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1 IMPACT OF A PILOT PATIENT-CENTERED CULTURALLY SENSITIVE HEALTH CARE INTERVENTION ON THE HEALTH OUTCOMES OF RACIAL/ETHNIC MINORITY AND LOW-INCOME PRIMARY CARE PA TIENTS WITH HYPERTENSION By LISA ANN FERDINAND 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 2008
2 2008 Lisa Ferdinand
3 To my Family and Friends.
4 ACKNOWLEDGMENTS This dissertation would not have been possi ble without the assist ance of m any people and organizations. First and foremost, I must acknow ledge the unwavering love and support of my family and friends. In particular, I would like to th ank my parents, my sisters, Mr. Ruan Mitchell, Mrs. Marilyn Mitchell, Mrs. Cynetta Lai Leung, Dr. Anacaona de Lima, Dr. Beverly Brady, Dr. Pam Wright, and Dr. Billy Johnson for listening, editing, praying, and believing. Second, I am grateful for the guidance and su pport of my dissertation chairperson, Dr. Carolyn M. Tucker, without whose knowledge, patie nce, encouragement, and generosity this research would not have been completed. Additionally, I must thank my committee members, Dr. Mary Fukuyama, Dr. Scott Miller, and Dr. Marilyn Thomas-Houston for their continued feedback, support, flexibili ty and patience throughout my dissertation process. I must also acknowledge the support of the Agen cy of Healthcare Research and Quality for providing the funding that supported this research study. I am simila rly grateful to the members past and present of the Behavior Medicine Resear ch Team at the University of Florida for their dedication, hard work, commitment, and continuous support. In addition, I am indebted to the faculty and graduate students of the Counseling Psychology program at the University of Florida, th e clinical staff at the University of Florida Counseling Center, and the clinical staff at the Georgia State Univ ersity Counseling Center. As a group you have given me a strong clinical and re search foundation and always supported and encouraged my clinical and research end eavors. Moreover, you embraced my personhood and never treated me like just a student or trainee for th is I am sincerely thankful. Finally, I am thankful to God for blessing me with health, a supportive community, and the talents that allowed me to complete this project. I hope to continue multiplying these talents as I forge ahead on the next phase of my professional journey.
5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........8 LIST OF FIGURES.........................................................................................................................9 ABSTRACT...................................................................................................................................10 CHAP TER 1 INTRODUCTION..................................................................................................................12 2 REVIEW OF THE LITERATURE........................................................................................ 19 The Health Disparities Problem Underlying National Calls for Patient-C entered, Culturally Competent, and Cultu rally Sensitive Health Care............................................. 19 Prevalence of Hea lth Disparities ..................................................................................... 19 Factors Influencing He alth Disparities ............................................................................23 Health care quality................................................................................................... 23 Health care access.................................................................................................... 24 Patient-provider communication.............................................................................. 26 Hypertension: A Major Health Disparities P roblem that Negatively Impacts Racial and Ethnic Minorities................................................................................................... 28 Solving the Health Disparities Problem: Th e Roles of Patient-Centeredness, Cultural Competence, and Cultural Sensitivity................................................................................. 30 Defining Patient-Centeredness........................................................................................30 Defining Cultural Competence........................................................................................ 31 Defining Cultural Sensitivity........................................................................................... 32 Do Patient-Centeredness and Cultural Comp etence lead to Improvem ents in Health Outcomes?....................................................................................................................33 Overview of existing models associati ng cultural com petence and/or patientcenteredness with patients health outcomes........................................................ 33 Assessing cultural competence and patient-centered care....................................... 36 Overview of the existing evidence associ ating general patient-centered and/or cultural com petence interventions wi th patients health outcomes...................... 39 General characteristics of health care provider cultural com petence training interventions.........................................................................................................41 Overview of existing literature associ ating cu lturally competent health care provider training interventions with health care delivery..................................... 44 Overview of existing literature associ ating cu lturally competent health care provider training interventions with patients perceptions of their health care environment.......................................................................................................... 45
6 Overview of existing literature associ ating cu lturally competent health care provider training interventions wi th patients health outcomes........................... 46 Patient-Centered Culturally Sensitive Health Care: Evolution of a New He alth Care Orientation with Potential for Reducing Health Disparities............................................... 49 Defining Patient-Centered Culturally Sensitivity Health Care.................................... 49 Operationalizing and Measuring Indicators of Patient-Centered Culturally Sensitive Health Care.................................................................................................................. 52 Differentiating Patient-Centered Culturally Sensitive Health Care from Cultural Competence.................................................................................................................. 54 The Tucker Patient-Centered Culturally Sensitive Health Care Model ................................. 55 Overview of the PC-CSHC Model..................................................................................56 Research Supporting the PC-CSHC Model..................................................................... 57 Associations among perceived cultural sens itivity, interpersona l control, health care satisfaction, and health pr om oting lifestyle behaviors.................................. 57 Association between hea lth care satisfaction and treatm ent adherence................... 59 Associations of treatment adherence a nd engagement in a health prom oting lifestyle with health outcomes/statuses................................................................. 59 The PC-CSHC Intervention Program.....................................................................................60 Health Care Physical Environment and Clinic Interventions .......................................... 61 Health Care Provider and Offi ce Staff Training Interventions .......................................62 Patient Training/Empowerment Interventions................................................................ 63 3 METHODS.............................................................................................................................65 Participants.............................................................................................................................65 African American Patients..............................................................................................65 White Patient Participants............................................................................................... 66 Clinic Staff.......................................................................................................................67 Measures.................................................................................................................................67 Procedure................................................................................................................................71 Participant Recruitment................................................................................................... 72 Patient recruitment................................................................................................... 72 Provider and office support staff recruitment.......................................................... 74 Overview of the Research Study for Testing the Effects of the PC-CSHC Intervention Program ...................................................................................................76 Descriptions of the Three Components of the PC-CSHC Intervention Program ............ 77 Component 1: The physical enviro nm ent and policies intervention........................77 Component 2: Health care pr ovider/office staff training ......................................... 78 Component 3: Patient empowerment training.......................................................... 83 4 RESULTS...............................................................................................................................88 Descriptive Data for all Major Variables................................................................................ 88 Results of the Preliminary Pearson Correlations.................................................................... 89 Results of Analyses to Test Research Questions 1 and 2 ....................................................... 90
7 Research Question 1........................................................................................................ 90 African American pa tient participants .....................................................................91 White patient participants......................................................................................... 91 Research Question 2........................................................................................................ 92 Hypothesis 1................................................................................................................... .93 African American pa tient participants .....................................................................93 White patient participants......................................................................................... 96 Hypothesis 2................................................................................................................... .96 Diastolic blood pressure readings............................................................................ 98 Systolic blood pressure readings.............................................................................. 98 5 DISCUSSION.......................................................................................................................105 Summary of the Results........................................................................................................ 105 Descriptive Data............................................................................................................ 105 Hypothesis 1.................................................................................................................. 107 Hypothesis 2.................................................................................................................. 110 Research Question 1...................................................................................................... 111 Research Question 2...................................................................................................... 112 Limitations and Directions for Future Research................................................................... 113 Design Limitations........................................................................................................ 114 Assessment Limitations................................................................................................. 116 Training Limitations...................................................................................................... 117 Conclusions and Implications for Counseling Psychologists ...............................................117 APPENDIX A DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ)....................................................... 121 B MEDICAL DATA QUESTIONNAIRE (MDS).................................................................. 123 C MARLOW-CROWNE SOCIAL DESIRABILI TY SCALE (MCSDS)............................... 125 D TUCKER CULTURALLY SENSITIVE HEALTH C ARE INVENTORY-AFRICAN AMERICAN PATIENT FORM (T-CUSCHI-AA).............................................................. 127 E TUCKER CULTURALLY SENSITIVE HE ALTH C ARE INVENTORYCaucasian AMERICAN PATIENT FORM (T-CUSCHI-CA).............................................................. 134 F STUDY PARTICIPATION INVITATION LETTER.......................................................... 141 G STUDY QUESTIONNAIRE PACKET COVER LETTER................................................. 143 REFERENCES............................................................................................................................145 BIOGRAPHICAL SKETCH.......................................................................................................157
8 LIST OF TABLES Table page 3-1 Demographic Characteristics of Patient Pa rticip ants in the Present Study by Race.......... 87 4-1 Means and standard deviations for the va riables investigated in the present study at baseline by race/ethnicity ................................................................................................. 100 4-2 Pearson correlations among the major variab les of interest in the present study for patient participants at baseline by race /ethnicity and for the total sample...................... 101 4-3 Results of MANOVA testing differences at baseline in m ean scores for the components of the T-CSHCI-patient form in association with group, gender, and gender x group for White patient participants................................................................. 101
9 LIST OF FIGURES Figure page 3-1 Flowchart Showing the Order of and Time line f or the Recruitment, Intervention and Data Collection Activities in the PC-CSHC Intervention Program...................................86 4-1 Profile plot showing the means for the provider behaviors and attitudes component of the T-CSHCI patient for m for African Am erican patient participants from baseline to post-intervention by clinic...........................................................................................102 4-2 Profile plot demonstrating time x gender interaction effect in cultural sensitivity ratings of office staff behaviors and at titudes for African American patient participants. ......................................................................................................................102 4-3 Profile plot demonstrating gender x race in teraction effect for systo lic blood pressure means for African American patient participants............................................................ 103 4-4 Profile plot showing means for systolic blood pressure readings of African Am erican patient participants by time, group, and time x group..................................................... 103 4-5 Profile plot showing means for systolic blood pressure readings of W hite Patient participants by time, group, and time x group................................................................. 104
10 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 IMPACT OF A PILOT PATIENT-CENTERED CULTURALLY SENSITIVE HEALTH CARE INTERVENTION ON THE HEALTH OUTCOMES OF RACIAL/ETHNIC MINORITY AND LOW-INCOME PRIMARY CARE PA TIENTS WITH HYPERTENSION By Lisa Ann Ferdinand May 2008 Chair: Carolyn M. Tucker Major: Counseling Psychology The present study sought to address the health disparities pr oblem by using a literaturebased model as a framework to examine the long itudinal impact of a p ilot 15-month intervention program on the cultural sensitivit y ratings and health outcomes of low-income African American and White patients with hypertension. Participants consisted of 110 African American patients, 115 White patients, and 48 clinic staff. Patients were administered a Demographic Questionnaire, a Medical Data Questionnaire, the Tucker-Culturally Sensitive Health Care In ventory Patient Form, and the Marlow-Crowne Social Desirability Scale Short Form. Clinic staff completed a Clinic Staff Demographic Data Questionnaire. Participants were recruited from two community-based clinics, one of which served as an intervention clinic. Results of conducted analyses did not offer statistically signi ficant support that participating in the intervention program resu lted in higher ratings of perceived cultural sensitivity or improved health outcomes. Ho wever, important trend effects were found. Specifically, results indicated that the cultural sensitivity ratings of providers behaviors and attitudes by African American patients at the intervention clinic increased more than their
11 counterparts at the control clinic at post-intervention. In addi tion, the systolic blood pressure readings of African American pati ents at the intervention clinic decreased over the course of the intervention period compared to their counterparts at the control clinic. It was also found that the African American female patients rated both their providers behaviors and attitudes and thei r office staffs behaviors and at titudes as significantly more culturally sensitive than did their male counterpa rts at both baseline and post-intervention, and White female patient participants rated their prov iders behaviors and attitudes as significantly more culturally sensitive than did their male counterparts at baseline. Together these findings suggest that there may be gender differences in perceived cultural sensitivity of health care experienced. In sum, the results of this study provide s upport for replicating it with larger patient populations as the trend effects re ported suggested that, with great er power, a significant impact of the tested intervention pr ogram may have been empirically evidenced. Furthermore, the results of the present study hi ghlight the importance of conducing future research focused on examining gender differences in per ceived culturally sensitivity ratings.
12 CHAPTER 1 INTRODUCTION The term health disparities refers to existi ng differences among specific groups with regard to adverse health conditions, including differences in the incidence, prevalence, mortality, and burden of diseases (National Inst itutes of Health, 1999). Health di sparities have been especially well documented for members of low-income and racial and ethnic minority groups at all points in the health care process, at all sites of care, and for many me dical conditions. The following six health care areas are particularly affected: infant mortality, ca ncer screening and management, cardiovascular disease, diabetes, HIV infections/AIDS, and immuni zations (Agency for Healthcare Research and Quality [AHRQ], 2003, 2005; Centers for Disease Control and Prevention [CDC], 2005; United States Departme nt of Health and Human Services [HHS], 2000). Health disparities among racial and ethni c minorities and individuals from lower socioeconomic backgrounds have been attributed to: (a) a number of biological causes such as genetic predispositions for certain medical conditions that tend to cluster in populations targeted by health disparities initiatives (e.g., Collins, Green, Guttmacher, & Guyer, 2003); (b) a number of social and environmental factors such as economics, culture, and sociopolitical power (e.g., Johnson et al., 1995); and (c) racism-related stress (e.g., Clark, Anderson, Clark & Williams, 1999). However, extensive research suggests that social and environmental influences are the largest contributors to the health disparities problem (e.g., Institute of Medicine, 2002). In particular, recent research has focused on socioc ultural differences among and between patients, health care providers, and the health care syst em that: (a) engender poor communication between patients and their providers, (b) crea te disparities in the quality of health care given to majority patients as compared to low-income and racial /ethnic minority patients, and (c) contribute to
13 disparities between majority patients and low-in come and racial/ethnic minority patients with regard to their access to health care (AHRQ, 2003; 2005). Patient-centeredness, cultural competence, and cultural sensitivity are health ca re orientations that concentrate on addressing the sociocultural differences that exist among an d between patients, heal th care providers, and the health care system. As suc h, these health care orientations have all been proposed in the health care disparities literature as potential ta rgets to bring about solu tions to the health and health care disparities problems. Patient-centeredness includes perceiving and ev aluating health care from the patients perspective and adapting care to meet the pati ents needs and expecta tions (Beach, Saha, & Cooper, 2006). Cultural competence refers to, the ability to understand an d work with patients whose beliefs, values and histor ies are significantly different from ones own (Rothschild, 1998, p. 299), and it emphasizes having the awareness, knowledge, skills and experiences needed for working with culturally diverse patients (Campi nha-Bacote, 2002). Cultural sensitivity has been defined as an ongoing awareness of cultural di fferences and similari ties among populations (Majumdar, Browne, Roberts & Carpio, 2004). Experts in the health care field have suggested that improvi ng cultural competence and/or cultural sensitivity may reduce racial and ethnic health and health care disparities through a range of interventions focused on changing the health care system, educating and/or training providers and patients, and fostering partnerships with the communities in which patients live (e.g., Betancourt, Green, Carillo, & Park, 2005; Br anch & Fraser, 2000). Importantly, educating and training health care organiza tion staff has been recognized as the single most important element in ensuring the cultural competence of an organization (HHS Office of Minority Health [OMH], 2001). However, few studi es exist that have actually studied the effects of cultural
14 sensitivity and cultural competence interven tions, including educational and training interventions for providers, on patients health status outcomes. Furthermore, few models exist that predict the paths through which such effects could occur. The lack of empirical evidence linking cultural sensitivity or cultural competen ce interventions to improvements in patients health outcomes has in turn led to ambivale nce within the medical community regarding the utility and effectiveness of cultural sensit ivity and cultural competence interventions (Betancourt, 2004). It is also important to note that the terms cultural competence and cultural sensitivity have multiple definitions that have often been used inter-changeably in the health care literature, leading to criticisms regarding the lack of shared and validated definitions of these terms in the existing literature (e.g. Beach et al., 2006). Moreover, despite the focus on patient-centered care that has been emphasized by national health care organizations (e.g., IOM, 2002), definitions of cultural competence and cultural sensitivity, and interventions based on those definitions, have often excluded the perspectives of patients. Rather, definitions and models of cultural competence and/or sensitivity have largely been derived from the expert opinions of physicians and other health care providers (e.g., Thom, Tirado, Woon & McBride, 2006, p. 1). In an effort to invite patients perspectives into the literature on health and health care disparities, Tucker and her colleagues conducte d a program of research focused on assessing patient-identified needs among low-income and raci al/ethnic minority patien ts with regard to their health care, and developing interventions focused on addressing these needs (Tucker et al., 2003; Tucker, Herman et al., 2007). These resear chers coined the term patient-centered culturally sensitive health care, which they assert differs from existing constructs in the literature in its emphasis on a ssessing and being responsive to patients needs/desires and
15 involving patients as active partne rs in their health care. Specif ically, patient-centered culturally sensitive health care is cultural competence pl us and (a) emphasizes displaying patient-desired modifiable provider and staff beha viors and attitudes, implementing health care center policies, and displaying physical health car e center environment characteristics that culturally diverse patients identify as indicators of respect for their culture and that enable these patients to feel comfortable with, trusting of, and respected by their health care providers and office staff; (b) conceptualizes the patient-provi der relationship as a partnershi p that emerges from patientcenteredness; and (c) is patient empowerment orie nted (Tucker, Herman et al., 2007). Supporting Tucker and her colleagues assertions that pati ent-centered culturally sensitive health care differs from constructs such as cultural competence and cultural sensitivity is research suggesting that even when health care providers have the stated goal of patient empowerment practices such as involving patients as health care partners, these providers often undermine their stated goal in covert and subtle ways that are per ceived by patients (e.g., Paterson, 2001). In an attempt to address the lack of models and empirical research re lating constructs such as patient-centered culturally sensitive health car e to patients health st atus outcome variables, Tucker, Herman et al. (2007) recently proposed a literature-based Patien t-Centered Culturally Sensitive Health Care (PC-CSHC) Model to explain linkages among (a) patient-centered culturally sensitive health care interventions, (b) the experience of patient-centered culturally sensitive health care by low-income and racial ly/ethnically diverse patients who use communitybased physical health care clinics, and (c) these patients health outcomes/statuses. This Model suggests that (a) patient-centered culturally se nsitive health care tr aining promotes patientcentered culturally sensitive hea lth care, as indicate d by physical environment characteristics and policies of the health care clinic, provider behavi ors and attitudes, and office staff behaviors and
16 attitudes; (b) this care influences patients perc eived levels of provider cultural sensitivity and interpersonal control, both of which impact patien ts level of engagement in a health promoting lifestyle and level of health care satisfaction; (c) the latter influences patients level of treatment adherence; and (d) both level of treatment adhe rence and level of engagement in a health promoting lifestyle directly influence patients health outcomes/statuses. The PC-CSHC Model is depicted in Figure 1. Using the PC-CSHC Model as a guiding fram ework, the proposed study will investigate the impact of a pilot Patient-Centered Culturally Sensitive Health Care Intervention Program (the PC-CSHC Intervention Program) on health status outcomes of low-income African American patients and White patients diagnosed with hyperten sion alone, or in combination with diabetes, coronary heart disease and/or high cholesterol. In so doi ng, the proposed study seeks to contribute empirically to the literature suggestin g that patient-centered culturally sensitive health care educational and training interventions are necessa ry at every learner leve l of the health care system, consistent with mandates issued by the OMH (2001). Ultimately, the goal of the proposed study is to address the health and heal th care disparities problem. This goal is aligned with calls for counseling psychologists to: (a ) use their knowledge of counseling theories, research, and practice to addre ss the pressing health and health care challenges facing the United States (Carter, 2003); (b) be more involved in behavioral medicine and health psychology (Altmaier, 1991; Klippel and DeJoy, 1984); and (c ) more clearly demonstrate their commitment to the social justice identity of the field thr ough the elimination of social ills such as oppression and inequality (Baluch, Pieterse, & Bolden, 2004; Helms, 2003; Speight & Vera, 2004; Vera & Speight, 2003).
17 Based on Tuckers PC-CSHC Model the following hypotheses will be examined in the proposed study: (1) Following the implementation of a pilot PC-CSHC Intervention Program at a primary care clinic (i.e., the intervention clinic), an intervention group of patients who participate in the program (i.e., adult primary care African Americ an patients and White patients from primarily low-income backgrounds who have been diagnosed with hypertension alone, or in combination with diabetes, coronary heart dise ase, and/or high cholesterol) wi ll evidence significantly higher ratings of perceived cultural sensitivity in provide r and office staff behaviors and attitudes, and in their health care clinic environment (i.e., phys ical characteristics a nd policies) than will a control group of patients who ar e demographically and medically similar to the intervention group participants, and who receive care at a primary care clinic that is similar to the intervention clinic, but who are not exposed to the PC-CSHC Interven tion Program (i.e., the control clinic). (2) Following the implementation of the PC -CSHC Intervention Program mentioned in Hypothesis 1, the patients who participate in the PC-CSHC Program (i.e., the intervention group at the intervention clinic ) will evidence significantly lower di astolic and systolic blood pressure readings than will the patients who are not exposed to the intervention program (i.e., the control group at the control clinic). The following 2 exploratory research questions will also be investigated: (1) Among the patient research participants in the proposed research, are there significant differences in their perceived cultural sensitivit y ratings at baseline (i.e ., prior to implementing the PC-CSHC Intervention Program) in associati on with gender or group (i.e., control vs. intervention)?
18 (2) Among the patient participants in the proposed research, are there significant differences in health outcomes (i.e., diastolic an d systolic blood pressure readings) at baseline (i.e., prior to implementing the PC-CSHC Intervention Program) in association with race (i.e., African American vs. White), gender, or group (i.e., control vs. intervention)? Patient Health Outcome/Status Variables Patient-Centered Culturally Sensitive Health Care Patient-Perceived Cultural Sensitivity Patient-Perceived Interpersonal Control Patient-Centered Culturally Sensitive Health Care Intervention Program Physical Health Care Environment Provider/Staff Behaviors Patient Behaviors Patient Treatment Adherence Patient Satisfaction Patient Health Promoting Lifestyle Figure 1-1. The Patient-Centered Culturally Sensitive Health Care Model (PC-CSHC Model).
19 CHAPTER 2 REVIEW OF THE LITERATURE This chapter presents an overview of the ex isting literature that addresses the need for patien t-centered culturally sensitive health care interventions and for examining the impact of such interventions on patient health outcomes. First, a discussion of the health disparities problem underlying growing national calls for patient-centeredness, cultural competence and cultural sensitivity in the health care delivery pro cess is presented. The literature on hypertension is given special attention as hypertension is a major health disparity problem one that disproportionately affects racial and ethnic minorities. Second, th e roles of patient-centeredness, cultural competence, and cultural sensitivity in solving the health disparities problem are explored. Third, recently advocated patient-centered culturally sensitive health care to help solve the health disparities problem is define d and differentiated from similar health care orientations set forth in the heal th care literature. Fourth, the Tu cker Patient-Centered Culturally Sensitive Health Care (PC-CSHC) Model that theorizes linkages between patient-centered culturally sensitive health care and health outcom es is described and the literature supporting the model is presented. Finally, the Patient-Centere d Culturally Sensitive Health Care (PC-CSHC) Intervention Program tested in the proposed rese arch is briefly descri bed and research on each sub-component of this intervention program is pr esented. In each instance the relevance of the literature to the proposed study wi ll be discussed, and the manner in which the proposed study extends the existing lite rature is highlighted. The Health Disparities Problem Underlyi ng National Calls for Patient-Centered, Culturally Competent, and Culturally Sensitive Health Care Prevalence of Health Disparities W ithin the past three decades several reports issued by the United States Department of Health and Human Services (HHS) and other go vernmental and non-governmental agencies have
20 focused on: (a) highlighting the prominent health disparities that exist between majority groups and the primary racial and ethnic minority groups (i.e., African Americans, Asian Americans/Pacific Islanders, Hispanics, and Native Americans), among the primary racial and ethnic minority groups, and between higher and lower income groups; and (b) identifying strategies to eliminate these disparities (e .g., Agency for Healthcare Research and Quality [AHRQ], 2003, 2005; HHS, 2000). In the National Healthcare Disparities Report ([NHDR]; AHRQ, 2003), which was the first a nnual report on health care disp arities intended to provide a balanced summary of the state of health and health care disparities in the U.S., it was stated that although the health of Americans in the past 100 years has improved overall, the following were also true: (a) clear disparities persist in life span, health status, and health care use among different racial, ethnic, and soci oeconomic groups in the U.S.; (b ) the number of Americans who are vulnerable to experience the effects of such di sparities is expected to increase over the next 50 years; and (c) disparities are pervasive national problems affecti ng health care at all points in the process, at all sites of care, and for many medical conditions. Importantly, the findings of the 2005 NHDR were largely consistent with the firs t NHDR, and demonstrated that disparities related to race, ethnicity, and socioeconomic status continue to pervade the American health care system (AHRQ, 2005). According to the Centers for Disease Control and Prevention ([CDC], 2005), the following six health areas particularly reflect the disparit ies that affect multiple racial and ethnic minority groups at all life stages: infant mortality, can cer screening and management, cardiovascular disease (CVD), diabetes, HIV infections/AIDS, and immunizations. The incidence, mortality, and survivorship statistics associated with these health areas are alarming.
21 The U.S. ranks poorly relative to other industrialized nations on infant mortality, and there are large disparities by race, ethnicity, and socio economic status (Shi, Stevens, Wulu, Politzer & Xu, 2004; Wise, Kotelchuck, Wilson, & Mills, 1985). In fact, the infant mora lity rate for African American infants is more than twice the rate for White infants (13.6 deaths per 1,000 live births for African Americans vs. 5.7 deaths per 1,000 live births for Whites); and among American Indian and Alaska Native populations, the death rate is 51% higher than among White individuals (OMH, 2007b). In addi tion, although the infant mortality rate for Hispanic infants and White infants is the same, the infant morta lity rate within the Puer to Rican subgroup is 40% higher than Whites (OMH, 2007b). With regard to cancer, compared to non-Hispanic Whites, Hispanics have higher rates of cervical, esophageal, gallbladder, and stomach cancers; Asian Americans have higher rates of stomach and liver cancers; and Alaska Natives ha ve higher rates of colo rectal cancer (AHRQ, 2003). The incidence of cancer amon g African Americans is approximately 35% higher than for non-Hispanic Whites, and African American men ha ve the highest prevalence of prostate cancer in the world (Bennett, 2004). In addition, Hispanic women are twice as likely to die of cervical cancer as non-Hispanic White wo men, and are more likely to die of breast cancer than are women of any other racial or ethnic group (CDC, 2005). Furthermore, it has been reported that cancer survival is lower among African American s compared to non-Hispanic Whites for almost all cancers regardless of site or stag e of treatment (Ghafoor et al., 2002). The statistics for cardiovascular disease (C VD) are equally striking. Heart disease and stroke are the leading causes of death among all racial and ethnic groups in the U.S. (CDC, 2005). However, compared to non-Hispanic White s, heart disease deaths are higher among African Americans and lower among Hispanics, Asian Americans, and American Indians
22 (AHRQ, 2003). Among African Americans and Hispanics age 20, stroke incidence is almost 2.5 times higher as compared to non-His panic Whites (Bennett, 2004). In addition, hypertensionan important risk factor for CVDis 40% more prevalent among African Americans compared to non-Hispanic Whites; and, African Americans develop hypertension at an earlier age, experience a more severe course, and are at higher risk for problems such as kidney failure and hypertension-related deat h (Meyers, Wollery, & Creswell, 2004). The CDC (2005) further reported that in 2000, Am erican Indians, Alaska Natives, African Americans, and Hispanics were all 2 to 3 times more likely to have diagnosed diabetes when compared to non-Hispanic Whites. The findings from the CDC were no less astonishing for HIV infections, AIDS, and immuniza tions. Although African Ameri cans and Hispanics together represented less than 30% of the U.S. populatio n in 2004, they accounted for 69% of adult AIDS cases and 78% of pediatric estimated AIDS cas es. Furthermore, in 2001, Hispanics and African Americans aged 65 and older were less likel y than non-Hispanic Whites to report having received influenza and pneumococcal vaccines. Numerous studies have also indicated an association between low socioeconomic status and the occurrence of heart disease, diabetes, obesity, low birth weight, and illness related to death (e.g., Adler et al., 1994; HHS 2000). In addition, the NHDR indicated that cancer death rates tend to be higher among people of lower socioeconomic class, and that persons of lower socioeconomic status are more likely to die from HIV (AHRQ, 2003). These and other differences in health status between the poor and the affluent are often a ttributed to unhealthy behaviors and inadequate access to health care among people of lower socioeconomic status. These factors, however, only accoun t for a proportion of the socioeconomic differences in health
23 (Institute Of Medicine [IOM], 2002; Lu, Samu els, & Wilson, 2004); health care disparities persist even when these factors are controlled. Factors Influencing Health Disparities A variety of biological (e.g., Collins, Green, Guttm acher, & Guyer, 2003), and social and environmental (e.g., Clark, Anderson, Clark, & W illiams, 1999; Johnson et al., 1995) factors have been associated with the health disparities problem among racial and ethnic minorities, and individuals from lower socioeconomic backgrou nds. However, the growing health disparities literature has increasingly sugge sted that social and environm ental factors are the largest contributors to the health disp arities problem (e.g., IOM, 2002), with sociocultural differences among and between patients, health care providers and the health care system being cited by health care experts as central c ontributors to the problem (Betan court, Green & Carrillo, 2002). More specifically, Betancourt (2006 ) indicated that the root causes of health disparities stem from: (a) health system factors, including issues related to the complexity of the health care system, and the disproportionate difficulty mi nority patients may experience navigating the system; (b) care-process variab les, including stereotyping am ong health care providers and clinical uncertainty due to poor communication between patients and providers; and, (c) patientlevel variables, including the refusal of services, poor adhere nce to treatment and delay in seeking care. The impact of health system f actors, care-process variables and patient-level variables on health care quality, health care a ccess, and patient-provider communication is discussed below. Health care quality The following are am ong the more striking resear ch findings regarding health care quality dimensions that have been reported in the health care literature: (a) African American enrollees in Medicare in the U.S. receive less primary and preventative care and experience higher rates of
24 amputations than non-Hispanic Whites (Gornick et al., 1996); (b) Af rican Americans and Hispanics with extremity fractures are less likely than non-Hispanic Whites to receive analgesics at emergency care departments (Todd, Deaton, D Adamo, & Goe, 2000); (c) ethnic and racial minorities and persons of lower socioeconomic status are less likely to receive cancer screening services (AHRQ, 2003); (d) African Americans, Asian Americans/Pacific Islanders, American Indians, and Alaska Natives are all less likely to receive a kidney transpla nt within 3 years of renal failure compared to non-Hispanic Wh ites (AHRQ, 2003); (e) racial, ethnic, and socioeconomic disparities in recommendations fo r and receipt of coronary revascularization procedures have been repeatedly demonstrated (Carlisle et al ., 1999; Hannan et al., 1999; Okelo et al., 2001; Schneider et al ., 2001; Watson et al., 2001); (f) diabetic patients of low socioeconomic position are less likely to receive some recommended diabetic treatment services (AHRQ, 2003); (g) primary care physicians focus mo re on biomedical than psychosocial aspects of their patients illnesses, especially when the patient s are African American and have low incomes (Roter et al., 1997); and (h) non-Hispanic Whites and men are more likely to be referred for cardiac catheterization than African Amer icans and women, respectively (Schulman et al., 1999). These findings clearly demonstrate that hea lth system factors and care-process variables, such as stereotyping, impact the quality of hea lth care that racial a nd ethnic minority and lowincome patients receive. In so doing, health syst em factors and care-pro cess variables contribute to the national health disparities problem. Health care access Access to he alth care typically refers to us ing health care services in a timely manner in order to achieve the best health care outcomes (Millman, 1993). Patients from racial and ethnic minority and low socioeconomic backgrounds are le ss likely to enter the health care system, and
25 are more likely to encounter structural barriers once they interact with the health care system (AHRQ, 2003). Entry into the health care system Entry into the health care system refers to the likelihood that an individual will (a) have health insurance covera ge and (b) have a usual source of health care (AHRQ, 2003). Multiple studie s suggest that racial and ethnic minorities and individuals from low socioeconomic backgrounds, particularly low-income non-White Hispanics, are more likely to be either uninsured or underinsured even when they have stable jobs (Doty & Holmgren, 2004; Hoffman, Schoen, Rowland & Davis, 2001). Individuals who lack health in surance and a usual source of care are more likely to delay seeking health care, to go without needed health care, and to have troub le paying their medical bills; furthermore, they are less likely to have a regular doctor, to have prescriptions filled, and to receive follow-up care following an emergency ro om visit (Klein, Glied, & Ferry, 2005). These individuals are subsequently at risk for a range of negative health-related outcomes including receiving less preventative care, receiving diagno ses at more advanced disease states, receiving less therapeutic care, and having po orer health statuses, all of wh ich have made lack of health insurance the sixth-leading cause of death among people ages 25 years (AHRQ, 2003; Davis, 2003; Schoen & DesRoches, 2000). Structural barriers within the system. Structural barriers to health care include factors that affect a persons ability a nd willingness to obtain health care and adhere to treatment recommendations of health care providers. The NHDR (AHRQ, 2003) concluded that African Americans and the uninsured are more likely to report waiting over one ho ur at the Emergency Room for semi-urgent or non-urgent care, and to report leaving the Em ergency Room without ever being seen. Geographic availa bility of health institutions and resources may also have a
26 differential impact on racial and ethnic groups (IOM, 2002). For instance, one study found that only 25% of pharmacies in predominantly non-W hite neighborhoods carri ed opioid analgesic supplies compared to 72% of pharmacies in predominantly White neighborhoods (Morrison, Wallenstein, Natale, Senzel, & Huang, 2000). Other stru ctural barriers to he alth care noted in the literature include poor transportati on to clinics, and an inability to schedule appointments during hours convenient to patients, especially those in low-skill or low-paying jobs (Millman, 1993). Patient-provider communication Am erican Indians and Alaska Natives, Asia n Americans/Pacific Islanders, African Americans, Hispanics, low-income populations, and individuals without a high school diploma are more likely than non-Hispanic Whites, individuals with middle and high income levels, and individuals who attended colle ge, respectively, to report poo r communication with their physicians (AHRQ, 2003). Pati ent-provider communication can be hindered by a number of factors, all of which may be associated with poorer health outcomes among patients. These factors include (a) differences in communica tion style and language between patients and providers, (b) levels of general il literacy and health illiteracy among patients, and (c) differences in healthand illness-related cultural beliefs held by patients and providers. Differences in communication style and language When health care providers give information and explanations to their patients, and show sensitivity, reassurance and support, their patients tend to have a greater understandin g of health issues and to be more committed to treatment recommendations (Suarez-Almazor, 2004). However, current research suggests that patients expectations of medical encounters ar e often not fulfilled (Platt et al., 2001; SuarezAlmazor, 2004). For example, African American s, Asian Americans, and Hispanics and low income populations are more likely to feel disenfranchised in the decision-making process compared to non-Hispanic Whites with highe r incomes (AHRQ, 2003). Furthermore, Johnson,
27 Roter, Powe and Cooper (2004) found that doctors we re less likely to engage African American patients in conversation compared to non-Hispanic White patients, and the tone of visits with African American patients was generally less friendly than with non-Hispanic White patients. Differences in patient-provider communication st yles and expectations can be exacerbated by differences in language between patients and physicians. In the year 2000, 47 million people in the U.S. spoke a language othe r than English at home, and almost 12 million people lived in households where no one was fl uent in English (Shin & Br uno, 2003). In fact, language differences and resulting poor communication ar e among the most challenging areas of serving immigrant and ethnically diverse patients (Cleme nt, 1992). A shortage of bilingual providers and trained professional interpreters, insufficient re imbursement for language services by insurers, and inadequate language services in medical settings may discourage non-English speaking patients from receiving and seeking care (Hornbe rger et al., 1996; Weech-Maldonado, Morales, Spritzer, Elliott, & Hays, 2001; Youdelman & Perkins, 2005). Levels of general and health illiteracy The IOM (2004) reported that approximately 90 million adults may lack the necessary literacy skil ls to effectively use the U.S. health system, with literacy levels being lower among the elde rly, those with lower educational levels, those who are poor, minority populations, and groups w ith limited English proficiency (e.g., recent immigrants). Furthermore, those who need heal th information the most often have the least access to it, as such information is often distri buted through sources with which racial and ethnic minorities, as well as individuals from low so cioeconomic backgrounds, may have less contact (e.g., the internet) (AHRQ, 2003). Ironically, a st udy of U.S. physicians revealed that the majority of them believed that the ability of thei r patients to speak English rarely or never have
28 played a role in any differences or disparitie s in health care that exist among their patients (Kaiser Family Foundation, 2002). Differences in cultural beliefs Communication between the provider and patient may also be affected by cultural factors other than language. Specifically, indi viduals from different cultural backgrounds (a) may construct their own meanings and explanations for illness and these constructions may conflict with the traditional Western biomedical model of medicine (Borrayo & Jenkins, 2003; Kundhal & Khundal, 2003), (b) may misrepresent symptoms to their health care providers, as certain illnesses and symptoms (e.g., symptoms of depression in many Asian cultures) are stigmatized in some cu ltures (Kundhal & Khundal, 2003), and (c) may avoid preventive care such as breast cancer screening due to cultural health beliefs about the causes and risks associated with various diseases (e.g., Borrayo & Jenkins, 2003; Mitchell, Lannin, Mathews, & Swanson, 2002; Palmer, Fernandez, Tortolero-Luna, Gonzales, & Mullen, 2005). Furthermore, as many as 50% of patients w ho require health care use complementary and alternative medicines (e.g., herb al remedies), and the major ity of these patients do not communicate this information to their phys icians (Robinson & McGrail, 2004); yet, complimentary and alternative medicines may interfere with conven tional treatments. Nondisclosure of the use of these medicines can t hus impact patients well-being and chances of survival (Tasaki, Maskarinec, Shumay, Tatsumura, & Kakai, 2002). Hypertension: A Major Health Disparities Pr oblem that Negatively Impacts Racial and Ethnic Min orities According to the HHS Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Trea tment of High Blood Pressure (HHS, 2003), there are four blood pressure classifications: normal, prehypertension, stage 1 hyperte nsion, and stage 2 hypertension. Individuals with a systolic blood pressure of less than 120 mmHg and a diastolic blood pressure
29 of less than 80 mmHg are classi fied as having normal blood pr essure. Individuals with prehypertension have a systolic bl ood pressure that ranges from 120 to 139 mmHG, or a diastolic blood pressure that ranges from 80 to 89 mmHg. Individuals with stage 1 hypertension have a systolic blood pressure that ranges from 140 to 159 mmHg, or a diastolic blood pressure that ranges from 90 to 99 mmHg. Finally, individu als who are classified as having stage 2 hypertension have a systolic blood pressure that is greater th an or equal to 160 mmHg or a diastolic blood pressure that is greater than or equal to 100 mmHg. The proposed study focuses on adult male and female African American a nd White primarily low-income patients with prehypertension, stage 1 hypertensio n, or stage 2 hypertension, alone or in combination with one or more other chronic health problems (i.e., di abetes, coronary heart disease, and/or high cholesterol). Adult patients with hypertension alone, or hype rtension in combination with other chronic problems were chosen as the target population fo r the proposed study for several reasons. First, hypertension or high blood pressure affects appr oximately 50 million individuals in the United States (HHS, 2003); however, most persons with hypertension do not have their blood pressure under control, and among this group the pr oportion who are aware of having a high blood pressure is higher among women than among me n (CDC, 2005). Second, hypertension (i.e., stage 1 or stage 2) continues to be more pr evalent among racial and ethnic minorities. For example, the OMH reported that African American s are 1.5 times more likely than non-Hispanic Whites to have high blood pressure, and Americ an Indian/Alaska Native adults are 1.3 times more likely than White adults to have high blood pressure (OMH, 2007a). Third, the relationship between blood pressu re and CVD is continuous, consis tent and independent of other risk factors the higher the blood pressure, the greater the chance of heart at tack, heart failure,
30 stroke, and kidney disease (HHS 2003). Importantly, the CDC (2005) has identified CVD as one of the six areas that most reflect dispari ties among racial and et hnic minorities. Fourth, hypertensive patients, especially those with othe r chronic conditions, have the challenge of being adherent to multidimensional treatment regimens over long periods of time; therefore, they are required to interact with health care providers and o ffice staff personnel who may or may not be culturally sensitive. As such, testing the impact of a patient-centered culturally sensitive health care intervention program on the h ealth outcomes of hypertensive patients is extr emely relevant to the health disparities literature. Solving the Health Disparities Problem: Th e R oles of Patient-Centeredness, Cultural Competence, and Cultural Sensitivity The disparities in health and health care, in cluding those related to hypertension, have been clearly documented and have been found to be larg ely attributable to so ciocultural differences among and between patients, health care provi ders, and the health care system. Patientcenteredness, cultural competence and cultural sensitiv ity are all constructs related to health care movements that have focused on addressing these sociocultural differences. As such, promotion of patient-centeredness, cultural competence, an d cultural sensitivity have been put forward as integral components of any interventions or strate gies launched to address the health disparities problem. Defining Patient-Centeredness In their paper summ arizing the role of patie nt-centeredness in health care quality, Beach, Saha, and Cooper (2006) suggested that core f eatures of patient-cen teredness include: (a) understanding the patient as a unique person, (b) e xploring the patients experience of illness, (c) finding common ground regarding treatment through shared decision-making, and (d) emphasizing the development of the doctor-patient relationship. These authors concluded that,
31 in essence, patient centeredness involves perceiving and eval uating health care from the patients perspective and then adapting care to m eet the need and expectat ions of patients (p. vi). Echoing these sentiments, the 2001 IOM report, Crossing the Quality Chasm described compassion, empathy, and responsiveness to the need s, values, and expressed preferences of the patient as hallmarks of patient-centeredness. Defining Cultural Competence Wu and Martinez (2006) define d cultural com petency as, A system of health care services delivery in which care and services are provided in a way that respects the patient and results in each patient receiving equal care regardless of cultural background, national origin, race or et hnicity, English-language fluency, literacy level, socioeconomic status, or other relevant factors (p. 1) In a similar vein, Betancourt, Green, Carri llo, & Ananeh-Firempong (2003), suggested that cultural competence entails understa nding the importance of social and cultural influences on patients health beliefs and behaviors, considering how these factors interact at multiple levels of the health care delivery system, and devising inte rventions that consider these issues to assure quality health care delivery to diverse patient populations. Betancourt et al. also proposed a three-level framework for achieving cultural competence that includes: (a) organizational cultural competence interventions, designed to ensu re that the leadership and workforce of the health care delivery system is dive rse and representative of its population; (b) structural cultural competence interventions, designed to ensure that the structural processes within a health care delivery system allow full access to quality health care for all of its patients; and (c) clinical cultural competence interventions, designed to e nhance provider knowledge of the relationship between soicocultural factors and health beliefs and behaviors a nd to equip providers with the tools and skills to manage these factors appropriately.
32 Defining Cultural Sensitivity The term s cultural sensitivity and culturally sens itive health care have often been used interchangeably with the term cultural competence in the health care litera ture. In fact, in their review on the evidence base for cultural co mpetency in health care, Goode, Dunne, and Bronheim (2006) searched health databases us ing both cultural competence and cultural sensitivity as keywords, thus acknowledging the tendency for health care researchers to consider the terms equivalent. Indeed, a lthough Resnicow, Baranowski, Ahluwalia, and Braithwaite (1999) suggest that cu ltural competence is a descriptor of practitioners, and cultural sensitivity is a descriptor of messages and ma terials (Resnicow et al., 1999), definitions of cultural sensitivity are often similar to those offered for cultural competence. For example, Majumdar, Browne, Roberts, and Carpio (2004) defined cultural sens itivity as, an ongoing awareness of cultural differences and similariti es among populations. It is the need to be responsive to national and racial characteristics (p. 162). Othe r authors consider cultural sensitivity as one of several dimensions of cultural competence (e.g., Kim-Godwin, Clarke, & Barton, 2001). Given the tendency for the terms cultural competence and cultural sensitivity to be used interchangeably in the health disparities literature, for the remainder of this literature review, the more widely used term cultural competence (broadly defined to include cultural sensitivity), will be focused upon in describing relevant theoretical, assessment and outcome research. Beach et al. (2006) suggested that while patie nt-centeredness and cultural competence both aim to improve health care quality, they emphasi ze different aspects of quality. Whereas patientcenteredness movements aim to elevate quality for all patients, moveme nts focused on cultural competence aim to balance quality, to improve equity, and reduce disp arities by specifically improving care for people of color and other disa dvantaged populations. Beach et al. further
33 contended that patient-centered and culturally competent health care systems and health care interactions are both integral for individualized and equitable care that is safe, effective, efficient and timely, and that such high quality car e leads to improved health outcomes. Do Patient-Centeredness and Cultural Competence lead to Improvements in Health Outcome s? Although some experts in the field have advocat ed for cultural competency as a matter of social justice, regardless of its impact on outcomes (Branch & Fraser, 20 00), the assumption that patient-centered and/or culturally competent inte rventions can lead to improved health outcomes has been the primary impetus for national calls for patient-centered and culturally competent care. For example, the IOM (2002) included pa tient-centered care among its 6 domains for improving quality of care for patient outcomes. Yet, very little empirical research actually exists that links patient-centered and/or culturally competent care to improvements in patient health outcomes (Betancourt et al., 2002; Kim-Godwin et al., 2001). In part, this lack of empirical evidence is attributable to: (a) a lack of clear and testable models that clearly describe a path through which cultural competence and/or patient -centeredness could impact health outcomes and (b) problems with assessing patient-centeredness and cultural competence. Overview of existing models associating cu ltural competence and/or patient-centeredness w ith patients health outcomes Kazdin (2003) indicated that to understand human functioning and phenomena of interest (e.g., the health disparities problem), we should not simply collect facts or empirical findings; rather, we should aim to relate these findings to each other and to other phenomena in a cohesive way. Theoretical and/or conceptu al models offer one mechanism for understanding associations among related phenomena. As previously described, a large literature now ex ists that empirically documents the existence of health and health care disparities, and ma ny experts in the field suggest that cultural competence and patient centeredness are ke y components to reducing or
34 eliminating these disparities through improving he alth outcomes. However, few models have been proposed in the literature that clearly specify how increases in cultural competence and/or patient centeredness in health care could contribute to improved h ealth outcomes among patients. Furthermore, those that do exist often l ack specific and measurable constructs. For example, Kim-Godwin et al. (2001) propos ed a model for the delivery of culturally competent community care that linked cultural co mpetence to health outcomes. This model is comprised of three sets of constructs: (a) cultural competence, whic h consists of four interdependent dimensions including caring (attitudes, judgments and ac tions that show support and professional skills), cultural sensitivity (the desire and effort to develop programs and services in a manner that resp ects the cultural diversity of populations), cultural knowledge (knowledge of integrated systems of learned behavior that are characteristic of members of groups and their system of attitudes, feelings, and values) and cultural skills (abilities, roles and functions in community settings); (b) the health care system, which consists of an integration of a complex array of other systems including the cu ltural system, the community system, and the health system; and (c) health outcomes, which refer to public health indicators such as incidence and prevalence rates. These authors proceeded to develop and test a measure of cultural competence (the Cultural Competence Scale) in order to test the dimensions of cultural competence set forth by the model, but failed to specify how the cultural competence dimensions could be empirically linked to health outcomes through the health care sy stems pathway that is stipulated by the model. Beach et al. (2006) outlined a model that br oadly suggested that patient-centered and culturally competent health care systems and health care interactions would lead to individualized (i.e., patient-ce ntered) and equitable care, whic h would improve the quality of
35 care in terms of safety, effectiveness, efficienc y, and timeliness, which would in turn lead to improved health outcomes. Though intuitively compe lling, the lack of specificity of the models constructs impedes the generation of testable hypotheses from the model. In their conceptual model that attempted to link cultural competency to eliminating racial and ethnic health disparities, Branch and Fras er (2000) perhaps outlined the most specific published model linking cultural competence to imp roved outcomes in the published literature. Based on a review of the cultural competency literature between 1990 and 2000, these authors suggested that cultural competency techniques could be clustere d into nine categor ies: interpreter services, recruitment and retention, training, co ordinating with traditional healers, use of community health workers, culturally competent health promotion, inclusion of family and/or community members, immersion into another culture, and administrative and organizational accommodations. Branch and Fraser then proposed a model s uggesting that cultural competency techniques could potentially change both clinician and client behavior by (a) improving communication, (b) increasing trust, (c) creating a greater knowledge of the diffe rences among racial and ethnic groups in epidemiology and treatment efficac y, and (d) expanding understanding of patients cultural behaviors and environments. These auth ors further suggested that these behavior changes could lead to the provi sion of more appropriate servi ces such as (a) prevention and screening activities being undertaken with full knowledge of risk factor s, (b) better informed diagnoses, and (c) treatment related patient educ ation that is culturally tailored to improve adherence. Finally, the model suggests that the provision of these more appropriate services would lead to improved outcomes such as higher levels of health status, in creased overall functioning,
36 and improved satisfaction among patients. The fact that Branch and Frasers conceptual model has not been tested empiricall y, despite being proposed several years ago, may speak to the models complexity and the lack of adequate measures to assess the techniques associated with the delivery of culturally comp etent and patient-centered care. Assessing cultural competence and patient-centered care Much of the literature on assessing cultural competence has focused on the effectiveness of cultural competency educational and training initia tives. This literature consistently suggests that assessing the effectiveness of cultural competen ce and patient centered care is limited because there is no consensus on the defi nition of cultural competence, and no standard curricula or universally accepted certificati on or credentialing for cultura l competence (e.g., OMH, 2001; Betancourt, 2003). Price et al. (2005) documented further limitatio ns in a systematic review of empirical studies evaluating cultural comp etence training of health professionals between 1980 and 2003. Their review yielded 64 articles that met the follo wing inclusion criteria: (a) they were written in English, (b) they were publishe d after 1980, (c) they included huma n data or original data, (d) they had a full article available fo r review, (e) they were relevant to minority health, (f) they had an intervention or had an eval uation of an intervention, and (g ) they targeted health care providers or organizations. Analysis of the 64 articles included in the revi ew led Price et al. to conclude that studies evaluating cultural competence training of health professionals lack methodological rigor in five quality domains: (a) repres entativeness of the target ed providers (e.g., most of the studies lacked an adequate description of th e setting and population from whic h study subjects were drawn and few adequately described provider demographics); (b) completeness of th e description of the intervention (e.g., most articles cl early stated their objectives, but only 21 described interventions
37 with enough detail to facilitate replication of them); (c) potential for bias and confounding (e.g., only 8 studies employed concurrent and simila r comparison groups); (d) outcome assessment (e.g., only 27 studies used objective evaluation stra tegies such as written examinations or validated self-efficacy scales, and 15 studies re ported outcomes that did not match the study objectives); and (e) reporting analytic approach (e.g., only 14 of the 64 studies reported the number and reasons for noninclusion of data in the analysis and only 15 studies reported the magnitude of the difference between groups and an index of variability). Based on their review, Price et al. concluded th at, the quality of evidence from interventions to improve cultural competence of health professionals is generally poor.[and] of particular concern is that the quality of the literature does not appear to be consistently impr oving over time (p. 583). Assessing cultural competency training progr ams is further compromised because, although many assessment tools continue to be de veloped and reviewed, th ese assessments have not been rated against each other or validated, subsequently making it difficult to determine and compare the effectiveness of cultural competence education and training programs (Hobgood, Sawning, Bowen & Savage, 2006; OMH, 2001). Furthermore, courses on cultural competence may pose significant challenges for evaluation because : (a) the effects of social desirability may bias evaluations of attitudes about race, ethnicity, class and cultu re; (b) measures that evaluate knowledge or facts do not necessarily capture the fluidity of culture and diversity among different racial, ethnic and cultura l groups; and (c) less than favor able evaluations may be given to courses that require students to discuss personal and priv ate perceptions about race, ethnicity, culture and class because such courses may be viewed negatively (Betancourt, 2003). Standard 9 of the OMHs national standards for culturally and lingui stically appropriate services (CLAS) in health care states: health care organizations s hould conduct initial and
38 ongoing organizational self-assessments of CLAS -related activities and are encouraged to integrate cultural and linguistic competence -related measures into the internal audits, performance improvement programs, patient sa tisfaction assessments, and outcomes-based evaluations (OMH, 2001, p. 88). However, organi zational cultural competency assessments perhaps face greater challenges than those associated with assessing health care personnel. For example, much of the existing cultura l competency literature focuses on the importance of cultural awareness, knowledge, attitudes and skills of individuals, without describing how health systems can become cultura lly competent, and most articles describe a single approach to cultural competency, making it difficult for health systems to identify an overview of techniques available to them (Bra nch & Fraser, 2000). In addition, the dearth of literature addressing the costs and benefits to the system resulting from cultural and linguistic competency interventions represents a significant barrier to attracting i nvestments from health care organizations already burde ned with burgeoning health car e expenditures. Finally, funding shortages may impact coalitions and grant-funde d projects aimed at investigating and achieving organizational competence (Chrisman, 2007). Importantly, efforts have been made to addre ss these gaps in the literature. For example, experts in the field have o ffered frameworks for achieving organizational competency (e.g., Chrisman, 2007; Thompson-Robinson et al., 2006) Furthermore, the OMH final report on the CLAS standards included recommendations for tools for organizationa l self-assessment of cultural competence (OMH, 2001). In addition, researchers are beginning to assess the business case for cultural competency (e.g., Goode et al., 2006) Perhaps in response to such initiatives, it appears that a growing number of organizations in academia, government, managed care and community health care are overcoming the challe nges associated with integrating cultural
39 competency into health care systems (Betanco urt et al., 2002; Betancour t, Green, Carrillo, & Park, 2005; Wu & Marinez, 2006), and developi ng measures and benchmarks for assessing organizational cultural competency (e .g. Siegel, Haugland, & Chambers, 2003). Ngo-Metzger et al. (2006) a ddressed another important i ssue in assessing cultural competency that has been often neglected in the literature. These author s suggested that, given the emphasis on patient-centeredness in the health care literatur e, measuring the quality of culturally competent care should involve obtaini ng the patients perspectives. These authors further indicated that obtaining patients perspect ives was particularly important when measuring five of multiple domains that the authors beli eve contribute to culturally competent care. Whereas the first two of these domains involve in teractions between patients and providers, the last three involve patient-provider interactions as well as patients interactions with other health care staff and the health care system overall. The five domains are: (a) patient-provider communication, (b) respect for patient preferen ces/shared decision-making, (c) experiences leading to trust or distrust, (d ) experiences of discrimination, a nd (e) linguistic competency. Yet, cultural competence has historically been, and continues to be, assessed primarily from the providers perspective. For example, in a system atic review of health care provider education interventions designed to imp act cultural competence among providers, only 4 of 34 studies reviewed assessed cultural competence from the patients perspectives (Beach et al., 2005). Overview of the existing evidence associatin g general patient-centered and/or cultural competenc e interventions with patients health outcomes In a recent report assessing the evidence for cu ltural and linguistic competency in health care, Goode et al. (2006) sugge sted that the lack of empi rical evidence linking cultural competence to health outcomes is indicative of the developmental stage of the field. As with most new areas of complex research, most of the present literature focuses on defining concepts
40 and issues and identifying important research questions. Goode et al. conducted a literature review of studies focused on cultural and/or linguistic competence from January 1995 to March 2006 and found 365 studies that addressed cultu ral and linguistic competence and health outcomes and well-being; however, only 25 of these studies used experimental designs focused on outcome research, with the majority of thes e studies focused on pract ice or service delivery (i.e., clinical and structural cultural co mpetence interventions), and only 1 focused on organizational or policy levels (i .e., organizational cultural comp etency interven tions). Notably, the studies reviewed focused on a range of the culturally co mpetent intervention techniques described by Branch and Fraser (2000) including interpreter serv ices, training, use of community health workers, culturally competent health pr omotion, inclusion of fa mily and/or community members, and administrative and organizationa l accommodations. Unfortunately, Goode et al. were unable to determine the differential impact of various techniques from the information available. Based on their review of the l iterature, Goode et al. concl uded that the current evidence provided supports the efficacy of cultural and linguistic competency interventions at the organizational and practice levels, in terms of in termediate outcomes of short-term interventions, such as increased rates of cancer screening, impr oved adherence to treatment regimens, or better physiologically based measures. However, at the ti me of the review, none of the studies directly addressed the ultimate outcome of decreased in cidence of a disease fo r a population, or decrease in morbidity or mortality as a result of the intervention used. It is additionally noteworthy that none of the studies included in the Goode et al. review focused specifically on training interventions, making it difficult to isolate th e impact of training interventions on health outcomes among patients.
41 Furthermore, Goode et al. identified the following problems with the 25 studies using experimental designs to examine the associations between cultural and linguistic competence and health outcomes that were reviewed: (a) studies initiated an intervention with a sample from only one diverse racial or ethnic group ; (b) studies often called an inte rvention culturally competent or a related term, but without fully describing or defining the culturally competent terms or elements; (c) studies often did not isolate cultural competency as an independent variable in the design and did not measure its sole effects; (d) studies often did not include a control group; (e) studies compared interventions to groups that received a differe nt intervention, thereby making it difficult to interpret the results; and, (e) studies reported the re sults of the intervention as a whole, making the results difficult to interpret. Goode et al.s suggestions for future research in the area included the following: (a) use of validated and shared definitions of cultural co mpetence; (b) refined population definitions to include cultural variables other th an race, ethnicity or language; (c ) use of designs that test the specific effects of cultural competence; (d) im plementation of longitudinal and large sample studies to investigate ultimate health outcomes; and (e) use of methods and measures that examine the relationship among organizational polic ies, structures and practices, quality and effectiveness of care, and hea lth outcomes and well-being. General characteristics of health care provide r cultura l competence training interventions In their final report on the national standard s for CLAS in health care, the Office of Minority Health in the HHS (OMH 2001) indicated that staff e ducation and training was likely the single most important element in ensuri ng the cultural and linguist ic competence of an organization. Health care provide r training interventions have va ried with regard to training level, training content, and cont act time. For example, in the B each et al. (2006) review, of the 34 intervention programs reviewed, 21 programs ta rgeted pre-professionals (i.e., students), 1
42 program targeted residents/fellows, 1 program ta rgeted pre-professionals and residents/fellows, 9 programs targeted professionals, and 1 program targ eted professionals and residents/fellows. In addition, programs differed in terms of the degr ee to which the curricular content focused on specific cultural content, general concepts of cu lture, racism, doctor-patient interactions, gender, access, and socioeconomic status, with some pr ograms focusing on as many as four of these content areas, and others focu sing on only one content area. Programs further differed in their contact time with program participants, varying from one four-hour session total to sessions of varying leng th that were held over a 4-year period of time. Importantly, Beach et al. concluded that both lo nger and shorter duration interventions were associated with positive outcomes. In addition, curricular content focusi ng on general concepts of culture and specific cultural information (alone and together) were also associated with positive outcomes. However, more recently, there have been calls for a more exclusive focus on each of these content areas (e.g., Brathwa ite & Majumdar, 2006; Eiser & Ellis, 2007). Cultural competence training interventions ha ve also included a va riety of curricular methods. For example, the curricular training met hods reported in one or more of the 34 studies included in the Beach et al. (2005) review of health care provider educational interventions are: (a) audio/visual (7 studies), (b) group discussions (17 studies), (c) case scenarios (12 studies), (d) clinical experiences (10 studies), (e) interviewi ng members of another cu lture (6 studies), (f) lectures (15 studies), (g) cultura l immersion experiences (7 studies ), (h) demonstrations or role modeling (5 studies), (i) language lessons (3 studies), (j) food shopping/planning (1 study), (k) hospital tours (1 study), (l) cultu ral and history learning (1 study), (m) drill/practice exercises (3 studies), (n) brainstorming (2 studies), (o) conduction of commun ity activities (1 study), (p) community service (1 study), (q) home visits (1 study), (r) outreach w ith national prevention
43 organization (1 study), (s) written assignments (1 study), (t) visits to loca l hospitals and health centers (1 study), (u) field trips into patient co mmunities (1 study), (v) web pages (1 study), (w) written and verbal presentations (1 study), (x) s imulations of clinical encounters (1 study), (y) personal experiences (1 study), and (z) wr itten cultural autobiography (1 study). Interestingly, 6 studies described training programs that used 1 curricular method, 21 studies described programs that combined betw een 2 or 3 curricular methods, and 6 studies described training programs that combined betw een 5 and 9 curricular methods. Notably, Beach et al. concluded that experientia l as well as non-experiential inte rventions were associated with positive outcomes. However, these authors were unable to conclude which types of training interventions were most effective in impacting targeted outcomes (i.e., health care provider knowledge, attitudes and skills) due to the hetero geneity and intermingli ng of curricular content and methods. In addition, more recent research suggests that having both affective/experiential and cognitive components may be more benefici al (e.g., Caffrey, Neander, Markle, & Stewart, 2005) In a similar effort to organize the literature on teaching culturally appropriate health care, Hobgood et al. (2006) conducted a re view of educational models and methods, and suggested that there are 6 primary educati onal models used to teach cultural competency to health care providers. These models include: (a) portfolio m odels, which comprise activities focused on selfevaluation and self-reflection; (b) cultural immersion models, which emphasize cultural exposure; (c) literary or media models, which employ poetry, movies, shor t stories, and other media to explore culture, relations hips and difficult patient interactions; (d) clinical experience models, which employ clinical experiences in cu ltural competency trainings; (e) simulation models, which use structured clinical exams and other simulations to teach and assess cultural
44 competency skills; and (f) didactic models, which employ lectures and small group discussions in cultural competency trainings. However, consistent with the Beach et al. review findings, Hobgood et al. suggested that trai ning programs often use a mixedmethod approach that offers more than one type of educational experience. More recent examples of mixed-method training programs that have been reported in the literature include a five-component cultural competence course that targeted public he alth nurses in Canada, and which primarily used didactic and simulation educational approaches (Brathwaite, 2005); and a one-year course offered at the School of Health Professions and Studies at a University of Michigan commuter campus, which employed didactic, literary, clin ical, portfolio, cultural immers ion, and simulation educational experiences (Selig, Tropia no, & Greene-Moton, 2007). Overview of existing literature associating culturally competent health care provider training in terventions with health care delivery In an attempt to critically evaluate the imp act of health care provider training interventions on health care delivery, Beach et al. (2005) performed a systematic review of such interventions from 1980 to June 2003 using keywords such as c ultural sensitivity, transcultural, cultural diversity, multicultural, and cultural compet ency. This review identified 34 empirical articles that had a beforeand after-inte rvention evaluation or had a control group for comparison. The results of the Beach et al. revi ew provided excellent evidence that cultural competence training (broadly defined) improves the knowledge of health professionals and good evidence that such training impacts the attit udes and skills of health professionals. More specifically, 17 of the 19 articles that focused on knowledge demonstrated a beneficial effect, 21 of the 25 studies that focused on evaluating att itudes demonstrated a beneficial effect, and all of the 14 studies that evaluated skills de monstrated a beneficial effect. These authors also concluded that there were beneficial effects for both longer and shorter
45 duration interventions, experientia l and non-experiential interventi ons and for curricula focusing on general concepts of culture as well as specific cultu ral information. It is noteworthy that only 4 of the 34 studi es reviewed by Beach et al. used patient perceptions (versus provid er self-reports, video or audio tapes, exams, etc.) to assess differences in cultural competence prior to and following cu ltural competence training interventions. In addition, few studies have evaluated whether changes to providers knowledge, attitudes and skills persist over time, and whether reported ch anges actually correlate with participants behavior during clinical encount ers. However, such evaluations seem necessary given the prevalence of self-report data and paper and pencil assessment instruments, and the influence of social desirability and other biases on these modes of assessment (Bet ancourt, 2003; Crandall, George, Marion, & Davis, 2003; Hobgood et al., 2006). Overview of existing literature associating culturally competent health care provider training in terventions with patients perc eptions of their health care environment As noted earlier, few studies have examined th e impact of culturally competent educational training provider interventions from the pers pective of patients. Yet, obtaining patient perspectives is important as physicians knowledge and intention to provide culturally competent and patient-centered care are no t enough to ensure that such car e will be delivered (Opie, 1998). For example, in a qualitative study examini ng self-care decision making among 22 Type 1 diabetes patients, Paterson (2001) found that providers often contradicted their stated goal of patient empowerment in covert and subtle ways that were identifiable by patients. Providers in this study frequently discounted the experiential knowledge of diabetics over time and did not provide patients with the resources n ecessary to make informed decisions. The existing research suggests that there are mixed results regarding the efficacy of provider education training interv entions when evaluated from th e patients perspectives. For
46 example, in all four studies included in the B each et al. (2005) review that elicited patient evaluations of cultural competen ce training outcomes, there was evidence of increased patientperceived cultural competence following traini ng interventions. However, in a recent longitudinal study conducted by Thom, Ti rado, Woon, and McBride (2006) involving 429 patients among whom were non-Hispanic White, La tino/Hispanic, African-American, and Asian patients, no significant changes in patient-re ported cultural competen cy ratings following 2 interventions were found. In the first intervention, providers were given feedback on baseline cultural competency patient ratings In the second intervention providers were given feedback on baseline cultural competency ratings, and given a 4.5-hour cultural compet ency training. At sixmonth follow-up there was little change in cultur al competency ratings for either intervention group and no significant group differences in the amount of change after controlling for patient characteristics and baseline values of outcome measures. Differences in findings among the Thom et al. study and those included in the B each et al. review ma y stem from: (a) the longitudinal nature of the Thom et al. study, a nd (b) differences in definitions of cultural competency and patient-reported evaluation methods used in the studies. Overview of existing literature associating culturally competent health care provider training in terventions with patients health outcomes Although multiple studies have investigated the impact of various culturally competent interventions on a variety of patie nt health status outcomes (Goode et al., 2006), only two studies have investigated the specific impact of cultura lly sensitive or culturally competent training interventions on such outcomes. In the first of these studies, Majumdar et al. (2004) conducted a randomized control longitudinal study assessing the effects of cultural sensitivity training on health care provider attitudes a nd patient outcomes. The study was executed in Canada and involved 114 health care providers and 133 patient s of mostly Canadian, British and European
47 origin. These researchers found that, at post-inte rvention, there were no st atistically significant differences in mean scores between patients in the control group (i.e., those treated by providers who did not undergo cultural sensitivity training) and in the intervention group (i.e., those treated by providers who did undergo cultural sensitivity training) on mean levels of client satisfaction, mental health, physical healt h, and activities of daily living. However, patients in the intervention group demonstrated higher levels of social functioning and an improvement in overall functional capacity (as assessed by the Off-Axis Ratio Multidimensional Measure of Functional Capacity) without a sign ificant increase in expenditures for health care after 1.5 years following the training intervention. It is difficult to determine how the results of the Majumdar et al. study generalize to the case of low-income and racial/ethnic minority patients in the US, especially given several criticisms of this study that are consistent with those previously highlighted by Price et al. (2005) and Goode et al. (2006). For example, Majumdar et al. failed to disclose the details of the cultural sensitivity training intervention that wa s provided in their study. Furthermore, these researchers failed to operationalize mental health, physical health, an d activities of daily living (e.g., no sample items were given for the a ssessments that measured these constructs). As such, it is unclear what specific patient health outcomes were meas ured in the studies, and what specific behaviors or attitudes demonstrated the increases in social functioning and functional capacity that the study reported. In addition, although these authors reported the national identity and language of the participating patients, they fa iled to report the racial and ethnic identities and social economic statues for the patient participants. In the second published study that has eval uated the impact of culturally competent training interventions on patient health status outcomes, Thom et al. (2006) investigated the
48 impact of a 4.5-hour cultural competency traini ng on the health outcomes of 429 patients with either diabetes or hypertension. The study invo lved 53 primary care physicians at 4 diverse practice sites. At all four practice sites, phys icians received feedback on cultural competency behaviors reported by their patient s; however, two of the practi ce sites were also randomly assigned to receive the training intervention, which was based on a cultural competency model that was developed by one of the researchers an d an expert panel of physicians. This model focused on knowledge of patients (including knowledge of patients cultural health beliefs and identification of their level of acculturation w ith respect to mainstr eam health beliefs), communication skills (including liste ning, explaining, acknowledging, providing recommendations, and working effectively with in terpreters), and cultur al brokering (including negotiating a treatment plan with patient and family, understanding community resources available to patients, and worki ng with the health care system to meet the needs of culturally diverse patients). At six-month follow-up, these researchers repor ted no measurable impact of the tested cultural competence training on di sease-specific patient outcome s (e.g., patients satisfaction, weight, or systolic blood pressure), compared to outcomes of patients who had been treated by physicians who had not received the training (i.e., physicians who only received feedback on cultural competency behaviors reported by their patie nts). In attempting to interpret their results, Thom et al. suggested that the brevity of th eir intervention (4.5 hours) and the lack of reinforcement of behaviors learned in the tr aining during the 6-m onth period between the training and the outcome measurement period ma y have contributed to their non-significant findings. The Thom et al. study is the only one th at has assessed the l ongitudinal impact of cultural competency trainings on disease-specific patient outco mes over a 6-month period. The
49 study suggests that positive trai ning effects on physician knowledge attitudes and skills that have been reported in the lit erature (e.g., Beach et al., 2006) may not persist over time, and highlights the need for longitudinal studies focused on patient-centered evaluations of such trainings to extend the present literature base. In summary, patient-centered, culturally sensit ive, and culturally competent care have all been promoted in the literature as central mech anisms for addressing the health and health care disparities problems through improving patient health outcomes. However, very little empirical research exists that links patient centered, cultura lly sensitive and/or culturally competent health care interventions (including heal th care provider and office staff training interventions) to improvements in patients health outcomes. Mo reover, although some evidence does support the efficacy of patient-centered, culturally sensitive, and culturally competent interventions in terms of intermediate outcomes, a lack of clear and te stable models, as well as problems with assessing these constructs continue to plague research in this area. The following section describes a new construct patient-centered cultu rally sensitive health care. Th e proposed study seeks to expand the existing literature by using a clear and testable literature-based model to examine whether patient-centered culturally sensitive health car e training interventions are associated with improvements in health outcomes among patients. Patient-Centered Culturally Sensitive Heal th Care: Evolution of a New Health Care Orien tation with Potential for Reducing Health Disparities Defining Patient-Centered Cultur ally Sensitivity Health Care Ironically, despite the emphasis on patient-centere dness tha t is touted in the health care literature, missing from most existing definitions of cultural competence or cultural sensitivity is any mention of the importance of patient perspe ctives or experiences. Definitions have also relied on broad, unobservable characte ristics that are difficult to te ach and evaluate. In an effort
50 to move beyond and integrate core features of prior definitions of patie nt-centeredne ss, cultural competence and cultural sensitivity, Tucker and her colleagues (Herman et al., 2007) offered a definition of patient-centered cu lturally sensitive health care. This definition has been described as cultu ral competence plus and emphasizes the perspectives of culturally dive rse patients, rather than prof essional experts, on behaviors, attitudes and health care environment charac teristics and policies that convey patientcenteredness and cultural sensitivity. According to these research ers, patient-centered culturally sensitive health care: (a) emphasizes displaying patient-desired modifiab le provider and office staff behaviors and attitudes, implementing health care center policies, and displaying physical health care center environment characteristics that culturally diverse patients identify as indicators of respect for their culture and enable these patients to feel comfortable with, trusting of, and respected by their health care providers and office staff; (b) conceptualizes the patientprovider relationship as a partnership that emerges from patient-cen teredness; and (c) is patient empowerment oriented. Brief explanations of these characteristics are described below. Display of patient-identified indicators Because health care providers and office staff often participate in expert-centered culturally co mpetent health care training and yet not display this competence at post-training in ways that are recognized by cultu rally diverse patients (Paterson, 2001), it seems important that such training be primarily based on what culturally diverse patients view as indicators of cultural sensitivity. Obtaining this information requires (a) providing opportunities for culturall y diverse patients to identify the indicators of culturally sensitive health care and evaluate the level of occurrence of these indicators, and (b) using this patient evaluation feedback to de velop, modify and evaluate trai ning and other interventions to improve health care quality as perceived by culturally diverse patients. This assessment,
51 feedback-based intervention, and evaluation proce ss must be ongoing over time given that (a) the composition of providers, office sta ff and patients at any health care center changes periodically and (b) individual health care professionals and or ganizations vary in their opportunities for and commitment to becoming more culturally sensitive, t hus requiring this cultural sensitivity to be a developmental process. Patient-centered patient-provider partnerships Central to these partnerships are providers who demonstrate empathy, compassion, a nd responsiveness in rela tion to the assessed needs, values, and preferences of their patien ts, and patients who are actively involved in identifying these needs, values and preferences (Paterson, 2001). These pa rtnerships have been associated with increased treatment adherence by patients (Beck, Daughtridge & Sloane, 2002), improvements in the health statuses of patients (Michie, Miles, & Weinman, 2003), and reductions in misdiagnosis of patients heal th problems due to poor patient-provider communication (DiMatteo, 1998). Furthermore, patients want to be active partners in their health care (Earnest, Ross, Wittevrongel, Moore & Lin, 2004; Ross, Moore, Earnest, Wittevrongel & Lin, 2004). Patient-empowerment oriented There is agreement among researchers that empowerment of minorities must include enabling them to experience a psychological sense of personal and interpersonal contro l; and attending to social, po litical, and legal factors that influence this perceived control (McWhirter, 1991; Paterson, 2001). Thus, promotion of this perceived control among minority patients likel y requires the supportive involvement of these patients and their health care cent er providers and offi ce staff as well as individuals at their health care centers who control th e resources and policies of these centers (e.g., administrators).
52 Operationalizing and Measuring Indicators of Patient-Centered Culturally S ensitive Health Care A central feature of Tuckers definition of patient-centered culturally sensitive health care (Herman et al., 2007) is the commun ication or display of specific patient-identified modifiable provider and office staff behaviors and attitudes, and clinic environmen t characteristics and policies that show respect for patients and thei r cultures and/or make patients feel comfortable with and trusting of their health care providers, and that enable patients to feel comfort and a sense of belonging in their health care settings. In order to iden tify these modifiable provider and office staff behaviors and attit udes, and clinic characteristics and policies, Tucker and her colleagues conducted 2 studies with convenience samples of primarily low-income African American, Hispanic and White patient-participants. Focus Group Study In the first of these studies, Tucker et al. (2003) conducted 20 ethnicity and gender concordant focus groups with 52 African American pa tient participants (31 men and 31 women), 45 Hispanic patient partic ipants (18 men and 27 women), and 38 White patient participants (15 men a nd 23 women), who were recruite d from four community-based primary care clinics in north centr al Florida that serve a dispr oportionately high percent of lowincome patients and patients who identify as ra cial/ethnic minorities. The focus groups were conducted in community settings (e.g., library meeting rooms and church es), and the following questioning route was used to guide the focu s group discussions: (a ) What does/could your doctor do to make you feel comfortable/uncomfort able with him or her? (b) What makes you trust/not trust your doctor? What could your doctor do to help you trust him or her more? (c) What does/could your doctor do to show you respect and be sensit ive to your needs? (d) What could your doctor do to show that he or she is sensitive to your needs and is respectful of you as
53 an African American /Hispanic/ White? (e) What can doctors do to become better at helping patients from your racial, langua ge or cultural background? African American, Hispanic, and White focus group patient participan ts identified 176, 125 and 197 behaviors, attitudes and/or clinic ch aracteristics and policie s, respectively, that made them feel comfortable with, trusting of, and/or respected by hea lth care providers and office staff, and/or that made th em feel a sense of comfort and/ or belonging at the health care clinic. Validating focus group findings To verify and extend the findings of the focus group studies, Tucker, Herman et al. (2007) used the focus-group generated items to develop race/ethnicity-specific forms of a Health Care Importance Rating Survey (HIRS). These researchers then asked an independent sample of patients, who were demographically similar to those in the focus group study, to complete the rele vant (i.e., race/ethni city-specific version) HIRS by rating the importance of each item using a scale from 1 to 5 where 1 = not at all important and 5 = extremely important. The part icipants in the validation study consisted of 82 African American (17 men and 65 women), 45 Hispanic (15 men and 30 women), and 94 White (26 men and 68 women) mostly low-income patient participants who were recruited from Area Health Education Clinics throughout Florida. Notably, the racial/ethnic groups represente d among those who completed the HIRS rated 86% to 100% of the behaviors and attitudes concerning provider behaviors and attitudes as important. Furthermore, the African American pa tients rated 87% of the clinic office staff behaviors and attitudes and 59% of the clinic physical characteristics as important. The Hispanic patients rated 100% of the clinic office staff beha viors and attitudes and 82% of the focus clinic
54 physical characteristics as importa nt. Finally, the White patients rated 87% of the clinic office staff behaviors and attitudes, and 55% of the clinic physical characteristics as important. In sum, there was a high degree of within-gr oup consistency (i.e., within racial/ethnicityspecific samples) between independent samples of primarily low-inco me African American, Hispanic, and White primary care pa tient participants on attitudes and behaviors of health care providers and office staff, and on the clinic e nvironment characteristics that convey patientcentered culturally sensitive health care. The items that were rated as important in the validation study were used to construct the Tucker-Cultura lly Sensitive Health Care Inventory Patient Form (T-CUSHCI Patient Form; Tucker, Mirsu-Pa un et al., 2007) that will be used to measure participants perceived level of culturally sensitive health car e in the proposed study. Detailed descriptions of the development of and reliability date for the T-CUSCHCIs are given in Chapter 3. The items that were rated as important in the validation study were also used to develop the pilot Patient-Centered Culturally Sensitive (PC-CS HC) Intervention Program that will be tested for its effects in the proposed study. Differentiating Patient-Centered Culturally S ensitive Health Care from Cultural Competence Tucker and her colleagues (Tucker et al., 2005 ) sought to empirically determine if there was a difference between the constructs patie nt-centered culturally sensitive health care and cultural competence. In order to do this, thes e researchers asked 22 ph ysicians and 10 other health care providers (e.g., nurse practitioners) to complete se lf-report measures of cultural competence (Cultural Competence Self Assessmen t Questionnaire Service Provider Version [CCSQ-SPV]; Mason, 1995) and patient-centere d cultural sensitivity (Tucker-Culturally Sensitive Health Care Inventories Physician and Health Care Provider Forms [T-CSHCI-PF Form and T-CSCHI-HCP Form]; Tucker, Mi rsu-Paun et al., 2007). Bivariate Pearson
55 correlational analyses revealed that only one of seven subscales of the CCSQ-SPV was significantly correlated with the T-CSHCI-PF, and indicated no signi ficant correlations between the CCSQ-SPV and the T-CSHCI-HCP. Tucker a nd her colleagues concluded that patientcentered culturally sensitive health care and cu lturally competent heal th care are related, but different constructs and furthe r suggested that interventions based on both of these types of health care are needed to effectiv ely address health disparities. In summary, patient-centered culturally sensitive health care is a fairly new, important and clearly defined construct for describing health care that attends to the needs of culturally diverse people. It is novel in that it takes into account patients pe rspectives and needs. Moreover, it is clearly operationalized so th at it can be measured empirically from the perspectives of patients and/or health care providers and office st aff, thus allowing interventions based on the construct to be evaluated with cl early interpretable resu lts. The proposed study attempts to address the health disparities problem by testing the specific effects of a PatientCentered Culturally Sensitive Health Care (P C-CSHC) Intervention Program on the health outcomes of mostly low-income patients with hy pertension alone or with other chronic health problems a group at risk for health disparities. The model that guides the proposed study will be described in the next section. The Tucker Patient-Centered Cultura lly Sensitive Health Care Model Wu and Martinez (2006) lam ented that, although there has been a profusion of research in the field of cultural competency, especially research focused on defining cultural competence, there has been considerably less work focused on taking cultural competency from theory to action. In a similar vein, recogni zing that the relationship between culturally competent health care and health outcomes has not been thoroughly tested, Kim-Godwin et al. (2001) suggested that both qualitative studies (e.g., focus group with culturally diverse populations) and
56 quantitative studies could be used to develop and test m odels suggesting hypothesized relationships between cultural competence in health care and major morbidity and mortality indicators. In an effort to address this dearth in the literature, Tucker, Herman et al. (2007) proposed the Patient-Centered Culturally Sensitiv e Health Care (PC-CSHC) Model to describe how a patient-centered culturally sensitive hea lth care intervention program, based on these researchers earlier desc ribed qualitative focus group data, co uld be ultimately associated with improved health outcomes of patients. The PC-CSHC Model thus offers health care organizations a framework for taking patient-centered culturally competent health care from theory to action. Overview of the PC-CSHC Model The PC-CSHC Model is a form ative but testab le literature-based model for understanding the theorized associations between (a) patient-ce ntered culturally sensitive health care and (b) patients health promoting treatment behavior s (e.g., treatment adherence), engagement in a health promoting lifestyle (e.g., eating healthy), and health outcome/health statuses (e.g., blood pressure). In sum, the PC-CSHC Model hypothe sizes relationships am ong health care system factors, health care process variables, and patien t-level health related variables the root causes of disparities (Betan court, 2006) and patien t health outcomes. Specifically, the PC-CSHC Model postulates that (a) patient-centered culturally sensitive health care interventions promote patient-centered culturally sensitiv e health care as indicated by clinic physical environment charact eristics and policies, provider behaviors and attitudes, and office staff behaviors and attitudes; (b) this care influences patients perceived levels of provider cultural sensitivity and interpersonal control, both of which impact patients level of engagement in a health promoting lifestyle and level of health care satisfaction; (c) the latter influences
57 patients level of treatment adherence; and (d) both level of treatment adherence and level of engagement in a health promoting lifestyle directly influence health outcomes/statuses. The proposed study is a longitudinal study th at examines the impact of a PC-CSHC Model-based pilot interventi on program (i.e., the PC-CSHC Intervention Program) on lowincome hypertensive patients (a ) perceptions of cultural sensi tivity in the health care they experience and (b) health outcome s (i.e., diastolic and systolic blood pressure) over a 15-month period. The proposed study will extend the existing literature base and addresses several of the methodological concerns identified by Price et al. (2005) and Goode et al. (2006) by: (a) implementing a clearly defined and replicable cu lturally sensitive health care intervention program that is based on patients perspectives regarding health care providers and office staff members views of what constitutes culturally se nsitive health care; (b) evaluating the impact of this intervention progra m on clearly operationalized health outcome measures; (c) utilizing patient assessments versus provider self-assessments of patient-centered culturally sensitive health care; (d) controlling for the impact of so cial desirability on found in tervention effects; and (e) assessing whether any positive changes in patients perceived levels of patient-centered culturally sensitive health care associated with the tested PC-CSHC Intervention Program persist over an extended (i.e., a 5-month period) following participation in the final component of the PC-CSHC Intervention Program. Th e following section describes th e literature supporting the PC-CSHC Model. Research Supporting the PC-CSHC Model Associations among perceived cultural sensit ivity, interp ersonal control, health care satisfaction, and health prom oting lifestyle behaviors. Research suggesting a link between patient-p erceived cultural sensitivity and patientreported health care satisfacti on includes a study by Joffe, Manocchia, Weeks, & Cleary (2003)
58 exploring what patients value in their hospital care. These resear chers found that patients selfreported levels of confidence and trust in their providers, treatment with respect and dignity by their providers, and attention to their physical comfort by their provider s (i.e. patients selfreported levels of patient-centered culturally sensitive health care) were all significantly associated with patients positive evaluations of their hospital care (i.e., patient satisfaction). Harris, Luft, Rucy, & Tierney (1995) similarly found among African American patients that these patients level of trust in their providers and level of perceived treatment with respect and dignity by their providers were si gnificantly associated with their (the patients) le vel of health care satisfaction, which in turn was found to be a significant predictor of higher adherence to medical regimens and better health among these patients. Support for the hypothesized link between patient s perceived cultural sensitivity and their engagement in a health promoting lifestyle comes from research that provides evidence of the effectiveness of culturally sensitive health pr omotion programs implemented with adults who have low levels of literacy (Winkleby, Howa rd-Pitney, & Albright, 1997) and working-class, multiethnic workers (Sorensen et al., 2005). Such programs have also been effective in helping women living in a low-income community quit sm oking (OLoughlin, Renaud, & Paradis, 1996). Support for the theorized link between patients perceived interpersona l control and patient satisfaction comes from the results of a study by Jahng, Martin, Golin, and Dimatteo (2004). These researchers found that when patients who desi re to be involved in th eir care were matched with providers who support such patient involvement, high levels of perceived patient satisfaction resulted. It has also been found that physicians who s ee their relationships with their patients as partnerships have mo re satisfied patients compared to physicians who have more authoritarian relationships with th eir patients (Like & Zyzanski, 1987).
59 Research suggesting an association between perceived interpersonal control by patients and their level of engagement in health promoti ng lifestyle behaviors has also been reported in the medical literature. For example, Auerbach et al. (2002) found that patien ts ability to engage in behaviors to control their diabetes was relate d to their desire for be havioral involvement in their own health care. Association between health care satisfaction and treatment adherence. In the f ormative PC-CSHC Model patient health care satisfaction is th eorized to directly influence patient treatment adherence; however, pa tient health care satisfaction is not directly associated with health outcomes/statuses. Ind eed no evidence for causal paths going from health care satisfaction to health outcomes was found in a one-year longitudinal study of 590 older patients health statuses and h ealth care satisfactio n (Hall, Milburn, & Epstein, 1993). However, it has been found that health care satisfaction predicts more con tinuous health care, adherence to medical regimens, and ultimately better health (DiPalo, 1997; Greenfield & Attkisson, 1989; Hall et al., 1993; Harris et al ., 1995). The associa tion between health care satisfaction and treatment adherence among African Americans ha s also been well docum ented (Harris et al., 1995). Associations of treatment adherence and engageme nt in a health pro moting lifestyle with health outcomes/statuses. Support for these theorized associations comes in part from the conclusion in the Institute of Medicines 2002 Report (titled Unequal Treatm ent: Confronting Racial and Ethnic Disparities in Health Care) that the link between improved patient-provider communication and health status of patients may be through improved patient satisf action and treatment adherence. Furthermore, a number of studies suggested th at there is an association between engagement in health promoting behaviors and health outcomes/statu ses. For example, in a 12-week after-school
60 health education, activ ity, and food monitoring intervention program to increase fruit and vegetable consumption among Afri can American children, adolescen ts and their parents, it was found that program participation (i.e., engagement in health promoting behaviors) resulted in improvements in body fat level, BMI, and endurance walk/run time among the participating parents, and improvements in systolic blood pressure among the children and adolescents (Engels, Gretebeck, Gretebeck, & Jimenez, 2005). In another study, Rimmer et al. (2000) examined the effects of a 12-week health pr omotion intervention among a predominantly urban group of adult African American stroke survivors. Results revealed that compared to a control group, the intervention group partic ipants had made significant higher gains on a number of health outcome measures at th e post-intervention period, includi ng reduced total cholesterol and reduced weight. The PC-CSHC Intervention Program The PC-CSHC Intervention Program includes three sub-components. The first subcom ponent involves changing the physical health care clinic environment and clinic policies in ways that allow culturally diverse patients to feel a sense of comfort a nd belonging in the clinic, and partnering with health care administrators and providers in maki ng these changes. The second sub-component of the in tervention program involves trai ning health care providers and office staff to engage in beha viors and display attitudes that mostly low-income culturally diverse primary care patients (i.e., African Amer ican and White primary care patients similar in socio-demographic characteristics to the patients in the proposed research) have identified as behaviors and attitudes that make them feel comfortable with, trusting of, and respected by their health care providers/office staff and that make them feel that their cultur e is respected. Finally, the third sub-component in the PC-CSHC Inte rvention Program involves training/empowering patients to motivate/inspire desi red behaviors and att itudes from providers and office staff and
61 desired changes in the health care clinic physi cal environment and policies, especially those behaviors, attitudes and environment and policy ch anges earlier identified by similar patients as indicators of patient-centered cu lturally sensitive health care. It is noteworthy that the PC-CSHC Interventi on Program can be differentiated from other reported intervention programs that address cu lturally appropriate hea lth care delivery by its focus on all rather that one or two of the followi ng variables: patient f actors, provider factors, and health care system factors. In addition, th e PC-CSHC Intervention Pr ogram meets several of the recommendations for taking cultural competency from theory to action that were set forth by Wu and Martinez (2006). Specifically, the PC-CSHC Intervention Program: (a) invites community representation and fee dback in all three intervention components; (b) attempts to integrate patient-centered cultural sensitivity into multiple systems (i.e., clinic physical environment and policies, providers, office staff, and clinic administrators) of the health care organization; (c) attempts to ensure that th e changes made are manageable, measurable, and sustainable; and (d) elicits a commitment from leadership to the changes made during the intervention program. Finally, the PC-CSHC Inte rvention Program fulfills the CLAS guidelines for facilitating community and patient involveme nt in designing and implementing CLAS-related activities (OMH, 2001). For example, community repr esentatives participate as panelists in the provider training sub-component of the PC-CSHC Intervention Program and as co-facilitators in the patient-empowerment trai ning sub-section of the PC-C SHC Intervention Program. The following sub-sections focus on briefly describing the literatures relevant to each of the PCCSHC Intervention Programs sub-components. Health Care Physical Environm ent and Clinic Interventions Although considerably less attention in the he alth care literature ha s focused on changing the physical environm ent of health care sites (e .g., health clinics/cente rs) to achieve cultural
62 sensitivity and/or cultural competency, there ar e increasing calls in the literature for such changes. For example, Kune-Karrer and Taylor (1995) called for the removal of artwork and paintings in clinics and hospitals that may be culturally insensitive. In addition, Branch and Fraser (2000) suggested that hea lth care systems could alter their physical environments to make them more welcoming to minority group members. Furthermore, the CLAS standards mandate that health care organizations make availabl e easily understood patient-related materials and post signage in the languages of the commonly en countered groups and/or groups represented in the service area (OMH, 2001, p. 77). Perhaps more importantly, however, is the grow ing literature base s uggesting that patients consider their physical health car e environments and policies as im portant indicators of culturally competent health care, and that su ch indicators are associated w ith patient health outcomes. For example, participants in focus groups of lo w-income and racial/ethnic minority patients identified physical and policy aspects of health ca re clinic environments as important aspects of patient-centered culturally sensitive health care (Tucker et al., 2003). Additionally, the inclusion of providers and office staff at health care clinics who speak th e language of their patients has been advocated and has been found to be associated with lower health dist ress, less pain severity, and fewer pain effects among patie nts (Ferguson et al., 1998). Health Care Provider and Office Staff Training Interventions The vast m ajority of interventions designed to achieve cultural sensitivity/competence have focused on clinical cultural competence interventi ons; that is, those interventions designed to enhance provider knowledge of the relationship be tween sociocultural fact ors and health beliefs and behaviors and to equip providers with th e tools and skills to manage these factors appropriately. The focus on clinical cultural sensitivity/ competence interventions, in part,
63 reflects increasing mandates from national health care organizations that cultural competence education must be integrated into trai ning programs at every learner level. For example, the national CLAS standards in health care included the following mandate: health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery (OMH, 2001, p. 59). Additionally, the Association of American Medical Colleges has approved mandatory diversity accred itation requirements, and in some st ates legislation has been proposed requiring questions related to cultural competence on board examinations (OMH, 2001). The response to such mandates has been a mushrooming of the literature on cultural competency education and training generally (Beach et al., 20 06), and health care field-specific educational initiatives and/or frameworks for achieving cu ltural sensitivity/competence (e.g., Hobgood et al., 2006; Reynolds et al., 2005; Shaya & Gbarayor, 2006), detailed de scriptions of which were given in earlier sections of this literature review. Patient Training/Empowerment Interventions The increased attention that pa tient training and empower ment has received in the health care literature is evidenced in th e twelfth national standard for CL AS in health care, which calls for health care organizations to develop participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involvement in designi ng and implementing CLAS-related activities (OMH, 2001, p. 102). Similarly, Betancourt et al (2002), in outlining recommendations and practical approaches for eliminating racial and ethnic disparities in heal th care through cultural competency, called for programs to be developed th at help patients navigate the health care system and become a more active pa rtner in the clinical encounter. It is noteworthy that there is a wide body of literature on the use of culturally competent interventions to increase patient
64 education and empowerment focused on health-rel ated behaviors including: patient-provider communication (Tran et al., 2003) genetic counseling (Charles Kessler, Stopfer, Domchek, & Halbert, 2005), cancer screen ing (Braun, Fong, Kaanoi, Kamaka & Gotay, 2005; Powe, Ntekop & Barron, 2004; Tu et al., 2006), health prom otion (Melkus et al ., 2004) and adherence behaviors (e.g., Russell, 2006). However, no reported studies to date have utilized patient empowerment trainings specifically to help patie nts learn how to elicit culturally sensitive or competent health care delivery.
65 CHAPTER 3 METHODS Participants Six hundred patients (300 at the control clinic, 300 at the intervention clinic) and 48 clinic staff (i.e., health care providers and office support staff) were invite d to participate in the present study. A total of 224 patients (121 pa tients at the control clinic, 103 at the control clinic) and all of the clinic staff who were invited to particip ate qualified for and gave their written consent to participate in the present study and comprised the final study sample. The demographic characteristics of the patient participan t sample are presented in Table 3-1. African American Patients A total of 110 African Am erican patient par ticipants participated in the present study. Twenty-five (23%) of these patient participan ts were male and 85 (77%) were female. The patient participants ranged in age from 28 85 years, with a mean age of 52.7 years. The distribution of self-reported househ old incomes for the sample is as follows: (a) 49.1% earned below $10,000, (b) 10% earned between $10,001 and $20,000, (c) 9.1% earned between $20,001 and $30,000, (d) .9% earned between $30,001 and $40,000, (e) 2.7% earned above $40,001, and (f) 28.2% did not report a household income. Th e distribution of self -reported educational attainment for the African American patient participant sample is as follows: (a) 15.4% did not attain a high school diploma, (b) 30% attained a high school diploma, (c) 12.7% attained some college education or technical school training, (d) 3.6% attained a college education, (e) 2.7% attained professional or graduate educati on, and 35.5% did not report their educational attainment. In addition, 79.1% of the African American patient particip ants indicated that English was their preferred language, whereas 20. 9% of these participan ts did not specify a language preference.
66 With regard to their medical history, 11.8% of the African American patient participants reported being diagnosed with high blood pre ssure alone, whereas 43.6% reported being diagnosed with high blood pressure with at leas t one other chronic condi tion. The distribution of self-reported number of years since being diagnosed with high blood pressure is as follows: (a) 16.4% had been diagnosed for one year or less, (b) 18.2% had been diagnosed for 2-3 years, (c) 8.2% had been diagnosed for 4-5 years, (d) 8.2% had been diagnosed for 6-7 years, (e) 4.5% had been diagnosed for 8-9 years, (f) 20% had been diagnosed for more than 10 years, and (e) 24.5% did not report the length of time they had been dia gnosed with hypertension. White Patient Participants A total of 114 W hite patient participants participated in the present study. Thirty-nine (33.9%) of these patient particip ants were male and 76 (66.1%) were female. The White patient participants ranged in age from 25 89 years, with a mean age of 57.5 years. The distribution of self-reported household incomes for the sample is as follows: (a) 22.6% earned below $10,000, (b) 14.8% earned between $10,001 and $20,000, (c) 11.3% earned between $20,001 and $30,000, (d) 7.8% earned between $30,001 and $40,000, (e) 21.7% earned above $40,001, and (f) 21.7% did not report a household income. Th e distribution of self -reported educational attainment for the White patient participant sample is as follows: (a) 6.9% did not attain a high school diploma, (b) 20.9% attain ed a high school diploma, (c) 28.7% attained some college education or technical school trai ning, (d) 11.3% attained a college education, (e) 11.3% attained professional or graduate educat ion, and 20.9% did not report thei r educational attainment. In addition, 77.4% of the White patie nt participants indicated that English was their preferred language, 1.7% indicated that a language other than English or Spanish was their preferred language, and 20.9% of these pa rticipants did no t specify a language preference.
67 With regard to their medical history, 2.6% of the White patient partic ipants reported being diagnosed with high blood pressure alone wher eas 34.2% reported being diagnosed with high blood pressure with at least one other chronic condition. The distribution of self-reported number of years since being diagnosed with high blood pressure is as follows: (a) 21.7% had been diagnosed for one year or less, (b) 7.8% had been diagnosed for 2-3 years, (c) 7.8% had been diagnosed for 4-5 years, (d) .9% had been diagno sed for 6-7 years, (e) 4.3% had been diagnosed for 8-9 years, (f) 17.4% had been diagnosed for more than 10 years, and (e) 40% did not report the length of time they had been diagnosed with hypertension. Clinic Staff Thirty-two health care provi ders (22 physicians and 10 ot her health care providers; 19 fe males and 13 males) participated in the present study. Of these providers, 9.4% were African American, 3.1% were Asian American/Pacific Islander, 75% were Eu ropean American, 9.4% were Hispanic, and 3.1% identified as other. These providers ranged in age from 26 years to 60 years with a mean age of 37.7 years. This group consisted of US citizens (78.1%) and non-US citizens (21.9%), among whom only 3 (9.4%) re ported being fluent in Spanish, and 4(12.5%) indicated being fluent in a langua ge other than English. The mean number of years in clinical practice for this provider group was 9.5 years. In addition to the pr oviders, 16 office staff participated in the present study, all of whom were females and US citizens. Of these staff participants, 25% were African American and 75% were European American. Staff participants ranged in age from 28 years to 71 years, with a mean age of 44.9 years. Their mean number of years in clinical pr actice was 12.3 years. Measures The health care provider and office staff participants in the study anonym ously completed a Clinic Staff Demographic Data Questionnaire (CSDDQ) to obtain information about these
68 participants gender, race/ethnicity, job title, la nguage fluency (in Engl ish and other languages), and number of years in pract ice at the clinic site. The patient participants in the study anonymous ly completed an Assessment Battery (AB) consisting of various instruments to measur e the following variables: (a) demographic characteristics and medical history, (b) patient part icipants perceived level of cultural sensitivity in the health care they experience, and (c) pa tient participants tendency to respond to the assessments in the AB in a socially desirable manner. Patient participants health outcomes were also assessed by obtaining their systolic and diasto lic blood pressure readings from their clinic charts, after obtaining their writ ten consent. Copies of the in struments in the AB that was completed by patient participants may be found in the appendices; however, brief summaries are described below: Patient participant demographic data questionnaire (PPDDQ). This questionnaire was constructed and administered to obtain informa tion on participants age, gender, race/ethnicity, education, language preference, and socioeconomic status. Medical data questionnaire (MDQ). This questionnaire was constructed to obtain information on patient participants medical history with hypertens ion, and other chronic conditions such as diabetes and high cholesterol. Tucker-culturally sensitive health ca re patient inventory patient forms (T-CSHCI Patient Forms). Tucker and her colleagues deve loped race/ethnicity-speci fic T-CSHCI Patient Forms to assess patients perceived level of cultu ral sensitivity in the health care that they experience. The T-CSHCI Patient Forms consist, in part, of behaviors a nd attitudes of health care providers that patients who use community health care clinics have identified as making them feel trusting of and comforta ble with their health care providers and that make them feel
69 that their health care provider is respectful of their culture. Additionally, the inventories include behaviors of clinic office staff and physical characteristics and policies of the health care clinic environment that such patients have identified as promoting their comfort and sense of belonging at their health care clinic. The directions for the T-CSHCI Patient Forms instruct respondents (i.e ., patients) to rate how much they agree that: (a) their health care provider displa ys each of the listed provider behaviors and attitudes (b) the office staff at their clinic display each of the listed behaviors and attitudes, and (c) their clinic operates in accordance with the listed policies and has the listed physical environment characteristics. The rating options are on a Likert Rating Scale where 4 = strongly agree, 3 = agree, 2 = disagree, and 1 = st rongly disagree. Mean scores (ranging from 1 4) are obtained for the following components of the T-CSHCI Patient Form: (a) the provider behaviors and attitudes component (b) the office staff behaviors and attitudes component, and (c) the clinic characteristics and policies component. Higher m ean scores indicate higher levels of perceived patient-centered cultural se nsitivity in health care experienced. There are African American, Hispanic and White American forms of the T-CSHCI Patient Form. The forms for African American patients and White patients were used in the present study. The form that was administered to a particular patient participant depended on the patients self-identified racial/e thnic affiliation. A sample item fr om the African American form of the T-CSHCI Patient Form is the person I s ee most often for my health care when I visit my clinic talks to me during my visit. A sample item from the White American form of the TCSHCI Patient Form is the clinic staff memb ers at my clinic do not show prejudice against me.
70 The reliability data of the African American form of the T-CSHCI Patient Form and the reliability of the White American form of the T-CSHCI Patient Form were determined using a sample of 89 low-income African American patients and 91 low-income White patients, respectively, all of whom were attending community-based primar y care clinics (Tucker et al., 2007). These patients were each administered a TCSHCI Patient Form twice, 5 months apart. For the African American form of the T-CS HCI Patient Form, five-month test-retest reliabilities for the provider be haviors/attitudes component, clinic office staff behaviors/attitudes component, and clinic environment characteri stics and policies component were .99, .98, and .98, respectively; split-half reliabilities for th ese T-CSHCI Patient Form components were .94, .95, and .97, respectively; and internal consis tencies for these T-CSHCI Patient Form components were .98, .95, and .97, respectively. For the White American form of the T-CSHCI Patient Form, five-month test-retest reliabi lities for the provider behaviors/attitudes component, clinic office sta ff behaviors/attitudes component, and clinic environment characteristics and policies component were .99, .98, and .97, respectively; split-half reliabilities for these components were .75, .69, and .85, respectiv ely; and internal co nsistencies for these components were .99, .98, and .92, respectively. The Marlowe-Crowne social desirability scale short form (MCSDS-SF). The MCSDS (Strahan & Gerbasi, 1972) is a 20-item scale that is used to measure the degree to which participants respond to questionnai res, such as those in the as sessment battery, in a socially desirable manner. The Short-Form is based on the original 33-item instrument developed by Crowne & Marlowe (1960). The Kuder-Richardson 20 (KR-20) reliability coefficients for the short version are comparable to those of the original versi on (KR-20 = .83 for college females and .78 for college males). Studies revealed th at Pearson correlations between the original
71 version and the short version were as high as .98, indicating adequate construct validity for the short version (Strahan & Gerbasi, 1972). Respondent s were asked to mark True or False in response to ten items keyed in the true direction and then items keyed in the false direction. Raw scores are summed and then averaged to give a final range between 0 and 1, with higher scores indicating high need for approval. Procedure This study occurred as one part of a larger National Institute of Health grant-funded research program on patient-centered culturally sensitive health care. Th e present study involved two community-based primary care clinics in a m oderately-sized city in North Central Florida that serve demographically simila r populations of primarily low-income patients. One clinic was arbitrarily assigned to be the intervention clinic and the other clinic was assigned to be the control clinic. To be included in the study, patient participants met the foll owing criteria: (a) they were 18 years or older; (b) they obtained health services at one of the two community clinics at least 3 times in the year prior to the study; (c) they identified as African American not of Hispanic origin, or White not of Hispanic orig in; (d) they had a diagnosis of hypertension, alone or in combination with diabetes coronary artery disease, and/or high cholesterol for at least 1 year prior to the start of the study; (e) they were able to communicate effectively with others verbally or in writing in his or her native language; and (f ) they gave witnessverified and written consent to participate. The present study occurred in two stages. The fi rst stage focused on participant recruitment and involved a multi-modal patient recruitment st rategy and a clinic staff member recruitment strategy. The second stage involve d testing the effects of th e Patient-Centered Culturally Sensitive Health Care (PC-CSHC) Intervention Program. Prior to implementing both stages of
72 this study, the administrators of both clinics were contacted to obtain th eir endorsement for the research. Participant Recruitment Patient recruitment A m ulti-modal recruitment strategy was used to recruit patients in order to address the well-documented challenges of r ecruiting, enrolling and/or reta ining low-income and minority patient participants in health disparities resear ch, which result from: (a) mistrust due to power differences and past experiences, (b) fears of mi streatment and exploitation, and (c) fears that data will be used to advance researchers careers and portray communities in a negative light rather than to address community health problems (Adderley-Kelly & Green, 2005; Dancy, Wilbur, Talashek, Bonner, & Barnes-Boyd, 2004; Loftin, Barnett, Bunn & Sullivan, 2005; Yancey, Ortega, & Kumanyika, 2006). These challe nges often lead to in adequate numbers of needed participants for rigorous examination of intervention effects a nd/or ethnicity-specific analyses, which allow results to be appropr iately generalized (Y ancey et al., 2006). The recruitment of patient participants in the present study involved the following: (a) awarding a health care provider at the intervention clinic and a pr ovider at the c ontrol clinic a $300 honorarium each to identify up to 1000 potential pa tient participants at his or her respective clinic who meet the criteria for research participati on, and (b) awarding an office support staff person at each clinic a $300 honor arium to do the tasks involved in mailing each of the potential patient participants an invitation packet. In addition, the following two supplemental recruitment strategies were implemented: (a) a recruitmen t poster, specifying the inclusion criteria for participation, was displayed in both the intervention clinic and the control clinic that invited potential patient participants who met the specifi ed criteria to fill out a slip to receive an invitation packet for the research study; and (b) a commercial wa s televised on a local television
73 station inviting potential patient pa rticipants to call the Principal Investigator (PI) to request an invitation packet for the research study. Th e slips provided on the posters requested the following contact information: name, telephone number address, race/ethnici ty, and clinic name. Potential patient participants were mailed an invitation packet. Invitation packets for all recruitment methods contained: an invitation letter, an informed consent form with appropriate HIPPA language, and a brief demographic data form. The invitation letter sent to all participants was designed to: (a) describe the research study, (b) request agreement to be considered for research participation and to later participate if they were randomly selected to do so, (c) inform patient participants that their selection for an i nvitation to participate would be the result of an arbitrary selection process, (d) explain what participation would involve and how their confidentiality would be prot ected, (e) explain how much th ey would be paid for their participatory time in the study (i.e., $20 each time they complete a set of questionnaires and $60 for participating in a one-time 4-hour patient training workshop on strategies for obtaining culturally sensitive health care), and (f) request a telephone number to contact the patient participants by telephone to inform them whether or not they were selected to be a patient participant. All of the potential patient participants were told that, if they were selected to participate, their participation in the research would involve completing a set of que stionnaires, which would take them approximately 45-minutes to complete six times (although only two of the six datasets were used in the present study; see Figure 3-1) and that they could choose to have a family member, friend, or researcher read the questionnaires to them. Th e potential patient participants at the intervention clinic were also told in letter s sent to them that, afte r their fourth time of completing questionnaires, they would be asked to participate in a 4hour training to promote
74 culturally sensitive health care among patients. The potential patient participants at the control clinic were told that, after completing the sixth set of questionnaires, th ey would be invited to participate in a 4-hour training to promote culturally sensitive health care among patients. This latter training was provided for pa tients at the control clinic because it is ethically appropriate to do so. Patients who were willing to be considered fo r research participation were asked to: (a) read and sign the informed consent form in front of a witness, (b) complete a brief demographic data form (soliciting the patients name, gender, race, age, socioeconomic status, number of visits to their clinic in the la st year, and telephone number), and (c ) to return this information to the PI in a pre-stamped and pre-addressed retu rn envelope that will be provided. Using a stratified sampling procedure, th e PI used demographic data that was returned by potential patient participants to select the final group of patient participants from the intervention clinic and the final group of patient participants from th e control clinic, such that these groups were similar in terms of gender and race. These patien t participants were then contacted by telephone (or by letter if no telephone was available) to inform them that they had been selected as research participants, and approximately when they woul d receive their first set of questionnaires to complete. The participant data returned to th e researchers was kept confidential according to University of Florida policies and State law; furt hermore, this data was kept in a locked filing cabinet. All subsequent data sent to participants was pre-coded a nd thus did not include patients names. This was done to further protect partic ipant confidentiality. A master list containing participant names and codes was kept by the PI in a locked filing cabinet. Provider and office suppo rt staff recruitment Each of the following three groups of clinical staff at the intervention and control clinics was invited to participate in the present study: (a) physicians, (b) othe r health care providers
75 (e.g., nurses, nurse and physician assistants), and (c) office suppor t staff. The procedure for recruiting potential clinic provider and staff pa rticipants involved sending each clinic staff member a letter (along with two copies of an informed consent form and the Clinic Staff Demographic Data Questionnaire [CSDDQ]) from the Principal Investig ator and the Clinic Administrator which stated the purpose of the st udy and requested research participation. It was stated in each letter that pa rticipation would involve: (a) comp leting a set of questionnaires 6 times (although the CSDDQ is the only questionnaire that is relevant to the present study), (b) participating in a 4-hour provi der and staff training session on patient-centered culturally sensitive health care delivery, and (c) giving witness-verified written consent to participate. Furthermore, in the letter that each potential clin ic provider and staff participant received, it was stated that providers a nd staff who participated in th e present study would receive the appropriate continuing medical e ducation credits plus $90 for part icipating in the staff training, and $20 for completing each set of questionnaires. In addition, it was explained that to protect their anonymity, the clinic providers and staff who agreed to be research participants would be asked to generate their own confidential research code to place on their CSDDQ rather than their names. Additionally, the potential clinic provider and staff participants were informed in the letter that (a) all completed questionnaire data would be mailed directly to the researchers or placed in sealed envelopes and deposited in a tamp er-proof box at their clinic from where they would be retrieved by the research ers, and (b) the researchers woul d keep this data in a locked file in the Psychology Department to protect the confidentia lity of all of the clinic providers and staff who agreed to be research participants. Clinic providers and office staff members who ag reed to participate in the research were instructed in the invitation letter to sign both c opies of the witness-verified informed consent
76 form and to return one of these copies to th e researchers along with a completed CSDDQ via a provided pre-addressed, stamped e nvelope within one week. Clinic providers and office staff members at the intervention clinic and at the cont rol clinic who returned the requested completed CSDDQ and signed informed consent form within the specified timeframe were mailed the first set of questionnaires to be completed within one week of receiving th e requested documents. Overview of the Research Study for Testing th e Effects of the PC-CSHC Intervention Program Each of the three components of the PC-C SHC Intervention Program (i.e., the physical environment and policies intervention component, the health care provider/office staff training intervention component, and the patient empowerment training component) occurred 5 months apart over a total period of 15 months (see Figure 3-1). The interventions occurred sequentially and within the first 2 months of each 5-month period, allowing patient participants up to 3 months to experience each inte rvention before being re-admin istered the Assessment Battery (AB). The interventions were implemented sequen tially, rather than simu ltaneously in order to allow the impact of each inte rvention component on the variables under investigation to be independently ascertained for analyses relevant to the larger National Institute of Health research program on patient-centered culturally sensitive health care, of which the present study was a part. Importantly only the baseline data (i.e., the data collected prior to the PC-CSHC Intervention Program), and the data collected following the implementation of the final component of the PC-CSHC Intervention Progr am (i.e., the patient empowerment training component) were used in the present study (see Figure 3-1). Prior to beginning the intervention program (i.e., at baseline), and following each intervention at the intervention clinic (at the end of each of the 5-month periods), patientparticipants at both clinics were sent the AB, which was pre-c oded as earlier described, and
77 asked to complete it and return it in pre-stamped and pre-addresse d return envelopes. Within 2 weeks of completing the AB, each participant was mailed a check for $20. Each patient participant who attended the patient training intervention was mailed a check for $60, 2 weeks after the training. Each clinic provider and office staff member participant who attended the clinic provider and office sta ff training was mailed a check for $90 within 2 weeks following the training. In addition, following each co mponent of the intervention at the intervention clinic (i.e., at the end of each 5-month period) trained research assistants obtained patients health outcome data (i.e., their systolic and dias tolic blood pressure read ings) from their clin ic charts. Finally, following the final data collection period, the three components of the Intervention Program were implemented simultaneously at the control cl inic; however, no post-in tervention data was collected, as implementing a version of the Inte rvention Program at the control clinic was an ethically responsible action rather than a research activity. The schedule for implementing the Intervention Program and collecti ng the data for the study is summ arized in Figure 3-1 below. Descriptions of the Three Components of the PC-CSHC I ntervention Program Component 1: The physical enviro nment and policies intervention The PC-CSCH physical health care environm ent and policies intervention com ponent consisted of modifying the intervention clinic environment and policies so that they were consistent with earlier mentioned patient-identified culturally sensitive health care characteristics. These modifications included: (a ) creating and displaying a culturally sensitive calendar that highlights cultural ho lidays, especially those relevant to the cultures that are most represented at the target clinic; (b) displayi ng culturally sensitive educational brochures (e.g.,written in Spanish), especially on topics that are relevant to the groups most represented at the clinic; (c) displaying cultura lly sensitive magazines (e.g., magazines that highlight AfricanAmerican and Hispanic people and culture); (d ) creating and displayi ng comment cards and
78 locked suggestion box in which the cards can be placed so that patients can give feedback to the clinic staff (including providers and administrators); (e) obtaining and displaying bilingual restroom signs; (f) obtaining and di splaying toys for patients childre n to play with in the waiting area; (g) displaying culturally se nsitive posters, especially on t opics that are relevant to the groups most represented at the c linic; (h) displaying culturally sens itive art featuring people from different cultures; (i) creati ng and displaying a bilingual polic y brochure; (j) creating and displaying a Patients Bill of Ri ghts brochure; (k) creating and displaying a Clinic Policies brochure; and (l) purchasing a DVD/VCR player so that DVDs and videos on health topics of interest to the patients served can be played in the waiting area. Component 2: Health care provider/office staff train ing This component of the PC-CSHC Intervention Program consisted of a 4-hour provider/office staff training workshop focused on training clinic providers and office staff in skills and strategies for engaging in patient-identified behaviors and attitudes that indicate patient-centered culturally sensi tive health care (Tucker et al., 2003). The workshop comprised 5 main components: (a) a pre-workshop introduct ion, (b) an overview of the existing health disparities literature, (c) teach ing of techniques (ways to engage in verbal and non-verbal behaviors as well as ways to display attitude s) that indicate provider/sensitivity sensitivity training, (d) small group discussions and (e) a patient panel. Notably, the first 2 components of the training program were more cognitive, while the last 3 components were more experiential. In addition, whereas the first 2 components focused primarily on increasing participants knowledge of culturally sensitiv e health care, the last 3 co mponents focused on increasing participants knowledge of culturally sensitive health care, helping participants to examine their attitudes towards culturally diverse patients, and teaching participants skills to engage in the delivery of culturally sensitive health care (i.e., knowledge, awareness, and skills). Importantly,
79 the workshop components also included curricular content focused on general aspects of culture, specific cultural content, and sociocultural factor s that impact provider-pa tient interactions all of which have been associated with positive training outcomes (Beach et al., 2006). Each of these components will be briefly described below. Pre-workshop introduction. During the pre-workshop introduction, which lasted approximately 15 minutes, provider and office st aff participants were introduced to the intervention program presenters, asked to co mplete a pre-workshop knowledge assessment to assess pre-workshop knowledge in the areas of the training, and introduced to the program objectives. Overview of health disparities literature. In the second component of the provider/office staff training intervention, which lasted approximately 1 hour, the term patient-centered culturally sensitive health care was defined, ba ckground literature on the health disparities problem was presented, and evidence for the asso ciation between improved culturally sensitive and competent health care and improved health outcomes among patients was discussed. As part of this process, examples of the focus group generated views of patie nts that provided the foundation for the training were presented by playing sound clips containing actual patient quotes recorded by diverse patients Finally, the behaviors and att itudes of providers and office staff that were rated the most important indicators of culturally sensitive health care by culturally diverse patients were also presented. TIPS training The third component of the workshop lasted approximately 1.25 hours and focused primarily on skills training related to th e earlier-presented patient behaviors that were rated as very important indicators of culturall y sensitive health care. This component of the workshop utilized Meichenbaums (1977) cogniti ve modeling and self-instruction training
80 approach. This approach empowered learners (i.e., health care providers and office staff) by using a step-by-step teaching a nd learning method that made learning simple and easy. This approach also used demonstration modeling and role-plays as well as learning theory-based strategies. The latter strategies included (a) using praise and enc ouragement in response to efforts to learn and actual learning of new behaviors, attitudes, and skills; and (b) encouraging the learners (e.g., providers a nd office staff) to praise themselves for their efforts to use and actual use of target behaviors, attitudes, and skills. The training content emphasized skills, behaviors, and attitudes for effectively communicating with patients who ar e not highly educated and/or are not fluent in English toward the goals of building rapport a nd trust, and showing empathy in interactions with culturally diverse patients. The skills training included a focu s on the following: (a) the behaviors and skills for conveying an empathetic attitude (i.e., the actions and skills for conveying respect, warmth, and genuineness), and (b) the microskills de scribed by many counseling psychologists (e.g., Ivey, DAndrea, Ivey, & Simek-Morgan, 2002). Th ese microskills include (a) culture-informed nonverbal attending skills includi ng effective use of eye contact, body language, vocal tone and speech rate, physical space, and time; (b) listeni ng skills including use of open ended questions, encouraging, paraphrasing, reflection of feeli ng and summarization; (c) influencing skills including interpretation/reframing, giving di rectives, advice/inform ation provision, selfdisclosure, feedback, identificati on of logical consequences, and use of an influencing summary; and (d) supportive confrontation skills. In this component of the workshop, providers we re also invited to vi ew three culturally sensitive health care demonstr ation videos, which showed act ual practicing physicians (one African American, one Hispanic, and one non-Hi spanic White physician in each video) and
81 office staff (non-Hispanic White) di splaying via role-plays many of the behaviors, attitudes, and skills that indicate patient-centered culturally sensitive health care (e .g., greeting the patients with a smile, explaining the consequences of medications, and responding supportively to the patients comments about faith and prayer). Each videotaped ro le-play was of a physician alone or with office staff providing health care servic es to a patient (i.e. an African American, Hispanic, or non-Hispanic White patient) with or without accompanying family members. Furthermore, the provider(s) in ea ch videotape was racially/ethnical ly different from the patient. Providers were asked to be aware of their attitudes during the role-plays and to use the knowledge and skills already presented to evaluate the demonstration role-plays. The following questions, among others, were used to facilitate this process: What struck you most about the demonstration you just saw? Are there any be haviors that you think the providers (and/or office staff) could have demonstrated to more ef fectively show culturally sensitive health care based on the TIPS that were presented? Small group discussions. This component of the workshop lasted 45 minutes and commenced with a presentation on (a) common culture -specific as well as more universal beliefs held among culturally diverse individuals (i.e., pa tients and potential pati ents) regarding health care and the contributors to h ealth, illness, and healing; (b) historical, cultural, and socioeconomic context factors that often impact health, il lness, healing, and treatment adherence/non-adherence of particular groups of patients; and (c ) how these and other sociocultural differences among patients, health care providers and the health care system can contribute to health disparities. Following this presentation, providers were asked to break into small groups based on their roles in the health care organiza tion (e.g., physician, nurse practitione r, office staff) to discuss
82 how interpersonal (i.e., individual attitudes) and organizational (i.e., heat h care system factors) barriers could prevent them from engaging in the TIPS (i.e., behavi ors, attitudes, and skills for demonstrating culturally sensitive health care) pr eviously taught. Examples of questions that provider participants were encour aged to consider included: W hat personal and organizational barriers will keep you from implementing patientcentered culturally sens itive health care? What resources are needed to facilitate the provision of patient-centered culturally sensitive health care at your health care s ite? and What strategies can be used to overcome barriers that exist and to maximize resources that are present? Providers and office staff were also invited to identify their anxieties, frustrat ions, and stressors related to provi ding health care to low-income patients and to culturally diverse patients. Af ter 15 30 minutes, each small group reported on their discussion to the larger group, and ther e was a large group discussion focused on overcoming the barriers presented. With the par ticipants permission, the feedback presented was anonymously recorded (i.e., combined together so that individual comments cannot be linked to individual participants) so th at it could be communicated to the health care organization administrators. Patient Panel Finally, in the last component of th e provider and office staff educational training workshop, which lasted approximately 45 minutes, participants were given the opportunity to anonymously submit, or directly as k questions to a panel of culturally diverse patients at the workshop to elicit helpful inform ation for (a) providing care to patients that reflects sensitivity to the conditions and constraints that negatively impact their health and health care, and (b) understanding the health and health care behaviors of culturally diverse patients. At the end of the workshop, partic ipants were asked to complete a post-training knowledge
83 assessment and to publicly commit to doing someth ing learned at the workshop to promote their cultural sensitivity/competence. Component 3: Patient empowerment training The patient health and health care empower m ent training compone nt of the PC-CSHC Intervention Program consiste d of a 4-hour workshop for cult urally diverse patients. The workshop comprised 4 main components: (a) a wo rkshop introduction and an overview of health disparities problem, (b) skills training, (c) sma ll group discussion, and (d) a provider panel. As with the provider educational training work shop, the patient empowerment training workshop included both cognitive and experi ential activities. In addition, in order to increase participation, child-care services and refreshm ents were provided for particip ants. Each component of the workshop is described below. Workshop introduction In the first component of th e patient empowerment training intervention, which lasted approximately 25 minutes, participants were introduced to the intervention program presenters, asked to co mplete a pre-workshop knowledge assessment to assess pre-workshop knowledge in the areas of the training, and introduced to the program objectives. Participants were then given a definition of patient-centered culturally sensitive health care and a brief summary of the health disparities problem. Skills Training The second component of the patient empowerment training intervention lasted approximately 1.5 hours and consisted of sk ills training in the following areas to empower and enable patient participants to inspire cultu rally sensitive health care behaviors from their clinic providers and office staff: (a) assertiven ess skills, (b) behavioral management skills (e.g. use of praise of specific clinic provider and office support sta ff behaviors that patients would like demonstrated more often), (c) stress and anxiet y management skills, (d) cognitive-behavioral anger management skills, and (e) skills for giving negative feedback and positive feedback to
84 others (e.g., to providers and clinic office staff) in constructive and respectful ways. These skills were taught using Meichenbaums cognitive mode ling and self-instruction training approach, which was earlier described. Role-plays, group discussions, demonstrations, and power point slides were all used as traini ng tools. Importantly, the skills training component of the patient workshop also involved educating patient partic ipants about the relatio nship between negative emotional states (e.g., stress, anxiety, depressi on, and anger) that can result from culturally insensitive interactions with clinic staff, and thei r experience of chronic i llness. As such, patients were additionally encouraged to participate in health promotio n activities (e.g., exercising, eating healthy meals) to help improve bot h their physical and mental health. In addition, community repres entatives, who were trained prior to the workshop, participated in presenting some of the skills that were discu ssed. Finally, this component ended with a summary of tips and strategies that particip ants could use for a successful health care visit. Examples of tips for obtaining patient-centere d culturally sensitive health care included the following: (a) taking a list or having a family member/friend list your (the patients) questions and symptoms so that you can simply give the list to your provider at the beginning of the health care visit, (b) introducing yourself as you wish to be called (e.g., as Mr., Ms., or Seor[a] Jones), (c) bringing a tape recorder or a friend to take notes on the vi ews of the attending provider regarding your health problems and the reco mmended treatment for these problems, and (d) requesting that the provider give you literature on any diagnoses made and on any medications recommended. Small group discussions. In this component of the work shop, which lasted approximately 45 minutes, participants were firs t presented with the list of th e most important indicators of patient-centered culturally sensi tive health care identified by focu s group participants (Tucker et
85 al., 2003). Participants were then divided into small groups to discuss how the behaviors taught during the skills-training component could be used to elicit the culturally sensitive health care behaviors that were presented. Patient participants were additionally asked to share what strategies they had used in the past to elicit such behaviors, or to overcome barriers related to eliciting the desired behaviors. Cu lture-specific behaviors such as how to e ffectively request or express concerns regarding a Spanish interpreter were also di scussed in these small groups. Panel discussion The final component of the works hop lasted approximately 1 hour. It involved a discussion among primary care clinic pr oviders and clinic office staff comprising a clinic staff panel, and patient participants in the workshop. Th e purpose of the panel discussion was to engender patient-provider communication about health and he alth care stressors with the ultimate goal of facilitating supportiv e patient-provider alliances ve rsus adversarial relationships. In particular, patients were inv ited to anonymously submit, or dire ctly ask the pane l participants questions about their health care or the health care system, and panelists were invited to share individual or systemic frustrations of which th e patients may not have been aware. The workshop ended by asking participants to complete a post-training knowledge assessment and to publicly commit to doing something learned at the works hop to engender cultural sensitivity/competence among their health care providers and office staff.
86 Figure 3-1. Flowchart Showing the Order of and Timeline for the Recruitment, Intervention and Data Collection Activities in the PC-CSHC Intervention Program.
87 Table 3-1. Demographic Characteristics of Patie nt Participants in the Present Study by Race. Characteristics N % African American Patients Gender Male Female Income Less than $10,000 $10,0001 $20,000 $20,001 $30,000 $30,001 $40,000 Above $40,001 Education No high school diploma High school diploma Some college College Professional/graduate Self-reported diagnosis High blood pressure only High blood pressure with another condition 110 25 85 54 11 10 1 3 17 33 14 4 3 13 48 48.9 22.7 77.3 49.1 10.0 9.1 .9 2.7 15.4 30.0 12.7 3.6 2.7 11.8 43.6 White Patients Gender Male Female Income Less than $10,000 $10,0001 $20,000 $20,001 $30,000 $30,001 $40,000 Above $40,001 Education No high school diploma High school diploma Some college College Professional/graduate Self-reported diagnosis High blood pressure only High blood pressure with another condition 114 39 76 26 17 13 9 25 8 24 33 13 13 3 39 51.1 33.9 66.1 22.6 14.8 14.4 10.0 27.8 6.9 20.9 28.7 11.3 11.3 2.6 34.2
88 CHAPTER 4 RESULTS This chapter presents the results of analys es conducted to addr ess the hypotheses and research questions set forth in this study. The resu lts are divided into four m ajor parts. First, the descriptive data for al l of the major variables in the st udy are reported. Second, the results of preliminary Pearson correlational analyses th at were conducted to assess the degree of association at baseline between the major variables under inves tigation, and to determine the degree of association between th e Marlowe-Crowne Social Desira bility Scale Short Form and each of the other variables are presented. Third, the results of general linear model analyses that were executed to address the two research questi ons are presented. Finally, the results of general linear model analyses that were conducted to test the two primary hypot heses addressed by the present study are presented. Descriptive Data for all Major Variables Table 4-1 p resents the baseline means, standa rd deviations, and ranges for each variable under investigation in this study. Perhaps most intere sting in Table 4-1 is th e data suggesting that both African American patient participants and Wh ite patient participants rated their providers behaviors and attitudes as more culturally sens itive than their office staffs attitudes and behaviors, which were in turn rated as more cultu rally sensitive than the clinic environment. In addition, the data suggest that, at baseline, African American patie nt participants rated both their office staffs behaviors and attit udes and their clinic environments as more culturally sensitive than did White patients. In contra st, White patient participants appeared to rate their providers behaviors and attitudes as more culturally se nsitive than did African American patient participants at baseline.
89 Results of the Preliminary Pearson Correlations Three Pearson correlation analyses w ere conducted to examine the degree of association among the major variables under in vestigation and to examine th e associations between these variables and social desirability (as measured by the Marlowe-Crowne Social Desirability ScaleShort Form). The major variables of study includ ed in each correlational analysis along with social desirability were patient perceived pati ent-centered cultural sensitivity as indicated by mean scores for components of the T-CSHCI (i .e., the provider behavior/attitudes component, the office staff behaviors/attit udes component, and the clinic physical environment and policies component), and systolic and diastolic blood pr essure. The results of the three correlation analyses performed are shown in Table 4-2. The fi rst of the correlational analyses was performed using the data of the African American patient participants, the second was performed using the data of the White patient participants, whereas th e third was performed using the total sample of participants. Most noteworthy in Table 4-2 are the modera te to high intercorrelations among the three T-CSHCI component mean scores for the African American patient participants and for the White patient participants. Specifically, for the African American patients, intercorrelations among the mean component scores ranged from r = .767, p < .01 (provider behaviors/attitudes and clinic physical environment characteristics and policies) to r = .844, p < .01 (office staff behaviors/attitudes and clinic physical environm ent characteristics and pol icies). For the White patients, intercorrelations ranged from r = .501, p < .01 (provider behavior s/attitudes and office staff behaviors/attitudes) to r = .774, p < .01 (office staff behaviors and clinic physical environment characteristics and policies). In addition, significant but low correlations were found between mean systolic and diastolic hypertension scores for both racial/ethnic groups ( r = .495 for the African American
90 patients and r = .392 for the White patients; p < .01). Importantly, at base line social desirability scores were not significantly correlated with any of the majo r self-report variables under investigation in the present study, suggesting that neither African American patient participants nor White patient participants responded to the in struments to assess these variables in a socially desirable manner. Results of Analyses to Test Research Question s 1 and 2 Research Question 1 The first research question under investigation explored whether, am ong patient participants in the present study, there were significant differen ces in mean perceived patientcentered cultural sensitivity ratings on the comp onents of the T-CSHCI-Patient Form (i.e., the provider behaviors and attitudes component, the o ffice staff behaviors and attitudes component, and the clinic physical environment and policie s component) at baseline in association with gender or group (intervention vs. control). Given the significant intercor relations among the three mean component T-CSHCI-Patient Form scores at baseline that were identified in the preliminary correlation analyses, this research question was addressed using two multivariate analyses of covariance (MANOVAs) one with the African American patients data from the TCSHCI-Patient Form, and one with the White pa tients data from the T-CSHCI-Patient Form (given race-specific versions of these assessment instruments). In each of these analyses, the mean scores for each T-CSHCI-Patient Form component (i.e., the provider behaviors and attitudes comp onent, the office staff behaviors and attitudes component, and the clinic physical environment and policies component) at baseline were the dependent variables, and gender, group, and gender x group were the independent variables. It is important to note that data sets for reported analyses were not available from all African American and White patient par ticipants who consente d to participate in the study because many
91 participants (a) did not complete all parts of the assessment battery at baseline and/or postintervention, and/or (b) did not have health ou tcome data (e.g., blood pressure readings) that was accessible to the research team during data collection. African American patient participants For the Af rican American patient participants data from 88 participants (6 males and 46 females at the intervention clinic, and 14 males and 22 females at the control clinic) were available for analysis. Results indicated that there were no significant multivariate effects for gender, group or gender x group. White patient participants Data f rom 88 White patient participants (11 males and 21 females at the intervention clinic, and 22 males and 34 females at the control clinic) were available for analysis. Results from the MANOVA revealed a significant multivariate effect for gender (Wilks = .902, F (1, 84) = 2.981, p < .05) and group (Wilks = .911, F (1, 84) = 2.669, p = .05; see Table 4-3); however, the multivariate effect for the group x gender interaction was not significant. Three follow-up ANOVAs were conducted to fu rther understand the multivariate effects that were obtained, consistent with suggesti ons made by Weinfurt (2000). In these ANOVAs, a different one of the three mean scores for th e components of the T-CS HCI-Patient Form for White patient participants was the dependent variable, and group, gender and gender x group were the independent variables. The result s of the ANOVA that was run for the provider behaviors and attitudes component of the T-CSHCI-Patient Form for White patient participants revealed only a significant betw een-subjects effect for gender ( F (1, 84) = 7.844, p < .01), which accounted for about 9% of the variance in the mean scores for the provider behaviors and attitudes component. Thes e results suggest that, at baseline, mean scores for the provider attitudes and behaviors compone nt of the T-CSHCI-Patient Form for White female patient
92 participants ( M = 3.51) were significantly higher than the m ean scores for the provider attitudes and behaviors component of the T-SCHCI-Patient Form for White male patient participants in the present study ( M = 3.24). The other two follow-up ANOVAs revealed no significant effects. In sum, the analyses to test the first resear ch question suggest that at baseline, African American patients in the present st udy did not differ significantly in their ratings of the perceived cultural sensitivity of their providers behaviors and attitudes, of their office staffs behaviors and attitudes, or of their clinic physical environment and policies in association with group (i.e., being the group at the interventi on clinic or the group at the c ontrol clinic), group or gender x group. In contrast, the findings suggest that White patients in the present study differed significantly in their ratings of the perceived cultural sensitivity of thei r providers behaviors and attitudes in association with gende r. Specifically, White female patients as compared to the male patients rated their providers attitudes and be haviors to be more cu lturally sensitive. Research Question 2 The second research question under investig ation exam ined whether, among patient participants in the present st udy, there were significant differe nces in health outcomes (i.e., diastolic and systolic blood pr essure readings) at baseline (i.e., prior to the PC-CSHC Intervention Program) in associ ation with race/ethnicity (i.e ., African American vs. White), gender, or group (i.e., the patient participants at the c ontrol clinic vs. thos e at the intervention clinic). Given the signif icant intercorrelations at baseline among the systolic and diastolic blood pressure readings for the total sample that were identified in the preliminary Pearson correlations that were conducted (see Tabl e 4-2), a MANOVA was conducted to address this research question. In this MANOVA systolic and diastolic blood pressure readings were the dependent variables, and race/ethnicit y, gender, group, gender x group, gr oup x race/ethnicity, gender x race/ethnicity, and gender x group x race/ethni city were the independent variables.
93 For these analyses data were available from 36 patients at the control clinic (4 White males and 4 African American males, 8 White fema les and 20 African American females) and 65 patients at the intervention clinic (15 White males and 9 African American males, 28 White females and 13 African American females). Results indicated that there were no significant multivariate effects for race/ethnic ity, gender, group, or the 2or 3-way interactions of these variables, suggesting that, at ba seline, African American patient participants and White patient participants in this study did not significantly differ in their diastolic or sy stolic blood pressure readings in association with their race/ethnicity, gender, group, gender x group, gender x race/ethnicity, or gende r x group x race/ethnicity. Hypothesis 1 Hypothesis 1 stated that, following the im pl ementation of a pilot PC-CSHC Intervention Program at a primary care clinic (i.e., the intervention clinic), the group of patients who participated in the Program (i.e., adult prim ary care African American patients and White patients from primarily low-income backgrounds who have been diagnosed with hypertension alone, or in combination with di abetes, coronary artery disease, and/or high cholesterol) would evidence significantly higher ratings of perceive d cultural sensitivity in provider and office staff behaviors and attitudes, and in their health care clinic environm ent (i.e., physical characteristics and policies) than would a control group of pa tients who were demographically and medically similar to the intervention group of patients and who received care at a primary care clinic that was similar to the intervention clinic (i.e., the control clinic) but who were not exposed to the Program. African American patient participants For the Af rican American patient sample, the data of 17 patient participants (5 female patients from the intervention clinic, and 4 male and 8 female patients from the control clinic)
94 were available to test Hypothesi s 1. Due to the small number of datasets available for analysis (and the consequent reduced power for detecting significant results), three repeated measures ANOVAs were conducted to test Hypothesis 1, instead of the proposed MANCOVA (which would be ideal given the found significant correl ations among the dependent variables examined to assess intervention effects). Furthermore, repeated measures were deemed appropriate given the results of the analyses to address Research Question 1, which suggested that there were no significant baseline differences in the cultural sensitivity ratings for each component of the TCSHCI Patient Form for African American patien t participants in asso ciation with group. In each repeated measures ANOVA, a differe nt one of the three components of the TCSHCI-Patient Form for African Americans was included as the de pendent variable. Time (i.e., baseline vs. 15-months post-i ntervention), time x group, and time x gender were the withinsubjects factors in each repeated meas ures ANOVA, whereas group and gender were the between-subjects factors. Given th e absence of African American male patient participants at the intervention clinic at post-intervention, group x gender and time x group x gender interactions were not examined. Results from the repeated measures ANOVA w ith mean scores for the provider behaviors and attitudes component of the T-CSHCI-Patient Form as the dependent variable indicated a significant within-subjects effect for time ( F (1, 14) = 4.549, p = .05). This effect was driven by the fact that mean scores for the provider behaviors and attitudes component scores at postintervention were significantly higher than the mean scores for the provider behaviors and attitudes component at baseline ( M = 3.21 at baseline; M = 3.39 at post-intervention). Importantly, analysis of profile plots suggest th at although patient partic ipants at both clinics experienced an increase in perceived cultura l sensitivity ratings from baseline to post-
95 intervention, the patient participants at the inte rvention clinic experienced a larger increase than did patients at the control cl inic (see Figure 4-1), although the absence of a significant group x time interaction effect suggests that the difference in increased ratings between the two groups was not sufficient to attain statistical significance. In addition, results of the repeated measures ANOVA with mean scores for the provider behaviors and attitudes component indicated a significant between -subjects effect for gender (F (1, 14) = 7.222, p <. 05). Mean scores suggested th at African American wo men at baseline and at post-intervention rated their providers behaviors and attitudes as significantly more culturally sensitive than did their male counterparts ( M = 3.40 for females at baseline, M = 2.58 for males at baseline; M = 3.54 for females at post-intervention, M = 2.90 for males at post-intervention). Results from the repeated measures ANOVA with mean scores for the office staff behaviors and attitudes component of the T-CSHCI-Patient Form as the dependent variable indicated a significant between-s ubjects effect for gender ( F (1, 14) = 5.03, p < .05). Mean scores suggested that African American female patients at baseline and at post-intervention rated office staffs behaviors and attitudes as more culturally sensitive than did their African American male counterparts ( M = 3.35 for females at baseline, M = 2.94 for males at baseline; M = 3.55 for females at post-intervention, M = 2.40 for males at post-intervention). In addition, results indicated a significant time x gender interaction effect ( F (1, 14) = 6.908, p < .05). Analysis of profile plots of the estimated marginal means and mean difference scores to understand this significant time x gender interaction indicated that African American female patient participants rated their office staffs behavi ors and attitudes as more cultu rally sensitive than African American male patient participants at both baseline and post-intervention; however, the difference between the culturally sensitivity rating s of staff behaviors and attitudes of African
96 American female patients and African American male patients was larger at post-intervention compared to this difference at baseline (M ean Difference Score at baseline = .409; Mean Difference Score at post-interv ention = 1.15; see Figure 4-2). Results from the repeated measures ANOVA with mean scores for the clinic environment component of the T-CSHCI-Patient Form as the de pendent variable sugges ted that there were no significant between-subjects (i.e., group and gender), within-subjects effects (i.e., time), or interaction effects (i.e., time x group or time x ge nder). These findings sugge st that the cultural sensitivity ratings of the clinic environmen t did not differ significantly by gender, group (intervention clinic vs. control clinic), or time (baseline vs. post-intervention), or by any 2-way interactions of these variables for the African American patien t participants in this study. White patient participants For the W hite patient sample, data from 14 patie nts (5 male and 8 female patients at the control clinic; 1 female patient at the intervention clinic) were available for analysis. Because the data for only 1 patient from the intervention clin ic were available, Hypothesis 1 could not be tested with the data from the White patient sample. Hypothesis 2 Hypothesis 2 stated that, following the im pl ementation of the PC -CSHC Intervention Program, the participants who are exposed to the Intervention Program will evidence significantly lower diastolic and sy stolic blood pressure readings than will the control group of participants who are not exposed to the Intervention Program. Data from 37 patient participants were available to test Hypothesi s 2 (5 African American female patients, 1 White male patient and 1 White female patient at the intervention c linic; and 5 African American male patients, 9 African American female patients, 6 White male patients, and 10 White female patients at the control clinic). Given the small sample of patients available at the intervention clinic (i.e., seven
97 patients) and the consequent reduced power available for detec ting significant results using the originally proposed MANOVA, two repeated measures ANOVAs were conducted to test Hypothesis 2. In the first of these repeated measures ANO VAs, mean diastolic blood pressure scores was the dependent variable, group, gender, race, group x gender, group x race/ethnicity, and race/ethnicity x gender were the between-subject factors, and time, time x group, time x gender, time x race/ethnicity, time x group x gender, tim e x group x race/ethnicity, and time x gender x race/ethnicity were the within-s ubjects factors. In the second repeated measures ANOVA, mean systolic blood pressure scores was the depende nt variable, group, gender, race, group x gender, group x race/ethnicity, and race/eth nicity x gender were the betw een-subject factors, and time, time x group, time x gender, time x race/ethnicity, time x group x gender, time x group x race/ethnicity, and time x gender x race/ethnicity were the within-subjects factors. Given the absence of African American male patient particip ants at the intervention clinic, time x group x gender x race and group x race x gender interactions were not examined in either of the repeated measures ANOVAs to test Hypothesis 2. It is also is noteworthy that in c ontrast to the analyses in which perceived cultural sensitivity was the dependent variable (i.e ., analyses to test Hypothesis 1 and Research Question 1), for both repeated measures ANOVAS with blood pressure readings as the dependent variables, data from both African American and White patient participants were included into the same anal ysis. Whereas two different assessment instruments were used to evaluate perceived cultural sensitivity for African American patient participants and White patient participants (i.e., the African American and White vers ions of the PC-CSHCPatient Forms), this was not the case for assess ing blood pressure readin gs; as such, the data could be combined, thus allowing more power for analyses.
98 Diastolic blood pressure readings Results of the repeated measures ANOVA using diastolic blood pressu re readings as the dependent variable revealed no si gnif icant within-subject, between-s ubject or interaction effects. These results suggest that the patient participants in this study di d not significantly differ in their diastolic blood pressure readi ngs by gender, group (interventi on vs. control), race/ethnicity (African American vs. White), time (baseline vs post-intervention), or a ny interaction of these variables. Systolic blood pressure readings Results of the repeated measures ANOVA using systolic blood pressure readings as the dependent variable indicated a signif icant gender x race/ethnicity interaction effect ( F (1, 30) = 7.02, p = .05). Profile plot analysis to understand this interacti on indicated that whereas the African American male patient participants ha d lower systolic blood pressure readings than African American female patient participants at both testing times, the White male patient participants had higher systolic blood pressure readings th an the White female patient participants at both test times (see Figure 4-3). Overall, the analyses to test Hypothesis 2 suggested that the mean diastolic and systolic blood pressure readings of patie nt participants who were expo sed to the Intervention Program did not significantly differ from those of patie nt participants who we re not exposed to the Intervention Program. However, it is noteworthy that profile pl ots demonstrating means for both groups (i.e., intervention vs. contro l) at both testing times (baselin e vs. post-intervention) suggest that the mean systolic blood pressure readings of African American patien ts at the intervention clinic decreased over time (i.e., from baseline to post-intervention), whereas the mean systolic blood pressure readings of their c ounterparts at the control clinic stayed about the same as shown in Figure 4-4. Moreover, Figure 4-5 suggests that this was not the ca se for White patients in the
99 study (although it is import ant to note that the profile plot shown was based on the limited data of 2 White patient participants at post-intervention). It is notewort hy that the small sample size of participants available to test Hypothesis 2 may have precluded the detection of any significant time x group and/or time x group x race interaction effects that may have been revealed with larger patient participant samples of African American patient participants and White patient participants.
100 Table 4-1. Means and standard devi ations for the variables inves tigated in the present study at baseline by race/ethnicity. Variables NMSD Range African American Patient Participants Provider Behaviors/Attitudes 893.26.55 1.63-4.00 Office Staff Behaviors/Attitudes 893.18.55 1.52 .00 Clinic Environment 883.11.52 1.72-4.00 Diastolic Blood Pressure 4782.317.54 64.85-101.14 Systolic Blood Pressure 47134.1611.20 111.33-159.43 Social Desirability 89.68.18 .20-1.00 White Patient Participants Provider Behaviors/Attitudes 883.41.48 2.18-4.00 Office Staff Behaviors/ Attitudes 882.99.44 1.57-4.00 Clinic Environment 882.95.37 1.84-4.00 Diastolic Blood Pressure 5580.077.35 65.11-101.75 Systolic Blood Pressure 55134.4713.33 108.40-178.25 Social Desirability 89.61.21 .15-1.00
101 Table 4-2. Pearson correlations among the major va riables of interest in the present study for patient participants at baseline by race/ethnicity and for the total sample. 1234 56 African American Patient Participants 1. Provider Behaviors/Attitudes -.795**.767**-.061 .067.081 2. Office Staff Behaviors/ Attitudes -.844**-.049 .132.018 3. Clinic Environment --.091 .026.029 4. Diastolic Blood Pressure .495**-.313 5. Systolic Blood Pressure --.151 6. Social Desirability White Patient Participants 1. Provider Behaviors/Attit udes -.501**.574**-.290 -.226-.025 2. Office Staff Behaviors/ Attitudes -.774**-.101 -.021.139 3. Clinic Environment --.169 .090.209 4. Diastolic Blood Pressure .392**.035 5. Systolic Blood Pressure --.063 6. Social Desirability Total Sample 1. Provider Behaviors/Atti tudes -.628**.642**-.193 -.103.001 2. Office Staff Behaviors/ Attitudes -.823**-.043 .059.106 3. Clinic Environment --.101 .064.135 4. Diastolic Blood Pressure .427**-.076 5. Systolic Blood Pressure --.076 6. Social Desirability Table 4-3. Results of MANOVA testing differen ces at baseline in mean scores for the components of the T-CSHCI-patient form in association with group, gender, and gender x group for White patient participants. Wilks Fd fp 2 Gender .9022.9811, 84.036 .098 Group .9112.6691, 84.053 .089 Gender x Group .966.9621, 84.415 .034
102 TIME2 1Means for Provider Behaviors and Attitudes3.6 3.5 3.4 3.3 3.2 3.1 3.0 CLINICIntervention Control Figure 4-1. Profile plot showing the means for the provider behavi ors and attitudes component of the T-CSHCI patient form for African American patient participants from baseline to post-intervention by clinic. TIME2 1Means for Staff Behaviors and Attitudes3.8 3.6 3.4 3.2 3.0 2.8 2.6 2.4 2.2 GENDERMale Female Figure 4-2. Profile plot demonstrating time x gender interaction effect in cultural sensitivity ratings of office staff behaviors and at titudes for African American patient participants.
103 GENDERFemale MaleMeans for Systolic Blood Pressure150 140 130 120 RACE/ETHNICITYCaucasian American African American Figure 4-3. Profile plot demonstrating gender x race interaction eff ect for systolic blood pressure means for African American patient participants and White patient participants. TIME2 1Means for Systolic Blood Pressure138 137 136 135 134 133 132 131 130 CLINICIntervention Control Figure 4-4. Profile plot s howing means for systolic blood pressu re readings of African American patient participants by time, group, and time x group.
104 TIME2 1Means for Systolic Blood Pressure150 140 130 120 CLINICIntervention Control Figure 4-5. Profile plot showing means for systolic blood pressure readings of White Patient participants by time, group, and time x group.
105 CHAPTER 5 DISCUSSION The purpose of this chapter is to (a) summ ar ize and interpret the results of the present study, (b) identify limitations of the study and offer directions for future research, and (c) discuss the implications of the present study for counseling psychologists. Summary of the Results Descriptive Data The descriptive data reported were interesting in several regards. First, African American patient participants and White patient particip ants rated their provide rs behaviors as more culturally sensitive than their office staffs attitude s and behaviors, which were in turn rated as more culturally sensitive than th e clinic environment. These fi ndings are perhaps not surprising given that the vast majority of interventions designed to achieve cultural sensitivity/competence have focused on enhancing the knowledge of health care providers (versus office staff) about the relationship between sociocultural factors and health beliefs and equipping these providers with the tools and skills to manage these factor s appropriately. Moreover, whereas medical associations have increasingly approved manda tory diversity accred itation requirements (e.g., OMH, 2001), thus providing the impetus for heal th care providers to in crease their level of cultural sensitivity, this mandate has not applie d to office staff and clinic administrators. Consequently, office staff and clinic admi nistrators likely do not seek cultural competency/sensitivity training. Without such training it is understandab le that the cultural sensitivity of office staff and clinic physical ch aracteristics and policies ma y not be at the level that they could be. The present results suggest the need to addr ess the cultural sensitivity of the office staff and clinic physical environment characteristics and policies, as earlie r concluded in a focus
106 group study to operationalize cultural sensitivity from the perspectives of culturally diverse patients (e.g., Tucker et al., 2003), and as mandated in the National Standards for Culturally and Linguistically Appropriate Servi ces in Health Care (OMH, 2001). In addition, the descriptive da ta indicated that, at baseline, African American patient participants rated both their offi ce staffs behaviors and attitudes a nd their clinic environments as more culturally sensitive than did White patients, whereas White patient s rated their providers behaviors and attitudes as more culturally sensitive than did Af rican American patients. These findings are interesting as they highlight the fact that although both African American patient participants and White patient participants rated their providers behaviors and attitudes as most important (compared to office sta ffs behaviors/attitudes and the clinic environment) as earlier reported, there were ethnic/racial differences in mean ratings. These findings may be partially explained by the fact that 75% of the provider sample were White, whereas only 9.4% of the provider sample were African Am erican. As such, there may have been fewer instances of behaviors (e.g., misunderstandings or differences in cultural health beliefs) that may have been perceived as culturally insens itive among White patient participants compared to African American patient participants. In addition, African American patient participants may have been more attuned to culturally sensitive behaviors demonstrated by o ffice staff members and in the clinic physical environment and policies leading to higher ratings of these behavi ors and clinic characteristics among this patient sample compared to White patient participants. This view is consistent with earlier reported focus group findings, which sugge sted that African American patients may consider the behaviors of support staff and characteristics of the clinic physical environment and
107 policies as more central to their overall experi ence of cultural sensitivity, compared to White focus group patients (Tucker et al., 2003). It is also noteworthy that a la rger percentage of African Amer ican patient participants in the present study were from low-income bac kgrounds (e.g., 49.1% of the African American patient sample earned below $10,000 compared to 22.6% of the White patient sample). As such, high ratings of office staffs be haviors and attitudes and the clinic physical environment and policies may reflect the emphasis that patient s from lower income backgrounds may put on aspects of the health care environment such as having easy access to th e clinic and health information and being treated quickly and fairl y, which may be less rele vant to higher income patient populations (e.g., patients in low-paying jobs may have lo wer general and health literacy and very limited ability to reschedu le appointments during clinic hours). Hypothesis 1 Hypothesis 1 stated that, following the im pl ementation of a pilot PC-CSHC Intervention Program at a primary care clinic (i.e., the intervention clinic), a group of patients who participated in the Program (i.e., adult prim ary care African American patients and White patients from primarily low-income backgrounds who have been diagnosed with hypertension alone, or in combination with di abetes, coronary artery disease, and/or high cholesterol) would evidence significantly higher ratings of perceived cultural sensitivity in provider and office staff behaviors and attitudes, and in their health care clinic environm ent (i.e., physical characteristics and policies) than would a control group of pa tients who were demographically and medically similar to the intervention group participants a nd who received care at a primary care clinic that was similar to the intervention clinic (i.e., the c ontrol clinic), but who were not exposed to the Program. This hypothesis was tested separately fo r African American patient participants and White patient participants (given that there were different assessment instruments to measure
108 perceived cultural sensitivity for these two groups) using three repeated measured analyses of variance (ANOVAs) for each racial/ethnic group. Unfortunately, limited data following the 15-m onth intervention period precluded testing Hypothesis 1 for the White patient participants. Results of analyses to test Hypothesis 1 with the African American patient par ticipant data did not support Hy pothesis 1, as there were no significant main or interaction e ffects found that would have suggested significant differences in patient-centered cultural sensitivity ratings be tween groups (control vs. intervention) at postintervention. Nonetheless, the results of analyses that were conducted to test Hypothesis 1 yielded some interesting findings. First, results of the repeated measures ANOVA with mean scores for the provider behaviors and attitudes component of the T-CSHCI-Patient Form as the dependent variable suggested that African American patient participants in the pres ent study at both the intervention clinic and the control clinic rated their provider s behaviors and attitude s as significantly more culturally sensitive following the 15-month intervention period than they did at baseline. It is noteworthy that analysis of prof ile plots suggested that althou gh patient participants at the intervention clinic and the contro l clinic both rated their provide rs behaviors and attitudes as significantly more culturally sensitive following th e intervention than at baseline, the increase from baseline to post-interventi on in the intervention group was la rger than the increase in ratings from baseline to post-intervention for th e control group. These findings suggest partial, though non-statistically significan t support for Hypothesis 1, a nd support the importance of replicating the present study with a larger sample of participants. Second, the results of the repeated measures ANOVAs with both the providers behaviors and attitudes component and the office staff s behaviors and attitudes component of the T-
109 CSHCI-Patient Form indicated that African American female patien t participants at baseline and following the 15-month post intervention period both rated their provid ers behaviors and attitudes and their office staffs be haviors and attitudes as signifi cantly more culturally sensitive than did their African American male counterparts (at the control c linic as there were no African American male participants at the intervention c linic at post-interventio n). In addition, results indicated the difference between African American female and male patient participants ratings of their office staffs behaviors and attitudes was larger at post-intervention compared to this difference at baseline. It is first important to note th at these results need to be inte rpreted with caution, given that there were more females than males available fo r analysis (20 males and 69 females at baseline, 4 males and 13 females at post-intervention) and th is may have skewed the results. In addition, there were no African American males at the inte rvention clinic available for analysis precluding the emergence of any group x ge nder interaction effects. Nonetheless, the results suggest that African American female patient participants in this study appeared to perceive both their providers and office staffs attitudes and behaviors as more culturally sensitive than African American male patient participants. These results are particularly interesting given th at gender disparities in health care, which suggest that women may receive a poorer quality of health care than their male counterparts, continue to be well documented (e.g., AHRQ, 2003; Schulman et al., 1999). The results of the present study may reflect a larger degree of mist rust among African American ma les versus African American females with regard to health care interactions, esp ecially given the fact that health care atrocities such as those committed in the Tuskegee Syphilis Study targeted African American males. This distrust may subsequently lead to higher expe ctations among African Am erican males regarding
110 behaviors and attitudes that are considered indicators of cultur ally sensitive health care among health care providers and office staff. However, it is noteworthy, that while the presence of distrust in the African American community resulting from awareness of studies like the Tuskegee Syphilis Study is well documented, less well documented is the differential experience of distrust among African Amer ican males and females (e.g., Adderley-Kelly & Green, 2005; Dancy, Wilbur, Talashek, B onner, & Barnes-Boyd, 2004). The present findings highlight the importanc e of conducting future research focused on examining gender differences in perceived cultural sensitivity among specific racial/ethnic groups, as such research is lack ing. Special attention needs to be given to recruiting African American male patient participants in such research. Finally, results of the rep eated measures ANOVA with mean scores for the clinic environment component of the T-CSHCI-Patient Fo rm as the dependent variable suggested that African American patient partic ipants did not signifi cantly differ in their perceived cultural sensitivity ratings of the clinic physical enviro nment and policies with regard to gender, group (intervention vs. control), time (baseline vs. post-intervention) or any interaction of these variables and thus did not support Hypothesis 1. Th ese results are interest ing given that in a focus group study conducted by Tucker et al. (2003), both African American and Hispanic focus group participants noted the impor tance of changes to the clinic environment and policies as central to their experience of patient-cen tered culturally sensitive health care. Hypothesis 2 Hypothesis 2 stated that, following the im pl ementation of the PC -CSHC Intervention Program, the participants who are exposed to the Intervention Program will evidence significantly lower diastolic and sy stolic blood pressure readings than will the control group of participants who are not exposed to the Intervention Program. Results of analyses to test
111 Hypothesis 2 did not support this Hypothesis, although profile plot analysis suggested that, with larger patient participant sample s significant time x group and/or time x group x race interactions may have been found. Specifically, these profile plots showed that the mean systolic blood pressure readings of African American patient pa rticipants at the intervention clinic decreased over time (i.e., from baseline to post-intervention) the systolic blood pressu re readings of their African American counterparts at the c ontrol clinic stayed about the same. In addition, it is notable that at baseline both African Americ an patient participants and White patient participants had mean diastolic and mean systolic blood pressure readings in the prehypertensive range (i.e., mean diastolic bl ood pressure for White patients = 82.31 and for African American patients = 80.07; mean syst olic blood pressure for White patients = 134.16 and for African American patients = 134.47). It is worth considering that the Intervention Program may have been more successful at decr easing these blood pressure readings (consistent with Hypothesis 2) if they had been in the stage 1 or stage 2 hypertensi on ranges (i.e., systolic blood pressure readings >140 mmHg and diastolic blood pressure readings > 90 mmHg ). Indeed, it is likely that the patients who comprised the participant sample at baseline were already being medically treated for high blood pressure, and, as a consequence, the test of the impact of the pilot PC-CSHC Intervention Program on blood pressure readings of the participating patients was not a reliable one. Research Question 1 The first research question under investigation explored whether, am ong patient participants in the present study, there were significant differen ces in mean perceived patientcentered cultural sensitivity ratings on the comp onents of the T-CSHCI-Patient Form (i.e., the provider behaviors and attitudes component, the o ffice staff behaviors and attitudes component, and the clinic physical environment and policie s component) at baseline in association with
112 gender, group (intervention vs. c ontrol), or gender x group. Results of analyses to test Research Question 1 among African American patient participants revealed no significant differences at baseline in association with gender, group, or gender x group on any of the components of the TCSHCI-Patient Form. This finding suggests that a ny differences in perceived patient-centered culturally sensitive health care that were found at post-intervention could be attributed to the effect of the PC-CSHC Interven tion Program rather than pre-ex isting differences at baseline. Results of analyses to test Research Questi on 1 among White patient participants indicated that, at baseline, mean scores for the provide rs behaviors and attitudes component of the TCSHCI-Patient Form for White females in the present study were significantly higher than the mean scores for White males. These results may refl ect the fact that a majority of providers at the control and intervention clinics were female ( 60%) and White (75%); as such, White female patient participants may have felt more positiv ely towards their providers compared to male patient participants. Importantly, this interpretation is consistent with the finding in a focus group study that White female participants reported a preference for female physicians, especially for gynecologic examinations (Tucker et al., 2003). Research Question 2 The second research question under investig ation exam ined whether, among patient participants in the present st udy, there were significant differe nces in health outcomes (i.e., diastolic and systolic blood pr essure readings) at baseline (i.e., prior to the PC-CSHC Intervention Program) in associ ation with race/ethnicity (i.e ., African American vs. White), gender, group (i.e., the patient pa rticipants at the control clinic vs. those at the intervention clinic), race/ethnicity x gender, race/ethnic ity x group, or race/ethnicity x gender x group. Results of analyses to test Research Questi on 2 suggested that African American patient participants and White patient participants in this study did not diffe r significantly in their
113 diastolic or systolic blood pressure in asso ciation with their race/ ethnicity, gender, group, race/ethnicity x gender, race/ethnicity x group, or race/ethnicity x gender x group. The lack of significant race/ethnicity differences in blood pressure read ings at baseline is particularly interesting given the well-documented disparities in the incidence of high blood pressure among racial and ethnic minorities co mpared to White individuals (e.g., CDC, 2005; HHS, 2003; OMH, 2007a). The finding of no racial/et hnic differences in blood pressure readings at baseline in the present study may reflect the f act that both racial/ethnic minority groups of patient participants who participated in the present study were already being treated for hypertension, as suggested by the fact that these participants baseline systolic and diastolic blood pressure readings were in th e prehypertensive range. It is al so possible that patients with higher blood pressure readings from either or both racial/ethnic minority groups chose not to participate in the study during the initial recrui tment phase (e.g., because participating in a study focused on hypertension may have increased their anxiety about having the diagnosis), creating a selection bias that resulted in more patients w ith prehypertensive blood pressure readings (vs. patients with blood pressure readings in the stage 1 or stage 2 hypert ension ranges) in the participant sample at baseline. Nonetheless, the findings of Research Question 2 suggest that any differences in diastolic or systolic bl ood pressure readings that were found at postintervention could be attributed to the effect of the PC-CSHC Intervention Program rather than pre-existing differences at baseline. Limitations and Directions for Future Research Before reviewing the im plications of the pr esent study, it is necessa ry to describe the limitations of this pilot test of the PC-CSHC Intervention Program. The limitations existed in the design, assessment, and training areas of the present study.
114 Design Limitations Design lim itations include threats to external, in ternal and statistical conclusion validity, as well as conceptualization challenges that were in herent in the present st udy. Regarding external validity, which addresses the extent to which th e results can be generalized or extended to people, settings, times, measures and characteri stics other than those in the present study, the present study was primarily limited by the small samp le of participants. As described in Chapter 3, notable challenges exist to recruiting and retaining lowincome and ethnic minority participants in research studies including mistru st of researchers, fears of mistreatment and exploitation, and fears that data will be used to portray communities in a negative light (Adderley-Kelly & Green, 2005; Dancy et al., 2 004; Loftin, Barnett, Bunn & Sullivan, 2005; Yancey, Ortega, & Kumanyika, 2006). It is likely that the pres ent study faced some of these challenges, despite the use of a multi-modal recruitment strategy and the inclusion of community members in different phases of the studys implemen tation. It is also possible that some of these challenges contributed to a very small sample at post-intervention for analysis, especially at the intervention clinic. Specifically, whereas the numbe rs of African American patient participants and White patient participants at baseline were 110 and 114, respectively, the number of African American patient participants and White patient participants at post-inte rvention were 19 (5 of which were at the intervention clinic) and 18 (2 of which were at the intervention clinic), respectively. In addition, the longitudinal design of the study (i.e., 15-months from baseline to postintervention) likely also impacted retention of patient participants Indeed, over the course of the study, at least 2 patient participan ts died, while several other patie nt participants moved without forwarding addresses or had thei r phones disconnected and, as su ch, could not be contacted for follow-up data collection. These problems ar e particularly common among low-income
115 participant samples. Unfortunately, the small sample size limits the generalizability of the present findings, which may not apply beyond in dividuals who are similar to the patient participants in this study. Internal validity refers to the extent to wh ich the intervention, rather than extraneous influences, can be considered to account for intervention effects found. Threats to internal validity from at least one source should be considered as a lim itation to the present study. Indeed, while every effort was made on the part of the principal investigator to choose intervention and control clinics that had demographically sim ilar patient and staff populations, and to use participant selection criteria to further increas e the similarity of th e patient population, it is possible that pre-existing differe nces, or differences that devel oped over the course of the study, between the populations at the intervention and control clinics, may have impacted results. Statistical conclusion validity refers to the exte nt that a relation is shown, demonstrated or evident, and how well the investigation can detect effects if they exist. As has been discussed earlier, the small sample size, especially at th e intervention clinic, of the post-intervention sample very likely compromised the statistical co nclusion validity of the reported findings, as low power may have prevented the detection of main and interaction e ffects in the performed statistical analyses. The present study also faced conceptual lim itations, as the model that guided the study may not adequately address all of the variables that likely impact ratings of patient-centered culturally sensitive health care or health status outcomes. For example, the PC-CSHC Model addresses the potential impact of the physical en vironment characteristics and policies of the health care clinic on culturally sensitivity ratings and subsequently on patient health outcomes. However, it does not address the potential mediating and/or moderating effects of
116 socioenvironmental stressors such as low socio-economic status and racism-related stress, which have both been linked to the in cidence of chronic illnesses such as hypertension (e.g., Johnson et al, 1995; Clark et al., 1999), on patient health outcome s or health status variables. For example, it may be the case that, in the absence of racism-rela ted stress in the general environment, increases in patient-perceived cultural sensitivity may impact patient health outcomes/health status variables more than in the presence of racism -related stress. Similarly, patients confronting stresses as a result of socioeconomic status may be more or less likely able to demonstrate changes in health outcomes or health statuses as a result of increases in patient-perceived cultural sensitivity, depending on their poverty level. Given all of the design limitations addresse d above, future research should focus on replicating the present study with a larger sample size to address the threat s to external, internal and statistical conclusion validity identified, and thus to increase the accuracy and generalizability of findings. In addition, future research should attempt to investigate the moderating and mediating effects of socioenvir onmental stressors on th e relationship between patient-perceived culturally sensitive heath care and patient outcomes/health statuses. Assessment Limitations The assessm ent related limitations of the pr esent study include using the pilot Tucker Culturally Sensitive Health Care Inventories-Pati ent Forms (T-CSHCI-PF) to help evaluate the PC-CSHC Intervention Program. Speci fically, the reliabilities have been established only with a non-representative sample of the patients who par ticipated in the presen t study. In addition, it is important to note that both of the T-CSHCIs that were used in the present study included over 100 items, and therefore are not yet practical for regular use by researchers or health care professionals. Future research to overcome the a ssessment related limitations of the present study should include conducting studies to establish the reliab ilities and validities of the T-CSHCI
117 Patient-Forms using a national sample of patie nts, and conducting factor analyses of the inventory items in each T-CSHCI with the goal of reducing the number of items on each to make using them more practical. Training Limitations One im portant training-related limitation of the present study was that the PC-CSHC Intervention Program involved only a one-time 4-hour training workshop for clinic providers and office staff, and a one-time 4-hour training workshop for patients. Furthermore, the workshops were time consuming and difficult to incorporate into the busy schedules of clinic providers, office staff, and patients. Indeed, the attrition of patient participants at the intervention clinic, especially White patient participants and African American male patient participants, may in part be attributable to the time de mands required for participation in the patient training workshop. Notably, following their systematic review of health care provider education interventions designed to impact cultural competence, Beach et al. (2005) concluded that both shorter term (4hour) and longer-term (sessions of varying length held over a 4-year period) interventions were associated with positive outcomes. However, Thom et al. (2006) suggested that the impact of shorter-term training programs may be negligible unless behaviors learne d during the trainings are actively reinforced. To addre ss this training specific limitation in future research similar to the present study, the training workshops should be divided into consecutive one-hour sessions to facilitate learning and practicing/reinforcement of taught skills. Conclusions and Implications for Counseling Psychologists The present study sought to addres s the health disparities prob lem related specifically to hypertension, by using a literature-based model (i.e., the PC-CSHC Model) as a framework to examine the longitudinal impact of a pilot PC-CSHC Intervention Program on the health outcomes (i.e., systolic and diasto lic blood pressures) of primaril y low-income African American
118 primary care patients and White primary care patients with pre-hypertension or hypertension (alone, or with diabetes, corona ry artery disease, and/or high cholesterol). Results of conducted analyses did not offer statistically significant support for the stated hypotheses; however, trend results suggest that, with larger participant sa mples and thus greater st atistical power, the PCCSHC Intervention Program may have evidenced significant intervention effects, especially among African American patient participants. Fu rthermore, the findings of the present study highlighted the importance of conducting futu re research focused on examining gender differences in perceived culturally sensitiv ity ratings, especially among ethnic minority populations. There are several implications of the above findings for counseling psychologists. First, the trend results from this study, which was spearheaded by counseling psychology faculty and graduate students, suggest that counseling psyc hologists can conduct such research toward the goal of decreasing health care and health dispar ities that negatively impact low-income and ethnic minority populations. Involvement in such rese arch is consistent with the social justice identity of the counseling psyc hology field (Baluch et al., 2004; Speight & Vera, 2004), as well as with specific calls for couns eling psychologists to be involved in multidisciplinary efforts to eliminate health disparities that continue to represent a significant form of oppression to minority populations (Buki, 2007). Importantl y, in order to conduct research and intervention programs, and to participate in policy development to help reduce health disparit ies, the education and training that is emphasized in the counseli ng psychology field needs to be expanded. For example, training of counseling psychologists ne eds to include training in how health care systems and clinics operate. Furthermore, counseling psychologists training should incorporate a focus on culturally sensitive health promotion strategies.
119 In addition to conducting research to examin e the impact of intervention programs such as the one tested in the pres ent study, counseling psychologists can also be involved in more peripheral roles in such research studies as members of multidisciplinary health promotion research teams concerned with intervention research aimed at promoting patient-centered culturally sensitive health care and ultimately reducing health disparities. Such teams can benefit from the expertise of counseling psychologists in the areas of multicultu ral training, assessment and research that makes these professionals uniquely equipped to train health care professionals to provide patient-centered culturally sensitive health care. Because patient-centered culturally sensitive health care involves empowering patients promoting this care is consistent with the empowerment of clients that has long been a cen tral component of counseling interventions (Lee, 1991; McWhirter, 1991). Indeed, counseling psychologists are well equipped to empower patients to elicit patient-center ed culturally sensitive health care through patient empowerment training workshops and through counseling interventions with clients who in teract regularly with the health care system who deserve such empowerment. Finally, counseling psychologists can use the PC-CSHC Intervention Program to inform their efforts to promote client-centered cultura lly sensitive counseling in mental health care settings (e.g., counseling centers and community mental health centers). Such counseling may indeed help to eliminate the pr oblem of the underutiliz ation of mental hea lth care services by minorities. First, however, client-centered cultura lly sensitive counseling needs to be defined by culturally diverse clients. Counseling psychologist s can facilitate this definition development by conducting focus groups with minority clients to identify specific behavior s and attitudes of their counselors and office staff members as well as p hysical environment characteristics and policies at counseling centers and mental health clinics th at enable these clients to (a) feel comfortable
120 with, trusting of, and respected by their counseling cen ter counselors and office staff members, and (b) feel a sense of belonging at the counselin g center. Obtained focus group data could then be used to enhance the provision of culturally sensitive mental health counseling to culturally different clients. The obtained fo cus group data could also be used to create a culturally sensitive counseling inventory for clients to evaluate their counselors, counseling office staff, and counseling center physical environments a nd policies. Indeed, pr oviding clients with opportunities for such evaluations tr uly represents culturally sensitiv e counseling at its very best.
121 APPENDIX A DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ) Please prov ide the requested inform ation by shading in your answer. It should look like this: 1. What is your gender? Male Female 2. Your Race/Ethnicity: Cuban/Cuban-American Dominican Republican Mexican/Mexican-American/Chicano(a) Puerto Rican Other Hispanic/Latino (please specify: _____________________) Caucasian/White/European-American African-American/Black-American Other (please specify: _____________________) 3. Current relationship status: Single, living without a partner Single, living with a partner Married, living with a partner Married, not living with a partner Divorced or separated Widow/Widower 4. Employment Status: Work Full Time Work Part Time Do not work 5. Highest level of educati on that you have completed : Elementary School Middle/Junior High School High School Some College/Technical School College Professional/Graduate School 6. Annual household income level: Below $10,000 $10,001 to $20,000 $20,001 to $30,000 $30,001 to $40,000 Above $40,001 7. Do you have children? Yes (How many?:________) No
122 8. If so, do your children live with you? Yes No 9. Religious Preference: Catholic Baptist Presbyterian Methodist Islamic Buddhist Jewish Other (Please specify: _________) 10. Language Preference (for future mailings): English Spanish Other (Please specify: ________________________) 11. Which clinic do you attend? Family Practice Medical Group Eastside Community Health care center Other (Please specify: ________________________) 12. Have you changed clinics since beginning this research study? Yes No 13. Have you changed doctors since beginning this re search study? Yes No 14. What other research studies are you involved with at your clinic? (check all that apply) Florida Healthy State Program Medicaid Study Other (pl ease list): _________________________________________ 15. Has there been a change in your primary car e physician or nurse practitioner since you last completed these surveys? Yes No If Yes, please explain: ____________________________________________ 16. Did you receive any help when filling out these surveys? Yes No 17. How many times have you visited your clinic since last completing these surveys? ________ 18. How many years have you lived in this community? __________ 19. What is your Age? __________
123 APPENDIX B MEDICAL DATA QUESTIONNAIRE (MDS) Directions: For this set of ques tions, please fill in the blank or sh ade in the circle nex t to the appropriate response from the c hoices given. Remember, your answ ers to all questions in this packet are kept strictly conf idential and private. Questions ONE through SEVEN are only about hypertension, if you do not have hype rtension, please do not answer these. 1. If you have high blood pressure how many years has it been sin ce your health care provider told you (Circle one)? 0-1 years 2-3 years 4-5 years 6-7 years 8-9 years 10 + years 2. Have you experienced symptoms related to the high blood pressure (Circle one)? YES NO 3. If you have experienced symp toms, please list them here: 4. Which of the following has your physician or other health care provider recommended to treat your high blood pressure (Check all that apply)? Medication Diet Exercise Weight Loss Other____________________________________________________ 5. Have any other members of your family been diagnosed with high blood pressure? YES NO 6. If other members of your family have high bl ood pressure, what re lation are they to you (check all that apply): Mother Son Father Daughter Grandmother Aunt Grandfather Uncle 7. How much do you agree or di sagree that you can get ample amounts of education and consultation about hypertension (Circle your answer)? Strongly Agree Somewhat Agree Neutra l Somewhat Disagree Strongly Disagree
124 8. What illnesses are you currently diagnos ed with? (check all that apply) Diabetes (Low Blood Sugar) High cholesterol (Hyperlipidemia) High blood pressure (Hype rtension) Coronary Artery Disease Other (please list): ________________________________________ 9. How long ago were you told that you had the conditions listed above? ILLNESS OR CONCERN YEARS _________________________________________________________________ ____________________ _____________________________________________ ____________________ _____________________________________________ ____________________ _____________________________________________ 10. Are you currently on any medications? YES If Yes, please list them: ___________________________ NO 11. Has your physician recommended you to exercise, diet, or take medications for any of these other illnesses or medical concerns? If so, please list: YES NO
125 APPENDIX C MARLOW-CROWNE SOCIAL DESI RABILI TY SCALE (MCSDS) Directions: For each of the following statements please fill in where you consider the statement to be True (T) or False (F). True False 1. I never hesitate to go out of my way to help someone in trouble. 2. I have never intensely disliked anyone. 3. I sometimes feel resentful when I dont get my way. 4. I like to gossip at times. 5. There have been times when I felt like rebelling against people in authority even though I knew they were right. 6. I can remember playing sick to get out of something. 7. There have been occasions when I took advantage of someone. 8. Im always willing to admit it when I make a mistake. 9. I always try to practice what I preach. 10. I sometimes try to get even, rather than forgive and forget. 11. When I dont know something I dont at all mind admitting it. 12. I am always courteous, even to people who are disagreeable. 13. At times I have really insi sted on having things my way. 14. There have been occasions when I felt like smashing things. 15. I would never think of letting some one else be punished for my wrongdoings. 16. I never resent being asked to return a favor.
126 17. I have never been irked when people expressed ideas very different from my own. 18. There have been times when I was quite jealous of the good fortune of others. 19. I am sometimes irritated by people who ask favors of me. 20. I have never deliberately said something to hurt someones feelings.
127 APPENDIX D TUCKER CULTURALLY SENSITIVE HEALTH C ARE INVENTORY-AFRICAN AMERICAN PATIENT FORM (T-CUSCHI-AA) DIRECTIONS : Take a few seconds to think about your experi ences with the person you see most often for health care at your health care c linic. This person might be a doctor, a nurse practitioner, or some other health care provider. Now please rate how much you agree that this person shows each characteristic or behavior listed below when pr oviding you with health care. Please use a rating of 4, 3, 2, or 1 where 4 = Strongly Agree, 3 = Agree, 2 = Disagree, and 1 = Strongly Disagree. Shade in the circle below the rating you choose like this Please rate all characteristics and behaviors listed on each page. Do not give us your name. Your ratings will be confidential Thus, please give honest ratings. Strongly Agree Agree Disagree Strongly Disagree 4 3 2 1 THE PERSON I SEE MOST OF TEN FOR MY HEALTH CARE WHEN I VISIT MY CLINIC: 1. Is compassionate or shows that he or she cares about how I feel. 2. Is honest and direct with me. 3. Is dedicated to her or his work. 4. Has a lot of schooling. 5. Knows what he or she is doing. 6. Responds to my requests. 7. Appears to be concerned about my well-being.* 8. Treats all of her or his patients equally. 9. Makes helpful and reasonable recommendations. 10. Explains things so that I understand them 11. Shows that he or she is trying to help me out. 12. Treats me like a person, not just a number.* 13. Shows that he or she is inte rested in more than just making money. 14. Follows a common procedure for treating all of his or her patients. 15. Shows that he or she is familiar with my health. 16. Consults with others to help me. 17. Is not scared to touch me.
128 18. Takes my concerns seriously.* 19. Tries to communicate with me. 20. Talks to me during my visit. 21. Does not look down on me.* 22. Prescribes medicine only when he or she is sure of my illness. 23. Correctly diagnoses and treats my illness. 24. Is available for me. 25. Is consistent in her or his diagnosis and treatment of my illness. 26. Prescribes medicine only when he or she is sure of my illness. 27. Explains things so that I can understand them 28. Listens to me. 29. Takes her or his time with me during my visit. 30. Lets me explain my symptoms before examining me. 31. Examines me carefully before making any decisions. 32. Refers me to a specialist when he or she cannot help me. 33. Explains everything he or she does to me. 34. Knows her or his limits as to what she or he can treat. 35. Does not make me wait long. 36. Puts on a fresh pair of gloves while I am in the examining room. 37. Follows up on m y visits. 38. Talks to me before making decisions about prescriptions and treatments. 39. Has a positive attitude. 40. Keeps up with new research and treatments. 41. Treats me with respect.* 42. Puts my mind at ease. 43. Is polite.* 44. Gives me the information that I need. 45. Is sensitive to my needs. 46. Treats all of her or hi s patients the same way. 47. Speaks English well enough for me to understand what he or she is saying. 48. Lets me know about illnesses and diseases common among African Americans.
129 49. Prepares me for the next steps in treating my illness. 50. Shows that he or she remembers me.* 51. Looks professional. 52. Understands my fina ncial situation.* 53. Comforts me.* 54. Makes me feel appreciated. 55. Shows care and concern for my ch ild. [If no children, please do not rate this.] 56. Tries to help me out. 57. Creates positive feeli ngs during my visit. 58. Chats with me during my visit. 59. Is nice.* 60. Is respectful of my religious beliefs.* 61. Knows how to make me feel comfortable.* 62. Understands the African American culture.* 63. Has training in working with African American patients.
130 Now please rate how much you agree that overall the staff members at your clinic show each of the following characteristics and behavior s. To do this, use the same scale as above and choose one of the four ratings for each characteristic and behavior, then shade in the circle below the rating you choose like this Please rate all of the listed characteristics and behaviors. Strongly Agree Agree Disagree Strongly Disagree 4 3 2 1 THE CLINIC STAFF MEM BERS AT MY CLINIC: 1. Are friendly.* 2. Are helpful.* 3. Are polite.* 4. Are professional. 5. Are skilled at working with people. 6. Are welcoming. 7. Give me a card to remind me of my next appointment. 8. Call me the day before my appointment to confirm it. 9. Get back with me as promised. 10. Appear concerned about my well-being. 11. Treat me with respect. 12. Do not make unprofessional comments. 13. Treat me like a person, not a number. 14. Make fair decisions about who the doctor is going to see next. 15. Do not discriminate against me because of my race.* 16. Do not look down on me.* 17. Do not stereotype African Americ an patients as unable to read and uneducated. 18. Allow me to reschedule a missed appointment within a reasonable time. 19. Keep my business confidential and private. 20. Do not gossip about patients. 21. Do not grab my children from me [If no children, please do not rate this.] 22. Do what the doctor told them to do for me. 23. Work with my case even if I cannot pay the doctors bills.
131 24. Pay attention to me.* 25. Listen to my complaints.* 26. Know my name.* 27. Admit me quickly after my initia l registration or sign-in as a patient. 28. Take care of me as soon as I walk in. 29. Get the doctor to see me at the time of my appointment. 30. Work quickly to process my paperwork before and after I see the doctor. 31. Let me know if there are any changes to my record. 32. Give more work effort to seeing patients in the clinic than to answering phone calls. 33. Allow m e to discipline my children while I am inside the clinic. [If no children, please do not rate this.]
132 Now please rate how much you agree that the following clinic characteristics exist at your health care clinic. To do this, us e the same scale as above and choose one of the four ratings for each clinic characteristic, then shade in the circle below the rating you choose like this Please rate all of the liste d the clinic characteristics. Strongly A g ree Agree Disagree Strongly Disagree MY HEALTH CARE CLINIC: 4 3 2 1 1. Is a clean place. 2. Is a comfortable place. 3. Does not smell. 4. Is professional looking like a clinic should be. 5. Has affordable services. 6. Has doctors and nurses visibly moving about treating patients. 7. Has short waiting times to see the doctors. 8. Has procedures to make sure that I am seen by the doctor at the 9. Is a calm place. 10. Is open late for patient s who work during the day. 11. Has fresh air. 12. Has brochures available about i llnesses or diseases common to 13. Has signs and posters about illnesses and procedures on the walls. 14. Has a hotline I can call for illness information. 15. Has a sign-in sheet. 16. Has large and spacious or roomy waiting rooms. 17. Has warm waiting rooms. 18. Has waiting rooms that are not crowded. 19. Has many chairs in the waiting room. 20. Has comfortable chairs in the waiting room. 21. Has many convenient places to park your car or other vehicle. 22. Has warm examining rooms. 23. Has many receptionists and staff members working. 24. Has African American doctors working at the clinic. 25. Has African American staff working at the clinic. 26. Has the same doctors all the time. 27. Makes sure that I am treated with in 15 minutes of my appointment.
133 28. Makes sure that neither patient s nor staff are allowed to gossip. 29. Has a social worker at the clin ic available to help me with insurance and disability problems.
134 APPENDIX E TUCKER CULTURALLY SENSITIVE HE ALTH C ARE INVENTORYCAUCASIAN AMERICAN PATIENT FORM (T-CUSCHI-CA) DIRECTIONS: Take a few seconds to think about your experien ces with the person you see most often for health care at your health care clinic. This p erson might be a doctor, a nurse practitioner, or some other health care provider. Now please rate how much you agree that this person shows each characteristic or behavior listed below when providing you with health care. Please use a rating of 4, 3, 2, or 1 where 4 = Strongly Agree, 3 = Agree, 2 = Disagree, and 1 = Strongly Disagree. Shade in the ci rcle below the rating you choose like this Please rate all characteristics and behaviors listed on each page Do not give us your name. Your ratings will be confidential. Thus, please give honest ratings. Strongly Agree Agree Disagree Strongly Disagree 4 3 2 1 THE PERSON I SEE MOST OFTEN FOR MY HEALTH CARE WHEN I VISIT MY CLINIC: 1. Is concerned about my well-being. 2. Is confident in her or his skills. 3. Is honest and direct with me. 4. Is courteous. 5. Is knowledgeable. 6. Is respectful of me. 7. Is more knowledgeable about medicine than I am. 8. Takes time with me. 9. Understands my feelings and views. 10. Listens to me. 11. Consults with others to help me. 12. Knows me and my case. 13. Explains things in ways I can understand. 14. Refers me to specialists when he or she cannot solve my bl 15. Examines me thor oughly or carefully. 16. Prescribes medications only after examining me. 17. Reviews my records before making a diagnosis. 18. Reviews my records before prescribing medications or ttt 19. Pays attention to her or his work. 20. Charges reasonable prices for services. 21. Does not stereotype me or assume I am like other patients.
135 22. Speaks and understands English well enough for me to itithhhi 23. Understands her or his re sponsibility for my health. 24Admits when he or she makes a mistake. 25Is willing to learn. 26Asks me questions about my symptoms. 27. Asks me about how I am feeling. 28. Explains medications and procedures in ways I can understand. 29. Treats me like a person. 30. Does not think that I am looking for a way to get high when I kfidii 31. Does not question the truth or accuracy of what I say I am fli 32. Does everything possible to help me out. 33. Does not try to diagnose all of my problems as psychological or iid 34. Treats all patients equally. 35. Is concerned about my present s ituation and my future situation. 36. Does not talk down to me. 37. Gives me information about my test results without my having tkfth 38. Has a good bedside manner during an emergency. 39. Pays attention to my opinions. 40. Understands my financial situation. 41. Enjoys what he or she is doing. 42. Tries to make my visit a positive experience. 43. Makes me feel noticeably better after my visit. 44. Shows appreciation for me and all of her or his patients. 45. Is nice. 46. Is welcoming. 47. Is open to alternative medication or treatments. 48. Is open to holistic ideas about health care. 49. Makes me feel like my visit to the clinic was informative or dti 50. Does not make me wait long. 51. Refers me for tests that I think I need. 52. Follows up on my visits. 53. Does not bring a group of me dical students into my room ithtii 54. Leads a discussion of difficulties I might have with her or his bidifftf 55. Is educated about working with patients of different cultures and iltt 56. Tries to educate me. 57. Makes me feel accepted.
136 58. Gives me personal attention. 59. Looks me in the eyes. 60. Checks out my problem as soon as I go in to see her or him. 61. Refers me to a specialist when I request it. 62. Tries to connect with me. 63. Understands that people of di fferent cultures have, and believe idifftdilti 64. Understands that Caucasian/White Americans are not iltitdtffi 65. Works to make the clinic more racially integrated. 66. Hires staff who are eager to please.
137 Now please rate how much you agree that overall the staff members at your clinic show each of the following characteristics and behavior s. To do this, use the same scale as above and choose one of the four ratings for each characteristic and behavior, then shade in the circle below the rating you choose like this. Please rate all of the listed characteristics and behaviors. Strongly Agree Agree Disagree Strongly Disagree 4 3 2 1 THE CLINIC STAFF MEMBERS AT MY CLINIC: 1. Are considerate. 2. Are helpful. 3. Are knowledgeable. 4. Treat me like an individual. 5. Run the clinic efficiently (without wasting time). 6. Respond quickly to my doctors requests. 7. Send me correct bills. 8. Do not threaten to send my name to a collection agency when I diithbill 9. Follow up on my paperwork and visits. 10. Do not act smug or uppity. 11. Do not show prejudice against me. 12. Do not put me on hold for long periods of time when I call. 13. Do not move me around from examining room to examining room before I see a doctor. 14. Are caring. 15. Are encouraging. 16. Are friendly. 17. Are genuine or sincere. 18. Are pleasant to me on the phone. 19. Are available whenever I visit the clinic. 20. Are willing to please me. 21. Prepare me mentally for uncomfortable procedures. 22. Focus on my particular problem. 23. Keep all the people at the clinic organized. 24. Acknowledge my arrival for my appointment. 25. Take time with me. 26. Tend to me quickly.
138 27. Process my requests quickly. 28. Tell me exactly how much the tests are going to cost. 29. Explain items and charges on my bill. 30. Mail forms so I do not have to drive to the clinic to pick them up. 31. Do not shut the sliding gla ss window on me immediately after I ii 32. Do not assume that I can afford to pay for treatment and ditiifIddtl 33. Do not assume I am trying to cheat the system if I regularly ask ffl 34. Do not immediately put me on hold when I call the clinic. 35. Are welcoming.
139 Now please rate how much you agree that the following clinic characteristics exist at your health care clinic. To do this, use the same scale as above and choose one of the four ratings for each clinic characteristic, then shade in the circle below the rating you choose like this Please rate all of the lis ted clinic characteristics. Strongly Agree Agree Disagree Strongly Disagree MY HEALTH CARE CLINIC: 4 3 2 1 1. Has a place to discuss your probl ems privately with the doctor or nurse. 2. Has a door that does not allow waiting patients to see into the examining room. 3. Has short waiting times to see a doctor. 4. Has doctors available for a ppointments during an emergency. 5. Has free parking. 6. Has accessible parking for disabled patients. 7. Is managed by individuals who wa nt to improve my experiences at the clinic, not just to make money. 8. Is managed by individuals who let doctors do their jobs. 9. Has a program to help low income patients receive treatments they cannot afford. 10. Has procedures to make sure that patients get quality care regardless of how little they can pay for health care. 11. Is a cheerful place. 12. Is a comfortable place. 13. Is an inviting place. 14. Is conveniently located. 15. Meets the requirements of the Americans with Disabilities Act (ADA). 16. Is open to accept emergencies any time of the day or any day of the year. 17. Is open until late in the evening. 18. Is well-staffed even in the evenings. 19. Has a friendly atmosphere. 20. Has educational materials on di seases that are available for patients. 21. Has magazines. 22. Has comfortable chairs.
140 23. Has a short wait to get an appointment at the clinic. 24. Has the same doctors available every time I go. 25. Has a rotation system where new doctors fill in when the doctors on shift are overworked. 26. Has plenty of parking. 27. Has safe parking. 28. Has many doctors working. 29. Has a pharmacy that is stocked with all the medications my doctor might prescribe. 30. Has fully open receptionist areas where I can sign in and talk to the receptionist. 31. Has a designated person to an swer questions a bout charges and fees. 32. Has someone in the clinic who ha s control over what I am charged for and how much it costs. 33. Has many clinic staff members working.
141 APPENDIX F STUDY PARTICIPATION INVITATION LETTER Dear Patie nt: You have an opportunity to participate in a University of Florida research study about your experiences as a patient at the Family Practice Medical Group. WHAT IS THIS ABOUT? The researcher wants to know about your ex periences with your doctors, nurses, and clinic staff. The information you give us is very important because it may help us improve the health care and support that you and other pa tients like you receive from healthcare providers. WHAT DO YOU HAVE TO DO? If you agree to participate, we will ma il Study Questionnaires to you. Depending on when you join the study and/or when you stop participation, you will be asked to complete between two and six assessment packets approximately once every four to six months. You may also participate in a short traini ng session near the end of the study. HOW LONG IS IT GOING TO TAKE? Completing the Study Questi onnaires should take no more than one hour each. WILL MY ANSWERS BE KEPT PRIVATE? Yes! Nobody will know if you agree to participate. Nobody at the Family Practice Medical Group will see your answers if you complete the questionnaires. WILL I BE PAID? Yes, you will be paid twenty dollars ($20 ) each time you complete and return the Study Questionnaires that we will send you. Y ou will also receive sixty dollars ($60) if you decide to come to the traini ng session near th e end of the study. HOW CAN I FIND MORE ABOUT THIS? Please read the Informed Consent Form (i n English or Spanish) that was mailed with this letter, or call the Principal Researcher (D r. Carolyn Tucker) at (352) 392 0601, ext. 260. WHAT SHOULD I DO IN CASE I DECIDE TO PARTICIPATE? 1. Sign the last page of both Inf ormed Consent Forms (English or Spanish). Keep one copy for yourself. 2. Complete the Demographic Data Form. 3. Complete the Medical Data Form. 4. Return one copy of the Informed Consent Form, the Demographic Data Form and the Medical Data Form in the pr e-addressed, postage paid envelope. DO NOT add postage, just seal the enve lope and put it in your mailbox.
142 WHAT SHOULD I DO IF I MOVE? If you move after you return the Informed Consent Form and before you receive more information from us, simply call (352) 392-0601, ext. 260 between 10:00 a.m. and 4:00 p.m. Feel free to call collect if necessary. WHO CAN ANSWER SOME MORE QUESTIONS I HAVE? If you have any questions about this resear ch, contact the Principal Researcher, Dr. Carolyn M. Tucker, at (352) 392-0601, ext. 260. Thank you for your time. We hope you will consider participating in this study. Sincerely, Dr. Karen L. Hall Medical Director, Family Practice Medical Group
143 APPENDIX G STUDY QUESTIONNAIRE PACKET COVER LETTER Dear Patient: Thank you for your sustained interest in our re search project. W e are a Research Team, supervised by Dr. Carolyn M. Tucker, Distinguished Alumni Professor at the University of Florida. The purpose of this pr oject is to determine ways to increase the level of cultural sensitivity in health care provided to patients. The other purpose of this project is to see if patients benefit from more culturally sensitive health care. Participation in this study involves completi ng a set of questionnaires. One of these questionnaires includes a list of be haviors of health care provider s and clinic personnel and a list of clinic characteristics that pa tients have told us indicate sens itivity to their culture. Although we do not believe that your completing this questionnaire or the other questionnaires will cause you any harm, you do have the right to skip any questions that you find offensive and you have the right to stop completing a questionna ire if it makes you feel uncomfortable. You will be asked to complete these same questi onnaires again in approximately five months. If you choose to complete the questionnaires again, you will again receive compensation for your time. You may decide later whether or not you would like to complete the questionnaires again. Your participation in this res earch project is voluntary. If you experience any discomforts with completing these questionnaires, you may call Dr Carolyn M. Tucker, at (352) 392-0601 ext. 260, and/or the University of Florida Institut ional Review Board (IRB) Office at (352) 846-1494 to discuss your concerns. Your information will not be shared with your doctor or other members of the health care staff at your clinic. Also, your name will not be placed on any of the questionnaires that you complete. Instead, the information from you will be assigned a code number. The list of names that identify these codes will be kept in a separate locked location from the information that you provide us with. The questionn aires that you provide us will be destroyed as soon as all information from you and other participants has b een gathered. All this information will be locked in file cabinets in Dr. Tucker's lab in th e psychology building at the University of Florida. All information from participants will be combin ed so that no one can identify your information. The information you give us is very important b ecause it may help us improve the health care and support that you and other patients like you may receive from health care providers. In return for your participation in our study, you will be mailed a payment of $20 within three (3) weeks of when we receive your completed qu estionnaires and payment release form. Please, in addition to completing the questionnai res, sign and return the completed Payment Release Form. We need your name, address, an d social security number requested on this form so that we can send you a check for $20. Your signed Informed Consent Form (which you returned previously) and Payment Release Forms w ill be locked in a separate file cabinet from the locked file cabinet in which your completed que stionnaires will be kept. This will be done to further protect your confidentiality.
144 In order to participate, please complete the enclosed questionnaires and Payment Release Form, then return them by mail in the pre-paid reply envelope provided This should only take about an hour. If you need help comp leting the questionnaires, you may ask a family member or friend to read them to you; howev er, we only want your opi nions to the questions You may also call Dr. Carolyn M. Tucker at (352) 392-0601, Ext. 260 to set up an appointment to have a Research Assistant read the questionnaires to you at th e health care clinic that you attend. If you have any questions about this research proj ect, please call a member of our research team at the (352) 392-0601 ext. 260. We are l ooking forward to yo ur participation. Sincerely, Dr. Carolyn M. Tucker Distinguished Alumni Professor Professor of Psychology Professor of Pediatrics Professor of Community Health and Family Medicine
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157 BIOGRAPHICAL SKETCH Lisa Ferdinand was born in Jam aica a nd raised in Trinidad and Tobago. She graduated with a Bachelor of Science degr ee in Psychology from McGill University in Montreal in 1997 and later obtai ned her Masters of Educatio n in School Counseling from Boston University in 1998. Lisa then returned to Trinidad where she worked as a social worker in a childrens home, and then as a consultant for a leading human resource consulting firm in the country. She also lectured and counseled part-time, served as a Board Member for an organization that helped at-risk children, and became involved in the Trinidad and Tobago Coalition against Domestic Violence. Lisa returned to the United States in 2002 to pursue her doctoral degree in Counseling Psychology at the University of Flor ida. She received her Master of Science in Psychology in 2004 and successfully complete d a clinical internship at the Georgia University Counseling Center in August 2007. Lisas research program during her training has focused primarily on health pr omoting behaviors among culturally diverse adolescents, and the provision of culturall y sensitive healthcare to low-income and culturally diverse primary care patients. However, she also has keen clinical and research interests in multicultural counse ling, especially as it pertains to international students. Lisa is a member of the American Psychological Association, and continues to present at national and international conf erences, and to publish on topi cs related to her research and clinical interests. Lisa is currently employed as a Counseling Associate at the University of Florida Counseling Center. Upon completing her Ph.D. program, she intends to pursue licensure and seek a full-time academic or clinical faculty position.