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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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