the knowledge skills experiences, and awareness needed to provide healthcare that is respectful of and takes into account a patient's specific culture (Tucker et al. 2001 ) Cultural sensitivity in healthcare has three defining characteristics (Tucker et al. 2003) It involves 1) communicating or displaying culture-related knowledge skills and awareness in ways that make people feel that their culture is respected and that make them feel comfortable with and trusting of the healthcare they receive; 2) embracing the view that culturally diverse patients are the experts at identifying the behaviors/attitudes and healthcare environment variables that are indicators of culturally sensitive healthcare ; and 3) engaging in specific provider and staff behaviors and provider/staff-patient interactions as well as promoting physical healthcare environments that encourage patient trust in comfort with and feelings of being respected by healthcare providers and staff (Tucker et al. 2003) Another way to differentially conceptualize these two constructs is to regard Cultural Competence as a set of knowledge skills experiences and awareness defined by experts and Cultural Sens i t i v i ty as the effective d i splay of

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86 this expert-defined set of knowledge, skills experiences and awareness in ways that facilitate patients awareness/experience of this knowledge skills experiences and awareness When participants were asked to report perceptions of their own Cultural Competence they were in essence asked to report how extensive they perceived this expert-defined set of knowledge skills experiences and awareness to be within themselves Alternatively when participants were asked to report perceptions of their own Cultural Sensitivity, they were in essence asked to report how well they perceived themselves to be engaging in the behaviors and displaying the knowledge skills experience and awareness that culturally diverse patients have reported to be important. The findings from this study support that these two variables Cultural Competence and Cultural Sensitivity are separate constructs and support their treatment as such in the study discussion Constantine (2000) discussed how Social Desirability is a primary concern associated with instruments that utilize self-report to measure multicultural competence and Sadowsky (1996) recommended that studies requiring completion of such instruments also include a measure of Social Desirability. It was expected that participants would likely be concerned with the potential impact their participation in the study and their self-reports of Cultural Sensitivity and Cultural Competence could have on professional evaluations of themselves as healthcare providers. While the many steps taken to ensure confidentiality were explained to participants during the recruitment phase (e.g ., voluntary participation use of a healthcare professional private identification number

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87 confidentiality of individual response sets separation of identifying information from all other measures etc.), it was anticipated that fear of the consequences of participant data identification might bias the responses on the assessment battery. Thus the Marlowe-Crowne Social Desirability Scale short-form CSDS-SF) by Marlowe and Crowne (1964) was used to measure the participants' tendency to respond to questions in a socially desirable manner. The purpose of including the M-CSDS-SF was to determine if Social Desirability was significantly correlated with any of the major variables of interest and if necessary, to then control for any observed influence of Social Desirability on the major variables of interest. Table 4.2 describes the study findings indicating that there was no relationship between scores on the M-CSDS-SF and any of the study variables : (a) level of self-reported Cultural Sensitivity (CS) (b) level of self-reported Cultural Competence (CC), (c) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Minority Group (MPI-EMG), (d) amount of self-reported experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant (MPI-EGD) (e) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Minority Group (MSI-EMG) and (f) amount of self-reported experience in Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant (MSI-EGD) Thus the data suggest that Social Desirability did not play a role in participants responses to the measures in the assessment battery Consequently Social Desirability was not used as a

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88 control variable in any of the subsequent analyses to test the investigated hypotheses or in any of the post hoc analyses Multicultural Interactions and Cultural Sensitivity Hypothesis One was as follows: 1) Healthcare providers' self-reports of the amount of experience in multicultural social interactions will be a significant positive predictor of self-reported Cultural Sensitivity whereas healthcare providers' self-reports of the amount of experience in multicultural professional interactions will not be a significant positive predictor of self-reported Cultural Sensitivity The direction of this hypothesis was based upon Multicultural Counseling and Therapy theory s implied importance of social immersion in culturally different groups in developing sensitivity to multicultural issues (Sue Ivey & Pedersen 1996) Hypothesis One was only minimally supported by the study findings Consistent with the first hypothesis was the finding that for this participant sample healthcare providers self-reports of the amount of experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant was not found to be a significant predictor of self reported Cultural Sensitivity Contrary to the first hypothesis healthcare providers self-reports of the amount of experience in Multicultural Professional Interactions with people of an Ethnic Minority Group were found to be a significant positive predictor of self-reported Cultural Sensitivity. Although this finding contradicted the original study hypothesis one potential explanation of this finding is that the experience of providing healthcare within multicultural interactions is a sub-type of the social immersion described by Sue Ivey and

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8 9 Pedersen (1996) as being necessary for the development of sensitivity to cultural issues The healthcare provider-patient interaction is often an intimate one with complex interrelationships necessitating that the provider seek self-awareness of her/his own culture while facilitating the patient's expression of important cultural issues that may affect the relationship treatment adherence and medical outcomes The professional interaction also allows for feedback to be given to the provider about the patient s perceptions of the provider s Cultural Sensitivity via several avenues : direct feedback from the patient feedback extrapolated from the provider s perceptions of the interaction the patient's treatment adherence keeping of follow-up appointments and satisfaction levels with medical outcomes. In particular, this study investigated self-reported patient-defined Cultural Sensitivity involving 1) communicating or displaying culture-related knowledge skills and awareness in ways that make people feel that their culture is respected and that make them feel comfortable with and trusting of the healthcare they receive ; 2) embracing the view that culturally diverse patients are the experts at identifying the behaviors/attitudes and healthcare environment variables that are indicators of culturally sensitive healthcare ; and 3) engaging in specific provider and staff behaviors and provider/staff-patient interactions as well as promoting physical healthcare environments that encourage patient trust in comfort with and feelings of being respected by healthcare providers and staff (Tucker et al., 2003) It is probable that the therapeutic alliance many healthcare providers strive to achieve in order to successfully deliver healthcare allows for

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90 much learning about the diverse cultural contexts within which patients and providers operate, which may then contribute to the development of patient defined Cultural Sensitivity. As providers gain greater amounts of experience in Multicultural Professional Interactions with patients from an Ethnic Minority Group they may then perceive themselves to have higher levels of patient defined Cultural Sensitivity or the ability to effectively communicate a set of culturally relevant knowledge, skills, experiences, and awareness in a manner that patients perceive as culturally sensitive In addition it is interesting to consider how the definition of the amount of experience in multicultural professional interactions influenced the predictive relationship with self-reported Cultural Sensitivity For this participant sample as expected, healthcare providers self-reports of the amount of experience in Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant were not found to be a significant predictor of self reported Cultural Sensitivity whereas contrary to what was expected healthcare providers self-reports of the amount of experience in Multicultural Professional Interactions with people of an Ethnic Minority Group were found to be a significant positive predictor of self-reported Cultural Sensitivity A possible explanation for this finding is that in order for an individual to perceive thats/he manifests patient-defined Cultural Sensitivity in the del i very of healthcare it is salient that the individual recognizes that the person with whom s/he is having the multicultural professional interaction is of an ethnic minority group versus of an ethnic majority group or of an ethnic group different from that of the provider

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9 1 This recognition of the patient s membership in an ethnic minority group may then contribute to the provider s stored knowledge about interactions with members of that group and further the perception that s/he (the provider) is cumulatively more culturally sensitive because of that interaction. This is a critical study finding because the indication that experience providing healthcare to patients from ethnic minority groups is important i n increasing self-reports of Cultural Sensitivity has direct implications for healthcare organizations that seek to increase the Cultural Sensitivity of their staff. Contrary to Hypothesis One, healthcare providers self-reports of the amount of experience in multicultural social interactions were not found to be a significant positive predictor of self-reported Cultural Sensitivity regardless of whether that experience was measured as Mult i cultural Social Interactions with people of an Ethnic Minority Group or Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant. This finding did not support the original study hypothesis based upon MCT theory s implied importance of social immersion in culturally different groups i n developing sensitivity to multicultural issues (Sue Ivey & Pedersen 1996). A possible explanation for this negative finding is that regardless of the operationalization of multicultural social interactions this var i able is not related to self-reported Cultural Sensitivity An alternative explanation for this finding may lie with the study s reliance on self-report data Partic i pants perceptions of displayed Cultural Sensitivity may not be synonymous with the perceptions of other observers such as the pat i ents of these prov i ders or a third-party rater

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92 Before ruling out the influence of experience in multicultural social interactions in terms of predicting displayed Cultural Sensitivity within a healthcare provider patient interaction it would be useful to conduct further research that correlates both provider and patient assessments of Cultural Sensitivity with the provider s self-reported experience in multicultural social interactions. Pope-Davis et al. (2001) points out that much of the body of research dealing with how appropriately healthcare providers address the needs of the diverse community they serve focuses on the perceptions of the healthcare providers and not on the perspectives of their clients. The authors discuss the importance of integrating the perspective of clients into the research on multiculturalism by gathering data on client preferences and expectations Wood and Mallinckrodt (1990) state that when attempting to bridge the gap of cultural understanding those providing the training in Cultural Sensitivity must be sure that the skills presented are valued by the client not just by the healthcare provider. The inventory used in the present study to assess Cultural Sensitivity the T-CUSHCI, takes this vital step forward called for by Pope-Davis et al. (2001) and Wood and Mallinckrodt (1990) by allowing providers to make self-reports of their level of engagement in culturally sensitive healthcare as defined by patients However, it would be even further illuminating to collect mirror image reports by the patients of the same interactions and establish the level of correlation between the two sets of perceptions by patients and providers. Hypothesis Two was as follows : The predictive relationship between healthcare providers self-reports of amount of experience in multicultural social

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93 interactions and these providers self-reported Cultural Sensitivity will be stronger for Multicultural Social Interactions with people of an Ethnic Group Different from that of the participant rather than for Multicultural Social Interactions with people of an Ethnic Minority Group MCT theory suggests that there is tremendous value in social immersion with people of cultures different from the self in terms of developing sensitivity to multicultural issues (Sue Ivey & Pedersen 1996) Therefore it was proposed that providers social exposure to people who are culturally different from themselves would account for more variance in the criterion variable of Cultural Sensitivity than would social exposure to people who are of an ethnic minority group Hypothesis Two was not supported by the study findings. For the participants in this study contrary to the second hypothesis, the predictive relationship between healthcare providers self-reports of amount of experience in multicultural social interactions and the providers self-reported Cultural Sensitivity was not stronger for Multicultural Social Interactions with people of an Ethnic Group Different from that of the healthcare provider than for Multicultural Social Interactions with people of an Ethnic Minority Group In other words healthcare providers social exposure to people who are culturally different from themselves did not account for more variance in the criterion variable of Cultural Sensitivity than did social exposure to people who are of an ethnic minority group Multicultural Interactions and Cultural Competence Hypothesis Three was as follows : Healthcare providers self-reports of the amount of experience in multicultural profess i onal interactions will be a significant

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94 positive predictor of self-reported Cultural Competence, whereas healthcare providers' self-reports of the amount of experience in multicultural social interactions will not be a significant positive predictor of self-reported Cultural Competence. The direction of this hypothesis was based upon the research on Cultural Competence, which indicates that it is composed of a set of expert defined attitudes, knowledge, skills, and behaviors (Tucker et al. 2001 ). The more experience healthcare providers have had in ostensibly demonstrating these expert-defined attitudes, knowledge skills and behaviors in the actual delivery of multicultural healthcare the higher their self-reports of Cultural Competence were hypothesized to be Hypothesis Three was supported by the study findings. Healthcare providers' self-reports of the amount of experience in multicultural professional interactions were found to be a significant positive predictor of self-reported Cultural Competence, whereas healthcare providers self-reports of the amount of experience in multicultural social interactions were not found to be a significant predictor of self-reported Cultural Competence. Multicultural professional interactions were a significant positive predictor of self-reported Cultural Competence regardless of whether these professional interactions were measured as amount of experience providing healthcare to patients of an ethnic group different from that of the provider or as amount of experience in healthcare provision to patients of an ethnic minority group. This finding is a relatively intuitive one as the more experience providers perceived themselves as having had in multicultural professional interactions the greater

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95 the amount of Cultural Competence or expert-defined knowledge skills experiences and awareness they would be expected to perceive themselves as having It is likely that the more opportunity providers have had to deliver healthcare to culturally diverse patients the more culturally competent they would perceive themselves to be in the provision of healthcare during multicultural professional interactions This study finding demonstrated the importance of actually having had in vivo experience providing healthcare to culturally diverse patients in the development of healthcare providers' self-reports of their own Cultural Competence The finding that self-reports of multicultural professional interactions or healthcare provision to culturally diverse patients, are important in healthcare providers self-reports of Cultural Competence has direct implications for healthcare organizations that seek to increase the Cultural Competence of their staff As predicted in Hypothesis Three self-reported multicultural social interactions were not found to be a significant predictor of self-reported Cultural Competence regardless of whether these social interactions were measured as amount of experience socially with people of an ethnic group different from that of the provider or as amount of experience socially with people of an ethnic minority group Cultural Competence represents having the knowledge skills experiences and awareness needed to provide healthcare that is respectful of and takes into account a patient's specific culture during the act of healthcare provision (Tucker et al. 2001) The finding was expected since experience socially while interacting with culturally diverse people was not theorized to

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96 differentially contribute to participants self-reports of how much culturally competent knowledge skills experiences and awareness they demonstrated in their professional role of healthcare provision Hypothesis Four was as follows : The predictive relationship between healthcare providers self-reports of amount of experience in multicultural professional interactions and the providers self-reported Cultural Competence will be stronger for Multicultural Professional Interact i ons with people of an Ethnic Minority Group rather than for Multicultural Professional Interactions with people of an Ethnic Group Different from that of the participant. Since Cultural Competence represents having an expert-defined knowledge base specific to various ethnic groups it was hypothesized that the more experience providers have providing healthcare to patients from ethnic minority groups the larger the body of culturally competent knowledge they would perceive themselves as possessing In other words it was proposed that healthcare provision to people who are of an ethnic minority group would account for more variance in the criterion variable of Cultural Competence than would healthcare provision to people who are of an ethnic group different from that of the provider Hypothesis Four was supported by the study findings As was expected the predictive relationship between healthcare providers self-reports of amount of experience in multicultural professional interactions and the providers self reported Cultural Competence was stronger for amount of experience in healthcare provision to people of an ethnic minority group than for amount of experience providing care to people of an ethnic group different from that of the

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9 7 healthcare provider In other words, as hypothesized healthcare provision to people who are of an ethnic minority group accounted for more variance in the criterion variable of Cultural Competence than did healthcare provision to people who are of an ethnic group different from that of the provider A possible explanation for this finding is that in order for a provider to perceive thats/he demonstrates Cultural Competence in the delivery of healthcare, it is more salient that the provider recognizes that the person with whom s/he is having the multicultural professional interaction is of an ethnic minority group versus of an ethnic group different from herself or himself This recognition of the patient's membership in an ethnic minority group may then contribute to the provider s stored knowledge about interactions with members of that group and further the perception thats/he (the provider) is cumulatively more culturally competent with members of that ethnic group because of that interaction. As a result of each Multicultural Professional Interaction with a patient of an Ethnic Minority Group healthcare providers may then perceive themselves as having more Cultural Competence or an expert-defined set of knowledge skills, experiences, and awareness about patients of a given ethnic minority group This is a crucial study finding because the indication that amount of experience providing healthcare to patients from ethnic minority groups is more important in increasing self-reports of Cultural Competence than is amount of experience providing healthcare to patients from ethnic groups different from that of the provider has direct implications for healthcare organizations that seek to increase the Cultural Competence of their staff

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98 Overall Trends Among Study Findings In summary, the study findings demonstrate that the greater the amount of experience in multicultural professional interactions, the greater the amount of expert-defined multicultural information or Cultural Competence, perceived by the healthcare provider to be learned from those interactions. However multicultural professional interactions were found to be significantly positively predictive of patient-defined Cultural Sensitivity for healthcare provision to patients of an ethnic minority group but not for healthcare provision to patients of an ethnic group different from that of the provider These findings imply that for this participant sample multicultural professional interactions played a role in the development of healthcare providers Cultural Competence and Cultural Sensitivity. In addition the study findings did not demonstrate that the greater the amount of experience in multicultural social interactions the greater the amount of expert defined multicultural information or Cultural Competence perceived to be learned from those interactions. Also the findings did not demonstrate that the greater the amount of experience in multicultural social interactions the greater the display of patient-defined Cultural Sens i tivity or communication of the multicultural or culturally competent information learned from those interactions during the provision of healthcare in a manner perceived by patients as culturally sensitive. These findings imply that for this participant sample there was not a significant relationship between multicultural social interactions and Cultural Competence or between multicultural social interactions and Cultural Sensitivity

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99 Jack and Satterfield (2002) take the position that Cultural Sensitivity in healthcare is the extent to which Cultural Competence is incorporated in the delivery of healthcare implying that they are two different skill sets This study provides support for the argument that growth of these two skill sets is promoted by different types of multicultural interactions For this participant sample multicultural social interactions do not appear to affect the development of self reported Cultural Competence and do not appear to affect how effectively this competence is communicated to the patient in a sensitive manner or in other words the self-reported display of Cultural Sensitivity However for this participant sample multicultural professional interactions do appear to positively affect the development of self-reported Cultural Competence Multicultural professional interactions also appear to affect how effectively this expert-defined competence is communicated in a manner perceived as culturally sensitive by the patient or in other words the self-reported display of Cultural Sensitivity Theoretical and Practical Implications The findings from this study have several possible theoretical and practical implications for increasing awareness of and effectively dealing with multicultural issues in the provision of healthcare The implications of this research are : (1) support for utilizing Multicultural Counseling and Therapy theory in research to develop ways to help healthcare providers engage in culturally sensitive and competent healthcare provision to patient populations that are fast increasing in cultural diversity ; (2) evidence of specific factors that differentially affect the development of both self-reported patient-defined culturally sensitivity and self

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100 reported expert-defined culturally competent healthcare; and (3) identification of modalities for developing trainings for healthcare providers to embrace multicultural issues in patient care According to Multicultural Counseling and Therapy (MCT) theory besides traditional book learning experiential train i ng that i ntegrates the cognitive affective and behavioral experiences must be tapped (Sue Ivey & Pedersen 1996, p 50). This theory proposes the crucial nature of the learning experience provided by immersion in culturally different groups and points to the importance of multicultural interactions in order to develop an awareness of cultural issues. Extrapolating from MCT theory it seemed reasonable to expect that exposure to people from culturally diverse groups would be pos i t i vely associated with self reported Cultural Sensitivity and Cultural Competence. Overall this study s findings strongly support MCT theory s position that experience in multicultural interactions facil i tates the development of competence w i th and sensitivity to cultural issues There are two other pivota l implicat i ons o f the study for the application of MCT theory to meet the contemporary challenge of ass i sting in the training of healthcare providers to take a multicultural approach in the del i very of medical science First the type of multicultural interaction or i mmers i on in cu l turally diverse groups whether social or professional played a major role in determ i ning if there was a connection between multicultural interact i ons and Cultural Sensitivity, and multicultural interactions and Cultural Competence Self-reported multicultural professional interactions were a sign i ficant positive predictor of both

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1 0 1 self-reported Cultural Sensitivity and Cultural Competence However contrary to the present study's extrapolation from MCT theory self-reported multicultural social interactions were not predictive of self-reported Cultural Sensitiv i ty or Cultural Competence. This suggests that future research is warranted to ident i fy more precisely how different types of cultural immersion contribute to the development of self-reported Cultural Sensitivity and Cultural Competence Second the study findings of the differential predictive ability of self reported multicultural interactions based on how "multicultural is operationalized have exciting theoretical and practical implications. Utiliz i ng the definition of multicultural interactions as experience with people from an ethnic minority group rather than experience with people from an ethnic group different from that of the provider led to stronger study findings for both self-reported multicultural social interactions and multicultural professional interactions and for both self-reported Cultural Sensitivity and Cultural Competence. This implies that MCT theory s call for immersion with people from culturally different backgrounds may need to be further refined to reflect that immersion with people from an ethnic minority group may more strongly facilitate an awareness of multicultural issues Practically speaking this study s findings suggest that in the identification of specific suggestions for providing trainings to improve healthcare providers Cultural Sensitivity and Cultural Competence one must consider how multicultural interactions are defined (e.g. recommending an increase i n healthcare providers professional interact i ons with both specific communities of ethnic minority groups and people from ethnic groups different from that of the i ndiv i dua l provide r i n

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102 order to increase expert-defined Cultural Competence; recommending that organizations facilitate medical students' provision of care to patients from ethnic minority groups in order to increase the i r patient-defined Cultural Sensitivity) Both Cultural Sensitivity and Cultural Competence make their own essential contribution to a multicultural approach in the delivery of healthcare services. Cultural competence offers the extensive knowledge base of the myriad cultural specifics accumulated by experts and researchers in the field while cultural sensitivity reflects if the manner in which the knowledge is applied during the healthcare process is perceived as appropriate by patients A heartening practical implication of this study of the two constructs is the suggestion that they involve knowledge and skills that can be developed over time. Limitations Limitations of this study include having a small sample size It is unknown how utilizing a larger sample size would have affected the study findings Also the participant sample had an overrepresentation of Caucasian American participants raising questions about the generalizability of the study findings to healthcare providers from ethnic minority groups Additionally because the participants for the study were only recruited from primary care clinics in Florida the generalizability of the findings to providers in other parts of the nation is unknown Another limitation of this study is the subjective nature of the questionnaire items used to assess participants self-reported amount of experience in multicultural social interactions and multicultural professional interactions, and

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10 3 levels of self-reported Cultural Sensitivity and Cultural Competence For example two participants may have comparable amounts of quantitative experience providing healthcare to African American patients but one participant may report that she has much experience providing healthcare to patients of this ethnicity while the other participant may report that she has only moderate or little experience In addition the study also relies on participants self-report of levels of Cultural Sensitivity and Cultural Competence which may or may not coincide with patients or independent raters perceptions of the providers Cultural Sensitivity and Cultural Competence Such limitations are however inherent in any study that utilizes self-report to assess perceptions In addition due to the fact that the T-CUSHCI was developed from research with three specific cultural groups African Americans Hispanic/Latino(a) Americans and Caucasian Americans the HCP-DDQ only solicited data on the multicultural social interactions and multicultural professional interactions participants had had with those three groups However patient defined Cultural Sensitivity and expert-defined Cultural Competence during healthcare provision can theoretically be displayed with patients of any ethnicity Therefore participants were asked to report the i r own Cultural Sensitivity and Cultural Competence without any indication to refer to interactions w i th people of specific ethnic groups while they were asked to report amount of experience i n multicultural social interactions and multicultural professional interactions with people from only three select ethnic groups This may then lim i t the generalizab i lity of the study find i ngs regarding the ability of social and / or

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104 professional multicultural interactions to predict Cultural Sensitivity and Cultural Competence with patients from ethnic groups other than African Americans Hispanic/Latino(a) Americans, and Caucasian Americans. A related limitation of this study stems from the limited ethnicity of the sample population from whom the T-CUSHCIPhysician Form and Health Care Provider Form were created The medical community has acknowledged that the success of the clinical encounter of a healthcare provider with a patient often depends on the provider s possessing or soliciting an understanding of the patient s culture (Second National Conference in Quality Health Care for Culturally Diverse Populations 2000). Undeniably the use of the T CUSHCI in research on multicultural issues in healthcare represents a great advancement in the literature since culturally diverse pat i ents developed the various indicators of Cultural Sensitivity This measure provides the medical community with cultural information using the patient as expert However the T CUSHCI was developed from focus groups of patients from three ethnic groups only African American Hispanic/Latino(a) American and Caucasian American This may impede the generalizability of the study findings when the instrument is used with providers who work primarily with patients of other ethnic minority groups such as Asian American or individuals of biracial or multiracial heritage Ultimately there are obvious limits on the acquisition of Cultural Competence or the expert-defined set of culturally relevant knowledge, skills, experiences and awareness due to the expanding diversity of the population and in consideration of such issues as acculturation However it can be hoped

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1 05 that healthcare providers can develop and apply patient-defined Cultural Sensitivity to a multicultural interaction with patients of any ethnicity regardless of about which specific ethnic groups providers perceive themselves to be cultural competent. The goal for health care providers is to accompany knowledge of the culture with awareness respect, and acceptance of the client s cultural beliefs and practices (Bronner 1994 p 15) Future Research Future research is needed that examines the correlation between both healthcare providers and patients perceptions of the level of expert-defined Cultural Competence and patient-defined Cultural Sensitivity exh i bited with i n the delivery of healthcare Using such methodology would provide crucial feedback for providers in terms of the patients views and allow for refinement of these two important skill sets. Also further research that utilizes larger samples of participants including those from other ethnic groups such as Asian Americans would allow greater insight into the interplay of cultural components in the patient-provider relationship In addition a vital next step in advocating healthcare delivery that takes a multicultural approach would be to conduct research that examines the relationship among the variables of Cultural Competence and Cultural Sensitivity and provider and patient satisfaction with the healthcare provision patients adherence to treatment and their eventual medical outcomes There are also several questions that future research might address Does academic training on the constructs of Cultural Competence and Cultural

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106 Sensitivity in healthcare delivery versus experiential learning with patients from culturally different groups equally influence providers and patients perceptions of the level of Cultural Competence and Cultural Sensitivity in the care provided? What factors do providers perceive to be influential in their development of Cultural Competence and Cultural Sensitivity? Do providers from the majority ethnicity group develop Cultural Competence and Cultural Sensitivity in the same manner as providers from ethnic minority groups? Conclusion It was concluded from this study that self-reported amount of experience in multicultural professional interactions has a significant predictive relationship with healthcare providers' self-reported levels of Cultural Competence and Cultural Sensitivity while self-reported amount of experience in multicultural social interactions does not significantly predict healthcare providers self reported levels of Cultural Competence and Cultural Sensitivity In addition these relationships vary according to how multicultural interactions are defined : as amount of experience with people of an ethnic minority group or as amount of experience with people of an ethnicity different from that of the provider The study findings suggest that healthcare organizations that wish to promote Cultural Competence and Cultural Sensitivity in the provision of patient care should particularly emphasize the importance of healthcare providers seeking further experience in the delivery of healthcare to patients from ethnic minority groups While this study provides insight into factors that assist in the development of Cultural Competence and Cultural Sensitivity much more

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107 research is needed so that comprehensive trainings that successfully aid the medical community in using a multicultural approach to patient care can be devised Such action may improve patient and provider sat i sfaction w i th the quality of care patient treatment adherence and patient treatment outcomes and hopefully contribute to a reduction in the disparity of healthcare exper i enced by patients from ethnic minority groups

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APPENDIX A HEALTHCARE PROFESSIONAL DEMOGRAPHIC DATA QUESTIONNAIRE Confidential PIN: Please provide each type of requested information by writing in your answer in the lines provided or by shading in the circle beside your answer like this: 1. Your Age: __ 2. Your Gender: 0 Female 0 Male 3. Your Nationality: ____________ 4. Your Race/Ethnicity: 0 African American/Black American 0 Asian American/Pacific Islander 0 Caucasian/White American 0 Chicano(a) / Mexican American 0 Latino(a)/Hispanic American 0 Native American 0 Other (please specify): ____ _____ 5. Your Religious Preference: 0 Agnostic 0 Jewish 0 Atheistic 0 Muslim 0 Baptist 0 Presbyterian 0 Buddhist 0 No Preference 0 Catholic 0 Other (please specify): 0 Hindu 108

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10 9 6. Your professional Identity/Job Title (e.g., nurse physician P.A. front desk clerk, etc.): 7. The clinic at which you are currently employed ('Family Practice or 'E astside'): 8. Total time as an employee at your current health care provision site: __ years months -9. Total time spent in Clinical Practice: __ years months -The estimated percentage of your time spent in direct patient care in last 12 months : % ---11. Your native/first language: 12. List any languages (including English) that: a You speak fluently: b. You read: c. You have pent time learning to speak and/or read:

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110 13. Have you ever participated in any other workshops or questionnaires dealing with Culturally Sen itive Healthcare before beginning the present study? 0 Yes 0 No 14. Have you ever participated in any other workshops or questionnaires dealing with Culturally Competent Healthcare before beginning the present study? 0 Yes 0 No 15. How many hours in Cultural Competence, Cultural Awareness, or Cross-Cultural Awareness training have you participated in? ------(hours) 16. How many hours in Cultural Sensitivity training have you participated in? ______ (hour ) Please respond to the questions below by bubbling in one of the five responses to the left of each question, like this: None / Little / Some / Much / Very Much 0 0 0 0 0 17 Rate how much experience you have had providing health care to Black American patient s. 0 0 0 0 0 18. Rate how much experience you have had providing health care to Hispanic/ Latino(a) American patients. 0 0 0 0 0 19. Rate how much experience

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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 I 1 0 0 0 0 0 0 0 0 0 0 you have had providing health care to White / aucasian American patients 20. Rate how much experience you have had providing health care to l ow-i n come Black American patients 21 Rate how much experience yo u have had providing health care to l ow-income Hispanic / Latino(a) merican patients. 22 Rate how much experience you have had providing health care to l ow-income White / Caucasian American patients 23. As an adult how much time have you spent socially with Black Americans? 24 As an adult how much time have you spent socially with Hi s panic / Latino(a) Americans? 25. As an adult how much time have you spent socially with White / aucasian Americans? 26. Rate ho knowledgeable you b e li eve you are about Black Americans a an ethnic group 27. Rate how knowledgeable you believe you are about Hi panic / Latino(a) Americans as an ethnic group. 28. Rate how knowledgeable you beli e yo u are about White / aucas1an m e ricans as an ethnic group. 29. Rate ho much yo u are in o l ed in the analysis or formation of clinic polic y.

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APPENDIX B TUCKER-CULTURALLY SENSITIVE HEALTHCARE INVENTORY FOR PHYSICIANS DIRECTIONS : Take a few seconds to think about your current work as a physician. Now please read the statements listed below and rate how much you agree that each statement describes you in your current work as a physician. Please use a rating of 4, 3, 2 or 1 where 4 = "Strongly Agree ", 3 = Agree 2 = Disagree" and 1 = "Strongly Disagree ." Shade in the circle beneath the rating that you choose like this: Keep in mind that your ratings are anonymous and confidential. Thus, please give truthful and accurate ratings and rate all statements .... .... "SJ>~ I., C)J) I., C 0Jl C 0Jl 0 I., I., 0 I., 0Jl 0Jl -~ I., 00 < < Q r.n Ci 4 3 2 1 0 0 0 0 1 I am confident in my abi l ities as a physician 0 0 0 0 2. I am consistent in my care-giving. 0 0 0 0 3 I am right about why my patients are sick. 0 0 0 0 4. I am honest and direct with my patients 0 0 0 0 5 I am humble when dealing with my patients 0 0 0 0 6 I am friendly to my patients 0 0 0 0 7. I am patient with my patients 0 0 0 0 8 I am polite to my patients. 0 0 0 0 9 I am relaxed with my patients. 0 0 0 0 10. I am welcoming to my patients. 0 0 0 0 11. I am compassionate with my patients. 0 0 0 0 12 I am helpful to my patients 0 0 0 0 13. I am respectful of my patients. 0 0 0 0 14 I take care of my patients immediately in emergencies 0 0 0 0 15 In private and/or in public I sometimes embarrass my patients 11 2

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11 3 0 0 0 0 16 I am courteous to my patients 0 0 0 0 17 I treat my patients problems appropriately 0 0 0 0 18 I am sensitive to my patients needs 0 0 0 0 19 I am respectful of my patients religious beliefs 0 0 0 0 20 I am well educated 0 0 0 0 21 I am knowledgeable about the field of medicine 0 0 0 0 22. I am willing to learn 0 0 0 0 23 I am open to ideas regarding alternative medicine 0 0 0 0 24 I pay attention to my patients concerns 0 0 0 0 25 I am dedicated to my work 0 0 0 0 26 I have a lot of schooling 0 0 0 0 27 I know what I am doing with my patients 0 0 0 0 28 I stereotype some of my patients 0 0 0 0 29 I know the limits of my skills 0 0 0 0 30 I am more knowledgeable about medicine than are my patients. 0 0 0 0 31 I pay attention to my work 0 0 0 0 32 I explain everything I do to my patients 0 0 0 0 33 I understand my responsibility for my patients health. 0 0 0 0 34 I acknowledge when I make a mistake. 0 0 0 0 35 I know my limits as to what I can treat. 0 0 0 0 36 I act professionally when working with patients 0 0 0 0 37 I talk to my patients during their visits 0 0 0 0 38 I listen to what my patients have to say 0 0 0 0 39 I treat my patients with tenderness 0 0 0 0 40 I am open to holistic ideas about health care 0 0 0 0 41 I mistakenly diagnose my patients problems as psychological. 0 0 0 0 42 I pay attention to my patients opinions 0 0 0 0 43 I take all my patients concerns seriously even if I do not think the concerns are serious 0 0 0 0 44. I am interested in my patients problems 0 0 0 0 45 I am concerned about my patients well-be i ng 0 0 0 0 46 I know my patients and their cases 0 0 0 0 47 I take care of my patients when they need treatment.

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114 0 0 0 0 48. I am nice to my patients. 0 0 0 0 49. I make my patients feel like their visits to the clinic were informative or productive. 0 0 0 0 50. I care more about my patients than about making money 0 0 0 0 51 I make my patients feel at home when they are at the clinic 0 0 0 0 52 I put my patients minds at ease 0 0 0 0 53. I show my patients that I am familiar with their health 0 0 0 0 54 I am w i lling to answer all of my patients questions. 0 0 0 0 55. I assume my patients are just looking for a way to get high when they ask for pa i n medic i nes 0 0 0 0 56. I answer my patients questions completely 0 0 0 0 57. I understand my patients f i nancial situa t ions 0 0 0 0 58 I treat all my patients w i th r espect. 0 0 0 0 59. I give equal opportunit i es for t r eatment to all my patients 0 0 0 0 60 I have a good beds i de manner with all my pat i ents 0 0 0 0 61 I trea t my patients like individuals 0 0 0 0 62 I try to make my patients visits posit i ve exper i ences for them 0 0 0 0 63 I have a pos i tive attitude when working w i th my pat i en t s 0 0 0 0 64 I make all my patients feel appreciated 0 0 0 0 65 I prepare my pat i en t s fo r the next steps in t reating their illnesses 0 0 0 0 66 I question the truth o r accu r acy of wha t my patients say they are feeling 0 0 0 0 67 I create pos i tive feelings i n my patients during the i r visits 0 0 0 0 68 I chat with my patients during their visits 0 0 0 0 69 I take care of any patient who needs trea t ment. 0 0 0 0 70 I refer my patients fo r tests that they t hink they need 0 0 0 0 71 I do everyth i ng possible to help out my patients 0 0 0 0 72 I treat all my pat i ents equally 0 0 0 0 73 I am concerned about my patients present and future situations. 0 0 0 0 7 4 I try to educate all of my patients.

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11 5 0 0 0 0 75 I make my patients feel accepted. 0 0 0 0 76 I give my patients personal attention 0 0 0 0 77 I talk down to some of my patients 0 0 0 0 78 I look my patients in the eyes when talking with them 0 0 0 0 79 I try to connect with my patients. 0 0 0 0 80 I know how to make my patients feel comfortable 0 0 0 0 81 I give my patients information about their test results without them asking for the results 0 0 0 0 82 I respond to my patients requests 0 0 0 0 83 I make helpful and reasonable recommendations 0 0 0 0 84 I treat my patients like people, not just numbers 0 0 0 0 85 I show my patients that I remember them. 0 0 0 0 86 I comfort my patients 0 0 0 0 87 I try to communicate with my patients 0 0 0 0 88 I am available for my patients 0 0 0 0 89 I put on a fresh pair of gloves in front of my patients. 0 0 0 0 90 I refer my patients to another physician when I cannot treat them. 0 0 0 0 91 I explain the medications I prescribe to my patients 0 0 0 0 92 I refer my patients to a specialist when they request it. 0 0 0 0 93 I take time with my patients while examining and treating them 0 0 0 0 94 I am prepared to examine my patients when I walk into the examining room 0 0 0 0 95. I evaluate my patients problems as soon as they come in to see me 0 0 0 0 96 I ask my patients questions about their symptoms 0 0 0 0 97 I charge reasonable prices for my services 0 0 0 0 98. I let my patients explain their symptoms before I examine them 0 0 0 0 99 I thoroughly and completely examine my patients 0 0 0 0 101 I examine all my patients according to a standard procedure 0 0 0 0 102 I review my patients records before making my diagnoses 0 0 0 0 103 I review my patients records before prescribing them

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116 medications or treatments 0 0 0 0 103 I am scared to touch my patients. 0 0 0 0 104 I prescribe medicine only after examining my patients 0 0 0 0 105. I consult with others in order to help my patients. 0 0 0 0 106 I prescribe medicine only when I am sure of my patients illnesses 0 0 0 0 107 I correctly diagnose and treat my patients illnesses. 0 0 0 0 108 I am consistent in my diagnoses and treatments of my patients illnesses 0 0 0 0 109 I talk to my patients before making decisions about prescriptions and treatments 0 0 0 0 110 I examine my patients carefully before making any decisions 0 0 0 0 111 I expla i n things in ways my patients can understand 0 0 0 0 112 I refer my patients to spe ci alists when I cannot solve their problem 0 0 0 0 113 I have training in working with African-American patients 0 0 0 0 114 I enjoy what I do as a phys i cian 0 0 0 0 115 I speak and understand English well enough to communicate with my pat i ents 0 0 0 0 116 I prescribe treatments and medicines that work 0 0 0 0 117 I make my patients wait long 0 0 0 0 118 I treat my patients specific problems 0 0 0 0 119 I am informative to my pa t ients 0 0 0 0 120 I make my patients feel noticeably better after their visits 0 0 0 0 121 I look profess i onal when working with patients 0 0 0 0 122 I keep up with new research and treatments 0 0 0 0 123 I ask my patients to make several return visits 0 0 0 0 124 I follow up after my patients visits 0 0 0 0 125 I am educated in working with patients of different cultures and social statuses. 0 0 0 0 126 I understand the African American culture. 0 0 0 0 127 I understand that people of different cultures have and believe in

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11 7 different medical practices 0 0 0 0 128 I understand that Caucasian/\/Vhite Americans are not necessarily assertive at a physician s office 0 0 0 0 129 I bring medical students into a patient s room without the patient's permIssIon 0 0 0 0 130 I work to make the clinic more racially integrated 0 0 0 0 131. I show care and concern for my patients children. 0 0 0 0 132 I treat my patients children well. 0 0 0 0 133. I send my patients to another physician when I cannot communicate with them 0 0 0 0 134 I am understanding about the difficulties my patients might have relating to me because of our cultural and/or economic differences 0 0 0 0 135. I let my African American patients know about illnesses and diseases common among members of their race. 0 0 0 0 136. I ask my patients about how they are feeling 0 0 0 0 137 I hire staff who are eager to please patients 0 0 0 0 138 I try to help out my patients 0 0 0 0 139 I look down on some of my patients 0 0 0 0 140 I explain the procedures I prescribe to my patients 0 0 0 0 141 I show my patients that I understand their feelings and views

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APPENDIX C TUCKER-CULTURALLY SENSITIVE HEALTHCARE INVENTORY FOR HEALTHCARE PROVIDERS DIRECTIONS : Take a few seconds to think about your current work as a health care provider. Now please read the statements listed below, and rate how much you agree that each statement describes you in your current work as a health care provider Please use a rating of 4 3 2 or 1 where 4 = Strongly Agree ", 3 = Agree" 2 = "Disagree" and 1 = Strongly Disagree ." Shade in the circle beneath the rating that you choose like this : Keep in mind that your ratings are anonymous and confidential. Thus please give truthful and accurate ratings and rate all statements. 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1. 0 2 0 3 0 4 0 5 0 6 0 7 0 8. 0 9 0 10 0 11 0 12. 0 13 0 14 0 15 I am confident in my abilities as a health care provider I am consistent in my care-giving I am right about why my patients are sick. I am honest and direct with my patients. I am humble when dealing with my patients. I am friendly to my patients I am patient with my patients. I am polite to my patients I am relaxed with my patients I am welcoming to my patients I am compassionate with my patients I am helpful to my patients. I am respectful of my patients I take care of my patients immediately in emergencies. In private and/or in public I sometimes embarrass my 118

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11 9 patients 0 0 0 0 16. I am courteous to my patients 0 0 0 0 17 I treat my patients problems appropriately 0 0 0 0 18 I am sensitive to my patients needs 0 0 0 0 19 I am respectful of my patients religious beliefs 0 0 0 0 20 I am well educated 0 0 0 0 21 I am knowledgeable about the field of medicine 0 0 0 0 22 I am willing to learn 0 0 0 0 23 I am open to ideas regarding alternative medicine 0 0 0 0 24 I pay attention to my patients concerns 0 0 0 0 25 I am dedicated to my work 0 0 0 0 26 I have a lot of schooling 0 0 0 0 27. I know what I am doing with my pat i ents 0 0 0 0 28 I stereotype some of my patients 0 0 0 0 29 I know the limits of my skills 0 0 0 0 30 I am more knowledgeable about medicine than are my patients 0 0 0 0 31 I pay attention to my work 0 0 0 0 32 I explain everything I do to my patients 0 0 0 0 33 I understand my responsibility for my patients health 0 0 0 0 34. I acknowledge when I make a mistake 0 0 0 0 35 I know my limits as to what I can treat. 0 0 0 0 36 I act professionally when working with patients 0 0 0 0 37 I talk to my patients during their visits 0 0 0 0 38. I listen to what my patients have to say 0 0 0 0 39 I treat my patients with tenderness 0 0 0 0 40 I am open to holistic ideas about health care 0 0 0 0 41 I m i stakenly diagnose my patients problems as psychological. 0 0 0 0 42 I pay attention to my pat i ents op i nions 0 0 0 0 43 I take all my patients concerns seriously even i f I do not think the concerns are ser i ous 0 0 0 0 44 I am interested in my patients problems 0 0 0 0 45 I am concerned about my patients well be i ng 0 0 0 0 46 I know my patients and their cases 0 0 0 0 47 I take care of my patients when they need treatment.

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1 2 0 0 0 0 0 48 I am nice to my patients. 0 0 0 0 49. I make my patients feel like their visits to the clinic were informative or productive 0 0 0 0 50 I care more about my patients than about making money. 0 0 0 0 51 I make my patients feel at home when they are at the clinic 0 0 0 0 52 I put my patients m i nds at ease 0 0 0 0 53 I show my patients that I am familiar with their health. 0 0 0 0 54. I am willing to answer all of my patients questions 0 0 0 0 55 I assume my patients are just looking for a way to get high" when they ask for pain medicines 0 0 0 0 56 I answer my patients questions completely 0 0 0 0 57 I understand my patients financial situations. 0 0 0 0 58 I treat all my patients with respect. 0 0 0 0 59 I g i ve equal opportun i t i es for treatment to all my patients 0 0 0 0 60 I have a good bedside manner w i th all my pat i ents 0 0 0 0 61 I treat my patients like individuals 0 0 0 0 62 I try to make my patients vis i ts positive experiences for them. 0 0 0 0 63 I have a pos i t i ve attitude when working with my pat i ents 0 0 0 0 64 I make all my patients feel apprec i a t ed 0 0 0 0 65 I prepare my pat i en t s fo r the next steps i n treat i ng thei r i llnesses 0 0 0 0 66 I question the truth or accuracy of what my pat i ents say they are feel i ng 0 0 0 0 67 I create positive fee l ings in my pat i ents dur i ng their visits 0 0 0 0 68 I chat with my pat i ents du r ing the i r v i sits 0 0 0 0 69. I take care o f any pat i ent who needs t rea t ment. 0 0 0 0 70 I refer my pa t ients for tests that they t hink they need 0 0 0 0 71 I do everything possible to help out my patients 0 0 0 0 72 I treat al l my patients equally 0 0 0 0 73 I am concerned about my patients present and future situations 0 0 0 0 74 I try to educate all of my patients 0 0 0 0 75 I make my patients f eel accepted

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1 2 1 0 0 0 0 76. I give my patients personal attention 0 0 0 0 77. I talk down to some of my patients 0 0 0 0 78. I look my patients in the eyes when talking with them 0 0 0 0 79. I try to connect with my patients. 0 0 0 0 80. I know how to make my patients feel comfortable 0 0 0 0 81. I give my patients information about their test results without them asking for the results. 0 0 0 0 82. I respond to my patients requests. 0 0 0 0 83 I make helpful and reasonable recommendations 0 0 0 0 84 I treat my patients like people, not just numbers. 0 0 0 0 85. I show my patients that I remember them 0 0 0 0 86. I comfort my patients 0 0 0 0 87 I try to communicate with my patients. 0 0 0 0 88. I am available for my patients 0 0 0 0 89 I put on a fresh pair of gloves in front of my patients 0 0 0 0 90 I refer my patients to another health care provider when I cannot treat them. 0 0 0 0 91 I explain the medications I prescribe to my patients 0 0 0 0 92 I refer my patients to a specialist when they request it. 0 0 0 0 93. I take time with my patients while examining and treating them. 0 0 0 0 94 I am prepared to examine my patients when I walk into the examining room. 0 0 0 0 95. I evaluate my patients problems as soon as they come in to see me. 0 0 0 0 96. I ask my patients questions about their symptoms 0 0 0 0 97 I charge reasonable prices for my services 0 0 0 0 98 I let my patients explain their symptoms before I examine them 0 0 0 0 99. I thoroughly and completely examine my patients 0 0 0 0 100. I examine all my patients according to a standard procedure 0 0 0 0 101 I review my patients records before making my diagnoses 0 0 0 0 102 I review my patients records before prescribing them medications or treatments. 0 0 0 0 103 I am scared to touch my patients 0 0 0 0 104 I prescribe medicine only after examining my patients 0 0 0 0 105 I consult with others in order to help my patients.

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122 0 0 0 0 106. I prescribe medicine only when I am sure of my patients illnesses 0 0 0 0 107. I correctly diagnose and treat my patients' illnesses 0 0 0 0 108 I am consistent in my diagnoses and treatments of my patients' illnesses 0 0 0 0 109 I talk to my patients before making decisions about prescriptions and treatments. 0 0 0 0 110 I examine my patients carefully before making any decisions. 0 0 0 0 111 I explain things in ways my patients can understand 0 0 0 0 112. I refer my patients to specialists when I cannot solve their problem 0 0 0 0 113 I have training in working with African-American patients 0 0 0 0 114 I enjoy what I do as a health care provider 0 0 0 0 115 I speak and understand English well enough to communicate with my patients 0 0 0 0 116 I prescribe treatments and medicines that work. 0 0 0 0 117 I make my patients wait long 0 0 0 0 118 I treat my patients specific problems. 0 0 0 0 119. I am informat i ve to my patients 0 0 0 0 120 I make my patients feel noticeably better after their visits 0 0 0 0 121. I look professional when working with patients. 0 0 0 0 122 I keep up with new research and treatments 0 0 0 0 123. I ask my patients to make several return visits. 0 0 0 0 124. I follow up after my patients visits. 0 0 0 0 125 I am educated in working with patients of different cultures and social statuses 0 0 0 0 126 I understand the African American culture 0 0 0 0 127 I understand that people of different cultures have and believe in different medical practices. 0 0 0 0 128 I understand that CaucasianNVhite Americans a r e not necessarily assertive at a health care prov i der s off i ce 0 0 0 0 129. I bring medical students into a patient's room without the patient's permission 0 0 0 0 130 I work to make the clinic more racially integrated 0 0 0 0 131 I show care and concern for my patients' ch i ldren 0 0 0 0 132 I treat my patients children well. 0 0 0 0 133 I send my patients to another health care provider

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1 23 when I cannot communicate with them 0 0 0 0 134 I am understanding about the d i fficult i es my patients might have relating to me because of our cu l tura l and/or econom i c differences 0 0 0 0 135 I let my African American patients know about illnesses and diseases common among members of their race 0 0 0 0 136 I ask my patients about how they are feel i ng 0 0 0 0 137 I h i re staff who are eager to p l ease patients 0 0 0 0 138 I try to help out my pat i ents 0 0 0 0 139 I look down on some of my pat i ents 0 0 0 0 140 I explain the procedures I prescr i be to my pat i ents. 0 0 0 0 141 I show my pat i ents tha t I understand their feel i ngs and v i ews.

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APPENDIX D CULTURAL COMPETENCE SELF-ASSESSMENT QUESTIONNAIRE SERVICE PROVIDER VERSION C onfid e nti a l PIN : ------This questionnaire is designed to assess cultural competence training needs of mental health and human service professionals The self-assessment process is used to develop agency-specific training interventions which address cross cultural weaknesses and build upon cross-cultural strengths of the staff generally and organization specifically Cultural competence is a developmental process ; therefore the goal is to promote positive movement along the cultural competence continuum Thus the assessment should be viewed as an indication of areas in which the agency and staff can over time enhance attitudes practices policies, and structures concerning service delivery to culturally diverse populations. Your responses are strictly confidential and will solely be used to identify areas in which planned growth and greater awareness can occur Instructions: Please circle or otherwise mark the response that most accurately reflects your perceptions If you have trouble understanding a question answer to the best of your ability Feel free to expand your responses or note concerns on the back of the pages. Inapplicable questions will be statistically eliminated from the analysis Please keep in mind that there is no way to perform poorly KNOWLEDGE OF COMMUNITIES 1 How well are you able to describe the communities of color in your service area? 0 NOT AT ALL 0 BARELY 1 24 0 FAIRLY WELL 0 VERY WELL

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1 25 2 Please list the cultural group(s) of color who reside in your service area and how much of the overall population this represents : Group Percent of Population Percent of Populat i on in Service Area in State 3 How well are you able to describe within-group differences? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 4 How well are you able to describe the strengths of the groups of color in your service area? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 5 How well are you able to describe the social problems of the groups of color in your service area? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 6 To what extent do you know the following demographic characteristics within communities of color in your service area? (Bubble in your response for each area ) NOT AT BARELY FAIRLY VERY ALL WELL WELL a Unemployment Rates 0 0 0 0 b Geographic Locations 0 0 0 0 C Income Differentials 0 0 0 0 d Educat i onal Attainment 0 0 0 0

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a b C d e f g. h. 1 26 e. Birth/Death Rates 0 0 0 0 f Crime Rates 0 0 0 0 g Homicide Rates 0 0 0 0 h. Owner Occupancy Rates 0 0 0 0 7 To what extent do you know the following resources regarding the people of color in your service area? (Bubble in your response for each area ) NOT AT ALL BARELY FAIRLY VERY WELL WELL Social Historians 0 0 0 0 Informal Supports and 0 0 0 0 Natural Helpers Formal and Social 0 0 0 0 Service Agencies Formal Leaders 0 0 0 0 Informal Leaders 0 0 0 0 Business People 0 0 0 0 Advocates 0 0 0 0 Clergy or Spiritualists 0 0 0 0 8 Do you know the prevailing beliefs customs norms and values of the groups of color in your service area? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 9 Do you know the social service needs within communities of color that go unaddressed by the formal social service system? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL

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1 2 7 1 0 Do you know of social service needs that can be addressed by natural networks of support within the communities of color? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 11 Do you know of any conflict between or within groups of color in your service area? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 12 Do you know the greeting protocol within communities of color? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 13 Do you know the cultural-specific perspectives of mental health/illness as viewed by the groups of color in your area? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 14 Do you understand the conceptual distinction between the terms immigrant" and refugee ? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 15 Do you know what languages are used by the communities of color in your area? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 16 Are you able to describe the common needs of people of all colors in your community? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL

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1 2 8 PERSONAL INVOLVEMENT 17 Do you attend cultural or racial group holidays or functions within communit i es of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 18 Do you interact socially with people within your service area? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 19. Do you attend school-based meetings that impact people of color in your service area? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 20 Do you attend community forums or ne i ghborhood meetings within communities of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 21. Do you patronize businesses owned by people of color in your service area? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 22. Do you pursue recreational or leisure activities within communities of color? 0 0 0 0 NOT AT ALL SELDOM SOMETIMES OFTEN 23 Do you feel safe within communities of color? 0 0 0 0 NOT AT ALL SELDOM SOMETIMES OFTEN

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a b C d. e f g h i. J 1 29 24 Do you attend interagency coordination (IAC ) meet i ngs that impact service delivery in communities of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 25 Do you attend community or culturally-based advocacy group meetings within communities of color 0 0 0 0 NOT AT ALL SELDOM SOMETIMES OFTEN RESOURCES AND LINKAGES 26. Does your agency work collaboratively with programs that provide ... NOT AT BARELY FAIRLY VERY ALL WELL WELL Employee Training? 0 0 0 0 Educational Opportun i ty? 0 0 0 0 Housing? 0 0 0 0 Alcohol/Substance Abuse 0 0 0 0 Treatment? Maternal and Child Health 0 0 0 0 Services? Public Health Services? 0 0 0 0 Juvenile Justice Services? 0 0 0 0 Recreation Services? 0 0 0 0 Child Welfare Services? 0 0 0 0 Youth Development 0 0 0 0 Services?

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130 Does your agency have linkages with institutions of higher education (e.g. colleges, universities or professional schools) that can provide accurate information concerning communities of color? 0 NONE 0 AFEW 0 SOME 0 MANY Does your agency have linkage with civil rights, human rights or human relations groups that provide accurate information concerning populations of color? 0 NONE 0 AFEW 0 SOME 0 MANY Does your agency have linkages with the U S Department of Census local planners, chambers of commerce or philanthropic groups who can provide you with accurate information regarding populations of color? 0 NONE 0 AFEW 0 SOME 0 MANY Does your agency publish or assist in the publication of information focusing on cultural groups of color? 0 NONE 0 AFEW 0 SOME 0 MANY 27 Has your agency conducted or participated in a needs assessment utilizing providers in communities of color as respondents? 0 NEVER 0 ONCE OR TWICE 0 A FEW TIMES 0 A NUMBER OF TIMES

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1 3 1 28 Has your agency conducted or participated in a needs assessment utilizing consumer or family members of color as respondents? 0 NEVER 0 ONCE OR TWICE 0 A FEW TIMES 0 A NUMBER OF TIMES 29 Does your agency have linkages with advocates for communities of color who can provide reliable information regarding community opinions about diverse and important issues? 0 NONE 0 AFEW 0 SOME 0 MANY 30 Does your agency conduct open house-type events to which you invite providers consumers and others concerned with service delivery to communities of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 31. Does staff utilize cultural consultants who can help them work more effectively within a cultural context? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 32 Does your agency utilize interpreters to work with non-English speaking persons? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 33 Does your agency subscribe to publications (local or national) in order to stay abreast of the latest information about populations of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 38 Do staff have access to culturally-related materials (books video etc .) ?

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a. b C 0 NONE 0 AFEW 1 32 0 SOME 0 MANY 39 Do you maintain a personal library with cultural resources? 0 NONE 0 AFEW 0 SOME 0 MANY 40 Do agency staff regularly attend cross-cultural workshops? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 41 Are agency staff encouraged to take ethnic studies courses? 0 0 0 0 NOT AT ALL SELDOM SOMETIMES OFTEN 42 Do agency workspaces contain cultural art i facts? 0 0 0 0 NONE AFEW SOME MANY STAFFING 43 Are there people of color on the staff of your agency? 0 0 0 0 NONE AFEW SOME MANY 44 Are there people of color represented in NONE AFEW SOME Administrative positions? 0 0 0 Direct service positions? 0 0 0 Administrative support 0 0 0 positions? MANY 0 0 0

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1 33 d Operational support 0 0 0 0 positions? e Board positions? 0 0 0 0 f Agency consultants? 0 0 0 0 g (Sub)contractors? 0 0 0 0 45 Does your agency ... NEVER SELDOM SOMETIMES REGULARLY a hire natural helpers or other non0 0 0 0 credentialed people of color as paraprofessionals? b hire practicum 0 0 0 0 students or interns of color? C out-station staff in 0 0 0 0 communities of color? d hire bilingual staff? 0 0 0 0 46 Does your agency prepare new staff to work with people of color? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 47 Does your agency provide training that helps staff work with people of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 48 Does your agency emphasize active recruitment of people of color? 0 NONE 0 A LITTLE 0 SOME 0 A LOT

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1 34 49 How well has your agency been able to retain people o f color on staff? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL

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1 35 50 Does your agency staff routinely discuss barriers to working across cultures? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 51. Does agency staff routinely discuss their feelings about working with consumers/co-workers of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 52. Does agency staff routinely share practice-based success stories involving people of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 53 Does your agency direct students of color towards careers in human services or related occupations? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 54 Does your agency convene or reward activities that promote learning new languages relevant to the communities of color that the agency serves? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN SERVICE DELIVERY AND PRACTICE (For Direct Service Staff Only) 55 Are you familiar with the limitations of mainstream diagnostic tools as applied to people of color? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL

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136 56 Do you discuss racial/cultural issues with consumers in the trea t ment process? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 57. Do you willingly share information w i th clients about your personal or professional background 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 58 Do you share some of your persona l feelings w i th cl i ents? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 59 Do you assess client acculturat i on o r assi mil at i on with r espect to the mainstream culture? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OF T EN 60 How well do you use cultural st r engths and resources when p l ann i ng services to clients of color? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 61 Do you use cultural references or histo r ical accompl i shments as a source of empowerment for people of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 62 Do you use treatment interventions that have been developed for populations of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OF T EN

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1 37 63 Do your treatment plans contain a cultural perspective (e.g ., role of extended family spirituality/religious beliefs issues related to the formation of cultural identity) that acknowledges different value systems of people of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 64 Do you advocate for quality of life issues (e g ., employment housing educational opportunities) identified as important by communities of color in your service area? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 65 Are you familiar with the use of moderator variables? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 OFTEN 0 VERY WELL 66 Do you use ethnographic interviewing as a technique to gather more accurate information? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 67 Do you use self-disclosure in the treatment process? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 0 OFTEN 68 Do you encourage the involvement of extended family members of significant others in diagnosis treatment planning or evaluation of treatment? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 69 Do you see clients outside of your usual office setting? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 0 OFTEN

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138 70 Do you use clergy or peop l e from the spiritual community to enhance services to the people of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 71 Do you dismiss clients that come late for their appointments? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 72. Do you use consumer satisfaction measures to evaluate service delivery? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 73. Do you ensure that clients of color have transportation, childcare, and other arrangements which facilitate access to your services? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN ORGANIZATIONAL POLICY AND PROCEDURES 7 4 As matter of formal policy, does your agency .. CURRENTLY CONSIDERING WRITING POLIC NO POLICY POLICY FORMAL YIN POLICY PLAC E a. Use culture0 0 0 0 specific assessment instruments for diagnosis? b Use culture0 0 0 0 specific treatment approaches?

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1 39 C Envision community 0 0 0 0 empowerment as a treatment goal? d Review case 0 0 0 0 practice on a regular basis to determine relevancy to clients of color? e. Provide or 0 0 0 0 facilitate child care? f Provide or 0 0 0 0 facilitate transportation (e.g. bus tickets ride-sharing)? g Allow access after regular 0 0 0 0 business hours (e.g. through message-beeper agreements with crisis-providers etc )? h Specifically consider 0 0 0 0 culture in service plans? i. Conduct outreach to community based 0 0 0 0 organizations service agencies natural helpers or extended families? j Take referrals from 0 0 0 0 non-traditional sources? k Translate agency materials into languages 0 0 0 0

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that reflect the linguistic diversity in your service area? I. Advocate for better quality of life for persons of color in addition to providing services? 0 140 0 0 75 In general how well are policies communicated to agency staff? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 0 76 Is information on the ethnicity or culture of clients specifically recorded in your organization s management information system? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL REACHING OUT TO COMMUNITIES a b 77 How well do you assure that communities of color are aware of your program and the services and resources you offer? 0 NOT AT ALL 0 BARELY 0 FAIRLY WELL 0 VERY WELL 78 Does your organization or agency reach out to ... NEVER SELDOM SOMETIMES REGULARLY Churches and other places of worship clergy 0 0 0 0 persons ministerial alliances or indigenous religious leaders in communities of color? Medicine people health clinics 0 0 0 0 chiropractors naturopaths herbalists or midwives that provide service in communities of

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color? c Publishers broadcast d or other media sources within communities of color? Formal entities that provide services? e. Cultural racial or tribal organizations where people of color are likely to voice complaints or issues? f. Business alliances or organizations in communities of color? 1 4 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 79.Are people of color depicted on agency brochure or other print media? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN 80. Does your agency participate in cultural political religious or to the events or festivals sponsored by communities of color? 0 NOT AT ALL 0 SELDOM 0 SOMETIMES 0 OFTEN

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APPENDIX E MARLOWE-CROWNE SOCIAL DESIRABILITY SCALE SHORT FORM Directions : For each of the following statements please fill i n where you consider the statement to be True (T) or False (F). 1 I never hesitate to go out of my way to help someone in trouble 2 I have never intensely disliked anyone 3 I sometimes feel resentful when I don t get m y way 4 I like to gossip at times 5 There have been times when I felt like rebell i ng against people in aut h o ri ty even thoug h I knew they were right. 6 I can remember playing s i ck to get out of something 7 There have been occasions when I took advantage of someone 8 I m always will i ng to admit i t when I make a mistake 9 I always try to practice what I preach 10 1 sometimes try to get even rather than forgive and forget. 11 When I don t know something I don t at all m i nd admitting it. 12 1 am always courteous, even to people who are disagreeable 142 True False 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

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1 43 13 At times I have really insisted on having things 0 0 my way. 14 There have been occasions when I felt like 0 0 smashing things 15 1 would never think of letting someone else be 0 0 punished for my wrong-doings 16 1 never resent being asked to return a favor 0 0 17.1 have never been irked when people 0 0 expressed ideas very different from my own. 18 There have been times when I was quite 0 0 jealous of the good fortune of others 19.1 am sometimes irritated by people who ask 0 0 favors of me 20. I have never deliberately said something to 0 0 hurt someone's feelings

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APPENDIX F HEALTHCARE PROFESSIONAL INVITATION COVER LETTER Dear Health Care Profess i onal : We are writ i ng to invite you to participate in an NIH funded research projec t that is being conducted by Dr Carolyn Tucker Distinguished Alumni Professor Dr. Larry Rooks, Director of the North Florida Area Health Education Centers Network (AHEC) and Dr. R. W. Curry Professor and Cha i r Department of Community Health and Family Medicine The purpose of this project is to develop a culturally sensitive health care training program here at UF. You and other Health Care Profess i onals from Family Practice Med i ca l Group and Eastside Community Practice are being invited to part i cipate in this s t udy Participation will involve completing a ques t ionna i re battery s i x times over the next three years. Also in the next two to three years you will be i nvited to participate in a training workshop on culturally-sensitive health care The study is designed to ensure that your questionnaire responses will be anonymous and confidential. We do not believe that participating i n th i s study will cause you any harm However you do have the right to stop comp l eting the questionnaire battery if it makes you feel uncomfortable and to skip any questions that you find offensive. You can also choose at any t i me over the course of the study to discontinue your part i cipat i on. Your refusal to participate will in no way affect your employment status Furthermore at no point will any University or clinic administrative personnel have access to individual responses or data from you or other participants in this study. The following precautions have been taken in order to ensure the confidentiality of your responses : 1) You are asked not to place your name on the enclosed questionna i res Instead please generate a Health Care Professional Private Identification Number (PIN) with the first 4 letters of the city in which you were born followed by the 4 numbers representing the month and day on which you were born (e g ., GAIN-0201 fo r Gainesville February 1 st ) Please place this PIN on each questionnaire in the space provided It is important that you use the same PIN on all questionnaires each time you complete the battery so that your data can be tracked throughout the course of the longitudinal study without your name ever being connected to the data you provide 1 44

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145 2) After signing the Informed Consent Form and completing the Payment Release Form you are asked to separate these two forms from the questionnaires and place them in separate envelopes and then in separate lock-boxes. Questionnaires will be kept in a locked filing cabinet in Dr Tucker s laboratory at the University of Florida. Informed Consent and Payment Release Forms will be kept in a separate filing cabinet to ensure that your identity can never be linked to your completed questionnaires If you would like to participate in this study, please do the following within one week of receiving this packet: 1) FIRST, sign both of the two enclosed Informed Consent Forms to indicate your willingness to voluntarily participate in the project. Insert one signed copy of the Informed Consent Form along with the Payment Release Form into the envelope provided marked "Informed Consent/Payment Release" and drop the envelope in the locked box marked "Informed Consent/Payment Release" located at your clinic. 2) AFTER reading and signing the Informed Consent Forms, please complete the enclosed questionnaire battery, which should take approximately 45 minutes to complete, and seal the completed battery in the provided envelope marked "Questionnaires", and drop this envelope in the locked box marked "Questionnaires" located at your clinic. Participation in this study is voluntary If you decide to participate, you will receive $20.00 compensation each time you complete a questionnaire battery. You will also receive $90 00 compensation, and continuing medical education credits for completing the training workshop We hope that you find this NIH funded study interesting and valuable We look forward to your participation and believe that this study offers great potential for helping Health Care Professionals, such as yourself optimize their ability to provide culturally sensitive health care to culturally diverse patients If you have any questions or desire further information about this study please call the Principal Investigator Dr Carolyn Tucker at (352) 392-0601 ext. 260 Sincerely Dr. Larry Rooks Regional Director North Florida Area Health Education Centers

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146 Dr. Robert Curry Jr Professor and Chair, Community Health and Family Medicine Dr. Carolyn M Tucker Distinguished Alumni Professor Professor of Psychology and Director of Training Professor of Pediatrics Professor of Community Health and Family Medicine

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LIST OF REFERENCES Anderson R. Barbara A. Weisman, C ., Scholle S ., Binko J. Schneider T. Freund K ., & Gwinner V. (2001) A qualitative analysis of women's satisfaction with primary care from a panel of focus groups in the National Centers of Excellence in Women's Health Journal of Women s Health & Gender-Based Medicine, 10, 637-647 Beal, A. (2003) Healthcare workforce diversity: Developing physician leaders The Sullivan Commission on Diversity in the Healthcare Workforce, October 3, 2003,pp 1-15. New York NY: The Commonwealth Fund Boeke A. (2000) Women and E-health Health Management Technology, 21, 48 Borgen, F. (1992). Expanding scientific paradigms in counseling psychology. In S D. Brown & R. W Lent (Eds.) Handbook of counseling csychology (2 nd ed ) New York NY : John W i ley and Sons Bronner Y (1994) Cultural sensitivity and nutrition counseling Topics in Clinical Nutrition, 9, 13 19. Brown L. S. (1994) Subversive dialogues: Theory in feminist therapy. New York NY : BasicBooks. Brown L. S. (2000). Feminist therapy. In C R Snyder & R. E. Ingram (Eds ) Handbook of psychological change: Psychotherapy processes & practices for the 21 s t century (pp 358-380) New York NY : John Wiley & Sons Inc Cohen J ., Cohen P. West S & Aiken L. (2003) Applied multiple regression/ correlation analysis for the behavioral sciences (3 r d Ed ) Mahwah NJ: Lawrence Erlbaum. Collins K ., Hughes D Doty M Ives B ., Edwards J ., & Tenney K (2002) Diverse communities, common concerns : Assess i ng healthcare quality for minority Amer i cans New York NY : The Commonwealth Fund Constantine M (2000). Self report mult i cultural competence sca l es : Their relation to social desirability attitudes and multicultural case conceptualization Journal of Counseling Psychology, 47 155-164 1 47

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148 Crowne D., & Marlowe D (1964). The approval motive: Studies in evaluative dependence. New York NY: Wiley. DiPalo, M. (1997) Rating satisfaction research: Is it poor fair good very good or excellent? Arthritis Care and Research, 10, 422-430. Engel, G. L. (1977) The need for a new medical model: A challenge for biomedicine. Science, 196, 129-136 Ferguson, B (1991 ) Concepts, models, and theories for immigrant health care In B. Ferguson & E. Browne (Eds ) Health care and immigrants: A guide to the helping professions (pp. 123-167). Sydney Australia : Maclennan & Petty. Fraboni, M., & Cooper, D. (1989) Further validation of three short forms of the Marlowe-Crowne scale of social desirability Psychological Reports, 65, 595-600 Glaser B & Strauss A. (1967). The discovery of grounded theory : Strategies for qualitative research. Chicago, IL: Aldine Publishing Company Heppner, P Kivlighan D Jr & Wampold B (1999) Research design in counseling Belmont CA: Wadsworth Huff, R. & Kline, M. (1999) Health promotion in the context of culture. In R.M. Huff & M.V. Kline (Eds.), Promoting health in multicultural populations: A handbook for practitioners (pp 3-22) Thousand Oaks CA : Sage Publications. Institute of Medicine (1999) Leading health indicators for health people 2010 : Final report. Washington D.C : Institute of Medicine. Jack, L, Jr., & Satterfield, D (2002). Cultural sensitivity : Definition application and recommendations for diabetes educators. The Diabetes Educator, 28, 922-927 Kagawa-Singer M., & Chung R. (1994) A paradigm for culturally based care in ethnic minority populations. Journal of Community Psychology, 22, 192208 Landrine, H. & Klonoff, E (1992). Culture and health-related schemas: A review and proposal for interdisciplinary integration. Health Psychology, 11, 267276. Lauerman C (2002) Female practices benefit doctors and patients Marketing to women : Assessing women and women s sensibilities, 15, 8-9

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1 49 Leppert, P ., Partner S ., & Thompson A (1996) Learning from the community about barriers to health care. Obstetrics & Gynecology, 87, 140-141 Lewis M K (2002). Multicultural health psychology: Special topics acknowledging diversity Boston MA: Allyn & Bacon Mason, J. (1995) Cultural competence self-assessment questionnaire : A manual for users Portland OR: Portland State University Research and Training Center on Family Support and Children s Mental Health Minorities in Medicine (1998) Council on graduate medical education : 1 ih report. U.S. Department of Health and Human Services Montague, A. (Ed ) (1964). The concept of race London England : Collier Books Morrow S. & Smith M (2000) Qualitative research for counseling psychology In S. D Brown & R W. Lent (Eds.) Handbook of counseling psychology (3 rd ed ) (pp 199-232) New York NY: John Wiley & Sons Inc Nelson H ., & Jurmain R. (1988). Introduction to physical anthropology (4 th ed .). St. Paul, MN : West NOVA Online (2001). Hippocratic oath Modern version. http://www pbs org/wgbh/nova/doctors/oath modern.html (June 2005) Pachter L. (1994 ) Culture and clinical care : Folk illness bel i efs and behaviors and their implications for health care delivery Journal of the American Medical Association, 271, 690-694 Pedersen P (1991 ). Multiculturalism as a fourth force in counseling (special issue) Journal of Counseling and Development, 70, 47-59 Ponterotto J. & Casas J (1991 ) Handbook of racial/ethnic minor ity counseling research Springfield IL : Thomas Pope-Davis D. Liu W ., Toporek R. & Brittan-Powell C. (200 1) What's missing from multicultural competency research : Review introspection and recommendat i ons Cultural Diversity and Ethnic Minority Psychology 7, 121-138 Ratcliff K S (2002) Women and health : Power, technology, inequality, and conflict in a gendered world Boston MA : Allyn & Bacon Ridley C ., Mendoza D ., Kanitz B. Ang ermeier, L ., & Zenk R. ( 19 ). Journal of Counseling Psychology 41, 125 136.

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150 Robins, L., & White, C. (2001). Assessing medical students' awareness of and sensitivity to diverse health beliefs using a standardized patient station. Academic Medicine, 76, 76-79. Robinson, T. L. & Howard-Hamilton, M. F. (2000) The convergence of race, ethnicity, and gender: Multiple identities in counseling. Upper Saddle River NJ : Prentice-Hall, Inc Roter D. Stewart M ., Putnam S ., Lipkin M. Stiles W ., & lnui T. (1997) Communication patterns of primary care physicians. Journal of the American Medical Association, 277 350-356 Safran D., Taira D. Roger W ., Kosinski M ., Ware J. & Tarlov, A. (1998). Linking primary care performance to outcomes of care The Journal of Family Practice, 47, 213-220 Salganicoff A ., Beckerman J Z. Wyn R. & Ojeda V. D (2002) Women's health in the United States : Health coverage and access to care Menlo Park CA : The Henry J Kaiser Family Foundation Schneider E. Zaslavsky A ., & Epstein A (2002) Racial disparities in the quality of care for enrollees in Medicare managed care. Journal of the American Medical Association, 287, 1288-1294 Schulman, K. Berlin J ., Harless W. Kerner J ., Sistrunk, S ., Gersh B ., Dube R. Taleghani C. Burke J ., Williams S. Eisenberg, J. & Escarce J. (1999). The effect of race and sex on physicians recommendations for cardiac catheterization The New England Journal of Medicine, 340, 618626 Second National Conference on Quality Health Care for Culturally Diverse Populations : Strategy and Action for Communities Providers and a Changing Health Care System (2000) Http : //www diversityrx org/CCCONF/OO/INDEX.html (June 2005) Sadowsky G (1996) The multicultural counseling inventory : Psychometric properties and some uses in counseling training In G R. Sadowsky & J C lmpara (Eds ) Mental health assessment in counseling and clinical psychology (pp. 283-324) Lincoln NE : Buros Institute of Mental Measurements. Stevens, J. (2002) Applied multivariate statistics for the social sciences (4 th ed ) Mahwah NJ : Lawrence Erlbaum Associates Inc

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1 5 1 Stewart A ., Napoles-Springer A. Perez-Stable E ., Posner S Bindman A ., Pinderhughes H ., & Washington A (1999) Interpersonal processes of care in diverse populations Milbank Quarterly 77 305-339 Strauss A ., & Corbin J (1990) Basics of qualitative research : Grounded theory procedures and techniques Newbury Park CA : Sage Sue D (1995) Toward a theory of multicultural counseling and therapy In J A Banks & C A McGee Banks (Eds.) Handbook of research on mult i cultural education (pp 647 659) New York NY : Macmillan Sue D ., Ivey A. & Pedersen P (1996) A theory of multicultural counseling and therapy Pacific Grove CA: Brooks/Cole Publishing Company Takeuchi D & Uehara E. (1996) Ethnic minority health services : Current research and future conceptual direction. In B L. Levin & J Petrila (Eds.) Mental health services: A public health perspective NY: Oxford Press Tang S Y S ., & Anderson J M (1999) Human agency and the process of healing: Lessons learned from women living with a chronic illness "rewriting the experience Nursing Inquiry 6 1 83-93 Taylor, S. E (1999). Health psychology (4 t h ed.) Boston MA : McGraw-Hill Tegtmeyer R. (1997) Women's bodies are not "deficit" models of nature Women's International Network. 23, 14-15 Tucker C ., Herman K ., Delgado-Romero, E ., Hackshaw R., Byrd C ., & Ferdinand L. (unpublished manuscript). Rationale and recommendations for culturally sensitive health care University of Florida Tucker C. Herman K Pedersen T. Higley B ., Ivery P. Hackshaw R. & Pacheco M (2001 ) Patient-defined culturally sensitive health care In American Psychological Association Division 17 Counseling Psychology Student Affiliate Group Newsletter V. 23 Issue 2 Spring Tucker C. Herman K ., Pedersen T. Higley B ., Montrichard M ., & Ivery P (2003) Cultural sensitivity in physician-patient relationships : Perspectives of an ethnically diverse sample of low income primary care patients Journal of Medical Care 41, 859 870 United States Census Bureau ( 1998) http : / / www census gov / prod / 3/98pubs / p23194 pdf ( June 2005 ).

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15 2 Wilde B. Starrin B ., Larsson G ., & Larsson M (1993) Quality of care from a patient perspective : A grounded theory study Scandinavian Journal of Caring Sciences 7 113-120 Wood P & Mallinckrodt B (1990) Culturally sensitive assertiveness training for ethnic minority clients Professional Psychology : Research and Practice, 21, 5-11

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BIOGRAPHICAL SKETCH Rhonda Lucy Hackshaw is a nat i ve of Tr i nidad and Tobago born in 1973 She immigrated to the United States to pursue her family s shared goals of higher education and learning She attended the University of Flor i da beginning in 1991 and graduated with honors and a Bachelor of Science degree in psychology in 1995 In 1997 she received a Master of Sc i ence in exerc i se and sport sciences from the University of Florida. She earned a Doctor of Philosophy degree with a minor in health psychology from the University of Flor i da i n 2005 She completed an American Psychological Association-approved pre-doctoral internship at the University of California San Diego in 2004 and a pre doctoral fellowship specializing i n sport psychology at that university in 2005 She is excited to commence a year-long post-doctoral fellowsh i p in Clin i ca l Psycho l ogy at Sharp Mesa Vista hospital in San Diego California. 1 53

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I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate in scope and quality as a dissertation for the degree of Doctor of Philosophy I certify that I have read this study and that in my opinion i t conforms to acceptable standards of scholarly presentation and is fully adequate in scope and quality as a dissertation for the degree of Doctor of Philosophy & ~P~ GregiJeyer Professo r of Psychology I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentation and is fully adequate in scope and quality as a dissertation for the degree of Doctor of Philosophy I certify that I have read this study and that in my opinion it conforms to acceptable standards of scholarly presentat i on and is fully adequate in scope and quality as a dissertation for the degree of Doctor of Ph i losophy Peter Giacobbi Assistant Professor of Applied Physiology and Kinesiology

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This dissertation was submitted to the Graduate Faculty of the Department of Psychology in the College of Liberal Arts and Sciences and to the Graduate School and was accepted as partial fulfillment of the requirements for the degree of Doctor of Philosophy August2005 Dean Graduate School

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, = ' t ,,. ; .. . -U NIVERSITY OF F LORIDA 1111111111111111 1 1 1 111111111 1 11111111 1 1 1 1111111111 1 1 111111 111111 3 1262 08553 8873


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