Manhattan Cross Cultural Group
The Quality Interactions® E-Newsletter
An Update on Issues in Cross-Cultural Healthcare

Introduction to the Quality Interactions® Newsletter

Welcome to the 12th issue of the Quality Interactions e-newsletter. This is a quarterly supplement to the Quality Interactions e-learning program that aims to provide updates on the field of cultural competence. Each issue includes a feature article, a literature update, and policy briefs on topics related to cultural competence and health disparities, including practical tips, case vignettes, and new research findings.

Feature Article

Mistrust and Trust-Building Across Cultures

Trust is a crucial element in the therapeutic alliance between patient and health care provider. It facilitates open communication and is directly related to patient satisfaction and adherence to provider recommendations (1). Yet research highlights that public trust in health care has dropped to an all time low from 1966 to 2002 (2). While trust in one's own personal physician has stayed somewhat higher in general, many minority patients have less inherent trust in the health care system due to historical mistreatment and fear of discrimination (4,5). Clearly, these concerns have basis in fact. The Tuskegee study of untreated syphilis has left a lasting legacy of fear and mistrust of the medical establishment among the African American community. Numerous studies showing striking disparities in care between African Americans and whites have intensified and validated these concerns.

Mistrust is far from limited to African Americans of course. Native Americans have experienced tremendous historical injustices, and suffer significant health disparities as well. A recent survey by the Kaiser Family Foundation showed that Latinos and Asians also are much more likely than whites to worry that they will be treated unfairly by the health care system due to their race/ethnicity (6). The majority of Americans also may have reasons to distrust the medical community; previous bad experiences, poor communication, disrespectful treatment, and the general loss of control that patients experience when ill can compromise trust for patients across all cultural, ethnic, racial and socioeconomic backgrounds.

It is wise for providers not to blindly assume that patients will trust them fully. Being aware of cues that may be signs of some degree of mistrust is particularly helpful. Patients may express concerns about whether a particular test is necessary, or they may mention some bad experience in the past, for example. These should be taken seriously and should lead to direct efforts at reassurance and trust building. This includes developing good rapport, communicating effectively, allowing patients a decision-making role in their own care, and respecting patients' needs, fears and concerns. Here is a list of helpful suggestions for building trust with patients, especially across cultures.

Literature Update

A pair of studies published in the October 26 issue of the Journal of the American Medical Association (JAMA) shed interesting new light on the link between quality and racial and ethnic disparities in health care. There has been debate about whether disparities in care have more to do with minority patients receiving their care in different hospitals than white patients, or if the care they receive within hospitals is different.

  • A study by Liu and colleagues looked at whether race/ethnicity influenced whether patients received one of ten complex surgical procedures at hospitals that performed a high or low volume of these procedures. The investigators found that Black, Asian and Hispanic patients were less likely than White patients to receive procedures at high volume hospitals, which are known to have better surgical outcomes. This was true for 6, 5 and 9 of the 10 procedures respectively. The authors comment that efforts should be made to understand the patient and systems level factors that support these inequities so we can do something to address them.
  • Another study in the same issue of JAMA by Trivedi and colleagues explored the question of whether or not general quality is related to racial disparity. They studied Medicare health plans and found that the ones that performed well on various quality measures did not necessarily have less racial disparity. In fact there was no significant correlation. These seem to be separate and complementary measures of performance. The authors recommend that health plans report not only their performance on overall quality, but also their performance on racial/ethnic disparities.

Policy Update

Minority Health Improvement & Health Disparity Elimination Act Introduced into Senate

On September 29th, 2006, the Minority Health Improvement and Health Disparity Elimination Act (S-4024) was introduced into Congress by Senator Bill Frist (R-TN). The bill, co-sponsored by Senators Kennedy (D-MA), Obama (D-IL) and Bingama (D-NM), was designed to address racial and ethnic disparities in health care in the U.S. Some of the major provisions include:

  • Strategies to improve cultural competency and communication for providers.
  • Demonstration projects for access, awareness, and outreach activities by public and private organizations and community-based consortia.

  • Grant programs for health care delivery sites to conduct research to improve the health of racial and ethnic minority and other health disparity populations.

  • Support for public-private partnerships to evaluate and identify best practices in disease management strategies and interventions.

  • Creates an FDA advisory committee on pharmacogenomics and emerging issues, which shall make policy and guidance recommendations on issues related to racial and ethnic minorities.

  • Collection and reporting of data by race and ethnicity, as well as geographic location, socioeconomic position, and health literacy where practicable, while ensuring appropriate privacy and security protection for the data.

  • Grants for health care providers, academics and policy organizations to enhance, improve, and disseminate data to identify and address health and health care disparities.

The bill has currently been referred to the Senate Committee on Health, Education, Labor and Pensions and is expected to be taken up in 2007.


  1. Peterson, L.A. “Racial Differences in Trust: Reaping What We Have Sown.” MedicalCare, 2002, 40 (2), 81-84.
  2. Morto, C.C. “Initiative Looks for Ways to Build Trust.” []. Mar. 11, 2003.
  3. Gamble, V.N. “Under the Shadow of Tuskegee: African Americans and Health Care.” American Journal of Public Health, 1997, 87(11), 1773-1778.
  4. Doescher, M.P., Saver, B.G., Franks, P., Friscella, K. “Racial and Ethnic Disparities in Perceptions of Physician Style and Trust.” Archives of Family Medicine, 2000, 9, 1156-1163.
  5. Thom, D.H., Campbell, B. “Patient-Physician Trust: An Exploratory Study.” The Journal of Family Practice, 1997, 44(2), 169-176.
  6. Race, Ethnicity, and Medical Care: Public Perceptions and Expectations. Kaiser Family Foundation,, accessed November 2004.
  7. Liu JH, Zingmond DS, McGory ML, SooHoo NF, Ettner SL, Brook RH, Ko CY. Disparities in the utilization of high-volume hospitals for complex surgery. JAMA. 2006 Oct 25;296(16):1973-80
  8. Trivedi AN, Zaslavsky AM, Schneider EC, Ayanian JZ. Relationship between quality of care and racial disparities in Medicare health plans. JAMA. 2006 Oct 25;296(16):1998-2004
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