نژاد، وضعیت اجتماعی اقتصادی و اهمیت درک شده خودارائه گری مثبت در مراقبت های بهداشتی

Abstract Hundreds of studies have documented disparities in medical treatment in the USA. These findings have generated research and initiatives intended to understand and ameliorate such disparities. Many articles examine disadvantaged patients’ beliefs and attitudes toward health care, but generally limit their investigation to how these beliefs and attitudes influence adherence and utilization. Thus, this approach fails to consider whether patients use particular strategies to overcome providers’ potentially negative perceptions of them and/or obtain quality medical care. In this paper, we examine positive self-presentation as a strategy that may be used by disadvantaged groups to improve their medical treatment. Analysis of survey data (the 2004 Greater Cincinnati Survey) suggests that both African Americans and lower socioeconomic status persons are more likely than whites or higher socioeconomic status persons to report that positive self-presentation is important for their getting the best medical care. Based on these findings, we suggest several routes for future research that will advance our understanding of patients’ everyday strategies for getting the best health care.

Introduction …The physician looked at my daughter, looked at me, asked some quick questions, did a cursory exam, and said “she's fine, go home.” … I adopted a different approach with that emergency room doctor. I became more assertive, more intense, threw some medical terms back at her. Enough so that she called the attending physician, who ordered more tests, including a chest X-ray. What they found was that my daughter had pneumonia… Although we walked out of the hospital having gotten the appropriate tests and with the antibiotics we needed, it was not so easy… Dr. Risa Lavizzo–Mourey, describing her strategies for getting appropriate care for her daughter1 Hundreds of studies have documented disparities in medical treatment in the USA (Smedley, Stith, & Nelson, 2003). Furthermore, there is strong evidence that stereotypes associated with sex, age, diagnosis, sexual orientation, sickness, socioeconomic status, obesity, and more recently, race/ethnicity influence providers beliefs about and expectations of patients (Bonvicini & Perlin, 2003; Douglas, Kalman, & Kalman, 1985; Foster et al., 2003; McKinlay, Potter, & Feldman, 1996; Najman, Klein, & Munro, 1982; Schulman et al., 1999; Shortt, 2001; Tait & Chibnall, 1997; van Ryn & Burke, 2000; Wileman, May, & Chew-Graham, 2002). These findings have generated considerable research intended to understand and inform programs aimed at ameliorating such disparities. Many articles examine the dimensions of disadvantaged patients’ beliefs and attitudes toward health care, but generally limit their investigation to how these beliefs and attitudes influence adherence and utilization (Bussey-Jones & Genao, 2003; Lannin et al., 1998; Mathews, Lannin, & Mitchell, 1994; Oomen, Owen, & Suggs, 1999; Uba, 1992). Consequently, work on disparities generally fails to examine the degree to which patients are consciously strategic in their behavior with providers in order to overcome providers’ potentially negative perceptions of them and/or obtain quality medical care. Are patients who are at greater risk of receiving poor treatment more likely than others to report that strategies for improving providers’ perceptions of them are important to getting good medical care? If the experience of unfair treatment and/or observations of inequality have an impact on patient behavior when seeking care, we would expect African American and low socioeconomic status patients to be more likely than their white and high socioeconomic status counterparts to perceive strategies of positive self-presentation—such as friendly manner and nice clothing—as important for obtaining optimal medical care. In this paper, we use survey data to determine whether race or socioeconomic status predicts the degree to which positive self-presentation is considered important for obtaining optimal medical care. The study of strategies for getting the best medical care is important because it can give insight into how patients’ social location (e.g., race and social class) influence their approach to health care. In addition, development of interventions to decrease bias in health care, as well as all patient activation interventions, are more likely to be effective if the strategies patients already use are well understood, including sociodemographic variation in strategy use.

Results Table 1 presents the distribution of the variables. The mean importance of positive self-presentation is 24.4 out of a possible of 28, indicating that most people felt that positive self-presentation is important for receiving the best medical care possible. Table 2 presents the mean importance of positive self-presentation by the independent variables. There is a significant association between self-presentation and all independent variables except insurance coverage. All of the hypothesized relationships are in the expected direction. African Americans, on average, rate positive self-presentation as more important than whites. Those with less education and less income also rate positive self-presentation as more important than their more advantaged counterparts. Table 1. Weighted percentage and unweighted frequency distribution of variables Percentage (mean) Unweighted n Dependent variable Strategies importance (24.39) 1189 Race White 75.28 695 Black 24.72 510 Socioeconomic status Education Less than high school 19.19 94 High school 27.40 306 Some college 27.74 411 College graduate 25.68 393 Income Under $10,000 19.30 170 $10,000–19,999 20.19 261 $20,000–29,999 20.84 261 $30,000–49,999 10.76 144 $50,000 and over 28.91 343 Controls Sex Male 45.16 391 Female 54.84 814 Age 18–19 24.75 241 30–45 28.65 360 46–64 24.59 382 Over 65 22.00 197 Insurance coverage Have insurance 87.98 1057 No insurance 12.02 147 Table options Table 2. Strategies mean importance by independent variables Sum of strategies importance Race** White 24.06 Black 25.42 Socioeconomic status Education** Less than high school 25.81 High school 24.57 Some college 24.22 College graduate 23.33 Income** Less than $10,000 25.29 $10,000–19,999 25.10 $20,000–39,999 24.48 $40,000–59,999 23.55 More than $60,000 23.50 Controls Sex** Male 23.96 Female 24.75 Age** 18–19 23.38 30–45 24.24 46–64 24.46 Over 65 25.63 Insurance coverage Have insurance 24.38 No insurance 24.40 *p<0.05, **p< 0.01 for adjusted Wald test. Table options The multivariate results are shown in Table 3. As expected from the bivariate distribution, we found that African Americans’ average rating is 1.3 points higher than whites’, controlling for age, gender, and insurance status (Model 1, p<0.01). This result indicates that in the existing system of education and income inequality African Americans are more likely than whites to perceive positive self-presentation as very important for receiving the best medical care. Table 3. OLS regression models predicting importance of positive self-presentation Model 1 Model 2 Race Black race 1.33 0.95 (0.22)** (0.23)** Socioeconomic status Education −0.40 (0.14)** Income −0.24 (0.09)** Controls Male −0.66 −0.53 (0.24)** (0.23)* Age 0.69 0.62 (0.12)** (0.11)** Have insurance −0.21 0.20 (0.37) (0.38) Constant 22.87 24.50 (0.46)** (0.60)** Observations 1163 1163 R2 0.10 0.14 Standard errors in parentheses. *p<0.05, **p< 0.01. Table options Model 2 introduced indicators for education and income to Model 1. Both education and income were significant predictors of the rating of the importance of strategies (p<0.01). Persons with less education and less income were more likely than their advantaged counterparts to believe that positive self-presentation is important for receiving the best medical care, which supports the second hypothesis. For example, an individual with a high school degree and $10,000–20,000 annual income would rate strategies as 1.0 point higher than a counterpart with a college degree and $30,000–50,000 annual income. Of note, the inclusion of indicators of socioeconomic status reduced the coefficient for race, but race remained a significant predictor of perceived self-presentation importance (p<0.01). Among the control variables, both age and gender are significant (p<0.05), with increasing age and being female predicting higher rating positive self-presentation. Again, the only variable not significantly related to self-presentation is insurance status. Finally, additional models tested whether the effect of education and income varies by race. Neither interaction term was significant (p>0.10, not shown).