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Healthcare Mistreatment and Continuity of Cancer Screening
among Latino and Anglo American Women in Southern
California
Hector Betancourt,
Department of Psychology, Loma Linda University, USA and Universidad de La Frontera, Chile
Patricia M. Flynn, and
Department of Psychology, Loma Linda University.
Sarah R. Ormseth
Department of Psychology, Loma Linda University.
Abstract
The aim of this research was to examine the relation of perceptions of healthcare mistreatment and
related emotions to continuity of cancer screening care among women who reported healthcare
mistreatment. The structure of relations among cultural beliefs about healthcare professionals,
perceptions of mistreatment, mistreatment-related emotions, and continuity of screening was
investigated. Participants included 313 Anglo and Latino American women of varying
demographic characteristics from Southern California who were recruited using multistage
stratified sampling. Structural equation modeling confirmed the relation of perceptions of
mistreatment to continuity of care for both Anglo and Latino American women, with ethnicity
moderating this association. For Anglo Americans, greater perceptions of mistreatment were
negatively related to continuity of screening. However, for Latinas the relation was indirect,
through mistreatment-related anger. While greater perceptions of mistreatment were associated
with higher levels of anger for both ethnic groups, anger was negatively related to continuity of
care for Latino but not for Anglo women. Furthermore, cultural beliefs about professionals were
indirectly related to continuity of screening through perceptions of mistreatment and/or
mistreatment-related anger. These findings highlight the importance of the role of cultural and
psychological factors in research and interventions aimed at improving patient-professional
relations with culturally diverse women.
Keywords
perceived mistreatment; emotions; culture; cancer screening; health disparities
The United States Institute of Medicine report Unequal Treatment indicated that differences
in quality of healthcare partially accounted for disparities in a variety of health behaviors
and outcomes among racial, ethnic, and socioeconomic groups (Smedley, Stith, & Nelson,
2003). In fact, patients’ perceptions regarding the quality of their healthcare have been found
to influence breast and cervical cancer screening and continuity of care (Blanchard & Lurie,
2004; Facione & Facione, 2007). From a health disparities perspective, the finding that
continuity of care was associated with improved cancer screening rates (Menec, Sirski, &
Attawar, 2005) is particularly relevant because minority populations, such as Latin
Correspondence concerning this article should be addressed to Hector Betancourt, Department of Psychology, Loma Linda University,
Loma Linda, CA 92354. hbetancourt@llu.edu .
NIH Public Access
Author Manuscript
Women Health. Author manuscript; available in PMC 2012 January 1.
Published in final edited form as:
Women Health
. 2011 January ; 51(1): 1–24. doi:10.1080/03630242.2011.541853.
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Americans in the U.S. (Latinos1), are less likely to have a usual source of care, even after
controlling for insurance status (Zuvekas & Taliaferro, 2003).
Recent research has identified variations in perceived quality of physician care among
various ethnic populations in the U.S. (Blendon et al., 2008). Some Latino populations in
particular have reported significantly lower quality of care than mainstream, non-Latino
White (Anglo2) Americans. For instance, Mexican American and Central/South American
patients were significantly less likely than Anglo Americans to report that they received
excellent or good quality of care, that their provider listened to them carefully, and that they
felt comfortable asking their healthcare professional questions.
Perceiving that one has been treated poorly in the healthcare setting has implications for
subsequent patient-physician encounters and future health behaviors. Because interpersonal
continuity of care reflects the ongoing relationship between a patient and their healthcare
professional and implies a sense of trust and responsibility (Saultz, 2003), the perception
that quality of care is poor or that one has been mistreated may elicit negative emotional
reactions which may in turn disrupt continuity of care. In fact, patients who reported that
their physician did not listen to what they had to say were more likely to discontinue care
with that healthcare professional (Federman et al., 2001). In regards to breast cancer
screening, Latino American women have reported discourteous behavior on the part of
health professionals as a barrier to repeat mammography screening (Moy, Park, Feibelmann,
Chiang, & Weissman, 2006). Given the increasing disparities in breast cancer screening
between Latino American and Anglo American women over the last decade (Ries, Melbert,
Krapcho, et al., 2008), a better understanding of perceptions of mistreatment is necessary.
Ethnic Diversity, Cultural Beliefs about Health Professionals, and
Perceptions of Mistreatment
Despite the increasing diversity of the U.S. population, our healthcare system is largely
based on Anglo American cultural assumptions (Roosa, Dumka, Gonzales, & Knight, 2002).
From the perspective of cultural psychology, the cultural divide between mainstream
healthcare professionals and the diverse patients they serve is likely to influence the
interactions between healthcare professionals and their patients. In regards to the healthcare
professional, their own cultural beliefs and behavioral expectations regarding patients, in
addition to a lack of understanding of their patients’ culture, may influence how they treat
and interact with diverse patients and the effectiveness of the care they provide. From the
perspective of culturally diverse patients, their own cultural beliefs, values, norms, and
expectations about healthcare professionals may influence not only their health behavior but
also their perceptions of care and interactions with healthcare professionals.
The socially shared experience of lower quality of care and perceived mistreatment among
members of non-dominant ethnic or socioeconomic status (SES) communities may result in
socially shared beliefs about healthcare and healthcare professionals that can in turn
influence the clinical encounter. According to theoretical considerations regarding the study
of culture and behavior (Betancourt & Flynn, 2009), these socially shared beliefs become
part of the group’s culture and may subsequently negatively influence their perceptions,
emotional reactions, and interactions with healthcare professionals. This may in turn disrupt
1The term Latino refers to the individuals or populations of the U.S. who came originally from Latin America or a region of the U.S.
that was once part of Latin America.
2Anglo American refers to non-Latino White individuals or populations of the U.S. who came originally from the United Kingdom or
other European backgrounds, who share the English language and Anglo American cultural heritage (see Betancourt and Fuentes,
2001).
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continuity of care and contribute to perpetuating and potentially exasperating ethnic and
SES health disparities, such as those concerning cancer screening and outcome.
A number of cultural beliefs relevant to health professionals have been identified among
Latino American populations in the U.S. For instance, Latinas reported that health
professionals who perform mammograms are ‘harsh’ or ‘cold’ (Moy et al., 2006). Other
research has identified Latino cultural beliefs regarding the trustworthiness of healthcare
professionals (Buki, Borrayo, Feigal, & Carrillo, 2004). Recent research employing the
bottom-up methodological approach to the study of culture (Betancourt, Flynn, Riggs, &
Garberoglio, 2010) identified and developed an instrument to assess cultural beliefs about
health professionals. Latinas were significantly more likely than Anglo women to report
socially shared unfavorable beliefs about health professionals performing breast and cervical
cancer screening exams, including lack of concern, compassion, and trustworthiness.
Findings from this research revealed that cultural beliefs directly influenced cancer
screening behavior and in some cases, the influence was indirect through psychological
factors. For instance, higher levels of negative cultural beliefs about health professionals
were associated with higher levels of anxiety, fear, and worry. Moreover, ethnicity
influenced these relations in that the role of emotions was stronger for Latinas.
The Present Study
The aim of the present research was to examine the relation of perceptions of healthcare
mistreatment and related emotions to cancer screening continuity of care among women
who reported healthcare mistreatment. These relations were examined among Anglo
American and Latino American women who indicated they experienced mistreatment on the
part of healthcare professionals during routine breast and cervical cancer screening exams.
Because cultural beliefs are likely to influence behavior as well as psychological processes
(see Figure 1), the direct as well as indirect relation of cultural beliefs about healthcare
professionals to continuity of cancer screening was also tested through perceptions of
healthcare mistreatment and related emotions.
The research was guided by Betancourt’s theoretical model for the study of culture and
behavior (Betancourt, Hardin, & Manzi, 1992; Betancourt & Lopez, 1993), adapted for
health behavior (Betancourt & Flynn, 2009). Consistent with the conceptual model, for the
purpose of this study, culture was defined in terms that are relevant to health behavior and
are amenable to measurement, such as socially shared beliefs, values, norms, and practices
(Betancourt & Lopez, 1993). The model specifies how culture relates to health behavior and
mediating psychological factors as well as to population categories conceived as sources of
cultural variation. Therefore, in addition to the associations among perceptions and
emotional reactions to mistreatment and patients’ continuity of cancer screening care, this
study investigated the nature of relations among ethnicity, SES, age, cultural beliefs about
healthcare professionals, perceptions of healthcare mistreatment, related emotions, and
continuity of cancer screening care.
According to the model, perceptions of healthcare mistreatment and related emotions are
considered psychological processes (C) that directly related to health behaviors, such as
continuity of cancer screening care. Perceptions of mistreatment and related emotions (C)
are also likely to be associated with aspects of culture (A). Such aspects of culture may be
shared among members of a racial, ethnic, SES, gender, age or religious group. In fact, these
cultural elements are likely to be not only related to psychological processes (e.g.
perceptions of mistreatment and related emotions) but also to health behaviors, such as
continuity of care. Therefore, the relation of culture to health behavior was expected to be
direct and/or indirect, through its relation to psychological processes.
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It was hypothesized that for both Anglo and Latino American women, perceptions of
healthcare mistreatment would be negatively associated with continuity of cancer screening
directly and/or indirectly through mistreatment-related emotions. Specifically, higher levels
of perceived mistreatment were expected to be associated with higher levels of
mistreatment-related anger and a lower probability of continuity of cancer screening care. It
was also hypothesized that higher levels of negative cultural beliefs about healthcare
professionals would be related to discontinuity of care, both directly and indirectly, through
higher levels of mistreatment-related psychological processes. Finally, consistent with
previous research (Betancourt, et al., 2010), it was hypothesized that ethnicity would
moderate the relations among mistreatment-related anger and continuity of care.
Specifically, it was expected that the relations among emotions and cancer screening would
be stronger for Latinas.
Method
Participants and Procedures
As part of a larger research program investigating cultural and psychological processes
relevant to cancer screening, multi-stage, stratified sampling was conducted to obtain nearly
equal proportions of Latino and Anglo participants from varying demographic
characteristics in Southern California. According to MacCallum, Browne, and Sugawara’s
(1996) methods for estimating minimum sample size for covariance structure modeling
based on a test of close fit [α = .05, β = .80, Root Mean Square Error of Approximation
(RMSEA) values of Є0= .05, Єa = .083, df = 60], a sample of 187 participants was adequate
to have sufficient statistical power to detect this level of significance.
Using U.S. Census tract data from the Federal Financial Institutions Examination Council,
projections regarding ethnicity, SES, and age were anticipated for potential recruitment
sites, including churches, markets, universities, free/low-cost health clinics, mobile home
parks, and community settings. The 2007 American Cancer Society guidelines recommend
breast cancer screening annually for women 40 years of age and older (Smith, 2006);
therefore, specific sites such as community centers that offered older adult activities (e.g.
water aerobics, jazzercise classes), were identified that would provide a larger proportion of
women from this age group.
Once permission from key personnel at the selected sites was obtained, an English and/or
Spanish recruitment flyer was posted at each setting describing the study, eligibility for
participation, and the time and on-site location where interested participants could go to
complete an instrument. As a result of this approach, a precise rate of eligibility could not be
estimated as it was impossible to determine how many of the women who read the flyers
were eligible to participate, yet chose not to participate in the study.
Institutional Review Board (IRB) approval for the study protocol was granted prior to data
collection. When interested participants arrived at the noted settings, bilingual research
assistants explained the purpose of the study and restated that women were only eligible to
participate if they were Latino or Anglo American, at least 21 years of age, able to read
English or Spanish, and had never been diagnosed with breast or cervical cancer.
Participants’ eligibility was later confirmed through the demographic information obtained
from the data collection instrument.
3The null hypothesis indicates the degree of fit based on the Є index, so that Є0 is the value specified by the H0 and Єa represents the
degree of lack of fit of the specified model in the population. The difference between Є0 and Єa reflects the effect size,
conceptualized as the degree to which H0 is incorrect.
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After participants provided signed, written consent, women were randomly assigned either
the breast or cervical instrument. At settings specifically identified to recruit women 40
years of age and older, participants were only administered the breast cancer version of the
instrument. Participants completed the English or Spanish self-report sections of the
instrument relevant to this study in approximately 30 to 45 minutes; however the entire
instrument took approximately 60 to 75 minutes to complete. All participants were
compensated $20 for their time. Once data were collected from a number of sites, the
distributions of participants across demographic criteria were examined. Based on these
analyses, additional settings were identified to fulfill the particular demographic need and
flyers were posted advertising the relevant demographics.
As a result of recruitment efforts, 340 women reported to one of the noted settings. A total
of 9 women chose not to participate in the study due to the length of the instrument, yielding
a 97% participation rate. Approximately 5.4% of the 331 women who completed the
instrument were not eligible after reviewing the demographic information. Seventeen
participants indicated they were from an ethnic group that was not Latino or Anglo
American, and one participant indicated that she was a breast cancer survivor. As a result, a
total of 313 Latino American (n = 166) or Anglo American (n = 147) women participated
and were eligible for this study.
Measures
All scales were translated into Spanish by a group of bilingual experts of different Latin-
American nationalities through the double-back translation procedure in order to eliminate
parochial wording and ensure comprehension (Brislin, Lonner, & Thorndike, 1973).
Ethnicity—Ethnicity was self-reported by participants and included as a moderating
variable in the structural equation models.
Sources of cultural variation: SES and age—Research testing Betancourt’s model
for the study of culture has indicated that SES is an important source of cultural variation
(Betancourt et al., 2010). A measure used in previous research with diverse populations (e.g.
Betancourt, et al., 2010; Flynn, 2005) was employed to assess SES. Participants indicated
their annual household income based on five categories: $0-14,999; $15,000-$24,999;
$25,000-$39,999; $40,000-59,999; and $60,000 and above. Women also indicated their
number of years of education, which was coded into five categories (< high school, high
school, 1-2 yrs college, 3-4 yrs college, > 4 yrs. College) to be consistent with the five
income categories. Because age is also an important source of cultural variation (Powe,
2001), participants indicated their age in years. Both SES and age were included in the
multivariate models as sources of cultural variation.
Cultural beliefs about healthcare professionals—Cultural beliefs were assessed
using one of the five subscales from the Cultural Cancer Screening Scale (CCSS;
Betancourt, et al., 2010). The CCSS includes 20 items designed to assess cultural beliefs,
expectations, and norms relevant to breast and cervical cancer screening among Latino and
Anglo women. The CCSS has demonstrated adequate reliability (Latino α = .84; Anglo α = .
83), measurement equivalence (Tucker Phi = .98), and predictive validity with breast and
cervical cancer screening behaviors (Betancourt, et al., 2010). Five items from the negative
beliefs about health professionals’ subscale were used in the present study. A sample item
was “Health professionals that perform breast (cervical) cancer screening exams are not
compassionate for what their patients are going through.” All items were based on a 7-point
Likert scale with higher scores indicating greater cultural beliefs. The reliability for this
subscale was adequate (Latino α = .759; Anglo α = .742).
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Perceptions of interpersonal healthcare mistreatment scale—This scale included
11 items which were developed and/or adapted based on a review of existing scales (see
Tucker, 2008), such as the Princess Margaret Hospital Patient Satisfaction with Doctor
Questionnaire (Loblaw et al., 2004), the 9-Item Visit Satisfaction Questionnaire adapted by
the American Medical Group Association (see Barr, 2002), and the Survey of Race,
Ethnicity, and Medical Care (Kaiser Family Foundation, 2002). The 11 items represented
instances of healthcare mistreatment as reflected by a lack of respect, privacy concerns, and
communication issues.
The instrument was operationalized based on Krieger’s (1999) recommendations for
measuring perceived discrimination. Two components were assessed: 1) ‘exposure’ to
negative interpersonal experiences with a healthcare professional, and 2) ‘intensity’ of the
negative interpersonal experience. For each item, participants were asked if they had
experienced the negative incident with their health professional during routine breast
(cervical) cancer screening exams. If affirmative, participants were asked the extent to
which the incident was a problem for them based on a 7-point Likert scale (not at all
problematic = 0 to very problematic = 6). Principal axis factor analyses of the scale resulted
in one factor for both the Latino American and Anglo American samples, respectively, with
items loading at or above .514. The reliability of the scale was strong for Latino American
(α = .935) and Anglo American (α = .899) women.
Mistreatment-related anger—Participants indicated the extent to which they
experienced anger towards their health professional as a result of their mistreatment
experience(s). This item was placed on a 7-point Likert scale, with higher scores
representing greater anger.
Continuity of cancer screening care—Participants were asked “as a result of this
incident, how likely are you to use this healthcare professional again for your breast
(cervical) cancer screening examination” and “how likely are you to use his healthcare
facility again for your breast (cervical) cancer screening examination.” Items were placed on
a 7-point Likert scale with higher scores indicating greater continuity of care. The reliability
of this scale was strong (Latino α = .916; Anglo α = .914).
Covariates—Based on existing items used in previous research (Betancourt et al., 2010),
additional items were included to assess relevant covariates, such as participants’ insurance,
country of birth, generation status, survey language, usual place of healthcare, having a
regular health professional, patient-professional ethnic concordance, number of health
professional visits over the last two years, and professional recommendation of breast/
cervical cancer screening.
Statistical Analyses
All hypotheses were tested using Bentler’s structural equations program (EQS; Bentler,
2005) with the maximum likelihood method of estimation. To maintain a simplified model
without using up model degrees of freedom (see Kammeyer-Mueller & Wanberg, 2003), the
variance from covariates found to significantly influence the study variables were
partitioned from the covariance matrix prior to structural equation modeling (SEM). Due to
theoretical considerations, age, education, and income were included in the test of structural
equation models as sources of cultural variation. Adequacy of fit was assessed using the
nonsignificant χ2 goodness-of-fit statistic, a ratio of less than 2.0 for the χ2/df (Tabachnick &
Fidell, 1996), a Comparative Fit Index (CFI) of .95 or greater (Bentler, 2005), and a
RMSEA of less than .05 (Browne & Cudeck, 1993) including the 90% confidence interval
typically used in EQS (Kline, 2005). Modifications of the hypothesized model were
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performed based on results from the Lagrange Multiplier (LM) test and the Wald test in
addition to theoretical considerations.
To test ethnicity-based differences in the magnitude of the relations among the study
variables, multi-group structural equation modeling (e.g. a test of invariance) was also
conducted. Separate models were tested for Latino and Anglo American women, and all
structural paths were constrained to be equal. If the constrained structural model showed a
decrement in fit based on a significant Δ χ2 or Δ CFI of .01 or greater as compared to the
reference model, the LM Test of equality constraints was assessed for evidence of
noninvariance (Cheung & Rensvold, 2002). Equality constraints were considered
noninvariant and released in a sequential manner if doing so dramatically improved the
model fit (LM χ2 ≥ 5.0 per df; Scott-Lennox & Lennox, 1995). Since it is necessary in cross-
cultural research to establish that differences observed between groups are not due to
measurement artifacts (van de Vijver & Leung, 1997), measurement equivalence was
examined prior to invariance testing.
Results
Of the 313 participants, a total of 283 Latino (n = 151) and Anglo (n = 132) women reported
at least one instance of healthcare mistreatment. The demographic characteristics of the 15
Latino and 15 Anglo women who did not experience mistreatment did not differ from the
retained sample, with one exception. Latino participants who reported no instances of
perceived mistreatment were more likely to have completed the English instrument, χ2(1) =
6.06, p = .014.
A missing variables analysis revealed no statistically reliable deviation from randomness
based on Little’s Missing Completely at Random (MCAR) test for either Latino (p = .517)
or Anglo American (p = .753) women. Therefore, scores for 42 women with missing values
were imputed using the expectation-maximization (EM) algorithm and scores for 20 women
were deleted, as their information could not be reliably imputed. As a result, data from 263
(Latina = 140; Anglo = 123) women were available for analyses. Latino and Anglo
American women were represented across all levels of income, education, and age,
respectively. Still, within the corresponding strata Latinas were overall younger, of lower
SES, more likely to be uninsured, more likely to receive their healthcare from an emergency
room/county hospital, and less likely to have patient-professional ethnic concordance than
their Anglo counterparts (Table I).
Of these, 125 women responded to items related to breast cancer screening, and 138
responded to the same items worded in relation to cervical cancer screening. The
demographic background of these two samples was not significantly different except for age
(t (261) = −3.32, p = .001). Women who completed the breast cancer (M = 46.59, SD =
13.65) as compared to the cervical cancer instrument (M = 40.64, SD = 15.30) were
significantly older. This was expected based on efforts to recruit a larger number of women
over 40 years of age to complete the breast cancer section. Furthermore, no significant
differences were observed between the two samples in terms of mean scores on any of the
study variables, including continuity of care. Based on these results, it was deemed
appropriate to combine the groups to form a sample of 263.
Perceptions of Interpersonal Healthcare Mistreatment
The percentage of women who reported having experienced a negative interpersonal
incident and the percentage who perceived the incident as mistreatment were, for the most
part, similar for the two ethnic groups with the exception of two incidents (Table 2). Latinas
were significantly more likely to report having experienced ‘the professional not being
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honest’ and ‘the professional not returning their calls.’ Latinas were also more likely to
perceive these two instances as mistreatment. On the other hand, more ethnic differences in
the ‘intensity’ of mistreatment were observed. In fact, 7 of the 11 negative interpersonal
healthcare incidents were, on average, reported to be more problematic for Latino American
than Anglo American women.
Correlations and Analysis of Covariates
The correlations of a number of covariates not central to the study hypotheses were
examined (Table 3). For Latinas, greater intensity of perceived mistreatment was associated
with having a county hospital/public hospital/emergency room as a usual place of
healthcare, not normally seeing the same healthcare professional, seeing a healthcare
provider from the same ethnic background as themselves, and completing the English
survey. Latinas reported greater continuity of cancer screening care with the healthcare
professional if they always saw the same healthcare professional. In addition, Latinas
reported greater continuity of cancer screening care with the healthcare facility if they
completed the Spanish survey.
For Anglo women, greater intensity of perceived mistreatment was significantly associated
with having a county hospital/public hospital/emergency room as a usual place of
healthcare, and not normally seeing the same healthcare professional. Also, greater
cumulative experience of perceived mistreatment was significantly associated with less
frequent health professional visits over the last two years. Furthermore, Anglo participants
reported significantly greater continuity of cancer screening care with the health professional
if they normally saw the same healthcare professional and if the patient and professional had
ethnic concordance.
The variance explained by these covariates was partitioned from the indicators of the noted
outcomes prior to structural equation modeling analyses. Fischer’s r-to-z test of difference
revealed a number of significantly different bivariate correlations based on ethnicity,
confirming the necessity for conducting a test of invariance (Table 4).
Structural Equation Modeling
Test of the hypothesized model—Prior to conducting a test of the model for the Latino
American and Anglo American samples independently, the data were screened and results
revealed a normal distribution and no multivariate outliers. The model fit the data well and
was considered optimal in representing data for each ethnic group [for Latino Americans:
CFI = .99, χ2 (29, n = 140) = 33.64, p = .253, χ2/df = 1.16, RMSEA = .034; for Anglo
Americans: CFI = 1.00, χ2 (29, n = 123) = 21.99, p = .854, χ2/df = 0.758, RMSEA = .000]
(Figure 2). The factor structure, including the direction and significance of factor loadings
was similar for both groups. However, some differences were observed in magnitude and
significance of the associations between factors. These differences were examined in
subsequent multiple group analyses.
Test of configural invariance (Table 5, Model 1)—Testing for measurement
equivalence began with the least restrictive model in which only the factor structure of the
baseline model, namely the number of factors and the factor-loading pattern, was checked
for equality across ethnic groups. The requirement for configural invariance suggested that
the same items must be indicators of the same factor for Latino Americans and Anglo
Americans, yet differences in factor loadings are permitted across groups (Byrne, 2006). The
fit indices revealed an excellent fit CFI = 1.00; χ2 = 58.43 (60, N = 263), p = .533; χ2/df = .
97; RMSEA < .001.
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Test of measurement invariance (See Table 5, Model 2)—In the second level of
measurement equivalence, the factor loadings of the baseline model were constrained to be
equal across ethnic groups, making these coefficients invariant between Latino Americans
and Anglo Americans. The fit of the constrained measurement model was also excellent
[CFI = 1.00, χ2 (65, n = 263) = 59.13, p = .682, χ2/df = 0.91, RMSEA = .00]. Because the
difference between the fit of the constrained measurement model and the configural model
was not significant, measurement equivalence was supported. Because, the measurement
model operated similarly for both Latino Americans and Anglo Americans, any group
variations observed in the multi-group structural model could be interpreted as cross-cultural
differences (see Chen, 2008).
Test of structural invariance (See Table 5, Model 3)—To test for differences in the
magnitude of the paths among the study variables across ethnicity, constraints were imposed
on all of the structural paths. Specifically, invariance tests for path coefficients (structural
regression paths) were used to test whether the relations between factors varied as a function
of ethnic group. In comparison with the measurement model (Model 2), the constrained
structural model showed a decrement in fit [Δχ2 (7) = 22.45, p = .002], due to the
noninvariance of two structural paths. A review of the LM Test of equality constraints
statistics revealed significant between-group differences in the path from Perception of
Mistreatment to Continuity of Care (for Latinas: β = .17, p = .202; for Anglos: β = −.56, p
= .024) as well as the path from Anger to Continuity of Care (for Latinas: β = −.34, p < .
001; for Anglos: β = .04, p = .709).
Test of partial structural invariance (See Table 5, Models 4 and 5)—The largest
improvement in model fit was obtained by releasing the path constraint from Perception of
Mistreatment to Continuity of Care, LM χ2(1) =8.42, p = .004 (Model 4). However, a
difference in model fit was still observed with the measurement model [Δχ2 (6) = 13.83, p
= .032]. Based on the Lagrange multiplier test (LM χ2(1) = 5.01, p = .025), the second
constraint from the path between Anger and Continuity of Care was released resulting in an
excellent fit [CFI = 1.00, χ2 (70, n = 263) = 67.49, p = .563, χ2/df = .96, RMSEA = .000].
This model (Model 5) was comparable to the measurement model indicating that no
additional paths should be released.
Test of research hypotheses (Table 6)—As indicated in the test of invariance,
ethnicity moderated two of the paths included in the hypothesized model, resulting in
different combinations of significant direct and indirect relations for the Latino and Anglo
American samples. Specifically, ethnicity moderated the relations relevant to the first
hypothesis concerning the direct and/or indirect associations between Perceptions of
Healthcare Mistreatment and Continuity of Cancer Screening Care. For Anglo women,
higher levels of Perceived Mistreatment were negatively related to Continuity of Cancer
Screening Care (β = −.56, p = .024). However, no significant direct relation was observed
for Latinas. In contrast, for Latinas the association of Perceptions of Mistreatment with
Continuity of Care was indirect through Mistreatment Related Anger (βindirect = −.12, p = .
010), which was not the case for Anglo women. Although Perceptions of Mistreatment were
related to higher levels of Anger for both Latino (β = .41, p < .001) and Anglo women (β = .
55, p < .001), Anger was negatively associated with Continuity of Care for Latino American
(β = −.34, p < .001), but not for Anglo American women. These findings were consistent
with the third hypothesis, which predicted that ethnicity would moderate the relations
between Anger and Continuity of Care.
The second hypothesis was partially confirmed. Cultural Beliefs about Healthcare
Professionals were not directly associated with Continuity of Cancer Screening Care for
either Latino or Anglo American women. However, Cultural Beliefs were related to
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Continuity of Care indirectly through mistreatment-related psychological processes.
Specifically, higher levels of cultural beliefs were related to higher levels of perceived
mistreatment for both Latino (β = .51, p < .001) and Anglo Americans (β = .73, p < .001).
For Anglo women, Cultural Beliefs were negatively, indirectly related to Continuity of Care
through Perceptions of Mistreatment (βindirect = −.39, p = .025), while this association was
through both Perceptions of Mistreatment and Mistreatment-Related Anger for Latinas
(βindirect = −.07, p <.001).
In addition to findings concerning the moderating role of ethnicity, the test of the
hypothesized model confirmed the role of SES and age as sources of cultural variation.
Specifically, results showed that lower SES was related to higher levels of Negative Cultural
Beliefs about Healthcare Professionals (Latinas: β = −.30, p = .005; Anglos: β = −.20, p = .
057). Furthermore, younger age was associated with higher levels of Negative Cultural
Beliefs among Anglo American women (β = −.33, p < .001) and to a lesser extent for
Latinas (β = −.10, p = .13).
Discussion
Overall, this research revealed that patients’ mistreatment-related psychological processes
were associated with continuity of cancer screening care for both Latino American and
Anglo American women. Consistent with the conceptual model guiding the research, results
also showed that cultural beliefs regarding healthcare professionals were strongly related to
patients’ perceptions of healthcare mistreatment. These in turn were found to relate directly
to continuity of care for Anglos, and for Latinas indirectly through mistreatment-related
emotions. In addition to providing evidence for the hypothesized structure of associations
among cultural and psychological variables in relation to continuity of cancer screening
care, the results shed light on the role of SES and age as sources of variation in cultural
beliefs associated with the experience of healthcare mistreatment. These findings have
important implications for patient-professional relations and the effectiveness of healthcare
systems, interventions, and policies.
The moderating role of ethnicity on some of the relations, particularly in the case of
psychological processes and continuity of care, is interesting from both a conceptual and a
practical perspective. Results revealed that even though mistreatment-related psychological
processes were negatively related to continuity of care for both Latino and Anglo women,
the nature of that relation was different for participants of the two ethnic groups. In the case
of Anglo women, perceptions of mistreatment were directly and negatively associated with
continuity of care. Although those perceptions also elicited negative emotions for Anglo
women, for them these emotions did not play a significant role in terms of continuity of
cancer screening care. For Latinas, the negative emotional reaction elicited by the perception
of mistreatment was more important in influencing continuity of screening care than the
perception of mistreatment itself. These results echo previous findings concerning the
relation of screening-related anxiety emotions to compliance with clinical breast exams and
Pap tests, which were found to be more important for Latino American than for Anglo
American women (Betancourt, et al., 2010).
Consistent with the model for the study of culture, cultural beliefs about healthcare
professionals were strongly related to perceptions of mistreatment for both Latino and Anglo
women. Although beliefs about health professionals did not show a significant direct
relation to continuity of screening, they had an indirect negative relation through
mistreatment-related psychological processes. This suggests that research investigating only
the role of cultural factors on health behavior, without considering psychological processes
that are related to those cultural factors, may lead to the erroneous conclusion that culture
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does not play a role in health behavior. Because according to theory, those psychological
processes are more direct determinants of behavior, considering cultural variables along
with the corresponding psychological factors is expected to lead to more effective culture-
based interventions (Betancourt, et al., 2010).
A number of preliminary analyses not related to the study hypotheses are also worthy of
discussion. For instance, research regarding patient-professional relations often highlights
the importance of racial/ethnic concordance of the patient and the professional (Chen, Fryer,
Phillips, Wilson, & Pathman, 2005). However, results from the present research indicate that
Latinas who saw a Latino healthcare professional were more likely to perceive healthcare
mistreatment than those who saw a non-Latino professional. These findings raise interesting
empirical questions. For instance, future research could examine whether culturally based
social-class issues or differences in level of acculturation may in part account for this
observation and potentially contribute to the cultural divide between minority health
professionals and their ethnically-concordant patients. From this perspective, patient-
professional differences in education, income, and region or country of origin may
contribute to a cultural divide that, along with discrepancies in expectations, can exacerbate
patients’ perceptions of mistreatment. Because the Institute of Medicine (Smedley et al.,
2003) recommended increasing the minority health force as a remedy to health disparities,
more attention should be given to the nature of the patient-professional clinical encounter
among members of various ethnic and SES groups.
Despite the significance of the study findings, some limitations of the research must be
considered. First, one limitation was the moderately large amount of missing data, which
may have been due to the length of the survey instrument. Second, although findings from
the test of structural invariance revealed two statistically significant noninvariant structural
paths, the relatively small sample size may have resulted in the inability to detect additional
significant paths while adequately controlling for covariates. Furthermore, while the
theoretical model on which the hypothesized relations were based provided meaningful
support for the SEM findings, the cross-sectional design of this study did not allow for the
assessment of temporal relations of variables and thus causal relationships.
Another limitation of the study was the nature of the sample and data collection. For
instance, some degree of social acceptability bias may have occurred due to the use of self-
report instruments. In addition, the possibility of selection and participation biases may have
affected the generalizability of the findings. For instance, although the Latina population of
this study reflected the demographic reality of Southern California, the sample was
predominantly from a Mexican cultural background. Therefore, it is unclear whether the
hypothesized model will function similarly with Latinos from other national origins, regions
in the U.S., acculturation levels or educational levels. Furthermore, because the purpose of
this study was to examine the relation of perceptions of mistreatment and related emotions
to continuity of screening, only women who reported healthcare mistreatment were included
in the analyses. Therefore, due to the nature of the sample it was not possible to investigate
factors that may contribute to the lack of perceived mistreatment more generally. This
represents a noteworthy area of future research.
Although a number of professional level characteristics were considered as covariates in the
models tested, future research should also explore additional characteristics such as gender,
medical specialty, and Spanish fluency which may be particularly relevant to patients’
perceptions of mistreatment and continuity of cancer screening care. Consistent with
research regarding the role of patient language and satisfaction with care (Schutt, Cruz, &
Woodford, 2008), this research revealed that Latinos who completed the survey in English
reported greater intensity of mistreatment. Such findings warrant a better understanding of
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the role of language on perceptions of mistreatment. Other aspects relevant to perceptions of
mistreatment, such as the amount of time that has passed since the mistreatment incident
occurred and its influence on continuity of care also represent interesting questions for
future research.
The results, which emerged from the test of theory-based hypotheses, have important
implications for interventions with both health professionals and their diverse patients.
These findings should be used to educate and raise health professionals’ level of awareness
regarding the importance of effective patient-professional relations and their influence on
continuity of care. Such education efforts may in turn help to reduce disparities in continuity
of care as well as breast and cervical cancer screening among Latino and Anglo American
women in the U.S.
Results concerning the moderating role of ethnicity, suggest that efforts designed to improve
relations among healthcare professionals and their Anglo as compared to Latino patients,
may want to emphasize different aspects. For instance, in working with Anglo patients,
healthcare professionals may be more effective at improving continuity of cancer screening
care by recognizing their patients’ perceptions of the clinical interactions. In fact, a greater
understanding of patients’ causal attributions for the negative interpersonal incident could
greatly improve intervention efforts and patient-physician relations. When working with
Latino patients, healthcare professionals may want to pay attention to not only their patients’
perceptions of the clinical encounter but also to their emotional reactions to these
interactions. Furthermore, because cultural beliefs are relevant to health behavior,
interventions should address the cultural constructs (Borrayo, Thomas, & Lawsin, 2004)
relevant to improving continuity of care.
Acknowledgments
This research was supported by a NIH grant 1R21CA101867-01A2 to H. Betancourt, PI, through the National
Cancer Institute and the Office of Research on Women’s Health.
We would like to thank Jennifer Tucker for her assistance with data collection as well as Dr. Ellen Gold and three
anonymous reviewers for their valuable comments on an earlier version of this article. We would also like to thank
the women that graciously agreed to participate in this study and the community organizations that facilitated this
process.
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Figure 1.
Betancourt’s model of culture and behavior adapted for the study of health behavior
(Betancourt & Flynn, 2009)
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Figure 2.
Final model with estimated path coefficients and factor loadings for Latino and Anglo
subgroups.
*p < .05; **p < .01; ***p < .001.
Note. Paths for Anglo Americans are represented in parentheses. Variance from a number of
covariates (see Table 3) were controlled for prior to SEM.
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Table 1
Demographic Characteristics of Study Participants by Ethnicity
Latino
(n = 140) Anglo
(n = 123)
n (%) n (%)
Annual Household Income*
< $14,999 35 (25.00) 23 (18.70)
$15-24,999 22 (15.71) 14 (11.38)
$25-39,999 29 (20.71) 20 (16.26)
$40-59,999 22 (15.71) 20 (16.26)
< $60,000 32 (22.86) 46 (37.40)
Education*
Less than high school 40 (28.57) 8 (6.50)
High school 29 (20.71) 26 (21.14)
1-2 yrs college 39 (27.86) 38 (30.89)
3-4 yrs college 16 (11.43) 15 (12.20)
< 4 yrs college 16 (11.43) 36 (29.27)
Marital Status
Single 34 (24.29) 20 (16.26)
Married 76 (54.29) 70 (56.91)
Divorced 23 (16.43) 22 (17.89)
Widowed 6 (4.29) 11 (8.94)
Not specified 1 (0.71) 0 (0.00)
Health insurance*106 (75.14) 115 (93.50)
Usual place of health care*
Emergency room/county or community hospital 41 (29.29) 12 (9.76)
Private doctor/private or university hospital 99 (70.71) 111 (90.24)
Normally see same doctor 103 (73.57) 98 (79.68)
Patient-professional ethnic concordance*20 (14.29) 46 (37.40)
Place of birth*
Mexico 47 (33.57) 0 (0.00)
Central America/Caribbean 8 (5.71) 0 (0.00)
South America 2 (1.43) 0 (0.00)
Canada 0 (0.00) 2 (1.63)
Europe 0 (0.00) 3 (2.44)
Not specified 1 (0.71) 0 (0.00)
United States 82 (58.57) 118 (95.93)
Spanish survey*41 (29.29) 0 (0.00)
Mean (SD)Mean (SD)
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Latino
(n = 140) Anglo
(n = 123)
n (%) n (%)
Age in years*39.74 (13.08) 47.72 (15.56)
Number of doctor visits past 2 years 6.10 (11.04) 6.30 (6.00)
*p < .05 for differences between the Latinas and Anglos
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Table 2
Perceptions of Interpersonal Healthcare Mistreatment
Ever Experienced
n(%) Perceived as Mistreatment
n(%) Intensity
M(SD)
Latino Anglo Latino Anglo Latino Anglo
Did not listen to me or give me a chance to say all
of the things I wanted to say 130 (92.86) 112 (91.06) 70 (50.00) 62 (50.40) 3.46(1.84) 2.94(1.77)
Did not explain things to me or provide me with
enough information 133 (95.00) 120 (97.56) 71 (50.70) 60 (48.80) 3.53(1.91) 2.75(1.57)
Used words that I did not understand 137 (97.86) 118 (95.94) 73 (52.10) 53 (43.10) 3.53(1.92) 2.65(1.47)
Did not act friendly towards me 135 (96.43) 120 (97.56) 65 (46.40) 54 (43.9) 3.25(1.92) 2.70(1.52)
Did not pay attention to my need for privacy 136 (97.14) 118 (95.94) 60 (42.90) 43 (35.00) 3.23(1.98) 2.37(1.64)
Treated me like an object 136 (97.14) 116 (94.31) 51 (36.40) 49 (39.80) 3.18(1.87) 2.19(1.28)
Kept me waiting terribly long 135 (96.43) 122 (99.19) 99 (70.70) 82 (66.70) 3.64(1.94) 3.28(1.67)
Rushed or hurried when he/she treated me 136 (97.14) 120 (97.56) 83 (59.20) 65 (52.80) 3.27(1.88) 2.86(1.67)
Did not return my calls 131 (93.57) 104 (84.55) 59 (42.10) 37 (30.10) 3.74(1.96) 2.57(1.73)
Did not treat me with respect 136 (97.14) 119 (96.75) 54 (38.60) 37 (30.10) 3.26(2.03) 2.27(1.39)
Was not totally honest with me about my condition 135 (96.43) 115 (93.50) 58 (41.40) 28 (22.80) 3.48(1.97) 2.21(1.40)
Mean (SD) for all negative interpersonal incidents 10.61 (1.70) 10.42 (1.68) 5.31 (4.21) 4.63 (4.02) 3.27 (1.60) 2.67 (1.31)
Note. Intensity rating ranges from 1 to 6. Boldface indicates that groups differ significantly at p < .05.
*p < .05,
**p < .01,
***p < .001.
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Table 3
Correlation Coefficients for Covariates
Intensity
of
Mistreatment
Cumulative
Mistreatment
Experience
Continuity of
Care:
Professional
Continuity of
Care:
Facility
Latino
Usual place of healthcare −.182
*
- - -
Have a regular HCP −.256
**
-.201*-
Patient- HCP ethnic concordance .174*- - -
Survey language .203*- - −.168
*
Anglo - - - -
Usual place of healthcare −.188
*
- - -
Have a regular HCP −.232
**
-.226*-
Patient- HCP ethnic concordance - - .217*-
Number of HCP visits in 2 years - −.235
**
- -
Note. A dash indicates the correlation was not significant. HCP = healthcare professional
*p < .05,
**p < .01,
***p< .001.
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Table 4
Intercorrelations, Means, and Standard Deviations as a Function of Ethnicity
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
1. SES --
2. Education .786 *** --
3. Income .817 *** .642*** --
4. Age .150 .118 .122 --
5. Cultural beliefs about healthcare
professionals −.322
***
-.253** −.263
**
−.149 --
6. Parcel 1 −.261
**
−.205
*
−.213
*
−.120 .809*** --
7. Parcel 2 −.270
**
−.212
*
−.220
**
−.124 .837*** .677*** --
8. Perceptions of healthcare mistreatment −.165 −.130 −.135 −.076 .513*** .415*** .429*** --
9. Mistreatment intensity −.122 −.096 −.100 −.056 .378*** .306*** .317*** .737*** --
10. Cumulativemistreatment experience −.139 −.110 −.114 −.064 .432*** .350*** .362*** .843*** .621*** --
11. Anger toward professional −.068 −.054 −.056 −.032 .212*.172*.178*.414*** .305*** .348*** --
12. Continuity of care −.034 −.027 −.028 −.016 .105 .085 .088 .075 .056 .063 −.248
**
--
13. Healthcare professional −.031 −.024 −.025 −.014 .095 .077 .080 .068 .050 .058 −.225
**
.907 *** --
14. Healthcare facility −.031 −.024 −.025 −.014 .097 .078 .081 .069 .051 .059 −.229
**
.922 *** .836*** --
M2.76 2.56 2.95 39.74 2.63 2.74 2.52 0.52 3.69 0.51 2.76 4.52 4.39 4.51
(3.39) (3.37) (3.42) (47.72) (2.19) (2.30) (2.07) (0.48) (3.03) (0.46) (2.71) (4.93) (4.47) (4.94)
SD 1.28 1.32 1.49 13.08 1.49 1.52 1.75 0.37 1.98 0.39 2.16 2.13 2.18 2.13
(1.27) (1.28) (1.54) (15.56) (1.11) (1.22) (1.22) (0.33) (1.95) (0.37) (1.94) (2.13) (2.08) (2.19)
Note. Intercorrelations for Latinos (n = 140) are in upper portion of cell, values in parentheses represent Anglos (n = 123). Boldface indicates that groups differ significantly at p < .05. Parcel 1 includes 3
items and Parcel 2 includes 2 items from the CCSS.
*p < .05,
**p < .01,
***p < .001.
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Table 5
Model summary for tests of configural, measurement, and structural invariance across ethnicity
Model χ 2df CFI*RMSEA*(90% CI) Model
Comparison Δ χ2Δ df Δ CFI*
Model 1 Configural
No constraints 58.43 60 1.00 <.001 (.000, .036) — — — —
Model 2 Measurement Model
(factor loadings constrained across ethnicity) 59.13 65 1.00 .000 (.000, .030) 2 vs. 1 0.70 5 .000
Model 3 Structural Model
(constrained factor loadings and 7 structural paths) 81.58 72 1.00 .023 (.000, .044) 3 vs. 2 22.45** 7 .000
Model 4 Structural Model
(constrained factor loadings and 6 structural paths,
released Mistreatment*→Continuity*)72.96 71 1.00 .010 (.000, .038) 4 vs. 2 13.83*6 .000
Model 5 Structural Model
(constrained factor loadings and 5 structural paths,
released Mistreatment*→Continuity* and
Anger→Continuity*)
67.49 70 1.00 <.001 (.000, .033) 5 vs. 2 8.36 5 .000
*Note. CFI = Comparative Fit Index; RMSEA = Root Mean Square Error of Approximation; Mistreatment = Perceived Healthcare Mistreatment; Continuity = Continuity of Cancer Screening Care
**p = .002;
*p = .032.
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Table 6
Standardized Path Coefficients for Tests of Hypotheses
Latino Anglo Path
Moderated
Hypothesis 1
Direct paths:
Mistreatment→Continuity of Care .17 −.56
*
Yes
Mistreatment→Anger .41*** .55*** No
Indirect paths:
Mistreatment→Anger→Continuity of Care −.12
**
.02 —
Hypothesis 2
Direct paths:
Cultural Beliefs→Continuity of Care .09 .19 No
Cultural Beliefs→ Mistreatment .51*** .73*** No
Indirect paths:
Cultural Beliefs→Mistreatment→Continuity of Care .00 −.39
*
—
Cultural Beliefs→Mistreatment→Anger→Continuity of Care −.07
***
.02 —
Hypothesis 3
Anger→Continuity of Care −.34
***
.04 Yes
Note. Mistreatment = Perceived healthcare mistreatment; Cultural Beliefs = Cultural beliefs about healthcare professionals
*p < .05,
**p < .01,
***p< .001.
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