HUD-Assisted Adults' Perceptions of Cultural Competency Among Healthcare Providers

Katina Norwood (Social Science Analyst), Jacquie Bachand (Social Science Analyst), and Veronica Garrison (Social Science Analyst)

Introduction

On January 20, 2021, President Biden signed Executive Order 14901: Further Advancing Racial Equity and Support for Underserved Communities Through the Federal Government, which tasked the federal government with delivering more equitable resources and benefits to the public, including underserved communities.

In response, HUD established two overarching priorities into its Fiscal Year 2022–2026 Strategic Plan: increase equity across all HUD programs, and improve the customer experience for those seeking and receiving HUD services. HUD's Office of Policy Development and Research supports these priorities by researching various aspects of household well-being that affect housing outcomes, such as access to and receipt of equitable healthcare services.

This article explores the healthcare experiences of HUD-assisted adults by examining their self-reported perceptions of their healthcare providers' cultural competency and provision of patient-centered care. To do so, we draw on data from the National Health Interview Survey (NHIS), the nation's largest population health survey, that have been linked with HUD administrative data on public and assisted housing programs.

Highlights and Key Findings

• Approximately half (47.7%) of HUD-assisted adults in the sampleⁱ prioritized having healthcare providers who understand or share their cultural background, and nearly two-thirds (62.6%) reported having access to culturally concordant or competent healthcare providers.

• Among HUD-assisted adults, a higher percentage of those who identified with a racial and/or ethnic minority group placed importance on having culturally competent healthcare providers than did white, non-Hispanic respondents.

• Most HUD-assisted adults (92.6%) reported that their healthcare providers often treated them respectfully, and slightly more than half (60.2%) reported that providers consistently asked them about their care opinions or beliefs.

• Most HUD-assisted adults (88%) reported that healthcare providers gave them information that was easy to understand.

Background

Our examination leveraged responses to a novel set of supplementary variables included in the 2017 NHIS that focused on cultural competency.ⁱⁱ Through an ongoing relationship with the Centers for Disease Control and Prevention's National Center for Health Statistics (NCHS), NHIS data and HUD administrative data are regularly linked, allowing researchers to examine health characteristics among HUD-assisted adults at the time of their health interview.

Although relatively new and limited to 1 year of data, the NHIS 2017 cultural competency variables already have been examined in published health research. Previous research reveals a mismatch between patients' preference for a healthcare professional with a shared cultural background and being connected with a healthcare professional who meets this criterion. Specifically, several studies show that patients who prioritize having access to healthcare professionals who share their cultural backgrounds are less likely to be matched with health professionals who share their background. These studies also found that, compared with white, non-Hispanic patients, patients who identify with a racial and/or ethnic minority group more strongly favor having healthcare professionals who share their racial and ethnic identities, but they are less likely to be matched with healthcare professionals who share these identities. This finding is particularly important for members of the HUD-assisted population, most of whom identify with a racial or ethnic minority group. In addition, previous research indicates that access to and receipt of culturally competent care is associated with improved health behaviors.

The complementary relationship between housing security and positive health outcomes is well documented. Understanding HUD-assisted households' healthcare experiences may help inform more targeted and effective housing services to support household success. Linking the 2017 NHIS responses with HUD administrative data illustrates these experiences and supports HUD's commitment to better understanding the unique needs of HUD-assisted households.

Methods

NCHS has conducted the NHIS, an annual cross-sectional survey, for nearly seven decades. Researchers consider the NHIS to be the nation's primary source of health information on U.S. households, collecting data on a representative sample of approximately 35,000 households each year.

In 2011, NCHS and HUD partnered to link NHIS data with HUD administrative data, allowing HUD to identify health information on assisted households. HUD has several programs that provide recipients — primarily extremely low-income households — a monthly subsidy to make housing affordable. This data linkage effort includes three of the agency's largest programs —the Housing Choice Voucher, public housing, and multifamily programs — and spans two decades (1999 to 2019).

The NHIS asks a series of core health questions alongside rotating supplemental questions. In 2017, the Office of Minority Health, part of the Office of the Assistant Secretary for Health at the U.S. Department of Health and Human Services, sponsored a set of questions centered on patients' perception of their care provider's cultural competence. These questions focused on whether the patient feels respected, informed, and involved in their care.ⁱⁱⁱ

Presented analyses used a sample of HUD-assisted adults who lived in HUD-assisted housing at the time of the 2017 NHIS survey. These HUD-assisted adults responded to a subset of questions centered on patients' perception of their care provider's cultural competence. The final study sample consisted of 882 adults aged 18 or older who received HUD assistance at the time of their 2017 NHIS interview.

Key Findings

Finding 1: Approximately half (47.7%) of HUD-assisted adults prioritize having healthcare providers who understand or share their culture, and nearly two-thirds (62.6%) reported having access to culturally concordant and/or competent providers.

Healthcare providers who demonstrate cultural concordance with (or cultural competency toward) their patients are linked to positive health outcomes. Our findings indicate approximately 47.7 percent of HUD-assisted adults place great importance on having healthcare providers who understand or share their culture (figure 1). Despite cultural concordance being a lower priority for nearly half of HUD-assisted adults, nearly two-thirds (62.6%) of these respondents reported having access to healthcare providers who share a common culture (figure 2). This finding suggests that many HUD-assisted adults can connect with their preferred providers, which may positively influence their health outcomes.

Figure 1

Source: 2017 National Health Interview Survey linked with HUD administrative data.

Figure 2

Source: 2017 National Health Interview Survey linked with HUD administrative data.

Finding 2: When compared with non-Hispanic white, HUD-assisted adults, a higher percentage of HUD-assisted adults who identify with a racial and/or ethnic minority group consider access to culturally competent health providers important.

The percentage of HUD-assisted adults who prioritized having culturally concordant healthcare providers was greater among those who identify with a racial and/or ethnic minority group than among non-Hispanic white, HUD-assisted adults. Despite this finding, we observed that HUD-assisted adults who identify with a racial and/or ethnic minority group reported a lower rate of accessing culturally concordant providers (figure 3). For example, among HUD-assisted respondents, only 36.4 percent of non-Hispanic white adults expressed that having healthcare providers understand or share their culture was important to them compared with 61.3 percent of Hispanic adults, 56.5 percent of non-Hispanic Black adults, and 78.1 percent of adults identifying as another race or ethnicity. However, 67.3 percent of non-Hispanic white adults reported being able to see culturally concordant or competent providers compared with only 62.3 percent of Hispanic adults, 60.1 percent of non-Hispanic Black adults, and 64.5 percent of adults identifying as another race or ethnicity. This finding aligns with research documenting the disparity between patient preference and patient experience among patients who identify with a racial and/or ethnic minority group.

Figure 3

Source: 2017 National Health Interview Survey linked with HUD administrative data.

Finding 3: Most HUD-assisted adults (92.6%) reported that they often are treated with respect by healthcare providers, but only slightly more than half (60.2%) reported that they are consistently asked about their care opinions or beliefs by providers.

We found that most HUD-assisted adults (92.6%) believe that their healthcare providers treat them with respect (figure 4), however, fewer of them (60.2%) indicate that their providers ask them about their care opinions or beliefs (figure 5).^iv This trend is consistent across the three HUD program categories examined (figure 6). These findings suggest that room for improvement in the patient-provider relationship exists. Research suggests that respectful interactions indicate higher levels of information exchange between providers and patients, which could help more fully inform HUD-assisted adults about their conditions and treatment. However, if providers are not actively including HUD-assisted adults in their treatment plans, these patients may be less likely to adopt their providers' health recommendations and consequently may experience worse health outcomes. Because patient-centered communication is associated with increased patient trust, satisfaction, and compliance with care recommendations, providers may try to improve the patient-provider relationship by engaging HUD-assisted adults in healthcare decisions.

Figure 4

Source: 2017 National Health Interview Survey linked with HUD administrative data.

Figure 5

Source: 2017 National Health Interview Survey linked with HUD administrative data.

Figure 6

Source: 2017 National Health Interview Survey linked with HUD administrative data.

Finding 4: HUD-assisted adults reported that healthcare providers often provide information that is easy to understand.

Effective communication influences patient engagement and is associated with positive patient outcomes, whereas ineffective communication is associated with negative patient health outcomes. In an encouraging finding, most HUD-assisted adults (88%) reported that the health information their providers share is easy to understand (figure 7).

Language concordance also is associated with positive patient health outcomes. Although most HUD-assisted adults (88.9%) completed the NHIS interview in English, more than 10 percent of adults completed the interview in a different language (7.5% in Spanish, 3.6% in another language). This finding indicates that language concordance is critical to a sizable portion of HUD-assisted households. HUD may consider the importance of language concordance in current and future programming.

Figure 7

Source: 2017 National Health Interview Survey linked with HUD administrative data.

Discussion

HUD-assisted adults report overall positive perceptions of their healthcare providers' cultural competency and provision of patient-centered care. Although presenting the 2017 NHIS linked with HUD administrative data is an important first step toward understanding the healthcare experiences of HUD-assisted adults, more research is needed. Specifically, more current research investigating HUD-assisted adults' perceptions of their healthcare providers is needed.

Future research can also examine how access to and receipt of equitable health care impacts HUD-assisted adults' housing outcomes. For example, researchers might consider the impact Federally Qualified Health Centers — federally funded healthcare organizations that often are in communities where HUD-assisted households reside — have on HUD-assisted adults.

Investigating the health and housing relationship aligns with HUD's Fiscal Year 2022–2026 Strategic Plan goal to focus on fortifying support for underserved communities and vulnerable populations. By understanding HUD-assisted households' health outcomes, HUD can better tailor programming to strengthen general household stability and well-being.

Table 1.
To view a table of summary statistics detailing respondent demographic information and responses to the cultural supplemental questions, please click here.

Table 2. 
To view a cross tabulation comparing respondent demographic information with responses to the cultural competency supplemental questions, please click here.

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ⁱ Our results apply to the HUD-assisted adults in this sample. This article refers to these sampled adults as "HUD-assisted adults."

ⁱⁱ These supplementary variables were sponsored by the Office of Minority Health within the U.S. Department of Health and Human Services' Office of the Assistant Secretary for Health. They are unique to the NHIS 2017 data collection.

ⁱⁱⁱ Exact questions can be located on the 2017 NHIS Sample Adult file, Question IDs: AAU.610_00.010-AAU.610_00.050. 

^iv Our findings align with a study conducted by Blewett, Hardeman, Hest, and Winkelman, who examined 2017 NHIS data using a sample of 78,543 respondents in which 22,864 respondents were asked the Office of Minority Health supplemental questions. They found that 58.5 percent of respondents reported that healthcare professionals asked their opinions or beliefs about care always or most of the time. Lynn A. Blewett, Rachel R. Hardeman, Robert Hest, and Tyler N.A. Winkelman. 2019. "Patient perspectives on the cultural competence of US health care professionals," JAMA Network Open 2:11, e1916105.