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AFRICAN-AMERICAN PREFERENCE FOR SAME-RACE HEALTHCARE PROVIDERS: THE ROLE OF HEALTHCARE DISCRIMINATION

Objective: To determine the extent to which African Americans prefer same-race clinicians

and the extent to which: 1) knowledge of

historical mistreatment; 2) perceptions of

current racial inequities in medical treatment;

and 3) personal experiences of discrimination

are associated with preference for same-race

healthcare providers among African Ameri-

cans.

Design: Statistical analysis of a nationally

representative telephone survey designed by

the Henry J. Kaiser Family Foundation and

conducted by Princeton Survey Research

Associates (PSRA). Bivariate significance is

determined by using chi-square tests of

association. Multinominal logistic regression

models adjust for age, gender, income, edu-

cation, and self-reported health status.

Results: Approximately one in five African

Americans states a preference for a same-race

healthcare provider. Neither knowledge of

historical mistreatment nor perceptions of

current racial inequities in medical treatment

are related to preferred race of healthcare

providers. In contrast, personal experiences of

discrimination in health care are associated

with a preference for same-race healthcare

providers.

Conclusions: The results suggest that while knowledge of unfair treatment historically and

perceptions of current racial inequity do not

affect preferences, personal experiences of

unfair treatment may have a significant effect

on African-American patients’ preferences re-

garding health care. Findings suggest that

rather than focusing on how historical mis-

treatment and current inequities in medical

treatment affect individual patients, research

should focus on individual experiences. (Ethn

Dis. 2005;15:740–747)

Key Words: African Americans, Discrimina- tion, Professional Patient Relations

Jennifer Malat, PhD; Michelle van Ryn, PhD, MPH

INTRODUCTION

While only 4% of physicians are

Black, <20% of African Americans report having a same-race physician,

1

which makes African-American patients

much more likely than other-race

patients to receive health care from

African-American physicians. 2–4

Re-

searchers have assumed that patient

preferences influence the race of pa-

tients’ healthcare providers, but the

nature of preferences and what factors

inform them have not been clarified. 5

Explicating this relationship can provide

insight into the sometimes problematic

relationship between healthcare workers

and African-American patients and

improve efforts to ensure that appropri-

ate health care is provided to African

Americans. This paper examines pre-

ferred healthcare provider race among

African-American adults and assesses

the extent to which perceptions of racial

discrimination are associated with these

preferences.

BACKGROUND

Research on how patients choose

physicians suggests that patients usually

do not undertake a systematic review of

physicians. 6,7

Nonetheless, interperson-

al expectations or belief systems appear

to influence preferences for healthcare

provider characteristics. Research in this

area generally examines women’s pref-

erence for female clinicians and finds,

for example, that women tend to prefer

a female gynecologist because of factors

like religious beliefs and interpersonal

comfort. 8,9

Healthcare provider race has not

been adequately explored as a social

factor influencing patients’ choice of

provider. Extant research is based on

local samples or asks about factors that

influenced selection of one’s regular

physician. 2,10

The limitation of the

latter approach is that if preference for

a Black physician exceeds the supply,

some respondents are not able to express

their preference. Research is needed that

overcomes these limitations in the

assessment of preferred provider race.

The poor relationship historically

between the African-American commu-

nity and the medical and public health

communities may lead to a preference

among African Americans for same-race

healthcare providers. For example, when

medicine sought professional status in

the United States, African Americans’

unjust legal and social standing, along

with White physicians’ prejudice, led to

medical experimentation and abuse. 11

The oft-cited Tuskegee Syphilis Study,

which occurred in the middle of the

20th century, is one incident in a long

history of mistreatment. 12

Some authors

From the Department of Sociology, University of Cincinnati, Cincinnati, Ohio (JM); Department of Family Medicine and Community Health and Division of Epide- miology, University of Minnesota, Minne- apolis, Minnesota (MVR).

Address correspondence and reprint requests to Jennifer Malat; Department of Sociology, University of Cincinnati; PO Box 210378; Cincinnati, OH 45221; 513-556- 4709; 513-556-0057 (fax); jennifer.malat@ uc.edu

This paper examines preferred

healthcare provider race

among African-American

adults and assesses the extent

to which perceptions of racial

discrimination are associated

with these preferences.

740 Ethnicity & Disease, Volume 15, Autumn 2005

have reported that mistrust of medical

and public health workers among

African Americans is one consequence

of this history. 5

However, while re-

searchers and practitioners have specu-

lated that this history affects African

Americans’ preference for the race

of their healthcare providers, no

empiric research has assessed this re-

lationship.

While medical and public health

practices have changed in the past

several decades, inequities in medical

care persist. African Americans are less

likely than Whites to receive appropri-

ate medical care, from basic treatment

to high technology services, for a num-

ber of health problems. 13

For example,

studies of the racial disparity in treat-

ment of heart disease and stroke

generally report that Whites are more

likely to undergo invasive medical

procedures. 14–17

While researchers have

persuasively documented this gap, little

is known about its effect on the thinking

of African-American patients. LaVeist

and colleagues 18

have shown that per-

ceptions of unequal treatment in health

care are related to lower patient satis-

faction, which suggests that racial dis-

parities in care influence African-Amer-

icans’ attitudes toward care.

In addition to knowledge of group-

level inequities, individuals may have

personal experiences of racial discrimi-

nation in medical encounters. Percep-

tions of personal unfair treatment have

been linked to patient sociodemo-

graphic characteristics, 19

and some evi-

dence from a small sample shows that

these perceptions can affect patient

behavior. 20

In sum, both knowledge

of unequal treatment of African

Americans and personal experiences

of discrimination may increase Afri-

can-American patients’ likelihood of

preferring a same-race healthcare pro-

vider.

The aim of this paper is to de-

termine the extent to which African

Americans prefer same-race healthcare

providers and to assess how perceptions

of racial discrimination in health care

affect racial preferences. Specifically, the

analysis will evaluate the extent to

which: 1) knowledge of historical mis-

treatment; 2) perceptions of current

racial inequities in medical treatment;

and 3) personal experiences of discrim-

ination predict preference for same-

race healthcare providers. Understand-

ing how perceptions of racial discrimi-

nation affect preferences can provide

insight into decision making by African

Americans and help guide medical out-

reach to African Americans, who con-

tinue to suffer poor health and reduced

access to care at a higher rate than

Whites. 21

METHODS

Data The data come from a subsample of

the 1999 telephone survey, ‘‘Americans’

Perceptions of Racial Disparities in

Health Care.’’ Detail on the methods

can be found in Lillie-Blanton et al. 22

Briefly, the survey included a nationally

representative sample of 3886 adults

living in households with telephones in

the continental United States. A dispro-

portionate stratified sample of random-

digit telephone numbers was used

to oversample African-American and

Latino respondents. The analysis in

this paper was limited to the non-

Hispanic Black sample (n51,189). Seventy-two percent of the residential

numbers in the sample were contacted

by an interviewer; of these, 69%

answered screener questions, 93% of

those screened were found eligible for

the interview, and 98% of eligible

respondents completed the interview.

Therefore, the final response rate was

49%. 23

Measures The dependent variable, preferred

provider race, was assessed by the survey

question, ‘‘If you had to choose, would

you prefer to be treated by a doctor or

nurse of your own race or ethnic group,

or not?’’

Knowledge of historical mistreat-

ment is indicated by knowledge of the

Tuskegee Syphilis Study. In the survey,

respondents were asked whether they

had heard of the Tuskegee Syphilis

Study. Those who responded ‘‘yes,’’

were asked which of three options

described the Tuskegee Syphilis Study:

1) a much-criticized government study

of syphilis treatment involving African-

American men (correct); 2) the African-

American airmen who fought in World

War II; or 3) a study of heart disease

among African-American men. The

response choice order was randomized

in the administration of the survey. For

the present analysis, these two variables

were used to create a new variable.

Report of having heard of the study and

identifying the correct description of the

study were labeled as ‘‘correctly identi-

fied’’ on the new variable. Responding

that one had not heard of the study, or

failing to correctly identify it, were

labeled ‘‘did not know/incorrectly iden-

tified.’’ Nearly 72% of African Amer-

icans who had heard of the study

correctly identified it.

Perceptions of current inequities in

the delivery of health care were assessed

with two survey items. Respondents

were asked, ‘‘how often do you think

a person’s race or ethnic background

affects whether they can get routine

medical care when they need it’’ and

‘‘specialized treatments or surgery when

they need it.’’ Response categories were

very often, somewhat often, not too

often, and never.

Perceptions a

of personal experiences

of racial discrimination in health care

a Qualifying discrimination reports as ‘‘per- ceptions’’ may be less than ideal because it implies doubt about the veracity of respon- dents’ reports. Nonetheless, because the data are not the result of researcher observation, respondent reports of discrim- ination are often referred to as ‘‘percep- tions’’ of discrimination (eg, references 19,20,41)

PREFERENCE FOR SAME-RACE PROVIDERS - Malat and van Ryn

Ethnicity & Disease, Volume 15, Autumn 2005 741

were measured with two items. The

first asked whether during the past

few years respondents had been

treated unfairly because of their racial

or ethnic background. The second item

asked the same about the respondents’

family. Response categories were yes

and no.

Several control variables were in-

cluded in the multivariate models. The

survey collected respondents’ age in

years. Based on findings from research

on cohort differences in racial atti-

tudes, 24

age was grouped into three

categories: 18–44 years, 45–54 years,

and $55 years. Education data were

collected by asking respondents the

highest grade or degree completed.

The responses were recorded in eight

categories, which were recoded into four

categories: less than high school, high

school diploma or equivalent, some

college, and a college degree or more.

The respondents’ household income

was assessed by a pair of questions.

The first asked whether the respondents’

income was more or less than $25,000.

Based on this response, respondents

were asked to place their income in

a more precise income category. More

than 15% of the African Americans in

the sample were missing data on this

control variable. Based on responses to

these variables, a new variable with five

categories was created: ,$20,000,

$20,000–$35,000, $35,001–$50,000,

.$50,000, and missing. Last, health

status was included in the analysis with

the standard self-reported health item,

‘‘In general, how would you describe

your own health? Is it excellent, good,

only fair or poor?’’ Self-reported health

is a good indicator of overall health

status. 25

Analytic Plan Except when noted, weights were

applied to the data presented here.

Weights took into account region of

residence, gender, age, race, and educa-

tion as well as known nonresponse

biases in telephone interview surveys.

The demographic weighting parameters

were developed from an analysis of

the March 1998 Current Population

Survey. The weights were derived

by using an iterative technique that

simultaneously balances the distribu-

tions of all weighting parameters. 23

In addition, all of the parameter

estimates presented in this paper were

estimated by using the statistical pack-

age, Stata version 7.0. 26

Stata can adjust

standard errors to reflect complex

(rather than simple random) survey

designs. In this analysis, the five strata

used in the sample selection are ac-

counted for in the calculation of the

standard errors. Weights were applied to

the models by using Stata’s ‘‘svy’’

commands.

Significance values for bivariate

associations were determined by using

chi-square tests of association. Multi-

variate analyses use multinominal logis-

tic regression models, which simulta-

neously estimate binary comparisons

among the categories of the dependent

variable. The explanatory variables were

added in conceptually meaningful

blocks to a baseline model that included

only the control variables. As will be

seen, many of the explanatory variables

do not achieve significance. Entering

the variables in conceptual blocks allows

one to easily observe the effect of each

conceptual block. In analysis not pre-

sented, all variables were included in

a single model and produced similar

results. The relative risk ratios compar-

ing those who prefer a same-race

healthcare provider and those who have

no preference, and those who prefer

a different-race healthcare provider and

those who have no preference are

presented. Significance values were de-

termined with a Wald test for the

coefficients or block of coefficients.

Significance values are not calculated

for a single comparison on the de-

pendent variable (eg, between prefer

same race and no preference only),

but for the complete multinomial

model and all possible comparisons

on the dependent variable. Further,

significance values are based on the

block of variables entered simultane-

ously.

RESULTS

Table 1 presents the distribution of

the variables for African Americans.

Approximately 20% of African Amer-

icans stated a preference for a same-race

provider, while two thirds responded

that they had no preference. Forty-two

percent of African Americans correctly

identified the Tuskegee Syphilis Study.

More than 60% of African Americans

feel that race affects routine and spe-

cialized medical treatment either very

often or somewhat often. Finally, re-

ports of unfair treatment of family

members are slightly more common

than reports of personal unfair treat-

ment (18.6% vs 14%). The distribution

of the latter four variables was presented

previously by Lillie-Blanton et al 22

in

their analysis of these data. Table 1 also

presents the distribution of the control

variables.

Table 2 presents the distribution

of preferred healthcare provider race

by the explanatory and control variables.

The association between correctly iden-

tifying the Tuskegee Syphilis Study

and preferred healthcare provider

race is not statistically significant

(P..05). Similarly, the perceived diffi- culties of obtaining routine and special-

ty medical treatment are not signifi-

cantly associated with pr eferr ed

healthcare provider race (P..05). In contrast to these results, personal and

familial experiences of discrimination in

health care are significantly associated

with preference for same-race healthcare

providers. African Americans who re-

port racial unfair treatment in health

care of themselves or a family member

are more likely to prefer a same-race

healthcare provider (36.6% vs 18.1%,

P,.01, and 35.3% vs 17.5%, P,.01, respectively).

PREFERENCE FOR SAME-RACE PROVIDERS - Malat and van Ryn

742 Ethnicity & Disease, Volume 15, Autumn 2005

Overall, demographic and health

variables have disparate relationships

with preferred race of healthcare pro-

vider. Education and self-reported

health status are not significantly

related to preferred provider race.

Gender is marginally significant, with

African-American men being more

likely than African-American women

to prefer a same-race healthcare pro-

vider (P5.09). Income also has a mar- ginally significant relationship to the

dependent variable; those with the

highest incomes are most likely to

state a preference for a same-race

healthcare provider (P5.05). Age is significantly associated with preference

(P,.01). African Americans older than 55 are the least likely to state a prefer-

ence for a same-race healthcare pro-

vider; the middle age group (45–

54 years of age) is most likely to state

a preference for same-race healthcare

providers.

The multivariate analyses replicate

nearly all of the bivariate findings.

Neither knowledge of the Tuskegee

Syphilis Study nor perceptions that the

provision of health care is inequal are

significantly related to preferred health-

care provider race for African Americans

(see Table 3, models 1 and 2). In

contrast, familial and personal experi-

ences of unfair treatment in health care

are significant predictors of preferred

healthcare provider race (P,.05). Ad- justing for the other variables in the

model, African Americans who report

having been treated unfairly because of

race in the medical setting are 1.9 times

more likely to prefer a same-race

healthcare provider versus stating no

preference and 1.84 times more likely to

prefer a same-race healthcare provider

versus a different-race healthcare pro-

vider (see Table 3). Similarly, report of

family experiences of unfair racial

treatment in health care significantly

increases the probability of preferring

a Black healthcare provider over

having no preference (relative risk

ratio51.59, P,.05). The findings

Table 1. Distribution of variables

Weighted % Unweighted N

Dependent variable Preferred provider race

Own race 20.7 255 Other 12.6 157 No preference 66.7 768

Explanatory variables Knowledge of Past Unfair Treatment Knowledge of Tuskegee Syphilis Study

Correctly identified 42.1 573 Did not know / Incorrectly identified 57.9 616

Knowledge of Current Health Care Inequalities Race affects receipt of routine care

Very often 24.4 316 Somewhat often 37.3 434 Not too often 28.9 315 Never 7.4 88

Race affects receipt of specialized treatment Very often 26.7 337 Somewhat often 37.5 414 Not too often 26.3 287 Never 9.6 112

Experiences of Personal Unfair Treatment Respondent treated unfairly due to race

Yes 14.0 167 No 86.0 1009

Family member treated unfairly due to race Yes 18.6 241 No 81.4 901

Control variables Gender

Male 44.6 489 Female 55.4 700

Age 18–44 59.5 734 45–54 15.7 196 55 or older 24.8 237

Education Less than high school 21.6 176 High school 40.0 443 Some college 24.2 330 College or more 14.2 234

Income Under $20,000 30.4 342 $20,000–$35,000 24.1 285 $35,000–$50,000 16.5 200 Over $50,000 12.6 181 Missing 16.4 181

Self-rated health Excellent 25.3 315 Good 47.7 567 Fair 20.4 249 Poor 6.7 52

Note: Except race/ethnicity variable, table includes only non-Hispanic Black respondents.

PREFERENCE FOR SAME-RACE PROVIDERS - Malat and van Ryn

Ethnicity & Disease, Volume 15, Autumn 2005 743

are inconsistent in that personal

experience of unfair treatment increases

the probability of preferring another-

race doctor over no preference, while

familial experience decreases the prob-

ability.

Tests for the significance of the

control variables show that age is the

only consistently significant variable in

the multivariate models. Those age $55

are less likely than their younger

counterparts to state a preference for

a Black healthcare provider over a dif-

ferent-race provider or having no pref-

erence. Gender is significant in one

model (P,.05, model 2); men are more likely to state a preference for same-race

providers.

DISCUSSION

One finding of this analysis is that

approximately one in five African

Americans reports a preference for

a same-race healthcare provider. We

are aware of no other study assessing

preference for same-race providers in

a national survey of African Americans.

Extant local studies tend to find no or

low stated preference for Black provid-

ers 27,28

; however, this finding is not

consistent. 29

The present study finds

a preference, though limited, for same-

race providers. These results may be

because the proportion of African

Americans preferring a same-race pro-

vider is indeed low. However, other

explanations are possible as well. For

example, only 4.4% of physicians and

8.8% of nurses are Black, 30

and some

respondents may not state a preference

for an unavailable provider, feeling that

it is useless. Also, respondents may be

reluctant to state a preference to an

unknown survey interviewer. In partic-

ular, perceived race of the interviewer

can affect responses to questions about

racial topics. 31,32

This dataset contains

no information about the race of the

Table 2. Preferred race of healthcare provider by explanatory and control variables

Same race Different race No preference

Explanatory variables Knowledge of Past Unfair Treatment Knowledge of Tuskegee Syphilis Study

Correctly identified 23.6 13.3 63.2 Did not know / Incorrectly identified 18.7 12.1 69.3

Knowledge of Current Health Care Inequalities Race affects receipt of routine care

Very often 25.8 12.4 61.8 Somewhat often 19.9 14.7 65.5 Not too often 20.8 11.0 68.1 Never 11.1 10.8 78.1

Race affects receipt of specialized treatment Very often 20.5 10.7 68.8 Somewhat often 23.6 12.1 64.3 Not too often 21.4 13.9 64.7 Never 12.6 10.9 76.5

Personal Experiences of Unfair Treatment Respondent treated unfairly due to race*

Yes 36.6 13.8 49.6 No 18.1 12.5 69.4

Family member treated unfairly due to race* Yes 35.3 11.3 53.5 No 17.5 13.0 69.6

Control variables Gender

Male 24.3 10.2 65.6 Female 17.9 14.5 67.6

Age3 18–44 22.2 11.7 66.1 45–54 31.0 15.4 53.6 55 or older 9.7 13.3 77.1

Education Less than high school 17.3 13.1 69.7 High school 19.3 10.3 70.4 Some college 24.1 14.4 61.5 College or more 24.1 14.8 61.1

Income Under $20,000 19.4 13.6 67.0 $20,000–$35,000 12.9 13.8 73.3 $35,000–$50,000 27.7 10.2 62.1 Over $50,000 32.4 13.5 54.2 Missing 18.4 10.5 71.1

Self-rated health Excellent 23.3 14.7 62.1 Good 20.1 10.9 69.0 Fair 18.1 13.8 68.2 Poor 25.5 13.6 60.8

* P,.01 for chi-square test, 3 p,.05 for chi-square test Note: Includes only non-Hispanic Black respondents. . . .one in five African

Americans reports a preference

for a same-race healthcare

provider.

PREFERENCE FOR SAME-RACE PROVIDERS - Malat and van Ryn

744 Ethnicity & Disease, Volume 15, Autumn 2005

interviewer or the respondent’s percep-

tion of the interviewer’s race.

Previous researchers have speculated

that knowledge of past mistreatment

of African Americans might influence

patients’ behaviors and preferences. 5,33

The present data do not support

this notion. Knowledge of the Tuskegee

Syphilis Study is not associated with

preferred healthcare provider race. One

possible explanation for this result is

that the Tuskegee Syphilis Study is

a historical event, which can be used

to understand current events, but none-

theless lies in the past. Dwelling on past

unfair treatment would make navigating

daily life difficult for most people.

Another potential explanation for the

difference between publicly expressed

sentiment and the present finding is

that, when communicating with public

health officials, African Americans may

more readily discuss historic abuses than

personal experiences. Publicly describ-

ing personal experiences of unfair

treatment may be difficult for a variety

of reasons, such as uncertainty about the

cause of the bad experience, a desire for

privacy, or fear of being discounted

or labeled overly sensitive. Pointing

to well-documented cases of poor

historic treatment may provide a way

to more safely protest personal mis-

treatment.

We also found that perceptions of

present inequities in medical care are

Table 3. Models predicting preferred healthcare provider race

Model 1 Model 2 Model 3

Own Race Other Race Own Race Other Race Own Race Other Race Risk Ratio Risk Ratio Risk Ratio Risk Ratio Risk Ratio Risk Ratio

Explanatory variables Personal unfair treatment 1.89* 1.84*

Family member treated unfairly 1.59* 0.88*

Race affects receipt of specialized treatment (very often excluded)

Somewhat often 1.97 1.13 Not too often 1.70 1.77 Never 1.31 1.44

Race affects receipt of routine care (very often excluded)

Somewhat often 0.52 1.16 Not too often 0.62 0.58 Never 0.33 0.67

Know of Tuskegee Syphilis Study 1.06 1.20

Control variables Male 1.33 0.68 1.28* 0.58* 1.26 0.70

Age (under 44 excluded) 45–54 1.593 1.583 1.463 1.353 1.66* 1.64* 55 and more 0.393 1.013 0.333 0.833 0.47* 1.08*

Income (under $20,000 excluded) $20,000–$35,000 0.57 0.88 0.57 0.84 0.54 0.96 $35,000–$50,000 1.35 0.69 1.48 0.77 1.39 0.72 Over $50,000 1.64 1.05 1.75 1.14 1.72 1.13 Missing 0.88 0.73 0.99 0.58 0.86 0.77

Education (high school excluded) Less than high school 1.05 1.25 1.12 1.18 1.00 1.09 Some college 1.24 1.54 1.23 1.74 1.16 1.61 College or more 1.04 1.30 1.01 1.47 0.87 1.38

Self Rated Health (excellent excluded) Good 0.86 0.68 0.98 0.80 0.84 0.65 Fair 0.97 0.84 1.13 1.07 0.95 0.89 Poor 1.62 0.90 1.89 1.27 1.48 0.73

(N) (1150) (1099) (1099)

* p,.05 for Wald test of coefficients/block of coefficients. 3 p,.01 for Wald test of coefficients/block of coefficients. Note 1: Includes only non-Hispanic black respondents. Note 2: ’No Preference’ omitted category of dependent variable.

PREFERENCE FOR SAME-RACE PROVIDERS - Malat and van Ryn

Ethnicity & Disease, Volume 15, Autumn 2005 745

not related to preferred race of health-

care provider. One explanation is that

some African Americans may believe

that a healthcare provider’s race is

unrelated to the likelihood of African

Americans receiving fair medical treat-

ment. Racial inequities in medical care

may be attributed, for instance, to

patient characteristics like insurance

coverage. Or inequities may be attrib-

uted to other healthcare provider char-

acteristics such as class status. Indeed,

LaVeist and colleagues 19

found that

class-based interpersonal discrimination

is the most frequently reported form of

discrimination among African Ameri-

cans. In these circumstances, racially

concordant care would not ensure better

treatment.

In this analysis, the only form of

unfair medical treatment that affected

preferences was personal experiences of

discrimination. Reports of unfair treat-

ment were associated with greater likeli-

hood of preferring a same-race provider

versus no preference. These results

support other research that shows

perceptions of being treated unfairly in

health care can affect patients’ behav-

ior. 20

The present analysis reinforces

existing studies by testing the effect in

a population-based national sample.

However, the present analysis also

produces another result: personal unfair

treatment is associated with greater

likelihood of preferring an other-race

provider over no preference. Because

this relative risk ratio is only making

a comparison between preference for

other-race providers and no preference,

it does not diminish the effect described

for preference for same-race providers.

Taking these effects together, experienc-

ing unfair treatment appears to increase

the likelihood of developing a prefer-

ence. Together these results give insight

into how African Americans choose

physicians; personal experiences of un-

fair racial treatment in health care may

be influential in decision making. That

personal experiences are significant may

not be a particularly remarkable finding.

Yet, that they are the only significant

finding suggests that more attention

should be given to individuals’ experi-

ences with discrimination along with

a focus on group-level unfair treatment.

Some effects of control variables are

worth considering. The oldest group

was least likely to prefer a same-race

healthcare provider, while the middle

group was most likely. These differences

may be influenced by cohort experiences

in relation to the civil rights movement.

Some researchers have suggested that

experiences during young adulthood

influence individuals’ attitudes through-

out life. 24

In this case, the oldest group

came of age before the civil rights

movement and may have lower expecta-

tions for same-race care or simply be less

likely to state a preference to a survey

interviewer. Those in the middle age

group came of age during the civil rights

movement and may be most assertive in

their efforts to receive equal treatment.

Finally, the youngest group came of age

after the civil rights movement and may

expect fair treatment and have experi-

ences with integration that reduce their

preference for same-race providers com-

pared to older respondents.

The analyses in this paper produced

an inconsistently significant gender

effect. Results suggest that women may

be less likely than men to prefer same-

race healthcare providers. For women of

color making choices about health care,

gender may be an equal, or greater,

concern when selecting a physician.

Other research has shown that, partic-

ularly for reproductive health concerns,

women prefer female over male physi-

cians. 8,9

The desire for a female physi-

cian, in combination with low expecta-

tions for finding an African-American

female physician, may reduce African-

American women’s likelihood of stating

a preference for a same-race healthcare

provider.

Limitations The response rate to the survey is

less than ideal. However, research on

nonresponse suggests that low response

rate may be less of a problem than

researchers previously thought because

nonresponse does not appear to corre-

late with many substantive variables. 34

A second limitation is that, to the extent

that African Americans are reluctant to

speak freely with a survey interviewer,

using survey methods to ask questions

about discrimination may underesti-

mate perceptions of unfair treatment.

Third, a larger sample size might have

resulted in smaller standard errors,

making some nonsignificant results

significant.

Finally, there may be other un-

measured factors that influence pre-

ferred healthcare provider race. For

example, respondents might be influ-

enced by their relationship with their

present provider. If they have a good

relationship with their current provider,

this provider’s race may influence their

response to this item. Another possible

unmeasured factor is internalized rac-

ism, or belief in negative stereotypes of

African Americans. 35

In this case the

belief that Black doctors are less qual-

ified than White doctors may influence

preferred provider race, but the hypoth-

esis has not been tested. 36

Assessment of

the practice location of doctors may also

affect preference for same-race provid-

ers. Since Black doctors may be more

likely to work in facilities that have

fewer resources, some people may base

their preferences on the perceived

quality of care available in the locations

where African-American doctors are

more likely to practice.

Complete understanding of how

patients choose healthcare professionals

requires recognition that perceptions of

racial discrimination influence attitudes

toward healthcare providers. The anal-

ysis presented in this paper indicates

that knowledge of historical or current

unfair treatment may not influence

preferred healthcare provider race, but

personal experiences of discrimination

help form preferences. Researchers and

outreach workers should be cognizant

PREFERENCE FOR SAME-RACE PROVIDERS - Malat and van Ryn

746 Ethnicity & Disease, Volume 15, Autumn 2005

that personal experiences of unfair

treatment may have a significant effect

on patients’ attitudes and beliefs.

ACKNOWLEDGMENTS Earlier versions of this paper were presented by the first author (JM) at the 2003 annual meetings of the American Sociological

Association in Atlanta, Georgia and the 2004 annual meetings of the American Public Health Association in Washington, DC. This research was supported, in part,

by a grant to the first author from the Charles P. Taft Memorial Fund at the University of Cincinnati. We thank David

C. Lundgren and Hyun Joo Oh for pro- viding helpful comments on earlier drafts of this paper.

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AUTHOR CONTRIBUTIONS Design and concept of study: Malat Data analysis and interpretation: Malat Manuscript draft: Malat, van Ryn Statistical expertise: Malat Acquisition of funding: Malat Administrative, technical, or material assis-

tance: Malat, van Ryn

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Ethnicity & Disease, Volume 15, Autumn 2005 747