We successfully developed a Patient-reported Clinicians’ Cultural Sensitivity Survey (CCSS), a multi-dimensional patient-reported survey of clinicians’ cultural sensitivity. Patients were able to distinguish between clinicians’ sensitivity to a variety of cultural beliefs and practices ranging from those related to complementary and alternative medicine to attitudes about preventive care and experiences of discrimination. We were able to operationalize a number of cultural domains that affect health care from the patient perspective that have not been previously addressed in patient-reported measures of cultural competence. The construct validity and reliability of the English and Spanish versions of the CCSS measures were generally supported. Furthermore, the measures were viewed as conceptually distinct from each other and from other measures of clinicians’ interpersonal processes of care, such as elicitation of patients’ concerns, respect, and patient-centered decision making. For the most part, they were also associated with patient satisfaction.
The CCSS fills a gap in the availability of measures of cultural competence by adding many cultural dimensions from the perspectives of ethnically diverse patients that can influence the quality of medical encounters. Much of the research exploring racial/ethnic differences in quality of care has used ethnic and language concordance of clinicians and patients as explanatory factors, both of which are crude markers of specific cultural differences between providers and patients related to language, norms, health practices, preferred interpersonal styles, and experiences of discrimination. This study advances work on cultural sensitivity measures in several ways: it includes cultural constructs important to the quality of health care from the perspectives of White, Latino and African American patients; it includes cultural factors that are universal (can be generally applied) to these groups along with factors that are group-specific (relevant only for a specific cultural or ethnic group); it disentangles clinicians’ cultural sensitivity from cultural sensitivity of the health care environment and patient-centered care; and it includes English- and Spanish-speaking Latinos. We included both general and group-specific cultural constructs because both types of factors may be important in patient assessments of their care and as potential mechanisms of health disparities. 11
For example, evidence suggests that for Spanish-speaking Latinos, sensitivity to language needs may help explain ethnic disparities in patient outcomes. 13, 14
Reflecting the variability of ethnic groups in the U.S., the measures include cultural factors that are generally applicable to ethnically diverse patients along with factors that are group-specific. These new measures should help advance investigation of how clinicians’ sensitivity to specific cultural factors affects health outcomes or explains observed health disparities.
Two concepts, sensitivity to patients’ beliefs about taking prescription medications and spirituality, were challenging to operationalize and require further developmental work to improve their content validity. Additional items need to be tested to ensure that the content validity or breadth of these constructs is adequately represented.
Results for the prescription medications items suggest that this construct may be composed of two constructs, elicitation of patients’ concerns and providing explanations about their medications. We retained the elicitation of patients’ concerns about use of prescription medications item as a single-item measure to assess how well the clinician elicits any culturally mediated beliefs about medications so that any misconceptions can be addressed.
Spirituality, while important and relevant to health from the perspective of patients, is rarely discussed in the context of medical encounters based on our findings. However, for certain ethnic minority groups its role in coping with illness and promoting healing is important. 21-23
Assessing patients’ religious orientations is important for delivering culturally relevant care. 24
Thus, greater attention to the assessment of patients’ perceptions of clinicians’ sensitivity to spiritual issues is warranted.
The relatively low levels of cultural sensitivity on many of the measures suggests that there is significant room for improvement on these physician practices, especially from the perspective of Spanish-speaking patients. This is consistent with a previous study of patient-reported cultural sensitivity measures. 7
In addition, reports of worse cultural sensitivity among Spanish-speaking compared to English-speaking Latinos could reflect the effects of language barriers between patients and clinicians or less acculturation to mainstream beliefs. From the patient perspective, physicians tended to do best on eliciting causal attributions for their illness and being sensitive to modesty issues; reports of discrimination also tended to be low. According to patients, physicians did less well with eliciting patient preferences regarding involving family members and discussing spiritual beliefs that might be related to care.
Since our survey consists of reports of the frequency of specific clinician behaviors, it has the potential to identify specific targets for clinician training and quality improvement. Evidence suggests that providing physicians with cultural competence training can lead to self-reported improvements in specific behaviors, such as asking patients about the use of folk remedies and examining patients in a culturally appropriate manner. 6
Thus, assessing these behaviors from the patient’s point of view could result in higher quality care for patients who typically have experienced poorer care. The CCSS can complement existing quality of care measures by expanding their content to include cultural factors that are important to racially and ethnically diverse patients.
Results of this study may not generalize to people who are younger or non-Latino since only older Latinos were included in this study. Although this initial study only involved Latinos, the original qualitative work that guided the framework and development of items was conducted in African Americans and Whites, as well as Latinos. 12
A strength of this study is that it involved a variety of clinic settings (three community clinics and a large multi-specialty group practice) and locations (Southern and Northern California). However, the relevance of these measures for populations outside of California and for various Asian groups is unknown. Our approach, which asks patients to report the frequency of clinicians’ culturally sensitive behaviors, differs from another cultural competency survey that asks patients to rate the cultural awareness and skills of physicians. 8
Future studies can explore the relationships between reports and ratings of culturally sensitive care and patient outcomes.
Ultimately, tools such as this can be used to assess the impact of clinicians’ cultural sensitivity on the outcomes of ethnically diverse patients. One of these outcomes, patient satisfaction, is a metric that is becoming part of many organizations’ and third-party payers’ pay for performance criteria. With the current emphasis on patient-centered care and pay for performance, it is important to ascertain if the health care needs of culturally diverse populations are being met. To do so, the health care industry must be certain that current measures of quality of care are capturing aspects of quality that are relevant for ethnically diverse patients.
Though many minority patients prefer ethnic and language concordant physicians, 25
such physicians are seldom available due to their underrepresentation in the health care work force. 26
With such shortages of ethnically and linguistically diverse physicians, directed efforts are required to provide high quality care to multi-ethnic populations that is sensitive to their culturally-mediated preferences. These groups tend to experience poorer quality of care and greater communication problems during their visits than their White counterparts, which, in turn, contribute to health disparities and higher health care costs. The 2009 U.S. health care system costs of racial and ethnic disparities associated with preventable diseases is estimated to be $23.9 billion dollars. 27
In light of these costs, expansion of cultural competence measures makes sense not only on the grounds of equity, but also financially. With projected changes in the age and racial/ethnic composition of the U.S. population, culturally competent health care will continue to increase in importance.