Patients’ Perceived Cultural Sensitivity of Health Care Office Staff and Its Association with Patients’ Health Care Satisfaction and Treatment Adherence
Whitney Wall, Carolyn M. Tucker, Julia Roncoroni, Blake A. Allan, Phillip Nguyen
Journal of Health Care for the Poor and Underserved, Volume 24, Number 4, November 2013, pp. 1586-1598 (Article) Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/hpu.2013.0170
For additional information about this article https://muse.jhu.edu/article/524339
Access provided at 12 Apr 2019 23:14 GMT from Linköpings universitet
ORIGINAL PAPERS
Patients’ Perceived Cultural Sensitivity of Health Care Office Staff and Its Association with Patients’ Health Care Satisfaction and Treatment Adherence Whitney Wall, MPH Carolyn M. Tucker, PhD Julia Roncoroni, MS Blake A. Allan, MS Phillip Nguyen Abstract: Research suggests that patients’ interactions with their front desk office staff and patient-centered culturally sensitive health care are important factors in diverse patients’ overall health care satisfaction. Yet, patient-centered culturally sensitive health care research has focused almost exclusively on provider care. This study tested the hypothesis that patient-perceived cultural sensitivity of front desk office staff has a significant positive association with patient treatment adherence and that this relationship is mediated by patient health care satisfaction. Study participants were a culturally diverse sample of 1,191 patients from health care sites across the U.S. Results of a meditational analysis supported the tested hypothesis. Patient health care satisfaction fully mediated the relationship between patient-perceived cultural sensitivity of front desk office staff and patient treatment adherence. The patient satisfaction and cultural sensitivity variables explained 10% of the variance in patient treatment adherence. Training front desk office staff in patient-centered culturally sensitive health care may improve patients’ health care satisfaction and treatment adherence. Key words: Culture, patient-centered care, health care satisfaction, treatment adherence.
P
atient-centered culturally sensitive health care (PC-CSHC) has been highlighted as a best-practice approach for improving patients’ health outcomes and reducing health disparities. It is defined as health care that acknowledges diverse patients’ perceptions regarding the health care characteristics that enable patients to feel comfortable with, trusting of, and respected by their health care providers, office staff, and health care center environment.1 Patients’ perceptions of the cultural sensitivity of their providers has been found to influence their adherence to their provider’s treatment recommendations.1 Furthermore, diet, medication, and other treatment adherence by patients are positively associated
The authors are affiliated with the Department of Psychology, University of Florida. Please address correspondence to Whitney Wall, MPH, Department of Psychology, University of Florida, P.O. Box 112250, Gainesville, FL 32610–0165
© Meharry Medical College Journal of Health Care for the Poor and Underserved 24 (2013): 1586–1598.
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with their health outcomes. A meta-analysis conducted by DiMatteo and colleagues2 suggests that significant differences in health outcomes can be attributed to treatment adherence. They found that patients with high levels of treatment adherence experienced better health outcomes than patients with low levels of treatment adherence. Importantly, approximately one third of patients do not follow their health care providers’ treatment recommendations.3 There are many sides of health care delivery that influence treatment adherence. A number of research studies suggest that patient-perceived provider cultural sensitivity positively affects patients’ health care satisfaction.1,4 Other studies suggest that patients’ health care satisfaction is positively associated with their treatment adherence.5,6 Furthermore, Tucker et al.1 tested an empirically-based model of culturally sensitive health care delivery and found that patient-perceived provider cultural sensitivity was positively and significantly associated with patient satisfaction and patients’ dietary adherence among a sample of African American patients. Such research has prompted calls for the infusion of cultural competence and sensitivity trainings in medical school curriculums across the United States.7,8 While such training seems justified, the health care experience encompasses much more than isolated patient-provider interactions. On average, patients seeking outpatient care spend less than 20 minutes with their providers.9 In contrast, patients typically spend much more than 20 minutes interacting with the front desk office staff—a group that executes important, but often undervalued, roles in the health care delivery process. In a focus group study to determine the views of culturally diverse patients regarding the characteristics of patient-centered culturally sensitive health care, it was found that the cultural sensitivity of the front desk office staff was an important aspect of such care.10 Barr and Wanat11 conducted similar focus groups with ethnic minorities to determine specific cultural barriers to health care access and found that patients frequently identified nonmedical office staff as an obstacle to their care. Sofaer and Firminger12 also confirmed the important role of health care office staff in culturally sensitive health care delivery, as defined by patients. Finally, in a recent study conducted by Otani and colleagues,13 it was found that patients’ reported satisfaction with their office staff was more important than patients’ reported satisfaction with their providers in predicting patients’ overall evaluation of their health care. Despite these findings, the present authors have found no studies investigating whether patient-perceived cultural sensitivity of front desk office staff is significantly associated with patient treatment adherence or health outcomes. Perhaps this is because the work of the front desk office staff is not considered to be an aspect of patient-centered care, although the fact is that the front desk office staff executes important patient care roles, including welcoming and orienting patients to the health care environment, collecting sensitive patient information, and communicating important care related messages pertaining to treatment recommendations, prescriptions, and referrals. The present study examines the association of patient-perceived cultural sensitivity of front desk office staff with patients’ health care satisfaction and their treatment adherence. It is hypothesized that patients’ perceived cultural sensitivity of their front desk office staff will predict patients’ self-reported treatment adherence, and that the relationship between these variables will be mediated by patients’ health care satisfaction.
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Methods Participants. Study participants (N = 1,602) were recruited from 67 health care sites across the United States; however, only the 1,191 study participants who provided the complete data needed for data analyses in this study served as the study sample. Participating sites were located in each of the four major geographical regions in the United States: 50% of the sites were located in the West, 30% in the South, 10% in the Midwest, and 5% in the Northeast. A small percentage of participating sites (5%) did not report their geographic location. Of the 67 health care sites recruited, 71.4% were community health care centers; 12.5% were private practices; 7.1% were health departments; 5.4% were hospitals; and 3.6% were other types of sites (e.g., rehabilitation facilities). The inclusion criteria for study participation are as follows: (a) is age 18 or older, (b) has been receiving health care at one’s health care site for at least one year, (c) is able to communicate either verbally or in written form in either Spanish or English, and (d) gives written informed consent to participate. Of the participants included in the study sample (N = 1,191), 32.8% were male; 65.5% were female; and 1.7% did not specify their gender. This gender distribution is consistent with other health care research and reflects greater utilization of health care services by females than males.14,15 The sample participants were ethnically diverse: 38.5% of the study participants selfidentified as White American, 21.1% as African American, 29.4% as Hispanic, 4.1% as American Indian/Native American, 3.3% as Asian/Asian American/Pacific Islander, and 3.6% self-identified as “other” race/ethnicity. The age distribution among these participants was as follows: 37.7% aged 18–34, 45.9% aged 35–54 years, 16.4% aged 55 years or older. Additional demographic data are provided in Table 1. On average, the median income level was $20,001–$30,000 (SD = .67). Most participants reported that they were single living without partner (34.6%) and most participants reported their highest level of education to be high school (35.2%). Chi-square analyses were performed to determine if the 1,602 study participants significantly differed from the study sample of 1,191 participants with regard to major demographic variables, including gender, age, race/ethnicity, income, and education level. Results revealed significant differences in the race/ethnicity composition of these two groups of participants, χ2(5) = 22.95, p < .01, with a greater representation of individuals who self-identified as White/European American among those in the study sample (i.e., participants with no missing data needed for data analyses in this study). There were also significant differences in education levels, χ2(5) = 34.87, p < .01, with a slightly higher representation of college-educated participants among those in the study sample. There were no significant differences between the study participants and the sample for the present study with regard to gender, age, and income (p > .01). Instruments. Patient participants completed a confidential assessment battery (AB) consisting of the following: (a) the General Adherence Measure (GAM),16 (b) the Patient Satisfaction Questionnaire Short Form (PSQ-18),17 (c) the Tucker-Culturally Sensitive Health Care Office Staff Inventory-Patient Form (T-CSHCOSI-PF), and (d) the Demographic Data Questionnaire. The instruments in this AB were also translated into Spanish by two Hispanic graduate students whose first language is Spanish and then back-translated from Spanish to English by a certified Spanish translator. This
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Table 1. DEMOGRAPHIC CHARACTERISTICS OF THE STUDY PARTICIPANTS Characteristic Income Less than 10,000 10,000- 20,000 20,001–30,000 30,001–40,000 40,001–50,000 50,001–60,000 Missing Marital Status Single living w/o partner Single living w/partner Married living w/partner Married not living w/partner Divorced or Separated Widow/Widower Missing Highest Education Completed Elementary School Middle/Junior High School High School Some College/Technical School College Graduate School Missing
N
%
458 282 155 77 38 68 113
38.5 23.7 13.0 6.5 3.2 5.7 9.5
412 220 354 41 96 44 24
34.6 18.5 30.3 3.4 8.1 3.7 2.0
46 107 419 348 161 58 52
3.9 9.0 35.2 29.2 13.5 4.9 4.4
translator made a few adjustments in the Spanish versions of the instruments to obtain the best consistency between Spanish and English words. The General Adherence Measure (GAM). The GAM consists of five items measured on a four-point Likert scale on which 1 = none of the time and 4 = all of the time.16 This self-report measure asks patients to rate their adherence to treatment, such as medication adherence and non-medication adherence (e.g., adherence to diet and exercise recommendations). Sample items on the GAM include: “I had a hard time doing what my provider suggested I do,” and “I was unable to do what was necessary to follow my provider’s treatment plans.” Previous research findings suggest that the GAM has acceptable internal consistency reliability, with a Cronbach’s alpha of .80.16 For the present study, Cronbach’s alpha for the GAM was .67. Tucker-Culturally Sensitive Health Care Office Staff Inventory—Patient Form (T-CSHCOSI-PF). The T-CSHCOSI-PF consists of 31 items that measure the level of self-reported patient-centered cultural sensitivity of the behaviors and attitudes of
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Cultural sensitivity of office staff
the office staff at ones’ health care center.10 This instrument comprises two subscales: (1) sensitivity/interpersonal skill and (2) professionalism/punctuality/responsiveness. A sample item on the sensitivity/interpersonal skill subscale is “The front desk office staff members at my health care center or office are friendly and pleasant.” A sample item on the professionalism/punctuality/responsiveness subscale is “The front office staff members at my health care center or office take care of me as I enter the waiting room.” All items are rated on a Likert scale ranging from 1 = strongly disagree to 4 = strongly agree. This instrument has been reported to have excellent internal consistency, with a Cronbach’s alpha that exceeded .90 among an ethnically diverse sample. In the present study, the Cronbach’s alpha for the T-CSHCOSI-PF was .97. The Patient Satisfaction Questionnaire Short Form (PSQ-18). Health care satisfaction was assessed using the general satisfaction subscale of the PSQ-18.17 This subscale includes two items that access one’s overall satisfaction with their health care experience. Both items are measured on a 5-point Likert scale on which 1 = Strongly Agree, 2 = Agree, 3 = Uncertain, 4 = Disagree, 5 = Strongly Disagree. A sample item on this subscale is “The medical care I have been receiving is just about perfect.” The PSQ-18 has been reported to have excellent internal consistency, with a Cronbach’s alpha that exceeded .90 among an ethnically diverse sample.18 In the present study, Cronbach’s alpha was .57. Demographic Data Questionnaire. The demographic data questionnaire was created by the Principal Investigator for the present study to collect general demographic information on each participant including gender, age, marital status, race/ethnicity, level of education, and household income. Procedure. Phase one (recruitment of health care sites). Internet searches were used to identify health care sites (e.g., community health care centers, private practices, health departments, and hospitals) located in the four major geographical regions of the United States. Efforts were made to identify and recruit sites that were located in/ around culturally diverse communities with disproportionately large percentages of African Americans/Blacks and Hispanics—two groups that are more typically culturally different from their health care providers than Whites, and also most negatively impacted by health disparities.19 Additionally, efforts were made to identify and recruit diverse sites (i.e., small and large sites as well as different types of sites). The identified sites were sent an invitation letter that (a) explained the purpose and objectives of the study, (b) described the potential benefits of study participation, including a monetary stipend, and (c) provided the research team’s contact information and asked to contact this team if interested in participating in the study. Those sites that agreed to participate in the study were assisted by the research team in getting needed IRB approval at their site. Upon receiving IRB approval, each site officially became a site participant in the study. Contacts at these sites were also asked to invite other nearby health care sites to participate in the study. This recruitment method is referred to in the research literature as the snowball recruitment technique. Phase two (recruitment of on-site data collection coordinators and data collectors). Health care sites that agreed to participate were asked to identify a staff person to serve as data collection coordinator (DCC). The DCC was responsible for identifying
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two community members to serve as data collectors (DCs). The DCC was mailed all study materials pertaining to participant recruitment and study implementation (i.e., payment release forms, informed consent forms, and assessment batteries in English and Spanish). Members of the research team conducted trainings via conference call with the DCC and DCs at each participating site to guide participant recruitment and study implementation. Phase three (recruitment of patient participants). Data collectors identified potential patient participants at their respective health care sites who met the criteria for research participation. They were responsible for recruiting participants, which involved disseminating flyers to patients in the waiting rooms at their respective health care sites, and providing patient volunteers who met the participation criteria with information about the study. This information included the following: (a) a description of the research study, (b) a list of specific responsibilities constituting research participation, (c) specific steps taken by the research team to ensure confidentiality in relation to study participants, and (d) an explanation of compensation for study participation. Research participation by participants specifically included: (a) signing the informed consent form (ICF) in front of a witness, (b) completing a set of questionnaires (which took approximately 45 minutes), (c) signing a payment release form, (d) placing their signed informed consent form and completed questionnaires into provided separate envelopes, and then (e) dropping these envelopes into a data collection box in the waiting room at the health care site where the participant was recruited. Following completion of data collection at the health care sites, the DCCs mailed the envelopes that were in the data collection boxes to the researchers via express mail. Several procedures were used to promote high consistency across the participating sites with regard to the execution of study roles by the trained site research partners (DCCs and DCs) for each part of the study. These training related procedures included: (a) sending each DCC step-by-step procedures for executing their roles, (b) reviewing these procedures in follow-up telephone conference calls followed by administration of training competency test questions to be sure that the procedures were learned, (c) reviewing the training procedures with the DCCs until all competency test questions regarding these procedures were correctly answered, and (d) having the researchers who trained the DCCs use a training manual and training scripts to make sure that the content of this training was the same across sites. It is noteworthy that the training of the DCCs by the research team included a focus on how to recruit DCs and train them (a) to recruit patient participants and administer the study assessment battery to these participants, and (b) to keep patient participants’ data confidential. The training of the DCs by the DCCs occurred individually or in small groups to facilitate asking and answering questions in an effort to maximize learning. The DCCs were given a script and training manual for training the DCs. The DCCs also asked competency test questions (the answers to which were in the training manual) to the DCs to ensure comprehension. Training of the DCCs and the DCs included a focus on ways to be culturally sensitive (i.e., ways to promote comfort, trust, and feelings of being respected). Members of the research team were available to both the DCs and DCCs for additional training
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and/or consultation as requested by either group or as deemed needed by members of the research team based on weekly oral reports on how each aspect of the research was progressing. Other procedures used to promote high consistency across the participating sites with regard to the execution of study roles by site research partners were (a) use of weekly telephone calls to pose questions that were designed to determine if the study procedures were being followed, (b) periodic observation of DCs by the DCCs at each site during recruitment of patients and administration of the assessment battery, and (c) observation-based feedback from the DCCs to the DCs regarding what they did well or should do differently to be in compliance with the research protocol. To maintain participant confidentiality, completed questionnaires were kept separate from patients’ signed informed consent forms. Furthermore, the completed questionnaires and informed consent forms were each kept in a locked file in the principal investigator’s research lab on the University of Florida campus. As compensation for their time, patient participants were paid $15, DCCs were paid $50, and DCs were paid $8 per hour for a maximum of 16 hours.
Results All data were inspected for normality. Skewness and kurtosis statistics did not exceed one, and the visually inspected histograms appeared to be normally distributed. Data on the means, standard deviations, and score ranges for the study variables (i.e., patientperceived cultural sensitivity of front desk office staff, patient health care satisfaction, and self-reported treatment adherence) are presented in Table 2. A Pearson correlation analysis was conducted to examine the associations among the study variables. The found inter-correlations among these variables, as well as the scale properties for these variables, are presented in Table 3. The study variables (i.e., cultural sensitivity of front desk office staff, health care satisfaction, and treatment adherence) were correlated significantly and positively with one another, and ranged from low to high. Notably, patients’ ratings on the sensitivity/interpersonal skill subscale of the Tucker-Culturally Sensitivity Health Care Office Staff Inventory—Patient Form (T-CSHCOSI-PF) had significant positive correlations with their scores on the
Table 2. MEANS, SDS, AND RANGES FOR THE STUDY VARIABLES Characteristic Treatment adherence Satisfaction T-CSHCOSI subscale 1 T-CSHCOSI subscale 2
N
M
SD
1191 1191 1191 1191
3.15 3.53 3.30 3.12
.57 .96 .63 .63
T-CSHCOSI = Tucker-Culturally Sensitive Health Care Office Staff Inventory
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Table 3. CRONBACH’S ALPHAS, AND INTERCORRELATIONS FOR STUDY VARIABLES Variable 1. Treatment Adherence 2. Satisfaction 3. T-CSHCOSI subscale 1 4. T-CSHCOSI subscale 2
1
.323* .165* .159*
2
.401* .447*
3
Α
.779*
.67 .57 .97 .97
* p
Whitney Wall, Carolyn M. Tucker, Julia Roncoroni, Blake A. Allan, Phillip Nguyen
Journal of Health Care for the Poor and Underserved, Volume 24, Number 4, November 2013, pp. 1586-1598 (Article) Published by Johns Hopkins University Press DOI: https://doi.org/10.1353/hpu.2013.0170
For additional information about this article https://muse.jhu.edu/article/524339
Access provided at 12 Apr 2019 23:14 GMT from Linköpings universitet
ORIGINAL PAPERS
Patients’ Perceived Cultural Sensitivity of Health Care Office Staff and Its Association with Patients’ Health Care Satisfaction and Treatment Adherence Whitney Wall, MPH Carolyn M. Tucker, PhD Julia Roncoroni, MS Blake A. Allan, MS Phillip Nguyen Abstract: Research suggests that patients’ interactions with their front desk office staff and patient-centered culturally sensitive health care are important factors in diverse patients’ overall health care satisfaction. Yet, patient-centered culturally sensitive health care research has focused almost exclusively on provider care. This study tested the hypothesis that patient-perceived cultural sensitivity of front desk office staff has a significant positive association with patient treatment adherence and that this relationship is mediated by patient health care satisfaction. Study participants were a culturally diverse sample of 1,191 patients from health care sites across the U.S. Results of a meditational analysis supported the tested hypothesis. Patient health care satisfaction fully mediated the relationship between patient-perceived cultural sensitivity of front desk office staff and patient treatment adherence. The patient satisfaction and cultural sensitivity variables explained 10% of the variance in patient treatment adherence. Training front desk office staff in patient-centered culturally sensitive health care may improve patients’ health care satisfaction and treatment adherence. Key words: Culture, patient-centered care, health care satisfaction, treatment adherence.
P
atient-centered culturally sensitive health care (PC-CSHC) has been highlighted as a best-practice approach for improving patients’ health outcomes and reducing health disparities. It is defined as health care that acknowledges diverse patients’ perceptions regarding the health care characteristics that enable patients to feel comfortable with, trusting of, and respected by their health care providers, office staff, and health care center environment.1 Patients’ perceptions of the cultural sensitivity of their providers has been found to influence their adherence to their provider’s treatment recommendations.1 Furthermore, diet, medication, and other treatment adherence by patients are positively associated
The authors are affiliated with the Department of Psychology, University of Florida. Please address correspondence to Whitney Wall, MPH, Department of Psychology, University of Florida, P.O. Box 112250, Gainesville, FL 32610–0165
© Meharry Medical College Journal of Health Care for the Poor and Underserved 24 (2013): 1586–1598.
Wall, Tucker, Roncoroni, Allan, and Nguyen
1587
with their health outcomes. A meta-analysis conducted by DiMatteo and colleagues2 suggests that significant differences in health outcomes can be attributed to treatment adherence. They found that patients with high levels of treatment adherence experienced better health outcomes than patients with low levels of treatment adherence. Importantly, approximately one third of patients do not follow their health care providers’ treatment recommendations.3 There are many sides of health care delivery that influence treatment adherence. A number of research studies suggest that patient-perceived provider cultural sensitivity positively affects patients’ health care satisfaction.1,4 Other studies suggest that patients’ health care satisfaction is positively associated with their treatment adherence.5,6 Furthermore, Tucker et al.1 tested an empirically-based model of culturally sensitive health care delivery and found that patient-perceived provider cultural sensitivity was positively and significantly associated with patient satisfaction and patients’ dietary adherence among a sample of African American patients. Such research has prompted calls for the infusion of cultural competence and sensitivity trainings in medical school curriculums across the United States.7,8 While such training seems justified, the health care experience encompasses much more than isolated patient-provider interactions. On average, patients seeking outpatient care spend less than 20 minutes with their providers.9 In contrast, patients typically spend much more than 20 minutes interacting with the front desk office staff—a group that executes important, but often undervalued, roles in the health care delivery process. In a focus group study to determine the views of culturally diverse patients regarding the characteristics of patient-centered culturally sensitive health care, it was found that the cultural sensitivity of the front desk office staff was an important aspect of such care.10 Barr and Wanat11 conducted similar focus groups with ethnic minorities to determine specific cultural barriers to health care access and found that patients frequently identified nonmedical office staff as an obstacle to their care. Sofaer and Firminger12 also confirmed the important role of health care office staff in culturally sensitive health care delivery, as defined by patients. Finally, in a recent study conducted by Otani and colleagues,13 it was found that patients’ reported satisfaction with their office staff was more important than patients’ reported satisfaction with their providers in predicting patients’ overall evaluation of their health care. Despite these findings, the present authors have found no studies investigating whether patient-perceived cultural sensitivity of front desk office staff is significantly associated with patient treatment adherence or health outcomes. Perhaps this is because the work of the front desk office staff is not considered to be an aspect of patient-centered care, although the fact is that the front desk office staff executes important patient care roles, including welcoming and orienting patients to the health care environment, collecting sensitive patient information, and communicating important care related messages pertaining to treatment recommendations, prescriptions, and referrals. The present study examines the association of patient-perceived cultural sensitivity of front desk office staff with patients’ health care satisfaction and their treatment adherence. It is hypothesized that patients’ perceived cultural sensitivity of their front desk office staff will predict patients’ self-reported treatment adherence, and that the relationship between these variables will be mediated by patients’ health care satisfaction.
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Methods Participants. Study participants (N = 1,602) were recruited from 67 health care sites across the United States; however, only the 1,191 study participants who provided the complete data needed for data analyses in this study served as the study sample. Participating sites were located in each of the four major geographical regions in the United States: 50% of the sites were located in the West, 30% in the South, 10% in the Midwest, and 5% in the Northeast. A small percentage of participating sites (5%) did not report their geographic location. Of the 67 health care sites recruited, 71.4% were community health care centers; 12.5% were private practices; 7.1% were health departments; 5.4% were hospitals; and 3.6% were other types of sites (e.g., rehabilitation facilities). The inclusion criteria for study participation are as follows: (a) is age 18 or older, (b) has been receiving health care at one’s health care site for at least one year, (c) is able to communicate either verbally or in written form in either Spanish or English, and (d) gives written informed consent to participate. Of the participants included in the study sample (N = 1,191), 32.8% were male; 65.5% were female; and 1.7% did not specify their gender. This gender distribution is consistent with other health care research and reflects greater utilization of health care services by females than males.14,15 The sample participants were ethnically diverse: 38.5% of the study participants selfidentified as White American, 21.1% as African American, 29.4% as Hispanic, 4.1% as American Indian/Native American, 3.3% as Asian/Asian American/Pacific Islander, and 3.6% self-identified as “other” race/ethnicity. The age distribution among these participants was as follows: 37.7% aged 18–34, 45.9% aged 35–54 years, 16.4% aged 55 years or older. Additional demographic data are provided in Table 1. On average, the median income level was $20,001–$30,000 (SD = .67). Most participants reported that they were single living without partner (34.6%) and most participants reported their highest level of education to be high school (35.2%). Chi-square analyses were performed to determine if the 1,602 study participants significantly differed from the study sample of 1,191 participants with regard to major demographic variables, including gender, age, race/ethnicity, income, and education level. Results revealed significant differences in the race/ethnicity composition of these two groups of participants, χ2(5) = 22.95, p < .01, with a greater representation of individuals who self-identified as White/European American among those in the study sample (i.e., participants with no missing data needed for data analyses in this study). There were also significant differences in education levels, χ2(5) = 34.87, p < .01, with a slightly higher representation of college-educated participants among those in the study sample. There were no significant differences between the study participants and the sample for the present study with regard to gender, age, and income (p > .01). Instruments. Patient participants completed a confidential assessment battery (AB) consisting of the following: (a) the General Adherence Measure (GAM),16 (b) the Patient Satisfaction Questionnaire Short Form (PSQ-18),17 (c) the Tucker-Culturally Sensitive Health Care Office Staff Inventory-Patient Form (T-CSHCOSI-PF), and (d) the Demographic Data Questionnaire. The instruments in this AB were also translated into Spanish by two Hispanic graduate students whose first language is Spanish and then back-translated from Spanish to English by a certified Spanish translator. This
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Table 1. DEMOGRAPHIC CHARACTERISTICS OF THE STUDY PARTICIPANTS Characteristic Income Less than 10,000 10,000- 20,000 20,001–30,000 30,001–40,000 40,001–50,000 50,001–60,000 Missing Marital Status Single living w/o partner Single living w/partner Married living w/partner Married not living w/partner Divorced or Separated Widow/Widower Missing Highest Education Completed Elementary School Middle/Junior High School High School Some College/Technical School College Graduate School Missing
N
%
458 282 155 77 38 68 113
38.5 23.7 13.0 6.5 3.2 5.7 9.5
412 220 354 41 96 44 24
34.6 18.5 30.3 3.4 8.1 3.7 2.0
46 107 419 348 161 58 52
3.9 9.0 35.2 29.2 13.5 4.9 4.4
translator made a few adjustments in the Spanish versions of the instruments to obtain the best consistency between Spanish and English words. The General Adherence Measure (GAM). The GAM consists of five items measured on a four-point Likert scale on which 1 = none of the time and 4 = all of the time.16 This self-report measure asks patients to rate their adherence to treatment, such as medication adherence and non-medication adherence (e.g., adherence to diet and exercise recommendations). Sample items on the GAM include: “I had a hard time doing what my provider suggested I do,” and “I was unable to do what was necessary to follow my provider’s treatment plans.” Previous research findings suggest that the GAM has acceptable internal consistency reliability, with a Cronbach’s alpha of .80.16 For the present study, Cronbach’s alpha for the GAM was .67. Tucker-Culturally Sensitive Health Care Office Staff Inventory—Patient Form (T-CSHCOSI-PF). The T-CSHCOSI-PF consists of 31 items that measure the level of self-reported patient-centered cultural sensitivity of the behaviors and attitudes of
1590
Cultural sensitivity of office staff
the office staff at ones’ health care center.10 This instrument comprises two subscales: (1) sensitivity/interpersonal skill and (2) professionalism/punctuality/responsiveness. A sample item on the sensitivity/interpersonal skill subscale is “The front desk office staff members at my health care center or office are friendly and pleasant.” A sample item on the professionalism/punctuality/responsiveness subscale is “The front office staff members at my health care center or office take care of me as I enter the waiting room.” All items are rated on a Likert scale ranging from 1 = strongly disagree to 4 = strongly agree. This instrument has been reported to have excellent internal consistency, with a Cronbach’s alpha that exceeded .90 among an ethnically diverse sample. In the present study, the Cronbach’s alpha for the T-CSHCOSI-PF was .97. The Patient Satisfaction Questionnaire Short Form (PSQ-18). Health care satisfaction was assessed using the general satisfaction subscale of the PSQ-18.17 This subscale includes two items that access one’s overall satisfaction with their health care experience. Both items are measured on a 5-point Likert scale on which 1 = Strongly Agree, 2 = Agree, 3 = Uncertain, 4 = Disagree, 5 = Strongly Disagree. A sample item on this subscale is “The medical care I have been receiving is just about perfect.” The PSQ-18 has been reported to have excellent internal consistency, with a Cronbach’s alpha that exceeded .90 among an ethnically diverse sample.18 In the present study, Cronbach’s alpha was .57. Demographic Data Questionnaire. The demographic data questionnaire was created by the Principal Investigator for the present study to collect general demographic information on each participant including gender, age, marital status, race/ethnicity, level of education, and household income. Procedure. Phase one (recruitment of health care sites). Internet searches were used to identify health care sites (e.g., community health care centers, private practices, health departments, and hospitals) located in the four major geographical regions of the United States. Efforts were made to identify and recruit sites that were located in/ around culturally diverse communities with disproportionately large percentages of African Americans/Blacks and Hispanics—two groups that are more typically culturally different from their health care providers than Whites, and also most negatively impacted by health disparities.19 Additionally, efforts were made to identify and recruit diverse sites (i.e., small and large sites as well as different types of sites). The identified sites were sent an invitation letter that (a) explained the purpose and objectives of the study, (b) described the potential benefits of study participation, including a monetary stipend, and (c) provided the research team’s contact information and asked to contact this team if interested in participating in the study. Those sites that agreed to participate in the study were assisted by the research team in getting needed IRB approval at their site. Upon receiving IRB approval, each site officially became a site participant in the study. Contacts at these sites were also asked to invite other nearby health care sites to participate in the study. This recruitment method is referred to in the research literature as the snowball recruitment technique. Phase two (recruitment of on-site data collection coordinators and data collectors). Health care sites that agreed to participate were asked to identify a staff person to serve as data collection coordinator (DCC). The DCC was responsible for identifying
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two community members to serve as data collectors (DCs). The DCC was mailed all study materials pertaining to participant recruitment and study implementation (i.e., payment release forms, informed consent forms, and assessment batteries in English and Spanish). Members of the research team conducted trainings via conference call with the DCC and DCs at each participating site to guide participant recruitment and study implementation. Phase three (recruitment of patient participants). Data collectors identified potential patient participants at their respective health care sites who met the criteria for research participation. They were responsible for recruiting participants, which involved disseminating flyers to patients in the waiting rooms at their respective health care sites, and providing patient volunteers who met the participation criteria with information about the study. This information included the following: (a) a description of the research study, (b) a list of specific responsibilities constituting research participation, (c) specific steps taken by the research team to ensure confidentiality in relation to study participants, and (d) an explanation of compensation for study participation. Research participation by participants specifically included: (a) signing the informed consent form (ICF) in front of a witness, (b) completing a set of questionnaires (which took approximately 45 minutes), (c) signing a payment release form, (d) placing their signed informed consent form and completed questionnaires into provided separate envelopes, and then (e) dropping these envelopes into a data collection box in the waiting room at the health care site where the participant was recruited. Following completion of data collection at the health care sites, the DCCs mailed the envelopes that were in the data collection boxes to the researchers via express mail. Several procedures were used to promote high consistency across the participating sites with regard to the execution of study roles by the trained site research partners (DCCs and DCs) for each part of the study. These training related procedures included: (a) sending each DCC step-by-step procedures for executing their roles, (b) reviewing these procedures in follow-up telephone conference calls followed by administration of training competency test questions to be sure that the procedures were learned, (c) reviewing the training procedures with the DCCs until all competency test questions regarding these procedures were correctly answered, and (d) having the researchers who trained the DCCs use a training manual and training scripts to make sure that the content of this training was the same across sites. It is noteworthy that the training of the DCCs by the research team included a focus on how to recruit DCs and train them (a) to recruit patient participants and administer the study assessment battery to these participants, and (b) to keep patient participants’ data confidential. The training of the DCs by the DCCs occurred individually or in small groups to facilitate asking and answering questions in an effort to maximize learning. The DCCs were given a script and training manual for training the DCs. The DCCs also asked competency test questions (the answers to which were in the training manual) to the DCs to ensure comprehension. Training of the DCCs and the DCs included a focus on ways to be culturally sensitive (i.e., ways to promote comfort, trust, and feelings of being respected). Members of the research team were available to both the DCs and DCCs for additional training
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and/or consultation as requested by either group or as deemed needed by members of the research team based on weekly oral reports on how each aspect of the research was progressing. Other procedures used to promote high consistency across the participating sites with regard to the execution of study roles by site research partners were (a) use of weekly telephone calls to pose questions that were designed to determine if the study procedures were being followed, (b) periodic observation of DCs by the DCCs at each site during recruitment of patients and administration of the assessment battery, and (c) observation-based feedback from the DCCs to the DCs regarding what they did well or should do differently to be in compliance with the research protocol. To maintain participant confidentiality, completed questionnaires were kept separate from patients’ signed informed consent forms. Furthermore, the completed questionnaires and informed consent forms were each kept in a locked file in the principal investigator’s research lab on the University of Florida campus. As compensation for their time, patient participants were paid $15, DCCs were paid $50, and DCs were paid $8 per hour for a maximum of 16 hours.
Results All data were inspected for normality. Skewness and kurtosis statistics did not exceed one, and the visually inspected histograms appeared to be normally distributed. Data on the means, standard deviations, and score ranges for the study variables (i.e., patientperceived cultural sensitivity of front desk office staff, patient health care satisfaction, and self-reported treatment adherence) are presented in Table 2. A Pearson correlation analysis was conducted to examine the associations among the study variables. The found inter-correlations among these variables, as well as the scale properties for these variables, are presented in Table 3. The study variables (i.e., cultural sensitivity of front desk office staff, health care satisfaction, and treatment adherence) were correlated significantly and positively with one another, and ranged from low to high. Notably, patients’ ratings on the sensitivity/interpersonal skill subscale of the Tucker-Culturally Sensitivity Health Care Office Staff Inventory—Patient Form (T-CSHCOSI-PF) had significant positive correlations with their scores on the
Table 2. MEANS, SDS, AND RANGES FOR THE STUDY VARIABLES Characteristic Treatment adherence Satisfaction T-CSHCOSI subscale 1 T-CSHCOSI subscale 2
N
M
SD
1191 1191 1191 1191
3.15 3.53 3.30 3.12
.57 .96 .63 .63
T-CSHCOSI = Tucker-Culturally Sensitive Health Care Office Staff Inventory
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Table 3. CRONBACH’S ALPHAS, AND INTERCORRELATIONS FOR STUDY VARIABLES Variable 1. Treatment Adherence 2. Satisfaction 3. T-CSHCOSI subscale 1 4. T-CSHCOSI subscale 2
1
.323* .165* .159*
2
.401* .447*
3
Α
.779*
.67 .57 .97 .97
* p
