Primary Care Provider Cultural Competence and Racial Disparities in HIV Care and Outcomes
Section of General Internal Medicine, Portland VA Medical Center, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA, . Journal of General Internal Medicine
(Impact Factor: 3.42).
01/2013; 28(5). DOI: 10.1007/s11606-012-2298-8
BACKGROUND: Health professional organizations have advocated for increasing the "cultural competence" (CC) of healthcare providers, to reduce racial and ethnic disparities in patient care. It is unclear whether provider CC is associated with more equitable care. OBJECTIVE: To evaluate whether provider CC is associated with quality of care and outcomes for patients with HIV/AIDS. DESIGN AND PARTICIPANTS: Survey of 45 providers and 437 patients at four urban HIV clinics in the U.S. MAIN MEASURES: Providers' self-rated CC was measured using a novel, 20-item instrument. Outcome measures included patients' receipt of antiretroviral (ARV) therapy, self-efficacy in managing medication regimens, complete 3-day ARV adherence, and viral suppression. KEY RESULTS: Providers' mean age was 44 years; 56 % were women, and 64 % were white. Patients' mean age was 45; 67 % were men, and 77 % were nonwhite. Minority patients whose providers scored in the middle or highest third on self-rated CC were more likely than those with providers in the lowest third to be on ARVs, have high self-efficacy, and report complete ARV adherence. Racial disparities were observed in receipt of ARVs (adjusted OR, 95 % CI for white vs. nonwhite: 6.21, 1.50-25.7), self-efficacy (3.77, 1.24-11.4), and viral suppression (13.0, 3.43-49.0) among patients of low CC providers, but not among patients of moderate and high CC providers (receipt of ARVs: 0.71, 0.32-1.61; self-efficacy: 1.14, 0.59-2.22; viral suppression: 1.20, 0.60-2.42). CONCLUSIONS: Provider CC was associated with the quality and equity of HIV care. These findings suggest that enhancing provider CC may reduce racial disparities in healthcare quality and outcomes.
Available from: Debra Roter
- "These findings have not been replicated until now. Furthermore , clinician respect for patients may be particularly relevant in HIV care due to several factors such as racial/ethnic differences between patients and clinicians        , HIV-related stigma [20– 22], and stigma towards substance use disorders   . Patients with active substance abuse perceive less respect from clinicians and demonstrate less engagement in HIV care . "
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ABSTRACT: Attitudes towards patients may influence how clinicians interact. We investigated whether respect for patients was associated with communication behaviors during HIV care encounters.
We analyzed audio-recordings of visits between 413 adult HIV-infected patients and 45 primary HIV care providers. The independent variable was clinician-reported respect for the patient and outcomes were clinician and patient communication behaviors assessed by the Roter Interaction Analysis System (RIAS). We performed negative binomial regressions for counts outcomes and linear regressions for global outcomes.
When clinicians had higher respect for a patient, they engaged in more rapport-building, social chitchat, and positive talk. Patients of clinicians with higher respect for them engaged in more rapport-building, social chitchat, positive talk, and gave more psychosocial information. Encounters between patients and clinicians with higher respect for them had more positive clinician emotional tone [regression coefficient 2.97 (1.92-4.59)], more positive patient emotional tone [2.71 (1.75-4.21)], less clinician verbal dominance [0.81 (0.68-0.96)] and more patient-centeredness [1.28 (1.09-1.51)].
Respect is associated with positive and patient-centered communication behaviors during encounters.
Clinicians should be mindful of their respectful attitudes and work to foster positive regard for patients. Educators should consider methods to enhance trainees' respect in communication skills training.
Copyright © 2015. Published by Elsevier Ireland Ltd.
Available from: Bertrand Lebouche
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ABSTRACT: Suboptimal adherence to antiretroviral therapy (ART) significantly contributes to a viral breakthrough leading to HIV resistance to treatment. This resistance, in a person living with HIV (PLHIV), may cause the transmission of resistant viral strains to their partners, a major concern for public health. Difficulties in adherence treatment raise an ethical debate: should ART be prescribed for PLWHV who may use them incorrectly? From an interdisciplinary analysis based on the ethics of responsibility framework, one can argue that adherence in the treatment of PLHIV does not solely rely on the individual but also on interpersonal and collective responsibility. Thus, according to philosophers, to assist the poor and the sick is an ethical responsibility. Second, medical ethics states that the foundation of professional practice is based on the obligation to care and treat patients. Third, medical issues associated with the prediction of adherence show that physicians do not have the adequate skills and tools to evaluate and predict it. Interventions based on predictive models and change of non-adherent behaviors seems to predominate in the medical field, although they appear less effective than models of psychosocial theories. Finally, in legal terms, the refusal to prescribe violates rights and freedoms of individuals. Thus, barriers concerning adherence are involved at different levels of responsibility. It would thus be unethical to refuse to prescribe ART to PLHIV under the pretext of non-adherence.
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