Interpersonal Processes of Care: Conceptual Framework
Persons of lower socioeconomic status (SES) and members of racial and ethnic minority groups experience poorer
health and increased health risk factors. Quality of care is one of many hypothesized mechanisms to explain the
disparities. Interpersonal processes of care is one component of quality, defined as the social-psychological
aspects of the patient-physician interaction, such as communication, friendliness, and sensitivity. Most research
into interpersonal processes evaluates it as a one-dimensional variable.
This conceptual framework specifies interpersonal processes of care as multidimensional and incorporates
perspectives of diverse racial and ethnic and socioeconomic groups. The framework is based on literature about
patient-doctor relationships, concepts and measures of quality of care and satisfaction with interpersonal
processes of care, extensive clinical experience with minority and lower-socioeconomic status populations, and
qualitative studies of the interpersonal experiences of ethnically diverse patients.
History: The framework was initially developed and tested in a sample of patients of a general medicine clinic
(Stewart at el., 1999). It was subsequently refined through qualitative studies of adults from diverse racial/ethnic
groups. We present the initial concepts as well as the refined concepts. Three key domains are defined, each with
subdomains: communication, decision making, and interpersonal style. The initial domains were intentionally broad
to capture the richness of IPC. In attempting to achieve psychometric invariance across several diverse groups, we
lost some of the depth of the domains. Because there is substantial value in the original (1999) framework, we
encourage others to utilize it as a basis for research in interpersonal processes in diverse populations.
Citations:
Stewart AL, Nápoles-Springer A, Pérez-Stable E, Posner SF, Bindman AB, Pinderhughes HL, and Washington AE.
Interpersonal Processes of care in diverse populations. Milbank Q 1999;77: 305-339.
Stewart AL, Nápoles-Springer AL, Gregorich SE and Santoyo J. Interpersonal processes of care: Patient-reported
measures for diverse groups. Health Serv Res, 2007 Jun;42 (3 pt 1):1235-56.
Center for Aging in Diverse Communities, Measurement Core
University of California, San Francisco
http://medicine.ucsf.edu/cadc/cores/measurement/ipcindex.html
Last Updated October 2007
Interpersonal Processes of Care: Conceptual Framework
Original Framework (1999)
Concept/Domain
Definition
COMMUNICATION
Refined Framework (2007)
Concept/Domain
Definition
COMMUNICATION
General clarity
Ability of clinicians to communicate;
clinician uses vocabulary familiar to
patient, speaks clearly and slowly, and
confirms that patients understand.
Hurried
communication
Lack of clarity, defined as ability of
clinicians to communicate, including
speaking slowly and using words that
are not hard to understand. Hurried
and distracted, defined as ignoring
patient, being distracted, and acting
bothered when patients ask several
questions
Elicitation of and
responsiveness to
patient problems,
concerns and
expectations
Clinicians elicit most important
concerns, help patients discuss
concerns, ask about concerns if not
volunteered, listen carefully and pay
attention without being distracted,
indicate they are aware of patient’s
concerns, and take concerns seriously.
Elicited concerns,
responded
Clinicians elicit most important
concerns, listen carefully, and take
concerns seriously.
Explanation of condition,
progress, and prognosis
Information provided to patients (and
their families) about their condition,
changes in condition, and prognosis.
Written information is provided. Test
results are explained in terms of what
they mean for the patient’s condition,
diagnosis, and prognosis.
Explained results,
medications
Information provided to patients
about their test results and results of
physical exam. Information provided
to patients about medications
including what happens if they don’t
take medications and possible side
effects.
Explanation of process of
care
Technical processes of care are
explained (tests, procedures,
treatments, therapies, referrals and
follow-up visits) including what to expect
when receiving them (e.g. discomfort,
possible side effects). For complex
information, clear instructions are
provided.
Explanation of self-care
Information provided to patients (and
their families or caregivers) about
medication dose and schedule, how to
monitor symptoms, when to call the
doctor, when to resume normal activities
Center for Aging in Diverse Communities, Measurement Core
University of California, San Francisco
http://medicine.ucsf.edu/cadc/cores/measurement/ipcindex.html
Last Updated October 2007
Interpersonal Processes of Care: Conceptual Framework
Original Framework (1999)
Concept/Domain
Definition
Refined Framework (2007)
Concept/Domain
Definition
or return to work, and other activities to
restrict.
Empowerment
Patients given a sense that they can
affect their health outcomes; personal
responsibility is encouraged.
DECISION MAKING
DECISION MAKING
Responsiveness to
patient preferences
regarding decisions
If patient desires involvement in decision
making, clinician explains alternative
treatment options, explains how each
might differ in terms of outcomes,
discusses pros and cons of each option,
considers patient preferences, and
arrives at mutually agreeable treatment
strategies.
Consideration of
patient’s desire and
ability to comply with
recommendations
Clinician determines extent to which
patients can and wants to fulfill
expectations of treatment regimen;
takes into account treatment
recommendations; makes modifications
accordingly.
INTERPERSONAL STYLE
Patient-centered
decision making
Clinician asks patients if they would
be able to follow recommendations,
and/or if they would have any
problems doing the recommended
treatments. Patient and clinician
work out a treatment plan together,
and if there are choices, clinician asks
if patient would like to help decide.
INTERPERSONAL STYLE
Friendliness,
courteousness
Clinicians and office staff treat patients
in friendly, courteous manner and make
them feel welcome.
Respectfulness
Clinicians show respect, genuine interest
in patients, pay attention to privacy
when examining patients and when
discussing their condition, and do not
talk down to them.
Compassionate,
respectful
Clinicians provide compassion,
support, and encouragement and
show concern about patients’ feelings
during encounter. Clinicians show
respect and treat patients as equals.
Center for Aging in Diverse Communities, Measurement Core
University of California, San Francisco
http://medicine.ucsf.edu/cadc/cores/measurement/ipcindex.html
Last Updated October 2007
Interpersonal Processes of Care: Conceptual Framework
Original Framework (1999)
Concept/Domain
Definition
Discrimination
Clinicians or office staff do not
discriminate against patients because of
their gender, race/ethnicity, education,
income, language, or sexual orientation.
Clinicians and office staff ensure that
patients not made to feel inferior.
Cultural sensitivity
Clinicians demonstrate willingness to
elicit and incorporate patients’ culturally
based attitudes, values and beliefs about
their health and health care; may
include patients’ expectations of
clinician’s role, preferences for family
involvement in care, preferred
communication style, illness attribution,
and religious beliefs.
Emotional support,
reassurance
Clinicians provide reassurance and
empathy during encounter, try to help
patient feel better, convey information in
a manner that alleviates anxiety and
fear.
Refined Framework (2007)
Concept/Domain
Definition
Disrespectful office staff
Office staff are rude or talk down to
patients; office staff give patients a
hard time or have a negative attitude
toward patients.
Discrimination
Clinicians do not discriminate against
or pay less attention to patients
because of their race/ethnicity.
Clinicians do not make assumptions
about patients’ level of education or
income.
See our framework of culture in the
medical encounter and the following
citation: Nápoles-Springer AM,
Santoyo J, Houston K, Pérez-Stable
EJ, Stewart AL. Patients’ perceptions
of cultural factors affecting the quality
of their medical encounters. Health
Expectations, 2005:8:4-17.
Center for Aging in Diverse Communities, Measurement Core
University of California, San Francisco
http://medicine.ucsf.edu/cadc/cores/measurement/ipcindex.html
Last Updated October 2007