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J Best Pract Health Prof Divers. Author manuscript; available in PMC 2016 April 12. Published in final edited form as: J Best Pract Health Prof Divers. 2010 ; 3(1): 59–69.

Recent Perceptions of Health Service Providers Among African American Men: Framing the Future Debate Danelle Stevens-Watkins, PhD1 and Howard Lloyd, BA2 1Spalding

University

2Department

of Educational, Counseling, & School Psychology, University of Kentucky

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Abstract This article reviews the literature on African American men’s perceptions of health service providers and their possible association with health disparities and decreased likelihood that these patients will seek outpatient and preventative health care. The literature suggests that barriers to receiving health care service include not feeling respected or heard by providers. A brief discussion of the dangers of a color-blind approach, findings from implicit association studies on race, and negative media portrayals are offered as possible explanations. Specific questions provide a starting point to increase the self-awareness of health service providers. The importance of patient-centered communication is discussed, and conclusions offered, emphasizing the need for more racial/ethnic minority researchers, educators, and health care providers.

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Introduction

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Health disparities have been an increasingly important research topic in the past decade. African American men are less likely to use outpatient health care services than other groups, and some studies have shown that their perceptions of the quality of the services provided are contributing factors (Dunlop, et al., 2002; Ravenell, Whitaker, & Johnson, 2008). Health service professionals and academic scholars and researchers participating in multicultural psychology classes and training sessions have consistently expressed their desire to increase their competence to work with Black men and other diverse populations, but scant data are available on how many actually continue the ongoing work needed to become competent. This article reviews the literature of the past decade on African American men’s health care use and perceptions of health care providers and proposes a starting point for practitioners to improve their service provision to their African American male patients.

Health Care Use among African American Men Understanding how African American men use health care has become a priority in the effort to reduce health disparities among this population. Studies have shown that, compared to White men, African American men are less likely to have a primary care physician and

Corresponding Author: Danelle Stevens-Watkins, PhD Spalding University 845 S. Third Street Louisville, Kentucky, 40203 (502) 585-9911 ext. 2015(office) (502) 585-7158 (Fax).

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more likely to be seen in emergency settings (Green, Baker, & Ndao-Brumblay, 2004; Schappert, & Burt, 2006; Weinick, Zuvekas, & Cohen, 2000). Using data from a nationally representative survey, Husaini et al. (2004) found that after controlling for socio-economic status across the life span, African American men aged 18-64 and over 65 reported significantly lower rates of service use compared to African American women and White men and women. Specifically, those between 18 and 64 had significantly lower rates of hospitalization, outpatient services, and physician visits. Those over 65 had more hospitalizations and spent significantly more nights in the hospital but made significantly fewer visits to the doctor. In a study examining knowledge and attitudes about prostate screening, Barber et al., (1998) found that a large proportion of African American men reported a lack of regular physician visits and preventative care and tended to use acute care settings for treatment.

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Research suggests that perceptions about how they are treated, particularly in racially discordant interactions, may contribute significantly to lower rates of health care use by African American men (LaVeist, Isaac, & Williams, 2009; Musa, et al., 2009; Ravenell, Whitaker, & Johnson, 2008; Smedley, Stith, & Nelson, 2003; Watkins. & Neighbors, 2007; Whaley, 2004).

The Danger of a Color-blind Approach, Perceived Racism, Stereotypes, and Perceptions of African American Men

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Evidence suggests that non-Hispanic White practitioners are proud of their “color-blind” approach, ignoring racial differences in treating diverse patients (Plaut, Thomos, & Goren, 2009). For many, that pride is based on what they were taught from childhood and often seems to come from a genuine belief that all should be treated equally. In reality, everyone is not treated equally. Research associates a color-blind approach with lower levels of empathy (Burkard, & Knox, 2004) and lower levels of multicultural competence (Neville, Spanierman, & Doan, 2006). Even if race is not explicitly discussed between practitioner and patient, it is noted by both. Despite the possible good intentions of color-blindness, implicit association tests (IAT) have shown that health service professionals do “see” color and make automatic associations (Sabin, et al., 2009; White-Means, et al., 2009), which may be dangerous, impeding their the ability to work effectively with people of color.

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Historic and present-day images of African American men may contribute to negative perceptions. Media and influences from popular culture significantly affect the racial socialization process and societal perceptions about African American men. Repeatedly circulated images include the absent father, pimp, drug dealer, sexual predator, and gangster and such qualities as unintelligent, violent, and unemployable (Caldwell, & White, 2001; Johnson, 2006). When African American men are repeatedly portrayed negatively, even to the point of dehumanization (Johnson, 2006), dismissing their needs to be heard and respected becomes easier. Franklin (1999) used the term invisibility syndrome to describe the way that African American men tend to be assessed and addressed on the basis of inaccurate assumptions and negative stereotypes, as opposed to their individual characteristics. Health care

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professionals, who often profess to have chosen their career so they can help people, may be blinded and misguided by stereotypes and negative portrayals of African American men to the detriment of their patients. For example, van Ryn and Burke (2000) asked physicians to rate their patients on a variety of characteristics. Their findings demonstrated that, irrespective of patients’ socio-economic status, physicians perceived African Americans as more likely to be addicted to drugs, less intelligent, and less likely to comply with treatment recommendations than White patients. Their study shows how race influences provider perceptions, which could result in disparate treatment and reinforce the patient’s mistrust.

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Perceived racism and mistrust have been cited as preventing African American men from seeking physical and mental health services (LaVeist, Isaac, & Williams, 2009; Musa, et al., 2009; Ravenell, Whitaker, & Johnson, 2008; Smedley, Stith, & Nelson, 2003; Watkins, & Neighbors, 2007; Whaley, 2004). In a study examining trust in the health care system among African American and White adults over the age of 65, Musa, et al. (2009) found that African Americans’ relatively high distrust of their physician resulted in underuse of preventative services.

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Research examining the motivation to seek health care services found an accepting and caring environment was a critical factor for African American men (Plowden, & Young, 2003). Part of providing such an environment involves listening, respecting, and validating the patient. All three would seem a given in clinical settings, but research on perceptions among African American male patients has demonstrated that they were not (Wade, 2006). Ravenell, Whitaker, and Johnson (2008) conducted a qualitative study with African American men aged 16-75. Participants recounted many negative experiences in dealing with doctors. They reported feeling as though they were not being heard, that their complaints were not taken seriously, and that they were unimportant to doctors because of cultural differences. A theme that emerged in the study was that although inability to pay for medical care was a barrier for some men, many who were insured and had the means to pay said that, based on their past experiences with medical professionals, services were not worth paying for. After repeated negative experiences with health care professionals, some African American men avoid the health care system and are hesitant to seek care when needed (Blanchard, & Lurie, 2004; Ravenell Whitaker, & Johnson, 2008).

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Using ethnography and participatory research strategies with African American men aged 18-25, Kendrick, Anderson, and Moore (2007) found that what was most important to these patients was having the opportunity to share their stories. The study demonstrated that African American men may not verbalize their symptoms according to diagnostic manuals and suggested that clinicians learn to glean diagnostic assessment data from the patient’s story. Practitioners demonstrating a willingness to deviate from traditionally structured interviews and to listen actively helped to alleviate patients’ perceptions of mistrust and to facilitate forthright discussion. The patient was more inclined to perceive the interaction as beneficial. The study concluded that African American men must have a voice in planning interventions and making decisions about their health care.

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The Importance of Self-Assessment and Adoption of a Patient-Centered Approach in Working with African American Men The often implicit nature of racial prejudice and discrimination may lead patients to perceive their clinical interactions as negative, although the health service provider’s negativity may be largely unintentional. Subtle and unintentional biases, often driven by stereotypes, exist even among educated White health care providers who support egalitarian ideals and denounce racial prejudice (Smedley, Stith, & Nelson, 2003). These heuristic stereotypes affect their perceptions of patients of color, particularly in the time-pressured, cognitively demanding interactions typical of health care settings (Smedley, Stith, & Nelson, 2003). Clinicians must be trained to investigate their own racial biases and negative stereotypes and to bring them into conscious awareness.

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Practitioners working with African American men have an ethical responsibility to educate themselves on best practices with this population. Cross-cultural and multicultural education should start before a practitioner begins to see patients and continue throughout their years of practice. Caldwell and White (2001) suggest that practitioners undergo a process of selfinterrogation and self-confrontation that may reveal the subliminal messages learned from years of racial socialization. Parham (1999) suggests that practitioners confront their stereotypes of African American men by addressing the following questions with colleagues, friends, and others: 1) What are my impressions of African American masculinity? 2) What were my first experiences with a Black man?

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3) What have I learned from my family, friends, and education about slavery, civil rights movements, and the Black power movement? 4) Do I hold images of Black men as absent fathers, superstar athletes, entertainers, criminals, or comedians? 5) What stereotypes of Black men do I have? 6) What are my fears and attractions regarding Black men?

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Self-interrogation and self-confrontation are processes that cannot happen overnight or by simply answering the preceding questions. Health service providers can only initiate behavior change after experiencing an increase in self-awareness. They must find someone they can trust, such as a supervisor or peer, to discuss and to reflect on the developmental process (Caldwell & White, 2001). By discussing the racial socialization process, they may be able to engage in difficult dialogue, increase self-awareness, and, in turn, provide better services to African American male patients. Recent literature regarding patient/provider interactions advocates for providers to take a patient-centered approach to improve the quality of care given to all patients. Patientcentered communication has been described as empathic and responsive (Institute of Medicine, 2001). Specific skills providers can adopt include using open-ended questions to allow patients to describe their experience, rather than listing symptoms; summarizing to

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relay to patients that they have been listened to and heard; and refraining from interrupting patients when they are sharing because, once interrupted, they rarely continue to express their concerns (Barrier, Li, & Jensen, 2003).

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Research has shown that African American patients may not always receive patient-centered treatment. For example, Cooper and Roter (2003) examined patient/provider interactions in racially concordant and discordant settings. They found that visits between White physicians and African American patients were the least patient-centered compared to visits with African American physicians and White patients, which were rated highest. The use of a patient-centered communication style with African American male patients may assist in buffering perceived racism and barriers of mistrust in the provider/patient relationship. For African American men, patient-centered communication may be viewed as a sign of respect (Hammond, 2010) and demonstrate sensitivity to the pervasive negative stereotypes and history of abuses in health care settings. Patient-centered communication may also help in forging a relationship with health care providers and facilitating preventative health care, moving toward reducing overall health disparities among African American men (Betancourt, Green, & Carrillo, 2000).

Conclusions

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Although combating health disparities among African American men is a multilevel, systemic problem, single decisions made by individuals–increasing self-awareness and using patient-centered communication–can have a long-lasting impact on patients’ lives. Faculty teaching students in health service fields must continue their multicultural training and education beyond the courses required to obtain their degrees. Students and faculty working with diverse populations must understand that cultural competency is an ethical responsibility, enabling them to provide the quality care African American men deserve. Specific recommendations relevant to the education and training of health service professionals include recruitment and retention of underrepresented minorities in health service professions (Smedley, Stith, & Nelson, 2003). Research demonstrates that professionals from racial and ethnic minority groups have been more successful in recruiting minority patients for participation in clinical research, which is important to advancing understanding of best practices with African American populations. Increasing the number of minority service providers in prevention programs and primary care settings may help increase their use by African American men (Lopez, et al., 2008; Smedley, Stith, & Nelson, 2003). Last, having a diverse faculty and student body in educational and clinical settings provides a rich learning experience for all students and may help to safeguard against the view that multicultural competency is an afterthought in training and service delivery.

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Recent Perceptions of Health Service Providers Among African American Men: Framing the Future Debate.

This article reviews the literature on African American men's perceptions of health service providers and their possible association with health dispa...
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