Evaluating Patient and Family Experience Among Spanish-Speaking and LatinX Patients: a Scoping Review of Existing Instruments.

INTRODUCTION: LatinX populations are rapidly growing in the USA, but still report lower levels of patient centered care and satisfaction when compared to their non-LatinX white counterparts. This review encompasses literature which describes patient experience instruments that (1) evaluate LatinX experience, (2) have validated Spanish versions, or (3) measure language-concordant care experiences. METHODS: A scoping review of literature in Ovid Medline, CINAHL, and PsycINFO was conducted. Articles were excluded if they were not applicable to the health care industry, did not include a patient experience instrument, or did not include LatinX or Spanish-speaking individuals within their study population. Data extraction was performed for concepts measured, study size, population, health care setting, and languages validated. RESULTS: This review identified 224 manuscripts. Of these, 81 met full inclusion criteria and represented 60 unique instruments. These covered six categories: general patient experience (43%, n = 26/60), experiences of discrimination/mistrust (12%, n = 7/60), cultural factors (10%, n = 6/60), patient-provider relationship (10%, n = 6/60), and communication (8%, n = 5/60). The remaining instruments measured multiple categories (17%, n = 10/60). Just over one third of instruments (n = 24, 5 pediatric, 19 adult) were validated in Spanish and an additional 14 (23%) were validated in English alone. Finally, 4 (7%) instruments were identified which were developed for use in a language concordant setting. CONCLUSION: Many instruments were identified which evaluate LatinX patient experience; however, none was both validated in Spanish and measured in all key categories of experience described above. Additionally, few instruments were developed for holistic evaluation of patient experience in pediatric or language concordant care settings.

Patient perspectives on how to demonstrate respect: Implications for clinicians and healthcare organizations.

OBJECTIVE: Clinicians and healthcare organizations are ethically obligated to treat patients with respect, yet it is not clear what actions best demonstrate respect to patients. This exploratory qualitative study aimed to understand what actions on both an individual and organizational level effectively demonstrate respect for primary care patients. METHODS: We conducted semi-structured telephone interviews with primary care patients in an integrated healthcare delivery system in Oregon and an integrated safety net health system in Colorado who were participating in a genomics implementation research study of a hereditary cancer screening program. We systematically coded interview transcripts using a coding framework developed based on iterative review of the interview guide and transcripts. We further analyzed the data coded with sub-codes relating to patients' experiences with respect in healthcare using a descriptive content analysis approach. RESULTS: We interviewed 40 English-speaking (n = 30, 75%) and Spanish-speaking (n = 10, 25%) patients. Most interviewees identified as female (n = 35, 88%) and either Hispanic/Latino(a) (n = 17, 43%) or White or European American (n = 15, 38%). Interviewees identified two categories of efforts by individual clinicians that demonstrate respect: engaging with patients and being transparent. They identified five efforts by healthcare organizations: promoting safety and inclusivity, protecting patient privacy, communicating about scheduling, navigating financial barriers to care, and ensuring continuity of care. CONCLUSIONS: Our findings suggest that patients' experiences of respect depend on efforts by individual clinicians as well as healthcare organizations. Our findings offer insight into how clinicians can build stronger partnerships with patients and how organizations can seek to promote access to care and patient safety and comfort. They also illustrate areas for future research and quality improvement to more effectively respect patients.

Inpatient Culture and Satisfaction With Care: A Novel Perspective.

BACKGROUND: Hospital professionals must attend to patients' satisfaction with care. Along with technical quality of care, patients' personal characteristics may affect that satisfaction, but standard demographics research often overlooks cultural links. METHODS: We, therefore, asked 58 San Antonio, Texas, inpatients their satisfaction with care and examined responses for attitudes related to ethnic-Mexican-American (MA), Euro-American (EA), or African-American (AA)-and gender cultures. RESULTS: Many attitudes occurred widely. Most respondents expected doctors to attend them faithfully, inform them honestly, and pursue their needs and wishes singularly. Most also trusted doctors, and expressed satisfaction with doctors' generally exemplary character and service ethic. But most respondents also feared hospital treatments, and some expressed dissatisfaction that doctors had inadequately informed them or ignored their wishes. Only rare attitudes distinguished particular ethnic-gender groups. Unlike other groups few EA or AA men expressed dissatisfactions. But some MA and EA women said hospitals use too many caregivers or coordinate care poorly. Furthermore, most AA women expressed no explicit trust in doctors, and most EA women expressed actual distrust of doctors, often doubting their technical competence or altruism. CONCLUSIONS: These findings suggest a novel perspective: a unique inpatient culture, largely unaffected by ethnic group or gender. Patients interpret their hospital experience through that culture. Hospital professionals might respond with both universal measures (addressing patients' fears, dissatisfactions, and distrust) and targeted ones (explicitly asking EA and AA men about dissatisfactions, and AA and EA women about distrust). Such culturally grounded measures may help maintain or increase inpatients' satisfaction.

Addressing Disparities in Prenatal Care via Telehealth During COVID-19: Prenatal Satisfaction Survey in East Harlem.

OBJECTIVE: In the setting of an inner city, safety net hospital, patient satisfaction with prenatal care conducted via telehealth was compared with in-person visits at the height of the novel coronavirus disease 2019 (COVID-19) pandemic. STUDY DESIGN: Through this cross-sectional study, patients were identified who received at least one televisit and one in-person visit during the COVID-19 pandemic. The Short Assessment of Patient Satisfaction (SAPS) survey was used to measure patient satisfaction. Surveys pertaining to in-person and televisits were conducted at the end of a telephone encounter, and overall satisfaction scores were documented. Patients were excluded if they received in-person or virtual care only and not both. The SAPS score correlated with the degree of patient satisfaction. RESULTS: A total of 140 patients were identified who received both virtual and in-person prenatal care from March 1, 2020 to May 1, 2020. One hundred and four patients (74%) agreed to be surveyed: 77 (74%) self-identified as Hispanic and 56 (54%) stated that their primary language was Spanish. The overall median satisfaction score for televisits and in-person visits was 20 (interquartile range [IQR]: 20, 25) and 24 (IQR: 22, 26) (p = 0.008, Z score = 2.651). In patients who self-identified as Hispanic or identified their primary language as Spanish, there was no statistically significant difference in their satisfaction scores. CONCLUSION: While there were lower scores in patient satisfaction for televisits in every category, there were no clinically significant differences since all medians were in the "satisfied" range. By lowering patient exposure to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), especially for those at risk for reduced access to care and higher COVID-19 cases by zip code, telehealth allowed for appropriate continuation of satisfactory prenatal care with no impact on patient perceived satisfaction of care. KEY POINTS: · Telehealth allowed for continuation of satisfactory prenatal care in Hispanic patients.. · Hispanic patients are at risk for reduced access to care.. · Telehealth was a useful tool for achieving patient-perceived satisfactory care..

Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings.

Importance: The Press Ganey Outpatient Medical Practice Survey is used to measure the patient experience. An understanding of the patient- and physician-related determinants of the patient experience may help identify opportunities to improve health care delivery and physician ratings. Objective: To evaluate the associations between the patient experience as measured by scores on the Press Ganey survey and patient-physician racial/ethnic and gender concordance. Design, Setting, and Participants: A cross-sectional analysis of Press Ganey surveys returned for outpatient visits within the University of Pennsylvania Health System between 2014 and 2017 was performed. Participants included adult patient and physician dyads for whom surveys were returned. Data analysis was performed from January to June 2019. Exposures: Patient-physician racial/ethnic and gender concordance. Main Outcomes and Measures: The primary outcome was receipt of the maximum score for the "likelihood of your recommending this care provider to others" question in the Care Provider domain of the Press Ganey survey. Secondary outcomes included each of the remaining 9 questions in the Care Provider domain. Generalized estimating equations clustering on physicians with exchangeable intracluster correlations and cluster-robust standard errors were used to investigate associations between the outcomes and patient-physician racial/ethnic and gender concordance. Results: In total, 117 589 surveys were evaluated, corresponding to 92 238 unique patients (mean [SD] age, 57.7 [15.6] years; 37 002 men [40.1%]; 75 307 White patients [81.6%]) and 747 unique physicians (mean [SD] age 45.5 [10.6] years; 472 men [63.2%]; 533 White physicians [71.4%]). Compared with racially/ethnically concordant patient-physician dyads, discordance was associated with a lower likelihood of physicians receiving the maximum score (adjusted odds ratio [OR], 0.88; 95% CI, 0.82-0.94; P < .001). Black (adjusted OR, 0.73; 95% CI, 0.68-0.78; P < .001) and Asian (adjusted OR, 0.55; 95% CI, 0.50-0.60; P < .001) patient race were both associated with lower patient experience ratings. Patient-physician gender concordance was not associated with Press Ganey scores (adjusted OR, 1.00; 95% CI, 0.96-1.04; P = .90). Conclusions and Relevance: In this study, higher Press Ganey survey scores were associated with racial/ethnic concordance between patients and their physicians. Efforts to improve physician workforce diversity are imperative. Delivery of health care in a culturally mindful manner between racially/ethnically discordant patient-physician dyads is also essential. Furthermore, Press Ganey scores may differ by a physician's patient demographic mix; thus, care must be taken when publicly reporting or using Press Ganey scores to evaluate physicians on an individual level.

Racial differences in the relationship between surgical choice and subsequent patient-reported satisfaction outcomes among women with early-stage hormone-positive breast cancer.

PURPOSE: The last fifteen years has seen a rising proportion of women who are eligible for breast conserving therapy (BCT) choosing mastectomy despite equivalent survival in early-stage breast cancer. We aim to explore potential racial differences in the association of surgical choice with subsequent patient-reported satisfaction outcomes. METHODS: Women who were within one year of diagnosis with hormone receptor (HR)-positive breast cancer were asked the Short Version of Patient Satisfaction Questionnaire (PSQ-18), which assesses their overall satisfaction with their medical care. We conducted bivariate analyses, including paired t-tests, to clarify differences in these patient-reported factors by surgical choice and race. Multivariable linear regression models were used to adjust for clinical and demographic control variables. RESULTS: For the sample of 279 women who underwent definitive surgery, women who received a mastectomy had lower levels of overall satisfaction, 71 vs. 75 (out of 90) (p = .001). In stratifying this relationship by race, the difference in total satisfaction score was largest among Black women (69 among mastectomy patients vs. 75 among BCT patients; p = 0.016). On multivariable linear regression, Black race and mastectomy status (together) exhibited a significantly large negative association with total satisfaction score, with negative associations across all domains of the PSQ-18. CONCLUSION: Despite the high prevalence of mastectomy among Black women with early-stage, HR-positive breast cancer, this population is more likely to report lower levels of patient satisfaction compared to patients receiving BCT. These findings suggest there may be potential racial differences in the psychosocial consequences of surgical choice.

Veterans' perceptions of racial bias in VA mental healthcare and their impacts on patient engagement and patient-provider communication.

OBJECTIVES: Drawing from social identity threat theory, which posits that stigmatized groups are attuned to situational cues that signal racial bias, we examined how African-American veterans evaluate verbal and non-verbal cues in their mental health encounters. We also explored how their evaluations of perceived racial bias might influence their healthcare engagement behaviors and communication. METHODS: We interviewed 85 African-American veterans who were receiving mental health services from the US Department of Veterans Affairs (VA), examining their views and experiences of race in healthcare. We analyzed the data using a constructivist grounded theory approach. RESULTS: Participants identified several identity threatening cues that include lack of racial diversity representation in healthcare settings, and perceptions of providers' fears of Black patients. We describe how participants evaluated situational cues as identity threats, and how these cues affected their engagement behaviors and healthcare communication. CONCLUSION: Our findings revealed situational cues within clinical encounters that create for Black veterans, fear of being negatively judged based on stereotypes that have characterized African-Americans. PRACTICE IMPLICATIONS: We discuss the implications of these findings and provide suggestions on how to create identity safe environments for minority patients that include delivery of person-centered care, and organizational structures that reduce providers' burnout.

Retaining Hispanics: Lessons From the Hispanic Community Health Study/Study of Latinos.

We aimed to examine the retention of Hispanics/Latinos participating in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a prospective cohort study of 16,415 adults in 4 US cities who were enrolled between 2008 and 2011. We summarized retention strategies and examined contact, response, and participation rates over 5 years of annual follow-up interviews. We then evaluated motivations for participation and satisfaction with retention efforts among participants who completed a second in-person interview approximately 6 years after their baseline interview. Finally, we conducted logistic regression analyses estimating associations of demographic, health, and interview characteristics at study visit 1 (baseline) with participation, high motivation, and high satisfaction at visit 2. Across 5 years, the HCHS/SOL maintained contact, response, and participation rates over 80%. The most difficult Hispanic/Latino populations to retain included young, single, US-born males with less than a high school education. At visit 2, we found high rates of motivation and satisfaction. HCHS/SOL participants primarily sought to help their community and learn more about their health. High rates of retention of Hispanics/Latinos can be facilitated through the employment of bilingual/bicultural staff and the development of culturally tailored retention materials.

Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training.

Since publication of Unequal Treatment by the Institute of Medicine in 2003, there has been a growing recognition of the role of provider implicit racial bias in patient care. Provider implicit racial bias has been consistently negatively associated with both care satisfaction and provider trust among racial/ethnic minority patients. This suggests provider implicit racial bias likely manifests through their communication behaviors, which in turn may offer a means of addressing racial disparities in healthcare and ultimately in health. However, identifying provider communication behaviors that mediate the links between provider implicit racial bias and patient outcomes is challenging. In this paper, we argue that identifying these provider communication behaviors requires (1) taking into account findings from social psychology research of implicit racial bias and (2) incorporating the perspectives of racial/ethnic minority patients into patient-provider communication research. We discuss the utility of mixed methods research designs as a framework for resolving this complex scientific question. Research that draws on social psychology research of implicit racial bias and incorporates the racial/ethnic minority patient perspectives can inform the development of communication skills training programs for students and residents in various healthcare fields. Such programs are one element of a broader effort to reduce racial/ethnic disparities in healthcare.

Hospital Consumer Assessment of Healthcare Providers and Systems: Do Patient Demographics Affect Outcomes in Total Knee Arthroplasty?

BACKGROUND: The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a nationally standardized tool to assess patient experience between hospitals. The HCAHPS survey can affect hospital reimbursement. This study aims to determine if HCAHPS scores vary by a number of demographic variables in patients undergoing primary total knee arthroplasty (TKA). METHODS: Patients who underwent primary TKA and returned a completed HCAHPS survey were included in this study. HCAHPS surveys were collected from our institution's Center for Quality and Patient Safety department, which was cross-referenced with our hospital's electronic data warehouse. Patient demographics, surgical factors, and quality outcomes were queried, and multivariable linear regression was performed. RESULTS: In total, 1028 HCAHPS questionnaires after primary TKA were evaluated. The average age of patients was 65.9 ± 9.0 years and 67.9% (698 patients) were female. Average body mass index was 32.5 ± 6.9 kg/m2. Sixty-nine percent of the patients (1287 patients) were discharged home versus 10.3% (106 patients) to another facility. Mean length of stay was 2.9 ± 1.4 days. Age was correlated with a 0.3% decrease in top-box response rate (P < .01) for each 1-year increase in age. Compared to Caucasian race, African American race was correlated with a 5.6% increased rate for top-box response (P < .01), while Asian race (P = .42) and unknown race (P = 1.00) demonstrated no significant difference. Marital status demonstrated that divorced/separated status resulted in a significant 5.4% decrease in top-box response rates (P < .05). Similarly, single (P = .12) and widowed (P = .09) statuses also demonstrated a trend toward lower top-box response rates when compared to married or partnered patients. For each day increase in length of stay, HCAHPS top-box response rates decrease by 1.6% (P < .01). Gender, body mass index, smoking status, insurance type, and discharge disposition were not found to be significantly correlated with HCHAPS top-box response rate (P > .05). CONCLUSION: HCAHPS scores in patients undergoing primary TKA are influenced not just by hospital and surgeon factors such as length of stay but by demographic variables such as age, race, and marital status. As surgeons become more involved with the burden of improving patient experience, they should be aware that static demographic variables can have a significant effect on HCAHPS scores.

Antenatal care for Somali-born women in Sweden: Perspectives from mothers, fathers and midwives.

OBJECTIVE: To explore Somali-born parents' experiences of antenatal care in Sweden, antenatal care midwives' experiences of caring for Somali-born parents, and their respective ideas about group antenatal care for Somali-born parents. DESIGN: Eight focus group discussions with 2-8 participants in each were conducted, three with Somali-born mothers, two with fathers and three with antenatal care midwives. The transcribed text was analysed using Attride-Stirling's tool "Thematic networks". SETTING: Two towns in mid-Sweden and a suburb of the capital city of Sweden. PARTICIPANTS: Mothers (n = 16), fathers (n = 13) and midwives (n = 7) were recruited using purposeful sampling. FINDINGS: Somali-born mothers and fathers in Sweden were content with many aspects of antenatal care, but they also faced barriers. Challenges in the midwife-parent encounter related to tailoring of care to individual needs, dealing with stereotypes, addressing varied levels of health literacy, overcoming communication barriers and enabling partner involvement. Health system challenges related to accessibility of care, limited resources, and the need for clear, but flexible routines and supportive structures for parent education. Midwives confirmed these challenges and tried to address them but sometimes lacked the support, resources and tools to do so. Mothers, fathers and midwives thought that language-supported group antenatal care might help to improve communication, provide mutual support and enable better dialogue, but they were concerned that group care should still allow privacy when needed and not stereotype families according to their country of birth. KEY CONCLUSIONS: ANC interventions targeting inequalities between migrants and non-migrants may benefit from embracing a person-centred approach, as a means to counteract stereotypes, misunderstandings and prejudice. Group antenatal care has the potential to provide a platform for person-centred care and has other potential benefits in providing high-quality antenatal care for sub-groups that tend to receive less or poor quality care. Further research on how to address stereotypes and implicit bias in maternity care in the Swedish context is needed.

Characteristics of cataract surgery patients influencing patient satisfaction scores.

PURPOSE: To determine factors that influence patient satisfaction scores in individuals who have recently had cataract surgery. SETTING: Byers Eye Institute, Palo Alto, California, USA. DESIGN: Prospective case series. METHODS: Selected questions from the Press Ganey survey and the National Eye Institute Visual Function Questionnaire-25 were administered to each patient immediately after completion of a clinic visit. The correlation between patient-specific variables and the answer to the survey question "likelihood of recommending our practice to others," a surrogate for overall patient satisfaction, was assessed using the Student t test. A logistical regression model was used to adjust for potentially confounding variables. RESULTS: One hundred forty-three patients were recruited from 4 providers; 57 (39.8%) were men, and the mean age was 70.0 years ± 11.6 (SD). The main outcome was the proportion of scores less than 5, or "very good," for the likelihood of recommending the practice to others. There was a statistically significant association between a non-5 patient satisfaction score and self-reported ethnicity of Asian or Pacific Islander compared with other ethnicities (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.0-5.1; P = .049); other possible correlates were not statistically significant. The relationship persisted after adjustment for potential confounding variables (OR, 2.6; 95% CI, 1.1-6.3; P = .027). CONCLUSION: In postoperative cataract patients, Asian or Pacific Islander ethnicity, a factor out of the control of the provider and clinic staff, was associated with a lower overall Press Ganey patient satisfaction score compared with patients of all other ethnicities.

Inpatient care experiences differ by preferred language within racial/ethnic groups.

OBJECTIVE: To describe differences in patient experiences of hospital care by preferred language within racial/ethnic groups. DATA SOURCE: 2014-2015 HCAHPS survey data. STUDY DESIGN: We compared six composite measures for seven languages (English, Spanish, Russian, Portuguese, Chinese, Vietnamese, and Other) within applicable subsets of five racial/ethnic groups (Hispanics, Asian/Pacific Islanders, American Indian/Alaska Natives, Blacks, and Whites). We measured patient-mix adjusted overall, between- and within-hospital differences in patient experience by language, using linear regression. DATA COLLECTION METHODS: Surveys from 5 480 308 patients discharged from 4517 hospitals 2014-2015. PRINCIPAL FINDINGS: Within each racial/ethnic group, mean reported experiences for non-English-preferring patients were almost always worse than their English-preferring counterparts. Language differences were largest and most consistent for Care Coordination. Within-hospital differences by language were often larger than between-hospital differences and were largest for Care Coordination. Where between-hospital differences existed, non-English-preferring patients usually attended hospitals whose average patient experience scores for all patients were lower than the average scores for the hospitals of their English-preferring counterparts. CONCLUSIONS: Efforts should be made to increase access to better hospitals for language minorities and improve care coordination and other facets of patient experience in hospitals with high proportions of non-English-preferring patients, focusing on cultural competence and language-appropriate services.

Determinants of physician-patient communication: The role of language, education and ethnicity.

AIM: The value of patient-centredness, of which effective physician-patient communication is one key element, has been established within medicine. However, research shows social differences in medical communication according to the patient's social background. This study examines the role of the patient's ethnicity, educational background and language proficiency in relation to physician-patient interaction in 31 countries. METHOD: More than fifty thousand patients were given a standardized questionnaire to gain insights into the professional behaviour of their family physician and their own expectations and actions. RESULTS: While no effect of ethnicity was found, there was a significant effect of patients' language proficiency and educational level. Patients with lower language proficiencies were more likely to experience more negative interactions with their physicians. Second-generation migrants who did not fill in the questionnaire in an official language were more negative about the patient-physician interaction. Patients who had a greater chance of having a positive patient-physician interaction were more likely to be higher educated. CONCLUSION: Despite the shift towards patient-centred care in medicine, physician-patient communication is still determined by the patient's educational background and language proficiency. PRACTICE IMPLICATION: GPs should primarily be trained to tailor their communication styles to match patients' backgrounds.

Racial/ethnic differences in reporting versus rating of healthcare experiences.

Asians are reported to have poorer healthcare experience than non-Hispanic Whites (NHWs), but the sources of the differences are not understood. One explanation is Asian's reluctance to choose extreme responses in survey. We thus sought to compare NHW-Asian differences in responses to healthcare experience surveys when asked to report versus rate their experiences. Patients of an outpatient care system in 2013 to 2014 in the United States were studied. Patient experience surveys were sent after randomly selected clinic visits. Responses from 6 major Asian subgroups and NHWs were included (N = 61,115). The surveys used a combined questionnaire of Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) and Press Ganey surveys. CG-CAHPS questions are framed as "reporting" and Press Ganey questions as "rating" of experiences. We compared the proportion of favorable (or top box) responses to 2 related questions, one from CG-CAHPS and another from Press Ganey, and assessed racial/ethnic differences when using each of the 2 related questions, using a Pearson chi-squared test for independence. All Asian subgroups were less likely to select top box than NHWs for all questions. The Asian-NHW differences in 'rating" questions were larger than the difference in related "reporting" questions. Of those who chose top box to CG-CAHPS questions (e.g., "Yes" on a question asking "Waited < 15 minutes"), their responses to related Press Ganey questions varied widely: 47% to 57% of Asian subgroups versus 67% of NHWs rated wait time as "Very good." The extent of racial/ethnic differences in patient-reported experiences varies based on how questions are framed. The observed poorer experiences by Asians are in part explained by their worse rating of similar objectively measurable experiences.

State Policies And Enrollees' Experiences In Medicaid: Evidence From A New National Survey.

Medicaid provides health insurance to more than seventy million Americans, yet there has been little systematic analysis of what factors influence enrollees' satisfaction with and access to care. Using a nationally representative survey of more than 270,000 Medicaid enrollees in 2014-15, we examined the consumer perspective on care in Medicaid. Average satisfaction ratings were 7.9 out of 10.0, but there were significant disparities across racial/ethnic groups. Satisfaction and access measures were generally similar among enrollees in managed care versus fee-for-service Medicaid. Access was significantly better in states where more physicians per capita accepted Medicaid patients: A one-standard-deviation increase in participating physicians per 100,000 population was associated with a 4.6-percentage-point increase in having a personal doctor. This was particularly true in fee-for-service Medicaid, and measures of physicians per capita were stronger predictors of patient experience than the simple percentage of doctors who accept Medicaid. Among those in Medicaid managed care, greater spending per enrollee was a significant predictor of satisfaction and access. Our findings emphasize that physician availability makes a difference in patients' experiences in Medicaid, and they indicate that racial/ethnic disparities in those experiences persist even among a uniformly insured population.

Health care access and satisfaction in Judean and Samarian communities: opportunities for improving care.

BACKGROUND: There are distinctive potential barriers to optimal health care in Judea and Samaria because of access and satisfaction levels, including obstacles such as its isolation and health care capacity. However, there is a lack of research focusing on health care for the Jewish communities in this region, often referred to as the West Bank. RESEARCH QUESTIONS: What is the level of health care access and satisfaction for Israelis living in the Jewish communities in Judea and Samaria? How do these results compare to parallel results for Israelis in general? How do these results vary by subgroups, in particular by location? METHODS: Two hundred fourty six residents of Judea and Samaria in six diverse, Jewish communities were surveyed, with a 76% response rate. Descriptive analyses were performed for all variables. Bivariate analyses for access and satisfaction measures were performed by key demographic variables. Comparisons were also made with Israelis in general (the vast majority of whom do not live in Judea or Samaria), by comparing our survey results to the results of 2016 Myers-JDC-Brookdale Institute national satisfaction survey. Our survey questions were based on this national survey, tested and used for several cohorts. RESULTS: Of those surveyed, 14% decided to forego treatment because of the distance, although only 3% declined treatment because of cost. There was a diversity of results in terms of satisfaction measures, although in no categories were even half of respondents very satisfied; results ranged from 7% very satisfied with health care system overall to 47% very satisfied with their family physician's attitude. Variations were found by community with local council communities generally, but not always, having the highest satisfaction. Compared to Israelis in general, Israeli residents of Judea and Samaria reported generally lower satisfaction, including 9% fewer being very satisfied with the health plan overall and 10% fewer being very satisfied with referrals. However, 7% more had confidence in getting the best treatment. CONCLUSIONS: Access to care involves more than just coverage. Health care system problems among Israelis living in Judea and Samaria include not just quantity, but quality of services offered. There is a need for improvement not only in health care resources, but also in the level of access and satisfaction in this region.

Interacting With Providers: An Intersectional Exploration of the Experiences of Carers of Aboriginal Children With a Disability.

Intersectionality has potential to create new ways to describe disparities and craft meaningful solutions. This study aimed to explore Aboriginal carers' experiences of interactions with health, social, and education providers in accessing services and support for their child. Carers of Aboriginal children with a disability were recruited from an Australian metropolitan Aboriginal community-controlled health service. In-depth, semistructured interviews were conducted with 19 female carers. Intersectionality was applied as an analytical framework due to the inherent power differentials for Aboriginal Australians and carers for people with a disability. Marginalization and a lack of empowerment were evident in the experiences of interactions with providers due to cultural stereotypes and racism, lack of cultural awareness and sensitivity, and poverty and homelessness. Community-led models of care can help overcome the intersectional effects of these identities and forms of oppression in carers' interactions with providers and enhance access to care.

Spanish Language Concordance in U.S. Medical Care: A Multifaceted Challenge and Call to Action.

Patient-physician language discordance within the growing Spanish-speaking patient population in the United States presents a significant challenge for health systems. The Civil Rights Act, an Executive Order, and federal standards establish legal requirements regarding patients' legal right to access medical care in their language of origin and to culturally and linguistically appropriate services, and national competency standards for undergraduate and graduate medical education and licensing examinations support the importance of patient-physician communication. However, no requirements or guidelines currently exist for medical Spanish educational resources, and there is no standardized process to assess the competency of medical students and physicians who use Spanish in patient care. Relatedly, existing data regarding current medical Spanish educational resources are limited, and Spanish proficiency evaluations are often based on self-assessments. Future efforts should use a multifaceted approach to address this complex challenge. A standardized process for Spanish-language-concordant medical care education and quality assurance should incorporate the validation of medical Spanish educational resources, competency requirements for medical usage of Spanish, an incentivized certification process for physicians who achieve medical Spanish competency, and health system updates that include routine collection of language concordance data and designation of Hispanic-serving health centers.