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Testing the Roles of Perceived Provider Fairness and Patient-Provider Ethnicity/Race Concordance in a Patient-Centered Culturally Sensitive Health Care Model

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Title:
Testing the Roles of Perceived Provider Fairness and Patient-Provider Ethnicity/Race Concordance in a Patient-Centered Culturally Sensitive Health Care Model
Creator:
Nghiem, Khanh Ngoc
Place of Publication:
[Gainesville, Fla.]
Florida
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University of Florida
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english
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1 online resource (99 p.)

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Counseling Psychology
Psychology
Committee Chair:
TUCKER,CAROLYN M
Committee Co-Chair:
MILLER,SCOTT A
Committee Members:
CHOI,CHUN-CHUNG
PUIG,ANA
Graduation Date:
5/3/2014

Subjects

Subjects / Keywords:
African Americans ( jstor )
Cultural studies ( jstor )
Health care industry ( jstor )
Modeling ( jstor )
Patient satisfaction ( jstor )
Physicians ( jstor )
Psychological counseling ( jstor )
Questionnaires ( jstor )
Trucks ( jstor )
White people ( jstor )
Psychology -- Dissertations, Academic -- UF
fairness -- patients -- satisfaction
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bibliography ( marcgt )
theses ( marcgt )
government publication (state, provincial, terriorial, dependent) ( marcgt )
born-digital ( sobekcm )
Electronic Thesis or Dissertation
Counseling Psychology thesis, Ph.D.

Notes

Abstract:
There is a lack of research that links patient-perceived provider fairness and patient-provider ethnicity/race concordance with provider cultural sensitivity, patients' trust in their provider, and patients' satisfaction with their provider. The present study was designed to test an aspect of the Patient-Centered Culturally Sensitive Health Care (PC-CSHC) Model that was modified to include provider fairness and patient-provider ethnicity/race concordance. Specifically, the present study sought to (a) test the associations of the modified PC-CSHC model among a sample of ethnically/racially diverse patients; and (b) explore if the associations in the modified PC-CSHC model differ for African American (AA), Hispanic/Latino(a) (H/L), and White American (WA) patients. Participants in this study were 1,654 ethnically/racially diverse patients, each of whom have received health care from one of 67 health care sites across the U.S. The analyses revealed that provider fairness but not ethnicity/race concordance has significant positive associations with provider cultural sensitivity, trust in provider, and satisfaction with provider for the total participant sample. However, the sensitivity/interpersonal skill aspect of provider cultural sensitivity has a negative association with provider fairness in the total patient participant sample. Furthermore, analyses revealed that ethnicity/race concordance has a significant positive effect on provider cultural sensitivity, provider fairness, and patient satisfaction for WA patients only. In contrast, there was a significant negative effect of ethnicity/race concordance on the respect/ communication aspect of provider cultural sensitivity for the H/L patients and no significant effect for AA patients. Provider fairness was found to be positively associated with provider satisfaction for AA, H/L, and WA patients. Furthermore, provider fairness was found to be associated with the competence/confidence aspect of provider cultural sensitivity and trust in provider for AA and WA patients. These findings provide support for the role of provider fairness in the PC-CSHC model and suggest that patient-provider ethnicity/race concordance may not be an important aspect of ethnic/racial minority patients' health care experience. Other factors such as patient-perceived cultural or socioeconomic similarity of their health care provider may be more important to ethnic/racial minority patients. These findings suggest the need to customize communication and health care interventions for ethnically/racially diverse patients. ( en )
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis:
Thesis (Ph.D.)--University of Florida, 2014.
Local:
Adviser: TUCKER,CAROLYN M.
Local:
Co-adviser: MILLER,SCOTT A.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-11-30
Statement of Responsibility:
by Khanh Ngoc Nghiem.

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Embargo Date:
11/30/2014
Resource Identifier:
907379421 ( OCLC )
Classification:
LD1780 2014 ( lcc )

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TESTING THE ROLES OF PERCEIVED PROVIDER FAIRNESS AND PATIENTPROVIDER ETHNICITY / RACE CONCORDANCE IN A PATIENT CENTERED CULTURALLY SENSITIVE HEALTH CARE MODEL BY KHANH N. NGHIEM A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2014 1

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2014 Khanh N. Nghiem 2

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ACKNOWLEDGMENTS I am very fortunate and blessed to have had so many people support me through the dissertation process as well as my journey towards becoming a better professional and person. My deepest appreciation goes to my dissertation committee chair and academic adv isor, Dr. Carolyn M. Tucker, for her mentorship during my graduate education as well as her encouragement, guidance, direction, and advocacy throughout the process of completing this dissertation. Her passionate commitment to her students and research cont inues to inspire me. I also would like to thank my dissertation committee members, Dr. ChunChung Choi, Dr. Scott Miller, and Dr. Ana Puig, for their patience, understanding, and willingness to meet short deadlines in order to help me succeed. I would li ke to thank my friend and colleague, Dr. Manny Lopez for his valuable feedback, comprehensive edits, and moral support. Thank you to Ms. Rebecca Richko and Ms. Jackie Rollins for their help with the many details of the process. I would also like to extend a very special thanks to the wonderful people at Ball State University Counseling Center, especially Dr. Pei Yi Lin, Dr. Jay Zimmerman, Dr. Lee Van Donselaar, and Dr. June Payne. I am appreciative of Dr. Pei Yi Lin in particular for her warm support, mento rship, and friendship. I could not have asked for more supportive and understanding colleagues and friends. My writing days would have been very bleak without them. Last but not least, I would like to thank the family and friends in my life who inspired and supported me all along this journey. I would like to thank Delphia Flenar, Shengying Zhang, and David Yau for their friendship, kindness, and willingness to lend an ear. Thank you to Minh Nguyen for his support and assistance. I am grateful to Quang Nguyen for his love and unwavering belief in me that has helped me through many difficult moments. Thank you to my brother, Khoa Nghiem for his generosity, big heart, and humor that have helped me remember 3

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the important things in life. I am deeply indebte d and thankful to my parents. Without their sacrifices and love, I would not be the professional and the person that I am today. I am grateful for their dedication and belief in me. Their journey to the U.S. and their resilience have continued to inspire m e to grow, overcome challenges, and remain committed to my professional and personal goals. 4

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TABLE OF CONTENTS P age ACKNOWLEDGEMENTS .............................................................. .......................... ...... 3 LIST OF TABLES ............................................................................ ........................ ........ 7 LIST OF FIGURES ........................................................................... ....................... ........ 8 ABSTRACT .............................................................................. .............................. .. ........ 9 CHAPTER 1 INTRODUCTION ... Statement of the P roblem...................................................................................... Aims of the Study................................................................................................. Hypotheses and Research Question ...................................................................... 11 11 14 14 2 REVIEW OF THE LITERATURE Role of Cultural Sensitivity in Reducing Health Disparities................................ Patient Centered Culturally Sensitive Health Care (PC CSHC)................. Patient Centered Culturally Sensitive Health Care (PC CSHC) Model .. Assessment of Patient Centered Culturally Sensitive Health Care.............. Investigating an Aspect of the PC CSHC Model.................................................. Patient Satisf action....................................................................................... Trust in Provider.......................................................................................... Expanding an Aspect of the PC CSHC Model..................................................... Rationale for Examining Perceived Provider Fairness and Patient Provider Ethnicity/Race Concordance in an Aspect of the PC CSHC Model........................................................................................................ Provider Fairness.......................................................................................... Patient Provider Ethnicity/Race Concordance............................................. 18 18 19 20 21 23 23 25 28 29 31 33 3 METHOD Participants ... Instruments ... Procedure ......... Data Analyses .................. 40 40 40 43 45 4 RESULTS Results of the Descriptive Statistics...................................................................... Analysis to Test the Modified Aspect of the PC CSHC Model and Hypotheses ................................................................................................... ...... 48 48 49 5

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Analysis to Test the Research Question................................ ....................... ......... Testing Direct and Indirect Effects of Ethnicity/Race Concordance on Cultural Sensitivity, Trust, Fairness, and Satisfaction..................................................... Testing Direct and Indirect Effects of Perceived Provider Cultural Sensitivity on Trust in Provider, Provider Fairness, and S atisfa ction with Provider........... 50 52 53 5 DISCUSSION Summary of Findings............................................................................................ Hypotheses................................................................................................... Research Question........................................................................................ Interpretations of Findings.................................................................................... Limitations of the Study and Directions for Future Research.............................. Implications for Counseling Psychologists....................................................... Conclusion............................................................................................................ 64 64 64 65 66 68 71 72 APPENDIX A DEMOGRAPHIC AND HEALTH DATA QUESTIONNAIRE (DHDQ).......... B HEALTH CARE JUSTICE INVENTORY (HCJI).............. ................................ C PATIENT SATISFACTION QUESTIONNAIRE SHORT FORM (PSQ18) D TUCKERCULTURALLY SENSITIVE HEALTH CARE PROVIDER INVENTORY (T CSHCPI).... ............................................................................... E PATIENT PACKET COVER LETTER................................................................. F PATIENT INFORMED CONSENT FORM.......................................................... 74 77 78 80 82 84 LIST OF REFERENCES ........................................................................ ................. ......... 87 BIOGRAPHICAL SKETCH ............................................................ .......................... ...... 99 6

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Table LIST OF TABLES Page 3 1 Items on each s ub s cale of the Tucker Culturally Sensitive Health Care Provider Inventory (T CSHCPI) ......................................................................... 47 4 1 Demographic c haracteristics for the African American (AA), Hispanic/Latino(a) (H/L), White American (WA) Patient Participants, and for the t otal patient participants .............................................................................. 55 4 2 Correlations among Variables of Study for the Total Patient Participant ... 56 4 3 Correlations among variables of s tudy for the African American, Hispanic/Latino(a), and White American patient participants ........................... 57 4 4 Means, s tandard d eviations and missing data total for the v ariables of s tudy for the African American, Hispanic/Latino(a), and White American patient participants, and for the t otal patient participants ............................................... 58 4 5 Results of the m ultigroup a nalyses to t est the modified PC CSHC Model a cross African American, Hispanic /Latino(a), and White American patient participant g roups ............................................................................................... 59 7

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Figure LIST OF FIGURES Page 1 1 Patient Centered Culturally Sensitive Health C are (PC CSHC) Model...... ............ 1 6 1 2 Modified m odel a dapte d from the PC CSHC Model to be t ested in the present s tudy........................................................................................................................ 17 4 1 Reduced m odel with standardized p arameters estimates for t otal p atien t participant ( N = 1,654; all paramet ers had critical ratio s > 1.96).... 60 4 2 Reduced m odel with s tandardized parameters e stimates for African American patient participants ( N = 323; all paramet ers had critical ratios > 1.96).................. 61 4 3 Reduced m odel with s tandardized p arameters e stimates for Hispanic/Latino(a) patient participants ( N = 553; all paramet ers had critical ratios > 1.96).................. 62 4 4 Reduced m odel with s tandardized parameters e stimates for White American pa tient p articipants ( N = 531; all paramet ers had crit ical ratios > 1.96).................. 63 8

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Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy TESTING THE ROLES OF PERCEIVED PROVIDER FAIRNESS AND PATIENTPROVIDER ETHNICIT Y/RACE CONCORDANCE IN A PATIENT CENTERED CULTURALLY SENSITIVE HEALTH CARE MODEL By Khanh N. Nghiem May 2014 Chair: Carolyn M. Tucker Major: Counseling Psychology There is a lack of research that links patient perceived provider fairness and patient provider ethnicity/race concordance with provider cultural sensitivity, patients trust in their provider, and patients satisfaction with their provider. The present study wa s designed to test an aspect of the Patient Centered Culturally Sensitive Health Care (PC CSHC) Model that was modified to include provider fairness and patient provider ethnicity/race concordance. Specifically, the present study sought to (a) test the associations of the modified PC CSHC model among a sample of ethnically/racially diverse patients; and (b) explore if the associations in the modified PC CSHC model differ for African American (AA), Hispanic/Latino(a) (H/L), and White American (WA) patients. Participants in this study were 1,654 ethnically/racially diverse patients, each of whom have received health care from one of 67 health care sites across the U.S. The analyses revealed that provider fairness but not ethnicity/race concordance has signific ant positive associations with provider cultural sensitivity, trust in provider, and satisfaction with provider for the total participant sample. However, the sensitivity/interpersonal skill aspect of provider cultural sensitivity has a negative associatio n with provider fairness in the 9

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total patient participant sample. Furthermore, analyses revealed that ethnicity/race concordance has a significant positive effect on provider cultural sensitivity, provider fairness, and patient satisfaction for WA patients only. In contrast, there was a significant negative effect of ethnicity/race concordance on the respect/ communication aspect of provider cultural sensitivity for the H/L patients and no significant effect for AA patients. Provider fairness was found to be positively associated with provider satisfaction for AA, H/L, and WA patients. Furthermore, provider fairness was found to be associated with the competence/confidence aspect of provider cultural sensitivity and trust in provider for AA and WA patients. These findings provide support for the role of provider fairness in the PC CSHC model and suggest that patient provider ethnicity/race concordance may not be an important aspect of ethnic/racial minority patients health care experience. Other factors su ch as patient perceived cultural or socioeconomic similarity of their health care provider may be more important to ethnic/racial minority patients. These findings suggest the need to customize communication and health care interventions for ethnically/rac ially diverse patients. 10

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CHAPTER 1 INTRODUCTION Statement of the Problem Health disparities are inequalities in health outcomes an d access to health care that disproportionately impact ethnic/racial minority groups and other disadvantaged groups. There has been an increased focus on decreasing health disparities that disproportionately impact ethnic/racial minority groups particularly as the U.S. becomes increasingly more diverse. The U.S. Census Bureau (2010) estimated that ethnic/racial m inorities currently comprise 37% of the total population and are projected to comprise 57% of the total population in 2060. The U.S. is projected to become a majorityminority nation for the first time in 2043 which means that no group will be the majority although the nonHispanic White population will remain the largest group. Health disparities as well as lower rates of access and utilization of health care services have been documented amongst ethnic/racial minorities (Agency for Healthcare Research and Quality [AHRQ], 2003; 2009; Center for Disease Control [CDC], 2009; U.S. Department of Health and Human Services [U.S. DHHS], 2009). Consequently, there have been urgent calls to reduce health disparities and improve hea lth care quality and delivery for ethnic/racial minorities ( AHRQ, 2009; U.S. DHHS 2009). It has been suggested that c ulturally sensitive health care systems are contributors to reducing health disparities (American College of Physicians, 2004). However, there is little consensus as to the specific definitions of cultural sensitivity and cultural competence (Goode, et al., 2006). Furthermore, only a few studies have demonstrated links between cultural sensitivity and patient health outcomes (Thom & Tirado 2006; U.S. DHHS, 2001). This paucity of research may be due to a lack of a comprehensive theory that link culturally sensitive health care to patient health outcomes Tucker and her col leagues (2007; 2011) developed the Patient Centered 11

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Culturally Sensit ive Health Care (PC CSHC) Model ( Figure 1 1) which is a model that link s patient perceived cultural sensitivity to treatment and dietary adherence through associations with patient trust in provider and patient satisfaction Of specific relevance to the present study is the model's assertion that patient perceived cultural sensitivity of providers promotes patient's trust in providers, which in turn increases patient's satisfaction with their providers. Patient perceived provider fairness and patient provider ethnicity/race concordance may be associated with patient perceived cultural sensitivity, patient's trust in providers, and patient satisfaction with provid ers. However, patient perceived provider fairness and patient provider ethnicity/ra ce concordance are not included in the above mentioned PC CSHC Model. U nequal treatment received by ethnic /racial minorities negatively impact s their health care experience. Specifically, ethnic/racial minority patients reported being treated with lower r espect by their health care provider, having lower trust and confidence in their provider, and feeling disenfranchised in their health care (Cooper Patrick et al., 1999; Harris et al., 1995; Thomas, Groff, Tsang, & Carlson, 2009). Furthermore, studies have show n that providers tend to not discuss alternative treatments, not mention enrollment in clinical trials to test new treatments and spend less time with ethnic/racial minority patients compare d to nonHispanic White patients (King & Wheeler, 2004; Shaya & Blume, 2005). Unequal treatment may be the result of providers having stereotypes about ethnic/racial minority patients' health related behaviors. For example, van Ryn and Burke (2000) reviewed 618 medical encounters and found that providers belie ved that African American patients were more likely to abuse drugs and alcohol, less likely to follow treatment recommendations, and less likely to participate in rehabilitation therapy. Given the time pressures and the responsibility that providers have i n managing very complex health care tasks during brief encounters with patients, 12

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it is possible that providers may be particularly vulnerable to the use of stereotypes in patientprovider interactions (van Ryn & Burke, 2000) especially when providers are stressed or fatigued (Burgess, et al., 2010) Although these stereotypes may be unintentional and unconscious ( Blair, Steiner, & Havranek, 2011; Burgess, van Ryn, Dovidio, & Saha, 2007), they can negatively impact patient provider interactions and health outcomes for ethnic/racial minority patients. Given the above mentioned research on unequal treatment of ethnic/racial minority patients by their providers, it is surprising that there is a lack of research regarding patient perceived fairness from provide rs. There have been only a few studies that have investigated patients perceived fairness from providers (Fondacaro et al., 2005; Holmvall, Twohig, Frances, & Kelloway, 2012; Hughes & Larson, 1991). T here are no published studies that have examined how pa tients perceived fairness from providers may affect their trust in their providers and in turn their satisfaction with their providers Moreover, there are no published studies that have investigated the influence of patient perceived provider cultural se nsitivity or competence on patient perceived fairness of providers. It has also been suggested that concordance between patients and providers may reduce overt discrimination and stereotyping (Ashton, Haidet, Paterniti, et al., 2003; Van Ryn, 2002) by reducing the provider's biased interpretations and assumptions regarding patients' symptoms and behaviors (Balsa &McGuire, 2003). Patients' perceived ethnicity /race similarity with their provider is called ethnicity/race concordance. The underlying assumption is that providers from similar demographics as the patient will elicit increased patient perceived patient provider similarity such that the patient feels trusting of and comfortable with this provider. Furthermore, providers with similar demographics as the patient may understand their patient's experiences 13

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and cultural practices more and potentially exhibit less ethnic/racial bias than providers with less similar demographics Thus, the patient will presumably have higher patient satisfaction and treatment adherence in patient provider relationships that are ethnicity/race concordant Aims of the Study The findings from the aforementioned studies provide an impetus for the present st udy The present study responds to the lack of research that examines how patient perceived provider fairness and patient provider ethnicity/race concordance affects patients' per ceived cultural sensitivity of their providers and other patient provider interpersonal processes. Specifically, the present study will (a) test a modified version of the PC CSHC Model ( see Figure 1 2 ) to determine if patient provider ethnicity/race concordance and perceived provider f airness are associated with patient satisfaction with their provider via associations with patientperceived provider cultural sensitivity and patient trust in provider ; and (b) explor e if these associations in the modified version of the PC CSHC Model di ffer for African American, Hispanic/Latino(a), and White patient partici pants The present study is novel because additional factors (i.e., perceived provider fairness and patient provider ethnicity/race concordance) are included in the PC CSHC Model Additionally, the present study is novel in that (a) it is the first to specify the mechanisms that link patientprovider ethnicity/race concordance to patient satisfaction with provider (b) it expands the PC CSHC Model to include examination of the influence of patient provider ethnicity/race concordance and patient perceived provider fairness on patient satisfaction with providers, and (c) it includes African American, Hispanic/Latino(a), and nonHispanic White patient participants in the testing of this model Hypotheses and Research Question 14

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The present study tested the following hypotheses and research question : Hypotheses 1. P atient provider ethnicity/race concordance will have a direct effect on patients trust in provider, perceived provider cultural sensitivity (each of the three factors of cultural sensitivity: com petence/confidence, sensitivity/interpersonal skill, respect/communication) and perceived provider fairness. 2. Patient provider ethnicity/race concordance will have an indirect effect on perceived patient satisfaction with provider through perceived trust in provider, perceived provider cultural sensitivity, and perceived provider fairness. 3. Perceived trust in provider, perceived provider cultural sensitivity, and perceived provider fairness will have direct effects on perceived patient satisfaction with provide r Research Question In addition to testing the above hypotheses, the following research question was also addressed: 1. Do the proposed paths in the modified PC CSHC Model differ for African American, Hispanic/Latino (a), and White American patient participants ? 15

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Figure 11. Patient Centered Culturally Sensitive Health Care (PC CSHC) Model 16

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Figure 12: Modified model adapted from the PC CSHC Model to be tested in the present study. 17

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CHAPTER 2 LITERATURE REVIEW Role of Cultural Sensitivity in Reducing Health Disparities Health disparities are inequalities in health outcomes and access to health care that disproportionately impact ethnic/racial minority groups and other disadvantaged groups. Specifically, ethnic/racial minorities continue to demonstrate poorer health indicators when compared to their nonHispanic White counterpart s, particularly in six health areas: infant mortality, diabetes, cardiovascular disease, cancer screening and management, HIV/AIDS, and child and adult immunizations (USDHHS, 2001). There have been documented disparities in these health areas with regards to health care access and health care quality. Blacks and Hispanics reported lower access to health care tha n nonHispanic Whites (AHRQ, 200 9). Ethnic/racial minorities and lower income individuals reported receiving lower health care quality than nonHisp anic Whites or those with higher incomes (AHRQ, 2009). These differences in health care access and quality all contribute to the existing health disparities (Institute of Medicine, 2004). According to the American College of Physicians (2004), culturally responsive health care systems are specific quality of care contributors to reducing health disparities in the U.S. Culturally responsive health care has been defined as acknowledging and respecting cultural differences among minority groups that impact th eir health behaviors and health outcomes, and applying this awareness in health care delivery (USDHHS, 2001). It has been asserted that cultural competence and cultural sensitivity of providers are positively associated with increased patient satisfaction, treatment adherence, and health outcomes ( Betancourt & Green, 2010; Lie, Lee Ray, Gomez, et al., 2011). 18

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Cultural competence in health care has been defined as a set of behaviors, attitudes, and policies that generates and demonstrates understanding, appr eciation, and respect for cultural differences and similarities within, among, and between groups (LavizzoMourey & MacKenzie, 1996; U.S. Department of Health a nd Human Services [USDHHS], 2001 ). Culturally responsive health care includes having the knowledge and skills to work with culturally diverse patien ts as well as demonstrating this knowledge and these skills to patients (USDHHS, 2001). As such, cultural responsiveness is considered to be subsumed under the broader concept of cultural competenc e. The construct of cultural sensitivity has been defined as services such as offering clinic materials to patients that are relevant to their needs and expectations (USDHHS, 2001). Patient Centered Culturally Sensitive Health Care (P C CSHC) The need for cultural sensitiv ity and cultural competence in health care is apparent; however, there is little consensus as to the specific definitions of these terms (Goode, et al., 2006). Additionally, these constructs do not take into account the importance of patie nts perceptions and experiences. Tucker and her colleagues (2007, 2013) have argued for the need for culturally sensitive health care that (a) is patient defined rather than expert defined, (b) is empirically based and can be tested and (c) includes inventories that patients can assess the cultural sensitivity of their providers, office staff, and clinic environment as well as self assessm ents of the cultural sensitivity of providers and office staff. Patient centered culturally sensitive health c are and the Patient Centered Culturally Sensitive Health Care (PC CSHC) Model were developed i n response to these needs. T he defining characteristics of patient centered culturally sensitive h ealth c are are that it: (a) emphasizes displaying patient/client desired, modifiable provider and staff behaviors and attitudes that culturally diverse patients/clients identify as indicators of respect for their culture 19

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and that enable these patients/clients to feel comfortable with, trusting of, and respected by their health care providers and office staff; (b) includes having physical health care center environment characteristics and policies that enable patients to feel a sense of belonging and comfort at the center; (c) conc eptualizes the patient provider relationship as a partnership that emerges from patient centeredness; and (d) is patient empowerment oriented (Tucker et al., 2007). Furthermore, patient centered culturally sensitive health care has been described as cultural competence plus a concept that recognizes the importance of displaying cultural competence and of identifying and being responsive to what patients want, need, perceive, and feel in the health care process (Herman, Tucker, Ferdinand, et al., 2007). Patient Centered Culturally Sensitive Health Care (PC CSHC) Model The literature based PC CSHC M odel (Figure 1 2) is the first to provide a conceptual framework that demonstrates linkages between patients' perceived cultural sensitivity in their health care to health behaviors that impact their health outcomes. T ucker and colleagues (2011) found that the PC CSHC M odel is viable for explaining how patient perceived provider cultural sensitivity impacts patients' health outcomes. The PC CSHC Model specifically asserts that (a) patient perceived provider cultural sensitivity predicts higher levels of patient satisfaction with care patient perceived interpersonal control in interactions with others (e.g., providers), and trust in provider, and lower levels of physical stress, and (b) trust in provider, interpersonal control, low levels of physical stress, and satisfaction with provider indirectly link patient perceived provider cultural sensitivity to both higher levels of patient treatment adherence (i.e., dietary and medication adherence) and engagement in a health promoting lifestyle. An empirical test of the PC CSHC Model link ed 20

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patient perceived provider cultural sensitivity to patients' dietary adherence through patient trust in provider and patient satisfaction (Tucker et al., 2011). Additionally, Tucker and co lleagues (2011) found ethnicity/race differences in the linkages between perceived provider cultural sensitivity and self reported health behaviors. Specifically, a mong African American patients there was a stronger association between patient perceived provider cultural sensitivity and patient satisfaction with care; whereas among nonHispanic White patients there was a stronger association between patient perceived provider cultural sensitivity and trust in provider. It was also found that there was a direct link between patient perceived provider cultural sensitivity and self reported dietary adherence among the African American patients, but not among the nonHispa nic White patients. The se ethnic/racial differences are particularly relevant in that patients from minority groups may deem certain factors in the patient provider relationship as more or less influential on the ir health related behaviors. This study by T ucker and colleagues (2011) provide partial support for the PC CSHC Model. Assessment of Patient Centered Culturally Sensitive Health Care Inventory There are increasing calls for the development of measures that assess patient centered culturally sensitive health care (AHRQ, 2005). Research has demonstrated that despite health care providers extensive training in cultural competence, they may not display the behaviors and attitudes and promote physical environments that clients experience as cultu rally competent (Paterson, 2001). Therefore, assessments that are based on what patients find as important to their health care experience are more likely to be effective than assessments based on what professional heath experts view as important character istics of health care provision. Tucker and colleagues developed the Tucker Culturally Sensitive Health Care Inventory (T CSHCI) to 21

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address the lack of assessments of patient centered culturally sensitive health care as defined by culturally diverse patien ts (Tucker, Mirsu Paun, van den Berg, et al., 2007). The development of the T CSHCI was based on data from ethnicity/race and gender concordant focus groups consisting of mostly low income African American, Hispanic American, and White American patients in which these patients were asked to identify specific provider and clinical staff behaviors and attitudes, and clinic characteristics that enable them to feel comfortable with, trusting of, and respected in the health care process (Tucker, Herman, Peder sen, et al., 2003). The focus group data were used to construct pilot ethnicity/race specific inventories to assess patient centered culturally sensitive health care. African American, Hispanic, and nonHispanic White patients who did not participate in th e focus groups rated the importance of each item on the inventory for their respective ethnicity/race (Tucker, Mirsu Paun, van den Berg, et al., 2007). These importance ratings were made using a 1 to 5 rating scale, and only the health care provider items with mean ratings of 3 or higher were retained in the pilot T CSHCIs. Factor analyses performed on these retained items revealed factors that focus on areas other than providers knowledge behaviors, and attitudes Furthermore, the factors and items were consistent across ethnicity/race; thus, the pilot ethnicity/race specific inventories were combined into one pilot inventory. This inventory was originally part of a three section pilot inventory that included patients' perceived cultural sensitivity displ ayed by health care providers, patients perceived cultural sensitivity displayed by front desk office staff, and patient perceived cultural sensitivity of health care centers physical environment characteristics and policies. This 3part pilot inventory was later divided into three separate inventories one inventory for each part. These three inventories are as follows: (1) the Tucker Culturally Sensitive Health Care Provider Inventory, which is used by patients to assess the cultural 22

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sensitivity of provider s' behaviors and attitudes, (2) the Tucker Culturally Sensitive Health Care Office Staff Inventory, which is used by patients to assess the cultural sensitivity of office staff behaviors and attitudes, and (3) the Tucker Culturally Sensitive Health Care Clinical Environment Inventory, which is used by patient to assess the cultural sensitivity of center policies and physic al environment characteristics. These pilot inventories were administered in a study of patients in 67 health care s ites across the nation and the inventories were finalized (Tucker, Nghiem, Marsiske, & Robinson, 2013) For the present study, the final and now published version of the Tucker Culturally Sensitive Health Care Provider Inventory (Tucker et al. 2013) will be used. Investigating an Aspect of the P C CSHC Model The PC CSHC M odel asserts that patients' perceived cultural sensitivity in their health care is linked to patient satisfaction, trust in provider, dietary adherence, and engagement in a health promoting lifestyle, and ultimately to health outcomes. The aspect of the model that is the fo cus of the present study is the aspect that includes the association of provider cultural sensitivity with trust in provider and patient satisfaction Patient Satisfaction In the last two decades, p atient satisfaction has emerged in the health care literature as an important measure of health care quality due to its implications for health care management, health care delivery, and patient outcomes. Despite patient satisfaction being a widely investigated construct, there is a lack of consensus regar ding a clear definition and conceptualization of patient satisfaction (Gill & White, 2009). Some researchers have simply defined patient satisfaction as the extent to which the patient is satisfied with his/her health care ex perience (Hays, 2009). O thers h ave operationalized patient satisfaction as the degree of 23

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congruence between patients' health care expectations and their perceptions of the health care they actually received (Heidegger, Saal & Nuebling, 2006) or the extent to which patients' expectations have been exceeded versus not been met (Friesner et al., 2009). The difficulties in defining this construct have been related to lack of agreement on the specific determinants of patient satisfaction. The most common health care dimensions in effectively evaluating patient satisfaction have included the following: (a) provider's interpersonal skills (b) health care access, (c) u se of health care facilities, (d ) positive health outcomes a nd outcome continuity, (e ) and provider's attention to psychosocia l factors (Heidegger et al, 2006; van Campen et al., 1995; Vrijhoef et al., 2009). A measure that has been reported to best assess these identified dimensions in comparison to other measures is the Patient Satisfaction Questionnaire (PSQ) (Ware, Snyder, Wright, & Davies, 1983). The PSQ, its revised version, the PSQ III (Marshall, Hays, Ron, Sherbourne, & Wells, 1993), and the short form version, the PSQ 18 (Marshall & Hays, 1994) have been widely used measures of patient satisfaction in health care research (Marshall et al., 1993) due to their high internal consistencies Additionally, the PSQ 18 was found to be moderately correlated with other patient s atisfaction assessments and produced similar median scores across individuals with different chronic conditions (Vrijhoef et al., 2009). Furthermore, the PSQ 18 was developed based on patients' perceptions of specific aspects that they valued regarding their satisfaction. The present study will utilize the PSQ 18 as a measure of patient satisfaction. The relationship between patient satisfaction with health care and positive patient outcomes have been well documented. Patients who are satisfied with their health care are more likely to adhere to treatment recommendations, use medical services, have higher medical trust, have positive health outcomes, and report positive provider patient relationships (Baker, 24

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Mainous, Gray, & Love, 2003; Castro & Ruiz, 2009; Cvengros, Christensen, Hills, & Rosenthal, 2007; Golin et al., 2002; Hirsh, Atchinson, & Berger, 2005; Thomas et al., 2009). Moreover patients who were satisfied with their health care also reporte d experiencing better health, utilized medical services and pursued health screenings (Arahony & Strasser, 1992; DiPalo, 1997; Henderson et al., 2004; Pascoe 1983). Patients who reported dissatisfaction with their health care were more likely to wait longer before seeking health services and tend to visit emergency rooms rather than return to their providers (Ware et al., 1983). Patient satisfaction has critical implications for ethnic/racial minority patients' use of health care services. Ethnic/racial minority patients who were more satisfied with their health care providers were more likely to adhere to treatment, utilize medic al services, and reported increased medical trust, health outcomes, and communication with their health care providers (Castro & Ruiz, 2009; Golin, DiMatteo, Duan, Leake, & Gelberg, 2002; Thomas et al., 2009). Somkin and colleagues ( 2004) found that Africa n American, Asian American, and Hispanic/Latino women who were more satisfied with the interpersonal aspects of their health care were more likely to obtain regular mammograms. Trust in Provider Trust has been recognized as an important component of the health care system, particularly within the patientprovider relationship. Trust between patient and providers have been defined as "an expectation that medical care providers will act in ways that demonstrate that the patient's interests are a priority" ( Halbert, Arm strong, Gandy, & Shaker, 2006, pg.67). Trust has been widely studied in the health care literature and found to be positively associated with increased patient satisfaction, treatment adherence continuity of care, and health care status (Emanu el & Dubler, 1995; Kao et al 1998; Safran et al ., 1998; Thom et al ., 2004; Thom et a l ., 25

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1999). Furthermore, greater trust in providers have been demonstrated to be related to higher rates of self efficacy in treatment regimens and positive expectations for health outcomes (Lee & Lin, 2009) and higher engagement in preventative services such as cancer screening and routine checkups ( Ling, Klein, & Dang, 2006; Musa et al ., 2009; O'Malley, 2004). Despite racially diverse patients report ing that trust in p roviders is of particular value to them (Tucker et al., 2003), t here is evidence of lower levels of trust in providers for ethnic/racial minority patients (Musa et al., 2009; Rawaf & Kressin, 2007) White patients were significantly more likely to report trusting their providers as reliable sources of health information compared to African American patients (Brodie et al., 1999). For example, Carpenter and colleagues (2009) conducted in home interviews with African American and White male patients over 50 years old within weeks of their prostate cancer diagnosis and found that compared to African American patients, White patients were more likely to report trusting their provider and seeing the same provider at regular medical encounters. Even after account ing for socio demographic factors (e.g., marital status, education), Halbert et al. (2006) found that African American patients had lower levels of trust in their providers than White patients. Furtherm ore, these researchers found that the major predictor of low trust among African American patients were low quality interactions with providers. Low levels of trust in providers may have serious implications for patients health outcomes as patients with low trust levels may not be as likely to share crucial health information with their providers, resulting in inaccurate diagnoses and treatment decisions (Finney Rutten et al., 2006). Additionally, patients with lower trust in their providers may have health needs that are untreated due to health care avoidance. Lower trust in provider among ethnic/racial minority patients may contribute to health disparities as these patients may be unlikely to continue wi th 26

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treatment or participate in treatment, have decreased treatment adherence, and avoid seeking health care for their medical needs (Devlin, et al., 2006; Finney Rutten et al., 2006; IOM, 2002) Several suggestions have been posited to explain the lower levels of trust in providers among ethnic/racial minority patients. One explanation offered is that ratings of lower trust in health care may be based on previous negative experiences, such as receiving biased treatment and being misunderstood in their health care experiences, as has been reported by ethnic and racial minorities (Armstrong, et al., 2007; Collin s et al., 2002; Martin, et al., 2013). Hausmann and colleagues (2013) suggested that among Black patients, lower trust in providers may be mediated by perceived interpersonal racial discrimination in their health care experience. These r esearchers finding s suggest that Black patients perceived interpersonal racial discrimination may negative ly impact trust in providers Similarly, these findings provide support for the assertion that cultural mistrust is a mediator between interpersonal racial discrimination and trust in providers (Benkert, et al., 2006). Another explanation conceptualizes trust as having two dimensions: interpersonal trust and social trust. Interpersonal trust pertains to interpersonal experien ces with provi ders that a patient may develop as he/she interact s with a particular provider or providers in general (Finney Rutten et al., 2006; Silk, 2008; Stewa rt et al., 2000). For example, a patients interpersonal trust might increase if his/her provider or other providers exhibit desired behaviors, such as listening carefully to the patient or demonstrating sensitivity and respect to the patient. Interpersona l t rust operates on an individual level whereas social trust operat es at a societal level. Social trust is developed through a collective experience and can be influenced by media and popular perceptions (Pearson & Raeke, 2000). 27

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Social trust include s the broader context of attitudes, beliefs, and perceptions that a society hold s towards a cultural group of which the patient is a member. For example, African American s distrust in providers has been linked to the Tuskegee Syphilis Study (Freimuth et al., 2001; Reverby, 2010; Shavers, Lynch, & Burmeister, 2001). This study, which was conducted by the U.S. Public Health Service, investigated the natural progression of untreated syphilis amongst rural African American men over a 40 year period (19321972) These African American men, 399 who had contacted syphilis prior to the study and 201 without the disease, received free medical care, meals, and burial services for their study participation but were never informed that they had syphilis nor were t hey ever treated for this disease. Furthermore, during much of the nineteenth and twentieth centuries following the abolishment of slavery, Jim Crow laws resulted in medical facilities being designed as separate but equal for Black and White patients. Th e facilities and quality of care for Black patients were generally poorer. Hence many African Americans experienced overt racism, unequal treatment, and negative interactions within the health care system despite the separate but equal mandate. Indeed, m istrust of providers can become functional paranoia for ethnic/racial minority individuals when dealing with powerful institutions such as hospitals and their staff members (Watts, 2004). Pearson and Raeke (2000) pointed out that interpersonal trust must be viewed in the context of social trust and that both types of trust might produce the lower levels of trust reported among ethnic/racial minority patients. Expanding an Aspect of the PC CSHC Model As earlier mentioned the PC CSHC M odel offers an explanation of the linkages between culturally sensitive health care and patients health behaviors, and ultimately patients health outcomes. This model does not include the roles of perceived provider fairness and of patient 28

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provider ethnicity/race concordance among these linkages. The present study will investigate these factors among the linkages between patient perceived cultural sensitivity, patient perceived trust in provider, and patient satisfaction with provider. Rationale for Examining Perceived Provider Fairness and Patient Provider Ethnicity /Race Concordance in an Aspect of the PC CSHC Model Alarmingly, t here is evidence of ethnic/racial differences in the quality of patient provider relationships. For example, it has been found that e thnic/racial minority patients were less likely to receive emphatic responses and health care information from their providers, and were less likely to be encouraged to participate in health care decisions by their providers (Ferguson & Candib, 2002). Providers also exhibited less nonverbal attention, empathy, courtesy, and information giving (Hooper, Comstock, Goodwin, & Goodwin, 1982); spent less time providing health education and answering questions (Oliver, Goodwin, Gotler; 2001); and are more verbally dominant and less patient centered with ethnic /racial minority patients than White patients (Johnson, Roter, Powe & Cooper, 2004). It has also been reported that providers have poorer interpersonal skills, provide less information and use a less participa tory decision making style with ethnic/racial minority patients compared to White patients (Ashton et al., 2003). These findings suggest that the unequal treatment received by ethnic/racial minorities negatively impact their health care experience. Fifteen percent of African American patients, 13% of Hispanic patients, and 11% of Asian patients believed they would receive better health care if they were of a different race or ethnicity, compared with 1% of white patients (Collins, Hughes, Doty, et al ., 2002). Coran and colleagues (2013) found that 74% of ethnic/racial minority patients reported feeling that their providers didn't understand their values and background compared to 16% of majority patients. Black patients were significantly more likely 29

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than W hite patients to believe that their race negatively impacted their health care experience ( Johnson, Saha, Arbelaez, et al., 2004). Interestingly, Macintosh and colleagues (2013) found that ethnic/racial minorities who reported being perceived as White by providers are more likely to receive preventative vaccinations and less likely to report health care discrimination compared to ethnic/racial minorities who reported being perceived as an ethnic/racial minority by providers. In a qualitative study, Af rican American patients with diabetes identified provider bias/discrimination and cultural discordance as issues that they perceive as negatively impact ing their providers' decision making behaviors such as sharing less health education information and te st results (Peek, Odoms Young, Quinn, et al., 2010). These patients also described their providers as more likely to be domineering. In the same study, these African American patients identified mistrust of White providers, negative attitudes, and internal ized racism as issues that may negatively impact their health care decisions such as being less likely to sha re health information and being less likely to adher e to treatment recommendations. Although providers may strive to keep their clinical work free from biases, bias can occur without intention or awareness. Past studies indicate that providers do hold stereotypes that influence their clinical work and these stereotypes are often without conscious awareness (van Ryn, 2002; van Ryn & Burke, 2000). Des pite the substantial decline in overt expressions of prejudice, it is still possible to hold biases without full conscious awareness. Such unconscious bias was reported in a study in which it was found that providers are less likely to refer African Americ an women for cardiac catheterization than White men, W hite women, and African American men ( Schulman, Berlin, Harless, et al., 1999). Given the time pressures and the responsibility that providers have in managing very complex health care tasks during brief 30

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encounters with patients, it is possible that providers may be particularly vulnerable to the use of stereotypes in patient provider interactions (van Ryn & Burke, 2000) especially when providers are stressed or fatigued (Burgess et al ., 2010) Although these stereotypes may be unintentional and unconscious ( Blair, Steiner, & Havranek, 2011; Burgess, van Ryn, Dovidio, & Saha, 2007), they can negatively impact patient provider interactions and health outcomes for ethnic/racial minority p atients. Johnson, Roter, Power, et al. (2004) found that providers were verbally dominant and were less patient centered in their approach with African American patients than with White patients. Furthermore, in the same study, providers and African American patients displayed less positive affect in their interactions. Positive affect in medical encounters have been associated with mutual liking and respect (van Wieringen, Harmsen, & Bruijnzeels, 2002). Negative affect may be interpreted as reflecting negative attitudes; for example, negative affect such as anxiety could be interpreted as dislike. White providers may experience more anxiety as a result of wanting to appear nonprejudiced whereas Black patients may experience more anxiety as a result of anticipation of potential prejudice (Dovidio & Gaertner, 2004; Hyers & Swim, 1998). Provider Fairness Patients perceived fairness from providers has been conceptualized in the health care literature as an important aspect of healt h care justice. Health care justice is conceptualized as having two dimensions: procedural justice and distributive justice. Procedural justice refers to perceived fairness in how decisions are made whereas distributive justice refers to perceived fairness in the decision outcomes ( Lind & Ty ler, 1988; Tyler et al., 1997). Research in procedural justice was initially investigated in the legal context (Thibaut & Walker, 1975) whereas distributive justice is a concept that originated from the employment context (Adams, 31

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1965). Usage of these concepts has expanded into the health care context (Fondacaro, Frogner, & Moos, 2005; Murphy, Bergman, & Fondacaro, 1999) Fondacaro and colleagues (2005) have found that procedural justice was a better predictor of patient satisfaction than distributive justice. These researchers suggested that procedural justice actually has three factors: 1) whether patients are treated with personal dignity and respect in a manner that affirms trust (trust), whether they are treated in a neutral and nondiscriminatory manner (impartiality), and whether they are provided an opportunity to participate in decision making (voice/participation). The se researchers developed the Healt h Care Justice Inventory (HCJI), which includes an assessment of trust, impartiality, and voice/participation. The HCJI has two different versions: the Provider version, which assesses patients interactions with their health care provider and the Health Plan version, which assesses patients int eractions with their h ealth care plan representative. As this study focuses on patients interactions with providers, only the Provider version of the HCJI was used. Many of the research studies on health care justice have focused on fairness regarding access to care, allocation of resources, responsibility and advocacy regarding patient rights, medical decision making, and outcomes ( Bauer, 2003; Elovainio, Kivimaki, & Vahtera, 2002). However, there have been only a few studies that have investigated patients perceived fairness from providers (Fondacaro et al., 2005; Holmvall, Twohig, Frances, & Kelloway, 2012; Hughes & Larson, 1991). Holmvall and colleagues (2012) concluded that health care justice and commitment to health care framew orks are import ant dimensions of the patient provider relationship. Hughes and Larson (1991) argue for procedural justice as a theoretical framework for investigating patient health care involvement. 32

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Th e minimal amount of research in this area is surprising, especially given that much of the he alth disparities literature has looked at culturally sensitive/competent health care delivery to reduce health care biases. Despite the extensive literature that shows evidence of differences in health care delivery and quality of care for ethnic/racial minority patients compared to White patients, it is unknown how patients perceived fairness from providers may affect their trust in their providers and in turn their satisfaction with their provider. Moreover, there are no published investigations that have looked at the influence of providers cultural sensitivity or competence on perceived fairness from providers. The present study will investigate the relationship between these two variables. Patient Provider Ethnic ity /Race Concordance There is a growing body of research regarding patients' perceived similarity with their providers. The underlying assumption is that providers from similar demographics as the patient will elicit more perceived similarity such that the patient feels more trust and comfort with interactions with this provider. Furthermore, providers with similar demographics as the patient may understand their patient's experiences and cu ltural practices more and potentially exhibit less ethnicity/race bias Thus, the patient will presumably have higher patient satisfaction and treatment adherence in patient provider relationships that are ethnicity/race concordance. It has also been suggested that concordance between patients and providers may reduce overt discrimination and stereotyping (Ashton, Haidet, Paterniti, et al., 2003; Van Ryn, 2002) by reducing the provider's biased interpretations and assumptions in regar d to patients' symptoms and behaviors (Balsa &McGuire, 2003). Providers ethnicity/race has been found to be an important factor for adults in the selection of health care providers (Gary & Stoddard, 1997; Saha, Taggart, Komaromy, & 33

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Bindman, 2000). Ethni c/racial m inority patients are more likely to choose ethnic/racial minority providers ( Gra y & Stoddard, 1997; Saha, Taggart, Komaromy, & Bindman, 2000). Saha and colleagues (2000) found that approximately one fourth of African American and Latino patients who had chosen same race physicians reported explicitly considering the physicians ethnicity or race in making their selection Lee and colleagues (2008) hypothesized that the relationship between ethnicity/race and level of interpersonal care in the health care process seem s to be mediated by ethnicity/race concordance; when patients and physicians are of the same ethnicity /race relational aspects of the health care process, such as partner ship, respect and communication have been fostered. There have been mixed findings from the patient provider ethnicity/race concordance research literature. Some studies provide support for the benefits of ethnicity/race concordance between patients and p roviders. Primary care providers of the same ethnicity/race as his/her patients has been associated with high levels of patients' utilization and perceived quality of pr imary and specialty care, partnership in decision making, and satisfaction with care ( Cooper Patrick, Gallo, Gonzales, et al., 1999; Ferguson & Candib, 2002; King, Wong, Shapiro, Landon, & Cunningham, 2004; LaVeist & Carroll, 2002; LaVeist, Diala, & Jarrett, 2000; LaVeist & Nuru Jeter, 2002; LaVeist, NuruJeter, & Jones, 2003; Malat, 2001; Saha, Komaromy, Koepsell, & Bindman, 1999). Ethnicity/race concordance in the patient provider relationship may enhance th ese aspects of care through e ffective communication, increased interpersonal trust, and mutual understanding of health needs, behaviors, and expectations ( Burgess, Fu, & van Ryn, 2004; van Ryn & Fu, 2003; van Ryn, 2002; Williams & Rucker, 2000) It has been found that patients who are from the same ethnicity/race as their provider reported higher quality of care and receipt of preventive care, as well as higher levels of satisfaction with health care than patients who 34

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reported a different ethnicity/race from their providers (Laveist & Carroll, 2002; Laveist & Nuru Jeter, 2002; Saha, Komaromy, Koepsell, et al. 1999). Patients who had et hnicity/race concordance with their providers also reported using needed health care services and reported less delays in seeking care than patients who did not have ethnicity/race concordance with their providers (LaVeist, NuruJeter, & Jones, 2003). Ethn ic/racial minority patients who had providers from the ethnicity/race reported more positive patient affect, longer visits (Cooper Patrick, et al., 1999), higher rates of patient centered communication from their providers (Johnson, Roter, Powe, & Cooper, 2004), and higher ratings of perceived respect from their providers (Malat, 2001). Patients reported lower levels of participatory decision making, less satisfaction in ethnicity/race disconcordant provider interactions, and lower levels of trust in their provider (Boulware et al., 2003; Doescher et al ., 2000; Roter, 2003). Saha et al. ( 1999) found that patients with providers of their own race were more likely to rate these providers as excellent and to report being satisfied with health care received than patients with physicians of a diffe rent race. Cooper Patrick and colleagues ( 1999) reported similar findings, with patients seeing physicians of their own race being more satisfied and rating their physicians decision making style as more participatory t han patients in race discordant relationships. Communication in racially discordant patient provider medical interactions is usually less productive and positive in content and tone than in racially concordant interactions. For example, compared to racially concordant patient provider medical interactions, racially discordant ones are characterized by less: positive affect (Johnson, Roter, Powe, & Cooper, 2004), relationship building (Siminoff, Graham, & Gordon, 2006), treatment planning (Oliver, Goodwin, Gotler, 35

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Gregory, & Stange, 2001), and health information exchange (Eggly et al., 2011; Gordon, Street, Sharf, Kelly, & Souchek, 2006). In light of these findings, it is not surprising that minority patients would prefer to see a provider of the same ethn ic or racial background. Other studies suggest that minority patients deliberately choose provider s of their own race because of personal preference and language issues, not s olely because minority provider s are more likely to be located in their communiti es ( Gray & Stoddard, 1997; Saha et al ., 2000; Laveist & Carroll, 2002; Laveist & NuruJeter, 2002). Striley (2006) suggest ed that patients who were race matched with their providers preferred the match. Other studies have found that positive benefits for patients in ethnicity/race concordant patient provider relationships only exist for certain ethnic /race groups. For example, Black patients who repor ted a preference for a provider of the same ethnicity/race were mor e likely to rate their provider as excel lent (Chen, Fryer, Phillips, et al., 2005) and were more likely to report that evidence based prevention and other healthcare needs were met (Saha, Komaromy, Koepsell, et al., 1999). Moreover, Black patients tend to be more satisfied with their medical enc ounter (LaVeist & Nuru Jeter, 2002; Robins, White, Alexander, Gruppen, & Grum, 2001) and with their medical care (LaVeist & Carroll, 2002; Saha, Komaromy, Koepsell, & Bin dman, 1999) when their provider is Black than when their provider is White. LaVeist, N uruJeter, and Jones (2003) further reported that Black patients were more likely to schedule appointments with their providers and were less likely to postpone or delay these appointments when they had a Black provider rather than a White p rovider even a fter controlling for health status. Smith (2013) found that for White patients, ethnicity/ race concordance between patient and provider did not affect prescription use but for Black patients, ethnicity/ race concordance 36

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was a significant predictor of util ization. Unexpectedly, Black patients with B lack p roviders had lower rates of prescription use than those with White provider s. Smit h posits this could be because B lack patients with Black provider s may have better relationships, which enable them to bette r consider and implement life style changes as a substitute for medicine. Saha et al. (1999, 2000) found that among a sample of White, B lack, and Hispanic patients surveyed patients were more likely to choose provider s of their own ethnicity/race Garcia et al. (2003) also found that B lack and Hispanic patients tend to prefer provider s from their own ethnic/racial group. Although national surveys re port that the majority of Black patients do not openly express a preference for an ethnicity/ra ce concordant provider there is evidence that, if given a choice, Black patients prefer an ethnicity/ race concordant p rovider (LaVeist & Nuru Jeter, 2002). Malat and colleagues (2009) concluded that Blacks are more likely than W hites to believe that same race provider s better understand their health problems and to expect more positive interactions with same race provider s compared to different race provider s. Leong and colleagues (2010) found in their Australian study of 3 immigrant groups (plus AngloAustralians) i n an emergency department, preference for a p rovider from the same ethnic/racial background ranged from 40% (Italian) to 82% (Vietnamese). In the same study, providers substantially underestimated the preference of Vietnamese patients for an ethnically/rac ially concordant provider but overestimated this preferenc e for AngloAustralian patients The researchers posited that m uch of this preference for a n ethnically/racially concordant provider seems to be driven by perceived problems wit h communicating with a provider outside the patients ethnic /racial group. 37

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Other studies have found no evidence of benefits for patients in ethnicity/race concordant patient provider relationships (Bleich, 2012; Jerant, Bertakis, Fenton, et al., 2011; Kumar, Schlundt, & Wall ston, 2009; Stevens, 2003; Traylor, Subramanian, Uratsu, et al., 2010). Communication style may be more important than ethnicity/race in patient satisfaction among Whites and B lacks (Aruguete & Roberts, 2002). Street (2007) found that patient provider conc ordance had little effect on provider communication and perceptions with one disturbing exception providers were more contentious with B lack patients whom they also perceived as less effective communicators and less satisfied with care. Follow up analyses in this study indic ated that Black providers communication style with B lack patients was not signi ficantly different than W hite and Asian provider s, al though Black and W hite provider s did perceive Black patients as better communicators than did Asian provider s. In one study, not only were there no benefits to having a provider who was the same ethnicity/race as the patient, it was reported that patientprovider ethnicity/race concordance was actually detrimental to or associated with worst patient outcomes (Blanchard, Nayar, & Lurie 2007) Specifically, these researchers found that Hispanic/Latino patients reported higher discrimination from Hispanic/Latino providers and lower patient satisfaction than Hispanic/Latino patients with non Hispanic/Lati no providers U sing a nationally representative sample, Malat and Hamilton (2006) found that only 20% of African Americans preferr ed a provider of the same race. Sacks (2013) found that Black wom en do not necessarily prefer a B lack provider because they ma y not be assured of receiv ing the best health c are from another Black provider. Additionally, this researcher found that having a B lack provider did not necessarily result in little or no discriminatory treatment. 38

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Overall, the evidence is inconclusive on whether patient provider ethnicity/race concordance improves patient health outcomes, patient provider communication, and perceptions of respect (Meghani et al. 2009). Despite minority patients' typical preference to see a p rovider from the same ethnic or racial background, they were far less likely to do so than White patients (Roter, 2003). The reason for this is not clear although it suggests that other factors may be associated with patient provider ethnicity/race concordance Padela and colleagues (2010) found that a minority of providers believed that shared similar characteristics with patients were beneficial to the medical encounter compared to a majority of patients who believed that shared characteristics with their providers were beneficial to patient provider relationships and interactions This finding seems to suggest that providers and patients may not have similar expectations or values regarding what's important in patientprovider interactions 39

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CHAPTER 3 METHODS Participants The participants in the present study were those in a larger national study by Tucker (2008) on patient centered culturally sensitive health care. However, the particular set of participants and/or the use of their data are unique to the present study. The inclusion criteria for patient participants in the larger study and thus in the present study were: (a) being 18 years or older, (b) having seen a health care provider at least once in the past year, (c) being able to communicate effectively with others verbally or in writing in Spanish or English, and (d) giving written consent to participate. If participants could not read the consent forms and questionnaires and needed assistance in completing these documents, they could ask a data collector, friend, or family member to assist. Data from 1,725 primary care clinic patients who w ere recruited through 67 recruited health care sites were analyzed in this study. This sample was comprised of 1032 (62.4%) women and 519 (31.4%) men. In term s of age range, approximately 16.4% of the sample was between 18 and 24 years old, 19.9% between 25 and 34, 20.5% between 35 and 44, 212.2% between 45 and 54, 11.9% betw een 55 and 64, and 4.7% was older than 65. In terms of income range, approximately 57.7% reported an income of less than $20,000 and 26.7% reported incomes greater than $2 0,001 (Table 4 1) Of the 67 participating health care sites, 47.5% were community health care centers, 10.0% were hospitals, 5.0% were private practices, 2.5% were health departments, an d 35% were other/non specified sites. With regard to site location, 53.8% were located in the west, 30.8% in the south, 10.3% in the midwest, and 5.1% in the northeast. Instruments 40

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Patient participants in this study anonymously completed the following instruments as part of the assessment battery (AB) used in the larger national study: (a) a Demographic Data Questionnaire (DDQ), (b) the Health Care Justice Inventory (HCJI), (c) Patient Satisfaction Questionnaire Short Form (PSQ 18), and (d) the Tucker Culturally Sensitive Health Care Provider Inventory (T CSHCPI). The Demographic Data Questionnaire ( DDQ) was developed by the researchers for the larger study and contains questions to ascertain the following patien t participant informatio n: ethnicity /race gender, age, education level, household income, and providers ethnicity/race. Ethnicity/race concordance was determined by the comparing if the patients' self reported ethnicity/race and their provider's ethnicity/race matched. The ethnicity/race concordance variable was coded as 1 if there was no concordance or match and 2 if there was a match or concordance. Hence in the data analyses, a positive relationship to another variable indicates ethnicity/race concordance is associated with higher levels of th at variable. The Health Care Justice Inventory (HCJI ; Fondacaro, Frogner, & Moos, 2005) is a measure of procedural and distributive justice in the health care context The HCJI consists of two versions : one assessing the patient's interactions with their provider and the other assessing the patient's interactions with their health care plan representative. For the purposes of this study, the version assessing the patient's interactions with their providers will be used. This version has three subscales the Trust subscale, Impartiality subscale and the V oice/Participation subscale. Only the Trust and Impartiality subscales will be used in the present study There are five items on each of the subscales All items on the se subscales are rated on a 4 point Likert scale ranging from 0 = Strongly D isagree to 3 = Strongly Agree." Subscale scores are obtained by summing the item scores on each subscale and higher scores indicate greater perceived trust in or fairness 41

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by their health care provider. The se sub scales ha ve high internal consistencies, with alphas = .93 and .91 for the Trust and Impartiality subscales respectively (Fondacaro et al., 2005). Sample items from the Trust subscal e and Impartiality subscale respectively include "You accept your health care provider's decisions." and "Your health care provider was biased against you." The Patient Satisfaction Questionnaire Short Form (PSQ 18) (Marshall & Hays, 1994) is an 18item scale which assesses patients attitudes toward their health care providers, and their satisfaction with the health care they receive. The PSQ 18 consists of seven sub scales: Accessibility and Convenience, Communication Interpersonal Manner, Technical Qua lity, Financial Aspects, Time Spent with Doctor, and General Satisfaction. The PSQ 18 have no total score. Certain subscales (i.e., T he Technical Quality, Interpersonal Manner, Communication, and Time Spent with Doctor subscales ) can be combined and averag ed to produce a measure of satisfaction with provider care For the purpose d study, only the Satisfaction with Physician subscale will be used Sample items on the Satisfaction with Provider subscale include "My doctors treats me in a friendly and courteous manner." and "Doctors usually spend plenty of time with me."All items on the PSQ 18 are rated on a 5 point Likert scale, ranging from 1 = Strongly Disagree to 4 = Strongly A gree, such that higher scores indicate greater patient satisfaction. The PSQ 18 has been reported to have a high internal consistency that exceeded .90 among population samples from various ethnic and racial groups (Marshall & Hays, 1994). The 27item Tucker Culturally Sensitive Health Care Provider Inventory (T CSHCPI) a ssesses patients perceived levels of patient centered cultural sensitivity displayed by their providers ( Tucker, et al., 2013; Tucker et al., 2007). The T CSHCPI consists of three sub scales with nine items each: Competence/Confidence, Sensitivity/Interpe rsonal Skill, and Respect/Communication. All items on the se subscales are rated on a 4 point Likert scale, ranging 42

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from 1 = Strongly D isagree to 4 = Strongly Agree. Mean scores are calculated for each subscale such that higher scores indicate greater p erceived cultural sensitivity. The internal consistencies for the subscales of the T CSHCPI are as follows: .96 for the Competence/Confidence subscale, .94 for the Sensitivity/Interpersonal subscale, and .94 for the Respect/Communication sub scale. Sampl e items for each of these sub scales include "The health care provider I see most often when I visit my health care office or cente r knows what he or she is doing" ( Competence/Confidence subscale); "The health care provider I see most often when I visit my health care office or center lets me know about illnesses and diseases a mong people of my race/ethnicity" ( Sensitivity/Interpersonal sub scale); and "The health care provider I see most often when I visit my health care office or center takes my concern s seriously even if he or she does not consider them to be serious ( Respect/Communication sub scale). The items on each of the subscales are included in Table 3 1. Procedures Data collection for the present study involved a three step process. In Step One, a multidisciplinary and culturally diverse research team identified a list of national organizations with some focus on health care (e.g., the American Medical Association and the Commission on Minority Health) and potential hea lth care sites The identified organizations and health care sites were sent an invitatio n letter that: (a) explained the patient centered culturally sensitive health care assessment study; (b) requested their participation and/or assistance in recruiting health care sites that might be interested in participating in this study ; and (c) provided a number and e mail address for contacting the research team to express study participation interest and/or to learn more a bout the study. Members of the research team arranged telephone meetings with organization member s 43

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and health care sites that responded to the sent invitation letter. In these telephone meetings it was explained that: (a) the purpose of the present study was to establish the usefulness of an in ventory for assessing the cultural sensitivity of providers behaviors and attitudes; (b) the potential benefits of the study include identification of areas for training providers to be culturally sensitive in ways that are desired by patients; (c) partic ipation in the study would involve disseminating the assessment battery for patients to complete to the patients at their health care site, collecting the completed assessment batteries, and returning the completed assessment batteries via a provided pres tamped return box; (d) participa tion also involved obtaining Institutional Review Board (IRB) approval for the study at their health care site with the assistance of the research team, and that obtaining this approval and data collection must occur within three months; (e) at each site Data Collection Coordinators (i.e., a health care site staff person) and Data Collectors (i.e., two community members) would be trained via telephone on all research participation procedures; and (f) the Data Collector Coord inators, Data Collectors, and patient participants would be paid for their participation. In Step Two, an administrator who agreed to have her/his health care site participate in the study identified a staff person to be a Data Collection Coordinator (DC C), who in turn identified two community members to be Data Collectors (DCs). The DCC was mailed recruitment and study participation materials (i.e., payment release forms, informed consent forms, and assessment batteries). Upon receipt of these materials, the DCC and administrator at each site and members of the research team worked collaboratively to obtain IRB approval at the site. Next, the DDC and the DC s were trained by members of the research team via telephone to execute their roles, whic h are described in Step Three. In Step Three, the DCs distributed patient recruitment flyers (that included participation 44

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criteria) to patients in the waiting rooms of their health care sites, and posted these flyers in these rooms Patients who met the participant inclusion criteria and decided to participate in the study did the following with any needed assistance from the DCs: (a) read and signed the informed consent form, (b) completed the assessment battery (AB) without placing a name on it; (c) signed a Payment Release Form that included a name and address to which payment should be mailed; and (d) returned all forms that included their names to a DC in one sealed envelope and the completed AB in another sealed envelope. These sealed envelopes were r eturned to the DCC to be mailed to the researchers at the end of the 3 month data collection period. The latter action avoided connection of a participants name to her/his assessment battery, thus protecting the confidentiality of the patient participants All data were processed in accordance with the ethical standards of the (IRB) at the university where the research team members are based. For study participation, patient participants were each paid $15, each DCC was paid $50, and each DC was paid $8 pe r hour for a maximum of 16 hours for a maximum payment of $128. All payments were made via money orders and all study participants (i.e., patients, DCCs, and DCs) were paid within six weeks following the end of the study at their site. Data Analyses Struc tural equation modeling (SEM) was used to test the modified model depicted in Figure 12 and to test the hypotheses. Specifically, analyses were conducted to examine if patient provider ethnicity/race concordance, patient perceived provider cultural sensit ivity, patient trust in physician, and patient perceived provider fairness will have direct and indirect effects on patients' satisfaction with providers using the AMOS 17.0 program (SmallWaters Corp., Chicago, IL). Model fit was evaluated using multiple indicators of fit: the chi 45

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index, the comparative fit index (CFI), the root mean square error of approximation (RMSEA), the normedfit index (NFI), and the Tucker Lewis Index (TLI). To examine the research question reg arding if the paths in the modified model differs for African American, Hispanic/Latino(a), and White patients, the modified model was tested wi th simultaneous multigroup path analyses (Tabachnick & Fidell, 1997). The invariance of the measurement models across ethnic/race groups was tested using full information maximum likelihood (FIML) estimation under the assumption that missing data was missing at random (Arbuckle, 1996; Little, 1995). FIML has been selected in previous studies as an optimal method for handling missing data (Muthen & Shedden, 1999; Schafer & Graham, 2002). A fully recursive model across the three ethnicity/race groups of patients was estimated using the proposed model (Figure 12) by constraining all path coefficients (parameters) to be equal across both groups. Secondly, the path coefficients were freely estimated across groups. Chi square difference test s were used to compare the se three models and to evaluate if the paths predicted in the theoretical model differed across the ethnicity/race groups. To detect which paths were different for the groups, each groups path coefficients (parameters) was significant paths were eliminated by setting the param eters equal to zero to test whether a more parsimonious model fit the data equally well. Chi square difference test was used to evaluate the relative improvement or deterioration of the new model, and the three models were compared. Lastly, a new and parsi monious model was tested for each ethnicity/race group separately. 46

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Table 3 1. Items on each sub s cale of the Tucker Culturally Sensitive Health Care Provider Inventory (T CSHCPI) The health care provider I see most often when I visit my health care center office: Competence/Confidence SubScale 1. Knows what he or she is doing. 2. Is confident in his or her abilities. 3. Is well educated. 4. Is dedicated to his or her work. 5. Enjoys what he or she is doing. 6. Is honest and direct with me. 7. Is right about why I am sic k. 8. Seems interested in my problem. Sensitivity/Interpersonal Skill Sub Scale 1. Is respectful of my religious beliefs. 2. Shows care and concern for my child/children. 3. Understands my culture. 4. Lets me know about illnesses and diseases common among people of my race/ethnicity. 5. Understands my financial situation. 6. Follows up on my visits. 7. Prepares me for the next steps in treating my illness. 8. Shows appreciation for me and all of his or her other patients. 9. Does not make me wait long. Respect/Communication Sub Scale 1. Does not talk down to me. 2. Does not try to diagnose all my problems as psychological or in my mind. 3. Does not embarrass me in private or public. 4. Tries to communicate with me. 5. Does not question the truth or accuracy of what I am feeling. 6. Takes all my concer ns seriously even if he or she does not consider them to be serious. 7. Tries to educate me. 8. Prescribes medicine only when he or she is sure of my illness. 9. Takes my concerns seriously. 47

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CHAPTER 4 RESULTS This chapter presents the results of the analyses c onducted to address the hypotheses and research question set forth in the present study. The results are divided into five major parts. First, the descriptive data for all of the investigated variables are reported for the entire sample and then separately for each ethnic/racial group. Second, results of the independent sample t tests conducted to assess for any significant ethnic/ racial group differences in the investigated demographic patient characteristics. Third, the results of a preliminary Pearson correlational analysis that included all variables of study, and the means and standard deviations for the se variables are presented. Fourth, the results of the structural equation modeling analyses that were per formed to test the hypotheses are presented. Finally, the results of t he simultaneous multigroup analyses that were performed to address the research question are presented. Results of the Descriptive Statistics Prior to performing the major analyses in this study, ethnicity/race concordance, patie nt perceived provider cultural sensitivity, trust provider, perceived provider fairness, and patient satisfaction with provider were examined through various SPSS programs for accuracy of data entry, missing values, and fit between distributions and the as sumptions of a multivariate analysis. A total of eight cases were deleted because they were missing data on all variables of interest. Sixty three cases were identified as univariate outliers with a z score standard deviation greater than 2.99 With all 63 outliers and the 8 totally missing data cases deleted, 1,654 cases remained: 553 Hispanic/Latino(a), 531 White American, 323 African American, 64 American Indian, 53 Asian/Pacific Islander, 21 other, and 104 participants who did not indicate their ethnicity/race. 48

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Results from the independent sample t tests revealed several statistically significant differences in demographic characteristics between the African American (AA), Hispanic/Latino(a) (H/L) and the White American groups (Table 4 1). Specifically, the AA group had lower income and was unemployed compared to the H/L and WA groups. The AA group was also older in age and was less educated compared to the H/L group. The H/L group was younger, had less education, and lower income compared to the WA group. Pearson correlations were conducted to examine the associations among the major variables of interest in this study in the total sample and separately for each ethnicity/race group (Table 4 2 and Table 43 ) Means, standard deviations, and missing data for the major variables for each ethnicity/race group and the total patient participant group in the present study are presented in Table 4 4. Analysis to Test the Modified Aspect of the PC CSHC Model and Hypotheses Structural equation model analys es using the AMOS 20.0 program (SmallWaters Corp., Chicago, IL) were conducted to test the hypotheses in this study. These hypotheses are that (a) patient provider ethnicity/race concordance will have a direct effect on patients trust in provider, perceived provider cultural sensitivity (competence/confidence, sensitivity/interpersonal skill, respect/communication), and perceived provider fairness; (b) patient provider ethnicity/race concordance will have an indirect effect on perceived patient satisfaction with provider through perceived trust in provider, perceived provider cultural sensitivity, and perceived provider fairness; and (c) perceived trust in provider, perceived provider cultural sensitivity, and perceived provider fairness will have direct effe cts on perceived patient satisfaction with provider. 49

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The modified Patient Centered Culturally Sensitive Health Care (PC CSHC) Model was tested with the total sample ( N = 1,654). The modified model yielded an acceptable level of fit 2 (1, N = 1,654) = 0.773, CFI = 1.000, RMSEA = 0.00, NFI = 1.000, and TLI = 1.002. Despite the acceptable level of fit, several parameters were not significant in this model. To test a more parsimonious model, the nonsignificant parameters were deleted from the model and this new reduced model was tested. The reduced model showed a comparable fit to 2 (7, N = 1,654) = 7.310, CFI = 1.000, RMSEA = 0.0005, NFI = 0.998, and TLI = 1.000. The reduced model is shown in Figure 41. The hypothese s were partially supported in that perceived trust in provider, perceived provider cultural sensitivity, and perceived provider fairness were found to have direct effects on perceived patient satisfaction with provider. However, the model did not support t he hypotheses that ethnicity/race concordance will have significant positive direct effects or indirect effects on patient perceived provider cultural sensitivity, trust in provider, provider fairness, or satisfaction with provider. Analysis to Test the Research Question Multigroup structural equation model analysis (SEM) was conducted using the AMOS 20.0 program (SmallWaters Corp., Chicago, IL) to test the research question in this study, which is as follows: Do the proposed paths in the modified PC CSHC Model differ for African American, Hispanic/Latino(a), and White American patient participants? First, using the modified PC CSHC Model, a fully recursive model was estimated across the full sample of African American (AA), Hispanic/Latino(a ) (H / L), and White American (WA) patient participants by constraining all path coefficients or parameters to be equal across the three ethnicity/race groups. The constrained model (Figure 42) yielded an acceptable level of fit 2 (3, N = 323) = 0.758, CFI = 0.986, RMSEA = 0.032, NFI = 0.977, and TLI 50

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= 0.966, suggesting that ethnicity/race concordance and patient provider relationship interpersonal factors (i.e., patientperceived provider cultural sensitivity, trust in provider, perceiv ed provider fairness) are linked to patient satisfaction with provider among African American, Hispanic/Latino(a), and White American patient participants. To test if there would be ethnicity/race group differences in the linkages between ethnicity/race c oncordance and patient satisfaction with provider, the path coefficients 2 difference test of differences between the two models (constrained and unconstrained) supp orted the second hypothesis in that the parameters of the three ethnicity/race groups were significantly different from each other. Based on fit indices, the unconstrained model provided a better fit of 2 (3, N = 323) = 32.796, CFI = 1.000, RMSEA = 0.000, NFI = 1.000, and TLI = 1.017 ( Tabl e 4 5). To detect which paths were different for the three ethnicity/race groups, each group's parameters were compared and assessed for statistical significance at the a priori alpha level of 0.05. The significant tests of the parameters showed that eight parameters for the AA g roup, nine parameters for the H/L group, and six parameters for the WA group did not reach statistical significance with P values greater than 0.05 and a crit ical ratio greater than 1.96. To test whether a more parsimonious model would fit the data equally wel0l, t he nonsignificant parameters were eliminated by setting the parameters to zero. The new reduced model was subjected to the same method of model fit. With the nonsignificant parameters removed, the model fit indices of the reduced model f or each ethnicity/race group were better than the constrained model but had 2 (26, N = 323) = 32.796, CFI = 0.998, RMSEA = 0.014, NFI = 0.991, and TLI = 0.994. The reduced model was not significantly different from the 51

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unconstrained model (Table 45) although the reduced model is more parsimonious. Comparisons of the models representing each ethnicity/race group revealed different significant parameters in each parsimonious new model. The standardized parameters for the reduced model for African American, Hispanic/Latino(a), and White American patient participants are presented in Figure 4 2, Figure 43, and Figure 44 respectively. The differences in each model are tested and discussed in the direct/indirect effects sections. Testing Direct and Indirect Effects of Ethnicity/Race Concordance on Cultural Sensitivity, Trust, Fairness, and Satisfaction To test the aforementioned direct and indirect effects, significance tests were conducted using bootstrapped estimates of standard errors. Five thousand bootstrapped samples were sampled. Group differences in effect strength were also examined by constructing 95% confidence intervals using the standard errors in each ethnicity/race group. The effects from each group were then examined for overlap with the confidence intervals of the other groups. Examining the direct effects, ethnicity/race concordance had a significant negative effect on t he patient perceived respect/communication subscale of provider cultural sensitivity for H/L 0.10, p < 0.05). In other words, H/L patients who perceived their providers' ethnicity/race as concordant with their ethnicity/race reported lower p erceived cultural sensitivity with regard to respectful communication. Ethnicity/race concordance had significant positive effects on the patient perceived respect/communication subscale of provider cultural sensitivity, trust in provider, and provider fai respectively, p < 0.01). In other words, WA patients who perceived their providers' ethnicity/race as concordant with their ethnicity/race reported higher perceived cultural sensitivity with regards to r espectful communication, and reported higher trust in their provider, and higher provider fairness. There were no significant direct effects of ethnicity/race concordance for AA patients. 52

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Ethnicity/race concordance had significant positive indirect effect s on satisfaction with provider through its relationship with trust in provider and provider fairness for the WA patients p < 0.0001). Therefore, patient perceived ethnicity/race concordance led to increased satisfacti on with provider through patients' increased trust of providers and increased perceptions of provider fairness for the WA patients. There were no other significant indirect effects for the other variables of interest for the other ethnicity/race groups. Te sting Direct and Indirect Effects of Perceived Provider Cultural Sensitivity on Trust in Provider Provider Fairness, and Satisfaction with Provider To test the aforementioned direct and indirect effects, significance tests were conducted using bootstrapped estimates of standard errors. Five thousand bootstrapped samples were sampled. Group differences in effect strength were also examined by constructing 95% confidence intervals using the standard errors in each ethnicity/race group. The effects from each group were then examined for overlap with the confidence intervals of the other groups. Examining the direct effects, patientperceived provider cultural sensitivity had significant positive effects on trust in provider, provider fairness, and satisfacti on with provider for all three ethnicity/race groups although the effect between these variables differ for each group. Specifically, the patient perceived competence/confidence aspect of provider cultural sensitivity led to increased trust in provider for all three ethnicity/race groups although this effect 0.725, respectively, p < 0 .000). The p atient perceived sensitivity/interpersonal skill aspect of provider cultural sensitivity led to increased trust in provider for all three ethnicity/race groups although this effect was significantly larger for the H/L patients (p < 0.000) than AA or WA p < 0.01). The p atient perceived 53

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respect/communication aspect of provider cultural sensitivity led to increased trust for only the p < 0.01). The p atient perceived competence/confidence aspect of provider cultural sensitivity led to incr eased patient p < 0.01). The p atient perceived competence/confidence aspect of provider cultural sensitivity led to increased satisfaction with provider for all three ethnicity/race groups although this effect was significantly larger for WA and H/L ( p < 0.000) than for AA p < 0.01). The p atient perceived sensitivity/interpersonal skill aspect of provide r cultural sensitivity led to increased satisfaction with provider although this effect was significant larger for WA patients (p < 0.000) than for AA p < 0.01). Finally, trust in provider a nd patient perceived provider fairness ( p < .000) led to increased satisfaction for all three ethnicity/race groups, although the effect of trust in provider 0.2p < 0.01). Examining indirect effects, t he p atient perceived competence/confidence and sensitivity/interpersonal skill aspects of provider cultural sensitivity had significant positive indirect effects on satisfaction with pro vider through its relationship with trust for all three ethnicity/race groups. 54

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Table 4 1. Demographic c haracteristics for the African American (AA), Hispanic/Latino(a) (H/L), White American (WA) patient participants and for the t otal patient participants Characteristic AA H/L WA Total N % N % N % N % Age 1824 49 15.2 121 21.9 73 13.7 271 16.4 2534 42 13.0 141 25.5 103 19.4 329 19.9 3544 75 23.2 119 21.5 114 21.5 339 20.5 4554 97 30.0 73 13.2 133 25.0 351 21.2 5564 39 12.1 42 7.6 83 15.6 197 11.9 65 or O lder 19 5.9 26 4.7 24 4.5 78 4.7 Total 321 99.4 522 94.4 530 99.8 1565 94.6 Education* H igh S chool E ducation 156 48.3 318 57.5 229 43.2 790 47.8 > H igh S chool E ducation 151 46.8 195 35.3 285 53.7 722 43.6 Total 307 95.1 513 92.8 514 96.8 1512 91.4 Employment Status Full Time Employed 68 21.1 187 33.8 199 37.5 504 30.5 Part Time Employed 63 19.5 98 17.7 92 17.3 291 17.6 Do Not Work 187 57.5 213 38.5 232 43.7 733 44.3 Total 318 98.5 498 90.1 523 98.5 1528 92.4 Gender Female 217 67.2 353 63.8 353 66.5 1032 62.4 Male 98 30.3 165 29.8 177 33.3 519 31.4 Total 30.3 97.5 518 93.7 530 99.8 1551 93.8 Household Income 235 72.8 296 53.6 306 57.6 955 57.7 > $20,000 52 17.4 133 24.0 196 36.9 441 26.7 Total 291 90.1 429 77.6 502 94.5 1396 84.4 Marital Status Single 197 61.0 340 43.4 272 51.2 813 49.2 Married 67 20.7 228 41.2 183 34.4 530 32.1 Divorced/Separated 33 10.2 26 4.7 52 9.8 133 8.0 Widow/Widower 19 5.9 15 2.7 17 3.2 62 3.7 Total 316 97.8 509 92.0 524 98.7 1538 93.0 Note: *Significant nonparametric independent t tests of association, p < 0.01. 55

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Table 4 2. Correlations among var iables of s tudy for the t otal patient p articipant Variable 1 2 3 4 5 6 7 1. CSHC Competence/ 1 .677** .737** .021 .204** .522** .511** Confidence 2. CSHC Sensitivity/Interpersonal --1 .722** .053 .129* .501** .507** Skill 3. CSHC Respect/Communication ----1 .039 .211** .468** .499** 4. Ethnicity/Race Concordance ------1 .073* .009 .056 5. Provider Fairness --------1 .363** .302** 6. Satisfaction with Provider ----------1 .482** 7. Trust in Provider ------------1 Note. Correlation coefficients with an and ** are significant at the 0.05 and 0.01 level, respectively, according to a one tailed test. 56

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Table 4 3. Correlations among variables of s tudy for the African American, Hispanic/Latino(a), and White Am erican patient participants Variable 1 2 3 4 5 6 7 African American Patients 1. C SHC Competence/ 1 .636** .717** .115 .233** .508** .567** Confidence 2. CSHC Sensitivity/Interpersonal --1 .684** .036 .096* .450** .504** Skill 3. CSHC Respect/Communication ----1 .018 .181** .418** .546** 4. Ethnicity/Race Concordance ------1 .025 .011 .033 5. Provider Fairness --------1 .325** .283** 6. Satisfaction with Provider ----------1 .465** 7. Trust in Provider ------------1 Hispanic/Latino(a) Patients 1. CSHC Competence/ 1 .647** .650** .049 .113** .389** .426** Confidence 2. CSHC Sensitivity/Interpersonal --1 .671** .042 .092* .376** .503** Skill 3. CSHC Respect/Communication ----1 .082 .106** .308** .411** 4. Ethnicity/Race Concordance ------1 .054 .055 .033 5. Provider Fairness --------1 .379** .271** 6. Satisfaction with Provider ----------1 .438** 7. Trust in Provider ------------1 White American Patients 1. CSHC Competence/ 1 .729** .826** .045 .306** .634** .604** Confidence 2. CSHC Sensitivity/Interpersonal --1 .785** .129* .217** .609** .535** Skill 3. CSHC Respect/Communication ----1 .156* .315** .603** .567** 4. Ethnicity/Race Concordance ------1 .175** .121* .187** 5. Provider Fairness --------1 .374** .356** 6. Satisfaction with Provider ----------1 .555** 7. Trust in Provider ------------1 Note. Correlation coefficients with an and ** are significant at the 0.05 and 0.01 level, respectively, according to a one tailed test. 57

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Table 4 4. Means, standard deviations and missing data total for the variables of s tudy for the African American, Hispanic/Latino(a), and White American patient participants and for the t otal patient participants Variable M SD Missing Data ( N ) African American Patients CSHC Competence/ Confidence 3.355 .525 5 CSHC Sensitivity/Interpersonal Skill 3.205 .554 4 CSHC Respect/Communication 3.280 .535 7 Ethnicity/Race Concordance 1.21 .406 206 Provider Fairness 12.073 4.146 8 Satisfaction with Provider 3.695 .718 2 Trust in Provider 12.079 2.795 8 Hispanic/Latino(a) Patients CSHC Competence/Confidence 3.393 .489 29 CSHC Sensitivity/Interpersonal Skill 3.181 .540 23 CSHC Respect/Communication 3.241 .532 30 Ethnicity/Race Concordance 1.36 .481 203 Provider Fairness 11.262 4.178 23 Satisfaction with Provider 3.607 .610 11 Trust in Provider 11.731 2.681 20 White American Patients CSHC Competence/Confidence 3.350 .499 6 CSHC Sensitivity/Interpersonal Skill 3.124 .547 6 CSHC Respect/Communication 3.311 .525 10 Ethnicity/Race Concordance 1.75 .434 339 Provider Fairness 13.082 3.416 7 Satisfaction with Provider 3.567 .713 2 Trust in Provider 11.933 2.637 6 Total Patients CSHC Competence/Confidence 3.365 .502 62 CSHC Sensitivity/Interpersonal Skill 3.173 .545 60 CSHC Respect/Communication 3.278 .533 70 Ethnicity/Race Concordance 1.44 .496 937 Provider Fairness 12.134 3.985 59 Satisfaction with Provider 3.632 .682 30 Trust in Provider 11.911 2.667 55 58

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Table 4 5. Results of the m ultigroup a nalyses to t est the m odified PC CSHC Model a cross African American, Hispanic/Latino(a), and White American patient participant g roups Model df 2 RMSEA (90% CI) CFI NFI TLI Constrained Model 3 86.115 0.032 (0.0240.41) 0.986 0.977 0.966 Unconstrained Model 35 0.758 0.000 (0.000.024) 1.000 1.000 1.017 Reduced Model 26 32.796 0.014 (0.000.026) 0.998 0.991 0.994 Model Comparisons df 2 diff p value Constrained and Unconstrained 32 85.357 0.000 Unconstrained and Constrained 23 32.038 0.099 59

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Figure 41. Reduced model with s tandardized pa rameters e stimates for t otal patient p articipant ( N = 1,654; all parameters had critical ratios > 1.96). 60

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Figure 42. Reduced m odel with s tandardized parameters estimates for African American patient participants ( N = 323; all parameters had critical ratios > 1.96). 61

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Figure 43. Reduced m odel with s tandardized parameters e stimates for Hispanic/Latino(a) patient participants ( N = 553; all parameters had critical ratios > 1.96). 62

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Figure 44. Reduced m odel with s tandardized parameters e stimates for White American patient pa rticipants (N = 531; all parameters had critical ratios > 1.96). 63

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CHAPTER 5 DISCUSSION The purpose of the present study was to test a modified version of an aspect of the Patient Centered Culturally Sensitivity Health Care (PC CSHC) Model. The modified version of the aspect of the PC CSHC Model that was tested is different from the original PC CSHC Model in that two new variables were tested: ethnicity/race concordance and provider fairness. Specifically, the links between (a) ethnicity/race concordanc e and provider fairness and satisfaction with provider, and (b) provider fairness and satisfaction with provider were examined among ethnically/racially diverse patients. The linkage variables that were examined are patient perceived provider cultural sens itivity (competence/confidence, sensitivity/interpersonal skill, and respect/communication) and trust in provider. These linkages were also compared for each group of African American (AA), Hispanic/Latino(a) (H/L), and White American (WA) patients. This c hapter presents a summary and interpretation of the findings of this study, a discussion of its limitations, and a discussion of the implications of this study for counseling psychologists. Summary of Findings Hypotheses The following hypotheses were tested in this study: 1. Patient provider ethnicity/race concordance will have a direct effect on patients trust in provider, perceived provider cultural sensitivity (each of the three factors of cultural sensitivity: competence/confidence, sensitivity/inter personal skill, respect/communication), and perceived provider fairness. 2. Patient provider ethnicity/race concordance will have an indirect effect on perceived patient satisfaction with provider through perceived trust in provider, perceived provider cultu ral sensitivity, and perceived provider fairness. 64

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3. Perceived trust in provider, perceived provider cultural sensitivity, and perceived provider fairness will have direct effects on perceived patient satisfaction with provider. The structural equation model (SEM) analyses on the total sample revealed non significant links between ethnicity/race concordance and patient perceived cultural sensitivity trust in provider, provider fairness, and patient satisfaction. Thus, the hypotheses that ethnicity/race co ncordance would have significant positive direct and indirect effects on the variables of interest were not supported. As hypothesized in hypothesis 3, the SEM analyses revealed significant positive direct effects and indirect effects of competence/confid ence and respect/communication aspects of provider cultural sensitivity on perceived trust in provider, provider fairness, and patient satisfaction. Patients who reported higher levels of competence/confidence and respect/communication aspects of perceived cultural sensitivity also reported higher levels of trust in provider, provider fairness, and satisfaction with provider. However, patients who reported higher levels of sensitivity/interpersonal skills reported lower levels of perceived provider fairness Although this hypothesis for this study was partially supported, these findings do provide support for the importance of patient perceived provider fairness on patient satisfaction in the tested aspect of the PC CSHC Model for the total sample of patient participants Research Question The following research question was addressed in the present study: 1. Do the proposed paths in the modified PC CSHC Model differ for African American (AA), Hispanic/Latino(a) (H/L), and White American (WA) patient participants? The multigroup analyses to address this research question revealed differences in the proposed paths in the modified PC CSHC Model for AA, H/L, and WA patients. Specifically, 65

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ethnicity/race concordance did not have a significant direct or in direct effect on patient perceived provider cultural sensitivity, trust in provider, provider fairness, or satisfaction with provider for the AA patients; however this was not the case for the H/L and WA patients. For the H/L patients, ethnicity/race conco rdance had a significant negative direct effect on the respect/communication aspect of provider culturally sensitivity. In other words, H/L patients who perceived their providers' ethnicity/race to be concordant with their ethnicity/race reported lower per ceived respectful communication. For WA patients, ethnicity/race concordance had significant positive direct and indirect effects on the respect/communication aspect of provider culturally sensitivity and on trust in provider, provider fairness, and satisf action with provider. WA patients who perceived their providers ethnicity/race to be concordant with their ethnicity/race reported higher levels of perceived respectful communication, trust in provider, provider fairness, and satisfaction with provider. Competence/confidence and sensitivity/interpersonal skill of patient perceived cultural sensitivity were found to have direct and indirect effects on patient satisfaction through perceived fairness for only the AA and WA groups. For the H/L group, there we re no direct effects of the subscales of provider cultural sensitivity on provider fairness or indirect effects of the subscales of provider cultural sensitivity on satisfaction with provider through perceived fairness. Thus, based on the data collected in this study, H/L patients perceptions of provider cultural sensitivity seem to be unrelated to their perceptions of provider fairness. Interpretations of Findings In this study it appears that ethnicity/race concordance has a stronger influence on aspects of perceived provider cultural sensitivity, provider fairness, and patient satisfaction for the WA patients than for the H/L patient participants and that ethnicity/race concordance does not have a 66

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significant influence at all for the AA patient participa nts. Although the influence of ethnicity/race concordance was positive on all of the aforementioned study variables among the WA patients, the influence of ethnicity/race concordance was negative among the H /L patients. Furthermore, this negative influenc e was on only one of the study variables respect/ communication. This result supports Blanchard and colleagues (2007) finding that Hispanic/Latino patients reported higher discrimination from Hispanic/Latino providers and lower patient satisfaction than Hispanic/Latino patients with nonHispanic/Latino providers. It may be that the education level and other cultural differences between H/L providers and their H/L patients result in communication gaps between these providers and patients. These researchers suggest that cultural concordance may be more important to the patient or sociodemographic differences may account for perceptions of disrespect. It may be that because of a shared H/L identi t y between the H/L providers and the H/L patients, the provide rs inaccurately assume that they do not need to make the effort to adjust their communication to fit that of their patients in light of the common aspects of their heritage. Together, these findings suggest that having patients choose their providers and/or be empowered with being able to easily change their providers may be beneficial for patients because some may value patient provider ethnicity/race concordance. It is also noteworthy that patients in all three racial/ethnic groups who reported higher per ceived provider fairness also reported higher satisfaction with their providers than patients who reported lower perceived provider fairness. Thus, this research provides additional support for similar findings in past research studies (Fondacaro, et al., 2005; Holmvall, Twohig, Frances, & Kelloway, 2012). Furthermore, AA and WA patients who experience their providers as being culturally sensitive, particularly with their competence and confidence in their medical skills, 67

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also reported increased trust and h ence increased satisfaction with their provider. However, perceived provider fairness was not found to be associated with patient perceived provider cultural sensitivity among the H/L patients. H/L patients may not view provider fairness as being related to the patient provider relationship. The findings from this study suggest that ethnicity/race concordance may not play a significant role for ethnic/racial minority patients, particularly as other factors such as patient perceived cultural sensitivity, tr ust in provider, and perceived provider fairness have been shown in this research to be stronger factors that impact satisfaction with care. The finding that the sensitivity/interpersonal skill variable of provider cultural sensitivity has a negative assoc iation with provider fairness in the total patient participant sample is surprising although this association is not found when comparing the AA, H/L, and WA patient participant groups. This could be that the total patient participant sample includes other ethnicity/racial groups such as American Indian, Asian/Pacific Islanders, and multiracial patients. Other ethnicity/race groups not examined in this study may view sensitivity/interpersonal skill as being not conducive to their provider being impartial an d fair The findings suggest that perceived provider fairness play a significant role in patient satisfaction for ethnic/racial minority patients and provide support for future research that examines perceived provider fairness in testing of the PC CSHC model with an ethnically/racially diverse population. Additional research regarding the impact of perceived provider fairness on patients' trust in providers, patient satisfaction with provider, and other health outcomes (e.g., treatment adherence) is need ed. Limitations of the Study and Directions for Future Research The results of the present study must be interpreted in the context of several limitations. The first limitation is the present study's generalizability to the population of our nation at larg e. 68

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Some of the participating health care sites were not randomly recruited for participation in this study. Furthermore, participants from these health care sites self selected to participate. Multiple site recruitment strategies were used to recruit health care sites including asking for volunteer sites and asking participating sites to recruit other sites to participate in the study. As a result, a large number of participating sites were from urban settings and from more populous states. In addition, par ticipants were invited to participate by study sponsored Data Collectors who were often community members and fellow patients at the participating sites. In summary, the patient participants for this study were not subject to a random selection process. Th us, the present study should be replicated with a larger and randomly selected patient sample from randomly selected sites. The second limitation of this study is the use of self report measures. Self report measures may encourage socially desirable rathe r than accurate responses. Despite this limitation, self report measures are commonly used in health care quality and health psychology research and have been found to generate reliable data (Bhandari & Wagner, 2006). Future studies similar to the present study should include a social desirability measure so that this can be controlled for in participants responses. The third limitation is that the analyses in the present study did not include American Indian, Asian/Pacific Islander, and multiracial patient participants due to an insufficient number of these participants. Several recruitment strategies were implemented to increase the numbers of these patients including the recruitment of health care sites that provide medical services to a large ethnical ly and racially diverse patient population. Furthermore, the measures used in this study were available in Chinese, Spanish, and Vietnamese to encourage patients to participate. It is important to ensure that the measures that were used in this study are available in additional 69

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languages, which could help overcome potential language barriers for groups of people who speak languages other than English, Chinese, Spanish, and Vietnamese. Multimodal recruitment strategies such as involving well known community members of diverse ethnic/racial groups to serve as Data Collectors will be important in future studies similar to the present study. Despite these efforts, researchers were unable to recruit Asian, American Indian, and multiracial patient participants and thus future research should be sure to include participants from these populations. The fourth limitation is that a large number of participants from the larger study from which this research is a part of did not report their provider's ethnicity/race by leaving this item blank ( N = 937 or 56.7% of the total participants in this study). These participants were not included in the ethnicity/race concordant variable but were included in the other variables of study in the SEM models utilizing full informati on maximum likelihood estimation in the present study. Participants may have chosen not to report their ethnicity/race for a number of reasons, such as they may not have known their provider's ethnicity/race, they may have worried that their responses were inaccurate, or they may have avoided utilizing ethnicity/race as a self descriptor. Norton and colleagues (2006) demonstrated that individuals are more reluctant to use race than other characteristics such as hair color in their descriptors of other peopl e. Follow up studies by Norton and colleagues and other researchers (e.g., Apfelbaum, Sommers, & Norton, 2008; Goff, Jackson, Nichols, et al., 2013; Gof f, Steele, & Davies, 2008) suggest that individuals are reluctant to talk about race or use race as a descriptor due to their concern with appearing prejudiced. Future research studies that involve having patients report the perceived ethnicity/race of their provider should include language that may deter reluctance to provide this information. Alternatively future studies can also ask participants if their providers 70

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ethnicity/race is concordant with their own rather than asking participants to identify their providers ethnicity/race. Implications for Counseling Psychologists There are several implicatio ns of the findings in the present study for counseling psychologists. Given counseling psychologists training in multicultural counseling, focus on multicultural competence and social justice, and training and experience in conducting culturally sensitive research with diverse populations, counseling psychologists are well suited to (a) develop training programs to facilitate providers' cultural sensitivity with culturally diverse patients, including AA, H/L) and WA patients, and (b) conduct research to identify ways to promote patients trust in their providers, the perceived fairness of their providers, and satisfaction with their providers. Counseling psychologists' are trained as effective communicators and facilitators of communication and are poised to effectively improve patient provider relationships and ultimately patients' satisfaction with their provider and care. Due to their unique training in multiculturalism and communication, counseling psychologists can empower patients and their families to engage in assertive communication with their providers, provide training for health care professional staff, advocate for marginalized patients, and act as consultants for patients and providers (Tucker, et al., 2007). Counseling psychologists have mult iple roles in empowering patients to have a voice in their health care experience or ask for the health care they desire, such as requesting an ethnically/racially concordant provider or a provider with specific demographics or expertise. Counseling psychologists can also play a major role in providing training to address potential biases or stereotypes that may unintentionally occur or be manifested in the health care 71

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system, including among providers and office staff members, and in the health care site' s physical characteristics and policies. Therefore, counseling psychologists are well prepared to design interventions designed to increase patient perceived provider fairness. These interventions are in line with the social justice focus of the counseling psychology field and they can be very influential in creating systemic change at health care sites. Finally, counseling psychologists can be especially impactful in providing training for future medical professionals such as medical, pharmacy, and nursin g students. Specifically, counseling psychologists can use their knowledge of behavior and learning theory and cultural competencies to design and implement training programs designed to increase students' abilities to interact with marginalized patients in a patient centered culturally sensitive way. Conclusion The present study responds to the lack of research that examines how patient provider ethnicity/race concordance and patient perceived provider fairness affects patients' perceived cultural sensitivity of their providers, provider fairness, and patient satisfaction. The present study also tested a modified version of an aspect of the Patient Centered Culturally Sensitive Health Care (PC CSHC) Model in an effort to possibly improve upon this model. Overall, the findings from the present study provided suppor t for the role of patient provider ethnicity/race concordance impacting the respect/communication aspect of patient perceived provider cultural sensitivity, patients' trust in providers, provider fairness, and satisfaction with provider for White American patients. The findings also supported the role of provider fairness impacting patients' satisfaction with care for African American, Hispanic/Latino, and White American patients. The findings from the present study suggest the need to customize communica tion and health care interventions for ethnically/racially diverse patients. Such customized interventions 72

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have potential implications for decreasing health disparities and underutilization of health care services among ethnically/racially diverse patients and majority patients. The findings from the present study also have important implications for the training of health care professionals to provide patient centered culturally sensitive health care. Health care professionals can attend to issues of ethni city/race concordance and provider fairness when working with diverse patients. Furthermore, health care sites can do much to impact ethnicity/race concordance and provider fairness and attend to these variables in health service delivery. By attending to ethnic/race concordance and provider fairness, counseling psychologists and health professionals can promote cultural sensitivity and patientcentered culturally sensitive health care, which in turn promotes improved health outcomes for ethnically/racially diverse patients. 73

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74 APPENDIX A DEMOGRAPHIC AND HEALTH DATA QUESTIONNAIRE (DHDQ) Direction s : Please answer the questions below b y filling in the blank or shading in the circle next to the answer you choose like this: 1. What is your gender? Male Female 2. What is your age? Age 18 24 Age 45 54 Age 25 34 Age 55 64 Age 35 44 Age 65 or older 3. Which of the following best describes you? Single, living without a partner Marrie d not living with a partner Single, living with a partner Divorced or separated Married, living with a partner Widow/Widower 4. Please shade in one or more of the circles below that best describes your race/ethnicity: African American/Black American Hispanic/Hispanic American/Latino(a) White/European American Other American Indian/Native Americ an (please specify : ) Asian /Asian American/Pacific Islander 5. If Hispanic/Latino or Asian/Asian American, please shade in one or more of the cir c les that best describes your ethnicity: If Hispanic/Latino(a) shade below: If Asian/Asian American shade below: Cub an/Cuban American Chinese/Chinese American Mexican/Mexican Am erican/Chicano(a) Vietnamese/Vietnamese American Puerto Rican Filipino/Filipino American Other Hispanic/Latino(a) Other Asian (please specify: _____ ) (please specify: _____ ) 6. What is the highest level of education that you have completed? Elementary School Some College/Technical School Middle/Junior High School College High School Graduate School 7. What is your employment status? Work Full Time

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75 Work Part Time Do Not Work 8. What is your yearly household incom e ? Less than $10,000 $30,001 40,000 $10,000 20,000 $40,001 50,000 $ 20,001 30,000 $50,001 60,000 9. Ho w religious are you? Not At All Religious Religious Slightly Religious Very Religious Somewhat Religious 10. How spiritual are you? Not At All Spiritual Spiritual Slightly Spiritual Very Spiritual Somewhat Spiritual 11. How often do you pray/meditate? Never Often Rarely Very Often Sometimes 12. Where do you usually receive your health care services? Health Care Center/Clinic Private Practice Hospital Other Health Department (please specify: ) 13. What is the gender of the primary health care provider that you see most often? Male Female 14. What do you think is the age of the health care provider that you see most often? Age 18 24 Age 45 54 Age 25 34 A ge 55 64 Age 35 44 Age 65 or older 15. What is the race/ethnicity of the health care provider that you see most often? African American/Black American Hispanic/Latino(a) White/European American Other

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76 American Indian/Native American (please specify: ) Asian/Asian America 16. How many times each year do you see the health care provider that you see most often? 1 time 6 to 10 times 2 to 5 times Over 10 times 17. Where were you born? In the United States In Another Country 18. Where were your parents born? In the United States In Another Country 19. Do you have children? Yes (How man y ? ) No 20. If so, do your children live with you? Yes No 21. Where in the United States is your community located? Midwest (Ohio to Kansas) Northeast (Pennsylvania to Maine) Southeast (West Virginia to Texas) West (New Mexico to California, including Hawaii and Alaska) 22. In general, how would you describe your health? Excellent Fair Very Good Poor Good 23. What is your height? feet and inches 24. What was your weight the last time you were weighed? pounds

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77 APPENDIX B HEALTH CARE JUSTICE INVENTORY (HCJI) Directions: Rate each item on a scale from 0 (strong l y disa g ree) to 3 (strongly agree). Please shade in the circle beneath the answer you choose like this: Strongly Disagree Mainly Disagree Mainly Agree Strongly Agree 0 1 2 3 1. You accept your decisions. 2. You felt comfortable with the way your health care provider handles situations. 3. You fully agreed with the solutions that you and y our health care provider arrived at. 4. The decisions about your health care have been based on as much good information as possible. 5. Your health care provider was honest with you. 6. Your health care provider probably treated you worse than other patients because of your personal characteristics. 7. Your health care provider was biased against you. 8. Your health care provider probably gave you less respect than other patients. 9. You were treated by your health care 10. Your health care provider showed little concern for you as an individual.

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78 APPENDIX C PATIENT SATISFACTION QUESTIONNAIRE SHORT FORM (PSQ 18) D irection s : 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 ba d about the medical care you have received. Shade in the circle beneath the rating that you choose like this: How strongly do you AGREE or DISAGREE with each of the fol l owing sta t ements: Strongly A gree A gree Uncertain Disa gree Strongly Disa gree 1. Doctors (health care p roviders) are good abo u t explaining the re a son for medical tests. 2. I think my (health care pro v everything needed to provide co m plete medical care. 3. The medical c a re I ha v e been receiving is just about perfect. 4. Someti m es doctors (health care pro v iders) ma k e me wonder if their dia g nosis is corre c t. 5. I feel confident that I can get the m edical care I need without being s e t back financially. 6. When I g o for medical care, they (health care pro v iders) are careful to ch e ck ever y thing when treating and examining m e. 7. I have to pay for m ore of my m edical care than I can afford. 8. I have easy acce s s to the medical care speciali s ts I need. 9. Where I g et medical care, people have to w a it too long for emergency treatment. 10. Doctors (health care p roviders) act too busin e sslike and impersonal towar d s me. 11. My doctors (health c a re pro v iders) treat m e in a very friendly and cour t eous manner. 12. Those who provide m y medical care so m etimes hurry too much when they treat me.

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79 Strongly A gree A gree Uncertain Disa gree Strongly Disa gree 13. Doctors (health care p roviders) sometimes i g nore what I tell them. 14. I have so m e doubts about the abi l ity of the doctors (health care providers) who treat m e. 15. Doctors (health care p roviders) usually spend p lenty of time with me. 16. I find it hard to g et an app o intment for m edical care ri g ht away. 17. I am dissatisfied with some things a bout the m edical care I receive. 18. I am able to get medical care w henever I need i t

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80 APPENDIX D TUCKER CULTURALLY SENSITIVE HEALTH CARE PROVIDER INVENTORY ( T CSHCPI ) Directions: Please fill out the survey using the following steps: Take a moment to think about your experiences with the provider you see most often at your health care center or office. This provider might be a doctor, a nurse practitioner, or some other health care provider. Now please rate how much you agree that this provider shows each health care characteristic or behavior listed below Please use a rating of 1, Please shade in the circles below like this: Strongl y Disagree Disagree Agree Strongly Agree THE HEALTH CARE PROVIDER I SEE MOST OFTEN WHEN I VISIT MY HEALTH CARE CENTER OR OFFICE: 1. Is honest and direct with me. 2. Is dedicated to her or his work. 3. Enjoys what he or she is doing. 4. Is well educated. 5. Is knowledgeable about medicine. 6. Knows what he or she is doing. 7. Is confident in his or her abilities. 8. Is right about why I am sick. 9. Seems interested in my problem. 10. Takes my concerns seriously. 11. Does not question the truth or accuracy of what I am feeling. 12. Does not try to diagnose all my problems as psychological or 13. Does not talk down to me. 14. Tries to communicate with me. 15. Tries to educate me. 16. Takes all my concerns seriously even if he or she does not consider them to be serious.

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81 Strongly Disagree Disagree Agree Strongly Agree 17. Does not embarrass me in private or public. 18. Prescribes medicine only when he or she is sure of my illness. 19. Does not make me wait long. 20. Follows up on my visits. 21. Lets me know about illnesses and diseases common among people of my race/ethnicity. 22. Prepares me for the next steps in treating my illness. 23. Understands my financial situation. 24. Shows appreciation for me and all of his or her other patients. 25. Shows care and concern for my child/children. 26. Is respectful of my religious beliefs. 27. Understands my culture. Please list any additional comments or suggestions about your experience regarding the cultural sensitivity of your health care experience on the lines provided below:

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82 APPENDIX E PATIENT PACKET COVER LETTER Dear Patient: Patient Centered Culturally Sensitive Health Care and Health Promotion Project. The purpose of this study is to find out about how patients view the attitudes and behaviors of their health care providers and office staff, and to find out about how patients view the characteristics and policies of their health care c Participation in this study involves completing the attached questionnaires, which should take less than one hour. The study is designed to make sure that your responses will be anonymous. Your individual information and resp onses will not be seen by anyone other than the researchers who are conducting this study. Also, your name will not be placed on the questionnaires that you complete. In addition you may stop completing the questionnaires if it makes you feel uncomfortable and you may skip any question that you do not wish to answer. Participation in this study is completely voluntary. We believe that the information you give us is very important because it may help us improve the health care that you and other patients like you may receive from health care providers. If you decide to participate in this study, you can indicate your willingness to do so by signing the informed consent form and completing the attached questionnaires. If you would like help completing the questionnaires, you can ask a family member or friend to read them to you and record your responses on the form; however, they will not be compensated for doing so. Please keep a copy of the informed consent for yourself, and place the signed copy in the white envelope and seal it. Then place the set of completed questionnaires in the brown envelope and seal it. Please hand the two sealed envelopes to the person that approached you about participating in this study, or place it in the data collection box n ear the front desk. For your participation you will be mailed a $15 gift card that can be used at most stores or a $15 money order (but not both). You will receive this gift card or money order within three weeks after I receive your signed informed consen t form and completed questionnaires. If you have any questions or desire further information about this study, please call my research associates at (toll free) 1 866 290 5770 ext. 255. If you have any concerns about this study please call the University of Florida Institutional Review Board office at (352) 846 1494. If you agree to be a research participant, thank you for agreeing to do so. Sincerely, Carolyn M. Tucker, Ph.D.

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83 Distinguished Alumni Professor Joint Professor of Psychology and Professor of Community Health and Family Medicine Professor of Pediatrics (Affiliate)

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84 APPENDIX F PATIENT INFORMED CONSENT FORM Informed Consent to Participate in Research and Authorization for Collection, Use, and Disclosure of Information for Phase I Patient Participants PLEASE SIGN BOTH COPIES OF THIS FORM AND RETURN ONLY ONE TO THE RESEARCHERS You are being asked to take part in a research study. This form provides you with information about the study and seeks your permission for the collection, u se, and disclosure of your 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 part, 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 ben efits that you would otherwise be entitled to. 1. Name of Participant ("Study Subject"): ______________________________________________ (Please put your first and last name here) 2. Title of Research Study: Patient Centered Culturally Sensitive Health Care and Health Promotion Project 3. Source of Funding or Other Material Support: This research is being funded by the Robert Wood Johnson Foundation. 4. Purpose of the research study: The purpose of this study is to find out about how patients view the attitudes and behaviors of their health care providers and office staff, and to find out about how patients view the offices. 5. What you will be asked to take part in the study: You will be asked to fill out a set of questionnaires. Specifically, one questionnaire will ask how much you agree or disagree with statements that describe certain behaviors and attitudes o f your health care provider and office staff. It will also ask you how much you agree or disagree with about your lifestyle and culture, your relations with health care providers, your stress level, and your health behaviors. You will also be asked to complete a questionnaire about yourself which asks about your age, gender/sex, race, years of having any long term health problems, any communication problems yo u may have, how you pay for your health care, your current health e and address below for payment purposes.

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85 Filling out all of the questionnaires should take less than one hour. Please try to complete the you leave. One of our research assistants will be at your clinic to help you fill out the questionnaires if you need any help or have any questions. You will be paid for your participation. To see how much money is paid for participation, see Section 7 of this form. 6. Possible Risks and Benefits: We do not expect any risk to you for participating in this study. There are no known risks to completing the questionnaires. We do not anticipate that you will benefit directly by participating in this project. 7. Compensati on: You will be paid $15 compensation in the form of a money order for participating in this research. This compensation will be mailed to you at the address you provide below. 8. Confidentiality: Your identity will be kept confidential to the extent p rovided by law. Your name will not be placed on the questionnaires. Instead, researchers will place a code number on the surveys that you fill out. Your questionnaires 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 individual responses will only be seen by the researchers who are conducting this study and only they w ill know whether you are participating in the study or not. Also, your answers on the questionnaires will be completely anonymous. 9. Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not particip ating. In addition you may stop completing the questionnaires if it makes you feel uncomfortable, and you may skip any question that you do not wish to answer. 10. Right to withdraw from the study: You have the right to withdraw from the study at anytim e without consequence, but you will only receive your gift card or money order once we receive your completed set of questionnaires. Whom to contact if you have questions about the study: Carolyn M. Tucker, Ph.D. Distinguished Alumni Professor Joint P rofessor of Psychology and Professor of Community Health and Family Medicine Professor of Pediatrics (Affiliate) 1 352 273 2153 or (Toll free) 1 866 290 5770 Whom to contact about your rights as a research participant in the study: University of Florida Institutional Review Board Office

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86 Box 112250 University of Florida Gainesville, FL 32611 22250 (352)392 0433 Agreement: I have read the procedure described above. I voluntarily agree to participate in the procedure and I have re ceived a copy of this description. Participant:_________________________________ Date:___________ Investigator:________________________________ Date:___________ Name and Address for Payment: Please write your name and the address where you would like your gift card to be mailed: Name: _____________________________________ Address Line 1: _____________________________________ Address Line 2: _____________________________________ City, State, Zip _____________________________________ *Please place the first copy of this form in the white envelope and keep the second copy for your records.

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87 LIST OF REFERENCES Adams, J. S. (1965). Inequity in social exchange. In L. Berkowitz (ed.), Advances in E xperimental Social P sychology. New York: Academic Press. Agency for Healthcare Research and Quality. (2003). National Healthcare D isparities R eport (DHHS Publication No. 05 0014). Rockville, MD: Government Printing Office. Agency for Healthcare Research and Quality (2005). 2005 National Healthcare Disparities Report (HHS Publication). Rockville, MD: Government Printing Office. Agency for Healthcare Research and Quality. (2009). 2008 N ational H ealthcare Disparities R eport (DHHS Publication No. 09 0002). Rockville, MD: Government Printing Office. Aharony, L., & Strasser, S. (1993). Patient satisfaction: what we know about and what we still need to exp lore. Medical C are R eview 50 (1), 49 79. doi: 10.1177/002570879305000104 American College of Physicians (2004). Racial and ethnic disparities in health care. A position paper of the American College of Physicians. Annals of Internal Medicine 141(3) 226 232. Apfelbaum, E. P., Sommers, S. R., & Norton, M. I. (2008). Seeing race and seeming racist? Evaluating strategic colorblindness in social interaction. Journal of personality and social psychology 95 (4), 918. doi:10.1037/a0011990 Armstrong, K., Ravenell, K. L., McMurphy, S., & Putt, M. (2007). Racial/ethnic differences in physician distrust in the United States. American Journal of Public Health 97 (7), 1283. doi: 10.2105/AJPH.2005.080762 Aruguete, M. S., & Roberts, C. A. (2002). Participants' r atings of male physicians who vary in race and communication style. Psychological R eports 91 (3), 793 806. doi: 10.2466/pr0.2002.91.3.793 Ashton, C. M., Haidet, P., Paterniti, D. A., Collins, T. C., Gordon, H. S., O'Malley, K., ... & Street, R. L. (2003). Racial and ethnic disparities in the use of health services. Journal of General Internal Medicine 18 (2), 146 152. doi: 10.1046/j.1525 1497.2003.20532.x Baker, R., Mainous Iii, A. G., Gray, D. P., & Love, M. M. (2003). Exploration of the relationship between continuity, trust in regular doctors and patient satisfaction with consultations with family doctors. Scandinavian J ournal of P rimary H ealth C are 21 (1), 27 32. Balsa, A. I., & McGuire, T. G. (2003). Prejudice, clinical uncertainty and stereotypin g as sources of health disparities. Journal of Health Economics, 22, 89 116. doi :10.1016/S0167 6296(02)00098 X

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88 Bauer, K. (2003). Distributive Justice and Rural Healthcare. International Journal of Applied Philosophy 17 (2), 241 252. Benkert R., Peters, R. M., Clark, R., & Keves Foster, K. (2006). Effects of perceived racism, cultural mistrust and trust in providers on satisfaction with care. Journal of the National Medical Association, 98 (9), 1532 1540. Betancourt, J. R., & Green, A. R. (2 010). Commentary: linking cultural competence training to improved health outcomes: perspectives from the field. Academic Medicine 85 (4), 583 585. Bhandari, A., & Wagner, T. (2006). Self reported utilization of health care services: Improving measurement and accuracy. Medical Care Research and Review, 63, 217 235. doi: 10.1177/1077558705285298 Blair, I. V., Steiner, J. F., & Havranek, E. P. (2011). Unconscious (implicit) bias and hea lth disparities: Where do we go from here? The Permanente Journal 15 (2), 71. Blanchard, J., Nayar, S., & Lurie, N. (2007). Patient provider and patient staff racial concordance and perceptions of mistreatment in the health care setting. Journal of General Internal Medicine 22 (8), 1184 1189. doi: 10.1007/s11606 007 0210 8 Bleich, S. N., Simon, A. E., & Cooper, L. A. (2012). Impact of patient doctor race concordance on rates of weight related counseling in visits by Black and White obese individuals Obesity 20 (3), 562 570. doi: 10.1038/oby.2010.330 Boulware, L. E., Cooper, L. A., Ratner, L. E., LaVeist, T. A., & Powe, N. R. (2003). Race and trust in the health care system. Public H ealth R eports 118 (4), 358 365. Brodie, M., Kjellson, N., Hoff, T., & Parker, M. (1999). Perceptions of Latinos, African Americans, and Whites on media as a health information source. The Howard Journal of Communications, 10 147 167. doi: 10.1080/106461799246799 Burgess, D. J. (2010). Are providers more likely to cont ribute to healthcare disparities under high levels of cognitive load? How features of the healthcare setting may lead to biases in medical decision making. Medical Decision Making 30 (2), 246 257. doi: 10.1177/0272989X09341751 Burgess, D. J., Fu, S. S., & van Ryn, M. (2004). Why do providers contribute to disparities and what can be done about it? Journal of General Internal Medicine, 19, 1154 1159. doi :10.1111/j.1525 1497.2004.30227.x Burgess, D. J. van Ryn, M., Dovidio, J., & Saha, S. (2007). Reducing racial bias among health care providers: Lessons from social cognitive psychology. Journal of General Internal Medicine, 22 (6), 882 887. doi: 10.1007/s11606 007 0160 1

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99 BIOGRAPHICAL SKETCH Khanh N. Nghiem was born in a refugee camp in Thailand; at that time, her parents and brothe r were on their way to America. Vietnam War in search of a better home and a hopeful future. Three months later, they relocated to Oklahoma City, Oklahoma, which she would come to regard as her home. In 2003, she received her Bachel or of Science degree in psychology and a minor in biology from Oklahoma State University. In 2006, she received her Master of Science degree in psychology from the University of Florid a Cognitive Psychology program. She was accepted in the University of Fl orida Counseling Psychology doctoral program and worked on several community based health care research projects. H er research focused on empowering low income and ethnically/racially diverse primary care patients to receive and access the health care they desire to improve their health outcomes Khanh completed her clinical internship at APA accredited Ball State University Counseling Center in 2013 and received her Ph.D. from the University of Florida in the spring of 2014. She recently ac cepted a staff p sychologist position at Ball State University Counseling Center


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INGEST IEID ETAD4M0QT_GKCPM6 INGEST_TIME 2014-10-03T21:51:09Z PACKAGE UFE0046321_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES