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Justice in the Health Care Provider and Patient Relationship: Appraisals of Multicultural Competence, Procedural Justice...


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1 JUSTICE IN THE HEALTH CARE PROVIDER AND PATIENT RELATIONSHIP: APPRAISALS OF MULTICULTURAL CO MPETENCE, PROCEDURAL JUSTICE, AND DISTRIBUTIVE JUSTICE By ANGELICA BROZYNA A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2006

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2 Copyright 2006 by Angelica Brozyna

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3 Dedicated to my parents, A licja and Kazimierz Brozyna

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4 ACKNOWLEDGMENTS I would like to express my sincere gratitude to my advisor and committee chair, Dr. Mark Fondacaro, for the countless hours he spent in assi sting and guiding me throughout this process. I would also like to thank my committee members, Dr. Greg Neimeyer and Dr. Lonn LanzaKaduce, for their assistance and wisdom in comple ting this project. I woul d also like to extend a warm thanks to my parents, Alicja and Kazimi erz Brozyna, for their cons tant support. Finally, I would also like to thank my fr iends, Jessica Jones and Jennifer Stuart, for their assistance.

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5 TABLE OF CONTENTS Page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........6 ABSTRACT....................................................................................................................... ..............7 CHAPTER 1 INTRODUCTION................................................................................................................... .8 2 METHODS........................................................................................................................ .....23 Participants................................................................................................................... ..........23 HIPPA Training................................................................................................................. .....24 Procedure...................................................................................................................... ..........24 Materials...................................................................................................................... ...........24 Demographic Questionnaire............................................................................................24 Health Care Justice Inventory-Provider..........................................................................24 Adherence to Treatment Measure...................................................................................25 Modified Cross-Cultural Couns eling Inventory-Revised................................................26 3 RESULTS........................................................................................................................ .......29 Patient Appraisals and Patients Dem ographic and Health Characteristics...........................29 Provider Scales and Multicultural Competence.....................................................................29 Factors of Procedural Justic e and Multicultural Competence................................................30 Patient Appraisals and Treatment Adherence.........................................................................31 4 DISCUSSION..................................................................................................................... ....34 APPENDIX A DEMOGRAPHIC AND MEDI CAL DATA QUESTIONS...................................................40 B HEALTH CARE JUSTICE INVE NTORY PROVIDER (HCJI-P)...................................42 C ADHERENCE TO TREATMENT MEASURE....................................................................46 D MODIFIED CROSS-CULTURAL COUN SELING INVENTORY-REVISED...................48 E ITEMS FOR THE THREE HCJ I-PROVIDER SUBSCALES..............................................50 LIST OF REFERENCES............................................................................................................. ..51 BIOGRAPHICAL SKETCH.........................................................................................................54

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6 LIST OF TABLES Table Page 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 Just ice Subscales to Predict Multicultural Competence..................................................................................................................... ...33

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7 Abstract of Thesis Presen ted 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 CO MPETENCE, PROCEDURAL JUSTICE, AND DISTRIBUTIVE JUSTICE By Angelica Brozyna December 2006 Chair: Mark R. Fondacaro Major Department: Psychology This study examined the relationships between procedural and dist ributive justice with multicultural competence and treatment adherenc e. One hundred ninety-eight college students participated in an internet study that assessed interactions with th eir health care providers using the Health Care Justice Inventor y-Provider (HCJI-P), consisting of three scales of procedural justice (Trust, Impartiality, and Participation). Pa rticipants also complete d a self-report measure of treatment adherence and a modified CrossCultural Counseling Inve ntory-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 dist ributive 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 treatment adherence.

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8 CHAPTER 1 INTRODUCTION In the past decade, there has been an increase in research within heal th care regarding the patient-provider relationship. This research has fo cused 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 re garding health status and treatment as well as participation in treatment decisions are related to patient satisfaction (Fondacaro, Frogner, & Moos, 2005). While importan t strides have been made in identifying aspects of physician/patient deci sion making that contribute to pa tient satisfaction, there remains a lack of empirical research concerning the de cision 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 mi norities may have significant implications for patient satisfaction, treatment adherence, an d health status (IOM 2002; Khan, 2004; Hays & DiMatteo, 1987). Therefore, it is important to study the multicultural co mpetence of health care providers and the factors that are valued by patients in the patient-provider relationship, specifically with regard to ethnic and racial mi norities. Therefore, this study will examine the extent to which patients' appraisals of multicul tural competence are related to perceptions of three specific dimensions of proce dural justice (Trust, Impartialit y, and Participation) within the patient/provider relationship. Research regarding the multicultural competence of health care providers is vital to address bot h 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 populati on in the United States.

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9 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 increase d from 2.8% to nearly 3.6% (Bigby, 2003). In 1999, it was reported that almost 26 million American s identified themselves as foreign-born and more than a quarter of these immigrants had co me to the US within the past 10 years. The Census Bureau estimated that in 1996, approxi mately 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 incr ease in the future as well. The Census Bureau estimates that by the ye ar 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 requ ire 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, percei ve 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 th eir 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 hea lth care. This assessment consisted of reviewing

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10 over 100 studies that measured the quality of health care for various ethnic groups, while controlling for factors such as income and insuran ce. The results revealed that even when health care access-related factors are cont rolled, minorities are less likely than Whites to receive needed services and receive lower quality health care tr eatment than Whites. The Institute of Medicine determined two sets of factors that may contribut e to these ethnic disparities in health care. The first factor is a lack of cultural resources in th e 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 agains t 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 f ound that African Americans are slightly more likely to refuse some medical treatment reco mmendations from health care providers (IOM, 2002). In a qualitative study by Chubon (1989), it was found that out of fourteen AfricanAmerican patients who were give n 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, whic h resulted in their nona dherence 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, dise ase progression, premature disability, and death

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11 (Khan, 2004; LaFleur, 2004). It has been estimate d that only 70-80% of patients consistently follow short-term regimens for an acute prob lem, fewer than 60% comply with preventive regimens, and less than 50% adhere with r ecommendations for lifestyle change (Hays & DiMatteo, 1987). There are many possi ble variables currently studied in health care research that may contribute to nonadherence to treatment recommendations. One of the most recently studied aspects regarding treatment adhe rence has been patient-provider interaction. For example, using the Health Compliance Model, it was found that the subject-provide r interaction is an important component of treatment compliance and the respons iveness of the health care provider to patient complaints appears to be correlated with adhe rence (Heiby & Carlson, 198 6). In addition, it has been reported that a poor physician-patient relatio nship will adversely aff ect adherence (Patel & David, 2004). Another factor relate d to treatment adherence is patient satisfaction. Patients satisfaction with the services they receive ha s been shown to predict treatment success and medical adherence (Patel & David, 2004). This da ta suggests that decrea sed patient satisfaction may reduce medical adherence. Nonadherence to treatment recommendations oc curs among patients in all ethnic groups, social classes and health care delivery systems (Hays & DiMatt eo, 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 f actors include a possible element of distrust in the patient-provi der relationship, and perceiving th eir health care provider does not understand them due their cultural background. Thes e gaps in research regarding culturally responsiveness within h ealth care demonstrate a need for fu rther research of health care providers abilities in worki ng with diverse populations.

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12 Cultural responsiveness is defined as a prof essionals skill in working with ethnic populations (Ponterotto, Fuertes, & Chen, 2000). Specifically, cultu ral responsiveness encompasses acknowledgement, showing interest in, having knowledge of, and appreciating a persons ethnicity and culture. It includes placing the problem of the client within a cultural context (Ponterotto et al., 2000). Cultural re sponsiveness and multicultural competency have been extensively studied and described within th e counseling field. Cultural responsiveness is a concept included in a multicultu ral 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 couns eling psychology (LaFromboise, Coleman, & Hernandez, 1991). To address this need for cross-cultural comp etence in counseling, D.W. Sue et al. (1982) presented the Cross-Cultural Counseling Competen cy Model in a Division 17 Report. The CrossCultural Counseling Competency Model is a long -standing model of mu lticultural competence within the counseling field that has guided cultur ally informed education in clinical practice, research, and training. The competencies within th e model have been organized into three areas: Counselor Awareness and Beliefs; Counselor Unde rstanding of clients culturally different worldview; and Developing Appropriate Interven tion Strategies (Ponterotto et al., 2000). Counselor Awareness and Beliefs refers to counse lors racial and cultura l self-awareness, which also includes the understanding of a counselors own culturally biased be liefs, attitudes of themselves, and of people from other cultures. Counselor Understanding of clients worldview includes counselor understanding of a clients worl dviews, perceptions, beliefs and sociopolitical experiences and how these affect treatment pl anning. The third area focuses on the development and use of counseling intervention strategies that focus on counselor s using interventions that are

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13 sensitive to the clients beliefs and attitude s (Fuertes, Bartolome o, & Nichols, 2001). Using these three broad categories, sp ecific competencies were then reorganized into Awareness and Beliefs, Knowledge, and Skills (Ponterotto et al., 2000). D.W. Sues model of multicultural competen ce 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. Sec ond, 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 endor sed the model (Ponterotto et al., 2000). The first instrument designed and published to operationalize D.W. Sues multicultural competence model was an observer-report measure, identified as the Original Cross-Cultural Counseling Inventory (CCCI), de veloped by Hernandez and LaFr omboise (1985). It was based on the 11 cross-cultural counseli ng competencies described in th e Division 17 position paper. These competencies were categorized into th ree main areas: Cultural awareness and beliefs, cultural knowledge, and cu ltural skills. The CCCI was then slightly modified and the revised version was named the CCCI-R. These minor modi fications included the addition of two items that directly assess general understanding of th e counseling process (LaFromboise et al., 1991). The Cross-Cultural Counseling Inventor y-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 de velopment of three self-report instruments followed the creation of the CCC I-R: the Multicultural Awareness-KnowledgeSkills Survey (MAKSS; DAndrea, Daniels, & Heck, 1991); the Multicultural Counseling Inventory (MCI; Sodowsky, Taffe, Gutkin, & Wise, 1994); and the Multicultural Counseling

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14 Awareness Scale (MCAS)-Form B (Ponterotto, Ri eger, Barrett, & Sparks, 1994). However, the CCCI-R has received the most empirical scruti ny among this array of multicultural competence measurements (Ponterotto et al., 1994). Initially, multicultural competence research was conducted primarily within the field of counseling psychology. However, the concept of multicultural competence has been expanding to other areas as well, such as policy organiza tions (Mays, Siantz, & Viehweg, 2002) and within health care (Campinha-Bacote, 2002). The Campi nha-Bacote Model define s cultural competence as the process in which a health care provider co ntinuously 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 de sire (Campinha-Bacote, 2002). A self-report instrument was developed with this model, The Inventory Fo r 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. Nevert heless, it does not a ddress the absence of measures within the health care context that allo w the patient to appraise their experience of multicultural competence of their health care provider. As a result, the CCCI-R was modified for use re garding patients apprai sals of their health care providers multicultural competence. Applying multicultural competencies from the counseling context to the health car e context is feasible due to the similarities in the therapeutic

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15 roles of counselors and physicians. In fact, th e same steps that physicians are recommended to use in encouraging mutual participation in cl inical-decision making (i.e., establishment of conducive atmosphere; ascertain the patients goal s and expectations; edu cating 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 et hnic awareness in ones own beliefs and attitudes towards others in order to give patients or c lients 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 hea lth care context and factors that contribute to why ethnic disparities o ccur. In addition, the as pects 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 ha s provided some insight in the patient-physician relationship is procedural and distributive justice (Fondacaro, 1995). Procedural justice focuses on how decisions are made while distri butive justice focuses on the deci sion 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 (pro cedural justice) as they do a bout the outcome of the decision (distributive justice), particularly within heal th care decision making (Fondacaro et al., 2005). Research in distributive justice has studied thr ee unidimensional construc ts that contribute to decision making outcomes: Equity, Equality, an d Need (Fondacaro et al., 2005). Equity is concerned with whether outcomes are proportionate to the previous behaviors and efforts (Steil & Makowski, 1989). Equality refe rs to whether resources have been allocated equally despite

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16 previous contributions (Steil & Makowski, 1989). Need refers to whether the outcome is based on what the individual need s (Steil & Makowski, 1989). However, recent research by Fondacaro et al. (2 005) 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 provi der and health plan contexts. In addition, it has been frequently found in procedural justice rese arch that evaluations of leaders are strongly affected by the perceived fairness of procedures a ssociated 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 & Wa lker (1975), the term pr ocedural justice is defined as the social consequen ces of variation in procedures, emphasizing the procedural effects on judgments of fairness. Prior to this, the st udy of justice in psychology was mainly concerned with distributive justice or out come fairness (Lind & Tyler, 19 88). 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 ac tions leading to the outcome (L ind & Tyler, 1988). In fact, the majority of provider characteristics and ac tions preferred by patients seem to reflect considerations of procedural just ice; that is, concerns about the process of health care decision making (Fondacaro et al., 2005). In addition, concer ns with the fairness of the decision making process are particularly salient within health care due to the h ealth disparities among individuals with low incomes and ethnic minority backgrounds (IOM, 2002). Therefore, studying aspects of procedural justice may be importa nt specifically within multicultura l competence in health care. Procedural justice research first focused on the legal context but th e 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,

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17 1999). Fondacaro (1995) has indicated th at the principles used to ev aluate 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 multicultura l responsiveness charac teristics of ones health care provider that were valued by patients in previous st udies were trustworthiness, respectfulness, collaboration, effective communi cation 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 w ith the three dimensions of procedural justice: Trust, Impartiality, and Participa tion. Trust of the health care pr ovider consists of whether the patient feels comfortable with how their provider handled the situa tion, if they feel their health care provider was honest with them, and if the patie nt feels the health care provider gave viable treatment options (Fondacaro et al., 2005). The Impa rtiality aspect is base d 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 w ith ones health care provider (Fondacaro et al., 2005). Participation in decisi on making may include a persons control over input into the decision making (p rocess control) and a persons 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 truste d by the patient (Emanuel & Dubler, 1995). Such modifiable maladaptive behaviors can includ e smoking, unhealthy eating, and/or non-adherence to medication. Research on procedur al justice has previous ly found that ratings of the fairness of procedures seem to increase when people perceive that they have been tr eated in a dignified way

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18 that increases trust between that perceiver a nd 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 car e 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 ma y 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 ge nerate the decision allows participation by those affected (Thibaut & Walker, 1975). Conseque ntly, a patient particip ating in the decision making process with their health care provider may be more likel y to accept the decision made. Moreover, these aspects of pro cedural justice (Trust, Impartia lity, and Participation) appear to be valued in the patient-p rovider 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 st udy on cultural sensitivity by Tu cker et al. (2003), low-income primary care patients from three cultural groups were studied: African Americans, European Americans and Latino-Americans. Results indica ted that African American patients described trustworthiness as an important indicator of the cultural sensitivity of the health care provider.

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19 African Americans also reporte d feeling manipulated when e xperimental treatments were performed and not fully explained. European Amer icans 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 thei r health care provider. Several Latino Americans complained about the inequity of the triage de cisions by the health car e 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 percepti ons of a fair process were important to the patients, rather than the outcome itself. Qualities such as empathy, acceptance, and respectfulness were emphasi zed 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; th ey felt that this affected th eir 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 we re that culturally diverse patients desire interper sonally oriented physician beha viors, such as listening, asking questions, demonstrating concern, communicat ing effectively and providing a thorough examination (Tucker et al., 2003). Recent studies have observed the influence pr ocedural and distributive justice have on health care decision making, patient satisfaction, and treatment adhe rence. 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 participati on 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

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20 Fondacaro et al. (2005), procedur al justice factors were more strongly related to patient satisfaction than distributive fact ors within the health care provide r context. All three dimensions of procedural justice (Trust, Im partiality, 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 controlle d (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 satisf action; all three scales also accounted for unique variance in satisfaction wi th the health care provider. These findings suggest that patient satisfacti on ratings are higher when patie nts perceive the decision making process as fair. In addition, a significant re lationship was found between the three procedural justice scales and treatment adherence to re commendations made by the health care provider (Williams, 2005). When multiple regression analyses were conducted with these three scales as predictors and treatment adhere nce as the criterion, Trust and Impartiality accounted for unique variance in treatment adherence by patients (Will iams, 2005). This preliminary research also suggests that Trust and Impartiality are especi ally salient for ethni c and racial minority populations (Williams, 2005). Therefore, it is im portant to study the relationships between appraisals of Trust, Impartiality, and multicul tural competence of the health care provider. The purpose of this study is to examine th e 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, Impa rtiality, and Participation) within the patientprovider relationship. Another objec tive of this study is to contri bute to the va lidation of the

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21 Health Care Justice Inventory and expand on th e work of Fondacaro et al. (2005) and Williams (2005). Based on past research on health care decisi on 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 apprai sals 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 relati onship between multicultural competence and the factors of procedural justi ce and distributive justice. Hypothesis 2: Patients appraisals of multic ultural 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 regr ession analysis with the dimensions Impartiality, Trust, and Participation as predictors, Impartiality will account for unique variance in multicultural competence, even after contro lling 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 th e health care context (Fondacaro et al., 2005) and the use of unbiased pro cedures 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-p rovider relationship were found to be particularly salient in treatment adherence for minorities, both procedural justice factors Trust and Impartiality will be

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22 related to treatment adherence. Moreover, explor atory analyses will examine the extent to which Trust, Impartiality, and Multicult ural Competence each account for unique variance in treatment adherence.

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23 CHAPTER 2 METHODS Participants Participants were recruited from the psychology resear ch pool of undergraduates at the University of Florida. Participants received academic credit for compensation. The academic credit was factored into the part icipants grade but did not determine the final grade. Participants were prescreened for those who have received he alth care services within the last year and included males and females of varying socioeco nomic status, racial id entification, and ethnic backgrounds. Participants were treated in acco rdance with the Ethical Principles of Psychologists and Code of Conduct (A merican Psychological Association, 2002). The sample consisted of 198 individual s between the ages of 19 and 26 with M = 19.8 ( SD = 1.09). The sample consisted of 59 males (2 9.8%) 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 freshm en, 22.7% were sophomores, 13.6% were juniors, and 3.5 % were seniors. The ethnic make-up of the study sample incl uded 68.7% Whites, 1% American Indians, 6.1% Asians, 10.1% African Americans, 9.6% Hisp anic/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 work ing full time, and 0.5% reported working full and part time. For annual income, 64.1% repor ted 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 %

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24 reported being in good health, 4% reported being in fair health, and 0.5% reported being in poor health. HIPPA Training Research investigators that needed access to participant data completed the University of Floridas HIPPA 102 General Knowledge (or A nnual Review) Test of Knowledge. The test consisted of questions regarding the regulati ons and penalties for obtaining, maintaining, protection, storage, and removal of health care information from patie nts. This test is required for all faculty, staff, and students who have access to health care data. Procedure Participants were asked to complete a we b-based study with a demographic and health information questionnaire and three inventory measures: the Health Ca re Justice InventoryProvider (HCJI-P), the Modified Cross-Cultura l Counseling Inventory-Revised (CCCI-R), and the Adherence to Treatment Measure. The demo graphic information questionnaire and the four measures were posted on the psyc hology subject pools website. Materials Demographic Questionnaire The demographics form asked participants questions regarding their sex, age, marital status, years of formal education, ethnic b ackground, employment status and annual income. There were also questions referr ing to participants medical conditions, hospitalizations within the past year, annual check-ups, a nd overall health status. Health Care Justice Inventory-Provider The Health Care Justice Inventory-Provide r (HCJI-P) is an integrated measure of procedural and distributive justice in the hea lth care context (Fondacaro et al., 2005). The first portion, Section A, asks participants to describe a visit with their current doctor or other health

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25 care provider in the last 12 months in which a de cision was made about thei r health care. Section B asks subjects if the experience they descri bed involved a routine he alth 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 Pa rticipation. Participants would be asked to reflect on the experience they described in Section A while answering these questions. After the procedural justice items, particip ants were asked to answer eight distributive justice items while focusing on their health care experience. All que stions in Section C we re rated in a 4-point Likert scale, ranging from 1 (st rongly disagree) to 4 (strongl y agree). After the distributive justice items, there were two ite ms 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 consistenc ies, with alphas = .93, .91, and .91 for the subscales Trust, Impartiality, and Particip ation (Fondacaro et al., 2005). In addition, the scores on each scale range from 0-15. Adherence to Treatment Measure The Adherence Measure is a th ree 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 aske d by health care providers for di abetes, hypertension, and heart disease patients. In this first section, patients are asked if thei r health care pr ovider suggested these recommendations as part of their regimen, s caled from 1 (none of the time) to 4 (all of the time). The second section consists of ques tions regarding how ofte n 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 aske d how difficult it was to follow treatment recommendations, which consisted of five items scal ed from 1 (none of the time) to 4 (all of the time). For the purposes of this research study, the general adhere nce questions (third

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26 section) were used to score treatment adhere nce of participants in order to assess overall treatment adherence rather than sp ecific 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 hyperten sion and heart disease w ithin 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 card iac rehabilitation program. Items 1 and 3 were reversed scored. In scoring, the responses were averaged together. Th e internal consistency reliability of the scale was acceptable with alpha = .81 (DiMatteo et al.,1992). Although there have been problems reported re garding a self-report measure of treatment adherence due to social desirabi lity, patients self-reports are less complex to obtain and more cost-effective than other methods The correlation be tween 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 additi on, the correlations between the specific adherence sections and the general adherence section were low, from .12 to 0.29 (DiMatteo et al., 1992). Therefor e, the general adherence measur e seems to assess information that cannot be obtained from the specific adherence measures alone. Furthermore, using a selfreport measure allowed patients to rate adhe rence on all possible treatments, including nonmedication treatments such as diet and exercise. Modified Cross-Cultural Co unseling Inventory-Revised The Modified Cross-Cultural C ounseling Inventory-Revised consists of 20 items, the same number of items as the original Cross-Cu ltural Counseling Invent ory-Revised (CCCI-R) (LaFromboise et al., 1991). The original CCCI-R is a measure used by an evaluator or supervisor to assess another counselors multicultural comp etence. However, in this study, a patient needs to evaluate their perception of the health care providers multicultural competence. In order for

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27 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 clients cultur e to Health care provider demonstrates knowledge about patients 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 c ontinued to use a 6-point Likert scale, ranging from 1 (strongly disagree) to 6 strongly agre e). The necessity of modifying a measure originally intended for use by counselor supervis ors limits the psychometri c validity of the data. Nevertheless, there was no other instrument foun d that assesses a hea lth care providers multicultural competence by a patient. There have been numerous empirical studies lo oking 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 represen ted 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 tr aining in multicultural competence, rate thirteen videotapes of Anglo-American st udents counseling clients. The inte r-rater reliability coefficient was .78 among the raters. The criterion-relate d validity of the CCCI was evaluated in two studies. In a study by Hernandez and Kerr (1985) it was discovered that counselors with

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28 previous training in multicultural issues were rated higher on the CCCI than were counselors with no previous training. In another study by Pomales, Clai born, and LaFromboise (1986), it was found that counselors acting in a culturally responsive manner were rated significantly higher on the CCCI than counselors demonstrating cultura lly 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 ScaleForm B (MCAS-Form B), the Multicultural Counse ling Inventory (MCI) a nd the Multicultural Awareness-Knowledge-and Skills Survey (MAKSS). Su fficient content validity has also been demonstrated by independent raters from e ducational 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 multic ultural competence. In addition, factor analysis demonstrates evidence of construct validity. Th e reported coefficient alpha was reported at .95, which demonstrates high reliability (LaFromboise et al., 1991).

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29 CHAPTER 3 RESULTS Patient Appraisals and Patients Dem ographic and Health Characteristics No significant relationships were found between patients ratings of their provider and their demographic characteristics, including ag e, 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 ones gender or ethnic background differed in terms of pr ovider ratings and treatment adherence, t-tests for independent means were conducted. Participan ts who identified w ith 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 he alth care providers as more culturally competent than men (see Table 1). Procedural jus tice was also found to va ry by gender; that is, women tended to rate their health care providers somewhat highe r 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-Cultur al Counseling Inventor y-Revised. Consistent with the first and second hypothesis, patients appr aisals of the multicultural competence of their health care providers were signifi cantly related with patients a ppraisals of health care decision

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30 making along global dimensions of both pr ocedural and distributive justice ( r s = .62 and .58, respectively, all p s < .01). To further explore this relati onship, forced entry multiple regression analyses were conducted with procedural and distributive jus tice as the pr edictors and multicultural competence as the criterion. Both procedural justice and distributive justice accounted for unique variance in multicultural co mpetence and remained significant, even after controlling for relevant variables of ethnic ity and gender (betas=.38 and .28, respectively, p s < .01). Therefore, patients who considered their he alth care providers decision making processes and outcomes as fair also tended to report their health care provi der as culturally competent. Overall, the two scales accounted for 36.4 % of unique variance in multicultural competence appraisals of health care providers. In additi on, procedural justice accounted for 32.9% of unique variance and distributive just ice accounted for 30.2% of th e variance in multicultural competence, after controlling for gender and ethnicit y in the first step of two separate three step hierarchical multiple regressi on analyses (betas = .38 and .28, ps < .01). Procedural justice accounted for 6.1% of unique variance in multicultu ral competence, after controlling for gender, ethnicity, and distributive justi ce in the hierarchical multiple regression analyses (beta = .38, p < .01). Distributive justice accounted for 3.4% of th e unique variance in multicultural competence, after controlling for gender, ethnicit y, and procedural justice (beta = .28, p < .01). Factors of Procedural Justi ce and Multicultural Competence All three of the Provider procedural justice sc ales (Trust, Impartiality, and Participation) were significantly related to appraisals of multicultural competence (see Table 2). Forced entry multiple regression analyses were then conducted w ith Trust, Impartiality, and Participation as predictors and multicultural comp etence 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 th an Impartiality, accounted for uni que variance in appraisals of

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31 multicultural competence of ones health care provider (see Table 3). This relationship remained significant and essentially unchanged after contro lling for ethnicity and gender. As a result, patients who considered their health care provid er trustworthy also repo rted their health care provider as more culturally competent. Patient Appraisals and Treatment Adherence Patients treatment adherence was assessed base d on the mean ratings patients provided for five questions regarding their ability to adhere to their providers treatment recommendations. Consistent with the fourth hypothe sis, all three of the Provider pr ocedural justice scales (Trust, Impartiality, and Participation) were found signi ficantly related to treatment adherence (see Table 2). Forced entry multiple regression analyses were conducted to further examine this relationship, with Trust, Impartiality, and Particip ation as predictors with treatment adherence as the criterion, controlling for ethnicity and heal th status. Trust was found to account for unique variance and made a significant co ntribution to the model (beta = .28, p < .01). Thus, patients who indicated their health care provider was trus tworthy, reported higher levels of treatment adherence to their providers treatment recommendations. In addition, multicultural competence was signifi cantly related to treatment adherence (see Table 2). As described in the fourth hypothesi s, the relationship between Trust, Impartiality, and multicultural competence was explored throu gh forced entry multiple regression analyses, with Trust, Impartiality, and multicultural compet ence as predictors and treatment adherence as the criterion. Multicultural comp etence accounted for unique varian ce in treatment adherence to provider treatment reco mmendations (beta = .21, p < .05), even after contro lling for ethnicity and health status. Multicultural comp etence accounted for 2.5% of the vari ance in patients appraisals of multicultural competence of their health care provider.

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32 However, when forced entry multiple regre ssion analyses were conducted with Trust and multicultural competence as predictors with tr eatment 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 c onsidered their health care provider trustworthy and culturally compet ent also reported higher levels of treatment adherence with their providers treatment recommendations. Ov erall, the two scales accounted for 12.6% of unique variance in patients treatment adherenc e to provider recommendations. Moreover, Trust accounted for 9.8% of unique variance in trea tment 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, ethni city, and multicultural competence (beta= .18, p < .05). Multicultural competence accounted for 2.8% of the unique variance in treatment adherence, after controlling for h ealth, ethnicity, and Trust (beta = .22, p < .01).

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33 Table 1. Mean Ratings of Providers on Indices of Multicultural Competence and Procedural Justice by Males and Females Provider Appraisals Males Gender Mean ( SD ) 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 Jus tice and Multicultural Competence and Treatment Adherence Provider Appraisals Multicultural Competence 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 Subscales to Predict Multicultural Competence Multicultural Competence Trust .42** Impartiality .13 Participation .13 Note: Entries are standardized beta weights; ** p < .01

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34 CHAPTER 4 DISCUSSION The central aim of this study was to determin e the role of procedural and distributive justice in the appraisals of multicultural comp etence of health care providers. Additionally, the study aimed to examine the relationships between specific factors of proc edural justice (Trust, Impartiality, and Participation) with multicultural competence and treatment adherence. This was done through appraisals of health care providers from participan ts obtained from an internetbased study, utilizing the Health Care Justice Inventory-Prov ider, Adherence to Treatment Measure, and the Modified Cross-Cu ltural Counseling Inventory-Revised. Overall, four hypotheses were examined in the present investigation. In support of the first hypothesis, patients appraisals of their health care provider s multicultural competence were significantly related with patients appraisals of their providers hea lth care decision making along global dimensions of both pr ocedural and distributive justic e. Consistent with the second hypothesis, there was a slightly higher corr elation between multicu ltural competence and procedural justice than with di stributive justice. Further examin ation of this relationship was conducted using multiple regression analyses w ith procedural and distributive justice as predictors and multicultural compet ence as the criterion. Both pro cedural and distributive justice were found to account for unique variance in multic ultural 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 just ice in multicultural competence a nd health care decision making. In addition, procedural justice accounte d 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

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35 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 multicultu ral competence than distributive justice. Previous research by Hughes and Larson (1991) also f ound procedural justice factors to be influential within the health care context. In additi on, studies have also shown proce dural justice factors as more strongly related to patient satisf action than distributive factors w ithin the health care provider context (Fondacaro et al., 2005; Williams, 2005). Mo reover, research by Tucker et al. (2003) has also found that qualities such as trust, aski ng questions, demonstrati ng concern, and treating patients fairly were valued as indicators of cultu ral sensitivity, which are related to the specific factors of procedural justice. In regards to the thir d hypothesis, Impartial ity was predicted to acc ount for unique variance in multicultural competence. However, this hypot hesis was not supported. An interesting result was found in which Trust, rather than Impartia lity, was found to account for unique variance in multicultural competence, after controlling for gender and ethnicity. This illustrates that individuals who consider their hea lth care provider trustworthy also tended to report their health care provider as culturally competent. This provide s 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 pro cedural 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 res earch by Tucker et al. ( 2003), in which trust was found valuable with all three cu ltural groups studied (African-A mericans, European-Americans,

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36 and Latino-Americans) but Latino-American patients reported valuing fair treatment and communication while African-American patients em phasized participation and trustworthiness. For the final hypothesis, both Trust and Impartia lity were found significantly related to treatment adherence to provider recommendations However, only Trust accounted for unique variance in treatment adherence, providing only partial support fo r the fourth hypothesis An additional aim of this study was to conduct explor atory analyses to examin e the roles of Trust, Impartiality, and multicultural competence in treatm ent 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 trustw orthy and culturally competent will have higher levels of treatment adherence. As a result, ther e are exciting implications for future health care provider trainings that can in corporate these factors. Overall, the results of this study shed so me new light on the health care provider and patient relationship. However, th ere were some limitations with this investigation. First, the participants in this study cons isted of students from the University of Floridas psychology research pool. This provided a large sample of in dividuals who have utiliz ed health care services and thus provided a basis for which relationships between procedural justice, multicultural competence, and treatment adherence can be asse ssed. Nevertheless, the sample was not diverse with the majority of the sample (76.8%) reported being between th e ages of 19-20 years old with 29.8% males and 70.2% females. In addition, th e study consisted of 68.7% of participants identified as White with 31.3% i ndividuals reported being an ethni c or racial minority. However, the majority of the individuals registered for the psychology research pool reported being

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37 between the ages of 18-20 (91.6%), female (69 %), and White (63%). Future research should target a more diverse and represen tative sample of participants. In addition, the majority of the sample re ported being in exce llent or very good health. This may have resulted in decreased intera ction as well as possibl y 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 de velopment of a cultural competence measure in the health care context thr ough the modification of the CCCI-R, which has been shown to be a valid and reliable measure in the counseling cont ext (Ponterotto et al., 19 94). By modifying this measure for use within the patient and health car e provider relationship, it is one of the initial measures that allowed patients to appraise th e multicultural competence of their health care provider. However, due to this modifica tion, 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 subject to social desirability, which represents another limitation of this study that further research can address. Future research should also look at relations hips between gender a nd 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 u tilizations 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 significa nce of gender in the choice of a health

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38 care provider and the role it may have in the differences within appraisals of multicultural competence and procedural justice. Therefore, it would be interest ing to look at gender differences within patient and he alth care provider relationships. Ho wever, it is important to note that even after controlling for gender, results from this investigation were found significant, which illustrates valuable and stable relationshi ps between procedural and distributive justice with multicultural competence and treatment adherence. While there has been important previous re search studying procedural justice factors within a health care framework in relation to patient satisfacti on, the study of the relationships between procedural justice with appraisals of multicultural co mpetence and treatment adherence is relatively new. Prior research has shown that procedural justice fact ors (Trust, Impartiality, and Participation) are criteria people use to eval uate procedural fairness within the health care context. This study has demonstr ated significant relationships be tween procedural justice with multicultural competence and treatment adherence. Furthermore, this study has continued to validate measures that assess procedural justice w ithin 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 project introduces an in strument that allows patients to evaluate the multicultural competence of their health care provider. In addition, results from this study have esta blished 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 findi ngs from this study show that participants who reported their health care provider to be tr ustworthy and multiculturally competent reported

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39 higher levels of treatment adherence. This demo nstrates that the health care provider-patient relationship is important in treatment adhere nce to provider recommendations, which can be utilized in future trainings for health care provide rs 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 reporte d to be less likely to adhere to treatment recommendations (IOM, 2002). As a result, studyi ng these factors that co ntribute to treatment adherence can increase positive health outcomes. Also, future trainings can educate health care providers in developing trust and establishi ng multicultural competence with patients from different cultural backgrounds.

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40 APPENDIX A 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 judgmentPLEASE DO NOT OMIT ANY. Thank you for your participation! Background Information 1 2 1. What is your sex? Male Female 2. What month, day, and year were you born? ___________ ___________ ___________ Month Day Year 3. What is your current marital status? 1 2 3 4 5 Never Married Separated Divorced Widowed Married 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 6 American Asian Black Hispanic White Other Indian or Latino 6. Are you currently working for pay either full-time or part-time? 1 2 3 4 No Yes, partYes, fullYes, fulltime only time only and part-time 7. If No how long has it been since you were ___________ or __________ employed? months years

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41 8. What are your own an nual earnings before taxes (wages, salary, commissions)? 1 4 7 Less than $10,000 $30,000 39,999 $60,000 69,999 2 5 8 $10,000 19,999 $40,000 49,999 $70,000 or more 3 6 $20,000 29,999 $50,000 59,999 9. Do you have any medical conditions or ailments, or an y problems with emotions or behavior, such as depression, excessive drinking, severe memory problems, or trouble with the law? 1 2 Yes No 10. If Yes: Write in the name of the c ondition(s) in the space below. Name of Condition ________________________ ________________ 1 2 11. Were you hospitalized for any reason in the last year ? Yes No 12. If Yes: Altogether, how many days were you hospitalized in the last year ? ___________ days 13. During the last 12 months not counting checkups, how many times have you seen a doctor? ___________ times 14. In general, would you say your health is: 1 2 3 4 5 Excellent Very Good Good Fair Poor

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42 APPENDIX B HEALTH CARE JUSTICE INVENTORY PROVIDER (HCJI-P) This survey asks questions about your heal thcare and your experi ence with your current doctor or other healthcare provider (for example, nur se 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 docto r 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 exam ple, switching from one medica tion to another, running a diagnostic test, having an ope ration vs. no operation, etc.) Please describe the situation: ______________________________________________________________________________ Section B Please answer the following questions about the situation. Yes No 12 16. Did this situation involve a rout ine healthcare visit? 17. Did the situation involve an emergency? 18. Is this a health care pr ovider at the Student Health Care Center?

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43 Section C Please rate the situation you desc ribed 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. 20. Your provider treated you in an impartial manner. 21. Your provider handled the situation in a very thorough manner. 22. Your provider did something improper. 23. Your provider treated you with respect. 24. You were treated as if you didnt matter. 25. You accepted your providers decision. 26. Your provider asked for your input before a decision was made. 27. Your provider was open to your point of view. 28. Your provider handled the situation in a very careless manner. 29. Your provider was honest with you. 30. Your provider showed little concern for you as an individual.

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44 Strongly Mainly Mainly Strongly Disagree Disagree Agree Agree 31. You were treated as a valued 1 2 3 4 patient of your providers practice. 32. You fully agreed with the solutions that you and your provider arrived at. 33. Your provider did not pay attention to what you had to say. 34. Your provider was biased against you. 35. The decision was based on as much good information and informed opinion as possible. 36. You felt comfortable with the way your provider handled the situation. 37. Your provider treated you with dignity. 38. Your provider probably gave you less respect than other patients. 39. You had a choice to reject your providers recommendation. 40. Your provider asked about your preferences for what should be done. 41. You felt you had personal control over how the situation was handled. 42. You felt you had personal control over the decision that was made. 43. Overall, your provider treated you fairly. 44. Overall, you were satisfied with the way your provider treated you during decision making. 45. Your provider probably treated you worse than other patients because of your personal characteristics.

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45 Strongly Mainly Mainly Strongly Disagree Disagree Agree Agree 46. You could have had the decision reconsidered. 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. 48. All in all, the decision was fair to you. 49. Overall, you were very satisfied with the decision. 50. The decision was very favorable to you. 51. The decision was influenced by what was covered in your health plan. 52. The decision was based on treating all patients equally. 53. Your needs were not met. 54. Regardless of effort or input, the outcome here was based on meeting your needs. ________________________________________________________________________ Very Mainly Mainly Very Dissatisfied Dissatisfied Satisfied Satisfied 55. Now, please rate your 1 2 3 4 satisfaction with your provider. 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?

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46 APPENDIX C 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: Yes No 12 57. Follow a low salt diet? 58. Follow a low-fat or weight loss diet? 59. Follow a diabetic diet? 60. Take prescribed medication? 61. Check your blood for sugar? 62. Take part in a cardiac reha bilitation program? 63. Exercise regularly? 64. Socialize more than usual with others? 65. Cut down on the alcohol you drink? 66. Stop or cut down on smoking? 67. Check your feet for minor bruises, injuries, and ingrown toenails? 68. Cut down on stress in your life? 69. Use relaxation techniques like biofeedback or self-hypnosis? 70. Carry something with sugar in it as a source of glucose for emergencies? 71. Carry medical or health supplies needed for your self-care?

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47 How often have you done each of the following in the past 12 months? None of Some of Most of All of the time the time the time the time 1 2 3 4 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 or self-hypnosis? 85. Carry something with sugar in it as a source of glucose for emergencies? 86. Carry medical or health supplies needed for your self-care? How often was each of the following statements true for you during the last 12 months ? None of Some of Most of All of the time the time the time the time 1 2 3 4 87. I had a hard time doing what my provider suggested I do. 88. I followed my providers suggestions exactly. 89. I was unable to do what was necessary to follow my providers 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 1992, DiMatteo, Hays, and Sherbourne

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48 APPENDIX D MODIFIED CROSS-CULTURAL COUNSELI NG 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 opini on so please make a judgment on the basis of what the statements in this inventory mean to you. Plea se rate the behavior according to this scale: Rating Scale: 1 = strongly disagree 4 = slightly agree 2 = disagree 5 = agree 3 = slightly disagr ee 6 = strongly agree 92. Health care provider is awar e of his or her own cultural heritage. 1 2 3 4 5 6 93. Health care provider va lues and respects cultural differences. 1 2 3 4 5 6 94. Health care provider is awar e of how own values might affect this patient. 1 2 3 4 5 6 95. Health care provider is co mfortable with differences between health care prov ider and patient. 1 2 3 4 5 6 96. Health care provider is w illing to suggest referral when cultural differences are extensive. 1 2 3 4 5 6 97. Health care provider unders tands current socio-political system and its impact on the patient. 1 2 3 4 5 6 98. Health care provider dem onstrates knowledge about patients culture. 1 2 3 4 5 6 99. Health care provider ha s a clear understanding of healthcare decision making process. 1 2 3 4 5 6 100. Health care provider is awar e of institutional barriers which might affect patients circumstances. 1 2 3 4 5 6

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49 101. Health care provider elicits a variety of verbal and nonverbal responses from the patient. 1 2 3 4 5 6 102. Health care provider accur ately sends and receives a variety of verbal and non-verbal messages. 1 2 3 4 5 6 103. Health care provider is ab le 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 patients cultural experience, values, and/or lifestyle. 1 2 3 4 5 6 106. Health care provider presents his or her own values to the patient. 1 2 3 4 5 6 107. Health care provider is at eas e talking with this patient. 1 2 3 4 5 6 108. Health care provider recognizes those limits determined by the cultural di fferences between health care provider and patient. 1 2 3 4 5 6 109. Health care provider appr eciates the patients social status as an ethnic minority. 1 2 3 4 5 6 110. Health care provider is aware of the professional and ethical responsibili ties 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

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50 APPENDIX E ITEMS FOR THE THREE HC JI-PROVIDER SUBSCALES Trust-P 1. You accepted your providers decision. 2. You felt comfortable with the way your provider handled the situation. 3. You fully agreed with the solutions that you and your pr ovider arrived at. 4. The decision was based on as much good info rmation and informed opinion as possible. 5. Your provider was honest with you. Impartiality-P 1. Your provider probably treated you worse than other patients because of your personal characteristics. 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 didnt matter. 5. Your provider showed little conc ern for you as an individual. Participation-P 1. You had a choice to reject your providers 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 pref erences for what should be done.

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51 LIST OF REFERENCES Bigby, J. (2003). Beyond culture: Strategies for caring fo r patients from diverse racial, ethnic, and cultural groups. In J. Bigby (Eds.), Cross-cultural medicine (pp. 1-28). Philadelphia: American College of Physicians. Brody, D.S. (1980). The patients ro le in clinical decision-making. Annals of Internal Medicine, 93, 718-722. Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13 (3), 181-184. Chubon, S.J. (1989). Personal descriptions of compliance by rural southern Blacks: An exploratory study. The Journal of Compliance in Health Care, 4 (1), 23-37. Counseling Psychology Division 17 of Amer ican Psychological Association. (2002). Guidelines for multicultural counseling proficiency for ps ychologists: Implicati ons for education and training, research and clinical practice Washington, DC: American Psychological Association. Retrieved November 1, 2004, from 3http://www.div17.org/mccomp.html DAndrea, M., Daniels, J., & Heck, R. (1991). Ev aluating the impact of multicultural counseling training. Journal of Counseling and Development, 70 143-150. DiMatteo, M.R., Hays, R.D., & Sherbourne, C. D. (1992). Adherence to cancer regimens: Implications for treati ng the older patient. Oncology, 6 50-57s. Doutrich, D. (2004). Education a nd practice: Dynamic partners for improving cultural competence in public health. Family Community Health 27 (4), 298-307. Emmanuel, E.J., & Dubler, N.N. (1995). Preservi ng the physician-patient relationship in the era of managed care The Journal of the American Medical Association 273(4) 323-329. Fuertes, J.N., Bartolomeo, M., & Nichols, C. M. (2001). Future research directions in the study of counselor multicultural competency Journal of Multicultural Counseling and Development 29 (1), 3-12. Fondacaro, M.R. (1995). Toward a synthesis of law and social science: Due process and procedural justice in the contex t of national health care reform. Denver University Law Review, 72 (2), 303-358. Fondacaro, M.R., Frogner, B., & Moos, R. (2005) Justice in health care decision-making: Patients appraisals of health care provi ders and health plan representatives. Social Justice Research, 18 (1), 63-81. Hall, M.A., Dugan, E., Zheng, B., & Mishra, K. (2001). Trust in physicians and medical institutions: What is it, can it be measured, and does it matter? The Milbank Quarterly 79 (4), 613-639.

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52 Hays, R.D., & DiMatteo, M.R. (1987). Key issu es and suggestions for patient compliance assessment: Sources of information, focus of measures, and nature of response options. The Journal of Compliance in Health Care, 2 (1), 37-53. Heiby, E.M., & Carlson, J.G. (1986) The Health Compliance Model. The Journal of Compliance in Health Care, 1 (2), 135-152. Hernandez, A.G., & Kerr, B.A. (1985, August). Evaluating the triad model and traditional cross-cultural counseling training Paper presented at the 93rd Annual Convention of the American Psychological Association at Los Angeles, CA. Hughes, T.E., & Larson, L.N. (1991). Patient involv ement in health care: A procedural justice viewpoint. Medical Care, 29 (3), 297-303. Institute of Medicine. (2002, March 20). Unequal treatment: What hea lthcare providers need to know about racial and ethnic di sparities in healthcare. Retrieved October 10, 2004, from 3http://www.iom.edu/reports.asp. Keene, J., & Li, X. (2005). Age and gender differences in health service utilization. Journal of Public Health, 27 (1) 74-79. Khan, J.D. (2004, July 1). Non-compliance with proven treatments increase s healthcare costs. Managed Healthcare Executive. Retrieved April 15, 2005, from 3http://www.managedhealthcareexecutive.com. LaFleur, O.J. (2004). Methods to measure patient compliance with medication regimens. Journal of Pain and & Palliative Care Pharmacotherapy, 18 (3), 81-87. LaFromboise, T.D., Coleman, H.L.K., & Herna ndez, A. (1991). Development and factor structure of the Cross-Cultural Counseling Inventory-Revised. Professional Psychology: Research and Practice, 22 (5), 380-388. Lind, E.A., & Tyler, T. (1988). The social psychology of procedural justice. New York, NY: Plenum Press. Mays, R.M., Siantz, M.L., & Viehweg, S.A. (2002). Assessing cultural competence of policy organizations. Journal of Transcultural Nursing, 13 (2), 139-144. Murphy-Berman, V., Cross, T., & Fondacaro, M. R. (1999). Fairness and health care decision making: Testing the group value model of procedural justice. Social Justice Research, 12 (2), 117-129. Patel, M.X., & David, A.S. (2004). Medication ad herence: Predictive factors and enhancement strategies. Psychiatry, 3 (10), 41-44. Pomales, J., Claiborn, C.D., & LaFromboise, T.D. (1986). Effects of Bl ack students racial identity on perceptions of White couns elors varying in cu ltural sensitivity. Journal of Counseling Psychology, 33 57-61.

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53 Ponterotto, J.G., Fuertes, J.N., & Chen, E.C. ( 2000). Models of multicultural counseling. In S.D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (3rd ed., pp. 639-669). New York: Wiley. Ponterotto, J.G., Rieger, B.P., Barrett, A ., & Sparks, R. (1994). Assessing multicultural counseling competence: A re view of instrumentation. Journal of Counseling and Development, 72 316-322. Sodowsky, G.R., Taffe, R.C., Gutkin, T.B., & Wise, S. L. (1994). Development of the Multicultural Counseling Inventory: A self-re port measure of multicultural competencies. Journal of Counseling Psychology, 41, 137-148. Steil, J.M, & Makowski, D.G. (1989). Equity, e quality, and need: A stud y of the patterns and outcomes associated with their use in intimat e relationships. Social Justice Research, 3, 121-137. Sue, D.W., Bernier, J., Durran, M., Feinberg, L., Pedersen, P., Smith, E., & Vasquez-Nuttall, E. (1982). Position paper: Multicultural c ounseling competencies. The Counseling Psychologist, 10, 45-52. Thibaut, J., & Walker, L. (1975). Procedural justice. Hillsdale, NJ: Erlbaum. Tucker, C.M., Herman, K.C., Pederson, T. R., Higley, B., Montrichard, M., & Ivery, P. (2003). Cultural sensitivity in physician-patient relations hips, perspectives of an ethnically diverse sample of low-income primary care patients. Medical Care, 41 (2), 859-870. Tyler, T.R., & Beis, R. (1990). Beyond formal procedures: The interp ersonal context of procedural justice. In J.S. Carroll (Eds.), Applied social psychology in business settings (pp. 77-98). Hillsdale, NJ: Erlbaum. Williams, C. (2005). Manuscript in progress, University of Florida Gainesville.

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54 BIOGRAPHICAL SKETCH Angelica Brozyna was born March 11, 1981, in Ch icago, Illinois. Ange lica grew up with her parents, Alicja and Kazimi erz Brozyna. Angelica attended Ma ine South high school in Park Ridge, Illinois, and graduated in 1999. After gra duating, Angelica attended University of Illinois at Urbana-Champaign and graduated with a Bach elor of Science degree in psychology. After completing her bachelors degree, Angelica work ed as a counselor at the Jennings Group Home for adolescent children. Angelica then conti nued her education in the counseling psychology program at the University of Florida in 2004. Ange lica will receive her Mast er of Science degree in 2006 and plans to continue on to receive her Ph.D.


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Permanent Link: http://ufdc.ufl.edu/UFE0017926/00001

Material Information

Title: Justice in the Health Care Provider and Patient Relationship: Appraisals of Multicultural Competence, Procedural Justice, and Distributive Justice
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0017926:00001

Permanent Link: http://ufdc.ufl.edu/UFE0017926/00001

Material Information

Title: Justice in the Health Care Provider and Patient Relationship: Appraisals of Multicultural Competence, Procedural Justice, and Distributive Justice
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0017926:00001


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JUSTICE IN THE HEALTH CARE PROVIDER AND PATIENT RELATIONSHIP:
APPRAISALS OF MULTICULTURAL COMPETENCE, PROCEDURAL JUSTICE, AND
DISTRIBUTIVE JUSTICE






















By

ANGELICA BROZYNA


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

2006
































Copyright 2006

by

Angelica Brozyna





























Dedicated to my parents, Alicja and Kazimierz Brozyna









ACKNOWLEDGMENTS

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


Page

ACKNOWLEDGMENTS .............. ...............4.....


LIST OF TABLES .........__.. ..... .__. ...............6....

AB S TRAC T ......_ ................. ............_........7


CHAPTER


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......... ....


APPENDIX


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


Table Page

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
DISTRIBUTIVE JUSTICE

By

Angelica Brozyna
December 2006

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

treatment adherence.









CHAPTER 1
INTTRODUCTION

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, &

Hernandez, 1991).

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

(2005).

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

adherence.









CHAPTER 2
IVETHOD S

Participants

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

health.

HIPPA Training

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.

Procedure

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.

Materials

Demographic Questionnaire

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).









CHAPTER 3
RESULTS

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
Mean (SD)


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
Provider Appraisals
Multicultural Treatment
Competence 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
Competence
Multicultural Competence

Trust .42**

Impartiality .13

Participation .13

Note: Entries are standardized beta weights; ** p < .01









CHAPTER 4
DISCUSSION

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.








APPENDIX A
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


O Male


0 Female


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
Married

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


0 Other


6. Are you currently working for pay either full-time or part-time?


dO No 0 es, part-
time only


O ves, full-
time only


O ves, full-
and part-time


7. If No, how long has it been since you were
employed?


or
months years








8. What are your own annual earnings before taxes (wages, salary,
com missions)?

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


12. IfYes:
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


days


times


5
0 Poor


O No










APPENDIX B
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:


Section B


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?


Yes No









Section C


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
impartial manner.

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
with respect.

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









APPENDIX C
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:

Yes No
1 2
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
3 4


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
or self-hypnosis?
85. Carry something with sugar in it as a source
of glucose for emergencies?
86. Carry medical or health supplies needed for
your self-care?


How often was each of the following statements true for
None of
the time

87. I had a hard time doing what
my provider suggested I do. O


you during
Some of
the time
2


the last 12
Most of
the time
3


ninibslll?
All of
the time
4


88. I followed my provider's suggestions
exactly.

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









APPENDIX D
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
heritage.
1 2 3 4 5 6

93. Health care provider values and respects cultural
differences.
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
the patient.
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
and patient.
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










APPENDIX E
ITEMS FOR THE THREE HCJI-PROVIDER SUB SCALES


Trust-P

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.

Impartiality-P

1. Your provider probably treated you worse than other patients because of your personal
character stics.
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.

Participation-P

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.









LIST OF REFERENCES


Bigby, J. (2003). Beyond culture: Strategies for caring for patients from diverse racial, ethnic,
and cultural groups. In J. Bigby (Eds.), Cross-culturalnzedicine (pp. 1-28). Philadelphia:
American College of Physicians.

Brody, D.S. (1980). The patient's role in clinical decision-making. Annals oflnternal2\~edicine,
93, 718-722.

Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare
services: A model of care. Journal of Transcultural Nursing, 13(3), 1 81-1 84.

Chubon, S.J. (1989). Personal descriptions of compliance by rural southern Blacks: An
exploratory study. The Journal of Compliance in Health Care, 4(1), 23-37.

Counseling Psychology Division 17 of American Psychological Association. (2002). Guidelines
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BIOGRAPHICAL SKETCH

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.