Evidence
Sixty-one studies were identified that examined the relationship between patients’ socio-economic and demographic characteristics and their reported satisfaction with healthcare. These studies were observational in design and included one meta-analysis. They focused on a range of different issues, used a variety of methods, and ranged in size from 52 respondents to over 50,000. The main features and findings of these studies are summarised in Table 20 in alphabetical order of first author.
Gender
No firm conclusions may be drawn about the relationships between reported satisfaction and gender. Among the 39 studies that investigated this issue: women were significantly more satisfied in six (15.4%); men were significantly more satisfied in seven (17.9%); and the relationship was not significant in 26 (66.7%). Any consideration of the effect of gender on satisfaction would need to account for the different patterns of healthcare utilisation by men and women.
Age
The findings of the 58 studies that investigated the relationship between reported satisfaction and age confirmed the conventional wisdom: older
46 TABLE 20 Summary of studies investigating the relationship between patients’socio-economic and demographic characteristics,and satisfaction ReferenceCountryContextNo.MethodFocusGenderAgeRaceSocio- SettingDesignresponseseconomic Al-Bashir and UKEmpirical760InterviewPeople’s priorities–Preferences vary–– 232 Armstrong,1991General practiceObservationalwith age Anderson and USAEmpirical134TelephoneNature of relationship –nsnsLess well educated 287 Zimmerman,1993Ambulatory careObservationalwith doctormore satisfied Annandale and UKEmpirical985InterviewDisagreementsnsns–Non-manual more 222 Hunt,1998Healthcare in generalObservationaldisagreements 116 Avis et al.,1997UKTheoretical89InterviewSatisfaction (qualitative)ns––– Hospital outpatientObservational 267 Baker,1996UKEmpirical19,450Questionnaire Consultation satisfactionMen moreOlder more–– General practiceObservationalin clinicsatisfiedsatisfied Bartlett et al.,USAEmpirical63TelephoneInterpersonal skills ––Black people Better educated 288 1984Ambulatory careObservationalof physicianless satisfiedless satisfied Bertakis et al.,USA,CanadaEmpirical550Questionnaire Physician communicationWomen more Older more White people Higher income more 234 1991Primary careObservationalin clinicskillssatisfied on satisfiedmore satisfiedsatisfied on inter- emotional scalepersonal scale Bruster et al.,UKPragmatic5,150InterviewIn-hospital problemsWomen more Younger more Non-white Social class and 251 1994In hospitalObservationalproblemsproblemspeople more income ns problems 352 Bryson,1996UKPragmatic3,633Interview and NHSWomen more Older more –– Medical care in generalObservationalquestionnairesatisfiedsatisfied 241 Carmel,1985IsraelEmpirical476InterviewSatisfaction with services–Older more –– In hospitalObservationalsatisfied 238 Cleary et al.,1989USAEmpirical598MailIn-hospital carensns–– In hospitalObservational 239 Cleary et al.,1991USAEmpirical6,455TelephoneProblems–Older less Non-white Poorer more problems In hospitalObservationalproblemspeople more problems 237 Cleary et al.,1992USAEmpirical6,455TelephoneProblems and satisfaction–Older less satisfied,nsIncome ns In hospitalObjectivemore problems continued
TABLE 20 contd Summary of studies investigating the relationship between patients’socio-economic and demographic characteristics,and satisfaction ReferenceCountryContextNo.MethodFocusGenderAgeRaceSocio- SettingDesignresponseseconomic 223 Cohen,1996UKEmpirical2,569MailDissatisfactionWomen more Older less –Manual groups less Hospital inpatient/Observationaldissatisfied dissatisfiedsatisfied outpatient(marginal) Comstock et al.,USAEmpirical150Questionnaire Physician inter-nsOlder more ns– 279 1982Hospital outpatientObservationalin clinicpersonal skillssatisfied Coyle et al.,UKEmpirical2,783MailSatisfaction with servicesnsOlder more –Less well educated 263 1992Primary careObservationalsatisfiedmore satisfied Department of UKPragmatic50,000MailPatient experiencesns<45 years Ethnic minorities Social class 264 Health,1999General practiceObservationalless satisfiedless satisfiedns DiMatteo and Hays,USAEmpirical329Questionnaire Physician services–Older more –Technical skill 290 1980Family practiceObservationalin clinicsatisfiedimportant to higher social groups Eguskiza et al.,SpainEmpirical420InterviewPhysician inter-–Older more –Less well educated 247 1995Primary careObservationalpersonal skillssatisfiedmore satisfied Esteban de la Rosa SpainEmpirical2,483InterviewSatisfactionnsYoung less –Better educated 235 et al.,1994Healthcare in generalObservationalsatisfiedless satisfied Etter and Perneger,SwitzerlandPragmatic720MailSatisfaction:nsnsNon-Swiss – 250 1997Ambulatory careObservationalvarious aspectsless satisfied (Natural experiment) Fitzpatrick and UKEmpirical95InterviewConsultationnsns–Education,social class 291 Hopkins,1981Hospital outpatientObservationalns 229 Fleming,1981USATheoretical589InterviewSatisfaction:–Older less –– In hospitalObservationalvarious aspectscritical Fox and Storms,USATheoretical2,582TelephoneSatisfactionWomen more Older more nsLower income, 297 1981Healthcare in generalObservationalsatisfiedsatisfiedless well educated ns Greenley et al.,USATheoretical366InterviewSatisfaction:physician nsOlder more White people Income ns 230 1982Primary careObservationaland servicesatisfiedmore satisfiedLess well educated Hospital outpatientmore satisfied continued 47
48 TABLE 20 contd Summary of studies investigating the relationship between patients’socio-economic and demographic characteristics,and satisfaction ReferenceCountryContextNo.MethodFocusGenderAgeRaceSocio- SettingDesignresponseseconomic 224 Gross et al.,1998USAEmpirical2,315Questionnaire Time spent nsOlder more White people Education ns Primary careObservationalin clinicwith physiciansatisfiedmore satisfied Hall and Dornan,International Empirical110StudiesSatisfactionnsOlder more nsMore education less 316 1990Healthcare Reviewsatisfiedsatisfied in generalHigher social class, income ns Halpin SchaufflerUSAEmpirical5,432MailHealth education –ns–Education ns 270 et al.,1996Primary careObservationalby doctor 211 Harvey et al.,1999USAEmpirical266Interview and General satisfaction–Older more –Education ns Ambulatory careObservationalquestionnairesatisfied Hjortdahl and NorwayEmpirical3,044MailSatisfaction with doctor nsns–– 280 Laerum,1992General practiceObservationaland overall Hopton et al.,UKEmpirical1,599QuestionnaireConsultationnsYounger more White people Social class ns 225 1993General practiceObservationalin clinicdissatisfiedmore satisfied Hsieh and Kagle,USAEmpirical401MailSatisfaction Women more Older and youngerNon-white people – 194 1991Primary careObservational(6 dimensions)satisfiedmore satisfiedless satisfied (marginal) 302 Hulka et al.,1971USAEmpirical254InterviewSatisfaction with doctor nsnsnsBetter educated Healthcare in generalObservationaland servicesmore satisfied 303 Hulka et al.,1975USAEmpirical1,713InterviewSatisfactionWomen more Young more White people Social class ns Healthcare in generalObservationalsatisfieddissatisfiedmore satisfied Jackson et al.,USAEmpirical500In clinic Satisfaction–Older more –– 150 2001Ambulatory careObservationaland mailsatisfied 243 Kane et al.,1997USATheoretical2,116MailSatisfaction with hospital –Younger more nsBetter educated In hospitalObservationaland doctorsatisfiedmore satisfied Income ns Kasteler et al.,USAEmpirical576Interview“Doctor shopping”–––More high-income 123 1976Healthcare in generalObservationalpeople “doctor shop” continued
TABLE 20 contd Summary of studies investigating the relationship between patients’socio-economic and demographic characteristics,and satisfaction ReferenceCountryContextNo.MethodFocusGenderAgeRaceSocio- SettingDesignresponseseconomic 206 Kerr et al.,1998USAEmpirical17,196TelephoneDesire to disenrolWomen more nsnsHigher income/lower Healthcare in generalObservationallikely to want education more/less to leavelikely to want to leave Khayat and Salter,UKPragmatic2,173MailSatisfactionWomen less Younger less –Home owners,higher 71 1994General practiceObservationalsatisfiedsatisfiedsocial classes less satisfied 213 Korsch et al.,1968USAEmpirical800InterviewPatient–doctor –––Social class, Ambulatory careObservationalinteractioneducation ns 298 Krupat et al.,2000USAEmpirical453MailPatient centrednessnsnsnsEducation ns Primary careObservational 240 Krupat et al.,2000USAEmpirical3,602InterviewProblem–Older less –– In hospitalObservationalproblems Like and Zyzanski,USATheoretical144Questionnaire Aspects of clinical Women more –nsEducation,income ns 216 1987Ambulatory careObservationalin clinicencountersatisfied Linder-Pelz and USATheoretical155Questionnaire SatisfactionnsOlder more nsBetter educated 197 Stewart,1986Ambulatory careObservationalin clinicsatisfiedmore satisfied 204 Linn,1975USAEmpirical1,739QuestionnaireHealthcare encounternsOlder more Black and His- Less well educated Ambulatory careObservationalin clinicsatisfiedpanic people more satisfied more satisfied Linn and Greenfield,USAEmpirical519MailSatisfactionnsOlder more Non-whiteEducation ns 226 1982Hospital outpatientObservationalsatisfiedpeople more satisfied 265 Malbon et al.,1999UKEmpirical1,139TelephoneSatisfaction–Older more –Social class ns General practiceObservationalsatisfied Nelson and Larson,USAEmpirical2,160MailGood and bad surprises–Older more –Better educated 199 1993In hospitalObservationalsatisfiedless satisfied 228 Patrick et al.,1983UKEmpirical1,000InterviewSatisfactionWomen more Older less –Social class ns Healthcare in generalObservationaldissatisfieddissatisfied continued 49
50 TABLE 20 contd Summary of studies investigating the relationship between patients’socio-economic and demographic characteristics,and satisfaction ReferenceCountryContextNo.MethodFocusGenderAgeRaceSocio- SettingDesignresponseseconomic 249 Pilpel,1996IsraelEmpirical148InterviewSatisfactionnsOlder less satisfied–Better educated In hospitalObservationalless satisfied 227 Rogut et al.,1996USAPragmatic3,423TelephoneProblems with inter-–Younger more Minorities (not Low earners more In hospitalObservationalpersonal careproblemsblack,Hispanic) problems more problems 248 Segest,1988DenmarkEmpirical2,320InterviewDissatisfaction–Older less –Better educated Healthcare in generalObservationaldissatisfiedless dissatisfied 201 Sixma et al.,1998NetherlandsTheoretical13,014InterviewSatisfactionnsOlder more –– General practiceObservationalsatisfied 236 Soh,1991USAEmpirical1,210InterviewSatisfactionnsnsnsBetter educated Healthcare in generalObservationalmore satisfied 295 Stiles et al.,1979USAEmpirical52Questionnaire Physician nsnsnsEducation ns Primary careObservationalin clinicinteraction Thomas et al.,UKEmpirical1,559MailNursing experiences–Older more –Education ns 155 1996In hospitalObservationalsatisfied 281 Treadway,1983UKEmpirical81InterviewConsultationnsOlder more –Education social General practiceObservationalsatisfiedclass ns 114 Weiss,1988USATheoretical400InterviewsPhysician characteristicsnsnsnsEducation,income ns Primary careObservational Williams and UKEmpirical357MailAspects of general –Older more –Social class, 269 Calnan,1991General practiceObservationalpracticesatisfiededucation ns Wilson et al.,UKEmpirical893Questionnaire Interpersonal aspects Men moreOlder more –– 231 1995Primary careObservationalin clinicof consultationsatisfiedsatisfied 48 Zapka et al.,1995USAPragmatic3,151MailOverall satisfactionnsOlder more Minorities less Income ns Healthcare in generalObservationalsatisfiedsatisfiedBetter educated less satisfied ns,not significant;–,variable not investigated
51 respondents were significantly more satisfied in 41
(70.7%); younger respondents were significantly more satis-fied in four (6.9%); and the relationship was not significant in 13 (22.4%).
Various explanations are advanced for the reason why older people generally report higher satis-faction, and research is required to investigate these further. It may reflect generational or life-cycle effects: that older people are more stoical and accepting than the young, or that they engender more respect and care from their providers. Alternatively, it may be a cohort effect and that they have lower expectations based on prior experiences when standards were lower. A study of users’ preferences showed significant differences between younger and older groups.232 There are particular circumstances that may explain findings that do not support the trend.
In one study, satisfaction was polarised, being highest in the very young age group as well as among the oldest.194Three other studies all focused on hospital inpatients. One showed that younger surgery patients were more satisfied 6 months after discharge than those who were older. This study also showed that health status correlated with satisfaction.243In another study, older patients reported more sources of dissatis-faction with their hospital stay, but this was exclusively due to their extensive communication problems. In all other areas the younger patients complained more.237The final study concentrated heavily on interpersonal aspects of care, which may have resulted in the lower recorded satisfaction among elderly patients.249
Racial, ethnic and minority groups
A total of 29 studies were carried out that investi-gated the relationship between race or ethnicity and satisfaction. This was found to be significant in 15 cases. In 11 (73.3%) of these studies, black and other visible minority groups were found to be less satisfied. In two studies of chronically sick outpatients, non-white people (terminology used by article) were more satisfied.204,226One study showed significant differences between various minority groups.227In the last investigation, set in Switzerland, non-Swiss ambulatory patients were found to be less satisfied with the care they received than the indigenous population.250
Socio-economic status
Several indicators of socio-economic status were used across the studies. In general, the findings about the relationships between socio-economic indicators were inconsistent and inconclusive.
The effect of level of education on satisfaction was considered by 31 investigators. Education was not found to have a significant influence on satis-faction in 15 (48.3%) studies. Higher levels of education were associated with significantly less satisfaction in 11 (35.4%) studies, and significantly more satisfaction in five (16.2%).
The differences between manual and non-manual workers or between social classes was investigated in 15 studies. No significant differences in satisfaction were observed by 12 investigators. Of the other three, non-manual groups were significantly more dissatisfied in two71,222and manual groups were significantly less satisfied in the other.223
The effect of income on reported satisfaction was explored in 14 studies. It was not significant in nine cases. Higher income has been associated with greater satisfaction with doctors’ inter-personal communication skills234and people with lower incomes have been observed to report more problems with in-hospital stays.227,239In two investigations, set in the USA, higher income groups were more likely to want to change their health plan.123,206
Discussion
With the exception of age, evidence on the effect of socio-economic and demographic factors on satisfaction is equivocal. A high proportion of investigators found these factors to be non-significant independent influences on satisfaction.
However, investigators should be aware of the potential significance of background variables such as these on satisfaction outcomes, and routinely incorporate them as covariates in their study designs. An understanding of the characteristics of the study sample enables subgroup analyses and informs the targeting of follow-up actions.
Further research
About one half of the studies identified in this group were specifically orientated towards investigating the relationship between socio-economic and demographic features and satisfaction. In the others, these variables were included as confounding factors and analysed in an essentially empirical manner. Further research of a more theoretical nature may be warranted to probe how and why socio-economic and demo-graphic factors may influence satisfaction in a range of conditions and settings. Such investi-gations may lend themselves to qualitative approaches, which were not well represented in the present sample.
52
A particular area requiring investigation is the way in which socio-economic and demographic factors influence expectations. Some conceptual models of satisfaction position expectations as intervening variables. They acknowledge their significance as determinants of reported satisfaction, but argue that expectations are influenced by the social, cultural, economic and demographic characteristics of the respondents. Rigorous analyses of the relationship between background variables, expectations and satisfaction are required. These need a firm theoretical basis and sound testing, using both qualitative and quantitative approaches.