Racial and Ethnic Differences in Patient Perceptions of Bias and Cultural Competence in Health Care

Rachel L. Johnson, BA; Somnath Saha, MD, MPH; Jose J. Arbelaez, MD, MHS; Mary Catherine Beach, MD, MPH; Lisa A. Cooper, MD, MPH

In This Article

Abstract and Introduction

Objectives: To determine: 1) whether racial and ethnic differences exist in patients' perceptions of primary care provider (PCP) and general health care system-related bias and cultural competence; and 2) whether these differences are explained by patient demographics, source of care, or patient-provider communication variables.
Design: Cross-sectional telephone survey.
Setting: The Commonwealth Fund 2001 Health Care Quality Survey.
Subjects: A total of 6,299 white, African-American, Hispanic, and Asian adults.
Measurements and Main Results: Interviews were conducted using random-digit dialing; oversampling respondents from communities with high racial/ethnic minority concentrations; and yielding a 54.3% response rate. Main outcomes address respondents' perceptions of their PCPs' and health care system-related bias and cultural competence; adjusted probabilities (Pr) are reported for each ethnic group. Most racial/ethnic differences in perceptions of PCP bias and cultural competence were explained by demographics, source of care, and patient-physician communication variables. In contrast, racial/ethnic differences in patient perceptions of health care system-wide bias and cultural competence persisted even after controlling for confounders: African Americans, Hispanics, and Asians remained more likely than whites (P < .001) to perceive that: 1) they would have received better medical care if they belonged to a different race/ethnic group (Pr 0.13, Pr 0.08, Pr 0.08, and Pr 0.01, respectively); and 2) medical staff judged them unfairly or treated them with disrespect based on race/ethnicity (Pr 0.06, Pr 0.04, Pr 0.06, and Pr 0.01, respectively) and how well they speak English (Pr 0.09, Pr 0.06, Pr 0.06, and Pr 0.03, respectively).
Conclusion: While demographics, source of care, and patient-physician communication explain most racial and ethnic differences in patient perceptions of PCP cultural competence, differences in perceptions of health care system-wide bias and cultural competence are not fully explained by such factors. Future research should include closer examination of the sources of cultural bias in the US medical system.

Racial and ethnic disparities in health care access and quality have been extensively documented.[1] In 2002, the Institute of Medicine report Unequal Treatment[2] confirmed that racial and ethnic disparities in health care are not entirely explained by differences in access, clinical appropriateness, or patient preferences. The report suggested that disparities in health care exist in the broader historical and contemporary context of social and economic inequality, prejudice, and systematic bias. Because most studies of disparity have focused on technical aspects of care, such as the receipt of certain tests, therapies, and procedures, less is known about interpersonal aspects of care that may contribute to observed disparities in health care quality.

Recent work shows that ethnic minorities, who are commonly in ethnic-discordant relationships with health professionals, rate the quality of interpersonal care by physicians and within the health care system in general more negatively than whites.[3,4,5,6,7,8,9,10,11] Researchers have also provided evidence that bias and stereotyping exists among health care providers.[12,13] Moreover researchers assert that the cultural orientation of the medical care system is less congruent with the cultural perspectives of some patient groups than others.[14,15,16] Given the important role that interpersonal processes, including manifestations of bias and cultural competence, may play in the provision of health care to racial and ethnic minorities,[14,15,17] measures of these phenomena might be important indicators of individual physician and health care system cultural competence.

No single definition of cultural competence is universally accepted. However, several definitions currently in use share the requirement that health care professionals adjust and recognize their own culture in order to understand the culture of the patient.[18] Cultural and linguistic competence can be conceptualized in terms of organizational, structural, and clinical (interpersonal) barriers to care.[19] The Office of Minority Health defines cultural competence as the ability of health care providers and health care organizations to understand and respond effectively to the cultural and linguistic needs brought by patients to the health care encounter.[20] At the patient-provider level, it may be defined as the ability of individuals to establish effective interpersonal and working relationships that supercede cultural differences.[3] The Liaison Committee on Medical Education includes the need for medical students to recognize and address personal biases in their interactions with patients among their objectives for cultural competence training.[21] Medical educators have defined eight content areas (general cultural concepts, racism and stereotyping, physician-patient relationships, language, specific cultural content, access issues, socioeconomic status, and gender roles and sexuality) that are taught within a commonly accepted rubric of cross-cultural education curricula.[22]

Building on these definitions, frameworks, and objectives, we hypothesized that racial and ethnic differences exist in patient perceptions of: 1) individual physicians' bias and cultural competence; and 2) bias and cultural competence experienced at health care system-wide levels. Second, we hypothesized that these differences would be partially explained by demographic factors, access to care, patient-physician communication, and patients' health literacy.