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O R I G I N A L P A P E R

Assessing Cultural Perspectives on Healthcare Quality

Ann D. Bagchi • Raquel af Ursin • Alicia Leonard

Published online: 14 October 2010

� Springer Science+Business Media, LLC 2010

Abstract This study explores cultural differences in per-

ceptions of quality of care and examines whether existing

surveys, such as the Consumer Assessment of Healthcare

Providers and Systems (CAHPS �

) questionnaires, ade-

quately capture conceptions of healthcare quality among

members of racial/ethnic minority groups. Eight focus

groups with African Americans, Asian Indians, Latinos, and

whites were organized into two 45-minute segments. In one

segment, participants rated the quality of care depicted in a

video; in the other they discussed the concept of ‘‘healthcare

quality.’’ We found that members of racial/ethnic minority

groups are more likely than whites to identify cultural

competency and providing a holistic approach to care as

important to healthcare quality. Neither of these concepts is

currently included in the core CAHPS �

questionnaire. The

CAHPS �

and other quality surveys may not accurately

capture concepts of healthcare quality that members of

racial/ethnic minority groups deem most important.

Keywords CAHPS� � Race/ethnicity � Quality � Cultural competency

Background

The Consumer Assessment of Healthcare Providers and

Systems (CAHPS �

) project was initiated in 1995 by the

Agency for Healthcare Research and Quality (AHRQ) to

create a standardized set of surveys to describe patients’

perspectives on the quality of their health plans. The

CAHPS �

surveys have since become a cornerstone for

evaluations of healthcare quality across health plans and

settings [1]. However, as Morales et al. note, ‘‘Most existing

consumer surveys were developed for a target population

consisting of persons who are employed, insured, accul-

turated, English-proficient, well-educated, and of moderate

to high socio-economic status.’’ [2] Research shows that a

variety of patient characteristics (such as marital status,

socioeconomic circumstances, and cultural background) are

associated with differences in perceptions of healthcare

quality and should be taken into consideration when inter-

preting quality ratings [3, 4]. Although the CAHPS �

sur-

veys have been adapted over the years to represent better the

needs and preferences of a variety of groups [5–12], little

research has been done to examine whether the measures

included in the CAHPS �

adequately capture those aspects

of healthcare encounters that racial and ethnic minority

group members consider the most essential for rating the

quality of care they receive [13–18].

The present study used qualitative methods to explore

cultural differences in perceptions of healthcare quality

across four racial/ethnic groups and was designed to

answer the following research questions: (1) How do

patients define quality with respect to interactions with

physicians and other staff members during office visits?;

(2) Are there differences across racial/ethnic groups in the

factors considered important to healthcare quality?; (3) Do

the CAHPS �

surveys capture aspects of care that affect the

perceptions of healthcare quality among members of racial/

ethnic minority groups?; and (4) How can consumer sur-

veys be adapted to account better for racial/ethnic differ-

ences in assessments of healthcare quality?

A. D. Bagchi (&) Research Division, Mathematica Policy Research,

600 Alexander Park, Princeton, NJ 08540, USA

e-mail: [email protected]

R. af Ursin � A. Leonard Survey Division, Mathematica Policy Research,

Princeton, NJ, USA

123

J Immigrant Minority Health (2012) 14:175–182

DOI 10.1007/s10903-010-9403-z

Conceptual Framework

The conceptual model guiding the study is a modification

of Donabedian’s framework, which describes ‘‘quality

assessment’’ (that is, the measurement of healthcare qual-

ity) in terms of care structure (facilities and equipment),

processes (activities involved in diagnosis and treatment),

and outcomes (changes in individuals brought about by

the care they receive) [19]. Figure 1, adapted from Sofaer

and Firminger, presents our model for understanding

patients’ assessment of care at a given point in time and

takes into account the ways that patients’ expectations

and experiences (for example, characteristics, cultural

norms, knowledge of care processes, and health care

needs) interact to shape their perceptions of the care they

receive [20].

Methods

Participant Recruitment

We conducted eight 90-minute focus groups with adults

(18 or older), with two focus groups for each of the fol-

lowing racial/ethnic groups: African Americans, Latinos,

Asian Indians (hereafter ‘‘Indians’’), and whites. For each

focus group, we recruited 15 participants (for a potential

total sample of 120), assuming that 10–12 would actually

attend each discussion. We used three sources to recruit

participants: cold calls using lists of telephone numbers

from areas with high concentrations of the specific target

populations (as identified using Census tract data), flyers

posted in train stations and supermarkets in the same tar-

geted areas, and an ad on Craigslist.org. Sixty-eight percent

of participants were recruited through the Craigslist ad,

21% via the flyers, and the remaining 11% through cold

calls.

Data Collection

The focus groups were organized into two 45-minute

segments: in Segment 1, we showed a video depicting a

healthcare encounter between a white, male physician and

an elderly, Asian (non-Indian), female patient. We used

the same video (‘‘A Somatic Complaint,’’ from Kaiser

Permanente’s Cultural Issues in the Clinical Setting video

series) for each group in order to ensure that all participants

viewed exactly the same encounter. To ensure consistency

and because the video was in English, we recruited only

English-speaking participants. Participants were asked to

rate the quality of care depicted in the video based on

questions adapted from the CAHPS �

and other health

quality surveys. In Segment 2, the focus group moderator

led a more general discussion of how participants think

about quality in healthcare. To address the potential for

response bias, we alternated the order of the segments

across the two focus groups within a given racial/ethnic

group. Data analyses revealed no differences in response

patterns based on segment order.

Measures

Research staff took notes during the focus group sessions

and kept audio recordings which were transcribed into text

documents and analyzed using Atlas.ti, a software program

for the analysis of qualitative data. After reviewing notes,

the two senior members of the study team (AB and RA)

developed a list of themes related to healthcare quality that

could be identified as arising from each of three sources:

(1) the core CAHPS �

Clinical and Group Survey instru-

ment, (2) supplemental CAHPS �

questionnaire items, and

(3) discussions among focus group participants. They then

met to compare lists and create a final, consolidated list of

key topics from the focus group discussions.

We employed a hierarchy to assign a source to each

concept; items mentioned in the core CAHPS �

questionnaire

were attributed to that source even if they were mentioned in

the supplemental surveys or by focus group participants.

Those topics not included in the core CAHPS �

but included

in the supplemental surveys were attributed to the supple-

ment, even if discussed in the focus groups. A topic was

assigned to the focus group category only if it was not

included in either the core or supplemental CAHPS �

items.

The hierarchy was used to help identify themes that were not

included in the CAHPS �

questionnaires.

Analysis

Using the final list of themes, two research assistants coded

the transcribed text files in Atlas.ti using text units (con-

tinuous segments of speech) as the unit of analysis. To test

Patient Characteristics

Cultural norms Knowledge of care process

Patient health care needs

Patient expectations for care

Patient experiences with care

Patient‘s perception of the encounter

Patient’s criteria for quality

Patient’s quality assessment

Fig. 1 Conceptual model

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123

for inter-rater reliability, we had both research assistants

code several pages of selected text and then checked the

agreement in coding between the two. The kappa statistic

was 0.73 (standard error = 0.13), indicating substantial

agreement in coding, significantly better than that attrib-

utable to chance.

Results

Participants

Across all of the groups, there were 84 participants with

nearly equal numbers of participants across the four

groups; a slightly larger number of African Americans

participated in the study than among members of the other

groups (Table 1). To ensure some balance in the distribu-

tion of demographic characteristics of participants, we

attempted to target recruitment by age and gender. Among

the final group of participants, 56% were female and the

majority (66%) was 45 or younger. Although there were

some differences in the sociodemographic characteristics

of participants, the small sample size and the unreliability

of estimates preclude reporting of inferential statistics to

compare the different groups either to each other or to the

larger U.S. population.

Components of Healthcare Quality

Table 2 presents the key components of healthcare quality

mentioned during focus group discussions, including an

example of how the concept can contribute to a good quality

healthcare visit and the source of the concept (i.e., core

CAHPS �

, supplemental CAHPS �

, or excluded from the

CAHPS �

but mentioned by focus group participants). The

following four concepts were among the most frequently

mentioned across all four ethnic groups as significant com-

ponents of quality in healthcare encounters: waiting times,

patient-provider communication, a doctor’s technical skills,

and a doctor’s respect for patients (Table 3). A variety of

themes emerged with respect to each of these broader

concepts.

Table 1 Characteristics of focus group participants

African

Americans

Latinos Asian

Indians

Whites Total

Participants (n) 24 19 20 21 84

Distribution (%) (%) (%) (%) (%)

Gender

Female 75 53 35 57 56

Male 25 47 65 43 44

Age

18–25 13 63 60 29 39

26–45 42 26 25 48 36

46 and older 46 10 15 24 25

Education

High school or less 13 11 10 10 11

Some college 33 63 45 52 48

College graduate 54 26 45 38 42

Household income

Less than $40,000 29 47 10 19 26

$40,000–$59,999 13 21 20 14 17

$60,000–$79,999 21 11 15 29 19

$80,000–$99,999 13 0 15 24 13

$100,000 or more 25 16 40 14 24

Missing 0 5 0 0 1

United States residence

Born in the United States 92 47 45 100 73

Resident less than 10 years 0 16 25 0 10

Resident 10 years or more 8 32 30 0 17

Missing 0 5 0 0 1

Number of physician visits last year (average) 25 47 40 76 12

J Immigrant Minority Health (2012) 14:175–182 177

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Waiting Time

The CAHPS �

surveys address the question of waiting time

with respect to the structure and process of care (i.e., time it

takes to obtain an appointment and the time patients spend

waiting in the reception area and in the exam room). The

implicit assumption in quality surveys is that long wait

times are likely to negatively influence patients’ ratings of

healthcare quality. Study participants affirmed this senti-

ment, citing waiting times as one of the most important

components of quality care. However, participants also

cited situations in which they did not mind waiting. Study

participants felt that there should not be a set time for how

long a given visit should take, but that it should take ‘‘as

long as needed’’ to resolve a patient’s complaint. In some

cases, participants felt that long wait times could even be

Table 2 Key concepts associated with quality in health care

Concept a

Example of concept in good quality care Source b

Choice Doctor presents patient with treatment options Supplemental CAHPS �

Collaboration Doctor collaborates with other providers Focus group

Consensus Patient and doctor use consensus in decision making Focus group

Cost Doctor considers cost in treatment recommendations Supplemental CAHPS �

Culture Doctor is aware of and sensitive to patient’s culture Focus group

Demeanor Doctor’s demeanor is caring and sensitive Supplemental CAHPS �

Depression Doctor screens patients for depression Supplemental CAHPS �

Efficiency Office visits are efficient Focus group

Expertise Doctor’s expertise and technical skills are up to date Focus group

Explanations Doctor’s explanations are clear Core CAHPS �

Facility Facility is clean and accessible Focus group

Follow-up Doctor follows up with patients on test results Core CAHPS �

Gender Doctor takes into consideration the patient’s gender Focus group

Health concerns Health concerns of patient are adequately addressed Core CAHPS �

Holistic Approach Doctor takes a holistic approach in treating patients Focus group

Insurance status Insurance is not a factor in providing care Focus group

Listening ability Doctor listens carefully Core CAHPS �

Medical history Doctor is aware of patient’s medical history Core CAHPS �

Multitasking Doctor avoids multitasking during the visit Focus group

Needs of elderly Doctor is aware of special needs of elderly patients Focus group

Nurses Nurses provide enhanced care and communication Focus group

Patient informed Patient is informed of wait time Supplemental CAHPS �

Prescription Drugs Doctor explains reason for prescribing medications Focus group

Prevention Doctor educates patient on prevention measures Supplemental CAHPS �

Privacy Doctor respects patient’s privacy Focus group

Rapport Doctor develops a rapport with patient Focus group

Receptionists Receptionists are friendly and helpful Core CAHPS �

Recommendation Patient is willing to recommend doctor to others Supplemental CAHPS �

Referrals Doctor makes appropriate referrals Supplemental CAHPS �

Respect Doctor shows respect for patient Core CAHPS �

Tests Doctor orders appropriate tests Core CAHPS �

Thoroughness Doctor provides a thorough examination Supplemental CAHPS �

Time Doctor spends sufficient time with patient Core CAHPS �

Trust Patient trusts doctor Focus group

Wait time Wait time is reasonable Core CAHPS �

a The concepts are listed in alphabetical order.

b Each of the key concepts is assigned to one of three sources using the following hierarchy: (1)

Core CAHPS �

= concepts that are included in the core CAHPS �

survey instrument; (2) Supplemental CAHPS �

= concepts that are excluded

from the core CAHPS �

instrument but included in a supplemental survey; and (3) Focus group = concepts that are not currently included in

existing CAHPS �

surveys but were mentioned as important factors of health care quality by focus group participants

178 J Immigrant Minority Health (2012) 14:175–182

123

an indicator of higher quality care if the physician gave

each patient his or her full attention. However, participants

were in agreement that waiting times to receive an

appointment should be as short as possible.

Patient-Provider Communication

Study participants reported that developing a rapport

between the patient and provider was the best way to

ensure good communication and develop a consensus in

decision making. A number of participants noted that the

increased accessibility of medical information through the

internet has given patients a sense of empowerment to take

part in their healthcare and that physicians have to be

willing to build a partnership with patients when coming to

treatment decisions. Most participants said that both the

patient and physician are responsible for ensuring adequate

communication but that the physician bears a greater

responsibility. Some participants suggested that physicians

should follow the nursing model, which emphasizes taking

a caring and empathetic approach to communicating with

patients as a way to address patients’ emotional needs and

encourage greater disclosure.

Table 3 Number of mentions of each concept by racial/ethnic

group

a Concepts are listed in

decreasing order of frequency

with which they were

mentioned by all focus group

participants

Number of mentions

Concept a

African

Americans

Latinos Asian

Indians

Whites Overall

Wait time 58 57 66 37 218

Rapport 54 46 47 34 181

Expertise 22 28 44 11 105

Respect 35 19 30 20 104

Listening ability 33 17 26 9 85

Trust 15 25 13 27 80

Explanations 20 18 27 11 76

Referrals 22 22 21 9 74

Health concerns 18 26 17 12 73

Tests 26 15 12 15 68

Culture 17 18 8 11 54

Patient informed 12 10 9 14 45

Medical history 15 13 8 6 42

Recommendation 19 4 8 10 41

Thoroughness 16 12 4 9 41

Prescription drugs 16 4 16 3 39

Insurance status 9 8 12 9 38

Depression 7 10 10 10 37

Efficiency 15 8 6 8 37

Consensus 6 6 8 10 30

Cost 9 6 0 14 29

Needs of elderly 13 5 1 3 22

Holistic approach 9 2 5 3 19

Time 5 3 10 1 19

Nurses 6 5 7 0 18

Gender 4 6 5 0 15

Choice 10 1 2 0 13

Prevention 7 0 6 0 13

Demeanor 10 1 2 0 13

Facility 1 2 4 2 9

Follow-up 5 1 2 0 8

Multitasking 1 0 3 0 4

Privacy 1 0 3 0 4

Receptionists 2 0 2 0 4

Collaboration 3 0 0 0 3

J Immigrant Minority Health (2012) 14:175–182 179

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Doctor’s Technical Skills

Patients expect their physicians to show competence in

their medical skills. Some participants said they were put

off when physicians had to consult medical texts during

routine office visits. Others said that they did not mind

seeing a physician whose demeanor was uncaring or

unsympathetic so long as the doctor was able to diagnose

and treat them accurately. Technical skills were particu-

larly important in assessments of specialists; participants

had very low expectations for their social skills but high

expectations for their ability to resolve a health condition.

Doctor’s Respect for Patient

The importance of a provider’s respect for his or her patient

was commonly mentioned in focus groups with members of

racial and ethnic minority groups. However, the definition

of respect included many concepts not traditionally con-

sidered in most health quality assessments. For example,

although a doctor’s willingness to listen to a patient’s health

concerns and acceptance of patients’ views is a common

definition of respect and was mentioned across all ethnic

groups in our study, waiting time was also seen as a com-

ponent of respect. A number of participants said that they

feel ‘‘disrespected’’ when they have to wait for a long time

to see their provider, especially when they are not given

adequate time with the physician during the appointment.

Participants in the Indian group also noted that the physi-

cian in the video at one point turned the sole of his shoe to

his patient and pointed out that this gesture is considered

extremely disrespectful in many cultures; thus, doctors

should also be aware of cultural differences that might

affect perceptions of a physician’s respect for patients.

Racial/Ethnic Differences in Perceptions of Healthcare

Quality

A number of themes arose during the focus groups with

members of racial and ethnic minority groups that either

are not currently included in the CAHPS �

surveys or were

not included in discussions with white respondents. These

findings suggest that there are concepts related to quality in

healthcare encounters that are not adequately addressed in

existing questionnaires.

Culture was one of the most common themes in dis-

cussions with members of racial and ethnic minority

groups, both with respect to what was shown on the video

and in regard to personal experiences. In all of the focus

groups with African Americans, Latinos, and Indians,

participants speculated that cultural barriers between the

white physician and his Asian patient in the video nega-

tively affected their ability to communicate. White

respondents said that cultural differences had nothing to do

with what they also judged to be poor communication and

blamed the miscommunication on the doctor’s ‘‘arrogant

attitude’’ or the patient’s failure to be forthcoming with the

physician. However, minority group participants also felt

that differences in gender and age between the patient and

the physician created cultural barriers (for example, in

these groups it is traditionally less common to question the

physician, as this is seen as challenging the physician’s

knowledge and expertise), whereas whites did not believe

these differences were culturally-based.

With the exception of whites, participants across all of

the groups noted the importance of cultural competency

in facilitating communication; however, a number of

definitions of cultural competency arose during discus-

sions. A common perspective was that cultural compe-

tency represents openness to cultural differences and

accepting each patient as an individual. Attaining this

level of competency was seen as a matter of the physi-

cian simply listening respectfully to what the patient is

saying. However, a Latino participant said that although

‘‘cultural competency … is knowing the more important dos and don’ts for dealing with specific cultures,’’ doctors

should also attain competency through the diversity of

their staff.

Indian participants added that competency involves

taking a holistic approach to patient care and respecting the

traditional beliefs and practices of their patients. Although

not always mentioned in the context of cultural compe-

tency, the need for a holistic approach (one that addresses

the physical, spiritual, and emotional needs of the patient)

was a theme common in all discussions with racial/ethnic

minority groups, but one that did not arise at all in dis-

cussions with white participants.

When asked to define quality in a healthcare encounter,

there were differences across racial and ethnic minority

groups. African Americans defined quality as a sense of

trust and the physician really listening to his or her

patients. They were more likely to say that physicians

should focus on communication and show some famil-

iarity with their patients (for example, knowing and asking

about the patients’ family members) while at the same

time demonstrating up-to-date knowledge and profession-

alism. Latinos also emphasized communication, but more

often in terms of the physician asking the right questions.

Indians were more likely to define quality with respect to

technical skills and maintaining patient privacy. Unlike

members of other groups, Indians were more likely to say

that doctors are trained in medical diagnosis and treating

symptoms and should not be judged on their bedside

manners.

180 J Immigrant Minority Health (2012) 14:175–182

123

Discussion

Previous research has demonstrated differences in quality

ratings by race/ethnicity [3, 4, 21–28]. However, most of

these studies have used secondary data analysis to docu-

ment that differences exist and have not explored potential

explanations for where these differences arise. Some

studies suggest that there are racial/ethnic differences in the

perceptions of quality along Donabedian’s dimensions of

care, but this research has also not explored the reasons for

the differences observed [4, 22]. The limited qualitative

research that has been done confirms several of this study’s

findings, namely, that spirituality, family, and a respect for

traditional beliefs and practices are important components

of healthcare quality among members of racial/ethnic

minority groups [16, 29].

This study sought to further explore racial/ethnic dif-

ferences in conceptions of healthcare quality using a

qualitative study design. Like previous studies, we found

racial/ethnic variation in the factors identified as affecting

healthcare quality, but we also observed wide variation in

conceptions of ‘‘culture.’’ For example, whites were less

likely than members of racial/ethnic minority groups to

describe differences (in interactions and demographic

characteristics) as reflecting ‘‘culture’’ and more likely to

describe them as reflecting individual differences (e.g., the

physician’s ‘‘arrogant attitude’’). There were also differ-

ences across racial/ethnic minority groups in the definition

of ‘‘cultural competency.’’

Our results suggest that existing quality surveys do not

capture adequately all of the factors affecting healthcare

quality as defined by members of racial/ethnic minority

groups. Cultural sensitivity and competency are essential

components of healthcare quality among members of these

groups, but are not directly addressed in the core CAHPS �

survey and only vaguely mentioned in supplemental

CAHPS �

surveys (i.e., ‘‘Does your language, race, reli-

gion, ethnic background or culture make any difference in

the kind of counseling or treatment you need?) [30, 31]. At

the time of writing, AHRQ was developing a CAHPS �

supplement survey regarding patients’ assessments of their

physicians’ cultural competence [12, 32]. However, the

results of the present study suggest that concepts such as

language access, communication, health literacy, patient

preferences/shared decision making, discrimination, and

trust should form a core component of quality surveys in

order to accurately assess ratings of the quality of care by

members of racial and ethnic minority groups.

One limitation of the study design is that it looked at

perceptions of quality at a single point in time. Since

patients’ definitions of quality may change over time,

future research should examine racial/ethnic differences

in perceptions of healthcare quality longitudinally [33].

The study’s findings should also be confirmed using larger

sample sizes and with controls for other factors associated

with perceptions of healthcare quality (e.g., education, age,

and marital status).

New Contribution to the Literature

Our study is one of the few to examine perceptions of

healthcare quality across such a diverse group of racial and

ethnic groups and is the only one we are aware of that uses an

objective point of comparison to explore cultural differences

(i.e., the Kaiser video). There are a number of ways that the

results could contribute to improving healthcare quality for

members of racial and ethnic minority groups. First, findings

of cultural differences in definitions of what constitutes

quality of care could assist health plans and providers in

developing surveys that are more responsive to the needs and

interests of racial/ethnic minority groups. Second, under-

standing differences in conceptions of cultural competency

can help in designing and implementing more effective

training programs that will help build understanding and

trust between patients and providers. Ultimately, these

improvements will lead to better patient care and may assist

in reducing persistent racial/ethnic health disparities.

Acknowledgments We would like to acknowledge financial sup- port for this study from the Robert Wood Johnson Foundation, grant

number 63841.

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