Patient-Provider Communication and Adherence to Cholesterol Management Advice: Findings from a Cross-Sectional Survey

Abstract

High cholesterol is a preventable risk factor for heart disease. This study examines which aspects of patient-provider communication are associated with patient report of increased adherence to cholesterol management advice in a diverse, low-income patient population accessing the health care safety net, using the 2014 Health Center Patient Survey. Patient-provider communication measures included patient report of: how often a provider listened carefully, gave easy-to-understand information, knew important information about the patient's medical history, showed respect, and spent enough time with the patient. Outcome measures were patient report of following provider advice to eat fewer high fat or high cholesterol foods, manage weight, increase physical activity, or take prescribed medicine. In adjusted analyses, when patients perceived their provider always knew their medical history, patients were more likely to report taking prescribed medication (adjusted odds ratio [aOR]: 3.2; 95% confidence interval [CI]: 1.6, 6.6). Knowledge of medical history (aOR: 2.8, 95% CI: 1.4, 5.8), spending enough time (aOR: 2.3, 95% CI: 1.2, 4.4), and providing easily understandable information (aOR: 2.2, 95% CI: 1.0, 4.7) were significantly associated with report of following physical activity advice. Knowledge of medical history (aOR: 2.3, 95% CI: 1.0, 5.2) and providing easily understandable information (aOR: 3.3, 95% CI: 1.4, 7.9) were significantly associated with report of following weight management advice. This study indicates different components of patient-provider communication influence patient adherence to lifestyle modification advice and medication prescription. These results suggest a tailored approach to optimize the impact of patient-provider communication on cholesterol management advice adherence.

Introduction

High total cholesterol, defined as serum levels ≥240 mg/dL, affected approximately 12% of all American adults in 2015–2016 and 17% of those aged 40–59.¹ High cholesterol is a risk factor for heart disease and stroke, which are among the leading causes of death in the United States.¹ Though mean levels of high total cholesterol have declined in recent years,² the Healthy People 2020 target of a mean total blood cholesterol level of 177.9 mg/dL for adults has yet to be reached by any US demographic group.³

To combat the poor outcomes associated with hypercholesterolemia, the National Cholesterol Education Program recommends therapeutic lifestyle changes (diet, weight management, and physical activity) and treatment with medication to manage cholesterol.⁴ However, evidence is mixed on the extent to which patients adhere to recommended lifestyle or medication advice. One study found that of those advised to lower their cholesterol, 80% reported following diet advice, 79% weight advice, 70% exercise advice, and 76% reported taking medication.⁵ However, in a study of older women with hypercholesterolemia, only 20% of study participants reported a dietary intake consistent with National Cholesterol Education Program dietary goals.⁶ Further, reports on medication adherence for lipid-lowering medications tend to fall below 66%.⁷

Many factors influence whether a patient adheres to treatment recommendations, including the cost of medications and dosing frequency, and patient knowledge, beliefs, and experiences related to medications.⁸ Communication between patients and providers also may influence treatment adherence. Among the elements of patient-provider communication relevant to patient adherence are providers' ability to understand and discuss patient concerns, provide relevant information, encourage and have adequate time to answer questions, and show empathy.^8,9

Though studies have found an association between patient-provider communication and patient adherence for a range of chronic diseases, including asthma,¹⁰ diabetes,^11
–13 cancer,¹⁴ and cardiovascular disease,^15,16 many of these studies use different measures of patient-provider communication, making it difficult to determine which elements of patient-provider communication are associated with patient adherence. Further, there is a dearth of studies examining the association of patient-provider communication with adherence to cholesterol management advice. One study found a positive association between patient-provider communication and increased fruit and vegetable intake among adults with hypercholesterolemia when assessing patient-provider communication using a scale that included items such as providers taking the time to listen and provide prevention advice.¹⁶ However, because the patient population was limited to those who underwent coronary angiography, it is not clear whether the results are generalizable to patients who did not undergo a coronary procedure.

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) program administered by the Agency for Healthcare Research and Quality (AHRQ) includes survey questions that assess patient-provider communication quality by measuring patient report of how often providers listen carefully, know important information about the patient's medical history, explain things understandably, show respect, and spend enough time with patients.¹⁷ CAHPS measures have been used to assess the association between patient-provider communication and patient adherence, with studies reporting an association between CAHPS score and patient report of adherence to cardiometabolic and cancer treatments.^13
–15 However, because CAHPS measures are often reported as a scale it is unclear whether certain elements of patient-provider communication are more likely to influence patient adherence to provider treatment advice.

The goal of this study, therefore, was to assess which elements of patient-provider communication are associated with patient adherence to medication and therapeutic lifestyle advice in those with high cholesterol using standardized questions adapted from the CAHPS questionnaire. The research team analyzed survey data from a nationally representative sample of patients who receive care services from health centers funded by the Health Resources and Services Administration (HRSA). HRSA-funded health centers, tasked with providing high-quality, comprehensive care to underserved communities, served nearly 30 million patients in 2019.¹⁸ More than 40% of health center patients reported ever being told they had high levels of cholesterol by a health professional in 2014, compared to 36%-38% of the US adult population during 2013–2015.¹⁹ By examining data from health center patients, the team was able to explore the association of patient-provider communication in a care setting that treats a diverse patient population who have a burden of high cholesterol comparable to the US population.

Methods

Study population

The 2014 Health Center Patient Survey (HCPS) was used to conduct all analyses. The HCPS is a cross-sectional, in-person survey conducted among patients who receive their health care primarily at HRSA-funded health centers.²⁰ The survey employed a 3-stage sampling design to provide a nationally representative sample of health center parent organizations, clinic sites within the parent organization, and patients. Trained interviewers collected data on patient sociodemographic characteristics, health status, health care utilization, and satisfaction with care. Interviews were conducted between October 2014 and April 2015. Approximately 59% of all patients who were screened (and 91% of eligible patients) completed interviews, resulting in a HCPS study population of 7002 patients which represents approximately 22 million health center patients.

The study population for this analysis was restricted to health center patients who had ever been told they had high cholesterol, resulting in a total analytical sample size of 2044 health center patients.

Patient-provider communication variables

To assess patient-provider communication, the HCPS included a series of questions drawn from the CAHPS Clinician and Group Survey measures administered by AHRQ. The HCPS survey asked: in the last 12 months, how often did a patient's doctor or other health professional listen carefully, give easy-to-understand information about health questions, seem to know important information about the patient's medical history, show respect for what the patient had to say, and spend enough time with the patient. In version 2.0 of the CAHPS Clinician and Group survey, all of these survey items were categorized as a measure of how well providers communicate with their patients, though in version 3.0, knowing important information about a patient's medical history was categorized as use of information by providers to coordinate patient care.²¹ For the purpose of this analysis, the 5 survey items are considered indicators of patient-provider communication. Based on exploratory analyses, patient responses were dichotomized into always (for patients who reported Always) or not always (for patients who reported Usually, Sometimes, or Never). A patient response of Always was considered optimal patient-provider communication. Though CAHPS scores are often reported as composite scores to facilitate reporting,²² the goal of this study was to assess which elements of patient-provider communication are associated with patient adherence. As such, this study reports on the association for each survey item.

Outcome of interest

The primary outcome, following cholesterol management advice, was defined as patient report of following provider advice to lower their blood cholesterol through lifestyle changes or medication. Specifically, patients were asked if they were following advice to eat fewer high fat or high cholesterol foods (yes/no), to control or lose weight (yes/no), to increase physical activity or exercise (yes/no), or to take prescribed medicine (yes/no). For each type of advice, analysis was limited to patients who were advised by a doctor or health care provider to eat fewer high fat or high cholesterol foods, to control or lose weight, to increase physical activity or exercise, or to take prescribed medicine.

Covariates

Variables that were identified in the literature as potential confounders included: age; sex; race/ethnicity (Asian, non-Hispanic White, non-Hispanic African American, Hispanic/Latino, American Indian/Alaska Native); education status (less than high school, high school graduate, greater than high school); household income (0–199% of the Federal Poverty Level or 200% or higher than the Federal Poverty Level); preferred language (English only, language other than English only, English and a language other than English); marital status (married/domestic partner, widowed/divorced/separated, never married); urban or rural location of health center; insurance status; health status (excellent/very good/good or fair/poor); diagnosis of diabetes, hypertension, cardiovascular disease, or mental illness; smoking status (current smoker vs. not current smoker); body mass index (obese [≥30.0], overweight [25.0 to <30.0], normal weight or underweight [<25.0]); and whether the patient visited the health center in the past year.

Analytic approach

Chi-square tests of associations and t tests were used to assess the relationships between the patient-provider communication variables, the cholesterol management variables, and the covariates. Multivariate logistic regression was used to analyze the relationships between the patient-provider communication measures and the cholesterol management measures. A P value of <.05 was considered statistically significant. All analyses accounted for the survey design. SAS version 9.4 (SAS Institute Inc., Cary, NC) was used to conduct the analyses. Informed consent was obtained from all participants and institutional review board approval was obtained from RTI International, the organization in charge of data collection.

Results

Of the 2044 HCPS participants who reported ever being told they had high cholesterol, 55% were female, 60% were non-Hispanic White, 20% were Hispanic or Latino, and 17% were non-Hispanic African American. The mean age of the study population was 52 years (Table 1).

Table 1.

Patient Perception of Patient-Provider Communication, Adherence to Cholesterol Management Advice, and Selected Demographic and Health Characteristics Among Those Ever Told They Had High Cholesterol, 2014 Health Center Patient Study

Patient-provider communication
	n	Yes (%)	No (%)
Always Knows Medical History	2035	74.6	25.4
Always Spend Enough Time	2040	79.4	20.6
Always Gives Easy-to-Understand Information	1769	82.0	18.0
Always Shows Respect	2038	89.1	10.9
Always Listens Carefully	2043	79.3	20.7

Adherence to cholesterol management advice†
	N	Yes (%)	No (%)
Eat Fewer High Fat or High Cholesterol Foods	1725	88.6	11.4
Increase Physical Activity or Exercise	1598	82.7	17.3
Control or Lose weight	1390	88.3	11.7
Take Prescribed Medications	1535	89.2	10.8

Selected demographic and health characteristics
	N	%
Age (Mean/SE)	52.2	1.3
Sex
Female	1273	55.4
Male	771	44.6
Race
Asian	130	1.9
Native Hawaiian/PI	33	0.3
NH White	558	59.8
NH African American	459	17.1
Hispanic/Latino	664	19.5
American Indian/AN	185	1.3
Education
Less than High School	928	36.7
High School Equivalent	507	23.3
More than High School	602	40.0
Health Status
Excellent/Very Good/Good	834	43.7
Fair/Poor	1207	56.3
BMI
Obese (BMI ≥30.0	1038	60.3
Overweight (BMI 25.0 < 30.0)	565	27.2
Normal or underweight (BMI <25.0)	369	12.5
Diabetes
Yes	817	43.9
No	1227	56.1
Cardiovascular Disease
Yes	366	19.8
No	1678	80.2

All percentages are weighted to account for the sampling design.

†

Restricted to those who were given cholesterol management advice.

AN, Alaska Native; BMI, body mass index; NH, non-Hispanic; PI, Pacific Islander; SE, standard error.

Eighty-six percent of those reporting high blood cholesterol were given advice by their provider to eat fewer high fat or high cholesterol foods to manage their cholesterol, 78% were advised to increase exercise, 70% were advised to control or lose weight, and 78% were advised to take prescribed medication (data not shown). Of those given cholesterol management advice by their provider, more than 82% reported following the dietary fat or cholesterol advice, following exercise advice, following weight advice, or taking prescribed medications (Table 1).

Study participants generally reported optimal patient-provider communication (Table 1). More than three quarters reported their providers always seemed to know important information about their medical history, their provider always spent enough time with them, or that their providers always listened carefully. More than 80% reported their provider always provided easy-to-understand information about their health questions, or that their provider always showed respect (Table 1). In bivariate analysis, patients who were obese were more likely to report that their providers always seemed to know important information about their medical history, while patients with diabetes were more likely to report their providers always gave them easy to understand information (Table 2).

Table 2.

Patent Perception of Patient-Provider Communication by Selected Characteristics Among Those Ever Told They Had High Cholesterol, 2014 Health Center Patient Survey

	Always knows medical history (n = 2002)		Always spends enough time (n = 2007)		Always gives easy-to-understand information (n = 1740)		Always shows respect (n = 2005)		Always listens carefully (n = 2010)
	Yes	No	Yes	No	Yes	No	Yes	No	Yes	No
	(%)	(%)	(%)	(%)	(%)	(%)	(%)	(%)	(%)	(%)
Age ((Mean)/(SE))	52.1 (1.0)	52.9 (2.7)	52.3 (1.2)	51.8 (2.1)	52.1 (1.1)	51.1 (3.0)	52.0 (1.2)	53.9 (2.6)	52.5 (1.1)	51.2 (2.8)
Sex
Female	51.4	64.9	53.4	63.3	54.9	50.7	53.1	74.2	54.0	60.5
Male	48.6	35.1	46.6	36.7	45.1	49.3	46.9	25.8	46.0	39.5
Race
Asian	1.4	3.4	1.5	3.6	1.0	2.8	1.3	7.1	1.6	3.2
Native Hawaiian/Pacific Islander	0.4	0.2	0.3	0.3	0.3	0.3	0.3	0.3	0.4	0.2
Non-Hispanic White	59.3	60.1	59.7	60.7	60.6	60.1	59.6	62.5	57.2	70.0
Non-Hispanic African American	17.7	15.6	17.5	15.8	17.2	20.5	17.8	12.1	18.6	11.1
Hispanic/Latino	19.9	19.4	19.8	18.1	19.8	14.7	19.9	16.1	21.1	13.5
American Indian/Alaska Native	1.3	1.3	1.2	1.5	1.2	1.5	1.2	2.0	1.1	1.9
Education
Less than High School	39.6	29.0	38.6	29.4	39.7	23.2	38.4	23.7	39.1	27.6
High School Diploma or Equivalent	22.0	28.4	23.3	22.8	21.3	22.6	22.6	28.2	24.1	20.2
More than High School	38.4	42.6	38.0	47.7	39.0	54.2	39.0	48.1	36.8	52.2
Health Status
Excellent/Very Good/Good	44.6	39.4	44.3	41.4	44.7	38.0	43.8	43.5	47.1	30.8
Fair/Poor	55.4	60.6	55.7	58.6	55.3	62.0	56.2	56.5	52.9	69.2
BMI
Obese (BMI ≥30.0)	63.6	48.6	62.5	51.6	63.0	54.5	61.6	49.4	61.6	55.4
Overweight (BMI 25.0 to <30.0)	25.8	32.7	25.3	34.6	25.9	31.1	26.6	31.5	25.8	32.3
Normal or underweight (BMI <25.0)	10.6	18.7	12.2	13.8	11.1	14.4	11.8	19.1	12.6	12.3
Diabetes
Yes	44.4	42.6	44.3	41.9	47.2	32.9	45.0	34.5	44.2	42.7
No	55.6	57.4	55.7	58.1	52.8	67.1	55.0	65.5	55.8	57.3
Cardiovascular Disease
Yes	22.0	14.2	21.7	12.3	22.0	12.7	21.0	10.3	19.9	19.4
No	78.0	85.8	78.3	87.7	78.0	87.3	79.0	89.7	80.1	80.6

All percentages are column percentages and are weighted to account for the sampling design.

BMI, body mass index; SE, standard error.

In the adjusted analysis, the only patient-provider communication variable statistically significantly associated with taking prescribed medication was provider always seemed to know patient medical history (adjusted odds ratio: 3.2; 95% confidence interval: 1.6, 6.6) (Table 3). Three patient-provider communication variables were significantly associated with patient report of following advice to exercise: provider always seemed to know medical history, provider always spent enough time, and provider always gave easy-to-understand information (Table 3). Provider always gave easy-to-understand information was significantly associated with following weight advice, as was the association between following weight advice and provider always seemed to know medical history (Table 3). None of the patient-provider communication variables was associated with following providers' dietary fat or cholesterol advice. Neither provider listened carefully nor provider showed respect were significantly associated with following any provider cholesterol management advice.

Table 3.

Adjusted Odds Ratio for Adherence to Provider Cholesterol Management Advice by Patient Perception of Patient-Provider Communication among Patients Ever Told They Had High Cholesterol

	Eat Fewer High Fat or High Cholesterol Foods	Increase Physical Activity or Exercise	Control or Lose Weight	Take Prescribed Medications
	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)	aOR (95% CI)
Knows Medical History	2.0 (0.9, 4.4)	2.8 (1.4, 5.8)	2.3 (1.0, 5.2)	3.2 (1.6, 6.6)
Spends Enough Time	1.4 (0.7, 2.7)	2.3 (1.2, 4.4)	1.7 (0.7, 4.1)	1.0 (0.4, 2.4)
Easy to Understand Information	1.1 (0.5, 2.6)	2.2 (1.0, 4.7)	3.3 (1.4, 7.9)	1.2 (0.4, 3.7)
Shows Respect	1.3 (0.5, 3.4)	1.3 (0.5, 3.5)	2.3 (0.9, 5.9)	0.7 (0.2, 2.8)
Listens Carefully	0.9 (0.4, 1.9)	0.8 (0.4, 1.6)	1.1 (0.5, 2.2)	0.9 (0.3, 2.7)

Odds ratios compare Always versus Not Always (ie Usually, Sometimes, Never) responses for patient-provider communication; all models were adjusted for the covariates: age, sex, race, education, household income, preferred language, marital status, urban region, insurance status, health status, presence of diabetes, hypertension, cardiovascular disease, mental illness, smoking status, body mass index, and ≥1 health center visit in the prior year.

aOR, adjusted odds ratio; CI, confidence interval.

Discussion

Study analyses found evidence that several elements of patient-provider communication were significantly associated with patient report of following certain types of provider advice to manage high blood cholesterol. Specifically, when patients perceived that their providers always knew their medical history, they were more likely to report taking prescribed medications and following exercise and weight management advice; when patients perceived that their providers always spent enough time with them, they were more likely to report following exercise advice; and when patients perceived that their providers always provided them with easily understandable information, they were more likely to report following exercise and weight management advice.

This study has several strengths. By analyzing patient report of providers always engaging in elements of good communication, the research team was able to measure the impact of consistent optimal communication on patient adherence to cholesterol management advice. Consistency in optimal communication is a goal providers should strive for and study findings suggest that optimal communication, as reported by patients, may have an influence on patient behavior. Further, by examining the CAHPS measures separately, rather than as a score, the team was able to assess which elements of patient-provider communication are associated with each type of cholesterol management advice. This approach provides evidence for which components of patient-provider communication may be most effective in promoting adherence and enable providers to tailor their communication style to meet patient needs. Finally, by analyzing data from health center patients, evidence is provided that optimal patient-provider communication may be an effective tool in supporting adherence to cholesterol management in a low-income, diverse patient population.

To the research team's knowledge, no other studies have examined whether patient perception of provider knowledge of medical history is associated with adherence to cholesterol management advice among those with high cholesterol. One explanation for this finding is that knowing a patient's medical history may lead to more optimal selection of cholesterol medications based on a provider's knowledge of a patient's individual risk for cardiovascular disease and that patient's experience with previous treatments, including lifestyle interventions.⁷ Patients may be more likely to adhere to cholesterol management advice if they feel the advice is tailored to their unique circumstances. Another explanation revolves around links between patient-provider communication, provider empathy, and patient behavior. In a study of a large health system, there was a statistically significant correlation between provider empathy scores and patient perception of provider knowledge of medical history.²³ Other research has shown an association between provider empathy and control of low-density lipoprotein cholesterol in patients with diabetes.²⁴ More research is needed to understand the mechanisms through which patient perception of provider knowledge of medical history might influence patient likelihood of following cholesterol management advice, including the role of provider empathy.

In the present study analyses, when patients reported their providers always provided easy-to-understand information they were more likely to report following exercise and weight management advice, while patient report of providers always spending enough time was associated with report of following exercise advice. A study of patients who underwent coronary angiography found no association between declared increase in physical activity and a patient-provider communication score that included feeling the provider took time to listen and gave advice on prevention measures.¹⁶ The study used a different instrument to assess patient-provider communication than the CAHPS instrument used in the present analyses, though both instruments measure concepts related to providers explaining information about treatment.¹⁶ Further, the present analysis assessed the components of patient-provider communication separately.

Study findings suggest that patient-provider communication may influence behavior change, though the drivers of behavior change are multifaceted. The COM-B (capability, opportunity, motivation and behavior) model describes factors that interact to produce behavior change.²⁵ Capability includes the psychological and physical capacity to engage in the target behavior, motivation includes the automatic and analytic brain processes that influence behavior, and opportunity includes the physical and social factors that enable behavior.²⁵ Though some physical opportunity factors, such as patient access to safe places to exercise, are outside their direct purview, primary care providers can play a critical role in supporting sustained behavioral changes to prevent and manage chronic disease. Patient-provider communication can improve patients' opportunity to adhere to medication regimens²⁶ as well as their capability and motivation to undertake lifestyle changes through implementation of behavior change techniques. Specific techniques employed by primary care providers to achieve patient adherence to lifestyle changes include motivational interviewing, behavioral counseling, and provision of education and advice.²⁷ Providing simple advice has been found to be an effective technique to promote behavior change, and may be as effective as motivational interviewing.²⁷ Present study findings provide evidence that providing understandable information, and thus increasing patient capability, may promote lifestyle changes in patients. Further, a key element of motivational interviewing is the expression of empathy, which in turn may improve patient perception that their providers spend enough time with them.^27,28 More research is needed to understand the relationship between patient perception that providers always spend enough time with them, provider empathy, and motivation to adhere to lifestyle changes among those with high blood cholesterol.

Limitations

This study has some limitations. The research team relied on patient self-report of following provider advice. Patients may have inflated their responses on following provider advice because of social desirability.^29,30 In the data, patients' report of medication adherence (89%) is higher than estimates of adherence to lipid-lowering therapies reported in other studies.^7,31,32 This indicates that the estimates of medication adherence in the present study are likely an overestimate. There also is evidence that self-report of physical activity can be influenced by recall bias³³ and that patient social desirability personality traits may be associated with overestimating physical activity.³⁴ If patients who overestimate their adherence to provider advice also are more likely to report higher or lower patient-provider communication, there may be some bias in the effect estimates.

Another limitation is that study participants were asked if they made lifestyle modifications, but the survey did not assess the extent to which the behavior was modified. Therefore, it is unclear whether the changes made were substantial enough to improve cholesterol levels. Because of the cross-sectional nature of the HCPS, the team was unable to assess whether following advice was associated with subsequent reductions in patients' blood cholesterol. However, any lifestyle modification made with the intention of improving cholesterol management is a positive change.

A further limitation is the study sample was restricted to patients of HRSA-funded health centers, which serve primarily low-income and uninsured patients. Further study is needed to determine whether these results are generalizable to other patient populations.

Conclusion

Despite these limitations, study findings suggest that patient-provider communication may impact patients' likelihood of taking important steps to lower their cholesterol. These findings have a few implications. Providers may need additional support to increase or demonstrate knowledge of patients' medical history during clinical visits. Electronic health records (EHRs) may be a useful platform to support providers, especially if alerts in EHRs also could be used to notify of noncompliance to medication prescriptions,⁷ thus signaling to providers to implement evidence-based strategies to promote patient adherence. EHRs also can be used to promote disease management tools tailored to patients' needs and circumstances.³⁵ Appreciating the role that meaningful use of EHRs could play in optimizing health care delivery, HRSA has made substantial investments to accelerate EHR adoption and use across the Health Center Program by rewarding health centers that leverage their EHR systems to report on clinical quality measures they submit to HRSA through its Quality Improvement Awards (QIA) program.³⁶ Since implementation of the QIA, the proportion of health centers that use their EHR system to report clinical quality measures on all patients has grown more than 350%, from 332 health centers in 2014 to 1185 health centers in 2019.

Study findings suggest that to improve patient adherence to lifestyle modification cholesterol management advice, providers may want to focus on providing easily understandable information and improving the perception of time spent with patients. Techniques that support providing easy-to-understand information include providing advice both verbally and in written form, avoiding medical jargon, and checking for understanding, including use of the “teach-back” method.^8,28 Improving the perception of having spent enough time with patients includes demonstrating empathy and concern during visits, avoiding the appearance of being rushed, and favoring open-ended questions over close-ended questions.²⁸

High blood cholesterol is a preventable risk factor for poor cardiovascular disease outcomes. This study reveals actionable items the health care safety net can address to improve cholesterol management, with the potential for implications across a broader network of primary care. Study findings highlight that particular components of patient-provider communication may be an important aspect of care delivery, and might influence patient behavior, which in turn could improve health outcomes. The effective management of chronic health conditions, such as hypercholesterolemia, relies on the patient and provider dynamic. These findings provide some important considerations for improving that dynamic.

Footnotes

Disclaimer

The views expressed in this publication are solely the opinions of the authors and do not necessarily reflect the official policies of the US Department of Health and Human Services or the Health Resources and Services Administration, nor does mention of the department or agency names imply endorsement by the US Government.

Authors' Contributions

Dr. Hair conceived the study, analyzed and interpreted the data, drafted and revised the manuscript, approved of the version to be published, and is accountable for all aspects of the work. Dr. Sripipatana made substantial contributions to the concept and design of the study, interpreted the data, revised the manuscript, approved of the version to be published, and is accountable for all aspects of the work.

Author Disclosure Statement

The authors declare that there are no conflicts of interest.

Funding Information

The survey described in this article was funded by US Department of Health and Human Services, Health Resources and Services Administration under contract number GS10F0097L\HHSH250201200096G.

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