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Racial and Ethnic Concordance
Literature Review Abstracts

Blank MB. Tetrick FL III. Brinkley DF. Smith HO. Doheny V.
Racial Matching and Service Utilization Among Seriously Mentally Ill Consumers in The Rural South.
Community Mental Health Journal, 30(3):271-81, 1994 Jun. (38 ref)

The authors examined racial matching between case manager and client for 677 seriously mentally ill consumers served through a rural community mental health center in the southeastern United States. Nonparametric statistics indicated that client-case manager dyads were more likely to be of the same race than of different races. Same-race dyads tended to have greater service utilization as indicated by a greater number of made appointments over the study period. An interaction was found for failed appointments where African Americans in same-race dyads were more likely to fail appointments, while Caucasian consumers in same-race dyads were less likely to fail appointments. (38 ref)  

Cooper LA
Patient-Physician Race Concordance and Communication in Primary Care
A Study Funded by The Commonwealth Fund 1/101-3/31/02
Johns Hopkins Medical Institutions
Welch Center for Prevention, Epidemiology, & Clinical Research

Rationale: Numerous studies show that ethnic minority patients receive less optimal health care than white patients. However, relatively few studies have focused on racial differences in interpersonal aspects of care. Recent work shows that ethnic minority patients in race-discordant relationships have lower ratings of partnership with physicians, satisfaction, and perceived quality of care. (Cooper-Patrick et al, 1999, Saha et al, 1999) We are not aware of any published empirical studies of actual communication behaviors by patient and physician race/ethnicity. Understanding and improving physicians’ ability to communicate effectively with patients from ethnically and socially diverse backgrounds is essential to reducing disparities in health.

Objectives: The primary objectives of the proposed study are:

1. to use audiotape analysis to explore the ways in which race concordance affects patient-physician communication and
2. to describe how patient ratings of physicians’ participatory decision-making are associated with race concordance and with audiotape measures of patient-centered communication behaviors.

Secondary objectives are to explore the extent to which patient and physician attitudinal variables explain the differences in patient ratings of care by race concordance with physicians. We have chosen to limit this study to African-American and white patients and physicians in typical primary care practices. Future work will include physicians and patients of other ethnic groups and patients belonging to other underserved groups (i.e., individuals with chronic illness, low socioeconomic status, and inadequate health insurance coverage).

Expected Significance: First, the results from this study will inform health policy-makers in federal, state, and local organizations about how to make decisions that will address the needs of ethnic minority patients and their communities. Second, the study will identify important factors to incorporate in health professionals’ communication skills and cultural competence training. Third, the study will identify the important elements to include in ethnic minority patient activation and empowerment programs. Evidence from previous work in patient-physician communication suggests that these strategies aimed at providers and patients could improve outcomes and reduce racial and ethnic disparities in health care by increasing ethnic minority patients’ participation in medical decision-making. Fourth, this study may serve as a model for future research to explain how race concordance impacts upon health care for patients belonging to other racial and ethnic groups and how increasing patient-centered communication behaviors and cultural competence can be used to improve health care for patients belonging to other vulnerable groups.  

Flaskerud JH.
Matching Client and Therapist Ethnicity, Language, and Gender: A Review of Research.
[Review] [39 refs] Issues in Mental Health Nursing. 11(4):321-36, 1990.

The purpose of this article is to examine whether therapy process and outcome are influenced by a client-therapist ethnicity, language, or gender match. A review of research in this area does not demonstrate support for a client-therapist match on any of these variables. The methodological problems and unresolved conceptual issues involved in this research may limit the findings. The ethical and political context of the research and the implications for mental health nursing are explored. [References: 39]    

Flaskerud JH.
The Effects of Culture-Compatible Intervention on The Utilization of Mental Health Services by Minority Clients.
Community Mental Health Journal. 22(2):127-41, 1986 Summer.

This study examined the relationship between a culture-compatible approach to mental health service and utilization as measured by dropout and total number of outpatient visits. The sample (N = 300) was 23.5% Mexican, 22.8% White, 18.1% Black, 17.1% Vietnamese, 16.8% Filipino, and 1.7% other ethnic group. A culture-compatible approach was found to be effective in increasing utilization. Three culture-compatibility components were the best predictors of dropout status: language match of therapists and clients, ethnic/racial match of therapists and clients, and agency location in the ethnic/racial community. Pharmacotherapy, education, previous treatment and a diagnosis of psychosis were significantly related to remaining in therapy.  

Flaskerud JH. Akutsu PD.
Significant Influence of Participation in Ethnic-Specific Programs on Clinical Diagnosis for Asian-Americans.
Psychological Reports. 72(3 Pt 2):1228-30, 1993 Jun.

Flaskerud JH. Hu LT.
Participation in and Outcome of Treatment for Major Depression Among Low Income Asian-Americans.
Psychiatry Research. 53(3):289-300, 1994 Sep.

This study examined the relationship of four aspects of psychiatric treatment (use of medication, client-therapist ethnic match, treatment in an Asian-specific clinic, and professional therapist) to participation in treatment and outcome of treatment in low income Asian-American clients (n = 273) of the Los Angeles County mental health system who were diagnosed with major depression. Based on cultural responsiveness theory, the study tested the hypothesis that use of medication in treatment would have the greatest effect on participation and outcome followed, in order, by client-therapist ethnic match, treatment in an Asian-specific clinic, and treatment by a professional therapist. The hypotheses were largely supported: treatment with medication had a significant relationship to total number of treatment sessions (participation) and improvement in the admission-discharge Global Assessment Scale (GAS) score (outcome). Treatment by a therapist of the same ethnicity as the client and treatment in an agency designated to provide services to Asian clients both had significant relationships to the number of treatment sessions but not to GAS score improvement. Four covariates included in the analysis and treatment by a professional therapist had no relationship to either of the dependent variables.  

Flaskerud JH. Liu PY.
Effects of An Asian Client-Therapist Language, Ethnicity and Gender Match on Utilization and Outcome of Therapy.
Community Mental Health Journal. 27(1):31-42, 1991 Feb.

The purpose of this study was to examine the relationship of Asian client-therapist ethnicity, language and gender match on two measures of utilization: number of sessions with primary therapist and dropout from therapy; and one measure of client outcome: admission-discharge difference in Global Assessment Scale (GAS) scores. The sample consisted of 1746 Asian client episodes in Los Angeles County mental health facilities between January 1983 and August 1988. Various types of multiple regression analyses were used to investigate the relationship of language, ethnicity, and gender match to the three dependent variables and to eight socio-demographic variables. Either client-therapist language match or ethnic match significantly increased the number of client sessions with the primary therapist. However, only ethnicity match had a significant effect on dropout rate. Gain in GAS admission-discharge score was not affected by either a client-therapist ethnicity or language match. Gender match had no consistent effect on the dependent variables. Of the covariates examined, only therapist discipline (social worker) had a consistent effect on the dependent variables. It was concluded that both client-therapist language and ethnicity match are important variables affecting the utilization of treatment. Further research will be needed to separate the effects of language and ethnicity on therapy utilization.  

Flaskerud JH. Liu PY.
Influence of Therapist Ethnicity and Language on Therapy Outcomes of Southeast Asian Clients.
International Journal of Social Psychiatry. 36(1):18-29, 1990 Spring.

The purpose of this study was to examine the relationship of Southeast Asian client-therapist ethnicity and language match on three therapy outcomes: number of sessions with primary therapist, dropout from therapy and admission-discharge difference in Global Assessment Scale (GAS) scores. The sample consisted of 543 Southeast Asian client episodes in Los Angeles County mental health facilities between January 1983 and August 1988. Various types of multiple regression analyses were used to investigate the relationship of language and ethnicity match to the three outcome variables and to eight sociodemographic variables. Either therapist-client language or ethnicity match significantly increased the number of client sessions with the primary therapist. Dropout from therapy was significantly affected by a language match in the Cambodian sample only but the effect was to increase dropout. Neither ethnicity nor language match was significantly related to GAS score gain. Several possible explanations for these findings and their clinical significance were explored.    

Flaskerud JH. Soldevilla EQ.
Filipino and Vietnamese Clients: Utilizing an Asian Mental Health Center.
Journal of Psychosocial Nursing & Mental Health Services. 24(8):32-6, 1986 Aug.  

Handler A. Raube K. Kelley MA. Giachello A.
Women's Satisfaction with Prenatal Care Settings: A Focus Group Study.
Birth. 23(1):31-7, 1996 Mar.

Background: Patient satisfaction is considered, together with health status, to be an outcome of the delivery of health care services as well as a measure of its quality. A focus group study of 50 low-income Mexican-American Puerto Rican, African-American, and white women in Chicago, Illinois, explored the characteristics of prenatal care that affect women's satisfaction.

Methods: Transcripts from the focus groups were analyzed using researcher-derived coding categories to develop broad themes.

Results: Despite their diverse ethnic backgrounds, participants revealed few differences with respect to what they value in prenatal care. Aspects of care that appeared to affect women's satisfaction included the "art of care, " the technical competence of the practitioner, continuity of caregiver, and the atmosphere and physical environment of the care setting. The one characteristic that did not appear to affect satisfaction was the caregiver's ethnicity.

Conclusion: Knowledge of how the characteristics of prenatal care affect women's satisfaction can help increase use of care and ultimately improve perinatal outcomes.

Komaromy M. Grumbach K. Drake M. Vranizan K. Lurie N. Keane D. Bindman AB.
The Role of Black and Hispanic Physicians in Providing Health Care for Underserved Populations.
New England Journal of Medicine, 334(20):1305-10, 1996 May 16. (17)

Nickens HW.
The Rationale for Minority-Targeted Programs in Medicine in The 1990s.
JAMA. 267(17):2390, 2395, 1992 May 6.

Porter JR. Beuf AH.
The Effect of A Racially Consonant Medical Context on Adjustment of African-American Patients to Physical Disability.
Medical Anthropology. 16(1):1-16, 1994 Nov.

The effect of a racially consonant medical context on reaction to physical handicap stemming from disease is explored in a sample of 90 African-American patients with vitiligo, a disfiguring skin disorder. The adjustment of sixty-nine patients in a predominantly black hospital setting is compared to that of twenty-one patients in a predominantly white hospital setting. The patients in the predominantly black clinic, where the physicians, staff, and clientele are African-American, show significantly better adjustment than do African-American patients in a medical context that is primarily white. Interviews with a random sample of one-third of the patients in each clinic show that patients are significantly more positive to black physicians and a black hospital setting and that other patients of the same race provide informal networks of support, as does the predominantly African-American community in which the hospital is located. Implications for both medical theory and practice are suggested on the basis of these findings.

Saha S. Taggart SH. Komaromy M. Bindman AB.
Do Patients Choose Physicians of Their Own Race?
Health Affairs. 19(4):76-83, 2000 Jul-Aug.

This study seeks to determine whether minority Americans tend to see physicians of their own race as a matter of choice or simply because minority physicians are more conveniently located within predominantly minority communities. Using data from the Commonwealth Fund 1994 National Comparative Survey of Minority Health Care, we found that black and Hispanic Americans sought care from physicians of their own race because of personal preference and language, not solely because of geographic accessibility. As minority populations continue to grow, the demand for minority physicians is likely to increase. Keeping up with this demand will require medical school admissions policies and physician workforce planning to include explicit strategies to increase the supply of underrepresented minority physicians.  

Saha S. Komaromy M. Koepsell TD. Bindman AB.
Patient-Physician Racial Concordance and The Perceived Quality and Use of Health Care.
Archives of Internal Medicine. 159(9):997-1004, 1999 May 10.

Background: Patients from racial and ethnic minority groups use fewer health care services and are less satisfied with their care than patients from the majority white population. These disparities may be attributable in part to racial or cultural differences between patients and their physicians.

Objective: To determine whether racial concordance between patients and physicians affects patients' satisfaction with and use of health care.

Methods: We analyzed data from the 1994 Commonwealth Fund's Minority Health Survey, a nationwide, telephone survey of noninstitutionalized adults. For the 2201 white, black, and Hispanic respondents who reported having a regular physician, we examined the association between patient-physician racial concordance and patients' ratings of their physicians, satisfaction with health care, reported receipt of preventive care, and reported receipt of needed medical care.

Results: Black respondents with black physicians were more likely than those with nonblack physicians to rate their physicians as excellent (adjusted odds ratio [OR], 2.40; 95% confidence interval [CI], 1.55-3.72) and to report receiving preventive care (adjusted OR, 1.74; 95% CI, 1.01-2.98) and all needed medical care (adjusted OR, 2.94; 95% CI, 1.10-7.87) during the previous year. Hispanics with Hispanic physicians were more likely than those with non-Hispanic physicians to be very satisfied with their health care overall (adjusted OR, 1.74; 95% CI, 1.01-2.99).

Conclusions: Our findings confirm the importance of racial and cultural factors in the patient-physician relationship and reaffirm the role of black and Hispanic physicians in caring for black and Hispanic patients. Improving cultural competence among physicians may enhance the quality of health care for minority populations. In the meantime, by reducing the number of underrepresented minorities entering the US physician workforce, the reversal of affirmative action policies may adversely affect the delivery of health care to black and Hispanic Americans.

Sawyer L. Regev H. Proctor S. Nelson M. Messias D. Barnes D. Meleis AI.
Matching Versus Cultural Competence in Research: Methodological Considerations.
Research in Nursing & Health, 18(6):557-67, 1995 Dec. (51 ref)

Objective: The purpose of this paper is: to consider the complexities in using matching in research with diverse populations; to challenge the idea that matching of researchers and participants is the only strategy for generating culturally valid knowledge, and to argue that cultural competence, as a synthesis of cultural knowledge, sensitivity, and collaboration, could be used in facilitating the development of culturally competent nursing knowledge.

Design: NA.

Setting: NA.

Population: NA.

Interventions: NA.

Main Outcome Measure(s): NA.

Results/ Conclusions: Conceptual issues for cultural matching in research projects include:

1. what to match (ethnicity, geographic area and/or residence, language, social class, social values, gender, etc.),
2. when to match (during question development), data collection, data analysis, dissemination of findings,
3. and feasibility of matching (availability and costs).

Essential components in the conduct of culturally competent research include cultural knowledge, cultural sensitivity, and collaboration. Culturally competent knowledge will not be developed and expanded without methods and research processes that are more congruent with population diversity. We have argued that the complexity inherent in matching hinders, rather than promotes, the pursuit of cultural diversity in research. We further argued that matching may be one possible strategy but that it, in itself, does not ensure cultural competence in the research process.    

Snowden LR. Hu T. Jerrell JM.
Emergency Care Avoidance: Ethnic Matching and Participation in Minority-Serving Programs.
Community Mental Health Journal, 31(5):463-73, 1995 Oct. (18 ref)

Using data from a county level mental health service system, relationships were examined between ethnic matching, program involvement and emergency service use. When clients were matched with an ethnically similar clinician who was also proficient in their preferred language, they had fewer emergency service visits than did clients who were unmatched on the basis of ethnicity and language. Equally if not more significant than ethnicity or language matching was the client's program and the proportion of minority clients it served. Clients in programs serving a relatively large proportion of minority clients had fewer emergency service visits than those in programs serving a smaller proportion of minority clients. More research is needed to document the impact of matching along with greater attention to minority oriented programs. (18 ref)    

Takeuchi DT. Sue S. Yeh M.
Return Rates and Outcomes from Ethnicity-Specific Mental Health Programs in Los Angeles.
American Journal of Public Health. 85(5):638-43, 1995 May.

Objectives: The present study compared the return rate, length of treatment, and treatment outcome of ethnic minority adults who received services from ethnicity-specific or mainstream programs.

Methods: The sample consisted of 1516 African Americans, 1888 Asian Americans, and 1306 Mexican Americans who used 1 of 36 predominantly White (mainstream) or 18 ethnicity-specific mental health centers in Los Angeles County over a 6-year period. Predictor variables included type of program (ethnicity specific vs mainstream), disorder, ethnic match (whether or not clients had a therapist of the same ethnicity), gender, age, and Medi-Cal eligibility. The criterion variables were return after one session, total number of sessions, and treatment outcome.

Results: The study indicated that ethnic clients who attended ethnicity-specific programs had a higher return rate and stayed in the treatment longer than those using mainstream services. The data analyses were less clear cut when treatment outcome was examined.

Conclusions: The findings support the notion that ethnicity-specific programs seem to increase the continued use of mental health services among ethnic minority groups.

Turner CB. Turner BF.
Psychology Department, University of Massachusetts, Boston 02125-3393, USA.
Who Treats Minorities?
Cultural Diversity & Mental Health. 2(3):175-82, 1996.

We studied the characteristics of psychological service providers who treat ethnic minority clients in a representative random sample of psychologists listed in the National Register of Health Service Providers (NR) in 1986. Ethnic minority providers saw more than twice the proportion of ethnic minority clients than did non-Latino White providers (24.0% and 11.7%, respectively). Providers with cognitive-behavioral clinical/theoretical orientations saw significantly more ethnic minority clients than did those with psychodynamic or other orientations. Providers with eclectic orientations saw significantly more ethnic minority clients than did those with psychodynamic orientations, but eclectic providers did not differ from any other provider orientation group. The results suggest that more ethnic minority providers are needed and that other providers need to increase their ethnic minority clientele.  

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