In this sample of patients with diabetes receiving care in safety-net outpatient clinics, race/ethnicity, age, educational attainment, self-reported health status, depressive symptoms, and length of relationship with one’s primary care provider were significantly associated with specific aspects of culturally competent care. After full adjustment, participants with depressive symptoms were significantly more likely than those without depressive symptoms to report poor cultural competency in the Doctor Communication – Positive Behaviors domain, while African-Americans were significantly less likely than Whites to report poor cultural competency in the Doctor Communication – Positive Behaviors domain. Participants who reported a 3 year or longer relationship with their primary care provider were less likely than those with a briefer relationship with their primary care provider to report poor cultural competence in the Doctor Communication – Health Promotion and Trust domains, while participants with lower educational attainment were less likely than those with higher educational attainment to report poor cultural competence in the Trust domain. Overall, however, sociodemographic and clinical differences in reports of poor cultural competence were insignificant or inconsistent across the various domains of cultural competence. Our data suggests that cultural competence interventions in safety-net settings should be broadly implemented across populations, rather than being narrowly focused on specific sociodemographic or clinical groups.
There may be a number of factors contributing to our surprising finding that African-Americans were less likely than Whites to report poor cultural competency in the Doctor Communication – Positive Behaviors domain. First, all of our patients were recruited from the safety-net setting. Our clinical experience suggests that, compared to Mexican-American and African-American patients, many more White patients seeking care in these settings are homeless, use illicit substances, or have ongoing psychiatric illness. It may be that White patients experience less culturally competent care not because of their race but because of these other co-morbidities. Second, different racial/ethnic groups may have different expectations of their care, and these differences may be reflected in their reports of cultural competency. To the extent that cultural competency is related to patient satisfaction, our results are consistent with research showing that African-Americans sometimes report greater satisfaction than Whites in certain domains of care and practice settings.(9
) However, studies focusing more narrowly on domains of cultural competency have been relatively consistent in their finding that Whites report care that is more culturally competent.(15
) Further research will be needed to fully understand why Whites reported less culturally competent care in this setting.
Duration of relationship with one’s primary care provider was highly associated with cultural competency in the Doctor Communication - Health Promotion and Trust domains. In the safety-net setting from which we recruited, patients with a brief relationship with their primary care provider are more likely to receive care from a resident physician or mid-level health professional. It is therefore unclear from this data whether duration of relationship with one’s provider or provider level of experience is really the important predictor of cultural competency experiences. Although interventions may certainly be targeted toward extending the duration of patient-provider relationships (for example, by preventing discontinuous insurance enrollment), our data may also indicate the importance of focusing cultural competency training efforts on providers with the least clinical experience.
We observed a strong relationship between depressive symptoms and poor cultural competency in the Doctor Communication – Positive Behaviors domain. Studies examining patient satisfaction or perceptions of providers’ communication quality have also demonstrated associations with depressive symptoms,(17
) including among patients with diabetes.(22
) Medicare beneficiaries with depressive symptoms are significantly more likely to report worse experiences of care in other CAHPS domains as well.(23
) Although there is little research specifically focusing on perceptions of cultural competency among patients with depressive symptoms in the primary care setting, it is plausible that the association we observed between depression and poor cultural competency has multiple mechanisms. First, the manifestations of depression are culturally bound, and therefore providing optimal care to a patient with depression may require a higher level of cultural competency than providing care to a patient with a less culturally bound illness. Second, the perception of poor cultural competence may be a manifestation of the depression itself, i.e. patients with depression are more likely to report all aspects of their care as poor simply because they are depressed. Finally, patients with depression are “often disengaged, unassertive, and poorly informed”,(23
) which may limit providers’ opportunities for establishing rapport or demonstrating the cultural competence of their care. Based on these hypothetical pathways, it seems reasonable that cultural competency training courses for providers practicing in safety-net settings should specifically address the provision of culturally competent care to patients with depression, and the manifestations of depression in diverse populations. Although it may also seem reasonable to target cultural competency efforts to patients with depressive symptoms, such a narrow focus may miss a large number of patients experiencing less culturally competent care. Finally, improving treatment of depression may change patients’ perceptions of the cultural competence of their care. However, we are aware of no studies which specifically test the effects of these kinds of interventions on patient perceptions of cultural competence.
Our results have a number of limitations. Health care providers who are more values-motivated may gravitate toward jobs in safety-net settings, as these settings often present the greatest opportunity to interact with patients of diverse cultural backgrounds.(24
) Therefore cultural competence skills of providers in our sample may be higher than cultural competence skills of less highly selected providers. Similarly, practice organization and systems-based health care in the safety-net setting may respond to increased patient diversity with an increased emphasis on providing culturally competent care. Patient perceptions of cultural competence in settings outside the safety-net and large, diverse urban areas may therefore be lower. Patients without diabetes, and particularly those without health conditions that require highly effective and ongoing patient-provider communication, may exhibit different socioeconomic and clinical associations with cultural competence. Finally, we are not able to determine from this data whether perceptions of cultural competency explain any sociodemographic inequalities in health care outcomes.
Although some sociodemographic and clinical sub-groups in the safety-net setting report less culturally competent care, in general differences among groups are inconsistent across various domains of cultural competency. These findings suggest that cultural competency efforts in safety-net settings should be broadly targeted, rather than focusing on specific population subgroups.