In a recent article Associate Professor Samson Tse, from the Centre for Asian Health Research and Evaluation at the University of Auckland, says our health system is failing New Zealand's Asian community because it lumps them into a single group and does not address their individual health needs.

Dr Tse says more research is needed to find the reasons behind why communities' health are affected differently and argues that health policies need to be reviewed to take into account that different Asian communities have different needs.

He's completely right but not only do Asian communities have different needs, they also have different expectations of how these needs should be fulfilled.

So, in addition to gaining greater clarity regarding these needs, hospitals must assess levels of satisfaction regarding how these needs are satisfied. Only in this way can the variables leading to dissatisfaction can be identified and subsequently improved.

For the past four years, Health Services Consumer Research has monitored patient satisfaction in New Zealand District Health Boards in the quarterly published "New Zealand Patient Satisfaction Index". This report is based on the nationwide patient survey and draws on a database which presently consists of some 338,478 patient records and 5.5 million ratings from inpatients and outpatients in 21 District Health Boards.

The nation-wide inpatient survey asks inpatients discharged during the previous 14 days a set of 17 questions, 16 of which are specific to the quality of care received. These questions cover issues such as staff availability, quality of information received, informed consent, involvement of family, cultural sensitivity, impressions of cleanliness, quality of food, and feeling safe and secure. A final question asks patients: "Overall, how satisfied were you with our service?" Patients are asked to respond using the Likert-type rating scale: Very poor, poor, average, good, very good.

The data we analysed is based on responses obtained from 154,000 European; 22,630 Maori; 2,980 Pacific and 2,310 Asian inpatients. It shows that while the overall positive response to the question: "Overall, how satisfied were you with our service?" among Asian inpatients is no different from that among European patients - in both cases between 88% and 89% of all patients respond with either "good" or "very good" - a closer analysis reveals that only 50% of Asian patients respond with "very good" compared to 65% of European patients. Asian patients are more likely to respond with "good" (p<.01; see fig Figure 1).

Figure 1 Patient satisfaction among New Zealand inpatients

When we examine the data more specifically in terms of the ethnicity of the respondent we find that Chinese patients, and to a lesser extent Indian patients, are much less likely to respond with "very good" than European patients (p<.01; see Figure 2)

Figure 2 Patient satisfaction by ethnic group

What do we know about age or sex differences? Is the variance between these ethnic groups more salient with older patients or younger patients? Is the difference greater for women or men?
Further analyses of the data show that, compared to European women, Indian women tend to be less likely to express satisfaction (p<.01) whereas the same cannot be said for Chinese women. Among male patients, any difference in satisfaction rates becomes negligible.

With respect to age, Chinese patients with babies or very young infants (i.e. age band 0-4 yrs old) tend to be less satisfied (p<.01) whereas the young adult Chinese (i.e. age band 25-44 yrs) tend to express more satisfaction (p<.01) than their European counterparts. Age does not appear to be a factor influencing satisfaction among Indian inpatients .

When we ask whether this difference in overall satisfaction between Indian/Chinese and European patients is widespread, i.e. across the board, irrespective of DHB, we find that in some DHBs, e.g. Capital & Coast DHB, the difference in percentage terms is significant whereas in other DHBs, e.g. Auckland DHB, the difference is negligible (see Table 1).

Table 1 Difference between overall satisfaction ratings by DHB (Chinese/Indian patients >30)

But it can be argued that a measure of such a general, overall, satisfaction is so wide-ranging as to be somewhat meaningless. So we must ask: "Where do the greatest differences between European and Chinese and Indian patients lie?"

Reviewing responses to more specific aspects of care shows that, compared to European patients, both Chinese and Indian patients tend to be less satisfied with the quality of information they were provided with when they were assessed upon being admitted to hospital or being discharged from hospital (p<.01; see Figure 3).

Figure 3 Responses to "Please rate our Emergency Dept staff on telling you how they would treat your problem"

However, perhaps not unexpectedly, the greatest difference between European patients and Chinese and Indian patients was found to be in their responses to questions that asked them to rate staff on "… offering choices specific to their culture" and on being treated with " …. dignity and respect". With respect to the latter, 70% of European inpatients rated staff as being "very good" at this, compared to 57% of Indian patients and 49% of Chinese patients respectively (p<.01; see Figure 4)

Figure 4 Responses to "Please rate our staff on treating you with dignity and respect"

The situation among New Zealand outpatients is very similar to that of inpatients in that a comparable percentage difference exists between the three ethnicities with respect to an overall level of satisfaction as well as satisfaction with specific aspects of care.

The dataset we based our conclusions on consisted of 154,000 European; 22,630 Maori; 2,980 Pacific and 2,310 Asian outpatients. We found that Indian and Chinese outpatients tended to be less satisfied than European outpatients with the effort staff make on finding them a suitable appointment time, in providing adequate explanation of their condition and information on the possible treatment options, as well as how to manage their condition after their outpatient visit (p<.01).
Again, both cultural minority groups expressed less satisfaction with staff's ability to provide choices specific to their culture and were less likely to say that they were treated with dignity and respect. When asked to rate the cleanliness of the facilities, Chinese outpatients were less likely than European outpatients to respond with "very good" (p<.01).

From the above it is apparent that Indian and Chinese patients are less likely than European patients to express satisfaction with the quality of their care in New Zealand hospitals and outpatient clinics. However, whether this difference in satisfaction rating accurately reflects the standard of care or is an artefact of these two cultural groups having greater expectations is a moot point. Either way, if our objective is to meet patients' expectations regardless of any expectation they may have, it is clear that the standard of care in our medical facilities must improve for all patients.