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The Effects of an Intervention to Promote Customized Culturally Sensitive Health Care by Medical Student Providers

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Title:
The Effects of an Intervention to Promote Customized Culturally Sensitive Health Care by Medical Student Providers
Physical Description:
1 online resource (88 p.)
Language:
english
Creator:
Lopez, Manuel Thomas
Publisher:
University of Florida
Place of Publication:
Gainesville, Fla.
Publication Date:

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Counseling Psychology, Psychology
Committee Chair:
Tucker, Carolyn M
Committee Members:
Graber, Julia A
Fukuyama, Mary A
Moradi, Banafsheh
Torres-Rivera, Edil

Subjects

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

Notes

Abstract:
This study examined the effects of an intervention to promote customized culturally sensitive health care by medical student health care providers on these student providers’ self-evaluations of their cultural sensitivity following simulated clinical encounters with mock patients. In this study, 202 second year student providers engaged in simulated clinical encounters with 34 mock patients as part of their regular clinical training. These mock patients used the Tucker-Culturally Sensitive Health Care Provider Inventory – Clinical Tool Form A to indicate their top ten preferences for provider behaviors that have been shown in previous research to be indicators of health care provider cultural sensitivity. Student providers who were arbitrarily assigned to the Intervention Group had the opportunity to view their mock patients’ preferences prior to engaging in the simulated clinical encounters with these patients. Student health care providers in both groups subsequently self-evaluated their levels of cultural sensitivity in the health care they provided during the simulated clinical encounters using the Tucker-Culturally Sensitive Health Care Provider Inventory -- Provider Form. Statistical analyses revealed that student health care providers in the Intervention Group demonstrated higher self-ratings of culturally sensitive health care at post-test than student health care providers in the Control Group on some subscales of a culturally sensitivity health care provider inventory. Implications for the provision of culturally sensitive health care and the improvement of cultural sensitivity training for student health care providers are discussed.
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Manuel Thomas Lopez.
Thesis:
Thesis (Ph.D.)--University of Florida, 2013.
Local:
Adviser: Tucker, Carolyn M.

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Classification:
lcc - LD1780 2013
System ID:
UFE0045770:00001

MISSING IMAGE

Material Information

Title:
The Effects of an Intervention to Promote Customized Culturally Sensitive Health Care by Medical Student Providers
Physical Description:
1 online resource (88 p.)
Language:
english
Creator:
Lopez, Manuel Thomas
Publisher:
University of Florida
Place of Publication:
Gainesville, Fla.
Publication Date:

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Counseling Psychology, Psychology
Committee Chair:
Tucker, Carolyn M
Committee Members:
Graber, Julia A
Fukuyama, Mary A
Moradi, Banafsheh
Torres-Rivera, Edil

Subjects

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

Notes

Abstract:
This study examined the effects of an intervention to promote customized culturally sensitive health care by medical student health care providers on these student providers’ self-evaluations of their cultural sensitivity following simulated clinical encounters with mock patients. In this study, 202 second year student providers engaged in simulated clinical encounters with 34 mock patients as part of their regular clinical training. These mock patients used the Tucker-Culturally Sensitive Health Care Provider Inventory – Clinical Tool Form A to indicate their top ten preferences for provider behaviors that have been shown in previous research to be indicators of health care provider cultural sensitivity. Student providers who were arbitrarily assigned to the Intervention Group had the opportunity to view their mock patients’ preferences prior to engaging in the simulated clinical encounters with these patients. Student health care providers in both groups subsequently self-evaluated their levels of cultural sensitivity in the health care they provided during the simulated clinical encounters using the Tucker-Culturally Sensitive Health Care Provider Inventory -- Provider Form. Statistical analyses revealed that student health care providers in the Intervention Group demonstrated higher self-ratings of culturally sensitive health care at post-test than student health care providers in the Control Group on some subscales of a culturally sensitivity health care provider inventory. Implications for the provision of culturally sensitive health care and the improvement of cultural sensitivity training for student health care providers are discussed.
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Manuel Thomas Lopez.
Thesis:
Thesis (Ph.D.)--University of Florida, 2013.
Local:
Adviser: Tucker, Carolyn M.

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Classification:
lcc - LD1780 2013
System ID:
UFE0045770:00001


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1 THE EFFECTS OF AN INTERVENTION TO PROMOTE CUSTOMIZED CULTURALLY SENSITIVE HEALTH CARE BY MEDICAL STUDENT PROVIDERS By MANUEL THOMAS LOPEZ A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PAR TIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2013

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2 2013 Manuel Thomas Lopez

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3 To my family and friends who have accompanied me along this journey, and to all of the educat ors who have shaped my intellectua l and professional development

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4 ACKNOWLEDGMENTS I would like to thank Dr. Carolyn M. Tucker and the faculty and staff of the Department of Psychology at the University of Florida. I would also like to thank Dr. Rebecca Rainer Pauly, the faculty and staff of the University of Florida College of Medicine, and the faculty and staff of the Harrell Center at the University of Florida.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ .... 10 Statement Of The Problem ................................ ................................ ..................... 10 Purpose Of The Current Study ................................ ................................ ............... 19 Hypothesis And Research Question ................................ ................................ ....... 20 2 REVIEW OF THE LITER ATURE ................................ ................................ ............ 22 Patient Centered Care and Culturally Sensitive Health Care ................................ .. 23 Assessment Instruments For Measuring Cultural Sensitivity ................................ .. 29 Need For Interventions to Promote Cultural Sensitivity Among .............................. 31 Student Health Care Providers ................................ ................................ ............... 31 Calls For Customized Patient Centered Care ................................ ......................... 34 3 METHODS ................................ ................................ ................................ .............. 38 Participants ................................ ................................ ................................ ............. 38 Instruments ................................ ................................ ................................ ............. 39 Procedure ................................ ................................ ................................ ............... 41 Participant Recruitment ................................ ................................ .................... 41 Participant Assignment And Confidentiality ................................ ...................... 44 Data Collection ................................ ................................ ................................ 46 Pre intervention phase (10 minutes) ................................ .......................... 47 Clinical encounter intervention phase (20 minutes) ................................ ... 47 Post intervention data collection phase (10 minutes) ................................ 48 4 RESULTS ................................ ................................ ................................ ............... 49 5 DISCUSSION ................................ ................................ ................................ ......... 58 Summary And Interpretation Of Findings ................................ ................................ 58 Limitations Of The Current Study ................................ ................................ ............ 62 Implications For Physician Training ................................ ................................ ........ 65 Implications For Psychologists ................................ ................................ ................ 66 Implications For Future Research ................................ ................................ ........... 67 Conclusions ................................ ................................ ................................ ............ 67

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6 APPENDIX A INFORMED CONSENT FORM FO R STUDENT HEALTH CARE PROVIDERS .... 69 B INFORMED CONSENT FORM FOR MOCK PATIENTS ................................ ........ 71 C DEMOGRAPHIC DATA QUESTIONNAIRE FOR STUDENT HEALTH CA RE PROVIDERS ................................ ................................ ................................ ........... 73 D DEMOGRAPHIC DATA QUESTIONNAIRE FOR MOCK PATIENTS ..................... 74 E TUCKER CULTURALLY SENSITIVE HEALTH CARE PROVIDER INVENTORY CLINICAL TOOL FORM A F TUCKER CULTURALLY SENSITIVE HEALTH CARE PROVIDER INVENTORY PROVIDER FORM ................................ ................................ ............................... 77 LIST OF REFERENCES ................................ ................................ ............................... 79 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 87

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7 LIST OF TABLES Table page 3 1 Demographic data for student health care provider participants ......................... 48 4 1 Intercorrelations among dependent variables ................................ ..................... 56 4 2 Means of Patient Centeredness Subscale of the T CSHCIP Provider ............... 56 4 3 Means of Interpersonal Skills Subscale of the T CSHCIP Provider .................... 57 4 4 Means of the Cultural Knowledge and Responsiveness Subscale of the T CSHCIP Provider ................................ ................................ ............................... 57

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8 Abstract of Dissertation Presented to the Graduate School of the University of Florida i n Partial Fulfi llment of the Requirements for t he Degree of Doctor of Philosophy THE EFFECTS OF AN INTERVENTION TO PROMOTE CUST OMIZED CULTURALLY SENSITIVE HEALTH CARE BY MEDICAL STUDENT PROVIDERS By Manuel Thomas Lopez August 2013 Chair: Carolyn M. Tucker Major: Counseling Psychology This study examined the effects of an intervention to promote customized culturally sensitive health care by medical student health care providers on these evaluations of their cultural sensitivity following simulated clinical encounters with mock patients In this study 202 second year student providers engaged in simulate d clinical encounters with 34 mock patients as part of their regular clinical training. These mock patients used the Tucker Culturally Sensitive Health Care Provider I nventory Clinical Tool Form A to indicate their top ten preferences for provider behavi ors that have been shown in previous research to be indicators of health care provider cultural sensitivity Student providers who were arbitrarily assigned to the eng aging in the simulated clinical encounters with these patients. Student health care providers in both groups subsequently self evaluated their levels of cultural sensitivity in the health care they provided during the simulated clinical encounters using th e Tucker Culturally Sensitive Health Care Provider Inventory Provider Form Statistical analyses revealed that student health care providers in the Intervention Group demonstrated higher self ratings of culturally sens itive health care at post test than

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9 student health care providers in the Control Group on some subscales of a culturally sensitivity health care provider inventory Implications for the provision of culturally sensitive health care and the improvement of cultural sensitivity training for st udent health care providers are discussed.

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10 CHAPTER 1 INTRODUCTION Thomas Jefferson Statement of t he Problem The United States has long been a nation filled with people from diverse racial /ethnic backgrounds, and the proportion of individuals from minority non White racial /ethnic backgrounds has steadily been increasing. For example, according to the United States Census Bureau website (2012), between the years 2000 and 2010 the number of people who identified as A frican American increased by 12%, the number of people who identified as Asian increased by 43%, and the number of people who identified as Hispanic or Latino increased by 43%. During that same period, the number of people who identified as White increased by only 6%. Furthermore, it is predicted that (May, 1992). Media sources have recently carried stories stating that based on statistics from the United States Census B ureau, births of babies from racial /ethnic minority backgrounds now exceed births of babies from non Hispanic White backgrounds (Morello & Mellnik, 2012). Indeed, many urban areas of the United States already demonstrate rich cultural diversity such that people from non Hispanic White hometown county of Miami Dade, Florida, non Hispanic Whites account for only 15% of the population while individuals who identify as coming from Hisp anic or Latino backgrounds represent about 65% of the population of that urban metro area (United States Census Bureau, 2012).

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11 Many individuals from racial /ethnic minority backgrounds demonstrate disparities in economic attainment, incomes, and standards of living compared to their majority counterparts (e.g. Stanfield, 2011). This disparity especially holds true for individuals from African American and Hispanic or Latino backgrounds (Stanfield, 2011). These differences between members of racial /ethnic g roups are due to many factors, such as impoverished (Williams & Sternthal, 2010). The lower economic attainment by individuals from racial /ethnic minority backgrounds ha s direct ties to the overall health and wellbeing of these individuals, especially those from African American and Hispanic/Latino backgrounds (LaViest, 2005). These individuals from racial /ethnic minority backgrounds face financial difficulties in accessi ng health insurance and other associated health care resources even though the United States spends the most per capita on health related costs compared to other member nations of the Organization for Economic Co op eration and Development ([OECD] OECD, 201 1). Furthermore, the United States is the only member nation of the Organization for Economic Co operation and Development that does not provide universal health care services to its citizens (Spithoven, 2009), which further complicates access to health ca re for people from racial /ethnic minority backgrounds. It has been well documented that individuals from racial /ethnic minority backgrounds demonstrate poorer health outcomes across a variety of measures, and that these differences persist across the life d, & Adkins, 2012; Clancy, 2008 ). Examples of these disparities have been documented in the extant literature for some time, as evidenced by a study showing that individuals from African

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12 American backgrounds are more likely to risk death from chronic disease such as heart disease, cancer, and diabetes compared to their majority Non Hispanic White counterparts (e.g. Bernard, 1993). More recent statistics indicate that individuals from African American backgrounds have higher rates of cancer deaths, are more likely to be diagnosed with type 2 diabetes, evidence higher rates of tooth decay, and have disproportionately higher rates of HIV/AIDS when compared to their majority counterparts (National Center for Health Statistics, 2006, 2007; Pleis & Lethbridge ejku, M., 2006). Individuals from Hispanic or Latino backgrounds are also greatly affected by health disparities, and have been shown to demonstrate greater incidence of diabetes, cancer, heart, disease, and death compared to their non Hisp anic White counterparts (Mokuau & Fong, 1994). Additionally, individuals from Hispanic or Latino backgrounds, compared to their non Hispanic White peers, demonstrate higher rates of cancer death, are more likely to be diagnosed with type 2 diabetes, and ev idence higher rates of tooth decay (National Center for Health Statistics, 2006, 2007; Pleis & Lethbridge ejku, M., 2006). Given the current national debates regarding the provision of health care in this country and the disproportionate rates by which pe ople from African American and Hispanic or Latino backgrounds are affected by chronic illness, research to address these disparities is indeed timely and sorely needed (Agency for Healthcare Research and Quality [AHRQ], 2009; Tucker, Marsiske, Rice., Niels on, & Herman 2011). It may be tempting to attribute much of the cause of such disparities in the incidence of disease and in health outcomes to economic conditions such as lack of insurance and/or to genetic makeup; yet, social determinants of health tha t are related

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13 to cultural and racial backgrounds consistently have been shown to be factors in health disparities (Williams & Sternthal, 2010). In a review of the public health literature concerning health disparities between persons of African American an cestry and non Hispanic White backgrounds, Dressler, Oths, & Gravlee (2005) concluded that racial genetic models for understanding health disparities are not adequate to explain the higher rates of chronic illnesses between these racial groups. Other schol ars have concluded that even after controlling for access to care, which is often cited as a prime cause of the health disparities that plague the United States, individuals from African American backgrounds still demonstrate poorer health outcomes as comp ared to their majority counterparts (Schulman et al. 1999; U.S. Department of Health and Human Services [DHHS], 2000). racial profound impact on our society at large. A recent story covered by national media outlets described an Associated Press poll which found that over 50% of non Hispanic Whites harbor anti African American and/or anti Hispanic prejudices, and that rates of prejudice have actually increased since 2008 (The Associated Press, 2012). These negative attitudes towards people from racial and cultural min ority backgrounds have no doubt negatively impacted quality of care, access to care, satisfaction with health care, and rates of disease among these individuals (Williams & Sternthal, 2010). It is noteworthy that minority individuals often hold beliefs a nd engage in cultural practices that negatively impact their health care experiences and ultimately their health

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14 (Tucker, Daly, & Herman, 2010). For example, people from African American backgrounds may not be as trusting of their health care providers and the health care process as compared to their non Hispanic White counterparts (Davis, Brown, Allen, Davis, & Waldron, 1995). More recent research has shown that individuals from African American, Hispanic, and Asian backgrounds, among others, are more like ly than their non Hispanic White counterparts to report having difficulty communicating with their health care providers (AHRQ, 2003). Similarly, people from Hispanic or Latino backgrounds often hold beliefs that their illnesses are due to non medical fact ors such as the engagement in wrongdoing or sin (Da Silva, 1984). Furthermore, many individuals from racial and cultural minority backgrounds will often place their trust in non traditional medical practices, such as herbal and/or spiritual cures for illne sses (e.g. Burk, Wiser, & Keegan, 1995; Grossman, 1994). This problem is further compounded by physician related variables, as exemplified by findings from Johnson, Roter, Powe, & Cooper (2004) that health care providers were more likely to conversationall y engage their non Hispanic White patients as compared to patients from African American backgrounds. Numerous calls have been made for the provision of health care that is culturally sensitive (AHRQ, 2009; Tucker et al., 2011). As early as 1997, Pierce (1 997) described a lack of culturally appropriate treatment strategies as a primary contributing factor to health disparities. Indeed, the U. S. Department of Health and Human Services has made reducing health disparities one of the primary missions of its H ealthy People 2000, Healthy People 2010, and Healthy People 2020 campaigns, all of which are aimed at promoting health and wellness among all people in the U. S. (U.S. Department

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15 of Health and Human Services, 2000; U.S. Department of Health and Human Servi ces, 2008). The most recent version of these campaigns (i.e., Healthy People 2020) calls for complete health equity and the elimination of health disparities (U.S. Department of Health and Human Services, 2008). interchangeably in the health care research literature involving the reduction of health disparities, even though these terms have different meanings (Whaley, 2008). Culturally competent health care specifically refers to car e that is appropriate given the differences that exist between members of different cultural groups (U. S. Department of Health and Human Services, 2002). It also refers to specific behaviors and skills on the part of health care providers and staff member s that promote a demonstration of cross cultural understanding (Roysircar, 2003). Caldwell and colleagues have described the construct of cultural competence as the demonstration of specific knowledge and attentiveness to the unique practices of patients f rom minority backgrounds (Caldwell et al., 2008). Fundamentally, however, many definitions of cultural competence tend to be made from the viewpoint of health care providers and health care administrators, and often place erspectives regarding culturally appropriate health care behaviors and services that are desired (Herman et al., 2007). In recent years, the concept of cultural sensitivity has gained increasing traction within the health research community, and the provis ion of culturally sensitive health care has been touted as one method of improving the health and wellness of people from racial and cultural minority backgrounds and thus reducing health disparities (Betancourt, Green, Carrillo, & Park, 2005; Herman et al ., 2007; Tucker et al., 2011). In

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16 contrast to cultural competence, cultural sensitivity has been defined as being patient centered such that patients receiving culturally sensitive health care feel that their unique cultural needs and concerns are respecte d and addressed throughout their interactions within health care systems, and thus the provision of culturally sensitive health care enables these patients to feel more respected, comfortable with, and trusting of their health care providers (Tucker et al. 2003; Tucker et al., 2011). Culturally sensitive health care has also been defined as being patient centered in that it with health care providers and systems (Maju mdar, Browne, Roberts, and Carpio 2004). When culturally diverse patients feel more comfortable with and trusting of their health care providers, they demonstrate improved patient satisfaction and health outcomes (Joffe, Manocchia, Weeks, & Cleary, 2003). Tucker and her colleagues have advanced a specific view of culturally sensitive health care as one means of altering the existing health care industry in a way that is sensitive to the unique cultural practices and needs of racially and culturally divers e patients (Tucker et.al, 2007; Tucker et al., 2010, Tucker et al., 2011). These researchers assert that culturally sensitive health care must be defined by culturally diverse patients themselves because it is these patients that are the true experts on th e care that is most appropriate for them and on the characteristics of the health care process that will allow them to feel comfortable and respected. (Tucker et.al, 2007; Tucker et al., 2010 ; Tucker et al., 2011). Furthermore, it is necessary to account f or described, and culturally relevant desires, preferences, and needs in the health care delivery process. Although there have been numerous

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17 calls to increase the provision of culturally sensitive health care to individuals f rom racial and cultural minority backgrounds (e.g. AHRQ, 2009), the continuing existence of health disparities clearly underscores the need for further research on the facts that determine such care. One of the ways that this nation can reduce health dis parities is to educate the next generation of health care providers (e.g. medical students) in the necessary skills and knowledge for them to deliver culturally sensitive health care services to the /et hnic minority backgrounds (Washington et al., 2008). Despite the national calls for such training (AHRQ, 2009; Washington et al., 2008), past research has shown that many medical school programs do not offer courses in cultural sensitivity or cultural comp etence (Lum & Korenman, 1994; Dogra, Reitmanova, & Carter Pokras, 2010). Reasons cited for lack of such courses include financial limitations, limited availability of training resources to provide such education to medical students, and lack of consensus a mong medical school administrators regarding the best practices for providing cultural sensitivity training to medical students (Rapp, 2006). It has been stated that there is a lag between (a) calls for both the provision of culturally competent and cultu rally sensitive health care for patients from racial /ethnic minority backgrounds and for cultural sensitivity and cultural competence training of future health care providers, and (b) the actual training of medical students to be culturally sensitive/compe tent (Dogra et al., 2010). Although this lag exists, there are some medical schools that have acted to show the importance of such training. For example, the state of New Jersey is now requiring cultural sensitivity training as a

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18 requirement before physic ians can become licensed in the state (Salas Lopez, Holmes, Mouzon, & Soto Greene, 2007). Unfortunately, medical schools vary widely in the amount of cultural sensitivity training they require of their students and the depth of this training (Dogra et al., 2010). Research has also shown that many medical students enjoy cultural diversity training and feel they would like more cultural diversity training for themselves and their clinical faculty (Hung et al., 2007). Furthermore, m edical students from racia l /ethnic minority backgrounds who begin to practice medicine have reported feeling unprepared to effectively provide patient centered culturally sensitive health care to patients from racially /ethnically diverse backgrounds (Grumbach et al., 2003). Furthe rmore, Betancourt and Reid (2007) have asserted that the racial and cultural background of health care providers impacts the patient provider relationship such that health care providers from non Hispanic White backgrounds may inadvertently act in ways tha t communicate a lack of cultural sensitivity to their patients from racially and culturally diverse backgrounds. The need to provide cultural sensitivity training to future health care providers and the need to conduct research in the area of health disp arities are hindered by the lack of the necessary instruments to measure cultural sensitivity in the health care delivery process (Agency of Health Care Research and Quality, 2009; Tucker, Herman, Pedersen, Higley, Montrichard, & Ivery, 2003). For example until recently, few questionnaires existed to measure cultural competence or cultural sensitivity (Mirsu these constructs have involved the use of questionnaires that had n ot been validated and/or had not been shown to have adequate reliability (Thom, Tirado, Woon, &

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19 McBride, 2006). Furthermore, many of the studies that have focused on cultural competence and/or cultural sensitivity have defined these constructs from an expe rt or researcher defined perspective rather than from the perspectives of patients from racially /ethnically diverse backgrounds. Few studies of cultural sensitivity/competence have involved medical students or used assessments that are appropriate for use with these students (Mirsu Paun et al., 2010). Though recent research has yielded questionnaires that do measure cultural sensitivity within health care contexts, patients from some racial /ethnic minority groups still demonstrate individual differences and within group heterogeneity regarding the behaviors and practices that will enable them to feel respected within the health care process and more comfortable with and trusting of their health care providers (Betancourt & Reid, 2007). In recent years the re have been calls for the development of patient centered assessment instruments and treatments that are not only culturally sensitive, but also customized to the specific needs and wants of individual patients (Betancourt & Reid, 2007; Lauver, et al., 20 02). The use of standardized assessments to measure the provision of culturally sensitive health care and that will allow patients to easily and comfortably communicate their individualized needs and preferences to their health care providers is sorely ne eded. There is some recent preliminary evidence in the research literature to support the overall notion that customized culturally sensitive health care leads to improvements in some health outcome measures among culturally diverse patients (e.g. Caspar, Purpose of t he Current Study The purpose of the present study is to examine the effects of an intervention to promote customized culturally sensitive health care by medical student health care

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20 providers on evaluations of their cultural sensitivity following simulated clinical encounters with mock patients This intervention involved having each mock patient use a modified version of the Tucker Culturally Sensitive Health Care In ventory Clinical Tool Form A t o identify the provider behaviors and attitudes most important to her/him, and subsequently having her/his medical student provider review this health care information prior to the simulated patient provider clinical encounter This intervention occurred as part of the participating medical student medical students typically engage in simulated clinical encounters with mock patients as part of t he required medical curriculum. Hypothesis a nd Research Question The following hypothesis will be tested in the current study: S tudent health care providers in the Intervention Group will have higher self evaluations of their provision of culturally sensi tive health care (i.e. self evaluations of their Cultural Knowledge and Responsiveness, Patient Centeredness, and Interpersonal Skills using a culturally sensitivity health care provider inventory ) to their mock patients than student health care providers in the Control Group. The following exploratory research question will also be examined in the current study: At post intervention, do the student health care providers differ in their self evaluations of their provision of culturally sensitive health ca re to mock patients (i.e. self evaluations of their Cultural Knowledge and Responsiveness, Patient Centeredness, and Interpersonal Skills using a culturally sensitivity health care

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21 provider inventory ) in association with racial/ethnic background, group (e. g. Intervention Group or Control Group), and/or race by group?

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22 CHAPTER 2 REVIEW OF THE LITERA TURE According to the United States Census Bureau, the births of children from rac ial /ethnic minority backgrounds, as a whole, have exceeded those from non H ispanic Furthermore, people from all over the world have come to the United States for a variety of complex sociopolitical and anthropological reasons (Williams & Sternthal, 2010). Data minority racial /ethnic backgrounds is increasing over time (US Census Bureau, 2012), and as a whole, these individuals are projected to become a st atistical majority of the It is of national concern that individuals from minority racial /ethnic backgrounds been defined by Braveman and colleagues as: Systematic, plausibly avoidable health differences according to race/ethnicity, skin color, religion, or nationality; socioeconomic resources or position (reflected by e.g., income, wealth, education, or occupation); gender, sexual orientation, gender identity; age, geography, disability, illness, political or other affiliation; or other characteristics associated with discrimination or marginalization. (Bravemen et al., 2011, p. S150) Numerous studies have indicated that, in the United States, people from minority racial and cultural backgrounds are more likely than their non Hispanic White counterparts to experience cancer, HIV/AIDS prevalence and mortality, cardiovascular disease, obesity, diabetes, infant mortality, hyperte nsion, and renal disease. Individuals

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23 from minority backgrounds are also more likely to experience increased negative 1997). Furthermore, people from racial /ethnic minority backgrounds as compared to their non Hispanic White counterparts are more likely to consistently demonstrate negative health care experiences in relation to these diseases as evidenced by health outcome research (Bernard, 1993; Mokuau & Fong, 1994; Nationa l Center for Health Statistics, 2006; National Center for Health Statistics 2007; Pleis & Lethbridge ejku, M., 2006) The social environment has been universally considered to be an important contributor to health disparities (Tucker, Daly, & Herman 2010 ); consequently, there are increasing efforts to address the social determinants of health, including patient provider interactions that involve doctors from one racial/ ethnic group and patients from a different racial /ethnic group (AHRQ, 2011). Furtherm ore, there is growing consensus that it is important to educate future health care professionals about the concepts of cultural sensitivity and the provision of culturally sensitive health care, both of which specifically relate to the prevention and reduc tion of health disparities (AHRQ, 2009; Tucker et al., 2003). Patient Centered Care and Culturally Sensitive Health Care The interchangeably throughout the health care research literatu re. Both of these terms relate to providing health care that is appropriate for all patients, and are frequently used as adjectives to describe health care that is appropriate for patients from minority racial /ethnic backgrounds (Tucker et al., 2007; Whale y, 2008). However, these terms are quite different in their meaning and orientation (Whaley, 2008). Furthermore,

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24 although the constructs of cultural sensitivity and cultural competence are interrelated, Whaley (2008) used multivariate multidimensional scal ing and cluster analyses to show that these terms are semantically independent constructs. The term culturally competent health care has been defined by the United States Department of Health and Human Services, Health Resources and Services Administration (2001) as health care that involves an understanding of and appreciation for the differences that exist between groups of people from differing racial /ethnic backgrounds. Researchers have described cultural competence as health care ons of behaviors, knowledge, and skills that exemplify a cross cultural understanding of health care practices, policies, and systems. Improved cross cultural understanding in turn improves health care efficacy and health outcomes (Roysircar, 2003). The De partment of Health and Human Services defines cultural within the context of the cultural beliefs, behaviors and needs presented by consumers ited States Department of Health and Human Services, Office of Minority Health, 2001, p.138). These definitions of the construct of cultural competence attend to the need for health care providers to demonstrate specific knowledge of and attentiveness to c ultural practices of patients from racial and cultural minority backgrounds in their clinical interactions (Caldwell et al., 2008). Bach and Fraser (2000) have proposed a theoretical model that links the concept of cultural competence with specific health outcomes that will help reduce health disparities. Specifically, these researchers advocate the following to increase the level

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25 members: (a) medical interventions to h elp health care providers provide culturally competent care by invoking the use of interpreter services, (b) attention to the racial /ethnic providers, and (c) cultural competence promotion and training programs. These culturally relevant knowledge and skills when working with patients from racial /ethnic minority backgrounds, improve understanding of the health beliefs endorsed by these patients, and ultimately improve the health outcomes of these patients. Bach and Fraser (2000) further theorize that such improvements in health care delivery will improve trust and communication between health care providers and people from racial and cultural minority backgrounds. However, researchers have identified an important limitation of cultural competence, which is that this construct is often defined by health care experts, such as doctors and researchers, rather than b y racially /ethnically diverse patients who are expected to benefit from culturally competent health care providers and staff members (Tucker et.al, 2003). For example, in research by Kim Godwin and colleagues (Kim Godwin, Alexander, Felton, Mackey, & Kasak off, 2006) examining health care practices that might constitute culturally competent health care for Mexican farm workers, the nurses for these workers rather than the workers themselves were asked to identify culturally competent health care practices. F urthermore, in a study by Betancourt and colleagues (Betancourt et al., 2003) that attempted to identify specific indicators of awareness, knowledge, and skills of health care providers that constitute culturally competent health care included the perspect ives of managed care administrators,

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26 health care organization employees, and people employed in government and medical school settings but did not include the perspective of the racially /ethnically diverse patients themselves. Tucker and her colleagues ( a concept that includes a focus on cultural competence but emphasizes the views of racially/ethnically diverse patients regarding what constitutes culturally appropriate care. Thus, they have described c subsumes and improves upon the construct of cultural competence. Majumdar Browne, Roberts, and Carpio (2004) have stated that culturally sensitive health care is care that is attentive of patient needs and expectations. In this way, cultural sensitivity has been competence. Tucke r and colleagues (2007) further describe the concept of patient centered culturally sensitive health care as having four specific characteristics: (1) it emphasizes the perspectives of racially and culturally diverse patients as to what constitutes the pr ovision of health care that is culturally competent; (2) it is patient centered in that it conceptualizes the patient provider relationship as a partnership that includes the perspectives of these patients; (3) it is empowerment oriented in that racially /e thnically diverse patients are encouraged to share their views with their health care providers throughout the health care process; and (4) it includes specific and modifiable health care behaviors and attitudes, and health care physical environment and he alth care policies that enable racially and culturally diverse patients to feel comfortable with,

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27 trusting of, and respected throughout the health care process Patients who feel more comfortable with and trusting of their health care providers are more li kely to demonstrate improved patient satisfaction and health outcomes (Harris et al, 1995; Joffe et al., 2003). It is noteworthy that the concept of cultural sensitivity includes the notion that health care providers can modify specific behaviors and atti tudes in their interactions with patients from racially and culturally diverse backgrounds in order to improve the health care that these patients receive. The culturally sensitive provider patient relationship provides a context in which health care provi ders can solicit culture specific preferences and information from their patients that can improve the delivery of culturally sensitive health care to these patients. Furthermore, Earnest, Ross, Wittevrongel, Moore, and Lin (2004) found that racially /ethni cally diverse patients desire more active participation in the health care process and in their interactions with their health care providers. These points underscore the importance of intervening to promote cultural sensitivity within the patient provider relationship. The Patient Centered Culturally Sensitive Health Care (PC CSHC) Model Tucker and her colleagues have proposed the PC CSHC Model to explain the linkages between the concept of culturally sensitive health care, as defined by patients from raci al /ethnic minority backgrounds, and the health outcomes and health statuses of these patients (Tucker et al., 2007). Specifically, this model postulates that: (a) patient and provider training can promote patient centered culturally sensitive health care, as indicated by physical environment characteristics of the health care

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28 perceived levels of provider cultural sensitivity and interpersonal control, both of which im promoting lifestyle and in level of treatment adherence; and (d) both level of treatment adherence and level of en gagement in a health and statuses. (Tucker et al., 2007, p 680) Preliminary t esting of the PC CSHC Model provided partial support for some of the proposed links among its variables. Specifica lly, Tucker and her colleagues (Tucker et al., 2011) conducted research using a national sample of both African American patients (n = 110) and Non Hispanic White patients (n = 119) and conducted two separate path analyses by racial background to test the linkages hypothesized by the PC CSHC Model. The study concluded that perceived provider cultural sensitivity had their health care. This effect held true for the African American patients and the non Hispanic White patients; however, this effect was stronger with regard to health care satisfaction for the African American patients and stronger with regard to trust for the non Hispanic White patients. Furthermore, p erceived levels of provider cultural sensitivity had a direct positive effect on dietary adherence for African American patients only. Other linkages hypothesized by the PC CSHC Model were also partially their health care providers was positively linked to their health care satisfaction; however, this relationship was found to be stronger among the non Hispanic White patients as compared to their African

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29 American counterparts. Additionally, for both the A frican American patients and non Hispanic White patients, level of interpersonal control was positively linked to engagement in a health promoting lifestyle; however, this linkage was found to be stronger for the African American patients. Interpersonal co ntrol was also positively linked to dietary adherence among the African American patients only (Tucker et al., 2011). Furthermore, it was found that the perceived cultural sensitivity of health care satisfaction with trust in providers being the intervening variable. However, this indirect relationship was stronger for the non Hispanic White patients than for the African American patients. Assessment Instruments f or Measuring Cultural Sensitivity Th e growing diversity of the national population along with well documented health disparities between people from racial /ethnic minority backgrounds and their majority counterparts has led to calls from national health care organizations (e.g. AHRQ, 2009) f or the development of assessment instruments to measure culturally competent and culturally sensitive health care. Without adequate assessments to measure culturally competent and culturally sensitive health care, development of effective interventions to promote such health care is impeded. When assessing culturally competent and culturally sensitive health care, attention must be paid to the specific modifiable behaviors and attitudes of health care providers, especially concerning the interactions betw een these providers and their patients from racial /ethnic minority backgrounds. This is because the behaviors and attitudes of health care providers have been associated with improved health outcomes for these patients (e.g. Beck, Daughtridge, & Sloane, 20 02; DiMatteo, 1998). Faculty at The National Center for Cultural Competence (Goode, Dunne, & Bronheim, 2006)

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30 perceived cultural sensitivity and cultural competence. Such assessment instrument s may be used to help health care providers evaluate their own level of perceived cultural sensitivity in the health care they provide to patients from diverse racial /ethnic backgrounds, and these provider self evaluations can also help identify specific a reas where increased training is needed to promote cultural sensitivity (Mirsu Paun et al., 2010). Other assessment instruments have been developed to measure the constructs of cultural competence among health care providers. These include the Cultural Co mpetence Assessment (Schim, Doorenbos, Miller, & Benkert, 2003), the Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals Revised (IAPCC R) (Campinha Bacote, 2002), the Cultural Awareness Scale (Rew, Becker, Cookston, K hosropour, & Martinez, 2003), the Tool for Assessing Cultural Competence Training (TACCT) (Association of American Medical Colleges, 2005), and the Clinical Cultural Competency Questionnaire (CCCQ) (United States Department of Health and Human Services, 20 05). Most of these assessment instruments lack adequate reliability data, have not been tested across diverse health care settings, or are focused on measuring the construct of cultural competence among providers who treat patients of one or few specific r acial /ethnic minority groups (Caldwell et al, 2008 ). Tucker and her colleagues (Tucker et al., 2003; Tucker et al., 2011) have developed assessment instruments to measure provider cultural sensitivity. One of these assessment instruments is used to assess own levels of cultural sensitivity in the health care they provide to racially and culturally diverse patients, and one is used by patients to rate their perceptions of the cultural

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31 sensitivity of their health care p rovider(s). These assessment instruments have been labeled the Tucker Culturally Sensitive Health Care Provider Inventory (T CSHCPI) Provider Form and the T CSHCPI Patient Form, respectively. Need f or Interventions to Promote Cultural Sensitivity A mon g Student Health Care Providers It is important to train medical students, in addition to veteran health care providers, to be culturally sensitive because these students will constitute future generations of health care providers (Mirsu Paun et al., 2010 ). Cultural sensitivity training in medical school can provide student health care providers with the necessary skills, knowledge, and attitudes to enable their future racially/ethnically diverse patients to feel respected, comfortable, and trusting within the patient provider relationship. Providing student health care providers with intervention programs aimed at promoting cultural sensitivity has already been called for in the academic research literature (e.g. AHRQ, 2009; Washington et al., 2008). When medical schools adopt cultural sensitivity training, they send a message early on to student health care providers that cultural sensitivity is and will be an important part of their careers and interactions with patients from diverse backgrounds. However, many medical schools are constrained by various obstacles to offer such cultural sensitivity training to their students. These obstacles include limited finances to hire faculty and staff to provide cultural sensitivity training and a lack of consensus a mong medical school administrators regarding the best practices for providing this training (Dorga et al., 2010; Rapp, 2006). Another key obstacle that has been cited is that medical training programs are already constrained to provide student health care providers with a large body of biomedical health information within the standard four year curriculum, and thus there is limited

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32 room in the curriculum to provide cultural sensitivity training (Tervalon, 2003). The implication here is that by providing stu dent health care providers with cultural sensitivity training, these students will miss out on some other important aspect of their medical training. However, this assumption inadvertently minimizes the importance of cultural sensitivity training for futur e health care providers and the students themselves see this provision of cultural sensitivity training to student health care providers and the actual response of medica l schools throughout the country, even as many student health care providers themselves have demanded that such training be an increased part of their medical education (Dogra et al., 2010; Mirsu Paun, 2010). A report by the American Association of Medica l Colleges (AAMC, 2007) indicated that the racial /ethnic /ethnic makeup. Despite this, health care providers from non Hispani c White backgrounds still overwhelmingly populate the classes of students who matriculate through most medical schools. For example, of the 82,067 student health care providers enrolled in the United States in 2012, approximately 59% identified as being fr om non Hispanic White backgrounds, 22% from Asian backgrounds, 9% from Hispanic/Latino backgrounds, and 7% from African American backgrounds (see Table 31 of AAMC, 2012 for complete data). These statistics demonstrate that the racial and cultural makeup of the student health care provider population is still not representative of the racial and cultural profile of the

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33 Given the lack of cultural sensitivity training in medical education programs, many student health care providers who b egin to practice medicine, despite coming from minority racial and cultural backgrounds themselves, often feel unprepared to effectively provide patient centered culturally sensitive health care to patients from diverse backgrounds (Grumbach et al., 2003). It is interesting to note that much of the dissatisfaction with the lack of cultural sensitivity training in medical education comes from students from underrepresented racial /ethnic minority backgrounds themselves. This suggests that student health care providers from majority backgrounds may not have the same level of awareness regarding the importance of this training or the potential negative impacts of the lack of this training. Betancourt and Reid (2007) have asserted that the racial /ethnic backgroun d of health care providers impacts the patient provider relationship, and they hypothesize that health care providers from non Hispanic White backgrounds may inadvertently act in ways that communicate a lack of cultural sensitivity to their patients from d iverse backgrounds. Support for training student health care providers to be culturally sensitive also comes from research suggesting that health care providers behave differently by gender when interacting with culturally diverse patients. For example, r esearchers have found that male and female physicians do not differ in the biomedical knowledge they demonstrate and the quality of information they provide to patients (Hall & Roter, 2002; Roter, Hall, & Aoki, 2002); yet, they act differently in patient p rovider interactions. Compared to their male counterparts, female physicians are more likely to spend additional time with patients, provide them with more positive feedback regarding health behaviors, communicate with more empathy, and focus more on impro ving the

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34 physician patient relationship (Bylund & Makoul, 2002, Hall & Roter, 2002: Roter et al., 2002). Furthermore, research has shown that student health care providers from racial and cultural minority backgrounds and student health care providers who are women are more likely to demonstrate attitudes that promote racial, cultural, and gender equality than their majority and male counterparts, respectively (Lee & Coulehan, 2006). In sum, health care providers from racial /ethnic minority backgrounds are often called upon to serve diverse populations, and many of these health care providers feel unprepared to do so (Sequist et al., 2008). Furthermore, medical schools have faced numerous obstacles in attempting to implement needed cultural sensitivity trai ning for their students. This training is important because there are differences in how student health care providers perceive the importance of cultural sensitivity based on their identity statuses. Thus, it is important for researchers, physicians and student health care providers to understand how issues of race /ethnicity combine with issues of gender in the provision of patient centered culturally sensitive health care to patients from diverse backgrounds, and to attend to such issues in the cultural sensitivity training of student health care providers Calls f or Customized Patient Centered Care Existing research suggests that providing patient centered culturally sensitive health care to patients from racial and minority cultural backgrounds is link ed to patient treatment adherence and patient satisfaction, both of which are positively linked to Enacting training programs for physicians and student health care providers in order to provide them with the skills necessary to provide this care will be a crucial part of the

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35 years. However, one of the dangers of providing culturally sensitive h ealth care is that individuals may be stereotyped based on their racial /ethnic backgrounds and that individual differences will not be accounted for in health care delivery efforts (Betancourt & Reid, 2007). Recent calls from national health care organiz ations such as the Agency for Healthcare Research and Quality (2009) have highlighted the need to provide patient centered culturally sensitive health care at the individual level in addition to the community level. These organizations hold that it is impo rtant to attend to individual differences in values and preferences when providing patient centered culturally sensitive health care in order to provide patients from all racial /ethnic backgrounds the most effective care and to promote comfort, trust, and respect within the provider patient relationship, which in turn have been linked to improved health outcomes among patients (Lukoschek, 2003; Rose et al ., 2000). Specifically, these organizations have advocated having health care providers monitor their pa individualized preferences throughout patient provider interactions. However, the AHRQ (2009) has also noted that although many training p rograms such as medical schools promote patient centered culturally sensitive health care in some way, many do not include a focus on modifiable behaviors on the part of health care providers when providing this care. The research literature on individua lized health care is limited and faces numerous challenges (Caspar et al., 2009; Suhonen et al., 2010). The increased understanding of the role that genetics plays in health care and new advances in health

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36 care technology have led health care providers to focus on providing patients with care that is tailored to meet their unique biological and genetic profiles (e.g. Louca, 2012; Thomas, Phillips, Donnelly, & Tak Piech, 2010). However, providing patients with personalized and individualized health care that biomedical and genetic needs is needed, and such care must incorporate patient preferences regarding the health care they receive and the behaviors these patients expect from their health care providers. Although the Joint Com mission of the Institute of Family Centered Care (2010) has highlighted the need for individualized patient centered culturally sensitive individualized health care, many researchers have noted there is a lack of progress in providing such care to cultural ly diverse patients in the U.S. (e.g. Kagan, 2011). Kagan (2011) has identified key challenges in the provision of patient centered individualized care. These challenges include a lack of adequate understanding of the factors that contribute to a healthy patient provider relationship, the reality that some patients may not wish to take an active role in the health care decision making process, and the reality that some patients have health conditions or language barriers that effectively prevent them from communicating their individualized preferences to providers. In addition, the nascent research literature on the topic of patient centered individualized care is complicated by a lack of consensus regarding the terms that are used to describe this care. I n spite of these limitations, there is initial evidence that both patients and health care providers (Caspar, et al., 2009; Suhonen et al., 2009).

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37 Given the large number of people that deserve and need patient centered culturally sensitive health care, it is easy to overlook individual preferences as to what constitutes such care. Numerous social and economic factors, and limited numbers of health care providers relative to the number of patients seeking care, serve as obstacles to the provision of individualized care. However, inventories that allow racially and culturally diverse patients to communicate their individual preferences to their health care providers can serv e as useful, cost effective, and efficient tools for promoting individualized patient centered culturally sensitive health care by student health care providers and veteran health care providers. The effect of individualized feedback from culturally divers e patients to student health care providers and veteran health care providers on student health care evaluation of their perceived levels of cultural sensitivity has not been assessed.

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38 CHAPTER 3 METHODS Participants All instruments and p rocedures related to this research were approved by an Institutional Review Board at a large southeastern university. Primary research participants were second year student health care providers who were recruited from an existing course (i.e. Essentials o f Patient Care IV ) within the College of Medicine at the University of Florida. In order to fulfill course requirements, students in this course must engage in a variety of simulated interactions with mock patients who are employed by the College of Medici ne. These mock patients were racially/ethnically diverse community members who were paid by the College of Medicine to be mock patients in simulated health care visits (hereafter referred to as clinical encounters) for the purpose of training the student h ealth care providers. These mock patients were secondary research participants in this study and thus the data provided by these participants were not used in the analyses that were conducted for this study A total of 202 (79%) student health care provid ers from among the 256 students in the course titled Essentials of Patient Care IV volunteered to be primary research participants. These student health care providers ranged in age from 20 to 36 years of age and consisted of 98 ( 48.5 %) males, 84 ( 41.6 %) f emales, and 20 (9 .9 %) individuals who chose not to report their gender. Furthermore, of the participating student health care providers, 3 (1.5 %) self identified as African American, 36 (1 7. 8%) self identified as Asian American, 13 (6. 4 %) self identified as Hispanic/Latino, 120 (59. 4 %) self identified as non Hispanic White, 9 (4.5%) self identified as being of a race/ethnicity that was not listed on the demographic data questionnaire for this study, and 21 (10 .4 %)

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39 chose not to report their racial/ ethnic ba ckground Regarding their United States citizenship status, 173 (8 5. 6%) identified as being United States citizens, 7 (3 .5 %) identified as being non United States citizens, and 22 (1 0.8 %) chose not to report their citizenship status. See Table 3 1 for addi tional participant demographic information. The secondary participants in this study were 34 mock patients who volunteered to participate in this research, most of whom participated in more than one simulated clinical encounter with student health care pro viders. Of these 34 mock patients, 19 (56%) identified as male and 15 (44%) identified as female. Five (15%) participants identified as African American, 2 (6%) identified as Asian American, 4 (12%) identified as Hispanic/Latino, 20 (59%) identified as non Hispanic White, 2 (6%) identified as coming from a background that was not listed on the demographic data questionnaire for this study, and 1 (3%) chose not to report his/her racial/cultural identity. Regarding their United States citizenship status, 28 ( 82%) identified as being United States citizens while 6 (18%) identified as being non United States citizens. Instruments Several instruments constituted the assessment battery or the inventory based intervention in this research: 1. The Demographic Data Questionnaire for Student Health Care Providers (DDQ1). The DDQ1 is an 8 item instrument that was used to obtain information on racial/ethnic background, and citizenship status. 2. The Demographic Data Questionna ire for Mock Patients (DDQ2). The DDQ2 is a 6 item instrument that was gender, age, racia l /ethnic background, and citizenship status.

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40 3. The Tucker Culturally Sensitive Health Care Provider Inventory Clinical Tool Form A (T CSHCPI A). The T CSHCPI A is a self report inventory on which patients (i.e., mock patients in the case of this research) identify 10 of 27 listed behaviors and characteristics of their health care providers that are most important to these patients when they receive health care 4 The Tucker Culturally Sensitive Health Care Provider Inventory Provider Form (T CSHCPI Provider ; Tucker, Nghiem, Marsi ske, & Robinson, In Press ). The T CSHCPI Provider Form is a 33 item self report inventory on which health care providers (i.e., student health care providers in the case of this research) self evaluate their provision of patient centered culturally sensiti ve health care to culturally diverse patients. In the present research only three of the five subscales of this inventory were used. These three subscales are: (1) the Cultural Knowledge and Responsiveness ledge of specific items that culturally diverse patients have indicated are representative of being respectful of their (3) the Interpersonal Skills subscale that measures health care providers interpersonal behaviors in clinical interactions with diverse patients. These three subscales were selected in order to reduce the total number of items that participants were requir ed to complete within the time allotted by the medical school where this research was conducted and because the se subscales were the most relevant to this research. Furthermore, in a study that used these three subscales to assess the cultural sensitivity of advanced level student health care

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41 providers (Mirsu Paun et al., 2010), these subscales were found to be reliable. The authors of the T CSHCPI Provider Form reported that these three subscales to have split half reliability coefficients ranging from .68 to .92. For the sample in the present study the internal consistencies for the three subscales identified in this section and used in the present study were as follows : .81 for the Cultural Knowledge and Responsiveness subscale, .92 for the Patient Cen teredness subscale, and .89 for the Interpersonal Skills subscale. A sample item from that people from different cultures have and believe in different medical practices item f rom the Patient Centeredness subscale is, A The items on this instrument are different from items found on the T CSHCPI A. Procedure Participant Recruitment The principle investigator launched this study by explaining it to a professor in the University of Florida College Of Medicine who teaches a course titled The Essentials of Patient Care IV All student health c are providers in this course were second year student health care providers and all second year student health care providers at the College of Medicine were enrolled in this course at the time this research was conducted In order to fulfill curriculum r equirements apart from this research, students in this course must engage in a variety of simulated clinical encounters with mock patients who are employed by the College of Medicine.

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42 The purposes of these simulated clinical encounters are to provide stud ent health care providers with experience in working with culturally diverse primary care clinic patients, and provide a professional medical context in which to practice their professional interpersonal skills. For the simulated clinical encounters that t ook place when this research was conducted, all student health care providers, regardless of research participation status, were required to interview a mock patient who presented with diabetes and subsequently give the mock patient feedback regarding how to live healthier lives with diabetes. One week prior to the simulated clinical encounters, the professor for this course announced in class that there would be an optional research participation opportunity that would be presented to them at the time they arrive to engage in the clinical encounters for the course. It was further explained by this professor that this research activity involved providing patient centered care and that further details regarding their research participation would be provided t o them just before engaging in the clinical encounters. The data for this study were obtained during each of two semesters that the above mentioned course was taught in order to increase the number of research participants. These research procedures were the same for each semester of the course, and there were no apparent differences in student health care providers in each semester of the course. When student health care providers arrived at the training site in groups of 13 to 16 to engage in health ca re provision with mock patients as required for their course, they were taken to a conference room by an assistant course instructor and the principal investigator for this study, and they were given information by the instructor

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43 regarding the expectations for their performance in the patient interaction as outlined by the course instructor, which is a course requirement apart from this research. The instructor explained that each student health care provider had been arbitrarily assigned to a mock patient with type 2 diabetes in a specified room where the student would see the mock patient for 15 minutes to practice talking to a mock patient about how to live a healthier lifestyle with diabetes. Next the student health care providers were given information by the principal investigator about the optional opp ortunity to participate in the research study The principal investigator then explained the opportunity to simultaneously and voluntarily participate in a research study on patient provider interactions which would involve completing some assessment instruments prior to talking with their assigned mock patient with diabetes (i.e., prior to the clinical encounter with the mock patient) and completing some assessment instruments after talking with their as signed mock patient Student health care providers were also given a copy of the Informed Consent Form for this research for them to read and review. The principal investigator then answered any participation related questions. Student health care provid ers who volunteered to participate (79%) returned their completed Informed Consent Forms. Student health care providers also completed the Demographic Data Questionnaire at this time, and returned it along with their informed consent form in an unmarked ma nila envelope. This procedure was used to ensure that personally identifying information submitted on the Demographic Data Questionnaire could not be linked to her/his responses on the assessment battery. The Demographic Data Questionnai res were pre coded with a unique identifier so they could

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44 Student health care providers who chose not to participate in this study completed the clinical encounter required for their course and were invited to study duri ng data collection sessions. Mock patients for this study were recruited by virtue of their employment by the medical school at which this research took place. This medical school regularly recruits and employs individuals from the surrounding community to serve as mock patients for the purpose of participating in the clinical encounters with student health care providers This employment procedure was in no way related to the current research project. The principal investigator for this research explaine d the study to all of the mock patients prior to the arrival of the student health care providers. Specifically, these mock patients were told that this was a study on culturally sensitive health care and that their participation in it would involve procee ding with the simulated clinical encounter as normal and completing a set of questionnaires before and after the encounter. Mock patients were also given a copy of the Informed Consent Form for this research for them to read and review. The principal inves tigator then answered their questions about the study and then invited them to be voluntary secondary research participants. All of the mock patients agreed to be study participants and each read and signed an Informed Consent form. Participant Assignmen t a nd Confidentiality Mock patients and student health care providers participated in simulated clinical encounter sessions in which a maximum of 16 student provider patient dyads participated at one time This is because there were only 16 available medic al examination rooms assigned for student clinical encounters at the Harrell Center (i.e., the location of the clinical encounters). These clinical encounters sessions were

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45 repeated eleven times over the course of seven days. This repetition allowed for ea ch student health care provider participating in this research study to be scheduled in advance for one specific arbitrarily assigned simulated clinical encounter Simulated clinical encounters were scheduled arbitrarily by the course instructor so that al l student health care providers each conducted one simulated clinical encounter with a mock patient. This scheduling procedure and the simulated clinical encounters would have occurred regardless of whether or not the research in which they were asked to p articipate in took place. Each session of 13 to16 student health care providers was arbitrarily assigned by the principal investigator to the Intervention Group or the Control Group. Participant confidentiality was protected by researchers pre coding part assessment batteries and Demographic Data Questionnaires (both those of the student health care providers and the mock patients) with a unique identifier based on the date and time that the student engaged in the clinical encounter and the room n umber where the clinical encounter took place. The Demographic Data Questionnaires were completed and collected at the time when participants completed the informed consent forms and thus were not collected with the questionnaires that constituted the ass essment battery This allowed participants to avoid placing any personally identifying information on the questionnaires. This code number also allowed the principal investigator to match the pre test and post test data of each participant without the use of personally identifying information because pre test and post test data were matched

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46 The principal investigator kept a record of the participation code numbers and their assoc iated data, but researchers did not have access to a list of names or any other identifying information. Conversely, the professor of the course for which the clinical encounters are required did not have access to the list of participant code numbers and did not have access to information as to whether or not any specific student or mock patient employee chose to be a study participant. However, the professor did have a list of stude nt names and the room number where each student conducted the clinical encounter because this information is used by them in their evaluation of student health care providers There was no research participation incent ive for any of the research participants in this study. Data Collection The student health care provider research participants (primary research participants) and their mock patient research participants (secondary research participants) progress ed throug h the three research phases as follows: the Pre Intervention Phase (10 minutes), the Clinical Encounter Intervention Phase (20 minutes), and the Post Intervention Data Collection Phase (10 minutes ). These phases took place over the course of a 25 minute pe riod of time. All data collections for student health care providers took place in a conference room at the Harrell Center at the University of Florida. The Principal Investigator was present in this conference room during all data collection sessions to a nswer questions and personally collect completed questionnaires. These three research phases are described in detail below:

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47 Pre i ntervention p hase (10 minutes) Prior to engaging in a simulated clinical encounter with a student health care provider, each mock patient completed the Tucker Culturally Sensitive Health Care Provider Inventory A and the DDQ 2 a few minutes prior to this clinical encounter and did so in the simulated exam room where the clinical encounter occurred. Specifically, each mock patie nt indicated the 10 provider cultural sensitivity indicators on the T CSHCPI A that she/ he most wanted to see displayed by health care providers who provide her/him health care. The T CSHCPI A completed by each mock patient was collected for use during the Clinical Encounter Intervention P hase. Clinical encounter intervention p hase (20 minutes) During this phase each student health care provider in the Intervention Group (a) reviewed for 5 minutes the T CSHCPI A that was completed by their assigned mock patient and that indicated the 10 provider cultural sensitivity indicators that the patient most wanted to see displayed by health care providers who provide her/him health care and (b) conducted for 15 minutes the simulated clinical encounter with the mo ck patient, which involved talking with this patient about how to live a healthier lifestyle with diabetes and trying to engage in/display the 10 provider cultural sensitivity indicators most important to the patient. Conversely, each student health care p rovider in the control group (a) reviewed for 5 minutes general medical information regarding type 2 cultural sensitivity indicators identified on the completed T CSHCPI A, and (b) conducted for 15 minutes the simulated clinical encounter with a mock patient just as was done by the student health care providers in the Intervention Group.

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48 Post intervention data c ollection p hase (10 minutes) In this research phase each stude nt health care provider in the Intervention Group and each in the Control Group completed the T CSHCPI Provider Form. Specifically, each of these student providers self evaluated her/his level of provider cultural sensitivity. Table 3 1. Demographic data for student health care provider p articipants Variable N Participant by % Gender Male Female Not Reported 98 84 20 4 8.5 4 1.6 9.9 Racial/Ethnic Identity African American Asian Hispanic/Latino White Other No t Reported 3 36 13 120 9 21 1.5 1 7.8 6. 4 59. 4 4.5 10.4 Citizenship Citizen Non Citizen Not Reported 173 7 22 8 5. 6 3.5 10.8

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49 CHAPTER 4 RESULTS The hypothesis and research question s et forth in this study as well as the analyses to address each are described in this section. Pre screening analyses were conducted on all variables to ensure that data were normally distributed. These preliminary screening analyses indicated that all data were normally distributed and did not demonstrate skewness and kurtosis values greater than an absolute value of 1. Furthermore, preliminary correlation analyses were conducted on the three subscales of the Tucker Culturally Sensitive Health Care Provider Inventory Provider Form (T CSHCPI Provider) which served as dependent variables in the analyses to test the hypothesis and research question set forth in this study. It was determined that these three subscales were only moderately correlated with each ot her and these correlations were significant which was expected given that they all measure aspects of the related construct of cultural sensitivity. The correlations were not higher than 0.6 7 and thus issues of multicollinearity were not accounted for in the analyses to address the hypothesis and r esearch question set forth in this study. See table 4 1 for additional information regarding these correlations. Furthermore, table s 4 2 4 3, and 4 4 provide information regarding the means of the dependent var iables that were examined in this study. The hypothesis for this research stated that student health care providers in the Intervention Group would have higher self evaluations of their provision of culturally sensitive health care (i.e. self evaluations o f their Cultural Knowledge and Responsiveness, Patient Centeredness, and Interpersonal Skills using a culturally

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50 sensitivity health care provider inventory) t o their mock patients than student health care providers in the Control Group. To test this hypot hesis, three separate independent t tests were conducted to compare the Intervention Group and Control Group with regard to their post test mean self evaluation of cultural sensitivity scores for the following subscales of the Tucker Culturally Sensitive H ealth Care Provider Inventory Provider Form (T CSHCPI Provider): (1) the Cultural Knowledge and Responsiveness subscale that measures indicated are representative of b eing respectful of their culture (2) the Patient care providers interpersonal behavior s in clinical interactions with culturally diverse patients Regarding the Cultural Knowledge and Responsiveness Subscale, participants in the Intervention Group reported higher levels of cultural knowledge and responsiveness ( M = 3.28, SE = 0.04) as comp ared to participants in the Control Group ( M = 3.19, SE = 0.05 ) but this difference was not significant t (195) = 1.36, p > .05 r = 0.10 The A post hoc power analysis was conducted to determine the power of this t test G*Power ( Faul, Erdfelder, Buchner, & Lang, 2009 ; Faul, Erdfelder, Lang & Buchner 200 7) was used to calculate an effect size d of 0.20 With a sample size of 124 participants in the Intervention Group and 7 3 participants in the Control Group and an alpha = .05,

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51 G*Power determined the power of this analysis to be 0.27 Thus, given the effect size and sample size, this analysis had limited statistical power. Regarding the Patient Centeredness subscale, parti cipants in the Intervention Group reported higher levels of patient centeredness ( M = 3.22 SE = 0.03) as compared to participants in the Control Group ( M = 3.17, SE = 0.04) but this difference was not significant t ( 198 ) = 0.87, p > .05, r = 0.06. The L of variance was not significant for this analysis. A post hoc power analysis was conducted to determine the power of this t test G*Power (Faul et al. 2009 ; Faul et al. 200 7) was used to calculate an effect size d of 0.13. W ith a sample size of 125 participants in the Intervention Group and 75 participants in the Control group, and an alpha = .05, G*Power determined the power of this analysis to be 0.14. Thus, given the effect size and sample size, this analysis had limited s tatistical power. For the Interpersonal Skills subscale, variance was significant for this t test. Therefore, the results for the analysis on this subscale that are reported below assume that the Intervention Group a nd the Control Group did not have homogeneity of variance. P articipants in the Intervention Group ( M = 3.44, SE = 0.04) did not report different levels of interpersonal skills compared to participants in the Control Group ( M = 3.48, SE = 0.04). This analys is was not significant t (171.94) = 0.77, p > .05 r = 0.06 A post hoc power analysis was conducted to determine the power of this t test G*Power (Faul et al. 2009 ; Faul et al. 200 7) was used to calculate an effect size d of 0.11. With a sample size o f 124 participants in the Intervention Group and 75 participants in the Control group, and an

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52 alpha = .05, G*Power determined the power of this analysis to be 0.12. Thus, given the effect size and sample size, this analysis had limited statistical power. T he exploratory research question in this study is as follows: At post intervention, do the student health care providers differ in their self evaluations of their provision of culturally sensitive health care to mock patients (i.e. self evaluations of t heir Cultural Knowledge and Responsiveness, Patient Centeredness, and Interpersonal Skills using a culturally sensitivity health care provider inventory) in association with racial/ethnic background, group (e.g. Intervention Group or Control Group), and/or race by group? To test this research q uestion, three univariate two way independent ANOVAs wer e conducted in which the dependent variable in each was a different one of the earlier described three subscales of the T CSHCPI Provider (Cultural Knowledge an d Responsiveness Subscale, the Patient Centeredness subscale, and Interpersonal Skills Subscale), and the independent variables in each were rac ial/ethnic background group (Intervention Group or Control Group), and race by group. Because of the limited nu mber of student health care provider participants from African American and Hispanic backgrounds in this research participants were pooled into three racial groups for the purpose of these ANOVAs. The three pooled racial groups examined in these analyses are : (1) participants from non Hispanic White backgrounds, (2) participants from African American or Hispanic backgrounds, and (3) participants from Asian backgrounds. Furthermore, because of the unequal sample sizes between these three pooled racial group s, three univariate ANOVAS were conducted instead of a MANOVA, and this has

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53 been described as being a more conservative method of analyzing these data (Tabacbhnick & Fidell, 2007). For the ANOVA with the Cultura l Knowledge and Responsiveness subscale as th e dependent variable, there was a significant main effect of group F (1, 196) = 5.24, p < .05, 2 = 0.021, indicating that at post test individuals in the Intervention Group ( M = 3.28, SD = 0.42) had higher self ratings on this variable as compared to thei r counterparts assigned to the Control Group ( M = 3.19, SD = 0.44). A post hoc power analysis using G*Power (Faul et al., 2009; Faul et al., 2007) calculated the power for this effect as 0.63. Thus, given the sample size and effect size, this analysis had adequate statistical power. There was not a significant main effect for racial/ethnic background F (2, 196) = 1.85, p > .05, 2 = 0.008. A post hoc power analysis using G*Power calculated the power for this effect as 0.37. Given the sample size and effect size, this analysis had limited statistical power. The mean self ratings by the student health care providers on the Cultural Knowledge and Responsiveness variable at post test by racial/ethnic background were as follows: (a) student providers from a non H ispanic White background (M = 3.19, SD = 0.41), (b) student providers from an African American or Hispanic background (M = 3.31, SD = 0.56), and (c) student providers from an Asian background (M = 3.34, SD = 0.41). G iven the sample size and effect size, th e ANOVA with the Cultura l Knowledge and Responsiveness s ubscale at the dependent variable had limited statistical power. There was not a significant interaction effect between racial/ethnic background by group F (2, 196) = 2.04, p > .05, 2 = 0.010. A post hoc power analysis using G*Power calculated the power for this effect as 0.41. Thus, given the sample size and effect size, this analysis had limited statistical power.

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54 For the ANOVA in which Patient Centeredness was the dependent variable, there was a si gnificant main effect of group F (1, 199) = 6.22, p > .05, 2 = 0.026, indicating that participants in the Intervention Group ( M = 3.22, SD = 0.34) repo rted higher self ratings on this variable as compared to participants in the Control Group ( M = 3.17, SD = 0.32). A post hoc power analysis using G*Power (Faul et al., 2009; Faul et al., 2007) calculated the power for this effect as 0.71. Thus, given the sample size and effect size, this analysis had adequate statistical power. There was not a significant mai n effect for racial/ethnic background F (2, 199) = 0.24, p > .05, 2 = 0 A post hoc power analysis using G*Power calculated the power for this effect as 0.08. Thus, given the sample size and effect size, this analysis had very limited statistical power. T he mean self ratings by the student health care providers on the Patient Centeredness variable at post test by racial/ethnic background were as follows: (a) student providers from a non Hispanic White background ( M = 3.19, SD = 0.31), (b) student provider s from an African American or Hispanic backgrounds ( M = 3.27, SD = 0.44), and (c) student providers from an Asian background ( M = 3.21, SD = 0.36). There was a significant interaction between racial/ethnic background by group F (2, 199) = 3.64, p < .05, 2 = 0.026. A post hoc power analysis using G*Power calculated the power for this effect as 0.68. Thus, given the sample size and effect size, this analysis had adequate statistical power. Post hoc pairwise comparisons utilizing a Bonferroni correction revea led that individuals who identified as coming from African American or Hispanic backgrounds were affected differently by the intervention as compared to their non Hispanic White and Asian counterparts. Specifically, participants from African American or Hi spanic backgrounds in the Intervention Group ( M = 3.48, SD = 0.42) reported higher self

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55 ratings of levels of responsiveness to patients concerns as compared to participants from African American or Hispanic backgrounds in the Control Group ( M = 3.03, SD = 0.36) and this difference was significant, p < .01. A post hoc power analysis using G*Power calculated the power for this effect as 0.68. Thus, given the sample size and effect size, this analysis had adequate statistical power. For the ANOVA with Interper sonal Skills as the dependent variable, there was no significant main effect for group F (1, 198) = 0.21, p > .05, 2 = 0, indicating that participants in the Intervention Group ( M = 3.44, SD = 0.40) did not report higher self ratings of their interpersona l behaviors in clinical interactions with culturally diverse patients as compared to participants in the Control Group ( M = 3.48 SD = 0.36). A post hoc power analysis using G*Power (Faul et al., 2009; Faul et al., 2007) calculated the power for this effect as 0.07. Thus, given the sample size and effect size, this analysis had very limited statistical power. There was no significant main effect for racial/ethnic background F (2, 198) = 0.10, p > .05, 2 = 0 A post hoc power analysis using G*Power calculate d the power for this effect as 0.05. Thus, given the sample size and effect size, this analysis had very limited statistical power. The mean self ratings by the student health care providers on the Patient Centeredness variable at post test by racial/ethni c background were as follows: (a) non Hispanic White backgrounds ( M = 3.45, SD = 0.36), (b) African American or Hispanic backgrounds ( M = 3.42, SD = 0.34), and (c) Asian backgrounds ( M = 3.47, SD = 0.41). There was no significant interaction between cultur al background by group F (2, 198) = 1.15, p > .05, 2 = 0.002. A post hoc power analysis using G*Power calculated the power for this effect as 0.26. Thus, given the sample size and effect size, this analysis had limited statistical power.

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56 Table 4 1. Interc orrelations among dependent variables Cultural Knowledge Patient Centeredness Interpersonal Skills Cultural Knowledge 1 0.59 p < .01 0.50 p < .01 Patient Centeredness 0.59 p < .01 1 0.67 p < .01 Interpersonal Skills 0.50 p < .01 0.67 p < .01 1 Table 4 2. Means of Patient Centeredness Subscale of the T CSHCPI Provider Variable N Mean SD Experimental Total 125 3.22 0.34 African American & Hispanic 8 3.48 0.42 Asian American 44 3.24 0.37 Non Hispanic White 73 3.17 0.30 Control Total 75 3.17 0.32 African American & Hispanic 7 3.03 0.36 Asian American 22 3.16 0.33 Non Hispanic White 46 3.20 0.32

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57 Table 4 3. Means of Interpersonal Skills Subscale of the T CSHCPI Pr ovider Variable N Mean SD Experimental Total 124 3.44 0.40 African American & Hispanic 8 3.53 0.42 Asian American 44 3.46 0.43 Non Hispanic White 72 3.41 0.39 Control Total 75 3.48 0.36 Af rican American & Hispanic 7 3.31 0.20 Asian American 22 3.47 0.37 Non Hispanic White 46 3.51 0.36 Table 4 4. Means of the Cultural Knowledge and Responsiveness Subscale of T CSHCPI Provider Variable N Mean SD Experimental Total 124 3.28 0.42 African American & Hispanic 8 3.52 0.47 Asian American 44 3.38 0.42 Non Hispanic White 72 3.19 0.39 Control Total 73 3.19 0.44 African American & Hispanic 7 3.07 0.59 Asian American 22 3.24 0.38 Non Hispanic White 44 3.19 0.45

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58 CHAPTER 5 DISCUSSION The study examined the effects of an intervention to promote customized culturally sensitive health care by student health care providers on these student provid evaluations of their cultural sensitivity following simulated clinical encounters with mock patients This intervention involved having each mock patient use a modified version of the Tucker Culturally Sensitive Health Care Inventory Clinical Too l Form A t o identify the provider behaviors and attitudes most important to her/him, and subsequently having her/his student health care provider review this health care information prior to the simulated patient provider clinical encounter. This intervent ion occurred as part of the participating training in a required course on the essentials of patient care in which student health care providers typically engage in simulated clinical encounters with mock patients as required by the medical curriculum. The first section of this chapter will summarize and interpret the findings of this study, and will be followed by a section that describes the limitations of this study. Subsequent sections will describe implications for physi cian training, implications for psychologists, and im plications for future research. A brief conclusion will also be provided Summary a nd I nterpretation o f Findings The hypothesis for this study stated that student health care providers in the Interventi on Group will have higher self evaluations of their provision of culturally sensitive health care (i.e. self evaluations of their Cultural Knowledge and Responsiveness, Patient Centeredness, and Interpersonal Skills using a cultural

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59 sensitivity heal th care inventory for health care providers ) to their mock patients than student health care providers in the Control Group. Specifically, i t was hypothesized that allowing student health care providers to see customized feedback regarding their mock eferences for provider behaviors that constitute customized culturally ratings of their provision of this care. The t tests that were performed to test this hypothesis revealed no significant differences at post test ratings of their provision of customized culturally sensitive health care in association with being in the Intervention Group or the C ontrol Group Thus the tested hypothesis was not supported. The limit ations of this study, which are described in a subsequent section may have limited the ability to detect significant differences in self assessed customized cultural sensitivity between student health care providers in the Intervention Group and student h ealth care providers in the Control Group. The exploratory research question posited in this study examined whether or not student health care providers differ ed in their self evaluations of their provision of customized culturally sensitive health care t o mock patients (i.e. self evaluations of their Cultural Knowledge and Responsiveness, Patient Centeredness, and Interpersonal Skills using a culturally sensitivity health care provider inventory) in association with racial/ethnic background, group (e.g. I ntervention Group or Contr ol Group), and/or race by group. This research question was informed by past studies show ing that student health care providers who begin to practice medicine, despite coming from minority racial /ethnic backgrounds themselves, oft en feel unprepared to effectively provide patient centered culturally sensitive health care to patients from racially/ethnically

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60 diverse back grounds (Grumbach et al., 2003) Furthermore, student health care providers from racial/ethnic minority backgrounds often end up practicing medicine with patients who also come from minority racial /ethnic backgrounds, partly because many of these patients choose physicians who identify as coming from minority racial /ethnic backgrounds ( e.g. Whitla et al., 2003). The AN OVA to address th e stated research question revealed that student health care providers in the Intervention Group as compared to their counterparts in the Control G roup had higher self ratings of their provision of customized culturally sensitive health ca re at post test in the area of Cultural Knowledge and Responsiveness Specifically, these results suggest that student health care providers in the Intervention Group, as compared to those in the Control Group, benefited from seeing their mock eferences for what constitutes customized culturally sensitive health care These student health care providers in the Intervention Group as compared to those in the Control Group subsequently rated themselves as having higher levels of knowledge of spec ific items that racially/ethnically diverse patients have indicated are representative of being respectful of their culture There were no significant differences between student health care providers who identified as coming from African American and Hisp anic backgrounds (who were grouped together for the purpose of examining this research question ) as compared to student health care providers who identified as coming from non Hispanic White backgrounds and Asian American backgrounds The ANOVA to address th e research question as it pertain ed to the Patient Centeredness aspect of customized c ulturally sensitive health care revealed that student health care providers in the Intervention Group reported higher self ratings of

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61 their provision of culturally sens itive health care than student health care providers in the Control Group Additionally, it was found that student health care providers from African American and Hispanic backgrounds (who were grouped together for the purpose of examining this research qu estion ) in the Intervention Group reported higher self ratings of levels of patient centeredness as compared to participants from non Hispanic White and Asian American backgrounds in the Control Group The student health care providers from African America n and Hispanic backgrounds may have been more sensitive to issues of cultural sensitivity when providing customized culturally sensitive health care. It is also noteworthy that self ratings of the provision of culturally sensitive health care on the Inter personal Skills aspect of this care at post test were not found to be significantly different between student health care providers in the Intervention Group and those in the Control Group One speculative explanation of this finding is that all student he alth care providers who served as participants for this study were enrolled in a course designed to teach the essentials of patient care a course designed to train student health care providers on how to interact with their patients Furthermore, these stu dent health care providers were evaluated on their ability to interact with mock patients during their simulated clinical encounters as part of their coursework Because of this student health care providers may have demonstrated a heightened sensitivity to behaving in ways that show strong interpersonal skills as a result of their awareness that they were being evaluated f or such skills as required by this course and r egardless of their group assignment

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62 Despite the lack of statistically significant find ings, there was an overall trend of student health care providers in the Intervention Group reporting higher mean self ratings of two aspects of their provision of customized culturally sensitive health care at post test as compared to their counterparts i n the Control Group at post test on two subscales of the T CSHCIPI Provider. Specifically, these non significant trends held true for student health care providers self ratings of their Cultural Knowledge and Responsiveness ( M = 3.28, SE = 0.04 for the In tervention Group vs. M = 3.19, SE = 0.05 for the Control Group) and the ir Patient Centeredness ( M = 3.22, SE = 0.03 for the Intervention Group vs. M = 3.17, SE = 0.04 for the Control Group). In sum, the findings from this study provide support for further investigations of whether or not providing student health care providers with feedback regarding their ovision of this care Although this study had several limitations, it has important implications for physician training and for psychologists who practice in the realms of health psychology and behavioral medicine. These limitations and implications are di scussed in the following sections Limitations of t he Current Study There are several limitations of the current study. One limitation is the small sample of student health care provider participants. Attempts were made to recruit a large number of these participants, but many of them (21%) decided not to participate in the study. One potential reason for the lack of participation of these student health care providers may be the lack of research participation compensation.

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63 Although the t tests that were used to test this hypothesis did not show significant differences between student health care providers in the Intervention Group and Control test, student health care providers in the I ntervention Group generally trended toward higher mean self ratings of their provision of customized culturally sensitive health care. The fact that these differences were not statistically significant may result from the small sample size and small effect sizes that were achieved from these analyses. One potential explanation for the lack of statistical significance may be that these small effect sizes in turn were related to the constricted range of responses available for participants to rate their self perceptions of their provision of culturally sensitive health care. The T CSHCPI Provider only allowed student health care providers to rate their levels of cultural sensitivity using a four point Likert scale, and this constricted range of responses may h ave limited the ability to find differences between groups in this small sample differences that may have been found had students been able to use a Likert scale with a wider range in their self evaluations. Thus, the small effect sizes for the interventio n coupled with the small sample size limited the ability to test the effects of the intervention to promote customized culturally sensitive care. Another limitation of this study is that it was conducted with student health care providers at only one medi cal school. Thus, there is a limited ability to generalize the results of this study to a larger population. Other limitations of this study include that it used self reported levels of customized cultural sensitivity by the student health care providers a nd did not examine the perspectives of the patients who were served by these student health care providers The small sample size of mock patients who

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64 participated in this research limited any attempt to collect meaningful data from these individuals. Yet, given that racial/ethnic diverse patients are the individuals who experience the negative health outcomes that result from the health disparities that plague our nation, future research should indeed assess whether or not these patients perceived their he alth care providers to be more culturally sensitive as a result of participating in interventions similar to the one tested in the current study. The use of mock patients in this study who were employees of the College of Medicine and paid to act as patie nts in the simulated clinical encounters with student health care providers was also a study limitation. It is important instead to use actual patients in order to improve the generalizability of the findings of future research that is similar to the curre nt study. Another limitation of this study is the attempted integration of the intervention into an existing training module involving clinical encounters. This integration effort resulted in an inadequate time for data collection (i.e., only 25 minutes). Consequently, assessment of social desirability and of constructs related to cultural sensitivity such as cultural competence could not be assessed in the present study. A further limitation of the current study is its post test only design. This design enabled statistical analyses that had limited statistical power to detect possible intervention effects. Had student health care providers been able to complete pre test assessment questionnaires in addition to post test questionnaires, more powerful repe ated measures analyses could have been performed to examine any changes in self

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65 health care from pre intervention to post intervention and to determine group differences in these changes. I mplicati ons f or Physician Training The results from this study have implications for the training of future health care providers namely medical students, to provide health care that is culturally sensitive and tailored to meet the cu stomized needs of racially and culturally diverse patients. As previously indicated in this paper, there have been numerous calls for the inclusion of cultural sensitivity skills training in medical school curricula (e.g. Mirsu Paun et al., 2010 The resul ts of this study provide partial support for the inclusion of interventions designed to help racially/ethnically diverse student health care providers improve their provision of customized culturally sensitive health care when working with racially/ethnica lly diverse patients Indeed, i t is noteworthy that the results of this study showed that the tested intervention had a n impact on student health care providers from racial /ethnic minority backgrounds such that student health care providers from African A me rican and Hispanic backgrounds in the Intervention Group had higher self ratings o n the Patient Centeredness aspect of customized cultural ly sensitiv e health care than non Hispanic White and Asian American studen t health care providers in the Control Gro up. I nterventions such as the one tested in the current study can be supplemented with cultural sensitivity training that is integrated into e xisting coursework with the goal of promoting the importance of this training among student health care providers particularly among those student health care providers who do not identify as coming from racial /ethnic minority backgrounds Such integrated training may encourage a process of lifelong learning whereby student health care providers who treat patients

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66 fr om racial /ethnic minority backgrounds are encouraged to learn about health care provision preferences. Implications f or Psychologists The results from this study also have implications for psychologists who practice in the realms of health psychology and behavioral medicine. Given these training in interpersonal communication skills development relationship building and attending to individual differences these professionals are uniquely poised to promote customized cultur ally sensitive health care through provider training to deliver such care. Many of these psychologists are also experience d in conducting research that examines cross cultural differences and interventions to address these differences. Thus, psychologists are uniquely suited for developing learning experiences for student health care providers that will promote their provision of customized culturally sensitive health care to racially/ethnically diverse patients Psychologists who specialize in health psyc hology or behavioral medicine are also particularly well trained to create and utilize assessment instruments s uch as the questionnaires used in this research to assess provider cultural sensitivity. Despite the calls in the academic research literature for the development of such assessment instruments (e.g. AHRQ, 2009; Washington et al., 2008) many obstacles have prevented their development ( e.g. Tervalon, 2003) Such assessments are needed to provide needed data to inform, customize, and evaluate trai nings for student health care provider s that will prepare them to provide customized culturally sensitive health care to culturally diverse patients.

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67 Implications f or Future Research The resu lts of this study provide support for similar research to the pr esent study that uses larger sample sizes In addition such future studies should include larger and more representative samples of racial/ethnic minority student health care providers and mock patients. Furthermore this research should ideally include p may help medical school administrators understand the need for provider cultural sensitivity training and how to best go a bout implementing such training Future research can also work tow ard continuing to develop the appropriate assessment instruments to measure constructs related to promoting customized culturally sensitive health care among student health care providers and assess the validity and reliability of such instruments. This s tudy was limited to examining customized cultural sensitivity as it pertains to individuals from different racial/ethnic backgrounds. F uture research on promoting customized culturally sensitive health care should ideally include the views of other cultura l groups such as LGBTQ groups and religious groups. Conclusions This study indicated that providing student health care providers with feedback from their racially /ethnically diverse patients regarding the behaviors these patients wish to see during thei r encounters with providers is an important part of promoting customized culturally sensitive health care among these providers Furthermore, this study provides support for future research to examine this intervention that uses larger diverse samples of s tudent health care providers and actual patients, includes the itivity, and uses a pre post test research design

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68 Additionally, because of their training in multicultural counseling and conducting culturally sensiti ve research, psychologists are ideal ly suited for conducting this research in partnershi p with medical school faculty. The r esults of this study and future similar research that tests intervention s in training student health care providers to provide custo mized patient centered c ulturally sensitive health care hold potential for ultimately helping to eliminate the health disparities that plague our nation.

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69 APPENDIX A INFORMED CONSENT FOR M FOR STUDENT HEALTH CARE PROVIDERS Informed Consent to Participate in Research and Authorization for Collection, Use, and Disclosure of Information for Student Health Care Providers PLEASE SIGN BOTH COPIES OF THIS FORM AND RETURN ONLY ONE TO THE RESEARCHERS You are being asked to take part in a research study. This form provides you with information about the study and seeks your permission for the collection, use and disclosure of your information necessary for the study. The Principal Investigator (the person in charge of this research) or a representative of the Prin cipal Investigator will also describe this study to you and answer all of your questions. Your participation is entirely voluntary. Before you decide whether or not to take part, read the information below and ask questions about anything you do not unders tand. If you choose not to participate in this study you will not be penalized or lose any benefits that you would otherwise be entitled to. 1. Name of Participant ("Study Subject"): ______________________________________________ (Please put your first and last name here) 2. Title of Research Study: Training Medical Students for Patient Interactions 3. Purpose of the research study: The purpose of this study is to find out how patients view the attitudes and behaviors of their student health care providers, and how student health care providers view their own behaviors in interactions with patients. 4. What you will be asked to do if you take part in the study: You will be asked to fill out a set of questionnair es about your lifestyle culture and culture and your perceived behaviors in interactions with your patients. Filling out the questionnaires should take less than ten minutes You will be asked to complete these questionnaires twice within a one hour perio d. Please return the completed questionnaires in the provided envelope to the research assistant who will be available to receive them from you 5. Possible Risks and Benefits: We do not expect any risk to you for participating in this study. There are no known risks to completing the questionnaire s We do not anticipate that you will benefit directly by participating in this project. However, you may become more aware of your behaviors with your patients. 6. Compensation: There is no compensation for your pa rticipation in this project. 7. Confidentiality: Your identity will be kept confidential to the extent provided by law. Your name will not be

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70 placed on the questionnaires. Instead, researchers will place a code number on the questionnaires that you fill out and on the provided envelopes You are to place your completed questionnaires in the brown envelope and your signed informed consent form in a white envelope. Each of these envelopes will be locked in a separate filing cabinet in room 293 at the Departmen t of Psychology University of Florida. Your individual responses will only be seen by the researchers who are conducting this study and will not be shared with anyone involved in training you or with anyone else. 8. Voluntary participation: Your participat ion in this study is completely voluntary. There is no penalty for not participating. You may stop completing the questionnaires at any time. 9. Right to withdraw from the study: You have the right to withdraw from the study at anytime without consequence Whom to contact if you have questions about the study: Carolyn M. Tucker, Ph.D. Distinguished Alumni Professor Joint Professor of Psychology and Professor of Community Health and Family Medicine Professor of Pediatrics (Affiliate) 1 352 273 2153 or (Toll free) 1 866 290 5770 or Dr. Rebecca R. Pauly Associate Vice President, Health Affairs Office of Equity and Diversity (352) 273 5310 Whom to contact about your rights as a research participant in the study: University of Florida Institutional Rev iew Board Office Box 112250 University of Florida Gainesville, FL 32611 22250 (352)392 0433 Agreement: I have read the procedure described above. I voluntarily agree to participate in the procedure and I have received a copy of this description. Particip ant:_________________________________ Date:___________ Investigator:________________________________ Date:___________ *Please place the first copy of this form in the white envelope and keep the second copy for your records.

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71 APPENDIX B INFORMED CO NSENT FORM FOR MOCK PATIENTS Informed Consent to Participate in Research and Authorization for Collection, Use, and Disclosure of Information for Mock Patients PLEASE SIGN BOTH COPIES OF THIS FORM AND RETURN ONLY ONE TO THE RESEARCHERS You are being a sked to take part in a research study. This form provides you with information about the study and seeks your permission for the collection, use and disclosure of your information necessary for the study. The Principal Investigator (the person in charge o f this research) or a representative of the Principal Investigator will also describe this study to you and answer all of your questions. Your participation is entirely voluntary. Before you decide whether or not to take part, read the information below an d ask questions about anything you do not understand. If you choose not to participate in this study you will not be penalized or lose any benefits that you would otherwise be entitled to. 10. Name of Participant ("Study Subject"): _________________________ _____________________ (Please put your first and last name here) 11. Title of Research Study: Training Medical Students for Patient Interactions 12. Purpose of the research study: The purpose of this study is to find out how patients view the attitudes and behaviors of their student health care providers, and how student health care providers view their own behaviors in interactions with patients. 13. What you will be asked to do if you take part in the study: You will be asked to fill out a set of questionnaires about your lifestyle and culture, and your perceived behaviors in interactions with your student health care providers. Filling out the questionnaires should take less than ten minutes You will be asked to complete these questionnaires twice within a one hour period. Please return the completed questionnaires in the provided envelope to the research assistant who will be available to receive them from you 14. Possible Risks and Benefits: We do not expect any risk to you for participating in this study. There are no known risks to completing the questionnaire s We do not anticipate that you will benefit directly by participating in this project. However, you may become more aware of your behaviors with your student health care providers. 15. Compensation: There is no compensation for your participation in this project.

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72 16. Confidentiality: Your identity will be kept confidential to the extent provided by law. Your name will not be placed on the questionnaires. In stead, researchers will place a code number on the questionnaires that you fill out and on the provided envelopes You are to place your completed questionnaires in the brown envelope and your signed informed consent form in a white envelope. Each of these envelopes will be locked in a separate filing cabinet in room 293 at the Department of Psychology University of Florida. Your individual responses will only be seen by the researchers who are conducting this study and will not be shared with anyone invol ved in training you or with anyone else. 17. Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. You may stop completing the questionnaires at any time. 18. Right to withdraw from the stu dy: You have the right to withdraw from the study at anytime without consequence Whom to contact if you have questions about the study: Carolyn M. Tucker, Ph.D. Distinguished Alumni Professor Joint Professor of Psychology and Professor of Community Health and Family Medicine Professor of Pediatrics (Affiliate) 1 352 273 2153 or (Toll free) 1 866 290 5770 or Dr. Rebecca R. Pauly Associate Vice President, Health Affairs Office of Equity and Diversity (352) 273 5310 Whom to contact about your righ ts as a research participant in the study: University of Florida Institutional Review Board Office Box 112250 University of Florida Gainesville, FL 32611 22250 (352)392 0433 Agreement: I have read the procedure described above. I voluntarily agree to part icipate in the procedure and I have received a copy of this description. Participant:_________________________________ Date:___________ Investigator:________________________________ Date:___________ *Please place the first copy of this form in the white envelope and keep the second copy for your records.

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73 APPENDIX C DEMOGRAPHIC DATA QUE STIONNAIRE FOR STUDE NT HEALTH CARE PROVIDERS Demographic Data Questionnaire for Student Health Care Providers Please provide the information requested by writing you r answer or filling in the circle by your answer like this: 1. Your Age: ____ years old. 2. Your Gender: Male Female 3. Your Race/Ethnicity (please choose): African American/Black Asian American/Pacific Islander Latino/His panic American Native American Non Hispanic Caucasian/White Other (please specify): _________________________ 4. Are you a citizen of the U.S.A.? No Yes 5. Please list any languages other than English that you speak: _____________ _______________ 6. What year in medical school are you? ___________ 7. Please rate your level of exposure to racial/ethnic minority patients. Very low Low Average High Very high 8. Please rate your level of exposure to low income pa tients. Very low Low Average High Very high

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74 APPENDIX D DEMOGRAPHIC DATA QUE STIONNAIRE FOR MOCK PATIENTS Demographic Data Questionnaire for Mock Patients Please provide the information requested by writing your answer or filling in the circle by your answer like this: 1. Your Age: ____ years old. 2. Your Gender: Male Female 3. Your Race/Ethnicity (please choose): African American/Black Asian American/Pacific Islander Latino/Hispanic American Native Am erican Non Hispanic Caucasian/White Other (please specify): _________________________ 4. Are you a citizen of the U.S.A.? No Yes 5. Please list any languages other than English that you speak: ____________________________ 6. Please rate your level of exposure to racial/ethnic minority health care providers. Very low Low Average High Very high

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75 APPENDIX E THE TUCKER CULTURALLY SENSITIVE HEALTH CARE PROVIDER INVENTORY CLINICAL TOOL FORM A T CSHC CT (Form A) DIRECTIONS Please identify the 10 behaviors and characteristics of doctors, nurses, and other health care providers that are most important to you when they provide health care to you. Do this by shading in the circle beside each of the 10 behaviors This information will help the health care provider that you see show the behaviors and characteristics that are most important to you when they interact with you. Please make sure to shade in the circle besi de only the 10 most important to you. 1. Is honest and direct with me. 2. Is dedicated to her or his work. 3. Enjoys what he or she is doing. 4. Is well educated. 5. Is knowledgeable about medicine. 6. Knows what he or she is doi ng. 7. Is confident in his or her abilities. 8. Is right about why I am sick. 9. Seems interested in my problem 10. Takes my concerns seriously. 11. Does not question the truth or accuracy of what I am feeling. 12. Does not diagnosis all 13. Does not talk down to me. 14. Tries to communicate with me. 15. Tries to educate me. 16. Takes all of my concerns seriously even if he or she does not consider them to be serious. 17. Does not embarrass me in private or public. 18. Prescribes medicine only when he or she is sure of my illness. 19. Does not make me wait long. 20. Follows up on my visits.

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76 21. Lets me know about illnesses and diseases common among people of my race /ethnicity. 22. Prepares me for the next steps in treating my illness. 23. Understands my financial situation. 24. Shows appreciation for me and all of his or her patients. 25. Shows care and concern for my child/children. 26. Is respectful of my religious beliefs. 27. Understands my culture. Carolyn M. Tucker, 2009

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77 APPENDIX F TUCKER CULTURALLY SENSITIVE HEALTH CARE PROVIDER INVENTORY PROVIDER FORM Directions: Take a few seconds to think about your current work as a health care provider. Now please read the statements listed below, and rate how much you agree that each statement describes you and your current work as a health care provider. Please use a rating of 4, 3, 2, or 1, in the circle beneath the rating that you choose like this: 1 2 3 4 1. I am welcoming and friendly with my patients. 2. I am relaxed with my patients. 3. I am compassionate and tender with patients. 5. I am willing to learn. 6. I explain everything I do to my pat ients. 7. I talk to my patients during their visits. 8. I am nice to my patients. 9. I make my patients feel like their visits to this health care center w ere informative or productive. 10. I care more about my patients than about making money. 11. I make my patients feel at home when they are at this health care center. 12. I put 13. I show my patients that I am familiar with their health. 14. I 15. I prepare my patients fo r the next steps in treating their illnesses. 16. I refer my patients for tests they think they need. 18. I kno w how to make my patients feel comfortable.

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78 20. I make helpful and reasonable recommendations. 21. I am available for my patients 22. I put on a fresh pair of gloves in front of my patients. 23. I explain the medications I prescribe to my patients. 24. I refer my patients to a special ist when they request it. 25. I take time with my patients while examining and treating them. 26. I am prepared to examine my patients when I walk into the examining room 28. I examine all my patients according to a standard procedure. 29. I prescribe treatments and medicines that work. 30. I am educated in working with patients of different cultures and social statuses. 31. I understand the culture of the racial/ethnic minority patients I have. 32. I understand that people of different cultures have and believe in different medical practices. 33. I work to make this health care center more racially integrated. Copyright 2003, Tucker

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79 LIST OF REFERENCES Agency for Healt hcare Research and Quality. (2003). National Healthcare Disparities Report (HHS Publication). Rockville, MD: U. S. Government Printing Office. Agency for Healthcare Research and Quality. (2009). National Healthcare Disparities Report Rockvill, MD: U. S. Government Printing Office, 2009. Available at: http://www.ahrq.gov/qual/qrdr09.htm. Accessed October 30, 2012. Anderson, G. F., & Poullier, J. P. (1999). Health care spending, access, and outcome: Trends in industrialized countries. Health Affairs, 18, 1 78 192. American Medical Association. (2006). Improving communication improvin g care: An Ethical Force Program Consensus Report. Retrieved November 2, 2012 from http://www.ama assn.org/ama1/pub/upload/mm/369/pcc consensus report.pdf. Association of Amer ican Medical Colleges (2005). Cultural Competence Education for Medical Students. Washington, DC. Association of American Medical Colleges. (2012). FACTS: Applicants, matriculants, enrollments, graduates, MD/PhD, and residency applicants data. Available at: https://www.aamc.org/data/facts/. Accessed January 19, 2013. Bach, C. & Fraser, I. (2000). Can cultural Competency reduce racial and ethnic health disparities? A review and conceptual model. Medical Care Research and Review 57(1) Supplement 1, 181 21 7. Beck, R. S., Daughtridge, R ., & Sloane P. D (2002). Physician patient communication in the primary care office: A systematic review. The Journal of the American Board of Family Practice, 15(1), 25 38. Betancourt, J. R., Green, A. R., Carrillo, J. E., & Ananeh Firempong, O. (2003). Defining cultural competence: A practical framework for addressing racial/ethnic disparities in health and health care. Public Health Reports, 118, 293 303. Betancourt, J. R., Green, A. R., Carrillo, J. E., & Park, E. R. (2005). Cultural competence and health care disparities: Key perspectives and trends. Health Affairs, 24(2), 499 505. we be surprised? Annals of Inte rnal Medicine 146(1) 68 69. Bernard, M. A. (1993). The health status of African American elderly. Journal of the National Medical Association, 85, 521 528. Braveman, P. A., Kumanyika, S., Fielding, J., LaViest, T., Borrell, L. N., Manderscheid, 2011). Health disparities and health equity: The issue is justice. American Journal of Public Health, 101(S1), S149 S155.

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80 ethnicity and health trajectories: Tests of three hypotheses across multipl e groups and health outcomes. Journal of Health and Social Behavior, 53, 359 377. doi: 10.1177/0022146512455333 Burk, M. E., Wieser, P. C., & Keegan, L. (1995). Cultural beliefs and health behaviors of pregnant Mexican American women: Implications for pri mary care. Advances in Nursing Science, 17, 37 52. Bylund, C. L. & Makoul, G. (2002). Empathic communication and gender in the physician patient encounter. Patient Education and Counseling 48(3) 207 216. Caldwell, L. D., Tarver, D. D., Iwamoto, D. K. Herzberg, S. E., Cerda Lizzaraga, & Mack, T. (2008). Definitions of multicultural competence: Frontline human service Journal of Multicultural Counseling and Development, 36, 88 100. Campinha Bacote, J. (1999). A model and instru ment for addressing cultural competence in health care. Journal of Nursing Education 38(5) 203 207. Campinha Bacote, J. (2002). The process of cultural competence in the delivery of health care Services: A model of care. Journal of Transcultural Nursing 13(3) 181 185. change models on long term care staff empowerment and provision of individualized care. Canadian Journal on Aging, 28(2), 165 175. Clancy, C. (2008) Improving care quality and reducing disparities. Archives Internal Medicine 168, 1135 1136. Cross, T, Barzon, J, Dennis, K & Isaacs, R 1989, Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington, DC: CASSP Technical Assistance Center, Georgetown University Child Development Center. Da Silva, G. C. (1984). Awareness of Hispanic cultural issues in the health care setting. 4 10. Davis, I. J., Brown, C. P., Allen, F., Davis, T., & Waldron, D. (1995). African American myths and health care: The sociocultural theory. Journal of the National Medical Association, 87, 791 794.

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81 DiMatteo, M. R. (1998). The role of the physician in the emerging health care environment. The Western Journal of Medicine, 168(5) 328 333. Dressler, W. W., Oths, K. S., & Gravlee, C. C. (2005). Race and ethnicity in public health research: Models to explain health disparities. Annual Review of Anthropology, 34, 231 252. Dogra, N., Reitmanova, N., & Carter Pokras, O. (2010). Teaching cultural diversity: Current status in U.K., U.S., and Canadian medical schools. Journal of General Internal Medicine, 25, 164 168. Earnest, M. A., Ross S. E., Moore, L., Wittev rongel, L., Moore, L. A., & Lin C. T. (2004). Use of a patient accessible electronic medical record in a practice for congestive heart failure: patient and physician experiences. Journal of the American Medical Information Association, 11 410 417. Faul, F., Erdfel der, E., Buchner, A., & Lang, A G. (2009). Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods, 41, 1149 1160 Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Powe r 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39, 175 191 Goode, T. D., Dunne, M. C., & Bronheim, S. M. (2006). The Evidence Base for Cultural and Linguistic Competency in Health Care. New York, NY: The Commonwealth Fund. Grossman, D. (1994). Enhancing your cultural competence. American Journal of Nursing, 94, 58 60. Grumbach, K., Coffman, J., Gandara, P., Munoz, C., Rosenoff, E., & Sepulveda, E. (2003). Strategies for improving the diversity of the health professions San Francisco, CA: The California Endowment. Hall, J. A. & Roter, D. L. (2002). Do patients talk differently to male and female physicians? A meta analytic review. Patient Education and Counseling 48(3) 217 224. Harris, L. E., Luft, F. C., Rudy, D. W., & Tierney, W. M. (1995). Correlates of health care satisfaction in inner city patients with hypertension and chronic renal insufficiency. Social Science and Medicine, 41, 1639 1645. Herman, K. C., Tucke r, C. M., Ferdinand, L. A., Mirsu Paun, A. M., Hasan, N. T., and Beato, C. (2007). Culturally sensitive health care and counseling psychology: An overview. The Counseling Psychologist, 35, 633 649.

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82 Hung, R., McClendon, J., Henderson, A., Evans, Y., Colqui tt, R., & Saha, S. (2007). Student perspectives on diversity and the cultural climate at a U.S. medical school. Academic Medicine, 82(2), 184 192. Joffe, S., Manocchia, M., Weeks, J. C., & Cleary, P. D. (2003). What do patients value in their hospital car e? An empirical perspective on autonomy centered bioethics. Journal of Medical Ethics, 29, 103 108. Johnson, R. L., Roter, D., Powe, N. R., & Cooper, L. A. (2004). Patient race/ethnicity and quality of patient physician communication during medical visits American Journal of Public Health, 94, 2084 2090. Kagan, S. H. (2011). Patient and family centered care is there individualized care here? Geriatric Nursing, 32(5), 365 367. Kim Godwin, Y. S., Alexander, J. W., Felton, G., Mackey, M. C., & Kasakoff, A. (2006). Prerequisites to providing culturally competent care to Mexican migrant farm workers: A Delphi study. Journal of Cultural Diversity, 13(1), 27 33. Lauver, D. R., Ward, S. E., Heidrich, S. M., Keller, M. L., Bowers, B. J., Brennan, P. F., Kirchh off, K. T., & Wells, T. J. (2002). Patient centered interventions. Research in Nursing and Health, 25, 246 255. doi: 10.1002/nur.10044 LaViest, T. A. (2005). Minority populations and health: An introduction to health disparities in the United States. San Francisco, CA: Jossey Bass. gender equality. Medical Education, 40(7), 691 696. Louka, S. (2012). Personalized medicine a tailored health care system: Challenges and opportunities. Croatian Medical Journal, 53(3), 211 213. and its treatment: A qualitative study. Journal of Health Care for the Poor and Underserved, 14(4), 566 587. Lu m, C. K., & Korenman, S. G. (1994). Cultural sensitivity training in U. S. medical schools. Academic Medicine, 69, 239 241. Majumdar, B., Browne, G., Roberts, J., & Carpio, B. (2004). Effects of cultural sensitivity training on health care provider attitu des and patient outcomes. Journal of Nursing Scholarship, 36, 161 166. May, J. (1992). Working with diverse families: Building culturally competent systems of health care delivery. The Journal of Rheumatology, 19, 46 48.

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83 Mirsu Paun, A., Tucker, C. M., He rman, K. C., & Hernandez, C. A. (2010). Validation of a provider self report inventory for measuring patient centered cultural sensitivity in health care using a sample of medical students. Journal of Community Health, 35, 198 207. doi: 10.1007/s10900 009 9212 2 Mokuau, N., & Fong, R. (1994). Assessing the responsiveness of health services o f ethnic minorities of color. Social Work in Health Care, 20, 23 34. Morello, C. & Mellnik, T. (2012, May 17). Census: Minority babies are now majority in United Stat es. The Washington Post. Retrieved from: http://articles.washingtonpost.com/2012 05 17/local/35458407_1_minority babies census bureau demographers whites. National Center for Health Statistics. (2006). Health, United States, 2006 with Chartbook on Trends in the Health of Americans. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. National Center for Health Statistics (2007). Health, United States, 2007 with Chartbook on Trends in the Health of Amer icans. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Organisation for Economic Co operation and Development. (2011). Health at a Glance 2011: OECD Indicators. Paris, France: Organisation for Eco nomic Co Operation and Development. Parks, G. S., & Rachlinski, J. J. (2010). Implicit bias, election '08, and the myth of a post racial America. Florida State University Law Review, 37, 659 716. Pierce, R. L. (1997). African American cancer patients and culturally competent care. Journal of Psychosocial Oncology, 15, 1 7. Pleis, J.R., & Lethbridge ejku, M. (2006). Summary health statistics for U.S. adults: National health interview survey, 2005 National Center for Health Statistics. 10(232). Availabl e at http://www.cdc.gov/ nchs/nhis.htm. Rapp, D. E. (2006). Integrating cultural competency in the medical curriculum. Medical Education, 40(12), 704 710. Rew, L., Becker, H., Cookston, J., Khosropour, S., & Martinez, S. (2003). Measuring cultural awaren ess in nursing students. Journal of Nursing Education 42(6) 249 257.

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84 Rose, L. E., Kim, M. T., Dennison, C. R, & Hill, M. N. (2000). The contexts of adherence for African Americans with high blood pressure. Journal of Advanced Nursing, 32, 587 594. Rot er, D. L., Hall, J. A., & Aoki Y. (2002). Physician gender effects in medical communication: a meta analytic review. Journal of the American Medical Association 288(6) 756 840. Roysircar, G. (2003). Counselor awareness of own assumptions, values, and bi ases. In C. Roysircar, P. Arredondo, J. N. Fuertes, J. G. Ponterotto, & R. L. Toporek (Eds.), Multicultural counseling competencies 2003: Association for Multicultural Counseling arid Development (pp. 18 36). Alexandria, VA: Association of Multicultural Co unseling and Development. Salas Lopez, D., Holmes, L., Mouzon, D. M., & Soto Greene, M. (2007). Cultural competency in New Jersey: evolution from planning to law. The Journal for Health Care for the Poor and Underserved, 18, 34 43. Schim, S.M., Doorenbos A.Z., Miller, J., & Benkert, R. (2003). Development of a Cultural Competence Assessment instrument. Journal of Nursing Measurement 11(1) 29 40. Schulman, K. A., Berlin, J. A., Harless, W., Kerner, J. F., Sistrunk, S., Gersh, B. J., Dube, R., Taleghan i, C. K., Burke, J. E., Williams, S., Eisenberg, J. M., & recommendations for cardiac catheterization. New England Journal of Medicine, 340, 618 626. Sequist, T. D., Fitzmaurice, G. M., Mar shall, R., Shaykevich, S., Safran D. G., Ayanian, J. Z. (2008). Physician performance and racial disparities in diabetes mellitus care. Archives of Internal Medicine, 168(11), 1145 1151. Spithoven, A. H. G. M. (2009). Why U.S. health care expenditure and ranking on health care indicators are so different from Canada's. International Journal of Health Care Finance and Economics, 9(1), 1 24. Stanfield, K. C. (2011). Persistent racial disparity, wealth and the economic surplus as the fund for reparations in the United States. Journal of Economic Issues, 45(2), 343 352. doi: 10.2753/JEI0021 3624450211 Suhonen, R., Gustafsson, M., Katajitso, J., Vlimki, M., & Leino Kilpi, H. (2009). Journal of Advanced Nursing, 66, 1035 1046.

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85 Tabachnick, B. G. & Fidell, L. S. (2007). Using Multivariate Statistics Boston, MA: Pearson. Academic Medicine, 78(6), 570 576. The Associated Press ( 2012, October 27). AP poll: Majority harbor prejudice against blacks. NBC News. Retrieved from: www.nbcnews.com. The Joint Commission for the Institute of Family Centered Care. (2010). Advancing effective communication, cultural competence, and patient a nd family centered care: A roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission for the Institute of Family Centered Care. Thom, D. H., Tirado, M. D., Woon, T. L., & McBride, M. R. (2006). Development and evaluation of a cultural competency t raining curriculum. BME Medical Education, 6(38). Accessed from: http://www.biomedcentral.com/1472 6920/6/38 Thomas A., Phillips, A., Donnelly, R., & Tak Piech, C. (2010). Comparative effectiveness, personalized medicine and innovation: The path forward. Pharmacoeconomics, 28(10), 923 30. Tucker, C. M., Daly, K. D., & Herman, K. C. (2010). Customized multicultural health counseling: Bridging the gap between mental and physical health for racial and ethnic minorities. In J. G. Ponterotto, C. M. Casas, L. M Suzuki, & C. M. Alexander (eds.), Handbook of Multicultural Counseling, Third Edition (pp. 505 516). Tucker, C. M., Herman, K. C., Ferdinand, L. A., Baily, T. R., Lopez, M. T., Beato, C., Adams, D., & Cooper, L. L. (2007). Providing patient centered cu lturally sensitive health care: A formative model. The Counseling Psychologist, 35, 679 705. Tucker, C. M., Herman, K. C., Pedersen, T. R., Higley, B., Montrichard, M., & Ivery, P. (2003). Cultural sensitivity in physician patient relationships: Perspecti ves of an ethnically diverse sample of low income primary care patients. Medical Care, 41(7), 859 870. Tucker, C. M., Marsiske, M., Rice, K.G., Nielson, J. J., & Herman, K. C. (2011). Patient centered culturally sensitive health care: Model testing and r efinement. Health Psychology 30, 342 350. Tucker, C. M., Nghiem, K. N., Marsiske, M., & Robinson. (I n press). Validation of a patient centered culturally sensitive health care provider inventory using a national sample of adult patients

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86 U. S. Census B ureau. (2012) American Fact Finder. Retrieved from: http://factfinder2.census.gov/faces/nav/jsf/pages/index.xhtml U. S. Department of Health and Human Services. (2000). Healthy People 2010, 2 nd ed. Washington, DC: U.S. Government Printing Office, 2000. Av ailable at: http://www.healthypeople.gov/2010/Publications/. Accessed October 30, 2012. U. S. Department of Health and Human Services (2005). Transforming the face of health professions through cultural and linguistic competence education: The role of the HRSA centers of excellence Washington, DC: United States Government Printing Office. U. S. Department of Health and Human Services. (2008). Committee on National Health Promotion and Disease Prevention Objectives for 2020. Washi ngton, DC: U.S. Government Printing Office, 2008. Available at: http://www.healthypeople.gov/2020/about/advisory/Reports.aspx. Accessed October 30, 2012. U. S. Department of Health and Human Services, Health Resources and Services Administration. (2001). Cultural competence works: Using cultural competence to improve the quality of health care for diverse populations and add value to managed care arrangements. Merrifield, VA: HRSA Information Center. U. S. Department of Health and Human Services, Office o f Minority Health. (2001). National Standards for Culturally and Linguistically Appropriate Services in Health Care: Final Report. Washington, DC: U. S. Government Printing Office. Washington, D. L., Bowles, J., Saha, S., Horowitz, C. R., Moody Ayers, S. Brown, A. F., Stone, V. E., & Cooper, L. A. (2008). Transforming clinical practice to eliminate racial ethnic disparities in healthcare. Journal of General Internal Medicine, 23(5), 685 691. doi: 10.1007/s11606 007 0481 0 Whaley, A. L. (2008). Cultural sensitivity and cultural competence: toward clarity of definitions in cross cultural counseling and psychology. Counseling Psychology Quarterly, 21, 215 222. doi: 10.1080/09515070802334781 Whitla, D. K., Orfield, G., Silen, W., Teperow, C., Howard, C., & Reende, J. (2003). Educational benefits of diversity in medical school: A survey of students. Academic Medicine, 78(5), 460 466. Williams, D. R., & Sternthal, M. (2011). Understanding racial ethnic disparities in health: Sociological contributions. Journa l of Health and Social Behavior, 51(S,) S15 S27. doi: 10.1177/0022146510383838

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87 BIOGRAPHICAL SKETCH Manuel Lopez has over twelve years of experience conducting research on culturally sensitive health care and health promotion programs that are aimed at i mproving the health outcomes of culturally diverse primary care patients with the ultimate aim of reducing health disparities. As a research director on the Behavioral Medicine Research team at the University of Florida, his research experience has centere d on promoting the engagement in healthy exercise and diet behaviors and reducing the engagement in health risk behaviors for low income peop le from diverse backgrounds by addressing unique cultural considerations that affect these behaviors and their associated outcomes. He has supervised the work of undergraduate research assistants and engaged in the development, implementation, and study of low cost novel health empowerment interventions in community based settings. His clinical interests center on promoting health and wellness of culturally diverse clients, and he has also provided crisis intervention counseling for the past five years by serving as a volunteer counselor for the Alachua County Crisis C enter, where he has counseled people on site as they experience various life crises. He was born and raised in Miami, Florida, a veritable cultural melting pot where he became interested in un derstanding cultural differences. He graduated Summa Cum Laude from the University of Florida with undergraduate degrees in psychology and a nthropology in the spring of 2005 and has also provided service to numerous educational organizations such as the U where he served as co chair of the Special Events Committee and served as chair of the Committee. Hi s future career interests are to conduct translational research aimed at

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88 improving the cultural sensitivity of health care systems and providers and promote cultural sensitivity skills training in medical education with the overarching goal of reducing hea lth disparities.