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Title:
Cultural competence in health care : a client-based perspective
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Language:
English
Creator:
Phillips, Karon
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University of South Florida
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Subjects

Subjects / Keywords:
Culture
Competency
Health Disparities
Interpersonal Sensitivity
Client-Provider Racial/Ethnic Concordance
Satisfaction with Care Received
Dissertations, Academic -- School of Aging Studies -- Doctoral -- USF   ( lcsh )
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non-fiction   ( marcgt )

Notes

Abstract:
ABSTRACT: In response to the presence of health disparities among a diverse population of older adults, creating culturally competent health care services has emerged as a possible method to help reduce and eventually eliminate inequalities in health care. However, little information exists concerning the effectiveness of cultural competence, and even less is known about how culturally competent clients perceive their providers to be. This dissertation examined a number of indicators related to cultural competence, including the predictors of client-provider racial/ethnic concordance, client perceptions of the interpersonal sensitivity of their health care providers, and the overall satisfaction with care reported by older Non-Hispanic White, African American/Black, Hispanic/Latino, and Asian American adults. In order to accomplish these aims, three related studies were conducted, all drawing on data from the 2001 Health Care Quality Survey conducted by the Commonwealth Fund. The first study focused on the factors that predicted racial/ethnic concordance between clients and their health care providers. The second study examined several factors that affect the clients' perception of their providers' interpersonal sensitivity. The third and final analysis utilized the outcome variables from the two previous studies, in addition to the client-level variables, to determine which factors predicted satisfaction with care received. The results show that the factors that predicted client-provider racial/ethnic concordance and perceived interpersonal sensitivity varied across the four groups. In addition, perceived interpersonal sensitivity was a significant predictor of satisfaction with care for all four of the groups. The findings from this dissertation contribute to a broader understanding of racial/ethnic differences in client-provider racial/ethnic concordance, perceptions of interpersonal sensitivity, and overall satisfaction with care among older adults from racially and ethnically diverse backgrounds.
Thesis:
Dissertation (Ph.D.)--University of South Florida, 2009.
Bibliography:
Includes bibliographical references.
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Mode of access: World Wide Web.
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Statement of Responsibility:
by Karon Phillips.
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Title from PDF of title page.
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Document formatted into pages; contains X pages.
General Note:
Includes vita.

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usfldc handle - e14.3171
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Cultural Competence in Health Care: A Client Based Perspective by Karon L. Phillips A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy School of Aging Studies College of Behavioral and Commu nity Sciences University of South Florida Co Major Professor: David A. Chiriboga, Ph.D. Co Major Professor: Yuri Jang, Ph.D. Tamara Baker, Ph.D. Mario Hernandez, Ph.D. Keith Whitfield, Ph.D. Date of Approval: October 16 2009 Keywords: Culture, C ompe tency He alth Disparities, Interpersonal Sensitivity, Client Provider Racial/ Ethnic Concordance Satisfaction with Care Received Copyright 2009, Karon L. Phillips

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DEDICATION I dedicate this dissertation to my grandmothers, Grammy (Gwen F. Ha lls), Bubbie (Helen Phillips), and my late grandfather Lee Halls. Their love and endless support throughout my life motivated me to pursue a career working with older adults, the segment of the population that I love the most. All three of them have been professors to me in the discipline of life and I am blessed to have been taught by them.

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ACKNOWLEDGEMENTS This data was funded and collected by the Commonwealth Fund and I would like to thank them for providing me with the opportunity to use these da ta. I would like to express my sincere gratitude and deepest appreciation to my co advisors Dr. David A. Chiriboga and Dr. Yuri Jang. Thank you for all your guidance and counsel throughout this journey. I would also like to thank Dr. Keith Whitfield for your endless wisdom about minority older adults and for all the encouragement over the years, Dr. Mario Hernandez for helping me to truly understand cultural competence, and Dr. Tamara Baker for endless advice, critiques, support and mentoring. In addit ion, I must send out a very special acknow ledgment and thank my parents and younger brother Austin for everything that they have done for me throughout my life and for constantly being my greatest source of support and strength throughout my undergraduate and graduate matriculation. I love you three with all my heart. To all my family and extended family, thank you all for the moral support throughout this journey To my very dear friends and fellow gerontologist Dr. Adrienne Morgan Dr. Besangie S ellars and Dr. Kim Stansbu ry thank you for all the help over the past five years To my best friends (Chanda Hadley Kea Sherwood Vidya Anegundi and Jessica Morrow ), thank you for all the encouragement and continued friendship. To my good friends LaS hanta Rice and Brandon Henry, thank you for reminding me to breathe. Lastly, I would like to thank my two Aging Studies ladies, Chivon Mingo and Whitney Mills for helping me to navigate the process

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i TABLE OF CONTENTS LIST OF TABLES ................................ ................................ ................................ ............. vi LIST OF FIGURES ................................ ................................ ................................ .......... vii ABSTRACT ................................ ................................ ................................ ..................... viii CHAPTER ONE: INTRODUCTION ................................ ................................ .................. 1 Introduction and Statement of the Research Problem. ................................ ............. 1 Purpose of the Study ................................ ................................ ................................ 4 Study Framework ................................ ................................ ................................ ..... 8 Significance o f the Study ................................ ................................ ........................ 9 Background. ................................ ................................ ................................ ........... 1 1 Behavioral and Ph ysical Health Disparities ................................ ............... 11 Health Care Barriers ................................ ................................ .................. 13 Eliminating Health Disparities ................................ ................................ ... 15 Cultural Competence ................................ ................................ ................. 16 Lack of Diversity among Health Care Professionals ................................ 18 Racial/Ethni c Concordance ................................ ................................ ........ 19 Advantages of Cultural Competence ................................ ......................... 21 Need for Cultura l Competence Research ................................ ................... 22 CHAPTER TWO: PREDICTORS OF CLIENT PR OVIDER RACIAL/ETHNIC CONCORDNACE ................................ ................................ ................................ ............. 23 Introducti on ................................ ................................ ................................ ............ 23

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ii Methods ................................ ................................ ................................ .................. 25 Sample ................................ ................................ ................................ ........ 26 Measures ................................ ................................ ................................ .... 26 Out come Variable ................................ ................................ .......... 26 Client Provider Racial/Ethnic Concordance ...................... 26 Inde pendent Variables ................................ ................................ ... 26 Socio Demographic Variables ................................ ........... 26 Health Related Var iables ................................ ................... 26 Analysis ................................ ................................ ................................ ...... 27 Resul ts ................................ ................................ ................................ .................... 27 Characteristics of the Sample ................................ ................................ ..... 27 Patterns of Client Provider Racial/Ethnic Concordance ............................ 29 Results from the Logistic Regression on Client Provider Racial/Ethnic Concordance ................................ ................................ .............................. 31 Discussion ................................ ................................ ................................ .............. 33 CHAPTER T HREE: CLIENT PERCEPTIONS O F THE INTERPERSONAL SENSIT IVITY OF THEIR HEALT H CARE PROVIDERS: THE POTENTIAL ROLE OF CLIENT PROVIDER RACIAL/ETHNIC CONCOR DANCE ................................ ... 39 Introduction ................................ ................................ ................................ ............ 39 Methods ................................ ................................ ................................ .................. 43 Sample ................................ ................................ ................................ ........ 43 Measures ................................ ................................ ................................ .... 44 Outcome Variable ................................ ................................ .......... 44

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iii Perceived Inter personal Sensitivity ................................ .... 44 Independent Variables ................................ ................................ ... 44 Client Provide r Racial/Ethnic Concordance ...................... 44 Socio Demographic Variables ................................ ........... 44 Healt h Related Variables ................................ ................... 45 Analysis ................................ ................................ ................................ ...... 45 Results ................................ ................................ ................................ .................... 46 Characteristics of the Sample ................................ ................................ ..... 46 Bivariate Correlations ................................ ................................ ................ 48 Results from the Hierarchical Regression Models o f Perceived Interper sonal Sensit ivity ................................ ................................ ............ 49 Discussion ................................ ................................ ................................ .............. 51 CHAPTER FOUR: OVERALL SATISFACTION WITH CARE RECEIVED: THE POTENTIAL ROLE OF CLIENT PROVIDER RACIAL/ETHNIC CONCOR DANCE AND INTERPERSONAL SE NSITIVITY ................................ ................................ ........ 55 Introduction ................................ ................................ ................................ ............ 55 Methods ................................ ................................ ................................ .................. 59 Sample ................................ ................................ ................................ ........ 60 Measures ................................ ................................ ................................ .... 60 Outcome Variable ................................ ................................ .......... 60 Satisf actio n with Care Received ................................ ........ 60 Cultur al Competence Variables ................................ ..................... 61 Client Provider Racial/Ethnic Concordance ...................... 61

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iv Perceived Interpersonal Sensiti vity ................................ .... 61 Co ntrol Variables ................................ ................................ ........... 61 Socio Demographic Variables ................................ ........... 61 Health Related Variab les ................................ ................... 62 Analysis ................................ ................................ ................................ ...... 62 Results ................................ ................................ ................................ .................... 63 Characterist ics of the Sample ................................ ................................ ..... 63 Biva riate Correlations ................................ ................................ ................ 65 Results from the Hierarchical Regression Models o f Satisfaction with Care ................................ ................................ ................................ ............ 67 Interpretation of Interactions within Each Racial/Ethnic Grou p ............... 69 Discussion ................................ ................................ ................................ .............. 70 CHAPTER FIVE: DISCUSSION ................................ ................................ ...................... 79 Summary of the Study ................................ ................................ ........................... 7 9 Overview of Findings ................................ ................................ ............................ 80 Adequacy of Modified Model of Access to Personal Health Care Services ......... 83 Key Findings by Race/Ethnicity ................................ ................................ ............ 84 Non Hispanic Whites ................................ ................................ ................. 84 African Americ ans/Blacks ................................ ................................ ......... 85 Hispanic s/Latinos ................................ ................................ ....................... 86 Asian Am ericans ................................ ................................ ........................ 87 Study Limitatio ns ................................ ................................ ................................ ... 87 Future Rese arch ................................ ................................ ................................ ..... 89

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v Final Thoughts ................................ ................................ ................................ ....... 90 REFERENCES ................................ ................................ ................................ .................. 92 AP PENDICES ................................ ................................ ................................ ................. 10 9 Appendix A : Model of Access to Personal Health Care Services ....................... 1 10 Appendix B : Culturally and Linguistically Appropriate Services (CLAS ) Standards ................................ ................................ ................................ .............. 11 1 A BOUT THE AUTHOR ................................ ................................ ....................... End Page

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vi LIS T OF TABLES Table 1. Sample Characteristics and Group C omparisons ................................ ..................... 28 Table 2. Comparison s of Client Provider Race /Ethnic Concordance ................................ ... 30 Table 3. Logistic Regression M odels for Client Provider Racial/Ethnic Concordance ........ 32 Table 4. Sample Characteristics an d Group C omparisons ................................ ..................... 47 Table 5 Correlation Coefficients of Independent Variables with Perceived Interpersonal Sensitivity ................................ ................................ ................................ .............................. 48 Table 6 Hierarchical Regression M odels of Perceived Interpersonal S ensitivity ................. 50 Table 7 Sample Characteristics and Group C ompar isons ................................ ..................... 64 Table 8 Correlation Coefficients of Independent Variables for Satis faction with Car e Received ................................ ................................ ................................ ................................ 66 Table 9 Hierarchical Regression M odels of Sat isfaction with Care Received ..................... 68 Table 10 Correlation Coefficients with S atisfaction with Care R eceived in Subgroups of Moderating F actors ................................ ................................ ................................ ................ 71

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vii LIST OF FIGURES Figure 1. Modified Model of Access to Personal Health Care Services ............................. 7 Figure 2. Outline for the Di ssertation ................................ ................................ .................. 9

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viii CULTURAL COMPETENCE IN HEALTH CARE: A CL IENT BASED PERSPECTIVE Karon L. Phillips ABSTRACT In response to the presence of health disparities among a diverse population of older adults, creating culturally competent health care services has emerged as a possible method to help reduce and eventuall y eliminate inequalities in health care. However, little information exists concerning the effectiveness of cultural competence and even less is known about how culturally competent clients perceive their providers to be This dissertation examined a nu mber of indicators related to cultural competence, including the predictors of client provider racial/ethnic concordance, client perceptions of the interpersonal sensitivity of their health care providers, and the overall satisfaction with care reported by older Non Hispanic White African American/Black, Hisp anic/Latino, and Asian American adults. In order to accomplish these aims, three related studies were condu cted, all drawing on data from the Commonwealth Fund 2001 Health Care Quality S urvey. The fi rst study focused on the factors that predict ed racial/ethnic concordance between clients and their health care providers The second study examined several factors that can interpersonal sensitivity

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ix inc luding client provider racial/ethnic concordance The third and final analysis utilized the outcome variables from the two previous studies in addition to the client level variables to determine which factors predict ed satisfaction with care received. The results show that the factors that predicted client provider racial/ethnic concordance and perceived interpersonal sensitivity varied across the four groups. In addition, perceived interpersonal sensitivity was a significant predictor of satisfaction with care for all four of the groups. The findings from this dissertation contribute to a broader understanding of racial/ethnic differences in client provider racial/ethnic concordance, perceptions of interpersonal sensitivity, and overall satisfaction w ith care among older adults from racially and ethnically diverse backgrounds.

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1 CHAPTER ONE : INTRODUCTION Introduction and Statement of the Research Problem Preparing for an aging population requires an understanding of how to better serve older adults fr om all racial/ ethnic backgrounds in health care settings It has been predicted that 25 percent of the older adult population will be part of an ethnic minority group by 2025 (U.S. Census Bureau 2000 ). Numerous studies have also noted that ethnic minori ty groups suffer from illnesses at rates higher than those of Non Hispanic Whites (Ferris, 2000). African Americans /Blacks for example, have higher rates of several diseases including HIV/AIDS and diabetes. The Institute of Medicine (2002) report, Une qual Treatment: Confronting Racial/Ethnic Disparities in Health Care concluded that racism exists in the health care system and identified the existing gaps between the health of racial/ ethnic minorities and non minorities. The national health objectiv es indicated in Healthy People 2000 and subsequently Healthy People 2010 recognized the need to improve the health of racial/ ethnic minorities and set forth specific goals for reducing disparities in disease, disability, and death among minority population s ( U.S. Department of Health and Human Services [DHHS] 2000; 1991). Similar to many other national organizations, these two national reports emphasize the need for health care professionals to acknowledge the importance of understanding the diverse healt h care needs of their clients. Despite the previous initiatives within the health care system to improve the overall quality of and access to care, the inequalities in health status and access to health care among ethnic minorities still exist.

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2 A priori ty of the Department of Health and Human Services and various other federal, state, and communit y organizations is to eliminate behavioral and physical health disparities. One of the primary methods suggested to help eliminate health disparities is to enh ance the cultural competence of providers and provider organizations. According to Cross, Bazron, Dennis and Isaacs (1989, p. iv), cultural competence is defined as a set of congruent behaviors, attitudes, and policies that come together in a system, age ncy, or amongst professionals to work effectively in cross cultural situations believed that cultural competence leads to an overall improvement in the quality of health care services. More specifically, cultural competence has been associ ated, in several preliminary studies, with increased client satisfaction, decreased rates of non compliance, and increased effectiveness of services (Campinha Bacote, 1991). The Institute of Medicine has acknowledged the importance of enhancing cultural c ompetence in health care in order to eliminate health disparities among racial/ ethnic minorities in se veral reports (Bentacourt, Green, Carrillo, & Park 2005). One of the suggestions made by the s promoting cultural sensitivity by providing training and education to health care providers (Bartels, 2003). While little research on its effectiveness actually exists, there are many proposed advantages to adopting a culturally competent approach to he althcare. The general acceptance of such an approach has been emphasized by both the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC), both of which suggest that physicians should receive education on how to provi de culturally competent health care (AMA, 2004; AAMC, 2002). One of the main benefits of incorporating cultural competence techniques into the health care system is that it can

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3 lead to a change in the behaviors of both the heal th care providers and the cl ients. This is accomplished by improving communication, increasing trust, and creating an understanding of t he differences among racial/ ethnic groups (e.g. Ngo Metzger et al., 2006) The Office of Minority Health (OMH) reports that cultural competence in health care can lead to better communication between providers and clients, b etter adherence to medication and positive lifestyle changes because of improved health status. I t has also been found to lower the use of emergency healthcare services ( Departm ent of Health and Human Services OMH, 2 002 ). While anecdotal evidence does suggest that there are multiple benefits associated with cultural competence, there is currently a lack of empirical evidence to support this proposed relationship (Brach & Fraser, 2000). For example, research has recognized that racial/ethnic concordance between clients and providers is an important cultural competence technique (Brach & Fraser, 2000 ; LaViest & Nuru Jeter, 2002; Schnittker & Liang, 2006 ) but there is a need for m ore research to support this claim There is also insufficient evidence concerning how cultural competence affects satisfaction with care ( e.g., Anderson Scrimshaw, Fullilove, Fielding, & Normand, 2003 ; Fortier & Bishop, 2003) Most importantly, there i s very little re perspective of cultural competence ( e.g., Geron 2002; Ngo Metzger et al., 2006) quality health care services ( Cree l, Sass, & Yinger, 2002), but because it can also prompt improvements in health outcomes (Bertrand et al. 1995; Creel et al., 2002; Kols & Sherman 1998; Vera 1993) In order for researchers to continue to support implementation of cultural competence in the health care system, more evidence based

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4 research is needed to show the potential benefits on the clients receiving the care (Brach & Fraser, 2000). Purpose of the Study Based on the need for research to support incorporating cultural competence int o the health care system, the purpose of this dissertatio n wa s to examine the factors that affect client provider racial/ethnic concordance, interpersonal sensitivity, and satisfaction with care across four different racial /ethnic groups. The four racial/ ethnic groups that were compared in this study are N on Hispanic White African American/Black Hispan ics/Latino, and Asian American The specific aims for this study wer e to : (1) determine client level factors (socio demographic, language of the interview and health related variables) that predict racial/ethnic concordance between clients and providers, (2) explore which factors predict the perceived interpersonal sensitivity of health care providers, (3) determine which factors serve as predictors of ove rall satisfaction with care received. The aims for this study were accomplished utilizing data from the Commonwealth Fund 2001 Health Care Quality Survey. The data were collected using rando m digit dialing and the focus of the survey was on factors influ encing the health care experiences of adul ts age 18 and older from diverse racial/ ethnic background s Using data for those participants who were aged 50 and over, t he foll owing secondary analyses were conducted: (1) cross tabs; (2) t tests; and (3) hierar chical l inear regression analysis or logistic regression analysis. There were three research questions addressed in this dissertation: (1) Which client level facto rs predict whether or not there was racial/ethnic concordance between

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5 the client and the provider?; (2) Which client level factors predict the perceived interpersonal sensitivity of health care providers, including racial/ethnic concordance between clients and providers?; (3) Which client level factors predict satisfaction with care among th e four racial /ethnic groups, i ncluding both racial/ethnic concordance between clients and providers and t he perceived interpersonal sensitivity of the provider as measures of cultural competence ? Each of these research questions was examined in a separate study (Chapters 2, 3, and 4). The following three hypotheses were examined: (1) the variables that predict racial/ethnic concordance between clients and providers varied across the four racial/ethnic groups; (2) clients who reported being treated by a pro vider of the same race /ethnicity and perceived their provider s to have high er lev els of interpersonal sensitivity; and (3) clients that had higher levels of satisfaction with care received care from a provider of the same race/ethnicity and perceived their provider to have hi gh levels of interpersonal sensitivity In the following three chapters e ach one of the aforementioned research questions is examined separately The first research question is examined in Chapter 2, entitled Predictors of Client Pro vider Racial/Ethnic Concordan ce Racial/ethnic concordance between clients and providers is closely related to cultural competence (e.g. Pope Davis et al., 2002 ). Racial/ethnic concordance has also been noted to be effective in the reduction of health di sparities (Komaromy et al., 1996; Saha, Arbelaez, & Cooper, 2003). This study examine d the factors that affect whether or not the re was racial/ethnic concordance, a match, between clients and their health care providers. The focus of the analyses was on determining whether or not any of the four racial/ethnic groups were

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6 more likely to be in a match and if there was any variation by the socio demographic variables (age, gender marital status, education, and income), the language of the interview, and hea lth related variables ( health insurance status self rated health, and total number of health conditions ) included in the analysis The second research question is examined in Chapter 3, which is entitled Client Perceptions of the Interpersonal Sensitivi ty o f Their Health Care Providers: The Potential Role of Racial/Ethnic Concordance Th e focus of this analysis was on identifying client level factors that predict interpersonal sensitivity Interpersonal sensi tivity is considered to be a key component of cultural competence (e.g., Hollander, 1985; Riggo, 1996) The particular factors of interest for this analysis were the socio demographic variab les, the language of the interview, and health related variables. Racial/ethnic concordance between clients and providers was a key covariate in this analysis The third research question was addressed in Chapter 4, Overall Satisfaction with Care Received: The Potential Role of Racial/Ethnic Concordance and Interpers onal Sensitivity This final set of analys e s explore d the factors that affected satisfaction with care received. Previous research has used satisfaction as a means to understanding how effective cultural competence is in the health care system (Fortier & Bishop, 2003). Using satisfaction as the outcome variable, the socio demographic variables, language of interview health related variables, client provider racial/ethnic concordance and the interpersonal sensitiv ity were included in this analysis as potential predictors. All three of these studies are outlined in Figure 1.

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7 Figure 1 Outline of the Dissertation

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8 Study Framework There were no well articulated theoretical models available that could provide specific guidance for the proposed multi racial/ethnic study of racial/ethnic concordance, interpersonal sensitivity and satisfaction with care. At the same time, several conceptual frameworks did provide a means of identifyin g key variables and basic relationships. There is substantial agreement across these frameworks concerning those factors that can influence an effectiveness and efficiency of the care they receive (e.g. Andersen, Harada, Chiu, & Makinodan, 1995; Brach & Fraser, 2000; Creel et al., 2 002; Institute of Medicine, 2002 ). The identified factors include the language, beliefs, values, ethnicity, and language of the individual care recipient. Given its compatibility with existing research and theoretical formulations, the decision was made to employ a conceptual framework based on the Services (Institu te of Medicine, 1993) (Figure 2 ) for this dissertation (See Appendix A for the complete conceptual framework). The basic premise of this conceptual model is that the participation of a client in the health care system is affected by several barriers and intervenin g conditions. For this study, the potential barriers to care included financial barriers and personal barriers. The intervening variables selected include those that have b een suggested to lead to higher perceived in terpersonal sensitivity ( Chapter 3 ) and to higher overall satisfaction with care (Chapter 4 ). Racial/ethnic concordance served as a potential intervening variable for interpersonal sensitivity (Chapter 3) Both racial/ethnic concordance and interpersonal sensitivity were viewed as potential intervening variabl es for satisfaction (Chapter 4 ).

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9 Figure 2 Modified Model of Access to Personal Health Care Services (Institute of Medicine) Significance of the Study The client perspective is generally missing from research on cultural competence (Pope Davis et al., 2 002) which generally focuses on characteristics of the providers and the institutional context. It is critically important to consider the views of the client perspective is considered. One way of validating the efficacy of cultural competence is to find out if clients from diverse cultures are satisfied with the quality of health care receive d (Ngo Metzger et al., 2006). Even though there are several positive outcomes th at have been associated with cultural competence, there are still many unaddressed issues and concepts. More empirical evidence is needed to support this proposed

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10 relationship (Brach & Fraser, 2000 ; Fortier & Bishop, 2003 ) and to address the clinical appl ication of cultural competence to patient care (Engebretson, Mahoney, & Carlson, 2008). This dissertation also incorporated a multi racial/ethnic perspective. While research on cultural competence has generally focused on the comparisons of Non Hispanic Whites to a single racial/ethnic group, r acial/ethnic minorities have different experiences with the health care system and it is important to determine the sources of these differences. There is a lack of research that has addressed questions related to cultural competence and racial/ethnic concordance. In order to support efforts that advocate for incorporating culturally competent practices into health care settings, more empirical research is needed. Previous research is primarily anecdotal or based on very small samples While some s tudies have illustrated the potent ial for positive outcomes with cultural competence, more research is needed in order to support incorporating cultural competence into the health care system. Overall, t his study examine d the perceptions that Non Hispanic Whites, African Americans/Blacks, Hispanics/Latinos, and Asian Americans have of their providers and the health care system This dissertation focused on the factors that predict racial/ethnic concordance with health ca re providers and the effects of this concordance on interpersonal sensitivity. In addition, this study examined the direct and interactive effect of cultural competence, measured by racial/ethnic concordance and interpersonal sensitivity, on client satisf action.

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11 Background The following background section for this dissertation begins with an overview of health disparities and the factors that influence these disparities. Next, i nformation about cultural competence as a means to eliminate health dispar ities is presented. The third component of this section includes the overall benefits of cultural competence. Lastly, the issues that need more research in cultural competence are discussed. Behavioral and Physical Health Disparities The 1985 Departm Black and Minority Health report has served as one of the landmark documents for addressing disparities in health care. This repo rt noted the excess in mortality rates among many racial/ ethnic min ority groups ( DHHS 1985). Subsequently additional studies examine d racial/ ethnic differences in the quality health care and service utilization. According to the Institute of Medicine over 175 research studies have indicated that there are health care disparities in diagnosis and treatment of a wide range of medical issues ( Betancourt et al., 2005 ). Several reports and studies have highlighted the presence of health disparities in the health care system and a large portion of the research on racial/ et hnic minorities has focused on the difficulties associated with accessing care as the main reason for the existence of health disparities (Institute of Medicine, 2002). Health disparities exist in both the behavioral and physical health domains. Accord racial/ ethnic minorities are less likely than Non Hispanic Whites to receive mental health care and when they receive care it is of poorer quality ( DHHS 1999). African Americans /Blacks are more likely

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12 than Non Hispanic White s to be diagnosed with certain mental illness including schizophrenia Hispanics/Latinos generally have mental illness at rates similar to Non Hispanic Whites but they have substantially higher rates of affective disorders. Asia n Americans are more likely to be misdiagnosed and under diagnosed (C enters for D isease C ontrol and Prevention 2006). There is also evidence that despite the higher prevalence rates of illnesses compared to Non Hispanic W hites, ethnic minorities are less likely to receive the best treatments available for dep ression and anxiety (Young, Klap, Shebourne & Wells, 2001). In addition to behavioral health disparities, there are some distinct differences in the prevalence of physical health illnesses among olde r ethnic minorities. For exam ple, older African Americans /Blacks, when compared to Non Hispanic White s, have higher rates of hypertension, heart disease, stroke, and renal disease. Hispanics /Latinos and African Americans /Blacks have significantly higher rates of Type 2 diabetes than N on Hispanic White s (Jackson & George, 1998). Similar to disparities in behavioral health, older ethnic minorities tend to have a lack of knowledge about the various diseases that can affect them stemming from the underutili zation health care. The underutilization of services by older ethnic minorities is associated with their cultural norms, discrimination, and barriers with accessing health care services due to language difficulty and low er socio economic status (Wallace, L evy Storms, Kington, & Anderson 1998). In addition to utilization issues that have received considerable attention from researchers, r esults from the Commonwealth Fund 2001 Health Care Quality Survey revealed that o ne in three Hispanics and one in four Asian Americans have difficulty communicating effectively with their physicians. Moreover, 15 percent of African

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13 Americans /Blacks 13 percent of Hispanics /Latinos and 11 percent of Asian Americans reported that they believed that the care they received w ould have been better if they were a di fferent race or ethnicity (Davis et al., 2006). Older ethnic minorities, in particular, are less likely to receive regular medical care and are disproportionately affected by differences in access to care (Byrd, 200 7). Studies have indicated that some health care providers do not offer options for certain tests and procedures to their older ethnic minority clients because they cannot financially afford these options (Byrd, 2007). Many older ethnic minorities may en ter later life with a cumulative disadvantage, leading to a greater number of health problems. The Cumulative Disadvantage Theory, also referred to as the Disadvantage Theory in Gerontology, supports the idea that inequality is the result of having amasse d years of poor health care utilization and declining health (Quadagno & Reid, 1999). This concept is based on collective groups such as cohorts and it leads researchers and health professionals to question the fairness in the distribution of health car e services, resources, and opportunities among older populations (Dannefer, 2003). Health Care Barriers It is generally agreed that health disparities arise from multiple pathways. Many of the disparities in health care stem from social and cultural iss ues. Some of the more specific reasons for the prevalence of both behavioral and physical health disparities on the client level include socio economic status, access to resources and health care, lack of research, lack of cultural competency in health ca re practices, lack of health insurance, stigmas about illness, and various cultural factors ( Smedley, Stith, & Nelson 200 3; Snowden, 2002). Health care barriers can be classified into three broad non mutually

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14 exclusive categories: clinical, structural, a nd organizational. T hese categories provide a framework for understanding barriers to accessing and receiving care. Barriers that are associated with the interactions betwe family and the provider are clinical barriers. These barriers occur when there are socio cultural differences that cause the client to not be fully understood by their provider. and negative attitudes toward medi cal care and the health care system (Berger, 1998). The negative effects of cultural and linguistic barriers on clients within the clinical setting include client dissatisfaction, poor adherence to treatment, and poorer health outcomes (Brac h & Fraser, 20 00; Morales, Cunningham, Brown, Liu, & Hays 1999). It is very important for the provider to carefully consider the social and cultu ral background of their clients. F ailure to do so can cause the provider to base their decisions and behaviors on stereoty pes (v an Ryn & Burke, 2000). Structural barriers may cause the client to have difficulty receiving services due to the complex, bureaucratic and archaic design s of some health care systems (Betancourt et al., 2005). These barriers in particular aff ect all clients that may be utilizing the services, but minority populations are particularly vulnerabl e due to socio cultural and health related disadvantages One major issue that falls under this set of barriers is the lack of interpreters and unavaila bility of culturally and linguistically appropriate health education material. These two factors are associated with overall client dissatisfaction, poor comprehension and compliance, and ineffective or lower quality care (Betancourt et al., 2005).

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15 Organ izational barriers largely revolve around the lack of diversity in the leadership and in the workforce of an organization (Betancourt et al., 2005). Some specific examples include limited hours of access to services and an intimidating initial intake proc esses that can cause an undocumented individual to become fearful of deportation. Research suggests that there is a link between having a lack of diversity in the leadership, policies, and procedures of an organization and being unable to properly serve m inorit y communities (Betancourt, Green, Carrillo, & Ananeh Firempong 2003). Several studies have noted that one of the factors associated with poorer health among African American/ Black and Hispanic/ Latino populations is the lack of African American/ Blac k and Hispanic/ Latino health care professionals (DHHS, 1991). Eliminating Health Disparities The national health objectives indicated in Healthy People 2000 and subsequently Healthy People 2010 have established the need to improve the health of ethnic mi norities (DHHS 2000; DHHS, 1991). Health care professionals must acknowledge the importance of understanding the diverse health care needs of their clients. Despite the previous efforts that have been made, inequalities in health status and access to he alth care among ethnic minorities still exist s It has become a priority of the D HHS and various other federal, state, and community organizations to eliminate behavioral and physical health disparities. One of the primary methods being used to help elim inate health disparities is incorporating cultural competence techniques into the health care system These techniques include providing cultural competence trainings to health care professionals, recruiting diverse employees, and employing policies that are respectful of the beliefs and values of the clients.

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16 C ultural competence generally speaking, has been reported to be associated with an overall improvement in the quality of health care services. More specifically, it has been associated with incre ased client satisfaction, decreased rates of non compliance, and increased effectiveness of services (Campinha Bacote, 1991). The Institute of Medicine has acknowledged the importance of cultural competence in health care in order to eliminate health disp arities among ethnic minorities in several reports (Betancourt et al., 2005). In addition, o ne of the suggestions made by the Commission on Mental Health includes promoting cultural sensitivit y among providers (Bartels, 2002 ). Cul tural Competence Cultural competence is defined differently by various people and organizations although there is substantial overlap in definitions (Brach & Fraser, 2000). A working definition of cultural competence was developed in 1988 by Terry Cross and colleagues and is frequently cited as a central definition. of congruent behaviors, attitudes, and policies that come together in a system, agency, or amongst professionals to work effectively in cross cult Cross et al., 1989, p. iv ). Most of the other de finitions of cultural competence that exist are variations of this one developed by Cross. Both t he National Center for Cultural Competence ( N CCC) and the O MH utilize this definition. Le ininger (1978) posited that there are two main factors that promote cultural development: maintaining a broad, objective, and open attitude towards individuals and their culture and see ing all individual differences. These two concepts provide an initial guide to beginning to conceptualize cultural competence and its utility as a mechanism to

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17 eliminate health disparities in the health care system. The NCCC has identified the following six reasons why it is important to support implementing cultural compet ence in the health care system: 1) the perception of illness and disease and their causes varies by culture; 2) diverse belief systems exist related to health, mental health, healing and well being; 3) culture influences help seeking behaviors and attitude s toward primary care providers; 4) individual preferences affect traditional and other approaches to primary care; 5) patients must overcome personal experiences of biases within primary care systems; and 6) primary care providers from culturally and ling uistically diverse groups are under represented in cu rrent service delivery systems. Cultural competence must address more than race and ethnicity. The concept of cultural competence is multidimensional and multifaceted ( e.g. Ngo Metzger et al., 2006; Suz uki, McRae, & Short, 2001; Sue, 2001). It does not mean to merely posses knowledge of different cultures and respect for different cultural perspectives. It requires obtaining and utilizing skills effectively in cross cultural situations (Cross et al. 19 89; Tirado, 1996). Lastly, integral to the efforts that focus on enhancing cultural competence is a n ongoing commitment to practice and policies that are appropriate for diverse populati ons (Andrulis, Delbanco, & Shaw Taylor 1999; Cross et al., 1989). As a means of promoting the application of cultural competence, a set of culturally and linguistically appropriate service (CLAS) standards were developed by the D HHS Office of Minority Health (DHHS OMH, 2001) (Appendix B ). These standards were originally conceived by Guadalupe Pacheco and the purpose of these standards is to populations who encounter barriers to accessing and receiving effective health and social

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18 services and to be inclusive SenGupta, Sampson, & Tervalon, 2003, p. 5). The standards are organized by the following themes: culturally competent care (Standards 1 through 3) ; language access services (Standards 4 through 7) ; and organizatio nal supports for cultural competence (Standards 8 through 14). Standards 1 through 7 address interventions that have the most direct impact on clinical care Standards 8 through 14 address organizational structures, policies and processes that support th e implementation of standards 1 through 7. Standards 4 through 7 are federal mandates for recipients of federal funds, which include Medicare and Medicaid. Although these are only guidelines, they serve as a framework for creating culturally competent pr ograms. Lack of Diversity among Health Care Professionals There is a significant lack of ethnic minority individuals serving as health care professionals and consequently the current health care workforce does not reflect the diverse American population. According to the Minority Affairs Consortium of the AMA 3.5 percent and five percent of the total physicians in the country are African American/ Black and Hispanic /Latino res p ectively, compared to the 55.8 percent that are Non Hispanic White ( AMA 2008 ). In 2000, African Americans /Blacks comprised less than nine percent of nurses and five percent of dentis ts (Sullivan Commission, 2004). The lack of health care providers from diverse backgrounds limits the number of clients that can be matched with a p rovider of the same race/ethnicity. Minority physicians have been found to be more likely to provide care to minority, poor, and sicker patients (e.g. Lloyd & Johnson, 1982; Moy & Bartman, 1995; Xu et al., 1997). In addition, African American/Black and H ispanic/Latino physicians are more likely to provide care to

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19 African American/Black, Hispanic/Latino, and low income patients than Non Hispanic White physicians (Komaromy et al., 1996). Previous research has noted that minority employees tend to provide h ealth care services that are more congruent with th e needs of minority populations (Brach & Fraser, 2000). Health care facilities with diverse health staffs provide patients with more opportunities to be matched providers of the same race/ethnicity. R acial/Ethnic Concordance Racial/e thnic concordance also referred to as matching, occurs when a client is matched deliberately or by chance, with a provider of the same race or ethnicity. Previous research has highlighted racial/ethnic concordance as an effective cultural competence technique ( e.g. Pope Davis et al., 2002) that aids in the reduction of health disparities (Komaromy et al. 1996; Saha, et al., 2003). Previous research has found that African American /Black Asian Am erican, and Mexican Americ an clients that utilized programs that were ethnic specific had a higher return rate and stayed in the treatment program longer than those that used the mainstream services (Leong, 2007). Previous research has also found that many clients have a preferenc e to be matched with a provider of the same race (Pope Davis et al., 2002; Schnittker & Liang, 2006). There are some caveat s that are associated with racial/ ethnic concordance that should be addressed in research. Some studies have noted that being in a match only matters to patients who prefer to be matched (Schnittker & Liang, 2006 ). Howard and colleagues (2001) found little evidence that racial/ ethnic concordance had an effect on care, use of services, and patient satisfaction. There is also some co ncern about the

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20 effectiveness of racial/ethnic concordance for all patients, regardless of race/ethnicity (Stepanikova, 2006). culture and previous experiences with th e medical system, should also be considered. Historically, many older African Americans /Blacks have displayed a mistrust of the health care system. The r esearch literature has noted that this mistrust may stem from several historical events and circumsta nces Some researchers for example, have speculated that this distrust of doctors may have its origins in the Tuskegee Syphilis Experiment where African American /Black men did not receive proper treatment for syphilis; however the history of this mistru st may date back to slavery ( Corbie Smith, Thomas, & St. George, 2002 ). There is evidence that p hysicians used enslaved African Americans /Blacks to perform experimental, and often painful, medical procedures (Gamble, 1997). In addition to having a distr ust of the medical system, many African Americans/Black s perceive African American/Black physicians to be inferior to Non Hispanic White physicians (Charatz Litt, 1992). The r easons for this perception vary, but may in part result from the historical disa dvantages in obtaining quality education. This brings into question how effective being in a racial/ethnic match with a health care provider would be among older African Americans/Blacks. Based on the history of African Americans /Blacks with the medical s ystem more research is needed to determine if racial/ethnic concordance is effective for all racia l/ethnic groups.

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21 Advantages of Cultural Competence Health care programs that have implemented cultural c ompetence strategies have found that there is an Aging Society, 2004 p. 6 ). It has been emphasized by both the AMA and the AAMC that physicians sh ould received education on how to deliver culturally competent health c are (AMA, 2004; AAMC, 2002). The benefits of incorporating cultural competence technique s into the health care system are that it can lead to change s the behaviors of both health care providers and clients by imp roving communication, increase patient trust of their providers, and create a n understanding of t he differences among racial/ ethnic groups (Brach & Fraser, 2000). These changes could in turn lead to more culturally appropriate services such as improved prevention and screening activities, better informed diagnoses, and culturally specific client centered education on treatment regimens (Brach & Fraser, 2000). One of the potential negative effects of not providing culturally co mpetent care is the potential conflict between c lients and providers that could lead to overall poorer quality of care (Remus, 2004). In addition, it is possible for financial risks to arise depending on the number and size of the minority population in the community that is utilizing the services provided (Remus, 2004). If an organization chooses to not make improvements in the cultural and linguistic appropriateness of the services being provided, ethnic minorities will be less inclined to utilize thes e services leading to a decrease in revenue. E xperts feel that cultural competence can improve health outcomes

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22 and improve the costs of care by making it more effective and efficient (Betancourt et al., 2005). Need for More Cultural Competence Research Despite the positive outcomes associated with cultural competence, there are some issues that must be considered. While some research has shown the potential benefits associated with cultural competence, more studies are needed to prove the true effectiv eness of it in the health care system (Brach & Fraser, 2000). Although previous research has established an agenda for creating and implementing cultural competence interventions, significant research is needed to order to thoroughly examine the effective ness of these interventions, particularly from the perspective of the clients ( Anderson et al., 2003 ; Geron, 2002; Perloff, Bonder, Ray, Ray, & Siminoff, 2006 ). cultural encounters in the clinic (Pope Davis et al., 2002). By asking questions about client satisfaction with services, information can be gathered about the strengths and weaknesses of various providers and organizations. The present dissertation seeks to address these iss ues and provide information as part of an effort to improve the ove rall qua lity of the health care services being provided.

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23 CHAPTER TWO: PREDICTORS OF CLIENT PROVIDER RACIAL/ETHN IC CONCORDANCE Introduction Previous researc h has noted that throughout the most of the twentieth century ethnic minorities received substandard health care, and this trend continues in the twenty first century (LaVeist & Nuru Jeter, 2002; Smedley, Stith, & Nelson 200 3). Experiences with substanda rd care, in turn, have been suggested to lead to disparities in both access to and utilization of health care services and a general mistrust of the medical system by racial/ethnic minorities (LaVeist, Nickerson, & Bowie, 2000b; LaViest & Nuru Jeter, 2002) This climate of distrust created additional barriers to the provision of quality care, and brought attention to the need for efforts to improve health care for racial/ethnic minorities. One of the main efforts to improve the level of trust and to enhan ce the overall cultural sensitivity of services consists of programs and initiatives designed to increase the number of ethnic minority physicians in the health care system (Carlisle, Gardner, & Liu, 1998; LaVeist & Nuru Jeter, 2002; Libby, Zhou, & Kindig, 1997). Evaluations of these efforts have found that minority physicians were more likely to provide care to minority, poor, and sicker patients (e.g. Lloyd & Johnson, 1982; Moy and Bartman, 1995; Xu et al., 1997). Komaromy and colleagues (1996), for exa mple, found that African American/ Black and Hispanic /Latino physicians were more likely than their Non Hispanic White counterparts to care for African African/ Black, Hispanic /Latino and low income patients.

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24 There is some evidence that health care faci lities with more minority employees are more likely to organize the delivery of health care services in ways that are more congruent with the needs of minority populations (Brach & Fraser, 2000). Having a higher proportion of minority employees also allow s providers to connect with more patients from diverse backgrounds. Research suggests that by having a diverse health care staff more patients can be matched with, and receive care from, providers of the same race/ethnicity. Previous research has found t hat client provider racial/ethnic concordance may result in an increase in access to services (Nickens, 1992). Studies have also found that many clients prefer to be matched with a provider of the same race /ethnicity (Pope Davis et al., 2002; Schnittker & Liang, 2006) and that racial/ethnic concordance significantly aids in the reduction of health disparities (Komaromy et al. 1996; Saha, Arbelaez, & Cooper, 2003). While there is research that supports the need for cl ient provider racial/ethnic concordance there are also studies reporting that racial/ethnic concordance may not be effective Schnittker and Liang (2006) found that racial/ethnic concordance only matters to patients who have a preference to be in a match with a health care provider of the sam e race/ethnicity Similarly, little evidence was found by Howard and colleagues (2001) to support a relationship between racial/ethnic concordance and the effectiveness of care, use of se rvices, or patient satisfaction. Stepanikova (2006) found that the importance of racial/ethnic concordance varies by the racial/ethnic background of the patient. This suggests that racial/ethnic concordance may not be universally effective for clients of all racial/ethnic backgrounds. These mixed results suggest that mo re research is needed in

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25 order to fully understand the effects of racial/ethnic concordance on cl ient provider interactions and its application in the health care system (Schnittker & Liang, 2006). Given the need for more research, the purpose of the pre sent study was to gain a better understanding of the factors associated with whether or not there was a racial/ethnic match between the client and their health care provider. We hypothesized that the client level factors, both socio demographic and health related, that predict whether or not a client was in a match will vary across the four racial/ethnic groups. The analyses were conducted by controlling for potential variables that might be linked to being in a match with a provider of the same race/eth n icity, such as the language the interview was conducted in and health related variables. Methods The data used in this study came f rom the Commonwealth Fund 2001 Health Care Quality Survey conducted by Princeton Survey Research Associates (PSRA) in 20 01. The survey consisted of a 25 minute telephone interview and the participant could choose to be interviewed in English, Spanish, Cantonese, Mandarin, Kor ean, or Vietnamese. The sample was drawn by using a standard list assisted random digit dialing (R DD) methodology. The complete sample obtained as a result of this was then divided into sub samples, based on the densities of African Americans, Hispanics, and African American households. The interviews were conducted from April 30 th through November 5, 2001. Up to 20 attempts were made to contact people to invite them to participate in the survey. There were a total of 6,722 r e spondents, representing a 54.3 percent survey response rate. This survey was designed with the intent of being able to gene ralize to the U.S. adult

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26 population age 18 and older, and to allow separate analyses of responses by racial /ethnic group. A dditional information about the methodology employed to collect this data is available elsewhere (see Princeton Su rvey Research Ass ociates, 2002 ). Sample For the purpose of the present study, we selected only those individuals aged 50 and older that reported that they had utilized health care services within the past two yea rs The final sample included 2 075 respondents representi ng the following four racial/ethnic groups: Non Hispanic W hite (n= 1 417 ), African American/Black (n= 330), Hispanic/Latino (n= 204), and Asian American (n=124 ). Measures Outcome V ariable Client Provider Racial/Ethnic Concordance. If the race/ethnicity of the provider was the same as the race/ethnicity of the respondent, a match was coded (0=no,1=yes). Independent variables Socio Demographic Variables Th e following socio demographic variables were included in the analysis: age, gender, marital status, education, and income. The language of interview was used as a proxy for English language fluency (0=interview not conducted in English, 1=interview conducted in English). Health Related V ariables. The health related variables included were health insura nce status, self rated health, and the total number of health conditions. For insurance, respondents were asked if they had any form of health insurance or a health plan, including any private health insurance plan or a government program such as Medicare or Medicaid (0=no health insurance coverage, 1=have health insurance

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27 coverage). For health status, a five point Likert scale was provided for respondents to rate their self rated health ( 1=poor, 2=only fair, 3=good, 4=very good,5=excellent ). For health conditions, respondents were asked to indicate if they had ever been told by their health care provider that they had high blood pressure, heart attac k or any other heart disease, cancer, diabetes or sugar diabetes, anxiety or depression, obesity, or asthm a The number of conditions was summated to represent the total number of health conditions. Analysis Bivariate correlations were used to examine the relationship s among study variables and to detect potential multicollinearity. A series of logis tic regression s were conducted in order to identify factors related to the presence or absence of being in a match The regressions were performed separately on each of the four racial/ethnic groups. The variables were entered in successive model s in an order that reflect ed the immediacy and stability of the variables with more stable or temporally distant variables in the earlier sets. The order of the models was: socio demographic variables (age, gender, marital status, education, and income), language of the interview, and health related variables (health insurance, self rated health, and health conditions). Results Characteristics of the Sample Descriptive information on the total sample and four racial/ethnic groups is summarized in Table 1. The re sults highlight the differences as well as the similarities across the four groups. The ages for the total sample ranged from 50 to 99 Over half the to tal sample was female, over 80 percent of the sample had received a high sch ool diploma or higher and 48.6 percent had incomes of $50,000 or less. The African

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28 Table 1. Sample Characteristics and Group Comparisons a Variable Mean/SD (%) Variable type Total sample (N=2075) Non Hispanic Whites (N=1417) African Americans/ Blacks (N=330) Hispanics/ Lati nos (N=204) Asian Americans (N=124) Demographic variables Age 64.9/12.16 65.7/12.06 63.9/12.09* 61.8/10.58*** 63.9/14.68 Female (67.1) (66.6) (69.1) (74.0)* (56.5)* Married (51.7) (53.6) (34.2)*** (53.4) (73.4)*** High school and beyond (81.8) (87 .3) (70.6)*** (56.8)*** (90.3)*** Income ( < 50K) (48.6) (45.7) (62.0)*** (54.3)*** (35.5)** Language of the interview (English) (95.0) (99.9) (99.7) (62.3)*** (80.6)*** Health related Variables Insured (93.1) (95.7) (86.4)*** (84.3)*** (95.2) Self rated health (Very good or higher) 3.26/1.14 3.36/1.13 2.97/1.08*** 2.89/1.19*** 3.26/1.14 Health conditions 1.20/1.90 1.18/1.17 1.39/1.21** 1.25/1.24 .81/1.14** Outcome Client provider r acial/ethnic concordance (54.9) (68.4) (23.0)*** (20.1)*** (43.5)* ** p < .05, ** p < .01, *** p < .001 a 2 test) were conducted by comparing each racial/ethnic group with Non Hispanic Whites.

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29 Americans/Blacks and Hispanics/Latinos appear to be less advantaged than the Non Hispanic Whites. Compared to the Non Hispanic Whites, African Americans/Blacks and Hispanics/Latinos were significantly younger, had lower levels of education, lower incomes, more health conditions, had lower self rated health, and were less likel y to have health insurance. African Americans/Blacks were the least likely to be married. Hispanics/Latinos were significantly more likely than Non Hispanic Whites to be female. Asian Americans were significantly less likely to be female, more likely to be married, more educated, more likely to have incomes higher than $50,000, and less likely to have health conditions when compared to Non Hispanic Whites. Patterns of Client Provider Racial/Ethnic Concordance The patterns of racial/ethnic concordance bet ween clients and their health care providers are presente d in Table 2. A total of 54.9 percent of the respondents were in matches with a provider of the same race/ethnicity. Probably due to the high proportion of Non Hispanic White providers in the Unite d States, there was close to 70 percent client provider matches for Non Hispanics Whites and one third or more of the clients in the other three groups had Non Hispanic White providers. Asian Americans were the second most likel y group to be in a match (4 3.5 percent ) with a provider of the same race/ethnicity. Client provider racial/ethnic conco rdance was observed in only 23 percent of Afr ican Americans/Blacks and 20.1 percent of Hispanic/Latinos. Non Hispanic Whites and Asian Americans were the least li kely to have an African American/Black provider. These findings show that racial/ethnic concordance is more likely to occur among Non Hispanic Whites and Asian Americans than African Americans/Blacks and Hispanics/Latinos.

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30 Table 2. Comparisons of the Client Provider Racial/Ethnic Concordance Race/Ethnicity of Provider Non Hispanic White African American/ Black Hispanic/ Latino Asian American Other a Race/Ethnicity of Client Non Hispanic White 969(68.4%) 20(1.4%) 27(1.9%) 95(6.7%) 85 (6.0%) African American/Black 132(40%) 76(23%) 9(2.7%) 21(6.4%) 17(5.1%) Hispanic/Latino 69(33.8%) 3(1.5%) 41(20.1%) 19(9.3%) 18(8.8%) Asian American 41(33%) 0 3(2.4%) 54(43.5%) 4(3.2%) a The grouping of Other includes Native Hawaiian, other Pacific Islander, American Indian, Alaskan Native, and other. This category was only included for health care providers.

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31 Results from the Logistic Regression on Client Prov ider Racial/Ethnic Concordance Prior to conducting multivariate analyses, bivariate correlations were assessed in order to assess potentially problematic interrelationships among the explanatory variables. The highest correlation coefficient was observed between education and income, for the Asian American group (r = 0 .55, p < .001), but it was not a concern for multicollinearity (Tabachnick & Fidell, 2001). The results of the logistic regression are presented in Table 3. The primary purpose of thes e analyses was to identify which variables predicted whether or not a client was in a match with a provider of the same race/ethnicity. The first set of variables addressed the socio demographic characteristics of the clients. Gender was a significant pr edictor for Non Hispanic Whites: female Non Hispanic Whites were significantly more likely to be in a match. Younger African Americans/Blacks were significantly less likely to be in a match In addition, both education and income were significant predict ors for African Americans/Blacks: the higher educated African Americans/Blacks were significantly more likely to be in a match and lower income was associated with a lower likelihood of being in a match. None of the socio demographic variables were signif icant for Hispanics/Latinos. Marital status was a significan t predictor for Asian Americans: Asian Americans who were married were close to four times more likely to be in a match. The second model set included only one variable, whether or not the lan guage of the interview was conducted in English. A variable that would seem relevant to both the Hispanic/Latino and Asian American groups, this variable was only significant for

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32 Table 3. Logistic Regr ession Models for Client Provider Racial/Ethnic Conc ordanc e a Step/ Variable Non Hispanic White African American/Black Hispanic/Latino Asian American Estimated Probability (95% CI) Estimated Probability (95% CI) Estimated Probability (95% CI) Estimated Probability (95% CI) 1 Age Gend er Marital status Education Income 0 .71 ( 0 .99, 1.02) 1.45(1.02, 2.06)* 0 .76( 0 .51, 1.12) 1.13( 0 .93, 1.37) 1.02( 0 .94, 1.10) 0 .96( 0 .93, 1.00)* 0 .53( 0 .26, 1.09) 0 .85(.42, 1.72) 1.56(1.09, 2.25)* 0 .80(.69, .92)** 1.02( 0 .97, 1.08) 1.30( 0 .48, 3.53) 1.62( 0 .5 5, 4.76) 1.12( 0 .70, 1.80) 0 .91( 0 .76, 1.10) 0 .95( 0 .90, 1.01) 2.20( 0 .75, 6.38) 3.95(1.06, 14.70)* 0 .56( 0 .28, 1.12) 0 .81( 0 .64, 1.03) 2 Language of the interview b 0 .25( 0 .09, .71)** 0 .13( 0 .01, 1.25) 3 Health insurance Self reported health Health conditions 2.53(1.19, 5.41)* 1.05( 0 .88, 1.26) 0 .89( 0 .76, 1.05) 3.00(.88, 10.30) 0 .90(.65, 1.26) 0 .94(.70, 1.26) 0 .32( 0 .07, 1.50) 1.01( 0 .66, 1.53) 0 .87( 0 .56, 1.34) 0 0 .70( 0 .36, 1.36) 0 .82( 0 .51, 1.31) p < .05, ** p < .01, *** p < .001 a 2 test) were conducted by comparing each racial/ethnic group with Non Hispanic Whites. b English fluency was not included in the logistic regression models for Non Hispanic Whites and Af rican Americans/Blacks.

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33 Hispanics/Latinos: those that were interviewed in Spanish were less likely to be in a match. The last model set was related to the health of the patient. Having health insurance was a significant predictor only f or Non Hispanic Whites. These results indicate that Non Hispanic Whites with health insurance were more than twice as likely to be in a match with a Non Hispanic White provider. The number of health conditions and self rated health were not significant f or any of the four groups. Discussion The overall purpose of this study was to identify factors related to client provider racial/ethnic concordance among Non Hispanic Whites, African Americans/Blacks, Hispanics/Latinos, and Asian Americans that partic ipated in the 2001 Health Care Quality Survey. While a number of reports have indicated that client provider racial/ethnic concordance is associated with better health outcomes, there have been very few studies that have examined factors that predict when racial/ethnic concordance occurs Differences by race/ethnicity indicated that these groups all had distinct socio demographic backgrounds. Compared to the Non Hispanic Whites, the African Americans/Blacks and Hispanic/Latinos were more likely to have lo wer incomes and less likely to have health insurance. African Americans/Blacks and Hispanics/Latinos were significantly less educated than their Non Hispanic White counterparts. Asian Americans had the highest percent age of people receiving an education of high school and beyond. Although these findings are not unique to this study (e.g Johnson, Saha,

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34 Arbelaez, Beach, & Cooper 2004), they do emphasize the fact that the samples varied in terms of their potential risk and vulnerabilities The logisti c regression models showed that the factors that predict racial/ethnic concordance between clients and providers differed across the four racial/ethnic groups. For N on Hispanic White s, racial/ethnic concordance was more likely to occur among women than me n Female patients are more likely than male patients to ask questions and build a partnership with their providers (Cooper Patrick et al., 1999) For women in general it may be more important to have an open and trusting relationship with their provider s and for this reason racial/ethnic concordance m ay be more important to them. Having health insurance also increased the likelihood of racial/ethnic concordance for Non Hispanic Whites. A higher percentage of Non Hispanic White clients in this study ha d health insurance when compared to African Americans/Blacks and Hispanics/Latinos and this may have influenced thi s finding. This result does raise the following question: if more of the African Americans/Blacks and Hispanics/Latinos had health insuranc e would they be more likely to have a provider of the same race/ethnicity ? Having health insurance allows clients to have more choices about the providers they are able to access, thereby increasing the possibility of racial/ethnic concordance Being younger and having a lower income decreased the odds of the African Americans/Blacks being in racial/ethnic matches with their provider Those with higher levels of e ducation, however, were 1.6 times more likely to be in a match with a provider of the sam e race/ethnicity. Previous research has found that people that obtain more formal education are more likely to have access to and use preventive health care (Dewar,

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35 1998). Higher educated African Americans/Blacks may have a preference to interact with pr oviders of the same race due to their similar cultural backgrounds and higher educational attainment. Since these results are independent of the effects of income and health insurance, they do suggest that culture and attitudes p lay a role in preference a nd choi ce. These results support the notion that when people have more choices about their health care they are more likely to be in a racial/ethnic match with their provider. The language of the interview was significant only for Hispanics/Latinos. Peop le who were interviewed in Spanish were less likely to be in a match with a provider of the same race/ethnicity. Previous studies have found that language barriers can have a negative impact on experiences with health care for Spanish speaking patients (e .g. Fernandez et a l., 2004; P rez Stable, Napoles Springer, & Miramontes, 1997; Todd, Samaroo, & Hoffman, 1993). Based on t hese findings language is an important aspect of racial/ethnic concordance for Hispanics/Latinos but paradoxically th ey were the l east likely of the four groups in the study to be in a racial/ethnic match with their providers, despite being a disadv antaged group in terms of socio demographic and health related characteristics. Somewhat mitigating this result is the possibility that there may be a greater availability of Spanish speaking providers that are not Hispanic/Latino, as well as a greater availability of translators. Asian Americans who were married were almost four times more likely to be in a match with a provider of the same race/ethnicity. This finding should be considered in the context that Asian Americans, despite the small sample size, were more likely to be in a match than African Americans/Blacks and Hispanics/Latinos. Marriage appears to have put the Asian Ameri cans in a particularly advantaged position with respect to

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36 racial/ethnic concordance. This may arise, in part, from spousal involvement in health care and health care decision making. A qualitative study by Andresen (2001) found that family members are of ten involved with the health care of Asian American patients Married couples may request to receive care from an Asian American provider more often than single patients. There are several limitations to the generalizability of this study. Only people with a regular health care provider were included in this analysis, since those who did not have a regular health care provider were not asked questions about the race/ethnicity of their provider. Another limitation was the use of the language that the in terview was conducted in as a proxy for English language fluency. There were only four possible racial/ethnic categories that a respondent and the provider could be classified into, thereby limiting information available about subgroups. Although this st udy explored factors that predicted when racial/ethnic concordance occurs, we were not able to control for the availability of providers. Data on whether or not a client specifically asked for a provider of a certain race/ethnicity was not available in th is dataset. Finally, the questionnaire was administered over the telephone and this presents a potential response bias since only people with home telephones were included. This is a noted negative aspect of conducting a telephone survey (e.g. Groves et al., 2004). The findings from this study contribute to a growing body of literature about racial/ ethnic concordance between clients and providers According to LaViest and Nuru Jeter (2002), very few studies have examined predictors of client provider r acial/ethnic concordance. More studies have focused on the impact of racial/ethnic concordance on various health outcomes, instead of the factors that predict when client

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37 provider racial/ethnic concordance occurs. Previous research has established that t he literature on racial/ethnic concordance is mixed regarding the utility of it in the health care system. Knowing the differences in these factors is one of the first steps to understanding the racial/ethnic differences in racial/ethnic concordance. The se finding also support the utility of pipeline programs that encourage underrepresented minorities to pursue careers in the health professions. Having a diverse work force can aid in the elimination of health disparities by allowing more racial/ethnic mi nority clients to have providers from similar racial/ethnic backgrounds. Future research directions should focus on examining additional variables that can care provider, such as preference. Previous studies have found evidence suggesting that having a preference for a provider of the same race/ethnicity can have an impact on satisfaction with care received (LaVeist & Nu ru Jeter, 2002). The decision making proc ess involved with whether or not racial/ethnic concordance occurs is an area that needs to be explored. Clients in certain geographic areas may have limited access to health care facilities and subsequently may not have a choice about the race/ethnicity o f their providers. The availability of providers by geographic region should be considered. Future studies should also examine whether clients, particularly Hispanics/Latinos and Asian Americans, have a stronger preference for a provider of the same race /ethnicity or do they prefer providers that speak the same language. Including interactions between client level variables and racial/ethnic concordance in future analyses will provide useful information about subgroups. Lastly, additional research shoul d focus on the impact that racial/ethnic concordance can have on cultural competence. Several studies have

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38 suggested that racial/ethnic concordance is an important cultural competence technique, but few have explored the relationship between this concorda nce and the perceived cultural competence of health care providers.

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39 CHAPTER THREE: CLIENT PERCEPTIONS O F THE INTERPERSONAL SENSITIVITY OF THEIR HEALTH CARE PROVIDER S: THE POTENTIAL RO LE OF CLIENT PROVIDER RACIAL/ETHNIC CONCOR DANCE Introduction Over the past few decades increasing attention has been paid to racial/ethnic disparities in health and developing methods to eliminate both behavioral and physical health disparities has become a national priority ( U.S. Department of Health and Human Services [D HHS] 2000; 1991). One of the primary methods suggested to help eliminate health disparities is to enhance the cultural competence of health care providers (e.g. Carrillo Green, & Betancourt 1999; Like, Steiner & Rubel, 1996 ) Cultural competence is de fined as a set of provider related behaviors, attitudes, and policies that come together in system in order to work effectively in c ross cultural situations (e.g., Brach & Fraser, 2000; Cross Bazron, Dennis & Isaacs 1989 p. iv ). A number of studies have found that cultural competence is linked to positive outcomes such as increased client satisfaction (e.g., Fortier & Bishop, 2003), increased effectiveness of s ervices (e.g., Campinha Bacote, 1991), and the optimization of health care for clients ( e.g ., Be tancourt Green, Carrillo, & Ananeh Firempong ; Giger et al., 2007; DHHS Office of Minority Health [OMH] 2001). While most of the attention has been directed at enhancing and assessing the cultural competence of providers, several researchers have not ed the importance of measuring competence from the perspective of patients and clients (e.g., Andresen, 2001;

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40 Blanchard & Lurie, 2004; Geron 2002; Ngo Metzger et al., 2006). Such a perspective is aligned with the in which the quality of care is assessed through the eyes of the patient ( Institute of Medicine, 2001 ; McWhinney, 1989; Ngo Metzger et al., 2006). In this model, the underlying theme is that providers must understand care from the perspective of their clients in order to provide high quality health care services (Creel, Sass, & Yinger, 2002). Among the proposed benefits of client satisfaction, continuous use of services, and an improvement in he alth outcomes (Bertrand Hardee, Magnani, Angle 1995; Creel, et al., 2002; Kols & Sherman 1998; Vera 1993) The dimensions of cultural competence that have been suggested to represent the discrimination, respect and trust (Ngo Metzger et al., 2006). The first two dimensions are generally related to communication and have received a great deal of attention, especially with respect to the ability to communicate effectively with the client. Discrimination has generally been studied outside the area of cultural competence. The last two dimensions focus on feelings of being disrespected and having a lack of trust, which represent s interpersonal sensitivity. Interpersonal sensitivity has been recognized as an important aspect of cultural competence (e.g., Hollander, 1985; Riggo, 1996) and having a lack of it has been noted as one of main sources of health disparities (e.g., Starr, 2008). The critical role of interpersonal sensitivity in health care utilization and quality of care has been highlighted in several empirical articles and commentaries (e.g. Fox & Stein, 1991; Murray Garcia, Schmittdiel, Grumbach, Quesenbeny 2000; Ngo Metzger et al., 2006; Stewart et al., 1995; Wright, Holcombe, & S almon, 2004). For example,

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41 Blanchard and Lurie (2004) found that perceptions of disrespect are more common among racial/ethnic minority groups than Non Hispanic Whites, and that respondents who felt as if they were being disrespected by their providers we re also more likely to delay getting medical treatment and less likely to follow the advice of their provider. In a study by Boulware and colleagues (2003), African American/ Blacks were shown to have a lower level of trust wi th their physicians than their N on Hispanic White counterparts. Researchers have suggested that negatively appraised interpersonal sensitivity such as feelings of disrespect and lack of trust may lead to various negative consequences neffectiveness, limited engagement between clients and providers, and reduced quality of care ( e.g., Bell at al., 2002; Ngo Metzger et al., 2006) Despite its importance, there is a lack of empirical research on predictors of interpersonal sensitivity acr oss diverse racial/ethnic groups, which is the major focus of the present study. One potential predictor of perceived inter personal sensitivity is whether a client is in a match with a health care provider of the same race/ethnicity (Pope Davis et al., 2002). Previous research has found that racial/ethnic concordance is often associated with improvements in both subjective and self assessed measures of provider knowledge and patient satisfaction (DHHS, 2004). Racial/ethnic concordance has been noted to 1992). Staffs with minority employees have a strong tendency to organize the delivery of health care services in ways that are more congruent with the needs of minor ity populations (Brach & Fraser, 2000). Some studies have found that clients prefer to be matched with a provider of the same race /ethnicity over a provider that of a different

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42 racial /ethnic background (Pope Davis et al., 2002 ; Schnittker & Liang, 2006 ) a nd that racial/ethnic concordance significantly aids in the reduction of health disparities (Komaromy et al. 1996; Saha, Arbelaez, & Cooper, 2003). Previous research has shown that patients who were matched with a provider of the same race /ethnicity were more satisfied with the services they received and tended to rate their physicians as excellent (LaVeist, Nuru Jeter, & Jones, 2003 ; Saha et. al, 1999 ) While some research supports the need for cl ient provider racial /ethnic concordance other studies th at have found contradictory results Schnittker and Liang (2006) found that racial/ethnic concordance only matters to patients tha t had a preference to be in a match Little evidence was found by Howard and colleagues (2001) to support a relationship bet ween ethnic concordance and the effectiveness of care, use of se rvices, or patient satisfaction (Schnittker & Liang, 2006). These mixed results suggest that more research is needed to explore the effects of racial/ethnic concordance on client provider int eractions and its application in the health care system (Schnittker & Liang, 2006). Based on the above re view as well as the general paucity of studies related to the interpersonal sensitivity component of cultural competence, the goal of the present stu dy was (1) to explore the health care providers sensitivity and (2) to examine the effect of racial/ethnic concordance on the perceived interpersonal sensitivity of the providers among older adults from dive rse racial/ethnic backgrounds (N on Hispanic Whites, African Americans /Blacks Hispanics /Latinos and Asian Americans). We hypothesized that a greater level of interpersonal sensitivity would be reported when the client was in a match with a provider of the sa me race Analyses were conducted with a control for potential variables that might be linked to

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43 racial/ethnic concordance and interpersonal sensitivity such as the language of the interview and health related variables. Methods The data used in this study came f rom the Commonwealth Fund 2001 Health Care Quality Survey conducted by Princeton Survey Research Associates (PSRA) in 2001. The survey was a 25 minute telephone interview and the participant could choose to be interviewed in English, Spanish, Cantonese, Mandarin, Kor ean, or Vietnamese. The sample was drawn by using a standard list assisted random digit dialing (RDD) methodology. The sample obtained as a result of this was then divided into sub samples, based on the densities of African Americ ans, Hispanics, and Asian American households. The interviews were conducted from April 30 th through November 5, 2001. Up to 20 attempts were made to contact people to invite them to participate in the survey. There were a total of 6,722 respondents, r epresenting a 54.3 percent survey response rate. This survey was designed with the intent of being able to generalize to the U.S. adult population age 18 and older, and to allow separate analyses of responses by racial /ethnic group. A dditional informati on about the methodology employed to collect this data is available elsewhere (see Prince ton Survey Research Associates, 2002 ). Sample For the purpose of the present study, we selected only those individuals aged 50 and older that reported that they had u tilized health care services within the past two years. The final sample included 2 075 respondents representing the following four racial/ethnic groups: Non Hispanic W hite (n= 1 417 ), African American/Black (n= 330), Hispanic/Latino (n= 204), and Asian American (n=124 ).

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44 Measure s Outcome Variable Perceived Interpersonal Sensitivity After a thorough review, t he following three questions from the survey were selected to represent interpersonal sensitivity : How much confidence and trust did you ha ve in the doctor treated you? ( 1=none at all 2 =no t too much, 3=fair amount, 4=great deal ); Did the doctor treat you with respect and dignity ( 1=none at all, 2 =no t too much, 3=fair amount 4=great deal ); I feel that my doctor understa nds my background and values. ( 1 =strongly disagree, 2 =somewhat disagree, 3=somewhat agree 4=strongly agree ). Internal consistency for these three items was 0 .70 0 .6 2 0 .6 2 and 0 .56 respectively, for the Non Hispanic Whites, African Americans/Blacks, Hispanics/Latinos, and Asian A mericans. These alpha levels indicate minimal but acceptable reliability. An exploratory factor analysis conducted on the three items extracted a single solution for all racial/ethnic groups. These variables were then combined into a composite variable interpersonal sensitivity of their provider. Independent V ariables Client Provider Racial/Ethnic Concordance. If the race/ethnicity of the provider was the same as the race/ethnicity of the respondent then it was co ded in a binary format as a match (0=no, 1=yes). Socio Demographic Variables Th e following socio demographic variables were included in the analysis: age, gender, marital status, education, and income. The language of interview was used as a proxy for En glish language fluency (0=interview not conducted in English, 1=interview conducted in English).

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45 Health Related V ariables. The health related variables included in the analyses were health insurance status, self rated health, and the total number of healt h conditions. Respondents were asked if they had any form of health insurance or a health plan, including any private health insurance plan or a government program such as Medicare or Medicaid (0=no health insurance coverage, 1=have health insurance cover age). A five point Likert scale was provided for respondents to indicate their self rated health ( 1=poor, 2=only fair, 3=good, 4=very good, 5=excellent ). Respondents were asked to indicate if they had ever been told by their health care provider that th ey had any of the following conditions: high blood pressure, heart attac k or any other heart disease, cancer, diabetes or sugar diabetes, anxiety or depression, obesity, or asthma Each condition that a respondent indicated that they had was summated to r epresent the total number of health conditions. Analysis Bivariate correlations were used to examine the relationship s among study variables and to detect potential multicollinearity. A series of hierarchical linear regression s were conducted in order to determine significant predictors of interpersonal sensitivity The regressions were performed separately on each of the four racial/ethnic groups. The variables were entered into the model in an order that reflect s differences in the immediacy and stability of the variables with variables that are more stable in the earlier sets and the variables that can change over time in the subsequent steps : demographic variables (age, gender, marital status, education, and income), language of the intervi ew, health related variables (health insurance, self rated health, and health conditions), and client provider racial/ethnic concordance.

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46 Results Characteristics of the Sample Descriptive information on the total sample and four racial/ethnic groups is su mmarized in Table 4, as well as results from the comparative analysis between Non Hispanic Whites and each of the racial/ethnic groups. The ages for the total sample ranged from 50 to 99 More than half the total sample was female Over 80 percent of th e sample had received a high sch ool diploma or higher and 48.6.percent had incomes of $50,000 or less. Africans Americans/Blacks were the least likely to be married. Compared to the Non Hispanic Whites, African Americans/Blacks and Hispanics/Latinos were significantly younger, had lower levels of education, had lower incomes, had more health conditions, were less likely to rate their health as very good or higher, and were less likely to have health insurance. Hispanics/Latinos were significantly more li kely than the Non Hispanic Whites to be female. Asian Americans, compared to Non Hispanic Whites, were significantly less likely to be female, more likely to be married, more educated, more likely to have incomes higher than $50,000, and less likely to ha ve health conditions. All three groups were significantly less likely than their Non Hispanic White counterparts to be in a match with a provider of the same race/ethnicity. Hispanics/Latinos and Asian Americans were both less likely than Non Hispanic Wh ites to perceive their providers as having high levels of interpersonal sensitivity. African hand, was not significantly different from the Non Hispanic Whites.

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47 Tab le 4. Sample Characteristics and Group Comparisons a a 2 test) were conducted by comparing each racial/ethnic group with Non Hispanic Whites. Variable Mean/SD (%) Variable type Total sample (N=2075) Non Hispanic Whites (N=1417) African Americans/ Blacks (N=330) Hispanics/ Latinos (N=204) Asian Americans (N=124) Demographic variables Ag e 64.9/12.16 65.7/12.06 63.9/12.09* 61.8/10.58*** 63.9/14.68 Female (67.1) (66.6) (69.1) (74.0)* (56.5)* Married (51.7) (53.6) (34.2)*** (53.4) (73.4)*** Beyond high school (81.8) (87.3) (70.6)*** (56.8)*** (90.3)*** Income ( < 50K) (48.6) (45.7) ( 62.0)*** (54.3)*** (35.5)** Language of the interview (95.0) (99.9) (99.7) (62.3)*** (80.6)*** Health related variables Insured (93.1) (95.7) (86.4)*** (84.3)*** (95.2) Self rated health (Very good or higher) 3.26/1.14 3.36/1.13 2.97/1.08*** 2.89/1.19 *** 3.26/1.14 Health conditions 1.20/1.90 1.18/1.17 1.39/1.21** 1.25/1.24 0 .81/1.14** Major Independent variable Client provider r acial/ethnic concordance (54.9) (68.4) (23.0)*** (20.1)*** (43.5)*** Outcome Interpersonal sensitivity 11.09/1.35 11.14/1 .33 11.21/1.24 10.86/1.53** 10.59/1.38*** p <.05, ** p <.01, *** p <.001

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48 Bivariate Correlations Prior t o conducting the multivariate analyses, bivariate cor relations were assessed for each of the fo u r subgroups. Table 5 highlights the correlations between all of the predictive variables and interpersonal sensitivity for each of the four racial/ethnic group s. Table 5. The Correlation of Independent Variables with Perceived Interpersonal Sensitivity Variable Variable type Non Hispanic Whites African Americans /Blacks Hispanics/ Latinos Asian Americans Socio Demographic Age 0 .10*** 0 .02 0 .06 0 .10 Fe male 0 .03 0 .05 0 .05 0 .60 Marital status 0 .05 0 .03 0 .11 0 .22* Education 0 .02 0 .03 0 .02 0 .12 Income 0 .02 0 .05 0 .07 0 .09 Language of the interview 0 .02 0 .04 0 .05 0 .07 Health related Health insurance 0 .09** 0 .03 0 .02 0 .19* Self rated he alth 0 .03 0 .06 0 .20** 0 .10 Health conditions 0 .04 0 .09 0 .06 0 .05 Client provider r acial/ethnic concordance 0 0 .01 0 .19* 0 .07 p < .05, ** p < .01, *** p < .001 Age was associated with interpersonal sensitivity for Non Hispanic Whites. None of the variables included in the study were associated with interpersonal sensitivity for African Americans/Blacks. For Hispanics/Latinos, higher self rated hea lth and being in a client

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49 provider match were both associated with interpersonal sensitivity. Lastly, having health insurance was associated with interpersonal sensitivity for Asian Americans. The highest correlation coefficients between all the variable s included in the study was observed between education and income (r = 0 .55, p < .001) in the Asian American group, but these correlations were not at levels that raised concerns about multicollinearity (Tabachnick & Fidell, 2001). Results from the Hiera rchical Regression Models o f Perceived Interpersonal Sensitivity The results of the hierarchical regression analyses are presented in Table 6. Model 1 included variables related to the socio demographic characteristics of the client. For Non Hispanic Wh ites, advanced age was associated with a greater perceived interpersonal sensitivity. For Asian Americans, those who were less educated reported a greater level of perceived interpersonal sensitivity of their provider For African Americans/Blacks and H ispanics/Latinos, none of the socio demographic indicators were found to be significant. The second model included only one new variable, whether or not the language of the interview was conducted in English or not. The variable was not included in the m odels for Non Hispanic Whites and African Americans due to a lack of variance. Significance was only observed in Hispanics/Latinos: those who were interviewed in Spanish were more likely to report greater levels of perceived interpersonal sensitivity. F or the third model, the variables included were related to the health of the respondent. Self rated health was a significant predictor for Non Hispanic Whites and Hispanics/Latinos. The number of health conditions was significant only for Hispanics/Latino s, indicating that Hispanics/Latinos with more health problems felt that

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50 Table 6. Regression Models of Perceived Interpersonal Sensitivity a Step/ Variable Non Hispanics Whites African Americans/ Blacks Hispanics/ Latinos Asian Americans 2 2 2 2 1 Age Gender Marital status Education Income 0 .10** 0 .02 0 .06 0 .06 0 .03 0 .02* 0 .05 0 .03 0 .01 0 .03 0 .04 0 .01 0 .16 0 .12 0 .13 0 .22 0 .16 0 .06 0 .13 0 .23 0 .10 0 .28* 0 .16 0 .14 2 Language of the interview b 0 .22* 0 .0 4* 0 .13 0 .01 3 Health insurance Self rated health Health conditions 0 .03 0 .07 0 .05 0 .01 0 .02 0 .15 0 .10 0 .02 0 .08 0 .28** 0 .30** 0 .10** 0 .06 0 .11 0 .01 0 .01 4 Client provider r acial/ethnic concordance 0 .03 0 0 0 0 .19* 0 .03* 0 .04 0 Total R 2 0 .03 0 .03 0 .23* 0 .16 p < .05, ** p < .01, *** p < .001 a values represent the values when they were entered into the hierarchical regression model. b Language of the interview was not included in the hierarchical linear regression models for Non Hispanic Whites and African Americans/Blacks.

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51 their providers had higher levels of interpersonal sensitivity. Health insurance status was not significant for any of the four groups. The last variable entered examined the effect of being in a match with a provider of the same race/ethnicity. This variable was significant only for Hispan ics/Latinos, indicating that Hispanics/Latinos that were in a match with a health care provider of the same race/ethnicity felt their providers had more interpersonal sensitivity. In addition to these five steps, several interaction terms were created th at contrasted all of the predictive variables with whether or not a client had a provider of the same race/ethnicity. These interaction terms were entered one at a time into the models. No significant interactions were found and therefore are not reporte d. Discussion The focus of this study was on the perception that clients had of how much interpersonal sensitivity their health providers displayed. Interpersonal sensitivity has been cast as an important component of cultural competence, but to date has received relatively little empirical attention. This study examined interpersonal sensitivity of health care providers and its correlated factors among older Non Hispanic Whites, African Americans/Blacks, Hispanics/Latinos, and Asian Americans that parti cipated in the 2001 Health Care Quality Survey. Comparisons of characteristics of each of the groups revealed interesting but largely expected differences. Compared to the Non Hispanic Whites, the African Americans/Blacks and Hispanic/Latinos were more likely to have lower incomes, less likely to have health insurance, and less likely to be in a match with a provider of the same race/ethnicity. African Americans/Blacks and Hispanics/Latinos were significantly

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52 less educated than their Non Hispanic White counterparts. Asia n Americans had the highest percent age of people receiving an education of high school and beyond. Both Hispanics/Latinos and Asian Americans, when compared to Non Hispanic Whites, viewed their providers as having significantly lower l evels of interpersonal sensitivity. The hierarchical regression models for interpersonal sensitivity indicated that the factors that predict client opinions about their health care providers vary by race/ethnicity. These results are in accordance with past findings suggesting that differences in health care preferences and values may vary by race/ethnicity (e.g., Ngo Metzger et al., 2006; Sciegaj, Capitman, & Kyriacou, 2004; Weech Maldonado Dagga & Hays, 2004) Self rated health was a common predicto r for Non Hispanic Whites, African Americans/Blacks, and Hispanics/Latinos. None of the factors were significant across all four groups. And, despite the fact that previous studies have indicated that health insurance status has an impact on the quality of health care received (e.g. Institute of Med icine, 2002), insurance status was not a significant predictor in this study. This study also sought to examine the effect of racial/ethnic concordance on interpersonal sensitivity and whether or there were v ariations by race/ethnicity. The results indicate that being in a match with a provider of the same race/ethnicity is very important for Hispanics/Latinos, but not for the other three groups. As previous research has suggested, this finding could be base d on the ability of the provider to communicate effectively with their clients ( Schnittker & Liang, 2006) R acial/ethnic concordance did not explain significant portions of the variance for the African American/Black and Asian American samples. It is also plausible that some additional factors not included in this study, such as acculturation, may account for this difference.

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53 The results from this analysis also indicate that language proficiency is a concept independent from that of racial/ethnic concord ance. Language was analyzed separately from racial/ethnic concordance in the regression analysis and racial/ethnic concordance was still significant. The study had several limitations that must be addressed. First, a universal measure of cultural compete nce does not exist and therefore measures vary by research study. Secondly, there was no accurate way to assess English fluency in the study. The language of the interview served as a proxy because the there was very little variation with the English flu ency variable, indicating that most of the sample was fluent in English, despite significant proportion of the respondents being interviewed in other languages. Lastly, the questionnaire was administered over the telephone and this presents a potential re sponse bias since only people with home telephones were included. Overall, the findings from this study contribute to a growing body of literature about cultural competence. Cultural competence is an emerging concept and this study provides empirical in formation about the factors that affect how much interpersonal sensitivity a potentially important domain of cultural competence clients perceive their providers to have. It is also one of a very few studies that seeks to examine the effects of client provider racial/ethnic concordance on interpersonal sensitivity. The racial/ethnic differences presented by the regression models support the current understanding that health care beliefs and preferences varies by race/ethnicity. Finally, this study sh ows that cultural competence is a complex and multi domain concept. The affect of cultural competence on clients may vary by racial/ethnic group and should be understood in this complexity before it is implemented in the health care system.

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54 Future resea rch directions should focus on examining additional variables that can utilization patterns. Perceptions of interpersonal sensitivity could also vary by the type o f provider and future studies should account for this. In addition, studies should compare perceptions of interpersonal sensitivity among providers that have undergone some cultural competence training to those that have not. Lastly, future research dire ctions should examine the effects of interpersonal sensitivity on other health outcomes, such as satisfaction with care received.

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55 CHAPTER FOUR: OVERALL SATISFACTION WITH CARE RECEIVED: THE POTENTIAL ROLE OF CLIENT PROVIDER RACIAL/ETHNIC CONCOR DANCE AND I NTERPERSONAL SENSITI VITY Introduction Satisfaction with care has been cited as an important outcome for assessing the quality of care received (Donabedian, 2003; Marcinowicz, Chlabicz, & Grebowski, 2009). Patient satisfaction has been used by researchers to help identify and develop strategies to improve the delivery of care (Coulter, 2003; Donabedian, 2003; Marcinowicz et al., 2009). Satisfaction is also associated with critical patient behaviors, including health services utilization (e.g. LaViest & Nu ru Jeter, 2002; Roghmann, Hengst, & Zastowny, 1979; Zastowny, Roghmann, & Cafferata, 1989) and compliance with a medical regimen (e.g. LaViest & Nuru Jeter, 2002, Smith, Ley, Seale, & Shaw, 1987). Among the several factors that have been found to predict s atisfaction with care received is cultural competence. Satisfaction has been viewed as a particularly important means to understanding the effectiveness of cultural competence in health care (Fortier & Bishop, 2003). Cultural competence has received cons iderable attention in its own right, since it has been suggested as a primary method to eliminate health disparities (e.g. Carrillo, Green, Betancourt, & 1999; Like, Steiner & Rubel, 1996 ). Efforts to promote cultural competence as a means of improving pa tient outcomes, including satisfaction, have become relatively common (e.g. Ahmed, Bates, & Romina, 2008; Betancourt, 2004;

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56 Goode, Dunne, & Bronheim, 2006; Nishimi, 2006; Wu & Martinez, 2006 ). Previous studies have noted that cultural competence is linked to positive outcomes such as increased client satisfaction (e.g., Fortier & Bishop, 2003), increased effectiveness of s ervices (e.g., Campinha Bacote, 1991), and optimized health care for clients ( e.g. Be tancourt, Green, Carrillo, & Ananeh Firempoing, 200 3 ; Giger et al., 2007; U.S. D epartment of H ealth and H uman S ervices [DHHS] Office of Minority Health [OMH], 2001 ). A few studies report empirical evidence that cultural competence is linked to increased client satisfaction (e.g., Fortier & Bishop, 2003; Ngo Metzger et al., 2006), but there remains a need for more research to support this claim (e.g., Anderson Scrimshaw, Fullilove Fie lding, & Normand 2003 ; Fortier & Bishop, 2003). In a review by Anderson and colleagues, for example, five cultural compe tence intervention s tudies were assessed in order to determine how e ffective they were in improving client satisfaction with care received The interventions reviewed included recruit ing and retain ing diverse staff members, interpreter services or bilingu al providers, cultural competency training for providers, use of culturally and linguistically appropriate education materials, and culturally specific healthcare settings The results indicated that these interventions did not have a significant effect o n satisfaction. Anderson and colleagues (2003) concluded that there are only a few studies that carefully examine the effect of cultural competence on satisfaction with care received. Future studies should focus on understanding the relationship between cultural competence, patient provider interactions, and satisfaction (Perloff et al., 2006).

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57 Part of the problem with studying the role of cultural competence in satisfaction is the lack of a universally agreed upon operational definition of cultural competence. Racial/ethnic concordance between the client and provider has been conceptualized as an indicator of cultural competence in health care (e.g. Pope Davis et al., 2002). Previous research has found evidence that racial/ethnic concordance is as sociated with a greater awareness of the culture and beliefs of the patient, resulting in improvements in the of provider knowledge and patient satisfaction (DHHS, 2002). Several studies have found that racial/ethnic concordance has an impact on satisfaction with care (e.g. Cooper & Powe, 2004; LaVeist & Nuru Jeter, 2002). Cl ients that have received care from a provider of the same race/ethnicity generally indicated that they were more satisfied with the services they received (LaVeist Nuru Jeter, & Jones, 2003 ; Saha, Komaromy, Koespell, & Bindman, 1999 ) Despite these positive associations with satisfaction, there is still some debate about the effectiveness of racial/ethnic concordance on satisfaction with care. Howard and colleag ues (2001) for example, report little evidence to support a relationship between racial/ethnic concordance and satisfaction. The mixed message regarding the role of racial/ethnic concordance may stem from the lack of in depth studies. Most of the resear ch has focused on the role of specific correlations rather than multivariate and interactive factors. In addition to racial/ethnic concordance, other studies have used definitions that focus on trying to identify the components of cultural competence. Af ter conducting a thorough search of the literature, Ngo Metzger and colleagues (2006) identified five domains that have been used

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58 perspective : communication, linguistic competence, discrimination, respect an d trust. The latter of these dimensions focus on feelings of being disrespected and having a lack sensitivity, which has been shown to constitute an important aspect of cultural competence (e.g., Hollander, 1985; Riggo, 1996). Researchers have suggested that negatively appraised interpersonal sensitivity, including feelings of disrespect and lack of mpliance, provider ineffectiveness, limited engagement between clients and providers, and reduced quality of care ( e.g., Bell et al., 2002; Ngo Metzger et al., 2006) Despite the reported importance of this construct in cultural competence, there is a lac k of empirical research on the impact of interpersonal sensitivity on overall satisfaction with care received. Another unexplored area of cultural competence and patient satisfaction lies in the level of analyse s. Racial/ethnic concordance and interper sonal sensitivity may be associated with satisfaction, but little attention has been given to more complex relationships. Interactions between demographic variables, client provider racial/ethnic concordance, and interpersonal sensitivity on satisfaction with care received are currently unexplored. There is some eviden ce, however, that suggests a cl care can be influenced by socio demographic variables, racial/ethnic concordance and interpersonal sensitivity. Previous research has found that socio demographic variables such as education and income can affect of the quality of their medical encounters (e.g. Npoles Springer, Santoyo, Houston, Prez Stable, & Stewart, 2005). Lower income and minority population s are more likely to feel as if their providers had a lack of respect for their health care prefere nces (Ngo Metzger et al.

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59 2006). Collins and colleagues (2002) found that populations with lower education and lower incomes experienced more difficulties in teracting with their health care providers. By examining the interactions between education and income, racial/ethnic concordance, and interpersonal sensitivity, more information can be obtained about subgroups of Non Hispanic Whites, African Americans/Bl acks, Hispanics/Latinos, and Asian Americans and their opinions about the health care they received. Based on the literature reviewed above, the goal of the present study was to examine the effect of cultural competence, measured by racial/ethnic concor dance and interpersonal sensitivity of providers, on overall satisfaction with care received among older adults from diverse racial/ethnic backgrounds (Non Hispanic Whites, African Americans/Blacks, Hispanics/Latinos, and Asian Americans). The direct and interactive roles of the predictive variables were examined in order to explore between group differences and within group variability. We hypothesized that the presence of cultural competence, being in a match with a provider of the same race/ethnicity a nd perceiving a provider to have a greater level of interpersonal sensitivity, would be associated with higher levels of satisfaction with care. Analyses were conducted with a control for potential variables that might be linked to satisfaction, such as t he language of the interview and health related variables. Methods The data used in this study came f rom the Commonwealth Fund 2001 Health Care Quality Survey conducted by Princeton Survey Research Associates (PSRA) in 2001. The survey was a 25 minut e telephone interview and the participant could choose to be interviewed in English, Spanish, Cantonese, Mandarin, Kor ean, or Vietnamese. The

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6 0 sample was drawn by using a standard list assisted random digit dialing (RDD) methodology. The sample obtained a s a result of this was then divided into sub samples, based on the densities of African Americans, Hispanics, and African American households. The telephone interviews were conducted from April 30 th through November 5, 2001. Up to 20 callbacks per perso n were made, in order to increase the acceptance rate. A total of 6,722 respondents were ultimately recruited into the study, representing a 54.3 percent survey response rate. This survey was designed with the intent of being able to generalize to the U. S. adult population age 18 and older, and to allow separate analyses of responses by racial /ethnic group. A dditional information about the methodology employed to collect this data is available elsewhere (see Princeton Su rvey Research Associates, 2002 ). Sample For the purpose of the present study, we selected only those individuals aged 50 and older that reported that they had utilized health care services within the past two years. The final sample included 2 075 respondents representing the following four racial/ethnic groups: Non Hispanic W hite (n= 1 417 ), African American/Black (n= 330), Hispanic/Latino (n= 204), and Asian American (n=124 ). Measures Outcome Variable Satisfaction with Care Received The survey included a single question concerning satisfaction. Respondents were asked how satisfied or dissatisfied they were

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61 with quality of health care they had received during the last two years (1=very dissatisfied, 2=somewhat dissatisfied, 3=somewhat satisfied, 4=very satisfied). Cultural Competen ce Variables Client Provider Racial/Ethnic Concordance. A match was coded (0=no, 1=yes) if the race/ethnicity of the provider was the same as the race/ethnicity of the respondent. Perceived Interperso nal S ensitivity. After a thorough review, t he followin g three questions from the survey were selected to represent interpersonal sensitivity : How much confidence and trust did you ha ve in the doctor treated you? (1=none at all, 2 =no t too much, 3=fair amount, 4=great deal); Did the doctor treat you with respec t and dignity (1=none at all, 2 =no t too much, 3=fair amount 4=great deal); I feel that my doctor understa nds my background and values. (1 =strongly disagree, 2 =somewhat disagree, 3=somewhat agree, 4=strongly agree ). Internal consistency for these three ite ms was 0 .70 0 .6 2 0 .6 2 and 0 .56 respectively, for the Non Hispanic Whites, African Americans/Blacks, Hispanics/Latinos, and Asian Americans. These alpha levels indicate minimal but acceptable reliability. An exploratory factor analysis conducted on th e three items extracted a single solution for all racial/ethnic groups. These variables were then interpersonal sensitivity of their provider. Control Variables Socio Demographic Variables Th e following socio demographic variables were included in the analysis: age, gender, marital status, education, and income. The language of interview was used as a proxy for English language fluency (0=interview not conducted in English, 1=int erview conducted in English).

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62 Health Related V ariables. The health related variables included in the analyses were health insurance status, self rated health, and the total number of health conditions. Respondents were asked if they had any form of healt h insurance or a health plan, including any private health insurance plan or a government program such as Medicare or Medicaid (0=no health insurance coverage, 1=have health insurance coverage). A five point Likert scale was provided for respondents to in dicate their self rated health ( 1=poor, 2=only fair, 3=good, 4=very good, 5=excellent ). Respondents were asked to indicate if they had ever been told by their health care provider that they had any of the following conditions: high blood pressure, heart attac k or any other heart disease, cancer, diabetes or sugar diabetes, anxiety or depression, obesity, or asthma Each condition that a respondent indicated that they had was summated to represent the total number of health conditions. Analysis B ivariate correlations were used to examine the relationship s among study variables and satisfaction. These correlations were also used to detect potential multicollinearity. A series of hierarchical linear regression s were conducted in order to determine significant predictors of satisfaction with care received The regressions were performed separately on each of the four racial/ethnic groups. The variables were entered into the model in an order that reflect s differences in the immediacy and stability of the variables with variables that are more stable or antecedent in the earlier sets and the variables that can change over time in the subsequent steps : demographic variables (age, gender, marital status, education, and income), language of the interv iew, health related

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63 variables (health insurance, self rated health, and number of health conditions), client provider ethnic concordance, and interpersonal sensitivity. Results Characteristics of the Sample Descriptive information on the total sample and four racial/ethnic groups is summarized in Table 7 The results highlight the differences as well as the similarities across the four groups. The ages for the total sample ranged from 50 to 99 Over half the total sample was female, ove r 80 percent of t he sample had received a high sch ool diploma or higher and 48.6 percent had incomes of $50,000 or less. Analyses were also conducted to identify areas in which the racial/ethnic groups being studied appeared to be more or less disadvantaged when compared with Non Hispanic Whites. In these analyses, the African Americans/Blacks and Hispanics/Latinos appear to be less advantaged than the Non Hispanic Whites. Compared to the Non Hispanic Whites, African Americans/Blacks and Hispanics/Latinos were significa ntly younger, had lower levels of education, lower incomes, more health conditions, had lower self rated health, and were less likely to have health insurance. African Americans/Blacks were the least likely to be married. Hispanics/Latinos were signifi cantly more likely than Non Hispanic Whites to be female. Asian Americans were significantly less likely to be female, more likely to be married, more educated, more likely to have incomes higher than $50,000, and less likely to have health conditions whe n compared to Non Hispanic Whites. As expected, all three racial/ethnic minority groups were significantly less likely than their Non Hispanic White counterparts to be in a match with a provider of the same

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64 Table 7 Sample Characteristics and Group C ompa risons a Variable Mean/SD (%) Variable type Total sample (N=2075) Non Hispanic Whites (N=1417) African Americans/ Blacks (N=330) Hispanics/ Latinos (N=204) Asian Americans (N=124) Demographic variables Age 64.9/12.16 65.7/12.06 63.9/12.09* 61.8/10.58 *** 63.9/14.68 Female (67.1) (66.6) (69.1) (74.0)* (56.5)* Married (52.0) (53.8) (34.5)*** (54.2) (73.4)*** High school and beyond (82.4) (87.8) (71.0)*** (57.4)*** (91.8)*** Income ( < 50K) (65.1) (61.4) (83.3)*** (74.5)*** (45.4)** Language of th e interview (English) (95.0) (99.9) (99.7) (62.3)*** (80.6)*** Health related variables Insured (93.2) (95.9) (86.4)*** (84.3)*** (95.2) Self rated health 3.26/1.14 3.36/1.13 2.97/1.08*** 2.89/1.19*** 3.41/1.09 Health conditions 1.20/1.90 1.18/1.17 1. 39/1.21** 1.25/1.24 0 .81/1.14** Major independent variables Client provider r acial/ethnic concordance (54.9) (68.4) (23.0)*** (20.1)*** (43.5)*** Perceived i nterpersonal sensitivity 11.09/1.35 11.14/1.33 11.21/1.24 10.86/1.53* 10.59/1.38*** Outcome Sat isfaction with care received 3.61/ 0 .66 3.63/ 0 .64 3.58/ 0 .71 3.58/ 0 .72 3.46/ 0 .62** p < .05, ** p < .01, *** p < .001 a 2 test) were conducted by comparing each racial/ethnic group with Non Hispanic Whites.

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65 race/ethnicity. Hispanics/Latinos and Asian Americans were both less likely than Non Hispanic Whites to perceive their providers as having high levels of interpersonal sensitivity, on the other hand, was not significantly different from Non Hispanic Whites. Lastly, Asian Americans had significantly lower levels of satisfaction with the care they received when compared to Non Hispanic Whites. African Americans/Blacks and Hispanics/Latinos had satisfaction levels similar to Non Hispanic Whites. Bivariate Correlations Prior to conducting the multivariate analyses, bivariate cor relations were assessed for each of the four subgroups. Table 8 highlights the correlations between all of the predictive variables and satisfaction for each of the four racial/ethnic groups. For Non Hispanic Whites, higher income, having health insurance, higher self rated health, and higher perceived interpersonal sensitivity were associated with satisfaction. Higher income and hi gher perceived interpersonal sensitivity were associated with satisfaction for African Americans/Blacks. Not being married, higher self rated health, and higher perceived interpersonal sensitivity were associated with satisfaction for Hispanics/Latinos. Lastly, not being married and higher interpersonal sensitivity were associated with satisfaction for Asian Americans. The highest correlation coefficient s between all the variables included in the study was observed between education and income (r = 0 .55, p < .001) and interpersonal sensitivity and satisfaction (r = 0 .55, p < .001) in the Asian American group, but these correlations were not at levels that raised concern s about multicollineari ty (Tabachnick & Fidell, 2001).

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66 Table 8 Correlation C oeffici en ts of Independent V ariables with S atisfaction with Care R eceived Variable Non Hispanic Whites African Americans/ Blacks Hispanics/ Latinos Asian Americans Age 0 .04 0 .02 0 .11 0 .03 Female 0 .00 0 .02 0 .04 0 .04 Marital status 0 .04 0 .03 0 .17* 0 26** Education 0 .03 0 .05 0 .14 0 .09 Income 0 .07* 0 .13* 0 .06 0 .05 Language of the interview 0 .02 0 .03 .0 0 .17 Health insurance 0 .08** 0 .03 0 .08 0 .05 Self rated health 0 .12*** 0 .08 0 .16* 0 .15 Health conditions 0 .04 0 .04 0 .13 0 .03 Client pr ovider r acial/ethnic concordance 0 .03 0 .01 0 .07 0 .14 Interpersonal sensitivity 0 .50*** 0 .43*** 0 .53*** 0 .55*** p < .05, ** p < .01, *** p < .001 Interpersonal sensitivity was a significant predictor of satisfaction for all four of the racial/ethnic g roups. This correlation was highest for the Asian American group (r =.55, p<.001). The variance inflation factor (VIF) was tested to check for potential multicollinearity between interpersonal sensitivity and satisfaction due to the strong correlations between the two variables. For Non Hispanic Whites (1.02), African Americans/Blacks (1.03), Hispanics/Latinos (1.31), and Asian Americans (1.20), the VIF values were less than 10 indicating that there is no concern for multicollinearity between interperso nal sensitivity and satisfaction (Hair, Black, Babin, Anderson, & Tatham,

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67 2007). This also supports the fact that interpersonal sensitivity, as a measure of cultural competence, is a separate construct from satisfaction. Results from the Hierarc hical R egression Models of Satisfaction with Care The results of the hierarchical regression analyses are presented in Table 9. Model 1 included variables related to the socio demographic characteristics of the client. The four groups differed in terms o f the significant correlates. For Non Hispanic Whites, advanced age was associated with satisfaction. For African Americans/Blacks, lower education and higher income were significant predictors of satisfaction with care. Not being married and lower educ ation were significant predictors for Hispanics/Latinos. For Asian Americans, not being married was a significant predictor of satisfaction. The second model included only one new variable, whether or not the language of the interview was conducted in English. The variable was not included in the models for Non Hispanic Whites and African Americans due to a lack of variance. Nearly all of the respondents in those two groups were interviewed in English. This variable was not significant for Hispanics/ Latinos or Asian Americans. The third model introduced variables related to the health of the respondent. Health insurance status was not a significant predictor for any of the four groups. Higher self rated health was a significant predictor of satisf action with care received for Non Hispanic Whites and Hispanics/Latinos. The number of health conditions was significant only for Hispanics/Latinos, indicating that Hispanics/Latinos with more health problems were satisfied with the care they received.

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68 Table 9. Hierarchical Regression Models of Satisfaction with Care Received a Step/ Variable Non Hispanics Whites African Americans/Blacks Hispanics/Latinos Asian Americans R 2 R 2 R 2 R 2 1 Age Gender Marital status Education Income .09* .01 .03 .01 .03 .01 .03 .06 .02 .20* .26** .05 .09 .07 .19 .33** .06 .10 .12 .10 .26* .16 .19 .13 2 Language of the interview b .10 .01 .03 .00 3 Health insurance Self rated health Health conditions .05 .17*** .01 .03*** .00 .02 .0 4 .00 .01 .31** .33** .12** .04 .29 .089 .05 4 Client provider r acial/ethnic concordance .01 .00 .01 .00 .04 .00 .02 .00 5 Interpersonal sensitivity .47*** .21*** .50*** .25*** .42*** .14*** .58*** .28*** 6a Education Interpersonal sensitivity 14*** .02*** .20* .03* 6b Education Racial/ethnic concordance .40** .01** 6c Income Interpersonal sensitivity .07* .01* .14* .02* .26** .06** p < .05, ** p < .01, *** p < .001 a values represent the values when they were entered into the hierarchical regression model. b Language of the interview was not included in the hierarchical linear regression models for Non Hispanic Whites and African Americans/Blacks.

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69 The variable added in the fourth model examined the effect of being in a match with a provider of the same race/ethnicity. It was included as one of the two components of cultural competence. T his variable was not a significant predictor of satisfaction for any of the four racial/ethnic groups. The last model included the perceived interpersonal sensitivity of the provider. This variable, the second component of cultural competence, was signi ficantly associated with satisfaction with the care that they received is predicted by higher perceived interpersonal sensitivity of their health care providers. In addition to these five steps, several interaction terms were created that contrasted two socio demographic variables, education and income, with whether or not a client was in a match with a provider of the same race/ethnicity and with the interpersonal sensitivity measure. These interaction terms were entered one at a time into the analyses as a separate last model. Only the statistically significant interactions are presented in Table 9. Each of these significant terms contributed from 1 percent to 2 percent of the variance. Significance was found in education interpersonal sensitivity and income interpersonal sensitivity in the Non Hispanic White sample; income interpersonal sensitivity in the African American/Black sample; education interp ersonal sensitivity and income interpersonal sensitivity in the Hispanic/Latino sample; and education racial/ethnic concordance in the Asian American sample. Interpretation of Interactions within Each Racial/Ethnic Group Further analyses were conduct ed for each of the significant interaction terms. Each racial/ethnic group was stratified into subgroups based on the interaction factors.

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70 Next, the correlations between the predictive variables and satisfaction were compared. Table 10 summarizes the su bgroup analyses. In selecting an approach to categorizing subjects, only the extreme categories were included. For education, subjects that had not received a high school diploma were considered to be the low education group. The high education group was defined as having a college degree or higher. The lower income group was defined as having an income of $19,999 or less and the higher income group had an income of $40,000 or greater. For the Non Hispanic White sample, the correlation between interpers onal sensitivity and satisfaction was significantly stronger in the higher educated group compared to the lower educated group. The correlation between interpersonal sensitivity and satisfaction was also stronger in the higher income group compared to the lower income group. In contrast, the correlation between interpersonal sensitivity and satisfaction in the African American/Black sample was stronger among the lower income group. For the Hispanic/Latino sample, the correlations for interpersonal sensit ivity and satisfaction were stronger among the higher educated and the higher income groups, compared to the lower educated and lower income groups. Lastly, the correlations between racial/ethnic concordance and satisfaction were not significant for eithe r of the education groups in the Asian American sample. Discussion The main focus of this study was on the influence of cultural competence on satisfaction with care. Cultural competence has been noted to have an impact on satisfaction with care, but th ere has been a lack of empirical research on this topic. The

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71 Table 10. Correlation Coefficients with Satisfaction with Care Received in Subgroups of Moderating Factors Race/ Ethnicity Variable Correlation coefficients with satisfaction Lower a education group Higher education group Z obs Lower b income group Higher income group Z obs Non Hispanic Whites Interpersonal sensitivity .295*** (N=159) .552*** (N=421) 3.38** .507*** (N=215) .525*** (N=493) .290 African Americans/ Blacks Interpersonal sensitivity .481*** (N=84) .329* (N=55) 1.03 Hispanics/ Latinos Interpersonal sensitivity .558*** (N=79) .775*** (N=32) 1.85 .393** (N=51) .655*** (N=45) 1.75 Asian Americans Client provider r acial/ethnic concordance .258 (N=7) .210 (N=70) p < .05, ** p < .01, *** p < .001 a Lower education was defined as not having completed high school or lower. Higher education was defined as having received a college degree o r better. b Lower income was defined as having an income of $19,999 or less. Higher income was defined as having an income of $40, 000 or greater.

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72 sample consisted of older Non Hispanic Whites, African Americans/Blacks, Hispanics/Latinos, and Asian Americans who reporte d having received health care over the past two years. Racial/ethnic concordance and interpersonal sensitivity were used to measure cultural competence. Several socio demographic and health related variables were also included as potential predictors of satisfaction with care. The comparison of the sample characteristics of each of the four groups helped explicate the linkages between race/ethnici ty, cultural competence, and cl ient satisfaction. In general, the differences indicated the existence of soc ial disadvantages for minorities, especially for the African American/Black and Hispanic/Latino groups. When compared to Non Hispanic Whites, the African Americans/Blacks and Hispanic/Latinos were more likely to have lower incomes and less likely to have health insurance. African Americans/Blacks and Hispanics/Latinos were significantly less educated than their Non Hispanic White counterparts. On the other hand, compared to all the groups, Asian Americans had the highest percent age of people in the sampl e receiving an education at the high school level and beyond. With respect to indicators of the cultural competence of their providers, African American/Blacks, Hispanics/Latinos, and Asian Americans were less likely to be in a match with a provider of t he same race/ethnicity compared to Non Hispanic Whites. This is largely due to the presence and availability of more Non Hispanic White providers in the United States. Hispanics/Latinos and Asian Americans, when compared to Non Hispanic Whites, viewed th eir providers as having significantly lower levels of interpersonal sensitivity. This finding is consistent with previous studies that have examined perceptions of providers by race/ethnicity (e.g. Johnson, Saha, Arbelaez,

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73 Beach, & Cooper, 2004 ). African Americans/Blacks, on the other hand, did not differ significantly from Non interpersonal sensitivity. It is plausible that the African Americans/Blacks and the Non Hispanic Whites in this study are more likely to share a similar set of expectations and opinions about the care they expect to receive from their providers. A previous study by Collins, Tenney and Hughes (2002) using data from the 2001 Health Care Quality Survey found that African Americ ans/Blacks were similar to Non Hispanic Whites in agreeing that their providers understood their background and values. For the outcome variable, satisfaction with care, the results were mixed. Asian Americans were significantly less satisfied with the overall care they received, when compared to Non Hispanic Whites. This finding is consistent with one previous study (Ngo Metzger, Legedza, & Phillips, 2004), but the researchers in that study, as well as the present one, were not able to discern the sour ce of this difference. Additional variables not included in the database, such as the acculturation level of these clients, may help in explaining this finding. In contrast, there were no significant differences in satisfaction when African Americans/Bla cks and Hispanics/Latinos were compared to Non Hispanic Whites. The differences by race/ethnicity set the stage for the multivariate analyses, and indicated that these groups all had distinct characteristics that could be expected to be associated with d ifferences in health care and satisfaction with care. The hierarchical regression models for satisfaction with care received indicated that there are some similarities across the four racial/ethnic groups on the socio demographic and health related variab les that predicted satisfaction. Better s elf rated health was a common

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74 predictor of higher satisfaction for Non Hispanic Whites and Hispanics/Latinos. Previous research has shown the connection between having better self rated health and higher satisfact ion with care (Mayo Clinic, 2009), although the causal links remain to be explored. Lower education was a significant predictor of satisfaction for African Americans/Blacks and Hispanics/Latinos Although the connection between lower education and satisf action is not unique to this study (e.g. Hall & Dornan, 1990), it does bring to question how differences in educational attainment can affect perceptions of care received. In addition to these predictors, there were some predictors that differed for ea ch racial/ethnic group. Age was a significant predictor for Non Hispanic Whites, with older people in this group tending to be more s atisfied with the care they received Higher income was a significant predictor of higher satisfaction for African Americ ans/Blacks. Having more health conditions was a significant predictor for Hispanics/Latinos. People with more health conditions were more likely to seek care and in consequence had more interactions with their health care providers (e.g. Nichols et al., 2007). For Asian Americans, not being married was a significant predictor of greater satisfaction with care. Despite the fact that previous studies have indicated that health insurance status has an impact on the perceived quality of health care received (e.g. Institute of Medicine, 2002), the presence of insurance was not a significant predictor for any of the four groups in this study. The results of this study suggest that, overall, racial/ethnic concordance between clients and their providers does n ot impact satisfaction with care received. This lack of an association contrasts with several previous studies (e.g., LaVeist & Nuru Jeter, 2002)

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75 that have found a connection between racial/ethnic concordance and satisfaction, but it does support the idea that it is not the client provider match alone that leads to higher satisfaction with care ( e.g. Schnittker & Liang, 2006) Studies have noted, for example, that having a preference for racial/ethnic concordance has an impact on satisfaction (e.g. LaVeis t & Nuru Jeter, 2002). Interpersonal sensitivity, however, was significant across all four groups, with d is directly predicted by the perception of their providers accordance with previous findings that cultural competence has an impact on overall satisfaction with care (e.g., Ngo Metzger et al., 2006 ) Of particular interest is that this finding also suggests that in terpersonal sensitivity is important to everyone, not just racial/ethnic minorities. Feeling that you can trust your provider and that they respect your beliefs and values are the two components of interpersonal sensitivity that were assessed. These two components appear to be important to people of all races and ethnicities. Providers that exhibit these traits embody the true essence of cultural competence. In addition to the direct effect model, interactive effects among socio demographic variables ( education and income) racial/ethnic concordance and interpersonal sensitivity were examined. Non Hispanic Whites with more education were found to have stronger associations between interpersonal sensitivity and satisfaction when compared to lower educat ed Non Hispanic Whites. In addition, Non Hispanic Whites with higher incomes had stronger associations between interpersonal sensitivity and satisfaction than their lower income counterparts. Both of these findings

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76 are consistent with previous studies th at have examined differences in satisfaction by race and found that Non Hispanic Whites and people with higher socio economic statuses are more satisfied with the care they receive (e.g. Myburgh, Solanki, Smith, & Lalloo 2005). In direct contrast to the results for Non Hispanic Whites, the association between interpersonal sensitivity and satisfaction was higher among lower income African Americans/Blacks. One of the potential reasons for this difference between Non Hispanic Whites and African Americans/ Blacks may lie in the different preferences that clients have and how a client expects to be treated by their health care provider (e.g. Myburgh et al., 2005). Higher income African Americans/Blacks may have higher standards of care and may expect more fr om their health care providers when compared to lower income African Americans/Blacks. There was a stronger association between greater interpersonal sensitivity and greater satisfaction among higher educated Hispanics/Latinos compared to the lower educate d group. In addition, Hispanics/Latinos with higher incomes had stronger associations with interpersonal sensitivity and satisfaction, compared to lower income Hispanics/Latinos. Similar Non Hispanic Whites, these findings are consistent with previous st udies. Higher educated Hispanics/Latinos give better evaluations of the quality of their medical care compared to those with lower education (e.g. Livingston, Minushkin, & Cohn, 2008). Hispanics/Latinos with higher incomes are more likely than lower and medium income patients to rate their medical care as excellent (e.g. Borders, Xu, Rohrer, & Warner, 2002). There are several limitations in this study that must be addressed. While satisfaction is a widely employed measure that is often used to gain an understanding of

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77 the quality of health care, it remains a subjective measure that could be affected by a host of factors not captured in this study. In addition, satisfaction with care was only represented by a single item in the survey Another limi tation of the study is that there was no way to accurately assess English fluency in the study. The language of the interview served as a proxy because there was very little variation with the English fluency variable. Most of the participants were repor ted as being fluent in English, despite a significant proportion of the respondents who were interviewed in other languages. Lastly, there were only four possible racial/ethnic categories that a respondent and the provider could be classified into, thereb y limiting information available about subgroups. The findings from this study contribute to a growing body of literature about how cultural competence can impact satisfaction with care. Research has begun to find evidence to support incorporating cultu ral competence into the health care system and this study provides some empirical information about the factors that affect overall satisfaction with care. In addition, this is one of a very few studies that examines the effects of client provider racial/ ethnic concordance on overall satisfaction with care. Although this study found that race/ethnic concordance did not have an impact on satisfaction, information was obtained about how racial/ethnic concordance interacts with other variables. The racial/e thnic differences presented by the regression models support the current understanding that different racial/ethnic group have different opinions about their health care beliefs and preferences. Finally, this study shows that components of cultural compet ence are associated with overall satisfaction with care received and this

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78 should be considered when developing and implementing cultural competence techniques.

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79 CHAPTER FIVE: DISCUSSION Summary of the Study Cultural competence among health care profess ionals has emerged as a key method to improving access to and utilization of health care services by racial and ethnic a set of congruent behaviors, attitudes, and policies that come together in a s ystem, agency, or amongst professionals to work effectively in cross cultural situations & Isaacs 1989, p. iv). Culture embodies integrated patterns of human behavior including language, thoughts, communications, actions, custom s, beliefs, values ( DHHS OMH, 2005 ) Competence involves being able to function effectively within the context of the cultural beliefs, behaviors, and needs (DHHS OMH, 2005 ) A key aspect of cultural competence is that the health care provider be convers ant with how culture and beliefs can affect how the client presents symptoms and responds to treatment. Currently, the major caveats associated with the field of cultural competence are the lack of research in general and an even greater lack of research that examines cultural competence from the perspective of the client The client perspective is important because it provides opinions and feedback about health care from the direct care recipients. Research is sorely needed in order to guide the effort s to increase the cultural competence of health care providers. In line with this need, there were three overall goals of this dissertation: (1) determine client level factors (socio demographic, language of the interview, and health related variables) th at predict when client provider

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80 racial/ethnic concordance occurs, (2) explore which factors predict the perceived interpersonal sensitivity of health care providers, (3) determine which factors serve as predictors of overall satisfaction with care received The data u sed in this study came from the Commonwealth Fund 2001 Health Care Quality Survey conducted by Princeton Survey Research Associates (PSRA) in 2001. The sample used in pursuit of all three goals, presented in the three sub studies, was comprise d of Non Hispanic Whites, African Americans/Blacks, Hispanics/Latinos, and Asian Americans ages 50 and older. This age range was selected in order to capture the full range of responses present in older populations. Overview of Findings The focus of the t hree sub studies was on factors that affected racial/ethnic concordance, interpersonal sensitivity, and satisfaction with care. The first of these studies focused on the socio demographic and health related factors that predict whether or not clients were in a match with a provider of the same race/ethnicity. The focus of the second study was on the factors that predict how much interpersonal sensitivity clients perceive their providers to have. Interpersonal sensitivity was selected since it has emerged as a key component of cultural competence. In addition to socio demographic and health related variables, client provider racial/ethnic concordance also examined as a predictor. The third and final sub study focused on the factors that predict overall s atisfaction with care received. All of the outcome variables from the previous papers were entered as potential factors that impact satisfaction, in addition to the socio demographic and health related variables.

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81 The results have implications for how we should develop efforts to promote cultural competence among health care providers and the health care system in general. The first study found that the factors that predict racial/ethnic concordance varied across the four racial/ethnic groups. The ma jority of Non His panic Whites, and well over 40 percent of Asian Americans in the study had providers of the same race/ethnicity. Hispanics/Latinos were the least likely to be in match and less than a fourth of African Americans/Blacks were in matches. T he following variables increased the likelihood that racial/ethnic concordance would occur: being female and having health insurance for Non Hispanic Whites; higher education for African Americans/Blacks; and being married for Asian Americans. There were no factors that increased the likelihood of client provider racial/ethnic concordance among Hispanics/Latinos The study in Chapter 3 focused on client perceptions of the interpersonal sensitivity of their providers. Compared to Non Hispanic Whites, Hisp anics/Latinos and sensitivity, on the other hand, were similar to that of the N on Hispanic Whites. Self rated health was a significant predictor for Non Hispanic Whites, African Americans/Blacks, and Hispanics/Latinos; having better self rated health was associated with higher perceived interpersonal sensitivity of health care provi ders. Racial/ethnic concordance was found to be a significant predictor of higher interpersonal sensitivity only for Hispanics/Latinos. In addition, being o lder for Non Hispanic Whites, having more health conditions for Hispanics/Latinos and being u nmar ri ed for Asian Americans were all significant predictors of perceived interpersonal sensitivity.

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82 The main focus of the study in Chapter 4 was to determine if cultural competence had an impact on satisfaction with care received. There were no differences between Non Hispanic Whites, African Americans/Blacks, and Hispanics/Latinos in their levels of satisfaction with care received. Asian Americans, however, had significantly lower levels satisfaction with care when compared to Non Hispanic Whites. Cultur al competence was measured using two constructs that w ere the focus of Chapters 2 and 3 : client provider racial/ethnic concordance and interpersonal sensitivity. Racial/ethnic concordance was not a significant predictor of satisfaction. Perceived interpe rsonal sensitivity of the provider, on the other hand, was a significant predictor of higher satisfaction for all four groups. This was the only variable that was significant across all four groups. Higher self rated health was a significant predictor fo r Non Hispanic Whites and Hispanics/Latinos. Lower education and higher income were significant predictors for African Americans/Blacks. Lower education and having more health conditions were significant predictors for Hispanics/Latinos. For Asian Ameri cans, not being married was a significant predictor of satisfaction. The results from the interaction effects and subsequent analyses found that Non Hispanic Whites with more education and higher incomes had strong associations between the perceived inte rpersonal sensitivity of their provider and satisfaction with care when compared the to lower educated and lower income groups. Lower income African Americans/Blacks had a strong association between interpersonal sensitivity and satisfaction, compared to higher income African Americans/Blacks. Lastly, higher educated and higher income Hispanics/Latinos similar to the Non Hispanic Whites, had

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83 strong associations between interpersonal sensitivity an d satisfaction, compared to low er educated and lower incom e Hispanics/Latinos. The overall findi ngs from this dissertation provided information about differences about rac ial/ethnic concordance, interpersonal sensitivity and satisfaction with care among four race/ethnic groups Different populations have dif ferent needs and it is important to understand the various cultural influences on these three areas These findings make a significant contribution to the existing body of literature that addresses the importance of cultural competence in health care Th is study provides concrete example s of factors that affect racial/ethnic concordance and interpersonal sensitivity; and how both of those factors impact satisfaction. Adequacy of the Modified Model of Access to Personal Health Care Services T he Institute (Institute of Medicine, 1993) served as the basic framework for the research in this health care sys tem is affected by several barriers and intervening conditions. Overall, the results from this study show that interpersonal sensitivity, as an intervening variable, is a major factor that affects satisfaction with care across all four racial/ethnic group s. The results also support the links between health care barriers (personal and financial), interpersonal sensitivity, and health outcomes. The results found in this dissertation however, do not support the links between barriers to care, racial/ethnic concordance, and health outcomes, specifically satisfaction with care. It is possible that there are some additional variables, such as service utilization patterns, that should be included in future modified version of the model of access to support the se relationships T he notion that

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84 racial/ethnic concordance is an intermediate step between the barriers to care and interpersonal sensitivity for Hispanics/Latinos was supported by the results of this study L astly, the findings from this dissertation su ggest that the application of this model varies by race/ethnicity, a possibility that should be recognized by those who seek to adopt the model for future research Key Findings by Race/Ethnicity Non Hispanic Whites Non Hispanic Whites with healt h insurance were more likely to have providers of the same race/ethnicity. They were able access more health care options and therefore had a greater choice in the selection of their provider. Moreover, there are many more opportunities to have providers that share cultural values and beliefs with clients from this race/ethnic group. Generally speaking, cultural competence is often not considered to be applicable to Non Hispanic White populations since they are not regarded as a disadvantaged group. Th is dissertation found that cultural competence more specifically perceived interpersonal sensitivity, is important for Non Hispanic Whites, not just racial/ethnic minorities. Health care professional should strive to respectful of the values and backgrou nds of all their patients. The Non Hispanic Whites who were better educated and had higher incomes had stronger associations between interpersonal sensitivity and satisfaction. Consistent with previous research (e.g. Myburgh et al., 2005) these finding support the notion that clients with a higher socio economic statuses have more positive experiences with health care.

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85 African Americans/Blacks Racial/ethnic concordance was more likely to occur among African Americans/Blacks with higher education. I nde pendent of the effects of income and health insurance, this finding suggests that for higher educated African Americans/Blacks compared to their lower educated counterparts having a provider with whom one shares cultural values and ideas is important. R acial/ethnic concordance, on the other hand, was not a significant predictor of perceived interpersonal sensitivity for African Americans/Blacks. While previous research (e.g. LaViest & Nuru Jeter, 2002) has supported the notion that racial/ethnic concord ance is important for African Americans/Blacks and other racial/ethnic minorities, this was not found to be true in this dissertation. This discrepancy is interesting, since in the present case it suggests that in actual practice, having a provider of the same race/ethnicity does not affect client perceptions of interpersonal sensitivity. An additional point that should be considered is African Americans/Blacks may not seek care from providers of the same race/ethnicity because these providers may be in t heir social network. In smaller communities, for example, providers may attend the same church as many of their cli ents, and it may be uncomfortabl e for them to interact with their provider socially and in a health care setting Even though racial/ethnic concordance was not important for this group, greater interpersonal sensitivity was a significant predictor of higher satisfaction with care. The lower income sub group of African Americans/Blacks had a stronger association between interpersonal sensitiv ity and satisfaction, compared to the higher income group. Since one can assume that those with lower incomes had less control and choice, these results

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86 suggest that having a provider that displays more interpersonal sensitivity may be particularly apprec iated by this group. Hispanics/Latinos The results of this study support the literature that highlights the importance of language for Hispanic/Latino popu lations. These results also provide an interesting paradox ; Hispanics/Latinos who were interviewed in Spanish and who for this reason could be expected to have mor e problems with communication were less likely to have a provider of the same race/ethnicity. In Chapter 3, Hispanics/Latinos that were in matches with a health care provider of the same race/ethnicity felt their providers had higher levels interpersonal sensitivity. Both of these findings bring question whether Hispanic/Latino clients prefer matches based on language or race/ethnicity. The fi ndings emphasize the fact that language barri ers can have a negative impact on the health care experiences of Spanish speaking Hispanics/Latinos ( e.g. Fernandez et al., 2004; Perez Stable, Napoles Springer, & Miramontes, 1997; Todd, Samaroo, & Hoffman, 1993 ) and that it is important for patients to i nteract with providers that they can communicate with effectively. The assimilation level of this group, not a subject that could be studied in this investigation, may also impact how well they are able to comprehend information related to their health (L ivingston, Minushkin, & Cohn, 2008). As with the Non Hispanic Whites and African Americans/Blacks, interpersonal sensitivity was a significant predictor of higher satisfaction. Higher associations between interpersonal sensitivity and satisfaction with care received were found in the higher educated and higher income sub groups. These results were similar to the Non Hispanic White sub groups and consistent with previous research (e.g. Borders, Xu, Rohrer, &

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87 Warner 2002; Livingston, et al. 2008) Thes e findings, however, were the opposite of what was found among the African Americans/Blacks. This difference between African Americans/Blacks and Hispanics/Latinos highlights the importance of not making generalizations about all racial/ethnic minority gr oups. Individuals within each racial/ethnic group have different preferences and values that should be respected. Asian Americans This study provided some support for the cultural stereotype of Asian Americans as being, on the whole, an advantaged racial/ethnic minority group. T he results from the analyses indicated that the Asian American respondents were higher educated, had higher incomes, and were more likely than the African Americans/Blacks and Hispanics/Latinos groups to have health insuran ce. Perhaps because of these socio demographic and health related advantages, there were more client provider racial/ethnic concordance among the Asian Americans when compared to African Americans/Blacks and Hispanics/Latinos. Married Asian Americans cli ents were more likely to be in a match, indicating that spouses are part of the health care decision making process. L ower education was a significant predictor of higher perceived interpersonal sensitivity. These lower educated clients may place a lot o f trust their providers and chose not become involved in decisions about their health care. Analogous with the other three racial/ethnic groups, interpersonal sensitivity is a key predictor of satisfaction with care for Asian Americans. Study Limit ations Despite many of the positive aspects of this study, there are several limitations that must be addressed. Only participants with telephones were able to participate in the

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88 study. Since those without telephones were not included, this does bring t o question the generalizability of the data collected. In addition, this study does not examine all of the potential barriers that could have an impact on access to and utilization of health care. The selected variables for the three sub studies can imp act the health care experiences of the four racial groups H owever, these experiences could also be impacted by life experiences that were not captured b y the survey. The language fluency variable was not able to be utilized because it was measured based the respondent and not necessarily on their ability. This, in turn, inflated the number of respondents that were reported as being fluent English speakers. The language of the interview variable was used as prox y for this variable, but it may be an underestimate of the true effect of language in this study. Some of the information collected was self reported and may not be accurate. For example, some of the respondents may have diabetes or high blood pr essure T hey however, may not be aware that they do and di d not indicate that they had either of these conditions when asked The list of possible conditions and health problems is not very exhaustive There could potentially be other conditions not in cluded in the questionnaire th at have an impact on the results found in this dissertation It is also very important to consider where these respondents live and the amount of access that they had to health care services. Clients in rural areas, compared to clients in suburban and urban areas, may have limited access to providers from diverse backgrounds. Lastly, t he racial/ethnic concordance variable used in the study is a crude determination. Client provider racial/ethnic concordance was determined us ing only four racial/ethnic categories thus

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89 preventing the possibility of discerning if matches were race/ethnic specific beyond the four categories Future Research Future research efforts should focus on examining the effects of racial/ethnic concorda nce and interpersonal sensitivity on utilization of health care. This dissertation has shown, in the third study, the connections between racial/ethnic concordance, interpersonal sensitivity, and satisfaction. The next step in understanding how cultural competence can be implemented into the health system is whether or not it can improve the access and utilization of health care services among older adults. Overall satisfaction with care received is often associated with health services utilization ( e.g. LaViest & Nuru Jeter, 2002; Roghmann, Hengst, & Zastowny, 1979; Zastowny, Roghmann, &Cafferata, 1989) and compliance with a medical regimen ( e.g. LaViest & Nuru Jeter, 2002, Smith et al., 1987). The findings from this dissertation can be used to support research that examines the effects of cultural competence on additional health outcomes. In addition to determining how cultural competence affects health outcomes, more research is needed to examine racial/ethnic differences with client provider ra cial/ ethnic concordance. Chapter 2 established that the factors that predict racial/ethnic concordance vary across the four groups. Racial/ethnic concordance was a significant predictor only for Hispanics/Latinos in Chapter 3. Previous research has supp orted the notion that being in a match with a health care provider of the same race/ethnicity can aid in the reduction of health disparities (Komaromy et al. 1996; Saha, Arbelaez, & Cooper, 2003). The findings from this study, however, indicate that racia l/ethnic concordance may only be important for Hispanics/Latinos. An additional variable that should be

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90 included in future analyses is personal preference for being in a match with a provider of the same race/ethnicity LaVeist and Nuru Jeter (2002) show ed that the preference for a match varied by race/ethnicity. Chapter 3 was limited because the language of the interview was used as a proxy for language fluency. Despite this limitation, the language of the interview was a significant predictor i n Chapter 3 for Hispanics/Latinos. Yet there remains a lack of research that has examined the relationship between language and cultural competence. Also, additional research efforts should focus on discerning how the language ability of the health care Language can have a significant impact on the interactions that Hispanics/Latinos have with their health care providers (e.g. Fernandez et al., 2004; P rez Stable, Napoles Spri nger, & Miram ontes, 1997; Todd et al. 1993). It is plausible that health literacy is connected to this relationship and should be included in future research efforts. This dissertation compared the characteristics and dynamics of several racial/ethnic groups with t hose of a Non Hispanic White group. Although this type of comparison is considered the norm in comparative research, this is only the beginning. In order to more fully understand the dynamics of each racial/ethnic group, both intensive within group studi es and studies that examine how the different groups diverge from each other are necessary. Final Thoughts H ealth policy researchers have recognized the need to study the inter related issues of health disparities, racial/ethnic differences in access and u tilization of health care services and cultural competence. As summed up by one researcher, there is a

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91 strong need for research in the following three areas within cultural competence : the perceptions of patients, clients, and care recipients and the rel ationships that they have with clinicians and other caregivers; the attitudes and behaviors of practitioners, clinicians, and other health care professional and whether or not they are culturally appropriate ; and the effectiveness of health care organizati ons in encouraging more cultural competence in the health care system (Geron, 2002 ). While this investigation represents only an initial exploration of cultural in the long run it is important to continue to meas ure and assess cultural competence for several reasons. First, practitioners need to determine the effectiveness of current cultural competence interventions and the strategies that are producing positive outcomes. Second, additional research may facilit ate the efforts of agency administrators to monitor how effectively health professionals are providing culturally appropriate and responsive care (Geron 2002). And third, proving the effectiveness of cultural competence may facilitate efforts to evaluate the effe ctiveness of cultural competence training and service provision. With respect to this last point, the National Technical Assistance Center indicates that conducting an assessment helps to document current realities as opposed to objective opinion s (NTAC, 2007). Assessments can also aid health care organizations in determining which services and programs are successful and which programs need to be revised. With the current emphasi s on health care reform, resear ch targeting cultural competence ta kes on the upmost sense of urgency.

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103 Nishimi, R. (2006). A framework for cultural competency : Measurement and accountability The Commonwealth Fund. Retrieved July 20, 2009, from http://www.commonwealthfund.org/Content/Publications/Commentaries/2006/Oc t/A Framework for Cultural Competency Measurement and Accountability.aspx. Prez Stable, E.J., N poles Springer, A.M., Miramontes, J.M. (1997). The effects of ethnicity and language on medical outcomes of patients with hypertension or diabetes. Medical Care 35(12), 1212 1219. Perloff, R.M., Bonder, B., Ray, G.B., Ray, E.B., & Siminoff, L.A. (2006). Doctor patient communication, cultural competence, and minority health. American Behavioral Scientist 49(6), 835 852. Pope Davis, D. B., Toporek, R. L., Ortega Villalobos, L., Ligiro, D.P., Brit tan Powell, C. S., Lui, W. M., Bashshur, M. R., Codrington, J. N., & Liang, C. T. H. (2002). Client perspectives of multicultural counseling competence: A qualitative examination. The Counseling Psychologist, 30(3), 355 393. Princeton Survey Research Associates (2002). Methodology: Survey on disparities in quali ty of health care Prepared for the Commonwealth Fund. Putsch, R., SenGupta, I., Sampson, A., & Tervalon, M. (2003). Reflections on the CLAS standards: Best practices, innovations and horizons Seattle, WA: The Cross Cultural Health Care Program. Quadagno, J., & Reid, J. (1999). The political economy perspective in aging. In V. L. Bengtson & K. W. Schaie (Eds.) Handbook of theories on aging (pp. 344 354). New York: Springer Rotter.

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104 Remus, B. (2004). Lack of cultural competency: A business and clinical risk. Journal of Healthcare Risk Management, 24 5 11. Riggio, R.E. (1996). Introduction to Industrial/Organizational Psychology (2 nd ed.). New York: Harper Collins. Roghmann, K.J., Hengst, A., & Zastowny, T.R. (1979). Satisfaction with medical care: Its measu rement and relation to utilization. Medical Care 17, 461 479. Saha, S., Arbelaez, J. J., & Cooper, L.A. (2003). Patient physician relationships and racial disparities in the quality of health c are. American Journal of Public Health, 93(10), 1713 1719. Sa ha, S., Komaromy, M., Koepsell, R.D., & Bindman, A.B. (1999). Patient physician racial concordance and the perceived quality of and use of health care. Archives of Internal Medicine 159, 997 1004. Schnittk er, J. & Liang, K. (2006). The promise and limits of racial/ethnic c oncordance in doctor patient i nteraction. Journal of Health Politics, Policy, and Law, 31, 811 838. Sciegaj, M., Capitman, J., & Kyriacou, C. (2004). Consumer directed community care: Race/ethnicity and individual differences in preferenc es for control. Gerontologist 44 (4), 489 499. Smedley, B.D, Stith, A.Y., & Nelson. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care Washington, D.C.: National Academy Press. Smith, N.A., Ley, P., Seale, J.P., & Shaw, J (1987). Health benefits, satisfaction, and compliance. Patient Education Counsel 10, 279 286.

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109 APPENDICES

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110 Appendix A: Model of Access to Personal Health Care Services

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111 Appendix B: Culturally and Linguistically Appropriate Services (CLAS) Standards St andard 1 Health care organizations should ensure that patients/consumers receive from all staff member's effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred l anguage. Standard 2 Health care organizations should implement strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demographic characteristics of the service area. Sta ndard 3 Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery. Standard 4 Health care organizations must offer and p rovide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation. Standard 5 Health car e organizations must provide to patients/consumers in their preferred language both verbal offers and written notices informing them of their right to receive language assistance services. Standard 6 Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpretation services (except on request by the patient/consumer). Standard 7 Health ca re organizations must make available easily understood patient related materials and post signage in the languages of the commonly encountered groups and/or groups represented in the service area. Standard 8 Health care organizations should develop, imple ment, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguistically appropriate services.

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112 Standard 9 Health care organizations shoul d conduct initial and ongoing organizational self assessments of CLAS related activities and are encouraged to integrate cultural and linguistic competence related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes based evaluations. Standard 10 Health care organizations should ensure that data on the individual patient's/consumer's race, ethnicity, and spoken and written language are collected in health records, integrated into the organiz ation's management information systems, and periodically updated. Standard 11 Health care organizations should maintain a current demographic, cultural, and epidemiological profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguistic characteristics of the service area. Standard 12 Health care organizations should develop participatory, collaborative partnerships with communities and utilize a variety of formal and informa l mechanisms to facilitate community and patient/consumer involvement in designing and implementing CLAS related activities. Standard 13 Health care organizations should ensure that conflict and grievance resolution processes are culturally and linguistic ally sensitive and capable of identifying, preventing, and resolving cross cultural conflicts or complaints by patients/consumers. Standard 14 Health care organizations are encouraged to regularly make available to the public information about their progr ess and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.

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ABOUT THE AUTHOR Karon Phillips is a native of the Metro Atlanta area. She received her B Degree from Cornell University in Africana Studies and a Certificate in Gerontology She entered the School of Aging Studies at the University of South Florida for her Ph.D. degree in the fall of 2004 From 2004 until 2008, Ms. Phillips was involved in several projects related to health disparities and cultural competence as a Graduate Research Assistant. She also co ncurrently completed her Master of Public Health degree from the College of Public Hea lth at the University of South Florida. She received several awards including the AARP Diversity and Aging Student Fellowship Florida Mental Health Institute Faculty a nd Staff Scholarship, and the Summer Training on Aging Research Topics Mental Health Fe llowship (START MH) She was also inducted into Phi Sigma Theta National Honor Society and the Omicron Delta Kappa National Leadership Society


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ABSTRACT: In response to the presence of health disparities among a diverse population of older adults, creating culturally competent health care services has emerged as a possible method to help reduce and eventually eliminate inequalities in health care. However, little information exists concerning the effectiveness of cultural competence, and even less is known about how culturally competent clients perceive their providers to be. This dissertation examined a number of indicators related to cultural competence, including the predictors of client-provider racial/ethnic concordance, client perceptions of the interpersonal sensitivity of their health care providers, and the overall satisfaction with care reported by older Non-Hispanic White, African American/Black, Hispanic/Latino, and Asian American adults. In order to accomplish these aims, three related studies were conducted, all drawing on data from the 2001 Health Care Quality Survey conducted by the Commonwealth Fund. The first study focused on the factors that predicted racial/ethnic concordance between clients and their health care providers. The second study examined several factors that affect the clients' perception of their providers' interpersonal sensitivity. The third and final analysis utilized the outcome variables from the two previous studies, in addition to the client-level variables, to determine which factors predicted satisfaction with care received. The results show that the factors that predicted client-provider racial/ethnic concordance and perceived interpersonal sensitivity varied across the four groups. In addition, perceived interpersonal sensitivity was a significant predictor of satisfaction with care for all four of the groups. The findings from this dissertation contribute to a broader understanding of racial/ethnic differences in client-provider racial/ethnic concordance, perceptions of interpersonal sensitivity, and overall satisfaction with care among older adults from racially and ethnically diverse backgrounds.
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