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Record for a UF thesis. Title & abstract won't display until thesis is accessible after 2008-06-30.

Permanent Link: http://ufdc.ufl.edu/UFE0021515/00001

Material Information

Title: Record for a UF thesis. Title & abstract won't display until thesis is accessible after 2008-06-30.
Physical Description: Book
Language: english
Creator: Mirsu-Paun, Anca
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: Psychology -- Dissertations, Academic -- UF
Genre: Counseling Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Statement of Responsibility: by Anca Mirsu-Paun.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Tucker, Carolyn M.
Electronic Access: INACCESSIBLE UNTIL 2008-06-30

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021515:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021515/00001

Material Information

Title: Record for a UF thesis. Title & abstract won't display until thesis is accessible after 2008-06-30.
Physical Description: Book
Language: english
Creator: Mirsu-Paun, Anca
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: Psychology -- Dissertations, Academic -- UF
Genre: Counseling Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Statement of Responsibility: by Anca Mirsu-Paun.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Tucker, Carolyn M.
Electronic Access: INACCESSIBLE UNTIL 2008-06-30

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021515:00001


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1 VALIDATION OF A PROVIDER SELF-REPORT INVENTORY FOR MEASURING PATI ENT-CENTERED CULTURAL SENSITIVITY IN HEALTH CARE By ANCA MIRSU-PAUN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007

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2 2007 Anca Mirsu-Paun

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3 ACKNOWLEDGMENTS As m y academic advisor says, It takes a village to raise a child. My graduate education in general, and my dissertation work in particul ar, have been a journey which I could not have made without the support, encouragements, help, c onstructive criticism, love trust, hope, and/or prayers that of a whole village of people that I was fortunate enough to meet and have in my life. My thoughts go to Dr. Carolyn Tucker, my chairperson and academic advisor. She recognized from the beginning my potential, co nstantly supported me emotionally and in tangible ways, encouraged my professional grow th, and did not accept anything but an excellent quality of my work. I am very happy and grateful that she did so; with her support and under her supervision and constant demand for improvement, I was able to discover more and more that I am capable of reaching a leve l of professional development which was difficult to believe possible at the very beginning of my academic and professional journey. I must express my gratitude to the kind a nd generous people from the University of Florida, University of South Florida, and th e Alachua County Crisis Center whom I met by virtue of my professional work, and who provided support and encouragements throughout this process: Dr. Paul Schauble, Dr. Jim Morgan, Dr. Nancy Coleman, Dr Wayne Griffin, Dr. Caridad Hernandez, Dr. Marshall Knudson, Gladys Co frin, Christine Alicot, Dr. Dale Hicks, Dr. Leonard Kirklen, Dr. Kristen Davis-John, Dr. Ri chard Temple, Dr. Jill Langer, Dr. Patricia Maher, and Dr. Margaret Booth-Jones. I also thank my doctoral committee for th eir support and willingness to meet short deadlines, my fellow interns for lending me their ear and for opening their hearts, and to my friend Khanh Nghiem for her invaluable help with various nuts and bolts throughout the process.

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4 Last but definitely not least, I will never be able to thank enough my parents, and especially my mother, for everything that they did to help me throughout this process. My mothers love, prayers, advice, s upport, willingness to listen to me whenever I needed to talk and constant reassurance gave me strength and motiv ated me to pursue my goals with confidence, humility, patience, respect, and passion. I am co nvinced that I would not be here without her support.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................3 LIST OF TABLES................................................................................................................. ..........7 LIST OF FIGURES.........................................................................................................................8 ABSTRACT.....................................................................................................................................9 CHAP TER 1 INTRODUCTION..................................................................................................................11 Statement of the Problem....................................................................................................... .11 Purpose of the Proposed Study...............................................................................................17 Research Questions............................................................................................................. ....18 2 REVIEW OF THE LITERATURE........................................................................................ 20 Definition of Patient-Centered Cult urally Sensitive Health C are........................................... 20 Review of the Existing Assessments of Culturally Com petent Health Care and Culturally Sensitive Health Care......................................................................................... 23 Development of the Pilot Tucker-C ulturally Sensitiv e Health Care ...................................... 25 Inventory (CSCHI)-Provider Form......................................................................................... 25 The Tucker Patient-Centered Culturally Sensitive Health Care Model .......................... 25 The Grounded Theory of Qualitative Research............................................................... 26 The Quality of Care Theory............................................................................................ 27 Literature and Research Evid ence S upporting the Need for.................................................. 28 Patient-Centered Culturally Sensitive Health Care ................................................................28 Evidence of the Need for Patient-Centered Culturally Sensitive Health Care from the Health Disparities Literature .................................................................................. 28 Evidence of the Need for Patient-Centered Culturally Sensitive Health Care from the Health Care Disparities Literature ......................................................................... 29 Evidence of the Need for Patient-Centered Culturally Sensitive Health Care from the Dem ographic Characteristics of the U. S. Medical Students and Physicians in the U.S..........................................................................................................................32 The Potential Usefulness of Patient-Cente red Culturally Sensitive Health Care ...................35 Assessments in Research to Reduce Disparities ..................................................................... 35 The Potential Usefulness of Patient-Cente red Culturally Sensitive Health Care ...................39 Assessments in Medical Training Efforts to Reduce Disparities ........................................... 39 3 METHOD......................................................................................................................... ......44 Participants.............................................................................................................................44 Instruments.................................................................................................................... .........46

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6 Procedure................................................................................................................................48 Recruitment of Research Collaborators and Research Assistants. ..................................48 Recruitment of Medical Student Participants.................................................................. 50 4 RESULTS...............................................................................................................................53 First Research Question........................................................................................................ ..53 Second Research Question.....................................................................................................61 Third Research Question........................................................................................................63 5 DISCUSSION.........................................................................................................................68 Summary and Interpretation of the Results............................................................................ 68 Research Questions 1 and 2............................................................................................. 68 Research Question 3........................................................................................................ 76 Limitations and Future Di rections of Research ......................................................................78 Implications of this Study..................................................................................................... ..81 Implications for Counseling Psychologists..................................................................... 82 Conclusions.............................................................................................................................85 APPENDIX A E-MAIL MESSAGE TO MEDICAL SCH OOL FACULTY CO-INVESTIGATORS ......... 86 B E-MAIL MESSAGE TO MEDICAL STUDENT PARTICIPANTS..................................... 87 C ONLINE COVER LETTER/INFORMED CO NSENT FORM W ITH UF IRB APPROVAL...........................................................................................................................88 D ONLINE PAYMENT INFORMATION W ITH UF IRB APPROVAL.................................90 E E-MAIL MESSAGE TO MEDICAL STUDEN TS W ITH PAYMENT INFORMATION... 91 LIST OF REFERENCES...............................................................................................................92 BIOGRAPHICAL SKETCH.......................................................................................................101

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7 LIST OF TABLES Table page 3-1 Participant dem ographic and medical education information........................................... 45 4-2 Eingenvalues and Variance Explained in the Initial Factor Solutions ............................... 55 4-3 Comparison of the Rotated Five-F actor and Six-Factor Solutions.................................... 57 4-4 Factor/Subscale Item Compositi on and Factor Loadings for the Five-Factor Solution.... 58 4-5 Percent of Variance and Num ber of Items per Factor/Subscale........................................ 60 4-6 T-CSHCI-Provider Form Factor/Subscale Correlations.................................................... 60 4-7 Descriptive Inform ation for the T-CS HCI-Provider Form Factors/Subscales.................. 61 4-8 T-CSHCI-Provider Form Factor/Subscale Psychometric Properties................................. 61 4-9 Pearson Correlations b etween the T-CSHC I-Provider Form Factors/Subscales and the CCSAQ........................................................................................................................62 4-10 Spearm an Correlation Coefficients for the Associations between the T-CSHCIProvider Form Factors/Subscales and Pa rticipants Demographic Variables................... 64 4-11 Spearm an Correlation Coefficients for the Associations between the T-CSHCIProvider Form Factors/Subscales and Part icipants Medical Training Variables............. 64 4-12 Multiv ariate Effects of Gende r, Race/Ethnicity, and Knowledge of Other Languages on the T-CSHCI-Provider Form Factors/Subscales........................................................... 66

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8 LIST OF FIGURES Figure page 4-1 Scree plot for the T-CSHCI-Provider Form items............................................................. 55

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9 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy VALIDATION OF A PROVIDER SELF-REPORT INVENTORY FOR MEASURING PATI ENT-CENTERED CULTURAL SENSITIVITY IN HEALTH CARE By Anca Mirsu-Paun December 2007 Chair: Carolyn M. Tucker Major: Counseling Psychology Patient-centered culturally sensitive health care systems are specific quality of care contributors to reducing health di sparities in this country. The la ck of assessments to evaluate levels of patient-centered culturall y sensitive health care that pa tients experience likely impedes current efforts to promote patient-centered quality health care in this country. Patient-centered culturally sensitive health car e is a new concept, introduced as cultural competence plus. Patient-centered culturally sensitive health care views culturally diverse patients as the true experts on the indicators of culturally sensitive/inse nsitive health care, is patient empowerment-oriented, and emphasizes displaying patient-desir ed provider and staff behaviors and attitudes, implemen ting health care policies, and di splaying physical health care characteristics identified by patients as culturally sensitive. This study (a) examined the reliability, construc t validity, and factor st ructure of the pilot Tucker-Culturally Sensitive Health Care Invent ory (T-CSHCI)-Provider Form using a sample of medical students who provide care to patients (i.e., 3rd and 4th year medical students), and (b) explored the associations between medical st udents self-reported scores on the T-CSHCIProvider Form and selected demographic and edu cation variables. Explor atory factor analyses

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10 with Varimax rotations, followed by reliability an d validity analyses, revealed the existence of five valid and reliable T-CSHCI-Provider Form factors: Patient-Center edness, Interpersonal Skills, Disrespect/Disempowerment, Competence, and Cultural Knowledge/Responsiveness. In addition, scores on selected T-CSHCI-Provider Form factors/subscales were significantly associated with medical students gender, race/ ethnicity, and ability to speak at least one language other than English.Male participants, as compared with female participants, rated themselves significantly lower on Interpersonal Skills and higher on Disrespect/ Disempowerment skills. African American particip ants, as compared with Asian American and non-Hispanic White participants, rated themselv es significantly higher on Cultural Sensitivity/ Responsiveness skills. Participants who reported speaking at least one other language in addition to English rated themselves significantly hi gher on Interpersonal Skills and Cultural Knowledge/Responsiveness skills as compared w ith participants who spoke English only. The present study provided evidence for using the T-CSHCI-Provider Form to assess the effectiveness of patient-centere d culturally sensitive health care training (such as pre-post training comparisons using the T-CUSHCI scores ). The T-CSHCI-Provider Form can also be used as a useful tool for self-d irected learning of patient-centered culturally sensitive health care behaviors and attitudes by advan ced medical students, which can benefit these students in their interactions with culturally diverse patients. In addition, the T-CUSHCI has potential for promoting needed research to determine if there are measurable links between culturally sensitive health care as define d by ethnic minority patients and the costly and unjust disparities between majority and minority Americans.

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11 CHAPTER 1 INTRODUCTION Statement of the Problem According to the Institute of Medicine ([IO M], 2003), racial/ethnic m inorities in the U.S. receive a lower quality of care than non-Hispanic Whites, and this difference contributes to the existing health disparities in this country. Alar ming examples of such disparities include the findings that racial/ethnic minority groups are more likely to be affected in six key health areas: infant mortality, diabetes, cardiovascular diseas e, cancer screening and management, HIV/AIDS, and child and adult immunizati ons (DHHS, 2001). According to the American College of Physicians (2004), culturally sensitive heal th care systems are specific quality of care contributors to reducing health di sparities in this country. In a ddition, a significant characteristic of culturally sensitive health care that can co ntribute to reducing h ealth care and health disparities is patient-centered care (i.e., perceivi ng and evaluating health care from the patients perspective and then adapting care to meet the needs and expecta tions of patients) (Beach, Saha, & Cooper, 2006). The call for patient-centered culturally sensitiv e health care that would meet the health needs of all racial/ethnic groups was stated in the Report on Mental Health from the Surgeon General (1999). This report assert ed that some of the limitations that likely impede efforts to promote patient-centered culturally sensitive heal th care include: (a) defi nitions of culturally competent health care and culturally sensitiv e health care that have been provided by professional experts with no input from patie nts themselves, (b) no c onsensus regarding the operational definitions of terms such as cultural competence and cultural sensitivity, and (c) a lack of assessments to measure levels of patient -centered culturally sensitive health care that patients experience, and (d) limited attention by re searchers to identifying culture-specific health

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12 care preferences among culturally diverse patients. These limita tions likely contribute to the existing paucity of (a) research to support the link be tween patient-centered culturally sensitive health care and patients health outcomes (Davis et al., 2005); (b) training programs to teach provider behaviors and attitudes characteristic of patient-centered culturally sensitive health care (Fortier & Bishop, 2004); and (c) evidence of systematic patient-centered culturally sensitive health care practices among health care providers in their inter actions with culturally diverse patients (Fortier & Bishop, 2004). The existing literature regarding multicultural pr actices associated with health care training and services utilizes several concepts am ong which are cultural competence and cultural sensitivity in health care. Each of these concepts brings a unique perspective regarding approaches to health care training and practice. Cultural competence in health care has been defined as a set of behaviors, attitudes, and po licies that ensure that a system, agency, program, or individual can function effectively and appropr iately in diverse cultural interactions and settings, and also ensures an understanding, apprec iation, and respect for cultural differences and similarities within, among and between groups (Un ited States Department of Health and Human Services [USDHHS], 2002). Culturally res ponsive health care has been defined as acknowledging and respecting cultu ral differences among minority groups that impact their health and behaviors and appl ying this awareness in health care delivery (USDHHS, 2001). Cultural responsiveness is typical ly used interchangeably with cultural competence, while considered to be subsumed under the broader co ncept of cultural compet ence. The construct of cultural sensitivity has been defined as the ability to adjust ones perceptions, behaviors, and practice styles to effectively meet the needs of different ethnic or racial groups (USDHHS,

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13 2007). This definition of cultural sensitivity resemb les the one of cultural competence applied at an individual/health care provider level. Patient-centered culturally sensitive health car e is a concept introduced by Tucker et al. (Tucker, 200; Tucker, Herman, Pedersen, Hi gley, Montrichard, and Ivery, 2003; Herman, Tucker, et al., in press) as cu ltural competence plus in that it extends beyond an emphasis on displaying cultural competence in health care to an emphasis on ascertaining what patients want, need, perceive, and feel in th e process of receiving culturally competent health care Tucker, Herman, et al. (in press). Patient -centered culturally sensitive hea lth care views culturally diverse patients as the true experts on the indicators of culturally sensitive/insens itive health care, and it is patient empowerment-oriented. Patient-centered culturally sensitiv e health care also emphasizes displaying patient-desired provider a nd staff behaviors and attitudes, implementing health care policies, and displaying physical hea lth care characteristics identified by patients as culturally sensitive (Tucker, Mirsu-Paun, et al., 2007). Currently there are increasing national calls for the development of reliable and valid assessments of patient-centered culturally sensitiv e health care. One such call has come from the Agency of Health Care Research and Quality [AHRQ] (2004). Specificall y, there is a need for assessments that emphasize specific provider behavi ors, attitudes, and kno wledge that culturally diverse patientsrather than prof essional expertsview as indicator s of respect for their culture and that enable these patients to feel comfortable with and trusti ng of their physical health care providers (Tucker, Herman, Pedersen, Higley, Montrichard, & Ivery, 2003 ; Tucker, Herman, et al., in press). Assessments of patient-centered cult urally sensitive health care are needed and can be successfully used to evaluate the effectiveness of health care training activitie s (e.g., medical

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14 school education or continuing medi cal education), to inform the pr ovision of culturally sensitive health care, and to conduct cultural ly sensitive health care research. According to the National Center for Cultu ral Competence (2006), the need for and the importance of valid and reliable assessments of patient-centered culturally sensitive health care are based on several assumptions: (a) cultural competence [and cultural sensitivity] are developmental processes and thus assessment inst ruments are necessary to identify areas of future growth and development, (b) health care providers can enhance their cultural awareness, knowledge, and skills over time and with approp riate feed-back and support, and (c) providers might already possess certain culturally sensitive health care skills or attitudes that assessments can help highlight, thus further assisting these providers to draw upon their strengths when they interact with racial/ethnic minority patients. Training activities. Assessments of patient-centered cu lturally sensitive health care are needed for engaging in the developmental a nd ongoing process of learning the behaviors and attitudes characteristic to culturally sensitive a nd culturally competent health care. Ideally, the initial stages of this ongoing process of acqui ring of the patient-centered culturally sensitive health care behaviors and attit udes would coincide with the fo rmal medical school training and would continue throughout a physicians medical career. Thus, assessments of patient-centered culturally sensitive health care are considered to be an essential component of cultural competence and cultural sensitivity medical sc hool training programs which address the core patient-centered culturally sensitive health care co mpetencies and skills to be further perfected through continuing medical practice and education. Cultural competence and cultural sensitivity focused curricula are increasingly being called for by leaders in the field of medical traini ng (AHRQ, 2004; Centers for Disease Control and

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15 Prevention [CDC], 2005). Such calls are being pr ompted by research findings and/or literature indicating that (a) training in providing culturally competent [and culturally sensitive] health care is an important strategy for eliminating racial an d ethnic disparities in he alth care and health (Rapp, 2006), (b) one of the most important met hods of creating a durable, culturally competent health care system is through the training of medical students (Ra pp, 2006; Tervalon, 2003), (c) training in cultural competence and cultural sensi tivity for advanced medi cal students (i.e., third and fourth year medical students who provide health care to patie nts) provides opportunities for the application of this training in interactions with their patients and for related assessment and feedback from these patients that can facilitate the cultural competence/sensitivity of the medical students who provide health care to these patients (Rapp, 2006), and (d) patient-centered culturally sensitive provider behaviors and attitude s can contribute to reducing health disparities between racial/ethnic minority patients and majority patient s by improving the health care satisfaction and treatment adherence among racia l/ethnic minority patients (Wilson et al., 2004). Consequently, there is a strong impetus for the development, implementation, and evaluation of cultural competency and cultural sensitivity trai ning programs for medical students who provide health care to culturally diverse patients. Despite this impetus for cultural competen ce and cultural sensitivity training, several obstacles make it difficult for such training to be implemented in medical schools. For example, medical faculty have not yet reached an agreemen t regarding (a) what should constitute patientcentered culturally sensitive hea lth care, (b) how this construct can be incorporated into the medical curricula in an effective manner, and (c) how the effectivene ss of patient-centered culturally sensitive health care training programs can be assessed (Betancourt, Green, & Carillo, 2005). Consequently, currently there is no uni versally required curri culum for promoting

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16 culturally competent and culturally sensitive health care (Welch, 1998). In addition, few studies have been published that repor t the use of assessments to evaluate the impact of cultural competence and cultural sensitivity traini ng (Thom, Tirado, Woon, & McBride, 2006). For example, a content analysis report from the US DHHS (2002) noted that information regarding the most effective types of cultural competence and cultural sensitivity training for health care providers is currently insuffici ent because of the lack of a ppropriate health care quality assessments (Fortier & Bishop, 2004). Valid a nd reliable assessments of patient-centered culturally sensitive health care are particularly ne eded given that medical students can experience extensive training in providing culturally compet ent health care and yet not display behaviors and attitudes which promote health care envir onments that patients experience as culturally sensitive (Paterson, 2001). Health care provision. Assessments of patient-centered cu lturally sensitive health care are also needed to evaluate and inform the provision of such care to cultura lly diverse patients. A plethora of research findings suppor t the view that the health care providers in the U.S., most of whom are non-Hispanic White, are not sufficiently pr epared to interact in a culturally sensitive manner with their increasingly diverse patients. Thus, it is not surprising that racial/ethnic minority patientsparticularly those who are Af rican American or Hispanic/Latinoare not satisfied with their health care (Mayberry, Mili & Ofili, 2000) and often feel discriminated against in the health care they receive (Chen, Fryer, Phillips, Wilson, & Pathman, 2005). Several authors have asserted that cult urally competent and culturally sensitive health care are both linked to patient satisfaction (D iPalo, 1997), treatment adherence (Salganicoff, 2002), and better health outcomes (Stansbury, Jia, Williams, Voge l, & Duncan, 2005). Despite these findings that support implementing patient-centered culturally sensitive health care practices, there are

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17 currently no published valid and reliable cultural ly sensitive health care assessment inventories for providing information that ca n help guide such practices. Research. Assessments of patient-centered culturally sensitive health care can also be used to conduct needed research to examine the asso ciations among health care provider engagement in culturally sensitive health care behaviors and patient satisfaction, patient adherence, and patient health outcomes. Currently, there is a pa ucity of empirical research evidence regarding the associations between patient-centered cultura lly sensitive health care practices and health outcomes/statuses of patients (Bet ancourt, 2005). However, such evid ence is required in order to promote adequate investments in health care resources, research, and training to promote culturally sensitive health care (Lavizzo-Mour ey & MacKenzie, 1995) and in order to discontinue the existing skepticism about th e value of cultural se nsitivity and cultural competency training for providers (Bentacourt, 2004). Purpose of the Proposed Study The proposed research responds to the call for and the need f or valid and reliable assessments of patient-centered culturally sensi tive health care. Specifically, the present study will (a) examine the reliability, construct validi ty, and factor structure of the pilot TuckerCulturally Sensitive Health Care Inventory (T-C SHCI)-Provider Form using a sample of medical students who provide care to patients (i.e., 3rd and 4th year medical students), and (b) explore the associations between medical students self-re ported scores on the T-CSHCI-Provider Form and selected demographic and educatio n variables (i.e., gender, age, ra ce/ethnicity, U.S. citizenship status, fluency in a language other than Eng lish, year in medical school, prior or current enrollment in a course on culturally competent/sen sitive health care, and self-reported level of experience with providing health care to racial/ethnic minority patients).

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18 The pilot T-CSHCI-Provider Form is a self-ass essment instrument for use by health care providers to report their perceive d level of engagement in patie nt-centered culturally sensitive health care behaviors and attitudes. The ite ms on the pilot T-CSHCI-Provider Form were generated or identified in a prior focus group study in which low-inco me African American, Hispanic/Latino, and non-Hispanic White primary care patients identified provider behaviors and attitudes that make them (the patients) feel tr usting of, comfortable with, and respected by their health care providers (Tucker, Herman, Pedersen, Higley, Montrichard, & Ivery, 2003). The preliminary reliability and validity data for the pilot T-CSHCI-Provi der Form suggested that this inventory is reliable and valid; however, these initial findings we re based on a small sample of providers (Tucker, Mirsu-Paun, et al., 2007). If the T-CSHCI-Provider Form is found to be valid and reliable for a large group of advanced medical students who provide health care, support will be provided for using this assessment instrument across the country to eval uate self-perceived levels of patient-centered culturally sensitive health care among medical stude nts who provide health care to culturally diverse patients. If these self-evaluations differ in association with any found specific factors that constitute the T-CSHCI-Provider Fo rm or in association with any of the demographic or training experience variables that will be investigated, gui dance will be provided for the type of general and individualized training that may help prep are medical students fo r providing culturally sensitive health care. Research Questions The following research questi ons will be addressed: 1. What are the dim ensions or factor structures that constitute patient-centered culturally sensitive health care as assessed by the T-CS HCI-Provider Form when this form is used with a sample of medical students who see patients?

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19 2. When used with a sample of medical stude nts who see patients, will any found T-CSHCIProvider Form subscales identified through fact or analytic procedures have high internal consistency, split-half reliability, and construct validity? The construct validity will be determined by examining the correlations be tween the T-CSHCI-Provi der Form subscales and the Service Delivery and Practice subs cale of the Cultural Competence Assessment Questionnaire-Service Provider Version. 3. Do levels of medical students self-assessed patient-centered cultural sensitivity in the health care they provide, as assessed by the T-CSHCI-Provider Form, differ in association with their gender, race/ethnicity, U.S. citizensh ip status, fluency in a language other than English, year of me dical school (i.e., 3rd or 4th), prior or current enro llment in a course on culturally competent/ sensitive health care, a nd self-reported level of experience with providing health care to raci al/ethnic minority patients and to low-income patients?

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20 CHAPTER 2 REVIEW OF THE LITERATURE The proposed study will exam ine the factor structure, reliability, and construct validity of the pilot Tucker-Culturally Sens itive Health Care Inventory (T -CSHCI)-Provider Form, which is used to assess perceived levels of patient-cente red culturally sensitive health care. In this literature review chapter, the definition of pa tient-centered culturally sensitive health care is provided, and the differences between this care and other types of he alth care quality are discussed. In addition, the steps used to develo p the pilot T-CSHCI-Provider Form are described. The limitations of the existing assessment inst ruments to evaluate cultural competence and cultural sensitivity in health care delivery are also discussed. Research and other literature evidencing the ne ed for patient-centered culturally sensitive health care and for assessments such as the pilo t T-CSHCI-Provider Form to evaluate levels of such care among advanced medical students are al so reviewed in this chapter. Finally, the potential usefulness of the T-CSHCI-Provider Fo rm for advancing health and health care disparities research and interven tions and for promoting medical training that better prepares medical students to provide health care to culturally diverse patients are presented in this chapter. Definition of Patient-Centered Culturally Sensitive Health Care The developm ent of the pilot T-CSHCI-Provide r Form is based on a conceptualization of patient-centered culturally sensitive health care that is alike and yet distin ct from other health care types described in the litera ture (e.g., culturally competent health care). Defining patientcentered culturally sensitive health care is warrant ed especially since experts in the field are still not in agreement regarding the definitions of different types of health care. Tucker and her colleagues (Tucker, Herm an, Pedersen, Higley, Montrichard, & Ivery, 2003) introduced the notion of patient-centered cu lturally sensitive health care and defined it as

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21 health care that focuses on displaying specifi c behaviors and attitude s, conveying knowledge, and creating physical health care environments and policies that culturally diverse patients rather than professional expertsvi ew as indicators of respect fo r their culture and that enable these patients to feel comforta ble with, trusting of, and respect ed by their providers. According to Tucker (Tucker, Herman, et al., in press; Tucker, Mirsu-Paun, et al., 2007) the specific characteristics of patient-centered culturally sens itive health care are as follows: (a) it includes but extends beyond cultural competen ce, and thus is referred to as cultural competence plus; (b) it conceptualizes the patient-provider relations hip as a partnership that emerges from patient centeredness; (c) it is patient em powerment oriented; and (d) it is displayed by patient-desired modifiable and measurable provider and staff behaviors and attitudes and clinic environment characteristics and policies that patients identify as making them feel comf ortable with, respected by, and trusting of their providers. Culturally sensitive health care is patient-cente red in that (a) it advoc ates for health care decisions that are consistent with patients wants, needs, and pref erences; (b) patients have the knowledge and support needed to share their wants, needs, and preferences with providers; and (c) patients are encouraged to pa rticipate in decision-making about their care in a manner that is respectful to their cultural background. Patient-centered car e involves a partnership among practitioners, patients, and their families, and central to these partners hips are providers who demonstrate empathy, compassion, and responsivene ss to the needs, values, and preferences of their patients (Institute of Medicine, 2002). In contrast, cultural competence is usually considered to be inclusive of awareness, knowledge, a nd skills of providers (Campinha-Bacote, 1999) without mentioning the importance of patients perspectives and/ or patients experiences with regard to their health care pr oviders behaviors and attitudes, their health care centers office

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22 staff members behaviors and attitudes, or their health care centers environment and policies. For example, in a published field study (Betancourt et al., 2003), thirty -seven experts in cultural competence (e.g., experts from managed care, or ganizations, government, and medical schools) were asked their perspectives on cultural competence, but patients were excluded from this group of experts. The construct of patient-centered culturally sensitive health care proposed by Tucker and her colleagues also emphasizes specific modifiab le provider and clinic staff behaviors and attitudes and health care environments and policies that are sensitive to and/or reflect what patients want, need, perceive, and feel in the process of receiving their health care. This emphasis renders patient-centered culturally sensitiv e health care to be a practical and relevant concept for developing the research, training, practice, and assessmen t tools required for improving the quality of health care at individua l, clinic/center, and organizational levels (Tucker, Herman, et al., in press). In contrast, cultural competence promot es constructs that are difficult to teach and evaluate, such as showing appreciation for cultural differences, avoiding stereotypes, or explaining an issu e from anothers perspective. Culturally sensitive health care interventions are also patient-empowerment oriented. Researchers focused on empowerment issues (e.g., Rappaport, 1987)in particular issues related to the empowerment of Blacks (Solomon, 1976) and Hisp anics (Gutirrez & Ortega, 1991) agree that empowerment must include prom otion of a psychological sense of personal and interpersonal control; attention to social, political and legal factors that influence valued social roles; and patient preferences in processes and outcomes such as health care decision-making and treatment choices, respectively. Such patient -centered patient-provider partnerships have been associated with increased treatment adhe rence by patients (Beck, Daughtridge, & Sloane,

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23 2002) and reductions in misdiagnosis of patients health problems due to poor communication (DiMatteo, 1998). Moreover, collab oration between patients and their providers was strongly associated with patient health status improvements (Michie, Miles, Weinman, 2003) such as control over levels of blood pressu re, blood glucose, cholesterol le vels, and pain levels (Wasson, Johnson, Benjamin, Phillips, & MacKenzie, 2006). It is also noteworthy that racial/ethnic minority and low-income patients want to be activ e partners in their heal th care (Earnest, Ross, Wittevrongel, Moore, & Lin, 2004). In contrast, cu lturally competent care focuses on providers racial or ethnic group-specific knowledge or attitudes and self-efficacy (Doorenbos, Schim, Benkert, & Borse, 2005) with no referen ce to patients wants and needs. Review of the Existing Assessments of Cult ura lly Competent Health Care and Culturally Sensitive Health Care According to the American Association of Medical Colleges (2005), studies that use standardized and valid measures of patient-centered culturally sensitive health care are critical in order to assess the effectiveness of cultural competence and cultural sensitivity training on providers attitudes, skills, knowledge, and behaviors in their interactions w ith culturally diverse patients. A review of the extant literature on assessments of culturally sensitive health care and culturally competent health care reveals that there are only a few published measures of culturally competent health care and no published measures of cu lturally sensitive health care and/or measures of patient-centered cultural sensitivity in physical health care provision. However, the Commonwealth Fund has identified the development and use of surveys/assessments of patient-cen tered culturally sensitive healthcare as part of its 2020 vision (Davis et al., 2005). Further, a recent AHRQ report refers to the development of such assessment instruments as a dire need (Beach et al., 2004).

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24 Examples of some of the existing health ca re provider self-assessments of culturally competent health care include the Cultural Competence Assessm ent (CCA) (Schim, Doorenbos, Miller, & Benkert, 2003), the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals-Revised (IAP CC-R) (Campinha-Bacote, 2002), the Cultural Awareness Scale (Rew et al., 2003), the Tool for Assessing Cultural Competence Training (TACCT) (AAMC, 2005), and the Clinical Cu ltural Competency Questionnaire (CCCQ) (US DHHS, 2005). These and similar measures of culturally compet ent health care are lim ited in one or more of the following ways: (a) the scope of item c ontent is limited to the developers operational definition of cultural competence, (b) the definitions of cultural competence are based on judgments or observations provided by experts or scholars rather than by the patients themselves who experience the quality of care pr ovided, (c) existing normative data is based on specific, non-representative samples such as hospi ce health care professi onals, (d) the existing measures lack empirical reliability across inde pendent samples beyond those which are used in their development, and (e) the existing measures focus on testi ng specific knowledge pertaining to racial/ethnic groups, which only operationalizes select asp ects of a broader concept of culturally sensitive health care. There is a need for reliable patient-centered culturally sensitive health care assessments to evaluate training programs to promote such care and to help facilitate medical students, physicians, a nd other health care providers self-assessment of levels of cultural sensitivity in their interactions with th eir culturally diverse patients. Such assessment data will have implications for improving the quality of health care experienced by culturally diverse patients, particularly those who are racial/ethnic minorities.

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25 Development of the Pilot Tucker-C ulturally Sensitive Health Care Inventory (CSCHI)-Provider Form To address the lim itations of existing culturally competent health care assessments, Tucker and her research team developed the pilot Tucker Culturally Sensitive Health Care Inventory (TCSHCI) Provider Form, which is based upon a patient -centered definition of health care, in accordance with Tuckers Patient Centered Culturally Sensitive Health Care Model (Tucker, Herman, et al., in press). The items of the pilo t T-CSHCI-Provider Form were identified in focus groups by low-income, primary care clinic patients (i.e., African American, Latino/Hispanic, and non-Hispanic White patients) as being characteristic of culturally sensitiv e health care in accord with the Grounded Theory of Qualitative Research (Morrow & Smith, 2000). These items consist of provider behaviors and attitudes and th us these items address the identity-orientation dimension of quality of care, as defined in the Qu ality of Care Theory (Wilde, Starrin, Larsson, & Larsson, 1993). The Tucker Patient-Centered Cultura lly Sensitive Health Care Model Tuckers lite rature-based Patient-Centered Culturally Sensitive Health Care Model (Tucker, Herman, et al., in press) postulates that (a) patient-centered culturally sensitive health care, as indicated by provider behaviors and at titudes as well as by clinic environmental characteristics and policies, influences patients perceived levels of provider cultural sensitivity and interpersonal controlboth of which impact patients level of engagement in a health promoting lifestyle and level of health care satisfac tion, (b) the latter influe nces patients level of treatment adherence, and (c) both level of trea tment adherence and level of engagement in a health promoting lifestyle directly influence health outcomes/statuses. A recent pilot test of Tuckers Patient Cent ered Culturally Sensitiv e Health Care Model separately with small samples of African American and non-Hispanic White primary care

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26 patients with hypertension and/or related chronic health problems (e.g., diabetes) provided some empirical support for this model. It is noteworth y that significant findings from a test of this model differed to some degree by race. Specifically, Tucker and her research team found that (a) among African American patients, perceived levels of culturally sensitive provider behaviors had significant positive associations with levels of engagement in health promoting behaviors and levels of patient satisfaction, which in turn ha d significant positive associations with glucose levels and levels of dietary adherence, respec tively; and (b) among non-Hispanic White patients, perceived levels of culturally sensitive provide r behaviors had significant positive associations with levels of engagement in health promo ting lifestyle behaviors and levels of patient satisfaction, which were significan tly associated with these pa tients levels of medication adherence, which in turn had a si gnificant positive association with their systolic blood pressure (Tucker, Herman, et al., in press). The Grounded Theory of Qualitative Research The Grounded Theory o f Qualitative Research (Morrow & Smith, 2000) supports qualitative analyses as an effective modality for studying the health care needs of culturally diverse patients. The items for the pilot T-CSHC I-Provider Form were identified in focus groups of mostly low-income African American, Hisp anic/Latino, and non-Hispanic White primary care patients at community-based health care clinics/ centers. These patients were asked in these groups to identify provider behaviors and attitudes, and clinic environmen tal characteristics and policies that enabled them to feel trusting of, co mfortable with, and respect ed by their health care providers, and that enabled them to experience a sense of belonging in their health care. The focus group sessions were recorded, transcribed, and analyzed using the constant comparative method that is consistent with the Grounded Theory of Qualitative Research.

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27 The Grounded Theory of Qualitative Research advocates for an inductive approach to research, in that (a) investigators and participan ts interact with each other as the researchers immerse themselves into the participants world, (b) participants often serve as co-researchers especially in interpreting and analyzing the data and determining the implications of the research findings, and (c) a theory emerges from the data itself through an emphasis on participant views rather than researcher views (Morrow & Sm ith, 2000; Strauss & Corbin, 1990). Specifically, data is collected from participants via such procedures as focus groups and then this data undergoes open, axial, and selective codings in order to identify cate gories, relationships between categories, and overall core themes. The results of these procedur es are then subjected to a constant comparative analysis against the ex tant data as new data continue to emerge. Once no new properties continue to emerge, the core ca tegory can be considered to be saturated. Rigor is determined by coherence of the data, st ructural corroboration via internal category consistency, comparisons to the new data for goodness of fit, and ecolo gical applicability as judged by the audience (Morrow & Smith, 2000; Strauss & Corbin, 1990). The Quality of Care Theory The Quality of Care Theory (W ilde, Starri n, Larsson & Larsson, 1993) provides theoretical support for patient-centered culturall y sensitive health care, and thus for inventories such as the pilot T-CSHCI-Provider Form to assess its occurrence. Overall, this theory asserts that there are four dimensions of health care. The first two of these dimensions have been traditionally recognized and valued, and they have been de scribed as resembling th e traditional medical model of care. These dimensions are (a) the me dical-technical competence of the caregivers and (b) the physical-technical conditions of the care organization. The ot her two dimensions that help define quality of care have been described as resembling the psychosomatic model of carea model more contemporary than the traditional me dical model and that recognizes the value of

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28 psychological and emotional aspects of health and illness. These second two dimensions are (a) the identity-orientation in the attitudes and actions of caregivers (i.e., show ing interest in treating the patient with respect, not treating the patient as one of the crowd, valu ing a patient-caregiver collaboration/partnership, and encouraging and s upporting patient involvement in the health-care delivery process) and (b) the socio-cultural atmo sphere of the care organization (i.e., resembling home, enabling comfort, allowing for so cializing and space to be alone). The pilot T-CSHCI aims to evaluate the identi ty-orientation dimension of quality of care. Specifically, the items constituting the pilot T-CSHCI-Provider Form identify health care provider behaviors and attitudes that African American, Latino/Hispanic, and non-Hispanic White patients identified in gender and race concordant focu s groups as making them feel trusting of, comfortable with, and respected by their providers (Tucke r, Herman, et al., 2003). Preliminary reliability coefficients for the pilo t T-CSHCI-Provider Form were calculated using a convenience sample of 22 providers. Its internal consistency was .98; its split-half reliability was .97; and its five-month test-retest reliability wa s .70. Given that these reliability findings are based on a small convenience sample, these data were viewed only as supportive of further development of the pilot T-CSHCI-Provider Form. Literature and Research Evidence Supporting the Need for Patient-Centered Culturally Sensitive Health Care Evidence of the Need for Patient-Centered Cu lturally Sens itive Health Care from the Health Disparities Literature The United States public health care system continues to be challenged by perpetuated racial/ethnic, socio-economic, and linguistic health care disparities (Agency for Healthcare Research and Quality [AHRQ], 2003; United Stat es of Health and Human Services [HHS], 2002). The term health disparities refers to existing differences among specific groups with regard to adverse health conditi ons, including differences in the incidence, prevalence, mortality,

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29 and burden of diseases (National Institutes of Health, 1999). The Unequal Treatment Report from the Institute of Medicine (IOM) defined disparities as differences in measures of health that remain after accounting for patients needs, preferences, and heal th care availability (Smedley, Smith, & Nelson, 2002). Evidence of existing health disparities is abundant. The 2004 National Health Disparities Report (AHRQ, 2005) states that when compared with non-Hispanic White Americans, African American patients receive poorer quality of health care on about two thirds of the reports health care quality measures, and Latino/Hispanic patients receive poorer quality of care for about half of the same health care quality measures (Moy, Dayton, & Clancy, 2005). In addition, according to a report from the National Institutes of H ealth, African Americans, Hispanics, and Native Americans as compared to non-Hispanic White Americans experience higher proportions of mortality and morbidity in at least seven area s: (1) cancer, (2) HIV/AIDS, (3) diabetes, (4) cardiovascular disease, (5) infant mortality and immunizations, (6) hype rtension, and (7) renal disease (DHHS, 2001). Evidence of the Need for Patient-Centered Cu lturally Sens itive Health Care from the Health Care Disparities Literature Health care disparities are de fined as differences in the tr eatment of individuals from different groups when these differences are not justified by clinical appropriateness or by patient preference (IOM, 2003). An increasingly large, c onsistent body of research indicates that race/ethnicity and income-related disparities in h ealth care quality still exist in the U.S. and are a significant contributor to the existing health dispar ities. For example, compared to majority and higher income patients, racial/eth nic minorities are less likely to receive even routine medical procedures, experience a lower quality of health services (Geiger, 2001; Lillie-Blanton et al., 2001; Rutledge, 2001), and experience lower health care satisfaction and poorer health status

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30 (Andrulis, 2003). In addition, studies of the Ve terans Health Administration, Medicare, and single health plans clearly demonstrate that ra cial/ethnic minority Americans have different experiences in the health care system as compar ed with racial/ethnic majority patients, even when they have similar medical conditions a nd medical coverage (Coni gliario et al., 2000; Oddone et al., 2002; Robbins et al ., 1998; Schneider et al., 2002; and Smedley et al., 2002). Factors associated with health care disparities include socio-economic status (SES) (Cohen, Farley, & Mason, 2003), insurance coverage disease stage/severi ty, access to health care services (Stewart & Napoles-Springer, 2003), treatment preferences, environmental hazards in homes and neighborhoods, the scarcity of eff ective disease prevention programs tailored to the needs of specific communities (Satcher, 2001), and shortages of health professionals in urban areas where minority populations are high (Rosenblatt, Andrilla Curtin, & Hart, 2006). When these factors are controlled for, existing health care disparities are usua lly reduced but are not eliminated. This reality suggests that other fact ors, such as social/envi ronmental health care factors (e.g., the interpersonal aspe cts of the health care environment) significantly contribute to the existing health care disparit ies. Evidence supporting this conclusion comes from research studies that link race/ethnicity-related health care disparities with (a) racial/ethnic minority patients mistrust of the health care system (Coleman-Miller, 2000) and perceived discrimination in the health care they received (Krieger, 1999), (b) poor co mmunication between racial/ethnic minority patients and their providers (Vermeire et al., 2001; Woloshin et al., 1995), and (c) lack of cultural sensitivity and cultural competence on the part of physicians and other health care workers (Rutledge et al., 2001; Geiger 2001; Canto, Allison, & Kiefe, 2000). Indeed, culturally insensitive health care sy stems represent a major contributor to the health disparities problem in the U.S. (Ameri can College of Physicians, 2004). According to

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31 Brach and Fraser (2002), the gr owing diversity among patients in this country increases the likelihood that cultural differences between patients and providers will lead to diagnostic errors, missed opportunities for screening, failure to take into account differing responses to medication, harmful drug interactions resulting from simultaneous use of conventional and traditional folk medications, and inadequate patient adherence to prescriptions, self-car e, and follow-up visits recommended by their providers. As a result, in recent years there have been increasing national calls for American health care providers to provi de patient-centered cultu rally sensitive health care, which could improve the quality of health care in the U.S. and could reduce the costly health disparities between majority and minor ity American patients (American College of Physicians, 2004; Betancourt, Green, Carrill o, & Ananeh-Firempong, 2003; Betancourt, Green, Carrillo, & Park, 2005; Genao, Busse y-Jones, Brady, Branch, & Corbie-Smith, 2003; Institute of Medicine, 2002). The sources of such national calls include two landmark reportsCrossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) and Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (Smedley, Stith, & Nelson, 2002). These calls for culturally competent and cultu rally sensitive health care are supported by literature such as the concep tual model proposed by Brach a nd Fraser (2002). This model provides a path from cultural competence techni ques to reduced health care disparities. Specifically, Brach and Frasers model indicates that interventions such as the use of interpreter services, racially or linguisti cally concordant clinicians and staff, and culturally competent education and training have the potential of increasi ng the knowledge of epidemiology, health beliefs, and effective treatments relevant in providing health care to racial/ethnic minority patients, which in turn can improve the communi cation and trust between health care providers and these patients. Brach and Frasers mode l indicates that impr oved patient-provider

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32 communication ultimately results in improved h ealth outcomes, increased health care access and quality, and improved health outcomes among racial /ethnic minority groups. It is noteworthy that Brach and Frasers model has not been empirically tested, which speaks to the current lack of empirical research and assessments to evidence the links between either culturally competent or culturally sensitive health care and reduced health care and health disparities. Evidence of the Need for Patient-Centered Cu lturally Sens itive Health Care from the Demographic Characteristics of the U.S. Medic al Students and Physicians in the U.S. According to the American Association of Medical Colleges (AAMC, 2007), among the 69,167 medical students who were enrolled in US medical schools in the year 2006, 63.0% identified as non-Hispanic White whereas only 20.9% identified as Asian, 7.6% as Hispanic (Mexican American, Puerto-Rican, Cuban, etc.), 7.2% as Black, 0.8% as Native American, 0.2% as Native Hawaiian, 1.4% as foreign/interna tional, and 1.86% identified as unknown. This race/ethnicity distribution among physicians mirrors the statistics for medical students. According to the American Medical Association, the race/ethnicity related statistics for the year 2004 among the physicians in this country were as follows: 47.8% non-Hispanic White, 8.3% Asian American, 3.2% Hispanic, 2.3% African American, .06% American Native, and 36% unknown race/ethnicity (AMA, 2007). Clearly, non-Hispanic Whites are the best represented racial group among medical stude nts and physicians in this country, while patients are increasingly becoming more r acially/ ethnically diverse (US Bureau of Census, 2002). This racial/ethnic homogeneity of tomorrows physician population in the context of an increasingly diverse U.S. genera l population and patient populati on is associated with medical students feeling unprepared to provide health care services to cultu rally diverse patients (Weissman et al., 2005). This state of affairs ma y contribute to the racial /ethnic disparities in access to care and in health care quality that ha ve a disproportionately negative impact on the

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33 health status of minority and lo w income patients (Grumbach et al., 2003). Support for this view comes from research findings i ndicating that racial/e thnic minority physicians as compared with majority physicians are more likely to see minority patients and to choose to practice in urban and underserved areas, including those areas with the greater concentration of underprivileged patients (Mertz and Grumbach, 2001). There is also some evidence that many minority patients prefer to receive care from provi ders of the same race/ethnicity and are more satisfied with care provided by providers of concordant race-ethnicity (Saha et al, 2000). A qualitative study from Nunez-Smith et al (2007) indicated that a providers race/ethnicity can play a significant role in the medical encounter in an overt or covert manner. The twenty-five African American providers who pa rticipated in this qu alitative study felt that race permeated their experience in the workplace, shaped their interpersonal interactions, and defined their institutional climate. These African American providers also reported that their responses to racism at work ranged from minimiza tion to confrontation and that the health care workplace was often silent on the issues of race. Given these findings, it is not surprising that Betancourt and Reid (2007) stated that one of the possible consequen ces of mostly White providers delivering health care to increasingly dive rse patients is that these providers are likely to unwillingly stereotype or act in a prejud icial manner toward their minority patients. Very limited research literature is currently av ailable regarding the cu ltural sensitivity or cultural competency of foreign/in ternational medical students and/or physicians in this country. A secondary data analysis study by Howard et al (2006) indicated that international medical school graduates as compared w ith US medical school graduates treated more African-American elders and more patients who ha d less education, lower incomes, less insurance, were in poorer health, and who lived in rural ar eas. At the same time, the elde rly non-Hispanic White (but not

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34 African American) patie nts raised communication, cultural co mpetency, and ageism concerns related to their health care interactions w ith their international medical school graduate physicians. Another significant demographic variable that has been associated with quality of care is provider gender. The gender distribution among medical students during the year 2006 was 48.7% females and 51.3% males (AAMC, 2007). Th e gender distribution among physicians in the U.S. during the year 2004 was 73.2% males and 26.6% females (AMA, 2007). A number of studies provide evidence that significant differences exist between male and female health care providers regarding their patterns of interaction with their patients. For example, there is research evidence to demonstrate that fema le providers as compared with male providers are more likely to take more time with their patients, to use more positive talk, to be emotionally focused, to use more partnership building tec hniques, and to use more posit ive nonverbal communication in their interactions with patient s (Hall & Roter, 2002; Roter, Hall, & Aoki, 2002). In addition, female providers seem to communicate higher degrees of empathy to their patients compared with male providers (Bylund & Makoul, 2002). However, research studies revealed no significant differences between male and female providers regarding the amount of biomedical information discussed and the qua lity of information provided to patients (Hall & Roter, 2002; Roter, Hall, & Aoki, 2002). Significant findings regarding the combined in fluence of race/ethnicity and gender on levels of cultural competence in health care were recently revealed in a study conducted by Lee and Coulehan (2006). These authors found that upon entry into medical school, women and minority group medical students sc ored significantly higher than males and non-Hispanic White students on the Quick Discrimination Index (QDI), a measure of racial diversity and gender

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35 equity attitudes. In addition, over a four-year period, minority medical students who participated in this study showed a signifi cant increase in their awareness of racial diversity and gender equity as measured by the QDI, while non-Hispanic White male medical student participants experienced a non-significant dec line in their QDI scores. Unfort unately, these findings speak to the current need for medical schools to implemen t effective patient-centered culturally sensitive health care training curricula that would address the learning needs of all medical students, and particularly the needs of White and male medical students. Findings demonstrating gender-re lated and race/ethnicity-relate d differences in health care behaviors of providers are noteworthy because th ey could produce corresponding differences in patients behaviors directed back at them. For example, a provider smiling is more likely to receive smiles back from patients (Bylund & Makoul, 2002). Clearly, high-quality medical training is needed that provides racially/ethnically diverse me dical students opportunities to assess their level of engagement in specific behaviors and attitudes that constitute patientcentered culturally sensitive health care. The Potential Usefulness of Patient-Cent ered Culturally Sensitive Health Care Assessments in Research to Reduce Disparities Currently there is a la ck of adequate research on health and health care disparities among m embers of racial/ethnic minority groups (AHRQ, 2004) despite that this type of research is necessary for generating profe ssional guidelines for the provis ion of quality health care to different minority groups (U.S. Surgeon General, 2001). According to Sue and Sue (2003), factors associated with the existing scarcity of research studies focused on the needs of racial/ethnic minority patients include (a) lack of sufficient research funding necessary to conduct such research, (b) lack of readily avai lable cross-culturally valid assessments and diagnostic procedures (e.g., measures that take into account cultural differences in symptom

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36 presentation), (c) lack of an adequate amount of knowledge and theo ry regarding culturally sensitive health care, and (d) lack of an agreement among res earchers regarding disparities research issues. A lack of valid and reliable assessment measures of culturally sensitive health care has also been identified as a factor associated with the current scarcity of research on culturally sensitive and culturally competent health care (Sue & Dhindsa, 2006). According to the conceptual framework pr ovided by Kilbourne, Switzer, Hyman, CrowleyMatoka, & Fine (2006), research to reduce health and health car e disparities in cludes three different types of approaches: (a) detection of health disparities, which involves identifying vulnerable populations, and developing valid measures for studying both; (b) understanding why disparities exist, which involves identifying factors that explain ga ps in health and health care between vulnerable and less vulnerable groups; and (c) reducing or eliminating the health care disparities through the development, implementa tion, and evaluation of intervention programs. The first type of research approach is the mo st common one, and yet it is the second and third approaches that can contribute in a meaningful manner to the reduction of existing health care and health disparities. The research literature suggests the existence of three determinants of health care and health disparities: (a) patient factors such as beliefs and preferences, cultural and familial context, education and resour ces, and biology; (b) provider factors such as knowledge and attitudes, competing demands, a nd biases; and (c) clinical enc ounter factors such as provider communication and culturally competent and/or cu lturally sensitive health care communication. Regarding the provider factors, there is some empirical evidence that links patient health outcomes/statuses to providers conscious or unconscious biases. An example of such research is a highly publicized research study by Schulman et al. (1999) which found that physicians were

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37 less likely to refer African Amer ican and female patients for cardiac catheterization as compared with male and non-Hispanic White patients, re spectively. In addition, it has been found that providers are less likely to schedule a lung cancer surgery for elderly African Americans versus non-Hispanic Whites even after controlling fo r socio-economic factors, access to care, and clinical severity (Bach, Cramer, & Warren, 1999). Regarding the clinical encounter factors me ntioned above, African American patients may feel less engaged with their care or less included in the decision-making process compared with non-Hispanic White patients, which in turn can lead to mistrust in treatment procedures (Burgess, Fu, & van Ryn, 2004). Lack of engageme nt in treatment among racial/ethnic minority patients and subsequent inadequate health care have been associated with provider communication style and with provider cultural sens itivity and/or provider cultural competence. For example, in a study that analyzed taped conversations between providers and patients, providers were more likely to communicate in a verbally dominant mann er with their African American patients compared with their non-Hisp anic White patients (Johnson, Roter, Powe, & Cooper, 2004). Providers may also fail to consider their patie nts culture within the clinical encounter and subsequently fail to provide culturally sensitive h ealth care to their cultur ally diverse patients or they may treat their racial/ethnic minority patients unfairly (Freimuth & Quinn, 2004). For example, the Commonwealth Fund (2001) conducted a telephone survey of close to 7,000 people to inquire whether African American, Hispan ic, Asian American, and non-Hispanic White patients who had had a medical visit in the last two years had trouble understanding their doctor, whether they felt that their doctor did not listen, and if they had medical questions they were afraid to ask. Survey results revealed that 19% of all patients experienced one or more of these

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38 problems; however, 16% non-Hispanic White patients reported experiencing such difficulties, compared with 23% of the African American patie nts, 33% of the Hispanic patients, and 27% of the Asian American patients. Moreover, findi ngs from another survey (Kaiser Family Foundation, 2006) included that si gnificant mistrust of the health care system exists among racial/ethnic minority patients and highlighted the importance of cultura lly sensitive provider communication to overcome such mistrust. Amo ng the patients who responded to this later survey, 36% of Hispanics and 35% of African Americans as compared with 15% of nonHispanic White patients felt that they had been tr eated unfairly in the heal th care system in the past. The Hispanic and African American patien t participants in this study also reported expectations that they will continue to be treated unfairly in the future. In sum, improving patient-provider communica tion through culturally sensitive health care behaviors by providers has been identified as a key factor for impr oving patient trust and ultimately for helping to reduce health care disparities (Braveman, 2003). Kilbourne, Switzer, Hyman, Crowley-Matoka, & Fine (2006) asserted that developing, implementing, and assessing effective provider training progr ams to promote engaging in health care behaviors represents the focus of the most important and yet the most challenging type of disparities research. Evaluation is an important component of an intervention process (Kilbourne, Switzer, Hyman, Crowley-Matoka, & Fine, 2006). Conducti ng health care quality research requires assessments of patient-centered culturally sensitive health caresuch as the T-CSHCI-Provider Formthat are constructed based on patient (rat her than expert) definitions of culturally sensitive health care, that utilize a clear opera tional definition of cultura l sensitivity, and that contain items that reflect the culture-specific health care pref erences among culturally diverse patients. Such assessments can be used to (a) coll ect data from providers regarding their level of

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39 performance in providing patient-centered cultu rally sensitive health care, (b) examine the association between health care providers self-reported leve ls of cultural sensitivity and measurable health outcomes, and (c) evaluate th e effectiveness of patie nt-centered culturally sensitive health care training programs by assessi ng and comparing preand post-training levels of providers self-reported pati ent-centered culturally sensitive health care behaviors. The Potential Usefulness of Patient-Cent ered Culturally Sensitive Health Care Assessments in Medical Training Efforts to Reduce Disparities The Institute of Medicine (IOM, 2002 ), the Society of Teachers of Family Medicine (STFM, 2005), and the Liaison Committee on Medica l Education (2005) have all emphasized the need for patient-centered culturally sensitive he alth care medical traini ng and practice with the goal of improving the quality of care and ultimately the elimination of health care disparities in this country. Addressing this ne ed requires valid and reliable instruments for assessing the effectiveness of thes e training programs. It is noteworthy that (a) medical students repr esent tomorrows professionals in the field of medicinethose who will provide health care to an increasingly diverse U.S. population and (b) despite the increased focus on provider culturally competent health care education programs, providers sometimes fail to engage in behavi ors and attitudes that patients experience as culturally sensitive (Paterson, 2001). It is especially noteworthy that medical students as well as more experienced physicians often feel unprepared to provide culturally sensitive health care to their culturally diverse patients (Weisman et al., 2005). Assessment represents an important component of medical school training programs (Rapp, 2006). The Liaison Committee for Medical Education (LCME) has included standards mandating that medical schools demonstrate th e achievement of learning objectives (e.g., students ability to successfully engage in cultur ally sensitive health care behaviors and attitudes)

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40 and that cultural competence and cultural sens itivity curricula include assessment of training outcomes (LCME, 2004). Valid and reliable assessments are indeed needed to evaluate the effectiveness of culturally se nsitive and culturally compet ent health care curricula. The criteria that can be used to establish the effectiveness of cu lturally competent and culturally sensitive training programs include (a) trainee mastery of culturally competent knowledge, attitudes, and skills; (b) successful application of culturally competent knowledge, attitudes, and skills in a culturally sensitive mann er by trainees; and (c) patient satisfaction and ultimately improved patient health outcomes (Bet ancourt, 2003). An increasing body of research literature uses these effectiveness criteria to ev aluate cultural competence and cultural sensitivity training programs in medical schools. Importantly, some of these crite ria are more commonly used than others (Betancourt, 2003). For exampl e, there are numerous modalities to determine whether students are acquiring th ese attitudes, knowle dge, and skills (e.g., preand posttests, surveying, structured interviewing, presentation of clinical cases, videotaped/audiotaped clinical encounters, etc). At the same ti me, there are fewer ways to dete rmine if students actually employ these attitudes, knowledge, and skills in a culturally sensitive manne r (e.g., medical record review, qualitative physician and patient interviews, or videot aped/ audiotaped clinical encounters). There are even fewer modalities for assessing the impact of cultural sensitivity and cultural competence training on health outcomes and quality of care (e .g., measurement of patient and provider satisfaction, an d medical record review). According to the National Research Council (1 996), the functions of assessment include (a) providing a description of students' level of attainment upon completion of an activity, module, or course, (b) providing diagnostic feedback to student s and instructors at periodic intervals (e.g., medical students can receive periodic feed-back regarding their levels of patient-

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41 centered culturally sensitive health care), (c) pr oviding instructors with feed-back regarding the effectiveness of a course in patient-centered culturally sensitive health care, and (d) building student/faculty insight a nd understandings about their own learning/teaching. The most commonly used assessment strategies to evaluate the effectiveness of training programs to promote culturally competent and cult urally sensitive health care are: (a) selfassessment by medical students or providers, (b ) assessment of students by faculty, and (c) patient assessment of their providers. Research findings suggest that self-assessments are the most effective and widely used methods of asse ssment. For example, a literature review of the existing cultural competence training in medi cal schools (AHRQ, 2004) indicates that most studies used provider self-assessment to eval uate the effectiveness of cultural competence medical curriculum. Self-assessments involve a self-judgment and making decisions about the next steps (Boud, 1995). Self-assessments present several advantages among which are the fo llowing: (a) they do not represent an end in itself and have to be followed by action (Boud, 1995); (b) they enhance ones motivation to improve his or her own knowledge, communication, and performance (Gordon, 1991); (c) they can be used to serve different functions such as competency assessment or professional growth assessment (Brown, Bull, & Pendlebury, 1997); (d) they provide an opportunity for self-evaluation without labeling ones performance due to the fact that an individual is compared with him or herself ove r time rather than with other individuals (Mason, 2001); (e) they foster reflection upon ones work due to the fact that the same person conducts the assessment and is being assessed (Evans, Mc Kenna, & Oliver, 2002); (f) they are likely to be more accurate than ratings by others due to a redu ced social desirability effect (Evans, McKenna, & Oliver, 2002); (g) they offer th e opportunity for trainees and/or students to set standards for

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42 themselves, which is likely to increase their motiv ation to adhere to these self-defined standards (Brown & Glasner, 1999); and (h) they allow trainers to function as consultants and/or moderators rather than examiners, which can he lp decrease trainees de fensiveness in their interactions with their trainers (Brown & Glasner, 1999). In sum, assessments are most valuable when they not only diagnose students level of attainment but also enhance furt her learning and skills development, as well as help promote the application of health care behaviors that cultur ally diverse patients pe rceive to be culturally sensitive. Assessments that focus on knowledge and skills reflect the tr aditional Western model that values knowledge of facts and mastery of cl inical skills over patient focused interactions, communication skills, and proce sses of self-reflection and self -critique (Tervalon & MurrayGarcia, 1998). Unfortunately, a recent study of professional competence found that few assessments are successful at measuring comp etencies other than core knowledge, problem solving skills, and basic clin ical skills (Epstein & Hunde rt, 2002). Unlike these existing assessments of culturally competent health care, the T-CSHCI-Provider Form focuses on assessing health care behaviors and attitudes that culturally diverse patients perceive to be culturally sensitive and has the potential to promote further learning by medical students. The need for and benefits of valid and reliab le assessments of patient-centered culturally sensitive health care previously outlined in this chapter provide support for further validation of the pilot T-CSHCI-Provider Form. T hus, the specific goals of this study are as follows: (a) to determine the factor structure of the T-CSHC I-Provider Form using a sample of medical students, (b) to determine the internal consistenc y, split-half reliability, a nd construct validity of the T-CSHCI-Provider Form factors/subscales prev iously identified throu gh factor analytic procedures, and (c) to determine if there are differences in medical students self-ratings of their

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43 cultural sensitivity as measured by the T-CSHCI-P rovider Form scores in association with selected medical student demographic and cl inical experience variables (i.e., gender, race/ethnicity, U.S. citizenship status, fluency in a language other than E nglish, year of medical school, prior or current enrollment in a course on culturally competent/ sensitive health care, and self-reported level of experience with providing health care to racial/ethnic minority patients and low-income patients).

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44 CHAPTER 3 METHOD Participants Participants were 217 medical st udents recruited from the Univer sity of Florida College of Medicine, the University of Miam i Miller School of Medicine, th e University of South Florida College of Medicine, and the School of Medicine at the University of Louisville. The criteria for inclusion in this study were: (a) being 18 or older, (b) being able to provide informed consent, and (c) being a 3rd or 4th year medical student (this criteri on was set to ensure that medical student participants were involve d at a level of training that in volved actually seeing patients). A total of 1,199 medical students (598 in their third year and 601 in th eir fourth year) were invited to participate in the present study and 217 of them actually participat ed, resulting in a return rate of 18.1%. Participant ages ranged from 22 years to 56 years (mean = 26 years, standard deviation = 3.4 years). One hundred and two (47%) of the part icipants were males and 114 (53%) of them were females. The race/ethnicity distributi on among participants was as follows: 144 (66.4%) Non-Hispanic White, 34 (15.7%) Asian Ameri can, 19 (8.8%) Latino/Hispanic American, 12 (5.5%) African American, and 8 (3.7%) of anot her ethnic/racial group (e.g., Indian, Greek, Nigerian, etc.). These percents indicating the racial/ethnic distri bution among participants in this study are representative of the racial/ethnic distribution among me dical students in the U.S. Of all of the participants 199 (91.7%) reported being citizens of the United States, and 18 (8.3%) reported being citizens of a country other than the United States. Regarding languages that participants spoke, 120 (55.3%) re ported speaking English excl usively and 97 (44.7%) reported speaking at least one other language in addi tion to English. In addition, 101 (46.5%) of

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45 participants reported being in their third year of medical school and 115 (53%) of them reported being in their fourth year of studies (Table 3-1). Table 3-1 Participant demographic a nd medical education information Frequency Percent Gender Male Female 102 114 47.0% 53.0% Ethnicity African American Asian American Latino/Hispanic American Non-Hispanic White Other 12 34 19 144 8 5.5% 15.7% 8.8% 66.4% 3.7% Citizenship status US citizen Non-US citizen 199 18 91.7% 8.3% Languages spoken English only English + 120 97 55.3% 44.7% Year in medical school Third Fourth 101 115 46.5% 53.0% Taken a cultural sensitivity class Yes No 110 106 50.7% 48.8% Experience with racial minority patients Very low Low Average High Very high 1 0 65 69 80 0.5% 0% 30.0% 31.8% 36.9% Experience with low income patients Very low Low Average High Very high 0 0 35 78 103 0% 0% 16.1% 35.9% 47.5% Some percents do not add up to 100% because of missing data.

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46 Instruments The assessm ent battery (AB) was comprised of three assessment instruments: the pilot TCSHCI-Provider Form, the Servi ce Delivery and Practice subscal e of the Cultural Competence Self-Assessment Questionnaire (CCSAQ), and a De mographic and Clinical Experience Data Questionnaire. Each of these measures is described below. The Pilot Tucker-Culturally Sensitive Hea lth Care Inventory (T-CSHCI) Provider Form is a 141-item self-report measure of behaviors and attitudes that mostly low-income racially/ ethnically diverse primary care patients have indi cated to be important for promoting trust in their provider, comfort with their provider, and feeling respected by their provider. The instructions on the T-CSHCI-Provider Form ask pr oviders to self-rate their level of agreement that each listed behavior and attitude is characteristic of th emselves using a scale from 1 (strongly disagree) to 4 (strongly agree). Each T-CSHCI-Provider Form item can thus be scored 1, 2, 3, or 4 and the total score is computed adding the scorings from each item. Higher scores indicate higher levels of patient-centered culturall y sensitive health care be haviors and attitudes. Examples of items on the T-CSHCI-Provider Form are as follows: I am honest and direct with my patients, I chat with my patients durin g their visits, and I let my African American patients know about illnesses and diseases comm on among members of their race. The pilot TCSHCI-Provider Form items were constructed based on what mostly low-income African American, Hispanic/Latino, and nonHispanic White primary care pati ents identified in an earlier study as culturally sensitive hea lth care provider behaviors and attitudes (Tucker et al., 2003). The pilot T-CSHCI-Provider Form items are worded to reflect culturally sensitive behaviors and attitudes, with the exception of six items that are reversed items (i.e., they reflect culturally insensitive physician behaviors and attitudes) Consequently, higher T-CSHCI-Provider Form

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47 scores indicate higher levels of engagement in culturally sensitive health care behaviors and attitudes. The Service Delivery and Practice subscale of the Cultural Competence Self-Assessment Questionnaire-Service Provider Version. Th e Cultural Competence Self-Assessment Questionnaire (CCSAQ) (Mason, 1995) is designed to a ssess cultural competence training needs of mental health and human service professionals Specifically, it assesses the degree to which specific culturally competent behaviors routin ely occur. The CCSAQ is composed of six subscales that include Knowledge of Comm unity, Personal Involvement, Resources and Linkages, Staffing, Service Deliver y and Practice (for direct service staff only), Organizational Policies and Procedures, and Reaching Out to Communities. All of the CCSAQ subscales have yielded alpha coefficients of .80 or higher, except the Persona l Involvement subscale which yielded an alpha coefficient of .60 (Mason, 1995). No validity coefficients were reported by the author of the CCSAQ. The items of the CCSAQ were initially developed based on a literature review followed by focus group discussions to facilitate the development of subscale items. Focus group members were professionals from th e service disciplines of mental health, child welfare, special education, matern al and child health, and alcohol and drug treatment. The author constructed the CCSAQ items based upon commen ts from these recognized experts (Mason, 1995). For the purpose of the present study, only the Se rvice Delivery and Practice subscale of the CCSAQ was used. This subscale is composed of 19 items that measure knowledge of problems with mainstream diagnoses, awareness of the par ticular needs of cultura lly diverse populations, and self-perceived ability to formulate treatment plans in accord with patients cultural values. The instructions on the CCSAQ Service Delivery a nd Practice subscale are to answer each item

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48 by marking the response that most accu rately reflects ones own perceptions. Sample items include Are you familiar with the limitations of mainstream diagnostic tools as applied to people of color? and Do you disc uss racial/cultural issues with consumers in the treatment process? Each item is rated on a scale from 1 (not at all) to 4 (very well /often) and the subscale score is computed as the mean score for all the subscale items. Higher scores indicate higher cultural competence in the service delivery and practice of health care providers. A brief Demographic and Clinical Experi ence Data Questionnaire (DCE-DQ) was constructed by the principal inves tigator for the purpose of this study. It solicits the following information from research participants: gender, age, race/ethnicity, nationality status (i.e., American or other), fluency in a language other than English, year of medical school (i.e., year 3 or 4), prior or current enrollment in a culturall y competent/ sensitive health care course, and selfreported level of experiences with providing health care to racial/ethnic mi nority patients and to low income patients using a s cale from 1 (very low level) to 5 (very high level). Procedure Recruitment of Research Collaborators and Research Assistants. The data f or the present study was collected from the University of Florida College of Me dicine, the University of Miami Miller School of Medicine, the Univers ity of South Florida College of Medicine, and the University of Louisville School of Medicine. Prior to the data collect ion procedures, approval was obtained from the University of Florida In stitutional Review Board (UF IRB) for conducting this study. Approval from the Institutional Review Board (IRB) of one of the participating universities (i.e., University of Louisville) was also required in order to collect data from the medical school of this institution. At a first step of the data collection, th ree medical school faculty members and/or administrators and one medical st udent were recruited to particip ate in this study. These medical

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49 school faculty and administrator collaborators an d medical student res earch assistant were chosen based on their self-stated interest in i ssues related to culturally competent/ culturally sensitive health care training and/or their associ ation with the target me dical student body based on their position title (e.g., Dean of Student Affairs, etc.). The ro le of the medical school faculty and administrator collaborators a nd medical student research assist ant was to forward to medical students at their respective sc hools via medical student e-mail list-serves an e-mail message inviting 3rd and 4th year medical students to par ticipate in the present study. The method for recruiting the medical school faculty and administrator collaborators and the medical student research as sistant involved sending them email correspondence. This e-mail correspondence contained information regardi ng the goals of the proposed study, research procedures, Institutional Review Board approval, the role of study collaborators in participant recruitment, participant inclusi on criteria, participant payment information, and the approximate length of time required for medical student participants to comple te the online AB (see Appendix A for a sample e-mail message). The medical sch ool faculty collaborators and medical student research assistant were also notified of the two-month time frame for completing the data collection for this study. In addi tion to the e-mail correspondence with the medical faculty and administrator collaborators and the medical research assistant, the principal investigators met in person with the medical school facu lty research collaborator located at the same university as the investigators for the present study. The purpose of this meeting was to identify ways to simplify the methods for participant recruitment. This coll aborator also helped to identify medical school research sites that would provide a fairly diverse population of medical st udents, thus increasing the likelihood of recruiting a divers e sample of study participants.

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50 Recruitment of Medical Student Participants. The medical school faculty research collaborators and the medical stude nt research assistant who agreed to help with recruitment of study participants were sent an e-mail message to be forwarded to the 3rd and 4th year medical student list-serves at their respective medical schools. This e-mail message was addressed to medical students and contained the following in formation: (a) the pur pose of the study, (b) details regarding the tasks that participation in this study involves, (c) the amount of time required for completing the online assessment batt ery [AB], (d) potential ri sks and benefits of being a research participant, (e) the amount paid to each pa rticipant for their research participation, and (g) informa tion regarding the ways that th e anonymity and confidentiality of participants answers would be protected. This me ssage also provided the web site address where participants could access the AB to be completed online (see Appendix B). Medical students interested in participating in this study were directed to access the online web site containing the assessment battery (AB) Once medical students accessed the web link, they first saw the online Informed Consent Form that briefly describes th e goals of the study, its benefits and risks, the monetary compensation fo r being a research part icipant (i.e., $10), the procedures to protect the anonymity and confid entiality of participants answers, the time required to complete the AB (i.e., approximately 20 minutes), and the principal investigators contact information (see Appendix C). Medical stude nts were asked to indicate their consent to participate in this study by checking a box at th e bottom of the online Informed Consent Form. After indicating their agreement to participate, me dical student participants were able to access and complete the AB. Due to budget restrictions, no more than 200 medi cal student participants could be offered the $10 payment for being research participants. Participants recruited at the University of

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51 Louisville, who were recruited to participate in this study at a late r point compared with the other participants, were invited and agreed to participate in the pres ent study without the $10 monetary incentive. Participants who received payment for their pa rticipation were asked to access a separate web page asking them to provide an e-mail addr ess where they wanted to be contacted with information regarding their payment. This web page also briefly stated that participants e-mail addresses were saved in a file completely separate from the file that contained their answers to the AB and that their answers could not be conne cted to their e-mail addresses (see Appendix D for a copy of this web page). The anonymity and confidentiality of part icipants answers were protected through storing these answers in a fi le which did not contain any identifiable information and which was completely independent from the file containing participants e-mail addresses. In addition, only the principal invest igators had access to both participants answers and their e-mail addresses. No later than three days after each partic ipant completed the online AB, one of the principal investigators sent each participant an e-mail message with detailed information regarding the payment process and with the form W-9 required for payment purposes attached to the message. The content of this e-mail message is provided in Appendix E. Medical student participants were instructed to return their completed W-9 forms by mail or fax them to the person in charge of processing participant payments at the university where the principal investigators were based. Participants who co mpleted the AB and the W-9 Form were mailed a $10 check within 6-8 weeks. In addition, particip ants were provided the contact information of the principal investigators, and they were invited to contact th e principal investigators in case

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52 they had questions, suggestions, or concerns. Th e data collection proce ss took approximately two months to complete.

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53 CHAPTER 4 RESULTS This chapter is organ ized in three parts, each of which presents the results of the statistical analyses conducted to address ea ch of the three research ques tions set forth in this study. Descriptive data for the variables of interest in this study and the results of preliminary analyses (e.g., correlations between the variables of intere st) are also presented. Al l statistical analyses were performed using the Statistical Package for Social Science (SPSS). First Research Question The first Research Ques tion was as follows: What are the dimensions of factor structures that constitute patient-centered culturally se nsitive health care as assessed by the T-CSHCIProvider Form when this form is used with a sa mple of medical students who see patients? To examine this research question, an exploratory factor analysis (EFA) with pr incipal axis factors (PAF) extraction and with both Varimax and Promax rotations was conducted using the Statistical Package for Social Sc iences (SPSS) Program. A factor an alysis brings intercorrelated variables together under more general, underlying variable s. The goal of factor analysis procedures is to explain the variance in the observed variables in terms of underlying latent factors. The steps recommended by Kahn (2006) fo r conducting a factor analysis were used in this study and an iterative approach to conduc ting factor analysis was adopted. Specifically, several separate factor solutions were first expl ored to identify the best combination of items with an identifiable underlying fact or structure. Once the best fact or solution was identified, the analyses were repeated with the specified number of factors. This type of iterative approach to exploratory factor analysis incr eases the likelihood of finding inte rpretable factor results (Kahn, 2006).

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54 As a first step, descriptive statistics were obtained for the T-CSHCI-Provider Form items. The normal distribution of the data was tested using the total score for the T-CSHCI-Provider Form, which was computed as the mean score for all the items of this assessment instrument. The skeweness coefficient was .105, the kurto sis coefficient was -1.27, and the KolmogorovSmirnov coefficient Z was 1.47, p < .05, indicating that the data slightly deviated from a normal distribution. The data factorability was tested using the Bartletts test of sphericity which was significant (p < .0001), suggesting that the data was suitable for fact or analysis. The factorability of data was also tested using Pearson correlations between the T-CSHCI-Provider Form items. The correlation matrix showed low to moderate correlation coefficients (i.e., the coefficient absolute values ranged from .02 to .63) sugge sting that a factor analysis would produce acceptable factor loadings for some of the TCSHCI-Provider Form items. Due to the large volume of correlations between the T-CSHCI-Provi der Form items to be analyzed (i.e., 141 by 141 correlation coefficients), the correlation matr ix could not be reproduced in this text. A principal axis factors (PAF) analysis wa s chosen in this study, in accord with recommendations from Costello & Osborne (2005) for data that is not no rmally distributed. The factor communalities (i.e., the es timates of the variance in each variable accounted for by the factor solution) were higher than .40, which is the commonly accepted minimum for communality values in the moderate range. In itial communalities ra nged from .96 to 1.00 and extraction communalities ranged from .58 to .93, indicating that all of the 141 T-CSHCIProvider Form items fit well the factor solutions that were obtained. The next step in the factor analysis was to use a scree plot to determine the number of factors to be retained, and the fiveor six-factor solutions that met the Guttman-Kaiser rule for

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55 factor retention. According to this rule, the items with an eingenvalue greater than 1 were retained (see Figure 4-1). The eingenvalues and the percentages of varian ce explained by each factor in the initial (unrotated) factor solutions are summarized in Table 4-2. Factor Number139 136 133130 127 124121 118115 112 109106 103 10097 9491 88 8582 7976 73 7067 64 6158 5552494643 40 3734 3128252219 16 13 10 741 Eigenvalue50 40 30 20 10 0 Figure 4-1 Scree plot for the T-CSHCI-Provider Form items Table 4-2 Eingenvalues and Variance Explai ned in the Initial Factor Solutions Five-Factor Solution Six-Factor Solution Eingenvalues Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 49.039 5.598 4.241 4.153 3.174 49.039 5.598 4.241 4.153 3.174 2.932 Percentage of Variance Explained Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 Cumulative Variance 34.61 34.61 2.81 2.75 2.06 46.00% 34.61 34.61 2.81 2.75 2.06 1.88 47.88%

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56 As the next step, the rotated factor solu tions were explored using both Varimax and Promax rotations. Field (2000) recommended conducting both types of factor rotations when the most appropriate type of rotati on is uncertain, in order to dete rmine which rotation can provide a more reliable and effective factor structure. A reliable factor struct ure is characterized by eingenvalues greater than 1, item loadings larger than .30, few cross-load ings between factors, and no factors with fewer than three items. A Varimax rotation, which is a type of orthogonal rotation, has the advantage that it rotates the fact or solution to maximize the variability of the loadings and it has the disadvantage that it k eeps the factors uncorrelated. A Varimax rotation usually provides a simpler factor structure compared with a Prom ax rotationwhich is a type of oblique rotation and represents a more comprehens ive type of factor rotation compared with a Varimax rotation. A Promax rotation allows factor s to be correlated and it provides an estimate of the correlations between factors, but it does no t always provide a structure that can be easily interpreted (Kahn, 2006). The results for this study revealed that the factors obtained th rough a Promax rotation correlated in the low and moderate range with eac h other (the factor co rrelation coefficients ranged from .01 to .65 with the majority of values being in the .2 to .3 range). These findings suggested the existence of factor correlations and supported using a Promax rotation. However, the factor solutions obta ined using a Varimax versus a Promax rotation had very similar item compositions (i.e., the T-CSHCI-Provider Form items had similar factor loadings). In addition, Field (2000) suggested that a Vari max rotation provides a more inte rpretable factor solution than a Promax rotation. Using a Varimax rotation al so presented the advantage of an easily interpretable T-CSHCI-Provider Form factor/s ubscale scoring guide. Since Promax rotation would allow the T-CSHCI-Provider Form items to load on more than one factor/subscale,

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57 scoring procedures would be more difficult to determine in this instance. In light of the differences between Varimax rotation and Promax rotation, it was determined that a Varimax rotation was more appropriate for identifying th e dimensions of patient-centered culturally sensitive health care using the T-CSHCI-Provider Form items. To determine the number of factors/subscales to be retained, the five-factor solution and the six-factor solution were compared based on (a ) the total variance expl ained by each of these two factor solutions, (b) the ex traction sum of squared loadings for each of the two factor solutions, (c) the rotation sum of squared loadings for each of the two factor solutions, and (d) the number of items per factor (Worthington & Whittaker, 2006). Table 4-3 shows the results for the five-factor solution and the sixfactor solution; the fi ve-factor solution was a better data fit. Table 4-3 Comparison of the Rotated Fi ve-Factor and Six-Factor Solutions Factor Solution Five Factors Six Factors Total Variance Explained 45.01%% 46.77% Extraction Sums of Squared Loadings Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 48.55 5.02 3.67 3.59 2.62 48.57 5.04 3.69 3.62 2.64 2.38 Rotations Sums of Squared Loadings Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 17.87 16.72 10.30 9.86 8.70 19.72 16.86 19.72 8.86 6.49 4.99 Number of Items Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Factor 6 48 36 21 23 13 50 36 19 21 11 4

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58 The step following the decision regarding the number of factor s/subscales to be retained was to repeat the factor analyses using five factors/subscales as th e default number, which increased the likelihood of obtaining an interpretable f actor solution (Kahn, 2006). The iterative process was used to eliminate items with the fo llowing characteristics: (a) items with factor loadings less than .32, (b) items with cross-load ings less than .15 difference from the highest factor loading, (c) items with absolute loadings higher than .32 on two or more factors/subscales, and (d) items with communalities less than .40 (Worthington & Whittaker, 2006). Using these item elimination criteria, a PAF factor analysis with Varimax rotation was conducted successively four times until no items met the abov e specified criteria anymore. Each time, 50 items, 21 items, 13 items, and 4 items respectively were eliminated. A total of 53 items were retained in the fina l factor solution. The fi nal factor solution is presented in Table 4-4 with the item loadings for each of the T-CSHCI-P rovider Form factors/ subscales highlighted and with the number of items per factor/subscale specified. The percent variance accounted for by each TCSHCI-Provider Form factor/subscale and the number of items per factor/subscale are shown in Table 4-5. The correlations between the five T-CSHCI-Provider Form factor s/subscales retained as the fina l factor solution are presented in Table 4-6. Table 4-4 Factor/Subscale Item Co mposition and Factor Loadings for the Five-Factor Solution Factor Loadings Item No. Item Summary 1 2 3 4 5 Factor 1: Patient Centeredness (23 items) 141 Shows understanding of patients feelings. .75 .22 .15 .15 .25 82 Responds to patients requests. .75 .19 .22 .18 .08 83 Makes helpful and reasonable recommendations. .74 .17 .23 .22 .06 95 Evaluates patients problems as soon as they come in. .69 .10 .20 .20 .12 88 Is available for patients. .65 .26 .21 .17 .20 119 Is informative to patients. .65 .29 .19 .22 .19

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59 Table 4-4. Continued. Factor Loadings Item No. Item Summary 1 2 3 4 5 93 Takes time with patients while examining them. .63 .17 .21 .21 .14 94 Is prepared to quickly examine patients. .61 .14 .23 .17 .18 116 Prescribes treatments and medicines that work. .61 .06 .15 .16 .13 49 Makes patients feel like their visits to the clinic were informative or productive. .61 .28 .22 .16 .09 52 Puts patients minds at ease. .60 .25 -.08 .18 .23 73 Is concerned about patients situations. .59 .20 .24 .13 .20 51 Makes patients feel at home while at the clinic. .59 .21 -.02 .01 .28 53 Shows patients familiarity with their health. .59 .26 -.11 .17 .20 80 Knows how to make patients f eel comfortable. .58 .17 -.03 .12 .30 65 Prepares patients for the next steps. .58 .17 .15 .23 .25 91 Explains prescribed medications. .54 .12 .26 .06 .31 92 Refers patients to a specia list upon request. .51 .05 -.05 .10 .05 100 Uses standard examining procedures. .49 .05 .11 .24 .14 50 Cares more about patients than making money. .41 .24 .16 -.04 .24 70 Refers patients for tests that th ey think they need. .40 .09 -.14 .04 .01 32 Explains everything he/she does to patients. .38 .16 .15 .23 .24 89 Puts on a fresh pair gloves in front of the patients. .38 .18 .23 .07 .33 Factor 2: Interpersonal Skills (7 items) 6 Is friendly to patients. .16 .73 .15 .17 .07 8 Is polite to patients. .31 .70 .13 .13 .01 11 Is compassionate with patients. .28 .64 .11 .16 .19 48 Is nice to patients. .32 .63 .24 .13 .08 37 Talks to patients during their visits. .26 .61 .22 .28 .05 22 Is willing to learn. .18 .41 .13 .27 .07 9 Is relaxed with patients. .22 .39 -.05 .11 .23 Factor 3: Disrespect/Disempowerment (8 items) 77 Talks down to some patients. .17 .03 .66 .12 .07 15 Sometimes embarrasses patients. .03 -.01 .58 .15 .12 139 Looks down on some patients. .21 .14 .56 -.08 .27 41 Mistakenly diagnoses patients problems as psychological. .11 .03 .54 -.09 -.06 129 Brings medical students into the room without patients permission. .03 .18 .53 .07 .00 117 Makes patients wait long. .03 .01 .50 .21 .10 66 Questions the truth of what patients say. .02 .16 .50 -.09 -.08 55 Assumes patients are ju st looking for a way to get high when they ask for pain medications. .19 .21 .46 -.17 .00 Factor 4: Competence (9 items) 21 Is knowledgeable about the field of medicine. .25 .05 -.01 .66 .01 20 Is well educated. .25 .19 .17 .62 -.03

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60 Table 4-4. Continued. Factor Loadings Item No. Item Summary 1 2 3 4 5 27 Knows what to do with patients. .06 .13 -.13 .62 .12 1 Is confident in his/her abilities. .16 .13 .08 .59 -.01 3 Is right about why patients are sick. .07 .06 -.17 .55 .28 26 Has a lot of schooling. .22 .21 .11 .40 .06 35 Is aware of limits in illnesses he/she can treat. .18 .10 .15 .36 .08 107 Correctly diagnose and treat patients illnesses. .26 .11 -.05 .36 .25 4 Is honest and direct with patients. .30 .25 .19 .30 .08 Factor 5: Cultural Knowledge/Responsiveness (6 items) 125 Is educated in working with patients of different cultures and social statuses. .21 .02 .11 .16 .64 126 Understands the African American culture. .22 -.01 -.07 .16 .60 130 Works to make the clinic more racially integrated. .20 .06 .01 -.02 .46 19 Is respectful of patie nts religious beliefs. .32 .25 .15 .25 .44 134 Understands about the difficulties related to cultural and/or economic differences. .32 .23 .10 .08 .40 127 Understands that people of different cultures believe in different medical practices. .29 .18 .21 .04 .39 Items presented in this table are abbreviations of the actual T-CSHCI-Provider Form items. Table 4-5 Percent of Variance and Numb er of Items per Factor/Subscale Factor Percent of Variance Number of Items 1 Patient-Centeredness 17.78% 23 2 Interpersonal Skills 7.32% 7 3 Disrespect/Disempowerment 6.76% 8 4 Competence 17.78% 9 5 Cultural Knowledge/R esponsiveness 5.46% 6 TOTAL 44.00% 53 Table 4-6 T-CSHCI-Provider Form Factor/Subscale Correlations Factor Factor PC (1) IS (2) D/D (3) C (4) CS/CR (5) PC (1) 1.00 IS (2) 0.649 1.00 D/D (3) -0.359 -0.351 1.00 C (4) 0.585 0.544 -0.233 1.00 CS/CR (5) 0.627 0.452 -0.226 0.392 1.00 1 = Patient-Centeredness (PC); 2 = Interpersonal Skills (IS); 3 = Disrespect/ Disempowerment (/D); 4 = Competence; 5 = Cu ltural Knowledge/Responsiveness. All correlations were significant at the p < .01 level.

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61 Second Research Question The second investigated Research Q uestion was as follows: When used with a sample of medical students who see patients, will any f ound T-CSHCI-Provider Form subscales identified though factor analytic procedures have high inte rnal consistency, splithalf reliability, and construct validity? The construct validity will be determined by examining the correlations between the T-CSHCI-Provider Form subscales a nd the Service Delivery and Practice subscale of the Cultural Competence Assessment Questionnaire-Service Provider Version? Descriptive statistics for each T-CSHCI-Provider Form factor/subscale are shown in Table 4-7. Table 4-7 Descriptive Information for the T-CSHCI-Provider Form Factors/Subscales T-CSHCI-Provider form factor/subscale N Minimum Maximum Mean Std. Dev. 1 Patient-Centeredness 216 2.57 4.00 3.30 .37 2 Interpersonal Skills 216 2.71 4.00 3.65 .34 3 Disrespect/Disempowerment 216 1.00 3.50 2.01 .44 4 Competence 216 2.33 4.00 3.28 .31 5 Cultural Knowledge/R esponsiveness 216 2.17 4.00 3.18 .41 The ratings for Factor 3 Disrespect/Disempower ment are reverse-scored; thus, high scores indicate low levels of patient-centere d culturally sensitive health care. Internal consistency of the T-CSHCI-Provider Form factors/subscales was examined using the Chrombachs Alpha coefficient, which provide s information regarding the strength of interitem correlations. The split-half reliability of th e T-CSHCI-Provider Form factors/subscales was computed using the Spearman-Brown split-half relia bility coefficient. As Table 4-8 indicates, the T-CSHCI-Provider Form factors/subscales were found to be valid and reliable. Table 4-8 T-CSHCI-Provider Form Fact or/Subscale Psychometric Properties T-CSHCI-Provider Form Factor/Subscale Internal Consistency Split-Half Reliability 1 Patient-Centeredness .94 .92 2 Interpersonal Skills .84 .82 3 Disrespect/Disempowerment .79 .75 4 Competence .80 .72 5 Cultural Knowledge /Responsiveness .77 .68 Correlations marked ** were significant at p < .01.

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62 The construct validity of the T-CSHCI Physic ian Form factors/subsca les was tested using Pearson correlations between the mean score of each of the T-CSHCI-Provider Form factors/subscales and the mean score on the Service Delivery subscale of the Cultural Competence Self-Assessment Ques tionnaire (CCSAQ). As indicated in the section describing the assessment battery for this study, the CCSAQ is a measure of culturally competent health care that is expected to be m oderately but not highly associated with the T-CSHCI due to the conceptual differences between culturally sensiti ve health care and culturally competent health care explained in Chapter 2 of this paper. The co rrelation coefficients ar e presented in Table 4-9. Table 4-9 Pearson Correlations between the TCSHCI-Provider Form Factors/Subscales and the CCSAQ T-CSHCI-Provider Form Factor/Subscale CCSAQ-Service Delivery 1 Patient-Centeredness .352(**) 2 Interpersonal Skills .245(**) 3 Disrespect/Disempowerment -.092 4 Competence .315(**) 5 Cultural Knowledge /Responsiveness .501(**) Correlations marked ** ar e significant at the 0.01 level (2-tailed). As Table 4-9 shows, the correlations between the T-CSHCI-Provider Form factors/subscales and the CCSAQ-Service Delivery subscale were low to moderate, and only the Disrespect/Disempowerment subscale did not corre late significantly with the Service Delivery subscale of the CCSAQ. In conclusion, the five T-CSHCI-Provider Form factors/subscales identified in this study through factor analyses conducted on data from 3rd and 4th year medical students proved to be valid and reliable constructs that independe ntly measure dimensions of patient-centered culturally sensitive health care.

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63 Third Research Question The third Re search Question examined in this study was as follows: Do levels of medical students self-assessed patient-cente red cultural sensitivity in the health care they provide, as assessed by the T-CSHCI-Provider Form, differ in association with their gender, race/ethnicity, U.S. citizenship status, fluency in a language ot her than English, year of medical school (i.e., 3rd or 4th), prior or current enrollment in a course on culturally competent/sensitive health care, and self-reported level of experience with providing health care to racial/ethnic minority patients and to low-income patients? Two separate multivariate analyses of variance (MANOVAs) were conducted, with gender, race/ethnicity, and fluency in a language other than English as independent variables in one analysis, and year of medical school, prior or current enrollment in a culturally competent/ sensitive health care course, and level of experi ence with providing health care to racial/ethnic minority patients and to low income patients as the independent variables in the other analysis. The dependent variables for both MANOVAs were scores for each factor/subscale of the TCSHCI-Provider Form (i.e., Patient-Centere dness, Interpersonal Skills, Disrespect/ Disempowerment, Competence, a nd Cultural Knowledge/Responsiven ess) as determined from the factor analytic procedures to address Research Question 1. A preliminary Spearman correlation analysis for use with categorical variables was performed to determine any relationship (a) between the dependent and the independent variables and (b) among the depende nt variables. These resulting correlations were used to (a) determine the variables to be entered in the multivariate analyses of variance (i.e., only the independent variables that were significantly associated with the dependent variables were considered for further analyses), and (b) dete rmine the degree of multicollinearity among the dependent variables. The correlation coefficients shown in Table 4-10 an d Table 4-11, indicated

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64 significant correlations between (a) participants gender and their self-reported levels of Interpersonal Skills and Disrespect/ Disempowerme nt behaviors and attit udes, (b) participants race/ethnicity and their levels of Interpers onal Skills and Cultural Knowledge/Responsiveness, (c) participants knowledge of a language other than English a nd their Interpersonal Skills and Cultural Sensitivity/ Responsiveness, (d) participan ts past or current enrollment in a cultural competence course and their levels of Patie nt-Centeredness, Competence, and Cultural Knowledge/Responsiveness, (e) pa rticipants prior exposure to racial/ethnic minority patients and their levels of Competen ce and Cultural Knowledge/Responsiv eness, and (f) participants prior exposure to low-income patients and their self-reported levels of Competence. Table 4-10 Spearman Correlation Coefficients for the Associations between the T-CSHCIProvider Form Factors/Subscales and Participants Demographic Variables Factor/Subscale Gender Race/ Ethnicity Citizenship Other Languages 1 Patient-Centeredness 0.116 0.032 -0.104 0.109 2 Interpersonal Skills 0.178** 0.136* -0.052 0.188** 3 Disrespect/Disempowerment -0.215** -0.047 -0.011 0.000 4 Competence -0.074 0.118 -0.095 0.125 5 Cultural Knowledge/Res ponsiveness 0.097 -0.173**-0.099 0.238** Correlation marked ** is significant at the 0.01 level. Correlation ma rked is significant at the 0.05 level. Table 4-11 Spearman Correlation Coefficients for the Associations between the T-CSHCIProvider Form Factors/Subscales and Part icipants Medical Training Variables Factor/Subscale Year in School Cultural Sensitivity Course Exposure to Minority Patients Exposure to Low Income Patients 1 Patient-Centeredness 0.032 0.148* 0.110 0.131 2 Interpersonal Skills -0.021 0.065 0.115 0.078 3 Disrespect/Disempowerment 0.062 -0.095 -0.104 -0.061 4 Competence 0.123 0.154* 0.187** 0.192** 5 Cultural Knowledge/Respons iveness 0.019 0.140* 0.194** 0.121 Correlation marked ** is significant at the 0.01 level. Correlation ma rked is significant at the 0.05 level.

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65 Preliminary correlations among the dependent variables (i.e., the T-CSHCI-Provider Form factors/subscales) were not hi gh enough to raise concern abou t the distinctiveness of the dependent variables (i.e., concern that they measured the same construct). The absolute values of the correlation coefficients between the depende nt variables ranged from .23 to .65 (see Table 46), which were smaller than the agreed-upon criteri on value of .70. The first MANOVA was conducted to determine if there are any signifi cant differences in participants self-reported scor es on the five T-CSHCI-Provider Form factors/subscales (i.e., Patient-Centeredness, Interpersonal Skills, Di srespect/ Disempowerment, Competence, and Cultural Knowledge/Responsiveness) in associa tion with their gender, race/ethnicity, and knowledge of one or more languages other than English. The multivariate analyses using Wilks Lambda indicated overall significant multivaria te effects for gender (F[5, 204] = 4.89, p < 0001, = .11), race/ethnicity (F[20, 677] = 2.80, p < .0001, = .06), and other languages (F[5, 204) = 3.16, p < .01, = .07). Specifically, the analyses of variance indicated the presence of significant main effects of (a) gender on Interpersonal Sk ills (F[1, 208] = 11.02, p < .001, = .05) and gender on Disrespect/ Disempowerment (F[1, 208] = 7.18, = .03), (b) race/ethnicity on Interpersonal Skills (F[4, 208] = 2.71, p < .05, = .05) and race/ethnicity on Cultural Knowledge/Responsiveness (F[4, 208] = 4.82, p < .001, = .08), and (c) other languages on Interpersonal Skills (F[1, 208] = 10.58, p < .001, = .05) and other languages on Cultural Knowledge/Responsiveness (F[1, 208] = 8.76, p < .005, = .04). The multivariate effects of gender, race/ethnicity, and citizenship status on the T-CSHCI-Provider Fo rm factors/subscales are summarized in Table 4-12.

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66 Table 4-12 Multivariate Effects of Gender, Race/Ethnicity, a nd Knowledge of Other Languages on the T-CSHCI-Provider Form Factors/Subscales Source Dependent Variable Df F p Partial Eta Squared Gender Patient-Centeredness 1 2.99 0.08 0.01 Interpersonal Skills 1 11.02 0.00 0.05 Disrespect/Disempowerment 1 7.18 0.00 0.03 Competence 1 0.57 0.45 0.00 Cultural Knowledge/Responsiveness 1 1.08 0.30 0.00 Race/Ethnicity Patient-Centeredness 4 0.85 0.49 0.01 Interpersonal Skills 4 2.71 0.03 0.05 Disrespect/Disempowerment 4 2.00 0.09 0.03 Competence 4 0.71 0.58 0.01 Cultural Knowledge/Responsiveness 4 4.82 0.00 0.08 Other Language Patient-Centeredness 1 2.87 0.09 0.01 Interpersonal Skills 1 10.57 0.00 0.04 Disrespect/Disempowerment 1 1.59 0.20 0.00 Competence 1 3.59 0.06 0.02 Cultural Knowledge/Responsiveness 1 8.76 0.00 0.04 Follow-up Tuckey post-hoc tests indicated that: (a ) male participants reported significantly lower scores than female part icipants on Interpers onal Skills (mean difference = -.15, p < .001), (b) male participants reported significantly higher scores than female participants on Disrespect/ Disempowerment (mean difference = .16, p < .01), (c) African American participants reported significantly higher scores than Asian Amer ican participants on Cultural Sensitivity/ Responsiveness (mean difference = .39, p < .05), (d) African American participants reported significantly higher scores than non-Hispanic White participants on Cultural Sensitivity/ Responsiveness (mean difference = .45, p < .005), (e) participants who reported speaking at least one other language in addition to English had si gnificantly higher Interpersonal Skills scores than participants who spoke E nglish only (mean difference = .16, p < .001), and (f) participants who reported speaking at least one other language in addition to English had significantly higher Cultural Knowledge/Responsiveness scores than participants who spoke English only (mean

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67 difference = .17, p < .005). It is noteworthy that although a significan t effect of race/ethnicity on Interpersonal Skills was found, th e post-hoc analyses did not show any significant differences in self-reported Interpersonal Skills scores. The second MANOVA was conducted to determine if there are any significant differences in participants self-reported scores on the five T-CSHCI-Provider Form factors/subscales (i.e., Patient-Centeredness, Interpersonal Skills, Di srespect/ Disempowerment, Competence, and Cultural Knowledge/Responsiveness) in association with particip ants enrollment in a cultural competence/sensitivity course, and their self-report ed levels of exposure to low-income and to racial/ethnic minority patients. The multivariate analyses using Wilks Lambda showed no significant multivariate effects of the independent variables in association with the dependent variables.

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68 CHAPTER 5 DISCUSSION The present study responded to ca lls for valid and reliable in strum ents for assessing selfreported levels of cultural sensitivity in heal th care provided (AHRQ, 2004). These calls are motivated by research that supports the view that patient-centered culturall y sensitive health care can contribute to reducing the ex isting health care and health disparities in this country, as well as by the scarcity of assessment instruments wh ich medical students and other providers can use to evaluate their perceived levels of patient-centered culturally se nsitive health care. The primary purpose of the present study was to determine th e factors/subscales of the T-CSHCI-Provider Form that represent dimensions of patient-centere d culturally sensitive health care as measured by the T-CSHCI-Provider Form and to explor e the reliability and validity of these factors/subscales. Another purpose of the present study was to examine the associations between medical students self-ratings on the T-CSHCI-Provider Form f actors/subscales and selected demographic and medical training characteristics of these student s. These medical training and demographic variables were gender, race/ethnicit y, U.S. citizenship status, fluency in a language other than English, year in medical school, pr ior enrollment in a culturally competent or culturally sensitive health care course, and self-reported level of experien ce in providing health care to racial/ethnic minority patients and low-income patients. The following sections summarize and interpret th e results from this study, the li mitations of the present study and future directions of research, as well as the implications of this study. Summary and Interpretation of the Results Research Questions 1 and 2 Research Q uestion 1 in the present study was: Wh at are the dimensions of factor structures that constitute patient-centered culturally se nsitive health care as assessed by the T-CSHCI-

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69 Provider Form when this form is used with a sample of medical stud ents who see patients? Research Question 2 in this study was: When us ed with a sample of medical students who see patients, will any found T-CSHCI-Provider Form subscales identified t hough factor analytic procedures have high internal consistency, split-half reliability, and construct validity? In order to address Research Questions 1 and 2, a principal axis factors (PAF) factor analysis with Varimax rotation followed by reliability and validity analyses to evaluate the psychometric properties of the resulting T-CS HCI-Provider Form factors/subscales were conducted. The PAF factor analysis with Varimax rotation revealed that a five-factor solution had the best data fit, accounti ng for a total of 45.01% of the data variance. A total of 53 items were retained in the final 5-factor solution, a nd 88 items were eliminated. The five T-CSHCIProvider Form factors/subscales obtained through factor anal yses on a sample of medical students who provide health care services (i.e., 3rd and 4th year medical students) were named Patient-Centeredness, Interpersonal Skills, Di srespect/Disempowerment, Competence, and Cultural Sensitivity/ Responsiveness based on the ite m content of these factors/subscales. The number of items retained for each of these f actors was 23, 7, 8, 9, and 6 respectively. In addition, the findings for Research Question 2 suggest ed that all five T-CSHCI-Provider Form factors/subscales were reliable. The Chrombachs Alpha coefficients of internal consistency ranged from .77 to .94 and the Spearman-Brown coeffi cients of split-half re liability ranged from .68 to .92. The five T-CSHCI-Provider Form factors/subs cales obtained through the factor analyses applied to the self-reported pati ent-centered culturally sensitive health care data obtained from advanced medical students are consis tent with the current literature on the quality of health care. Specifically, the five T-CSHCI-Provider Form fact ors/subscales that emerged from the factor

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70 analysis in the present study have been cited in the literature as necessary ingredients for culturally sensitive, culturally competent, and/or patient-centered health care. The first T-CSHCI-Provider Form factor/subscale that emerged was Patient-Centeredness. Sample items in this factor/subscale included I show my patients that I understand their feelings and views, I put my patients minds at ease, and I explain everything I do to my patients. Patient-centered physician behaviors and attitudes, as well as h ealth care systems, are considered to be of major importance for improving the quality of health care available to racial/ethnic minority patients and for reducing the race/ethnicity-rel ated health dispari ties in this country (Beach, Saha, & Cooper, 2006). Thus, the items of the Patient-Centeredness factor/subscale identified in this study are in accord with the de finitions and descriptions of patient-centeredness that are currently available, such as the concep tual model of patient-cen tered care developed by Mead and Bower (2000). This model describes patient-centered encounters between patients and health care providers as being composed of fi ve domains: (a) adopting the bio-psycho-social (i.e., not narrowly biomedical) perspective, (b) unde rstanding the patient as a person not an illness, (c) sharing power and responsibility between the doctor and the patient, (d) building a therapeutic alliance, and (e) unde rstanding the physician as a pers on rather than as a skilled technician in his/her interactions with patients (Mead & Bower, 2000). Patient-centered health care was defined by Beach, Saha, & Cooper ( 2006) as perceiving and evaluating health care from the patients perspective and then adapting care to meet the needs and expectations of patient s. Pilot evidence for the associations between patient-centered care and positive health outcomes such as blood pr essure is provided by the pioneering research conducted by Tucker (Tucker, Herman, et al., in press). In addition, Anderson et al. (1995) found that when patients were equipped with sufficient skills and support from the health services to

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71 feel empowered to make informed choices for th emselves, these patients reported increased selfefficacy and even a modest improvement in blood glucose leve ls. A study by Martin and Bass (1989) also showed that the extent to which pati ents with chronic illnes ses reported that their problems had been discussed in a helpful manner was positively associated with these patients self-reported treatment adherence. Patient-cente red care has also been found to have a positive association with levels of we ll-being and quality of life of patients with Type 2 diabetes (Kinmonth, Woodcock, Griffin, Sp iegal, & Campbell, 1998). The second T-CSHCI-Provider Form factor/subsca le that emerged in the present research was Interpersonal Skills. Sample items included I am friendly with my patients, I talk to my patients during their visits, and I am relaxed with my patients. Physicians interpersonal skills in the context of patient-physician communication have been examined as a significant dimension of the health care process, and have b een found to be critical in efforts to reduce the race/ethnicity-related health disparities that plague the U.S. (US DHHS, 2005). A consistent body of research suggests that there are indeed associations between health professionals interpersonal skills, which are reflected by the pa tients reports of feeli ng understood and at ease with their physician and trusting of their phys ician, and patient satisf action and/or improved health outcomes among patients. For example, physicians' nonverbal communi cation skills (i.e., physicians' ability to understand and attend to nonverbal communication and their capacity to express emotions appropriately through verbal and non-verbal message s) have been found to be positive predictors of patients satisfaction with health care rece ived (DiMatteo, Taranta, Friedman, & Prince, 1980). Significant associations we re also found between provider s interpersonal skills and patients reports of lower levels of pain (Selfe, Matthews, & Stones, 1998). Moreover,

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72 physicians interpersonal skills were rated by a large group of patients as one of the most important factors that can infl uence their satisfaction with th eir physicians (Anderson, Barbara, & Feldman, 2007). The third T-CSHCI-Provider Form factor/subs cale that emerged in the present study was Disrespect/ Disempowerment. Sample items included I talk down to some of my patients, I make my patients wait long, and In private or in public I sometimes embarrass my patients. The items of the Disrespect/Disempowerment TCSHCI-Provider Form factor address specific provider behaviors that cultura lly diverse and low-income patients identified as being disrespectful to them. Physicians behaviors that convey disrespect to their patients have been a topic of interest in the health care quality literature. However, due to evident research limitations such as ethical considerations, research focu sed on the effects of disrespectful/disempowering physician behaviors is overall difficult to conduct. According to the American Medical Association (AMA, 2003), such be haviors on the part of physici ans can generate patients reluctance to seek or to trust medical care, and thus create an environment that strains relationships among patients, physicia ns, and the health care team. The fourth T-CSHCI-Provider Form factor /subscale that emerged in this study was Competence. Sample items included I am knowledg eable about the field of medicine, I know what I am doing with my patients, and I know my limits as to what illnesses I can treat. Physician medical competence has been linked w ith trust in physician (Hall, Dugan, Zheng, & Mishra, 2001), which in turn has been associated with adherence to treatment recommendations, not changing physicians, not seeking second medical opinions, perceived e ffectiveness of care, and improvement in self-reported health (Safra n et al., 1998; Thom et al., 1999; Hall et al., 2002). In short, trust in physicia n established on the basis of phys icians medical competence is

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73 good for business, good for effective care, and good for reducing medical disputes (Hall, Dugan, Zheng, & Mishra, 2001 p. 629). Interesti ngly, Hall, Dugan, Zheng, & Mishra (2001) noted that perceived medical competence is oftentimes assessed by patients on the basis of their interactions with their health care provider ra ther than on the basis of objective measures of physicians medical knowledge. Thus, physician competence can be viewed as another dimension of the physician-pati ent communication process. The fifth T-CSHCI-Provider Form factor/subscal e that emerged from the present study was Cultural Knowledge/Responsiveness. Sample items included I understand the African American culture, I understand that peopl e of different cultures have, and believe in, different medical practices, and I am respectful of my patients religious beliefs. Calls such as the ones from the American College of Physicians (2004) and the United States Department of Health and Human Services (2001) have lead to increases in the amount of research focused on the need for and benefits of culturally sensitive, culturally competent, and culturally responsive health care providers and the health care systems. It is cu rrently accepted that physician behaviors which are sensitive and responsive to pati ents cultural backgr ound can contribute to reducing health care and health disparities (Beac h, Saha, & Cooper, 2006). It is noteworthy that the five T-CSHCI-Provide r Form factors/subscales identified in this study seem to address two of the dimensions of health care promoted by the Quality of Care Theory (Wilde, Starrin, Larsson, & Larsson, 1993). The Quality of Care Theory influenced the conceptualization of patient-cen tered culturally sensitive heal th care as measured by the TCSHCI-Provider Form and it promotes a view of health care as composed of four dimensions. Two of these dimensions resemble the tradit ional medical model of care (i.e., the medicaltechnical competence of the caregivers and the physical-tech nical conditions of the care

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74 organization) while the other tw o dimensions promote understanding a patient as more than an illness (i.e., the identity-orientation in the attitudes and actions of caregivers and the sociocultural atmosphere of the care organization). Th e T-CSHCI-Provider Form factors/subscales of Patient-Centeredness, Interpersonal Skills, Disrespect/Disempowerment, and Cultural Knowledge/Responsiveness seem to be consistent with the identity-orientation dimension of health care quality, while the Competence factor /subscale seems to be consistent with the medical-technical competence dimens ion of health care quality. The construct validity of the T-CSHCI-Pr ovider Form items was examined using the correlation coefficients between the T-CSHCI-Pr ovider Form factors/subscales and the Service Delivery subscale of the Cultural Competence Se lf-Assessment Questionnaire (CCSAQ). Four of these correlations were signifi cant and ranged from .24 (Interper sonal Skills) to .50 (Cultural Knowledge/Responsiveness), while one correl ation (Disresp ect/Disempowerment) was not significant. The conceptual differences betw een culturally competent and patient-centered culturally sensitive health care presented in Chapte r 2 of this paper explain the low to moderate correlations between four of th e five T-CSHCI-Provider Form f actors/subscales and the CCSAQ. Specifically, these correlations indicate that cultur ally competent health ca re and patient-centered culturally sensitive health care are two similar and yet independent constructs. Both the items of the Patient-Centeredness, Interpersonal Sk ills, Competence, and Cultural Knowledge/ Responsiveness factors/subscales of the T-CSHC I-Provider Form and the items of the Service Delivery subscale of the CCSAQ items address provider behaviors and attitudes that reflect (a) knowledge of the health issues confronting sp ecific racial/ethnic mi nority groups, (b) openness in the patient-provider communicati on process, (c) awareness of th e systemic factors (e.g., health care clinic characteristic s, lack of transportation, etc.) that might contribute to health care

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75 disparities, and (d) openness to exploring medi cal practices that people from various cultures embrace. Despite these similarities, the T-CS HCI-Provider Form factors/subscales and the Service Delivery subscale of the CCSAQ are also different in several significant ways. First, some of the CCSAQ items placed more value on provider knowledge (e.g., Are you familiar with the limitations of mainstream diagnostic tools as applied to people of color?) rather than interpersonal behaviors while the T-CSHCI-Pr ovider Form items address mostly provider behaviors (e.g., I refer my patie nts to a specialist when they request it). Second, the Service Delivery subscale of the CCSAQ consists of it ems that are more general (e.g., How well do you use cultural strengths and resour ces when planning services to pa tients of color?) than the TCSHCI-Provider Form items (e.g., I am respectful of my patients religious beliefs). Third, some of the items on the Service Delivery S ubscale of the CCSAQ address provider knowledge that is not directly related to the patient-provider interacti ons (e.g., Are you familiar with the use of moderator variables?) while the T-CS HCI-Provider Form items mostly address the provider-patient interactions (e.g., I put my patients minds at ease). Indeed, the above differences between the it ems on the Service Delivery Subscale of the CCSAQ and the items on the T-CS HCI-Provider Form items seem to provide evidence for the fact that cultural sensitivity is cultural competence plus (Tucker, 200; Tucker, Herman, Pedersen, Higley, Montrichard, a nd Ivery, 2003; Herman, Tu cker, et al., in press) in that the items of the latter extend beyond an emphasis on di splaying cultural competence in health care to an emphasis on engaging in specific provider beha viors and attitudes that patients want, need, perceive, and feel in the process of re ceiving culturally competent health care. The non-significant association between the Disrespect/Disempowerment T-CSHCIProvider Form factor/subscale and the Service Delivery and Practice subscale of the CCSAQ

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76 also provides support for the conceptual differe nce between patient-cente red culturally sensitive health care and culturally competent health care. Specifically, the concept of patient-centered culturally sensitive health care seems more comprehensive than the one of culturally competent health care since it includes a focus not only on behaviors and attitudes considered sensitive to patients cultural backgrounds but also behaviors and attitudes that are not sensitiv e to patients cultural background. Research Question 3 Research Q uestion 3 explored the associati ons between medical st udents self-ratings on the T-CSHCI-Provider Form factors/subscales an d selected demographic and medical training variables (i.e., gender, race/ethnicity, U.S. citizen ship status, fluency in a language other than English, year in medical school, prior enrollment in a culturally competent or culturally sensitive health care course, and self-re ported level of experience w ith providing h ealth care to racial/ethnic minority patients and low income pa tients). The multivariate analyses of variance (MANOVA) with gender, race/ethnicity, and fluency in a language other than English as the independent variables and the sc ores on the five T-CSHCI-Provide r Form factors/subscales as the dependent variables followed by Tuckeys po st-hoc analyses revealed that: (a) male participants as compared with female partic ipants rated themselves significantly lower on Interpersonal Skills and higher Disrespect/Disem powerment; (b) African American participants as compared with Asian American and non-Hisp anic White participants rated themselves significantly higher on Cultural Sensitivity/ Resp onsiveness; (c) participants who reported speaking at least one other language in addition to English rated themselves significantly higher on Interpersonal Skills and Cu ltural Knowledge/Respons iveness than participants who spoke English only.

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77 The significant association found between gende r and self-reported sc ores on Interpersonal Skills and Disrespect/Disempowerment skills sugge sts that there are differences between male and female medical students regarding their ability to interact with culturally diverse patients in a culturally sensitive manner. These findings suggest that female medical students who participated in the present study perceived them selves as more effective than male medical student participants regarding a more general dime nsion that seems to refe r to interpersonal and empathy skills. These findings are not surprising gi ven the research literature that supports the view that female physicians are more attuned to the non-verbal communication patterns between them and their patients, show more empathy in the health care process, and display overall improved communication skills compared with th eir male counterparts (Hall & Roter, 2002; Roter, Hall, & Aoki, 2002). It is noteworthy that no si gnificant differences were found between female and male medical students regarding their self-reported scores on Patient-Centeredness, Competence, and/or Cultural Knowledge/Responsiveness. The found association between ethnicity and Cultural Knowledge/Responsiveness scores supports the view that medical students own racial/ethnic mi nority group membership might equip them with useful tools for engaging in a culturally sensitive and respectful manner with their culturally diverse patients. However, th ese findings from African American and Asian American medical student participants in this study did not shed light regarding which aspect of being a member of these racial/ethnic groups co ntributed to higher levels of self-reported Cultural Knowledge/Responsiveness. For example, research literature in dicates that a match between the race/ethnicity of patients and that of their physicians can contribute to improved communication (Nunez-Smith et al., 2007). Thus, African American medical students might experience higher levels of comfort and self-confidence in inter acting with Afri can American

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78 patients. Another possible explanation is that th e African American and Asian American medical students who participated in this study were able to draw upon personal experiences of discrimination and perceived lack of power in order to better connect with their minority patients, which allowed these patients to feel empowered and respected in the health care provision process. Future research is needed to explore the found link be tween medical students race/ethnicity and their self-report ed levels of patient-centered cultu rally sensitive health care as measured by the T-CSHCI-Provider Form. The significant associations between ability to speak one or more language(s) other than English and Interpersonal Skil ls and Cultural Knowledge/Responsiveness scores suggest that medical students who reported knowledge of at least another language in addition to English evaluated themselves higher regarding their interpersonal interactions with their patients and their cultural knowledge/responsivene ss. It is possible that these medical students knowledge of at least one language other than English represen ts an indicator of thei r increased openness and willingness to meet the needs of culturally diverse patients and to be respectful of these patients needs and wants. Medical students willingness to meet the needs of their patients could, in turn, enhance these medical students interpersonal and cultural knowledge/r esponsiveness skills and behaviors in their interactions w ith their patients. Further research is needed to explore the found associations between medical students ability to speak a language other than English and their self-reported levels of patientcentered culturally sensitive hea lth care as measured by the TCSHCI-Provider Form. Limitations and Future Directions of Research One lim itation of the present study is that the sample of partic ipants was relatively small (N = 217) for conducting some of the proposed st atistical analyses (i.e ., exploratory factor analyses). This relatively low number of partic ipants was due to constr aints such as financial

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79 constraints (i.e., participant payment) and time c onstraints (i.e., the need for data collection to occur within a specified amount of time). However, the num ber of medical students who participated in the present study was larger than the minimum number of pa rticipants that most authors consider acceptable for conducting a factor analysis. Despite this participant sample size limitation, the five T-CSHCI-Provider Form fact ors/subscales obtained through the exploratory factor analyses were highly relia ble and valid. Thus, the number of participants did not constitute a significant deterrent to identifying the dimensi ons or factor structures that constitute patientcentered culturally sensitive health care as a ssessed by a sample of advanced medical students using the T-CSHCI-Provider Form. A second limitation was that only two states (i.e., Florida and Kentucky) were participant recruitment locations. This limitation was caused by logistic difficulties such as finding medical faculty and administrator collaborators to help with the participant recruitment for this study. Medical school faculty from thr ee other universities in other U.S. states were contacted via email and invited to be collaborators in this st udy but this approach was not successful. However, despite the fact that the research participants came from a limited geographical area, the medical student sample for this study roughly paralleled the racial/ethnic and ge nder composition of the medical student population in this country. Future re search to test the reli ability of the five TCSHCI-Provider Form factors/subscales identified in this study is needed and this testing ideally should occur using a large, national sample of advanced medical students (i.e., 3rd and 4th year medical students). Such a national sample of pa rticipants would allow conducting a confirmatory factor analysis to test the identified five fact ors/subscales, since this t ype of factor analysis requires larger samples due to its increased complexity.

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80 A third limitation of this study is the inclusi on of only medical student s who provide health care. While a focus on this particular participan t group was necessary in order to demonstrate the T-CSHCI-Provider Form to be a valid and reliab le assessment instrument to be used in the context of formal medical educati on, future research is needed to explore the factor structure and the reliability and validity of the T-CSHCI-Provide r Form on a national sample of health care providers including but not limited to physicians, physician assistants, and nurse practitioners. The goal of such research would be to demonstr ate that the T-CSHCI-Provider Form is valid and reliable when used with a large and representati ve sample of health care providers throughout the country. Another limitation of the presen t study is that only one assess ment of culturally competent health care was used to validate the T-CHSCI Provi der Form factors/subscal es obtained in this study. Future research needs to test the va lidity of the T-CSHCI-P rovider Form using assessments of culturally competent health care ot her than the Service Delivery and the Service Delivery and Practice subscale of the CCSAQ. The correlatio n coefficients among other assessments of culturally competent health car e and the T-CSHCI-Provider Form ratings are expected to be in the moderate range, thus providing further evidence for the conceptual difference between patient-centered culturally sensitive health care and culturally competent health care. A fifth limitation of the present study was the f act that a measure of social desirability was not included in the assessment battery. Social science research often struggles with social desirability, especially when skill levels, know ledge, or engagement in socially desirable behaviors are being assessed. Soci al desirability is seen when individuals are motivated to present in a way society regards as positive, ther eby distorting their responses. Although social

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81 desirability is always a threat and limitation to social science research, it was expected that medical students who participated in this study would complete the online assessment battery in an honest manner due to the anonymous and sel f-selection based data collection process. Another reason for not including a measure of soci al desirability was re lated to the amount of time required for completing the online assessment ba ttery. Specifically, it wa s expected that the addition of a measure of social desirability would have increased the amount of time required to participate in this study, decrease d medical students willingness to participate, and ultimately would have decreased the partic ipation rate for this studywh ile it would not have added significantly to the overall purpose of this study. Implications of this Study One im plication of the present study is based on the finding that the T-CSHCI-Provider Form is a valid and reliable assessment instru ment. Specifically, it appears that the T-CSHCIProvider Form can be used with medical student s to assess their levels of patient-centered culturally sensitive health care behaviors and attitudes. Additionally, the T-CSHCI-Provider Form can be administered to medical students at multiple time points in order to examine their progress in engaging in patient-centered culturall y sensitive health care behaviors and attitudes and to provide these students with opportuni ties for diagnostic feed-back and autonomous learning (i.e., learning that is self-directed versus other-directed). The T-CSHCI-Provider Form can also be used in combination with the T-CS HCI Patient Formthe patient equivalent of the T-CSHCI-Provider Form which was also develope d by Tucker and her research teamwith the goal of determining the degree of agreement betw een medical students self-evaluations and the evaluations provided by their patients regardi ng the occurrence of health care behaviors and attitudes assessed by both forms.

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82 Third, subscales scores of the T-CSHCI-Provide r Form (versus a globa l score) present the advantage of providing more detail ed information about specific components of patient-centered culturally sensitive health care, which in turn can facilitate the development of effective training content modules (e.g., interpersonal skills, patientcenteredness skills, etc.) and training methods (e.g., providing specific feed-back to medical student trainees). The factors/subscales of the TCSHCI-Provider Form can also facilitate heal th-related research (e.g., determining which patient-centered culturally sensitiv e health care components are associated with specific health outcomes). It is particularly noteworthy that significan t differences were found in medical students self-reported scores on some T-CSHCI-Provider Form factors/ subscales (i.e., Interpersonal Skills, Disrespect/Disempowerment, and/or Cultur al Knowledge/Responsiveness) in association with these students race/ethnicit y, gender, and ability to speak at least one other language than English. The implication of this finding is that patient-centered culturally sensitive health care training in medical schools perhaps needs to be tailored to the self-evaluations of culturally diverse medical students regardi ng their perceived levels of behaviors and attitudes that constitute patient-centered culturally sensitive he alth care. A more general implication of this study is that the cultural diversity among health care providers repres ents a significant variable in efforts to improve the health care quality experienced by culturally diverse patients. Implications for Counseling Psychologists Counseling psychologists are equipped with a unique set of knowledge and skills that can be used for research, training, and interventions to prom ote patient-centered culturally sensitive health care and to help alleviat e the existing health disparities (Tucker, Ferdinand, et al., in press). These skills include but are not limited to (a) scientist-practitioner training skills, (b) knowledge of multicultural counseling theories and interventions, and (c) awareness of, and

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83 involvement with social advocacy issues. The T-CSHCI-Provider Form represents a valid and reliable self-assessment instrument for medical students to evaluate their levels of patientcentered culturally sensitive health care followi ng interventions by counseling psychologists to promote such care by medical students. Counseling psychologists can use their knowledg e of test development and validation to contribute to furthering the development of the T-CSHCI-Provider Form using national samples of medical students, physicians, a nd other health care providers. It is noteworthy that such efforts are currently underway through research conducted by Tucker and her research team. Furthermore, counseling psychologi sts can contribute to promoti ng assessments such as the TCSHCI-Provider Form by educating health care providers and administrators (i.e., medical school faculty, medical school administrators, an d medical students) about the advantages of using valid and reliable assessments of patient-centered culturally sensitive health care such as the T-CSHCI-Provider Form. Ways in which c ounseling psychologists can accomplish this goal include: (a) advocating for the eff ectiveness of patient-centered culturally sensitive health care provider behaviors and attitudes, (b) presenting to the medical community research evidence of the usefulness of medical students self-assessment s of their patient-centered culturally sensitive health care levels, (c) being involved with the development, implementation, and assessment of patient-centered culturally sensi tive health care training programs and (d) identifying, testing, and promoting specific ways in which medical students can use their T-CSHCI-Provider Form scores to increase their patie nt-centered culturally sensitive health care skills. Counseling psychologists can also use the T-CSHCI-Provider Form as a tool for developing patient-centered cultu rally sensitive health care me dical training programs and for assessing the effectiven ess of such programs. Specifically, counseling psychologists can use their

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84 knowledge of behavior and learni ng theories to design and imp lement training programs that would help medical students to improve their ab ility to interact with their culturally diverse patients in a patient-centered and culturally sensitive manner. Such patient-centered culturally sensitive health care training programs can consist of specific training modules that can be used to teach the patient-centered culturally sensitive health care dimensions represented by the five T-CHSCI Provider Form factors/subscales identified in the pres ent study. For example, a training module focused on Interpersonal Skills can teach me dical students specific skills for interacting with their culturally diverse patients in ways that demonstrate friendliness, politeness, compassion, being relaxed, and being willing to talk to patients. In addition, counseling psychologists can assess the effectiveness of patient-centered culturally sensitive health care training programs implemented in medical schoo ls through using the T-CSHCI-Provider Form as a self-assessment tool for medical students. The T-CSHCI-Provider Form can be administered at pre-, post-, and delayed post-tra ining in order to compare medi cal students performance over time as a function of assessment and training in pa tient-centered culturally sensitive health care. In addition, counseling psychologi sts can contribute to lobbyi ng efforts for promoting the implementation of patient-centered culturally sens itive health care training programs in medical schools across the country. Finally, counseling psychologists can become involved in conducting outcome research to evaluate the effects of patientcentered culturally sensitive hea lth care training on providers behaviors and attitudes, and on pa tients health care and health promotion behaviors and health status. Due to their knowledge and skills in research methods, counseling psychologists are particularly well trained to conduct such empi rical research and presents the findings in professional journals.

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85 Conclusions Overall, the findings from the present study support the view that the T-C SHCI-Provider Form is a valid and reliable measure of patie nt-centered culturally sensitive health care. Furthermore, five valid and reliable T-CSHCI-P rovider Form factors/subscales were identified through factor analyses, and signi ficant associations were found between the scores on these factors/subscales and medical students race/ethnici ty, their gender, and thei r ability to speak at least one language other than English. The present study provided evidence for using the T-CSHCI-Provider Form to assess the effectiveness of patient-centere d culturally sensitive health care training (such as pre-post training comparisons using the T-CUSHCI scores ). The T-CSHCI-Provider Form can also be used as a useful tool for self-d irected learning of patient-centered culturally sensitive health care behaviors and attitudes by advan ced medical students, which can benefit these students in their interactions with culturally diverse patients. In addition, the T-CUSHCI has potential for promoting needed research to determine if there are measurable links between culturally sensitive health care as define d by ethnic minority patients and the costly and unjust disparities between majority and minority Americans.

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86 APPENDIX A E-MAIL MESSAGE TO MEDICAL SCH OOL FACULTY CO-INVES TIGATORS Dear Dr. ____, My name is Anca Mirsu-Paun and I am a doctoral candidate at the Univers ity of Florida. I am writing to ask for your help w ith the data collection for a research study conducted for my doctoral degree, which aims to validate the Tuck er-Culturally Sensitive Health Care Inventory (T-CSHCI) Provider Form. This is a self-assessment instrument of culturally sensitive health care that was developed by Dr. Caro lyn Tucker and her research team as part of a larger, ongoing study conducted at the University of Florida. I am currently collecting data from me dical students who see patients (i.e., 3rd and 4th year students) from various medical sc hools across the country. This st udy received approval from the UF IRB (protocol # 2006-U-615). Taking the online survey takes approximately 20 minutes and medical students who agree to participate can receive $10 for thei r participation. More information about this study, as we ll as the assessment in strument per se can be found at this web address: http://survey.psych.ufl.edu/physician/ I hope that y ou will be interested to help us w ith this study that addresses an actual and much needed research topic. I believe that medical students can benefit from participating in this study on culturally sensitive health care in that anonymously answering the items of the T-CSHCIProvider Form will allow them to (a) self-evaluate th eir levels of cultural se nsitivity in the health care they provide, and also (b) gain a better understanding of what provider behaviors are considered to be culturally sensitive by culturally diverse patie nts (since the T-CUSHCI items address specific behaviors identified by patients themselves). In case you will decide to help us by inviting medi cal students at your school to participate in this study, please find the attached succinct messag e that you could use to forward to medical students. I very much appreciate your attention to this issue, and I would be happy to answer any further questions if needed. With my best regards, Anca Mirsu-Paun, M.S. Doctoral Candidate in Counseling Psychology University of Florida Department of Psychology P.O. Box 112250 Gainesville, Florida 32611-2250 E-mail: ancamp@ufl.edu Phone: (352)392-0601 Ext. 260 Fax: (352)392-7985

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87 APPENDIX B E-MAIL MESSAGE TO MEDICAL STUDENT PARTICIPANTS Hello, If you are a third or fourth year m edical student, please consider answering an online questionnaire on health care provision to culturally diverse patients. You will receive $10 for your participation. Your participation in this research study will be anonymous. In case you decide to answer this 20-minute online questionnaire, please go to http://survey.psych.ufl.edu/physician/ This research study is conducted at the Univers ity of Florida Departm ent of Psychology and it investigates culturally sensitive health care be haviors. The study has been approved by the University of Florida IRB (protocol # 2006-U-615). I hope that you will consider participating, a nd I would be happy to answer any questions you might have. The best way to contact me is at ancamp@ufl.edu Thank you for your attention, Anca Mirsu-Paun, M.S. Doctoral Candidate in Counseling Psychology University o f Florida

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88 APPENDIX C ONLINE COVER LETTER/INFORMED CONSENT FORM W ITH UF IRB APPROVAL Dear Medical Student: We are inviting medical students who are seei ng patients to particip ate in our study called Assessing Patient-Defined Cultu rally Sensitive Health Care. The purposes of this study are (a) to further develop the Tucker-Culturally Se nsitive Health Care Inventory (T-CUSHCI) Provider Form for use as a tool for providers to self-assess their level of engagement in behaviors and attitudes that culturally diverse patients view as indicators of cultural sensitivity, and (b) to determine the level of self-perceived patient-def ined cultural sensitivity that medical students report having. This research proj ect is being conducted by Dr. Ca rolyn M. Tucker, Distinguished Alumni Professor, Anca Mirsu-Paun, M.S., doc toral candidate, and Dr. Caridad Hernandez from the University of Florida. Participation in this research study includes completing an onl ine survey that should take approximately 20 minutes to complete. This rese arch study is designed to ensure that your responses will be anonymous and that your participation will be confidential. To ensure anonymity of your responses, DO NOT place your name on the survey. We do not believe that participating in this study will cause you any harm. However, you may stop completing the survey at any time and for any reason without penalty. You also have the right to not answer any questions that you do not want to answer. Participati on in this research study is completely voluntary and upon the comp letion of this online survey you will receive $10 for your participation. In order for you to rece ive your compensation, we will ask you to provide your email address, name, and mailing address. However, this information will be stored separately from your responses, a nd it will not be possible for anyone to connect you with your responses. If you decide to participate in this study, you can indicate your willingness to do so by clicking the link at the end of this letter. We look forward to your particip ation and believe that this study offers great potential for helping medical students to optimize their ability to provide culturally sensitive health care to their patients. If you have any questions or desi re further information about this study, please call Dr. Carolyn Tucker or An ca Mirsu-Paun at (352) 392-0601 ex t. 260. Questions or concerns about your rights as a research participant may be directed to the UFIRB office, University of Florida by mail (Box 112250Gainesville, FL 32611), phone (352) 392-0433, or e-mail irb2@ufl.edu. Sincerely, Carolyn M. Tucker, Ph.D. Distinguished Alumni Professor Joint Professor of Psychology and Professor of Community Health and Family Medicine Professor of Pediatrics (Affiliate) Anca Mirsu-Paun, M.S. Doctoral Candidate Department of Psychology

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89 I have read the information above, and by clic king the below link I agree to voluntarily participate in this research study. Press Here To Start The Survey Approved by University of Florida Institutional Review Board 02 Protocol # 2006-U-615 For Use Through 06-28-2007

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90 APPENDIX D ONLINE PAYMENT INFORMATION WITH UF IRB APPROVAL You have now completed the online assessment battery. If you have questions, concerns, or you just want to know more about this research please contact Dr. Carolyn M. Tucker at cmtucker@ufl.edu or Anca Mirsu-Paun at ancamp@ufl.edu. Please provide your e-mail address where you would like us to contact you with detailed information regarding your $ 10 payment. Your e-mail address will be saved in a confidential file that is separate from the file containing your answers. In order to protect your anonymity, there is no possibility of connecting the two files and we are not saving any IP or other information from your computer. Only the principal investigators will have access to both these files. We will contact you by e-mail within 3 days and you will be asked to provide your name and a mailing address where you would like to receive your payment check. PLEASE ENTER E-MAIL ADDRESS HERE Approved by University of Florida Institutional Review Board 02 Protocol # 2006-U-615 For Use Through 06-28-2007

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91 APPENDIX E E-MAIL MESSAGE TO MEDICAL STUDEN TS W ITH PAYMENT INFORMATION Dear Medical Student: Thank you so much for your partic ipation in the study entitled Assessing Patient-Defined Culturally Sensitive Health Care ." We received your data and would like to promptly process your payment. In order to process your payment, we need you to complete the attached W-9 form (the highlighted sections only are requi red). In accord with the University of Florida regulations, we cannot process your payment without having you r information on the W-9 form. Please send your completed W-9 to: Mail: Patty Troll (Cultu ral Sensitivity Study) University of Florida Department of Psychology PO Box 112250 Gainesville, FL 32611 Fax: 352-392-7985 (Attn: Patty TrollCultural Sensitivity Study) We anticipate that you will receive your $10 check within a minimum of 6-8 weeks. Please do not hesitate to send us any questions or comments that you might have. You can write to Anca Mirsu-Paun at ancamp@ufl.edu Sincerely, Anca Mirsu-Paun, M.S. Doctoral Candidate in Counseling Psychology University o f Florida Department of Psychology P.O. Box 112250 Gainesville, Florida 32611-2250 E-mail: ancamp@ufl.edu Phone: (352)392-0601 Ext. 260 Fax: (352)392-7985

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92 LIST OF REFERENCES Agency for Healthcare Research an d Quality (2003). National Healthcare Disparities Report (HHS Publication). Rockville, MD: Government Printing Office. Agency for Healthcare Research and Quality (2005). 2005 National Healthcare Disparities Report (HHS Publication). Rockville, MD: Government Printing Office. American Association of Medical Colleges. T ool for Assessing Cultural Competence Training (TACCT). Available at: http//www.aamc.org/ meded/tacct/start.htm Accessed April 25, 2006. American College of Physicians (2004). Racial and ethnic disparities in health care. A position paper of the American College of Physicians. Annals of Internal Medicine 141(3) 226-232. American Medical Association (2002). Physician characteristics and distribution in the U.S., 2001-2002 Edition American Medical Association (2003). Disres pect and derogatory conduct in the patientphysician relationship. Retrieved on May 27, 2007 from http://www.amaassn.org/ama/pub/category/11969.htm l Anderson, R., Barbara, A., & Feldman, S. (2007). Wh at patients want: A content analysis of key qualities that influence patient satisfaction. The Journal of Medical Practice Management 22(5) 255-261. Anderson, R.M., Funnell, M.M., Arnold, M.S., Fitz gerald, J.T., & Feste, C.C. (1995). Patient empowerment. Results of a randomized controlled trial. Diabetes Care, 18(7) 943-949. Andrulis, D. P. (2003). Reducing ra cial and ethnic disparities in disease management to improve health outcomes. Disease Management & Health Outcomes, 11 789. Association of American Medical Colleges (2005). Cultural Competence E ducation for Medical Students. Washington, DC. Bach, P.B., Cramer, L.D., & Warren, J.L. (1999). R acial differences in the treatment of earlystage lung cancer. New England Journal of Medicine 341(16) 1198-1205. Beach, M.C., Cooper, L.A., Robinson, K.A., Price, E.G., Gary, T.L., Jenckes, M.W., Gozu, A., Smarth, C., Palacio, A., Feuerstein, C.J., Bass, E.B., & Powe, N.R. (January 2004). Strategies for Improving Minor ity Healthcare Quality. S ummary Evidence Report/Technology Assessment No. 90. (Prepare d by the Johns Hopkins University Evidence-based Practice Center, Baltimore MD.) AHRQ Publication No. 04-E008-01. Rockville, MD: Agency for Healthcare Research and Quality. Beach, M.C., Gary, T.L., Price, E.G., Robinson, K., Gozu, A., Palacio A., Smarth C., Jenckes M., Feuerstein C., Bass, E.B., Powe, N.R ., & Cooper, L.A. (2006). Improving health

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101 BIOGRAPHICAL SKETCH Anca Mirsu -Paun was born in Romania, where she lived until the age of 23. She graduated with a B.S. in Psychology from the University of Bucharest in 2000 and she became a graduate student in counseling psychology at the University of Florida in 2001. As a graduate student, Anca worked with Dr. Carolyn M. Tucker and her research team as a dir ector on the Behavioral Medicine and Health Psychology Research Pr oject between 2002 and 2006, and she was also involved in the local community as a volunteer counselor at the Alachua County Crisis Center. Anca completed her pre-doctoral internship at the University of South Florida Counseling Center. She received her Ph.D. in 2007. Ancas was the recipient of the Threadgill Di ssertation Award from the College of Liberal Arts and Sciences at the University of Florid a, the Outstanding Researcher Award from the Behavioral Medicine Res earch Team at the University of Florida, the Outstanding International Student Award from the College of Liberal Arts and Sciences at the University of Florida, and the Richard McGee Service Award from the Alachua County Crisis Center. Ancas interests and hobbies include: spendi ng time with friends, tr aveling, exercising, watching movies, nature watching, mountain climbing, and gardening.