Conversations between doctors and patients about taking HIV medication as prescribed may differ depending on the patient’s race or ethnicity, research shows.
In HIV care, a key to health outcomes is whether people take their medications as prescribed.
The new findings are based on a highly structured analysis of recorded office visits between 45 health care providers and 404 patients, 245 of whom were black and 59 of whom were Hispanic.
Researchers used the Generalized Medical Interaction Analysis, which divides the dialogue into units called “utterances” based on speech acts such as asking questions, giving information, giving instructions, making requests, or expressing desires. It also classifies the topic or subject matter of each utterance.
Published in the journal AIDS and Behavior, the study produced three main findings:
- Different speech patterns: Because black patients spoke less to their providers than either white or Hispanic patients, they experienced significantly greater provider dominance in their discussions. Black patients and their providers exchanged fewer expressions of goals or values than did Hispanics and whites. Meanwhile, providers asked Hispanic patients fewer open-ended questions and their discussions involved less humor.
- More dialogue about HIV drug adherence with minorities: Providers and either black or Hispanic patients exchanged a higher volume of dialogue—more utterances—about adherence than did providers and white patients. This difference occurred regardless of how adherent patients were to their medication regimens or whether lab tests showed that their disease was under control.
- Directives, not problem solving: In those more extensive dialogues between black and Hispanic patients with their providers, there were not any more utterances about problem-solving than for whites. Instead there were more provider directives (e.g., “Take your medicine or you’ll get sick”) said to the minority patients than to whites.
The research does not reveal why providers—34 of whom were doctors and 30 of whom were white, with most of the rest of Asian ancestry—talked more with minority patients than with whites about adherence. One hypothesis, yet to be tested, is that the providers may be attempting to compensate for what they read in studies about lower adherence among minorities.
Lack of trust?
“The possibility that seems most compelling to me is the doctors don’t trust their black and Hispanic patients as much to be adherent,” says M. Barton Laws, assistant professor of health services policy and practice at Brown University. “It has been epidemiologically observed that they do tend to be less adherent, but it’s not because they are black or Hispanic.”
Other factors likely cause a lack of adherence, but how the providers spoke to minority patients didn’t correlate with whether they were adherent, Laws says. Doctors also didn’t spend much time trying to find out whether patients faced barriers to staying on their medications and helping find solutions.
In previous research analyzing office visits, Laws and colleagues found that physicians generally tended to use more directives than engage in problem solving when addressing HIV adherence. But research in behavioral counseling shows that simply exhorting people again and again does not make them more likely to engage in a desired behavior.
The emphasis on directives, rather than problem solving, is likely a product of how providers relate to all patients, he says, regardless of race. However, the other differences in the overall visits are suggestive of ways in which differences in culture and background may affect communication.
The current study doesn’t examine whether the racial differences in the dialogue lead to different clinical outcomes, but that question can now be investigated, Laws says.
“We’ve found there is something going on and it would be good to understand it better.” Ongoing work with collaborators is assessing whether provider communication styles can be changed, and how communication patterns are associated with outcomes.
Researchers at Johns Hopkins University, Tufts Medical Center, Oregon Health and Science University, and Wayne State University contributed to the study, which was supported by the National Institute of Mental Health and the Agency for Healthcare Research and Quality.
Source: Brown University