WHAT CAUSES RACIAL DISPARITIES IN HEALTH CARE? A MIXED-METHODS STUDY OF PROVIDERS NEGOTIATING UNCERTAINTY IN ATTRIBUTING BLAME AND RESPONSIBILITY

Purpose:

To understand how primary care providers make attributions about causes of racial health care disparities.

Method: Fifty-three primary care providers completed a survey assessing their perceptions of the causes of racial health care disparities and subsequently participated in a qualitative interview. To prompt providers to discuss disparities, all interviewees read two narratives about providers struggling with issues related to race and then engaged in a semi-structured interview. Interviews were transcribed and a codebook created to capture patient-related, provider-related, health care system-related and social structural (including structural racism) contributors to health care disparities. The focus of the qualitative case study with content analysis  was exploration of how causal attributions differed based on providers’ prior categorization (from survey data) as low or high in external (i.e., beyond patient) attribution of health care disparities.

Result: Survey data demonstrate that providers attributed more responsibility for reducing health care disparities to the health care system (mean=4.5) and providers (4.3) compared to patients (2.9) and that attributions differed based on providers’ beliefs about the causes of disparities, with “high external” providers attributing greater responsibility to the health care system and providers than to patient factors. In-depth qualitative analysis revealed important distinctions in how providers talked about causal attributions and negotiated uncertainty. In particular, providers classified as “high external” demonstrated facility at holding more than one causal story at the same time and navigating ambiguity. For instance, while all providers described patient causal attributions for disparities in care, the “high external” group also endorsed structural factors. Similarly, “low external” providers expressed more certainty in their claims that a particular cause was not race, instead invoking patient behaviors, patient socioeconomic status, language, or health literacy. Less than half of “low external” providers discussed interpersonal or structural racism, while three-quarters of “high external” providers did. All providers discussed access to care as important determinants of racial health care disparities.

Conclusion: This study reveals the importance of qualitative data in understanding providers’   attributions for racial health care disparities, since providers differ not only in their assessment of causes and attributions of responsibility but also in how they talk and reason about these issues. This study provides a foundation for understanding how to engage providers, with varying predisposing beliefs, in efforts to reduce healthcare inequality.