Journals of Gerontology: MEDICAL SCIENCES Cite journal as: J Gerontol A Biol Sci Med Sci. 2014 November;69A(S2):S46–S53 doi:10.1093/gerona/glu174
© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].
Trust in Physicians Among U.S. Chinese Older Adults Melissa A. Simon,1 Manrui Zhang,2 and XinQi Dong2 1
Departments of Obstetrics and Gynecology, Northwestern University Medical Center, Chicago, Illinois. 2 Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, Illinois.
Address correspondence to Melissa A. Simon, MD, MPH, Departments of Obstetrics and Gynecology, Preventive Medicine and Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 633 North St Clair, Suite 1800, Chicago, IL 60611. Email: [email protected]
Methods. Data were drawn from the Population Study of Chinese Elderly, a population-based survey of U.S. Chinese older adults in the Greater Chicago area. Guided by a community-based participatory research approach, a total of 3,159 Chinese older adults aged 60 and above were surveyed. An 11-item scale was used to measure participants’ trust in physicians. Results. On a scale of 11–55, the level of trust in physician among U.S. Chinese older adults was 42.0 (SD = 6.3). Items related to confidence in physicians’ knowledge and skills were most commonly endorsed, including trusting physicians’ judgment on medical care (84.8%), trusting physicians’ advice (84.2%), and trusting physicians’ words that something is so and must be true (81.2%). Younger age, male gender, higher educational level, fewer years of residing in the United States and in the community, poorer self-reported health status, and poorer quality of life were associated with lower level of trust in physicians. Conclusions. Trust in physician is commonly endorsed among U.S. Chinese older adults. However, future longitudinal studies are needed to improve our understanding of risk factors and outcomes associated with trust in physicians among U.S. Chinese older adults. Key Words: Population studies—Older adults—Trust in physician—Chinese aging. Received May 21, 2014; Accepted August 19, 2014 Decision Editor: Stephen Kritchevsky, PhD
T
rust is fundamental in clinical patient–physician relationships (1). Patients’ trust in physicians (TIP) measures the extent to which patients believe that their physicians will act in their best interest to provide medical suggestions, care, and treatment (2). TIP is essential in assessing the quality and effectiveness of medical care because it influences patients’ willingness to seek care, adherence to physicians’ instructions, continuity of care, and overall health outcomes (3). In particular, TIP is critical for older adults due to the high prevalence of multimorbidity and complex medical needs for chronic disease management (4,5). With the rapidly evolving nature of the health care system, there is a growing need to advance our knowledge on TIP among older adults. Prior studies found that older age is associated with a higher level of TIP (2,5,6). However, these studies were based on the general population and were thus limited in providing detailed information on older adults specifically. Although we have improved knowledge about TIP among older adults in the recent years, most prior studies were based on more selected populations of older adults (7,8) or a single measure of TIP (9). S46
Furthermore, TIP as a multidimensional construct was measured qualitatively in many studies, and fewer studies explored TIP with quantitative measures (10). In addition, in quantitative studies, TIP was often conceptualized and measured in diverse ways with different subcomponents, which may make meaningful comparisons challenging (10). For instance, although fidelity and competence components are constantly enforced in most scales estimating TIP, Kao’ scale excludes honesty and behavior component, Wake Forest’s scale excludes confidentiality and behavior components, and Anderson et al. Trust in Physician Scale provides a coverage of all six components including fidelity, competence, honesty, confidentiality, global, and behavioral (11). An increasing body of literature documents racial/ethnic disparities in TIP. Although factors contributing to trust and distrust in physicians may differ across racial/ethnicity groups (12), minority groups were more likely to report greater distrust and lower satisfactory toward their physicians compared with dominant groups. In particular, literature suggests that Asian Americans displayed the lower level of satisfactory and less sharing in patient–physician relationship based on a 100-point self-reported rating (13).
Downloaded from http://biomedgerontology.oxfordjournals.org/ at Oakland University on July 7, 2015
Background. Trust in physicians influences the health and well-being of older adults and is an important indicator to assess the quality of medical care. However, Asian aging populations are often underrepresented in studies of patient trust in physicians. This study aims to examine the level of trust in physicians among Chinese older adults in a communitydwelling Chinese aging population.
Trust in Physicians Among Chinese Older Adults
Methods Population and Settings The Population Study of Chinese Elderly (PINE) is a population-based epidemiological study of U.S. Chinese older adults aged 60 and older in the Greater Chicago area. The purpose of the PINE study is to collect communitylevel data of U.S. Chinese older adults to examine the key cultural determinants of health and well-being. The project was initiated by a synergistic community-academic collaboration among the Rush Institute for Healthy Aging, Northwestern University, and many Greater Chicago area community-based social services agencies and organizations (19). In brief, the PINE study implemented culturally/linguistically appropriate community recruitment strategies guided by a community-based participatory research approach (20). Strictly following community-based participatory research approach, we assembled a Community advisory board that consisted of community stakeholders and residents enlisted through more than 20 social groups, community centers, and clinics in the greater Chicago area.
Community advisory board played a pivotal role in providing useful perspectives and strategies for aging research conduct and partnership sustainability. Furthermore, under the guidance of Community advisory board, our targeted community-based recruitment strategy engaged community centers as our main recruitment sites throughout the greater Chicago area, including more than 20 community-based social services agencies, community centers, faith-based organizations, senior apartments, and social clubs. In addition, other outreach channels were also utilized, such as local newspapers advertisements, flyers and posters, community-health educational workshops, word of mouth, participants’ referral, etc. Due to the closely knitted ethnic social network connecting the families of Chinese immigrants, over a third of our study participants learned about the project through family members, neighbors, acquaintance, or friends. All participants were consented and interviewed by trained bicultural research assistants in English or in a Chinese dialect, including Mandarin, Cantonese, Toishanese, and Teochow, according to participants’ preference. Field interviewers were recruited through community partners and were equipped with multilingual abilities. Prior to field interviews, all hired interviewers attended an intensive training that covered from proper data collection techniques, survey questionnaire administration, to in-person communication skills, basic understanding of health sciences research and mock-interview role play. During the field data collection period, booster trainings combined with staff meetings were conducted one to two times a month in order to reinforce specific aspects of inperson training and provide additional training on new issues emerged from the field work. Out of 3,542 eligible participants, 3,159 agreed to participate in the study, yielding a response rate of 91.9%. Based on U.S. Census 2010 and a random block census project, the PINE study is representative of the Chinese aging population in the Greater Chicago area (21). The study was approved by the Institutional Review Board at the Rush University Medical Center. Measurements Sociodemographics.—Basic demographic information was collected, including age, sex, education level, annual income, marital status, number of children, and living arrangement. Immigration data relating to participants’ years in the United States and years residing in the current community were also collected. Overall health status was measured by: “In general, how would you rate your health?” on a 4-point scale. Quality of life was assessed by asking participants: “In general, how would you rate your quality of life?” also on a 4-point scale. Health change in last year was measured by the question: “Compared to one year ago, how would you rate your health now?” on
Downloaded from http://biomedgerontology.oxfordjournals.org/ at Oakland University on July 7, 2015
A national survey suggests that Asian Americans are more likely than whites to report their physicians as not understanding of their needs and not spending enough time with them (14) based on a dichotomized measure of TIF (14). Despite that Asian Americans are often underrepresented in many studies, they are frequently treated as a homogeneous group in research, limiting our capability to distinguish cultural beliefs and health behaviors in diverse Asian subgroups with respect to TIP. The Chinese community is the oldest and largest Asian American subgroup in the United States (15). Older adults constitute a large segment of the general Chinese population in the United States, of whom 15.4% are aged 65 or older (15). More than 80% of Chinese older adults were foreign born, and approximately 30% of them immigrated to the United States after the age of 60. Their immigration experiences, degree of acculturation, and previous physician–patient relationships before residing in the United States may contribute to their current levels of TIP in the United States (16). A case study based on a U.S. Chinese immigrant family identified how TIP was influenced by their understanding of different cultures (17). However, the vast intragroup diversity in languages, education levels, socioeconomic status, and degree of acculturation among U.S. Chinese older adults contributes to the dearth of evidence-based research targeting at Chinese older adults (18). This study aims to contribute to the existing knowledge base of TIP among U.S. community-dwelling Chinese older adults by examining their level of TIP and the correlations between TIP and sociodemographic, overall health, and quality-of-life characteristics.
S47
S48
Simon et al.
a 5-point scale. Health changes were then categorized into three groups (improved, same, or worsened).
Results Sample Characteristics Of the 3,159 participants enrolled in the study, 58.9% were women, 71.3% were married, and 85.1% had an annual income below $10,000. The mean age of our participants was 72.8 (SD = 8.3) and the average years of education completed was 8.7 (SD = 5.1). The majority (92.7%) of our participants were born in mainland China and 53.9% preferred to complete the interview in Cantonese. More than half (57.3%) of the participants have lived in the United States for less than 20 years. Overall, 39.0% of participants perceived their health status as good or very good, and 50.4% perceived their quality of life as very good or good. Scale Reliability The alpha coefficient for the Chinese version of the TIP scale was .84 (Table 1). All correlations were significant at the .001 level. The inter-item correlations ranged from .05 to .69, demonstrating that the constructs were not too closely
Table 1. Endorsement of Trust in Physicians Scale Items Items of Trust in Physicians Scale 1. I doubt that my physician really cares about me as a person 2. My physician is usually considerate of my needs and puts them first 3. I trust my physician so much that I always try to follow his/her advice 4. If my physician tells me something is so, then it must be true 5. I sometimes distrust my physician’s opinion and would like a second one 6. I trust my physician’s judgment about my medical care 7. I feel my physician does not do everything he/she should for my medical care 8. I trust my physician to put my medical needs above all other considerations when treating my medical problems 9. My physician is a real expert in taking care of medical problems like mine 10. I trust my physician to tell me if a mistake was made about my treatment 11. I sometimes worry that my physician may not keep the information we discuss totally private
Strongly Disagree, N (%)
Disagree, N (%)
Neutral, N (%)
Agree, N (%)
Strongly Agree, N (%)
620 (20.0) 38 (1.2) 18 (0.6) 14 (0.5) 661 (21.3) 15 (0.5) 419 (13.6) 28 (0.9)
1,564 (50.4) 244 (7.9) 139 (4.5) 163 (5.3) 1,637 (52.7) 138 (4.4) 1,470 (47.7) 189 (6.2)
478 (15.4) 635 (20.6) 335 (10.8) 407 (13.1) 341 (11.0) 320 (10.3) 477 (15.5) 582 (18.9)
305 (9.8) 1,547 (50.2) 1,538 (49.4) 1,567 (50.4) 40 (12.9) 1,715 (55.2) 495 (16.1) 1,683 (54.8)
135 (4.4) 617 (20.0) 1,082 (34.8) 956 (30.8) 68 (2.2) 920 (29.6) 218 (7.1) 592 (19.3)
41 (1.3) 110 (3.8) 865 (28.4)
396 (12.9) 525 (18.2) 1,685 (55.3)
704 (23.0) 926 (32.0) 342 (11.2)
1,439 (47.0) 1,009 (34.8) 133 (4.4)
483 (15.8) 327 (11.3) 21 (0.7)
Downloaded from http://biomedgerontology.oxfordjournals.org/ at Oakland University on July 7, 2015
Trust in physician.—We used the 11-item Anderson et al. Trust in Physician Scale to assess a patient’s interpersonal trust in his or her physician from three aspects: physician dependability, confidence in physician knowledge and skills, and confidentiality and reliability of information received from the physician (2). Participants were asked how strongly do they agree or disagree on a 5-point Likert scale that they trusted their physician’s judgment on medical care, medical advice, opinions, and words that something is so and that their physicians are experts on medical problems like theirs. Moreover, we asked participants how much they trust their physicians to consider and prioritize their medical needs when treating medical problems, to tell them if a mistake was made in treatment, to keep information private, to care about them as a person, and to do everything they should for patients. We created a continuous TIP variable by summing scores from the 11 items. Aggregate scores range from 11 to 55, with higher scores indicating greater level of TIP. The reliability of the TIP scale was 0.85 and 0.90 in Anderson’s original work (2). Content validity was assessed by a group of bilingual and bicultural study researchers with expertise in Chinese cultural issues, health, and aging. The original English versions of the instruments were first translated into Chinese by a bilingual research team. Due to the vast linguistic diversity of our study population, the Chinese version was then back translated by bilingual and bicultural investigators fluent in dialects including Mandarin and Cantonese to confirm consistency in the meaning of the Chinese version with the original English version. Both written scripts (traditional and simplified Chinese characters) were subsequently examined. More than 20 Community advisory board members subsequently examined the Chinese versions to ascertain that the meanings of the items in Chinese conveyed the meanings to Chinese older adults from diverse linguistic backgrounds.
Data Analysis Descriptive univariate statistics were used to summarize the sociodemographic, family composition, and healthrelated characteristics of the sample population. We examined the psychometric properties of the TIP scale to test their adequacy and expanded use to U.S. Chinese older adults. Internal consistency reliability was assessed by determining the coefficient alpha and inter-item correlation coefficients. Means and standard deviations were used to describe TIP. The analysis of variance F test was used to examine whether level of trust differed significantly by age, gender, income, education, health status, years of residence in the United States, or years of residence in the community. Pearson correlation coefficients were used to examine the correlations between different variables and TIP. Statistical analyses were conducted using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).
S49
Trust in Physicians Among Chinese Older Adults
correlated to indicate unidimensionality. Item 3 (trust following physician’s advice), Item 4 (physician tells me something is so, then it must be true), and Item 6 (trust physician’s judgment) showed some of the highest inter-item correlation coefficients, ranging from .65 to .69.
TIP Level TIP levels differed by age (p < .001), gender (p < .001), education (p < .001), and income (p < .001; Table 3). Participants aged 80 and older were more likely to report a higher TIP score (M = 43.3, SD = 6.2) than younger participants. Men showed a lower TIP level (M = 41.3, SD = 6.3) in comparison with women (M = 42.4, SD = 6.3). The TIP level was higher among participants with 0–6 years of education (M = 43.1, SD = 5.9) compared with participants with higher educational attainment. Participants with annual income of more than $20,000 had lower TIP (M = 39.8, SD = 7.0) compared with lower income participants.
Correlations Higher TIP was significantly correlated with older age, female gender, lower educational level, being unmarried, having more children, having lived longer in the United States, having lived longer in the community, China as the country of origin, living with fewer persons, better overall health status, and better quality of life (Table 4). Income and health change over the last year were not significantly correlated with TIP. Discussion As the first population-based study that examined interpersonal TIP among U.S. Chinese older adults, we found that TIP was commonly endorsed, especially items related to confidence in physician knowledge and skills. However, a lower level of TIP was present among participants who were younger, male, or had higher educational level, lived fewer years in the United States and in the community, or had poorer self-reported health status and quality of life. Items related to confidence in physician knowledge and skills were most commonly endorsed, such as trusting
Table 2. Trust in Physicians Scale and Item—Total Correlation and Correlation Coefficients Items 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Alpha If Item Removed
1
2
3
4
5
6
7
8
9
10
11
.83 .82 .82 .82 .83 .82 .85 .82 .84 .84 .84
1.0 0.38 0.33 0.31 0.32 0.31 0.39 0.31 0.14 0.25 0.28
1.0 0.50 0.48 0.33 0.48 0.26 0.65 0.34 0.35 0.26
1.0 0.69 0.44 0.65 0.23 0.51 0.32 0.33 0.28
1.0 0.48 0.68 0.22 0.52 0.34 0.37 0.27
1.0 0.48 0.27 0.36 0.22 0.22 0.33
1.0 0.22 0.55 0.34 0.32 0.30
1.0 0.22 0.05 0.25 0.22
1.0 0.37 0.35 0.26
1.0 0.19 0.15
1.0 0.14
1.0
Downloaded from http://biomedgerontology.oxfordjournals.org/ at Oakland University on July 7, 2015
Endorsement of TIP Scale Items Descriptive data for the 11-item TIP scale are highlighted in Table 2. A high percentage of older adults trusted their physician’s judgment on medical care (84.8%), medical advice (84.2%), and words that something is so and must be true (81.2%). Moreover, most participants trusted their physicians to consider their needs (70.2%) and prioritize their medical needs when treating medical problems (74.1%). However, only 62.8% of participants agreed that their physicians were experts on medical problems like theirs and 46.1% participants trusted their physician to tell them if a mistake was made in their treatment. With regard to items worded in a negative direction, the majority of participants disagreed or strongly disagreed about: worrying that physicians may not keep information private (83.7%), distrusting physician’s opinion and wanting a second opinion (74.0%), doubting that physicians really cared about them as a person (70.4%), and feeling that physicians did not do everything they should have for their medical care (61.3%).
TIP levels also differed by years in the United States (p < .01), country of origin (p < .05), and preferred language (p < .001; Table 3). Participants who lived in the United States for less than 10 years presented a lower level of TIP (M = 41.3, SD = 6.4). Older adults who were born in Hong Kong/Macau (M = 40.3, SD = 6.4) and Taiwan (M = 40.9, SD = 8.0) had relatively lower level of TIP compared with those born in Mainland China (M = 42.0, SD = 6.3). Participants who preferred to be interviewed in Cantonese (M = 42.0, SD = 6.2) and Toishanese (M = 43.0, SD = 6.1) presented a higher level of TIP than those who were interviewed in Mandarin or in English. In addition, the level of TIP differed by overall health status (p < .01) and quality of life (p < .001). Lower levels of TIP were present among participants who reported poor health status (M = 41.1, SD = 7.1) and poor quality of life (M = 38.4, SD = 5.9).
6.2
40.5
6.3
41.3
5.9
43.1
6.5
41.3
7.1
42.6
7.8
44.6
SD
6.5
SD
6.3
6.2
SD
6.1
SD
Quality of Life
11–20 (N = 958)
5.8
SD
6.2
Mean
42.0
43.0
6.1
SD
Toishanese (N = 729)
Mean
41.8
40.9
Mean
SD
6.8
SD
8.0
SD
6.5
SD
7.0
Mandarin (N = 687)
40.9
Mean
Taiwan (N = 42)
42.2
Mean
21–30 (N = 759)
Mean
Preferred Language
6.4
6.1
SD
6.0
SD
6.0
SD
75–79 (N = 546)
6.0
SD
40.6
Mean
English (N = 33)
42.3
31+ (N = 561)
Others (N = 81) Mean
42.2
Mean
38.4
Mean
41.1
Poor (N = 98)
Poor (N = 594) Mean
41.3
Mean
5.6
SD
5.5
SD
6.1
SD
5.9
SD
7.1
SD
6.0
SD
$15,000–$19,999 (N = 68)
42.8
Mean
80+ (N = 666)
39.8
Mean
>$20,000 (N = 86)
43.3
Mean
Downloaded from http://biomedgerontology.oxfordjournals.org/ at Oakland University on July 7, 2015
Cantonese (N = 1,656)
6.3
42.0
40.3
Mean SD
Hong Kong/Macau (N = 104)
SD 6.6
Worsened (N = 1,332)
41.6
Mean
Fair (N = 1,441)
42.0
Mean
Fair (N = 1,303)
40.9
Mean
Country of Origin
6.2
SD
SD
42.1
Mean
42.2
SD
Income
13+ (N = 651)
6.3
SD
$10,000–$14,999 (N = 304)
40.7
Mean
42.1
Years in the United States
Same (N = 1,502)
Mean
Age 70–74 (N = 597) Mean
Overall Health Status
6.2
SD
Health Change Over Past Year
42.2
Mean
Good (N = 1,352)
42.3
Mean
Good (N = 1,073)
42.7
Mean
$5,000–$9,999 (N = 1,597)
41.3
Mean
7–12 (N = 1,086)
42.4 Education
Women (N = 1,804)
Mean
6.6
SD
Mean
6.4
41.3
Sex
41.3
Mean
65–69 (N = 635)
Mainland China (N = 2,878)
SD
0–10 (N = 813)
6.2
41.8
Mean
SD
Mean
Improved (N = 269)
SD
Mean
Very Good (N = 213)
SD
Mean
Very Good (N = 135)
SD
Mean
$0–$4,999 (N = 1,017
SD
Mean
0–6 (N = 1,349)
SD
Mean
Men (N = 1,301)
SD
Mean
60–64 (N = 661)
Table 3. Endorsement of Trust in Physicians by Sociodemographics and Health Measures
7.0
© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].
Trust in Physicians Among U.S. Chinese Older Adults Melissa A. Simon,1 Manrui Zhang,2 and XinQi Dong2 1
Departments of Obstetrics and Gynecology, Northwestern University Medical Center, Chicago, Illinois. 2 Rush Institute for Healthy Aging, Rush University Medical Center, Chicago, Illinois.
Address correspondence to Melissa A. Simon, MD, MPH, Departments of Obstetrics and Gynecology, Preventive Medicine and Medical Social Sciences, Feinberg School of Medicine, Northwestern University, 633 North St Clair, Suite 1800, Chicago, IL 60611. Email: [email protected]
Methods. Data were drawn from the Population Study of Chinese Elderly, a population-based survey of U.S. Chinese older adults in the Greater Chicago area. Guided by a community-based participatory research approach, a total of 3,159 Chinese older adults aged 60 and above were surveyed. An 11-item scale was used to measure participants’ trust in physicians. Results. On a scale of 11–55, the level of trust in physician among U.S. Chinese older adults was 42.0 (SD = 6.3). Items related to confidence in physicians’ knowledge and skills were most commonly endorsed, including trusting physicians’ judgment on medical care (84.8%), trusting physicians’ advice (84.2%), and trusting physicians’ words that something is so and must be true (81.2%). Younger age, male gender, higher educational level, fewer years of residing in the United States and in the community, poorer self-reported health status, and poorer quality of life were associated with lower level of trust in physicians. Conclusions. Trust in physician is commonly endorsed among U.S. Chinese older adults. However, future longitudinal studies are needed to improve our understanding of risk factors and outcomes associated with trust in physicians among U.S. Chinese older adults. Key Words: Population studies—Older adults—Trust in physician—Chinese aging. Received May 21, 2014; Accepted August 19, 2014 Decision Editor: Stephen Kritchevsky, PhD
T
rust is fundamental in clinical patient–physician relationships (1). Patients’ trust in physicians (TIP) measures the extent to which patients believe that their physicians will act in their best interest to provide medical suggestions, care, and treatment (2). TIP is essential in assessing the quality and effectiveness of medical care because it influences patients’ willingness to seek care, adherence to physicians’ instructions, continuity of care, and overall health outcomes (3). In particular, TIP is critical for older adults due to the high prevalence of multimorbidity and complex medical needs for chronic disease management (4,5). With the rapidly evolving nature of the health care system, there is a growing need to advance our knowledge on TIP among older adults. Prior studies found that older age is associated with a higher level of TIP (2,5,6). However, these studies were based on the general population and were thus limited in providing detailed information on older adults specifically. Although we have improved knowledge about TIP among older adults in the recent years, most prior studies were based on more selected populations of older adults (7,8) or a single measure of TIP (9). S46
Furthermore, TIP as a multidimensional construct was measured qualitatively in many studies, and fewer studies explored TIP with quantitative measures (10). In addition, in quantitative studies, TIP was often conceptualized and measured in diverse ways with different subcomponents, which may make meaningful comparisons challenging (10). For instance, although fidelity and competence components are constantly enforced in most scales estimating TIP, Kao’ scale excludes honesty and behavior component, Wake Forest’s scale excludes confidentiality and behavior components, and Anderson et al. Trust in Physician Scale provides a coverage of all six components including fidelity, competence, honesty, confidentiality, global, and behavioral (11). An increasing body of literature documents racial/ethnic disparities in TIP. Although factors contributing to trust and distrust in physicians may differ across racial/ethnicity groups (12), minority groups were more likely to report greater distrust and lower satisfactory toward their physicians compared with dominant groups. In particular, literature suggests that Asian Americans displayed the lower level of satisfactory and less sharing in patient–physician relationship based on a 100-point self-reported rating (13).
Downloaded from http://biomedgerontology.oxfordjournals.org/ at Oakland University on July 7, 2015
Background. Trust in physicians influences the health and well-being of older adults and is an important indicator to assess the quality of medical care. However, Asian aging populations are often underrepresented in studies of patient trust in physicians. This study aims to examine the level of trust in physicians among Chinese older adults in a communitydwelling Chinese aging population.
Trust in Physicians Among Chinese Older Adults
Methods Population and Settings The Population Study of Chinese Elderly (PINE) is a population-based epidemiological study of U.S. Chinese older adults aged 60 and older in the Greater Chicago area. The purpose of the PINE study is to collect communitylevel data of U.S. Chinese older adults to examine the key cultural determinants of health and well-being. The project was initiated by a synergistic community-academic collaboration among the Rush Institute for Healthy Aging, Northwestern University, and many Greater Chicago area community-based social services agencies and organizations (19). In brief, the PINE study implemented culturally/linguistically appropriate community recruitment strategies guided by a community-based participatory research approach (20). Strictly following community-based participatory research approach, we assembled a Community advisory board that consisted of community stakeholders and residents enlisted through more than 20 social groups, community centers, and clinics in the greater Chicago area.
Community advisory board played a pivotal role in providing useful perspectives and strategies for aging research conduct and partnership sustainability. Furthermore, under the guidance of Community advisory board, our targeted community-based recruitment strategy engaged community centers as our main recruitment sites throughout the greater Chicago area, including more than 20 community-based social services agencies, community centers, faith-based organizations, senior apartments, and social clubs. In addition, other outreach channels were also utilized, such as local newspapers advertisements, flyers and posters, community-health educational workshops, word of mouth, participants’ referral, etc. Due to the closely knitted ethnic social network connecting the families of Chinese immigrants, over a third of our study participants learned about the project through family members, neighbors, acquaintance, or friends. All participants were consented and interviewed by trained bicultural research assistants in English or in a Chinese dialect, including Mandarin, Cantonese, Toishanese, and Teochow, according to participants’ preference. Field interviewers were recruited through community partners and were equipped with multilingual abilities. Prior to field interviews, all hired interviewers attended an intensive training that covered from proper data collection techniques, survey questionnaire administration, to in-person communication skills, basic understanding of health sciences research and mock-interview role play. During the field data collection period, booster trainings combined with staff meetings were conducted one to two times a month in order to reinforce specific aspects of inperson training and provide additional training on new issues emerged from the field work. Out of 3,542 eligible participants, 3,159 agreed to participate in the study, yielding a response rate of 91.9%. Based on U.S. Census 2010 and a random block census project, the PINE study is representative of the Chinese aging population in the Greater Chicago area (21). The study was approved by the Institutional Review Board at the Rush University Medical Center. Measurements Sociodemographics.—Basic demographic information was collected, including age, sex, education level, annual income, marital status, number of children, and living arrangement. Immigration data relating to participants’ years in the United States and years residing in the current community were also collected. Overall health status was measured by: “In general, how would you rate your health?” on a 4-point scale. Quality of life was assessed by asking participants: “In general, how would you rate your quality of life?” also on a 4-point scale. Health change in last year was measured by the question: “Compared to one year ago, how would you rate your health now?” on
Downloaded from http://biomedgerontology.oxfordjournals.org/ at Oakland University on July 7, 2015
A national survey suggests that Asian Americans are more likely than whites to report their physicians as not understanding of their needs and not spending enough time with them (14) based on a dichotomized measure of TIF (14). Despite that Asian Americans are often underrepresented in many studies, they are frequently treated as a homogeneous group in research, limiting our capability to distinguish cultural beliefs and health behaviors in diverse Asian subgroups with respect to TIP. The Chinese community is the oldest and largest Asian American subgroup in the United States (15). Older adults constitute a large segment of the general Chinese population in the United States, of whom 15.4% are aged 65 or older (15). More than 80% of Chinese older adults were foreign born, and approximately 30% of them immigrated to the United States after the age of 60. Their immigration experiences, degree of acculturation, and previous physician–patient relationships before residing in the United States may contribute to their current levels of TIP in the United States (16). A case study based on a U.S. Chinese immigrant family identified how TIP was influenced by their understanding of different cultures (17). However, the vast intragroup diversity in languages, education levels, socioeconomic status, and degree of acculturation among U.S. Chinese older adults contributes to the dearth of evidence-based research targeting at Chinese older adults (18). This study aims to contribute to the existing knowledge base of TIP among U.S. community-dwelling Chinese older adults by examining their level of TIP and the correlations between TIP and sociodemographic, overall health, and quality-of-life characteristics.
S47
S48
Simon et al.
a 5-point scale. Health changes were then categorized into three groups (improved, same, or worsened).
Results Sample Characteristics Of the 3,159 participants enrolled in the study, 58.9% were women, 71.3% were married, and 85.1% had an annual income below $10,000. The mean age of our participants was 72.8 (SD = 8.3) and the average years of education completed was 8.7 (SD = 5.1). The majority (92.7%) of our participants were born in mainland China and 53.9% preferred to complete the interview in Cantonese. More than half (57.3%) of the participants have lived in the United States for less than 20 years. Overall, 39.0% of participants perceived their health status as good or very good, and 50.4% perceived their quality of life as very good or good. Scale Reliability The alpha coefficient for the Chinese version of the TIP scale was .84 (Table 1). All correlations were significant at the .001 level. The inter-item correlations ranged from .05 to .69, demonstrating that the constructs were not too closely
Table 1. Endorsement of Trust in Physicians Scale Items Items of Trust in Physicians Scale 1. I doubt that my physician really cares about me as a person 2. My physician is usually considerate of my needs and puts them first 3. I trust my physician so much that I always try to follow his/her advice 4. If my physician tells me something is so, then it must be true 5. I sometimes distrust my physician’s opinion and would like a second one 6. I trust my physician’s judgment about my medical care 7. I feel my physician does not do everything he/she should for my medical care 8. I trust my physician to put my medical needs above all other considerations when treating my medical problems 9. My physician is a real expert in taking care of medical problems like mine 10. I trust my physician to tell me if a mistake was made about my treatment 11. I sometimes worry that my physician may not keep the information we discuss totally private
Strongly Disagree, N (%)
Disagree, N (%)
Neutral, N (%)
Agree, N (%)
Strongly Agree, N (%)
620 (20.0) 38 (1.2) 18 (0.6) 14 (0.5) 661 (21.3) 15 (0.5) 419 (13.6) 28 (0.9)
1,564 (50.4) 244 (7.9) 139 (4.5) 163 (5.3) 1,637 (52.7) 138 (4.4) 1,470 (47.7) 189 (6.2)
478 (15.4) 635 (20.6) 335 (10.8) 407 (13.1) 341 (11.0) 320 (10.3) 477 (15.5) 582 (18.9)
305 (9.8) 1,547 (50.2) 1,538 (49.4) 1,567 (50.4) 40 (12.9) 1,715 (55.2) 495 (16.1) 1,683 (54.8)
135 (4.4) 617 (20.0) 1,082 (34.8) 956 (30.8) 68 (2.2) 920 (29.6) 218 (7.1) 592 (19.3)
41 (1.3) 110 (3.8) 865 (28.4)
396 (12.9) 525 (18.2) 1,685 (55.3)
704 (23.0) 926 (32.0) 342 (11.2)
1,439 (47.0) 1,009 (34.8) 133 (4.4)
483 (15.8) 327 (11.3) 21 (0.7)
Downloaded from http://biomedgerontology.oxfordjournals.org/ at Oakland University on July 7, 2015
Trust in physician.—We used the 11-item Anderson et al. Trust in Physician Scale to assess a patient’s interpersonal trust in his or her physician from three aspects: physician dependability, confidence in physician knowledge and skills, and confidentiality and reliability of information received from the physician (2). Participants were asked how strongly do they agree or disagree on a 5-point Likert scale that they trusted their physician’s judgment on medical care, medical advice, opinions, and words that something is so and that their physicians are experts on medical problems like theirs. Moreover, we asked participants how much they trust their physicians to consider and prioritize their medical needs when treating medical problems, to tell them if a mistake was made in treatment, to keep information private, to care about them as a person, and to do everything they should for patients. We created a continuous TIP variable by summing scores from the 11 items. Aggregate scores range from 11 to 55, with higher scores indicating greater level of TIP. The reliability of the TIP scale was 0.85 and 0.90 in Anderson’s original work (2). Content validity was assessed by a group of bilingual and bicultural study researchers with expertise in Chinese cultural issues, health, and aging. The original English versions of the instruments were first translated into Chinese by a bilingual research team. Due to the vast linguistic diversity of our study population, the Chinese version was then back translated by bilingual and bicultural investigators fluent in dialects including Mandarin and Cantonese to confirm consistency in the meaning of the Chinese version with the original English version. Both written scripts (traditional and simplified Chinese characters) were subsequently examined. More than 20 Community advisory board members subsequently examined the Chinese versions to ascertain that the meanings of the items in Chinese conveyed the meanings to Chinese older adults from diverse linguistic backgrounds.
Data Analysis Descriptive univariate statistics were used to summarize the sociodemographic, family composition, and healthrelated characteristics of the sample population. We examined the psychometric properties of the TIP scale to test their adequacy and expanded use to U.S. Chinese older adults. Internal consistency reliability was assessed by determining the coefficient alpha and inter-item correlation coefficients. Means and standard deviations were used to describe TIP. The analysis of variance F test was used to examine whether level of trust differed significantly by age, gender, income, education, health status, years of residence in the United States, or years of residence in the community. Pearson correlation coefficients were used to examine the correlations between different variables and TIP. Statistical analyses were conducted using SAS, Version 9.2 (SAS Institute Inc., Cary, NC).
S49
Trust in Physicians Among Chinese Older Adults
correlated to indicate unidimensionality. Item 3 (trust following physician’s advice), Item 4 (physician tells me something is so, then it must be true), and Item 6 (trust physician’s judgment) showed some of the highest inter-item correlation coefficients, ranging from .65 to .69.
TIP Level TIP levels differed by age (p < .001), gender (p < .001), education (p < .001), and income (p < .001; Table 3). Participants aged 80 and older were more likely to report a higher TIP score (M = 43.3, SD = 6.2) than younger participants. Men showed a lower TIP level (M = 41.3, SD = 6.3) in comparison with women (M = 42.4, SD = 6.3). The TIP level was higher among participants with 0–6 years of education (M = 43.1, SD = 5.9) compared with participants with higher educational attainment. Participants with annual income of more than $20,000 had lower TIP (M = 39.8, SD = 7.0) compared with lower income participants.
Correlations Higher TIP was significantly correlated with older age, female gender, lower educational level, being unmarried, having more children, having lived longer in the United States, having lived longer in the community, China as the country of origin, living with fewer persons, better overall health status, and better quality of life (Table 4). Income and health change over the last year were not significantly correlated with TIP. Discussion As the first population-based study that examined interpersonal TIP among U.S. Chinese older adults, we found that TIP was commonly endorsed, especially items related to confidence in physician knowledge and skills. However, a lower level of TIP was present among participants who were younger, male, or had higher educational level, lived fewer years in the United States and in the community, or had poorer self-reported health status and quality of life. Items related to confidence in physician knowledge and skills were most commonly endorsed, such as trusting
Table 2. Trust in Physicians Scale and Item—Total Correlation and Correlation Coefficients Items 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Alpha If Item Removed
1
2
3
4
5
6
7
8
9
10
11
.83 .82 .82 .82 .83 .82 .85 .82 .84 .84 .84
1.0 0.38 0.33 0.31 0.32 0.31 0.39 0.31 0.14 0.25 0.28
1.0 0.50 0.48 0.33 0.48 0.26 0.65 0.34 0.35 0.26
1.0 0.69 0.44 0.65 0.23 0.51 0.32 0.33 0.28
1.0 0.48 0.68 0.22 0.52 0.34 0.37 0.27
1.0 0.48 0.27 0.36 0.22 0.22 0.33
1.0 0.22 0.55 0.34 0.32 0.30
1.0 0.22 0.05 0.25 0.22
1.0 0.37 0.35 0.26
1.0 0.19 0.15
1.0 0.14
1.0
Downloaded from http://biomedgerontology.oxfordjournals.org/ at Oakland University on July 7, 2015
Endorsement of TIP Scale Items Descriptive data for the 11-item TIP scale are highlighted in Table 2. A high percentage of older adults trusted their physician’s judgment on medical care (84.8%), medical advice (84.2%), and words that something is so and must be true (81.2%). Moreover, most participants trusted their physicians to consider their needs (70.2%) and prioritize their medical needs when treating medical problems (74.1%). However, only 62.8% of participants agreed that their physicians were experts on medical problems like theirs and 46.1% participants trusted their physician to tell them if a mistake was made in their treatment. With regard to items worded in a negative direction, the majority of participants disagreed or strongly disagreed about: worrying that physicians may not keep information private (83.7%), distrusting physician’s opinion and wanting a second opinion (74.0%), doubting that physicians really cared about them as a person (70.4%), and feeling that physicians did not do everything they should have for their medical care (61.3%).
TIP levels also differed by years in the United States (p < .01), country of origin (p < .05), and preferred language (p < .001; Table 3). Participants who lived in the United States for less than 10 years presented a lower level of TIP (M = 41.3, SD = 6.4). Older adults who were born in Hong Kong/Macau (M = 40.3, SD = 6.4) and Taiwan (M = 40.9, SD = 8.0) had relatively lower level of TIP compared with those born in Mainland China (M = 42.0, SD = 6.3). Participants who preferred to be interviewed in Cantonese (M = 42.0, SD = 6.2) and Toishanese (M = 43.0, SD = 6.1) presented a higher level of TIP than those who were interviewed in Mandarin or in English. In addition, the level of TIP differed by overall health status (p < .01) and quality of life (p < .001). Lower levels of TIP were present among participants who reported poor health status (M = 41.1, SD = 7.1) and poor quality of life (M = 38.4, SD = 5.9).
6.2
40.5
6.3
41.3
5.9
43.1
6.5
41.3
7.1
42.6
7.8
44.6
SD
6.5
SD
6.3
6.2
SD
6.1
SD
Quality of Life
11–20 (N = 958)
5.8
SD
6.2
Mean
42.0
43.0
6.1
SD
Toishanese (N = 729)
Mean
41.8
40.9
Mean
SD
6.8
SD
8.0
SD
6.5
SD
7.0
Mandarin (N = 687)
40.9
Mean
Taiwan (N = 42)
42.2
Mean
21–30 (N = 759)
Mean
Preferred Language
6.4
6.1
SD
6.0
SD
6.0
SD
75–79 (N = 546)
6.0
SD
40.6
Mean
English (N = 33)
42.3
31+ (N = 561)
Others (N = 81) Mean
42.2
Mean
38.4
Mean
41.1
Poor (N = 98)
Poor (N = 594) Mean
41.3
Mean
5.6
SD
5.5
SD
6.1
SD
5.9
SD
7.1
SD
6.0
SD
$15,000–$19,999 (N = 68)
42.8
Mean
80+ (N = 666)
39.8
Mean
>$20,000 (N = 86)
43.3
Mean
Downloaded from http://biomedgerontology.oxfordjournals.org/ at Oakland University on July 7, 2015
Cantonese (N = 1,656)
6.3
42.0
40.3
Mean SD
Hong Kong/Macau (N = 104)
SD 6.6
Worsened (N = 1,332)
41.6
Mean
Fair (N = 1,441)
42.0
Mean
Fair (N = 1,303)
40.9
Mean
Country of Origin
6.2
SD
SD
42.1
Mean
42.2
SD
Income
13+ (N = 651)
6.3
SD
$10,000–$14,999 (N = 304)
40.7
Mean
42.1
Years in the United States
Same (N = 1,502)
Mean
Age 70–74 (N = 597) Mean
Overall Health Status
6.2
SD
Health Change Over Past Year
42.2
Mean
Good (N = 1,352)
42.3
Mean
Good (N = 1,073)
42.7
Mean
$5,000–$9,999 (N = 1,597)
41.3
Mean
7–12 (N = 1,086)
42.4 Education
Women (N = 1,804)
Mean
6.6
SD
Mean
6.4
41.3
Sex
41.3
Mean
65–69 (N = 635)
Mainland China (N = 2,878)
SD
0–10 (N = 813)
6.2
41.8
Mean
SD
Mean
Improved (N = 269)
SD
Mean
Very Good (N = 213)
SD
Mean
Very Good (N = 135)
SD
Mean
$0–$4,999 (N = 1,017
SD
Mean
0–6 (N = 1,349)
SD
Mean
Men (N = 1,301)
SD
Mean
60–64 (N = 661)
Table 3. Endorsement of Trust in Physicians by Sociodemographics and Health Measures
7.0
