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JUSTICE IN THE HEALTH CARE PROVIDER AND PATIENT RELATIONSHIP:
APPRAISALS OF MULTICULTURAL COMPETENCE, PROCEDURAL JUSTICE, AND
A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE
UNIVERSITY OF FLORIDA
Dedicated to my parents, Alicja and Kazimierz Brozyna
I would like to express my sincere gratitude to my advisor and committee chair, Dr. Mark
Fondacaro, for the countless hours he spent in assisting and guiding me throughout this process. I
would also like to thank my committee members, Dr. Greg Neimeyer and Dr. Lonn Lanza-
Kaduce, for their assistance and wisdom in completing this proj ect. I would also like to extend a
warm thanks to my parents, Alicja and Kazimierz Brozyna, for their constant support. Finally, I
would also like to thank my friends, Jessica Jones and Jennifer Stuart, for their assistance.
TABLE OF CONTENTS
ACKNOWLEDGMENTS .............. ...............4.....
LIST OF TABLES .........__.. ..... .__. ...............6....
AB S TRAC T ......_ ................. ............_........7
1 INTRODUCTION ................. ...............8.......... ......
2 M ETHODS .............. ...............23....
Participants .............. ...............23....
HIPPA Training ................. ...............24.......... ......
Procedure .............. ...............24....
Material s ................. .. ...............24.
Demographic Questionnaire ................. ...............24.................
Health Care Justice Inventory-Provider .............. ...............24....
Adherence to Treatment Measure ............... .......... ............2
Modif led Cross-Cultural Counseling Inventory-Revised ................. ............ .........26
3 RE SULT S .............. ...............29....
Patient Appraisals and Patients' Demographic and Health Characteristics ...........................29
Provider Scales and Multicultural Competence .............. ...............29....
Factors of Procedural Justice and Multicultural Competence ................. .......................30
Patient Appraisals and Treatment Adherence ................. ...............31........... ..
4 DI SCUS SSION ................. ...............3.. 4......... ....
A DEMOGRAPHIC AND MEDICAL DATA QUESTIONS ................. ........................40
B HEALTH CARE JUSTICE INVENTORY-- PROVIDER (HCJI-P) ................. ...............42
C ADHERENCE TO TREATMENT MEASURE .............. ...............46....
D MODIFIED CROSS-CULTURAL COUNSELING INVENTORY-REVISED ...................48
E ITEMS FOR THE THREE HCJI-PROVIDER SUB SCALES .................... ...............5
LIST OF REFERENCES ................. ...............51........... ....
BIOGRAPHICAL SKETCH .............. ...............54....
LIST OF TABLES
1 Mean Ratings of Providers on Indices of Multicultural Competence and Procedural
Justice by Males and Females............... ...............33
2 Intercorrelations Between Appraisals of Provider Procedural Justice and
Multicultural Competence and Treatment Adherence ................. .......... ...............33
3 Multiple Regression Using Procedural Justice Sub scales to Predict Multicultural
Competence ................. ...............33.................
Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science
JUSTICE IN THE HEALTH CARE PROVIDER AND PATIENT RELATIONSHIP:
APPRAISALS OF MULTICULTURAL COMPETENCE, PROCEDURAL JUSTICE, AND
Chair: Mark R. Fondacaro
Major Department: Psychology
This study examined the relationships between procedural and distributive justice with
multicultural competence and treatment adherence. One hundred ninety-eight college students
participated in an internet study that assessed interactions with their health care providers using
the Health Care Justice Inventory-Provider (HCJI-P), consisting of three scales of procedural
justice (Trust, Impartiality, and Participation). Participants also completed a self-report measure
of treatment adherence and a modified Cross-Cultural Counseling Inventory-Revised (CCCI-R)
measure to assess the multicultural competence of their health care provider. Multicultural
competence appraisals were found significantly related to appraisals of procedural and
distributive justice. Both distributive and procedural justice accounted for unique variance in
multicultural competence. Specifically, Trust was found to account for unique variance in
multicultural competence. Trust and Multicultural Competence accounted for unique variance in
In the past decade, there has been an increase in research within health care regarding the
patient-provider relationship. This research has focused on how patients' interactions with their
health care providers influence patient satisfaction. Research in the areas of procedural justice
has demonstrated that factors such as trust, respect, open communication regarding health status
and treatment as well as participation in treatment decisions are related to patient satisfaction
(Fondacaro, Frogner, & Moos, 2005). While important strides have been made in identifying
aspects of physician/patient decision making that contribute to patient satisfaction, there remains
a lack of empirical research concerning the decision making of racial and ethnic minorities as
well as the competence of health care providers in addressing health care needs of patients from
diverse racial and ethnic backgrounds (Institute of Medicine [IOM], 2002).
The unaddressed needs of racial and ethnic minorities may have significant implications
for patient satisfaction, treatment adherence, and health status (IOM 2002; Khan, 2004; Hays &
DiMatteo, 1987). Therefore, it is important to study the multicultural competence of health care
providers and the factors that are valued by patients in the patient-provider relationship,
specifically with regard to ethnic and racial minorities. Therefore, this study will examine the
extent to which patients' appraisals of multicultural competence are related to perceptions of
three specific dimensions of procedural justice (Trust, Impartiality, and Participation) within the
patient/provider relationship. Research regarding the multicultural competence of health care
providers is vital to address both the need to reduce the unjust health care disparities within
ethnic minority populations and to meet the important health care needs of an increasingly more
culturally diverse population in the United States.
The population of the United States has changed significantly between 1990 and 2000,
with significant increases in the proportion of ethnic and racial minorities. While the percentage
of Non-Hispanic Whites has decreased from 80% to 75%, the Black population has increased
from 12. 1% to 12.9%, the Hispanic population has increased from 9% to 12.5%, and the
Asian/Pacific Islander population has increased from 2.8% to nearly 3.6% (Bigby, 2003). In
1999, it was reported that almost 26 million Americans identified themselves as foreign-born and
more than a quarter of these immigrants had come to the US within the past 10 years. The
Census Bureau estimated that in 1996, approximately 5 million undocumented immigrants were
residing in the U.S., with this figure growing by about 250,000 annually. However, this data set
may undercount some immigrants groups by as much as 20% to 40% (Bigby, 2003).
The number of ethnic and racial minorities is expected to increase in the future as well.
The Census Bureau estimates that by the year 2050, the White Non-Hispanic population will
decrease to 52.8%, the Black Non-Hispanic population will stay at 13%, the Native
Alaskan/American Indian population will remain at under 1%, the Asian population will increase
to 8.2%, and the Hispanic population will increase to 24.5% (Bigby, 2003).
These increasing changes in the population require the American health care system to
adapt to the needs of people from numerous cultures and backgrounds. However, individuals
from racial and ethnic minority groups, especially Blacks and Latinos, perceive that they receive
a lower quality of health care than Whites in the United States. They reported that they had been
discriminated against because of their health insurance or financial status, their race or ethnicity,
and their uncertain or poor use of the English language (Bigby, 2003).
In 1999, the Institute of Medicine conducted an assessment for Congress regarding the
extent of racial and cultural disparities in health care. This assessment consisted of reviewing
over 100 studies that measured the quality of health care for various ethnic groups, while
controlling for factors such as income and insurance. The results revealed that even when health
care access-related factors are controlled, minorities are less likely than Whites to receive needed
services and receive lower quality health care treatment than Whites. The Institute of Medicine
determined two sets of factors that may contribute to these ethnic disparities in health care. The
first factor is a lack of cultural resources in the environment, such as a lack of translators to
address cultural and/or language barriers. The second factor is the health care visit being a
negative experience for the patient due to their interactions with the health care provider.
Additionally, three mechanisms were described that may contribute to this reported negative
experience: the provider may be biased against minorities; the provider may have a lack of
clinical knowledge about minorities and different ethnicities; and/or the provider may have
stereotypes about the behavior and health of minorities (IOM, 2002).
A study from the Institute of Medicine also found that African Americans are slightly more
likely to refuse some medical treatment recommendations from health care providers (IOM,
2002). In a qualitative study by Chubon (1989), it was found that out of fourteen African-
American patients who were given prescribed medical regimens, only one participant adhered to
their regimen faithfully. The examples provided by these patients all suggested that there were
problems in the physician-patient interaction, which resulted in their nonadherence to treatment
recommendations (Chubon, 1989).
One of the greatest challenges to the health care system is nonadherence to treatment
recommendations. The rate of non-compliance has been reported to be as much as 15% in some
studies and the cost of treatment nonadherence is estimated at $100 billion per year due to
adverse outcomes, such as hospitalizations, disease progression, premature disability, and death
(Khan, 2004; LaFleur, 2004). It has been estimated that only 70-80% of patients consistently
follow short-term regimens for an acute problem, fewer than 60% comply with preventive
regimens, and less than 50% adhere with recommendations for lifestyle change (Hays &
DiMatteo, 1987). There are many possible variables currently studied in health care research that
may contribute to nonadherence to treatment recommendations. One of the most recently studied
aspects regarding treatment adherence has been patient-provider interaction. For example, using
the Health Compliance Model, it was found that the subj ect-provider interaction is an important
component of treatment compliance and the responsiveness of the health care provider to patient
complaints appears to be correlated with adherence (Heiby & Carlson, 1986). In addition, it has
been reported that a poor physician-patient relationship will adversely affect adherence (Patel &
David, 2004). Another factor related to treatment adherence is patient satisfaction. Patients'
satisfaction with the services they receive has been shown to predict treatment success and
medical adherence (Patel & David, 2004). This data suggests that decreased patient satisfaction
may reduce medical adherence.
Nonadherence to treatment recommendations occurs among patients in all ethnic groups,
social classes and health care delivery systems (Hays & DiMatteo, 1987). However, ethnic and
racial minorities have been reported to be less likely to adhere to treatment recommendations
(IOM, 2002). It is uncertain why this difference occurs. Some factors include a possible element
of distrust in the patient-provider relationship, and perceiving their health care provider does not
understand them due their cultural background. These gaps in research regarding culturally
responsiveness within health care demonstrate a need for further research of health care
providers' abilities in working with diverse populations.
Cultural responsiveness is defined as a professional's skill in working with ethnic
populations (Ponterotto, Fuertes, & Chen, 2000). Specifically, cultural responsiveness
encompasses acknowledgement, showing interest in, having knowledge of, and appreciating a
person's ethnicity and culture. It includes placing the problem of the client within a cultural
context (Ponterotto et al., 2000). Cultural responsiveness and multicultural competency have
been extensively studied and described within the counseling field. Cultural responsiveness is a
concept included in a multicultural competence framework. In 1980, the Education and Training
Committee of Division 17 of the APA reported the immense need to create multicultural
counseling competencies for use in counseling psychology (LaFromboise, Coleman, &
To address this need for cross-cultural competence in counseling, D.W. Sue et al. (1982)
presented the Cross-Cultural Counseling Competency Model in a Division 17 Report. The Cross-
Cultural Counseling Competency Model is a long-standing model of multicultural competence
within the counseling field that has guided culturally informed education in clinical practice,
research, and training. The competencies within the model have been organized into three areas:
Counselor Awareness and Beliefs; Counselor Understanding of clients' culturally different
worldview; and Developing Appropriate Intervention Strategies (Ponterotto et al., 2000).
Counselor Awareness and Beliefs refers to counselors' racial and cultural self-awareness, which
also includes the understanding of a counselor' s own culturally biased beliefs, attitudes of
themselves, and of people from other cultures. Counselor Understanding of client' s worldview
includes counselor understanding of a client' s worldviews, perceptions, beliefs and sociopolitical
experiences and how these affect treatment planning. The third area focuses on the development
and use of counseling intervention strategies that focus on counselors using interventions that are
sensitive to the client's beliefs and attitudes (Fuertes, Bartolomeo, & Nichols, 2001). Using
these three broad categories, specific competencies were then reorganized into Awareness and
Beliefs, Knowledge, and Skills (Ponterotto et al., 2000).
D.W. Sue's model of multicultural competence has been described as having content
validity for three reasons. First, counseling experts have been working with the competencies
described in the model for two decades. Second, self and observer report measures of the
competencies have been created and used. Third, divisions 17 and 45 of the American
Psychological Association (APA), as well as six divisions of the American Counseling
Association (ACA) have officially endorsed the model (Ponterotto et al., 2000).
The first instrument designed and published to operationalize D.W. Sue's multicultural
competence model was an observer-report measure, identified as the Original Cross-Cultural
Counseling Inventory (CCCI), developed by Hernandez and LaFromboise (1985). It was based
on the 11 cross-cultural counseling competencies described in the Division 17 position paper.
These competencies were categorized into three main areas: Cultural awareness and beliefs,
cultural knowledge, and cultural skills. The CCCI was then slightly modified and the revised
version was named the CCCI-R. These minor modifications included the addition of two items
that directly assess general understanding of the counseling process (LaFromboise et al., 1991).
The Cross-Cultural Counseling Inventory-Revised (CCCI-R) was developed by
LaFromboise, Coleman, and Hernandez (1991). It was designed to accurately assess the
effectiveness of counseling with culturally diverse clients. The development of three self-report
instruments followed the creation of the CCCI-R: the Multicultural Awareness-Knowledge-
Skills Survey (MAKSS; D'Andrea, Daniels, & Heck, 1991); the Multicultural Counseling
Inventory (MCI; Sodowsky, Taffe, Gutkin, & Wise, 1994); and the Multicultural Counseling
Awareness Scale (MCAS)-Form B (Ponterotto, Rieger, Barrett, & Sparks, 1994). However, the
CCCI-R has received the most empirical scrutiny among this array of multicultural competence
measurements (Ponterotto et al., 1994).
Initially, multicultural competence research was conducted primarily within the Hield of
counseling psychology. However, the concept of multicultural competence has been expanding
to other areas as well, such as policy organizations (Mays, Siantz, & Viehweg, 2002) and within
health care (Campinha-Bacote, 2002). The Campinha-Bacote Model defines cultural competence
as the process in which a health care provider continuously tries to achieve the ability to work
within the cultural context of a patient, family or community. In this model, four constructs of
cultural competence are specified: cultural awareness, cultural knowledge, cultural skill and
cultural encounters (Doutrich, 2004). There has also been a more recent model created, the "The
Process of Cultural Competence in the Delivery of Healthcare Services," with the addition of a
fifth construct, cultural desire (Campinha-Bacote, 2002). A self-report instrument was
developed with this model, The Inventory For Assessing The Process of Cultural Competence
Among Healthcare Professionals Revised (IAPCC-R), which is used by health care providers to
assess their own multicultural competence. This is an exciting development because this measure
addresses the issue of a health care professional being able to accurately measure their own
competence with multicultural populations. Nevertheless, it does not address the absence of
measures within the health care context that allow the patient to appraise their experience of
multicultural competence of their health care provider.
As a result, the CCCI-R was modified for use regarding patients' appraisals of their health
care provider's multicultural competence. Applying multicultural competencies from the
counseling context to the health care context is feasible due to the similarities in the therapeutic
roles of counselors and physicians. In fact, the same steps that physicians are recommended to
use in encouraging mutual participation in clinical-decision making (i.e., establishment of
conducive atmosphere; ascertain the patient' s goals and expectations; educating the patient about
the nature of the problem; and eliciting the patients' informed suggestions and preferences) are
similar to the steps a counselor would use (Brody, 1980). Moreover, within both of these
professions there is a need for racial and ethnic awareness in one's own beliefs and attitudes
towards others in order to give patients or clients the best treatment possible. As stated in
numerous previous studies (Campinha-Bacote, 2002; Tucker et al., 2003), there has been a lack
of research on multicultural competence in the health care context and factors that contribute to
why ethnic disparities occur. In addition, the aspects of the patient-physician relationship that
have been studied have been narrow and limited (Fondacaro et al., 2005; Williams, 2005).
One area that has looked at the relationship between individuals and authority figures (such
as health care providers) and has provided some insight in the patient-physician relationship is
procedural and distributive justice (Fondacaro, 1995). Procedural justice focuses on how
decisions are made while distributive justice focuses on the decision outcome. In social justice
research, it has been found that individuals are concerned with as much or possibly more with
the process of decision making (procedural justice) as they do about the outcome of the decision
(distributive justice), particularly within health care decision making (Fondacaro et al., 2005).
Research in distributive justice has studied three unidimensional constructs that contribute to
decision making outcomes: Equity, Equality, and Need (Fondacaro et al., 2005). Equity is
concerned with whether outcomes are proportionate to the previous behaviors and efforts (Steil
& Makowski, 1989). Equality refers to whether resources have been allocated equally despite
previous contributions (Steil & Makowski, 1989). Need refers to whether the outcome is based
on what the individual needs (Steil & Makowski, 1989).
However, recent research by Fondacaro et al. (2005) found that procedural justice factors
were better predictors of patient satisfaction than distributive justice factors in the health care
context, specifically within the health care provider and health plan contexts. In addition, it has
been frequently found in procedural justice research that evaluations of leaders are strongly
affected by the perceived fairness of procedures associated with the leader (Lind & Tyler, 1988).
Therefore, the primary focus of this study will be on procedural justice.
In the book, Procedural Justice by Thibaut & Walker (1975), the term procedural justice is
defined as the social consequences of variation in procedures, emphasizing the procedural effects
on judgments of fairness. Prior to this, the study of justice in psychology was mainly concerned
with distributive justice or outcome fairness (Lind & Tyler, 1988). However, research has found
that people are usually not only concerned with the outcome but are as concerned or more with
the perceived fairness of the actions leading to the outcome (Lind & Tyler, 1988). In fact, the
maj ority of provider characteristics and actions preferred by patients seem to reflect
considerations of procedural justice; that is, concerns about the process of health care decision
making (Fondacaro et al., 2005). In addition, concerns with the fairness of the decision making
process are particularly salient within health care due to the health disparities among individuals
with low incomes and ethnic minority backgrounds (IOM, 2002). Therefore, studying aspects of
procedural justice may be important specifically within multicultural competence in health care.
Procedural justice research first focused on the legal context but the concepts developed
from that research increasingly have been used in many other contexts such as health care
decision making, workplace environments, and families (Murphy-Berman, Cross, & Fondacaro,
1999). Fondacaro (1995) has indicated that the principles used to evaluate procedural justice in
the legal context, which include impartiality, voice, respect, and trust, can also be applied to
measuring patients' perception and appraisals of their interactions with their health care
providers. In fact, the multicultural responsiveness characteristics of one' s health care provider
that were valued by patients in previous studies were trustworthiness, respectfulness,
collaboration, effective communication and choice (Tucker et al., 2003), which demonstrate
concern with the fairness of the decision making process in the health care provider and patient
relationship. These traits seem to be related with the three dimensions of procedural justice:
Trust, Impartiality, and Participation. Trust of the health care provider consists of whether the
patient feels comfortable with how their provider handled the situation, if they feel their health
care provider was honest with them, and if the patient feels the health care provider gave viable
treatment options (Fondacaro et al., 2005). The Impartiality aspect is based whether the patient
feels that their provider treated them in an unbiased manner. Participation is based on the concept
of having voice and participating in health care decision making with one' s health care provider
(Fondacaro et al., 2005). Participation in decision making may include a person's control over
input into the decision making (process control) and a person's control over the actual decision
made (decision control).
Trust appears to be an important component of the patient-physician relationship. Research
has found that patients are more likely to comply with a request to change maladaptive behaviors
when recommended by a physician that is trusted by the patient (Emanuel & Dubler, 1995). Such
modifiable maladaptive behaviors can include smoking, unhealthy eating, and/or non-adherence
to medication. Research on procedural justice has previously found that ratings of the fairness of
procedures seem to increase when people perceive that they have been treated in a dignified way
that increases trust between that perceiver and the person making the decisions (Tyler & Beis,
1990). It has also been shown that trust of health care providers is particularly valued by racially
diverse patients (Tucker et al., 2003). In fact, trust has been a widely studied concept (Hall,
Dugan, Zheng, & Mishra, 2001) within the health care context but little is known about what the
components are as well as how the components are defined and measured. Therefore, studying
trust within a procedural justice framework may contribute to a more refined understanding of
the patient-physician relationship.
Studies in procedural justice have indicated that individuals also value having more voice
in decisions (Lind & Tyler, 1988). Voice refers to whether the individual has an opportunity to
provide input and participate in the decision making process (Lind & Tyler, 1988). Increased
opportunities for participation in decision making result in more positive assessments of fairness
(Lind & Tyler, 1988). Thibaut and Walker also found that decisions were more likely to be
accepted by people when the procedure used to generate the decision allows participation by
those affected (Thibaut & Walker, 1975). Consequently, a patient participating in the decision
making process with their health care provider may be more likely to accept the decision made.
Moreover, these aspects of procedural justice (Trust, Impartiality, and Participation) appear
to be valued in the patient-provider relationship. Specifically, behaviors consisting of the
dimensions of Trust and Impartiality seem to be especially significant when evaluating
multicultural competence and sensitivity within the health care context. In the previously
mentioned qualitative research study on cultural sensitivity by Tucker et al. (2003), low-income
primary care patients from three cultural groups were studied: African Americans, European
Americans and Latino-Americans. Results indicated that African American patients described
trustworthiness as an important indicator of the cultural sensitivity of the health care provider.
African Americans also reported feeling manipulated when experimental treatments were
performed and not fully explained. European Americans emphasized that personal qualities such
as care and concern, respectfulness and honesty in a health care provider were important as well
as having a collaborative relationship with their health care provider. Several Latino Americans
complained about the inequity of the triage decisions by the health care staff; they got an
appointment (their desired outcome) but were not at all comfortable with how the process was
completed by the staff. Therefore, the perceptions of a fair process were important to the
patients, rather than the outcome itself. Qualities such as empathy, acceptance, and
respectfulness were emphasized by all three ethnic groups. The ability to communicate
effectively in Spanish or with interpreters appears to be a main feature of culturally sensitive
health care among Latino Americans; they felt that this affected their levels of trust with their
physicians. Latino Americans expressed worry about their message being missed or not
understood by the health care provider. The main themes of this study were that culturally
diverse patients desire interpersonally oriented physician behaviors, such as listening, asking
questions, demonstrating concern, communicating effectively and providing a thorough
examination (Tucker et al., 2003).
Recent studies have observed the influence procedural and distributive justice have on
health care decision making, patient satisfaction, and treatment adherence. In a study by Hughes
and Larson (1991), four vignettes were used to manipulate the participation and outcome
variables to determine what effect they have on the ratings of procedural justice, outcome
satisfaction and physician competence. It was found that participation did, in fact, increase the
evaluation of procedural justice. There were no significant effects of participation found with
physician competence or outcome satisfaction (Hughes & Larson, 1991). However, in a study by
Fondacaro et al. (2005), procedural justice factors were more strongly related to patient
satisfaction than distributive factors within the health care provider context. All three dimensions
of procedural justice (Trust, Impartiality, and Participation), as well as the Need aspect of
distributive justice, accounted for unique variance in patient satisfaction, even when health status
and demographic characteristics were controlled (Fondacaro et al., 2005). Moreover, in a study
by Williams (2005), a significant relationship was found between all three procedural justice
scales (Trust, Impartiality, and Participation) and patient satisfaction; all three scales also
accounted for unique variance in satisfaction with the health care provider. These Eindings
suggest that patient satisfaction ratings are higher when patients perceive the decision making
process as fair. In addition, a significant relationship was found between the three procedural
justice scales and treatment adherence to recommendations made by the health care provider
(Williams, 2005). When multiple regression analyses were conducted with these three scales as
predictors and treatment adherence as the criterion, Trust and Impartiality accounted for unique
variance in treatment adherence by patients (Williams, 2005). This preliminary research also
suggests that Trust and Impartiality are especially salient for ethnic and racial minority
populations (Williams, 2005). Therefore, it is important to study the relationships between
appraisals of Trust, Impartiality, and multicultural competence of the health care provider.
The purpose of this study is to examine the possible relationship between the patients'
general appraisals of the multicultural competency of their health care providers and their global
appraisals of procedural and distributive justice. This study will also examine the extent to which
patients' appraisals of multicultural competence are related to perceptions of three specific
dimensions of procedural justice (Trust, Impartiality, and Participation) within the patient-
provider relationship. Another obj ective of this study is to contribute to the validation of the
Health Care Justice Inventory and expand on the work of Fondacaro et al. (2005) and Williams
Based on past research on health care decision making and social justice, the following
predictions were made:
Hypothesis 1: Patients' appraisals of their health care providers' multicultural competence
will be positively correlated with patients' appraisals of their providers' health care decision
making along global dimensions of both procedural and distributive justice. This is an initial step
in developing a conceptual case for a relationship between multicultural competence and the
factors of procedural justice and distributive justice.
Hypothesis 2: Patients' appraisals of multicultural competence will have a higher positive
correlation with their appraisals of procedural justice than with their appraisals of distributive
justice. This is based on previous research that has found a relationship between procedural
justice and patient satisfaction (Hughes & Larson, 1991; Fondacaro et al., 2005).
Hypothesis 3: Using a multiple regression analysis with the dimensions Impartiality,
Trust, and Participation as predictors, Impartiality will account for unique variance in
multicultural competence, even after controlling for relevant demographic and background
characteristics. This hypothesis is supported by research indicating that the use of impartial
procedures is a distinct facet of the procedural justice construct in the health care context
(Fondacaro et al., 2005) and the use of unbiased procedures is thought to be an important aspect
of multicultural competence (Tucker et al., 2003).
Hypothesis 4: Consistent with the findings of Williams (2005), in which Trust and
Impartiality within the patient-provider relationship were found to be particularly salient in
treatment adherence for minorities, both procedural justice factors Trust and Impartiality will be
related to treatment adherence. Moreover, exploratory analyses will examine the extent to which
Trust, Impartiality, and Multicultural Competence each account for unique variance in treatment
Participants were recruited from the psychology research pool of undergraduates at the
University of Florida. Participants received academic credit for compensation. The academic
credit was factored into the participant' s grade but did not determine the final grade. Participants
were prescreened for those who have received health care services within the last year and
included males and females of varying socioeconomic status, racial identification, and ethnic
backgrounds. Participants were treated in accordance with the "Ethical Principles of
Psychologists and Code of Conduct" (American Psychological Association, 2002).
The sample consisted of 198 individuals between the ages of 19 and 26 with M~= 19.8
(SD = 1.09). The sample consisted of 59 males (29.8%) and 139 females (70.2%). The majority
(99.5%) of participants reported never being married while 0.5% reported being married. In
terms of college standing, 60. 1% were freshmen, 22.7% were sophomores, 13.6% were juniors,
and 3.5 % were seniors.
The ethnic make-up of the study sample included 68.7% Whites, 1% American Indians,
6.1% Asians, 10.1% African Americans, 9.6% Hispanic/Latino, and 4.5% members of "other"
racial/ethnic minority groups. In regards to work status, 62.1% reported not working, 36.9%
reported working part-time, 0.5% reported working full time, and 0.5% reported working full
and part time. For annual income, 64.1% reported earning less than $10,000 per year, 4%
reported earning between $10,000 and $19,999, 0.5% reported earning between $20,000 and
$29,999, and 0.5% reported earning between $30,000 and $39,999. In terms of health status,
22.2% reported being in excellent health, 50% reported being in very good health, 23.2 %
reported being in good health, 4% reported being in fair health, and 0.5% reported being in poor
Research investigators that needed access to participant data completed the University of
Florida' s "HIPPA 102 General Knowledge (or Annual Review) Test of Knowledge." The test
consisted of questions regarding the regulations and penalties for obtaining, maintaining,
protection, storage, and removal of health care information from patients. This test is required for
all faculty, staff, and students who have access to health care data.
Participants were asked to complete a web-based study with a demographic and health
information questionnaire and three inventory measures: the Health Care Justice Inventory-
Provider (HCJI-P), the Modified Cross-Cultural Counseling Inventory-Revised (CCCI-R), and
the Adherence to Treatment Measure. The demographic information questionnaire and the four
measures were posted on the psychology subj ect pool's website.
The demographics form asked participants questions regarding their sex, age, marital
status, years of formal education, ethnic background, employment status and annual income.
There were also questions referring to participant' s medical conditions, hospitalizations within
the past year, annual check-ups, and overall health status.
Health Care Justice Inventory-Provider
The Health Care Justice Inventory-Provider (HCJI-P) is an integrated measure of
procedural and distributive justice in the health care context (Fondacaro et al., 2005). The first
portion, Section A, asks participants to describe a visit with their current doctor or other health
care provider in the last 12 months in which a decision was made about their health care. Section
B asks subj ects if the experience they described involved a routine health care visit or an
emergency. Section C then includes 28 procedural justice items, which focus on the three facets
of procedural justice: Trust, Impartiality, and Participation. Participants would be asked to reflect
on the experience they described in Section A while answering these questions. After the
procedural justice items, participants were asked to answer eight distributive justice items while
focusing on their health care experience. All questions in Section C were rated in a 4-point
Likert scale, ranging from 1 ("strongly disagree") to 4 ("strongly agree"). After the distributive
justice items, there were two items asking the participants to rate their satisfaction with their
provider using a rating scale ranging from 1 ("strongly disagree") to 4 ("strongly agree").
Overall, the scale has high internal consistencies, with alphas = .93, .91, and .91 for the sub scales
Trust, Impartiality, and Participation (Fondacaro et al., 2005). In addition, the scores on each
scale range from 0-15.
Adherence to Treatment Measure
"The Adherence Measure" is a three section self-report instrument created in the Medical
Outcomes Study (DiMatteo et al., 1992). In the first part, specific treatment recommendations
are listed that are commonly asked by health care providers for diabetes, hypertension, and heart
disease patients. In this first section, patients are asked if their health care provider suggested
these recommendations as part of their regimen, scaled from 1 ("none of the time") to 4 ("all of
the time"). The second section consists of questions regarding how often the patient actually
carries out these activities, which are scaled from 1 ("none of the time") to 4 ("all of the time").
In the third section, patients were asked how difficult it was to follow treatment
recommendations, which consisted of five items scaled from 1 ("none of the time") to 4 ("all of
the time"). For the purposes of this research study, the general adherence questions (third
section) were used to score treatment adherence of participants in order to assess overall
treatment adherence rather than specific behaviors. Items in the first and second sections of this
measure regarding specific treatment adherence behaviors were not used to score treatment
adherence due to the low occurrence of hypertension and heart disease within the specific age
group of participants in this study (ages 19-26). These items referred to behaviors such as a
following a low salt diet and taking part in a cardiac rehabilitation program. Items 1 and 3 were
reversed scored. In scoring, the responses were averaged together. The internal consistency
reliability of the scale was acceptable with alpha = .81 (DiMatteo et al., 1992).
Although there have been problems reported regarding a self-report measure of treatment
adherence due to social desirability, patients' self-reports are less complex to obtain and more
cost-effective than other methods. The correlation between the General Adherence measure and
the socially desirable response set scale was relatively low (r = 0.15). This suggests that the
measure has low association with social desirability. In addition, the correlations between the
specific adherence sections and the general adherence section were low, from -0. 12 to 0.29
(DiMatteo et al., 1992). Therefore, the general adherence measure seems to assess information
that cannot be obtained from the specific adherence measures alone. Furthermore, using a self-
report measure allowed patients to rate adherence on all possible treatments, including
nonmedication treatments such as diet and exercise.
Modified Cross-Cultural Counseling Inventory-Revised
The Modified Cross-Cultural Counseling Inventory-Revised consists of 20 items, the same
number of items as the original Cross-Cultural Counseling Inventory-Revised (CCCI-R)
(LaFromboise et al., 1991). The original CCCI-R is a measure used by an evaluator or supervisor
to assess another counselor' s multicultural competence. However, in this study, a patient needs
to evaluate their perception of the health care provider's multicultural competence. In order for
patients to rate the extent to which the items on the CCCI-R describe their health care provider,
the CCCI-R was modified by changing the word "Counselor" to "Health care Provider" and
"Client" to "Patient". An example of this modification is a change from "Counselor
demonstrates knowledge about client's culture" to "Health care provider demonstrates
knowledge about patient' s culture". In addition, one of the items was changed from "Counselor
has a clear understanding of counseling and therapy process" to "Health care provider has a clear
understanding of the health care decision making process". These were the only modifications
made to the measure. The modified measure continued to use a 6-point Likert scale, ranging
from 1 ("strongly disagree") to 6 "strongly agree"). The necessity of modifying a measure
originally intended for use by counselor supervisors limits the psychometric validity of the data.
Nevertheless, there was no other instrument found that assesses a health care provider' s
multicultural competence by a patient.
There have been numerous empirical studies looking at the validity and reliability of the
CCCI-R. The content validity of it was assessed to determine if the CCCI-R items accurately
represented the cross-cultural competencies described in the report by Division 17. The content
validity of the CCCI-R has indeed been shown to be adequate, with a high percentage of
congruence among raters and items, which verifies that the multicultural competencies described
by Sue et. al (1982) are sufficiently represented by the questions created for the CCCI-R
(LaFromboise et al., 1991). The inter-rater reliability was studied by LaFromboise et al. by
having three expert raters, each with previous training in multicultural competence, rate thirteen
videotapes of Anglo-American students counseling clients. The inter-rater reliability coefficient
was .78 among the raters. The criterion-related validity of the CCCI was evaluated in two
studies. In a study by Hernandez and Kerr (1985), it was discovered that counselors with
previous training in multicultural issues were rated higher on the CCCI than were counselors
with no previous training. In another study by Pomales, Claiborn, and LaFromboise (1986), it
was found that counselors acting in a culturally responsive manner were rated significantly
higher on the CCCI than counselors demonstrating culturally nonresponsive behaviors (Pomales
et al., 1986).
As described in Ponterotto et al.(1994), the original CCCI-R is a multicultural competence
measure that has undergone the most empirical scrutiny when compared to other multicultural
counseling competence measures, such as the Multicultural Counseling Awareness Scale- Form
B (MCAS-Form B), the Multicultural Counseling Inventory (MCI) and the Multicultural
Awareness-Knowledge-and Skills Survey (MAKSS). Sufficient content validity has also been
demonstrated by independent raters from educational and counseling psychology PhD programs
who assessed the amount of agreement between the CCCI-R items and the competencies
described in the Sue et al. (1982) model of multicultural competence. In addition, factor analysis
demonstrates evidence of construct validity. The reported coefficient alpha was reported at .95,
which demonstrates high reliability (LaFromboise et al., 1991).
Patient Appraisals and Patients' Demographic and Health Characteristics
No significant relationships were found between patients' ratings of their provider and
their demographic characteristics, including age, education, employment, income, number of
times patients had seen a doctor in the last year, and length of hospital stay. However, patients
who reported themselves in good health were more likely to adhere to treatment
recommendations than patients in poor health (r = -.289, p < .05). In order to test whether one's
gender or ethnic background differed in terms of provider ratings and treatment adherence, t-tests
for independent means were conducted. Participants who identified with an ethnic background
other than White (M~= 94.4, SD = 13.96) were found less likely to rate their health care provider
as culturally competent than Whites (M~= 85.5, SD = 19.76), t(196) = 3.64, p < .01. In addition,
individuals who identified with an ethnic background other than White were less likely to adhere
to treatment recommendations (M~= 3 .38, SD = .46) than Whites (M~= 3.07, SD = .56), t(196) =
4. 15, p < .01. Moreover, women were found to rate health care providers as more culturally
competent than men (see Table 1). Procedural justice was also found to vary by gender; that is,
women tended to rate their health care providers somewhat higher overall in procedural justice
(see Table 1). Furthermore, women were found to rate health care providers somewhat higher on
Trust and Impartiality than men (see Table 1).
Provider Scales and Multicultural Competence
Patients' appraisals of their health care providers' multicultural competence were assessed
by their sum score on the Modified Cross-Cultural Counseling Inventory-Revised. Consistent
with the first and second hypothesis, patients' appraisals of the multicultural competence of their
health care providers were significantly related with patients' appraisals of health care decision
making along global dimensions of both procedural and distributive justice (rs = .62 and .58,
respectively, all ps < .01). To further explore this relationship, forced entry multiple regression
analyses were conducted with procedural and distributive justice as the predictors and
multicultural competence as the criterion. Both procedural justice and distributive justice
accounted for unique variance in multicultural competence and remained significant, even after
controlling for relevant variables of ethnicity and gender (betas=.38 and .28, respectively, ps <
.01). Therefore, patients who considered their health care providers' decision making processes
and outcomes as fair also tended to report their health care provider as culturally competent.
Overall, the two scales accounted for 36.4 % of unique variance in multicultural competence
appraisals of health care providers. In addition, procedural justice accounted for 32.9% of unique
variance and distributive justice accounted for 30.2% of the variance in multicultural
competence, after controlling for gender and ethnicity in the first step of two separate three step
hierarchical multiple regression analyses (betas = .38 and .28, ps < .01). Procedural justice
accounted for 6. 1% of unique variance in multicultural competence, after controlling for gender,
ethnicity, and distributive justice in the hierarchical multiple regression analyses (beta = .3 8, p <
.01). Distributive justice accounted for 3.4% of the unique variance in multicultural competence,
after controlling for gender, ethnicity, and procedural justice (beta = .28, p < .01).
Factors of Procedural Justice and Multicultural Competence
All three of the Provider procedural justice scales (Trust, Impartiality, and Participation)
were significantly related to appraisals of multicultural competence (see Table 2). Forced entry
multiple regression analyses were then conducted with Trust, Impartiality, and Participation as
predictors and multicultural competence as the criterion. For the third hypothesis, Impartiality
was predicted to account for unique variance in multicultural competence. However, the results
revealed that Trust, rather than Impartiality, accounted for unique variance in appraisals of
multicultural competence of one's health care provider (see Table 3). This relationship remained
significant and essentially unchanged after controlling for ethnicity and gender. As a result,
patients who considered their health care provider trustworthy also reported their health care
provider as more culturally competent.
Patient Appraisals and Treatment Adherence
Patients' treatment adherence was assessed based on the mean ratings patients provided for
five questions regarding their ability to adhere to their providers' treatment recommendations.
Consistent with the fourth hypothesis, all three of the Provider procedural justice scales (Trust,
Impartiality, and Participation) were found significantly related to treatment adherence (see
Table 2). Forced entry multiple regression analyses were conducted to further examine this
relationship, with Trust, Impartiality, and Participation as predictors with treatment adherence as
the criterion, controlling for ethnicity and health status. Trust was found to account for unique
variance and made a significant contribution to the model (beta = .28, p < .01). Thus, patients
who indicated their health care provider was trustworthy, reported higher levels of treatment
adherence to their providers' treatment recommendations.
In addition, multicultural competence was significantly related to treatment adherence
(see Table 2). As described in the fourth hypothesis, the relationship between Trust, Impartiality,
and multicultural competence was explored through forced entry multiple regression analyses,
with Trust, Impartiality, and multicultural competence as predictors and treatment adherence as
the criterion. Multicultural competence accounted for unique variance in treatment adherence to
provider treatment recommendations (beta = .21, p < .05), even after controlling for ethnicity and
health status. Multicultural competence accounted for 2.5% of the variance in patients' appraisals
of multicultural competence of their health care provider.
However, when forced entry multiple regression analyses were conducted with Trust and
multicultural competence as predictors with treatment adherence as the criterion, Trust and
multicultural competence each accounted for unique variance in treatment adherence (beta= .18,
p < .05; beta= .22, p < .01). Therefore, patients who considered their health care provider
trustworthy and culturally competent also reported higher levels of treatment adherence with
their providers' treatment recommendations. Overall, the two scales accounted for 12.6% of
unique variance in patients' treatment adherence to provider recommendations. Moreover, Trust
accounted for 9.8% of unique variance in treatment adherence and multicultural competence
accounted for 10.5% of the variance in treatment adherence, after controlling for health and
ethnicity in the first step of two separate three-step hierarchical multiple regression analyses
(beta= .18, p < .05; beta= .22, p < .01). Trust accounted for 2. 1% of unique variance in treatment
adherence, after controlling for health, ethnicity, and multicultural competence (beta= .18, p <
.05). Multicultural competence accounted for 2.8% of the unique variance in treatment
adherence, after controlling for health, ethnicity, and Trust (beta = .22, p < .01).
Table 1. Mean Ratings of Providers on Indices of Multicultural Competence and Procedural
Justice by Males and Females
Provider Appraisals Gender
Males Females t P Scale
Multicultural Competence 85.7( 20.1) 94.1(14.0) -2.92 .005** 20-120
Procedural Justice 10.6 (2.7) 11.7 (2.6) -2.82 .005** 0-15
Trust 10.8(3.4) 12.2(3.1) -2.48 .008** 0-15
Impartiality 12.1(2.7) 13.2(2.7) -2.70 .014* 0-15
Note. p <.05; ** p <.01
Table 2. Intercorrelations Between Appraisals of Provider Procedural Justice and Multicultural
Competence and Treatment Adherence
Trust 0.61** 0.35**
Impartiality 0.51** 0.31**
Participation 0.45** 0.17*
Multicultural Competence 0.41**
Note: p <.05; ** p <.01
Table 3. Multiple Regression Using Procedural Justice Sub scales to Predict Multicultural
Note: Entries are standardized beta weights; ** p < .01
The central aim of this study was to determine the role of procedural and distributive
justice in the appraisals of multicultural competence of health care providers. Additionally, the
study aimed to examine the relationships between specific factors of procedural justice (Trust,
Impartiality, and Participation) with multicultural competence and treatment adherence. This was
done through appraisals of health care providers from participants obtained from an internet-
based study, utilizing the Health Care Justice Inventory-Provider, Adherence to Treatment
Measure, and the Modified Cross-Cultural Counseling Inventory-Revised.
Overall, four hypotheses were examined in the present investigation. In support of the first
hypothesis, patients' appraisals of their health care providers' multicultural competence were
significantly related with patients' appraisals of their providers' health care decision making
along global dimensions of both procedural and distributive justice. Consistent with the second
hypothesis, there was a slightly higher correlation between multicultural competence and
procedural justice than with di stributive justice. Further examination of this relationship was
conducted using multiple regression analyses with procedural and distributive justice as
predictors and multicultural competence as the criterion. Both procedural and distributive justice
were found to account for unique variance in multicultural competence. Therefore, distributive
justice as well as procedural justice was found to be salient for individuals in appraisals of
multicultural competence. Consequently, it is important to further study the roles of both
procedural and distributive justice in multicultural competence and health care decision making.
In addition, procedural justice accounted for 6.1% unique variance (beta = .38, p < .01) and
distributive justice accounted for 3.4% unique variance (beta= .28, p < .01) when multiple
regression analyses were conducted controlling for the relevant factors. While both procedural
and distributive justice are valuable in multicultural competence appraisals of health care
providers, procedural justice accounting for more variance suggests procedural justice as having
a larger role within multicultural competence than distributive justice. Previous research by
Hughes and Larson (1991) also found procedural justice factors to be influential within the
health care context. In addition, studies have also shown procedural justice factors as more
strongly related to patient satisfaction than distributive factors within the health care provider
context (Fondacaro et al., 2005; Williams, 2005). Moreover, research by Tucker et al. (2003) has
also found that qualities such as trust, asking questions, demonstrating concern, and treating
patients fairly were valued as indicators of cultural sensitivity, which are related to the specific
factors of procedural justice.
In regards to the third hypothesis, Impartiality was predicted to account for unique variance
in multicultural competence. However, this hypothesis was not supported. An interesting result
was found in which Trust, rather than Impartiality, was found to account for unique variance in
multicultural competence, after controlling for gender and ethnicity. This illustrates that
individuals who consider their health care provider trustworthy also tended to report their health
care provider as culturally competent. This provides insight on traits individuals find pertinent to
the multicultural competence of health care providers, which has implications on future training
in multicultural competence. Also, Trust may be both an important predictor in multicultural
competence as well as an outcome. In addition, due to the majority of the population being
White, future research should focus on studying procedural justice factors (Trust, Impartiality,
and Participation) with a more diverse sample, which may find differences in the factors
different ethnicities value. This is found in research by Tucker et al. (2003), in which trust was
found valuable with all three cultural groups studied (African-Americans, European-Americans,
and Latino-Americans) but Latino-American patients reported valuing fair treatment and
communication while African-American patients emphasized participation and trustworthiness.
For the final hypothesis, both Trust and Impartiality were found significantly related to
treatment adherence to provider recommendations. However, only Trust accounted for unique
variance in treatment adherence, providing only partial support for the fourth hypothesis. An
additional aim of this study was to conduct exploratory analyses to examine the roles of Trust,
Impartiality, and multicultural competence in treatment adherence. Multiple regression analyses
found that Trust and multicultural competence each accounted for unique variance in treatment
adherence, even after controlling for ethnicity and health status. This suggests that individuals
who consider their health care provider as trustworthy and culturally competent will have higher
levels of treatment adherence. As a result, there are exciting implications for future health care
provider training that can incorporate these factors.
Overall, the results of this study shed some new light on the health care provider and
patient relationship. However, there were some limitations with this investigation. First, the
participants in this study consisted of students from the University of Florida' s psychology
research pool. This provided a large sample of individuals who have utilized health care services
and thus provided a basis for which relationships between procedural justice, multicultural
competence, and treatment adherence can be assessed. Nevertheless, the sample was not diverse
with the maj ority of the sample (76.8%) reported being between the ages of 19-20 years old with
29.8% males and 70.2% females. In addition, the study consisted of 68.7% of participants
identified as White with 31.3% individuals reported being an ethnic or racial minority. However,
the maj ority of the individuals registered for the psychology research pool reported being
between the ages of 18-20 (91.6%), female (69%), and White (63%). Future research should
target a more diverse and representative sample of participants.
In addition, the maj ority of the sample reported being in "excellent" or very good"
health. This may have resulted in decreased interaction as well as possibly different interactions
with their health care providers. In future research, it would be interesting to study the
relationships between procedural justice, multicultural competence, and treatment adherence
with a wider range of health conditions and issues.
This study was a preliminary phase in the development of a cultural competence measure
in the health care context through the modification of the CCCI-R, which has been shown to be a
valid and reliable measure in the counseling context (Ponterotto et al., 1994). By modifying this
measure for use within the patient and health care provider relationship, it is one of the initial
measures that allowed patients to appraise the multicultural competence of their health care
provider. However, due to this modification, the measure may have limited validity in this
context. Future research should focus on further validation of this measure. In addition, the
items on the scale may also be subj ect to social desirability, which represents another limitation
of this study that further research can address.
Future research should also look at relationships between gender and procedural justice
factors. In this study, women were found to rate their health care providers as more culturally
competent than men. Women were also found to tend to rate their health care providers
somewhat higher overall in procedural justice, as well as specifically higher on Trust and
Impartiality than men. This may be due to higher utilizations of health care services by females,
which would result in more interactions with their health care providers (Keene & Li, 2005). In
addition, future studies should also investigate the significance of gender in the choice of a health
care provider and the role it may have in the differences within appraisals of multicultural
competence and procedural justice. Therefore, it would be interesting to look at gender
differences within patient and health care provider relationships. However, it is important to note
that even after controlling for gender, results from this investigation were found significant,
which illustrates valuable and stable relationships between procedural and distributive justice
with multicultural competence and treatment adherence.
While there has been important previous research studying procedural justice factors
within a health care framework in relation to patient satisfaction, the study of the relationships
between procedural justice with appraisals of multicultural competence and treatment adherence
is relatively new. Prior research has shown that procedural justice factors (Trust, Impartiality,
and Participation) are criteria people use to evaluate procedural fairness within the health care
context. This study has demonstrated significant relationships between procedural justice with
multicultural competence and treatment adherence. Furthermore, this study has continued to
validate measures that assess procedural justice within the health care system and expands on the
work of Fondacaro et al. (2005) and Williams (2005). Additionally, while there have been
previous measures that have allowed health care providers to assess their own multicultural
competence, this research proj ect introduces an instrument that allows patients to evaluate the
multicultural competence of their health care provider.
In addition, results from this study have established Trust and multicultural competence as
important predictors of treatment adherence. The costs of treatment nonadherence have been
profound with negative health outcomes such as hospitalizations, premature disabilities, and
even death (Khan, 2004; LaFleur, 2004). The findings from this study show that participants
who reported their health care provider to be trustworthy and multiculturally competent reported
higher levels of treatment adherence. This demonstrates that the health care provider-patient
relationship is important in treatment adherence to provider recommendations, which can be
utilized in future training for health care providers and patients as well as future research. The
importance of multicultural competence in treatment adherence has vital implications with ethnic
and racial minorities, who have been reported to be less likely to adhere to treatment
recommendations (IOM, 2002). As a result, studying these factors that contribute to treatment
adherence can increase positive health outcomes. Also, future training can educate health care
providers in developing trust and establishing multicultural competence with patients from
different cultural backgrounds.
DEMOGRAPHIC AND MEDICAL DATA QUESTIONS
DIRECTIONS: These are questions you must fill out individually. Please out fill
the following questions. Be sure you check every scale even though you may feel
that you have insufficient information on which to make a judgment--PLEASE DO
NOT OMIIT ANY. Thank you for your participation!
Backg rou nd I information
1. What is your sex?
2. What month, day, and year were you born?
Month Day Year
3. What is your current marital status?
0 Never 0 nMared O Separated O Divorced Widowed
4. What is your college standing? (1) freshman (2) sophomore
(3) junior (4) senior (5) grad school
5. What is your ethnic background?
1 2 3 4 5
O American 0 Asian 0 Black 0Hispanic White
Indian or Latino
6. Are you currently working for pay either full-time or part-time?
dO No 0 es, part-
O ves, full-
O ves, full-
7. If No, how long has it been since you were
8. What are your own annual earnings before taxes (wages, salary,
O Less than$10,000 0 $30,000 -39,999 O $60,000 -69,999
O $10,000 19,999
O $20,000 29,999
O $40,000 49,999 O $70,000 or more
O $50,000 59,999
9. Do you have any medical conditions or ailments, or any problems with
emotions or behavior, such as depression, excessive drinking, severe memory
problems, or trouble with the law? 1y 27N
10. If Yes: Write in the name of the conditions) in the space below.
Name of Condition
11. Were you hospitalized for any reason in the last year? O ves
Altogether, how many days were you hospitalized
in the last year?
13. During the last 12 months, not counting
checkups, how many times have you seen a doctor?
14. In general, would you say your health is:
Excellent 0 Very Good bOGood O Fair
HEALTH CARE JUSTICE INVENTORY-- PROVIDER (HCJI-P)
This survey asks questions about your healthcare and your experience with your current
doctor or other healthcare provider (for example, nurse practitioner, physician's assistant, etc.).
Please answer each question as accurately as you can.
15. Section A
We would like to learn about your reactions to how your current doctor or other healthcare
provider makes decisions about your healthcare. Please describe an experience you had with
your doctor or another healthcare provider in the last 12 months in which a decision was made
about your healthcare (for example, switching from one medication to another, running a
diagnostic test, having an operation vs. no operation, etc.)
Please describe the situation:
Please answer the following questions about the situation.
16. Did this situation involve a routine healthcare visit?
17. Did the situation involve an emergency?
18. Is this a health care provider at the Student Health Care Center?
Please rate the situation you described on each item on a scale
from 1 (strongly disagree) to 4 (strongly agree).
Strongly Mainly Mainly Strongly
Disagree Disagree Agree Agree
1 2 3 4
19. Your provider listened to you. O O O O
20. Your provider treated you in an 0 0 0 0
21. Your provider handled the O O O O
situation in a very thorough manner.
22. Your provider did something
improper. O O O O
23. Your provider treated you O O O O
24. You were treated as if
you didn't matter. O O O O
25. You accepted your provider' s
decision. O O O O
26. Your provider asked for your O 0 0 0
input before a decision was made.
27. Your provider was open to your
point of view. O O O O
28. Your provider handled the
situation in a very careless manner. O O O O
29. Your provider was honest
with you. O O O O
30. Your provider showed little concern
for you as an individual. O O O O
Strongly Mainly Mainly Strongly
Disagree Disagree Agree Agree
31. You were treated as a valued 1 2 3 4
patient of your provider' s practice. O O O O
32. You fully agreed with the solutions
that you and your provider arrived at. O O O O
33. Your provider did not pay attention
to what you had to say. O O O O
34. Your provider was biased against you. O O O O
35. The decision was based on as much
good information and informed opinion
as possible. O O O O
36. You felt comfortable with the way
your provider handled the situation. O O O O
37. Your provider treated you
with dignity. O O O O
38. Your provider probably gave you
less respect than other patients. O O O O
39. You had a choice to rej ect
your provider' s recommendation. O O O O
40. Your provider asked about your
preferences for what should be done. O O O O
41. You felt you had personal control
over how the situation was handled. O O O O
42. You felt you had personal control
over the decision that was made. O O O O
43. Overall, your provider treated you fairly. O O O O
44. Overall, you were satisfied with the
way your provider treated you during
decision making. O O O O
45. Your provider probably treated you
worse than other patients because of your
personal characteristics. O O O O
Strongly Mainly Mainly Strongly
Disagree Disagree Agree Agree
46. You could have had the decision
reconsidered. O O O O
Now, we would like you to focus on the OUTCOME of the situation you listed above.
Strongly Mainly Mainly Strongly
Disagree Disagree Agree Agree
47. The decision was based on meeting 1 2 3 4
your health needs. O O O O
48. All in all, the decision
was fair to you. O O O O
49. Overall, you were very satisfied
with the decision. O O O O
50. The decision was very favorable
to you. O O O O
51. The decision was influenced by
what was covered in your health plan. O O O O
52. The decision was based on treating
all patients equally. O O O O
53. Your needs were not met. O O O O
54. Regardless of effort or input, the
outcome here was based on meeting
your needs. O O O O
Very Mainly Mainly Very
Dissatisfied Dissatisfied Satisfied Satisfied
55. Now, please rate your 1 2 3 4
satisfaction with your provider. O O O O
Definitely Probably Probably Definitely
No No Yes Yes
56. Finally, would you be 1 2 3 4
willing to recommend your
provider to friends or family
members? O O O O
ADHERENCE TO TREATMENT MEASURE
Now we would like to learn about your healthcare behaviors. Next, we have a list of things your
provider may have recommended that you do as part of your treatment. As you read each one,
please tell us if your provider has recommended that you do any of the following behaviors in
the last 12 months:
57. Follow alow salt diet? O 0
58. Follow a low-fat or weight loss diet? O 0
59. Follow a diabetic diet? O 0
60. Take prescribed medication? O O
61. Check your blood for sugar? O O
62. Take part in a cardiac rehabilitation program? O O
63. Exercise regularly? O O
64. Socialize more than usual with others? O O
65. Cut down on the alcohol you drink? O O
66. Stop or cut down on smoking? O O
67. Check your feet for minor bruises, injuries,
and ingrown toenails? O O
68. Cut down on stress in your life? O O
69. Use relaxation techniques like biofeedback
or self-hypnosis? O O
70. Carry something with sugar in it as a source
of glucose for emergencies? O O
71. Carry medical or health supplies needed for
your self-care? O O
How often have you done each of the following in the past 12 months?
None of Some of
the time the time
Most of All of
the time the time
72. Follow a low salt diet?
73. Follow a low-fat or weight loss diet?
74. Follow a diabetic diet?
75. Take prescribed medication?
76. Check your blood for sugar?
77. Take part in a cardiac rehabilitation program?
78. Exercise regularly?
79. Socialize more than usual with others?
80. Cut down on the alcohol you drink?
81. Stop or cut down on smoking?
82. Check your feet for minor bruises, injuries,
and ingrown toenails?
83. Cut down on stress in your life?
84. Use relaxation techniques like biofeedback
85. Carry something with sugar in it as a source
of glucose for emergencies?
86. Carry medical or health supplies needed for
How often was each of the following statements true for
87. I had a hard time doing what
my provider suggested I do. O
the last 12
88. I followed my provider's suggestions
89. I was unable to do what
was necessary to follow my
provider' s treatment plans.
90. I found it easy to do the things
my provider suggested I do.
91. Generally speaking, how often
during the past 12 months were you
able to do what your provider told you?
Copyright (0 1992, DiMatteo, Hays, and Sherbourne
MODIFIED CROSS-CULTURAL COUNSELING INVENTORY-REVISED (CCCI-R)
We would like to learn about your perceptions of the Cross Cultural Competence of your health
care provider. We are interested in your opinion so please make a judgment on the basis of what
the statements in this inventory mean to you. Please rate the behavior according to this scale:
Rating Scale: 1 = strongly disagree 4 = slightly agree
2 = disagree5=age
3 = slightly disagree 6 = strongly agree
92. Health care provider is aware of his or her own cultural
1 2 3 4 5 6
93. Health care provider values and respects cultural
1 2 3 4 5 6
94. Health care provider is aware of how own values might
affect this patient.
1 2 3 4 5 6
95. Health care provider is comfortable with differences
between health care provider and patient.
1 2 3 4 5 6
96. Health care provider is willing to suggest referral when
cultural differences are extensive.
1 2 3 4 5 6
97. Health care provider understands current socio-political
system and its impact on the patient.
1 2 3 4 5 6
98. Health care provider demonstrates knowledge about
patient' s culture.
1 2 3 4 5 6
99. Health care provider has a clear understanding of
healthcare decision making process.
1 2 3 4 5 6
100. Health care provider is aware of institutional barriers
which might affect patient' s circumstances.
1 2 3 4 5 6
101. Health care provider elicits a variety of verbal and non-
verbal responses from the patient.
1 2 3 4 5 6
102. Health care provider accurately sends and receives a
variety of verbal and non-verbal messages.
1 2 3 4 5 6
103. Health care provider is able to suggest institutional
intervention skills that favor the patient.
1 2 3 4 5 6
104. Health care provider sends messages that are appropriate
to the communication of the patient.
1 2 3 4 5 6
105. Health care provider attempts to perceive the presenting
problem within the context of the patient' s
cultural experience, values, and/or lifestyle.
1 2 3 4 5 6
106. Health care provider presents his or her own values to
1 2 3 4 5 6
107. Health care provider is at ease talking with this patient.
1 2 3 4 5 6
108. Health care provider recognizes those limits determined
by the cultural differences between health care provider
1 2 3 4 5 6
109. Health care provider appreciates the patient' s social status
as an ethnic minority.
1 2 3 4 5 6
110. Health care provider is aware of the professional
and ethical responsibilities of a health care provider.
1 2 3 4 5 6
111. Health care provider acknowledges and is comfortable
with cultural differences.
1 2 3 4 5 6
@Alexis Hernandez and Teresa LaFromboise, 1983
ITEMS FOR THE THREE HCJI-PROVIDER SUB SCALES
1. You accepted your provider's decision.
2. You felt comfortable with the way your provider handled the situation.
3. You fully agreed with the solutions that you and your provider arrived at.
4. The decision was based on as much good information and informed opinion as possible.
5. Your provider was honest with you.
1. Your provider probably treated you worse than other patients because of your personal
2. Your provider was biased against you.
3. Your provider probably gave you less respect that other patients.
4. You were treated as if you didn't matter.
5. Your provider showed little concern for you as an individual.
1. You had a choice to rej ect your provider' s recommendation.
2. You felt you had personal control over the decision that was made.
3. You could have had the decision reconsidered.
4. You felt you had personal control over how the situation was handled.
5. Your provider asked about your preferences for what should be done.
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Angelica Brozyna was born March 11, 1981, in Chicago, Illinois. Angelica grew up with
her parents, Alicja and Kazimierz Brozyna. Angelica attended Maine South high school in Park
Ridge, Illinois, and graduated in 1999. After graduating, Angelica attended University of Illinois
at Urbana-Champaign and graduated with a Bachelor of Science degree in psychology. After
completing her bachelor' s degree, Angelica worked as a counselor at the Jennings Group Home
for adolescent children. Angelica then continued her education in the counseling psychology
program at the University of Florida in 2004. Angelica will receive her Master of Science degree
in 2006 and plans to continue on to receive her Ph.D.