Key Points
Question
Are patients in racial and ethnic minority groups with eye conditions less likely to feel treated with respect and be asked about their opinions/beliefs by their clinicians compared with non-Hispanic White patients?
Findings
In this cross-sectional analysis, racial and ethnic minority participants with vision-threatening eye conditions self-reported not always being treated with respect by their clinician more often than non-Hispanic White participants, but more likely to report always being asked about their opinions/beliefs.
Meaning
Because asking participants about their opinions/beliefs was associated with increased reporting of feeling respect, asking about opinions/beliefs may lead to more patients reporting feelings of being treated with respect by their clinician.
This cohort study evaluates the association between racial and ethnic minority status and the perception of being treated with respect by clinicians using data from the National Health Interview Survey.
Abstract
Importance
The perception of being treated with respect by clinicians may be a driver of disparities in individuals in racial and ethnic minoritie groups with eye diseases. Understanding these drivers may help identify potential interventions to reduce eye health disparities to prevent vision loss and blindness.
Objective
To evaluate the association between racial and ethnic minority status and the perception of being treated with respect by clinicians.
Design, Setting, and Participants
This cross-sectional analysis of a nationally representative cohort study using data from the National Health Interview Survey (NHIS) included participants in the 2017 survey with complete data on outcomes, associated factors, and covariates. Data analysis took place from January 2021 to February 2021. Using a population-based survey conducted in the US in 2017 by the US census bureau on behalf of the National Center for Health Statistics, NHIS study participants (age ≥18 years) who self-reported having an eye disease (macular degeneration, diabetic retinopathy [DR], glaucoma, cataracts) were included, and patients who self-reported as Black, Asian, other/multiple races, or Hispanic ethnicity were considered to be in racial and ethnic minority groups.
Main Outcomes and Measures
Multivariable logistic regression models were used to evaluate the association of minority status with self-reported “always” being treated with respect by clinicians and self-reported “always” being asked about opinions/beliefs about medical care.
Results
Participants in racial and ethnic minority groups had 23% lower odds of reporting being treated with respect compared with non-Hispanic White patients (adjusted odds ratio [AOR], 0.77; 95% CI, 0.61-0.97; P = .03). A minority of participants had 66% higher odds of reporting being asked about their beliefs (AOR, 1.66; 95% CI, 1.39-1.98; P < .001). For all patients, being asked about opinions/beliefs by their clinician was associated with a 5.8 times higher odds of reporting being treated with respect (AOR, 5.80; 95% CI, 4.35-7.74; P < .001).
Conclusions and Relevance
In this nationally representative US population of patients with eye diseases, being a patient in a racial or ethnic minority group was associated with feeling less respected by health care professionals compared with non-Hispanic White patients. Asking about opinions and beliefs, regardless of race or ethnicity, is associated with patients feeling that they are treated with respect.
Introduction
Vision loss is a substantial public health issue.1 In eye health and vision care, there are concerning health disparities. These health disparities in the treatment of eye diseases have led to disparities in vision outcomes, with poor vision and blindness disproportionately affecting people from racial and ethnic minority backgrounds including Black, Asian, and other/multiple races and Hispanic ethnicity.2,3,4,5,6 Though there is research focused on disparities pertaining to eye health and vision care, the drivers of these disparities are not well understood. One area of focus pertaining to these disparities is respect.
In studies outside of ophthalmology research, patients who perceive that they are being treated with respect by their clinician and whose health care professionals solicit their opinions/beliefs during medical decision-making are more likely to report greater satisfaction with their care and improved quality of life.6 In prior studies,7,8 patients described feeling respected by a clinician means feeling valued as a person and involves being treated with empathy, autonomy, and dignity. Understanding what a patient wants in their health care and what they believe about their health plays a role in this.7,8 People who have lower socioeconomic status and who are from racial and ethnic minority backgrounds have reported feeling that they are treated with less respect and are less involved with decision-making surrounding their health care compared with White people.7 This may be a contributor to disparities in health outcomes.
Among participants with vision-threatening eye disease, it is currently not understood if individuals in racial and ethnic minority groups feel they are treated with respect by their clinicians and if they feel they are asked about their opinions/beliefs for medical care. By determining if there is an association between racial and ethnic minority status and being treated with respect and being asked about opinion/beliefs of medical care, interventions can be developed to address health disparities in eye health and vision care.
This research aims to determine within the National Health Interview Survey (NHIS), a nationally representative sample of noninstitutionalized adults in the US, the frequency that patients in racial and ethnic minority groups feel they were treated with respect and asked about their opinions/beliefs about medical care by their clinician compared with non-Hispanic White participants. Furthermore, this research aimed to determine if there was an interaction between participants reporting clinicians asking about opinions/beliefs of medical care and participants perceiving that they were treated with respect.
Methods
Study Population
The study population came from the NHIS, which is a nationally representative survey. The NHIS for 2017 included information on eye disease, so adult study participants (aged ≥18 years) who self-reported having the eye diseases that are the leading causes of blindness and low vision in the US (macular degeneration, diabetic retinopathy [DR], glaucoma, cataracts) were included in the study population.9 Any participant who self-reported “White only” race and reported “not Hispanic” ethnicity was considered not to be in a racial or ethnic minority group. Any participant who self-reported a race other than White (including Black/African American, American Indian, Alaskan Native, Asian, other race, or multiple race), or who reported Hispanic ethnicity was considered to be in a racial and ethnic minority group.
Demographic Variables
The NHIS included information on social determinants of health. The variables that were included for adjustment in the analysis were gender (male/female), age, education, race, ethnicity. The NHIS asked participants “Are you male or female?” Though it is impossible to determine how the participants interpreted this question, we report this self-reported variable as gender, which is a social construct. Age categories included those aged 18 to 39 years, 40 to 64 years, 65 to 74 years, 75 to 84 years, and 85 years and older. Educational achievement was self-reported as less than a high school diploma, a high school diploma, an associate degree, a college degree, or higher. Race was also self-reported as White, Black, Asian, and other/multiple races. Ethnicity included either non-Hispanic or Hispanic.
Patient Experience
Outcome variables that were assessed were “How often did your health care providers ask for your opinions/beliefs about your medical care or treatment?” and “How often were you treated with respect by your health care providers?” Response options for both questions were “always,” “most of the time,” “some of the time,” and “none of the time.” Respect toward patients is morally important and is central to the clinical experience, thus the response of “always” reporting of “How often were you treated with respect by your health care providers” was the benchmark for the analysis compared with all other responses.7,8
Analyses
Descriptive characteristics were stratified by whether or not participants reported “always” being treated with respect, using a χ2 test for comparisons. A multivariable logistic regression model was used to evaluate the association of minority status with “always” being asked about opinions/beliefs about medical care. This model was adjusted for age, education, and sex. A second multivariable logistic regression model was used to evaluate the association of minority status with “always” being treated with respect by clinicians. This model was adjusted for age, education, sex, and whether or not the patient reported “always” being asked about opinions/beliefs about medical care. Next, a third multivariable logistic regression model was used to determine the association of minority status with “always” being treated with respect by clinicians adjusting for being asked about opinions/beliefs about medical care because this is associated with the perception of being treated with respect. In this model, an interaction between minority status and being asked about opinions/beliefs to see if minority status influenced the association of being asked about opinions/beliefs with perception of being treated with respect was evaluated. Stata statistical software (version 16.1, StataCorp) was used for all analyses, which accounted for complex survey design and sample weights.10
Results
The total study population for analysis included 5343 individuals with vision-threatening eye diseases; 3296 (61.69%) identified as women. Most participants were aged 40 years or older (5254 [98.34%] of the study population). Study participants from racial and ethnic minority backgrounds, including participants who identified as Black, Hispanic, Asian, or having multiple races and those who identified as Hispanic comprised 21.11% of the study population (349 individuals identified as being of Hispanic ethnicity and 824 individuals identified as Black, Asian or having multiple/other races). About half (3235 [46%]) of the study population had an educational status of a high school diploma or less. The most prevalent vision-threatening eye condition was cataracts (4747 [89%] participants) (Table 1).
Table 1. Characteristics of NHIS Study Population.
| Characteristic | Unweighted No. (weighted %) | P valuea | |
|---|---|---|---|
| Always treated with respect by clinician (n = 4373) | Most/some/none of the time, treated with respect by clinician (n = 856) | ||
| Female gender | 2674 (57.79) | 544 (59.70) | .37 |
| Age, y | |||
| 18-39 | 64 (2.223) | 24 (4.546) | <.001 |
| 40-64 | 928 (25.11) | 248 (33.45) | |
| 65-74 | 1572 (35.87) | 298 (31.32) | |
| 75-84 | 1239 (25.78) | 204 (23.08) | |
| ≥85 | 570 (11.02) | 82 (7.604) | |
| Educational achievement | |||
| <High school | 636 (14.25) | 128 (14.92) | .15 |
| High school | 2005 (46.06) | 384 (43.18) | |
| Associate degree | 477 (10.89) | 110 (14.10) | |
| College degree | 1239 (28.79) | 232 (27.79) | |
| Race | |||
| Asian | 124 (3.49) | 41 (6.185) | .005 |
| Black | 412 (9.188) | 95 (11.4) | |
| White | 3739 (85.07) | 690 (79.16) | |
| Other/multiple | 98 (2.253) | 30 (3.249) | |
| Hispanic ethnicity | |||
| Non-Hispanic | 4096 (91.28) | 798 (90.86) | .79 |
| Hispanic | 277 (8.72) | 58 (9.135) | |
| Racial and ethnic minority statusb | |||
| Nonminority | 3498 (77.45) | 639 (71.10) | .37 |
| Minority | 875 (22.55) | 217 (28.90) | |
| Eye disease | |||
| AMD | 540 (11.54) | 119 (13.48) | .18 |
| Glaucoma | 681 (16.37) | 144 (17.85) | .42 |
| Cataracts | 3903 (88.02) | 748 (83.90) | .02 |
| DR | 208 (5.306) | 51 (7.757) | .03 |
Abbreviations: AMD, age-related macular degeneration; DR, diabetic retinopathy; NHIS, National Health Interview Survey.
P values from χ2 test.
Racial and ethnic minority status was defined as anyone who self-reported Black, Asian, other, multiple races, or Hispanic ethnicity. Participants may have reported being in both race and ethnic minority groups.
The univariate model was used to build the multivariable model. In the adjusted model, participants in a racial and ethnic minority group were less likely to report that they were always asked about their opinions/beliefs about their medical care or treatment by their clinicians compared with non-Hispanic White participants (AOR, 1.66; 95% CI, 1.39-1.98; P < .001). Those with an associate degree had a 22% lower likelihood of reporting that they were always asked about their opinions/beliefs about their medical care or treatment by their clinician compared with those with less than a high school education (AOR, 0.71; 95% CI, 0.59-1.03; P = .08). Only 29.25% of patients not in a racial and ethnic minority group reported always being asked about their opinions/beliefs by their clinician compared with 40.62% (59.38% stating they were not always being asked about their opinions/beliefs by their health care provider) of participants not in a racial and ethnic minority group (Table 2).
Table 2. Multivariable Model of “How Often Did Your Health Care Providers Ask for Your Opinions/Beliefs About Your Medical Care or Treatment?”.
| Variable | AOR (95% CI) | P value |
|---|---|---|
| Racial and ethnic minority status | ||
| Minority | 1.66 (1.39-1.98) | <.001 |
| Nonminority | 1 [Reference] | |
| Gender | ||
| Female | 1.02 (0.88-1.18) | .78 |
| Male | 1 [Reference] | |
| Age, y | ||
| 18-39 | 1 [Reference] | |
| 40-64 | 1.24 (0.65-2.36) | .51 |
| 65-74 | 1.28 (0.67-2.44) | .45 |
| 75-84 | 1.26 (0.66-2.40) | .47 |
| ≥85 | 1.11 (0.58-2.13) | .75 |
| Education | ||
| <High school | 1 [Reference] | |
| High school | 0.87 (0.70-1.09) | .24 |
| Associate degree | 0.78 (0.59-1.03) | .08 |
| College degree | 0.90 (0.71-1.14) | .38 |
Abbreviation: AOR, adjusted odds ratio.
In the multivariable model, patients in a racial and ethnic minority group were less likely to state that they were treated with respect by their clinician compared with non-Hispanic White patients (AOR, 0.77; 95% CI, 0.61-0.97; P = .03). Those who were aged 65 years or older were significantly more likely to report that they were always treated with respect by their clinicians compared with those between the ages of 18 and 39 years (65-74 years, AOR, 2.26; 95% CI, 1.28-4.01; P = .005; 75-84 years, AOR, 2.18; 95% CI, 1.22-3.87; P = .008; and 85 years and older, AOR, 2.82; 95% CI, 1.52-5.25; P = .001). Of patients not in racial and ethnic minority groups, 79.21% (95% CI, 74.87%-83.54%) reported that they were always treated with respect, compared with just 74.68% (95% CI, 69.32%-80.04%) of those in racial and ethnic minority groups (Table 3).
Table 3. Multivariable Model of “How Often Were You Treated With Respect by Your Health Care Providers?”.
| Variable | AOR (95% CI) | P value |
|---|---|---|
| Racial and ethnic minority status | ||
| Minority | 0.77 (0.61-0.97) | .03 |
| Nonminority | 1 [Reference] | |
| Gender | ||
| Female | 0.92 (0.77-1.09) | .33 |
| Male | 1 [Reference] | |
| Age, y | ||
| 18-39 | 1 [Reference] | |
| 40-64 | 1.55 (0.87-2.76) | .13 |
| 65-74 | 2.26 (1.28-4.01) | .005 |
| 75-84 | 2.177 (1.22-3.87) | .008 |
| ≥85 | 2.82 (1.52-5.25) | .001 |
| Education | ||
| <High school | 1 [Reference] | |
| High school | 1.06 (0.78-1.43) | .67 |
| Associate degree | 0.77 (0.53-1.11) | .17 |
| College degree | 1.01 (0.72-1.40) | .97 |
Abbreviation: AOR, adjusted odds ratio.
In the multivariable model, asking about opinions/beliefs was associated with being treated with respect (AOR, 5.80; 95% CI, 4.35-7.74; P < .001). After adjusting for the sex, age, education, and asking about opinions/beliefs, patients in racial and ethnic minority groups were still less likely to report being treated with respect by their clinicians (AOR, 0.64; 95% CI, 0.05-0.81; P < .001). In addition, those who were aged 65 years or older were significantly more likely to report that they were always treated with respect by their clinicians compared with those between the ages of 18 and 39 years (65-74 years, AOR, 2.21; 95% CI, 1.24-3.95; P = .007; 75-84 years, AOR, 2.10; 95% CI, 1.18-3.74; P = .01; and 85 years and older, AOR, 2.96; 95% CI, 1.58-5.54; P = .001). An interaction between asking about opinions/beliefs and minority status was evaluated and no interaction was found (Table 4). In this model, always being asked about opinions/beliefs was associated with reduced racial and ethnic disparities in being treated with respect. Among participants who reported not always being asked about opinions/beliefs, 64.3% (adjusted predicted proportion; 95% CI, 57.8%-70.8%) of participants in a racial and ethnic minority group reported being treated with respect compared with 73.6% (adjusted predicted proportion; 95% CI, 68.7%-78.4%) of participants who were not part of a racial and ethnic minority. However, among those who reported always being asked about opinions/beliefs, 91.0% (adjusted predicted proportion; 95% CI, 88.1%-94.0%) of those in a racial and thnic minority group reported being treated with respect compared with 94.1% (adjusted predicted proportion; 95% CI, 92.1%-96.0%) of those who were not part of a racial and ethnic minority.
Table 4. Multivariable Model of “How Often Were You Treated With Respect by Your Health Care Providers?” Adjusting for “How Often Did Your Health Care Providers Ask for Your Opinions/Beliefs About Your Medical Care or Treatment?”.
| Variable | AOR (95% CI) | P value |
|---|---|---|
| Asking about opinions/beliefs | ||
| Always asked | 5.80 (4.35-7.74) | <.001 |
| Most/some/none | 1 [Reference] | |
| Racial and ethnic minority status | ||
| Minority | 0.64 (.050-0.81) | <.001 |
| Nonminority | 1 [Reference] | |
| Gender | ||
| Female | 0.91 (0.77-1.09) | .30 |
| Male | 1 [Reference] | |
| Age, y | ||
| 18-39 | 1 [Reference] | |
| 40-64 | 1.52 (0.85-2.71) | .16 |
| 65-74 | 2.21 (1.24-3.95) | .007 |
| 75-84 | 2.10 (1.18-3.74) | .01 |
| ≥85 | 2.96 (1.58-5.54) | .001 |
| Education | ||
| <High school | 1 [Reference] | |
| High school | 1.11 (.82-1.50) | .50 |
| Associate degree | 0.82 (0.56-1.20) | .32 |
| College degree | 1.05 (0.74-1.47) | .79 |
Abbreviation: AOR, adjusted odds ratio.
Discussion
Among the population with vision-threatening eye conditions, patients in racial and ethnic minority groups were more likely to not report being treated with respect by their clinicians using NHIS nationally representative data. This association was still noted after adjusting for self-reported gender, age, and education. Being asked about opinions/beliefs was associated with being treated with respect for both racial and ethnic minority and non-Hispanic White participants. Importantly, the racial and ethnic minority population reported higher odds of being asked about opinions/beliefs pertaining to their medical care compared with the non-Hispanic White population. The associations of being asked about opinions/beliefs on feeling treated with respect was the same for both racial groups, meaning that if the racial and ethnic minority participants had not been asked about their opinions and beliefs at a higher rate, the disparity in feeling treated with respect might have been even greater. Still, 59.38% of patients in racial and ethnic minority groups reported not being asked about opinions and beliefs. Ensuring that more patients in racial and ethnic minority groups are asked about medical opinions and beliefs could increase the proportion of them who feel they are treated with respect.
This cross-sectional analysis focused on people with vision-threatening eye disease. Previous work evaluating the general US population also found that non-White respondents were less likely to report being treated with respect.11 Research has shown that both Black and Hispanic patients have greater mistrust of health care professionals and expect to receive more discriminatory treatment compared with White patients.12,13 There has been a history of discriminatory treatment and racism within scientific research with such events as the Tuskegee syphilis experiment and the ethics in the misappropriation of cells from Henrietta Lacks.14,15 In addition, medical mistrust stems from inequities in health care facilities, health care insurance, and health care practices.14,15,16 In our study, older adults were more likely to report always being treated with respect. This may be because, as shown in prior studies, clinicians may be more likely to have patient-centered encounters with older patients. A study with 177 patients at a large family medicine clinic found that physicians were more likely to have patient-centered encounters, which focus on the patient’s beliefs, preferences, and needs, with patients who were aged 65 years and older.17 Regardless of race, asking about opinions/beliefs was associated with the perception of respect. Involving patients in decision-making pertaining to their care is perceived as a sign of respect.7 Respect by physicians has been associated with trust by the patient, which can lead to a cohesive patient-physician relationship to carry out a successful treatment plan.18 When patients feel respected, they are more likely to attend their health care appointments.19 So, if patients do not feel respected, there are great potential harms because research has shown missed appointments is a risk factor for all-cause mortality, as well as decline in visual acuity for patients with age-related macular degeneration (AMD).20,21,22
When clinicians ask about opinions/beliefs, patients feel that they are treated with respect. We found that patients in racial and ethnic minority groups were more likely to report being asked about their opinions/beliefs (AOR, 1.66; 95% CI, 1.39-1.98; P < .001) but less likely to report being treated with respect (AOR, 0.77; 95% CI, 0.61-0.97; P = .03). It is possible that patients in racial and ethnic minority groups were, in fact, asked more often about their opinions/beliefs. It is also possible that patients in racial and ethnic minority groups had lower expectations about being asked about their opinions/beliefs and so were more likely to take notice of being asked.23,24,25,26 In this study, reporting being asked about opinions and beliefs was associated with reporting being treated with respect for participants who were and were not in racial and ethnic minority groups, suggesting that if minority participants had not felt they were being asked about opinions and beliefs, the disparity in respect between those who were and were not in racial and ethnic minority groups may have been even greater. Patients whose clinicians solicit their opinions/beliefs during medical decision-making are more likely to report greater satisfaction with their care and improved quality of life.27 Furthermore, when there is communication and listening between both patients and clinicians, a shared understanding may be developed between the 2 parties that can be used for future decision-making regarding the patients’ health, which in turn can increase the patients’ quality of care.28 This has been seen in vision research pertaining to glaucoma; when clinicians asked about patients’ views of glaucoma and its treatment vs not asking, there was a statistically significant (adjusted probability, 0.70 vs. 0.39; P < .001) association with higher medication self-efficacy.29 In the present study, we were surprised to find that patients in racial and ethnic minority groups were more likely to report being asked about their opinions/beliefs (AOR, 1.66; 95% CI, 1.39-1.98; P < .001). Although it is possible that patients in racial and ethnic minority groups were, in fact, asked more often about their opinions/beliefs, it is also possible that patients in racial and ethnic minority groups had lower expectations about being asked about their opinions/beliefs for their medical care. This is because research has shown that there are racial and ethnic minority groups that are more likely to have negative views of both health care services and clinicians, so when they are asked, they might be likely to take notice.23,24,25,26
For patients with vision-threatening eye disease, being treated with respect by their clinician can create substantial benefits.18 Patients with vision-threatening eye conditions who feel that they are treated with respect by their clinician can experience greater content with their vision care as well as better clinical outcomes.7,29,30 If patients feel that they are not being treated with respect by their clinician, respect disparities will persist because research has shown that patients who feel that they have been disrespected by their clinician are more likely to wait to receive medical care and less likely to listen to the advice of their clinician.31 Clinicians should understand that respect is not just associated with being nice to their patients, but also engaging with their patients and valuing them.30
Limitations
This study has several limitations. First, the study relied on NHIS data, which is self-reported data of diagnosis of the vision-threatening eye conditions that were included (glaucoma, cataracts, AMD, and DR). This may have introduced recall bias in the study. Second, individuals reported if they were treated with respect by their clinician, but the questionnaire did not specifically ask about eye care professionals. Though the survey did not specifically ask about respect from eye care specialists, many of these participants with vision-threatening eye diseases should be seeing eye care clinicians for regular eye visits. The behavior of these specialists could be contributing to the participants’ perception of being treated with respect. Also, participants with eye diseases who have not been treated with respect by clinicians may view their eye care differently, whether or not it was an eye care specialist who showed the lack of respect.
Third, individuals reported if their clinician asked about their opinions/beliefs, again the questionnaire did not specifically ask about eye care professionals. Fourth, NHIS data do not include data on individuals in the active-duty Armed Forces, those without residences, and individuals in long-term care institutions or correctional facilities. Fifth, the racial and ethnic minority population only accounted for 21.11% of the study population. Finally, only the eye diseases and conditions mentioned were included in the study, so these results are not necessarily applicable to individuals with other eye diseases or conditions, including refractive error. These research findings do not represent these populations that have not been included in the data.
Conclusions
Despite racial and ethnic differences, these results suggest asking about opinions/beliefs and perceptions of being treated with respect are intertwined because the results showed 5.8 higher odds of reports of being treated with respect when asked about opinions/beliefs for all participants. Although racial and ethnic minority participants were more likely to report always being asked about their opinions/beliefs about their medical care or treatment, they were less likely to report always being treated with respect, which could contribute to racial disparities in vision outcomes. Furthermore, participants who were aged 65 years and older were more likely to report that they were always treated with respect by their clinicians. In this study, participants who reported that their health care professionals always asked about their opinions/beliefs were more likely to report always being treated with respect, regardless of race or ethnicity. These findings suggest that when clinicians ask about opinions/beliefs of their patients who are in racial and ethnic minority groups they may be more likely to feel that they are treated with respect by their clinician. Future work on the drivers that contributed to racial and ethnic minority patients’ reporting not being treated with respect but being asked about their opinions/beliefs might help clinicians gain insight on how to communicate with their patients and further address these drivers. In addition, it may be important to explore the practical health consequences of patients’ perceptions of respect and opinions/beliefs about their medical care or treatment, such as missed appointments or delays in care. Furthermore, research should examine if race and ethnicity of the health care professional affects the responses to being treated with respect and asked about opinions/beliefs. This is an important factor to identify because clinicians sharing the same race and ethnicity as their patient has been associated with improved health outcomes.32
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