Satisfaction With Care

Abstract

Objectives: This study examined how patients’ satisfaction with their care is affected by racial/ethnic concordance and patients’ perceived interpersonal sensitivity of their providers. The sample consisted of non-Hispanic Whites, African Americans/Blacks, Hispanics/Latinos, and Asian Americans age 50 and older. Method: Data came from the population-based Commonwealth Fund 2001 Health Care Quality Survey (n = 2,075). A hierarchical regression model of satisfaction was estimated for each racial/ethnic group with a sequential entry of variables: demographic and health-related variables, racial/ethnic concordance between patient and provider, and interpersonal sensitivity. Results: The influence of patient-provider racial/ethnic concordance on satisfaction with care was negligible, but the influence of interpersonal sensitivity was substantial (p < .001) in all racial/ethnic groups. Discussion: Findings suggest that racial/ethnic concordance may not be universally effective for diverse older populations, but perceived interpersonal sensitivity of the provider has a strong influence on older adults’ satisfaction with care regardless of their racial/ethnic background.

Keywords

satisfaction with care patient-provider racial/ethnic concordance interpersonal sensitivity

Introduction

Satisfaction with care is an important component of health services (Donabedian & Bashshur, 2003; Marcinowicz, Chlabicz, & Grebowski 2009). Higher levels of patient satisfaction have shown to be associated with positive patient behaviors such as proper utilization of health services and compliance with a medical regimen (LaVeist & Nuru-Jeter, 2002; Smith, Ley, Seale, & Shaw, 1987). For these reasons, factors that impact patient satisfaction have been used to identify and develop strategies to improve the delivery of health care (Coulter, 2003; Donabedian & Bashshur, 2003; Marcinowicz et al., 2009). For older adults in particular, positive health care delivery depends on the physician’s attention to their social, economic, cultural, and psychological vulnerabilities (Williams, Haskard, & DiMatteo, 2007). Previous research has found that racial/ethnic minorities report lower satisfaction with care compared to their White counterparts and one of the recommended strategies to improve this difference is to consider the patients’ cultural needs (Garroutte, Kuniovich, Jacobsen, & Goldberg, 2009). There is, however, a lack of research that has examined satisfaction specifically among diverse populations of older adults (Diógenes, Mendonça, & Guerra, 2009).

Another potential source of variation in patient satisfaction lies in patient-provider racial/ethnic concordance. However, findings from these studies are mixed; some researchers report a positive role of racial/ethnic concordance in increasing patient satisfaction (e.g., Cooper & Powe, 2004; LaVeist & Nuru-Jeter, 2003; Saha, Komaromy, Koepsell, & Bindman, 1999) whereas others found no such evidence of concordance impacting patient satisfaction (e.g., Howard, Konrad, Stevens, & Porter, 2001; Schnittker & Liang, 2006; Stepanikova, 2006). The mixed findings may be due to differences in the overall sample composition and the methodological approach used in this study and invite further investigation.

The perceived interpersonal sensitivity of the provider may also affect satisfaction. Conceptually, interpersonal sensitivity has three main components: experiencing and interacting with the environment, receiving attention, and factors that affect perception (Bernieri, 2001). Of these components, interpersonal sensitivity has been noted as one of the most important factors for patient satisfaction (Kivlin, 2002) and it embodies personality, attitudes, beliefs, and values (Hall, 2011).

Health care providers’ understanding of the cultural characteristics, values and traditions of their patients plays important roles in determining the overall quality of care (Lucas, Michalopoulou, Fazarano, Menon, & Cunningham, 2008). Researchers have suggested that feelings of disrespect and lack of trust experienced by patients may lead to negative consequences such as provider ineffectiveness, limited engagement between patients and providers, and reduced quality of care (Bell, Kravitz, Thom, Krupat, & Azari, 2002; Ngo-Metzger et al., 2006). Previous research has noted the relationship between the interpersonal style of health care providers and several dimensions of satisfaction with care and health-related quality of life (Ayanian et al., 2010; Bennett, Fuertes, Keitel, & Phillips, 2010; Busato & Künzi, 2010; Nápoles, Gregorich, Santoyo-Olsson, O’Brien, & Stewart, 2009). Nápoles and colleagues (2009) found that the interpersonal processes of care significantly impact satisfaction with care among English- and Spanish-speaking Latinos, African Americans, and non-Latino Whites. An area within this research that needs more attention is in understanding the impact of interpersonal sensitivity on overall satisfaction with care specifically among older adults from diverse racial/ethnic backgrounds.

Based on the literature reviewed above, the goal of the present study was to examine how older patients’ satisfaction with care is affected by (a) racial/ethnic concordance between the patient and the provider and (b) patients’ perceived interpersonal sensitivity of providers. Data were from a national sample of older adults from diverse racial/ethnic backgrounds, and we hypothesized that having a provider of the same race/ethnicity and perceiving a provider to have a greater level of interpersonal sensitivity would be associated with higher levels of satisfaction with care.

Method

Data set

The data used in this study came from the Commonwealth Fund 2001 Health Care Quality Survey conducted by Princeton Survey Research Associates (PSRA) in 2001 (Princeton Survey Research Associates, 2002). The survey was designed to collect a nationally representative sample of adults age 18 and older living in the continental United States. The survey was a 25-minute telephone interview and the participant could choose to be interviewed in English, Spanish, Cantonese, Mandarin, Korean, or Vietnamese. The sample was drawn by using a standard list-assisted random digit dialing (RDD) methodology. A total of 6,722 adults responded to the survey, with a response rate of 54.3 percent. Additional information about the methodology employed to collect these data is available in a report created by the Princeton Survey Research Associates, the questionnaire administrators (see Princeton Survey Research Associates 2002).

For the purpose of the present study, we selected only those individuals aged 50 and older who reported that they had utilized health care services within the past 2 years. We chose age 50 as the lower cutoff because of previous studies suggesting that racial/ethnic minorities experience the aging processes and disparities in health at earlier age than mainstream populations (Hayward, 2002; Hayward, Miles, Crimmins, & Yang, 2000; House et al., 1994). The final sample included 2,075 respondents, representing non-Hispanic Whites (n = 1,417), African American/Blacks (hereafter referred to as African American; n = 330), Hispanic/Latinos (hereafter referred to as Hispanic; n = 204), and Asian Americans (n = 124).

Measures

Satisfaction with care

The survey included a single question, asking respondents how satisfied they were with the quality of health care they had received during the last 2 years (1 = dissatisfied, 2 = somewhat satisfied, 3 = very satisfied).

Patient-provider racial/ethnic concordance

Respondents were asked to report their race/ethnicity and the race/ethnicity of their health care providers in separate questions. A match was coded (0 = no, 1 = yes) if the race/ethnicity of both the provider and respondent was the same.

Interpersonal sensitivity of the provider

This variable was operationalized in a manner consistent with previous descriptive findings from the Commonwealth Fund 2001 Health Care Quality Survey and research conducted by Johnson and colleagues (Collins et al., 2002; Johnson et al., 2004). The three items identified as being representing interpersonal sensitivity were “Did the doctor treat you with respect and dignity?” (1 = none at all, 2 = not too much, 3 = fair amount 4 = great deal); “I feel that my doctor understands my background and values.” (1 = strongly disagree, 2 = somewhat disagree, 3 = somewhat agree, 4 = strongly agree), and “How much confidence and trust did you have in the doctor that treated you?” (1 = none at all, 2 = not too much, 3 = fair amount, 4 = great deal). To further examine the utility of these three items as a measure, an exploratory factor analysis was performed. The three items yielded a single dominant solution in all racial/ethnic groups, and they showed acceptable internal consistencies for non-Hispanic Whites (α = .70), African Americans (α = .62), Hispanics (α = .62), and Asian Americans (α = .56). The total scores, ranging 3 to 12, were used in the analyses.

Background variables

Demographic variables included age (in years), gender (1 = male, 2 = female), marital status (1 = not married, 2 = married), and education (1 = high school incomplete, 2 = high school graduate, 3 = some college or technical, 4 = college graduate or graduate). A 5-point Likert-type scale was provided for respondents to indicate their self-rated health (1 = poor, 2 = only fair, 3 = good, 4 = very good, 5 = excellent).

Analysis Plan

Descriptive information on each racial/ethnic minority group was compared with Whites using t tests and chi-square analyses. Bivariate correlations (not shown in tabular format) were used initially to examine the underlying associations among the study variables and to detect potential collinearity. All correlation coefficients were below .55 and raised no concerns about collinearity (Tabachnick & Fidell, 2001).

A series of hierarchical linear regressions on patient satisfaction with care received were then performed separately on each of the four racial/ethnic groups. The predictor variables were entered as successive models in an order that reflects differences in the immediacy and stability of the variables, with variables that are more stable or antecedent in the earlier sets and the variables that can change over time in the subsequent steps: (a) demographic and health-related variables (age, gender, marital status, education, and self-rated health), (b) patient-provider racial/ethnic concordance, and (c) interpersonal sensitivity.

Results

Characteristics of the Sample

Descriptive information on the total sample and four racial/ethnic groups is summarized in Table 1. The results highlight the differences as well as the similarities across the four groups. The age range for the total sample was 50 to 99. Over half the total sample was female, and over 80 percent had received a high school diploma or higher. Compared to the non-Hispanic Whites, African Americans and Hispanics were significantly younger, had lower levels of education, and had lower self-rated health. African Americans were the least likely to be married. Hispanics were significantly more likely than non-Hispanic Whites to be female. Asian Americans were significantly less likely to be female, more likely to be married, and more educated, when compared to non-Hispanic Whites. As might be expected to result from the greater proportion of non-Hispanic Whites in the health professions, there was less patient-provider concordance among the minority groups.

Table 1.

Sample Characteristics by Percent or Average (Standard Deviation), and Group Comparisons^a

	Mean/SD (%)
Variable	Total sample (N = 2075)	Non-Hispanic Whites (N = 1417)	African Americans (N = 330)	Hispanics (N = 204)	Asian Americans (N = 124)
Age	64.9/12.16	65.7/12.06	63.9/12.09*	61.8/10.58***	63.9/14.68
Gender (% Female)	(67.1)	(66.6)	(69.1)	(74.0)*	(56.5)*
Marital status (% Married)	(52.0)	(53.8)	(34.5)***	(54.2)	(73.4)***
Education (% High school and beyond)	(82.4)	(87.8)	(71.0)***	(57.4)***	(91.8)***
Self-rated health	3.26/1.14	3.36/1.13	2.97/1.08***	2.89/1.19***	3.41/1.09
% Patient-provider racial/ethnic concordance	(54.9)	(68.4)	(23.0)***	(20.1)***	(43.5)***
Interpersonal sensitivity	11.09/1.35	11.14/1.33	11.21/1.24	10.86/1.53*	10.59/1.38***
Satisfaction with care received	2.62/0.60	2.64/0.59	2.61/0.63	2.60/0.64	2.46/0.62**

Comparative analyses (t or χ² test) were conducted by comparing each racial/ethnic group with Non-Hispanic Whites.

p < .05. **p < .01. ***p < .001.

Hispanics and Asian Americans were both less likely than non-Hispanic Whites to perceive their providers as having high levels of interpersonal sensitivity. African Americans’ perception of their providers’ interpersonal sensitivity, on the other hand, was not significantly different from non-Hispanic Whites. Lastly, Asian Americans had significantly lower levels of satisfaction with the care they received when compared to non-Hispanic Whites. In contrast, African Americans and Hispanics had satisfaction levels similar to non-Hispanic Whites.

Hierarchical Regression Models of Satisfaction With Care

The results of the hierarchical regression analyses are presented in Table 2. Model 1 included variables related to the sociodemographic characteristics of the patient and their self-rated health. The four groups differed in terms of the significant coefficients. For non-Hispanic Whites, higher self-rated health predicted higher satisfaction with care. For African Americans, none of the variables were significant predictors, while lower education and higher self-rated health were significant predictors for Hispanics. For Asian Americans, not being married was significantly associated with greater satisfaction with care.

Table 2.

Hierarchical Regression Models of Satisfaction With Care Received^a

	Non-Hispanics Whites		African Americans/Blacks		Hispanics/Latinos		Asian Americans
Step/variable	β	ΔR²	β	ΔR²	β	ΔR²	β	ΔR²
1 Age	.05	.02**	−.04	.02	−.01	.12**	−.01	.15*
Gender	.00		.01		−.06		−.16
Marital status	.02		.04		−.11		−.24*
Education	−.03		−.14		−.25**		−.22
Self-rated health	.13***		.11		.20*		.21
2 Patient-provider racial/ethnic concordance	.01	.00	.01	.00	.08	.00	−.05	.00
3 Interpersonal sensitivity	.48***	.22***	.42***	.17***	.45***	.18***	.49***	.22***

The β values represent the values for each step. Each ΔR² value represents the changes from the previous step.

p < .05. **p < .01. ***p < .001.

In the subsequent model, concordance between patients and provider in race/ethnicity was added, and it was not a significant predictor of satisfaction for any of the four groups.

The last model included the perceived interpersonal sensitivity of the provider. This variable was significantly associated with satisfaction for all groups. In other words, regardless of racial/ethnic group membership a patient’s satisfaction with the care that they received is predicted by higher perceived interpersonal sensitivity of their health care providers.

In addition to the direct effects, an interaction term between patient-provider racial/ethnic concordance and interpersonal sensitivity was added; however, no significance was obtained.

Discussion

The main focus of this study was on exploring the effects of race/ethnicity concordance of patient/provider and interpersonal sensitivity on satisfaction with received care. Our findings show that racial/ethnic concordance between patients and their providers—an aspect of the therapeutic relationship that has received considerable interest over the past 5 to 10 years—did not impact satisfaction with care received. This lack of an association contrasts with the previous research of LaVeist and Nuru-Jeter (2002), who report a connection between racial/ethnic concordance and satisfaction. The latter study, however, did not focus on older adults and did not considered interpersonal sensitivity. Older adults tend have positive health experiences when the physician is attentive to their needs (Williams et al., 2007). There appears to be a general lack of studies that have examined satisfaction among diverse populations of older adults.

Even though racial/ethnic concordance did not impact patient satisfaction in the present study, it may be important among specific subgroups of ethnic populations (Maghani et al., 2009). This is because a wide range of cultures and backgrounds can be found among those classified as Hispanics and Asians. There may well be several intragroup differences and preferences about the expectations of their health care providers and the health care they receive. An additional point that should be considered is that there is an underlying assumption that patients can identify with a provider who may look like them, speak the same language, or have a similar culture (Maghani et al., 2009). This may not always be the case.

Another possible reason for the lack of an effect is that racial/ethnic concordance may only become effective when it is combined with other factors, such as shared language, length of patient-provider relationship or the location of the health care facility (Maghani et al., 2009). Racial/ethnic concordance, in other words, may be part of a larger construct that combines patient, provider, and system variables (Maghani et al., 2009) to effectively provide higher quality health care. Recent studies that have examined whether or not patient-provider racial/ethnic concordance is important for racial/ethnic minority groups have found that patient satisfaction may be more associated with shared cultural beliefs about health, illness, values, and experience in society with their health care provider (Michalopoulou, Falzarano, Arfken, & Rosenbery, 2009). These findings relate well to the results of the present study regarding interpersonal sensitivity.

Interpersonal sensitivity on the other hand demonstrated significant relationships with patient care satisfaction across all four groups. Feeling that you can trust your provider, that they treated you with dignity and respect, and that they understood your background and values are the three components of interpersonal sensitivity that were assessed. Of particular importance is that interpersonal sensitivity was important to everyone, not just racial/ethnic minorities. Results from a recent study that examined patients’ perceptions of their physicians suggest that establishing a good interpersonal relationship is one of the factors associated with patient satisfaction (Michalopoulou et al., 2009). Overall, there appears to be a lack of literature that has examined interpersonal sensitivity, particularly as a predictor patient satisfaction among diverse older adults.

There are several limitations in the present study that must be addressed. First, sample weights were not used in this study because the overall purpose was to examine relationships between variables: the objective was not to develop population estimates. Second, while satisfaction is a widely employed measure that is often used to gain an understanding of the quality of health care, it was only represented by a single item in the survey. Finally, detailed information about ethnic subgroups and English proficiency were missing in the data set.

Despite the limitations, the findings from this study contribute to a growing body of literature about factors can impact satisfaction with care among diverse populations. While this literature is rich in case histories and models, there is a lack of empirical attention to the contribution of its several dimensions, and a particular lack of studies that have examined the role of provider sensitivity, as perceived by the client. In addition, few studies have examined provider sensitivity across multiple racial/ethnic groups. The racial/ethnic differences presented by the regression models described in this paper support the current understanding that different dynamics are generally at play when considering patient satisfaction across differing racial/ethnic groups. Finally, and perhaps most importantly, this study shows the importance of interpersonal sensitivity for all older patients, not just racial/ethnic minorities. Previous research suggests that interpersonal sensitivity could be included in clinical education since it is a trainable skill, despite the complex interaction of personal and socioenvironmental factors that affect such sensitivity (Hall, 2011). This information can be used by health care professionals to improve the overall quality of care for all older Americans.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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