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Association between Caregiver-perceived Health Care Provider Cultural Sensitivity and Child Health Status in the National Survey of Children's Health:2016–2020
Objectives. To examine the association between caregiver-perceived cultural sensitivity of health care providers and child health status in the United States. Methods. We analyzed National Survey of Children's Health data (n = 145,226) from 2016–2020. Using logistic regression, we determined odds of reporting a better health status by level of caregiver-perceived provider cultural sensitivity while controlling for potential confounders. Results. Children with providers perceived as more culturally sensitive by their caregivers had 2.38 times the odds (95% confidence interval: 1.73, 3.28) of enjoying a better caregiver-assessed health status compared with children whose providers were perceived as less culturally sensitive. Caregivers of BIPOC children in our sample were 1.99 times more likely (95% CI: 1.89, 2.10) to report their provider as only sometimes or never culturally sensitive. Conclusions. Cultural sensitivity of health care providers, as perceived by caregivers, was associated with caregiver-assessed child health status in our study. This association remained significant when controlling for various sociodemographic variables. Our findings highlight the need for more research around the potential positive impact that improving provider cultural sensitivity could have on the health of children who are Black, Indigenous, or other People of Color (BIPOC).
National Survey of Children's Health, cultural sensitivity, child health, BIPOC
According to the U.S. Census Bureau, roughly four out of every 10 Americans in 2019 was a Black, Indigenous, or other Person of Color (BIPOC) individual—including Latinx respondents who represent various racial identities, including White, but report a Hispanic ethnicity.1 Over the last several decades, researchers have highlighted the significant and persistent health inequities that exist in BIPOC communities throughout the United States.2–4 While the extent and nature of the problem of racial health inequity [End Page 951] is still being explored by practitioners, patients, and policymakers, evidence of its effect on the health status of Americans is consistent across many sources.5
Increasing provider cultural sensitivity*—broadly the ability to proficiently interact with individuals from diverse ethnic, racial, or social backgrounds—is one approach to close the existing gap in health disparities between BIPOC and non-Hispanic White (NHW) patients.6–9 However, not everyone accepts this approach.10–12 For example, in their 2008 article, Drevdahl, Canales, and Dorcy13 argue that evidence of the impact of provider cultural sensitivity on the health status or health outcomes of BIPOC individuals is lacking or minimal at best.
To resolve this ongoing debate, it is essential that we have a clear understanding of the measurable role that a health care provider's level of cultural sensitivity may play in predicting health outcomes for children in the United States—especially BIPOC children, whose racial or ethnic groups are often incongruous with that of their primary care provider. Over the last two decades, emerging research has begun to show that a health care provider's level of cultural sensitivity may be directly associated with physical and mental health outcomes for patients.14–16 In their 2010 systematic review of studies on cultural competence educational interventions for health professionals, Lie et al.17 found limited data supporting a positive association between provider participation in cultural competence education interventions and improved patient outcomes. However, as highlighted by Drevdahl et al,13 it is important to note the paucity of high-quality research focusing on this issue—while also noting that lack of evidence of an association does not equal lack of an association.18
Given the known relationship between childhood and adulthood health status, studying the impact of provider cultural sensitivity on children's health is especially important. Addressing modifiable factors impacting health during childhood can lead to improved health and well-being across the lifespan.19–21 The current literature exploring provider cultural sensitivity and child health status is scant. The purpose of this study is to address this gap in the literature by determining if there is an association between the caregiver-perceived level of provider cultural sensitivity and child health status among respondents to the National Survey of Children's Health (NSCH), a nationwide survey of child health and wellbeing. Our hypothesis is that children whose parents or caregivers report higher perceived cultural sensitivity of their provider will report a better health than those with lower caregiver-perceived cultural sensitivity.
Methods
We combined NSCH datasets from 2016–2020.22 To our knowledge, this is the first study to use NSCH data to explore the association between caregiver-perceived provider cultural sensitivity and child health status. The NSCH is a state-level, nationally representative, cross-sectional survey of American households throughout the 50 states of the U.S. and the District of Columbia with at least one child or adolescent under the age of 18 years eligible to participate, administered annually by the U.S. Census [End Page 952]
Flow diagram of total survey participants and number of respondents included in analyses of provider cultural competence and child health status for the 2016–2020 datasets.
Bureau.23 All participants were included in our analysis if they were not missing data on our primary exposure, outcome, or included covariates (see Figure 1). This study used deidentified data from a publicly available source; therefore, it did not qualify as human subjects research nor require institutional review board approval.
Measures
The outcome of interest for this study was child health status, the exposure of interest was caregiver-perceived provider cultural sensitivity, and potential confounders that we assessed include race, age, ethnicity, sex, household income, household language, and metropolitan residence status.
Child health status was measured using the question: "In general, how would you describe this child's health?" This variable was dichotomized to denote either better health status ("excellent," "very good," or "good") or poorer health status ("fair" or "poor").
We measured caregiver-perceived provider cultural sensitivity using the question: "During the past 12 months, how often did this child's doctors or other health care providers show sensitivity to your family's values and customs?" Response options for this item included "always," "usually," "sometimes," and "never." Participants were also able to indicate that the child had not had a health care visit within the last 12 months. We collapsed the responses of "sometimes" and "never" into one category, resulting in a three-level categorical variable for our analysis.
Selected demographic variables were race, ethnicity, sex, age, household income, household language, and metropolitan status. Race was categorized as White, Black/African American, or all other races. Ethnicity was categorized as not Hispanic or Latino, or Hispanic or Latino. Household language was categorized as English or all [End Page 953] other languages. Household income was categorized using the indicated federal poverty level (FPL) percentage as 400% FPL or above, 300–399% FPL, 200–299% FPL, or 0–199% FPL. Type of insurance was categorized as private insurance, public insurance, public and private insurance, or uninsured.
Statistical analysis
Data were analyzed using the 'survey' package in RStudio.24 We calculated descriptive characteristics for all participants and by exposure group. We used multiple logistic regression to evaluate the association between provider cultural sensitivity and child health status, as reported by the parent or caregiver.
Based on a review of the literature and variables available in the NSCH datasets, we selected potential covariates and assessed them for inclusion in the model using bivariate analysis. After determining the unadjusted odds ratio, we adjusted the model for each potential covariate separately to evaluate whether it changed the odds ratio by more than 10%. We tested for interaction by year by including a multiplicative interaction term in several potential models. Variables to include in the final model were chosen based on the change in odds ratio, a review of the literature, and model selection criteria that included ANOVA and AIC. All models were weighted to account for the NSCH's complex sampling design using NSCH-provided sampling weights.
Results
Study population
We combined yearly NSCH survey data for 2016 through 2020, resulting in 174,551 survey responses. After excluding participants missing data for health status, provider cultural sensitivity, and selected covariates, our sample included 145,226 observations for analysis. Most participants (n = 139,491, or 96.1%, unweighted) indicated that their provider always or usually showed sensitivity to their families' values and customs. Additionally, most parents (n = 143,348, or 98.7%, unweighted) reported their child's health status as excellent, very good, or good.
In our analysis sample, 68.7% (weighted) of participants reported their race as White, and 77.4% (weighted) reported not being Hispanic or Latino. Approximately twice as many participants reported being covered by private health insurance (61.9%, weighted) as by public health insurance (29.0%, weighted), and the most prevalent income level was 0–199% FPL (37.4%, weighted). BIPOC children in our sample were 1.64 times more likely (95% CI: 1.50, 1.80) to be in the poorer health status group than NHW children. See Table 1.
Caregiver-perceived provider cultural sensitivity and child health status
In the unadjusted model, caregiver respondents who perceived their provider as always culturally sensitive, relative to sometimes or never sensitive, had more than three times the odds of reporting a better health status (excellent, very good, or good health) for their child (unadjusted odds ratio [OR] = 3.42; 95% confidence interval [CI]: 2.54, 4.62). Caregivers of BIPOC children in our sample were 1.99 times more likely (95% CI: 1.89, 2.10) to report their provider as only sometimes or never culturally sensitive.
After performing a bivariate analysis of potential cofounders, testing for interaction by year, reviewing the relevant literature, and analyzing model fit using ANOVA and AIC, we adjusted for sex, race, ethnicity, insurance status, household income, and household language in the final model. In the adjusted model, caregivers who reported [End Page 954]
WEIGHTED PERCENTAGES OF SELECT SOCIODEMOGRAPHIC CHARACTERISTICS OF INCLUDED SURVEY RESPONDENTSa
the health care provider as being always culturally sensitive were more than twice as likely (adjusted OR = 2.38; 95% CI: 1.73, 3.28) to report their child's health status as better (excellent, very good, or good) compared with caregivers who reported their child's medical provider to be sometimes or never culturally sensitive. These results are consistent with current knowledge regarding the role and importance of provider cultural sensitivity.6–8 See Figure 2. [End Page 955]
Odds ratios and 95% confidence intervals for better child health status (n = 145,226) by perceived provider cultural sensitivity (reference group = sometimes or never sensitive). Adjusted model includes child's biological sex, age, race and ethnicity, insurance status, household income, and household language.
Discussion
In this nationally representative study, we found significant differences in the status of children's health based on the level of caregiver-perceived provider cultural sensitivity. In the final adjusted model, children whose caregivers perceived their health care providers as being always culturally sensitive had more than twice the odds of enjoying a better health status compared with children with providers who were perceived as less culturally sensitive. This study included the largest U.S. sample, to our knowledge, to analyze child health status based on the caregiver-perceived level of provider cultural sensitivity.
We hypothesized that children whose parents perceived their health care provider as more culturally sensitive would experience a better health status than those whose health care provider is perceived as less culturally sensitive. The null hypothesis is that health status would not differ for children based on the perceived cultural sensitivity of their provider. We found a measurable difference in child health status based on perceived provider cultural sensitivity.
Cultural sensitivity is a complex concept that may incorporate humility, experiential knowledge, and verbal and nonverbal communication.25,26 There is at least suggestive evidence showing that provider cultural sensitivity is associated with greater patient satisfaction.27–29 While satisfaction with provider communication may be a measure of patient perception rather than a direct result of provider communication practices,30,31 in the current study it is a factor that was less favorable among BIPOC children and families. Finding ways to improve perceptions of cultural sensitivity, and potentially improve child health status, thus has the potential to affect BIPOC individuals and communities more heavily than NHWs.
While this study drew on data related to child health status, it is important to note the very real potential that the effects of poor health in childhood could be lifelong. Not only will opportunities for health education and health promotion be diminished for these children, but their trust in the medical field will be diminished.21,32,33 As adults, [End Page 956] if this lack of trust translates to fewer visits or other engagements with a health care team, early detection of many chronic illnesses becomes less likely.32,33 The direct result, then, is continuing disparities in health in the adult American population.
Strengths and limitations
The strengths of this study include its use of publicly available data, a state-level and nationally representative sample population, and a large sample size. We believe this is the first study to explore caregiver-perceived provider cultural sensitivity and child health status based on the National Survey of Children's Health. However, this study has several limitations that are important to consider. As a cross-sectional survey, NSCH data are subject to participant response and recall bias. This includes the determination of child health status, which is determined by caregiver perception rather than clinical diagnoses. We cannot be sure how the time delay between the appointment with the health care provider and completion of this national survey may have affected responses regarding cultural sensitivity. Although we adjusted for child's biological sex, age, race and ethnicity, insurance status, household income, and household language, we cannot rule out confounding by unmeasured variables, including other social determinants of health (e.g., caregiver's level of education or type of occupation).
The NSCH survey tool does not directly measure a provider's level of cultural sensitivity training or practice. Studies such as those highlighted in Lie et al.17 would be more ideally situated to accomplish this. Although there is some evidence that training in cultural sensitivity leads to improved attitudes and skills for health care providers,34 more study is needed to better understand how reflective training rates and curricula may be of current health care practice. The NSCH questionnaire does, however, measure how culturally sensitive the survey respondents perceive their health care providers. This could be considered the "true" measure of cultural sensitivity, as the objective is not how providers view their own behavior but rather how patients perceive the quality of the interaction and care they receive from their provider.
Another limitation to these data is the lack of identifying cultural concordance between provider and patient. We cannot measure what role, if any, provider-patient cultural concordance may play in influencing the association because the NSCH questionnaire does not capture this relationship. A final note is that our findings do not include adjustments for children with chronic or acute illnesses, who might require more complex care or more stressful health care interactions, as this information is also not captured in the NSCH questionnaire.
Conclusion
Findings from the current study highlight the need to better understand the relationship between provider cultural sensitivity and patient health status as well as approaches for improving health status that center around cultural sensitivity. While debate about the best approaches for training providers in cultural sensitivity may continue for years to come, we found a significant, measurable association between caregiver-perceived provider cultural sensitivity and child health status in our sample. It is possible that the effects of this association may last throughout the life course. The authors call for continued—and significantly expanded—research into the role that provider cultural sensitivity plays not only in childhood health outcomes, but in improving the health of the U.S. [End Page 957]
DAMIAN M. CHASE-BEGAY, CLAIRE E. ADAM and ERIN SEMMENS are affiliated with the School of Public and Community Health Sciences in the College of Health at the University of Montana. ELIZABETH WILLIAMS is affiliated with the All Nations Health Center.
Conflict of Interest Disclosures (includes financial disclosures)
The authors have no conflicts of interest to disclose.
Funding/Support
This work was supported by the National Institute of General Medical Sciences (P20GM130418) and the Office of the Director (UG1OD024952) of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
References
Footnotes
* For consistency, the authors use the term "cultural sensitivity" but research in this area may also use terms such as cultural competence, cultural appropriateness, and cultural humility, among others.