OBJECTIVES: To determine: 1) whether racial and ethnic differences exist in patients’ perceptions of primary care provider (PCP) and general health care system-related bias and cultural competence; and 2) whether these differences are explained by patient demographics, source of care, or patient-provider communication variables.
DESIGN: Cross-sectional telephone survey.
SETTING: The Commonwealth Fund 2001 Health Care Quality Survey.
SUBJECTS: A total of 6,299 white, African-American, Hispanic, and Asian adults.
MEASUREMENTS AND MAIN RESULTS: Interviews were conducted using random-digit dialing; oversampling respondents from communities with high racial/ethnic minority concentrations; and yielding a 54.3% response rate. Main outcomes address respondents’ perceptions of their PCPs’ and health care system-related bias and cultural competence; adjusted probabilities (Pr) are reported for each ethnic group. Most racial/ethnic differences in perceptions of PCP bias and cultural competence were explained by demographics, source of care, and patient-physician communication variables. In contrast, racial/ethnic differences in patient perceptions of health care system-wide bias and cultural competence persisted even after controlling for confounders: African Americans, Hispanics, and Asians remained more likely than whites (P<.001) to perceive that: 1) they would have received better medical care if they belonged to a different race/ethnic group (Pr 0.13, Pr 0.08, Pr 0.08, and Pr 0.01, respectively); and 2) medical staff judged them unfairly or treated them with disrespect based on race/ethnicity (Pr 0.06, Pr 0.04, Pr 0.06, and Pr 0.01, respectively) and how well they speak English (Pr 0.09, Pr 0.06, Pr 0.06, and Pr 0.03, respectively).
CONCLUSION: While demographics, source of care, and patient-physician communication explain most racial and ethnic differences in patient perceptions of PCP cultural competence, differences in perceptions of health care system-wide bias and cultural competence are not fully explained by such factors. Future research should include closer examination of the sources of cultural bias in the US medical system.
bias cultural competence disparities racial and ethnic minorities
Mayberry RM, Mili F, Ofili E. Racial and ethnic differences in access to medical care. Med Care Res Rev. 2000;57(suppl 1):108–45.PubMedCrossRefGoogle Scholar
Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2003.Google Scholar
Cooper LA, Roter DL. Patient-Provider Communication. The Effect of Race and Ethnicity on Process and Outcomes of Healthcare. In: Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academy Press; 2003:552–93.Google Scholar
Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583–9.PubMedCrossRefGoogle Scholar
Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 1999;159:997–1004.PubMedCrossRefGoogle Scholar
Gross DA, Zyzanski SJ, Borawski EA, Cebul RD, Stange KC. Patient satisfaction with time spent with their physician. J Fam Pract. 1998;47:133–7.PubMedGoogle Scholar
Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. Impact of language barriers on patient satisfaction in an emergency department. J Gen Intern Med. 1999;14:82–7.PubMedCrossRefGoogle Scholar
Collins TC, Clark JA, Petersen LA, Kressin NR. Racial differences in how patients perceive physician communication regarding cardiac testing. Med Care. 2002;40(suppl 1):I27-I34.PubMedGoogle Scholar
Collins KS, Hughes DL, Doty MM, Ives BL, Edwards JN, Tenney K. Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. Findings from The Commonwealth Fund 2001 Health Care Quality Survey. New York: The Commonwealth Fund; 2002.Google Scholar
Blendon RJ, Scheck AC, Donelan K, et al. How white and African-Americans view their health and social problems. J Am Med Assoc. 1995;273:341–6.CrossRefGoogle Scholar
Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340:618–26.PubMedCrossRefGoogle Scholar
van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50:813–28.PubMedCrossRefGoogle Scholar
Kagawa-Singer M, Kassim-Lakha S. A strategy to reduce cross-cultural miscommunication and increase the likelihood of improving health outcomes. Acad Med. 2003;78:577–87.PubMedCrossRefGoogle Scholar
Wear D. Insurgent multiculturalism: rethinking how and why we teach culture in medical education. Acad Med. 2003;78:549–54.PubMedCrossRefGoogle Scholar
van Ryn M, Fu SS. Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health? Am J Public Health. 2003;93:248–55.PubMedGoogle Scholar
Health Resources and Services Administration Bureau of Health Professions, USDHHS. BHPR — Other Definitions of Cultural Competence. Available at: http:/bhpr.hrsa.gov/diversity/cultcomp.htm. Accessed August 21, 2003.Google Scholar
Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong O. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep. 2003;118:293–302.PubMedGoogle Scholar
United States Department of Health and Human Services, Office of Minority Health. National Standards for Culturally and Linguistically Appropriate Services in Health Care Final Report, March 1 2001. United States Department of Health and Human Services, OPHS, Office of Minority Health; 2001.Google Scholar
Liaison Committee on Medical Education. Functions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the M.D. Degree. Available at: http://www.lcme.org/functions2003july.pdf. Accessed January 19, 2004.Google Scholar
Dolhun EP, Munoz C, Grumbach K. Cross-cultural education in U.S. medical schools: development of an assessment tool. Acad Med. 2003;78:615–22.CrossRefGoogle Scholar
Cooper LA, Hill MN, Powe NR. Designing and evaluating interventions to eliminate racial and ethnic disparities in health care. J Gen Intern Med. 2002;17:477–86.PubMedCrossRefGoogle Scholar
Stata Statistical Software. College Station, Tex: Stata Corporation; 2001.Google Scholar
Betancourt JR, Green AR, Carrillo JE. Cultural competence in Health Care. Emerging Frameworks and Practical Approaches, 10-1-2002. The Commonwealth Fund. Quality of Care for Underserved Populations Field Report.Google Scholar
Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Ann Intern Med. 1999;130:829–34.PubMedGoogle Scholar
Campinha-Bacote J. A model and instrument for addressing cultural competence in health care. J Nurs Educ. 1999;38:203–7.PubMedGoogle Scholar
Zweifler J, Gonzalez AM. Teaching residents to care for culturally diverse populations. Acad Med. 1998;73:1056–61.PubMedCrossRefGoogle Scholar
Lurie N, Yergan J. Teaching residents to care for vulnerable populations in the outpatient setting. J Gen Intern Med. 1990;5(suppl 1):S26-S34.PubMedCrossRefGoogle Scholar
Berlin EA, Fowkes WC Jr. A teaching framework for cross-cultural health care. Application in family practice. West J Med. 1983;139:934–8.PubMedGoogle Scholar
Ngo-Metzger Q, Massagli MP, Clarridge BR, et al. Linguistic and cultural barriers to care. J Gen Intern Med. 2003;18:44–52.PubMedCrossRefGoogle Scholar
Tucker CM, Herman KC, Pedersen TR, Higley B, Montrichard M, Ivery P. Cultural sensitivity in physician-patient relationships. Perspectives of an ethnically diverse sample of low-income primary care patients. Med Care. 2003;41:859–70.PubMedCrossRefGoogle Scholar
Stewart AL, Napoles-Springer A, Perez-Stable EJ, et al. Interpersonal processes of care in diverse populations. Milbank Q. 1999;77:305–39, 274–339.PubMedCrossRefGoogle Scholar
Brach C, Fraser I. Can cultural competency reduce racial and ethnic health disparities? A review and conceptual model. Med Care Res Rev. 2000;57(suppl 1):181–217.PubMedCrossRefGoogle Scholar
Keeter S. Estimating telephone noncoverage bias with a telephone survey. Public Opin Q. 1995;59:196–217.CrossRefGoogle Scholar
Williams DR, Neighbors HW, Jackson JS. Racial/Ethnic discrimination and health: findings from community studies. Am J Public Health. 2003;93:200–8.PubMedCrossRefGoogle Scholar