ethnic group in self advocacy during the medical encounter

Original article

Keywords Self advocacy Men Medical encounter African Americans Hispanics

Keith T. Elder, PhD University of Alabama at Birmingham, School of Health Professions, Health Services Administration, LRC 325A, 1530 3rd Ave South, Birmingham, AL 35294, USA Jacqueline C. Wiltshire, PhD Florida A & M University, Institute of Public Health, College of Pharmacy and Pharmaceutical Sciences, Frederick S. Humphries Science Research Center, 209-D, Tallahassee, FL, USA Luceta McRoy, MA University of Alabama at Birmingham, School of Health Professions, Health Services Administration Birmingham, AL, USA Dayna Campbell, MPH University of South Carolina, Arnold School of Public Health, Health Services Policy and Management, Columbia, SC, USA Lisa C. Gary, PhD University of Alabama at Birmingham, UAB School of Public Health, Department of Health Care Organization and Policy, Birmingham, AL, USA Monika Safford, MD University of Alabama at Birmingham, Division of Preventive Medicine, Birmingham, AL, USA E-mail: [email protected]

Online 21 April 2010

Men and differences by racial/ethnic group in self advocacy during the medical encounter Keith T. Elder, Jacqueline C. Wiltshire, Luceta McRoy, Dayna Campbell, Lisa C. Gary and Monika Safford Abstract Background: This study examines differences in medical self advocacy in men by racial/ethnic group. Methods: This study used data from the 2000–2001 Household Component of the Community Tracking Survey. The study sample included 14,527 men aged 18–65 with at least 1 physician visit in the previous year. Binomial logit models were used to examine the predictors of self advocacy. Results: Compared to White men, Hispanic and African American men were slightly more likely to seek health information (odds ratio (OR) = 1.05) and (OR = 1.13), however the finding was not significant. African American (0R = 0.59) men were less likely to mention health information they sought to a physician during the medical encounter than White men. Among those men who sought health information and mentioned that information to a physician, Hispanic men (OR = 3.57) were more likely to perceive that tests were ordered based upon health information mentioned to the physician than White men. Conclusions: It is important for future studies to explore interventions to improve how African American men interface with the healthcare system. ß 2010 WPMH GmbH. Published by Elsevier Ireland Ltd.

Introduction The literature is replete with examples of the benefits of patient involvement during the medical encounter [1–7]. A positive physician–patient partnership gives the patient confidence and a sense of control in the disease management [2]. Toward that end, more patient control and more information provided by physicians are associated with better health status and greater medical adherence [1,2,4–7]. However, self advocacy extends beyond patient involvement; it encompasses gathering and using information to advance health [8]. African Americans (AAs) might benefit from self advocacy since their interactions with physicians seem to be less than whites [9]. The medical encounter appears to be different for AA compared to White patients [9,10].

ß 2010 WPMH GmbH. Published by Elsevier Ireland Ltd.

AA patients report fewer participatory visits with physicians than non-minority patients [9]. AAs are also more prone than Whites to report being treated with disrespect or unfairly during medical encounters [10]. Perceived mistreatment is associated with poorer medical adherence and delays in seeking health care [11]. Some of the interactions between the physician and patient can be attributed to race, culture, and social class [12–14]. The amount of information to discuss or withhold from a patient is related to physicians response to culture [13], social class, and race of patient [12,14]. Some of the differences observed in physician–patient interaction are associated with gender. Women appear to be more engaged in the healthcare encounter by actively participating in medical decision-making

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Original article and communication compared to men [15–18]. Relationship with physician also appears to be a stronger predictor of healthcare satisfaction for women than men [19]. In order to improve healthcare, Weismann et al concluded gender specific analysis should be done [20]. Men’s health remains a relatively recent area of study compared to women’s health in the United States and internationally [21– 25]. Men’s health has gathered momentum around the world since the late 1980s and early 1990s due to gaps in health status and health seeking behavior between men and women [22,25]. In general, women live on average 5–6 years longer than men [26] and men are three times less likely to have a physician visit compared to women [27]. However, the health of AA men continues to lag behind their White counterparts. AA men disproportionately suffer from, and experience disability from, preventable diseases, in addition to higher mortality, relative to Whites, triggering a description of a ‘‘crisis’’ of AA men’s health [28]. An AA male can expect to die 6 years earlier (at age 70 years) than his White (i.e., European American (EA)) male counterpart (at 76 years) [29]. Compared to White men, AA men have higher hypertension, diabetes, cancer morbidity and are more likely to die from heart disease (30%), stroke (60%), diabetes (200%), and prostate cancer (240%) [30]. The Institute of Medicine (IOM) concluded that AA men were less likely to use primary health and to receive quality health care compared to Whites even when they had insurance [31]. Historically they have had less access to culturally competent providers [32]. Thus, engaging in self advocacy in the medical encounter might improve outcomes and health status of AA men [33,34].

New Contribution Wiltshire et al (2006) found AA women were less likely to self advocate compared to White women [35]. That study showed women who obtained health information were more likely to mention that information to a physician than women without health information. AA women were 43% less likely to mention health information they acquired to a physician compared to White women. However, little is known about men’s involvement in healthinformation seeking and use, especially min-

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ority men [36]. This study examines self advocacy (i.e., seeking and use of health information) among men by race/ethnicity. To our knowledge, no study has examined men’s self advocacy using a community-based nationally representative sample. Thus, having insight on how men self advocate during the medical encounter is an important step in crafting interventions to improve how men interact with the health care system.

Subject, Materials, and Methods Data and Sampling Study data were drawn from the 2000–2001 Community Tracking Study (CTS) Household Survey, a nationally representative, telephoneadministered survey of 59,725 civilian, noninstitutionalized individuals. This cross-sectional survey was conducted by the Center for Studying Health System Changes. The CTS collected information on health and health care markets on randomly selected households from 60 communities across the United States. Detailed descriptions of the CTS survey and survey design have been published elsewhere [37,38]. The subpopulation of men (aged 18–65) included 14,527 men for the analyses who had had at least one medical encounter with a physician in the previous 12 months. Male respondents were excluded because of the following: (1) inapplicable, not ascertained, don’t know, and refused responses on outcome variables, (2) the race category ‘‘Other’’ was omitted from the analysis plan, and (3) missing values on the ‘‘usual source of care’’ variable. Our study was guided by Aday & Andersen’s Behavioral Model of Health Services Use [39]. That model was a modification of Andersen’s earlier model, which had the following goal: . . .. ‘‘to assist the understanding why families use health services; to define and measure equitable access to health care; to assist in developing policies to promote equitable access. . .’’.[40] The model posits health care utilization is a function of predisposing, enabling, and need variables. Predisposing characteristics pre-date the onset of illness for which health care services are sought (e.g., race/ethnicity, education, marital status, and employment status); enabling factors are

Original article resources that facilitate or hinder the use of desired or needed health services (e.g., health insurance status, usual source of care, residence, and poverty level); and the need factor is the illness/condition for which health care services are sought (e.g., perceived health status). This model, along with the parent model by Andersen, has been used to study predictors and determinants of health care use in underserved and vulnerable populations [41–43].

Variables under observation This study defines self-advocacy as health information-seeking, mentioned information to the physician, and patient perception that the physician used information to order a test, procedure, or prescription. In previous studies of self advocacy, authors have described self advocacy as the seeking, evaluating, and using information to benefit one’s health [8,33,34]. This definition of self advocacy has been used by Wiltshire et al to examine differences in medical self advocacy by racial/ethnic group in women [35]. In the CTS survey, respondents were asked the following questions: ‘‘During the past 12 months have you mentioned information to a doctor about a medical condition or treatment for you that you found out about yourself or were told by others?; Did the doctor order a test, procedure, or prescription for you mainly because of information that you mentioned or showed to him or her?’’ Responses were coded as yes or no. Based upon the scope of this study’s definition of self advocacy and the use of self advocacy in similar studies, no other questions were considered from the CTS survey [34,35]. The main independent variables for the study were race/ethnicity and use of health information. Race/ethnicity categories included White, African American, and Hispanic. Health information sources included internet, friends/ family, TV or radio, books/magazines/other source, and health care organization/professional. An indicator variable was constructed by combining all sources of health information. Variables representing predisposing, enabling, and need characteristics were included as control variables. These included age (18–24, 25–34, 35–44, 45–54,55–64, 65 and older), marital status (married/not married), rural residence (yes/no), education (
(100–199%), non-poor (200% and up), usual source of care (yes/no), insurance type (private, public, uninsured), and perceived health status (poor/fair, good, very good/excellent). Poverty level was calculated by dividing total family income by the US poverty threshold, adjusted for family size.

Statistical Analysis Descriptive and binomial logistic regression analyses were performed using SUDAAN, which makes adjustments for complex, multistage designs to produce accurate standard errors and significance tests [44]. The sample was weighted to represent the total United States population and to adjust for over-sampling and non-response. Descriptive analyses were conducted to assess variables across racial/ethnic groups. We used logistic regression analyses to assess racial/ethnic differences in self-advocacy (i.e., seeking information, using information in the medical encounter, and perceiving information is used by physician) among men. Odds ratios, confidence intervals, and P values are presented for each regression model. P and q values are also presented for descriptive statistics. All results were considered statistically significant at a P-value of <0.05. The overall fit of the logistic models were evaluated using Hosmer–Lemeshow (H-L) goodness-of-fit tests based on the Satterthwaite-adjusted F statistic and P values.

Results Characteristics of the Study Sample by Race/Ethnicity Table 1 presents the overall weighted percentages for the variables used in this analysis and the weighted percentages for the variables by race/ethnicity. The sample was 83% White, 10% AA, and 8% Hispanic. Over 50% of the men were between the ages of 35–64, 70.6% were married, 67.9% were employed, 92.3% had a usual source of care, 82.6% were non-poor, and 66.5% were privately insured. Approximately 51.7% of AAs were married, compared to 73.5% for Whites, and 63.4% for Hispanics. Hispanics were most likely to have less than a high school education (25.3%), to be uninsured (15.1%), and

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Original article Table 1 Demographics Demographics

Total (n =14527)

Age 18–24 8.5 (1242) 25–34 13.3 (1941) 35–44 20.7 (3004) 45–54 21.6 (3144) 55–64 15.8 (2294) 65+ 20.0 (2902) Married Yes 70.6 (10261) No 29.4 (4266) Rural living Yes 87.9 (12765) No 12.1 (1762) Educational level
White (n =12061)

Black (n = 1390)

Hispanic (n = 1076)

7.5 (908) 12.4 (1500) 20.8 (2505) 21.9 (2642) 16.1 (1941) 21.3 (2565)

12.4 (172) 14.6 (203) 20.3 (282) 22.1(307) 15.0 (208) 15.7 (218)

15 (162) 22.1 (238) 20.2 (217) 18.1 (195) 13.5 (145) 11.1 (119)

73.5 (8860) 26.5 (3201)

51.7 (719) 48.3 (671)

63.4 (682) 36.6 (394)

13.0 (1572) 87.0 (10489)

9.9 (137) 90.1 (1253)

4.9 (53) 95.1 (1023)

8.8 (1063) 32.3 (3900) 22.2 (2682) 36.6 (4416)

17.9 41.6 21.5 19.0

25.3 33.7 19.9 21.1

68.1 (8215) 31.9 (3846)

62.4 (868) 37.6 (522)

71.9 (774) 28.1 (302)

4.2 (512) 11.9 (1230) 85.6 (10319)

12.9 (180) 26.2 (251) 69.0 (959)

13.3 (143) 28.7 (208) 67.4 (725)

6.8 (815) 93.2 (11246)

10.1(141) 89.9 (1249)

15.5 (167) 84.5 (909)

67.6 (8159) 26.9 (3250) 5.4 (652)

58.3 (810) 31.4 (437) 10.3 (143)

63.8 (686) 21.2 (228) 15.1 (162)

60.5 (7302) 39.5 (4759)

55.8 (775) 44.2 (615)

51.4 (553) 48.6 (523)

14.8 (1784) 26.5 (3202) 58.7 (7075)

22.2 (309) 29.6 (412) 48.1 (669)

20.4 (219) 30.3 (326) 49.3 (531)

37.9 (4574) 62.1 (7487)

37.2 (517) 62.8 (873)

37.2 (400) 62.8 (676)

(2490) (578) (299) (264)

(272) (363) (214) (227)

HMO: Health Maintenance Organization.

poor (13.3%), while Whites were the least likely to have less than a high school education (8.8%), to be uninsured (5.4%), poor (4.2%), and in poor/fair health (14.8%). AA men were most likely to be in poor/fair health (22.2%). Overall, 37.8% of the men in this study sought health information from the internet, friends,

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TV or radio, books/magazines/other source, and health care professional/organizations.

Sought Health Information Table 2 shows the binomial logit model used to examine factors associated with self-advocacy

Original article Table 2 Sought health information Characteristics White (reference) African American Hispanic Married Yes (reference) No Education level College/post graduate (reference)
Odds ratio

95% CI

P

1.05 1.13

(0.90–1.22) (0.96–1.32)

0.539 0.147

1.23

(1.11–1.35)

<0.001

0.33 0.43 0.64

(0.27–0.39) (0.39–0.048) (0.57–0.71)

<0.001 <0.001 <0.001

0.9

(0.79–1.03)

0.121

1.07 0.87

(0.86–1.33) (0.76–1.01)

0.539 0.072

1.16

(1.03–1.31)

0.015

1.05 1.1

(0.89–1.24) (0.89–1.36)

0.543 0.358

0.91

(0.77–1.08)

0.274

0.81 0.98 0.87 0.71 0.6

(0.67–0.98) (0.83–0.98) (0.72–1.06) (0.58–0.87) (0.48–0.75)

0.032 0.825 0.175 0.001 <0.001

1.65 1.3

(1.46–1.86) (1.19–1.42)

<0.001 <0.001

0.98

(0.90–1.06)

0.552

HMO: Health Maintenance Organization.

(seeking health information). We examined these relationships among the men who sought health information (n = 5,491). Even though AAs and Hispanic men were slightly more likely to seek health information (odds ratio (OR) = 1.05, 95% Confidence Interval (CI) = 0.90–1.22; OR = 1.13, CI = 0.96–1.32, respec-

tively), the results were not statistically significant. Marital status, education level, employment status, age (18–24, 45–54, 55–64 years), and perceived health status were significant predictors of seeking health information and being near poor was marginally significant.

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Original article Mentioned Health Information to Provider Table 3 shows the results of the model used to explore self-advocacy (seeking health information and mentioning information to provider). AA men were 41% less likely to mention health

information they sought to their physician when compared to Whites (OR = 0.59 CI = 0.41–0.84). Hispanic men were also more likely to mention health information to their physicians compared to Whites (OR = 0.85, CI = 0.59– 1.22), however this was not significant at P <0.05. Other significant predictors for mention-

Table 3 Sought health information and mentioned to doctor Characteristics White (reference) African American Hispanic Married Yes (reference) No Education level college graduate (reference)
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Odds ratio

95% CI

P

0.59 0.85

(0.41–0.84) (0.59–1.22)

0.003 0.374

1.05

(0.88–1.27)

0.574

0.51 0.68 0.82

(0.38–0.69) (0.55–0.84) (0.67–1.01)

<0.001 <0.001 0.067

0.85

(0.61–1.20)

0.356

1.46 0.98

(1.04–2.04) (0.71–1.34)

0.028 0.875

1.26

(1.0–1.59)

0.051

1.29 0.68

(0.95–1.74) (0.44–1.04)

0.106 0.072

0.62

(0.38–1.0)

0.051

1.27 1.85 2.13 2.18 1.6

(0.88–1.85) (1.23–2.77) (1.47–3.1) (1.5–3.17) (1.08–2.38)

0.207 0.003 <0.001 <0.001 0.019

1.84 1.61

(1.49–2.26) (1.38–1.88)

<0.001 <0.001

1.23

(1.03–1.47)

0.021

Original article Table 4 Perceived tests ordered based on information presented to doctor Characteristics White (reference) African American Hispanic Married Yes (reference) No Education level College/post graduate (reference)
Odds ratio

95% CI

P

1.32 3.57

(0.71–2.47) (2.13–5.99)

0.386 <0.001

1.5

(1.11–2.03)

0.009

1.79 1.29 1.05

(0.99–3.23) (0.96–1.74) (0.75–1.46)

0.055 0.096 0.783

1.05

(0.64–1.74)

0.839

2.07 1.35

(1.12–3.83) (0.82–2.21)

0.019 0.242

1.22

(0.85–1.75)

0.279

0.96 0.73

(0.56–1.65) (0.44–1.04) (0.34–1.56)

0.894 0.42

1.14

(0.48–2.70)

0.765

1.09 0.81 0.87 0.65 0.72

(0.51–2.32) (0.38–1.71) (0.42–1.77) (0.32–1.33) (0.31–1.64)

0.828 0.573 0.691 0.242 0.429

0.84 0.96

(0.59–1.18) (0.71–1.29)

0.308 0.776

0.76

(0.58–1.0)

0.046

HMO: Health Maintenance Organization.

ing health information were educational level, poverty level, age, perceived health status, and Health Maintenance Organization (HMO) enrollee, employment status, age (25–34,35– 44, 45–54, 55–64 years), and perceived health status. Employment status and usual source of health care were marginally significant.

Mentioning Health Information Resulted in Tests/Procedures/Prescriptions Table 4 illustrates the results of the model used to assess the racial/ethnic differences among men who mentioned obtained health information and resulted in the physician ordering a

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Original article test, procedure, or prescription based on this information. The results reveal that Hispanic men, when compared to White men, were more than three times as likely to have a test ordered based on health information (OR = 3.57, CI = 2.13–5.99). AA men were 32% more likely to have a test ordered based on health information (OR = 1.32, CI = 0.71–2.47), however the results were not statistically significant. Marital status, poverty level (poor), and HMO enrollee were significant predictors of having a test ordered based on health information presented.

Discussion This study examined racial/ethnic differences in self advocacy among men using data from the 2000–2001 CTS. The major findings were that there was no significant difference in health information-seeking, however AA men were less likely to mention health information to a provider compared to White men. The latter finding supports Wiltshire et al’s finding that race impacts mentioning health information to a provider [35]. Those authors found AA women who sought information were less likely to mention health information to a provider compared to White women. Other studies have also shown that AAs are less likely to participate in the medical encounter [9,45,46]. Levinson et al found AAs were more likely than Whites to relegate healthcare decision-making to providers [47], which could shed light on their reluctance to share medical information with their providers. Another significant finding, that Hispanic men were more than three times more likely than White men to perceive that a test was ordered based upon information they provided, was not expected based upon earlier studies [10,48]. Hispanics have been more likely than AAs and Whites to report being treated with disrespect by their doctor [10]. Another important finding from this earlier study was that those for whom English was not the primary language were likely to report disrespect and to believe that if they were another race they would have received better care from their physician. Another study, by Lurie et al, examined the Consumer Health Plans Survey (CAPHS), and revealed that Hispanics were more likely than Whites to report

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worse experiences with care [48]. So, one plausible explanation for our finding is that Hispanics are likely to engage in extreme scoring [49]. In an examination of CAPHS rating by Hispanics, Weechs-Maldonado et al found that Hispanics were more inclined to rate aspects of their health plan a 10 (highest rating) compared to Whites [49]. There are some limitations to this research. First, the findings from cross-sectional data do not allow causal links to be established to self advocacy. Other factors not included in the CTS and our analysis might impact AA men’s willingness to share health information with their provider. For example, length of relationship with provider, racial concordance with provider, gender of physician, age of physician, and courtesy of staff have all been shown to impact the patient experience [9,10,32, 45,50–52]. Still, the data includes a representative sample of men and accepted measures for assessing self advocacy during the medical encounter [35]. The data used for the analysis is from 2000–2001, however the methods of describing and examining self advocacy have not changed much over the last decade [8,33– 35]. As significant, information on health information seeking in men, particularly racial/ethnic men, remains scarce [36]. Toward that end, health disparity continues to be an important issue in the United States, despite decades of focus and funding to combat it [53]. This study found that AA men are less likely than White men to share health information, which creates concern when considered with the other dynamics impacting AA men. Self advocacy has shown positive health benefits [34], so it is imperative that interventions be explored to improve how AA men interface with the health care system, particularly considering the dire health many AA men face [54]. The disconnect with self advocacy with AA men appears to surface during interactions with providers since they are less likely to share health information they have sought with the provider. Future research should examine why minority men are less likely to share health information with their provider and work with this group and with providers to increase beneficial interactions during the medical encounter. Increasing self advocacy in AA men during the medical encounter has the potential to mitigate some of the poor health outcomes they face.

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