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Unformatted text preview: Interpersonal Processes of Care
in Diverse Populations A N I TA L . S T E WA RT,
E L I S E O J . P E R E Z - S TA B L E , e t a l . ∗
University of California--San Francisco; Centers for Disease Control
and Prevention P ersons of lower socioeconomic status (ses) or
from racial and ethnic minority groups have substantially poorer
health and more health risk factors than their counterparts
(Bunker, Gomby, and Kehrer 1989; Pamuk, Makuc, Heck, et al. 1998;
Winkleby, Kraemer, Ahn, et al. 1998). Various explanatory hypotheses have been proposed, ranging from differential social, environmental,
economic, and lifestyle factors to differences in access to care (Bunker,
Gomby, and Kehrer 1989; Adler, Boyce, Chesney, et al. 1993). Less research has been done on the role of the quality of medical care.
Quality of care is defined by the Institute of Medicine as the degree
to which health services increase the likelihood of desired health outcomes and are consistent with current professional knowledge (Institute of Medicine 1990). Donabedian (1966) defines it in terms of structure (properties of care settings), process (interactions between patients
and providers), and outcome (states of individuals and populations that
are attributable to antecedent health care). Technical process, which is
Coauthors of the article are Samuel F. Posner, Andrew B. Bindman, Howard L.
Pinderhughes, and A. Eugene Washington. The Milbank Quarterly, Vol. 77, No. 3, 1999
c 1999 Milbank Memorial Fund. Published by Blackwell Publishers,
350 Main Street, Malden, MA 02148, USA, and 108 Cowley Road,
Oxford OX4 1JF, UK. 305 306 Anita L. Stewart et al. often distinguished from interpersonal process (Tarlov, Ware, Greenfield, et al. 1989; Davies and Ware 1991), includes tests, treatments, and
technical competence in performing diagnostic and therapeutic procedures (Donabedian 1966; 1992). Interpersonal process is defined as the
social--psychological aspects of the patient--physician interaction, such
as communication, friendliness, explanations, and being caring and sensitive to patients’ needs (Cleary and McNeil 1988).
Evidence is accumulating that technical care varies by racial and ethnic group (Wenneker, and Epstein 1989; Escarce, Epstein, Colby, et al.
1993; Todd, Samaroo, and Hoffman 1993; Yedidia 1994; FuentesAfflick, Korenbrot, and Greene 1995; Gornick, Eggers, Reilly, et al.,
1996; Kuppermann, Gates, and Washington 1996; Carlisle, Leake, and
Shapiro 1997), by socioeconomic status (Greenberg, Chute, Stukel, et al.
1988; Burstin, Lipsitz, and Brennan 1992; Manson-Siddle and Robinson
1998), and by both (Klabunde, Potosky, Harlan, et al. 1998). For example, various studies have found higher rates of cardiac procedures
in whites, compared with African Americans, after controlling for disease severity. This was true of both angioplasty and coronary artery bypass surgery (Maynard, Fisher, Passamani, et al. 1986; Peterson, Shaw,
DeLong, et al. 1997) and referral for cardiac catheterization (Schulman,
Berlin, Harless, et al. 1999).
There has not been much research on the mechanisms by which these
differences in health and technical processes occur, although some researchers are raising the question (Yedidia 1994). One emerging hypothesis is that the disparities may be attributable to differences between minorities and their counterparts in the interpersonal processes
between patients and clinicians (Kuppermann, Gates, and Washington
1996). If physicians make unilateral decisions, or if they fail to account
for patients’ cultural beliefs and preferences, then patient adherence to
instructions about self-care and drug dosage might be poor, leading
to worse health outcomes (Wenneker, and Epstein 1989; Escarce et al.
1993). When informational processes are improved, the results may be
better patient outcomes: patients gain more knowledge, achieve a sense
of empowerment, garner the information they need to manage their
own health, and feel more motivated and capable of managing their
Our central purpose in writing this paper is to present and validate,
from the perspective of patients, a conceptual framework of interpersonal processes that distinguishes specific components. The framework Interpersonal Processes of Care in Diverse Populations 307 is designed for all segments of the population, but it incorporates issues
that are important to minority or low-SES groups. We test the validity
of the proposed framework through analysis of a self-report instrument
for measuring these processes. Our long-term goal is to facilitate understanding of how the quality of interpersonal processes of care might
affect technical processes and outcomes of care in diverse populations,
and we propose that, ultimately, such indicators be routinely included
in quality assessment efforts. Limitations of Current Approaches
Current methods of assessing interpersonal processes are inadequate for
examining the effect of these processes on technical processes of care
and their outcomes. This inadequacy stems from three major sources.
First, although the concept of interpersonal processes is well known, it
is typically considered as a single, mostly undifferentiated, construct.
For example, commonly used patient satisfaction instruments combine
interpersonal processes items into one or two summary measures at most,
such as satisfaction with communication and interpersonal care
(MacKeigan and Larson 1989; Davies and Ware 1991). Even within
typical unidimensional definitions, questions vary considerably across
instruments, suggesting that there is no widely accepted measurement
definition of interpersonal processes. Information about which components of interpersonal interactions affect technical process and outcomes
would permit quality improvement efforts to focus specifically on these
components (Healy, Govoni, and Smolker 1995). Furthermore, concrete
provider behaviors are more likely to change if specific aspects are directly linked to good and bad outcomes of care (Inui, and Carter 1985;
Cleary, Edgman-Levitan, Roberts, et al. 1991) or to quality ratings.
A second, and more important, limitation of current approaches is
that few measures of interpersonal processes (e.g., satisfaction with interpersonal style) adequately reflect the issues of minority or vulnerable populations, primarily because they were not developed with these
groups in mind. Although many concepts are salient to everyone (e.g.,
adequacy of explanations, respect), other concepts of special importance
to minority or low-SES subgroups are seldom included (e.g., cultural
sensitivity, discrimination). Further, important issues, like respectfulness, are usually defined in global terms (e.g., Doctors treat you with 308 Anita L. Stewart et al. respect). To define more clearly how our target groups view concepts
like respect, we need to reflect their specific experiences: Do clinicians
talk in front of them as if they were not there (Cleary et al. 1991)? Do
clinicians address them by the name they prefer? One exception to this
limitation is the Consumer Assessment of Health Plans Study (CAHPS),
whose goal is to evaluate quality of care from the consumer perspective for use by consumers, employers, and other purchasers (Cleary and
Edgman-Levitan 1997; Crofton, Lubalin, and Darby 1999). The CAHPS
survey includes some questions about interpersonal processes that are
relevant to vulnerable patients (e.g., trouble communicating because of
language, frequency of having an interpreter if needed) in the Medicaid
supplement (Westat Inc. 1996).
A third shortcoming is that most measures of interpersonal processes
ask about patient satisfaction with these processes rather than inquiring
about what actually occurred. Such subjective evaluations of process are
based on patients’ expectations and are difficult to interpret in terms of
improving quality (Cleary and Edgman-Levitan 1997; Cleary 1998). Information about what actually happened is necessary for understanding
the mechanisms by which minority or low-SES patients receive poorer
technical care or have poorer health outcomes and for monitoring and
improving quality of care (Cleary and Edgman-Levitan 1997; Cleary
1998). The CAHPS survey and the Picker Institute scales (Picker Institute 1999) were designed explicitly to obtain reports of processes that
occurred during medical visits. Conceptual Framework of Interpersonal
Processes of Care
We begin by differentiating interpersonal processes of care into precise components. Our framework is based on the literature about the
patient--clinician relationship, concepts and measures of quality of care
and satisfaction with interpersonal processes, extensive clinical experience with minority and low-SES populations, and qualitative studies of
the interpersonal experiences of ethnically diverse patients. We distinguish three dimensions, each with multiple domains: communication,
decision making, and interpersonal style (table 1). Most of the domains
are not ‘‘new”; however, by establishing clear definitions of the constructs to be measured (table 2), this framework represents a step toward 309 Interpersonal Processes of Care in Diverse Populations TABLE 1 Conceptual Framework of Interpersonal Processes of Care
Elicitation of, and
• Condition, progress,
• Processes of care
• Self-care (general,
Empowerment 2. Decision making
Responsiveness to patient
Consideration of patients’
ability and desire to
recommendations 3. Interpersonal style
reassurance advancing the development of an adequate instrument. These constructs
are clearly interrelated, but they are hypothesized to be distinct aspects
of care. Communication
Communication is a highly plausible source of difficulty in achieving
optimal technical care and health outcomes for minority or low-SES patients, owing to language, educational, and cultural differences between
clinicians and patients. Although communication is an essential component of the physician’s role (DiMatteo 1998), it is often the aspect of
care with which patients are least satisfied (Aharony and Strasser 1993).
Cleary and McNeil (1988, 29) note that ‘‘accurate and complete communication between a physician and a patient is often a necessary condition
for the provision of technical care.” General Clarity of Communication
General clarity is the foundation upon which more specific aspects of
the communication are built. General clarity includes the clinician’s 310 TABLE 2 Definitions of Interpersonal Processes of Care, Item Stems for Final Scales, and Sources of Final Item Stems Concept: domain and definition Item contenta Sources of items or item
themes 1-Use medical words that you
did not understand; 2-how
often did you have trouble
understanding doctors at
this clinic because they
spoke too fast? 1-Adapted Marshall et al.
1993; Webster 1989;
2-adapted Wissow et al.
1994 Communication: elicitation of and responsiveness to patient
problems, concerns, and expectations: Clinicians generally
take enough time to elicit most important concerns,
help patients feel comfortable enough to discuss
concerns, ask about concerns if not volunteered,
listen carefully and pay attention without being
distracted, indicate they are aware of patient’s
concerns, and take concerns seriously. 1-Give you enough time to
say what you thought was
important; 2-listen carefully
to what you had to say;
3-ignore what you told
them; 4-take your
concerns seriously 1-Adapted Marshall et al.
1993; 2-adapted Marshall
et al. 1993; DiMatteo and
Hays 1980; Westat Inc.
1996; Webster et al. 1989;
3-Marshall et al. 1993,
Marshall and Hays 1994;
1995; DiMatteo and Hays
1980; Welch (personal
communication) Anita L. Stewart et al. Communication: general clarity: Basic ability to communicate; language ability of clinician when patient does
not speak English well; use of interpreter for those
with language differences: clinicians match level of
language to patients’ ability to understand, use little
medical jargon, speak clearly and slowly enough for
patients to understand, and determine that patients
understand. 1-Give you enough information
about your health problems;
2-make sure you understood
your health problems 1-Adapted Dawson 1991;
1995; Webster 1989 Communication: explanation of processes of care: The
purpose of technical processes of care is explained
(tests, procedures, treatments, therapies, referrals,
and follow-up visits); also what to expect when
receiving them (e.g., pain, discomfort, possible sideeffects). During examinations, clinicians orient
patients to what they are doing next. For
complex information, clear instructions are provided. 1-Explain why a test was being done;
2-explain how the test was done;
3-tell you what they were doing
as they examined you; 4-how often
did you feel confused about what
was going on with your medical care
because doctors at this clinic
did not explain things well? 1-Adapted Marshall et al.
1993; Cleary et al. 1991;
DiMatteo and Hays
1980; Webster 1989;
4-new Communication: explanation of self-care: Information
is provided to patients and their families or
caregivers on how to take care of themselves at
home to promote recovery or optimal health and
on self-management behaviors they should
practice. Information about medications is provided,
including the medication dose and schedule, how
to monitor symptoms, when to call the doctor, when
to resume normal activities or return to
work, and what other activities to restrict. 1-Tell you what you could do to take
care of your self at home; 2-tell
you how to pay attention to your
symptoms and when to call
If medications: 1-explain clearly how
to take the medicine (that is, 1-Adapted, Gerteis et al.
1993, Delbanco 1992;
2-new Interpersonal Processes of Care in Diverse Populations Communication: explanation of condition, progress, and
prognosis: Information is provided to patients (and
their families) about their condition, changes
in condition, and prognosis. Written information
is provided. Test results are explained in terms
of what they mean for the patient’s condition,
diagnosis, and prognosis. 1-Adapted, DiMatteo and 311 (continued ) 312 T A B L E 2 continued Concept: domain and definition Item contenta
when, how much, and for how
long); 2-go over all
medicines you were taking;
3-give you written instructions
about how to take the medicine
(other than what was on the
container); 4-tell you the reason
for taking the medicine; 5-tell
you about side-effects you
might get from your medicine Sources of items or item
Hays 1980, Cleary et al.
1991, Webster 1989;
2-new; 3-new; 4-adapted
Cleary et al. 1991; Gerteis
et al. 1993; 5-adapted
Cleary et al. 1991 1-Make you feel that following
your treatment plan would make
a difference in your health;
2-make you feel that your everyday
activities, such as your diet
and lifestyle, would make a
difference in your health All new Decision making: responsiveness to patient preferences
regarding decisions: To the extent that a patient desires
involvement in decision making (through clinician 1-Try to involve you or include
you in decisions about your
treatment; 2-ask how you 1-Adapted DiMatteo et al.
1993; Kaplan et al. 1995;
Westat Inc. 1996; Anita L. Stewart et al. Communication: empowerment: Patients are given a sense
that they have the ability to affect their health outcomes; personal responsibility is encouraged. 2-adapted Webster 1989;
1984; 4-new Decision making: consideration of patient’s desire and
ability to comply with recommendations:
Clinician determines extent to which patient can
and wants to fulfill expectations of treatment
regimen; takes this into account in treatment
recommendation; makes modifications accordingly. 1-Ask if you might have any problems
actually doing the recommended
treatment; 2-understand the kinds of
problems you might have in doing
the recommended treatment Interpersonal style: friendliness, courteousness:
Clinicians and office staff treat patients in
friendly, courteous manner, and make
them feel welcome. 1-Treat you in a friendly and courteous 1-Adapted Marshall et al.
manner; 2-make you feel as if you
1993; 1994; Davies and
weren’t welcome; 3-behave rudely
Ware 1991; Westat Inc.
1996; Webster 1989; 2adapted Commonwealth
1995; 3-new Interpersonal style: respectfulness: Clinicians show
respect, genuine interest in patient as a person, pay
attention to privacy when examining patients and 1-Seem to care about you as a person;
2-address you by the name that you
prefer; 3-talk in front of you as if you All new 1-Adapted Marshall et al.
1993; DiMatteo and Hays
1980; McCusker 1984;
(continued ) 313 felt about different treatments;
3-make decisions without
taking your preferences and
opinions into account; 4-how often
did you feel pressured by doctors
at this clinic to have a treatment
you were not sure you wanted? Interpersonal Processes of Care in Diverse Populations elicitation of patient preferences), the clinician
explains alternative treatment options if there are
any, explains how each might differ in terms of
outcomes, discusses pros and cons of each
option, considers patient preferences, and
arrives at mutually agreeable treatment
strategies. Concept: domain and definition
when discussing their condition, and
do not talk down to them. Item contenta
weren’t there; 4-respect your privacy
when examining you or when asking
you questions 314 T A B L E 2 continued Sources of items or item
Rubin 1990; 2-adapted
Webster 1989; 3-Cleary
et al. 1991; 4-adapted
Marshall et al. 1993;
Cleary et al. 1991; Davies
and Ware 1991, Gerteis
et al. 1993; Webster 1989 1-How often did the doctors or staff at 1-Welch (personal
this clinic make you feel inferior? 2communication); 2-adapted
how often did the doctors or staff at
this clinic have a negative attitude
toward you? 3-how often did you feel Commonwealth 1995;
discriminated against by the doctors 4-adapted Commonwealth
or staff at this clinic because of your
race or ethnicity? 4-how often did
you feel discriminated against by the
doctors or staff at this clinic because
of your education or income? Interpersonal style: cultural sensitivity: Clinician
demonstrates a willingness to elicit and
incorporate patients’ culturally based
attitudes, values, and beliefs about their No scale----items did not meet
psychometric criteria Anita L. Stewart et al. Interpersonal style: discrimination: Patients are not
discriminated against by clinicians or office
staff because of their gender, race/ethnicity,
education, income, language, or sexual
orientation. Clinicians and office staff ensure
that patients are not made to feel inferior. 1-Help you feel less worried about
1-Adapted Marshall et al.
your health; 2-compliment you on
1993; DiMatteo and Hays
how well you take care of your health; 1980; 2-adapted Wissow
3-treat you in a compassionate
et al. 1994; Webster 1989;
and caring manner
3-adapted FACCT Interpersonal Processes of Care in Diverse Populations health and health care; may include the
patients’ expectations of the clinician’s role,
preferences for family involvement in care,
preferred communication style, illness
attribution, and religious beliefs.
Interpersonal style: emotional support, reassurance:
Clinicians provide reassurance and empathy
during encounter, try to help patient feel better,
convey information in a manner that alleviates
anxiety and fear. a
Unless otherwise noted, items begin with the following phrase: ‘‘During the past 6 months, how often did doctors at this clinic. . ..” Response
choices were: always; often; sometimes; rarely; and never. 315 316 Anita L. Stewart et al. basic ability to communicate, particularly with patients who are not very
literate or who speak a different language. One study of indigent and
minority patients revealed that 35 percent of English-speaking and 62
percent of Spanish-speaking patients had inadequate functional health
literacy (ability to read and understand medical instructions and health
care information) (Williams, Parker, Baker, et al. 1995). Three studies have found that having a physician who speaks the patient’s language improves a variety of processes. For example, patients ask more
questions, and have better health outcomes as well, because they adhere more closely to instructions, keep more appointments, and recall
more information than patients whose physician does not speak their
language (Manson 1988; Seijo, Gomez, and Freidenberg 1991; P´
erezStable, Napoles-Springer, and Miramontes 1997). Professional interpre´
ters may be helpful to patients whose language differs from their physician’s; however, interpreters must be sufficiently trained to be able to
provide high-quality interpretation (Baker, Hayes, and Fortier 1998). A
study of older, minority women found that adherence was related to the
clarity and explicitness of physician instructions (Garrity and Lawson
1989). Elicitation of and Responsiveness to Patient
Concerns and Expectations
An essential component of any medical encounter is the ability of clinicians to learn from patients what is wrong. For ‘‘active” patients who
freely express their concerns, simply listening to the patient may be
enough. Other types of patients, like those from lower socioeconomic
classes, for example, may be more reticent (Bochner and Pendleton
1980). The burden of eliciting their concerns may then fall more heavily on the clinicians, who must apply skills and cultural competence in
drawing out such patients, especially about sensitive topics.
Physicians’ responsiveness to patients’ concerns and expectations can
be revealed by indicating that have heard these concerns and/or by suggesting strategies to address them. There is evidence that patients adhere better to instructions and experience more satisfaction with their
treatment when their expectations of care are fulfilled and they find
their clinicians to be responsive (Sherbourne, Hays, Ordway, et al. 1992;
DiMatteo, Sherbourne, Hays, et al. 1993). Interpersonal Processes of Care in Diverse Populations 317 Explanations and Information
Patients vary considerably in how much information they want about
their condition and its possible treatments. However, ‘‘the more information given to patients, the better the health outcomes” is the conclusion drawn in a review article (Kaplan, Greenfield, and Ware 1989). In
a meta-analysis of correlates of provider behavior, nonwhites received
less information than whites (Roter, Hall, and Katz 1988). A study
of 336 encounters with internists found that doctors often underestimated the desire of poorly educated or lower-class patients for information (Waitzkin 1984). Several studies demonstrate that minority and
low-SES patients desire more information than they receive and ask fewer
questions than other groups (Shapiro, Najman, Chang, et al. 1983;
Waitzkin 1985; Roter, Hall, and Katz 1988). The amount of information given may thus be inadequate for lower-SES or minority patients,
suggesting a potential mechanism by which they experience poorer
health outcomes than their counterparts. Patients value three types of
explanation: about their clinical status, progress, and prognosis; about
the technical processes of care; and about ways to facilitate autonomy,
care for themselves, and promote their own health (Gerteis, EdgmanLevitan, Daley, et al. 1993).
Explanations about Condition, Progress, and Prognosis. Several studies
have found that lower-income and less educated patients receive less information from their providers about their medical condition and prognosis (Hall, Roter, and Katz 1988). Patients and their families need information about the patient’s condition, prognosis, and test results that
can facilitate understanding.
Explanations about Processes of Care. During diagnosis and treatment,
patients require explanations about what is happening and what to expect in terms of tests, procedures, treatment regimens, therapies, referrals, and follow-up visits. Minority patients do not always receive
explanations about these processes (Hall et al. 1988). A study of patient-physician communication found that Latino women’s physicians were
less likely to discuss mammography, even though these women were just
as motivated as non-Latino women to undergo this screening if referred
by a physician (Fox and Stein 1991). In another study, African-American
women were less likely than white women to receive appropriate information regarding prenatal care (Kogan, Kotelchuck, Alexander, et al.
1994). 318 Anita L. Stewart et al. Explanations about Self-Care. Patients need information about how
to care for themselves at home to promote recovery or optimal health.
Information about implementing the recommended treatment regimen
and taking prescribed medications is especially critical. Empowerment
Empowerment refers to a process by which people gain mastery over
their lives (Minkler and Wallerstein 1990). In our definition of empowerment, clinicians encourage patients to assume personal responsibility
for their health and impart the idea that what patients do influences their
health. For example, referral to self-management groups for chronic disease (Lorig, Sobel, Stewart, et al. 1999) could help patients to become
more active participants in their own care. Some cultural groups may
hold fatalistic attitudes toward certain illnesses that the physician must
confront in order to bestow on patients the sense that they are capable
of managing their illness (P´
erez-Stable, Sabogal, Otero-Sabogal, et al.
1992). For minority or low-SES patients who may perceive that they
have a relative lack of control over their social circumstances, gaining
this sense of self-efficacy may motivate them to make positive changes in
adherence and health behaviors (Monta no, Kasprzyk, and Taplin 1996).
˜ The Decision-Making Process
Patients view decision making in the context of the clinician’s responsiveness to their preferences and his or her consideration of their ability
and desire to comply with recommendations. Responsiveness to Patient Preferences
We distinguish two constructs of patient preferences:
1. The preference for being involved in treatment decisions.
2. The preference for various treatment and outcome choices.
The Preference for Being Involved in Treatment Decisions. Patients vary in
the extent to which they want to be actively involved in their care and the
degree to which they want to share in decisions about their treatment: in Interpersonal Processes of Care in Diverse Populations 319 other words, to achieve what Schulman (1979) labeled an ‘‘active patient
orientation.” Hence, it is important to determine how much patients
would like to be involved in their own care. Depending on their culture,
patients may or may not perceive that it is appropriate to take an active
stance with respect to their clinicians. For some cultures, involving the
patient’s family in treatment decisions is the norm; clinicians may need
to take into account their patients’ views on this topic (Lipson, Dibble,
and Minarik 1996). A cross-cultural study of decision-making preferences found that Korean and Mexican Americans were less likely than
European and African Americans to feel that patients should be fully informed about their diagnosis and prognosis (Blackhall, Murphy, Frank,
et al. 1995). A sense of collectivism in many Latinos and Asians suggests that they might arrive at decisions only after taking into account
the interests and well-being of the extended family.
The Preference for Various Treatments or Outcomes. Patients have different values and vary in their preferences for treatment options and potential outcomes; thus, one needs to consider the importance of various
outcomes to patients (Eddy 1990). The potential clinical benefits of a
treatment option must be considered in light of the acceptability of its
benefits and risks to the individual patient (Sharpe and Faden 1996).
For minority or low-SES patients, factors like cultural beliefs about illness and treatment and the impact of a treatment on work capacity or
their family roles can influence their willingness to accept a particular
treatment option. Consideration of the Patient’s Ability and
Desire to Comply with Recommendations
Patients vary in their ability and desire to implement recommended
treatments. Low-SES patients may find it particularly hard to adhere to
recommendations because of limited financial resources or work-related
constraints. Hence, optimal care involves taking these issues into account in making treatment decisions. However, patients also may not
want to comply. Thus, what might be viewed as nonadherence may be
an intentional choice not to pursue a recommended treatment or test
because of its perceived risks (Zola 1980). Clinicians need to understand
patients’ thoughts about the recommended plan and to be aware of any
barriers to its implementation so that it can be modified if necessary. 320 Anita L. Stewart et al. Interpersonal Style of Clinicians
We distinguish five elements of interpersonal style:
1. friendliness, courteousness
4. cultural sensitivity
5. emotional support and reassurance
The clinician’s interpersonal style may influence patient outcomes even
more than the quantity of teaching and instructions (Aharony and
Strasser 1993). For Latino patients, this is especially relevant because
empirical evidence supports the adherence of many Latinos to a cultural
script called simpat´a---- a preference for positive interpersonal relations
ı(Triandis, Mar´n, Lisansky, et al. 1984).
ı Friendliness, Courteousness
The friendliness and courteousness of health professionals and staff are
long-standing elements in definitions of interpersonal processes. The opposite of an attitude of friendliness and courteousness might be an impersonal, businesslike manner (Marshall, Hays, Sherbourne, et al. 1993). Respectfulness
Respecting the patient is a common concept in definitions of interpersonal process, although it is rarely defined. Gostin (1995) notes that the
hallmark of respect is the regard, consideration, and deference shown to
the patient. Qualitative studies of minority and low-SES patients have
led to this definition of respect: the extent to which clinicians show genuine interest in the patient as a person, pay attention to privacy during
examinations and when discussing the patient’s condition with staff, and
avoid patronizing the patient (En Accion: National Hispanic Leadership
Initiative on Cancer 1993). Discrimination
Patient reports of discrimination by clinicians or related personnel are
increasing. In one study, 13 to 14 percent of African Americans reported Interpersonal Processes of Care in Diverse Populations 321 experiences of racial discrimination while receiving medical care, compared with 1 percent of whites (Krieger and Sidney 1996). In a national
survey of minority Americans, 9 percent reported feeling uncomfortable or being treated badly when receiving health care in the past year
(Commonwealth Fund 1995). A qualitative study of African-American
women found that many women reported being stereotyped by health
care clinicians as being unmarried, having many children, and being on
welfare (Murrell, Smith, Gill, et al. 1996). Such discrimination could
adversely affect health outcomes via mechanisms of poor adherence, lack
of follow-up, and discontinuity of care. Discrimination may account for
some of the observed racial differences in technical processes of care,
which are not well explained by SES or need for care (Council on Ethical
and Judicial Affairs 1990). Cultural Sensitivity
Important to the evaluation of quality of care is the clinician’s sensitivity
to, and respect for, the patients’ cultural beliefs about their health, particularly when these views do not conform to traditional medical models.
This quality is distinct from the clinician’s cultural competence, which
implies that he or she has acquired the skills to work effectively with patients from different cultures. We define cultural sensitivity, from the patient’s perspective, as the clinician’s willingness to identify and incorporate into their care patients’ culturally based attitudes, values, and beliefs
about their health and health care, expectations of the clinician’s role,
and preferred communication style. Cultural conventions or norms may
be the basis for Latino patients not asking questions (Poma 1983), and
culturally defined communication patterns may make it more difficult
for Latino men to disclose psychosocial problems, which may be manifested instead through somatic symptoms (Castillo, Waitzkin, Ramirez,
et al. 1995). Thus, culturally sensitive care would incorporate or take
into account these culturally prescribed patient styles. Emotional Support, Reassurance
Emotional support pertains to offering reassurance, caring, and empathy
during the encounter, particularly while information is being conveyed.
For example, empathy and support can be demonstrated through the
manner in which bad news is presented, the selection of a quiet location 322 Anita L. Stewart et al. for doing so, leaving enough time to allow the patient to respond, being
close to the patient, acknowledging the patient’s reaction, and conveying
the information in a warm, caring manner (Ptacek and Eberhardt 1996). Validation of Framework through
Interpersonal Processes Survey
To test the validity of the distinctions made in this framework, we developed a self-report survery, entitled ‘‘Interpersonal Processes of Care,”
reflecting our definitions of each concept. We used a report-based approach to assess patients’ perceptions of what had occurred during their
recent medical encounters. Data from the survey were used to confirm
the hypothesized structure of the items. Sources of Item Stems
The item pool was developed from literature on quality of care, physician--patient communication, patient satisfaction, and the physician-patient relationship, and from unpublished surveys. Nearly half the item
stems were adapted from existing surveys, and a few were taken either directly or slightly modified from existing literature or surveys
(DiMatteo and Hays 1980; McCusker 1984; MacKeigan and Larson
1989; Webster 1989; Rubin 1990; Cleary et al. 1991; Davies and Ware
1991; Dawson 1991; Delbanco 1992; Gerteis et al. 1993; Marshall
et al. 1993; Marshall and Hays 1994; Wissow, Roter, and Wilson 1994;
Kaplan, Gandek, Greenfield, et al. 1995; Commonwealth Fund 1995;
Westat Inc. 1996; FACCT 1997). The remaining items were new, based
on results of prior qualitative studies as well as on our definitions. All
reports of processes pertained to doctors at a particular medical clinic
over the past six months. Spanish and English versions of the survey
were developed simultaneously in order to decenter the English version
(i.e., assure that the English and Spanish versions were as similar as possible by changing English words as needed to enable selection of the
best Spanish word). Standard methods of translation and back translation were used (Mar´n and Mar´n 1991), with iterative pretesting and
revision. Interpersonal Processes of Care in Diverse Populations 323 Setting and Recruitment
The instrument was administered as part of a larger study evaluating a
primary care gatekeeper system within the adult medical clinic at San
Francisco General Hospital, a public sector facility. This facility serves
an ethnically diverse, primarily low-income population. The clinic provides primary care to over 5,000 adult patients per year. Medical residents provide approximately 70 percent of direct care to patients, and
faculty provides 30 percent. A computerized listing was generated of the
following types of patients:
1. patients who had made one or more visits in the prior six months
2. patients who were African American, non-Latino white, or Latino
3. patients who were 18 years and older
Ethnicity was recorded in the database by clinic registration personnel
and confirmed by self-identification in the interview. A total of 1,517
patients meeting inclusion criteria made up the sampling frame.
An initial contact letter indicated that they would be called and
invited to participate in a telephone interview about patient care.
Bilingual and bicultural interviewers conducted all interviews. Because
it was expected that a substantial portion of patients might be difficult
to reach by telephone, an additional interviewer conducted face-to-face
interviews at the clinic with patients on the list who had scheduled appointments and were unreachable by telephone. All patients were paid
$5.00 for the interview. Methods of Analysis
Our goal was to determine whether the hypothesized domains from the
framework could be measured by structured items and scored as scales
that were reliable and yet relatively independent. Multitrait scaling analysis, a confirmatory approach, was performed to examine the psychometric properties of the hypothesized scales (Stewart, Hays, and Ware 1992),
using MAP-R software (Ware, Harris, Gandek, et al. 1997). Multitrait
scaling analysis enables testing of assumptions on which Likert scaling
is based: 324 Anita L. Stewart et al. 1. Each item in a hypothesized grouping is substantially linearly
related to the total score computed from other items in the group
2. Each item correlates much higher with the construct it is hypothesized to measure than with other constructs (item discrimination).
3. Item groupings not hypothesized a priori are not identifiable from
4. Items in the same scale contain the same proportion of information about the construct (similar item--scale correlations).
5. Items measuring the same construct have approximately equal
variances and therefore do not need to be standardized.
For the first criterion, we used a conservative standard of .40, which
is typically applied to measures with some historical experience
(Stewart, Hays, and Ware 1992; Ware et al. 1997), despite the fact that
the scales are early in their development; a criterion of .30 is suggested
for newer scales (Nunnally 1978; Ware et al. 1997). For the second criterion, the MAP-R program identifies as a definite scaling error any item
that has a correlation with another scale that is significantly higher than
the correlation with its hypothesized scale. Items that correlate higher,
but not significantly higher, with another scale than with their hypothesized scale are considered as probable, rather than definite, scaling errors.
We utilized the criterion of a definite scaling error for omitting an item,
given the early phase of development.
The MAP analysis was conducted separately for the three main dimensions (communication, decision making, and interpersonal style) to
use the maximum sample size for each analysis. In the survey, two of
the six hypothesized communication scales contained skip patterns in
which a subset of items was answered only if the person answered ‘‘yes”
to receiving any tests or ‘‘yes” to receiving any medications in the prior
six months. Thus, analyses of communication scales were first done on
all communication items, which limited the sample to the 80 percent
that received a test and a medication (N = 433). Once these were completed, we analyzed the communication scales that did not include these
skip patterns to determine if any results changed with the total
sample. Interpersonal Processes of Care in Diverse Populations 325 Results
Of the original sampling frame, 603 (40 percent) completed the survey.
A large number could not be reached because their contact information was incorrect, which was expected. The response rate among those
who were contacted was 82 percent; it was 76, 85, and 77 percent for
African Americans, Latinos, and non-Latino whites, respectively. Rates
were similar for women and men (81 percent and 79 percent, respectively). The majority (83 percent) of the 603 respondents received the
survey over the phone, and 74 percent of Latinos completed the Spanishlanguage version.
Those who were contacted were more likely to be older, female, and
Latino ( p < .01). Among those contacted, Latinos were more likely to
complete the survey than whites or African Americans ( p < .05). There
were no differences in age or sex between respondents and those who
refused the interview.
The final sample of 603 patients ranged in age from 21 to 87 years
(M = 54; SD = 13). The breakdown of self-reported race and ethnicity
was Latino, 39 percent; African American, 33 percent; and white, 28
percent. Years of education ranged from 0 to 22 (M = 11; SD = 4); 50
percent were women, 39 percent reported speaking English poorly or
not at all. Fifty-nine percent rated their health as fair or poor. The payer
mix for the sample was 55 percent public (Medicare and Medicaid), 5
percent private, and 40 percent self-pay (no insurance).
Summary of Scale Characteristics. Table 3 summarizes the results for
all scales: the number of items in each scale; the range of item-scale
correlations; the internal-consistency reliability; and the scaling success
rate. The minimum item-scale correlation was .40 for all but one item.
Reliability coefficients ranged from .64 to .93. All but one were over .70,
our criterion of adequacy. The rate of definite scaling errors ranged from
75 to 100 percent, with 11 of 13 scales above the 80 percent threshold
(Ware et al. 1997). Final items are indicated in table 2.
Communication. Five of the six hypothesized communication scales
were confirmed by the analyses. ‘‘Explanations of self-care” was split into
two scales: ‘‘explanations of self-care” and ‘‘explanations of medications.”
The first contained items that were relevant to all respondents, and the
second contained items specifically about medications. The final general 326 Anita L. Stewart et al. TABLE 3 Internal-Consistency Reliability and Summary Statistics for 13 Interpersonal
Processes of Care Scalesa
process of care
reassurance N InternalScaling
No. of Item-scale consistency success rateb
items correlations reliability
100 433 2 .87 .93 100 433 4 .45--.70 .78 88 433 2 .70 .83 100 433 5 .47--.64 .74 97 433 2 .73 .84 100 545 4 .33--.56 .64 75 545 2 .75 .85 100 574 3 .54--.68 .76 78 574
100 N = 433--574.
Scaling success rates reflect the percentage of item scaling successes in which items
correlated significantly higher with their hypothesized scale than with the other scales
in the matrix.
a b Interpersonal Processes of Care in Diverse Populations 327 clarity scale omitted the items pertaining to people with language barriers and use of interpreters because these items did not meet the item
The correlations among the seven communication scales ranged from
.26 to .76 (median .57), indicating sufficient independence to consider
them as unique. The highest correlation was between the ‘‘explanations of condition, progress, and prognosis” and the ‘‘elicitation and
responsiveness to patient problems, concerns and expectations” scales.
Because of the strong conceptual distinction between these two constructs, this level of correlation is tolerable, at least in this developmental
phase (Ware et al. 1997). An analysis of the five scales that did not contain skip patterns in the total sample with nonmissing values (N = 556)
indicated that the scaling results were comparable.
Decision Making. Both decision-making scales were confirmed, and
the two scales had a correlation of .43, indicating independence. The
only issue was that one item (in the ‘‘responsiveness to patient preferences regarding decisions” scale) had an item-scale correlation of .33
(less than our .40 criterion). This item was one of two negatively worded
items. Upon removing this item, the correlation of the other negatively
worded item dropped below .40 as well (a typical finding when negatively and positively worded items appear in the same scale). We thus
included the item at .33 to maintain the content validity of the scale.
Interpersonal Style. Four of the five hypothesized scales were confirmed. The correlations among the four scales ranged from .48 to .62
(median .53), suggesting that these are relatively independent. The cultural sensitivity scale did not meet our criteria for psychometric
adequacy. For example, items did not meet our convergence criterion,
and they correlated more highly with the ‘‘emotional support” and
‘‘respectfulness” scales. Discussion and Implications
We have expanded traditional conceptualizations of interpersonal processes of care to delineate specific components and to specify domains
salient to minority or low-SES patients. The conceptual framework is operationalized in terms of patient reports of processes that occurred during
recent visits. Results generally support the structure of the framework,
with two exceptions: the ‘‘cultural sensitivity” and the ‘‘explanations of
self-care” scales. 328 Anita L. Stewart et al. Apparently the cultural sensitivity concept overlaps considerably with
more general ones, like respectfulness. In earlier sections, we described
several culturally based values and attitudes that affect interpersonal processes, such as collectivism, deference to authority, the importance of
dignity and respect, and a preference for positive interpersonal relations.
What needs to be established is whether these cultural constructs consist of basic values that are relevant to all groups (e.g., consideration
of others’ beliefs and opinions) or whether they are culture specific. It
is possible that cultural sensitivity can only be operationalized through
these more general domains. Despite this possibility, we believe that
the concept of cultural sensitivity has considerable face validity to those
from culturally unique backgrounds---- that is, those who feel the most
different from the majority of health care providers. Thus, we suggest
that further studies of cultural sensitivity be conducted.
Splitting the ‘‘explanations of self-care” concept into two scales improved the item-scale correlations and made more sense conceptually,
given the specific nature of explanations about medications. In other
scales, there were minor problems with some of the original items. For
example, in the original ‘‘general clarity” scale, we included items about
clinicians using an interpreter and speaking to patients in their own language if they had difficulty with English. These items had poor itemscale correlations, suggesting that it is difficult to include such specific
items in a scale intended for all persons. It is possible that a scale specific
to individuals with English-language barriers is needed.
Although the framework was generally supported by the findings,
there is clearly room for improvement in how well the final survey items
fully represent the definitions. Further, there may be areas in which existing confirmed concepts can be enriched in the future. For example,
involvement of family and friends in decision-making processes may
be an important addition to the decision-making concept (Ferguson,
Weinberger, Westmoreland, et al. 1998; Riehman, Sly, Soler, et al. 1998).
Further modifications and final specification of the scales and framework
should be based on additional validation studies. A revised instrument
with improved items based on specific qualitative studies of the problematic scales could result in better measurement of the existing definitions. In addition, tests of the survey in other diverse populations and in
different settings would be useful. With further development and validation, the concepts and measures could be applied in three areas: Interpersonal Processes of Care in Diverse Populations 329 1. To examine the extent to which these processes account for health
disparities between minority or low-SES patients and their counterparts.
2. To provide information to consumers of health care to facilitate
choosing among plans.
3. To identify specific aspects of interpersonal processes that might
be targeted for quality assessment and improvement. Interpersonal Processes as a Mechanism
for Explaining Health Disparities
One of our primary goals is to facilitate investigation of how interpersonal processes of care affect health outcomes or explain observed disparities in health outcomes. There is little research on the first of these
topics and virtually none on the second. Most of what is known of the
first comes from two studies: on how processes of care affect patient
satisfaction with care (Aharony and Strasser 1993) and on the effectiveness of communication on health outcomes (Leopold, Cooper, and
Clancy 1996). In the study by Peterson et al. (1997) cited above, in
which African Americans with coronary heart disease were less likely
than whites to undergo revascularization, the differences were associated
with a lower survival rate in African Americans. Thus, if interpersonal
processes, like decision making and communication, could improve the
rates of surgery, the outcomes would be better. Future studies are needed
to evaluate these associations. Selection of Health Plans and Providers
by Consumers and Purchasers
Information on interpersonal processes could be useful to consumers and
purchasers in selecting among health plans, where choice exists. Prior efforts at quality reporting have concentrated on technical aspects of care
(e.g., HEDIS, NCQA) and on patient satisfaction with access, providers,
and health plans. Most quality assessment efforts have not focused on
special issues of quality for disadvantaged or minority groups, where
poor quality is more likely to occur. Our concepts and measures reflect reports of what happened rather than opinions; reports have been
shown to be important to consumers in selecting health plans (McGee, 330 Anita L. Stewart et al. Kanouse, Sofaer, et al. 1999). In a review of how report cards are understood by patients, results indicated that patients seldom understood reports of technical processes (Jewett and Hibbard 1996), but they clearly
understood reports about interpersonal processes (which were poorly represented in the report cards that were studied). Therefore, augmentation
of surveys like CAHPS with more concepts on interpersonal processes
might provide consumers with useful information for selecting among
health plans. Quality Assessment and Improvement
Managed care systems are capturing larger shares of the health care market and are including more diverse patient groups. Understanding aspects of interpersonal processes could facilitate quality management,
especially when the enrolled population is diverse. The value of each
domain depends on its importance in terms of its ability to predict technical care and health outcomes, as well as the importance of the domain
to patients. To convert reports about interpersonal processes into quality
indicators, it is necessary first to determine whether the processes meet
guidelines for quality of care (Brook, McGlynn, and Cleary 1996). Once
it is shown that they do, patient-based information regarding these interpersonal processes can be incorporated into standard quality reports.
Cleary and McNeil (1988) suggest that interpersonal processes should
meet socially defined norms for social interaction among individuals.
Sufficient information is available on some of the variables in the
framework to begin testing interventions that are likely to improve the
quality of interpersonal care of patients from diverse groups and, in turn,
to improve the health of plan members. Interventions can be designed
to help both patients and clinicians. Interventions that have been undertaken to help patients participate more actively in their own care have
improved the overall interpersonal quality of care and health outcomes
(Kaplan, Greenfield, and Dukes 1993; Roter et al. 1995). Such interventions could help lower-SES or minority patients communicate better with clinicians. Although much has been accomplished in this area
(Kaplan, Greenfield, and Dukes 1993; Kaplan, Greenfield, and Ware
1989), more could be done to apply this work in diverse populations.
Interpersonal processes information could also be used to specify initiatives to improve quality through targeting the interpersonal skills of Interpersonal Processes of Care in Diverse Populations 331 clinicians during their medical training (Chassin, Galvin, and National
Roundtable on Health Care Quality 1998), particularly their interactions with diverse subgroups. Studies have demonstrated improvements
in patient outcomes following interventions to improve physician communication skills (Roter et al. 1995). The training of medical and mental health clinicians to provide better interpersonal care to minority patients is receiving more attention (Frankel, and Stein 1996; Yutrzenka
Information on interpersonal processes could also be used by health
plans to identify predictors of patient satisfaction or switching among
plans. For example, we know that patients rank patient--physician
communication as the second most important part of an office visit,
whereas physicians rank it sixth (Laine, Davidoff, Lewis, et al. 1996).
In attempting to improve interpersonal processes, it is essential to
keep in mind the structural constraints on such initiatives. The ability of
clinicians to respond to diverse needs is circumscribed by limitations on
the amount of time they can spend with patients, by organizational and
payer policies that structure protocols and treatment options for clinicians, and by other institutionally mandated or imposed regulations.
Thus, efforts to modify structural constraints may be a necessary first
step toward improving interpersonal processes for patients who need either more time or alternative approaches to care (e.g., use of interpreters,
lay health workers) to meet their special needs.
In sum, the current twin emphases---- on incorporating patient-reported information in assessments of the quality of care and on the diversity
of our nation’s population---- increase the effectiveness and relevance of
patient survey methods to policy formulation, as evidenced by the recent
U.S. Department of Health and Human Services’ Initiative to Eliminate
Racial and Ethnic Disparities in Health. Thus, we are challenged to refine our ability to incorporate patient perspectives in meaningful ways
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Acknowledgment: We are grateful to the anonymous reviewers of an earlier draft
for their helpful comments. We would also like to thank Dr. Lee Learman for
comments on early drafts of this work, Dr. Dean Schillinger and Karen Vranizan
for assistance in contacting patients, and to acknowledge the pilot work of
Dr. Melissa Welch on discrimination. Our work was sponsored by the Medical
Effectiveness Research Center (MERC), a MEDTEP Center (Agency for Health Interpersonal Processes of Care in Diverse Populations 339 Care Policy and Research Grant #HS07373), and by the Resource Center on
Minority Aging Research, which is supported by the National Institute on Aging, the National Institute of Nursing Research, and the Office of Research on
Minority Health, National Institutes of Health (Grant #P30 AG15272).
Address correspondence to: Anita L. Stewart, PhD, Professor in Residence, Institute
for Health & Aging, University of California--San Francisco, Box 0646, San
Francisco CA 94143-0646 (e-mail: [email protected]). ...
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