Multi-group Structural Equation Modeling Approach Research Articles

Racial differences in the effect of verbal and nonverbal memory on concrete planning for future care needs among older adults: a multi-group structural equation modeling approach

ABSTRACT Concrete planning for future care needs may positively impact older adults’ subsequent mental health and quality of life. However, the cognitive factors that facilitate concrete planning among Black and White older adults are still poorly understood. We investigated whether there are significant differences between Black (n = 159) and White (n = 262) older adults in concrete planning and explored racial differences in the relationship between verbal and nonverbal episodic memory and concrete planning. Results revealed that Blacks showed lower engagement in concrete planning and lower scores than Whites on each verbal and nonverbal memory task. For Blacks, but not Whites, verbal memory and nonverbal memory performance predicted concrete planning with higher nonverbal memory relating to less concrete planning and higher verbal memory associated with more concrete planning. Our findings suggest racial differences exist in how episodic verbal and nonverbal memory affect concrete planning, a crucial factor for older adults’ preparation for future care.

The mediating effect of feedback-seeking behavior on the relationship between ideal L2 writing self and story continuation writing performance: A multigroup structural equation modeling approach

The existing literature on the “the motivation → behavior → outcome chain” has implied that ideal L2 writing self should be equipped with appropriate behavioral strategies to facilitate writing achievement. Feedback-seeking behavior (FSB) includes both feedback monitoring and feedback inquiry and offers a novel perspective. Using a sample of 589 Chinese high school students with low, mid, high levels of writing proficiency, this study explores the mediating role of FSB in the relationship between ideal L2 writing self and story continuation writing performance. Structural equation modeling (SEM) results showed no significant mediating effect in the full sample model. However, such an effect varied across the different levels of L2 writing competence: (1) for the low-achieving students, the indirect path from ideal L2 writing self to writing performance via FSB was not evident; (2) for the mid-achieving students, feedback monitoring positively mediated the relationship between ideal L2 writing self and writing performance, whereas feedback inquiry had a negative mediation effect on this relationship; (3) for the high-achieving students, feedback monitoring had a significantly negative mediation effect, while feedback inquiry had a marginally positive mediation effect. The implications of the findings are discussed.

Consumers’ Intention to Purchase Functional Non-Dairy Milk and Gender-Based Market Segmentation

The increasing awareness of the benefits of functional non-dairy milk has been growing significantly due to the increasing recognition of the benefits of functional foods. Functional non-dairy milk provides a valuable alternative for lactose-intolerant people with other dietary restrictions preventing them from consuming dairy milk. However, some evidence suggests that not all consumers benefit equally from food. Previous research indicated that women more often purchase foods that are perceived to be healthy, while men are more likely to purchase foods that are perceived to be hedonistic. Thus, this study aimed to examine the significant relationships among factors influencing functional non-dairy milk purchase intention based on the theory of planned behavior (TPB) and to identify behavioral differences between men and women. We conducted a quantitative study using structured questionnaires and with 413 valid respondents that consume functional non-dairy milk in six regions of Thailand. Further, we used a multi-group structural equation modeling approach to explore and compare consumers’ intentions across genders. The results showed that trust and health consciousness positively influence an individual’s perceived behavioral control and then directly affect their attitude and purchase intention of functional non-dairy milk products. Additionally, the multi-group analysis proposed that men and women consumers significantly differ in their requirements for enjoyable experiences while consuming functional non-dairy milk. More specifically, hedonic eating value has a greater impact on men’s attitudes than women’s attitudes. This study deepens our understanding of the functional non-dairy milk industry in Thailand in terms of market segments based on gender.

Understanding Consumer Buying Intention of E-Commerce Airfares Based on Multivariate Demographic Segmentation: A Multigroup Structural Equation Modeling Approach

The internet offers enormous development opportunities for airline firms and a lot of information for consumers to pick the finest available options. This research aims to study the consumer buying intention of e-commerce airfares in an emerging economy based on the technology acceptance model. This article employed a sample of 3064 respondents at six airports in Thailand. It used cluster analysis (a multivariate analysis approach) to determine two main customer segments and then used a structural equation modeling (SEM) technique utilizing demographic segmentation as a moderator to explain the behaviors of those two segments. The findings demonstrated two customer segments: (1) the older with high and middle-income segment, and (2) the young with low-income segment. The empirical results revealed that price sensitivity and perceived ease of use substantially impacted behavioral intention to use e-commerce airfares in both segments. The users from segment (1) are more likely to look for the fun experience and entertainment value of using e-commerce airfares than those from segment (2). However, perceived usefulness is unlikely to be a vital factor in consumers’ purchasing decisions about using e-commerce airfares. It is recommended that airline companies and online travel agencies should consider perceived ease of use, price sensitivity, and hedonic motivation when implementing e-commerce airline websites for selling tickets.

Influence of Internal and External Controlling Teaching Behaviors on Students’ Motivational Outcomes in Physical Education: Is There a Gender Difference?

Purpose: Grounded in self-determination theory, this study examined gender latent mean differences in students’ perceptions of externally and internally controlling teaching behaviors, basic psychological need frustration, controlled motivation, amotivation, and oppositional defiance in the physical education context. Moreover, it analyzed the differentiated role that internal and external controlling behaviors play on these self-determination theory-related variables among girls and boys. Method: A sample of 1,118 students (Mage = 14.11 ± 1.50; 50.9% girls) participated in this research. A multigroup structural equation modeling approach was used to respond to the research questions. Results: Analyses revealed that girls reported more maladaptive outcomes in most self-determination theory-related variables than boys. Although externally and internally controlling behaviors of physical education teachers were positively related to maladaptive outcomes, the behaviors correlate differently between boys and girls. Conclusion: Findings highlight the importance of reducing externally controlling behaviors in boys and internally controlling behaviors in both genders, but particularly in girls.

Social Integration as Mediator and Age as Moderator in Social Capital Affecting Mental Health of Internal Migrant Workers: A Multi-Group Structural Equation Modeling Approach.

The rise of migrant workers has been a unique social phenomenon as China goes through industrialization, urbanization, and modernization. They are a special social group formed during the economic and social transition of the country. Migration of rural labor has pushed China on its new path toward industrialization and urbanization. Because of the urban-rural dual system of the country, however, it is difficult for migrant workers to be fully integrated into host cities, making them susceptible to negative emotions and mental health issues. Therefore, their mental health is an issue of great volume in the domains of social undertakings, people's livelihood, and public health. However, existing studies have paid limited attention to the psychological profile of migrant workers and even less to the interplays among their social capital, social integration, and mental health. Targeting China's internal migrant workers, this article tapped the interactions among their social integration, social capital, and mental health with a sample of the cross-sectional data from the China Labor Dynamics Survey (CLDS) in 2018. Multi-group structural equation modeling (SEM) was employed to test the moderating action of age by analyzing whether the mediation model differed significantly in the paths among young, middle-aged, and older migrant workers. The SEM based on bootstrapping suggested that, after controlling for the influence of gender, education, marital status, personal annual income, employer type, and self-rated health, migrant workers' social capital positively affect their mental health in a significant way, with social integration playing a mediating role. In terms of age difference, middle-aged migrant workers were more subject to the aforementioned mechanism than young ones, and young migrant workers were more affected by the mechanism than older ones. This study revealed different psycho-social interplays among social capital, social integration, and mental health across young, middle-aged, and elderly migrant workers. The findings could serve as an important theoretical reference and as practical guidance for improving policies concerning migrant workers' mental health and social benefits in the context of economic transition.

Exploratory multigroup structural equation modeling approach to analyzing H. pylori infection, serological pepsinogen levels, and life style factors in an elderly population in Costa Rica.

The aim of this work is to describe and analyze the association of PGI/PGII ratio (indicator of gastric atrophy) with H. pylori-CagA and life style factors such as caloric intake, obesity, and harmful habits amongst H. pylori-positive elderly people infected in Costa Rica using an exploratory multigroup structural equations model (SEM). Using a sample of 1748 H. pylori-positive elderly people from CRELES first wave study, a SEM was employed analyze if the relationships between PGI/PGII ratio with levels of H. pylori-CagA, caloric intake, obesity, and harmful habits, differs by sex, age and risk areas subgroups. The proposed SEMs exhibited a good fit in males (RMSEA = 0.039), females (RMSEA = 0.000), low-risk area (RMSEA = 0.038), middle-risk area (RMSEA = 0.042), individuals under 80 years (RMSEA = 0.038) and individuals aged 80 and over (RMSEA = 0.042), while an acceptable fit was observed for the high-risk area (RMSEA = 0.061). Fitted SEMs showed that CagA predicted PG-ratio as expected, with effects increasing with the risk area, but similar between sex and age groups. All indicators measuring obesity (BMI, arms, and waist) showed significant standardized coefficients, with similar effects between sex, age and risk area groups. No other significant effects or differences between groups were identified. We propose a good-fitted SEM model for the possible relationships between CagA and PG ratio and the geographical risk area level for elderly people. No differences were observed on measured parameters between male and female population, or between under 80 years and older individuals.

Assessing Determinants of Online Medical Services Adoption Willingness of General Hospital Physicians Using the Information-Motivation-Behavioral Skills Model: A Multi-Group Structural Equation Modeling Approach.

PurposePhysician adoption of online medical services (OMS) has been hastened by the COVID-19 pandemic, but their adoption willingness still requires to be improved. This study aims to construct a physician’s OMS adoption willingness model based on the information-motivation-behavioral skill (IMB) theory, explore the determinants affecting adoption willingness and its influencing pathways, and evaluate the moderating effects of OMS use experience on willingness through multi-group analysis.Participants and MethodsA cross-sectional survey was conducted among physicians in three public hospitals of Jiangsu province, China, from June to July 2020, using a multi-stage sampling method. Structural equation modeling was applied to analyze the valid data from 531 respondents.ResultsPhysicians’ willingness to adopt OMS was at a moderate level, with an average score of 14.27±3.34 (range: 4–20). The behavior model for physician’s OMS adoption willingness fitted well. Information (In), motivation (Mo), and behavioral skill (BS) explained 69% of the variance in adoption willingness (AW). Information could only exert completely indirect effect on willingness via behavioral skills (b = 0.202, 95% CI[0.122, 0.314]); motivation could both generate direct effect (β=0.368, p < 0.001) and partial indirect effect on willingness via behavioral skills (b = 0.160, 95% CI[0.092, 0.248]); and behavioral skills had a positive effect on willingness (β=0.424, p < 0.001). Furthermore, OMS use experience showed a significant moderating effect on the Mo → AW pathway, with inexperienced physicians’ willingness being significantly stronger influenced by motivation compared to experienced ones.ConclusionFindings from this study revealed the role of IMB model in interpreting and predicting physicians’ willingness to adopt OMS and the moderating effect of uptake experience, providing practitioners with a theoretical foundation and intervention framework for supporting OMS development efforts.

Exploratory multigroup structural equation modeling approach to analyzing H. pylori infection, serological pepsinogen levels, and life style factors in an elderly population in Costa Rica.

Exploratory multigroup structural equation modeling approach to analyzing H. pylori infection, serological pepsinogen levels, and life style factors in an elderly population in Costa Rica.

Mediator of school belongingness and moderator of migration status in the relationship between peer victimization and depression among Chinese children: A multi-group structural equation modeling approach

Peer victimization is a widespread threat to children's mental health. However, existing literature has yet to thoroughly investigate the mediators and moderators underlying the link between peer victimization and depression of Chinese children. Using a sample of school-aged children recruited through a multi-stage cluster random sampling in Southwest China (N = 1322), this study examined the mediating role of school belongingness between overt/relational victimization and children's depressive symptoms. In order to test the moderator of migration status, multi-group structural equation modeling (SEM) was adopted to investigate whether the paths in the mediation model were significantly different across migrant and non-migrant groups. Results indicated that overt and relational victimization had a direct impact on depression. School belongingness mediated the link between overt victimization and depression, but not the link between relational victimization and depression. Furthermore, migration status moderated the direct associations between peer victimization and depression. Specifically, the effect of overt victimization on depression was significant for migrant children but not for local children. By contrast, the effect of relational victimization on depression was significant for local children but not for migrant children. The contributions and implications of this study were discussed.

The Impact of Racial Microaggressions Across Educational Attainment for African Americans

ABSTRACT While separate bodies of research have emerged regarding racial microaggressions in postsecondary settings and the relationship between race-related stressors and health outcomes for African Americans, there is a dearth of empirical investigations that test the effects of “general happiness,” “job satisfaction,” and race-related stress based on the educational attainment of African Americans. This study examines the experiences of 3,320 African Americans who participated in the National Survey of American Life (NSAL) conducted by the Program for Research on Black Americans at the University of Michigan. Using a multigroup structural equation modeling approach, findings suggest that experience with more racial microaggressions tends to lead to less general happiness. Furthermore, greater racial microaggressions lead to less job satisfaction regardless of educational attainment. Findings demonstrate that racial microaggressions are entrenched in many parts of society that impact the health and education of African Americans. Authors provide suggestions for addressing racial microaggressions and disrupting whiteness.

Resources and Influences: Parents in Leadership Positions in Low-/Mid-SES and High-SES Schools in Israel

Purpose: This study focused on parents’ involvement in their children’s schools through participation in collective leadership roles. Based on Bourdieu’s approach the current analysis examined the link between parents’ types of resources, types of involvement in schools, and their influences over different school domains while comparing parents from two socioeconomic status (SES) levels (low/mid and high). Research Design: Participants comprised 624 parents from 21 randomly selected elementary schools, of which 10 were of low-/mid-SES and 11 high-SES schools. Data were collected by a questionnaire and analyzed based on multivariate analysis of variance and multi-group structural equation modeling approach. Findings: It was found that for holding leadership roles in schools, parents activate diverse education-related resources. Once gaining a formal leadership role parents may feel a legitimate right to influence schools, mainly on issues related to school management domains such as fundraising. Although, some differences occurred between high-SES and low-/mid-SES schools, there was a similarity regarding parents’ leadership roles that may benefit schools by bridging between the schools and their environment. Conclusions: As schools become more heterarchical, parent leadership may be able to play an increasingly significant role in facilitating the school principal’s work and fostering school improvement. Accordingly, school principals need to support and encourage parent leadership, particularly in low-SES schools. For that purpose, educators must be more attentive, accepting and value the resources of parents of low-SES schools.

Does gender really matter? A structural equation model to explain risky and positive cycling behaviors

IntroductionWhile the use of bicycles as mean of transport is growing worldwide, the increasing rates of traffic crashes involving cyclists have turned into a relevant scientific, public health, and road safety concern. According to several studies, and despite the fact that some countries are taking part in preventive actions, the data indicate that the problem of cycling injuries implies high costs for the community welfare, for the economy, and for healthcare systems, thus proving a clear need for solutions. In this regard, and considering the available empirical evidence, risky and positive riding behaviors have gained significant weight in terms of explaining, intervening in, and preventing traffic crashes of cyclists, and some evidence suggests that gender may influence the road behavior of users. ObjectiveThe objective of this study was to examine the effect of gender on cyclists' risky and positive riding behavior, considering a set of demographic, psychosocial and bike-use-related variables as potential predictors. MethodFor this cross-sectional study, data from 1064 cyclists (61.2% males and 38.8% females, aged between 17 and 80) from 20 countries, responding an electronic survey, were analyzed through a multi-group structural equation modeling approach. Results: Although hourly intensity, psychological distress and level of knowledge of traffic rules similarly predict the risky road behaviors of both genders, age and risk perception are significant behavioral predictors only in the case of male cyclists. On the other hand, positive behaviors of men are predicted by cycling intensity, knowledge of traffic rules and risk perception, while in the case of women psychological distress predicts -to a significant extent- positive behaviors. Age had no significant effect on the explanation of positive behaviors. ConclusionThe findings of this study support the influence of gender in the statistical explanation of risky and protective behaviors, and they also reveal differentiating variables predicting the riding behavior of male and female cyclists.

The Relationships Between Depressive Symptoms, Functional Health Status, Physical Activity, and the Availability of Recreational Facilities: a Rural-Urban Comparison in Middle-Aged and Older Chinese Adults.

This study drew upon the ecological system theory to demonstrate rural-urban differences in the relationships between the availability of recreational facilities, physical activity (PA), functional health status, and depressive symptoms in middle-aged and older Chinese adults. Nationally representative data (n= 5949) from the Chinese Health and Retirement Longitudinal Study (CHARLS, 2011-2013) were examined using the multigroup structural equation modeling approach. The results suggest that higher availability of recreational facilities in the urban communities was associated with higher levels of leisure time physical activity (LTPA), better functional capacity, and less occurrence of depressive symptoms among urban participants. In contrast, LTPA engagement among rural participants was low and had negligible mitigating effects on functional decline and depressive symptoms. The findings also show that functional health status mediated the association between total PA and depressive symptoms in both rural and urban participants. However, high levels of total PA were directly associated with elevated depressive symptoms, suggesting that the context of PA and related socioeconomic factors might explain this association after the non-LTPA components were included. The findings highlight how complex patterns of intrapersonal, behavioral, and environmental correlates influence depressive symptoms in middle-aged and older Chinese adults. The context of PA should be considered when creating targeted strategies to prevent depressive symptoms. As an inactive lifestyle evolves with China's rapid urbanization, joint efforts from public health and urban planning should be made to promote LTPA and develop active living communities for achieving optimal health in later life.

Posttraumatic Stress, Coping Flexibility, and Risky Drinking Among Trauma-Exposed Male and Female College Students: The Mediating Effect of Delay of Gratification

ABSTRACTBackground: The co-occurence of posttraumatic stress (PTS) and risky drinking has been demonstrated in diverse populations, including college students. However, the mechanisms underlying this co-occurrence, as well as the protective factors that may reduce risky drinking among trauma-exposed college students have yet to be fully understood in the literature. Objectives: The present study builds upon self-regulation theories and previous empirical work to determine whether the effects of PTS and coping flexibility on risky drinking were mediated by delay of gratification among trauma-exposed college students. In addition, the potential moderating effect of gender on these relationships was examined. Methods: Participants included 624 trauma-exposed college students (68.4% female) attending a public university in the southeast region of the United States. Data were collected through an online survey. The hypothesized model was examined using a multigroup structural equation modeling approach. Results: As hypothesized, PTS had a significant, positive indirect effect on risky drinking through delay of gratification; however, the effect of PTS on delay of gratification was stronger for males than for females. Results also indicated that the indirect effect of coping flexibility on risky drinking through delay of gratification was significant and negative for males and females.Conclusions/Importance: The findings of this study suggest that delay of gratification might be an important mechanism underlying the co-occurrence of PTS and risky drinking. In addition, our results highlight the potential benefits of coping flexibility for college students coping with PTS.

Item bias detection in the Hospital Anxiety and Depression Scale using structural equation modeling: comparison with other item bias detection methods

PurposeComparison of patient-reported outcomes may be invalidated by the occurrence of item bias, also known as differential item functioning. We show two ways of using structural equation modeling (SEM) to detect item bias: (1) multigroup SEM, which enables the detection of both uniform and nonuniform bias, and (2) multidimensional SEM, which enables the investigation of item bias with respect to several variables simultaneously.MethodGender- and age-related bias in the items of the Hospital Anxiety and Depression Scale (HADS; Zigmond and Snaith in Acta Psychiatr Scand 67:361–370, 1983) from a sample of 1068 patients was investigated using the multigroup SEM approach and the multidimensional SEM approach. Results were compared to the results of the ordinal logistic regression, item response theory, and contingency tables methods reported by Cameron et al. (Qual Life Res 23:2883–2888, 2014).ResultsBoth SEM approaches identified two items with gender-related bias and two items with age-related bias in the Anxiety subscale, and four items with age-related bias in the Depression subscale. Results from the SEM approaches generally agreed with the results of Cameron et al., although the SEM approaches identified more items as biased.ConclusionSEM provides a flexible tool for the investigation of item bias in health-related questionnaires. Multidimensional SEM has practical and statistical advantages over multigroup SEM, and over other item bias detection methods, as it enables item bias detection with respect to multiple variables, of various measurement levels, and with more statistical power, ultimately providing more valid comparisons of patients’ well-being in both research and clinical practice.

Posttraumatic stress, effort regulation, and academic outcomes among college students: A longitudinal study.

Entering college with posttraumatic stress disorder (PTSD) symptomatology has been linked to poor academic performance and increased risk for dropping out of college; however, little is known regarding the mechanisms by which PTSD symptoms have deleterious effects on college outcomes. Drawing from a self-regulated learning (SRL) perspective, which suggests that students' learning behaviors and outcomes can be influenced by contextual and developmental factors, we hypothesized that students who enter college with high PTSD symptomatology may experience difficulties in effort regulation, which in turn, may have deleterious effects on their academic performance and college persistence. These hypothesized relationships, as well as the potential gender differences in these relationships were examined using a longitudinal study design and a multigroup structural equation modeling approach. Of the 928 1st-year students who participated in the study, 484 (52.2%) students who reported lifetime exposure to traumatic events constituted the final sample of the study. The prevalence of PTSD among the trauma-exposed participants was 12.4%. After controlling for participation in on-campus activities and American College Testing (ACT) assessment scores, the relationship between PTSD symptomatology in the 1st semester of college and 2nd-year enrollment was mediated by effort regulation and 1st-year cumulative grade-point average (GPA). Specifically, participants who started college with higher levels of PTSD symptomatology also reported lower levels of effort regulation, which in turn, had a significant indirect effect on 2nd-year enrollment through 1st-year GPA. Results also indicated that the paths in the hypothesized model were not significantly different for men and women. (PsycINFO Database Record

Taking into account the impact of attrition on the assessment of response shift and true change: a multigroup structural equation modeling approach

Missing data due to attrition present a challenge for the assessment and interpretation of change and response shift in HRQL outcomes. The objective was to handle such missingness and to assess response shift and 'true change' with the use of an attrition-based multigroup structural equation modeling (SEM) approach. Functional limitations and health impairments were measured in 1,157 cancer patients, who were treated with palliative radiotherapy for painful bone metastases, before [time (T) 0], every week after treatment (T1 through T12), and then monthly for up to 2 years (T13 through T24). To handle missing data due to attrition, the SEM procedure was extended to a multigroup approach, in which we distinguished three groups: short survival (3-5 measurements), medium survival (6-12 measurements), and long survival (>12 measurements). Attrition after third, sixth, and 13th measurement occasions was 11, 24, and 41 %, respectively. Results show that patterns of change in functional limitations and health impairments differ between patients with short, medium, or long survival. Moreover, three response-shift effects were detected: recalibration of 'pain' and 'sickness' and reprioritization of 'physical functioning.' If response-shift effects would not have been taken into account, functional limitations and health impairments would generally be underestimated across measurements. The multigroup SEM approach enables the analysis of data from patients with different patterns of missing data due to attrition. This approach does not only allow for detection of response shift and assessment of true change across measurements, but also allow for detection of differences in response shift and true change across groups of patients with different attrition rates.

Ethnic density effects on psychological distress among Latino ethnic groups: An examination of hypothesized pathways

Studies among US Latinos provide the most consistent evidence of ethnic density effects. However, most studies conducted to date have focused on Mexican Americans, and it is not clear whether ethnic density effects differ across Latino sub-groups, generational status, or measures of ethnic density. In addition, the mechanisms behind ethnic density are not well understood. This study uses a multi-group structural equation modeling approach to analyze the Latino sample from the National Latino and Asian-American Study (n=1940) and examine ethnic density effects on psychological distress among Latino sub-groups, and explore two hypothesized mechanisms: increased neighborhood cohesion and reduced exposure to interpersonal racism. Results of the main effects between ethnic density and health, and of the hypothesized mechanisms, show clear differences across Latino ethnic groups, generational categories and measures of ethnic density. Findings highlight that ethnic density effects and their mechanisms depend on the current and historical context of Latino sub-groups, including reasons for migration and rights upon arrival.

Associations between patient–provider communication and socio-cultural factors in prostate cancer patients: A cross-sectional evaluation of racial differences

ObjectiveTo examine the association between socio-cultural factors and patient–provider communication and related racial differences. MethodsData analysis included 1854 men with prostate cancer from a population-based study. Participants completed an assessment of communication variables, physician trust, perceived racism, religious beliefs, traditional health beliefs, and health literacy. A multi-group structural equation modeling approach was used to address the research aims. ResultsCompared with African Americans, Caucasian Americans had significantly greater mean scores of interpersonal treatment (p<0.01), prostate cancer communication (p<0.001), and physician trust (p<0.001), but lower mean scores of religious beliefs, traditional health beliefs, and perceived racism (all p values <0.001). For both African and Caucasian Americans, better patient–provider communication was associated with more physician trust, less perceived racism, greater religious beliefs (all p-values <0.01), and at least high school education (p<0.05). ConclusionSocio-cultural factors are associated with patient–provider communication among men with cancer. No evidence supported associations differed by race. Practice implicationTo facilitate patient–provider communication during prostate cancer care, providers need to be aware of patient education levels, engage in behaviors that enhance trust, treat patients equally, respect religious beliefs, and reduce the difficulty level of the information.