Abstract
BACKGROUND: Differences in provider-patient health perceptions have been associated with poor patient outcomes, but little is known about how patients’ cultural identities may be related to discordant perceptions.
OBJECTIVE: To examine whether health care providers and American-Indian patients disagreed on patient health status ratings, and how differences related to these patients’ strength of affiliation with American-Indian and white-American cultural identities.
DESIGN: Survey of patients and providers following primary care office visits.
PARTICIPANTS: One hundred and fifteen patients ≥ 50 years and 7 health care providers at a Cherokee Nation clinic. All patients were of American-Indian race, but varied in strength of affiliation with separate measures of American-Indian and white-American cultural identities.
MEASUREMENTS: Self-reported sociodemographic and cultural characteristics, and a 5-point rating of patient’s health completed by both patients and providers. Fixed-effects regression modeling examined the relationships of patients’ cultural identities with differences in provider-patient health rating.
RESULTS: In 40% of medical visits, providers and patients rated health differently, with providers typically judging patients healthier than patients’ self-rating. Provider-patient differences were greater for patients affiliating weakly with white cultural identity than for those affiliating strongly (adjusted mean difference=0.70 vs 0.12, P=.01). Differences in ratings were not associated with the separate measure of affiliation with American-Indian identity.
CONCLUSIONS: American-Indian patients, especially those who affiliate weakly with white-American cultural identity, often perceive health status differently from their providers. Future research should explore sources of discordant perceptions.
Similar content being viewed by others
References
Frieden RB, Goldman L, Cecil RR. Patient-physician concordance in problem identification in the primary care setting. Ann Intern Med. 1980;93:490–3.
Maly RC, Leake B, Frank JC, DiMatteo MR, Reuben DB. Implementation of consultative geriatric recommendations: the role of patient-primary care physician concordance. J Am Geriatr Soc. 2002;50:1372–80.
Chesney AP, Brown KA, Poe CW, Gary HE Jr. Physician-patient agreement on symptoms as a predictor of retention in outpatient care. Hosp Community Psychiatry. 1983;34:737–9.
Fabrega H. Perceived illness and its treatment: a naturalistic study in social medicine. Br J Prev Soc Med. 1977;31:213–9.
Hewlett S. Patients and clinicians have different perspectives on outcomes in arthritis. J Rheumatol. 2003;30:877–9.
McRae C, Diem G, Vo A, O’Brien C, Seeberger L. Reliability of measurements of patient health status: a comparison of physician, patient, and caregiver ratings. Parkinsonism Relat Disord. 2002;8:187–92.
Starfield B, Wray C, Hess K, Gross R, Birk PS, D’Lugoff BC. The influence of patient-practitioner agreement on outcome of care. Am J Public Health. 1981;71:127–31.
Wartman SA, Morlock LL, Malitz FE, Palm E. Impact of divergent evaluations by physicians and patients of patients’ complaints. Public Health Rep. 1983;98:141–5.
Yager J, Linn LS. Physician-patient agreement about depression: notation in medical records. Gen Hosp Psychiatry. 1981;4:271–6.
Borawski EA, Kinney JM, Kahana E. The meaning of older adults’ health appraisals: congruence with health status and determinant of mortality. J Gerontol B Psychol Sci Soc Sci. 1996;51:S157–70.
Connelly JE, Smith GR, Philbrick JT, Kaiser DL. Healthy patients who perceive poor health and their use of primary care services. J Gen Intern Med. 1991;6:47–51.
Geest A, Engberg M, Lauritzen T. Discordance between self-evaluated health and doctor-evaluated health in relation to general health promotion. Scand J Prim Health Care. 2004;22:146–51.
Idler EL, Hudson SV, Leventhal H. The meanings of self-ratings of health: a qualitative and quantitative approach. Res Aging. 1999;21:458–76.
Idler EL. Age differences in self assessments of health: age changes, cohort differences, or survivorship? J Gerontol. 1993;48:S289–300.
Kivinen P, Halonen P, Eronen M, Nissinen A. Self-rated health, physician-rated health and associated factors among elderly men: the Finnish cohorts of the Seven Countries Study. Age Ageing. 1998;27:41–7.
LaRue A, Bank L, Jarvik L, Hetland M. Health in old age: how do physicians’ ratings and self-ratings compare? 1979;34:687–91.
Linn BS, Linn MW, Knopka J. The very old patient in ambulatory care. Med Care. 1978;16:604–10.
Mann S, Sripathy K, Siegler EL, Davidow A, Lipkin M, Roter DL. The medical interview: differences between adult and geriatric outpatients. J Am Geriatr Soc. 2001;49:65–71.
Rakowski W, Hickey T, Dengiz AN. Congruence of health and treatment perceptions among older patients and providers of primary care. Int J Aging Hum Dev. 1987;25:63–77.
Suarez-Almazor ME, Conner-Spady B, Kendall CJ, Russell AS, Skeith K. Lack of congruence in the ratings of patients’ health status by patients and their physicians. Med Decis Making. 2001;21:113–21.
van Doorn C. A qualitative approach to studying health optimism, realism, and pessimism. Res Aging. 1999;21:440–57.
Wilson CC, Netting FE. Comparison of self and health professionals’ ratings of the health of community-based elderly. Int J Aging Hum Dev. 1987;25:11–25.
Berkanovic E, Hurwicz ML, Lachenbruch PA. Concordant and discrepant views of patients’ physical functioning. Arthritis Care Res. 1995;8:94–101.
Calkins DR, Rubenstein LV, Cleary PD, et al. Failure of physicians to recognize functional disability in ambulatory patients. Ann Intern Med. 1991;114:451–4.
Kowh CK, Ibrahim SA. Rheumatology patient and physician concordance with respect to important health and symptom status outcomes. Arthritis Rheum. 2001;45:372–7.
Kwoh CK, O’Connor GT, Regan-Smith MG, et al. Concordance between clinician and patient assessment of physical and mental health status. J Rheumatol. 1992;19:1031–7.
Bradley C, Brewin CR, Duncan SLB. Perceptions of labour: discrepancies between midwives’ and patients’ ratings. Br J Obstet Gynaecol. 1983;90:1176–9.
Fagerberg CR, Kragstrup J, Stovring H, Rasmussen NK. How well do patient and general practitioners agree about the content of consultations? Scand J Prim Health Care. 1999;17:157–70.
Reiff M, Zakut H, Weingarten MA. Illness and treatment perceptions of Ethiopian immigrants and their doctors in Israel. Am J Public Health. 1999;89:1814–8.
Starfield B, Steinwachs D, Morris I, Bause G, Siebert S, Westin C. Patient-doctor agreement about problems needing follow-up visit. JAMA. 1979;242:344–6.
Bass MJ, Buck C, Turner L, Dickie G, Pratt G, Robinson HC. The physician’s actions and the outcome of illness in family practice. J Fam Pract. 1986;23:43–7.
Neville C, Clarke AE, Joseph L, Belisle P, Ferland D, Fortin PR. Learning from discordance in patient and physician global assessments of systemic lupus erythematosus disease activity. J Rheumatol. 2000;27:675–9.
Sewitch MJ, Leffondre K, Dobkin PL. Clustering patients according to health perceptions: relationships to psychosocial characteristics and medication nonadherence. J Psychosom Res. 2004;56:323–32.
Helman CG. Culture, Health and Illness. 4th ed. Boston, MA: Butter-worth-Heineman; 2000.
Kleinman AM. Patients and Healers in the Context of Culture. Berkeley, CA: University of California Press; 1980.
Angel R, Thoits P. The impact of culture on the cognitive structure of illness. Cult Med Psychiatry. 1987;11:465–94.
Molzahn AE, Northcott HC. The social bases of discrepancies in health/illness perceptions. J Adv Nurs. 1989;14:132–40.
U.S. Census Bureau. Statistical abstract of the United States. Section 2: Vital Statistics. 2003. Washington, DC: U.S. Department of Commerce; 2003.
Bartz R. Beyond the biopsychosocial model: new approaches to doctor-patient interactions. Fam Pract Res J. 1999;48:601–7.
Carrese JA, Rhodes LA. Bridging cultural differences in medical practice: the case of discussing negative information with Navajo patients. J Gen Intern Med. 2000;15:92–6.
Huttlinger K, Krefting L, Drevdahl D, et al. “Doing battle”: a metaphorical analysis of diabetes mellitus among Navajo people. Am J Occup Ther. 1992;46:706–12.
Lang GC. “Making Sense” about diabetes: Dakota narratives of illness. Med Anthropol. 1989;22:305–27.
Kramer BJ, Harker JO, Wong AL. Arthritis beliefs and self-care in an urban American Indian population. Arthritis Rheum. 2002;47:588–94.
Kramer BJ, Harker JO, Wong AL. Descriptions of joint pain by American Indians: comparisons of inflammatory and noninflammatory arthritis. Arthritis Rheum. 2002;47:149–54.
Templin DW, Boyer GS, Lanier AP, et al. Rheumatoid arthritis in Tlingit Indians: clinical characterization and HLA associations. J Rheumatol. 1994;21:1238–44.
The Cherokee Nation Health. Available at: www.cherokee.org/Services/Health.asp. Accessed July 14, 2004.
Berry JW, Poortinga YH, Segall MH, Dasen PR. Cross-Cultural Psychology: Research and Applications. New York, NY: Cambridge University Press; 1992.
Moran JR, Fleming CM, Somervell P, Manson SM. Measuring ethnic identity among American Indian adolescents. J Adolesc Res. 1999;14:405–26.
Oetting ER, Beauvais F. Orthogonal cultural identification theory: the cultural identification of minority adolescents. Int J Addict. 1990–1991;25:655–85.
Buchwald D, Beals J, Manson SM. Use of traditional health practices among Native Americans in a primary care setting. Med Care. 2000;38:1191–9.
Novins DK, Beals J, Moore LA, Spicer P, Manson SM, and the AI-SU-PERPFP Team. Use of biomedical services and traditional healing options among American Indians: sociodemographic correlates, spirituality, and ethnic identity. Med Care. 2004;42:670–9.
Ware JE Jr. How to Score and Interpret Single-Item Health Status Measures: A Manual for Users of the SF-8 Health Survey. Lincoln, RI: Quality Metric Inc.; 2001.
Sewitch MJ, Abrahamowicz M, Dibkin PL, Tamblyn R. Measuring differences between patients’ and physicians’ health perceptions: the patient-physician discordance scale. J Behav Med. 2003;26:245–64.
Maddox GL, Douglass EB. Self-assessment of health: a longitudinal study of elderly subjects. J Health Soc Behav. 1973;14:87–93.
Linn BS, Linn MW. Objective and self assessed health in the old and very old. Soc Sci Med. 1980;14A:311–5.
Linn MW, Linn BS, Stein SR. Satisfaction with ambulatory care and compliance in older patients. Med Care. 1982;20:606–14.
Blumer H. Symbolic Interactionism: Perspective and Method. Englewood Cliffs, NJ: Prentice-Hall; 1969.
Balsa AI, McGuire TG. Prejudice, clinical uncertainty and stereotyping as sources of health disparities. J Health Econ. 2003;22:89–116.
Todd KH, Deaton C, D’Adamo AP, et al. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35:11–6.
Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269:1537–9.
Hooper EM, Comstock LM, Goodwin JM, Goodwin JS. Patient characteristics that influence physician behavior. Med Care. 1982;20:630–8.
Johnson RL, Roter D, Powe NR, Cooper LA. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94:2084–90.
Davitz LJ, Pendleton SH. Nurses’ inferences of suffering. Nurs Res. 1967;18:100–7.
Freidin RB, Goldman L, Cecil RR. Patient-physician concordance in problem identification in the primary care setting. Ann Intern Med. 1980;93:490–3.
Hidding A, van Santen M. Comparison between self-report measures and clinical observations of functional disability in ankylosing spondylitis, rheumatoid arthritis and fibromyalgia. J Rheumatol. 1994;21:818–23.
Bachman J, O’Malley P. Yea-saying, nay-saying, and going to extremes: black-white differences in response styles. Public Opin Q. 1984;48:491–509.
Marin G, Gamba R, Marin B. Extreme response style and acquiescence among Hispanics: the role of acculturation and education. J Cross Cult Psychiatry. 1992;23:498–509.
Author information
Authors and Affiliations
Corresponding author
Additional information
Data collection was funded by a grant under the Resource Centers for Minority Aging Research program, by the National Institute of Nursing Research, and the Office of Research on Minority Health, National Institutes of Health. Research was also supported in part by grants P30AG/15297 from the National Institute of Aging and the National Institute of Nursing Research, P01 HS10854 from the Agency for Healthcare Research and Quality, and P60 MD000507 from the National Center for Minority Health and Health Disparities to Dr. S. Manson, and by a research expense grant from Boston College. The author gratefully acknowledges the guidance of the Cherokee Nation Institutional Review Board, as well as assistance in data collection and Cherokee translation by staff and volunteers at the research site, and the technical advice of Dr. Spero DManson.
Disclaimer: The opinions expressed in this paper are those of the authors and do not necessarily reflect the views of the Cherokee Nation.
The authors have no conflict of interest to declare for this paper.
Rights and permissions
About this article
Cite this article
Garroutte, E.M., Sarkisian, N., Arguelles, L. et al. Cultural identities and perceptions of health among health care providers and older American Indians. J Gen Intern Med 21, 111–116 (2006). https://doi.org/10.1007/s11606-006-0243-4
Received:
Revised:
Accepted:
Issue Date:
DOI: https://doi.org/10.1007/s11606-006-0243-4