Measuring African American Women’s Trust in Provider During Pregnancy Rosalind M. Peters, Ramona Benkert, Thomas N. Templin, Andrea E. Cassidy-Bushrow
Correspondence to Rosalind M. Peters E-mail: [email protected] Rosalind M. Peters Associate Professor, College of Nursing Wayne State University 5557 Cass Avenue—Room 358 Detroit, MI 48202 Ramona Benkert College of Nursing Wayne State University Thomas N. Templin College of Nursing Wayne State University Andrea E. Cassidy-Bushrow Department of Public Health Sciences Henry Ford Hospital, Detroit, MI
Abstract: Significant racial disparities exist in pregnancy outcomes, but few researchers have examined the relationship between trust in providers and pregnancy outcomes. The Trust in Physician Scale (TPS), the most widely used tool, has not been tested in pregnancy. We assessed the psychometric properties of the TPS and identified correlates of trust in 189 pregnant African American women. Evidence supports internal consistency reliability (>.85) and internal structure of the TPS (CFI ¼ .97; RMSEA ¼ .05; x2(42) ¼ 65.93, p ¼ .001), but TPS scores did not predict pregnancy outcomes. African American women reported a high level of trust in obstetric providers. Trust did not differ by provider type (physician or midwife) but was related to the women's history of perceived racism and strength of ethnic identity. ß 2014 Wiley Periodicals, Inc. Keywords: Trust in Physician Scale; health care providers; African American; antenatal care; pregnancy outcomes; confirmatory factor analysis; racism; health disparities Research in Nursing & Health, 2014, 37, 144–154 Accepted 27 November 2013 DOI: 10.1002/nur.21581 Published online 7 January 2014 in Wiley Online Library (wileyonlinelibrary.com).
Significant racial disparities exist in birth outcomes in the United States. African American women have about a 60% higher rate of preterm birth (16.77% vs. 10.50%) and an 88% higher rate of low birth weight infants (13.33% vs. 7.09%) than Caucasian women (Martin, Hamilton, Ventura, Osterman, & Mathews, 2013). These two factors are among the leading causes of infant mortality, resulting in infant mortality rates more than twice as high among Black versus White infants (Mathews & MacDorman, 2013). While population studies provide important information regarding birth disparities, information specific to individual women and practitioners is needed to identify where gaps in care may occur. It has been proposed that the frequency, timing, and content of prenatal visits be increased for women at high‐ risk for poor outcomes (Krans & Davis, 2012). In an era of evidence‐based practice, the application of evidence requires insuring that the care provided is responsive to the patient's needs, values, and beliefs (Grace & Powers, 2009). Before visits are increased, evidence is needed on the role of the patient‐provider interface, including elements of trust, in pregnancy outcomes. Discriminatory treatment in health care experienced by African Americans has been identified as contributing to lower trust in the provider (Benkert, Peters, Clark, & C
2014 Wiley Periodicals, Inc.
Keves‐Foster, 2006) as well as to racial disparities in health outcomes, including pregnancy outcomes (Benkert & Peters, 2005; Giurgescu, McFarlin, Lomax, Craddock, & Albrecht, 2011; Pascoe & Smart Richman, 2009; Peters, 2006). Patients' level of trust in the provider was positively correlated with patients' satisfaction with care, health‐seeking behaviors, adherence to medical treatment plans, and return for follow‐up appointments (Baker, Mainous, Gray, & Love, 2003; Kerse et al., 2004; O'Malley, Sheppard, Schwartz, & Mandelblatt, 2004; Thom, Ribisl, Stewart, & Duke, 1999; Trachtenberg, Dugan, & Hall, 2005). Among African American women, lower trust has also been associated with poorer health status (Wiltshire, Person, & Allison 2011). In non‐pregnant samples, African American patients reported significantly lower levels of trust than Caucasian patients (Muir et al., 2009). In African American men and women, less than high school education (Wiltshire et al., 2011), lower income (Halbert, Armstrong, Gandy, & Shaker, 2006), and no usual source of care (Halbert et al., 2006) were associated with lower trust in providers. In addition, African Americans' perceptions of racism and ethnic or racial identity attitudes have also been associated with trust in a health care provider. Specifically, there is an inverse relationship between perceived racism
TRUST IN PROVIDER/ PETERS ET AL.
and levels of trust, but a positive correlation between ethnic/racial identity and levels of trust in the provider (Benkert et al., 2006; Benkert, Hollie, Nordstrom, Wickson, & Bins‐Emerick, 2009). Trust in health care providers during pregnancy has received scant research attention, especially for African American women. Only one study was found in which 16 African American women were included in a qualitative study of trust among low‐income rural pregnant women (Jesse, Dolbier, & Blanchard, 2008). Little is known about the patient characteristics (e.g., demographics, perceptions) that may affect trust in an obstetrical care (OB/GYN) provider. Knowledge development is further hampered by the lack of a valid instrument to measure trust during pregnancy. The Trust in Physician scale (TPS; Anderson & Dedrick, 1990) was the first instrument developed to measure trust. Although the TPS remains widely used and is a benchmark against which to compare other trust instruments (Pearson & Raeke, 2000), no studies were found in which the TPS was used in pregnancy. Therefore, the purpose of this study was to examine the reliability and validity of the TPS for use in relation to obstetric providers and to identify patient characteristics associated with level of trust in obstetric providers. Such knowledge may be useful for assessing the quality of care provided to pregnant African American women.
Methods Sample and Setting The sample was recruited from the population of pregnant women receiving prenatal care in a large health system in metropolitan Detroit. Inclusion criteria included: self‐ identified as African American or Black, 18–44 years of age, in the second trimester of pregnancy (approximately 13–28 weeks gestation based on self‐reported last menstrual period or expected delivery date defined by ultrasound), and without evidence of illicit drug use or severe psychiatric illness. The study was approved by two institutional review boards. A total of 203 women from nine OB/ GYN clinics were recruited. We excluded 11 women who were unable to complete the entire research visit. We also excluded three women with morbid obesity (body mass index [BMI] >60 kg/m2) (Leykin & Pellis, 2009) due to the difficulty in assessing fundal height to estimate gestational age. The sample for analysis consisted of 189 women, which was judged sufficiently large to conduct a confirmatory factor analysis (CFA) of the TPS, based on simulation studies in which the stability of parameter estimates was largely a function of the magnitude of factor loadings and number of items on a factor (Hogarty, Hines, Kromrey, Ferron, & Mumford, 2005; MacCallum, Widaman, Zhang, & Hong, 1999). Using internal consistency reliability data from prior studies, we conservatively estimated a reliability of .80
Research in Nursing & Health
145
for the TPS in the current study. Using the Spearman– Brown Prophecy Formula (Nunnally & Bernstein, 1994) in reverse, we determined that the reliability of a single item in this 11‐item scale was .27. Given that the reliability of a single item in a CFA measurement model is the square of the standardized factor loading, we could then anticipate a factor loading of .52. With factor loadings of this magnitude, it is recommended that the number of subjects be greater than 10 times the number of variables (Hogarty et al., 2005). Thus an N ¼ 189 was judged sufficient to produce stable estimates of population parameters for the 11‐ item tool.
Instruments and Measures Donabedian's (1980, 1995) theoretical framework provides a systematic way to evaluate the quality of health care provided, and may assist in identifying the gap in care affecting birth outcomes among African American women. Within Donabedian's framework, three key elements are evaluated to assess quality of care. These elements include structure (conditions under which care is provided), process (the technical and interpersonal aspect of care), and outcomes (clinical as well as patient satisfaction outcomes) (Donabedian, 1980, 2003). Structure variables. Structure includes human, physical, and financial resources associated with providing care (Donabedian, 2003). The structure elements of care that were measured were health insurance, provider type (i.e., physician or midwife), and whether the provider changed over the course of the woman's pregnancy. These data were extracted from the electronic medical record (EMR). Process variables. Donabedian (1980, 2003) asserted that within the process component, the practitioner must manage both the technical and interpersonal aspects of the health situation. The technical aspect involves the application of the best scientific evidence, while interpersonal management involves understanding socially determined norms and values. Trust in provider was the key variable examined in assessing the interpersonal context of care. Based on evidence that trust is related to patients' characteristics such as demographics, perceptions, and beliefs, these also were assessed. Trust in physician. The women's level of trust in their OB provider was measured using the Trust in Physician Scale (TPS) scale, developed by Anderson and Dedrick (1990). The TPS is an 11‐item instrument in which responses are measured on a 5‐point scale from 1 strongly disagree to 5 strongly agree. Items measure patients' trust in the provider regarding dependability, confidence, and confidentiality of information. Higher scores reflect greater trust. For the current study, when completing the scale, participants were instructed to think of the obstetrician/ gynecologist, doctor, or certified nurse midwife (CNM) they had been seeing most often for prenatal care.
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The TPS has been reported to have high internal consistency, with Cronbach alphas from .85 to .90, including in samples with African American participants (Anderson & Dedrick, 1990). High internal consistency reliability (a > .88) also was reported in studies of African American patients when altered to assess trust in nurse practitioners as well as physician providers (Benkert et al., 2009; Benkert, Peters, Tate, & Dinardo, 2008). However, no reports were found of use of the instrument in a sample of pregnant women. Patients’ characteristics. Based on the empirical literature, factors associated with trust in provider included demographic data, health information, previous experiences of racism, and strength of ethnic identity. Demographic data. Self‐reported demographic data included age, education, and family income. Data regarding the woman's previous pregnancy history were obtained from the EMR. Perceived racism. The RaLES‐brief (Harrell, 1997; Harrell, Merchant, & Young, 1997) measures perceived racism across life situations, including that which is experienced directly, as well as vicariously, and trans‐generationally. The RaLES‐brief is a 9‐item instrument rated on a 5‐point scale (from 0 not at all to 4 extremely). Cronbach alpha has ranged from .79 to .87 (Benkert et al., 2006; Harrell, 1997; Peters, 2004). The Cronbach alpha in the current study was .77. Based on evidence that experiencing racism within health care settings is a specific source of stress for patients (Benkert & Peters, 2005; Peters, 2004, 2006), an additional item using a yes/no response option was added to measure whether participants had experienced racism specifically in health care. Ethnic identity. The Multi‐Group Ethnic Identity Measure (MEIM; Phinney, 1992) was used to assess participants' social identity and the value and emotional significance attached to being African American. Most of the research on the relationship between trust and social or ethnic identity has used racial categorizations (e.g., Black, Native American) as proxies for identity (Muir et al., 2009; Thom et al., 1999). However, Benkert et al. (2009) found that within African Americans, greater acceptance of one's racial identity was positively correlated with trust in their primary care providers. The MEIM consists of 14 items, rated on a 4‐point scale (1 strongly disagree to 4 strongly agree). Three general aspects of ethnic identity are assessed: ethnic attitudes and sense of belonging; ethnic identity of achievement; and ethnic practices. The 14‐item MEIM has reported Cronbach alphas >.80; Cronbach alpha was .87 in the current study. Outcome variables. The outcomes evaluated in the current study included adherence to prescribed medications, adherence to prenatal visit schedule, gestational age at birth, and birth weight. These data were obtained from the EMR. Adherence. Adherence to medications was based on patient's self‐reported adherence to prenatal vitamins
Research in Nursing & Health
and, if ordered, vitamin D, as recorded in the EMR. We also determined the total number of prenatal visits the participant had and whether those visits met the recommended prenatal schedule for uncomplicated pregnancies (i.e., one visit per month during weeks 4–28; every 2 weeks during weeks 28–36, and each week after week 36 until birth; Akkerman et al., 2012; Kirkham, Harris, & Grzybowski, 2005). Birth outcomes. Low birth weight was defined as
Correspondence to Rosalind M. Peters E-mail: [email protected] Rosalind M. Peters Associate Professor, College of Nursing Wayne State University 5557 Cass Avenue—Room 358 Detroit, MI 48202 Ramona Benkert College of Nursing Wayne State University Thomas N. Templin College of Nursing Wayne State University Andrea E. Cassidy-Bushrow Department of Public Health Sciences Henry Ford Hospital, Detroit, MI
Abstract: Significant racial disparities exist in pregnancy outcomes, but few researchers have examined the relationship between trust in providers and pregnancy outcomes. The Trust in Physician Scale (TPS), the most widely used tool, has not been tested in pregnancy. We assessed the psychometric properties of the TPS and identified correlates of trust in 189 pregnant African American women. Evidence supports internal consistency reliability (>.85) and internal structure of the TPS (CFI ¼ .97; RMSEA ¼ .05; x2(42) ¼ 65.93, p ¼ .001), but TPS scores did not predict pregnancy outcomes. African American women reported a high level of trust in obstetric providers. Trust did not differ by provider type (physician or midwife) but was related to the women's history of perceived racism and strength of ethnic identity. ß 2014 Wiley Periodicals, Inc. Keywords: Trust in Physician Scale; health care providers; African American; antenatal care; pregnancy outcomes; confirmatory factor analysis; racism; health disparities Research in Nursing & Health, 2014, 37, 144–154 Accepted 27 November 2013 DOI: 10.1002/nur.21581 Published online 7 January 2014 in Wiley Online Library (wileyonlinelibrary.com).
Significant racial disparities exist in birth outcomes in the United States. African American women have about a 60% higher rate of preterm birth (16.77% vs. 10.50%) and an 88% higher rate of low birth weight infants (13.33% vs. 7.09%) than Caucasian women (Martin, Hamilton, Ventura, Osterman, & Mathews, 2013). These two factors are among the leading causes of infant mortality, resulting in infant mortality rates more than twice as high among Black versus White infants (Mathews & MacDorman, 2013). While population studies provide important information regarding birth disparities, information specific to individual women and practitioners is needed to identify where gaps in care may occur. It has been proposed that the frequency, timing, and content of prenatal visits be increased for women at high‐ risk for poor outcomes (Krans & Davis, 2012). In an era of evidence‐based practice, the application of evidence requires insuring that the care provided is responsive to the patient's needs, values, and beliefs (Grace & Powers, 2009). Before visits are increased, evidence is needed on the role of the patient‐provider interface, including elements of trust, in pregnancy outcomes. Discriminatory treatment in health care experienced by African Americans has been identified as contributing to lower trust in the provider (Benkert, Peters, Clark, & C
2014 Wiley Periodicals, Inc.
Keves‐Foster, 2006) as well as to racial disparities in health outcomes, including pregnancy outcomes (Benkert & Peters, 2005; Giurgescu, McFarlin, Lomax, Craddock, & Albrecht, 2011; Pascoe & Smart Richman, 2009; Peters, 2006). Patients' level of trust in the provider was positively correlated with patients' satisfaction with care, health‐seeking behaviors, adherence to medical treatment plans, and return for follow‐up appointments (Baker, Mainous, Gray, & Love, 2003; Kerse et al., 2004; O'Malley, Sheppard, Schwartz, & Mandelblatt, 2004; Thom, Ribisl, Stewart, & Duke, 1999; Trachtenberg, Dugan, & Hall, 2005). Among African American women, lower trust has also been associated with poorer health status (Wiltshire, Person, & Allison 2011). In non‐pregnant samples, African American patients reported significantly lower levels of trust than Caucasian patients (Muir et al., 2009). In African American men and women, less than high school education (Wiltshire et al., 2011), lower income (Halbert, Armstrong, Gandy, & Shaker, 2006), and no usual source of care (Halbert et al., 2006) were associated with lower trust in providers. In addition, African Americans' perceptions of racism and ethnic or racial identity attitudes have also been associated with trust in a health care provider. Specifically, there is an inverse relationship between perceived racism
TRUST IN PROVIDER/ PETERS ET AL.
and levels of trust, but a positive correlation between ethnic/racial identity and levels of trust in the provider (Benkert et al., 2006; Benkert, Hollie, Nordstrom, Wickson, & Bins‐Emerick, 2009). Trust in health care providers during pregnancy has received scant research attention, especially for African American women. Only one study was found in which 16 African American women were included in a qualitative study of trust among low‐income rural pregnant women (Jesse, Dolbier, & Blanchard, 2008). Little is known about the patient characteristics (e.g., demographics, perceptions) that may affect trust in an obstetrical care (OB/GYN) provider. Knowledge development is further hampered by the lack of a valid instrument to measure trust during pregnancy. The Trust in Physician scale (TPS; Anderson & Dedrick, 1990) was the first instrument developed to measure trust. Although the TPS remains widely used and is a benchmark against which to compare other trust instruments (Pearson & Raeke, 2000), no studies were found in which the TPS was used in pregnancy. Therefore, the purpose of this study was to examine the reliability and validity of the TPS for use in relation to obstetric providers and to identify patient characteristics associated with level of trust in obstetric providers. Such knowledge may be useful for assessing the quality of care provided to pregnant African American women.
Methods Sample and Setting The sample was recruited from the population of pregnant women receiving prenatal care in a large health system in metropolitan Detroit. Inclusion criteria included: self‐ identified as African American or Black, 18–44 years of age, in the second trimester of pregnancy (approximately 13–28 weeks gestation based on self‐reported last menstrual period or expected delivery date defined by ultrasound), and without evidence of illicit drug use or severe psychiatric illness. The study was approved by two institutional review boards. A total of 203 women from nine OB/ GYN clinics were recruited. We excluded 11 women who were unable to complete the entire research visit. We also excluded three women with morbid obesity (body mass index [BMI] >60 kg/m2) (Leykin & Pellis, 2009) due to the difficulty in assessing fundal height to estimate gestational age. The sample for analysis consisted of 189 women, which was judged sufficiently large to conduct a confirmatory factor analysis (CFA) of the TPS, based on simulation studies in which the stability of parameter estimates was largely a function of the magnitude of factor loadings and number of items on a factor (Hogarty, Hines, Kromrey, Ferron, & Mumford, 2005; MacCallum, Widaman, Zhang, & Hong, 1999). Using internal consistency reliability data from prior studies, we conservatively estimated a reliability of .80
Research in Nursing & Health
145
for the TPS in the current study. Using the Spearman– Brown Prophecy Formula (Nunnally & Bernstein, 1994) in reverse, we determined that the reliability of a single item in this 11‐item scale was .27. Given that the reliability of a single item in a CFA measurement model is the square of the standardized factor loading, we could then anticipate a factor loading of .52. With factor loadings of this magnitude, it is recommended that the number of subjects be greater than 10 times the number of variables (Hogarty et al., 2005). Thus an N ¼ 189 was judged sufficient to produce stable estimates of population parameters for the 11‐ item tool.
Instruments and Measures Donabedian's (1980, 1995) theoretical framework provides a systematic way to evaluate the quality of health care provided, and may assist in identifying the gap in care affecting birth outcomes among African American women. Within Donabedian's framework, three key elements are evaluated to assess quality of care. These elements include structure (conditions under which care is provided), process (the technical and interpersonal aspect of care), and outcomes (clinical as well as patient satisfaction outcomes) (Donabedian, 1980, 2003). Structure variables. Structure includes human, physical, and financial resources associated with providing care (Donabedian, 2003). The structure elements of care that were measured were health insurance, provider type (i.e., physician or midwife), and whether the provider changed over the course of the woman's pregnancy. These data were extracted from the electronic medical record (EMR). Process variables. Donabedian (1980, 2003) asserted that within the process component, the practitioner must manage both the technical and interpersonal aspects of the health situation. The technical aspect involves the application of the best scientific evidence, while interpersonal management involves understanding socially determined norms and values. Trust in provider was the key variable examined in assessing the interpersonal context of care. Based on evidence that trust is related to patients' characteristics such as demographics, perceptions, and beliefs, these also were assessed. Trust in physician. The women's level of trust in their OB provider was measured using the Trust in Physician Scale (TPS) scale, developed by Anderson and Dedrick (1990). The TPS is an 11‐item instrument in which responses are measured on a 5‐point scale from 1 strongly disagree to 5 strongly agree. Items measure patients' trust in the provider regarding dependability, confidence, and confidentiality of information. Higher scores reflect greater trust. For the current study, when completing the scale, participants were instructed to think of the obstetrician/ gynecologist, doctor, or certified nurse midwife (CNM) they had been seeing most often for prenatal care.
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The TPS has been reported to have high internal consistency, with Cronbach alphas from .85 to .90, including in samples with African American participants (Anderson & Dedrick, 1990). High internal consistency reliability (a > .88) also was reported in studies of African American patients when altered to assess trust in nurse practitioners as well as physician providers (Benkert et al., 2009; Benkert, Peters, Tate, & Dinardo, 2008). However, no reports were found of use of the instrument in a sample of pregnant women. Patients’ characteristics. Based on the empirical literature, factors associated with trust in provider included demographic data, health information, previous experiences of racism, and strength of ethnic identity. Demographic data. Self‐reported demographic data included age, education, and family income. Data regarding the woman's previous pregnancy history were obtained from the EMR. Perceived racism. The RaLES‐brief (Harrell, 1997; Harrell, Merchant, & Young, 1997) measures perceived racism across life situations, including that which is experienced directly, as well as vicariously, and trans‐generationally. The RaLES‐brief is a 9‐item instrument rated on a 5‐point scale (from 0 not at all to 4 extremely). Cronbach alpha has ranged from .79 to .87 (Benkert et al., 2006; Harrell, 1997; Peters, 2004). The Cronbach alpha in the current study was .77. Based on evidence that experiencing racism within health care settings is a specific source of stress for patients (Benkert & Peters, 2005; Peters, 2004, 2006), an additional item using a yes/no response option was added to measure whether participants had experienced racism specifically in health care. Ethnic identity. The Multi‐Group Ethnic Identity Measure (MEIM; Phinney, 1992) was used to assess participants' social identity and the value and emotional significance attached to being African American. Most of the research on the relationship between trust and social or ethnic identity has used racial categorizations (e.g., Black, Native American) as proxies for identity (Muir et al., 2009; Thom et al., 1999). However, Benkert et al. (2009) found that within African Americans, greater acceptance of one's racial identity was positively correlated with trust in their primary care providers. The MEIM consists of 14 items, rated on a 4‐point scale (1 strongly disagree to 4 strongly agree). Three general aspects of ethnic identity are assessed: ethnic attitudes and sense of belonging; ethnic identity of achievement; and ethnic practices. The 14‐item MEIM has reported Cronbach alphas >.80; Cronbach alpha was .87 in the current study. Outcome variables. The outcomes evaluated in the current study included adherence to prescribed medications, adherence to prenatal visit schedule, gestational age at birth, and birth weight. These data were obtained from the EMR. Adherence. Adherence to medications was based on patient's self‐reported adherence to prenatal vitamins
Research in Nursing & Health
and, if ordered, vitamin D, as recorded in the EMR. We also determined the total number of prenatal visits the participant had and whether those visits met the recommended prenatal schedule for uncomplicated pregnancies (i.e., one visit per month during weeks 4–28; every 2 weeks during weeks 28–36, and each week after week 36 until birth; Akkerman et al., 2012; Kirkham, Harris, & Grzybowski, 2005). Birth outcomes. Low birth weight was defined as
