Reducing racial/ethnic disparities in health outcomes has been a focal point for healthcare improvement efforts [1
]. Because a patient’s engagement in healthcare can influence health outcomes [2
], the role of racial/ethnic differences in this engagement in creating health disparities has received considerable interest. For example, patients who are more actively engaged in their care achieve better control of their diabetes or high blood pressure and reported less conflict about difficult treatment decisions [6
]. Broadly, a link between health disparities and racial/ethnic differences in patient engagement is plausible as minority patients often report less engagement as well as lower satisfaction with their healthcare visits [4
Patient engagement is key across the three main tasks of a healthcare visit—relationship building, information exchange, and decision making [16
]. To date, how race/ethnicity is associated with engagement in these key tasks is not always clear. Specifically, engagement in building the physician-patient relationship or exchanging information is often reduced for minority patients [17
] and their physicians [18
], although not always [17
]. With regard to information exchange, however, racial/ethnic differences exist, but may be explained by variation in patient communication [23
], reflecting how this communication is co-constructed with one participant’s engagement influencing the other participants’. Studies on engagement in decision making are few and suggest active participation in decision making is less common among minority patients [8
Conflicting findings with regard to the association between patient race and engagement likely arise from multiple, complex influences on communication in the healthcare visit. Variations in clinical setting alone could be responsible for the disparate results in these studies (e.g., care in a clinic for veterans versus that of a cancer center). Further, patient engagement is shaped by a multitude of factors beyond the setting, but related to the patient and physician themselves and to characteristics of the visit [8
]. Prior studies were hampered by limited availability of data about these factors or by sample sizes, both of which make detecting significant associations challenging and prohibit consideration of important characteristics of the patient, physician or visit.
Resolution of these discrepancies is critical to understanding whether targeting patient engagement had the potential to reduce racial/ethnic disparities in health outcomes. For example, other factors such as the length or severity of the illness at the time of the visit could be associated with engagement but also with race (through delays in seeking care) [34
]. In addition, race/ethnicity may influence engagement through minority families’ often disadvantaged status, such as financial resources or education [23
]. Few studies consider the potential influence of income on patient communication [38
] in favor of understanding the role of educational attainment. Among those studies that do consider whether racial/ethnic disparities in engagement can be explained by disadvantaged status [23
], disparate conclusions arise where sometimes racial effects remain even after adjusting for education or income [35
]. Understanding the mechanisms through which race/ethnicity influence patient engagement, and ultimately health outcomes, informs the tailoring and targeting of interventions and encourages consideration of these factors in assessing outcomes such as engagement or health.
We sought to understand the impact of patient race on engagement by families and physicians across the three key visit tasks – relationship building, information exchange, and decision making in pediatric primary care visits. Further, we wished to examine how any racial/ethnic differences in engagement are influenced by disadvantaged status, as assessed by education and income. Our data included extensive surveys from over 400 children’s visits in ethnically diverse Los Angeles, CA, as well as visit videos from which to directly assess engagement.