Perceived racial discrimination is associated with negative health outcomes and behaviors, but the mechanisms underlying these relationships remain unknown. One possible mechanism is that perceived discrimination negatively influences patient perceptions of and interactions with the healthcare system. This pilot project was conducted to lay the groundwork for a study examining how patients' perceptions of past racial discrimination in healthcare settings influence their assessments of race concordant and race non-concordant physician-patient interactions in standardized video vignettes.
The objectives of this pilot work were to (1) produce professional videos of scripted physician-patient encounters, (2) pilot test the administration of videos and collection of survey responses from Veterans using a computer interface, and (3) provide preliminary data for effect size and power calculations for a larger study.
We developed 4 video vignettes in which a white or African American physician met with a white or African American patient with diabetes. The same script was used in all videos, with only the race of the video-physician and video-patient varying across videos. Preliminary versions of the videos were edited and finalized based on input gathered from African American and white Veterans who receive VA healthcare. We then developed and pilot-tested a computer-administered survey in which Veterans each viewed one randomly-assigned video and completed a survey about it using a laptop computer. The survey measured Veterans' evaluations of the quality of care depicted in the video, whether Veterans would recommend the video-physician to family or friends, and the extent to which Veterans thought that the video-patient would adhere to treatment recommendations. Veterans' perception of racial discrimination in their prior healthcare encounters (i.e., history of perceived discrimination) was also measured either before or after they watched the video. The sequence of the video and discrimination measure was counter-balanced across Veterans to account for the possibility that the order would affect Veterans' survey responses.
Veterans with diabetes were recruited from a single VA medical center via fliers, provider referrals, and word-of-mouth to complete the electronic surveys. Regression models were used to test whether the following were associated with Veterans' evaluations of overall quality of care in the video, willingness to recommend the video-physician, and the video-patient's likelihood of adherence: 1) Veteran race (African American vs. white), 2) main effects and interaction of video-physician and video-patient race, 3) main effect of Veterans' history of perceived discrimination, and 4) interactions between Veterans' history of perceived discrimination and video-physician and video-patient race. Due to the small sample, steps 2-4 of the models were conducted separately for African American and white Veterans. Sequence of the video and discrimination measure was controlled for in all analyses. Data were also used to calculate observed effect sizes and to estimate the number of Veterans needed to ensure adequate statistical power in a full-size study.
A total of 44 African American, 36 white, and 3 other-race Veterans viewed a randomly-assigned video and completed the electronic survey. Overall, the 4 videos were evaluated similarly to each other. African American and white Veterans did not differ in their evaluations of the videos with the following exception: African American Veterans were more likely to say they would recommend the African American video-physician than the white video-physician, whereas White Veterans were equally likely to recommend the white and African American video-physicians.
African Americans had a greater history of perceived discrimination than whites (Means=12.76 and 7.94, Standard Deviations=5.62 and 2.37, respectively, on a scale of 7-35). White Veterans' history of perceived discrimination was not associated with their evaluations of the care depicted in the videos, willingness to recommend the video-physician, or video-patient adherence, regardless of the race of the video-physician or video-patient. In contrast, African Americans' history of perceived discrimination was associated with their evaluations. Specifically, African American Veterans with greater histories of perceived discrimination: rated the quality of care received by the video-patient as lower (particularly when the video-patient was African American), were less likely to recommend the video-physician (regardless of the video-physician's or video-patient's race), and rated video-patients who met with the African American video-physician as less likely to adhere to treatment recommendations. The observed effect sizes tended to be small (change in R-squared ranged from .01-.09 across measures). A sample of 300-400 African American Veterans would provide sufficient statistical power to test the significance of effects similar in size to those observed in this pilot study.
This pilot study provides preliminary empirical evidence regarding the impact of Veterans' personal history of perceived racial discrimination in healthcare settings on their assessments of medical encounters. It thereby addresses an important gap in current understanding of the mechanisms by which discrimination can influence patient interactions with the healthcare system. The study findings, although based on a small sample, support the hypothesis that a history of perceived racial discrimination in healthcare can negatively affect how African American Veterans rate healthcare quality and healthcare providers. It underscores the importance of continuing to examine the role of perceived discrimination in the healthcare of Veterans, including the need to develop a better understanding of the circumstances under which perceived discrimination influences how Veterans perceive or interact with the healthcare system. This pilot study provides a strong foundation for the development of a larger study to examine this issue in a national sample of Veterans.
- Hausmann LR, Ibrahim SA. Racial and ethnic musculoskeletal health disparities and the role of culture. Paper presented at: Arthritis and Musculoskeletal Disparities National Summit; 2010 Sep 21; Bethesda, MD.