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Examination of Medication Adherence among African-American Low-Income Primary Care Hypertensive Patients Using the Patient-Centered Culturally Sensitive Health Care Model

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Examination of Medication Adherence among African-American Low-Income Primary Care Hypertensive Patients Using the Patient-Centered Culturally Sensitive Health Care Model

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African American culture ( jstor )
African Americans ( jstor )
African culture ( jstor )
Health care industry ( jstor )
Hypertension ( jstor )
Medication adherence ( jstor )
Medications ( jstor )
Patient satisfaction ( jstor )
Questionnaires ( jstor )
Research studies ( jstor )
City of Miami ( local )

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EXAMINATION OF MEDICATION ADHERENCE AMONG AFRIC AN-AMERICAN
LOW-INCOME PRIMARY CARE HYPERTENSIVE PATIENTS USING THE
PATIENT-CENTERED CULTURALLY SENSITIVE HEALTH CARE MODEL














By

TAMIKA R. BAILEY


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA


2006
































Copyright 2006

by

Tamika R. Bailey




































I dedicate this work to my mother Patricia O. Bailey who taught me to be independent
and to reach for the stars
















ACKNOWLEDGMENTS

First of all, I would like to especially extend my sincerest thanks and appreciation

to Dr. Carolyn M. Tucker, my mentor and committee chair, for her expertise and her

ongoing encouragement and support. Her commitment to excellence and dedication to the

community and the field of psychology will leave a lasting impression on me both

personally and professionally. I would also like to thank my committee members, Drs.

Allyson Hall and Mary Fukuyama, as well as Dr. Frederick Desmond, for their support

and for extending their expertise that led to completion of my proj ect. In addition, I want

to thank Khanh Ngheim and Allison Poimboeuf for providing support for completion of

this document.


I extend my gratitude to family members and close friends in and outside of

Gainesville, FL who have offered their friendship, time, support and wisdom. I would

also like to thank my brother Jibril keeping me young at heart even through the difficult

times. Special thanks go to Anca Mirsu Paun and other members of Dr. Tucker' s

Behavioral Medicine team, for their advice, support and mentorship. Last, but especially

not least, I thank my parents, Patricia O. Bailey and Roberto A. Bailey, for their lifelong

unconditional love, and unshakable support and faith in me.




















TABLE OF CONTENTS


IM Le

ACKNOWLEDGMENT S .............. .................... iv


LI ST OF T ABLE S ............ ............ .............. vii...


LIST OF FIGURES ............ ............ ..............viii..


AB STRAC T ................ .............. ix


CHAPTER


1 INTRODUCTION ................. ...............1.......... ......


Background ................. ...............1.................
Patient Satisfaction .............. ...............3.....
Cultural Sensitivity .............. ...............4.....
Interpersonal Control ................. ...............5.......... ......
Current Study ................. ...............6.......... ......

2 LITERATURE REVIEW ................. ...............9................


Medication Adherence and Hypertension .............. ...............10....
Patient Satisfaction ......................... .. ...... ...............1
Patient Satisfaction and Health Care Quality ................. ......... ................14
Patient Satisfaction as a Predictor of Medication Adherence ................... ..........16
Cultural Sensitivity ................. ...............17.......... .....
Culture and Health Care .............. .... ...... .... ...... .............. ............1
Cultural Sensitivity as a Predictor of Patient Satisfaction ................. ................19
The Patient-Centered Culturally Sensitive Health Care Model ..........................21
Interpersonal Control as a Predictor of Patient Satisfaction ................. ................. .28

3 METHODS .............. ...............35....


Participants .............. ...............35....
Instruments .................. ...... .............3

Demographic Data Questionnaire .............. ...............36....
Marlowe-Crown Social Desirability Scale ................. ...._.._ ................. 37
Medical Data Sheet. ................... .... ... ...... ... ...............37....
Tucker Culturally Sensitive Health Care Inventory .............. .....................3











Interpersonal Spheres of Control Scale (ICS) ................... ...............4
Patient Satisfaction ................ ...............40.................
Medication Adherence............... ...............4
Procedure ................ ...............42.................

4 RE SULT S .............. ...............46....


Descriptive Data for Main Study Variables............... ...............4
Preliminary Data Analyses ................ ....... ....... ...............4
Data Analyses to Test the Two Hypotheses in Thi s Study............_._. .........._._. ...47
Data Analyses to Test the Two Research Questions in This Study.............._._. .........49

5 DI SCUS SSION ..........._._ ....._. ._ ...............5 5....


Summary of Findings .............. ......... ..... .... ............5
Interpretation and Implications of the Research Findings ..........._.._.. ........._..__....5 8
Study Limitations and Future Research Direction............... ...............6
Conclusion ..........._.._ ....... ...............65.....

APPENDIX


A DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ) .............. .....................6

B MARLOWE-CROWNE SOCIAL DESIRABILITY SCALE (M-C SDS)................69

C MEDICAL DATA SHEET (MDS) .............. ...............71....

D TUCKER CULTURALLY SENSITIVE HEALTH CARE INVENTORY-
AFRICAN AMERICAN (T-CUSHCI-AA) .............. ...............74....

E INTERPERSONAL SPHERES OF CONTROL SCALE (ICS) ............... ...............76

F PATIENT SATISFACTION QUESTIONNAIRE (P SQ- 13) ................. ................. 77

G MORISKY MEDICATION ADHERENCE SCALE (MMA) ................. ................78

H STUDY PARTICIPATION INVITATION LETTER ................. ............ .........79

I INFORMED CONSENT FORM............... ...............81..


J STUDY QUESTIONNAIRE PACKET COVER LETTER ................. ................. .89

LIST OF REFERENCES ................. ...............91................

BIOGRAPHICAL SKETCH .............. ...............99....

















LIST OF TABLES


Table pg

3-1 Demographic and descriptive characteristics of the participant sample. .................44

4-1 Maj or variables of interest in this study. ................ ...............51........... .

4-2 Maj or variables of interest by age categories ................. ................ ......... .5 1

4-3 Maj or variables of interest by gender ................. ...............52..............

4-4 Maj or variables of interest by education level ................ .......... ..................52

4-5 Maj or variables of interest by income level ................ ...............53........... .

4-6 Correlations between all study variables of interest including social desirability. ..53

4-7 Hierarchical regression predicting patients' health care satisfaction (PSQ-18).......54

4-8 Hierarchical regression predicting patients' self-reported medication adherence
(M M A). ............. ...............54.....

















LIST OF FIGURES


figure pg

1-1 The patient-centered culturally sensitive health care model (pc-cshc) ......................8

4-1 Mean medication adherence as a function of number of years with hypertension
diagnosis and symptom status ................ ...............54................
















Abstract of thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

EXAMINATION OF MEDICATION ADHERENCE AMONG AFRIC AN-AMERICAN
LOW-INCOME PRIMARY CARE HYPERTENSIVE PATIENTS
USINTG THE PATIENT-CENTERED CULTURALLY SENSITIVE
HEALTH CARE MODEL

By

Tamika R. Bailey

August 2006

Chair: Carolyn M. Tucker
Major Department: Psychology

Utilizing the Patient-Centered Culturally Sensitive Health Care Model (PC-CSHC),

this study's obj ectives were to examine African-American low-income hypertensive

patients' levels of perceived cultural sensitivity of their health care experiences and

interpersonal control as predictors of their health care satisfaction, and to examine these

patients' health care satisfaction as a predictor of their self-reported medication

adherence. This study also examined the associations of the participating patients' age,

education level, and gender with their level of perceived cultural sensitivity of their

health care providers' behaviors and attitudes and their levels of interpersonal control and

health care satisfaction. It also examined the associations of participating patients'

symptom status and number of years since receiving a hypertension diagnosis with their

self-reported medication adherence.









Participants in this study were 88 African American patients who utilized one of

two community-based primary care clinics and who were recruited through clinic

mailings and recruitment posters displayed in the clinics. Recruited patients were mailed

an invitation packet that included an informed consent form to be signed and returned.

Patients who returned these forms signed were each mailed a questionnaire packet to be

completed and returned to the researchers in a provided pre-addressed stamped envelope.

Hierarchical multiple regression analyses revealed a significant positive association

between patients' levels of perceived cultural sensitivity of their health care providers'

behaviors and attitudes and patients' health care satisfaction, and it revealed

nonsignificant associations between patients' levels of interpersonal control and health

care satisfaction, and between their levels of health care satisfaction and self-reported

medication adherence. A multivariate analysis of covariance to examine age, gender, and

education level differences in patients' levels of perceived cultural sensitivity,

interpersonal control, health care satisfaction and self-reported medication adherence

revealed no significant multivariate effects. However, an analysis of variance to examine

differences in level of self-reported medication adherence in association with symptom

status and number of years since receiving a hypertension diagnosis revealed a significant

status x years since diagnosis interaction effect. Examination of this effect revealed

different and inconsistent patterns of medication adherence over time for the patients with

and those without symptoms of hypertension.

The limitations, implications, and conclusions of this study are presented. A maj or

conclusion was that results of this study provide support for patient-centered culturally

sensitive health care and that counseling psychologists are trained to provide this care.















CHAPTER 1
INTTRODUCTION

Background

The impact of hypertension on the American population is significant. It has

recently been estimated that 50 to 65 million Americans are currently diagnosed with

Hypertension or high blood pressure (American Heart Association [AHA], 2006;

Chobanian et al., 2003; Report of the Joint National Committee on Prevention, Detection,

Evaluation, and Treatment of High Blood Pressure [JNC-7] (2004). Untreated and

uncontrolled hypertension or high blood pressure (HBP) is a maj or risk factor for

cardiovascular disease (CVD), heart disease, kidney disease, and stroke (Chobanian et al.,

2003;National Heart, Lung, and Blood Institute [NHLBI], 2005; JNC-7, 2004). CVD is

the leading cause of death in the United States (AHA, 2006) and Coronary heart disease

(CHD) is a maj or killer of Americans. According to the AHA (2006), it is estimated that

403.1 billion dollars will be spent this year in CVD-related health care.

The current research study focused on African-American hypertensive patients. In

the case of African-Americans, hypertension poses significantly high health risks as they

are disproportionately affected by this illness. Specifically, African-Americans have the

highest hypertension prevalence rates compared to other racial/ethnic groups (CDC,

2005a; Hajj ar & Kotchen, 2003). Accordingly, African-Americans have the highest CVD

prevalence rates (AHA, 2006), and the leading cause of death for African-Americans is

CVD (American Heart Association (AHA, 2006). In addition, African-Americans have










higher rates of end stage renal disease (AHA, 2006) than European Americans and the

highest rates of stroke-related deaths (CDC, 2005b).

Although African-Americans with hypertension have a greater awareness about

their hypertensive status and are more likely to be receiving current treatment for their

hypertension compared to non-Hispanic Whites and Mexican Americans, African-

Americans have low hypertensive control rates. (Bosworth et al., 2006;CDC,

2005b;Hajj ar & Kotchen, 2003). Blood pressure control has been associated with

medication adherence and African-Americans who have poor control of their blood

pressure are more likely to be nonadherent with their medication (Bosworth et al., 2006).

The disparity in hypertension-related prevalence, blood pressure control rates and death

rates between African-Americans and other racial/ethic groups also prompted the current

study to determine what factors in the health care experiences of these patients may be

related to their medication adherence.

The JNC-7 (2004), a report by the National Heart, Lung, and Blood Institute which

outlines hypertension preventive and management guidelines for health care providers to

utilize, states that along with recommended lifestyle changes which include healthier

dietary intake, exercise and limited alcohol use, antihypertensive medications are usually

prescribed to control hypertension. Adhering to life-style changes as well as

pharmacological treatments is essential to controlling hypertension. Some of the

hypertensive medications noted in the report, which may be used at times in multi-drug

combination therapy, include diuretics such as Thiazide, Beta blockers, Calcium channel

blockers, ACEls, and ARBs.










Unfortunately, many individuals who are aware of their hypertensive status do not

follow these guidelines. Specifically, uncontrolled and untreated hypertension continues

to be a significant health risk partly due to nonadherence to hypertensive medication.

Non-adherence to hypertensive medication has been related to decreased blood pressure

control and increased risk of hypertension-related diseases (Morisky, Lawrence &

Levine, 1986). The current study examined the following factors that could be related to

the medication adherence of low income African-American hypertensive patients using a

culturally sensitive model: patient satisfaction, cultural sensitivity, and interpersonal

control .

Patient Satisfaction

There is evidence that medication adherence is related to patient satisfaction with

their health care provider (Murphy, Roberts, Martin, Marelich, & Hoffman, 2000;

Roberts, 2002). It has also been found that African-Americans who have negative

encounters or perceptions of their providers report being less likely to adhere to their

medication regimen (Lukochek, 2003). Specifically, African-Americans who negatively

perceive their interactions with their health care providers and distrust their health care

providers and prescribed medicines are more likely to be nonadherent to their medication

(Lukochek, 2003). This suggests that satisfaction with the patient-health care provider

relationship is an important determinant of medication adherence in African-Americans.

Further evidence indicating an important link between a patient' s satisfaction with

patient-provider relation and the patients' medication adherence level comes from the

JNC 7 Report. This report emphasizes that patients' health care motivation and

experiences are significant predictors of treatment adherence (JNC-7, 2004). Specifically,

this report cites research indicating that hypertensive patients' communication with and









relationship with their health care providers (which ideally should be built on "trust,"

"respect," "empathic" communication that promotes comfort, and "customer service

skills") impact these patients' level of motivation to adhere to their treatment (JNC-7,

2004, p.61). Motivation to be adherent to one's medication regimen and perceived

control over one's medication adherence have both been found to be factors in the self-

reported medication adherence levels of African-American renal disease (Tucker et al.,

2001). These findings provide support for the focus of an important aspect of the current

study of examining the relationship between patient satisfaction with their health care

provider and medication adherence among hypertensive African-American patients.

Cultural Sensitivity

Recently, increasing the cultural sensitivity of health care providers has become a

priority. As the population of the United States becomes increasingly ethnically and

racially diverse (United States Census Bureau, 2000), the need to provide health care that

is appropriately culturally sensitive is vital. This need has been further heightened by the

highly cited race and income related health disparities among Americans with regard to

health, access to health care, satisfaction with the quality of health care and treatment

outcomes disparities that disadvantage ethnic minorities and the poor (e.g. Agency for

Healthcare Quality and Research [AHRQ], 2003; Institute of Medicine [IOM], 2002;

United States Department of Health and Human Services [DHHS], 2000).

Furthermore, recent findings indicate that the quality of care that minorities

experience may be related to health care provider culturally-biased and discriminatory

practices that could result in inadequate treatment and care (Schulman et al., 1999).

Additionally, the quality of the communication process experiences between minority

patients and health care providers have been observed and have been reported by









minority patients to be unequivocal compared to the experiences of European American

patients' (Collins et al., 2001; Cooper-Patrick et al., 1999;Johnson, Roter, Powe, &

Cooper, 2004). Minority patients report perceiving that their race/ethnicity is related to

culturally insensitive health care provider communication and interpersonal

characteristics and is related to the quality of care they receive (Collins et al., 2001).

Moreover, minority patients who perceive that they are being discriminated against are

more likely to prefer and be satisfied with race-concordant health care providers (Chen,

Fryer, Philips, Wilson, & Pathman, 2005). In fact, there is evidence that race-discordance

between patients and providers is related to decreased satisfaction with health care

received, and that race-concordance between patients and providers is related to positive

communication processes, greater patient participation, and higher reports of patient

satisfaction (Cooper et al., 2004). Additionally, minority patients are more likely to

report dissatisfaction with their care when they perceive that this care is related to their

race/ethnicity (Collins, et al., 2001); furthermore, these patients are more likely to be

satisfied with race concordant health care providers (Chen et al., 2005).

Interpersonal Control

Recently, some researchers have related patients' dissatisfaction with their health

care to their perceived lack of personal control in both the health care process as well as

in their interpersonal interactions and communication with their health care providers.

Evidence suggests that patients prefer more patient-centered, collaborative and

participatory health care interactions with their health care providers (Roter et al., 1996;

Street, Krupat, Bell, Kravitz, & Haidet, 2003). However, health care providers often are

more directive and utilize less patient-centered approach when they communicate with

minority and African-American patients (Roter et al., 1996; Johnson et al., 2004). In light









of these findings, it is not surprising that some minority patients report that they are less

inclined to disclose illness or treatment issues with their providers (Collins et al., 2001).

Recently, empowerment interventions have been advocated by some researchers as an

approach to encourage disenfranchised groups, such as low income minorities, to

increase their sense of interpersonal control and power in various social contexts

(Rappaport, 1987; Solomon, 1976). Such empowerment interventions could be utilized as

a strategy for increasing minority patients' involvement in health promoting activities.

Current Study

The current research study, which is part of a larger federally-funded study,

approached the study of medication adherence in African-American hypertensive patients

by utilizing a culturally sensitive health care model called the Patient-Centered Culturally

Sensitive Health Care (PC-CSHC) model. The PC-CSHC model was used to examine the

medication adherence of low-income African-American hypertensive patients in hopes of

answering the calls for culturally sensitive and evidence-based research models for

understanding health care disparities. Specifically, this study (a) examined African-

American low-income hypertensive patients' level of perceived interpersonal control and

level of perceived cultural sensitivity in health care experienced with their health care

provider as predictors of their perceived health care satisfaction, and (b) examined these

patients' perceived health care satisfaction as a predictor of their medication adherence

(Figure 1-1).

The following hypotheses were tested:

Hypothesis 1: African-American low-income hypertensive patients' levels of

perceived cultural sensitivity in health care experienced with their health care provider

(i.e., health care provider behaviors/attitudes) and perceived interpersonal control will









have significant positive associations with their levels of health care satisfaction (i.e.,

patients' satisfaction with their health care providers communication and interpersonal

manner combined).

Hypothesis 2: African-American low-income hypertensive patients' levels of health

care satisfaction (i.e., satisfaction with health care providers' communication and

interpersonal manner combined) in association with patients' levels of perceived cultural

sensitivity in health care experienced with their health care provider(i.e., health care

provider behaviors/attitudes) and perceived interpersonal control, will significantly

predict patients' levels of self-reported medication adherence.

In addition to the above hypotheses, the following research questions have been

addressed:

Research question 1: Are there significant age, education level, and gender

differences in African-American low-income hypertensive patients' levels of perceived

cultural sensitivity in the health care they experienced with their health care provider (i.e.,

health care provider behaviors/attitudes), perceived interpersonal control, self-reported

medication adherence, and health care satisfaction?

Research question 2: Are there significant differences in African-American low-

income hypertensive patients' levels of self-reported medication adherence in association

with their number of years since receiving a hypertension diagnosis and symptom status

(i.e., symptomatic versus asymptomatic status)?






























Figure 1-1. The patient-centered culturally sensitive health care model (pc-cshc)















CHAPTER 2
LITERATURE REVIEW

The Medical Field's Definition of Hypertension
According to the medical field, Hypertension, or high blood pressure, is defined as

having a systolic blood pressure (SBP) of 140 mm Hg or higher or a diastolic blood

pressure (DBP) of 90 mm Hg or higher (JNC-7, 2004;NHLBI, 2005). The SBP is the

exerted pressure on the arterial walls when the heart contracts and the DBP is the exerted

pressure on the arterial walls when the heart relaxes. High blood pressure results from an

excessive amount of pressure exerted on the arterial walls when blood passes through.

Hypertension is diagnosed after at least two separate occasions or visits in which a

patient' s blood pressure readings averages at or above 140 SBP and/or 90 DBP (JNC-7,

2004).

Furthermore, there are three classifications of hypertension related to different

causal factors: "white coat hypertension," "primary/essential hypertension," and

"secondary hypertension." "White coat hypertension" is the direct result of the "white-

coat effect" which occurs when patients are hypertensive only when getting their blood

pressure checked during their doctor's visit (JNC-7, 2004). "Primary/essential

hypertension" is hypertension in which the cause is not known. "Secondary

hypertension" is hypertension that results from another primary medical condition or

from taking a specific medication. In addition, the severity level of hypertension is

differentiated according to two "stages (JNC-7,2004)." Stage one consists of having a

SBP between 140 and 159 or a DBP between 90 and 99. Stage two consists of having a









SBP greater than or equal to 160 or a DBP greater than or equal to 100. The stage of

hypertension that a patient is in determines the type of medication treatment they receive

(JNC-7, 2004).The present research study utilized African-American patients with both

stage one and stage two, primary/essential and secondary hypertension.

Medication Adherence and Hypertension

The Healthy People 2010 (DHHS, 2000) report produced by the United States

Department of Health and Human Services (DHHS) that contains information for

improving the health of Americans includes health obj ectives for our nation. These

obj ectives include lowering hypertension disease rates and promoting effective treatment

and control of hypertension. Specifically, these obj ectives include reducing the

proportion of adults with high blood pressure from 28% to 16%, increasing the

proportion of adults with high blood pressure whose blood pressure is under control from

18% to 50%, and increasing the proportion of adults with high blood pressure who are

taking action through healthy lifestyle changes to help control their blood pressure from

82% to 95%.

It is noteworthy that there are racial/ethnic disparities in the incidence and

management of blood pressure (CDC, 2005a). Minority Americans are at greater risk for

hypertension and hypertension-related risks compared to maj ority Americans (CDC,

2005a,b; AHA, 2006; Chobanian et al., 2003; Hajjar & Kotchen, 2006). African-

Americans in particular have poor blood pressure control despite being more likely to

report that they are in current treatment for hypertension (Burt, et al., 1995; CDC,

2005b).

In addition to race/ethnicity, there are several other risk factors associated with

hypertension and blood pressure control. These risk factors include age, gender,









socioeconomic status, and disease comorbidity (JNC-7, 2004). With regard to age, older

adults are at increased risk for hypertension and hypertension-related complications such

as CVD, stroke or death (CDC, 2005b; Chobanian et al., 2003; JNC-7, 2004).

Furthermore, older adults are at increased risk of having these hypertension-related

complications despite receiving treatment (Hajj ar & Kotchen, 2003). In terms of gender,

it has been reported in the past that males higher age adjusted prevalence rates of

hypertension compared to females (Burt et al., 1995); but more recently, it has been

reported that both males and females have similar prevalence rates (Hajj ar & Kotchen,

2006). However, women with hypertension as compared to their male counterparts may

have additional health complications related to their hypertension status (JNC-7, 2004).

Moreover, adults with comorbid diseases such as diabetes and ischemic heart disease in

addition to hypertension are at increased risk for hypertension- and medication-related

complications (Chobanian et al., 2003; JNC-7, 2004). Due to health care system-related

barriers and access issues, patients from low socioeconomic levels with chronic

conditions such as hypertension report being less likely to have treatment for or control of

their illness (Becker & Newsom, 2003).

Although effective anti-hypertensive medical therapy involves adhering to health-

promoting lifestyle changes such as dietary, exercise and weight management as well as

anti-hypertensive medication, the focus of this present study will be on the factors that

influence anti-hypertensive medication adherence. Medication adherence has been related

to blood pressure control, and decreased blood pressure control has been related to

increased health risks associated with hypertension (Bosworth et al., 2006; Morisky,

Green, & Levine, 1986). Research to understand and promote anti-hypertensive









medication adherence is warranted considering that antihypertensive medications often

control blood pressure when the other aspects of medical therapy for this problem are

ineffective.

Medical adherence, also commonly referred to as medical compliance, is defined as

"the extent to which a person's behavior taking medication, following a diet, and/or

executing lifestyle changes corresponds with agreed recommendations from a health

care provider (World Health Organization [WHO], 2003, pg. 3)." Patients are seen as

adhering well to their medication regimen if they report taking 80% of their medication

(Morisky et al., 1986). According to recent medication adherence literature reviews,

medication adherence is related to dosage frequency, type of medication prescribed,

symptom status; disease type and duration; demographic variables such as age, race and

gender; medication side effects, and health care systemic issues related to medication

costs, health care access and provider-patient interactions (Iskedij an et al., 2002; Krousel-

Wood, Thomas, Munter, & Morisky, 2004).

Nonadherence to one's medication regimen is reported to be linked to the perceived

quality of patient-health care provider interactions, particularly for African-Americans.

For some African-American hypertensive patients, nonadherence to antihypertensive

medications may be related to negative attitudes about taking prescribed medications and

preferences for alternative or complementary treatments for their hypertension stemming

from their health beliefs (Lukoschek, 2003). In addition, African-American hypertensive

patients' cultural and nonbiomedical expectations and beliefs regarding the duration of

the medication regimen or the potential for a cure from prescribed antihypertensive









medication may be related to their medication adherence level (Ogedegbe, Mancuso, &

Allegrante, 2004).

The symptom level of hypertensive patients may influence their medication

adherence. Nicknamed "the silent killer," hypertension is often associated with an

absence of observed symptoms. Consequently, some patients, due to the asymptomatic

characteristics of hypertension, may or may not adhere to their medication regimen

(Lukochek, 2003; Heurtin-Roberts, 1993;Wilson et al., 2002). Nonadherence related to

asymptomatic status could be related to simply forgetting to take their prescribed

medicine(s). In addition, some African-American patients, due to their health beliefs,

view hypertension as a symptomatic and episodic illness, and consequently, they take

their medications only when they experience physical symptoms (Heurtin-Roberts, 1993;

Lukochek, 2003; Ogedegbe, et al., 2004).

Ogedegbe, Harrison, Robbins, Mancuso, & Allegrante (2004) examined the

barriers and facilitators of anti-hypertensive medication adherence in African-American

primary care hypertensive patients. Patients in focus groups were asked the following

questions: 1) What difficulties do you have in taking your blood pressure medications as

prescribed by your doctor, 2) What situations make it hard for you to take your blood

pressure medications as prescribed by your doctor?, 3) What situations make it easy for

you to take your blood pressure medications as prescribed by your doctor?, and 4) What

are the skills that make it necessary for you to take your blood pressure medications as

prescribed? It was found that barriers to medication adherence included the following: (a)

forgetfulness (due to old age, rushing or busy schedules, and being away from home), (b)

patient misconceptions about hypertension and hypertension health risks, (c) negative










perceptions about their antihypertensive medications (e.g., negative attitudes about taking

medications and about their side effects), (d) medication regimen issues (e.g., medication

dosage frequency, and number of medications taken, and cost of needed medications), (e)

denial of their hypertension diagnosis, and (f) logistical barriers related to prescription

refi11s issues (e.g., difficulty getting medication refi11s or getting an appointment to get

refi11s, and running out of medication) and related to taking medications outside of the

home.

Ogedegbe, Harrison et al., (2004) also identified the following facilitators of

medication adherence in African-American primary care patients: (a) reminder

interventions (such as pillboxes, phone calls, taking blood pressure readings, being at

home), (b) increased knowledge about hypertension and associated medications, (c)

doctor-patient communication that involved physician-implemented patient education

about hypertension and associated medications, (d) patient involvement in their care

(assertiveness, asking doctor questions), (e) having a routine for taking their medications,

and (f) having social support networks.

In sum, existing literature suggests or implies that there are multiple factors

associated with medication adherence behavior. The present research examined three of

these factors--patient satisfaction, cultural sensitivity in health care experiences with

health care providers, and patient interpersonal control.

Patient Satisfaction

Patient Satisfaction and Health Care Quality

The definition of patient satisfaction that will be utilized is Donabedian's (1980)

proposition that a patient's satisfaction with health care is defined as a component of

quality of care based on the judgments, values, and expectations patients have about their









interactions with their health care provider and about the care they receive. So essentially,

patient satisfaction is a measure of the quality of health care that a patient perceives

she/he is receiving from their health care provider (s) or health care establishment

involved with their care.

According to the quality of care model set forth by Wilde, Starrin, Larsson, &

Larsson, (1993) patient perceived satisfactory health care is based on four quality of care

dimensions: (1) medical-technical competence of health care providers; (2) physical-

technical conditions of the service organization; (3) identity-orientation of the health care

providers' attitudes and behaviors; and (4) the socio-cultural atmosphere of the service

organization (Wilde et al., 1993).

In Wilde et al.'s (1993) model, both medical-technical competence of health care

providers and physical-technical conditions of the service organization are the

dimensions of care related to the traditional model of care in which the best knowledge

and technical resources are utilized to provide the most appropriate and competent

treatment for patients. An indicator of medical-technical competence is receiving

competent treatment, diagnosis, and examination services from a qualified health care

provider. Furthermore, examples of ideal physical-technical conditions that promote

quality care include a care environment that promotes comfort, safety, and cleanliness, as

well as one that provides the appropriate equipment to provide competent care.

Furthermore, according to Wilde et al. (1993), both the identity-orientation of the

health care providers' attitudes and behaviors and the socio-cultural atmosphere of the

service organization are dimensions related to the characteristics of the psychosomatic

model of care a model that is characterized by health care providers who treat patients









with humanity and a service organization that resembles a home. The identity-orientation

of health care providers that indicate quality of care include viewing their patients as

persons, providing respectful treatment of their patients, demonstrating honesty, trust and

empathy in interactions with patients and collaborating with patients on their medical

care. Examples of characteristics of the socio-cultural atmosphere (e.g., a health care

clinic environment) that promote patient satisfaction include a "home-like environment"

in the health care organization and nonconformity to a routine that undervalues a

patient' s needs and wishes.

Patient Satisfaction as a Predictor of Medication Adherence

The current study examined the relationship between medication adherence and

patient satisfaction. There is empirical evidence of a relationship between patient

satisfaction and medication adherence in certain patient populations. For example, studies

on the medication adherence of adults with HIV have shown that among these patients,

dissatisfaction with health care is related to lower medication adherence rates (Murphy et

al., 2000; Roberts, 2002). It has also been found that among patients with hypertension,

nonadherence to the hypertensive medication regimen is associated with unsatisfactory

patient-health care provider interactions and distrust of providers (Lukochek, 2003).

African-American patients' dissatisfaction with their health care has been related to

poor access to quality health care and to discrimination facilitated distrust of their health

care providers. Provider distrust may lead to poor continuity of care and distrust of the

treatment recommendations of their health care providers (Becker & Newsom, 2003).

Minority patients, particularly African-Americans, are more likely to comply with their

health care provider' s treatment recommendations if they believe that their health care

providers can be trusted and respect them and their culture (Collins, Clark, Petersen, &









Kressin, 2002;Luckoscheck, 2003;Murph et al., 2000;Roberts, 2002; Schneider,

Zaslaysky, & Epstein, 2002).

In the current study, patient satisfaction was examined as a predictor of medication

adherence in low income hypertensive African-American primary care patients.

Specifically, patients' satisfaction with their health care provider' s communication and

interpersonal manner combined was examined as a predictor of medication adherence

among our hypertensive patient participants.

Cultural Sensitivity

Culture and Health Care

The cultural background of an individual largely informs their worldview, which is

their perception of the world, as well as how they conceptualize and make sense of the

world (Sue, Ivey, & Pedersen, 1996). When individuals from different ethnic and cultural

backgrounds interact within a helping relationship, they are likely to operate under

different worldviews and these worldviews may determine the attitudes, beliefs and

behaviors of each person within the context of this relationship (Sue et al., 1996).

Differences between the worldview of a patient and health care provider may occur if

they are of a different cultural background. These differences may potentially

compromise the quality and satisfaction with care that a patient experiences within the

context of this relationship.

Many health care providers are often trained in the biomedical model (Engel,

1977). This model of care conceptualizes illness as biological and somatic, and gives

little importance to psychosocial influences on illness (Engel, 1977). The biomedical

model of illness and care that many health care providers utilize appears to be









incongruent with the culture-based health beliefs of their patients regarding their illness

and health (Engel, 1977).

Patients' cultural health beliefs about certain illnesses and cultural health practices

often differ from the traditional biomedical knowledge and practices of their health care

providers (Heurtin-Roberts, 1993; Lukoschek, 2003; Ogedegbe et al., 2004; Roter, et al.,

1997; Wilson et al., 2002). For example, some traditional African-American folk and lay

health beliefs regarding the meaning and treatment of hypertension appear to differ from

the current medical field' s biomedical definition of hypertension and guidelines for

medical treatment for controlling hypertension (Heurtin-Roberts, 1993; Ogedegbe et al.,

2004; Wilson et al., 2002). Differing cultural health beliefs and worldview between

health care providers and patients could pose a problem in diagnosing and treating

hypertension, especially if the health care provider is unaware of these differences.

The medical field's definition of hypertension contrasts with the African-American

folk health beliefs about hypertension that were identified in a study by Heurtin-Roberts

(1993). African-American patients in this study identified hypertension and high blood

pressure as two separate illness entities: "high blood" and "high-pertension." "High

blood" was seen as physical condition of the blood (e.g. blood rises up, blood is 'hot,'

'thick' and 'rich') caused by certain types of foods, hereditary factors, stress and heat.

"High blood" could be treated with antihypertensive medication, complementary home-

made remedies, dietary restrictions, and weight loss. On the contrary, "High-pertension"

was seen as a more dangerous condition involving unpredictable and momentary rapidly

elevated blood from a "resting" state, and as a manifestation of emotional and

psychological conditions such as problems with "nerves," stress, anger and worry.









Prescribed antihypertensive medication and health promoting lifestyle changes such as

diet and weight management treatment for "high-pertension" were not seen as beneficial

for controlling and alleviating the emotional and psychological conditions related to the

illness. This study suggests that some African-American patients may view hypertension

as a psychosocially based illness rather than as a biologically and somatically- based

illness the view of their health care providers.

In a focus group study by Wilson et al. (2002), it was found that many African-

American focus group members reported lay beliefs that: a) hypertension was caused by

stress, pork and evil spirits; b) hypertension was a symptomatic illness with symptoms

ranging from headaches to ear discomfort; and c) hypertensive "symptoms" could be

treated with garlic, vitamins, herbs, Epsom salt, vinegar and prayer. These beliefs

regarding hypertension may not be addressed by health care providers. Moreover,

miscommunication between health care providers and patients due to cultural health

belief differences regarding medical treatment of hypertension could lead to patient

dissatisfaction with their health care and nonadherence to prescribed antihypertensive

medications. In addition, discrepant expectations about the chronic nature, symptomatic

status, and medical treatment of hypertension between patients and health care providers

could result in poor satisfaction with medical treatment and poor medication adherence

(Heurtin-Roberts, 1993; Ogedegbe, Mancuso, & Allegrante, 2004).

Cultural Sensitivity as a Predictor of Patient Satisfaction

There is reported evidence that cultural insensitivity is linked to reports of lower

perceived satisfaction with health care by low-income and minority patients (e.g. AHRQ,

2003). Cultural insensitivity in the context of long-standing discriminatory and biased

health care provider health practices, differences in health care provider and patients









health-related cultural beliefs and world views, communication barriers, the status/power

differential between health care providers and patients, and lack of patient perceived

control have been linked to poor quality of care and health care dissatisfaction among

minority patients (e.g. AHRQ, 2003; IOM, 2002).

Health care provider discriminatory and biased practices have been documented

(Schulman et al., 1999). For example, in a study that involved assessing physicians'

patient referral for cardiac treatment, it was found that African-American and female

patients were referred for expensive cardiac catheterization less than White and male

patients (Schulman et al., 1999). Furthermore, a study by Blanchard and Lurie (2004)

found that compared to 9% of Caucasian Americans, over 14% of African-Americans,

19% of Hispanics, and 20% of Asian Americans felt that their health care provider was

disrespectful towards them and looked down upon them. In addition, Blanchard and

Lurie (2004) found that individuals with less than a college education were more likely to

feel disrespected by their health care provider than individuals with a college education.

Low-income and African-American patient's satisfaction with care received may

be related to differences in health care provider' and patients' cultural world view

(AHRQ, 2003). Some health care providers may assume that the Western worldview of

medicine and the biomedical model of illness that they are trained in, should be accepted

by their patients and thus may discount the importance of considering their patient' s

cultural health beliefs and attending to the sociocultural aspects of health care provision.

For example, a study by Roter et al. (1997) revealed that primary care physicians focused

less on socio-psychological issues related to their patients' illnesses and attended more to

the biomedical aspects of their patients' illnesses which resulted in lower patient









satisfaction ratings by African-American patients. Given the fact that most providers are

European American and that many health care providers are not properly trained in cross-

cultural health care (Weissman et al., 2005), minority patients may be more likely to

experience culturally biased practices of medicine, which may in turn result in

medication and overall treatment nonadherence.

Culture-specific and sensitive approaches to the care of culturally diverse

individuals have been supported in the counseling psychology literature as the most

appropriate way of addressing differences in worldview between a helping professional

and a culturally different individual (American Psychological Association [APA],

2003; Sue et al., 1996). There is a need for culturally sensitive theories and research

models to address reported racial and ethnic health disparities between majority groups,

and both low-income and minority groups. In particular, evidence-based research

supporting the relationship between culturally sensitive health care, health care quality,

patient satisfaction and health outcomes of patients is greatly needed. In addition,

research on culturally sensitive health care may lead to the development of health care

provider training interventions that could ultimately improve patients' health care

satisfaction and result in better health outcome for patients.

The Patient-Centered Culturally Sensitive Health Care Model

According to the PC-CSHC model, patient-centered culturally sensitive healthcare

influences patients' perceived levels of cultural sensitivity and interpersonal control, both

of which influence patients' engagement in a health promoting lifestyle and satisfaction

with the healthcare they experience, with the former (health promoting lifestyle) directly

influencing health outcomes/status (e.g., blood pressure level) and the latter (satisfaction

with health care) influencing treatment promoting behaviors (e.g., medication adherence),









which in turn also directly influences health outcomes/status (e.g., blood pressure)

(Tucker, in press).

Based on this model, the present study examined: (a) how low-income African-

American patients' perceived levels of cultural sensitivity in health care provider-patient

interactions and these patients' perceived interpersonal control are associated with their

satisfaction with their health care providers' communication and interpersonal manner,

and (b) the association between satisfaction with health care providers' communication

and interpersonal manner and medication adherence among these patients. The patient

participants in this research utilized community-based primary care clinics.

The first component of the PC-CSHC model examined in the current study is that

perceived cultural sensitivity in health care experienced with their health care provider

predicts a patient' s perceived health care satisfaction. Cultural sensitivity in health care

involves communicating or evidencing that one has cultural competence in ways that

make patients feel their culture is respected and which makes them feel comfortable with

and trusting of the health care they receive (Tucker et al., 2003; Tucker et al., in press).

Based on the PC-CSHC model, both cultural competence and cultural sensitivity

are essential to providing culturally sensitive health care which promotes patient

satisfaction. The PC-CSHC model treats culturally competent and culturally sensitive

care as two separate but related constructs. This is supported by literature which defines

these terms differently (Betancourt, Green & Carrillo, 2002; Campinha-Bacote, 2002;

Tucker et al., 2003; Tucker et al., in press). Cultural competence in health care, as

defined by experts in the health care Hield, involves having culture-related knowledge,

skills, experience, and awareness (Betancourt, Green & Carrillo, 2002; Campinha-









Bacote, 2002), whereas cultural sensitivity in health care involves communicating or

evidencing that one has cultural competence in ways that make patients feel their culture

is respected and which makes them feel comfortable with and trusting of the health care

they receive (Tucker et al., 2003; Tucker et al., in press). Therefore, based on the PS-

CSHC model, cultural sensitivity encompasses cultural competence (Tucker et al., in

press). Furthermore, according to the PS-CSHC model, cultural sensitivity is defined by

patients and thus utilizes a patient-centered care perspective (Tucker et al., 2003; Tucker

et al., in press) where as cultural competence has traditionally been defined by experts in

the health care Hield (Betancourt et al., 2002;Campinha-Bacote, 2002).

According to Tucker et al.'s PC-CSHC model, (in press) cultural sensitivity in

health care involves:

a) communicating or displaying cultural competence and sensitivity in ways that
patients report make them feel that they and their culture are respected, and that make
them feel comfortable with and trusting of the health care they receive; (b) embracing
the view that culturally diverse patients are the experts at identifying the
behaviors/attitudes and health care environment variables that make them feel
comfortable with and trusting of their health care providers, and that make patients
feel that they and their culture are respected; (c) viewing cultural distinctions as
differences rather than deficits or inadequacies, and recognizing the influences of
both culture and socioeconomic factors on health behaviors/problems; and (d)
engaging in specific health care provider and onfce staff behaviors and health care
provider/staff-patient interactions, as well as promoting physical health care
environments that encourage patients' trust in, comfort with, and feelings of being
respected by health care providers and clinic office support staff (Tucker et al., in
press)."

Most definitions of culturally sensitive health care in the literature are based on the

views of health care providers and researchers and fail to incorporate patient

perspectives. The PC-CSHC model of culturally sensitive health care emphasizes the

importance of attending to ethnically diverse patients' views about the behaviors, skills,

and attitudes as well as health care environment variables that make them feel









comfortable with, trusting of, and respected by their health care providers (Tucker et al.,

in press). Thus, cultural sensitivity in health care, according to the PC-CSHC model, is

patient-centered.

The literature has noted the value of a patient' s subj ective experience of their health

care as well as the value in applying a patient-centered approach to improving the quality

of their health care (Gerteis, Edgman-Levitan, Daley, & Delbanco, 1993). According to

Gerteis et al. (1993), patient-centered care involves attending to psychosocial aspects of

the patient's care experience which includes: (a) "[respecting] the patients' values,

preferences, and expressed needs (p. 5)," (b) attending to the patient' s "physical comfort"

needs in relations to their care (p. 8), (c) providing patients with "emotional support [to

alleviate their] fear[s] and anxiety[ies] (p. 9)," (d) educating and providing patients with

information related to their care (p. 10), (e) having competent and trustworthy staff and

services (p. 10) and (f) ensuring and providing patients with continuity of care outside

of the health care setting (pg. 10). Since patients are not as versed in the technical aspects

of their care, they may likely attend more to the psychosocial aspects of care which seem

to be of importance to them. Thus, patient-centered care pertains to viewing the patient as

a consumer of health care and ensuring that patients are provided medical care based on

the opinions of patients instead of health care experts.

The PC-CSHC model is based on a previous focus group study by Tucker et al.

(2003) in which self-identified African-American, Hispanic and European American low

income primary care patients were asked for their views about their health care

experiences and what behaviors, attitudes and skills they would like their health care

providers to possess. Specifically, they were asked the following questions: (a) What









does/could your doctor do to make you feel comfortable /uncomfortable with him or

her?; (b) What makes you trust/not trust your doctor? What could your doctor do to help

you trust him or her more?; (c) What does/could your doctor do to show you respect and

be sensitive to your needs?; (d) What could your doctor do to show that he or she is

sensitive to your needs and is respectful of you as an African-American?; (e) What can

doctors do to become better at helping patients from your racial, language or cultural

background? In addition, participants were also asked to identify characteristics of the

clinic office staff and physical clinic environment that made them feel a sense of comfort

and belonging at their health care clinic.

The study identified common universal and ethnicity-specific behaviors, skills, and

attitudes themes among the responses to these questions between patients of each ethnic

group. Examples of universal health care provider behaviors, skills, and attitudes themes

that all three ethnic/racial groups reported as promoters of comfort, trust, and/or respect

are: (a) listens to the patient, (b) makes eye contact with the patient when talking, (c)

shows empathy by making statements like "I understand," (d) demonstrates concern for

the patient, (e) is "nonjudgemental and avoids stereotyping," and (f) answers patients'

questions completely (Tucker, 2003; Tucker, in press). The African-American ethnic

group only reported that it was important to have a health care provider who: (a) does not

look down on you, (b) has "specific medical knowledge related to African-Americans,"

(c) is not scared to touch you as if you are dirty, (d) acknowledges their "fear of being

[used as] a guinea pig;" and (e) let' s you know about illnesses and diseases common

among African-Americans (Tucker et al., 2003, p. 863).









Based on the views of ethnically diverse patients, the PC-CSHC model of culturally

sensitive health care highlights the principles of trust, comfort, and respect as important

elements of culturally sensitive health care. Indeed, there is evidence that supports the

association between patients experiences of trust, comfort, and respect within the context

of their health care encounters with health care providers and their satisfaction with the

health care they receive (Beach et al., 2005;Collins et al., 2002;Tucker et al., 2003; Joffe,

Manocchia, Weeks, & Cleary, 2003).

Trust is a construct that African-American patients identify as important in their

relationship with their physician and in their adherence to treatment recommendations

(Collins et al., 2002; Tucker et al., 2003). However, many African-Americans, especially

low income African-Americans (Becker & Newsom, 2003), distrust medical

professionals, researchers and government agencies. This distrust is likely the product of

historical tragedies that victimized African-Americans--tragedies such as the Tuskegee

Syphilis study (e.g. Freimuth et al., 2001). There is research suggesting that distrust in

health care is indeed more common among African-Americans versus European

Americans. For example, in a national study it was found that even after controlling for

socioeconomic factors, African-Americans as compared to European Americans, were

less likely to trust that their doctors would be informative about the medical research

process and would be less protective of them in medical research (Corbie-Smith, Thomas,

St. George, 2002). It has been reported that a feeling of mistrust of their health care

providers and dissatisfaction with their treatment may lead some African-American

hypertensive patients to be less likely to adhere to their medication (Lukoschek, 2003).









It has been found that minorities who perceive that their health care provider treats

them with dignity and respect are more likely to report being satisfied with their care and

are more likely to report adherence to their treatment (Beach et al., 2005). Unfortunately,

African-Americans and other minorities, are more likely than European Americans to

report health care experiences where they have felt disrespected (Blanchard & Lurie,

2004;Collins et al., 2001; Collins et al.,2002; Johnson, Roter, et al., 2004;Johnson, Saha,

Arbelaez, Beach, & Cooper, 2004; Tucker et al., 2003). This perception of disrespect

may be related to the finding that African-Americans are more likely to report being

talked down to (Collins et al., 2001) or looked down on (Blanchard & Lurie, 2004;Tucker

et al., 2003).

Perhaps due to feelings of distrust and from their experiences of disrespect,

African-Americans may experience discomfort in the health care process. Such

discomfort may also be explained by findings that health care providers communicate

more negative affect and bias perceptions towards African-American patients compared

to European American patients (Johnson, Saha, et al., 2004; Van Ryn & Burke, 2000)

and that some low income minorities believe that the quality of their health care is related

to their race and ethnicity (Collins et al., 2001). Indeed, it is not surprising that African-

Americans may feel more comfort when relating to health care providers of their own

race (Chen et al., 2005). Unfortunately, due to the low number of minority health care

providers in the health care workforce, African-Americans are more likely to receive care

from race-discordant health care providers. Thus, these findings suggest that African-

American patients who prefer health care providers of the same race may be more likely

to be dissatisfied with their health care.









In conclusion, the PC-CSHC Model views ethnically diverse patients' cultural

distinctions as differences rather than deficits or inadequacies, and recognizes the

influences of both culture and socioeconomic factors on health behaviors and problems

(Tucker et al., in press). The PC-CSHC model is thus consistent with the difference

model approach advocated by Oyemade and Rosser (1980) which, contrary to the "deficit

model" approach, respects cultural differences when investigating the behavior of

different racial or ethnic groups by examining the behaviors of these groups in separate

models/analyses. Accordingly, the behavior of each racial/ethnic group is investigated

under conditions for which there are no adequate statistical controls such as poverty level

or cultural values. Consistent with the PC-CSHC Model and the difference model

approach, the current study will specifically focus on low-income African-American

hypertensive primary care patients and will examine these patients' perceived cultural

sensitivity in their health care experiences and their perceived interpersonal control as

predictors of their health care satisfaction, and will examine the latter as a predictor of

their self-reported medication adherence.

Interpersonal Control as a Predictor of Patient Satisfaction

The second component of the PC-CSHC model is that a patient' s perceived

interpersonal control in health care provider-patient interactions predicts her/his

perceived health care satisfaction. Interpersonal control refers to the level of control an

individual believes she/he has when confronting or "interacting with others in dyads and

group situations (Paulhus, 1983, p. 1254)." Interpersonal control is a sub-construct of

perceived control (also affiliated with locus of control or control expectancy). Perceived

control according to Social Learning Theory (Rotter, 1982), is defined as an individual's










perceived beliefs about the degree of control she/he has in receiving personal

reinforcements.

The construct of perceived control has been studied a great deal in psychological

research, and in the process, a number of central issues regarding the measurement and

dimensionality of this construct have been raised (Paulhus, 1983; Paulhus & Christie,

1981). Some researchers believe that perceived control is unidimensional (e.g. Rotter,

1966). For instance, Rotter (1966) asserted that an individual's perceived control, which

he termed locus of control, consists of two main categories: internal locus of control and

external locus of control. Individuals with an internal locus of control believe that they

can personally determine the types of reinforcements they receive; while individuals with

external locus of control believe that outside influences and circumstances determine the

types of reinforcements they receive (Rotter, 1966).

Other researchers believe that the perceived control construct consists of additional

dimensions besides internal-external controls (e.g. Paulhus 1983;Paulhus & Christie,

1981). For instance, one conceptual model of perceived control, first cited by Paulhus &

Christie (1981) is the Spheres of Control (SOC) model, in which perceived control is

thought to be multidimensional. Specifically, the SOC model asserts that the perceived

control construct is composed of three "behavioral spheres" of an individual's "life

space:" Personal efficacy, sociopolitical control, and interpersonal control (Paulhus,

1983; Paulhus & Christie, 1981). This model postulates that an individual's perception of

control is not stable, but dependent on the behavioral circumstances that the individual

may encounter. One of the noted advantages of independently observing an individual's

perceived control levels in different behavioral circumstances is the ability to study how









an individual's perception of control, or perceived ability to receive reinforcements, is

effected by their interactions with other individuals in different social situations (Paulhus

& Christie, 1981). Paulhus & Christie (1981) termed this type of perceived control as

interpersonal control.

Perceived interpersonal control can be conceptualized as a form of psychological

empowerment in that it involves processes and outcomes related to an individual's

perception of personal control in multiple behavioral and situational circumstances.

Specifically, empowerment is associated with multilevel processes and outcomes

designed to promote the power and status of disenfranchised individuals and groups so

that they perceive themselves as having greater interpersonal control (Rappaport, 1987;

Solomon, 1976). Greater perceived interpersonal control could allow these individuals to

participate in various activities and empowerment interventions that could result in

positive social, political, health and legal reinforcements. Members of low income and

minority groups have the greatest need for empowerment interventions because they may

be more likely to feel disempowered due to discriminatory practices and life

circumstances that may limit their opportunity to have an active and participatory role in

various life and social situations. Solomon (1976) asserted that empowerment involves

teaching disenfranchised minorities the necessary skills to exercise interpersonal

influence and to perform valued social roles while attending to the sociopolitical factors

that may influence these roles. Empowerment interventions can consist of encouraging

these groups' involvement and partnership with other individuals, organizations and

communities in order to establish equal or shared power (Peterson & Zimmerman, 2004;

Solomon, 1976).









The health care visit may represent one example of a social situation or behavioral

circumstance in which the dyadic nature of the interaction between a patient and health

care provider during a health care visit may impact the patient's perceived level of

interpersonal control (empowerment) or perceive ability to receive reinforcements. Due

to this type of interaction between a patient and health care provider, the level of

perceived control a patient has in this interpersonal interchange may be dependent on

how both the health care provider and patient perceive their control when relating with

each other. Thus, the reciprocity of control between health care providers and patients

during this interpersonal interchange may impact the patient' s perceived level of

interpersonal control (Auerbach, 2000, 2001;Kiesler & Auerbach, 2003).Examining how

the interpersonal control beliefs of patients may influence their interactions with health

care providers is particularly significant given the power differential between health care

providers and their patients as well as the significant effect of health care provider-patient

interactions on patient' s perceptions of the quality of their health care.

In addition, patients may differ on whether or not they desire to have control during

their interactions with health care providers, and this may be dependent on the level of

control they desire their health care provider to have during the health care visit

(Auerbach, 2001; Kiesler & Auerbach, 2003). For example, some patients may prefer

doctors who have high control and who they perceive as having a dominant or directive

style (Auerbach, 2001). Thus, these patients may in turn desire less control during their

interactions with health care providers.

However, other patients may prefer having shared control and active or

participatory involvement during their interactions with health care providers during their









health care visits (Auerbach, 2001). Thus, they may prefer doctors who have low control

and who they perceive as having a submissive, cooperative or collaborative style

(Auerbach, 2001). For those patients desiring control during their interactions with health

care providers, their level of interpersonal control could largely be determined by their

belief that their control behaviors may lead to reinforcements such as greater satisfaction

with their health care, as well as positive treatment benefits and health outcomes

(Auerbach, 2000, 2001; Kiesler & Auerbach, 2003).

The PC-CSHC model asserts that interpersonal control is associated with patient

satisfaction. According to the model, health care should be patient-defined and -centered.

Therefore, patients have shared power and control of their health care experiences with

their health care provider. Evidence suggests that patients who prefer collaborative,

patient-centered care are more likely to participate in their health care (Street et al.,

2003). There is evidence that African-American patients are less likely to perceive that

they can actively participate in decision-making concerning their health care than

European American patients (Cooper-Patrick et al., 1999). Thus, some African-American

patients desiring active participation in treatment process may not feel empowered to

participate.

There are several research studies that support the PC-CSHC model's assertion of

the association between interpersonal control and patient satisfaction. It was reported in a

nationally representative health care quality survey by the Commonwealth Fund, that

racial and ethnic health disparities in health care partly exist as a result of

miscommunication between health care providers and minority patients (Collins et al.,

2001). Particularly, minority patients reported that they have poorer communication with









their health care provider as a result of: 1) perceived disrespectful communication

between them and their health care provider, 2) disagreements with health care providers

about their treatment, and 3) their health care provider' s lack of inclusion of minority

patients in the treatment decision-making process (Collins et al., 2001). Moreover, as a

result of poor communication, minority patients reported being less inclined to disclose

illness or treatment issues, or to ask their health care providers treatment-related

questions (Collins et. al., 2001). Therefore, these reported factors may increase the

likelihood that African-Americans will receive poorer treatment adherence and health

outcomes. The implied low perceived interpersonal control in the health care experience

of some African-American patients may increase their likelihood of low health care

satisfaction, which may in turn result in poor treatment adherence and health outcomes as

suggested by the PC-CSHC Model.

Another study reported a positive association between shared communicative

power between Patient and their health care provider and the associated impact on health

status. Kaplan, Greenfield & Ware' s (1989) study of patient-health care provider

communication during the health care visit found that more information-seeking behavior

by patients, greater patient control, and more conversation controlled by patients was

associated with improved health status as measured by physiological (blood

pressure/blood sugar), behavioral (functional status), and subjective (patient perception of

overall health status) means. The study findings also indicated that more affective

expression by both patient and physician, in addition to more information giving by the

health care provider, were additionally related to health status. This study and the






34


previous study's findings support the relationship between interpersonal control and

patient satisfaction advocated by the PC-CSHC model.















CHAPTER 3
METHOD S

Participants

Participants in the study consisted of 89 low-income African-American primary

care patients who were recruited from two Gainesville, Florida community-based health

care clinics Eastside Health Center and Family Medical Group Practice as part of a

larger study of patient-centered culturally sensitive health care. Patients from these clinics

were similar in terms of their race, gender, age and payor/mix composition. Recruitment

and inclusion criteria were as follows: (a) having a diagnosis of hypertension with or

without another chronic condition for at least one year prior to the start of the larger

study; (b) being 18 years old or older; (c) having received health care services at their

health care clinic at least three times in the year prior to the start of the larger study; (d)

being able to communicate in their native language either verbally or in written form, and

(e) signing a witness-verified informed consent form that documents an agreement to

participate in the larger study.

In the larger study of culturally sensitive health care, a total of 269 low-income,

ethnically diverse primary care patients were invited to participate. Of those patients, 140

were African-American. Of those 140 African-American patients who were invited, 89

returned their assessment packet (a return rate of 63.6%), which was the current study's

sample. Of those 89 (0.01%) returned packets, one assessment packet was returned with

missing data from this sample. As a result, only data from a total of 88 African-American

patients were utilized in the current study. Specifically, this sample of African-American









patients consisted of 68 (77%) African-American females and 20 (23%) African-

American males. The age of the patients in this sample ranged from 28 to 85 and the

mean age was 52.69 years (sd = 11.54). Other demographic and descriptive

characteristics for this African-American sample are represented in Table 3-1.


Instruments

In the larger study, patient participants anonymously completed an assessment

packet that consisted of the following content: (a) a cover letter detailing the research

purpose, participation instructions, the confidential nature of the study, and precautions

taken to ensure participants' confidentiality; (b) a demographic data questionnaire and an

informed consent form; (c) a payment release form to facilitate payment reimbursement

for study participation; and (d) 12 brief study questionnaires. The current study utilized

data collected from a subset of 7 questionnaires from among the 12 questionnaires

administered in the larger study. Thus, the assessment battery (AB) for the present study

consisted of: (a) a Demographic Data Questionnaire (DDQ); (b) a Medical Data Sheet

(MDS); (c) the Marlowe-Crowne Social Desirability Scale, short-form (M-C SDS); (d)

the Tucker Culturally Sensitive Health Care Inventory for African-Americans (T-

CUSHCI-AA); (e) the Interpersonal Spheres of Control Subscale (ICS) of version three

of the Spheres of Control Scale; (f) The Patient Satisfaction Questionnaire Short-Form

(PSQ-18); and (g) The Morisky Medication Adherence Scale (MMA). Below is a

description of each of these questionnaires/measures:

Demographic Data Questionnaire

A Demographic Data Questionnaire (DDQ; see Appendix A) was utilized to collect

information about each African-American participant' s age, gender, highest level of









education, annual household income, number of years with a hypertension diagnosis,

symptomatic status, comorbidity status, and medication use.

Marlowe-Crown Social Desirability Scale

The Marlowe-Crowne Social Desirability Scale, short-form (M-C SDS; see

Appendix B) is a 20- item true/false scale developed by Crowne & Marlowe (1960) that

was used to determine if variance was accounted for based on a participant' s need to give

socially desirable responses. Test-retest reliabilities of .80 and .84 have been reported for

the M-C SDS (Fraboni and Cooper, 1989). A sample item from the scale is: "At times I

have really insisted on having things my way." Higher scores on the M-C SDS indicate a

more socially desirable response set.

Medical Data Sheet

A Medical Data Sheet (MDS; see Appendix C) was utilized to collect the following

hypertension-related medical and treatment information: (a) number of years since

receiving a hypertension diagnosis, and (b) current symptom status (i.e., symptomatic

versus asymptomatic status).

Tucker Culturally Sensitive Health Care Inventory

The Tucker Culturally Sensitive Health Care Inventory for African-Americans (T-

CUSHCI-AA; see Appendix D; Please note that only the first page of the T-CUSHCI-AA

is provided in the Appendix as copy permission for this inventory has not been granted)

was utilized to collect African-American low-income primary care patients' self-reported

perceived level of cultural sensitivity in their clinic environment and interactions with

health care providers and clinic-staff. The T-CUSHCHI-AA is based on health care

provider and clinic staff behaviors and attitudes that low income African-American









patients identified as indicators of patient-centered culturally sensitive health care via a

focus group study (Tucker et al., 2003).

Development of the T-CUSHI-AA involved two stages. In stage one, twenty ethnic

and gender concordant focus groups involving 135 African-American patients (21

women, 31 men), Hispanic patients (27 women, 18 men) and European patients (23

women, 15 men) recruited from four primary care community-based clinics were invited

to discuss behaviors and attitudes that indicate cultural sensitivity in the health care they

receive. Specifically, they were asked the following questions: (a) What does/could your

doctor/provider do to make you feel comfortable /uncomfortable with him or her?; (b)

What makes you trust/not trust your doctor/provider? What could your doctor do to help

you trust him or her more?; (c) What does/could your doctor/provider do to show you

respect and be sensitive to your needs?; (d) What could your doctor/provider do to show

that he or she is sensitive to your needs and is respectful of you as an African-American?;

(e) What can doctors/providers do to become better at helping patients from racial,

language or cultural background? The patients' responses to these questions were audio

recorded, transcribed, and analyzed using a constant comparative method.

In the second stage of development of the T-CUSCHI, the responses from each

ethnic group of patients were used to construct an ethnicity specific Health Care

Importance Rating Survey (HIRS). Next, 221 patients (82 African-American patients,94

European American patients, and 45 Hispanic American patients) similar to those in

stage one rated the importance of each culturally sensitive behavior and attitude that the

focus group patients reported as indicators of culturally sensitive health care Responses

on the HIRS were organized into five groups: (1) health care provider trust behaviors, (2)









health care provider comfort behaviors, (3) health care provider respect behaviors, (4)

clinic staff behaviors, and (5) clinic environment characteristics. Ratings of the

importance of the items constituting each of these Hyve groupings were made using a Hyve-

point scale where 1= not at all important, 2 = somewhat important 3= important, 4 = very

important, and 5 = extremely important. Items rated as 3, 4, or 5 on each ethnicity

specific HIRS, were used to construct a T-CUSCHI for each ethnic group (i.e., the T-

CUSCHI-AA, T-CUSHCI-HA, and T-CUSCHI-CA). The African-American version of

the HIRS was used to develop the T-CUSCHI-AA.

The T-CUSCHI-AA, which was used in the present study, consists of 3 subscales:

(1) Health Care Provider Behaviors and Attitudes (i.e., behaviors and attitudes that

promote patient trust, comfort, and respect), (2) Clinic Offce Staff Behaviors and

Attitudes, and (3) Clinic Environment Characteristics. Only the Health Care Provider

Behaviors and Attitudes subscale was used in the current study as it is specifically related

to patients' health care experiences with their health care providers. Sample items from

the Health Care Provider Behaviors and Attitudes subscale on the T-CUSCHI-AA are as

follows: (a) "Is honest and direct with me," (b) "Does not look down on me", and (c)

"Treats me with respect." The T-CUSCHI-AA consists of a 4-point likert scale from 4

(Strongly agree) to 1(Strongly disagree). The instructions on this inventory are for

participants to: (a) take a few seconds to think about their experiences with the health

care provider they see most often for health care at their health care clinic, and (b) rate

how much they agree that this health care provider shows each characteristic or behavior

listed in the inventory when providing them with health care.









The five-month test-retest reliability for the Health Care Provider Behaviors and

Attitudes sub scale of the T-CUSCHI-AA is .99 and its split-half reliability is .94. The

internal consistency of this inventory is .98 (Tucker et al., unpublished manuscript).

Interpersonal Spheres of Control Scale (ICS)

The Interpersonal Spheres of Control Scale (ICS; see Appendix E) was utilized to

measure degree of interpersonal control (Paulhus, 1983; Paulhus & Christie, 1981;

Paulhus & Van Selst, 1990). The ICS is one of three subscales of version three of the

Spheres of Control Scale (SOC-3), a scale that measures an individual's behaviorally-

based perceived utilization of control in three main spheres, or domains of their life:

personal control (PC), interpersonal control (ICS), and sociopolitical control (SPC). The

ICS subscale, which measures a person's perceived interpersonal control has a Crombach

Alpha of .83. Respondents are asked to rate how much they agree with the 10 items that

make up the ICS subscale using a 7-point Likert scale from 1 (disagree) to 7 (agree).

Negative item responses are reverse-scored and all 10 items are summed to calculate a

score. A sample item from the scale is: "I often find it hard to get my point of view across

to others."

Patient Satisfaction

The Patient Satisfaction Questionnaire Short-Form (PSQ-18; see Appendix F) is an

18-item survey that measures patients' general satisfaction with health care as well as

their satisfaction with specific aspects of their health care experiences with regards to the

characteristics of their doctors and the medical care services they receive (Marshall &

Hays, 1994). The PSQ-18 is a shorter version of the 50-item Patient Satisfaction

Questionnaire-III (PSQ-III) (Marshall & Hays, 1994; Marshall, Hays, Sherbourne, &

Wells, 1993). The PSQ-18 was developed and tested on a large multi-racial/ethnic sample









included in the Rand Medical Outcomes Study (MOS). The PSQ-18 reliability estimates

ranged from .64 to .77. The PSQ-18 consists of the following subscales: 1) General

Satisfaction; 2) Technical Quality (competence) of health care health care provider; 3)

Interpersonal Manner; 4) Communication; 5) Financial Aspects; 6) Time Spent with

Doctor; and 7) Accessibility and Convenience (Marshall & Hays, 1994). Some PSQ-18

items are worded so that agreement reflects satisfaction with medical care, whereas other

items are worded so that agreement reflects dissatisfaction with medical care. All items

were scored so that high scores reflected satisfaction with medical care. The average of

items that make up each individual subscale formed 7 total subscale scores. Items on the

PSQ-18 are rated on a 5-point likert scale from 1 (strongly agree) to 5 (strongly disagree)

or 5 (strongly agree) to 1 (strongly disagree).

The scores on the Interpersonal Manner and the Communication subscales were

used in the current study. Specifically, the scores for these two subscales were combined.

The Communication subscale measures satisfaction with the communication process

between the patient and health care provider. A sample item on this subscale is: "Doctors

sometimes ignore what I tell them." The Interpersonal Manner sub scale measures

patients' satisfaction with their health care providers' interpersonal mannerisms. A

sample item on this sub scale is: "My doctor treats me in a very friendly and courteous

manner." The reliability estimates for the communication subscale is .64 and for the

interpersonal manner subscale is .66.

Medication Adherence

The Morisky Medication Adherence Scale (MMA; see Appendix G). (Morisky et

al., 1986) is a four- item yes/no response, self-report measure of medication adherence.

The MMA has a reported Cronbach' s alpha internal consistency reliability of 0.61. The









current study found a Cronbach's alpha internal consistency reliability of .69 for the

MMA. The MMA is scored by totaling the number of "no" answers to the 4 questions

that constitutes this measure. Higher scores represent greater adherence to medication.

The four questions constituting the MMA are: "Do you ever forget to take your

medicine?"; "Are you careless at times about taking your medicine?"; "When you feel

better do you sometimes stop taking your medicine?"; and "Sometimes if you feel worse

when you take the medicine, do you stop taking it?";

Procedure

In the larger study of culturally sensitive health care in which the present study's

data was collected at baseline, patients who fit the study criteria were recruited through

the following two methods: (a) clinic mailings and (b) recruitment posters displayed in

the participating clinics. In the clinic mailings method, potential participants were

identified by clinic representatives from both Eastside Health Center (the intervention

clinic) and Family Medical Group Practice (the control clinic) and sent study

participation invitation packets consisting of the following:, (a) an invitation letter (see

Appendix H), (b) a Demographic Data Questionnaire (DDQ), (c) two copies of an

informed consent form (one to keep for their files and one to return signed; see Appendix

I) and (d) a stamped pre-addressed envelope to return these study materials. The

invitation letter stated the following: (a) the procedure that identified them to participate

in the study; (b) the purpose of the study; (c) the instructions for completing and

returning an informed consent form and DDQ if they agreed to participate; (d)

participation procedure information including that potential participants would receive a

participation packet within a few months of sending a signed informed consent form and

completed DDQ; (e) an explanation of how their confidentiality would be protected, (f)









the instruction that they should call the principal investigator in the event that their

mailing address information changes; and (g) participation incentive information

including that they would be paid $20 for completing some questionnaires that would be

mailed to them within two weeks, and (h) payment information including that they would

receive the $20 payment within three weeks of their participation.

Researchers mailed participation questionnaire packets to each person who returned

a signed informed consent form and completed the DDQ. These questionnaire packets

included the following: (a) a cover letter (see APPENDIX J); (b) a self-report Medical

Data Sheet (MDS); (c) the Assessment Battery (AB); (d) payment forms to receive $20

and (e) a pre-addressed and pre-stamped envelope for returning the completed versions of

these study materials. The cover letter mentioned that it would take approximately one

hour for participants to complete the questionnaire packet.

In the poster recruitment method, participants were recruited via recruitment

posters placed at both the intervention and control clinics. The content of the poster (a)

informed patients that University of Florida based research team requested their

participation in a study to examine ways of improving the health care and support they

receive from their health care providers, (b) specified the study inclusion criteria, (c)

indicated that patients would be mailed a payment of $20 within three weeks of their

participation, (d) instructed patients to complete contact information slips, which were

attached to the poster and requested the patient' s name, gender, race/ethnicity, telephone

number, and address, and (e) instructed patients to place completed slips into an envelope

attached to the poster. The slips were periodically collected and mailed to the researchers

by one research consultant at each of the participating clinics. Researchers then mailed an










invitation packet (i.e., an invitation letter, informed consent forms and DDQ, and a

stamped pre-addressed envelope for returning these study materials) to each potential

participant meeting the study criteria who completed a slip. Those patients who returned

a signed copy of the informed consent form and a completed DDQ were mailed the above

described questionnaire packet.

The order of the forms and questionnaires in the participation packet was

counterbalanced with the cover letter appearing first, and the Payment Release Form

appearing last always. To ensure the confidentiality of participants, participation

materials were pre-coded before being mailed to potential patient participants. In

addition, the received questionnaire data and patient identifying information were kept in

separate locked cabinets in the research lab used for this study (i.e., the Behavioral

Medicine Lab in the Psychology Department of the University of Florida).

Table 3-1. Demographic and descriptive characteristics of the participant sample.
Characteri sti c N % M~ SD
Age(years) 52.69 11.54
18 28 1 1.1
29 39 9 10.1
40 55 42 47.2
56 77 24 27.0
Unknown 13 14.6
Gender
Female 68 76.4
Male 20 22.5
Unknown 1 1.1
Income
Below $10,000 54 60.7
$10,001- $20,000 11 12.4
$20,001- $30,000 10 11.2
$30,001- $40,000 1 1.1
Above $40,001 3 3.4
Unknown 10 11.2


















































Note: The Unknown category is due to missing data information resulting from
unreported participant answers.


Table 3-1. Continued.
Characteri sti c
Education level
Elementary school
Middle/Junior high school
High school education
Some college/technical school
College education
Profes sional/graduate
Unknown
Number of years with hypertension diagnosis
0-1 Years
2-3 Years
4-5 Years
6-7 Years
8-9 Years
10+ Years
Unknown

Symptomatic status
Symptomatic
Asymptomatic
Unknown
Comorbidity status
Hypertension only
Hypertension plus other diseases
Unknown
Medication use
Yes
No
Unknown


N % M~ SD


3.4
15.7
37.1
15.7
4.5
3.4
20.2

20.2
22.5
10.1
10.1
5.6
24.7
6.7



76.4
16.9
6.7

74.1
22.5
7.8

93.3
3.4
3.4















CHAPTER 4
RESULTS

Descriptive Data for Main Study Variables

This section contains information regarding the variables of interest in the present

study. Table 4-1 provides the descriptive data for the maj or variables of interest. Tables

4-2 through 4-5 provide the means and standard deviations for the maj or variables of

interest by age, gender, education, and income.

Preliminary Data Analyses

A preliminary Pearson product-moment correlation analysis was conducted to

determine if there were significant correlations among all study variables of interest [i.e.,

perceived cultural sensitivity (T-CUSCHI-AA), perceived interpersonal control (ICS),

health care satisfaction (PSQ-18), medication adherence (MMA), age, education level,

gender, symptom status, and number of years since receiving a hypertension diagnosis.],

and to determine if social desirability (MC-SDS) scores were significantly correlated

with these study variables (Table 4-6).

As shown in Table 4-6, cultural sensitivity scores were found to have a moderately

high and significantly positive correlation with health care satisfaction (r = .721, p =

.001) and a low but significant positive correlation with symptom status (r = .306, p =

.005), suggesting that participants who reported higher levels of perceived cultural

sensitivity in health care experienced with their health care provider also reported higher

levels of health care satisfaction and greater reported hypertensive symptoms. In addition,

health care satisfaction scores were found to have a low but significantly positive









correlation with gender (r = .280, p = .009), suggesting that there is an association

between participant' s gender in relation to their level of health care satisfaction.

Furthermore, medication adherence scores were found to have a low but significantly

positive correlation with age (r = .254, p = .024), suggesting that there is an association

between participant' s age in relation to their level of medication adherence.

Social desirability scores were found to have a low but significant positive

correlation with health care satisfaction (r = .214, p = .046) and a significant moderate

positive correlation with interpersonal control (r = .356, p = .001), suggesting that

participants who scored higher on social desirability also reported higher levels of health

care satisfaction and perceived interpersonal control. Also, social desirability scores were

found to have a low but significant positive correlation with gender (r = .286, p = .007),

suggesting that there is an association between participant's gender and social

desirability. Therefore, social desirability was controlled for in all analyses involving the

variables patient satisfaction, interpersonal control, and gender.

Data Analyses to Test the Two Hypotheses in This Study

Hypothesis one in this study is as follows: African-American low-income

hypertensive patients' levels of perceived cultural sensitivity in health care experienced

with their health care provider (i.e., health care provider behaviors/attitudes) and

perceived interpersonal control will have significant positive associations with their

levels of health care satisfaction (i.e., patients' satisfaction with their health care

providers communication and interpersonal manner combined).

A hierarchical linear regression analysis was performed to test this hypothesis in

order to determine the amount of variance in patients' levels of health care satisfaction

(the criterion variable) uniquely explained by the incremental addition of the predictor









variables (i.e., patients' perceived cultural sensitivity and perceived interpersonal

control), controlling for social desirability. Social desirability was entered into the

analysis first, to control for any effects on health care satisfaction. Next, perceived

cultural sensitivity and perceived interpersonal control were simultaneously entered into

the model. The model containing all three predictor variables was significant, F(3, 84) =

33.185, p < .0005, and explained a large amount of variance in health care satisfaction

(R2 = .542). As shown in Table 4-7, perceived cultural sensitivity uniquely explained a

significant amount of variance in health care satisfaction, f = .707, t (3, 84) = 9.546, p <

.0005, whereas interpersonal control did not uniquely explain a significant amount of

variation in patient satisfaction.

Hypothesis two stated the following: African-American low-income hypertensive

patients' levels of health care satisfaction (i.e.,, satisfaction with health care providers'

communication and interpersonal manner combined) in association with patients' levels

of perceived cultural sensitivity in health care experienced with their health care

provider(i.e.,, health care provider behaviors/attitudes) and perceived interpersonal

control, will significantly predict patients' levels of self-reported medication adherence.

A hierarchical regression analysis was performed to test hypothesis two in order to

determine the amount of variance in patients' self-reported medication adherence (the

criterion variable) uniquely explained by the addition of the predictor variables,

controlling for social desirability. The predictor variables were perceived cultural

sensitivity, perceived interpersonal control and health care satisfaction. In this

hierarchical regression analysis, social desirability was entered into the model first,

followed by the simultaneous entry of perceived cultural sensitivity, perceived










interpersonal control, and health care satisfaction. The full model was not significant,

F(4, 81) = 1.491, p = .213 and none of the individual predictor variables uniquely

explained a significant portion of patients' self-reported medication adherence, as shown

in Table 4-8.

Data Analyses to Test the Two Research Questions in This Study

Research question one is as follows: Are there significant age, education level, and

gender differences in African-American low-income hypertensive patients' levels of

perceived cultural sensitivity in the health care they experienced with their health care

provider, perceived interpersonal control, self-reported medication adherence, and health

care satisfaction?

To address research question one, a multivariate analysis of covariance

(MANCOVA) was performed to determine possible differences in patient's levels of

perceived cultural sensitivity in the health care they experienced with their health care

provider, perceived interpersonal control, self-reported medication adherence, and health

care satisfaction in association with patients' age, education level and gender. The

independent variables were patients' age, education level, and gender. The dependent

variables were interpersonal control (ICS), self-reported medication adherence (MMA),

health care satisfaction (i.e., satisfaction with their providers' communication and

interpersonal manner combined), and perceived cultural sensitivity of provider behaviors

and attitudes. Social desirability was included in the model as a covariate. No significant

multivariate effects were found for age (Wilks' Lambda F(9, 82.898) = .977, p = .465),

education level (Wilks' Lambda F(15, 94.260) = .682, p = .796), or gender (Wilks'

Lambda F(3, 34) = .320, p = .81 1). In addition, separate follow-up analyses of variance

(ANOVAs) were conducted to determine if there were between group differences. These










analyses revealed no significant results. Thus, no further interpretation or analyses were

indicated.

Research question two is as follows: Are there significant differences in African-

American low-income hypertensive patients' levels of self-reported medication

adherence in association with symptom status (i.e.,, symptomatic versus asymptomatic)

and the number of years since receiving a hypertension diagnosis? To address research

question two, an analysis of variance (ANOVA) was performed to determine possible

differences in patients' self-reported medication adherence in association with their

symptom status and number of years since they have received a hypertension diagnosis.

The independent variables were number of years since receiving a hypertension diagnosis

and symptom status (i.e., symptomatic versus asymptomatic), and the dependent variable

was self-reported medication adherence. The results of this analysis revealed a significant

interaction effect between number of years since receiving a hypertension diagnosis and

symptom status, F(4,70) = 2.528, p < .048. Thus, the effect of self-reported symptom

status on medication adherence significantly varies relative to number of years since

receiving a hypertension diagnosis. A profie plot of this interaction effect is provided in

Figure 4-1.












Table 4-1. Maj or variables of interest in this study.
Variables and (measures) Min Max Mean SD Norm Mean

Cultural sensitivity (T-CUSHCI-AA)
Provider behaviors/attitudes subscale 1.63 4.00 3.26 .55 N/A

Interpersonal control (ICS) 15 70 44.72 10.17 48.80a
Health care satisfaction (PSQ-18)
Interpersonal manner (IM) 1.00 5.00 3.92 .89 4.09b
Communication (CM) 1.00 5.00 3.91 .88 3.74b
IM and CM combined 1.00 5.00 3.93 .75 N/A

Medication adherence (MMA) 0 4 2.48 1.39 2.31"


Note. a (Paulhus & Van Selst, 1990), b (Marshall & Hays, 1994), 0 (Morisky, Green, &
Levine, 1986).




Table 4-2. Maj or variables of interest by age categories.
Age
Variables 18 28 29 39 40 55 56 77 Unknown

and (measures)
(N=1) (N=9) (N=42) (N=24) (N=13)


Note: "lM and CM" denotes Interpersonal Manner and Commumication combined, "l-CUSHI-
AA" denotes Cultural Sensitivity: Provider Behaviors/Attitudes Subscale, "ICS" denotes
Interpersonal Control, "MMA" denotes Medication Adherence. No reported Standard
Deviation.


4.500*
3.318*
66.000*
2.000*


3.972 (.537) 3.905 (.843)
3.213 (.443) 3.259 (.585)
43.220 (6.360) 44.980 (10.218)
2.000 (1.323) 2.240 (1.411)


3.983 (.753) 3.868(.616)
3 .292 (.521) 3.234(.596)
45.920(10.818) 40.750(9.526)
3.000 (1.382) 2.690(1.251)


IM and CM
T-CUSCHI-AA
ICS
MMA












Table 4-3. Maj or variables of interest by gender.
Gender
Variables Male Female Unknown

and (measures)
(N= 20) (N= 68) (N= 1)


Note: "IM and CM" denotes Interpersonal Manner and Commumication combined, "T-
CUSHI-AA" denotes Cultural Sensitivity: Provider Behaviors/Attitudes Subscale, "ICS"
denotes Interpersonal Control, "MMA" denotes Medication Adherence. No reported
Standard Deviation.


Table 4-4. Maj or variables of interest by education level.
Variables and Measures
Education Level IM & CM T-CUSHI-AA ICS MMA

Elementary school 4.000 (.433) 3.333 (.577) 38.330 (2.082) 2.670 (2.309)
Middle/Junior high school 4.103 (.672) 3.388 (.590) 46.310 (9.286) 1.860 (1.562)
High school education 3.902 (.739) 3.233 (.4961) 43.580 (8.182) 2.590 (1.365)
Some college/tech school 3.786 (.692) 3.046 (.514) 46.640 (9.467) 2.790 (1.188)
College education 4.229 (.393) 3.193 (.284) 54.250 (17.056) 2.750 (.957)
Professional/Graduate 4.167 (.629) 3.015 (.845) 51.330 (24.194) 3.67 (.577)
Unknown 3.875 (1.001) 3.420 (.613) 42.000 (10.064) 2.220 (1.396)

Note: "IM and CM" denotes Interpersonal Manner and Communication combined, "T-CUSHI-
AA" denotes Cultural Sensitivity: Provider Behaviors/Attitudes Subscale, "ICS" denotes
Interpersonal Control, "MMA" denotes Medication Adherence. (Elementary school: N=3,
Middle/Junior high school: N=14, High school education: N=33, Some college/tech school:
N=14, College education: N=4, Professional/Graduate: N=3, Unknown: N=18)


IM and CM
T-CUSHI-AA
ICS
MMA


3.546 (.913)
3.122 (.546)
42.450 (7.338)
2.950 (1.276)


4.046 (.666)
3.291 (.541)
45.450 (10.884)
2.310 (1.395)


4.250*
3.903*
41.000*
4.000*











Table 4-5. Maj or variables of interest by income level.
Variables and Measures
Income IM & CM T-CUSHI-AA ICS MMA


Below $10,000 4.002 (.724) 3.316 (.541) 43.640 (8.246) 2.420 (1.393)
$10,001- $20,000 3.697 (.805) 2.984 (.498) 45.360 (9.201) 2.450 (1.440)
$20,001- $30,000 3.833 (.866) 3.191 (.666) 49.600 (10.895) 2.600 (1.350)
$30,001- $40,000 4.667* 4.000* 29.000* 4.000*
Above $40,001 3.667 (.520) 2.955 (.124) 56.670 (13.317) 3.33 (.577)
Unknown 3.950 (.840) 3.345 (.493) 42.800 (15.533) 2.300 (1.636)
Note: "IM and CM" denotes Interpersonal Manner and Communication combined, "T-
CUSHI-AA" denotes Cultural Sensitivity: Provider Behaviors/Attitudes Subscale, "ICS"
denotes Interpersonal Control, "MMA" denotes Medication Adherence. No reported
Standard Deviation. (Below $10,000: N=54, $10,001- $20,000: N=11, $20,001- $30,000:
N=10, $30,001- $40,000: N=1, Above $40,001: N=3, Unknown: N=10.)


Table 4-6. Correlations between all study variables of interest including social
desirability.
Variables 1 2 3 4 5 6 7 8 9 10
1. Cultural Sensitivity _.035 .721 .-020 .109 .131 .306** .035 .84 -. 190
(Provider behaviors/attitudes)
2. Interpersonal Control _.091 .141 -.042 .124 .076 -.036 .356** .228
3. Health Care Satisfaction -.053 .001 .280** .211 .059 .214 -.008
4. Medication Adherence .254 -.194 -.055 .080 .170 .231
5. Age _-.014 .092 .197 .096 -.111
6. Gender .189 -.090 .286* .125
7. Symptom Status _.134 .174 -.030
8. Number of Years with
Hypertension Diagnosis _-.137 .071
9. Social Desirability _.088
10. Education

Note. *p< .05, **p <.01;







54



Table 4-7. Hierarchical regression predicting patients' health care satisfaction (PSQ-18).
B SEB a t

Model
Cultural Sensitivity
(Provider behavior/attitudes) 0.970 0.102 0.707 9.546**
Interpersonal Control 0.001 0.006 0.014 0.179


Note. *p< .05, ** p <.0005




Table 4-8. Hierarchical regression predicting patients' self-reported medication
adherence (MMA).
B SEB a t

Model
Interpersonal Control 0.018 0.016 0.133 1.145
Cultural Sensitivity
(Provider behavior/attitudes) 0.394 0.418 0.154 0.942
Health Care Satisfaction -0.416 0.307 -0.227 -1.357


Note. All t-tests were non-significant.


111111 I
O-1 2-3 4-5 6-7 8-9 1 O+
Number of Years with Hypertension Diagnosis
Non-estimable means are not plotted



Figure 4-1 Mean medication adherence as a function of number of years with
hypertension diagnosis and symptom status


Symptom Status
- Asymptomatic
----- Symptomatic


4-
-






O

2-















CHAPTER 5
DISCUSSION

This chapter will provide a summary of the findings of this study and will provide

interpretations of the results. In addition, the implications, limitations, and future

direction of the research conducted will be discussed.

The current study utilized the Patient-Centered Culturally Sensitive Health Care

(PC-CSHC) model to examine the self-reported medication adherence of low-income

African-American hypertensive patients who utilize community-based primary care

clinics. Based on this model, the present study examined: (a) how low-income African-

American patients' perceived levels of cultural sensitivity in health care provider-patient

interactions and these patients' perceived interpersonal control are associated with their

satisfaction with their health care providers' communication and interpersonal manner,

and (b) the association between satisfaction with health care providers' communication

and interpersonal manner and medication adherence among these patients. The predictor

variables of cultural sensitivity, interpersonal control and health care satisfaction were

examined as factors in self-reported medication adherence of the above specified

African-American patients.

Summary of Findings

This study examined African-American low-income hypertensive patients' level of

perceived cultural sensitivity in health care experienced with their health care provider

and interpersonal control as predictors of their health care satisfaction, and it examined









these patients' health care satisfaction as a predictor of their self-reported medication

adherence.

Hypothesis one proposed that African-American low-income hypertensive patients'

levels of perceived cultural sensitivity in health care experienced with their health care

provider (i.e., health care provider behaviors/attitudes) and perceived interpersonal

control will have significant positive associations with their levels of health care

satisfaction (i.e., patients' satisfaction with their health care providers communication

and interpersonal manner combined).

This hypothesis was partially supported by the finding of a significant positive

association between low-income African-American hypertensive patients' level of

perceived cultural sensitivity and level of health care satisfaction. The finding that there

was not a significant association between interpersonal control and health care

satisfaction did not support this hypothesis.

Hypothesis two proposed that African-American low-income hypertensive patients'

levels of health care satisfaction (i.e.,, satisfaction with health care providers'

communication and interpersonal manner combined) in association with patients' levels

of perceived cultural sensitivity in health care experienced with their health care

provider(i.e.,, health care provider behaviors/attitudes) and perceived interpersonal

control, will significantly predict patients' levels of self-reported medication adherence.

This hypothesis was not supported as no significant association was found between the

individual predictor variables and level of self-reported medication adherence.

Two research questions were also examined: (1) Are there significant age,

education level, and gender differences in African-American low-income hypertensive










patients' levels of perceived cultural sensitivity in the health care they experienced with

their health care provider (i.e.,, health care provider behaviors/attitudes), perceived

interpersonal control, self-reported medication adherence, and health care satisfaction?;

(2) Are there significant differences in African-American low-income hypertensive

patients' levels of self-reported medication adherence in association with their number of

years since receiving a hypertension diagnosis and symptom status (i.e., symptomatic

versus asymptomatic status)? Findings from the analyses to examine research question 1

revealed no significant age, education level or gender differences in the participating

patients' levels of perceived cultural sensitivity in the health care they experience with

their health care provider, perceived interpersonal control, and self-reported medication

adherence. Findings from the analyses to examine research question 2 revealed no

significant differences in African-American low-income hypertensive patients' levels of

self-reported medication adherence in association with the number of years since

receiving a hypertension diagnosis and symptom status (i.e., symptomatic versus

asymptomatic status). However, there was a significant interaction effect between

number of years since receiving a hypertension diagnosis and symptom status was found.

A profie plot of this interaction revealed that from 0 to 6 years after receiving a

hypertension diagnosis, the mean self-reported medication adherence scores of the

asymptomatic group increased from 2.5 to 4 on a scale from 0 to 4, and then sharply

decreased to 0 at 6-7 years after receiving a hypertension diagnosis before they increased

to 3.5 for those who received a hypertension diagnosis over 10 years ago. In contrast, the

mean self-reported medication adherence scores of the symptomatic group decreased

from 2.5 to 1.5 during the 0 to 4/5 years after receiving a hypertension diagnosis and









then consistently increased from a mean of 1.5 to a mean of 3.5 6 years or more after

receiving a hypertension diagnosis.

Interpretation and Implications of the Research Findings

In the current research study a significant positive association was found between

low-income African-American hypertensive patients' levels of perceived cultural

sensitivity of the health care provided by health care providers and health care

satisfaction. Specifically, it is particularly noteworthy that, cultural sensitivity accounted

for over 70% of the variance in patient satisfaction compared to the minimal amount of

variance (5%) explained by patients' social desirability. Thus, there appears to be a

strong positive relationship between low income African-American hypertensive

patients' levels of perceived cultural sensitivity of the health care provided by health care

providers and health care satisfaction.

These Eindings provide some support for the PC-CSHC Model's assertion that

patient-defined culturally sensitive provider behaviors and attitudes are associated with

patient satisfaction with the quality of their health care they experience (Tucker, in

press). These Eindings are also consistent with past studies and reports that also have

documented that cultural sensitivity/cultural competence in the health care process is

related to patient satisfaction with health care (Collins et al., 2002; Cooper et al.,

2003;Cooper-Patrick et al., 1999; Johnson, Saha et al., 2004;Tucker et al., 2003; Tucker

et al., in press).These Eindings indicate the need for health care provider cultural

sensitivity training that is based on patient definitions and perceptions about what

constitutes culturally sensitive health care.

In addition, the finding that cultural sensitivity of health care providers as perceived

by low income African-American hypertensive patients predicts their health care









satisfaction also has important implications for counseling psychologists, especially given

the recent national calls for culturally competent and culturally sensitive health care to

help reduce health disparities (AHRQ, 2003; IOM, 2002; DHHS, 2000). The field of

counseling psychology has a long-standing history of promoting cultural competence,

cultural sensitivity and cultural-specific approaches to treating individuals that are

culturally different (Sue, Arredondo, & McDavis, 1992; Sue et al., 1996). Thus,

counseling psychologists have the necessary culture-specific knowledge and skills to help

address the calls for evidence-based research studies and interventions that examine the

health care quality and health care satisfaction issues related to ethnic and racial health

disparities. Additionally, given that counseling psychologists are trained in multicultural

competencies, they are highly qualified to develop both patient and health care provider

cultural-sensitivity training interventions designed to improve the health care experiences

of low income minority patients.

The current research study did not find a significant association between patients'

levels of interpersonal control and health care satisfaction. This finding is inconsistent

with the PC-CSHC model, which proposes that a patients' level of interpersonal control

is a predictor of patient satisfaction (Tucker, in press). In addition, this finding

contradicts previous research findings that reported a connection between increased

health care satisfaction and patients': (a) active involvement in their health care, (b)

increased participation in the health care process, (c) sense of control and (d)

empowerment (Auerbach, 2000;2001;Cooper-Patrick et al., 1999; Kiesler & Auerbach,

2003; Street et al., 2003).









The finding of no significant association between patients' perceived interpersonal

control and health care satisfaction may be due to the measure used to examine patients'

interpersonal control in the study. This measure was predominantly normed on

undergraduate students (Paulhus, 1983;Paulhus & Van Selst, 1990) and thus, it was likely

not a culturally appropriate measure for use with the low income African-American

primary care patients in the current study. Furthermore, the instrument did not directly

measure patients' interpersonal control in the context of patient-health care provider

interaction in health care.

The current research study did not find a significant association between self-

reported level of health care satisfaction and level of self-reported medication adherence.

The study focused on patients' satisfaction with their health care provider's

communication and interpersonal manner. This focus was based on evidence in the

literature that health care provider communication and interactions with their patients,

particularly minority patients, is associated with medication and treatment adherence.

However, the findings in this study did not support this relationship. This finding is also

inconsistent with the theorized link between patients' health care satisfaction and their

medication adherence set forth in the PC-CSHC Model. There are possible explanations

for this finding. For example, it is possible that individual factors not controlled for in the

study were intervening variables between participating patients' health care satisfaction

and medication adherence. Such factors could include costs of medication, a complex

medication regimen, appointment adherence, access and continuity of care issues, and

other patient-related and health system-related barriers (Jokisalo, Kumpusalo, Enlund,

Halonen & Takala, 2002; Ogedegbe, Harrison, et al., 2004). Some researchers have found









a relationship between decreased satisfaction and poor health status, suggesting that

patient satisfaction with their health care could be influenced by factors unrelated to their

experiences with their provider (Harris, Luft, Rudy, & Tierney, 1995). Other intervening

factors could include patient dispositional differences and psychological factors not

measured (Wang et al., 2002).

Another explanation of our finding of no association between patients' health care

satisfaction and medication adherence is that medication adherence was self-reported and

was based on only four question items. Some researchers have called for multiple

measures of medication adherence and inclusion of multiple measures of medication

adherence in research involving this variable (DiMatteo, 2004; Krousel-Wood et al.,

2004). Findings from the examination of research question one revealed that there were

no significant age, education level, or gender differences in our sample of African-

American low-income hypertensive patients' levels of perceived cultural sensitivity in the

health care they experienced with their health care provider, perceived interpersonal

control, self-reported medication adherence, and health care satisfaction. This result

could partly be due to the current study's sample characteristics. For example, some

participants chose not to report certain demographic information (i.e.,, age, education

level) which resulted in unknown data that could not be included in the data analysis to

address research question one. In addition, the unrepresentative sample likely impacted

the analysis to address research question one. Our sample consisted mostly of female

participants (76%), with few male participants, and consisted of mostly older adults (M =

52.69). Thus, the power of the analyses to determine gender and age differences in the

investigated variables was likely minimized.









It has been reported previously that expectations and beliefs of hypertensive

patients about hypertension and medication adherence is associated with whether or not

these patients experience symptoms or whether or not they believe that hypertension is a

chronic disease (Heurtin-Roberts, 1993; Lukochek, 2003; Ogedegbe, Mancuso et al.,

2004). Therefore, research question two examined whether number of years since

receiving a hypertension diagnosis and symptom status would be associated with self-

reported medication adherence. Findings from the examination of question two revealed a

significant interaction effect of number of years since receiving a hypertension diagnosis

and symptom status on medication adherence. These results suggest that low income

African-American hypertensive patients who are aymptomatic for hypertension may need

to be consistently encouraged to adhere to their medication regimens and to routinely

monitor their blood pressure.

Study Limitations and Future Research Direction

The results of this study should be interpreted cautiously as it has a number of

limitations that should ideally be addressed in future research. First, several competing

confound variables with respect to patient satisfaction and medication adherence, not

controlled for in the study, could have accounted for the nonsignificant findings for the

relationship between patient satisfaction and medication adherence. Specifically, patient

dispositional and psychological characteristics, disease characteristics and severity,

medication treatment experiences, and health-related influences outside of the health care

setting may possibly be linked to patient satisfaction and medication adherence behavior.

The nonrepresentative sample size and involvement of volunteer rather than randomly

selected patient participants are also limitations of the present study. Future similar










studies utilizing larger and more representative patient samples than in the current study

are needed.

Using only self-report measures in the current study is also a research limitation.

The instruments used to measure interpersonal control and medication adherence were

not specifically developed for use with African-Americans, particularly not with older

African-American patients. Furthermore, the interpersonal control construct addresses

perceived interpersonal control rather than interpersonal control specifically in health

care settings or in interactions with health care providers. In the future, similar research to

the present study should ideally utilize a health care specific measure of personal control.

Such a measure was not available when selecting the measures for this study.

It is also noteworthy that the Patient Satisfaction Questionnaire used in this study

may not have captured the full range of communication and interpersonal manner

dimensions affiliated with a patients' satisfaction with health care experienced with their

health care provider. Dipalo (1997) advocates for patient satisfaction measures that ask

patients to report instead of rate their satisfaction experiences. Such reports would allow

patients to provide unstructured, open-ended reporting on issues pertaining to their

perceived satisfaction with their care. Future studies similar to the present study could

utilize such measures of health care satisfaction.

Additionally, the 4-item Morisky Medication Adherence Questionnaire may not

have been sensitive to the complex nature of medication adherence behavior. There are a

number of other measures of medication adherence that have been utilized in other

studies including electronic monitoring, pharmacy prescription medication refills, pill

counts, medical records and self-blood pressure measurement (DiMatteo, 2004; Takiya,









Peterson, & Finley, 2004). However, self-report measures have been reported to be one

of the more frequently used measurements of medication adherence (DiMatteo, 2004). In

addition, many of these alternative methods have their own reliability and measurement

issues (Krousel-Wood et al., 2004). Compared to these alternative methods of measuring

medication adherence, the medication adherence self report measure used in this study of

medication adherence was feasible, economical, reliable and time efficient. Furthermore,

the internal consistency of this measure in the present study was moderately high (.69).

It is also noteworthy that social desirability had a significant though low correlation

with both patient satisfaction and interpersonal control. Such issues are inherent in

research using self-report measures. Unlike in many patient satisfaction studies, the

current study controlled for social desirability in the analyses to test our hypotheses and

research questions.

Furthermore, the cross sectional nature of the study did not allow long-term

observation of the variables of interest. For example, patient satisfaction levels,

hypertension symptom status and medication adherence may typically fluctuate or change

with time. Therefore, future research studies on the medication adherence of African-

American hypertensive patients should involve measurement of the associations between

adherence, patient satisfaction and symptom status over an extended period of time.

Finally, a limitation of the current study is that its findings can not be generalized

to all low-income African-American hypertensive patients. This is due to the fact that the

previous focus group studies utilized to develop the Tucker Culturally Sensitive Health

care inventories (Tucker et al., 2003) as well as the current study sample consisted of low

income African-American primary care patients from Florida. Thus, the socioeconomic,










geographical and cultural differences among low-income African-American patient

populations limit the generalizability of the findings from the present study. However,

this study's finding of an association between low income African-American primary

care hypertensive patients' perceived cultural sensitivity in their health care experienced

with their health care provider and their perceived level of health care satisfaction

provides support for similar future research studies like the present study that utilize

larger and more culturally diverse samples of African-American hypertensive patients

and more culturally appropriate measures.

Conclusion

Despite the limitations of the present study, support is provided for future research

to understand the links between culturally sensitive health care and health care

satisfaction. The PC-CSHC Model has potential for explaining these links; however,

future research to test this model is needed. Such future research would benefit from

culturally appropriate and obj ective measures of the investigated constructs. If such

research supports the hypotheses in the present study, needed support will be provided for

the investment of money to make health care delivery in this country more culturally

competent/sensitive.











APPENDIX A
DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ)


Please provide the requested information by shading in your answer.

It should look like this: *

1. What is your gender?
O Male
O Female

2. Your Race/Ethnicity:
O Cub an/Cub an-Ameri can
O Dominican Republican
O Mexican/Mexican-American/Chicano(a)
O Puerto Rican
O Other Hispanic/Latino (please specify:)
O Caucasian/White/European-American
O African-American/Black-American
O Other (please specify:)


3. Current relationship status:
O Single, living without a partner
O Single, living with a partner
O Married, living with a partner


Married, not living with a partner
Divorced or separated
Widow/Widower


4. Employment Status:
O Work Full Time
O Work Part Time
O Do not work

5. Highest level of education that you have completed:
O Elementary School
O Middle/Junior High School
O High School


Some College/Technical School
College
Professional/Graduate School


6. Annual household income level:


O Below $10,000
O $10,001 to $20,000
O $20,001 to $30,000
7. Do you have children?


O $30,001 to $40,000
O Above $40,001









O Yes (How many?:)
O No

8. If so, do your children live with you?
O Yes
O No

9. Religious Preference:
O Catholic
O Baptist
O Presbyterian
O Methodist
O Islamic
O Buddhist
O Jewish
O Other (Please specify:)
10. Language Preference (for future mailings):
O English
O Spanish
O Other (Please specify:)

11. Which clinic do you attend?
O Family Practice Medical Group
O Eastside Community Health Center
O Other (Please specify:)
12. Have you changed clinics since beginning this research study?
O Yes
O No
13. Have you changed doctors since beginning this research study?
O Yes
O No
14. What other research studies are you involved with at your clinic? (check all that
apply)
O "Florida Healthy State Program"
O "Medicaid Study"
O Other (please list):









15. Has there been a change in your primary care physician or nurse practitioner
since you last completed these surveys?
O Yes
O No
If Yes, please explain:

16. Did you receive any help when filling out these surveys?
O Yes
O No

17. How many times have you visited your clinic since last completing these surveys?


18. How many years have you lived in this community?


19. What is your Age?















APPENDIX B
MARLOWE-CROWNE SOCIAL DESIRABILITY SCALE (M-C SDS)

Directions: For each of the following statements, please fill in where you consider the
statement to be True (T) or False (F).
True False


1. I never hesitate to go out of my way to help O O
someone in trouble.


2. I have never intensely disliked anyone. O O


3. I sometimes feel resentful when I don't get my way. O O


4. I like to gossip at times. O O


5. There have been times when I felt like rebelling O O
against people in authority even though I knew they
were right.

6. I can remember "playing sick" to get out of O O
something.

7. There have been occasions when I took advantage O O
of someone.


8. I'm always willing to admit it when I make a O O
mistake.


9. I always try to practice what I preach. O O


I sometimes try to get even, rather than forgive and O O
forget.
10. When I don't know something I don't at all mind O O
admitting it.






70


11. I am always courteous, even to people who are O O
disagreeable.

12. At times I have really insisted on having things my O O
way.

13. There have been occasions when I felt like O O
smashing things.


14. I would never think of letting someone else be O O
punished for my wrong-doings.

15. I never resent being asked to return a favor. O O


16. I have never been irked when people expressed O O
ideas very different from my own.


17. There have been times when I was quite jealous of O O
the good fortune of others.

18. I am sometimes irritated by people who ask favors O O
of me.


20. I have never deliberately said something to hurt O O
someone's feelings.















APPENDIX C
MEDICAL DATA SHEET (MDS)

Directions: For this set of questions, please fill in the blank or shade in the circle next to
the appropriate response from the choices given. Remember, your answers to all
questions in this packet are kept strictly confidential and private. Questions ONE through
SEVEN are only about hypertension, if you do not have hypertension, please do not
answer these.


1. If you have high blood pressure, how many years has it been since your health care
provider told you (Circle one)?


0-1
years

O


2-3
years

O


4-5
years

O


6-7
years

O


8-9
years

O


10 plus
years

O


2. Have you experienced symptoms related to the high blood pressure (Circle one)?
O YES
O NO

3. If you have experienced symptoms, please list them here:




4. Which of the following has your physician or other health care provider
recommended to treat your high blood pressure (Check all that apply)?

O Medication
O Diet

O Exercise

O Weight Loss
O Other:










5. Have any other members of your family been diagnosed with high blood pressure?

O YES
O NO

6. If other members of your family have high blood pressure, what relation are they to
you (check all that apply):

O Mother
O Father
O Grandmother
O Grandfather
O Other
O Son

O Daughter
O Aunt
O Uncle


7. How much do you agree or disagree that you can get ample amounts of education and
consultation about hypertension (Circle your answer)?


O
Strongly Agree


O
Somewhat
Agree


O
Neutral


O
Somewhat
Disagree


O
Strongly
Disagree


8. What illnesses
O
O
O
O
O


are you currently diagnosed with? (check all that apply)
Diabetes (Low Blood Sugar)

High cholesterol (Hyperlipidemia)
High blood pressure (Hypertension)
Coronary Artery Disease
Other (please list):


9. How long ago were you told that you had the conditions listed above?

ILLNESS OR CONCERN


YEARS


















10. Are you currently on any medications?


If Yes, please list them:


O YES
O NO


11. Has your physician recommended you to exercise, diet, or take medications for any of
these other illnesses or medical concerns? If so, please list:

O YES
O NO















APPENDIX D
TUCKER CUL TURALLY SEN SITIVE HEAL TH CARE INVENT ORY-AFRICAN
AMERICAN (T-CUSHCI-AA)


DO NOT REPRODUCE WITHOUT THE WRITTEN PERMISSION
OF DR. CAROLYN M. TUCKER

DIRECTIONS:
Take a few seconds to think about your experiences with the person you see most often for
health care at your health care clinic. This person might be a doctor, a nurse practitioner, or some
other health care provider. Now please rate how much you agree that this person shows each
characteristic or behavior listed below when providing you with health care. Please use a rating
of 4, 3, 2, or 1 where 4 = "Strongly Agree", 3 = "Agree", 2 = "Disagree", and 1 = "Strongly
Disagree". Shade in the circle below the rating you choose like this *. Please rate all
characteristics and behaviors listed on each pae. Do not give us your name. Your ratin s will be
confidential. Thus, please give honest ratings.







4 3 2 1THE PERSON I SEE MOST OFTEN FOR MY
HEALTH CARE WHEN
I VISIT MY CLINIC:

O O O O 1. Is compassionate or shows that he or she cares about how I
feel.
O O O O 2. Is honest and direct with me.
O O O O 3. Is dedicated to her or his work.
O O O O 4. Has a lot of schooling.
O O O O 5. Knows what he or she is doing.
O O OO 6.
Responds to my requests.
O O O O 7. Appears to be concerned about my well-being.*
O O O O 8. Treats all of her or his patients equally.
O O O O 9. Makes helpful and reasonable recommendations.






75


O O O O 10. Explains things so that I understand them.
O O O O 11. Shows that he or she is trying to help me out.
O O O O 12. Treats me like a person, not just a number.*
O O O O 13. Shows that he or she is interested in more than just making
money .
O O O O 14. Follows a common procedure for treating all of his or her
pati ents.
O O O O 15. Shows that he or she is familiar with my health.




































In my personal relationships,
1 h other person usually has 000 0 0 0 0
mor control over the
rlationship than I do.


2Ihave no trouble making and 0 00 0 0 0 0
keeping friends


3 Im not good at guiding the 0 0 0 0 0 0 0
coreof conversation with
svrlothers.



4 I can usually develop a close 0 0 0 0 0 0 0
pesnlrelationship with
smoeI find appealing.


5 I can usually steer a 0 0 0 0 0 0 0
coversation towards the
toisI want to talk about.

6When I need assistance with 0 00 0 0 0 0
smting, I often find it
dfcutto get others to help.


7If there is someone I want to 000 0 0 0 0
metI can usually arrange it


8Ioften find it hard to get my 000 0 0 0 0
pont of view across to others.


9 Inattempting to smooth over 0 0 0 0 0 0 0
disagreement I sometimes
mae it worse.

I fnd it easy to play an
10 important part in most group 0 0 0 0 0 0 0
siuations.


APPENDIX E
INTERPERSONAL SPHERES OF CONTROL SCALE (ICS)


The following statements are about interactions and 'interpersonal control'. Please
read each statement carefully and bubble in the circle that matches how accurate you
believe that statement is about you. Please bubble only one circle for each statement.


Totally Mostly Somewhat
Inaccurate Inaccurate Inaccurate


Somewhat Mostly Totally
Accurate Accurate Accurate


Neutral



















APPENDIX F
PATIENT SATISFACTION QUESTIONNAIRE (PSQ-13)


Instructions: The following statements are some things people say about medical care. Please
read each one carefully, keeping in mind the medical care you are receiving now. (If you have not
received care recently, think about what you would exec if you needed care today.) There is no
right or wrong answer. We are interested in your feelings, good and bad, about the medical care
you have received.


(Color or bubble in only ONE answer on each line)


1. Doctors are good about explaining the reason for medical tests.

2. I think my doctor's office has everything needed to provide
complete medical care.

3. The medical care I have been receiving is just about perfect.

4. Sometimes doctors make me wonder if their diagnosis is correct.

5. I feel confident that I can get the medical care I need without
being set back financially.

6. When I go for medical care, they are careful to check everything
when treating and examining me.

7. I have to pay for more of my medical care than I can afford.

8. I have easy access to the medical care specialists I need.

9. Where I get medical care, people have to wait too long for
emergency treatment.

10. Doctors act too businesslike and impersonal towards me.

11. liy doctors treat me in a very friendly and courteous manner.

12. Those who provide my medical care sometimes hurry too much
when they treat me.

13. Doctors sometimes ignore what I tell them.

14. I have some doubts about the ability of the doctors who treat me.

15. Doctors usually spend plenty of time with me.

16. I find it hard to get an appointment for medical care right away.

17. I am dissatisfied with some things about the medical care I
receive.

18. I am able to get medical care whenever I need it.


Strongly
Agree
O

O


O

O

O


Agree Uncertain Disagree Strongly
Disagree
O O O O

O O O O


O O O O O


O O O O O


How strongly do you AGREE or DISAGREE with each of the following statements?















APPENDIX G
MORISKY DEDICATION ADHERENCE SCALE (1VMVA)

Directions: Please answer the following questions by circling either "yes" or "no".
Remember, your answers are completely confidential and will not be shared with anyone.

1. Do you ever forget to take your medicine?


Yes

No


2. Are you careless at times about taking your medicine?


Yes

No


3. When you feel better do you sometimes stop taking your medicine?


Yes

No


4. Sometimes if you feel worse when you take the medicine, do you stop taking it?


Yes

No

















APPENDIX H
STUDY PARTICIPATION INVITATION LETTER




Dear Patient:

You have an opportunity to participate in a University of Florida research study about your
experiences as a patient at the Family Practice Medical Group.

WHAT IS THIS ABOUT?
The researcher wants to know about your experiences with your doctors, nurses, and clinic
staff. The information you give us is very important because it may help us improve the
health care and support that you and other patients like you receive from healthcare
providers.

WHAT DO YOU HAVE TO DO?
If you agree to participate, we will mail Study Questionnaires to you. Depending on when you
join the study and/or when you stop participation, you will be asked to complete between two and six
assessment packets approximately once every four to six months. You may also participate in a
short training session near the end of the study.

HOW LONG IS IT GOING TO TAKE?
Completing the Study Questionnaires should take no more than one hour each.

WILL MY ANSWERS BE KEPT PRIVATE?
Yes! Nobody will know if you agree to participate. Nobody at the Family Practice Medical
Group will see your answers if you complete the questionnaires.

WILL I BE PAID?
Yes, you will be paid twenty dollars ($20) each time you complete and return the Study
Questionnaires that we will send you. You will also receive sixty dollars ($60) if you
decide to come to the training session near the end of the study.

HOW CAN I FIND MORE ABOUT THIS?
Please read the "Informed Consent Form" (in English or Spanish) that was mailed with this
letter, or call the Principal Researcher (Dr. Carolyn Tucker) at (352) 392 0601, ext. 260.

WHAT SHOULD I DO IN CASE I DECIDE TO PARTICIPATE? Sign the last page of both
"Informed Consent Forms" (English or Spanish). Keep one copy for yourself.
1. Complete the Demographic Data Form.
2. Complete the Medical Data Form.
3. Return one copy of the "Informed Consent Form", the Demographic Data Form and the Medical
Data Form in the pre-addressed, postage paid envelope. DO NOT add postage, just seal the
envelope and put it in your mailbox.

WHAT SHOULD I DO IF I MOVE?











If you move after you return the Informed Consent Form and before you receive more
information from us, simply call (352) 392-0601, ext. 260 between 10:00 a.m. and 4:00
p.m. Feel free to call collect if necessary.



WHO CAN ANSWER SOME MORE QUESTIONS I HAVE?
If you have any questions about this research, contact the Principal Researcher, Dr. Carolyn
M. Tucker, at (352) 392-0601, ext. 260.






Thank you for your time. We hope you will consider participating in this study.

Sincerely,

Dr. Karen L. Hall
Medical Director,
Family Practice Medical Group




























Patient Form









PLEASE SIGN BOTH COPIES OF THIS FORM AND
RETURN ONE TO THE RESEARCHERS

You are being asked to take padt in a research study. This form provides you with information about the
study and seeks your authorization for the collection, use and disclosure of your protected health
information necessary for the study. The Principal Investigator (the person in charge of 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
padt, read the information below and 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.



1. Name of Participant ("Study Subject")





2. Title of Research Study

A Patient-Centered Culturally Sensitive Care Model


3. Principal Investigator and Telephone Number(s)

Carolyn M. Tucker, Ph.D.
Distinguished Alumni Professor
Professor of Psychology, Director of Training
Professor of Pediatrics
Professor of Community Health and Family Medicine


APPENDIX I
INFORMED CONSENT FORM


IRB# 289-2002


Informed Consent to Participate in Research and
Authorization for Collection, Use, and Disclosure
ofProtected Health Information










(352) 392-0601 extension 260


4. Source of Funding or Other Material Support

This research is being funded by the Agency for Healthcare Quality and Research (AHRQ) of the
National Institutes of Health (NIH).


5. What is the purpose of this research study?

Sometimes people are not completely happy or satisfied with some behaviors of their health care
providers or with something about their health care clinic. Such dissatisfaction may be more likely in
patients who are culturally or racially different from their health care providers. This can be a problem
because being unhappy with one's health care provider can get in the way of a sick person getting
better. In this study, we want to do two things: (1) find out whether making health care more
culturally sensitive through a training program and some changes in the health care clinic will make
patients more satisfied with their health care and reduce their stress, and (2) teach patients how to
better communicate with health care providers so that the health care experience will be as satisfactory
as possible.


6. What will be done if you take part in this research study?

This study has seven parts; Parts A-G. If you choose and are selected to participate, you will be
invited to participate in five parts of the study. Below is a description of what participation in each
part of this study involves.

Parts A Part B Parts A and B of this study are already completed. These parts involved
recruitment of patients to fill out an initial set of surveys.

Parts C Part F -- If you participate in these four parts of the study, you will be asked each time to
fill out a set of surveys, with approximately 4 months between each of the parts. Specifically, one
survey will ask how much you agree or disagree with statements describing certain behaviors of your
health care providers that may or may not be culturally sensitive. Other surveys will ask about your
lifestyle, your relations with health care providers, your stress levels, and your involvement in various
health behaviors. You will also be asked to complete a survey about yourself which asks about your
age, gender/sex, race, years of having any long-term health problems, any communication problems
you may have, how you pay for your health care, your telephone number, your address, your current
clinic, and the number of visits that you have made to your current clinic in the past year.

Filling out all of these surveys will take about one hour. You may choose to do these four surveys in
one of two ways. The first way is to fill out the surveys at home and mail us the filled out surveys in a
pre-paid reply envelope, provided with the packet. The second way is to fill out the surveys at the
clinic that you attend. One of our research assistants will be at the clinic to help you fill out the
surveys if you need any help or have any questions. Your name will not be used on the surveys.
Instead, researchers will place a code number on the surveys that you fill out. Your surveys will be
immediately separated from any documents that may be able to identify you (like your signed
informed consent form) and locked in separate filing cabinets in room 293 at the Department of
Psychology at the University of Florida. Your health care provider will not see your filled out surveys
and will not be told whether you are participating in the study or not.

Part G -- If you participate in this part of the study, you will be asked to participate in a 4-hour patient
training on strategies for asking for and receiving more culturally sensitive and more desired health
care. You are not required to participate in this part of the research in order to participate in the
previous four parts. The patient training will involve you along with a small group of other patients.










During the training session, you will hear a brief talk by the trainer, watch videos on how to talk with
your doctor and other clinic staff members, and watch or participate in some demonstrations of how to
talk with ease to health care providers and other clinic staff. Although you are invited to participate in
all sections of this training, you do not have to participate in each activity and may stop whenever you
choose or when you feel uncomfortable.

You will be paid for your participation in each part. The amount that is paid for participation in the
first four parts is the same. Participants in the fifth part of the study will be paid differently than in the
first parts. To see how much money is paid for participation in each part. see section 10 of this form.


7. What are the possible discomforts and risks?

Some of the questions that you will be asked on the surveys could make you feel uncomfortable. If
you do feel uncomfortable, please feel free to skip that question or the entire questionnaire. There are
no other known physical or mental risks that you might experience from participating in this research.
Throughout the study, the researchers will notify you of any new information that may become
available and might affect your decision to remain in the study.

If you wish to discuss the information above or any discomforts you may experience, please call the
Principal Investigator listed on the front page of this form.


8a. What are the possible benefits to you?

If you decide to participate in the training workshop in 'Part-G', you may benefit from the research by
learning ways to comfortably talk with your healthcare providers or clinic staff and you may become
more satisfied with your healthcare.


8b. What are the possible benefits to others?

Your responses to the surveys throughout the study will be combined with the responses of several
hundred other research participants. When taken together, your responses may benefit other people by
helping to teach physicians, nurses, and other health care professionals ways of being more culturally
sensitive to all patients. These results may also increase patients' satisfaction with the health-care that
they receive.

9. If you choose to take part in this research study, will it cost you anything?

This research requires nothing more than your time. There will be no additional costs to you, your
family, or your friends.


10. Will you receive compensation for taking part in this research study?

The amount of money you will receive for participating in this study will depend on the parts of the
study in which you choose to participate. The amount of money that will be paid for participation in
each part is stated below:

1) If you agree to participate in Parts C-F of this study by completing some surveys, you will receive
$20 for each time you complete the surveys and return them to the Principal Investigator. The
maximum amount you may be paid is $80 for participation in all four parts.

2) If you agree to participate in Part G of this research study by participating in a four-hour training
workshop, you will receive $60 for your participation.











Thus, you may receive up to $140 if you participate in all five parts of this study.

Each time you complete a set of surveys and return them to the principal investigator, you will be
mailed a check for $20 within three weeks after the principal investigator receives the surveys. If you
mistakenly leave out the 'payment release form', you will be mailed another form to complete and
return so that you can receive your payment. After completing the final part of the research, should
you choose to do so, you will be sent a check for $60 within three weeks of completing the training.

Because you are being paid for taking part in this study, your name and social security number will be
reported to University administrative personnel for purposes of making and recording the payment.


11. What if you are injured because of the study?

If you experience an injury that is directly caused by this study, only professional consultative care that
you receive at the University of Florida Health Science Center will be provided without charge.
However, hospital expenses will have to be paid by you or your insurance provider. No other
compensation is offered. Please contact the Principal Investigator listed in Item 3 of this form if you
experience an injury or have any questions about any discomforts that you experience while participating
in this study.


12. What other options or treatments are available if you do not want to be in this study?




The option to not taking part in this study is doing nothing. If you do not want to take part in this
study, tell the Principal Investigator or his/her assistant and do not sign this Informed Consent Form.



13a. Can you withdraw from this research study?


You are free to withdraw your consent and to stop participating in this research study at any time. If
you do withdraw your consent, there will be no penalty, and you will not lose any benefits you are
entitled to.

If you decide to withdraw your consent to participate in this research study for any reason, you should
contact Dr. Carolyn M. Tucker at (352) 392-0601 extension 260.

If you have any questions regarding your rights as a research subject, you may phone the University of
Florida Institutional Review Board (IRB) office at (352) 846-1494.


13b. If you withdraw, can information about you still be used and/or collected?

If you choose to withdraw from this research study, no further information will be collected. Also, at
your request, confidential information (data) that has already been collected and stored in a locked
filing cabinet will be destroyed and will not be used.


13c. Can the Principal Investigator withdraw you from this research study?











You may be withdrawn from the study without your consent for the following reasons:
1) You are unable to return a survey packet (or contact the Principal Investigator) within three
weeks of receiving the packet.
2) You change clinics before this research study is completed.
3) You are incarcerated (sent to prison) for longer than one-month during the course of this
research study.
4) You become employed by either the principal investigator, 'Eastside Community Healthcare
Center', or 'Family Practice Medical Group' (both clinics in Gainesville, Florida) during this
research study.
5) You do not qualify to be in the study because you do not meet the study requirements. Ask
the Principal Investigator if you would like more information about this.
6) The investigator decides that continuing in the study would be harmful to you.
7) The study is cancelled by the National Institutes of Health (NIH) and/or for other
administrative reasons.


14. How will your privacy and the confidentiality of your research records be protected?

Your research records that contain personal information (such as name, address, and phone number)
are kept in a separate locked location than your responses to the survey packets. Under no
circumstances will your name, address, phone number, gender, age, ethmicity, or any other information
be provided to any organization other than those listed below.

Authorized persons from the University of Florida and the Institutional Review Board have the legal
right to review your research records and will protect the confidentiality of them to the extent
permitted by law. Your physician, other health care providers, and clinic staff will not have access to
any component of your research records except as required by law. Otherwise, your research records
will not be released without your consent unless required by law or a court order.

If the results of this research are published or presented at scientific meetings, your identity will not be
disclosed. If you participate in this research, your protected health information will be collected, used,
and disclosed under the terms specified in sections 15-24, below.


15. If you agree to participate in this research study, what protected health information about you may
be collected, used and disclosed to others?

To determine your eligibility for the study and as part of your participation in the study, your protected
health information that is obtained from you, from review of your past or current health records, from
procedures such as physical examinations, x-rays, blood or urine tests or other procedures, from your
response to any study treatments you receive, from your study visits and phone calls, and any other study
related health information may be collected, used and disclosed to others. More specifically, the
following information may be collected, used, and disclosed to others:
Any information about your blood pressure, including blood pressure readings, dates of those
readings, and what your health care provider has prescribed for treatment.
Any information about your blood sugar levels, dates your sugar levels were checked, and whether
your doctor has prescribed any treatment for diabetes or other illness relating to blood sugar levels.
Any information about your cholesterol levels, dates of your cholesterol readings, and any
treatment your doctor has prescribed to change your cholesterol levels.
Any information about any diagnosed illnesses from the following list: hypertension (high blood
pressure), hyperlipidemia (high cholesterol levels), diabetes (high blood sugar), coronary artery
disease, and any other illness or disease of the heart.
Records of physical exams.
All dates that you have attended your healthcare clinic for medical reasons.











Your name and address though you personally provide this information each time you complete
the assessment questionnaires.
Information regarding your participation in other research programs and studies at your healthcare
clinic.


16. For what study-related purposes will your protected health information be collected, used and
disclosed to others?

Your protected health information may be collected, used and disclosed to others to find out your
eligibility for, to carry out, and to evaluate the results of the research study. More specifically, your
protected health information may be collected, used and disclosed for the following study-related
purposes) :
To determine the effectiveness of study interventions on perceptions of patients
To evaluate the effects of study interventions on typical health outcomes such as blood pressure,
blood sugar levels, and cholesterol levels.
To determine whether making health care more culturally sensitive through a training program and
some changes in the health care clinic will make patients more satisfied with their health care,
reduce their stress, and affect their health outcome measures.


17. Who will be authorized to collect, use and disclose to others your protected health information?

Your protected health information may be collected, used, and disclosed to others by:

the study Principal Investigator Carolyn M. Tucker, Ph.D. and her staff
other professionals at the University of Florida or Shands Hospital that provide study-related
treatment or procedures
the University of Florida Institutional Review Board


18. Once collected or used, who may your protected health information be disclosed to?

Your protected health information may be given to:

United States and foreign governmental agencies who are responsible for overseeing research, such
as the Food and Drug Administration, the Department of Health and Human Services, and the Office
of Human Research Protections
Government agencies who are responsible for overseeing public health concerns such as the Centers
for Disease Control and Federal, State and local health departments
the study sponsor Agency for Healthcare Research and Quality
The University of Florida in order to pay you, the University requires information such as your
name, address, and social security number. Your social security number will NOT be given to
ANY other source unless required by law.


19. If you agree to participate in this research, how long will your protected health information be
collected, used and disclosed?

Your protected health information (as listed in number 15 above) will be collected for no more than
five years from the date you sign this form. Use and disclosure of your protected health information
may be from 7 years from the date you sign this form. After 7 years, information without identifiers
will be stored forever in a secure database.











20. Why are you being asked to authorize the collection, use and disclosure to others of your protected
health information?

Under a new Federal Law, researchers cannot collect, use or disclose any of your protected health
information for research unless you allow them to by signing this authorization.


21. Are you required to sign this consent and authorization and allow the researchers to
collect, use and disclose (give) to others your protected health information?

No, and your refusal to sign will not affect your treatment, payment, enrollment, or eligibility for any
benefits outside this research study. However, you cannot participate in this research unless you allow
the collection, use and disclosure of your protected health information by signing this
consent/authorization.


22. Can you review or copy your protected health information collected, used or disclosed
under this authorization?

You have the right to review and copy your protected health information. However, you will not be
allowed to do so until after the study is finished.


23. Is there a risk that your protected health information could be given to others beyond your
authorization?

Yes. There is a risk that information received by authorized persons could be given to others beyond your
authorization and not covered by the law.


24. Can you revoke (cancel) your authorization for collection, use and disclosure of your protected
health information?

Yes. You can revoke your authorization at any time before, during or after your participation in the
research. If you revoke your authorization, no new information will be collected about you. However,
information that was already collected may still be used and disclosed to others if the researchers have
relied on it to complete and protect the validity of the research. You can revoke your authorization by
giving a written request with your signature on it to the Principal Investigator.


25. How will the researchers) benefit from your being in this study?

In general, presenting research results helps the career of a scientist. Therefore, the Principal
Investigator and her staff may benefit if the results of this study are presented at scientific meetings or
in scientific journals.












































Please provide the following information so that we can contact you regarding the research study and
so that we can mail you the surveys. Again, this information will be protected as discussed in Section
14 of this informed consent. Please write large and as legibly as possible. Feel free to call the Principal
Investigator at 392-0601, Ext. 260, if you feel your information may be hard to read.


Your Name (Please Print)


Your Address



City State
Zip Code


Area Code Phone Number
Extension


26. Signatures

As a representative of this study, I have explained to the participant the purpose, the procedures, the
possible benefits, and the risks of this research study; the alternatives to being in the study; and how
the participant's protected health information will be collected, used, and disclosed:


Carolyn M. Tucker, Ph.D. (Principal Investigator)


Date


You have been informed about this study's purpose, procedures, possible benefits, and risks; the
alternatives to being in the study; and how yourprotected health information will be collected, used and
disclosed. You have received a copy of this Form. You have been given the opportunity to ask
questions before you sign, and you have been told that you can ask other questions at any time.

You voluntarily agree to participate in this study. You hereby authorize the collection, use and
disclosure of your protected health information as described in sections 15-24 above. By signing this
form, you are not waiving any of your legal rights.


Date


Signature of Person Consenting



Signature of Witness

Contact Information


Date















APPENDIX J
STUDY QUESTIONNAIRE PACKET COVER LETTER


Dear Patient:

Thank you for agreeing to participate in our research proj ect. We are a Research
Team, supervised by Dr. Carolyn M. Tucker, Distinguished Alumni Professor at the
University of Florida. The purpose of this proj ect is to determine ways to increase the
level of cultural sensitivity in health care provided to patients. The other purpose of this
proj ect is to see if patients benefit from more culturally sensitive health care.
Participation in this study involves completing a set of questionnaires. One of these
questionnaires includes a list of behaviors of health care providers and clinic personnel
and a list of clinic characteristics that patients have told us indicate sensitivity to their
culture. Although we do not believe that completing this questionnaire or the other
questionnaires will cause you any harm, you do have the right to skip any questions that
you find offensive and you have the right to stop completing a questionnaire if it makes
you feel uncomfortable.
You will be asked to complete these same questionnaires again in approximately
five months. If you choose to complete the questionnaires again, you will again receive
compensation for your time. You may decide later whether or not you would like to
complete the questionnaires again.
Your participation in this research project is voluntary. If you experience any
discomforts with completing these questionnaires, you may call Dr. Carolyn M. Tucker,
at (3 52) 392-0601 ext. 260, and/or the University of Florida Institutional Review Board
(IRB) Office at (3 52) 846-1494 to discuss your concerns.
Your information will not be shared with your doctor or other members of the
health care staff at your clinic. Also, your name will not be placed on any of the
questionnaires that you complete. Instead, the information from you will be assigned a
code number. The list of names that identify these codes will be kept in a separate locked
location from the information that you provide us with. All this information will be
locked in file cabinets in Dr. Tucker's lab in the psychology building at the University of
Florida. All information from participants will be combined so that no one can identify
your information.
The information you give us is very important because it may help us improve the
health care and support that you and other patients like you may receive from health care
providers. In return for your participation in our study, you will be mailed a payment of
$20 within three (3) weeks of when we receive your completed questionnaires and
'payment release form'.
Please, in addition to completing the questionnaires, sign and return the completed
'Payment Release Form'. We need your name, address, and social security number










requested on this form so that we can send you a check for $20. Your signed Informed
Consent Form (which you returned previously) and Payment Release Forms will be
locked in a separate file cabinet from the locked file cabinet in which your completed
questionnaires will be kept. This will be done to further protect your confidentiality.
In order to participate, please complete the enclosed questionnaires and 'Payment
Release Form', then return them by mail in the pre-paid reply envelope provided. This
should only take about an hour. If you need help completing the questionnaires, you may
ask a family member or friend to read them to you; however, we only want your opinions
to the questions. You may also call Dr. Carolyn M. Tucker at (3 52) 392-0601, Ext. 260 to
set up an appointment to have a Research Assistant read the questionnaires to you at the
health care clinic that you attend.
If you have any questions about this research project, please call a member of our
research team at the (352) 392-0601 ext. 260. We are looking forward to your
participation.

Sincerely,





Dr. Carolyn M. Tucker
Distinguished Alumni Professor
Professor of Psychology
Professor of Pediatrics
Professor of Community Health and Family Medicine


Enclosures




Full Text

PAGE 1

EXAMINATION OF MEDICATION AD HERENCE AMONG AFRICAN-AMERICAN LOW-INCOME PRIMARY CARE HYPERTENSIVE PATIENTS USING THE PATIENT-CENTERED CULTURALLY SENSITIVE HEALTH CARE MODEL By TAMIKA R. BAILEY A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2006

PAGE 2

Copyright 2006 by Tamika R. Bailey

PAGE 3

I dedicate this work to my mother Patricia O. Bailey who taught me to be independent and to reach for the stars

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iv ACKNOWLEDGMENTS First of all, I would like to especially extend my sincerest thanks and appreciation to Dr. Carolyn M. Tucker, my mentor and committee chair, for her expertise and her ongoing encouragement and support. Her commitme nt to excellence and dedication to the community and the field of psychology w ill leave a lasting impression on me both personally and professionally. I would also like to thank my committee members, Drs. Allyson Hall and Mary Fukuyama, as well as Dr. Frederick Desmond, for their support and for extending their expertise that led to completion of my project. In addition, I want to thank Khanh Ngheim and Allison Poimboe uf for providing support for completion of this document. I extend my gratitude to family member s and close friends in and outside of Gainesville, FL who have offered their fr iendship, time, support and wisdom. I would also like to thank my brother Jibril keepi ng me young at heart even through the difficult times. Special thanks go to Anca Mirsu Paun and other members of Dr. TuckerÂ’s Behavioral Medicine team, for their advice, support and mentorship. Last, but especially not least, I thank my parents, Patricia O. Bailey and Roberto A. Bailey, for their lifelong unconditional love, and unshakabl e support and faith in me.

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v TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES............................................................................................................vii LIST OF FIGURES.........................................................................................................viii ABSTRACT....................................................................................................................... ix CHAPTER 1 INTRODUCTION........................................................................................................1 Background...................................................................................................................1 Patient Satisfaction.......................................................................................................3 Cultural Se nsitivity.......................................................................................................4 Interpersonal Control....................................................................................................5 Current Study................................................................................................................6 2 LITERATURE REVIEW.............................................................................................9 Medication Adherence and Hypertension..................................................................10 Patient Satisfaction.....................................................................................................14 Patient Satisfaction and Health Care Quality......................................................14 Patient Satisfaction as a Predic tor of Medication Adherence.............................16 Cultural Se nsitivity.....................................................................................................17 Culture and Health Care......................................................................................17 Cultural Sensitivity as a Predic tor of Patient Satisfaction...................................19 The Patient-Centered Culturally Sensitive Health Care Model..........................21 Interpersonal Control as a Pred ictor of Patient Satisfaction.......................................28 3 METHODS.................................................................................................................35 Participants.................................................................................................................35 Instruments.................................................................................................................36 Demographic Data Questionnaire.......................................................................36 Marlowe-Crown Social Desirability Scale..........................................................37 Medical Data Sheet..............................................................................................37 Tucker Culturally Sensitive Health Care Inventory............................................37

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vi Interpersonal Spheres of Control Scale (ICS).....................................................40 Patient Satisfaction..............................................................................................40 Medication Adherence.........................................................................................41 Procedure....................................................................................................................42 4 RESULTS...................................................................................................................46 Descriptive Data for Main Study Variables................................................................46 Preliminary Data Analyses.........................................................................................46 Data Analyses to Test the Tw o Hypotheses in This Study.........................................47 Data Analyses to Test the Two Research Questions in This Study............................49 5 DISCUSSION.............................................................................................................55 Summary of Findings.................................................................................................55 Interpretation and Implications of the Research Findings..........................................58 Study Limitations and Future Research Direction......................................................62 Conclusion..................................................................................................................65 APPENDIX A DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ).............................................66 B MARLOWE-CROWNE SOCIAL DESI RABILITY SCALE (M-C SDS)................69 C MEDICAL DATA SHEET (MDS)............................................................................71 D TUCKER CULTURALLY SENSITIVE HEALTH CARE INVENTORYAFRICAN AMERICAN (T-CUSHCI-AA)...............................................................74 E INTERPERSONAL SPHERES OF CONTROL SCALE (ICS)................................76 F PATIENT SATISFACTION QUESTIONNAIRE (PSQ-13).....................................77 G MORISKY MEDICATION A DHERENCE SCALE (MMA)...................................78 H STUDY PARTICIPATION INVITATION LETTER................................................79 I INFORMED CONSENT FORM................................................................................81 J STUDY QUESTIONNAIRE PACKET COVER LETTER.......................................89 LIST OF REFERENCES...................................................................................................91 BIOGRAPHICAL SKETCH.............................................................................................99

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vii LIST OF TABLES Table page 3-1 Demographic and descriptive characte ristics of the participant sample..................44 4–1 Major variables of in terest in this study...................................................................51 4–2 Major variables of inte rest by age categories...........................................................51 4–3 Major variables of interest by gender.......................................................................52 4–4 Major variables of interest by education level.........................................................52 4-5 Major variables of in terest by income level.............................................................53 4-6 Correlations between all st udy variables of interest incl uding social desirability...53 4-7 Hierarchical regression predicting pati ents’ health care sati sfaction (PSQ-18).......54 4-8 Hierarchical regression predicting pa tients’ self-reported medication adherence (MMA).....................................................................................................................54

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viii LIST OF FIGURES Figure page 1–1 The patient-centered culturally sens itive health care model (pc-cshc)......................8 4-1 Mean medication adherence as a func tion of number of years with hypertension diagnosis and symptom status..................................................................................54

PAGE 9

ix Abstract of thesis Presente d to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science EXAMINATION OF MEDICATION AD HERENCE AMONG AFRICAN-AMERICAN LOW-INCOME PRIMARY CARE HYPERTENSIVE PATIENTS USING THE PATIENT-CENTERED CULTURALLY SENSITIVE HEALTH CARE MODEL By Tamika R. Bailey August 2006 Chair: Carolyn M. Tucker Major Department: Psychology Utilizing the Patient-Centered Culturally Se nsitive Health Care Model (PC-CSHC), this studyÂ’s objectives were to examine Af rican-American low-income hypertensive patientsÂ’ levels of perceived cultural sensit ivity of their health care experiences and interpersonal control as predic tors of their health care sati sfaction, and to examine these patientsÂ’ health care satisfaction as a pr edictor of their self-reported medication adherence. This study also examined the associ ations of the particip ating patientsÂ’ age, education level, and gender with their leve l of perceived cultural sensitivity of their health care providersÂ’ behaviors and attitudes and their levels of interpersonal control and health care satisfaction. It also examined th e associations of pa rticipating patientsÂ’ symptom status and number of years since r eceiving a hypertension diagnosis with their self-reported medica tion adherence.

PAGE 10

x Participants in this study were 88 African American patients who utilized one of two community-based primary care clinics and who were recrui ted through clinic mailings and recruitment posters displayed in the clinics. Recruited patients were mailed an invitation packet that included an inform ed consent form to be signed and returned. Patients who returned these forms signed were each mailed a questionnaire packet to be completed and returned to the researchers in a provided pre-addressed stamped envelope. Hierarchical multiple regression analyses revealed a significant positive association between patientsÂ’ levels of perceived cultural sensitivity of their health care providersÂ’ behaviors and attitudes a nd patientsÂ’ health care sa tisfaction, and it revealed nonsignificant associations betw een patientsÂ’ levels of inte rpersonal control and health care satisfaction, and between their levels of health care satisfac tion and self-reported medication adherence. A multivariate analysis of covariance to examine age, gender, and education level differences in patientsÂ’ levels of perceived cultural sensitivity, interpersonal control, health care satisf action and self-reported medication adherence revealed no significant multivariate effects. Howe ver, an analysis of variance to examine differences in level of self-reported medica tion adherence in asso ciation with symptom status and number of years si nce receiving a hypertension di agnosis revealed a significant status x years since diagnosis interaction effect. Examinati on of this effect revealed different and inconsistent patter ns of medication adherence over time for the patients with and those without symptoms of hypertension. The limitations, implications, and conclusi ons of this study ar e presented. A major conclusion was that results of this study pr ovide support for patient-centered culturally sensitive health care and that counseling ps ychologists are trained to provide this care.

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1 CHAPTER 1 INTRODUCTION Background The impact of hypertension on the Ameri can population is significant. It has recently been estimated that 50 to 65 milli on Americans are current ly diagnosed with Hypertension or high blood pressure (A merican Heart Association [AHA], 2006; Chobanian et al., 2003; Report of the Joint National Comm ittee on Prevention, Detection, Evaluation, and Treatment of High Blood Pr essure [JNC-7] (2004). Untreated and uncontrolled hypertension or high blood pressu re (HBP) is a major risk factor for cardiovascular disease (CVD), heart disease, ki dney disease, and str oke (Chobanian et al., 2003;National Heart, Lung, and Blood Instit ute [NHLBI], 2005;JNC-7, 2004). CVD is the leading cause of death in the United St ates (AHA, 2006) and Coronary heart disease (CHD) is a major killer of Americans. Accord ing to the AHA (2006), it is estimated that 403.1 billion dollars will be spent this year in CVD-related health care. The current research study focused on African-American hypertensive patients. In the case of African-Americans, hypertension poses si gnificantly high health risks as they are disproportionately affected by this illness. Specifically, African-Americans have the highest hypertension prevalence rates compar ed to other racial/e thnic groups (CDC, 2005a; Hajjar & Kotchen, 2003). Accordingly, African-Americans have the highest CVD prevalence rates (AHA, 2006), and the leading cause of death for African-Americans is CVD (American Heart Association (AHA, 2006) In addition, African-Americans have

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2 higher rates of end stage rena l disease (AHA, 2006) than European Americans and the highest rates of stroke-rel ated deaths (CDC, 2005b). Although African-Americans w ith hypertension have a greater awareness about their hypertensive status and are more likely to be receiving current treatment for their hypertension compared to non-Hispanic Whites and Mexican Americans, AfricanAmericans have low hypertensive contro l rates. (Bosworth et al., 2006;CDC, 2005b;Hajjar & Kotchen, 2003). Blood pressure control has been associated with medication adherence and African-American s who have poor control of their blood pressure are more likely to be nonadherent wi th their medication (Bosworth et al., 2006). The disparity in hypertension-related prevalen ce, blood pressure control rates and death rates between African-Americans and other raci al/ethic groups also prompted the current study to determine what factor s in the health care experien ces of these patients may be related to their medi cation adherence. The JNC-7 (2004), a report by the Nationa l Heart, Lung, and Blood Institute which outlines hypertension preventive and management guidelines for health care providers to utilize, states that along with recommended lifestyle changes whic h include healthier dietary intake, exercise and limited alcohol us e, antihypertensive medications are usually prescribed to control hype rtension. Adhering to life-st yle changes as well as pharmacological treatments is essential to controlling hypertension. Some of the hypertensive medications noted in the report, which may be used at times in multi-drug combination therapy, include diuretics such as Thiazide, Beta blockers, Calcium channel blockers, ACEIs, and ARBs.

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3 Unfortunately, many individuals who are aw are of their hypertensive status do not follow these guidelines. Specifically, uncont rolled and untreated hypertension continues to be a significant health risk partly du e to nonadherence to hypertensive medication. Non-adherence to hypertensive medication has been related to decr eased blood pressure control and increased risk of hypertensi on-related diseases (Morisky, Lawrence & Levine, 1986). The current study examined the following factors that could be related to the medication adherence of low income Afri can-American hypertensive patients using a culturally sensitive model: patie nt satisfaction, cultural sensitivity, and interpersonal control. Patient Satisfaction There is evidence that medication adherence is related to patient satisfaction with their health care provider (Murphy, Robe rts, Martin, Marelich, & Hoffman, 2000; Roberts, 2002). It has also been found th at African-American s who have negative encounters or perceptions of their providers re port being less likely to adhere to their medication regimen (Lukochek, 2003). Specifi cally, African-Ameri cans who negatively perceive their interactions with their health care providers and distru st their health care providers and prescribed medicines are more likely to be nonadherent to their medication (Lukochek, 2003). This suggests that satisfaction with the patient-health care provider relationship is an important determinant of medication adherence in African-Americans. Further evidence indicating an important li nk between a patientÂ’s satisfaction with patient-provider relation and the patientsÂ’ medication adhe rence level comes from the JNC 7 Report. This report emphasizes that patientsÂ’ health care motivation and experiences are significant pr edictors of treatment adhere nce (JNC-7, 2004). Specifically, this report cites research i ndicating that hypertensive pati entsÂ’ communication with and

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4 relationship with their health care provider s (which ideally should be built on “trust,” “respect,” “empathic” communication that promotes comfort, and “customer service skills”) impact these patients’ level of motiv ation to adhere to their treatment (JNC-7, 2004, p.61). Motivation to be adherent to one’s medication regimen and perceived control over one’s medication adherence have both been found to be factors in the selfreported medication adherence levels of Afri can-American renal disease (Tucker et al., 2001). These findings provide support for the focu s of an important as pect of the current study of examining the relationship between pa tient satisfaction with their health care provider and medication adherence among hype rtensive African-American patients. Cultural Sensitivity Recently, increasing the cultural sensitivity of health care providers has become a priority. As the population of the United St ates becomes increasingly ethnically and racially diverse (United States Census Bureau, 2000), the need to provide health care that is appropriately culturally sens itive is vital. This need ha s been further heightened by the highly cited race and income related health disparities among Americans with regard to health, access to health care, satisfaction with the quality of health care and treatment outcomes – disparities that disadvantage et hnic minorities and the poor (e.g. Agency for Healthcare Quality and Research [AHRQ] 2003; Institute of Medicine [IOM], 2002; United States Department of Health and Human Services [DHHS], 2000). Furthermore, recent findings indicate th at the quality of care that minorities experience may be related to health care pr ovider culturally-biased and discriminatory practices that could result in inadequate treatment and care (Schulman et al., 1999). Additionally, the qual ity of the communication proce ss experiences between minority patients and health care provi ders have been observed and have been reported by

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5 minority patients to be unequi vocal compared to the experiences of European American patientsÂ’ (Collins et al., 2001; Cooper-Pat rick et al., 1999;Johnson, Roter, Powe, & Cooper, 2004). Minority patients report perceiving that their race/ethni city is related to culturally insensitive health care provider communication and interpersonal characteristics and is related to the qualit y of care they receive (Collins et al., 2001). Moreover, minority patients who perceive that they are being discriminated against are more likely to prefer and be satisfied with race-concordant health care providers (Chen, Fryer, Philips, Wilson, & Pathman, 2005). In f act, there is evidence th at race-discordance between patients and providers is related to decreased satisfacti on with health care received, and that race-concor dance between patients and prov iders is related to positive communication processes, greater patient pa rticipation, and higher reports of patient satisfaction (Cooper et al., 2004). Additionall y, minority patients are more likely to report dissatisfaction with their car e when they perceive that this care is related to their race/ethnicity (Collins, et al., 2001); furtherm ore, these patients are more likely to be satisfied with race concordant health care providers (Chen et al., 2005). Interpersonal Control Recently, some researchers have related pa tientsÂ’ dissatisfaction with their health care to their perceived lack of personal control in both the hea lth care process as well as in their interpersonal interactions and comm unication with their he alth care providers. Evidence suggests that patients prefer mo re patient-centered, collaborative and participatory health care inter actions with their health care providers (Roter et al., 1996; Street, Krupat, Bell, Kravitz, & Haidet, 2003). However, health care providers often are more directive and utilize less patient-cente red approach when they communicate with minority and African-American patients (Roter et al., 1996; Johnson et al., 2004). In light

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6 of these findings, it is not surprising that some minority patients report that they are less inclined to disclose illness or treatment issu es with their providers (Collins et al., 2001). Recently, empowerment interventions have be en advocated by some researchers as an approach to encourage dise nfranchised groups, such as low income minorities, to increase their sense of inte rpersonal control and power in various social contexts (Rappaport, 1987; Solomon, 1976). Such empowerm ent interventions could be utilized as a strategy for increasing minority patients’ involvement in health promoting activities. Current Study The current research study, which is pa rt of a larger fe derally-funded study, approached the study of medication adherence in African-American hypertensive patients by utilizing a culturally sensitive health care model called the Patient-Centered Culturally Sensitive Health Care (PC-CSHC) model. Th e PC-CSHC model was used to examine the medication adherence of low-income African-A merican hypertensive patients in hopes of answering the calls for culturally sensitive and evidence-based research models for understanding health care disp arities. Specifically, this study (a) examined AfricanAmerican low-income hypertensive patients’ level of perceived inte rpersonal control and level of perceived cultural sensitivity in heal th care experienced with their health care provider as predictors of thei r perceived health care satisfaction, and (b) examined these patients’ perceived health care satisfaction as a predictor of their medication adherence ( Figure 1–1 ). The following hypotheses were tested: Hypothesis 1: African-American low-income hypertensive patie nts’ levels of perceived cultural sensitivity in health care experienced with thei r health care provider (i.e., health care provider beha viors/attitudes) and perceive d interpersonal control will

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7 have significant positive associations with their levels of health care satisfaction (i.e., patientsÂ’ satisfaction with their health car e providers communication and interpersonal manner combined). Hypothesis 2: African-American low-income h ypertensive patientsÂ’ levels of health care satisfaction (i.e., satisfaction with health care providers Â’ communication and interpersonal manner combined) in association with patientsÂ’ levels of perceived cultural sensitivity in health care experienced with their health care provider(i.e., health care provider behaviors/attitudes) and perceived interpersonal control, will significantly predict patientsÂ’ levels of se lf-reported medication adherence. In addition to the above hypotheses, the fo llowing research questions have been addressed: Research question 1: Are there signifi cant age, education level, and gender differences in African-American low-income hypertensive patientsÂ’ levels of perceived cultural sensitivity in the health care they expe rienced with their health care provider (i.e., health care provider behaviors/attitudes), per ceived interpersonal control, self-reported medication adherence, and h ealth care satisfaction? Research question 2: Are there significan t differences in African-American lowincome hypertensive patientsÂ’ levels of self -reported medication adherence in association with their number of years since receiving a hypertension di agnosis and symptom status (i.e., symptomatic versus asymptomatic status)?

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8 Figure 1–1. The patient-centered culturally sensitive health care model (pc-cshc) Expert-Defined Cultural Competence Health Care Environment PatientPerceived Cultural Sensitivity Health Promoting Lifestyle Provider Behaviors Patient Behaviors Patient Interpersonal Control Patient-Defined Cultural Sensitivity Patient Satisfaction Treatment Adherence HEALTH OUTCOME VARIABLES 1. HDL Cholesterol 2. LDL Cholesterol 3. Blood Glucose 4. Blood Pressure 5. BMI 6. Physical Symptoms of Stress 7. Health-Related Quality of Life Patient-Centered Care

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9 CHAPTER 2 LITERATURE REVIEW The Medical Field’s Definition of Hypertension According to the medical field, Hypertensi on, or high blood pressu re, is defined as having a systolic blood pressure (SBP) of 140 mm Hg or higher or a diastolic blood pressure (DBP) of 90 mm Hg or higher (JNC-7, 2004;NHLBI, 2005). The SBP is the exerted pressure on the arterial walls when th e heart contracts and the DBP is the exerted pressure on the arterial walls when the heart relaxes. High blood pre ssure results from an excessive amount of pressure exerted on th e arterial walls when blood passes through. Hypertension is diagnosed after at least tw o separate occasions or visits in which a patient’s blood pressure read ings averages at or above 140 SBP and/or 90 DBP (JNC-7, 2004). Furthermore, there are three classificati ons of hypertension related to different causal factors: “white coat hypertension,” “primary/essential hypertension,” and “secondary hypertension.” “White coat hyperten sion” is the direct result of the “whitecoat effect” which occurs when patients ar e hypertensive only when getting their blood pressure checked during their doctor’s visit (JNC-7, 2004). “Primary/essential hypertension” is hypertension in which the cause is not known. “Secondary hypertension” is hypertension that results fr om another primary medical condition or from taking a specific medication. In addi tion, the severity level of hypertension is differentiated according to two “stages (JNC -7,2004).” Stage one consists of having a SBP between 140 and 159 or a DBP between 90 and 99. Stage two consists of having a

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10 SBP greater than or equal to 160 or a DBP greater than or equal to 100. The stage of hypertension that a patient is in determines the type of medication treatment they receive (JNC-7, 2004).The present research study utiliz ed African-American pa tients with both stage one and stage two, primary/e ssential and secondary hypertension. Medication Adherence and Hypertension The Healthy People 2010 (DHHS, 2000) re port produced by the United States Department of Health and Human Services (DHHS) that contains information for improving the health of Americans include s health objectives for our nation. These objectives include lowering hype rtension disease rates and pr omoting effective treatment and control of hypertension. Specifically, th ese objectives include reducing the proportion of adults with high blood pre ssure from 28% to 16%, increasing the proportion of adults with high blood pressure whose blood pressure is under control from 18% to 50%, and increasing the proportion of adults with high blood pressure who are taking action through healthy lifes tyle changes to help contro l their blood pressure from 82% to 95%. It is noteworthy that there are racial/e thnic disparities in the incidence and management of blood pressure (CDC, 2005a). Mi nority Americans are at greater risk for hypertension and hypertension-related risks compared to majority Americans (CDC, 2005a,b; AHA, 2006; Chobanian et al., 2003; Hajjar & Kotchen, 2006). AfricanAmericans in particular have poor blood pressu re control despite being more likely to report that they are in current treatment for hypertension (Burt, et al., 1995; CDC, 2005b). In addition to race/ethnicit y, there are several other risk factors associated with hypertension and blood pressure control. Th ese risk factors include age, gender,

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11 socioeconomic status, and disease comorbidity (JNC-7, 2004). With regard to age, older adults are at increased risk for hypertension and hypertensi on-related complications such as CVD, stroke or death (CDC, 2005b; Chobanian et al., 2003; JNC-7, 2004). Furthermore, older adults are at increase d risk of having these hypertension-related complications despite receiving treatment (Hajjar & Kotchen, 2003). In terms of gender, it has been reported in the past that male s higher age adjusted prevalence rates of hypertension compared to females (Burt et al., 1995); but more recently, it has been reported that both males and females have si milar prevalence rates (Hajjar & Kotchen, 2006). However, women with hypertension as co mpared to their male counterparts may have additional health compli cations related to their hype rtension status (JNC-7, 2004). Moreover, adults with comorbid diseases such as diabetes and ischemic heart disease in addition to hypertension are at increased ri sk for hypertensionand medication-related complications (Chobanian et al., 2003; JNC7, 2004). Due to health care system-related barriers and access issues, patients from lo w socioeconomic levels with chronic conditions such as hypertension re port being less likely to have treatment for or control of their illness (Becker & Newsom, 2003). Although effective anti-hyperten sive medical therapy invo lves adhering to healthpromoting lifestyle changes such as dietary, exercise and weight management as well as anti-hypertensive medication, the focus of th is present study will be on the factors that influence anti-hypertensive medication adherenc e. Medication adherence has been related to blood pressure control, and decreased bl ood pressure control has been related to increased health risks asso ciated with hypertension (Bosworth et al., 2006; Morisky, Green, & Levine, 1986). Research to unde rstand and promote anti-hypertensive

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12 medication adherence is warranted consideri ng that antihypertensive medications often control blood pressure when the other aspect s of medical therapy for this problem are ineffective. Medical adherence, also commonly referred to as medical compliance, is defined as “the extent to which a pers on’s behavior – taking medica tion, following a diet, and/or executing lifestyle changes corresponds with agreed recommendations from a health care provider (World Health Organization [W HO], 2003, pg. 3).” Patients are seen as adhering well to their medicati on regimen if they report ta king 80% of their medication (Morisky et al., 1986). According to recent me dication adherence literature reviews, medication adherence is related to dosage frequency, type of medication prescribed, symptom status; disease type and duration; de mographic variables such as age, race and gender; medication side effects, and health care systemic issues related to medication costs, health care access and pr ovider-patient interactions (I skedijan et al., 2002; KrouselWood, Thomas, Munter, & Morisky, 2004). Nonadherence to one’s medication regimen is reported to be linke d to the perceived quality of patient-health care provider interac tions, particularly for African-Americans. For some African-American hypertensive pa tients, nonadherence to antihypertensive medications may be related to negative attit udes about taking prescr ibed medications and preferences for alternative or complementar y treatments for their hypertension stemming from their health beliefs (Lukoschek, 2003). In addition, African-American hypertensive patients’ cultural and nonbiom edical expectations and beli efs regarding the duration of the medication regimen or the potential for a cure from prescribed antihypertensive

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13 medication may be related to their medica tion adherence level (Ogedegbe, Mancuso, & Allegrante, 2004). The symptom level of hypertensive pa tients may influence their medication adherence. Nicknamed “the s ilent killer,” hypertension is often associated with an absence of observed symptoms. Consequentl y, some patients, due to the asymptomatic characteristics of hypertension, may or may not adhere to their medication regimen (Lukochek, 2003; Heurtin-Roberts, 1993;Wilson et al., 2002). Nonadhe rence related to asymptomatic status could be related to si mply forgetting to take their prescribed medicine(s). In addition, some African-American patients, due to their health beliefs, view hypertension as a symptomatic and episod ic illness, and consequently, they take their medications only when they experience physical symptoms (Heurtin-Roberts, 1993; Lukochek, 2003; Ogedegbe, et al., 2004). Ogedegbe, Harrison, Robbins, Mancuso, & Allegrante (2004) examined the barriers and facilitato rs of anti-hypertensive medicati on adherence in African-American primary care hypertensive patients. Patients in focus groups were asked the following questions: 1) What difficulties do you have in taking your blood pressure medications as prescribed by your doctor, 2) What situat ions make it hard for you to take your blood pressure medications as prescribed by your doctor?, 3) What situations make it easy for you to take your blood pressure medications as prescribed by your doctor?, and 4) What are the skills that make it necessary for you to take your blood pressure medications as prescribed? It was found that ba rriers to medication adherenc e included the following: (a) forgetfulness (due to old age, rushing or bus y schedules, and being away from home), (b) patient misconceptions about hypertension and hypertension health risks, (c) negative

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14 perceptions about their antihype rtensive medications (e.g., ne gative attitudes about taking medications and about their si de effects), (d) medication regimen issues (e.g., medication dosage frequency, and number of medications taken, and cost of needed medications), (e) denial of their hypertension diagnosis, and (f) logistical barriers re lated to prescription refills issues (e.g., difficulty getting medication refills or getting an appointment to get refills, and running out of medication) and re lated to taking medications outside of the home. Ogedegbe, Harrison et al., (2004) also iden tified the following facilitators of medication adherence in African-American primary care patients: (a) reminder interventions (such as pillboxe s, phone calls, taking blood pr essure readings, being at home), (b) increased knowledge about hype rtension and associated medications, (c) doctor-patient communication that involved physician-implemented patient education about hypertension and associated medications (d) patient involvement in their care (assertiveness, asking doctor questions), (e) having a routine for taking their medications, and (f) having social support networks. In sum, existing literature suggests or implies that there are multiple factors associated with medication adherence behavior The present research examined three of these factors—patient satisfac tion, cultural sensitivity in health care experiences with health care providers, and patie nt interpersonal control. Patient Satisfaction Patient Satisfaction and Health Care Quality The definition of patient satisfaction that will be utilized is Donabedian’s (1980) proposition that a patient’s sa tisfaction with health care is defined as a component of quality of care based on the judgments, values, and expectations patien ts have about their

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15 interactions with their health care provider a nd about the care they re ceive. So essentially, patient satisfaction is a measure of the quali ty of health care that a patient perceives she/he is receiving from their health car e provider (s) or health care establishment involved with their care. According to the quality of care model se t forth by Wilde, Starrin, Larsson, & Larsson, (1993) patient perceived satisfactory he alth care is based on four quality of care dimensions: (1) medical-technical competen ce of health care providers; (2) physicaltechnical conditions of the service organization; (3) identity-orientation of the health care providers’ attitudes and behaviors; and (4) the socio-cultural atmosphere of the service organization (Wilde et al., 1993). In Wilde et al.’s (1993) model, both medi cal-technical competence of health care providers and physical-technical conditions of the service organization are the dimensions of care related to the traditiona l model of care in wh ich the best knowledge and technical resources are utilized to pr ovide the most approp riate and competent treatment for patients. An indicator of medical-technical competence is receiving competent treatment, diagnosis, and examina tion services from a qualified health care provider. Furthermore, examples of ideal physical-technical conditions that promote quality care include a care envir onment that promotes comfort, safety, and cleanliness, as well as one that provides the appropriate equipment to provide competent care. Furthermore, according to Wilde et al. ( 1993), both the identity-orientation of the health care providers’ attitude s and behaviors and the sociocultural atmosphere of the service organization are dimens ions related to the characteristics of the psychosomatic model of care – a model that is characterized by health care providers who treat patients

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16 with humanity and a service organization that resembles a home. The identity-orientation of health care providers that indicate quali ty of care include viewing their patients as persons, providing respectful treatment of th eir patients, demonstrating honesty, trust and empathy in interactions with patients and collaborating with patients on their medical care. Examples of characteristics of the socio-cultural atmosphere (e.g., a health care clinic environment) that pr omote patient satisfaction include a “home-like environment” in the health care organiza tion and nonconformity to a routine that undervalues a patient’s needs and wishes. Patient Satisfaction as a P redictor of Medication Adherence The current study examined the relations hip between medication adherence and patient satisfaction. There is empirical ev idence of a relationship between patient satisfaction and medication adherence in certai n patient populations. For example, studies on the medication adherence of adults with HIV have shown that among these patients, dissatisfaction with health care is related to lower medication adherence rates (Murphy et al., 2000; Roberts, 2002). It has also been found that among patients with hypertension, nonadherence to the hypertensive medication re gimen is associated with unsatisfactory patient-health care provider interactions a nd distrust of providers (Lukochek, 2003). African-American patients’ dissatisfaction with their health care has been related to poor access to quality health care and to discrimination facilita ted distrust of their health care providers. Provider distrust may lead to poor continuity of care and distrust of the treatment recommendations of their health care providers (Becker & Newsom, 2003). Minority patients, particularly African-Americans, are more likely to comply with their health care provider’s treatment recommendations if they believe that their health care providers can be trusted and respect them and their culture (Collins, Clark, Petersen, &

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17 Kressin, 2002;Luckoscheck, 2003;Murph et al., 2000;Roberts, 2002; Schneider, Zaslavsky, & Epstein, 2002). In the current study, patient satisfaction was examined as a predictor of medication adherence in low income hypertensive African-American primary care patients. Specifically, patientsÂ’ satisfaction with th eir health care providerÂ’s communication and interpersonal manner combined was examined as a predictor of medication adherence among our hypertensive pa tient participants. Cultural Sensitivity Culture and Health Care The cultural background of an individual la rgely informs their worldview, which is their perception of the world, as well as how they conceptualize and make sense of the world (Sue, Ivey, & Pedersen, 1996). When indi viduals from different ethnic and cultural backgrounds interact within a helping relationship, they are likely to operate under different worldviews and these worldviews ma y determine the attitudes, beliefs and behaviors of each person within the contex t of this relationship (Sue et al., 1996). Differences between the worldview of a patie nt and health care provider may occur if they are of a different cultural back ground. These differences may potentially compromise the quality and satisfaction with care that a patient experiences within the context of this relationship. Many health care providers are often trai ned in the biomedical model (Engel, 1977). This model of care conceptualizes illn ess as biological and somatic, and gives little importance to psychosoc ial influences on illness (Engel, 1977). The biomedical model of illness and care that many health care providers util ize appears to be

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18 incongruent with the culture-ba sed health beliefs of their pa tients regarding their illness and health (Engel, 1977). Patients’ cultural health beliefs about certa in illnesses and cultural health practices often differ from the traditional biomedical know ledge and practices of their health care providers (Heurtin-Roberts, 1993; Lukoschek, 20 03; Ogedegbe et al., 2004; Roter, et al., 1997; Wilson et al., 2002). For example, some traditional African-American folk and lay health beliefs regarding the meaning and trea tment of hypertension appear to differ from the current medical field’s biomedical de finition of hypertension and guidelines for medical treatment for controlling hypertensi on (Heurtin-Roberts, 1993 ; Ogedegbe et al., 2004; Wilson et al., 2002). Differing cultural health beliefs and worldview between health care providers and pa tients could pose a problem in diagnosing and treating hypertension, especially if th e health care provider is unaware of these differences. The medical field’s definition of hyperten sion contrasts with the African-American folk health beliefs about hypertension that were identified in a study by Heurtin-Roberts (1993). African-American patients in this study identified hypert ension and high blood pressure as two separate illness entities: “high blood” and “high-pertension.” “High blood” was seen as physical c ondition of the blood (e.g. blood rises up, blood is ‘hot,’ ‘thick’ and ‘rich’) cause d by certain types of foods, heredi tary factors, stress and heat. “High blood” could be treated with anti hypertensive medication, complementary homemade remedies, dietary restrictions, and wei ght loss. On the contra ry, “High-pertension” was seen as a more dangerous condition i nvolving unpredictable and momentary rapidly elevated blood from a “resting” state, and as a manifestation of emotional and psychological conditions such as problems with “nerves,” stress, anger and worry.

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19 Prescribed antihypertensive medication and h ealth promoting lifestyle changes such as diet and weight management treatment for “hig h-pertension” were not seen as beneficial for controlling and alleviating the emotional and psychological condi tions related to the illness. This study suggests that some Afri can-American patients may view hypertension as a psychosocially based illness rather than as a biologically and somaticallybased illness the view of their health care providers. In a focus group study by Wilson et al. (2002), it was found that many AfricanAmerican focus group members reported lay be liefs that: a) hypertension was caused by stress, pork and evil spirits; b) hypertension was a symptomatic illness with symptoms ranging from headaches to ear discomfort; and c) hypertensive “symptoms” could be treated with garlic, vitamins, herbs, Epso m salt, vinegar and prayer. These beliefs regarding hypertension may not be addre ssed by health care providers. Moreover, miscommunication between health care provid ers and patients due to cultural health belief differences regarding medical treatmen t of hypertension could lead to patient dissatisfaction with their health care and nonadherence to prescribed antihypertensive medications. In addition, discre pant expectations about the chronic nature, symptomatic status, and medical treatment of hypertension between patien ts and health care providers could result in poor sa tisfaction with medical treatmen t and poor medication adherence (Heurtin-Roberts, 1993; Ogedegbe, Mancuso, & Allegrante, 2004). Cultural Sensitivity as a Pred ictor of Patient Satisfaction There is reported evidence that cultural in sensitivity is linked to reports of lower perceived satisfaction with health care by low-income and minority patients (e.g. AHRQ, 2003). Cultural insensitivity in the context of long-standing discriminatory and biased health care provider health practices, differe nces in health care provider and patients

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20 health-related cultural beliefs and world view s, communication barrier s, the status/power differential between health ca re providers and patients, a nd lack of patient perceived control have been linked to poor quality of care and health care dissatisfaction among minority patients (e.g. AHRQ, 2003; IOM, 2002). Health care provider discriminatory and biased practices have been documented (Schulman et al., 1999). For example, in a study that involved assessing physiciansÂ’ patient referral for cardiac treatment, it wa s found that African-American and female patients were referred for expensive cardiac catheterization less than White and male patients (Schulman et al., 1999). Furtherm ore, a study by Blanchard and Lurie (2004) found that compared to 9% of Caucasian Americans, over 14% of African-Americans, 19% of Hispanics, and 20% of Asian American s felt that their heal th care provider was disrespectful towards them and looked down upon them. In addition, Blanchard and Lurie (2004) found that individuals with less than a college e ducation were more likely to feel disrespected by their hea lth care provider than individual s with a college education. Low-income and African-American patientÂ’s satisfaction with care received may be related to differences in health care providerÂ’ and patientsÂ’ cultural world view (AHRQ, 2003). Some health care providers may assume that the Western worldview of medicine and the biomedical model of illness that they are trained in, should be accepted by their patients and thus may discount the im portance of considering their patientÂ’s cultural health beliefs and attending to the sociocultura l aspects of health care provision. For example, a study by Roter et al. (1997) reve aled that primary care physicians focused less on socio-psychological issues related to th eir patientsÂ’ illnesses and attended more to the biomedical aspects of their patientsÂ’ illnesses which resulted in lower patient

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21 satisfaction ratings by African-American patients. Given the fact that most providers are European American and that many health care providers are not prope rly trained in crosscultural health care (Weissman et al., 2005), mi nority patients may be more likely to experience culturally biased practices of medicine, which may in turn result in medication and overall treatment nonadherence. Culture-specific and sensitive approaches to the care of culturally diverse individuals have been supported in the c ounseling psychology literature as the most appropriate way of addressing differences in worldview betw een a helping professional and a culturally different individual (A merican Psychological Association [APA], 2003;Sue et al., 1996). There is a need for culturally sensiti ve theories and research models to address reported racial and ethnic health disparities between majority groups, and both low-income and minority groups. In particular, evidence-based research supporting the relationship between culturally sensitive health care, health care quality, patient satisfaction and health outcomes of patients is greatly needed. In addition, research on culturally sensitive health care may lead to the development of health care provider training interventions that could ultimately improve patientsÂ’ health care satisfaction and result in bette r health outcome for patients. The Patient-Centered Culturally Sensitive Health Care Model According to the PC-CSHC model, patient-c entered culturally sensitive healthcare influences patientsÂ’ perceived levels of cultu ral sensitivity and inte rpersonal control, both of which influence patientsÂ’ engagement in a health promoting lifestyle and satisfaction with the healthcare they experi ence, with the former (health promoting lifestyle) directly influencing health outcomes/status (e.g., blood pr essure level) and the latter (satisfaction with health care) influencing treatment pr omoting behaviors (e.g., medication adherence),

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22 which in turn also directly influences health outcomes/status (e.g., blood pressure) (Tucker, in press ). Based on this model, the present study examined: (a) how low-income AfricanAmerican patientsÂ’ perceived levels of cultura l sensitivity in health care provider-patient interactions and these patientsÂ’ perceived inte rpersonal control are associated with their satisfaction with their health care provid ersÂ’ communication and interpersonal manner, and (b) the association between satisfacti on with health care pr ovidersÂ’ communication and interpersonal manner and medication adherence among these patients. The patient participants in this research utilized community-based primary care clinics. The first component of the PC-CSHC model examined in the current study is that perceived cultural sensitivity in health care experienced with thei r health care provider predicts a patientÂ’s perceived health care sa tisfaction. Cultural sensitivity in health care involves communicating or evid encing that one has cultural competence in ways that make patients feel their culture is respected and which makes them feel comfortable with and trusting of the health care they receive (Tucker et al., 2003; Tucker et al., in press). Based on the PC-CSHC model, both cultu ral competence and cultural sensitivity are essential to providing culturally sensit ive health care which promotes patient satisfaction. The PC-CSHC mode l treats culturally competent and culturally sensitive care as two separate but rela ted constructs. This is suppor ted by literature which defines these terms differently (Betancourt, Gr een & Carrillo, 2002; Ca mpinha-Bacote, 2002; Tucker et al., 2003; Tucker et al., in press). Cultural co mpetence in health care, as defined by experts in the health care fiel d, involves having culture-related knowledge, skills, experience, and awareness (Betan court, Green & Carrillo, 2002; Campinha-

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23 Bacote, 2002), whereas cultural sensitivity in health care involves communicating or evidencing that one has cultural competence in wa ys that make patients feel their culture is respected and which makes them feel comfor table with and trusting of the health care they receive (Tucker et al., 2003; Tucker et al., in press). Ther efore, based on the PSCSHC model, cultural sensitivity encompa sses cultural competence (Tucker et al., in press). Furthermore, according to the PS-CSHC model, cultural sensitivity is defined by patients and thus utilizes a pa tient-centered care perspectiv e (Tucker et al., 2003; Tucker et al., in press) where as cultural competence has traditionally been defined by experts in the health care field (Betancour t et al., 2002;Campinha-Bacote, 2002). According to Tucker et al.’s PC-CSHC mode l, (in press) cultural sensitivity in health care involves: a) communicating or displaying cultural comp etence and sensitivity in ways that patients report make them feel that they a nd their culture are respected, and that make them feel comfortable with a nd trusting of the health care they receive; (b) embracing the view that culturally diverse patients are the experts at identifying the behaviors/attitudes and health care environment variables that make them feel comfortable with and trusting of their hea lth care providers, and that make patients feel that they and their cu lture are respected; (c) viewi ng cultural distinctions as differences rather than deficits or inad equacies, and recognizing the influences of both culture and socioeconomic factors on health behaviors/problems; and (d) engaging in specific health care provider a nd office staff behaviors and health care provider/staff-patient intera ctions, as well as promo ting physical health care environments that encourage patients’ trus t in, comfort with, a nd feelings of being respected by health care provi ders and clinic office support staff (Tucker et al., in press). ” Most definitions of culturally sensitive heal th care in the literature are based on the views of health care prov iders and researchers and fail to incorporate patient perspectives. The PC-CSHC m odel of culturally sensitive health care emphasizes the importance of attending to ethni cally diverse patients’ views about the behaviors, skills, and attitudes as well as health care envi ronment variables that make them feel

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24 comfortable with, trustin g of, and respected by their health care providers (Tucker et al., in press). Thus, cultural sensitivity in hea lth care, according to the PC-CSHC model, is patient-centered. The literature has noted the value of a pati ent’s subjective experience of their health care as well as the value in applying a patien t-centered approach to improving the quality of their health care (Gerteis, Edgman-Lev itan, Daley, & Delbanco, 1993). According to Gerteis et al. (1993), patient-centered care involves atte nding to psychosocial aspects of the patient’s care experience which includes: (a) “[respecting] the patients’ values, preferences, and expressed needs (p. 5),” (b) attending to the patient’s “physical comfort” needs in relations to their care (p. 8), (c) providing patients with “emotional support [to alleviate their] fear[s] and anxiety[ies] (p. 9),” (d) educating and providing patients with information related to their care (p. 10), (e ) having competent and trustworthy staff and services (p. 10) and (f) en suring and providing patients with continuity of care outside of the health care setting (pg. 10) Since patients are not as ve rsed in the technical aspects of their care, they may likely attend more to the psychosocial aspects of care which seem to be of importance to them. Thus, patient-cen tered care pertains to viewing the patient as a consumer of health care and ensuring that patients are provided medical care based on the opinions of patients instead of health care experts. The PC-CSHC model is based on a previ ous focus group study by Tucker et al. (2003) in which self-identified African-Amer ican, Hispanic and European American low income primary care patients were asked for their views about their health care experiences and what behavior s, attitudes and skills they would like their health care providers to possess. Specifically, they we re asked the following questions: (a) What

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25 does/could your doctor do to make you feel comfortable /uncomfortable with him or her?; (b) What makes you trust/not trust your doctor? What could your doctor do to help you trust him or her more?; (c) What does/ could your doctor do to show you respect and be sensitive to your needs?; (d) What could your doctor do to show that he or she is sensitive to your needs and is respectful of you as an Afri can-American?; (e) What can doctors do to become better at helping patients from your r acial, language or cultural background? In addition, particip ants were also asked to id entify characteristics of the clinic office staff and physical clinic environment that made them feel a sense of comfort and belonging at their health care clinic. The study identified common universal and et hnicity-specific behaviors, skills, and attitudes themes among the responses to thes e questions between patients of each ethnic group. Examples of universal health care provide r behaviors, skills, and attitudes themes that all three ethnic/racial groups reported as promoters of comfort, trust, and/or respect are: (a) listens to the patien t, (b) makes eye contact with the patient when talking, (c) shows empathy by making statements like “I understand,” (d) demonstrates concern for the patient, (e) is “nonjudgemental and avoi ds stereotyping,” and (f) answers patients’ questions completely (Tucker, 2003; Tucker in press). The African-American ethnic group only reported that it was im portant to have a health car e provider who: (a) does not look down on you, (b) has “specific medical know ledge related to African-Americans,” (c) is not scared to touch you as if you ar e dirty, (d) acknowledges their “fear of being [used as] a guinea pig;” and (e) let’s you know about illnesses and diseases common among African-Americans (Tucker et al., 2003, p. 863).

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26 Based on the views of ethnically diverse pa tients, the PC-CSHC model of culturally sensitive health care highlights the principles of trust, comfort, and respect as important elements of culturally sensitive health care. Indeed, there is evidence that supports the association between patients experiences of trus t, comfort, and respect within the context of their health care encounters with health care providers and their satisfaction with the health care they receive (Beach et al., 2005;Co llins et al., 2002;Tucker et al., 2003; Joffe, Manocchia, Weeks, & Cleary, 2003). Trust is a construct that African-American patients identify as important in their relationship with their physician and in th eir adherence to treatment recommendations (Collins et al., 2002; Tucker et al., 2003). However, many African-Americans, especially low income African-Americans (Becke r & Newsom, 2003), distrust medical professionals, researchers and government agenci es. This distrust is likely the product of historical tragedies that victimized African -Americans--tragedies such as the Tuskegee Syphilis study (e.g. Freimuth et al., 2001). Ther e is research suggesting that distrust in health care is indeed more common am ong African-Americans versus European Americans. For example, in a national st udy it was found that even after controlling for socioeconomic factors, African-Americans as compared to European Americans, were less likely to trust that thei r doctors would be informative about the medical research process and would be less prot ective of them in medical re search (Corbie-Smith, Thomas, St. George, 2002). It has been reported that a feeling of mistrust of their health care providers and dissatisfaction with their treatment may l ead some African-American hypertensive patients to be less likely to a dhere to their medication (Lukoschek, 2003).

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27 It has been found that minorities who percei ve that their health care provider treats them with dignity and respect are more likely to report being satisfi ed with their care and are more likely to report adherence to their treatment (Beach et al., 2005). Unfortunately, African-Americans and other minorities, are more likely than European Americans to report health care experiences where they have felt disrespected (Blanchard & Lurie, 2004;Collins et al., 2001; Collins et al.,2002; Jo hnson, Roter, et al., 2004;Johnson, Saha, Arbelaez, Beach, & Cooper, 2004; Tucker et al., 2003). This perception of disrespect may be related to the finding that African -Americans are more likely to report being talked down to (Collins et al., 2001) or l ooked down on (Blanchard & Lurie, 2004;Tucker et al., 2003). Perhaps due to feelings of distrust an d from their experiences of disrespect, African-Americans may experience discomfort in the health care process. Such discomfort may also be explained by findi ngs that health care providers communicate more negative affect and bias perceptions towards African-American patients compared to European American patients (Johnson, Saha, et al., 2004; Van Ryn & Burke, 2000) and that some low income minorities believe that the quality of their health care is related to their race and ethnicity (Collins et al., 2001) Indeed, it is not surprising that AfricanAmericans may feel more comf ort when relating to health care providers of their own race (Chen et al., 2005). Unfortunately, due to the low number of minority health care providers in the health care workforce, Af rican-Americans are more likely to receive care from race-discordant health care providers. Thus, these findings suggest that AfricanAmerican patients who prefer health care provi ders of the same race may be more likely to be dissatisfied w ith their health care.

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28 In conclusion, the PC-CSHC Model views ethnically diverse patients’ cultural distinctions as differences ra ther than deficits or inadequacies, and recognizes the influences of both culture and socioeconomic factors on health behaviors and problems (Tucker et al., in press). The PC-CSHC mode l is thus consistent with the difference model approach advocated by Oyemade and Rosse r (1980) which, contrary to the “deficit model” approach, respects cultural differe nces when investiga ting the behavior of different racial or et hnic groups by examining the behavior s of these groups in separate models/analyses. Accordingly, the behavior of each racial/ethnic group is investigated under conditions for which there are no adequate statistical controls such as poverty level or cultural values. Consistent with th e PC-CSHC Model and the difference model approach, the current study will specifically focus on low-income African-American hypertensive primary care patients and will examine these patients’ perceived cultural sensitivity in their health care experiences and their perceived inte rpersonal control as predictors of their health car e satisfaction, and will examine the latter as a predictor of their self-reported medication adherence. Interpersonal Control as a Pred ictor of Patient Satisfaction The second component of the PC-CSHC m odel is that a patient’s perceived interpersonal control in health care provide r-patient interactions predicts her/his perceived health care satisfaction. Interpersona l control refers to th e level of control an individual believes she/he has when confrontin g or “interacting with others in dyads and group situations (Paulhus, 1983, p. 1254).” Interp ersonal control is a sub-construct of perceived control (also affiliated with locus of control or control expectancy). Perceived control according to Social Learning Theory (R otter, 1982), is defined as an individual’s

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29 perceived beliefs about the degree of cont rol she/he has in receiving personal reinforcements. The construct of perceived control has been studied a great deal in psychological research, and in the process, a number of cen tral issues regarding the measurement and dimensionality of this construct have been raised (Paulhus, 1983; Paulhus & Christie, 1981). Some researchers believe that perceived control is unidimensional (e.g. Rotter, 1966). For instance, Rotter (1966) asserted that an individual’s perc eived control, which he termed locus of control, consists of two main categories: internal locus of control and external locus of control. Indi viduals with an internal locus of control believe that they can personally determine the t ypes of reinforcements they r eceive; while individuals with external locus of control believe that outside influences and circumstances determine the types of reinforcements th ey receive (Rotter, 1966). Other researchers believe that the perceive d control construct consists of additional dimensions besides internal-external contro ls (e.g. Paulhus 1983;Paulhus & Christie, 1981). For instance, one conceptual model of perceived control, fi rst cited by Paulhus & Christie (1981) is the Spheres of Control (SOC) model, in which perceived control is thought to be multidimensional. Specifically, the SOC model asserts that the perceived control construct is composed of three “behavioral spheres” of an individual’s “life space:” Personal efficacy, sociopol itical control, and interp ersonal control (Paulhus, 1983; Paulhus & Christie, 1981). This model postula tes that an individual’s perception of control is not stable, but depe ndent on the behavioral circ umstances that the individual may encounter. One of the noted advantages of independently obser ving an individual’s perceived control levels in di fferent behavioral circumstances is the ability to study how

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30 an individualÂ’s perception of control, or pe rceived ability to recei ve reinforcements, is effected by their interactions with other indivi duals in different social situations (Paulhus & Christie, 1981). Paulhus & Chri stie (1981) termed this type of perceived control as interpersonal control. Perceived interpersonal cont rol can be conceptualized as a form of psychological empowerment in that it involves processes and outcomes related to an individualÂ’s perception of personal control in multiple behavioral and situational circumstances. Specifically, empowerment is associated with multilevel processes and outcomes designed to promote the power and status of disenfranchised indi viduals and groups so that they perceive themselves as having gr eater interpersonal c ontrol (Rappaport, 1987; Solomon, 1976). Greater perceive d interpersonal cont rol could allow these individuals to participate in various activi ties and empowerment interven tions that could result in positive social, political, health and legal re inforcements. Members of low income and minority groups have the greatest need for empowerment interventions because they may be more likely to feel disempowered due to discriminatory practices and life circumstances that may limit their opportunity to have an active and participatory role in various life and social situations. Solomon (1976) asserted th at empowerment involves teaching disenfranchised minorities the neces sary skills to exercise interpersonal influence and to perform valued social roles while attending to the sociopolitical factors that may influence these roles. Empowerment interventions can consist of encouraging these groupsÂ’ involvement and partnership with other individuals organizations and communities in order to establish equal or shared power (Peterson & Zimmerman, 2004; Solomon, 1976).

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31 The health care visit may represent one exam ple of a social situation or behavioral circumstance in which the dyadic nature of the interaction between a patient and health care provider during a health care visit may impact the patientÂ’s perceived level of interpersonal control (empower ment) or perceive ability to receive reinforcements. Due to this type of interaction between a patie nt and health care provider, the level of perceived control a patient has in this in terpersonal interchange may be dependent on how both the health care provider and patient perceive their contro l when relating with each other. Thus, the reciprocity of control between health care providers and patients during this interpersonal in terchange may impact the pa tientÂ’s perceived level of interpersonal control (Auerbach, 2000, 2001; Kiesler & Auerbach, 2003).Examining how the interpersonal control beliefs of patients ma y influence their interactions with health care providers is particularly significant given the power differential between health care providers and their patients as well as the si gnificant effect of hea lth care provider-patient interactions on patientÂ’s pe rceptions of the quality of their health care. In addition, patients may differ on whether or not they desire to have control during their interactions with health care provider s, and this may be dependent on the level of control they desire their health care provi der to have during th e health care visit (Auerbach, 2001; Kiesler & Auerbach, 2003). Fo r example, some patients may prefer doctors who have high control and who they perceive as having a dominant or directive style (Auerbach, 2001). Thus, these patients may in turn desire less control during their interactions with h ealth care providers. However, other patients may prefer having shared cont rol and active or participatory involvement during their interactions with hea lth care providers during their

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32 health care visits (Auerbach, 2001). Thus, they may prefer doctors who have low control and who they perceive as having a submi ssive, cooperative or collaborative style (Auerbach, 2001). For those patients desiring cont rol during their intera ctions with health care providers, their level of interpersonal control could la rgely be determined by their belief that their control behaviors may lead to reinforcements such as greater satisfaction with their health care, as well as positiv e treatment benefits and health outcomes (Auerbach, 2000, 2001; Kiesler & Auerbach, 2003). The PC-CSHC model asserts that interpers onal control is associated with patient satisfaction. According to the model, health care should be patient-d efined and -centered. Therefore, patients have shared power and c ontrol of their health care experiences with their health care provider. Evidence suggests that patients who prefer collaborative, patient-centered care are more likely to partic ipate in their health care (Street et al., 2003). There is evidence that African-American patients are less likel y to perceive that they can actively participate in decisionmaking concerning their health care than European American patients (Cooper-Patrick et al., 1999). Thus, some African-American patients desiring active participation in trea tment process may not feel empowered to participate. There are several research studies that support the PC-CSHC modelÂ’s assertion of the association between interpersonal control and patient satisfaction. It was reported in a nationally representative health care qual ity survey by the Commonwealth Fund, that racial and ethnic health disparities in health care partly exist as a result of miscommunication between health care providers and minority patients (Collins et al., 2001). Particularly, minority patients reported that they have poorer communication with

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33 their health care provider as a result of: 1) perceived disrespectful communication between them and their health care provider, 2) disagreements with health care providers about their treatment, and 3) their health care providerÂ’s lack of inclusion of minority patients in the treatment decision-making pr ocess (Collins et al., 2001). Moreover, as a result of poor communication, minority patients reported being less inclined to disclose illness or treatment issues, or to ask their health care providers treatment-related questions (Collins et. al., 2001). Therefore, these reported factors may increase the likelihood that African-Americans will receive poorer treatment adherence and health outcomes. The implied low perceived interperso nal control in the health care experience of some African-American patients may in crease their likelihood of low health care satisfaction, which may in turn result in poor treatment adherence and health outcomes as suggested by the PC-CSHC Model. Another study reported a positive asso ciation between shared communicative power between Patient and thei r health care provider and the associated impact on health status. Kaplan, Greenfield & WareÂ’s (1989) study of patient-health care provider communication during the health care visit found that more information-seeking behavior by patients, greater patient c ontrol, and more conversati on controlled by patients was associated with improved health status as measured by physiological (blood pressure/blood sugar), behavioral (functional st atus), and subjective (patient perception of overall health status) means. The study fi ndings also indicated that more affective expression by both patient and physician, in addition to more information giving by the health care provider, were additionally rela ted to health status. This study and the

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34 previous studyÂ’s findings support the relati onship between interpersonal control and patient satisfaction advocat ed by the PC-CSHC model.

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35 CHAPTER 3 METHODS Participants Participants in the study consisted of 89 low-income African-American primary care patients who were recruited from two Ga inesville, Florida community-based health care clinics Eastside Health Center and Fa mily Medical Group Practice as part of a larger study of patient-centered culturally sensi tive health care. Patients from these clinics were similar in terms of their race, gende r, age and payor/mix composition. Recruitment and inclusion criteria were as follows: (a ) having a diagnosis of hypertension with or without another chronic condition for at least one year prior to the start of the larger study; (b) being 18 years old or older; (c) havi ng received health care services at their health care clinic at least thr ee times in the year prior to the start of the larger study; (d) being able to communicate in their native language either verbally or in written form, and (e) signing a witness-verified informed consent form that documents an agreement to participate in the larger study. In the larger study of culturally sensitiv e health care, a total of 269 low-income, ethnically diverse primary care patients were in vited to participate. Of those patients, 140 were African-American. Of those 140 African -American patients who were invited, 89 returned their assessment packet (a return rate of 63.6%), which was the current studyÂ’s sample. Of those 89 (0.01%) returned packets, one assessment packet was returned with missing data from this sample. As a result, on ly data from a total of 88 African-American patients were utilized in th e current study. Specifically, this sample of African-American

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36 patients consisted of 68 (77%) AfricanAmerican females and 20 (23%) AfricanAmerican males. The age of the patients in this sample ranged from 28 to 85 and the mean age was 52.69 years (sd = 11.54). Other demographic and descriptive characteristics for this African-American sample are represented in Table 3-1. Instruments In the larger study, patien t participants anonymously completed an assessment packet that consisted of the following conten t: (a) a cover letter detailing the research purpose, participation instruc tions, the confidential nature of the study, and precautions taken to ensure participants Â’ confidentiality; (b) a demogra phic data questionnaire and an informed consent form; (c) a payment release form to facilitate payment reimbursement for study participation; and (d) 12 brief st udy questionnaires. The cu rrent study utilized data collected from a subset of 7 que stionnaires from among the 12 questionnaires administered in the larger study. Thus, the as sessment battery (AB) for the present study consisted of: (a) a Demographic Data Ques tionnaire (DDQ); (b) a Medical Data Sheet (MDS); (c) the Marlowe-Crowne Social Desirability Scale, short-form (M-C SDS); (d) the Tucker Culturally Sensitive Health Ca re Inventory for African-Americans (TCUSHCI-AA); (e) the Interpersonal Spheres of Control Subscale (ICS) of version three of the Spheres of Control Scale; (f) The Patient Satisfaction Qu estionnaire Short-Form (PSQ-18); and (g) The Morisky Medicati on Adherence Scale (MMA). Below is a description of each of these questionnaires/measures: Demographic Data Questionnaire A Demographic Data Questionnaire (DDQ; s ee Appendix A) was utilized to collect information about each African-American par ticipantÂ’s age, gender, highest level of

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37 education, annual household income, number of years with a hypertension diagnosis, symptomatic status, comorbidity status, and medication use. Marlowe-Crown Social Desirability Scale The Marlowe-Crowne Social Desirability Scale, short-form (M-C SDS; see Appendix B) is a 20item true/false scal e developed by Crowne & Marlowe (1960) that was used to determine if vari ance was accounted for based on a participant’s need to give socially desirable responses. Test-retest reliabilities of .80 and .84 have been reported for the M-C SDS (Fraboni and Cooper, 1989). A sample item from the scale is: “At times I have really insisted on having things my wa y.” Higher scores on th e M-C SDS indicate a more socially desirable response set. Medical Data Sheet A Medical Data Sheet (MDS; see Appendix C) was utilized to collect the following hypertension-related medical and treatment in formation: (a) number of years since receiving a hypertension diagnosis, and (b) cu rrent symptom status (i.e., symptomatic versus asymptomatic status). Tucker Culturally Sensitive Health Care Inventory The Tucker Culturally Sensitive Health Care Inventory for African-Americans (TCUSHCI-AA; see Appendix D; Please note that only the first page of the T-CUSHCI-AA is provided in the Appendix as copy permission for this inventory ha s not been granted) was utilized to collect African-American lowincome primary care pa tients’ self-reported perceived level of cultural sensitivity in thei r clinic environment and interactions with health care providers and clinic-staff. The T-CUSHCHI-AA is based on health care provider and clinic staff be haviors and attitudes that low income African-American

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38 patients identified as indicators of patient-centered culturally sensitive health care via a focus group study (Tucker et al., 2003). Development of the T-CUSHI-AA involved tw o stages. In stage one, twenty ethnic and gender concordant focus groups invol ving 135 African-American patients (21 women, 31 men), Hispanic pa tients (27 women, 18 men) and European patients (23 women, 15 men) recruited from four primary care community-based c linics were invited to discuss behaviors and attit udes that indicate cultural sensi tivity in the health care they receive. Specifically, they were asked the following questions: (a) What does/could your doctor/provider do to make you feel comfortabl e /uncomfortable with him or her?; (b) What makes you trust/not trust your doctor/provi der? What could your doctor do to help you trust him or her more?; (c) What doe s/could your doctor/provider do to show you respect and be sensitive to your needs?; (d) What could your doctor/provider do to show that he or she is sensitive to your needs a nd is respectful of you as an African-American?; (e) What can doctors/providers do to beco me better at helping patients from racial, language or cultural background? The patientsÂ’ responses to these questions were audio recorded, transcribed, and analyzed us ing a constant comparative method. In the second stage of development of the T-CUSCHI, the responses from each ethnic group of patients were used to cons truct an ethnicity specific Health Care Importance Rating Survey (HIRS). Next, 221 patients (82 African-American patients,94 European American patients, and 45 Hispanic American patients) similar to those in stage one rated the importance of each culturall y sensitive behavior a nd attitude that the focus group patients reported as indicators of cu lturally sensitive health care Responses on the HIRS were organized into five groups: (1) health care provider trust behaviors, (2)

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39 health care provider comfort behaviors, (3) health care provider respect behaviors, (4) clinic staff behaviors, and (5) clinic e nvironment characteristics. Ratings of the importance of the items constituting each of th ese five groupings were made using a fivepoint scale where 1= not at a ll important, 2 = somewhat impo rtant 3= important, 4 = very important, and 5 = extremely important. Items rated as 3, 4, or 5 on each ethnicity specific HIRS, were used to construct a TCUSCHI for each ethnic group (i.e., the TCUSCHI-AA, T-CUSHCI-HA, and T-CUSCH I-CA). The African-American version of the HIRS was used to develop the T-CUSCHI-AA. The T-CUSCHI-AA, which was used in the present study, consists of 3 subscales: (1) Health Care Provider Behaviors and A ttitudes (i.e., behaviors and attitudes that promote patient trust, comfort, and respect ), (2) Clinic Office Staff Behaviors and Attitudes, and (3) Clinic Environment Charac teristics. Only the Health Care Provider Behaviors and Attitudes subscale was used in the current study as it is specifically related to patients’ health care experien ces with their health care providers. Sample items from the Health Care Provider Behaviors and Attitudes subscale on the T-CUSCHI-AA are as follows: (a) “Is honest and direct with me,” (b) “Does not look down on me”, and (c) “Treats me with respect.” The T-CUSCHI-AA consists of a 4-point likert scale from 4 (Strongly agree) to 1(Strongl y disagree). The instructions on this inventory are for participants to: (a) take a few seconds to th ink about their experiences with the health care provider they see most often for health car e at their health care clinic, and (b) rate how much they agree that this health care pr ovider shows each characteristic or behavior listed in the inventory when providi ng them with health care.

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40 The five-month test-retest reliability fo r the Health Care Provider Behaviors and Attitudes subscale of the T-CUSCHI-AA is .99 and its split-half reliability is .94. The internal consistency of this inventory is .98 (Tucker et al., unpublished manuscript ). Interpersonal Spheres of Control Scale (ICS) The Interpersonal Spheres of Control Scal e (ICS; see Appendix E) was utilized to measure degree of interper sonal control (Paulhus, 1983; Paulhus & Christie, 1981; Paulhus & Van Selst, 1990). The ICS is one of three subscales of version three of the Spheres of Control Scale (SOC-3), a scale th at measures an indi vidual’s behaviorallybased perceived utilization of control in three main spheres, or domains of their life: personal control (PC), interpersonal control (ICS), and sociopolitical control (SPC). The ICS subscale, which measures a person’s perc eived interpersonal c ontrol has a Crombach Alpha of .83. Respondents are asked to rate how much they agree with the 10 items that make up the ICS subscale using a 7-point Likert scale from 1 (disagree) to 7 (agree). Negative item responses are reve rse-scored and all 10 items are summed to calculate a score. A sample item from the scale is: “I often find it hard to get my point of view across to others.” Patient Satisfaction The Patient Satisfaction Ques tionnaire Short-Form (PSQ-18; see Appendix F) is an 18-item survey that measures patients’ genera l satisfaction with health care as well as their satisfaction with specific as pects of their health care ex periences with regards to the characteristics of their doctors and the medi cal care services they receive (Marshall & Hays, 1994). The PSQ-18 is a shorter vers ion of the 50-item Patient Satisfaction Questionnaire-III (PSQ-III) (M arshall & Hays, 1994; Marshall, Hays, Sherbourne, & Wells, 1993). The PSQ-18 was developed and te sted on a large multi-racial/ethnic sample

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41 included in the Rand Medical Outcomes Study (MOS). The PSQ-18 reliability estimates ranged from .64 to .77. The PSQ-18 consists of the following subscales: 1) General Satisfaction; 2) Technical Quality (competence) of health care health care provider; 3) Interpersonal Manner; 4) Communication; 5) Financial Aspects; 6) Time Spent with Doctor; and 7) Accessibility and Conveni ence (Marshall & Hays, 1994). Some PSQ-18 items are worded so that agreement reflects satisfaction with medical care, whereas other items are worded so that agreement reflects dissatisfaction with medical care. All items were scored so that high scor es reflected satisfaction with medical care. The average of items that make up each individual subscale fo rmed 7 total subscale scores. Items on the PSQ-18 are rated on a 5-point like rt scale from 1 (strongly ag ree) to 5 (strongly disagree) or 5 (strongly agree) to 1 (strongly disagree). The scores on the Interpersonal Manner and the Communication subscales were used in the current study. Speci fically, the scores for these two subscales were combined. The Communication subscale measures satis faction with the communication process between the patient and health care provider. A sample item on this subscale is: “Doctors sometimes ignore what I tell them.” The Interpersonal Manner subscale measures patients’ satisfaction with their health care providers’ interpersonal mannerisms. A sample item on this subscale is: “My doctor tr eats me in a very friendly and courteous manner.” The reliability estimates for the communication subscale is .64 and for the interpersonal manner subscale is .66. Medication Adherence The Morisky Medication Adherence Scal e (MMA; see Appendix G). (Morisky et al., 1986) is a fouritem yes/ no response, self-report measur e of medicatio n adherence. The MMA has a reported Cronbach’s alpha in ternal consistency re liability of 0.61. The

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42 current study found a Cronbach’s alpha intern al consistency reliability of .69 for the MMA. The MMA is scored by totaling the number of “no” answers to the 4 questions that constitutes this measure. Higher scores represent greater adhere nce to medication. The four questions constituting the MMA ar e: “Do you ever forget to take your medicine?”; “Are you careless at times a bout taking your medicine?”; “When you feel better do you sometimes stop taking your medici ne?”; and “Sometimes if you feel worse when you take the medicine, do you stop taking it?”; Procedure In the larger study of culturally sensitiv e health care in which the present study’s data was collected at baseline, patients who fit th e study criteria were recruited through the following two methods: (a) clinic mailings and (b) recrui tment posters displayed in the participating clinics. In the clinic mailings method, pot ential partic ipants were identified by clinic representatives from bot h Eastside Health Cent er (the intervention clinic) and Family Medical Group Practice (the control clinic ) and sent study participation invitation packets consisting of the following:, (a) an invitation letter (see Appendix H), (b) a Demographic Data Ques tionnaire (DDQ), (c) two copies of an informed consent form (one to keep for thei r files and one to retu rn signed; see Appendix I) and (d) a stamped pre-addressed envelope to return these study materials. The invitation letter stated the fo llowing: (a) the procedure that identified them to participate in the study; (b) the purpos e of the study; (c) the inst ructions for completing and returning an informed consent form and DDQ if they agreed to participate; (d) participation procedure information including that potential participants would receive a participation packet within a few months of sending a signed informed consent form and completed DDQ; (e) an explanation of how th eir confidentiality would be protected, (f)

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43 the instruction that they should call the prin cipal investigator in the event that their mailing address information changes; and (g) participation incentive information including that they would be paid $20 for completing some questionnaires that would be mailed to them within two weeks, and (h) pa yment information including that they would receive the $20 payment within three weeks of their participation. Researchers mailed participation questionna ire packets to each person who returned a signed informed consent form and comple ted the DDQ. These questionnaire packets included the following: (a) a cover letter (see APPENDIX J); (b) a self-report Medical Data Sheet (MDS); (c) the Assessment Batter y (AB); (d) payment forms to receive $20 and (e) a pre-addressed and pre-stamped envelo pe for returning the completed versions of these study materials. The cover letter menti oned that it would take approximately one hour for participants to comple te the questionnaire packet. In the poster recruitment method, particip ants were recruited via recruitment posters placed at both the intervention and c ontrol clinics. The cont ent of the poster (a) informed patients that University of Flor ida based research team requested their participation in a study to examine ways of improving the health care and support they receive from their health car e providers, (b) specified the study inclusion criteria, (c) indicated that patients would be mailed a payment of $20 within three weeks of their participation, (d) instructed patients to co mplete contact information slips, which were attached to the poster and requested the pati entÂ’s name, gender, race /ethnicity, telephone number, and address, and (e) instructed patien ts to place completed slips into an envelope attached to the poster. The slips were periodically collected and mailed to the researchers by one research consultant at each of the par ticipating clinics. Researchers then mailed an

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44 invitation packet (i.e., an invitation letter, informed consent forms and DDQ, and a stamped pre-addressed envelope for returni ng these study materials) to each potential participant meeting the study cr iteria who completed a slip. T hose patients who returned a signed copy of the informed consent form and a completed DDQ were mailed the above described questionnaire packet. The order of the forms and questionnai res in the participation packet was counterbalanced with the cover letter appe aring first, and the Payment Release Form appearing last always. To ensure the conf identiality of participants, participation materials were pre-coded before being maile d to potential patien t participants. In addition, the received questionnai re data and patient identifyi ng information were kept in separate locked cabinets in the research la b used for this study (i.e., the Behavioral Medicine Lab in the Psychology Departme nt of the University of Florida). Table 3-1. Demographic and descriptive char acteristics of the participant sample. Characteristic N % M SD__ Age(years) 52.69 11.54 18 – 28 1 1.1 29 – 39 9 10.1 40 – 55 42 47.2 56 – 77 24 27.0 Unknown 13 14.6 Gender Female 68 76.4 Male 20 22.5 Unknown 1 1.1 Income Below $10,000 54 60.7 $10,001$20,000 11 12.4 $20,001$30,000 10 11.2 $30,001$40,000 1 1.1 Above $40,001 3 3.4 Unknown 10 11.2

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45 Table 3-1. Continued. Characteristic N % M SD__ Education level Elementary school 3 3.4 Middle/Junior high school 14 15.7 High school education 33 37.1 Some college/technical school 14 15.7 College education 4 4.5 Professional/graduate 3 3.4 Unknown 18 20.2 Number of years with hypertension di agnosis 0-1 Years 18 20.2 2-3 Years 20 22.5 4-5 Years 9 10.1 6-7 Years 9 10.1 8-9 Years 5 5.6 10+ Years 22 24.7 Unknown 6 6.7 Symptomatic status Symptomatic 68 76.4 Asymptomatic 15 16.9 Unknown 6 6.7 Comorbidity status Hypertension only 20 74.1 Hypertension plus other diseases 7 22.5 Unknown 62 7.8 Medication use Yes 83 93.3 No 3 3.4 Unknown 3 3.4 _________________________________________________________________ Note: The Unknown category is due to mi ssing data information resulting from unreported participant answers.

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46 CHAPTER 4 RESULTS Descriptive Data for Main Study Variables This section contains information regarding the variables of interest in the present study. Table 4-1 provides the descriptive data fo r the major variables of interest. Tables 4-2 through 4-5 provide the means and standard deviations for the major variables of interest by age, gender, education, and income. Preliminary Data Analyses A preliminary Pearson product-moment co rrelation analysis was conducted to determine if there were signifi cant correlations among all study variables of interest [i.e., perceived cultural sensitivity (T-CUSCHI-AA) perceived interpersonal control (ICS), health care satisfaction (PSQ-18), medication adherence (MMA), age, education level, gender, symptom status, and number of years since receiving a hypertension diagnosis.], and to determine if social desirability (MCSDS) scores were signi ficantly correlated with these study vari ables (Table 4-6 ) As shown in Table 4-6, cultural sensitivity scores were found to have a moderately high and significantly positive correla tion with health care satisfaction ( r = .721, p = .001) and a low but significant positive correlation with symptom status ( r = .306, p = .005), suggesting that particip ants who reported higher leve ls of perceived cultural sensitivity in health care experienced with th eir health care provider also reported higher levels of health care satisf action and greater reported hypert ensive symptoms. In addition, health care satisfaction scores were f ound to have a low but significantly positive

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47 correlation with gender ( r = .280, p = .009), suggesting that there is an association between participantÂ’s gender in relation to their level of health care satisfaction. Furthermore, medication adherence scores were found to have a low but significantly positive correlation with age ( r = .254, p = .024), suggesting that there is an association between participantÂ’s age in relation to their level of medication adherence. Social desirability scores were found to have a low but significant positive correlation with health care satisfaction ( r = .214, p = .046) and a significant moderate positive correlation with interpersonal control ( r = .356, p = .001), suggesting that participants who scored higher on social desira bility also reported higher levels of health care satisfaction and perceived in terpersonal control. Also, social desirability scores were found to have a low but significant positive correlation with gender ( r = .286, p = .007), suggesting that there is an association between participantÂ’s gender and social desirability. Therefore, social desirability was controlled fo r in all analys es involving the variables patient satisfaction, inte rpersonal control, and gender. Data Analyses to Test the Two Hypotheses in This Study Hypothesis one in this study is as fo llows: African-American low-income hypertensive patientsÂ’ levels of perceived cultural sensitivit y in health care experienced with their health care provider (i.e., h ealth care provider behaviors/attitudes) and perceived interpersonal control will have si gnificant positive associations with their levels of health care satisf action (i.e., patientsÂ’ satisfac tion with their health care providers communication and inte rpersonal manner combined). A hierarchical linear regression analysis was performed to test this hypothesis in order to determine the amount of variance in patientsÂ’ levels of h ealth care satisfaction (the criterion variable) uniquely explained by the incremental addition of the predictor

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48 variables (i.e., patientsÂ’ pe rceived cultural sensitivity and perceived interpersonal control), controlling for social desirabilit y. Social desirability was entered into the analysis first, to control for any effects on health care satisfaction. Next, perceived cultural sensitivity and perceived interpersonal control were simultaneously entered into the model. The model containing all thr ee predictor variables was significant, F (3, 84) = 33.185, p < .0005, and explained a large amount of variance in health care satisfaction (R2 = .542). As shown in Table 4-7, perceived cultural sensitivity uniquely explained a significant amount of variance in health care satisfaction, = .707, t (3, 84) = 9.546, p < .0005, whereas interpersonal control did not uniquely explain a si gnificant amount of variation in patient satisfaction. Hypothesis two stated the following: African-American low-income hypertensive patientsÂ’ levels of health car e satisfaction (i.e.,, satisfacti on with health care providersÂ’ communication and interpersonal manner combined ) in association with patientsÂ’ levels of perceived cultural sensitivity in health care experienced with their health care provider(i.e.,, health care pr ovider behaviors/attitudes) and perceived interpersonal control, will significantly pred ict patientsÂ’ levels of self -reported medication adherence. A hierarchical regression analysis was pe rformed to test hypothesis two in order to determine the amount of variance in patient sÂ’ self-reported medica tion adherence (the criterion variable) uniquely explained by th e addition of the predictor variables, controlling for social desirability. The pr edictor variables were perceived cultural sensitivity, perceived interpersonal contro l and health care sa tisfaction. In this hierarchical regression analysis, social desi rability was entered into the model first, followed by the simultaneous entry of perceived cultural sensitivity, perceived

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49 interpersonal control, and health care satis faction. The full model was not significant, F (4, 81) = 1.491, p = .213 and none of the individua l predictor variables uniquely explained a significant portion of patientsÂ’ self-reported medi cation adherence, as shown in Table 4-8. Data Analyses to Test the Two Research Questions in This Study Research question one is as follows: Are th ere significant age, education level, and gender differences in African-American lowincome hypertensive patientsÂ’ levels of perceived cultural sensitivity in the health car e they experienced with their health care provider, perceived interpersona l control, self-reported medi cation adherence, and health care satisfaction? To address research question one, a multivariate analysis of covariance (MANCOVA) was performed to determine possibl e differences in patientÂ’s levels of perceived cultural sensitivity in the health care they experienced with their health care provider, perceived interpersona l control, self-reported medi cation adherence, and health care satisfaction in association with patient sÂ’ age, education level and gender. The independent variables were patientsÂ’ age, education level, and gender. The dependent variables were interpersonal control (ICS), self-reported medication adherence (MMA), health care satisfaction (i.e., satisfacti on with their providersÂ’ communication and interpersonal manner combined), and perceived cultural sensitivity of provider behaviors and attitudes. Social desirability was included in the model as a covariate. No significant multivariate effects were f ound for age (WilksÂ’ Lambda F (9, 82.898) = .977, p = .465), education level (WilksÂ’ Lambda F (15, 94.260) = .682, p = .796), or gender (WilksÂ’ Lambda F (3, 34) = .320, p = .811). In addition, separate fo llow-up analyses of variance (ANOVAs) were conducted to determine if th ere were between group differences. These

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50 analyses revealed no significant results. Thus, no further interpretati on or analyses were indicated. Research question two is as follows: Are there significant differences in AfricanAmerican low-income hypertensive patient sÂ’ levels of self-reported medication adherence in associati on with symptom status (i.e.,, sy mptomatic versus asymptomatic) and the number of years since receiving a hypertension diagno sis? To address research question two, an analysis of variance ( ANOVA) was performed to determine possible differences in patientsÂ’ self -reported medication adherence in association with their symptom status and number of years since th ey have received a hypertension diagnosis. The independent variables were number of y ears since receiving a hypertension diagnosis and symptom status (i.e., symptomatic versus asymptomatic), and the dependent variable was self-reported medication adherence. The resu lts of this analysis revealed a significant interaction effect between number of years since receiving a hypert ension diagnosis and symptom status, F (4,70) = 2.528, p < .048. Thus, the effect of self-reported symptom status on medication adherence significantly va ries relative to number of years since receiving a hypertension diagnosis A profile plot of this inte raction effect is provided in Figure 4-1.

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51 Table 4–1. Major variables of interest in this study. Variables and (measures) Min Max Mean SD Norm Mean Cultural sensitivity (T-CUSHCI-AA) Provider behaviors/attitudes subscale 1.63 4.00 3.26 .55 N/A Interpersonal control (ICS) 15 70 44.72 10.17 48.80a Health care satisfaction (PSQ-18) Interpersonal manner (IM) 1.00 5.00 3.92 .89 4.09b Communication (CM) 1.00 5.00 3.91 .88 3.74b IM and CM combined 1.00 5.00 3.93 .75 N/A Medication adherence (MMA) 0 4 2.48 1.39 2.31c Note. a (Paulhus & Van Selst, 1990), b (Marshall & Hays, 1994), c (Morisky, Green, & Levine, 1986). Table 4–2. Major variables of interest by age categories. Age Variables 18 – 28 29 – 39 40 – 55 56 – 77 Unknown and (measures) (N=1) (N=9) (N=42) (N=24) (N=13) IM and CM 4.500* 3.972 (.537) 3.905 (.843) 3.983 (.753) 3.868(.616) T-CUSCHI-AA 3.318* 3.213 (.443) 3.259 (.585) 3.292 (.521) 3.234(.596) ICS 66.000* 43.220 (6.360) 44.980 (10.218) 45.920 (10.818) 40.750(9.526) MMA 2.000* 2.000 (1.323) 2.240 (1.411) 3.000 (1.382) 2.690(1.251) Note: “IM and CM” denotes Interpersonal Manner and Communication combined, “T-CUSHIAA” denotes Cultural Sensitivit y: Provider Behaviors/Attitudes Subscale, “ICS” denotes Interpersonal Control, “MMA” denotes Medi cation Adherence. No reported Standard Deviation.

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52 Table 4–3. Major variables of interest by gender. Gender Variables Male Female Unknown and (measures) (N=20) (N=68) (N=1) IM and CM 3.546 (.913) 4.046 (.666) 4.250* T-CUSHI-AA 3.122 (.546) 3.291 (.541) 3.903* ICS 42.450 (7.338) 45.450 (10.884) 41.000* MMA 2.950 (1.276) 2.310 (1.395) 4.000* Note: “IM and CM” denotes Inte rpersonal Manner and Co mmunication combined, “TCUSHI-AA” denotes Cultural Sensitivity: Prov ider Behaviors/Attitu des Subscale, “ICS” denotes Interpersonal Contro l, “MMA” denotes Medication Adherence. No reported Standard Deviation. Table 4–4. Major variables of in terest by education level. Variables and Measures Education Level IM & CM T-CUSHI-AA ICS MMA Elementary school 4.000 (.433) 3.333 (.577) 38.330 (2.082) 2.670 (2.309) Middle/Junior high school 4.103 (.672) 3.388 (.590) 46.310 (9.286) 1.860 (1.562) High school education 3.902 (.739) 3.233 (.4961) 43.580 (8.182) 2.590 (1.365) Some college/tech school 3.786 (.692) 3.046 (.514) 46.640 (9.467) 2.790 (1.188) College education 4.229 (.393) 3.193 (.284) 54.250 (17.056) 2.750 (.957) Professional/Graduate 4.167 (.629) 3.015 (.845) 51.330 (24.194) 3.67 (.577) Unknown 3.875 (1.001) 3.420 (.613) 42.000 (10.064) 2.220 (1.396) Note: “IM and CM” denotes Interpersonal Manner and Communication combined, “T-CUSHIAA” denotes Cultural Sensitivit y: Provider Behaviors/Attitudes Subscale, “ICS” denotes Interpersonal Control, “MMA” denotes Medi cation Adherence. (Elementary school: N=3, Middle/Junior high school: N=14, High school education: N=33, Some college/tech school: N=14, College education: N=4, Prof essional/Graduate: N=3, Unknown: N=18)

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53 Table 4-5. Major variables of interest by income level. Variables and Measures Income IM & CM T-CUSHI-AA ICS MMA Below $10,000 4.002 (.724) 3.316 (.541) 43.640 (8.246) 2.420 (1.393) $10,001$20,000 3.697 (.805) 2.984 (.498) 45.360 (9.201) 2.450 (1.440) $20,001$30,000 3.833 (.866) 3.191 (.666) 49.600 (10.895) 2.600 (1.350) $30,001$40,000 4.667* 4.000* 29.000* 4.000* Above $40,001 3.667 (.520) 2.955 (.124) 56.670 (13.317) 3.33 (.577) Unknown 3.950 (.840) 3.345 (.493) 42.800 (15.533) 2.300 (1.636) Note: “IM and CM” denotes Inte rpersonal Manner and Co mmunication combined, “TCUSHI-AA” denotes Cultural Sensitivity: Prov ider Behaviors/Attitu des Subscale, “ICS” denotes Interpersonal Contro l, “MMA” denotes Medication Adherence. No reported Standard Deviation. (Below $10,000: N=54, $10,001$20,000: N=11, $20,001$30,000: N=10, $30,001$40,000: N=1, Above $40,001: N=3, Unknown: N=10.) Table 4-6. Correlations between all study va riables of interest including social desirability. Variables 1 2 3 4 5 6 7 8 9 10 1. Cultural Sensitivity ___ .035 .721** .-020 .109 .131 .306** .035 .84 -.190 (Provider behaviors/attitudes) 2. Interpersonal Control ___ .091 .141 -.042 .124 .076 -.036 .356** .228 3. Health Care Satisfaction ___ -.053 .001 .280** .211 .059 .214* -.008 4. Medication Adherence ___ .254* -.194 -.055 .080 .170 .231 5. Age ___ -.014 .092 .197 .096 -.111 6. Gender ___ .189 -.090 .286** .125 7. Symptom Status ___ .134 .174 -.030 8. Number of Years with Hypertension Diagnosis ___ -.137 .071 9. Social Desirability ___ .088 10. Education ___ Note. p < .05, ** p < .01;

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54 Table 4-7. Hierarchical regres sion predicting patientsÂ’ health care satisfaction (PSQ-18). B SEB t Model Cultural Sensitivity (Provider behavior/attitudes) 0.970 0.102 0.707 9.546** Interpersonal Control 0.001 0.006 0.014 0.179 Note. p < .05, ** p < .0005 Table 4-8. Hierarchical regression predic ting patientsÂ’ self-reported medication adherence (MMA). B SEB t Model Interpersonal Control 0.018 0.016 0.133 1.145 Cultural Sensitivity (Provider behavior/attitudes) 0.394 0.418 0.154 0.942 Health Care Satisfaction -0.416 0.307 -0.227 -1.357 Note. All t -tests were non-significant. 0-12-34-56-78-910+Number of Years with Hypertension Diagnosis 0 1 2 3 4Mean Medication Adherence Symptom Status Asymptomatic Symptomatic Non-estimable means are not plotted Figure 4-1 Mean medication adherence as a function of number of years with hypertension diagnosis and symptom status

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55 CHAPTER 5 DISCUSSION This chapter will provide a summary of the findings of this study and will provide interpretations of the results. In addition, the implications, limitations, and future direction of the research conducted will be discussed. The current study utilized the Patient-Ce ntered Culturally Sensitive Health Care (PC-CSHC) model to examine the self-repor ted medication adherence of low-income African-American hypertensive patients w ho utilize community-based primary care clinics. Based on this model, the present study examined: (a) how low-income AfricanAmerican patientsÂ’ perceived levels of cultura l sensitivity in health care provider-patient interactions and these patientsÂ’ perceived inte rpersonal control are associated with their satisfaction with their health care provid ersÂ’ communication and interpersonal manner, and (b) the association between satisfacti on with health care pr ovidersÂ’ communication and interpersonal manner and medication adherence among these patients. The predictor variables of cultural sensitivity, interpersona l control and health care satisfaction were examined as factors in self-reported medi cation adherence of the above specified African-American patients. Summary of Findings This study examined African-American lowincome hypertensive patientsÂ’ level of perceived cultural sensitivity in health care experienced with thei r health care provider and interpersonal control as pr edictors of their he alth care satisfaction, and it examined

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56 these patientsÂ’ health care satisfaction as a predictor of their se lf-reported medication adherence. Hypothesis one proposed that African-Amer ican low-income hypertensive patientsÂ’ levels of perceived cultural sensitivity in heal th care experienced w ith their health care provider (i.e., health care pr ovider behaviors/attitudes) and perceived interpersonal control will have significant positive associations with their levels of health care satisfaction (i.e., patientsÂ’ sa tisfaction with their health care providers communication and interpersonal manner combined). This hypothesis was partially supported by the finding of a significant positive association between low-income African-A merican hypertensive patientsÂ’ level of perceived cultural sensitivity and level of h ealth care satisfaction. The finding that there was not a significant association between interpersonal contro l and health care satisfaction did not s upport this hypothesis. Hypothesis two proposed that African-Amer ican low-income hypertensive patientsÂ’ levels of health care satisfaction (i.e.,, satisfaction with h ealth care providersÂ’ communication and interpersonal manner combined ) in association with patientsÂ’ levels of perceived cultural sensitivity in health care experienced with their health care provider(i.e.,, health care pr ovider behaviors/attitudes) and perceived interpersonal control, will significantly pred ict patientsÂ’ levels of self -reported medication adherence. This hypothesis was not supporte d as no significant associat ion was found between the individual predictor variab les and level of self-reporte d medication adherence. Two research questions were also ex amined: (1) Are there significant age, education level, and gender differences in African-American low-income hypertensive

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57 patientsÂ’ levels of perceived cultural sensitiv ity in the health care they experienced with their health care provider (i .e.,, health care provider beha viors/attitudes), perceived interpersonal control, self-re ported medication adherence, an d health care satisfaction?; (2) Are there significant differences in African-American low-income hypertensive patientsÂ’ levels of self-repor ted medication adherence in asso ciation with their number of years since receiving a hypertension diagnosis and symptom status (i.e., symptomatic versus asymptomatic status)? Findings from the analyses to examine research question 1 revealed no significant age, education level or gender differences in the participating patientsÂ’ levels of perceived cultural sensitiv ity in the health care they experience with their health care provider, pe rceived interpersonal control, and self-reported medication adherence. Findings from the analyses to examine research question 2 revealed no significant differences in African-American lo w-income hypertensive patientsÂ’ levels of self-reported medication adhe rence in association with the number of years since receiving a hypertension diagnosis and symp tom status (i.e., symptomatic versus asymptomatic status). However, there was a significant interaction effect between number of years since recei ving a hypertension diagnosis and symptom status was found. A profile plot of this inte raction revealed that from 0 to 6 years after receiving a hypertension diagnosis, the mean self-repor ted medication adherence scores of the asymptomatic group increased from 2.5 to 4 on a scale from 0 to 4, and then sharply decreased to 0 at 6-7 years af ter receiving a hypertension diag nosis before they increased to 3.5 for those who received a hypertension di agnosis over 10 years ago. In contrast, the mean self-reported medication adherence scor es of the symptomatic group decreased from 2.5 to 1.5 during the 0 to 4/5 years after receiving a hypertension diagnosis and

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58 then consistently increased from a mean of 1.5 to a mean of 3.5 6 years or more after receiving a hypertension diagnosis. Interpretation and Implications of the Research Findings In the current research study a signifi cant positive association was found between low-income African-American hypertensive patientsÂ’ levels of perceived cultural sensitivity of the health care provided by health care providers and health care satisfaction. Specifically, it is particularly no teworthy that, cultural sensitivity accounted for over 70% of the variance in patient satis faction compared to the minimal amount of variance (5%) explained by patientsÂ’ social de sirability. Thus, there appears to be a strong positive relationship between low income African-American hypertensive patientsÂ’ levels of perceived cultural sensitiv ity of the health care provided by health care providers and health care satisfaction. These findings provide some support for the PC-CSHC ModelÂ’s assertion that patient-defined culturally sensitive provider be haviors and attitudes are associated with patient satisfaction with the quality of th eir health care they experience (Tucker, in press ). These findings are also consistent with past studies and repor ts that also have documented that cultural sensitivity/cultural competence in the health care process is related to patient satisfaction with health care (Collins et al ., 2002; Cooper et al., 2003;Cooper-Patrick et al., 1999; Johnson, Saha et al., 2004;Tuc ker et al., 2003; Tucker et al., in press).These find ings indicate the need for health care provider cultural sensitivity training that is based on patient definitions and perceptions about what constitutes culturally sensitive health care. In addition, the finding that cult ural sensitivity of health care providers as perceived by low income African-American hypertensi ve patients predicts their health care

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59 satisfaction also has important implications for counseling psychologists, especially given the recent national calls for cult urally competent and culturally sensitive health care to help reduce health disparities (AHRQ, 2003; IOM, 2002; DHHS, 2000). The field of counseling psychology has a long-standing hist ory of promoting cultural competence, cultural sensitivity and cultural-specific appr oaches to treating individuals that are culturally different (Sue, Arredondo, & Mc Davis, 1992; Sue et al., 1996). Thus, counseling psychologists have th e necessary culture-specific knowledge and skills to help address the calls for evidence-based research studies and interventions that examine the health care quality and health care satisfaction issues related to ethnic and racial health disparities. Additionally, give n that counseling psychologists are trained in multicultural competencies, they are highly qualified to de velop both patient and health care provider cultural-sensitivity training interventions designed to improve the health care experiences of low income minority patients. The current research study did not find a significant associati on between patientsÂ’ levels of interpersonal control and health care satisfaction. This finding is inconsistent with the PC-CSHC model, which proposes that a patientsÂ’ level of interpersonal control is a predictor of patient satisfaction (Tucker, in press ). In addition, this finding contradicts previous resear ch findings that reported a connection between increased health care satisfaction and patientsÂ’: (a) ac tive involvement in th eir health care, (b) increased participation in the health car e process, (c) sense of control and (d) empowerment (Auerbach, 2000;2001;Cooper-Patrick et al., 1999; Kiesler & Auerbach, 2003; Street et al., 2003).

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60 The finding of no significant association be tween patientsÂ’ perceived interpersonal control and health care satisfaction may be due to the measure used to examine patientsÂ’ interpersonal control in the study. This measure was predominantly normed on undergraduate students (Paulhus, 1983;Paulhus & Van Selst, 1990) and thus, it was likely not a culturally appropriate measure for use with the low income African-American primary care patients in the current study. Furt hermore, the instrument did not directly measure patientsÂ’ interpersonal control in th e context of patient-health care provider interaction in health care. The current research study did not find a significant associ ation between selfreported level of health care satisfaction and level of self-reported medication adherence. The study focused on patientsÂ’ satisfacti on with their health care providerÂ’s communication and interpersonal manner. Th is focus was based on evidence in the literature that health care provider communication and interactions with their patients, particularly minority patients, is associated with medication and treatment adherence. However, the findings in this study did not s upport this relationship. This finding is also inconsistent with the theorized link between patientsÂ’ health care satisfaction and their medication adherence set forth in the PC-CSH C Model. There are possible explanations for this finding. For example, it is possible that individual factors not controlled for in the study were intervening variables between partic ipating patientsÂ’ hea lth care satisfaction and medication adherence. Such factors co uld include costs of medication, a complex medication regimen, appointment adherence, acc ess and continuity of care issues, and other patient-related and health system-re lated barriers (Jokisalo, Kumpusalo, Enlund, Halonen & Takala, 2002; Ogedegbe, Harrison, et al., 2004). Some researchers have found

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61 a relationship between decrea sed satisfaction and poor heal th status, suggesting that patient satisfaction with their health care coul d be influenced by factors unrelated to their experiences with their provider (Harris, Luft, Rudy, & Tierney, 1995). Other intervening factors could include patient dispositiona l differences and psychological factors not measured (Wang et al., 2002). Another explanation of our finding of no a ssociation between patientsÂ’ health care satisfaction and medication adherence is that medication adherence was self-reported and was based on only four question items. So me researchers have called for multiple measures of medication adherence and incl usion of multiple measures of medication adherence in research involving this vari able (DiMatteo, 2004; Krousel-Wood et al., 2004). Findings from the examination of resear ch question one revealed that there were no significant age, education level, or gender differences in our sample of AfricanAmerican low-income hypertensive patientsÂ’ le vels of perceived cultural sensitivity in the health care they experienced with their hea lth care provider, pe rceived interpersonal control, self-reported medication adherence, and health care satisfaction. This result could partly be due to the cu rrent studyÂ’s sample characteristics. For example, some participants chose not to report certain de mographic information (i.e.,, age, education level) which resulted in unknown data that coul d not be included in the data analysis to address research question one. In addition, the unrepresentati ve sample likely impacted the analysis to address research question one Our sample consisted mostly of female participants (76%), with few male participants and consisted of mostly older adults (M = 52.69). Thus, the power of the analyses to de termine gender and age differences in the investigated variables was likely minimized.

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62 It has been reported previously that e xpectations and beliefs of hypertensive patients about hypertension and medication adhere nce is associated with whether or not these patients experience symptoms or whether or not they believe that hypertension is a chronic disease (Heurtin-R oberts, 1993; Lukochek, 2003; Ogedegbe, Mancuso et al., 2004). Therefore, research question two ex amined whether number of years since receiving a hypertension diagnosis and sympto m status would be associated with selfreported medication adherence. Findings from the examination of question two revealed a significant interaction effect of number of years since receiving a hypertension diagnosis and symptom status on medication adherence. These results suggest that low income African-American hypertensive patients who are aymptomatic for hypertension may need to be consistently encouraged to adhere to their medication regime ns and to routinely monitor their blood pressure. Study Limitations and Future Research Direction The results of this study should be inte rpreted cautiously as it has a number of limitations that should ideally be addressed in future research. First, several competing confound variables with respec t to patient satisfaction a nd medication adherence, not controlled for in the study, could have account ed for the nonsignificant findings for the relationship between patient satisfaction and medication adherence. Specifically, patient dispositional and psychological characteristics, disease characteristics and severity, medication treatment experiences and health-related influences outside of the health care setting may possibly be linked to patient sa tisfaction and medication adherence behavior. The nonrepresentative sample size and involve ment of volunteer rather than randomly selected patient participants are also limitations of th e present study. Future similar

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63 studies utilizing larger and mo re representative patient samples than in the current study are needed. Using only self-report measur es in the current study is also a research limitation. The instruments used to measure interpers onal control and medicat ion adherence were not specifically developed fo r use with African-Americans, particularly not with older African-American patients. Furthermore, the interpersonal control construct addresses perceived interpersonal control rather than in terpersonal control specifically in health care settings or in interactions with health car e providers. In the future, similar research to the present study should ideally ut ilize a health care specific measure of personal control. Such a measure was not available when se lecting the measures for this study. It is also noteworthy that the Patient Sa tisfaction Questionnaire used in this study may not have captured the full range of communication and interpersonal manner dimensions affiliated with a patientsÂ’ satisfact ion with health care experienced with their health care provider. Dipalo (1997) advocates for patient sa tisfaction measures that ask patients to report instead of rate their satisf action experiences. Such reports would allow patients to provide unstructured, open-ended reporting on issues pertaining to their perceived satisfaction with their care. Futu re studies similar to the present study could utilize such measures of health care satisfaction. Additionally, the 4-item Mo risky Medication Adherence Questionnaire may not have been sensitive to the complex nature of medication adherence behavior. There are a number of other measures of medication adhe rence that have been utilized in other studies including electronic monitoring, pharm acy prescription medication refills, pill counts, medical records and self-blood pr essure measurement (DiMatteo, 2004; Takiya,

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64 Peterson, & Finley, 2004). Howeve r, self-report measures have been reported to be one of the more frequently used measurements of medication adheren ce (DiMatteo, 2004). In addition, many of these alternative methods ha ve their own reliability and measurement issues (Krousel-Wood et al., 2004). Compared to these alternative methods of measuring medication adherence, the medication adherence se lf report measure used in this study of medication adherence was feasible, economical, reliable and time efficient. Furthermore, the internal consistency of this measure in the present study was m oderately high (.69). It is also noteworthy that social desirability had a significant though low correlation with both patient satisfaction and interpersonal control. Su ch issues are inherent in research using self-report measures. Unlike in many pati ent satisfaction studies, the current study controlled for soci al desirability in the analys es to test our hypotheses and research questions. Furthermore, the cross sectional nature of the study did not allow long-term observation of the variables of interest. For example, patient satisfaction levels, hypertension symptom status and medication ad herence may typically fluctuate or change with time. Therefore, future research st udies on the medication adherence of AfricanAmerican hypertensive patient s should involve measurement of the associations between adherence, patient satisfacti on and symptom status over an extended period of time. Finally, a limitation of the current study is that its findings can not be generalized to all low-income African-Ameri can hypertensive patients. This is due to the fact that the previous focus group studies utilized to de velop the Tucker Culturally Sensitive Health care inventories (Tucker et al., 2003) as well as the current study sample consisted of low income African-American primary care patient s from Florida. Thus, the socioeconomic,

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65 geographical and cultural differences am ong low-income African-American patient populations limit the generalizab ility of the findings from the present study. However, this studyÂ’s finding of an association betw een low income Afri can-American primary care hypertensive patientsÂ’ perceived cultural se nsitivity in their health care experienced with their health care provider and their perceived level of hea lth care satisfaction provides support for similar future research studies like the present study that utilize larger and more culturally diverse sample s of African-American hypertensive patients and more culturally appropriate measures. Conclusion Despite the limitations of the present study, support is provided for future research to understand the links between culturally sensitive health care and health care satisfaction. The PC-CSHC Model has poten tial for explaining these links; however, future research to test this model is need ed. Such future research would benefit from culturally appropriate and objective measures of the investigated constructs. If such research supports the hypothe ses in the present study, needed support will be provided for the investment of money to make health car e delivery in this country more culturally competent/sensitive.

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66 APPENDIX A DEMOGRAPHIC DATA QUESTIONNAIRE (DDQ) Please provide the requested inform ation by shading in your answer. It should look like this: 1. What is your gender? Male Female 2. Your Race/Ethnicity: Cuban/Cuban-American Dominican Republican Mexican/Mexican-American/Chicano(a) Puerto Rican Other Hispanic/Latino (please specify: _____________________) Caucasian/White/European-American African-American/Black-American Other (please specify: _____________________) 3. Current relationship status: Single, living without a partner Single, living with a partner Married, living with a partner Married, not living with a partner Divorced or separated Widow/Widower 4. Employment Status: Work Full Time Work Part Time Do not work 5. Highest level of educatio n that you have completed : Elementary School Middle/Junior High School High School Some College/Technical School College Professional/Graduate School 6. Annual household income level: Below $10,000 $10,001 to $20,000 $20,001 to $30,000 $30,001 to $40,000 Above $40,001 7. Do you have children?

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67 Yes (How many?:________) No 8. If so, do your children live with you? Yes No 9. Religious Preference: Catholic Baptist Presbyterian Methodist Islamic Buddhist Jewish Other (Please specify: _________) 10. Language Preference (fo r future mailings): English Spanish Other (Please specify: ________________________) 11. Which clinic do you attend? Family Practice Medical Group Eastside Community Health Center Other (Please specify: ________________________) 12. Have you changed clinics since beginning this research study? Yes No 13. Have you changed doctors since beginning this research study? Yes No 14. What other research studies are you involve d with at your clinic? (check all that apply) “Florida Healthy State Program” “Medicaid Study” Other (please list): _________________________________________

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68 15. Has there been a change in your primar y care physician or nurse practitioner since you last completed these surveys? Yes No If Yes, please explain: ____________________________________________ 16. Did you receive any help when filling out these surveys? Yes No 17. How many times have you visited your clin ic since last completing these surveys? ______________ 18. How many years have you lived in this community? __________ 19. What is your Age? __________

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69 APPENDIX B MARLOWE-CROWNE SOCIAL DESIRA BILITY SCALE (M-C SDS) Directions: For each of the following statem ents, please fill in where you consider the statement to be True (T) or False (F). True False 1. I never hesitate to go out of my way to help someone in trouble. 2. I have never intensely disliked anyone. 3. I sometimes feel resentful when I don’t get my way. 4. I like to gossip at times. 5. There have been times when I felt like rebelling against people in authorit y even though I knew they were right. 6. I can remember “playing sick” to get out of something. 7. There have been occasions when I took advantage of someone. 8. I’m always willing to admit it when I make a mistake. 9. I always try to prac tice what I preach. I sometimes try to get even, rather than forgive and forget. 10. When I don’t know something I don’t at all mind admitting it.

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70 11. I am always courteous, even to people who are disagreeable. 12. At times I have really in sisted on having things my way. 13. There have been occasions when I felt like smashing things. 14. I would never think of letting someone else be punished for my wrong-doings. 15. I never resent being asked to return a favor. 16. I have never been irked when people expressed ideas very different from my own. 17. There have been times when I was quite jealous of the good fortune of others. 18. I am sometimes irritated by people who ask favors of me. 20. I have never deliberately said something to hurt someoneÂ’s feelings.

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71 APPENDIX C MEDICAL DATA SHEET (MDS) Directions : For this set of questions, please fill in the blank or shade in the circle next to the appropriate response from the choices given. Remember, your answers to all questions in this packet are kept strictly confidential and private. Questions ONE through SEVEN are only about hypertension, if you do not have hypertension, please do not answer these. 1. If you have high blood pressure, how many years has it been sinc e your health care provider told you (Circle one)? 0-1 years 2-3 years 4-5 years 6-7 years 8-9 years 10 plus years 2. Have you experienced symptoms related to the high blood pressure (Circle one)? YES NO 3. If you have experi enced symptoms, please list them here: __________________________________________________________________________________________________ _________________ 4. Which of the following has your physi cian or other health care provider recommended to treat your high blood pressure (Check all that apply)? Medication Diet Exercise Weight Loss Other: _________________ ____________________ _______________

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72 5. Have any other members of your family been diagnosed with high blood pressure? YES NO 6. If other members of your family have high blood pressure, what relation are they to you (check all that apply): Mother Father Grandmother Grandfather Other ________________ Son Daughter Aunt Uncle 7. How much do you agree or disagree that you can get ample amou nts of education and consultation about hyperten sion (Circle your answer)? Strongly Agree Somewhat Agree Neutral Somewhat Disagree Strongly Disagree 8. What illnesses are you currently diagnosed with? (check all that apply) Diabetes (Low Blood Sugar) High choleste rol (Hyperlipidemia) High blood pressure (Hype rtension) Coronary Artery Disease Other (please list): ________________________________________ 9. How long ago were you to ld that you had the cond itions listed above? ILLNESS OR CONCERN YEARS _________________ _________________ ________________ _______________

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73 ____________________ _________________ _________________ ___________ ____________________ _________________ _________________ ___________ ____________________ _________________ _________________ ___________ 10. Are you currently on any medications? YES If Yes, please list them: ___________________________ NO 11. Has your physician recommended you to exercise diet, or take medications for any of these other illnesses or medical co ncerns? If so, please list: YES NO

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74 APPENDIX D TUCKER CULTURALLY SENSITIVE HEALTH CARE INVENTORY-AFRICAN AMERICAN (T-CUSHCI-AA) DO NOT REPRODUCE WITHOUT THE WRITTEN PERMISSION OF DR. CAROLYN M. TUCKER DIRECTIONS : Take a few seconds to think about your experi ences with the person you see most often for health care at your health care c linic. This person might be a doctor, a nurse practitioner, or some other health care provider. Now please rate how much you agree that this person shows each characteristic or behavior listed below when pr oviding you with health care. Please use a rating of 4, 3, 2, or 1 where 4 = “Strongly Agree”, 3 = “Agree”, 2 = “Disagree”, and 1 = “Strongly Disagree”. Shade in the circle below the rating you choose like this Please rate all characteristics and behaviors listed on each page. Do not give us your name. Your ratings will be confidential Thus, please give honest ratings. Strongly A g ree Agree Disagree Strongly Disa g ree 4 3 2 1 THE PERSON I SEE MO ST OFTEN FOR MY HEALTH CARE WHEN I VISIT MY CLINIC: 1. Is compassionate or shows that he or she cares about how I feel. 2. Is honest and direct with me. 3. Is dedicated to her or his work. 4. Has a lot of schooling. 5. Knows what he or she is doing. 6. Responds to my requests 7. Appears to be concerned about my well-being.* 8. Treats all of her or his patients equally. 9. Makes helpful and reasonable recommendations.

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75 10. Explains things so that I understand them. 11. Shows that he or she is trying to help me out. 12. Treats me like a person, not just a number.* 13. Shows that he or she is inte rested in more than just making money. 14. Follows a common procedure fo r treating all of his or her patients. 15. Shows that he or she is familiar with my health.

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76 APPENDIX E INTERPERSONAL SPHERES OF CONTROL SCALE (ICS) The following statements are about interac tions and ‘interpersonal control’. Please read each statement carefully and bubble in the circle that matches how accurate you believe that statement is about you Please bubble only one circle for each statement. Totally Inaccurate Mostly Inaccurate Somewhat InaccurateNeutral Somewhat Accurate Mostly Accurate Totally Accurate 1 In my personal relationships, the other person usually has more control over the relationship than I do. 0 0 0 0 0 0 0 2 I have no trouble making and keeping friends 0 0 0 0 0 0 0 3 I’m not good at guiding the course of conversation with several others. 0 0 0 0 0 0 0 4 I can usually develop a close personal relationship with someone I find appealing. 0 0 0 0 0 0 0 5 I can usually steer a conversation towards the topics I want to talk about. 0 0 0 0 0 0 0 6 When I need assistance with something, I often find it difficult to get others to help. 0 0 0 0 0 0 0 7 If there is someone I want to meet I can usually arrange it 0 0 0 0 0 0 0 8 I often find it hard to get my point of view across to others. 0 0 0 0 0 0 0 9 In attempting to smooth over a disagreement I sometimes make it worse. 0 0 0 0 0 0 0 10 I find it easy to play an important part in most group situations. 0 0 0 0 0 0 0

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77 APPENDIX F PATIENT SATISFACTION QU ESTIONNAIRE (PSQ-13) Instructions : The following statements are some things people say about medical care. Please read each one carefully, keeping in mind the medical care you are receiving now. (If you have not received care recently, think about what you would expect if you needed care today.) There is no right or wrong answer. We are interested in your feelings, good and bad about the medical care you have received. How strongly do you AGREE or DISAGREE with each of the following statements? (Color or bubble in only ONE answer on each line) Strongly Agree Agree Uncertain Disagree Strongly Disagree 1. Doctors are good about explaining the reason for medical tests. 2. I think my doctorÂ’s office has everything needed to provide complete medical care. 3. The medical care I have been receiving is just about perfect. 4. Sometimes doctors make me wonder if their diagnosis is correct. 5. I feel confident that I can get the medical care I need without being set back financially. 6. When I go for medical care, they are careful to check everything when treating and examining me. 7. I have to pay for more of my medical care than I can afford. 8. I have easy access to the medi cal care specialists I need. 9. Where I get medical care, peopl e have to wait too long for emergency treatment. 10. Doctors act too businesslike and impersonal towards me. 11. My doctors treat me in a very friendly and courteous manner. 12. Those who provide my medical care sometimes hurry too much when they treat me. 13. Doctors sometimes ignore what I tell them. 14. I have some doubts about the ability of the doctors who treat me. 15. Doctors usually spend plenty of time with me. 16. I find it hard to get an appointme nt for medical care right away. 17. I am dissatisfied with some things about the medical care I receive. 18. I am able to get me dical care whenever I need it.

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78 APPENDIX G MORISKY MEDICATION ADHERENCE SCALE (MMA) Directions: Please answer the following que stions by circling either “yes” or “no”. Remember, your answers are completely confiden tial and will not be shared with anyone. 1. Do you ever forget to take your medicine? Yes No 2. Are you careless at times a bout taking your medicine? Yes No 3. When you feel better do you sometimes stop taking your medicine? Yes No 4. Sometimes if you feel worse when you take the medicine, do you stop taking it? Yes No

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79 APPENDIX H STUDY PARTICIPATION INVITATION LETTER Dear Patient: You have an opportunity to participate in a University of Florida research study about your experiences as a patient at the Family Practice Medical Group. WHAT IS THIS ABOUT? The researcher wants to know about your experiences with your doctors, nurses, and clinic staff. The information you give us is very important because it may help us improve the health care and support that you and other patients like you receive from healthcare providers. WHAT DO YOU HAVE TO DO? If you agree to participate, we will mail Study Questionnaires to you. Depending on when you join the study and/or when you stop participation, you will be asked to complete between two and six assessment packets approximately once every four to six months. You may also participate in a short training session near the end of the study. HOW LONG IS IT GOING TO TAKE? Completing the Study Questionnaires should take no more than one hour each. WILL MY ANSWERS BE KEPT PRIVATE? Yes! Nobody will know if you agree to participate. Nobody at the Family Practice Medical Group will see your answers if you complete the questionnaires. WILL I BE PAID? Yes, you will be paid twenty dollars ($20) ea ch time you complete and return the Study Questionnaires that we will send you. You w ill also receive sixty do llars ($60 ) if you decide to come to the training se ssion near the end of the study. HOW CAN I FIND MORE ABOUT THIS? Please read the “Informed Consent Form” (in English or Spanish) that was mailed with this letter, or call the Principal Researcher (Dr. Ca rolyn Tucker) at (352) 392 – 0601, ext. 260. WHAT SHOULD I DO IN CASE I DECIDE TO PARTICIPATE? Sign the last page of both “Informed Consent Forms” (English or Spanish). Keep one copy for yourself. 1. Complete the Demographic Data Form. 2. Complete the Medical Data Form. 3. Return one copy of the “Informed Consent Form”, the Demographic Data Form and the Medical Data Form in the pre-addressed, postage paid envelope. DO NOT add postage, just seal the envelope and put it in your mailbox. WHAT SHOULD I DO IF I MOVE?

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80 If you move after you return the Informed Consent Form and before you receive more information from us, simply call (352) 392-06 01, ext. 260 between 10:00 a.m. and 4:00 p.m. Feel free to call collect if necessary. WHO CAN ANSWER SOME MORE QUESTIONS I HAVE? If you have any questions about this research, contact the Principal Researcher, Dr. Carolyn M. Tucker, at (352) 392-0601, ext. 260. Thank you for your time. We hope you will consider participating in this study. Sincerely, Dr. Karen L. Hall Medical Director, Family Practice Medical Group

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81 APPENDIX I INFORMED CONSENT FORM IRB# 289-2002 Informed Consent to Participate in Research and Authorization for Collection, Use, and Disclosure of Protected Health Information Patient Form PLEASE SIGN BOTH COPIES OF THIS FORM AND RETURN 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 authorization for the collectio n, use and disclosure of your protected health information necessary for the study. The Principal Investigator (the person in charge of 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 volunt ary. Before you decide whether or not to take part, read the information below a nd 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. 1. Name of Participant ("Study Subject") ________________________________________________________________________ 2. Title of Research Study A Patient-Centered Culturally Sensitive Care Model 3. Principal Investigator and Telephone Number(s) Carolyn M. Tucker, Ph.D. Distinguished Alumni Professor Professor of Psychology, Director of Training Professor of Pediatrics Professor of Community Health and Family Medicine

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82 (352) 392-0601 extension 260 4. Source of Funding or Other Material Support This research is being funded by the Agency fo r Healthcare Quality and Research (AHRQ) of the National Institutes of Health (NIH). 5. What is the purpose of this research study? Sometimes people are not completely happy or satis fied with some behaviors of their health care providers or with something about their health care clinic. Such dissatisfaction may be more likely in patients who are culturally or racially different from their health care providers. This can be a problem because being unhappy with one’s health care provid er can get in the way of a sick person getting better. In this study, we want to do two things: (1) find out whether making health care more culturally sensitive through a training program and some changes in the health care clinic will make patients more satisfied with their health care an d reduce their stress, and (2) teach patients how to better communicate with health care providers so that the health care experience will be as satisfactory as possible. 6. What will be done if you ta ke part in this research study? This study has seven parts; Parts A-G. If you ch oose and are selected to participate, you will be invited to participate in five part s of the study. Below is a descrip tion of what participation in each part of this study involves. Parts A – Part B – Parts A and B of this study are alread y completed. These parts involved recruitment of patients to fill out an initial set of surveys. Parts C – Part F -If you participate in these four parts of the study, you will be asked each time to fill out a set of surveys, with approximately 4 months between each of the parts. Specifically, one survey will ask how much you agree or disagree with statements describing certain behaviors of your health care providers that may or may not be cultu rally sensitive. Other surveys will ask about your lifestyle, your relations with health care providers, your stress levels, and your involvement in various health behaviors. You will also be asked to complete a survey about yourself which asks about your age, gender/sex, race, years of having any long-term health probl ems, any communication problems you may have, how you pay for your health care, your telephone number, your address, your current clinic, and the number of visits that you have made to your current clinic in the past year. Filling out all of these surveys will take about one hour You may choose to do these four surveys in one of two ways. The first way is to fill out the surveys at home and mail us the filled out surveys in a pre-paid reply envelope, provided with the packet. The second way is to fill out the surveys at the clinic that you attend. One of our research assistants will be at the clinic to help you fill out the surveys if you need any help or have any questions. Your name will not be used on the surveys. Instead, researchers will place a code number on th e surveys that you fill out. Your surveys will be immediately separated from any documents that may be able to identify you (like your signed informed consent form) and locked in separate filing cabinets in room 293 at the Department of Psychology at the University of Florida. Your hea lth care provider will not see your filled out surveys and will not be told whether you are pa rticipating in the study or not. Part G -If you participate in this part of the study, you will be asked to participate in a 4-hour patient training on strategies for asking for and receiving more culturally sensitive and more desired health care. You are not required to par ticipate in this part of the research in order to participate in the previous four parts. The patient training will invol ve you along with a small group of other patients.

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83 During the training session, you will hear a brief talk by the trainer, watch videos on how to talk with your doctor and other clinic staff members, and watch or participate in some demonstrations of how to talk with ease to health care providers and other clinic staff. Although you are invited to participate in all sections of this training, you do not have to participate in each activity and may stop whenever you choose or when you feel uncomfortable. You will be paid for your participation in each part. The amount that is paid for participation in the first four parts is the same. Participants in the fifth part of the study will be paid differently than in the first parts. To see how much money is paid for pa rticipation in each part, see section 10 of this form 7. What are the possible discomforts and risks? Some of the questions that you will be asked on the surveys could make you feel uncomfortable. If you do feel uncomfortable, please f eel free to skip that question or the entire questionnaire. There are no other known physical or mental risks that you might experience from participating in this research. Throughout the study, the researchers will notify you of any new information that may become available and might affect your deci sion to remain in the study. If you wish to discuss the information above or any discomforts you may experience, please call the Principal Investigator listed on the front page of this form. 8a. What are the possible benefits to you? If you decide to participate in the training workshop in ‘Part-G’, you may benefit from the research by learning ways to comfortably talk with your hea lthcare providers or clinic staff and you may become more satisfied with your healthcare. 8b. What are the possible benefits to others? Your responses to the surveys throughout the study will be combined with the responses of several hundred other research participants. When taken to gether, your responses may benefit other people by helping to teach physicians, nurses, and other health care professionals ways of being more culturally sensitive to all patients. These results may also incr ease patients’ satisfaction w ith the health-care that they receive. 9. If you choose to take part in this research study, will it cost you anything? This research requires nothing more than your tim e. There will be no additional costs to you, your family, or your friends. 10. Will you receive compensation for ta king part in this research study? The amount of money you will receive for participatin g in this study will depend on the parts of the study in which you choose to participate. The amou nt of money that will be paid for participation in each part is stated below: 1) If you agree to participate in Parts C-F of this study by comple ting some surveys, you will receive $20 for each time you complete the surveys and re turn them to the Princi pal Investigator. The maximum amount you may be paid is $80 for participation in all four parts. 2) If you agree to participate in Part G of this re search study by participating in a four-hour training workshop, you will receive $6 0 for your participation.

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84 Thus, you may receive up to $140 if you par ticipate in all five parts of this study. Each time you complete a set of surveys and return them to the principal investigator, you will be mailed a check for $20 within three weeks after the pr incipal investigator recei ves the surveys. If you mistakenly leave out the ‘payment release form’, you will be mailed another form to complete and return so that you can receive your payment. After completing the fi nal part of the research, should you choose to do so, you will be sent a check for $60 within three weeks of completing the training. Because you are being paid for taking part in this study, your name and social security number will be reported to University administrative personnel for purposes of making and recording the payment. 11. What if you are injure d because of the study? If you experience an injury that is directly caused by this study, only professional consultative care that you receive at the University of Florida Health Science Center w ill be provided without charge. However, hospital expenses will have to be paid by you or your insurance provider. No other compensation is offered. Please contact the Principal Investigator listed in Item 3 of this form if you experience an injury or have any questions about an y discomforts that you experience while participating in this study. 12. What other options or treatments are available if you do not want to be in this study? The option to not taking part in this study is doing nothing. If you do not want to take part in this study, tell the Principal Investigator or his/her assistant and do not sign this Informed Consent Form. 13a. Can you withdraw from this research study? You are free to withdraw your consent and to stop par ticipating in this research study at any time. If you do withdraw your consent, th ere will be no penalty, and you w ill not lose any benefits you are entitled to. If you decide to withdraw your consent to participate in this research study for any reason, you should contact Dr. Carolyn M. Tucker at (352) 392-0601 extension 260. If you have any questions regarding your rights as a research subject, you may phone the University of Florida Institutional Review Board (IRB) office at (352) 846-1494. 13b. If you withdraw, can information ab out you still be used and/or collected? If you choose to withdraw from this research study, no further information will be collected. Also, at your request, confidential information (data) that ha s already been collected and stored in a locked filing cabinet will be destroyed and will not be used. 13c. Can the Principal Investigator withdraw you from this research study?

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85 You may be withdrawn from the study without your consent for the following reasons: 1) You are unable to return a surv ey packet (or contact the Princi pal Investigator) within three weeks of receiving the packet. 2) You change clinics before this research study is completed. 3) You are incarcerated (sent to pr ison) for longer than one-month during the course of this research study. 4) You become employed by either the principal investigator, ‘Eastside Community Healthcare Center’, or ‘Family Practice Medical Group’ (both clinics in Gainesville, Florida) during this research study. 5) You do not qualify to be in the study because you do not meet the study requirements. Ask the Principal Investigator if you would like more information about this. 6) The investigator decides that continuing in the study would be harmful to you. 7) The study is cancelled by the National Institutes of Health (NIH) and/or for other administrative reasons. 14. How will your privacy and the confidentia lity of your research records be protected? Your research records that contai n personal information (such as name, address, and phone number) are kept in a separate locked location than your responses to the survey packets. Under no circumstances will your name, address, phone number, gender, age, ethnicity, or any other information be provided to any organization other than those listed below. Authorized persons from the University of Florid a and the Institutional Review Board have the legal right to review your research records and will prot ect the confidentiality of them to the extent permitted by law. Your physician, other health care providers, and clinic staff will not have access to any component of your research records except as required by law. Otherwise, your research records will not be released without your consen t unless required by law or a court order. If the results of this research are published or pres ented at scientific meetings, your identity will not be disclosed. If you participate in this research, your protected health information will be collected, used, and disclosed under the terms specified in sections 15-24, below. 15. If you agree to participate in this research study what protected health information about you may be collected, used and disclosed to others? To determine your eligibility for the study and as part of your participation in the study, your protected health information that is obtained from you, from review of your past or current health records, from procedures such as physical examinations, x-rays, blood or urine tests or other procedures, from your response to any study treatments you receive, from y our study visits and phone calls, and any other study related health information may be collected, used and disclosed to others. More specifically, the following information may be collected, used, and disclosed to others: Any information about your blood pressure, including blood pressure readings, dates of those readings, and what your health care pr ovider has prescribed for treatment. Any information about your blood sugar levels, dates your sugar levels were checked, and whether your doctor has prescribed any treatment for diabet es or other illness relating to blood sugar levels. Any information about your cholesterol levels, dates of your cholesterol readings, and any treatment your doctor has prescribed to change your cholesterol levels. Any information about any diagnosed illnesses from the following list: hypertension (high blood pressure), hyperlipidemia (high cholesterol levels), diabetes (high blood sugar), coronary artery disease, and any other illness or disease of the heart. Records of physical exams. All dates that you have attended your healthcare clinic for medical reasons.

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86 Your name and address – though you personally provide this information each time you complete the assessment questionnaires. Information regarding your participation in other research programs and studies at your healthcare clinic. 16. For what study-related purposes will your protect ed health information be collected, used and disclosed to others? Your protected health information may be collected, used and disclosed to others to find out your eligibility for, to carry out, and to evaluate the re sults of the research study. More specifically, your protected health information may be collected, used and disclosed for the following study-related purpose(s): To determine the effectiveness of study interventions on perceptions of patients To evaluate the effects of study interventions on typical health outcomes such as blood pressure, blood sugar levels, and cholesterol levels. To determine whether making health care more culturally sensitive through a training program and some changes in the health care clinic will make patients more satisfied with their health care, reduce their stress, and affect their health outcome measures. 17. Who will be authorized to collect, use and disc lose to others your protected health information? Your protected health information may be collected, used, and disclosed to others by: the study Principal Investigator Carolyn M. Tucker, Ph.D. and her staff other professionals at the University of Florida or Shands Hospital that provide study-related treatment or procedures the University of Florida Institutional Review Board 18. Once collected or used, who may your protected health information be disclosed to? Your protected health information may be given to: United States and foreign governmental agencies who are responsible for overseeing research, such as the Food and Drug Administration, the Department of Health and Human Services, and the Office of Human Research Protections Government agencies who are responsible for overseeing public health concerns such as the Centers for Disease Control and Federal, State and local health departments the study sponsor Agency for Healthcare Research and Quality The University of Florida – in order to pay you, the University requires information such as your name, address, and social security number. Yo ur social security number will NOT be given to ANY other source unless required by law. 19. If you agree to participate in this research, ho w long will your protected health information be collected, used and disclosed? Your protected health information (as listed in number 15 above) will be collected for no more than five years from the date you sign this form. Use and disclosure of your protected health information may be from 7 years from the date you sign this fo rm. After 7 years, inform ation without identifiers will be stored forever in a secure database.

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87 20. Why are you being asked to authorize the collectio n, use and disclosure to others of your protected health information? Under a new Federal Law, researchers cannot collect, use or disclose any of your protected health information for research unless you allow them to by signing this authorization. 21. Are you required to sign th is consent and authorization and allow the researchers to collect, use and disclose (give) to ot hers your protected health information? No, and your refusal to sign will not affect your treatment, payment, enrollment, or eligibility for any benefits outside this research study. However, you cannot participate in this research unless you allow the collection, use and disclosure of your protected health information by signing this consent/authorization. 22. Can you review or copy your protected health information collected, used or disclosed under this authorization? You have the right to review and copy your protect ed health information. However, you will not be allowed to do so until after the study is finished. 23. Is there a risk that your protected health in formation could be given to others beyond your authorization? Yes. There is a risk that informat ion received by authorized persons could be given to others beyond your authorization and not covered by the law. 24. Can you revoke (cancel) your authorization for collection, use and disclosure of your protected health information? Yes. You can revoke your authorization at any time before, during or after your participation in the research. If you revoke your authorization, no new in formation will be collected about you. However, information that was already collected may still be us ed and disclosed to others if the researchers have relied on it to complete and protect the validity of the research. You can revoke your authorization by giving a written request with your signature on it to the Principal Investigator. 25. How will the researcher(s) benefit from your being in this study? In general, presenting research results helps the career of a scientist. Therefore, the Principal Investigator and her staff may benefit if the results of this study are presented at scientific meetings or in scientific journals.

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88 26. Signatures As a representative of this study, I have explained to the participant the purpose, the procedures, the possible benefits, and the risks of this research study; the alternatives to being in the study; and how the participantÂ’s protected health information will be collected, used, and disclosed: ______________________________________________ _____________________ Carolyn M. Tucker, Ph.D. (Principal Investigator) Date You have been informed about this studyÂ’s purpose, procedures, possible benefits, and risks; the alternatives to being in the study; and how yourprotected health information will be collected, used and disclosed. You have received a copy of this Fo rm. You have been given the opportunity to ask questions before you sign, and you have been told that you can ask other questions at any time. You voluntarily agree to participate in this study You hereby authorize the collection, use and disclosure of your protected health information as described in sections 15-24 above. By signing this form, you are not waiving any of your legal rights. ______________________________________________ _____________________ Signature of Person Consenting Date ______________________________________________ _____________________ Signature of Witness Date Contact Information Please provide the following information so that we can contact you regarding the research study and so that we can mail you the surveys. Again, this information will be protected as discussed in Section 14 of this informed consent. Please write large and as legibly as possible. Feel free to call the Principal Investigator at 392-0601, Ext. 260, if you feel your information may be hard to read. Your Name (Please Print) Your Address City State Zip Code ( ) Area Code Phone Number Extension

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89 APPENDIX J STUDY QUESTIONNAIRE PACKET COVER LETTER Dear Patient: Thank you for agreeing to participate in our research project. We are a Research Team, supervised by Dr. Carolyn M. Tucker Distinguished Alumni Professor at the University of Florida. The purpose of this pr oject is to determine ways to increase the level of cultural sensitivity in health care pr ovided to patients. The other purpose of this project is to see if patien ts benefit from more cultur ally sensitive health care. Participation in this study involves completing a set of questionnaires. One of these questionnaires includes a list of behaviors of health care providers and clinic personnel and a list of clinic characteristics that patie nts have told us indicat e sensitivity to their culture. Although we do not believe that co mpleting this questionnaire or the other questionnaires will cause you any harm, you do have the right to skip any questions that you find offensive and you have the right to stop completing a questionnaire if it makes you feel uncomfortable. You will be asked to complete these same questionnaires again in approximately five months. If you choose to complete th e questionnaires again, you will again receive compensation for your time. You may decide later whether or not you would like to complete the questionnaires again. Your participation in this research pr oject is voluntary. If you experience any discomforts with completing these questionn aires, you may call Dr. Carolyn M. Tucker, at (352) 392-0601 ext. 260, and/or the Univer sity of Florida Institutional Review Board (IRB) Office at (352) 846-1494 to discuss your concerns. Your information will not be shared with your doctor or other members of the health care staff at your clinic. Also, your name will not be placed on any of the questionnaires that you complete. Instead, the information from you will be assigned a code number. The list of names that identify th ese codes will be kept in a separate locked location from the information that you provide us with. All this information will be locked in file cabinets in Dr. Tucker's lab in the psychology building at the University of Florida. All information from participants wi ll be combined so that no one can identify your information. The information you give us is very important because it may help us improve the health care and support that you and other pa tients like you may receive from health care providers. In return for your participati on in our study, you will be mailed a payment of $20 within three (3) weeks of when we receive your completed questionnaires and ‘payment release form’. Please, in addition to completing the ques tionnaires, sign and return the completed ‘Payment Release Form’. We need your na me, address, and social security number

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90 requested on this form so that we can send you a check for $20. Your signed Informed Consent Form (which you returned previ ously) and Payment Release Forms will be locked in a separate file cabinet from the locked file cabinet in which your completed questionnaires will be kept. This will be done to further protect your confidentiality. In order to participate, please complete the enclosed questionn aires and ‘Payment Release Form’, then return them by mail in the pre-paid reply envelope provided. This should only take about an hour. If you need help completing the questionnaires, you may ask a family member or friend to read them to you; however, we only want your opinions to the questions. You may also call Dr. Caro lyn M. Tucker at (352) 392-0601, Ext. 260 to set up an appointment to have a Research A ssistant read the questi onnaires to you at the health care clinic that you attend. If you have any questions about this rese arch project, please call a member of our research team at the (352) 392-0601 ext. 260. We are looking forward to your participation. Sincerely, Dr. Carolyn M. Tucker Distinguished Alumni Professor Professor of Psychology Professor of Pediatrics Professor of Community Hea lth and Family Medicine Enclosures

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91 LIST OF REFERENCES Agency for Healthcare Research and Quality (2003). National healthcare disparities report (HHS Publication). Rockville, MD: Government Printing Office. American College of Physicians. (2004). Raci al and ethnic disparities in health care: A position paper of the American college of physicians. Annals of Intern Medicine 141, 226–232. American Heart Association (2006). Heart disease and stro ke statistics — 2006 update Dallas, Tx.: Author. American Psychological Association (2003) Guidelines on multicultural education, training, research, practice, and orga nizational change for psychologists. American Psychologist, 58, 377–402. Auerbach, S. (2000). Should patients have c ontrol over their own health care?: Empirical evidence and research issues. Annals of Behavioral Medicine 22, 246–259. Auerbach, S. (2001). Do patients want control over their own health care?: A review of measures, findings, and research issues. Journal of Health Psychology 6, 191–203. Auerbach, S., Clore, J., Kiesler, D. O rr, T., Pegg, P. (2002). Relation of diabetic patients’ health-related control appraisa ls and physician-pa tient interpersonal impacts to patients’ metabolic control and satisfaction with treatment. Journal of Behavioral Medicine, 25, 17–31. Auerbach, S., Penberthy, A., & Kiesler, D. ( 2004). Opportunity for c ontrol, interpersonal impacts, and adjustment to a long-t erm invasive health care procedure. Journal of Behavioral Medicine, 27, 11–29. Beach, M., Sugarman, J., Johnson, R., Arbelaez J., Duggan, P., & Cooper, L. ( 2005). Do patients treated with dignity report higher satisfaction, adherence, and receipt of preventive care? Annals of Family Medicine 3, 331–338. Becker, G. & Newsom, E. (2003). Socioeconomic status and dissatisfaction with health care among chronically i ll african americans. American Journal of Public Health, 93 742–748. Betancourt, J., Green, A., & Carrillo, J. (2002). Cultural competence in health care: Emerging frameworks and practical approaches. New York: The Commonwealth Fund.

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92 Blanchard, J. & Lurie, N. (2004) "R-E-S-P-E-C -T: Patient reports of disrespect in the health care setting and its impact on care." Journal of Family Practice 53, 721. Bosworth, H., Dudley, T., Olsen, M., Voils, C. Powers, B., Goldstein, M., & Oddone, E. (2006). Racial differences in blood pressure control: patient explanatory factors. The American Journal of Medicine, 119, 70.e9–70.e15. Brenders, D. (1989). Perceived control and th e interpersonal dimens ion of health care. Health Communication, 1, 117–135. Burt, V., Whelton, P., Roccella, E., Brown, C., Cutler, J., Higgins, M., Horan, M., & Labarthe, D. (1995). Prevalence of hype rtension in the US adult population: Results from the third national health and nutrition examination survey, 1988– 1991. Hypertension 25, 305–313. Campinha-Bacote, J. (1994). Cultural competence in psychiatric mental health nursing: A conceptual model. Nursing Clinics of North America 29, 1–8. Centers for Disease Control a nd Prevention (2005a). Disparit ies in deaths from stroke among persons aged <75 yearsUnited States, 2002. Morbidity and Mortality Weekly Report (MMWR) 54, 477–481. Centers for Disease Control and Preventi on (2005b). Racial/et hnic disparities in prevalence, treatment and control of hypertension—United States, 1999-2002. Morbidity and Mortality Weekly Report ( MMWR), 54, 7–9. Chen, F., Fryer, G. Phillips, R., Wilson, E., & Pathman, D. (2005). Patients’ beliefs about racism, preferences for physicia n race, and satisfaction with care. Annals of Family Medicine, 3 138–143. Chobanian, A., Bakris, G. Black, H. Cushma n, W. Green, L. Izzo, J. Jones, D, Materson, B, Oparil, S., Wright, J., Rocce lla, E.(2003). The seventh report of the joint national committee on prevention, dete ction, evaluation, a nd treatment of high blood pressure: The JNC 7 report. Journal of the American Medical Association 289, 2560–2572. Collins, T., Clark, J., Petersen, L., & Kre ssin, N. (2002). Racial differences in how patients perceive physician communi cation regarding cardiac testing. Medical Care, 40 I-27–I34. Collins, K., Hughes, D. Doty, M. Ives, B. Edwards, J. Tenney, K. (2001). Diverse communities, common concerns: Assessi ng health care quality for minority Americans: Findings from the commonwea lth fund 2001 health care quality survey New York, NY: The Commonwealth Fund. Cooper, L., Roter, D., Johnson, R., Ford, D., Steinwachs, D., & Powe, N. (2003). Patientcentered communication, ratings of care, and concordance of patient and physician race. Annals of Internal Medicine, 139, 907–915.

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93 Cooper-Patrick, L., Gallo, J., Gonzales, J., V u, H. Powe, N. Nelson, C.,& Ford, D. (1999). Race, gender, and partnership in the patient-phys ician relationship. Journal of the American Medical Association 282, 583–589. Corbie-Smith, G., Thomas, S. & St. George, D. (2002). Distrust, race and research. Archives of Internal Medicine, 162 2458–2463. Crowne, D. P. & Marlowe, D. (1960). A new s cale of social desirabi lity independent of psychopathology. Journal of Consulting and Clinical Psychology, 24, 349–354. Donebadian, A. (1980). The definition of quality and its approaches to its assessment. Health Administration Press: Ann Arbor, Michigan. Dimatteo, M. (2004). Variations in patients’ adherence to medical recommendations: A qualitative review of 50 years of research. Medical Care, 42, 200–209. DiPalo, M. (1997). Rating satisfaction re search: is it poor, fair, good, very good, or excellent? Arthritis Care and Research, 10 422–430. Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136. Feste, C. & Anderson, R. (1995). Empow erment: from philosophy to practice. Patient Education and Counseling, 26, 139–144. Fraboni, M. & Cooper, D. (1989) Further validation of three short forms of the MarloweCrowne scale of social desirability. Psychological Reports, 65, 595–600. Freimuth, V.., Quinn, S., Thomas, S., Cole, G., Zook, E., & Duncan, T. (2001). African American’s views on research and the tuskegee syphilis study. Social Science & Medicine, 52, 797–808. Gerteis, M., Edgman-Levitan, S., Daley, J., & Delbanco, T. (1993). Through the patient’s eyes: Understanding and promoting patient-centered care. San Francisco: JossyBass. Greenfield, T. & Attkisson, C. (1989). Progress toward a mu lticultural service satisfaction scale for evaluating primar y care and mental health services. Evaluation and Program Planning, 12, 271–278. Hajjar, I. & Kotchen, T. (2003). Trends in pr evalence, awareness, treatment, and control of hypertension in th e united states, 1988–2000. Journal of the American Medical Association, 290, 199–206. Harris, L. Luft, F. Rucy, D. & Ti erney, W. (1995). Correlates of health are satisfaction in inner-city patients with hypertension and chronic renal insufficiency. Social Science and Medicine, 41, 1639–1645.

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94 Heurtins-Roberts, S. (1993). High-pertensionthe use of a chronic folk illness for personal adaptation. Social Science and Medicine, 37, 285–294. Institute of Medicine, Board of Health Sc iences Policy, Committee on Understanding and Eliminating Racial and Ethnic Disp arities in Health Care. (2002). Unequal treatment: Confronting racial and et hnic disparities in health care. Washington, D.C.: National Academy Press. Iskedijan, M., Einarson, T. MacKeigan, L. Shear, N., Addis, A., Mittmann, N., & Ilersich, A. (2002). Relationship between da ily dosage frequency and adherence to antihypertensive pharmacotherapy: evidence from a meta-analysis. Clinical Therapeutics 24, 302–316. Joffe, S., Manocchia, M., Weeks, J. C., & Clear y, P. D. (2003). What do patients value in their hospital care? An empirical persp ective on autonomy centered bioethics. Journal of Medical Ethics, 29 103–108. Johnson, R., Roter, D., Powe, N. & Cooper, L. (2004). Patient race/ethnicity and quality of patient-physician communica tion during medical visits. American Journal of Public Health, 94 2084–2090. Johnson, R. Saha, S., Arbelaez, J. Beach, M. & Cooper, L. (2004). Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. Journal of General Internal Medicine, 19, 101–110. Jokisalo E, Kumpusalo E, En lund H, Halonen P, Takala J. (2002). Factors related to noncompliance with antihypertensive drug therapy. Journal of Human Hypertension ,16, 577–583. Kaplan, S. Greenfield, S., & Ware, J. (1989) Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Medical Care 27, S110–S127. Kaplan, S. & Greenfield, S. (2004). The pa tient’s role in reducing disparities. Annals of Internal Medicine, 222–223. Kiesler, D. & Auerbach, S. (2003). Integrati ng measurement of control and affiliation in studies of physician-patient interac tion: the interpersonal circumplex. Social Science & Medicine, 57, 1707–1722. Krousel-Wood, M., Thomas, S., Muntner, P. & Morisky, D. (2004). Medication adherence: a key factor in achieving blood pressure contro l and good clinical outcomes in hypertensive patients Current Opinion in Cardiology, 19, 357–362. Lefcourt, H. (Ed.). (1981). Research with the locus of control construct: Vol. 1. Assessment Methods. New York: Academic.

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95 Lukoschek, P. (2003). African Americans’ beliefs and attitudes regarding hypertension and its treatment: a qualitative study. Journal of Health Care for the Poor and Underserved 14, 566–587. Marshall, G. & Hays, R. (1994). The patient satisfaction ques tionnaire short-form (PSQ18). Form P-7865. Rand Corporation: Santa Monica, CA. Marshall, G. Hays, R. Sherbourne, C. & Wells, K. (1983). The structure of patient satisfaction with outpatient medical care. Psychological Assessment 5, 477–483. Morisky, D., Green, L. & Levine, D. (1986). Conc urrent and predictive validity of a selfreported measure of medication adherence. Medical Care 24, 67–74. Murphy, D., Robert, K., Martin, D. Mareli ch, W., & Hoffman, D. (2000). Barriers to antiretroviral adherence am ong HIV-infected adults. Aids Patient Care and STDs 14, 47–58. National Heart, Lung, and Blood Institute (2005). Diseases and Conditions Index, High Blood Pressure Retrieved August 2, 2005, from http://www.nhlbi.nih.gov/health/d ci/Diseases/Hbp/HBP_WhatIs.html National Institutes of Health. (1999). What are health disparities ? Retrieved July 17, 2005, from http://healthdispa rities.nih.gov/whatare.html Ogedegbe, G., Mancuso, C. & Allegrante, J. (2004). Expectations of blood pressure management in hypertensive African Am erican patients: a qualitative study. Journal of the National Medical Association 96, 442–449. Ogedegbe, G., Harrison, M., Robbins, L., Manc uso, C. & Allegrante, J. (2004). Barriers and facilitators of medica tion adherence in hypertensive African Americans: A qualitative study. Ethnicity & Disease 14, 3–12. Oyemade, U. & Rosser, P. (1980). Development in Black Children Advances Behavioral Pediatrics, 1, 153–179. Paulhus, D.(1983). Sphere specific measures of perceived control. Journal of Personality and Social Psychology, 44 1253–1265. Paulhus, D., & Christie, R. (1981). Spheres of control: An interactionist approach to assessment of perceived cont rol. In H.L Lefcourt (Ed.), Research with the locus of control construct (pp. 161–188). New York: Academic Press. Paulhus, D., & Van Selst, M. (1990). The S pheres of Control scale: Ten years of research. Personality and Individual Differences 11, 1029–1036. Peterson, N. & Zimmerman, M. (2004). Beyond the individual: Toward a nomological network of organizational empowerment. American Journal of Community Psychology 34, 129–145.

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96 Rappaport, J. (1987). Terms of empowerment/exemplars of prevention: Toward a theory for community psychology, American Journal of Community Psychology, 15, 121– 147. Roberts, K. (2002). Physician-patient relations hips, patient satisfac tion, and antiretroviral medication adherence among hiv-infected a dults attending a pub lic health clinic. Aids Patient Care and STDs, 16 43–50. Rotter, J. (1966). Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs 80, 1–28. Rotter, J. (1982). The development and application of social learning theory. New York: Praeger. Roter, D. Stewart, M., Putnam, S. Lipkin, M., Stiles, W., & Inui, T. (1997). Communication patterns of primary care physicians. Journal of the American Medical Association 277, 350–356. Schneider, E. Zaslavsky, A. & Epstein, A. (2002). Racial dispari ties in the quality of care for enrollees in medicare managed care. Journal of the American Medical Association,287 1288–1294. Schulman, K., Berlin, J.., Harless, W., Kerner J. Sistrunk, S., Gersh, B. Dube, R., Taleghani, C., Burke, J., Williams, S., Eisenberg, J., & Escarce, J.(1999). The effect of race and sex on physicians’ r ecommendations for cardiac catheterization. The New England Journal of Medicine, 340 618–626. Solomon, B. (1976). Black empowerment: social work in oppressed communities New York: Columbia University Press. Street, R. Krupat, E., Bell, R. Kravitz, R. & Haidet, P. (2003). Beliefs about control in the physician-patient relationship: effect on communication in medical encounters. Journal of General Internal Medicine, 18, 609–616. Sue, D. (2001). Multidimensional facets of cultural competence. Counseling Psychologist, 29 790–821. Sue, D., Arredondo, P., & McDavis, R. (1992) Multicultural counseling competencies and standards: A call to the profession. Journal of Multicultural Counseling & Development 20, 64–89. Sue, D. Ivey, A. & Pedersen, P. (1996). A Theory of Multicultural Counseling and Therapy. Pacific Grove, California: Br ooks/Cole Publishing Company. Takiya, L., Peterson, A., & Finley, R. ( 2004). Meta-Analysis of interventions for medication adherence to antihypertensives. The Annals of Pharmacotherapy 38, 617–1624.

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97 Tucker, C., Herman, K., Pederson, T. Higl ey, B., Montrichard, M., & Ivery,P. (2003). Cultural sensitivity in physician-patient relationships: Perspectives of an ethnically diverse sample of low-income primary care patients. Medical Care, 41 859–870. Tucker, C., Herman, K. Ferdinand, L. Beat o, C., Adams, D., & Cooper, L. (in press). Providing culturally sensitive health care: A research-based patient-centered model. Tucker, C. Mirsu-Paun, A., Van den berg, J. & Ferdinand, L. (2006). Patient-centered assessment for measuring cultural sensitivity in community-based primary health care clinics. Unpublished manuscript. Tucker, C. Petersen, S., Herman, K. Fenne ll, R. Bowling, B., Pedersen, T., & Vosmik J. (2001). Self-regulation predictors of medication adherence among ethnically different pediatric patients with renal transplants. Journal of Pediatric Psychology, 26, 455–464. United States Census Bureau (2000). U.S. Interim Projections by Age, Sex, Race, and Hispanic. Table 1a. Projected Population of the United States, by Race and Hispanic Origin: 2000 to 2050 Re trieved June 18, 2005, from http://www.census.gov/ipc/www/usinterimproj/ United States Department of Health and Huma n Services, National Institutes for Health, National Heart, Lung, and Blood Institute (2005). Diseases and Conditions Index, High Blood Pressure. Retrieved August 2, 2005 from http://www.nhlbi.nih.gov/health/d ci/Diseases/Hbp/HBP_WhatIs.html U.S. Department of Health and Human Se rvices, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute, National High Blood Pressure Education Program Joint National Committee on Prevention Detection, Evaluation, andTreatment of High Blood Pressure. (2004). The seventh report of the Joint National Committ ee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. United States Department of Hea lth and Human Services. (2000). Healthy people 2010: Understanding and improving health. 2nd Edition. Washington, DC: U.S. Government Printing Office. Van Ryke, M. & Burke, J. (2000). The effect of patient race and socio-economic status on physicians’ perceptions of patients. Social Science and Medicine, 50, 813–828. Wang, P., Bohn, R. Knight, E., Glynn, R. Mogun, H., & Avorn, J. (2002). Noncompliance with antihypertensive me dications: The impact of depressive symptoms and psychosocial factors. Journal of General Internal Medicine, 17, 504– 511. Ware, J. Snyder, M. Wright, W. & Davi es, A. (1983). Behavioral consequences of consumer dissatisfaction with medical care. Evaluation and Program Planning 6, 291–297.

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98 Weissman, J., Betancourt, J., Campbell, E., Pa rk, E., Kim, M., Clarridge, B., Blumenthal, L., & Maina, A.(2005). Resident physicians ’ preparedness to provi de cross-cultural care. Journal of the American Medical Association. 294, 1058–1067. Wilde, B., Starrin, B., Larsson, G., & Larsson, M. (1993). Quality of care from a patient perspective: A grounded theory study. Scandinavian Journal of Caring Sciences, 7 113–120. Wilson, R. Freeman A., Kazda M., Andrews, T., Berry, L., Vaeth, P., & Victo, R. (2002). Lay beliefs about high blood pressu re in a low-to-middle-income, urban African-American community: an opportuni ty for improving hypertension control. The American Journal of Medicine, 112, 26–30. World Health Organization. (2003). Adherence to long-term therapies: evidence for action Retrieved on August 6, 2005 from http://www.who.int/chronic_c onditions/adherencereport/en/

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99 BIOGRAPHICAL SKETCH Tamika R. Bailey received her Bachelor of Arts degree in Psychology from the University of Miami in 1999. After receiving her undergraduate degree, Ms. Bailey worked for two years as a research as sistant on an NIH-funded, HIV Long-Term Survivors research study conducted at th e University of Miami Department of Psychology & Behavioral Me dicine. This study focused on psychological and immunological factors that may be associated wi th the long-term survival of adults living with HIV/AIDS. Additionally, Ms. Bailey worked for a year at the University of Miami Toppel Career Center facilitating career skills seminars and resume development workshops as a graduate assistant. While Ms. Bailey worked as a research and graduate assistant, she worked towards a Master of Science in Education de gree in Marriage and Family therapy, which she received in 2003. Ms. Bailey is a doctoral student at the University of Florida Counseling Psychology pr ogram. Her professional interests consist of conducting health and community-based psyc hological research in addition to teaching undergraduate students and couns eling clients. For the past two and a half years, Ms. Bailey has been working as a graduate research director on the Patient-Centered Culturally Sensitive Health Ca re research project under the direction of her research mentor and academic advisor Dr. Carolyn M. Tucker.