Clinical and Health Affairs
Mexican Patient Satisfaction in a Rural Minnesota Primary Care Clinic
By Katelyn Rogers, M.S.
Abstract
The Latino population in rural Minnesota has grown significantly in recent years. Despite the increase, few studies have considered whether these newcomers are satisfied with the care they receive from local medical clinics. This article describes the results of a pilot study that assessed 20 Mexican patients’ satisfaction with care they received in a primary care clinic in rural central Minnesota. Participants were interviewed using questions from Stewart’s Interpersonal Care Survey and open-ended questions. Results showed the patients were generally satisfied with their health care. However, they suggested improvements in the areas of communication and involvement in decisions. Answers to the open-ended questions suggested that even though patients seemed satisfied with their care, they still strongly desired a bilingual physician.
Minnesota is seeing an influx of immigrants from Latin America. According to the Chicano Latino Affairs Council, the proportion of people from Latin American countries in Minnesota will double from 3% to 6% by the year 2015.1 According to the 2000 census, 12.4% of legal Hispanic immigrants in Minnesota live in rural communities.2 This percentage is expected to increase. Little research has been done about these newcomers’ satisfaction with health care, especially in rural parts of the state. The one recent study conducted by Dewey and Elliott in 2001 found that only 35% of Latino patients surveyed in southern Minnesota clinics were generally satisfied with their health care, whereas another 45% conveyed concerns about the care they received.3
Previous research from elsewhere in the United States has identified barriers to care for Latino patients and reasons for their dissatisfaction with their care. In particular, language discordance between caregiver and patient has been found to decrease patient satisfaction.4 Baker et al. found that patients who communicated with their physician through an interpreter or who felt that they needed an interpreter but did not have one reported less satisfaction with their care than patients who could communicate adequately with their caregiver without the aid of an interpreter.5 In contrast, research has shown that language concordance between patient and physician increases satisfaction among Hispanic patients.6,7 Even studies that showed such patients were satisfied with their care indicated room for improvement, especially regarding the patient’s role in decision making.8 As a whole, previous research suggests that patient satisfaction decreases when there are cultural and language barriers between the physician and the patient. This is of particular concern because many studies show a correlation between effective physician-patient communication and patient health outcomes.9
Because of the projected growth of the Latino population in rural Minnesota, more research on Latino patient satisfaction and perceived barriers to care is needed. The goal of this study was to evaluate Latino patients’ ability to communicate with their physician at a clinic in central Minnesota and their satisfaction with the services offered by that clinic.
Methodology
The methodology for the study was reviewed and approved by the Research Subjects’ Protection Program at the University of Minnesota. The subjects of the study were all patients at a clinic in a town of 3,000 in central Minnesota. This particular community has seen an influx of residents from Mexico and other Latin American countries, with 9.4% of the population being of Hispanic origin. This percentage is more than 3 times greater than the Hispanic population in the state but closer to the national average of 12.5%.10,11
A convenience sample of 20 patients was selected for the study. All subjects were Mexican; 17 were women, and 3 were men. Their average age was 31.5 years. Each worked a household, factory, or manual labor job. On average, participants had completed the 6th grade. Eighty-five percent (n=17) could neither read nor speak English. The most common reason for the visit to the clinic was pregnancy-related care. Other reasons for visits fell into 4 categories: acute (minor illnesses, emergencies, X-rays, pain, or accompanying acutely ill children or grandchildren to the clinic), chronic (anemia), preventive (vaccinations and Pap smears), and other (surgery or accompanying spouses or grandparents to the clinic). Participants were identified by local translators or clinic staff and given a study number for identification purposes. All were interviewed by a researcher at the clinic or in their homes.
The researcher, who also conducted the interviews, first read a consent form in Spanish to the participants. In addition, each participant was given a paper version written in English. After verbal consent was obtained from the participant, the remainder of the interview was conducted in Spanish. Participants were also given Spanish and English copies of the interview questions. Because many of the participants did not know how to read, they were periodically asked if they had questions and whether they understood what was being asked; when needed, clarification was provided. The interview included 6 demographic questions, 4 questions about language ability, 29 questions from Stewart’s Interpersonal Care Survey, and 5 open-ended questions. Each interview lasted no longer than 30 minutes. Participants were given $10 for taking part. They also were informed during the consent process that the study would grant them the opportunity to have a voice about their health care.
Results were analyzed using item tabulations as well as analysis of general categories of concern. Both quantitative and qualitative data emerged. Simple descriptive statistics were used for the quantitative data and categories of concern were identified using qualitative data-filtering processes. After the initial qualitative categories of concern were compiled, they were validated by a content expert, who evaluated the proposed categories against the raw data.
Results
Sixty percent of participants (n=12) indicated that the physician sometimes spoke too fast for them to understand, and 45% (n=9) indicated the physician used words that were too difficult for them to understand. Twenty-five percent of patients (n=5) expressed concern about their physician appearing distracted during their consultation. On the other hand, patients generally stated that the physicians respected their concerns, with only 10% (n=2) indicating that the physicians did not inquire about them. Moreover, 80% of patients (n=16) said their physician almost always explained test and exam results, 95% (n=19) said they described how to use medications, and 85% (n=17) said their doctor informed them of their medications’ side effects. In addition, most patients (75%, n=15) indicated that the physician considered their wishes in making decisions about care. Nearly all of the participants (95%, n=19) sensed that their physician was compassionate. Furthermore, the participants rarely indicated that they felt they had been discriminated against by their physician; nor did they state that the office staff was rude or negative toward them. In general, results showed patients were satisfied with their interaction with their physician.
When asked what they liked most about their care in the open-ended question portion of the study, 8 (40%) said they liked their physician, 5 (25%) liked their interpreter, and 4 (20%) liked their treatment. Five (25%) reported liking everything. When asked what they liked least about their care, 8 (40%) indicated the inability to speak Spanish by the physician and nurses, and 3 (15%) mentioned that same difficulty with receptionists (Table 1). When asked what they would like to change about their care, 14 respondents (70%) said they would like bilingual physicians, another 9 (45%) suggested translated signs, and 5 (25%) asked for bilingual receptionists (Table 2). Another 2 participants (10%) wanted bilingual nurses and a bilingual pediatrician on staff. Participants then offered suggestions about how their desired changes could be accomplished. Half (n=10) suggested offering Spanish classes to the staff, while 30% (n=6) suggested making the ability to speak a second language a prerequisite for medical school. An additional 15% (n=3) suggested offering more cultural competency courses to premedical students during their undergraduate studies. Another 20% (n=4) thought organizing get-togethers between the Mexican community and physicians would reduce barriers to care. Fifteen percent (n=3) suggested organizing a support group for Mexicans so they could learn about their rights and options for getting medical care.
Discussion
The language barrier was the key issue that emerged from this small study that could have an effect on patient care and satisfaction. Seventeen of the participants could neither speak nor read English. Of the 4 physicians at the clinic, 1 spoke Spanish fluently, 2 others had limited ability, and 1 spoke no Spanish. Eleven of the participants reported that their physician did not speak Spanish, and most felt their doctor spoke too fast at times and often used words that were too difficult for them to understand even with the assistance of an interpreter.
In addition to affecting the patient’s understanding of their physician, the language barrier also may affect a physician’s ability to understand a patient’s attitudes and values and the level to which they are acculturated to U.S. society. In the case of these patients, a majority of whom were seen for pregnancy-related reasons (even 2 of the 3 men interviewed were at the clinic to accompany a pregnant wife), understanding of their values and traditions related to pregnancy and family could have a bearing on care. For example, within the Mexican culture, the importance of familism or familismo—the well-being of the family prevailing over the interests and necessities of each of its members—is well-recognized.12 Thus, male partners and other women are considered sources of social support, and it would be important for health care providers to involve them in a woman’s prenatal care.12,13 It would also be important to know that in Mexican culture, virginity until marriage is prized, pregnancy before marriage brings shame upon the family, and the use of contraceptives is not accepted.14 In this rural community, participants reported that there was not much intermingling between Minnesotans and Mexicans, suggesting a low level of acculturation among the newcomers and the likelihood that these patients uphold such traditional values.
Interestingly, despite the language barrier, most patients expressed satisfaction with the care provided by their physician. Participants who saw the physician who spoke Spanish as a first language were especially pleased. This suggests that a physician can communicate respect for cultural values and compassion for individuals even when he or she cannot speak the patient’s language.
Limitations of the study that might preclude generalizing the results include the fact that it was very small, that it was administered to some patients who were fairly new to the community, and that the majority of the respondents were young women seeking care for pregnancy. Yet, we feel the study makes an important point: Although patients clearly want to able to converse with their physician in their first language, they also appreciate other aspects of care, especially a physician’s caring attitude.
Conclusion
Addressing the health care needs of recent immigrants is not easy, and doing it adequately involves commitment on the part of the government, community, clinic, and providers within a clinic. Given the anticipated growth of the Latino population in the United States and in Minnesota, caring for non-English-speaking patients will continue to be an issue for all who work in health care. Therefore, in order to improve patient satisfaction among recent immigrants, clinics and providers will have to find ways to improve communication, either directly or through interpreters. The present study is an indicator that even small, rural clinics can deliver care that satisfies patients who are not native to this country. MM
Katelyn Rogers is a 2008 graduate of the University of Minnesota Duluth with a double major in biology and Spanish. She will begin medical school at the University of Minnesota in Duluth this fall.
The author would like to thank the Undergraduate Research Opportunity Program at the University of Minnesota for funding this study, the clinical staff who gave their time and effort, and her mentors, in particular, her research advisor Jane Hovland, Ph.D., at the University of Minnesota Medical School Duluth.
References
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