COUNSELING CENTER

UNIVERSITY OF MARYLAND

COLLEGE PARK, MARYLAND

Ethnically sensitive messengers: An exploration of the racial attitudes of health care workers and organ procurement officers

Alice A. Mitchell and William E. Sedlacek

Research Report #2-95

This study was funded by the

Division of Organ Transplantation,

Health Resources and Services Administration

Health and Human Services Department

COUNSELING CENTER

UNIVERSITY OF MARYLAND

COLLEGE PARK, MARYLAND

Ethnically sensitive messengers: An exploration of the racial attitudes of health care workers and

organ procurement officers

Alice A. Mitchell and William E. Sedlacek

Research Report #2-95

Summary

One of the problems facing transplant centers is the need to obtain organs for an ever-increasing patient population. With improved transplantation results and relaxed waiting list criteria have come an increasing number of candidates with end-stage organ disease. African-American and Hispanic clients comprise a high need, low donor populations.

Attenders at a recent conference of the Association of Organ Procurement Organizations completed the Situational Attitude Scale (SAS) to assess their attitudes in social situations toward target racial groups. Examination of some responses showed that study participants favored the person of color over the neutral person when the person of color was in a subservient role.

Organ procurement employees may feel that they are in a service role when requesting donor organs. The intersection of race and role may be particularly salient for these people. The addition of more people of color to the organ procurement effort will certainly help, but training for White procurement employees must also be included.

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refusal to allow an organ to be used for cadaver transplantation is two to three times higher among Black families than among White families (11, 12).

Several motivations appear to contribute to this lag. Prottas (13) discussed the proportionately small number of Black families seen by organ procurement specialists, mainly due to the lack of referrals from hospital staff concerning possible Black donors. Low donation, he suggested, may also be due to broken families, single parent families or extended families, all of whom have lower organ donating traditions. A major contributor, he concluded, was that White procurement workers were not familiar with Black family cultural attitudes. Three hypotheses may account for the low rate of minority donation: 1) donation may be deterred by cultural elements; 2) donations may be inhibited by socio-political dissension and 3) health professionals may be reluctant to approach minority families (14). Other reasons include 1) lack of transplant awareness, 2) religious myths and superstitions, 3) distrust of the medical community, 4) fear of premature declaration of death after signing an organ donor card, and 5) potential Black donors' preference for assurance of Black receivership (15).

In overcoming Black reluctance to donate organs, Callender (16) discussed six factors were important: 1) an ethnically directed community message, 2) volunteerism, 3) ethnically sensitive and similar messengers, 4) community empowerment, 5) private sector sponsorship and partnerships, and 6) coalitions

3 between transplant and community organizations (17). Thus, ethnic sensitivity appears to play a major role in increasing organ donation.

Latino Needs

As is the case for the African American population, while the rate of Latino organ donation is low, the need for donor organs is high. Studies of family refusal rates (FRR-rates at which family members refuse to provide cadaver organ donation) in three cities showed that Black and Latino FRR rates were higher than those of their White counterparts but these rates varied by city (18). Thus, Latino organ contribution is lower than White organ contribution. Perez (19) suggested that the language barrier and the significance of extended family members may play important roles in FRRs. The language barrier may be further increased by lack of translator familiarly with the cultural nuances of the target language (20) and the nuances of the culture itself, e.g. the need to contact extended as well as proximal family members may slow the response time in organ donation decisions.

Additionally, although information about other Latino groups is sketchy at best, Mexican Americans have a higher incidence of end-stage renal disease than the general population (21), a factor tied to the higher incidence of diabetes in this population. This may be related to a genetic heritage from Native Americans together with diet, as one of several strong environmental factors (22). Antigen differences, however, do not

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appear to be as great between Latino recipients and Anglo donors (23).

In summary, both African Americans and Latinos show a high need for donated organs but relatively low organ donation rates. Racial/ethnic attitudes of hospital personnel, including organ procurement officers, may contribute to these low rates of organ donation.

Racial Attitudes Study

Participants

At the recent national conference of the Association of Organ Procurement Organizations, 51 attenders participated in a study of their attitudes toward Blacks and Hispanics. Study participants were 25% male, 75% female; 4% of the respondents were African American, 8% Asian, 82% White, 4% Latino, and 2% Native American. Most were executive directors (33%), 22% were hospital educators, and 20% were in business and financial affairs offices. Procurement coordinators comprised 14% of the sample; public relations officers, 12%.

Instrument

Participants completed one of three versions of the Situational Attitude Scale (SAS) (24). Each SAS is a 100 item questionnaire which measures attitudes in social situations toward target racial groups. In this administration of the SAS, the three versions measured attitudes toward Hispanics, African Americans and people of an unspecified racial group. For each SAS version, ten social situations were presented. Situations

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are chosen for their potential to elicit prejudice should it be present in the participants. These included (1) meeting a new coworker, (2) seeing a [race specified or unspecified] man make all the decisions on a date, (3) a [race specified or unspecified] woman has a 'loose' reputation, (4) passing a street corner on which five young [race specified or unspecified] me n are loitering, (5) your best friend has just become engaged to a [race specified or unspecified] person, (6) a [race specified or unspecified] family moves next door to you, (7) a new [race specified or unspecified] person joins your social group, (8) a [race specified or unspecified] man appears at your door selling magazines, (9) you are stopped for speeding by a [race specified or unspecified] policeman, and (10) you get on a bus with [race specified or unspecified] people aboard and you are the only person who has to stand. Completed SAS instruments in which the race/ethnicity of the respondent was the same as the race/ethnicity specified were eliminated from further analysis.

For each social situation, participants were asked to indicate their emotional reaction to the situation via ten fivepoint semantic differential Likert items. High scores indicated a positive racial attitude. For example, given the situation "You meet your new coworker who is Black", participants were asked to circle a point between the adjectives (called 'semantic differentials', 25) "bad-good." Other adjective pairings included "unsafe-safe", "not angry/angry" to name just three of the ten semantic differentials accompanying this social

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situation. Sedlacek (26) described the SAS as being designed to elicit both overt and less conscious feelings and to control for socially desirable responses. Two or more forms of the SAS are created, though participants are not aware that other forms exist or that comparisons are being made. Scale reliabilities

(coefficient alpha) for each of the ten scales and for each of the three forms for this administration are reported in Table 1.

Most measures showed adequate reliability with the exception of the 'loiter' item and the 'reputation' item on the Hispanic form. For this reason, further results from all scales except the 'loiter' scenario will be reported below.

Insert Table 1 about here

Results

Participant responses were analyzed using multivariate analysis of variance (MANOVA) to determine whether responses differed according to the race of the reference person (form). Analysis showed that this difference was indeed present (Roys' F = .503, S = 2, M = 3 1/2, N = 18 1/2; p = .02). Subsequent univariate analyses of variance showed that situations 8 and 9 (man selling magazines and policeman stops you for speeding, respectively) contributed to the multivariate difference. Posthoc analysis (Fisher's LSD) showed that in both scenarios, responses on the Black and Hispanic forms were significantly different from the responses on their corresponding neutral forms. Table 2 details the average response by form.

Insert Table 2 about here

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In these two scenarios, examination of the average responses by form showed that study participants favored the person of color over the neutral person when the person of color was in a subservient role. Both the Hispanic reference person in the salesman scenario and the Black reference person in the policeman scenario were servile. In both scenarios, respondents felt least favorable toward the neutral reference person.

These results may parallel the explanation offered by Balenger, Hoffman, and Sedlacek (27) and Sedlacek and Brooks (28) in which Whites were more positive toward Blacks when a servicedelivery role was described. In previous research, this outcome was interpreted as part of the persisting stereotype of Blacks as being well suited for serving Whites.

Discussion

While the SAS items in this research were not specific to organ donation scenarios, some inferences may be advanced based on these results. Results of this analysis showed that organ procurement employees felt significantly more positive toward people of color in service, rather than non-service, roles. The impact of this comfort in status differential may warrant further exploration.

organ procurement employees, while professionals, may feel that they are in a service role when requesting donor organs. The intersection of race and role may be particularly salient for these people. The psychological valence may be different in cross-racial interactions, as noted by Helms (29). White organ

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procurement employees, dealing with White people significant to the donor, may experience little anxiety when placed in this service role. However, when dealing with donors of color, White procurement employees may experience some cognitive dissonance. White employees may be comfortable being served by people of color, but uncomfortable serving people of color. This feeling, coupled with a lack of cross-cultural understanding, may create a communication barrier between procurement and donor communities.

If this situation is true, it can certainly be aided by encouraging more people of color to join the procurement effort in fulltime and volunteer capacities, thereby decreasing crossracial dissonance. However, it would be a serious omission if equal effort were not also expended on educating White procurement employees on attitudes which may be preventing acquisition of the organs so disproportionately needed by communities of color.

Pedersen (30) noted that education is one part of a triumvirate of awareness, knowledge, and skill. He argued that attention to all phases is necessary for true multicultural development. Procurement employees unfamiliar with communities of color may wish not only to increase their knowledge but also to increase their skill in appreciating the concerns of those communities and the role of organ donation in those concerns.

Bowen's (31) differentiation concept may guide organ donation employees in better understanding the genesis of their cross-racial perceptions. This approach assists providers in

reflecting on the messages they received in their families, over generations, about ethnic minority people and how these attitudes may affect their working relationships. These and other reflective and active approaches may assist in securing needed organs for sorely underserved populations.

References

1.Perez LM, Schulman B, Davis F, Olson L, Tellis FA, Matas AJ. Organ donation in three major American cities with large Latino and Black populations. Transplantation 1988; 46: 553-7.

2. Chapa, J. Hispanics and organ donation: Prospects, obstacles and recommendations. The Surgeon General's workshop on Increasing Organ Donation Background Papers; US Department of Health and Human Services Public Health Service, Washington , DC July 8-10, 1991: 163-180.

3. Kasiske BL, Neylan JF, Riggio RR, Danovitch GM, Kahana K, Alexander SR, et al. The effect of race on access and outcome in transplantation. N Enql J Med. 1991; 324:302-7.

4. Callender CO. Organ/tissue donation in African Americans: A national strategem. The Surgeon General's workshop on Increasing Organ Donation Background Papers; US Department of Health and Human Services Public Health Service, Washington , DC July 8-10, 1991: 145-162.

5. Callender CO. Organ/tissue donation in African Americans: A national strategem. The Surgeon General's workshop on Increasing Organ Donation Background Papers; US Department of Health and Human Services Public Health Service, Washington , DC July 8-10, 1991: 145-162.

6. Dunson GM, Hurley CK, Hartzman RT, and Johnson AH. Unique HLA-D region heterogeneity in American Blacks. Transplan Proc. 1987;1987-1.

7. Kasiske BL, Neylan JF, Riggio RR, Danovitch GM, Kahana K, Alexander SR, et al. The effect of race on access and outcome in transplantation. N Engl J Med. 1991; 324;302-7.

8. Dunson GM, Hurley CK, Hartzman RT, and Johnson AH. Unique HLA-D region heterogeneity in American Blacks. Transplan Proc. 1987;19:870-1.

9. Johnson AH, Dunston GM, Hartzman RT, and Hurley CK. Polymorphism of the HLA-D region in American Blacks. In: Aizawa A, editors. Proceedings of the 3rd Asia-Oceania Histocompatibility Workshop Conference; Sapporo University Press, Sapporo, Japan 1986:548-51.

10. Salvatierra 0 Jr. Demographic and transplantation trends among minority groups. Transplant Proc. 1989;21:3916-7.

11. Perez LM, Schulman B, Davis F, Olson L, Tellis FA, Matas AJ. Organ donation in three major American cities with large Latino and Black populations. Transplantation 1988; 46: 553-7.

12. Greenstein SM, Schechner R, Senitzer D, Louis P, Veith FJ, Tellis VA. Does kidney distribution based upon HLA matching discriminate against blacks? Transplant Proc. 1989;21:3874-5.

13. Prottas JM. Encouraging altruism: public attitudes and the marketing of organ donation. Milbank Mem Fund 0f Health Soc. 1983; 61:278.

14. MAXIMUS. Evaluation of methods used by states to expand the number of organ and tissue donors. Executive Summary (Report to HRSA). 1988.

15. Callender C0, Bayton JA, Yeager CL, and Clark JC. Attitudes among Blacks toward donating kidneys for transplantation: A pilot project. J Natl Med Assoc. 1982;74:807-9.

16. Callender CO. Organ/tissue donation in African Americans: A national strategem. The Surgeon General's workshop on Increasing Organ Donation Background Papers; US Department of Health and Human Services Public Health Service, Washington , DC July 8-10, 1991: 145-162.

17. Callender CO. Organ/tissue donation in African Americans: A national strategem. The Surgeon General's workshop on Increasing Organ Donation Background Papers; US Department of Health and Human Services Public Health Service, Washington , DC July 8-10, 1991: 145-162.

18. Perez LM, Schulman B, Davis F, Olson L, Tellis FA, Matas AJ. Organ donation in three major American cities with large Latino and Black populations. Transplantation 1988; 46: 553-7.

19. Perez LM, Schulman B, Davis F, Olson L, Tellis FA, Matas AJ. Organ donation in three major American cities with large Latino and Black populations. Transplantation 1988; 46: 553-7.

20. Brooks TR. Pitfalls in communication with Hispanic and African-American patients: Do translators help or harm? J Natl Med Assoc. 1992;84:941-7.

21. Chapa, J. Hispanics and organ donation: Prospects, obstacles and recommendations. The Surgeon General's workshop on Increasing Organ Donation Background Papers; US Department of Health and Human Services Public Health Service, Washington , DC July 8-10, 1991: 163-180.

22. Diehl AK, Stern MP. special health problems of Mexican

Americans. Avd Intern Med. 1989;34:73-96.

23. Chapa, J. Hispanics and organ donation: Prospects, obstacles and recommendations. The Surgeon General's workshop on Increasing Organ Donation Background Papers; US Department of Health and Human Services Public Health Service, Washington , DC July 8-10, 1991: 163-180.

24. Sedlacek, WE, Brooks, GC Jr. Measuring racial attitudes in a situational context. Psychol. Rep- 1970;27:971-980. 25. Osgood C, Suci G, and Tannenbaum P. The measurement of meaning. Urbana: University of Illinois Press, 1957.

26. Sedlacek, WS. An empirical method of determining nontradiational group status. Measure Eval in Counsel and Devel. in press.

27. Balenger, VJ, Hoffman, MA, Sedlacek, WE. Racial attitudes among incoming White students: A study of 10-year trends. J Coll Stud Dev. 1992;33:245-252.

28. Sedlacek, WE, Brooks, GC Jr. Measuring racial attitudes in a situational context. Psychol Rep. 1970;27:971-980.

29. Helms, JE. Toward a theoretical explanation of the effects of race on counseling: A Black and White model. Couns Psychol. 1984;12:153-165.

30. Pedersen, PP. A handbook for developing multicultural awareness. Alexandria, VA: American Association for Counseling and Development, 1988. 31. Bowen, M. Family practice in clinical practice. New York: Jason Aronson.

Table 1: Scale (situation) reliabilities by form
	Form
Situation	All Forms	Neutral	Black	Hispanic
Complete SAS	0.93	0.89	0.95	0.95
Coworker	0.69	0.72	0.67	0.75
Date	0.91	0.9	0.95	0.68
Reputation	0.45	0.68	0.43	-0.66
Loiter	-0.02	0.13	0.11	0.13
Engaged	0.88	0.85	0.89	0.86
Neighbor	0.94	0.93	0.93	0.96
Social Group	0.86	0.76	0.88	0.91
Salesman	0.78	0.82	0.85	0.89
Policeman	0.82	0.74	0.7	0.83
Bus	0.88	0.89	0.88	0.88

Table 2: Means and Standard Deviations of responses by form (Neutral, Black, Hispanic)
	Form
Situation	Neutral		Black		Hispanic
Coworker	40.53	4.58	41.5	4.91	39.69	5.61
Date	24.58	7.4	30.75	9.55	27.75	4.37
Reputation	31.79	4.38	31.56	3.43	31	3.06
Loiter	28.32	2.52	29.31	2.6	28.31	2.89
Engaged	41.84	5.35	38.56	7.55	37.94	5.84
Neighbor	38.21	6.97	40.13	8.02	36.31	9.05
Social Group	39.58	3.92	41.06	5.86	38.31	6.64
Salesman	19.84	3.32	25.69	6.62	25.81	5.08
Policeman	29.26	6.05	37.62	5.03	35.44	6.03
Bus	33.37	8.06	35.5	7.53	32.81	7.82