Literature Evaluation Table

African American Experiences in Healthcare: “I Always Feel Like I’m Getting Skipped Over”

Adolfo G. Cuevas and Kerth O’Brien Portland State University

Somnath Saha Portland Veterans Affairs Medical Center, Portland, Oregon and

Oregon Health & Science University

Objective: Although African Americans perceive discrimination in health care settings, experience higher levels of medical mistrust compared with European Americans, and experience poorer communication with health care providers, little is known as to how these barriers to quality patient-provider relationships arise and manifest themselves. This study examined experiences of African American community members regarding these barriers and additionally explored participants’ perspectives on race in the patient-provider relationship. Methods: Focus groups were conducted as part of a study exploring participants’ experiences and relationships in health care settings. Sixty African American adults were recruited through community settings and activities to participate in 1 of 9 focus groups segmented by gender. Transcripts were reviewed for content related to perceived discrimination, mistrust, poor communication, and race discordance. Themes providing insight into participants’ subjective experience of these potential relationship barriers were derived through qualitative coding (using NVivo 10) and iterative discussion. Results: Perceived discrimination arose when African American patients, particu- larly women, felt their symptoms or problems were discredited. Medical mistrust occurred when clinicians did not convey respect to patients, leaving patients to wonder whether their clinician’s treatment was discriminatory or not. Poor communication arose when clinicians did not acknowledge patients’ perspectives during interactions. Patients often viewed these actions as discriminatory. Con- clusions: African Americans experience poor communication with their health care providers, medical mistrust, and perceived discrimination when accessing health care in numerous and sometimes interre- lated ways. The investigators recommend ways to reduce the experience of such barriers and to improve patient-provider relationships for African Americans in health care.

Keywords: communication, medical mistrust, patient–provider relationships, perceived discrimination, race concordance

Unequal treatment and use of health care are important factors contributing to existing health disparities for African Americans (Richardson & Norris, 2010; White, Haas, & Williams, 2012). Black patients receive lower quality of care than their White counterparts (Mayr et al., 2010), and are less likely to receive

many types of medical services and procedures (Egede & Bos- worth, 2008). Although many factors, such as location of health care facilities, may contribute to disparities on a broader level, localized contributions to disparities include the barriers patients experience when they encounter their clinicians during health care visits (Dovidio & Fiske, 2012; Penner et al., 2013). African Amer- icans report lower quality of care and they are more likely than European Americans to report communication problems with cli- nicians (Sorkin, Ngo-Metzger, & De Alba, 2010).

Research to date has identified that barriers to quality patient- provider relationships for African Americans include perceived discrimination (Forsyth, Schoenthaler, Chaplin, Ogedegbe, & Rav- enell, 2014; Greer, Brondolo, & Brown, 2014), medical mistrust (Shelton et al., 2010; Sheppard, Mays, Tercyak, & LaVeist, 2013), and poor communication (Rim et al., 2011). Very little is known, however, about what experiences shape these three barriers and how they manifest in patient-provider interactions. Additionally, research indicates that the match (or concordance) of patient and provider on racial characteristics matters to patient care (Bleich, Simon, & Cooper, 2012; Schoenthaler, Allegrante, Chaplin, & Ogedegbe, 2012); therefore an investigation of barriers to quality care should also consider patients’ experiences with providers’ racial concordance or discordance. Investigation to identify and describe these experiences can improve our understanding of Af-

This article was published Online First May 12, 2016. Adolfo G. Cuevas and Kerth O’Brien, Department of Psychology, Port-

land State University; Somnath Saha, Portland Veterans Affairs Medical Center, Portland, Oregon and Public Health & Preventive Medicine, De- partment of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University.

Project EQUALED was funded by a grant from the Robert Wood Johnson Foundation. The authors thank Cameron T. McCabe for his feedback on the manuscript, and Thomas Kindermann and Yves Labissière for their feedback and critique on early iterations of this work. In addition we thank the community leaders and organizations involved in Project EQUALED, whose expertise and collaboration helped to create this project and make it a success.

Correspondence concerning this article should be addressed to Adolfo G. Cuevas, who is now at Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Kresge Building, Rm 604a, 677 Huntington Ave, Boston, MA 02115. E-mail: acuevas@hsph .harvard.edu

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Health Psychology © 2016 American Psychological Association 2016, Vol. 35, No. 9, 987–995 0278-6133/16/$12.00 http://dx.doi.org/10.1037/hea0000368

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rican Americans’ perceptions of health care and contribute to reductions in health care disparities for African Americans.

Perceived Discrimination

A report of 43,020 U.S. adults that compared perceptions of health care discrimination among a variety of ethnic groups found that non-European Americans, particularly African Americans, were more likely to perceive discrimination in health care than Eu- ropean Americans (Abramson, Hashemi, & Sánchez-Jankowski, 2015). Benjamins (2012) found that individuals reporting per- ceived discrimination are less likely than others to obtain various health screenings, such as mammograms, breast exams, and dia- betes blood tests. Further, reports from African American patients of perceived discrimination are associated with lower likelihood of high-quality treatment and patient adherence (Cuffee et al., 2013; Forsyth et al., 2014; Shavers et al., 2012). Although there is mounting evidence to show that experience of discrimination affects the quality of care for African American patients, little is known as to which aspects of their health care experience patients themselves find discriminatory. Identifying factors that African American patients find to represent unfair treatment on the basis of their ethnic background can help patients and clinicians be more successful in the care relationship.

Medical Mistrust

An enduring distrust toward institutions and health professionals is linked to dissatisfaction, nonadherence, and underuse of health care services (Dale, Bogart, Wagner, Galvan, & Klein, 2014; Hammond, 2010; Moore et al., 2013). African American men sometimes choose not go to clinicians because of their lack of trust toward health care providers (Hammond, 2010). Mistrust is some- times based on personal past experience, but can also be learned from members of one’s reference group (Katz et al., 2009). Peek et al. (2010) suggest that mistrust may have been a response to experiences of discrimination, such as during the time of legalized segregation. This would have involved offering an adaptive re- sponse to Whites in health care, such as verbally agreeing to treatment recommendations from White providers, while privately disagreeing with such recommendations. Consequently, learned mistrust may become part of the schematic framework with which one sees, and responds to, medical interactions. Lack of trust is associated with lower medication adherence and patient satisfac- tion (Elder et al., 2012; Martin et al., 2013; Moore et al., 2013). Identifying the ways trust can be improved through the perspective of patients themselves can augment the quality of the patient- provider relationship and quality of care for African American patients.

Poor Communication

Patient ethnic background is an often overlooked but important variable within patient–provider communication studies (Nam, Chesla, Stotts, Kroon, & Janson, 2011). Beach et al. (2011), for example, found that Black patients diagnosed with HIV provided less information during patient-provider interactions. They also found that clinicians were more verbally dominant during the conversation. These findings imply that African American patients

are less active in the exchange of information and involvement in decision making, thus decreasing the chance of obtaining high- quality care. Recent studies find that perceived discrimination may contribute to poor communication. For example, Hausmann et al. (2011) found that high levels of reported racism among African American patients was associated with less positive nonverbal affect among patients and providers and with low patient ratings of ease of communication.

The Role of Race Discordance

Race discordance plays an important role in African American patients’ interactions with clinicians. For example, Traylor and colleagues (2010) found that African Americans patients in race concordant patient–provider relationships were more likely to ad- here to cardiovascular disease medication than African Americans in race discordant relationships. Recent findings suggest that Af- rican American patients in race concordant relationships rated their visits as significantly more participatory than patients who had race-discordant clinicians. For example, Schoenthaler et al. (2012) found that African American patients in race concordant relation- ships rated their interactions as more collaborative and were more likely adhere to doctor’s recommendation compared to African Americans in race discordant relationships. Because race discor- dance may contribute to the experience of discrimination, poor communication, and lack of trust among African American pa- tients, this research supplemented the examination of the three identified barriers in patient-provider relationships with partici- pants’ reports of experiences with race-discordant clinicians.

The literature points us to the three barriers of perceived dis- crimination, medical mistrust, and poor communication. There is ample evidence that these barriers negatively affect the quality of care African Americans receive in patient-provider relationships. Nevertheless, there is a paucity of studies that identify how these barriers are experienced by the patients themselves. The aim of the study is to understand how these barriers are experienced from the perspective of African American patients. Therefore, this study asked, “What situations give rise to perceived discrimination, medical mistrust, and poor communication when African Ameri- can patients speak about their experiences with, and their perspec- tives on, healthcare providers?” The study also asked, “How does ethnic/race discordance influence barriers experienced by African Americans, in their interactions with their clinicians?”

Method

This study took place as part of a larger project which aimed to identify the perspectives of people living with diabetes and/or hypertension on what constitutes good or bad relationships with clinicians. The larger study, known as Project EQUALED (Ex- ploring the Quality of African American and Latino/Latina Expe- riences with Doctors), enrolled participants of three ethnic groups (African Americans, Latinas/Latinos, and European Americans) to improve understanding of the community context influencing re- search findings, enhance trust among potential and actual partici- pants, and ensure the cultural appropriateness of the research and its conduct. The research team employed community-based par- ticipatory research (CBPR) principles in in many aspects of the research process such as development of the focus group discus-

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sion guide, engagement of community members as moderators, and recruitment of participants. All research procedures were reviewed and approved by the Oregon Health & Science Univer- sity Institutional Review Board.

Focus Group Facilitators

Focus group facilitators are the primary link between the goal of the research and the quality of focus group data (Morgan, 2010). Because potential topics such as racism and sexism would be broached in focus group discussions, focus group members would need to feel comfortable discussing these topics; additionally, as a community-based effort the project sought to strengthen local community research capacities (Minkler & Wallerstein, 2011). Therefore the research team recruited potential moderators from the local African American community. Community Advisory Board members and key informants identified several community members who were interested candidates for moderator training. The study’s academic investigators then conducted a 1-day, 8-hr training session. The morning session was didactic and included content on the purpose of focus groups, their advantages and disadvantages as a data collection method, and guidelines for having an effective focus group facilitation; the afternoon included mock focus groups in which trainees practiced asking questions and facilitating discussion. Mock focus group members were as- signed different roles and characteristics (e.g., shy and quiet, loud and dominating) to help trainees become accustomed to different scenarios. Trainees were compensated $20/hour for their time in training. Consistent with practices of self-reflection, a feature of trustworthiness in qualitative research (Elo et al., 2014), trainees indicated that they felt most capable of working in moderator pairs; thus, from a pool of potential facilitators, the academic investigators chose two African American men to comoderate men’s focus groups and two African American women to comod- erate women’s focus groups. The team chose moderators that would have similar characteristics to that of focus group partici- pants based on race and gender, as this too can enhance trustwor- thiness by reducing discomfort when discussing sensitive issues (Patton, 2002; Snipes et al., 2011). Trainees were chosen who the research team found to be most skillful, engaged, and interested during the training sessions. Because new comoderators needed experience to become comfortable leading discussions, the aca- demic investigators decided to keep the same comoderators across several groups. Each moderator was paid $80 per focus group.

Participants

Participants were recruited who had diabetes and/or hyperten- sion in part so that the investigators would learn from participants who interact with clinicians fairly regularly. The research team avoided clinics and hospitals as recruitment sites in order to keep the study procedures truly community-based, not clinic-based, and in order not to oversample from any particular health care facility or give the impression that the research was being conducted by a particular facility. This recruitment method allowed the research team to recruit patients who may have been in different hospital settings and may have had differing health care experiences with clinicians and medical staff. The research team recruited Portland, Oregon residents through attendance at community events, where

the project coordinator approached participants with a clipboard, and enrolled people face-to-face. The research team also recruited residents through flyers posted in a variety of venues (e.g., restau- rants and barber or beauty shops). Interested participants were able to contact the project coordinator for further information about enrollment in the study. Eligible participants needed to have been previously diagnosed with diabetes and/or hypertension, to self- identify as Black or African American, and to be over the age of 18. If eligible, the project coordinator offered potential timeslots for the focus group meetings. Once a timeslot was agreed on, the project coordinator provided the location for the focus group discussion. Once the project was underway, study participants spontaneously recruited others in their communities through word of mouth.

Procedure

The research team conducted focus groups to identify the per- spectives of participants, as well as understand their shared expe- riences, while accessing the language participants used to think and talk about the study topics. These purposes are consistent with social scientific uses of focus groups (Morgan, 2010). With help from the project’s Community Advisory Board, research team members created the focus group discussion guide to learn about people’s actual experiences in the health care system, particularly their interactions with clinicians and their values and preferences regarding clinician–patient interactions. During moderator training potential moderators provided further input to focus group guide revisions. The guide included questions about experiences with participants’ most recent visits to the clinician; good experiences with clinicians (i.e., actual experiences and what makes a good experience); bad experiences with clinicians (actual experiences and what would have made for a better experience); experiences and preferences regarding clinician race/ethnicity; trust and respect in their relationship with clinicians; and hypothetical advice to clinicians as to how to improve the experience of health care for patients (see Appendix).

The focus groups were segmented by gender, as the research team felt gender may intersect with other barriers African Amer- ican patients experience. Patients were not segmented by chronic illness (i.e., hypertension or diabetes) because many patients suf- fered from both conditions. In addition, the research team was interested in investigating patients’ health care experiences, rather than their experiences with the illness per se. Experiences of perceived discrimination, medical mistrust, and poor communica- tion were not explicitly included in the focus group guide, but these topics were often probed by the moderators when they arose.

The team did not explore all aspects of the focus group guide in each focus group, because of time constraints. The team prioritized the first few areas. The team later prioritized subsequent domains (beginning with trust and respect topics) based on how well the other areas were covered in previous focus groups, to provide a balance of topic coverage across focus groups. For several focus groups, particularly early on in the project, the team had a debrief- ing session afterward, to discuss themes that arose in the focus groups, and to fix moderating issues (e.g., facilitating the discus- sions more effectively).

Focus groups took place at a community coffee house in inner northeast Portland, Oregon, a location familiar to and convenient

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989AFRICAN AMERICAN EXPERIENCES IN HEALTHCARE

for many African American community members. Prior to the focus group discussions, participants were asked to read and sign the informed consent, which contained a brief description of the study’s purpose and the importance of keeping the discussions confidential. During focus group discussions, typically one mod- erator asked questions and led discussion while the other moder- ator took notes and monitored discussion to ensure balanced partici- pation. Consistent with principles of trustworthiness the investigators considered the extent of structure to create during the interviews (Elo et al., 2014), deciding on a semistructured approach that allowed the moderators freedom to probe interesting areas that occurred during the sessions and allowed participants to describe experiences in detail. Discussions typically lasted for about an hour and a half. After each focus group discussion the investigators distributed a brief questionnaire asking participants to provide demographic information such as year of birth and confirmation of gender and race/ethnicity. Participants were paid $40 each for their participation in the study.

Data Analysis

The focus group discussions were audiorecorded. A freelance transcriptionist transcribed all of the dialogue and placed the transcriptions into Microsoft Word documents. Each focus group was given its own file. The authors used the qualitative software NVivo 10 and employed an approach in which data relevant to our prespecified domains of interest were analyzed inductively for themes related to those domains (Burnard, Gill, Stewart, Treasure, & Chadwick, 2008). Beginning with the three barriers in patient– provider relationships derived from extant literature with African American patient samples, the first author coded all transcripts for perceived discrimination, medical mistrust, and poor communica- tion, applying a common set of codes and subcategories across all transcripts. The first author (A.G.C.)–an African American doc- toral candidate in psychology, with training in qualitative research and academic experience exploring health care disparities— coded approximately 25% of the transcripts. Findings were then dis- cussed with the other research team members, including a senior faculty member in psychology with experience in focus group methods and expertise in community health and psychol- ogy (K.O.), and a primary care physician and health services researcher with expertise in studying health care disparities and patient–provider relationships (S.S.). Any disagreements were resolved among the research team at the time. Once the team agreed on the coding scheme, the first author recoded the first 25% of the transcripts. The first author then met with the team once more to reach agreement on the coding and organization (Elo et al., 2014; Stewart & Shamdasani, 2014). After all of the data were coded, the first and second authors met frequently to discuss codes and reach agreement on the codes and subcate- gories. Next, the authors used these codes to investigate the comparisons or connections across groups and to generate themes describing participants’ experiences within the domains of interest (discrimination, mistrust, poor communication, and race discordance). The research team met to review analytic memos, to discuss discrepancies of thinking, and to reach agreement on analytic findings.

Results

A total of 60 African Americans participated in a total of 9 focus groups, including four groups of women and five of men. The majority of participants were middle-aged: 35 men participated with a mean age of 56 and ages ranging from 27 to 81, and 25 women participated with mean age of 58 and ages ranging 24 to 89. About three quarters of the participants had high blood pres- sure, about one half had diabetes, and about one third had both conditions.

Discussions of the three barriers examined in this study arose in both the men’s and women’s focus groups. Issues of perceived discrimination spontaneously arose from discussions on what makes a good clinician, whereas discussions of poor communica- tion manifested mainly when moderators asked participants what constitutes a good and bad relationship with doctors. Discussions on trust and race discordance also arose spontaneously, but mod- erators also explored these topics planfully in keeping with the discussion guide. The research team found relationships among these concepts: for example, statements about poor communication also referenced experiences of discrimination. Although the topic of race concordance was explicitly explored in the focus group discussions (e.g., preferences and experiences), the clinician’s race did not play a prominent role in patients’ experiences.

We describe below the major themes that arose within the domains of perceived discrimination, mistrust, communication, and race discordance.

Perceived Discrimination Arose When Patients Were Treated With Less Courtesy and Respect by Office Staff and Clinicians

African Americans often perceived discrimination when inter- acting with office staff and doctors. African American women, in particular, reported they had to assert their interests constantly to receive fair treatment. An African American woman described her negative experience receiving care from her clinician wherein she felt she was perceived as a drug user:

I think it’s because I’m a Black woman I do not get no medication or no kind of other kind of treatment. So, I’m saying, I think it’s that kind of an issue, because you got White druggies, they are all kinds of people are druggies, but they suspect the African American. [Empha- sis added]

Another African woman described a situation in which her symptoms were dismissed, and in which she believed she received substandard care:

They act like they’re afraid to touch you or they cannot tell you. . . . They cannot see anything on you and I have heard a lot of Black people have issues about that, where they act like they cannot see anything on you. . . . And a lot of time . . . they will not touch you. [Emphasis added]

Some participants reported that experiences of discrimination began at the front desk or waiting room of their doctors’ offices, well before they entered the doctors’ examining rooms. Partici- pants often felt mistreated by staff, and the ambiguity as to whether this mistreatment was related to their racial or ethnic background

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caused concern and distress. One participant discussed his expe- rience in a waiting room:

They saw me for the first time about a month ago. I always feel like I’m getting skipped over. I do not know if it’s a Black thing or not, but I always feel like, I was here before somebody else, and they went in before I did, but I sort of try to keep that to myself. [Emphasis added]

One woman perceived a difference in how the office staff interacted with African American patients compared to European American patients:

Well, um, my primary care doctor . . . is very helpful toward me, and she goes out of her way to help me, but I notice when I’m with the, um, when I’m in the receptionist’s area, the receptionists seem more willing to chit-chat with the white clients that come through than they are with me. They’ll have them standing there talking to them and laughing and joking, and when I step up and make a comment, you know, it’s all business. I feel (laughs), I feel like they’re prejudiced.

Mistrust Arose When Patients Felt They Were Being Treated Unfairly Because of Their Ethnic/Racial Background

Lack of trust seemed to pervade participants’ reports. Many African American women mentioned they did not trust physicians because they would not advocate for them because physicians often see patients as consumers rather than patients. A woman recommended that patients bring someone else along to the doctor visit to advocate for and support the patient, because the partici- pant does not trust doctors to treat patients well. She said, “I want to add that . . . if at all possible, they should never go to the doctor alone.”

In the men’s discussions, participants provided accounts in which mistrust was closely linked to perceived discrimination and poor communication. In other words, the feeling of being disre- spected led to mistrust and was sometimes attributed to discrimi- nation:

I didn’t trust [her]. . . . She just came in like she had a problem with me being a man or me being a Black man, one or the two. I wanted her to know, “I don’t like you! You’re rude. You’re completely rude.” I didn’t understand why.

Poor Communication Arose When Doctors Did Not Listen or Show Concern When Patients Discussed Their Health Issues

Listening and showing concern were highlighted in descriptions

of good and bad patient-provider communication. African Amer- ican women often described experiences in which the physicians did not take the time to listen to patients’ concerns or make sure the patients understood their treatment regimen.

Perceptions of poor communication contributed to perceived discrimination. Often participants attributed poor communica- tion to how the doctors responded to the patient’s racial/ethnic background. They believed that doctors (typically race- discordant doctors) devalued patients’ symptoms or ignored their comments because they were African American. One man described being upset when clinicians ignored his symptoms or issues:

It was more or less just being ushered out as quickly as possible. It’s as though when they see an African American come in there, it’s like we’re trying to get over and that’s the impression I get every Time I go. It’s a little upsetting.

Race Discordance Did Not Play a Role as Long as Patients Felt the Doctor Demonstrated Competence

Focus group participants varied in their preference or lack of preference for race-concordant doctors. Many said they did not care whether their doctor was African American as long as the doctor was competent. One participant described what she wanted from a doctor, which went beyond race, ethnicity, and culture:

I see a Black doctor now, but I do not think either way that it would make any difference, the culture or the race of the doctor. I just want to have a doctor that’s a good doctor, that’s willing to listen, and has a good understanding.

The men’s discussion groups echoed this preference: “If it happened to be a Black doctor, I wouldn’t have any problem with it, but I just want to have a good doctor.” Those who did prefer race-concordant doctors believed African American doctors were better communicators and more caring; as one woman expressed, “They are more compassionate. They always want to give you as much information and they seem to have empathy with you and everything.”

In sum, the three key relationship barriers identified in prior quantitative literature evinced themselves in participants’ com- ments, with participants also providing examples of how race concordance and discordance may play an important part in their interactions with health care providers.

Discussion

What do these findings tell us about patient–provider relation- ships for African Americans? The findings help us to understand what at least some African American patients considered discrim- inatory, what influenced their lack of trust toward clinicians, what factors negatively affected communication with clinicians, and why they might have preferred race-concordant clinicians. Find- ings also show ways in which these barriers are interrelated in participants’ own experiences, suggesting that future studies would do well to study these concepts together.

African American patients perceive more discrimination than do European American patients (Hausmann, Kwoh, Hannon, & Ibra- him, 2013; Sorkin, Ngo-Metzger, & De Alba, 2010), and for African American patients, perceived discrimination is associated both with poor quality of care and with poor adherence to medical care recommendations (Cuffee et al., 2013; Forsyth et al., 2014; Hausmann et al., 2010). But what exactly do African American patients find discriminatory? Our results indicate that the experi- ence of discrimination actually begins before the patient enters the clinician’s exam room. A long time in the waiting room, for example, led participants to question whether or not they were being discriminated against, and African American women, in particular, reported that medical staff interacted more warmly with European American patients. Patients also reported problems in the exam room, however, such as feeling symptoms or problems were dismissed, or that patients were viewed as drug users. Some

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991AFRICAN AMERICAN EXPERIENCES IN HEALTHCARE

experiences felt clearly discriminatory and caused distress or an- ger; other experiences left patients wondering whether the event had been discriminatory or not, with the ambiguity leaving the situation unresolved and potentially having a negative influence on future health care interactions.

Mistrust toward institutions and health professionals is also linked to underuse of health care services and negative health care experiences (Hammond, 2010; Moore et al., 2013). What factors in health care influence patients to mistrust clinicians? The way the health care system is structured leads at least some African Amer- icans to feel depersonalized and objectified, rather than being seen as people. They feel rushed during health care visits and they believe clinicians would not advocate on their behalf. Their reluc- tance to trust clinicians may stem from feeling disrespected, cou- pled with uncertainty as to whether the disrespect was related to physicians’ issues with their race. This negative experience and uncertainty led to patients’ keeping their distance from and dis- trusting clinicians. There also appeared to be a cycle of mutual mistrust, in which patients’ mistrust of clinicians developed out of their impressions that clinicians did not trust them as patients.

Pertaining to poor communication, prior studies have shown that African American patients report unfavorable interactions with their clinicians (Cooper et al., 2012; Blair et al., 2013). What are some of the factors that may negatively affect communication between clinician and patient? When group members spoke about negative experiences communicating with clinicians, they often spoke about how clinicians did not acknowledge their perspective during interactions. This lack of acknowledgment was often seen as discriminatory. This corroborates previous findings by Blair et al. (2013) and Cooper et al. (2012) that greater implicit racial bias among clinicians was associated with lower reported patient- centered care by Black patients. When patients have fewer oppor- tunities to be heard during the interaction, they are less likely to be engaged in the treatment. This in turn may lead them to receive less information from their clinicians and be less active partici- pants (Cooper et al., 2012; Eggly et al., 2015).

Race concordance is important to consider within the context of African American health care experience. Race-concordant patient-provider relationships are associated with medication ad- herence, improved communication and higher levels of trust than in race discordant relationships (Schoenthaler et al., 2014; Traylor et al., 2010). Therefore, we sought to identify whether the race/ ethnicity of the clinicians influenced the barriers experienced by African Americans. We asked participants to address race discor- dance directly; when they did address race discordance they fre- quently said they had no preference about a clinician’s ethnic background. Regardless of the clinician’s race or ethnicity, partic- ipants preferred having a good clinician who communicated well with patients. Those who did prefer a race-concordant clinician discussed how race-concordant clinicians are better communica- tors and more caring during interactions. This finding supports LaVeist and Nuru-Jeter’s (2002) argument that African Americans who prefer race-concordant clinicians believe that communication is easier and more comfortable. Patients with race-concordant clinicians may feel they are more a part of the decision-making process, and those who prefer a race-concordant clinician may also expect their clinician to exercise greater advocacy in patient care. It is important to note, however, that this study took place in a locality with very few African American physicians, and it is

plausible that some participants may not have had an experiential basis for comparison.

African American patients experienced perceived discrimina- tion, medical mistrust, and poor communication not as distinct barriers but as interrelated problems. For example, negative com- munications between patient and clinician were often seen as discriminatory events. Moreover, past negative interactions con- tribute to mistrust, which in turn contributes to reluctance in disclosing information in future visits with clinicians. The inter- relatedness of these barriers in conjunction with perceptions of race discordance indicates the complexity of patient experiences. It also provides insight into Greer, Brondolo, and Brown’s (2014) study that found an association between patients’ perceptions of their clinicians’ racial biases and patients’ mistrust of care. Clini- cians are more verbally dominant and engage in less patient- centered communication with African American patients than with White patients (Johnson et al., 2004). Further studies have found that clinician positive affective behavior (e.g., being empathic and using concern statements) is associated with patient trust toward clinicians (Martin et al., 2013), and patients’ ratings of provider communication is associated with great medical adherence (Schoenthaler et al., 2009).

African American patients view their experiences through a racial lens informed by past and current experiences of racial discrimination in encounters with social institutions. In the context of health care, such a lens may help patients to interpret their interactions with medical staff and clinicians, and this, in turn, may allow them to eventually cope with potentially discrimination- related stressors in the health care experience. In race-discordant patient–provider relationships, health care-related stressors are am- plified. Non–African American clinicians and medical staff may bring their own biases to their interactions with patients. Clinicians may not be conscious of their preferential treatment toward one particular group over another (Dovidio & Fiske, 2012; Penner et al., 2010; van Ryn & Saha, 2011).

Our findings suggest ways to improve trust and enhance com- munication with African American patients, and to avoid acts that might be perceived as discriminatory. Clinic staff can be more attentive to differential wait times and proactively explain the reasons for long waits. They might also try to be aware of differ- ences in the way they interact with African American patients and non-African American patients. Medical staff and clinicians can be mindful of stereotypes they may carry about patients based on race or appearance, and make conscious efforts to acknowledge exist- ing biases and overcome them. They can communicate in a way that validates patients’ perspectives, expresses concern and advo- cacy for patients’ well-being, and demonstrates respect and com- mon courtesy. Although these might appear to be rudimentary solutions, the fact that patients in our study reported that these behaviors were often not displayed suggests that there is room for improvement. Such improvement may require examination, and ultimately prevention, of unconscious biases affecting treatment.

Limitations

This study has several limitations and considerations. The data were collected approximately 10 years ago, which may call into question the present-day applicability of the findings. There is little evidence, however, that the issues of discrimination, mistrust, and

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poor communication in health care for African Americans have dramatically changed over the last decade. Moreover, evidence from recent studies suggests that the issues we explored are still very relevant to African Americans’ health care experiences today (Armstrong et al., 2013; Tajeu et al., 2015).

The authors note that in the focus group discussions, when the topic of discrimination in health care arose, some participants seemed reluctant to pursue the topic. This was the case even though discussion comoderators were of the same race and gender as study participants. Once the conversation opened up, partici- pants sometimes appeared unsettled trying to figure out whether or not an ambiguous negative event was discriminatory. The authors speculate that the context of the focus group discussion may have become part of the process of discrimination appraisal. Partici- pants’ reluctance may have been attributable in part to their avoid- ance of feeling the powerlessness of acknowledging unfair treat- ment (Stroebe, Barreto, & Ellemers, 2010). Although the theme of discrimination still manifested in the discussions, this reluctance may have caused an underreporting of more discriminatory inci- dents.

This study used one primary coder, which may have increased the potential for bias in the data analysis. To minimize bias and uphold both credibility and trustworthiness, the team employed the consolidated criteria for reporting qualitative research (COREQ; Tong, Sainsbury, & Craig, 2007). In particular, the team estab- lished transparency during the process of coding by having meet- ings where the coder and other team members reviewed analytic memos, discussed any discrepancies of thinking, and reached agreement on coded transcripts. This practice is consistent with Elo and colleagues’ (2014) suggestion to have one researcher responsible for the analysis while having others carefully follow-up on the whole analytic process by subsequently meeting and dis- cussing any divergent opinions concerning the categorization.

Most of the participants lived in Portland, Oregon, which has remained a city of relatively low racial diversity over time (U.S. Census Bureau, 2010). Because of the low proportion of African Americans in this geographic area, the reported experiences may differ in unknowable ways from experiences of African Americans in other geographic regions. Our focus group participants were far more likely to have received care from European American than African American clinicians, which limited their ability to reflect on experiences with race-concordant clinicians.

Recruitment for the focus groups was based on community events and contacts, and was limited to persons with diabetes, hypertension, or both. The inclusion criteria related to health conditions likely yielded an older sample than might have other- wise participated. In addition, as a method of data collection focus groups depend upon group interaction. Depending on the popula- tion, the topic, and potentially also upon situational factors, nor- mative influences can affect focus group participants’ commen- tary. Real or imagined social pressures can influence individuals’ decisions to report experiences that diverge from a perceived norm or indeed, diverge from what participants believe researchers wish to hear. This is an often-recognized limitation of focus groups (Stewart & Shamdasani, 2014). In part to minimize this problem, the focus group moderators welcomed all points of view on topics of discussion and solicited a wide range of experiences from study participants. Moderators were also community members who were not part of the academic research team. The focus groups were

moderated by facilitators of the same race and gender. This may have played an important role in having participants feel comfort- able sharing sensitive topics, such as racial discrimination and sexism. The authors believe that there may have been underreport- ing of negative experiences, particularly those involving race, if comoderators had been of a different racial background than participants.

Conclusion

Reducing situations that give rise to the barriers of perceived discrimination, medical mistrust, and poor communication may improve patient–provider interactions, and may in turn reduce the pervasive problem of racial and ethnic disparities in health care. Because these barriers seem to be interrelated, reducing the effects of one barrier in the relationship may help reduce the effects of the other barriers as well. Although the preference for racially con- cordant clinicians depends on the patient’s belief that racially concordant clinicians can deliver better care, eliminating the bar- riers of perceived discrimination, mistrust, and poor communica- tion in health care can ameliorate the negative health-related outcomes currently associated with care relationships that are race-discordant. Perceived discrimination, mistrust, and poor com- munication limit the quality of care for African Americans. Find- ings suggest avenues for reducing these barriers. Improving the patient-provider relationship in these ways can lead to more equi- table health care delivery and potentially better health outcomes for African Americans.

References

Abramson, C. M., Hashemi, M., & Sánchez-Jankowski, M. (2015). Per- ceived discrimination in U.S. healthcare: Charting the effects of key social characteristics within and across racial groups. Preventive Medi- cine Reports, 2, 615– 621. http://dx.doi.org/10.1016/j.pmedr.2015.07 .006

Armstrong, K., Putt, M., Halbert, C. H., Grande, D., Schwartz, J. S., Liao, K., . . . Shea, J. A. (2013). Prior experiences of racial discrimination and racial differences in health care system distrust. Medical Care, 51, 144 –150. http://dx.doi.org/10.1097/MLR.0b013e31827310a1

Beach, M. C., Saha, S., Korthuis, P. T., Sharp, V., Cohn, J., Wilson, I. B., . . . Moore, R. (2011). Patient-provider communication differs for black compared to white HIV-infected patients. AIDS and Behavior, 15, 805– 811. http://dx.doi.org/10.1007/s10461-009-9664-5

Benjamins, M. R. (2012). Race/ethnic discrimination and preventive ser- vice utilization in a sample of whites, blacks, Mexicans, and Puerto Ricans. Medical Care, 50, 870 – 876. http://dx.doi.org/10.1097/MLR .0b013e31825a8c63

Blair, I. V., Steiner, J. F., Fairclough, D. L., Hanratty, R., Price, D. W., Hirsh, H. K., . . . Havranek, E. P. (2013). Clinicians’ implicit ethnic/ racial bias and perceptions of care among Black and Latino patients. Annals of Family Medicine, 11, 43–52. http://dx.doi.org/10.1370/afm .1442

Bleich, S. N., Simon, A. E., & Cooper, L. A. (2012). Impact of patient- doctor race concordance on rates of weight-related counseling in visits by black and white obese individuals. Obesity, 20, 562–570. http://dx .doi.org/10.1038/oby.2010.330

Burnard, P., Gill, P., Stewart, K., Treasure, E., & Chadwick, B. (2008). Analysing and presenting qualitative data. British Dental Journal, 204, 429 – 432. http://dx.doi.org/10.1038/sj.bdj.2008.292

Cooper, L. A., Roter, D. L., Carson, K. A., Beach, M. C., Sabin, J. A., Greenwald, A. G., & Inui, T. S. (2012). The associations of clinicians’

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

ti on

or on

e of

it s

al li

ed pu

bl is

he rs

. T

hi s

ar ti

cl e

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

993AFRICAN AMERICAN EXPERIENCES IN HEALTHCARE

implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. American Journal of Public Health, 102, 979 –987. http://dx.doi.org/10.2105/AJPH.2011.300558

Cuffee, Y. L., Hargraves, J. L., Rosal, M., Briesacher, B. A., Schoenthaler, A., Person, S., . . . Allison, J. (2013). Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension. American Journal of Public Health, 103(11), e55– e62. http://dx.doi.org/10.2105/AJPH.2013.301554

Dale, S. K., Bogart, L. M., Wagner, G. J., Galvan, F. H., & Klein, D. J. (2014). Medical mistrust is related to lower longitudinal medication adherence among African-American males with HIV. Journal of Health Psychology, 15, 1180 –1186.

Dovidio, J. F., & Fiske, S. T. (2012). Under the radar: How unexamined biases in decision-making processes in clinical interactions can contrib- ute to health care disparities. American Journal of Public Health, 102, 945–952. http://dx.doi.org/10.2105/AJPH.2011.300601

Egede, L. E., & Bosworth, H. (2008). The future of health disparities research: 2008 and beyond. Journal of General Internal Medicine, 23, 706 –708. http://dx.doi.org/10.1007/s11606-008-0580-6

Eggly, S., Barton, E., Winckles, A., Penner, L. A., & Albrecht, T. L. (2015). A disparity of words: Racial differences in oncologist-patient communication about clinical trials. Health Expectations: An Interna- tional Journal of Public Participation in Health Care & Health Policy, 18, 1316 –1326. http://dx.doi.org/10.1111/hex.12108

Elder, K., Ramamonjiarivelo, Z., Wiltshire, J., Piper, C., Horn, W. S., Gilbert, K. L., . . . Allison, J. (2012). Trust, medication adherence, and hypertension control in Southern African American men. American Journal of Public Health, 102, 2242–2245. http://dx.doi.org/10.2105/ AJPH.2012.300777

Elo, S., Kääriäinen, M., Kanste, O., Pölkki, T., Utriainen, K., & Kyngäs, H. (2014). Qualitative content analysis: A focus on trustworthiness. SAGE Open, 4, 1–10. http://dx.doi.org/10.1177/2158244014522633

Forsyth, J., Schoenthaler, A., Chaplin, W. F., Ogedegbe, G., & Rav- enell, J. (2014). Perceived discrimination and medication adherence in black hypertensive patients: The role of stress and depression. Psychosomatic Medicine, 76, 229 –236. http://dx.doi.org/10.1097/ PSY.0000000000000043

Greer, T. M., Brondolo, E., & Brown, P. (2014). Systemic racism moder- ates effects of provider racial biases on adherence to hypertension treatment for African Americans. Health Psychology, 33, 35– 42. http:// dx.doi.org/10.1037/a0032777

Hammond, W. P. (2010). Psychosocial correlates of medical mistrust among African American men. American Journal of Community Psy- chology, 45, 87–106. http://dx.doi.org/10.1007/s10464-009-9280-6

Hausmann, L. R., Hannon, M. J., Kresevic, D. M., Hanusa, B. H., Kwoh, C. K., & Ibrahim, S. A. (2011). Impact of perceived discrimination in healthcare on patient-provider communication. Medical Care, 49, 626 – 633. http://dx.doi.org/10.1097/MLR.0b013e318215d93c

Hausmann, L. R., Kressin, N. R., Hanusa, B. H., & Ibrahim, S. A. (2010). Perceived racial discrimination in health care and its association with patients’ healthcare experiences: Does the measure matter? Ethnicity & Disease, 20, 40 – 47.

Hausmann, L. R., Kwoh, C. K., Hannon, M. J., & Ibrahim, S. A. (2013). Perceived racial discrimination in health care and race differences in physician trust. Race and Social Problems, 5, 113–120.

Johnson, R. L., Roter, D., Powe, N. R., & Cooper, L. A. (2004). Patient race/ethnicity and quality of patient-physician communication during medical visits. American Journal of Public Health, 94, 2084 –2090. http://dx.doi.org/10.2105/AJPH.94.12.2084

Katz, R. V., Green, B. L., Kressin, N. R., James, S. A., Wang, M. Q., Claudio, C., & Russell, S. L. (2009). Exploring the “legacy” of the Tuskegee Syphilis Study: A follow-up study from the Tuskegee Legacy Project. Journal of the National Medical Association, 101, 179 –183. http://dx.doi.org/10.1016/S0027-9684(15)30833-6

LaVeist, T. A., & Nuru-Jeter, A. (2002). Is doctor-patient race concordance associated with greater satisfaction with care? Journal of Health and Social Behavior, 43, 296 –306. http://dx.doi.org/10.2307/3090205

Martin, K. D., Roter, D. L., Beach, M. C., Carson, K. A., & Cooper, L. A. (2013). Physician communication behaviors and trust among black and white patients with hypertension. Medical Care, 51, 151–157. http://dx .doi.org/10.1097/MLR.0b013e31827632a2

Mayr, F. B., Yende, S., D’Angelo, G., Barnato, A. E., Kellum, J. A., Weissfeld, L., . . . Angus, D. C. (2010). Do hospitals provide lower quality of care to black patients for pneumonia? Critical Care Medicine, 38, 759 –765. http://dx.doi.org/10.1097/CCM.0b013e3181c8fd58

Minkler, M., & Wallerstein, N. (Eds.). (2011). Community-based partici- patory research for health: From process to outcomes. Malden, MA: Wiley.

Moore, A. D., Hamilton, J. B., Knafl, G. J., Godley, P. A., Carpenter, W. R., Bensen, J. T., . . . Mishel, M. (2013). The influence of mistrust, racism, religious participation, and access to care on patient satisfaction for African American men: The North Carolina-Louisiana Prostate Can- cer Project. Journal of the National Medical Association, 105, 59 – 68. http://dx.doi.org/10.1016/S0027-9684(15)30086-9

Morgan, D. L. (2010). Reconsidering the role of interaction in analyzing and reporting focus groups. Qualitative Health Research, 20, 718 –722. http://dx.doi.org/10.1177/1049732310364627

Nam, S., Chesla, C., Stotts, N. A., Kroon, L., & Janson, S. L. (2011). Barriers to diabetes management: Patient and provider factors. Diabetes Research and Clinical Practice, 93, 1–9. http://dx.doi.org/10.1016/j .diabres.2011.02.002

Patton, M. Q. (2002). Qualitative research & evaluation methods (3rd ed.). Thousand Oaks, CA: Sage.

Peek, M. E., Odoms-Young, A., Quinn, M. T., Gorawara-Bhat, R., Wilson, S. C., & Chin, M. H. (2010). Race and shared decision-making: Per- spectives of African-Americans with diabetes. Social Science & Medi- cine, 71, 1–9. http://dx.doi.org/10.1016/j.socscimed.2010.03.014

Penner, L. A., Dovidio, J. F., West, T. V., Gaertner, S. L., Albrecht, T. L., Dailey, R. K., & Markova, T. (2010). Aversive racism and medical interactions with Black patients: A field study. Journal of Experimental Social Psychology, 46, 436 – 440. http://dx.doi.org/10.1016/j.jesp.2009 .11.004

Penner, L. A., Hagiwara, N., Eggly, S., Gaertner, S. L., Albrecht, T. L., & Dovidio, J. F. (2013). Racial healthcare disparities: A social psycholog- ical analysis. European Review of Social Psychology, 24, 70 –122. http://dx.doi.org/10.1080/10463283.2013.840973

Richardson, L. D., & Norris, M. (2010). Access to health and health care: How race and ethnicity matter. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine, 77, 166 –177.

Rim, S. H., Hall, I. J., Fairweather, M. E., Fedorenko, C. R., Ekwueme, D. U., Smith, J. L., . . . Ramsey, S. D. (2011). Considering racial and ethnic preferences in communication and interactions among the patient, family member, and physician following diagnosis of localized prostate cancer: Study of a US population. International Journal of General Medicine, 4, 481– 486. http://dx.doi.org/10.2147/IJGM.S19609

Schoenthaler, A., Allegrante, J. P., Chaplin, W., & Ogedegbe, G. (2012). The effect of patient-provider communication on medication adherence in hypertensive black patients: Does race concordance matter? Annals of Behavioral Medicine, 43, 372–382. http://dx.doi.org/10.1007/s12160- 011-9342-5

Schoenthaler, A., Chaplin, W. F., Allegrante, J. P., Fernandez, S., Diaz- Gloster, M., Tobin, J. N., & Ogedegbe, G. (2009). Provider communi- cation effects medication adherence in hypertensive African Americans. Patient Education and Counseling, 75, 185–191. http://dx.doi.org/10 .1016/j.pec.2008.09.018

Schoenthaler, A., Montague, E., Baier Manwell, L., Brown, R., Schwartz, M. D., & Linzer, M. (2014). Patient-physician racial/ethnic concordance and blood pressure control: The role of trust and medication adherence.

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

ti on

or on

e of

it s

al li

ed pu

bl is

he rs

. T

hi s

ar ti

cl e

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

994 CUEVAS, O’BRIEN, AND SAHA

Ethnicity & Health, 19, 565–578. http://dx.doi.org/10.1080/13557858 .2013.857764

Shavers, V. L., Fagan, P., Jones, D., Klein, W. M., Boyington, J., Moten, C., & Rorie, E. (2012). The state of research on racial/ethnic discrimi- nation in the receipt of health care. American Journal of Public Health, 102, 953–966. http://dx.doi.org/10.2105/AJPH.2012.300773

Shelton, R. C., Winkel, G., Davis, S. N., Roberts, N., Valdimarsdottir, H., Hall, S. J., & Thompson, H. S. (2010). Validation of the group-based medical mistrust scale among urban black men. Journal of General Internal Medicine, 25, 549 –555. http://dx.doi.org/10.1007/s11606-010- 1288-y

Sheppard, V. B., Mays, D., Tercyak, K. P., & LaVeist, T. (2013). Medical mistrust influences black women’s level of engagement in BRCA 1/2 genetic counseling and testing. Journal of the National Medical Asso- ciation, 105, 17–22. http://dx.doi.org/10.1016/S0027-9684(15)30081-X

Snipes, S. A., Sellers, S. L., Tafawa, A. O., Cooper, L. A., Fields, J. C., & Bonham, V. L. (2011). Is race medically relevant? A qualitative study of physicians’ attitudes about the role of race in treatment decision-making. BMC Health Services Research, 11, 183–193. http://dx.doi.org/10.1186/ 1472-6963-11-183

Sorkin, D. H., Ngo-Metzger, Q., & De Alba, I. (2010). Racial/ethnic discrimination in health care: Impact on perceived quality of care. Journal of General Internal Medicine, 25, 390 –396. http://dx.doi.org/ 10.1007/s11606-010-1257-5

Stewart, D. W., & Shamdasani, P. N. (2014). Focus groups: Theory and practice (Vol. 20). Thousand Oaks, CA: Sage.

Stroebe, K., Barreto, M., & Ellemers, N. (2010). Experiencing discrimi- nation: How members of disadvantaged groups can be helped to cope

with discrimination. Social Issues and Policy Review, 4, 181–213. http:// dx.doi.org/10.1111/j.1751-2409.2010.01021.x

Tajeu, G. S., Cherrington, A. L., Andreae, L., Prince, C., Holt, C. L., & Halanych, J. H. (2015). “We’ll get to you when we get to you”: Exploring potential contributions of health care staff behaviors to patient perceptions of discrimination and satisfaction. American Journal of Public Health, 105, 2076 –2082. http://dx.doi.org/10.2105/AJPH.2015 .302721

Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for inter- views and focus groups. International Journal for Quality in Health Care, 19, 349 –357. http://dx.doi.org/10.1093/intqhc/mzm042

Traylor, A. H., Schmittdiel, J. A., Uratsu, C. S., Mangione, C. M., & Subramanian, U. (2010). Adherence to cardiovascular disease medica- tions: Does patient-provider race/ethnicity and language concordance matter? Journal of General Internal Medicine, 25, 1172–1177. http://dx .doi.org/10.1007/s11606-010-1424-8

U.S. Census Bureau. (2010). American FactFinder. Profile of general population and housing characteristics: 2000 and 2010. Retrieved Jan- uary 10, 2016, from http://factfinder.census.gov

van Ryn, M., & Saha, S. (2011). Exploring unconscious bias in disparities research and medical education. JAMA: Journal of the American Med- ical Association, 306, 995–996. http://dx.doi.org/10.1001/jama.2011 .1275

White, K., Haas, J. S., & Williams, D. R. (2012). Elucidating the role of place in health care disparities: The example of racial/ethnic residential segregation. Health Services Research, 47(3pt2), 1278 –1299. http://dx .doi.org/10.1111/j.1475-6773.2012.01410.x

Appendix

Project EQUALED Moderator Guide

• Orientation • Introduction of participants • Describe your most recent visit to the doctor • Good experiences with doctors

X Actual experiences X What makes a good experience

• Bad experiences with doctors X Actual experiences X What would have made for a better experience

• Physician race/ethnicity same or different as your own X Experiences X Preferences

• Personal and sensitive topics discussed with doctors • Trust

X Experiences of distrust

X What brings about trust • Respect

X Experiences of disrespect X How is respect demonstrated

• Following doctors’ recommendations about medications and procedures, lifestyle changes X Your experience not following doctors’ recommenda-

tions X What prompted non-adherence to recommendations X One piece of advice you’d like to give your doctor

Received July 1, 2015 Revision received February 2, 2016

Accepted February 12, 2016 �

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