Commentary on Patient-Provider Communication Quality, 2002–2016: A Population-based Study of Trends and Racial Differences

It has been over 2 decades since the US Department of Health and Human Service implemented the National Standards for culturally and Linguistically Appropriate Services (CLAS) standards1 to emphasize on engaging culturally and linguistically appropriate patient-provider communication as a strategy to improve access to health care and reduce health disparities was introduced.2,3 Culturally and linguistically appropriate services are vital to improving the quality of health services provided to all individuals, specifically those who have limited English proficiency (LEP). Quality health care and patient outcomes rely upon being able to communicate with providers, especially in a patient’s preferred language.4 This requires having access to health care and quality languages services for patients with LEP in the health care setting as directed in Title VI of the Civil Rights Act of 1964.5 Yet, studies consistently show that Asian Americans continuously report worse health care experiences than any other racial and ethnic groups in the United States.6

Cho and Chang’s7 study recognized the importance of including understudied Asian patients as a separate subgroup in the data compared with other races and ethnicities. Their study findings are consistent with racial/ethnic disparities in patient experiences, specifically Asian Americans’ low-quality patient-provider communication in health care settings. Researchers have suggested that this experience could be attributed to language barriers, cultural nuances, and/or Asians’ tendency to select options at the extreme ends of a response scale.8,9

In this commentary, the authors attempt to address the following questions: “Why do Asian patients continuously have the lowest quality of patient-provider communication over time?” and “What needs to be considered when examining the rating of patient-provider communication in Asian patients?”

WHY DO ASIAN PATIENTS CONTINUOUSLY HAVE THE LOWEST QUALITY OF PATIENT-PROVIDER COMMUNICATION OVER TIME?

Asian Americans’ sociodemographic characteristics alone, such as education, income, and health care access, do not sufficiently explain the health disparities they experience compared with other racial/ethnic groups.10,11 Existing studies of Asian Americans have either lumped them into a single group labeled “Asian Americans and Pacific Islanders,” collapsed into the category of “Other,” or excluded Asians as a racial group altogether. Thus, little or no accurate population-based data on Asian and Pacific Islander subgroups exist to identify their unique health problems.10,11 It is important to recognize that Asian American and Pacific Islanders encompass >50 ethnic subgroups that speak >100 dialects with a wide range of cultures, traditions, identities, and experiences; thus, aggregating health data of Asian Americans mask meaningful differences in Asian American subgroups.10,11 Although there are existing studies that compare the differences among American and Pacific Islanders, there are marked differences in sociodemographic characteristics, English fluency, immigration status, and health literacy, which impact health outcomes and the quality of patient-provider communication. Therefore, future studies should disaggregate Asian American health data by subgroup to provide meaningful health data and apply this knowledge to the planning and delivery of health care. For example, a previous study12 that examined patient-provider communication on cancer screenings among 5 Asian ethnic groups using the Health Information National Trends Survey demonstrated higher patient-provider communication satisfaction among higher education levels, English fluency, and health care access. While Japanese patients had higher ratings for overall patient-provider communication, Chinese patients rated lowest for the involvement in decisions about health care and the trust in providers, Vietnamese rated lowest for the chance to ask health-related questions and the time spent, Koreans rated lowest for the attention given to feeling and emotions and the management of uncertainly.12 The cultural differences between Asian patients and health care providers and Asian patients’ definition of effective patient-provider communication may result in poor outcomes of patient-provider communication.

Consequently, implications of low-quality patient-provider communication potentially may lead to decreased use of preventive services, lack of medical follow-up, higher rates of hospitalization, and drug complications.13 In the cancer screening literature, there has been substantial evidence showing that provider recommendation significantly improves cancer screening rates14; however, some studies have found alarmingly low provider-patient cancer screening communication.15 For Asians, a provider recommendation is the leading predictor of adherence to cancer screening.16,17 Therefore, culturally and linguistically appropriate, patient-centered strategies must be implemented to optimize high-quality patient-provider communication16 that will result in eliminating health disparities and improving health outcomes.

WHAT NEEDS TO BE CONSIDERED WHEN EXAMINING THE RATING OF PATIENT-PROVIDER COMMUNICATION IN ASIAN PATIENTS? Language Access

Aligning with Title VI of the Civil Rights Act, Section 1557 of the Affordable Care Act (ACA) entitles meaningful language access to individuals with LEP.18 Language access in health care occurs when patients are welcomed by providers regardless of their language ability and offered meaningful, quality language services as part of their care.19 For example, providing language assistance services to patients with LEP, including qualified interpreters and staff and written translations. Language access is a national health agenda and an important consideration in improving patient-provider communication, particularly among Asian Americans, for whom more than half (51% including 71% of Asian American adults) were born in another country.20 Only 57% of foreign-born Asians are proficient in English, and 66% of Asian American households speak a language other than English at home.20 Hence, language access is fundamental to LEP individuals accessing and receiving quality care.

Health Literacy

Health literacy, the ability of an individual to access, understand, and use health-related information and services to make appropriate decisions, is fundamental to reaching optimal health.21 Approximately one third to one half of the US adult population has low health literacy.22 A study of health literacy and health status among Asian Americans showed that low health literacy was significantly associated with self-reported poor health.23 Moreover, low health literacy is a barrier to managing chronic illnesses,22 using preventive services,24 and accessing health care.25 Given cultural and linguistic differences between patients and providers contribute to health disparities in Asian populations, efforts to promote health literacy among Asian American patients are essential.

Cultural Considerations

Many Asian Americans believe that their health care providers do not understand their cultural values and beliefs.7,26 As a result, they have less confidence in the care provided, leading to delayed diagnoses and worse outcomes. Asian culture (high-context culture) uses indirect and nonverbal communication (such as gestures, stance, eye contact, and tone) and focuses on underlying context, meaning, and tone in the message, and not just the words themselves. For example, Asian patients can misinterpret some nonverbal cues from health care providers that drive the perception of racial bias.27,28 In turn, Asian patients might perceive or experience poor clinical quality. Furthermore, racial bias in health care is a major contributor to health care disparities.29,30 Although most health care providers are committed to providing equitable treatment to all patients regardless of their racial background, they are not immune to social and cultural influences that can lead to implicit racial bias. Providers’ implicit racial biases can negatively impact the quality of patient-provider communication, patients’ health outcomes, and health care experiences.31,32

Responses to the Survey Questions

Researchers have also found that Asian Americans have a different response style to survey questions compared with other racial and ethnic groups.7,32 Some evidence suggests that Asian Americans tend to endorse middle response and avoid extreme responses, such as top or best choice in responding to surveys,7 while White, African American, and Hispanic students prefer extreme responses.33 Researchers suggested that a middling response style is culturally related to tendencies toward individualism or collectivism.32,33 Wang et al32 discussed that individuals living in collectivist cultures, such as Asians, are likely to select middle options because their cultures emphasize “the need to fit in with others and avoid conflict in society” (p. 2). While most Asians have a similar tendency in responding to the survey questions, it is important to remember that Asians are a heterogenous group with diverse backgrounds. Investigators should consider open-ended questions to better understand Asian patients’ cultural values and health care needs.

CONCLUSIONS

Improving the quality of patient-provider communication among racial/ethnic populations is a key factor in health equity. Specifically, future research is warranted to better understand the underlying factors that contribute to low-quality patient-provider communication in Asian Americans, specifically examining differences by Asian subgroups. Interventions aimed at narrowing the patient-provider communication disparity among Asian Americans should include concepts such as language access, health literacy, and cultural beliefs and values. These considerations for future research can foster meaningful dialogue, improve patient communication, empower patient engagement in their medical care, and ultimately improve patient outcomes.

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