Despite guaranteed access to services and recent gains in narrowing gaps in service utilization and health outcomes, racial healthcare disparities persist in the VA healthcare system, including mental healthcare. Patient-provider communication has been identified as a significant contributor to racial healthcare disparities. Yet, the views and experiences of racial and ethnic minority Veterans regarding health communication, particularly shared decision-making (SDM) processes in mental healthcare, remain understudied. Lack of understanding of minority groups' experiences and views of patient-provider communication processes limit the VA's efforts to provide equitable, evidence-based, and person-centered care to all Veterans, especially racial minority Veterans, a fast- growing Veteran population. To begin to address these issues, this project focused on African-American Veterans, and aimed to identify the factors and processes that influence minority Veterans' mental health communication, with the long-term goal to reduce racial healthcare disparities in the VA mental healthcare system.
This project included several objectives. First, we assessed how African-American Veterans with mental illness view treatment decision-making in psychiatric encounters. Second, we examined barriers and facilitators to SDM. Third, we compared views and factors affecting SDM between African-American Veterans from this study and White Veterans from a historical control group.
Participants in the study were 36 African-American Veterans with a diagnosis of mental illness receiving psychiatric outpatient medication management. We conducted semi-structured qualitative interviews and analyzed the data using an inductive approach informed by grounded theory. We also administered self-report measures that assessed patient-provider working alliance, attitudes towards medication, patient activation, and preferences for treatment decision-making. We examined the relationship between race and participants' characteristics on all measures, and compared African-American and White Veterans using t-tests, chi squares, and step-wise linear regression.
Participants in the study understood the concept of SDM and described it in terms that are consistent with definitions of SDM in the literature. They emphasized inclusion, collaboration, and agreement with providers as key components of SDM. For many participants, inclusion was particularly important; they want to be included in the treatment decision-making process and informed of treatment choices as well as providers' rationale for their treatment decisions. Most participants, 83% preferred to have a collaborative treatment decision making process with their mental health providers. However, only 40% reported that they actually experienced their preferred method of treatment decision making.
Participants identified several Veterans, providers, and system-level barriers barriers to their participation in SDM. Veteran-focused barriers include Veterans' lack of knowledge about how to initiate and participate in SDM, Veterans' low level of self-efficacy, ambivalence about treatment, and fear - fear of making poor decisions, of being judged, and of being retaliated against. Examples of provider-focused barriers are providers' openness to SDM and negative patient-provider relationship. System-level barriers include shortage of providers, providers' burnout, and lack of time.
Study findings also indicated that attention to the broader context of patient engagement as well as to Veterans' social contexts, such as their racial identity and lived experiences, are necessary for successful SDM. Participants viewed providers' lack of understanding of their socioeconomic conditions, which include their experiences as African-Americans, as a key barrier to engagement in services and participation in SDM. In contrast, active patient engagement, which involves patient activation, and strong patient-provider relationships appear to be prerequisites for SDM.
Comparisons between African-American and White Veterans (N=141) on two key aspects of patient engagement - patient activation and working alliance, showed significant differences. After adjusting for demographics, race was significantly associated with patient activation, working alliance, and medication adherence scores. African-American Veterans had significantly lower levels of patient activation and working alliance than White Veterans. Patient activation was also associated with working alliance, even after adjusting for sociodemographic factors and participants' length of time with their providers. Further, item-by-item examination of the Patient Activation Measure-MH indicated that African-American Veterans scored lower on items related to self-efficacy and patient-provider communication (e.g., "I am confident that I can tell my mental health clinician concerns I have even when he or she does not ask.").
Participants provided several suggestions for improving patient-provider communication among African-American and other minority Veterans. They involved 1) the use of peer support specialists to reach out to minority Veterans and to facilitate engagement in mental health services, 2) organizational support and resources to assist providers in their efforts to engage Veterans in SDM, which may include addressing issues such as staff burnout, providers' high caseloads, provider shortage, and time needed for providers to build relationships with Veterans, 3) stronger working alliance and relationships between Veterans and providers, and 4) providers' positive modeling and coaching in SDM.
Improving patient-provider communication among minority groups may potentially lead to better Veterans' health outcomes and reduced healthcare disparities. In this study, we identified several barriers to African-American Veterans' participation in SDM and engagement in mental health services. African-American Veterans experienced lower levels of self-efficacy compared to their White counterparts, which influence their participation in SDM and engagement in mental health services. Our findings suggest that interventions to promote SDM for minority Veterans should incorporate aspects of patient engagement, such as patient activation, and patients' social contexts. Our findings also indicate that organizations have an important role to play to support providers and Veterans in increasing their participation in SDM.
- Eliacin J, Coffing JM, Matthias MS, Burgess DJ, Bair MJ, Rollins AL. The Relationship Between Race, Patient Activation, and Working Alliance: Implications for Patient Engagement in Mental Health Care. Administration and policy in mental health. 2018 Jan 1; 45(1):186-192.
- Eliacin J, Rollins AL, Burgess DJ, Salyers MP, Matthias MS. Patient activation and visit preparation in African American veterans receiving mental health care. Cultural Diversity & Ethnic Minority Psychology. 2016 Oct 1; 22(4):580-587.
- Eliacin J, Rollins AL, Burgess DJ, Salyers MP, Matthias MS. Engaging African-American Veterans in Mental Health Care: Patients' Perspectives. The Journal of nervous and mental disease. 2016 Apr 1; 204(4):254-60.
- Eliacin J. Culture and Communication: The promise of shared decision-making to improve patient-provider communication among ethnic minority patients. Addressing Indiana's Mental Health in Urban and Rural Populations [Cyberseminar]. Indiana University-Purdue University Indianapolis. 2016 May 20.
- Eliacin J. Culture and Communication: The promise of shared decision-making to improve patient-provider communication among ethnic minority patients. Paper presented at: Indiana University Purdue University at Indianapolis Shared Decision Making Annual Summit; 2016 May 20; Indianapolis, IN.