We found that encounters between HIV providers and Hispanic compared to white patients were less patient-centered, with less psychosocial talk. We also found that, despite these differences, Hispanic patients in our study rated their providers’ communication more highly. Finally, we found that most other aspects of communication, such as physician verbal dominance and emotional tone, which had been previously shown to differ between African American and white patients, were no worse for Hispanic than for white patients.
The reasons that encounters with Hispanic patients were less patient-centered with less psychosocial talk are unclear. It is possible that providers perceive more cultural distance and are perhaps less comfortable exploring psychosocial topics with Hispanic patients. Alternatively, this finding may reflect cultural differences in patients’ comfort or expectations for discussing psychosocial topics with doctors. To address the possibility that our findings arose from language barriers, we compared Hispanic patients by English proficiency and found similarly low amounts of psychosocial talk among those who spoke English very well and those who did not. The fact that Hispanic patients did not perceive their care more negatively, despite the relative lack of patient-centeredness, may indicate either that their expectations are lower (and that they are therefore more easily satisfied), or that they prefer more biomedically-oriented visits. Alternatively, this may represent culturally different norms when responding to such questions. Nevertheless, it is important that HIV providers explore lifestyle and psychosocial issues with all patients, to the extent that these discussions provide information relevant to patient care and are valued or helpful to the patient. Based on our findings, this might, on average, require extra effort or questioning with Hispanic patients. Further research will be necessary to determine whether our findings are reproducible and, if so, what the barriers to psychosocial communication in patient–provider encounters with Hispanic patients are. Cultural competence training, shown to be effective in improving provider skills, may be helpful.21
Also interesting is our finding that communication measures previously shown to differ between African American and white patients, such as verbal dominance and emotional tone, were not different between Hispanic and white patients. Although we have to be cautious in assuming no differences based on this small sample of patients, the pattern of our findings indicated that Hispanic patients asked more questions and engaged in more patient-activating behaviors than white patients. Although patient question-asking may reasonably be a marker of increased patient involvement, the fact that Hispanic patients tended to ask more questions was not reflected in the patient-centeredness ratios, probably because that ratio is disproportionately influenced by the amount of psychosocial talk. One possible area in which a larger study may have uncovered ethnic differences is in provider socio-emotional talk, which was slightly lower for Hispanics. This may be related to the fact that there was less psychosocial talk, and further research should explore these two types of dialogue together.
Our findings should be interpreted cautiously. Although our analyses were hypothesis-driven, the number of communication outcomes we examined raises the possibility that some of our findings could have reached statistical significance by chance. We also may not have had a large enough sample size to detect racial/ethnic differences in some communication measures. Our results should therefore be considered preliminary and studied further in larger samples and in other settings and populations.
Our study has several additional limitations. The number of Hispanic patients from different countries of origin was too small to form conclusions about how communication may differ based on different cultural backgrounds within the Latino population. Neither were we able to code communication in Spanish, which limits our ability to understand how communication may differ for Spanish-speaking patients. Further research ought to explore differences in communication for both English and Spanish speaking Hispanic patients, which might provide further insight into whether the differences we observed arise primarily from different communication styles, cultural preferences, or language barriers. Also, patients and providers in our study knew that they were being recorded and may have attempted to communicate differently, which may have biased our study toward more favorable observed communication behaviors. Two prior studies, however, have directly addressed this issue, and neither found that recorded visits were substantively different from non-recorded ones.22,23
Moreover, the study sample was from only two sites, and took place in the context of HIV care, limiting the generalizability of the results. Finally, because of limited variation in provider race/ethnicity, we were unable to assess the effects of racial or ethnic concordance between patient and provider on communication.
In conclusion, we found that communication between Hispanic and white HIV-infected patients and their providers may differ in distinct ways. Hispanic patients in our study had more narrowly biomedical interactions, with less communication about psychosocial issues, than white patients. The fact that Hispanic patients rated their visits more positively than whites, raises the possibility that these racial/ethnic differences in patient–provider interactions may reflect differences in patient preferences and communication style, rather than “deficits” in communication. However, given the ubiquity and persistence of racial/ethnic disparities in the quality of care for HIV/AIDS and many other conditions, providers should ensure that adequate attention has been paid to psychosocial issues with all patients. Further research is needed to understand whether these efforts will improve patient experiences and outcomes.