Abstract
Background:
Health care constitutes an important aspect of services in the resettlement processes for newly arriving and resettling refugees.
Objectives:
We conducted a study to investigate levels of satisfaction related to health services delivered to refugee populations in a resettlement community and its surrounding areas.
Methods:
We used the experience of 92 adult refugee patients to examine social-cultural, clinical and economic characteristics affecting satisfaction with health care. A cross-sectional study using the Patient Satisfaction Questionnaire (PSQ) was conducted. Item analysis was conducted by considering each question on the PSQ as an item and by developing dimensions of satisfaction. Chi-square analyses were used to assess the relationships between satisfaction and patient factors.
Results:
Patients were satisfied with the initial health assessment (90%) and overall quality (86%). Only 59% of the patients were satisfied with phone interpreters. The general satisfaction dimension had a score of 4.05 on a scale of 5, while time spent with the doctor had the lowest score of 2.98. Having pre-arrival medical conditions was associated with poor satisfaction with both the initial health assessment (χ2=10.260; p=.036) and regular health services (χ2=4.550; p=.033).
Conclusion:
Although patients were generally satisfied with health services, improvements are recommended in different aspects of care to create a favorable environment of care and increase levels of satisfaction and trust with the healthcare system among refugee populations.
Keywords
Introduction
The United States (US) resettles between 50,000 and 70,000 refugees annually, and it is now home to nearly 75% of all permanently resettled refugees in the world.1-3 As a result, several American cities and towns are hosts to refugee families settled in the country under the US Refugee Resettlement Program. The ongoing resettlement of the refugee populations creates a need for consistent evaluation of service availability and utilization for refugee populations as they go through different phases of the resettlement process. Health services are a vital component of the services afforded to the refugee populations because of the vulnerability of the immigrant populations and public health implications associated with population movements.
Resettling individuals come from different cultural backgrounds and health practices; therefore, it is important for the healthcare system to determine any areas of concern in the services delivered to refugee populations both upon arrival and throughout their stay in the host communities. Patient satisfaction surveys provide a reliable way of gathering patient perspective on the quality of care, 4 and can be applied to refugee studies with the possibility of including culturally relevant elements. 5 The ratings from these surveys are particularly important for healthcare providers and policy makers attempting to make decisions that can potentially affect people of diverse cultural and belief backgrounds. 6
Upon arrival within the host community, the first contact between the refugee and the healthcare system occurs during the initial health assessment (IHA), a screening process that takes place within 60 days of arrival. Typically, local health departments conduct the IHA based on the Centers for Disease Control and Prevention (CDC) guidelines. 7 IHA involves screening for blood pressure, tuberculosis, diabetes and other conditions. 8 It is also used to establish vaccination status, conduct basic physical checkups, and ultimately prepare refugee populations to get into the mainstream of health care.
Patient satisfaction
Patient satisfaction has become one of the most important patient-based outcome measures in healthcare services, 9 and it is increasingly applied in the assessment of quality of care, 10 effective patient–provider partnerships, 11 and compliance with health services. 12 A study on the barriers to healthcare access among refugees found that most individuals consistently reported mistrust with the system and pointed out health care was impersonal and that providers cared more about their monetary gains. 13 In addition, patients complained of being unclear of who would pay for their services between themselves and the insurance companies. In other studies, asylum seekers were satisfied with the care received through the healthcare system, although they indicated some areas of dissatisfaction, including lack of confidence in practitioners and poor access to medication, 14 and lack of continuity of care, length of waiting times and access to interpreters. 15
Large numbers of arriving refugees have experienced traumatic events that make them more vulnerable to mental health disorders compared with the general population in host communities. In one investigation, satisfaction levels were compared in mental health services between specialized refugee treatment units and mainstream services; 16 it was demonstrated that patients expressed greater satisfaction with the care delivered by specialized refugee units.
Previous investigations into patient satisfaction among refugee populations have focused on mainstream health services. While this is encouraging and should be sustained, failure to examine satisfaction with IHA, which is the gateway to the healthcare system, may create harmful patterns of care in the future healthcare-seeking behaviors among refugees. For example, individuals who express dissatisfaction with IHA could potentially demonstrate unfavorable aspects of care including poor treatment compliance and mistrust of the medical community when they enter the mainstream of care; that is, they are likely to be associated with poor treatment outcomes.
The aim of this study was to examine the levels of refugee satisfaction with healthcare services. We examined satisfaction with both IHA and primary care services, and further conducted analyses to determine if satisfaction with IHA is associated with satisfaction with mainstream services. We used the experience of a growing body of refugees in a South Central Kentucky region for analyses. The study area has seen a considerable influx of refugee populations from different regions of the world since the mid-2000s. The analyses represent data collected between 2011 and 2012.
Methods
Participants
We carried out a cross-sectional study of patient satisfaction with health services. Patients recalled their experiences in the process of care and provided the requested information through structured interviews based on the Patient Satisfaction Questionnaire – Short Form (PSQ-18). 17 Additional questions were composed to capture information specific to refugee experience with IHA and to determine the role of pre-arrival medical conditions (i.e. medical conditions existing prior to US arrival) on satisfaction. The original 18 items in the PSQ covered seven dimensions of satisfaction, namely, general satisfaction; technical quality; interpersonal manner; communication; financial aspects; time spent for patients; and convenience and accessibility. Table 2 in the results section shows how satisfaction items were mapped to these dimensions. In addition, the instrument captured all relevant demographic information. Participants consented to the survey and no participant identifiers were recorded. The study was approved by the Institutional Review Board.
Participants were adults within refugee community households who had records of receiving health services at a local Community Health Center (CHC) within 24 months of their US arrival. The CHC is one of the referral centers in the community where a majority of refugee families receive primary care. It was used for the purpose of this study as the source of mainstream health services for the study population. Participants were recruited proportional to the distribution of language groups in the study area. Four groups comprising individuals speaking Burmese, Swahili, Arab and Nepali were included in the study. Qualified interpreters for each language were used to interpret the questions (written in English) for participants from their respective language groups. The interpreters recorded the responses in English according to the structure of the questionnaire.
The interpreters were recruited through local refugee resettlement agency (RRA); they were familiar within the refugee families through their engagement with RRA in dealing with refugee resettlement issues. All interpreters received training led by the principal investigator to familiarize themselves with the survey instrument, its administration and other study requirements. To avoid reporting bias, all interpreters were requested to review the questionnaire to identify any areas of cultural inappropriateness or areas that could entice respondents to produce traditionally desirable answers based on their country-of-origin’s rather than US experiences. This approach helped in avoiding mixed understanding of the questions among language groups, and it also ensured that the respondents were not limited in responding to any questions that might be perceived as sensitive or personal when interviewed by interpreters, who are often familiar with the refugee populations. Otherwise, familiarity of the interpreters within the community was helpful in ensuring effective patient participation, since this type of survey is not common to the refugee populations, who might also be concerned about sharing their information.
Analysis
Descriptive statistics for patient demographics and other information were performed. Data were generated in absolute numbers, percentages and graphical forms to display the results. Item analysis was performed (frequency and percentage) for each satisfaction item to determine the levels of agreement on a five-point PSQ-18 scale with these options: “Strongly Agree”, “Agree”, “Uncertain”, “Disagree”, and “Strongly Disagree.” Each language group in the study represented a unique cultural background. For this reason, our analyses were categorized on the basis of spoken language to assess any cultural specific differences in satisfaction. Mean scores with corresponding standard deviations for all satisfaction dimensions were computed. Pearson’s Chi-square analyses were performed to assess the association between satisfaction with IHA and satisfaction with mainstream services. Analyses were conducted using SPSS Version 19.0 (SPSS Inc., Chicago IL).
Results
A total of 92 adult members of the refugee families representing seven nationalities participated in the study. Of these, 40 (44%) spoke Burmese (Burma); 20 (22%) spoke Swahili (Burundi, Congo, and Rwanda); 17 (19%) spoke Arabic (Iraq and Somalia) and 14 (15%) spoke Nepali (Bhutan). All respondents had successfully completed IHA upon US arrival and had the experience of receiving services at the CHC. Table 1 presents distribution of the respondents’ demographic characteristics. Participants were 54.3% male and a majority were between the ages of 25 and 44 (67.4%). More than half (56.8%) went to school while in their countries of origin. Those who are employed made up 54.3% of the respondents. Nearly two-thirds of the respondents were Christians (62%), mainly including individuals from Bhutanese and African backgrounds.
Frequency distribution of patient demographic characteristics.
One of the aims of conducting IHA is to determine if incoming refugees have any pre-arrival medical conditions that may require immediate medical attention. Of those responding to the survey, 31.9% had major pre-arrival medical conditions that included tuberculosis, high blood pressure, chronic infections, and diabetes. Further, analysis showed the Burmese and Swahili-speaking groups had relatively higher rates of pre-arrival conditions; in particular, 46.4% of Burmese and 21.4% of Swahili speakers had these conditions.
Item responses and dimensions of satisfaction
Table 2 shows results obtained from the responses on all 26 satisfaction items. Generally, the refugee population in the study area reported high levels of satisfaction with the care they received. However, we found that refugees who had pre-arrival medical conditions expressed a different experience; a majority of the patients who expressed dissatisfaction with IHA reported also to have pre-existing medical conditions prior to their US arrival.
Patient responses according to PSQ-18 items on satisfaction with health services (n, %).
Items Mapped to Dimensions of Satisfaction: 1General Satisfaction; 2Technical Quality; 3Interpersonal Manner; 4Communication; 5Financial Aspects; 6Time Spent with Doctor; 7Accessibility and Convenience.
Most of the refugee families settling in US communities do not speak English or have limited proficiency that hinders adequate communication with healthcare providers. We assessed satisfaction with interpreter services to determine how patients cope with this problem. Most patients (73.5%) agreed that it is easy to get interpreter services, but a majority of patients preferred onsite to phone or language line interpreter services (84.8 vs. 63.5%). In addition, 65.9% of the patients were of the opinion that the type of care they receive would have been better if there were no language barriers (i.e. if they were proficient in English); at the same time, 67.4% agreed that the care they receive is not different from that offered to the general population. A majority (70%) of the respondents who were uncertain about affordability of medical care belonged to the Burmese community. Overall, 11.6% of the patients indicated that the care offered to refugee families was of lower quality compared with that offered to other populations in the host community.
As a result of language barrier, areas of possible concerns could be the availability of emergency services and effectiveness of the patient–provider relationship. In both these areas, patients reported high levels of satisfaction: specifically, 87.2% of the patients agreed that medical staff demonstrated courtesy and were supportive of their needs, while 63.1% agreed or strongly agreed that it is easy to get medical care in case of emergency.
Results on the dimensions of satisfaction scores are presented in Table 3. General satisfaction had the highest mean score of 4.05 on a scale of 5, followed by communication with a score of 3.85. Time spent with the doctor received the lowest score of 2.98. It is worthy to note that variability within item scores used in the dimension of “time spent with the doctor” cause this dimension to have an overall low score. For instance, although the item “physician spends enough time with me during visit” had a high individual score, other items including “access to specialists” and “interpretations during a doctor’s visit” had relatively low item scores.
Mean scores on the PSQ-18 dimensions of satisfaction.
Satisfaction with IHA and mainstream services
Figure 1 shows the response of the patients regarding their experience with both IHA and mainstream services. For IHA, the question was “I was satisfied with IHA at the health department upon my arrival,” and most respondents strongly agreed or agreed with the statement (87%). Only a small proportion of the patients were in disagreement with the statement (7.6%). Chi-square analysis showed satisfaction with IHA was not related to age, gender, language of origin, or education. However, we found that IHA was related to having a pre-arrival medical condition; those with pre-arrival medical conditions expressed lower levels of satisfaction (χ2=10.260; p=.036). The question for satisfaction with mainstream services was framed as “I am satisfied with overall quality of health services.” We found that 85.4% of the patients were satisfied with the quality of the overall care they received. Chi-Square test of association (Table 4) showed that IHA was strongly associated with satisfaction with mainstream services (χ2=40.447; p=.001).
Levels of satisfaction with mainstream and initial health assessment services.
Chi-square analysis for the association between patient satisfaction and patient factors.
Demographic and clinical factors of satisfaction
Descriptive analysis showed patients were satisfied with the care they receive based on all important demographic characteristics including age, gender, religious affiliation, and spoken language. Some differences were, however, found in relation to language barriers and existence of medical conditions prior to US arrival. Based on population groups, high proportions of dissatisfaction with care were detected in the Nepalese (37%) and Swahili (29%) -speaking populations. Chi-square tests were performed to determine the strength of these relationships (Table 4). We found that compared with patients with no pre-arrival medical conditions, those with pre-arrival medical conditions were more likely to agree that the care delivered to refugee populations is of poor quality compared with that delivered to the general population (χ2=4.550; p=.033). In addition, those who perceived care to be delivered differently between refugee and general populations were less satisfied with the overall quality of services (χ2=3.821; p=.050). Patients with access to phone interpreters expressed higher levels of satisfaction compared with those who were mainly served by phone-based language services (χ2=11.958; p=.001).
Separate Chi-square analyses showed that differences in the levels of satisfaction with interpreter services were found to be based on the spoken language. For example, while all language groups expressed satisfaction with phone interpreting services, only Burmese speakers showed problems in getting access to interpreters when they need them (χ2=21.483; p=.044). Although there were no statistical differences in the level of overall patient satisfaction by language groups in Chi-square analysis, the language barrier was seen as a factor of dissatisfaction in some items of satisfaction such as patient–provider interactions and adequacy of time spent with providers. Lastly, though marginally significant, unemployment was associated with low satisfaction with overall quality of services (χ2=3.555; p=.059).
Discussion
The main aim of this study was to determine the level of satisfaction with health services among refugee populations. Patient satisfaction survey is an important tool for gathering information necessary for improvements in patient experience and quality of care.18,19 In the current study we utilized PSQ-18 to assess levels of satisfaction among refugee populations receiving care at a local CHC. Our findings suggest several important implications related to health services delivered to refugee populations. The local provider communities and RRA are commended for success attained in integrating refugee families with the healthcare system. High satisfaction levels with both IHA and mainstream health services demonstrated in this study are encouraging. Service providers and RRAs should continue to improve their collaborative partnership while maintaining what is working, and at the same time determine areas of improvement in refugee health services during and beyond the resettlement process. It is practically possible to sufficiently address concerns in health care involving refugee populations if the existing partnerships of RRA, healthcare providers and other community stakeholders are maintained to ensure the needs of the target populations are met.
Our findings suggest the language barrier is one of the leading factors of dissatisfaction in the process of care involving refugee families. Similar finding have been previously reported in studies involving different refugee populations.20-22 In relation to this problem, patients have shown a clear preference for using onsite over phone interpreter services. Community organizations should join forces to create an environment that will attract bilingual individuals and skilled interpreters into receiving medical interpretation training so they can assist refugee families in health care and other social services. In addition, these individuals could be instrumental in the efforts to teach English as a second language (ESL) to refugee populations. Successful ESL programs would also address the concerns expressed by the patients that services they receive would be better if they knew the English language. Specifically, for the Burmese-speaking group, the low levels of satisfaction with interpreter services could be indicative of the complex structure of their language. That is, the large number of distinct dialect groups in the Burmese community 23 might make it difficult for every Burmese patient needing interpreter services to find an exact match of interpreter on a consistent basis.
Despite the best efforts and intentions of the healthcare providers and facilities in meeting the needs of refugee populations, we found that individuals who come to the US with major medical conditions tend to express lower rates of patient satisfaction. It is possible that these patients have unrealistic or false hopes of getting immediate treatment for their conditions, and they become easily discouraged and frustrated when the amount of time spent before they can receive the needed care is prolonged or when they are not informed about the underlying processes. It is also possible that the type of care received by the incoming refugees is different from their perception of “accustomed care” for their conditions. Part of the resettlement plans should involve pre-arrival reviews for medically complex cases to determine the best care plan, including putting in place procedures for expediting and coordinating care for those with pre-existing conditions. Efforts to timely educate incoming refugee families on how the US healthcare system functions should also be emphasized, by discussing how factors such as insurance coverage, completeness of patient history and coordination of care are relevant to health care. Although they have not been covered in this study, access issues such as language barriers and lack of medical interpretation skills might have contributed to poor satisfaction levels among persons with pre-arrival medical conditions. Community establishments under the leadership and experience of RRA in the region would be valuable in pooling community support necessary for alleviating any such access problems.
Refugees entering the US from different parts of the world are settled in American communities that are completely new, with a cultural environment demanding adjustments in both lifestyle and expectations. Consequently, several challenges emerge and create unintended dissatisfaction trends in the healthcare process. For instance, cultural variations 20 as well as incongruity between patient and provider expectations 24 may lead to perceptions that care received by the general population is better than that received by the refugee community. Case workers assigned to arriving refugees should use every opportunity to inform their clients of the different personal and system requirements that need to be met before they can enter the health system.
Healthcare providers are faced with major challenges in dealing with refugees from different cultural backgrounds and healthcare systems. The needs of providers while delivering care to refugee families have to be determined and adequately addressed to create an ideal environment for refugee health services. Healthcare facilities in areas with a high influx of refugees should find ways of incorporating culturally relevant resources, such as language services, into their practice. Contracts between healthcare facilities and language service establishments could be useful in creating a pool of qualified interpreters that would be available to support providers in service delivery. Lastly, discussions on experiences and challenges faced by providers based on community provider forums could be valuable in exploring the best ways of meeting the healthcare needs of the refugee populations and eventually finding best ways of coordinating the services within the community.
Conclusion and limitations
We used patient perspectives to determine areas of strength and improvements in health services provided to refugee populations. Patients indicated high rates of satisfaction with the services they received, suggesting that healthcare facilities and personnel are well prepared to deliver care of acceptable quality. Results suggested areas of dissatisfaction are mainly related to language barriers and interactions with the provider community. These issues could be effectively addressed, as a community concerns involving all stakeholder agencies in the resettlement plans.
Our study is limited to the experience of refugee population in one area of the country that hosts newly arriving and resettling refugees, and as such limits generalizations of the findings to the experience of the refugee populations across the country. A larger study involving refugee populations from different states with the potential of delineating urban and rural differences is recommended. Such a study could be useful in providing a national perspective of the barriers to health services involving refugee populations. Patient information was collected through interpreters. Although measures were taken to ensure that all questions carried the same meaning in all language groups, it is possible that some bias was introduced due to the way the questions were asked in the native language, or because of the way interpreters attempted to clarify any part of the questions. Lastly, we acknowledge that a cross-sectional study prohibits the ability of establishing firm conclusions on the experience of refugee populations in the process of care. A longitudinal study that follows up refugee groups over time from the point of arrival could be used to determine patterns of service utilization and assess satisfaction levels in IHA, as well as in transitional phases leading to the eventual utilization of mainstream services.
Footnotes
Declaration of conflicting interest
The authors declare that there is no conflict of interest.
Funding
This study was made possible by an internal faculty grant of the College of Health and Human Services, Western Kentucky University, Bowling Green, Kentucky, United States.