Keywords

Accessibility; Financial aspects; Health care; New mothers; Patient satisfaction; Stigma; Substance use disorder

Introduction

Access to affordable health care is a right - not a privilege - that many Americans are at risk of losing with the controversial push to repeal the Affordable Care Act (ACA). While various populations of Americans teeter on the brink of losing their health care coverage and could potentially face skyrocketing costs, vulnerable populations such as the elderly, those with disabilities, and lowincome families will be left without affordable and accessible health care. This also poses a grave concern for individuals with pre-existing mental and behavioural health conditions. As Saloner, Bandara, Bachhuber, and Barry [1] purported, individuals diagnosed with mental health and substance use disorders (SUDs) face barriers to obtaining health care coverage that lend to their low levels of treatment engagement; not to mention these barriers might also affect quality of care and negatively impact their patient satisfaction levels.

Within the ACA, federal law requires insurers to cover mental health and substance abuse treatment the same as they would other types of health care services, and it expands the Medicaid program [2]. However, House Republicans’ recent passing of the American Health Care Act (AHCA) has drawn a great deal of contention as it reduces protections for individuals with preexisting conditions, and will greatly affect health care affordability and accessibility for vulnerable populations. The AHCA paints the picture of a grim future of health care for New Jerseyans as the MacArthur Amendment threatens to eliminate health care coverage for more than 500,000 residents over the next three years, and supports major cuts to the Medicaid program [3]. The AHCA will have a great impact on individuals with disabilities and low-income families, and there is also a concern that it will have a detrimental effect on women’s health. Determining how the AHCA will affect vulnerable populations begs the question, what is the future of health care for pregnant and new mothers with SUDs who are already reluctant to engage in care and often report lower patient satisfaction ratings than non-substance using new mothers?

The assessment of patient satisfaction has become a growing practice in the health care industry as professionals and researchers seek to explore what factors influence a patient’s engagement, compliance, and retention in care. Rightfully so, the opinions and experiences of individuals seeking or engaging in care are increasingly being considered in the effort to reform health care. Not to mention, patient satisfaction ratings are also being used to determine compensation rates for health care providers. As noted in previous studies, patient satisfaction is derived of an amalgamation of several components that patients assess to establish a rating [4-8]. Hence, those electing to study patient satisfaction must consider the patient’s experiences in each of its various dimensions which include general satisfaction, technical quality, interpersonal manner, communication, time spent with doctor, financial aspects, and accessibility and convenience to develop a comprehensive understanding of how these factors have an impact on the health care experience.

A patient’s satisfaction with care is based on his/her perceptions of equity, accessibility, affordability, and quality [9,10]. And with growing efforts to correlate quality of care with patient outcomes, patient satisfaction is now being measured across various patient populations; yet, one group of patients continues to be overlookednew mothers with SUDs. Past studies acknowledge that pregnant women with SUDs tend to avoid engaging in pre- and postnatal care because they fear being stigmatized and/or discriminated against. Unfortunately, pregnant substance abusers have been known to employ various “strategies” to prevent the detection of their SUDs, and often skip their prenatal care appointments to avoid having to disclose their conditions and reduce their providers’ abilities to uncover their disorders [11]. While research findings support the belief that stigma has detrimental effects on treatment-seeking behaviours in individuals with mental illness, the same is true for those battling addiction [12]. Poor treatment engagement and compliance with prenatal care is a common challenge in vulnerable groups like pregnant substance abusers. However, international studies have found that patient-centered practices increase satisfaction within the various dimensions of prenatal care, promote better patient outcomes, improve health care compliance rates, strengthen the provider-patient relationship, and promote continued engagement in care within this population [13].

Ford [4] conducted a study on new mothers with and without SUDs to determine whether differences existed between their overall patient satisfaction levels. Within the study, Ford highlighted the social-interactive dimensions of patient satisfaction, which include general satisfaction, technical quality, interpersonal manner, communication, and time spent with doctor. Findings indicated that new mothers with SUDs reported lower levels of patient satisfaction than non-substance using new mothers in each of the dimensions analysed, reporting mean patient satisfaction levels of 2.8 and 3.6 respectively.

Based on the study’s results, Ford [4] was able to infer that new mothers with SUDs may not be treated with the same quality of care as their non-substance using peers, falling short of meeting their patient-centered expectations. Ford also inferred that due to their low levels of patient satisfaction, new mothers with SUDs are more likely to avoid pre- and postnatal care or receive care late in their pregnancies because they fear being stigmatized for their conditions. Ford noted that her study was limited in that it did not assess the participants’ satisfaction with health care affordability and accessibility, which are two very important components that contribute to an individual’s overall patient satisfaction rating.

Financial aspects

The cost of health care services can have positive effects on patient satisfaction [9]. In fact, most people seek to obtain reliable and affordable health care coverage that reduces or eliminates their out-of-pocket expenses. Studies indicate that patients are more satisfied with providers that assist them with accessing resources that will cover their medical expenses [9,14-16]. However, sometimes patients still find themselves basing their health care decisions on the amount that their treatment will cost. As it pertains to vulnerable populations being able to afford quality, patient-centred care, Mead et al. conducted focus groups to explore underserved patients’ perspectives on patientcentred primary care and found that “affordable care meant more to the groups than just wanting lower out-of-pocket costs. It also represented an approach to care where providers were sensitive to a patients’[sic] insurance status or ability to pay [sic] but did not allow these constraints to dictate treatment decisions” (p. 76).

Federally qualified health centers

Fortunately, vulnerable populations in the United States, with limited or no income, can obtain health care services at a federally qualified health centre (FQHC). FQHCs provide primary and preventative health care services to patients regardless of whether they can afford to pay; and patients seeking care are not required to have health insurance. Federal statutes require that FQHCs be in low-income communities or in areas where a medically underserved population exists. Not only do FQHCs make health care more accessible to the uninsured, they also increase accessibility for patients with Medicaid, Medicare, and private insurance, etc. Thus, new mothers with SUDs can obtain care at a FQHC and receive services without incurring the burden of cost that patients with private insurance might be responsible for after receiving care at a private doctor’s office, as health care services are also offered on a sliding fee scale through these entities. This factor could contribute to higher patient satisfaction levels.

Accessibility and convenience

Hennessy noted that just because there are several providers located in a certain region, that does not mean that individuals in that region are receiving sufficient health care services. As if having to deal with the stigma of being a mother with a SUD and limited finances are not already two strikes against them, new mothers with SUDs in Southern New Jersey face a barrage of other barriers that limit their access to care. For example, there is a very small number of prenatal care providers in Southern New Jersey who specialize in caring for pregnant women with SUDs. Furthermore, patients who receive care from a FQHC sometimes encounter challenges accessing specialized care or scheduling appointments in a reasonable timeframe, and spend more time in overcrowded lobbies waiting to see the doctor than they would if they received care at a private practice. These barriers may affect the patient-centred experience and a patient’s overall satisfaction with care.

Primary provider theory

The primary provider theory (PPT) [17] was adopted for this study as its tenets have been supported in research studies that have investigated the effects of patient-centred care on patient satisfaction. PPT was formally tailored to measure patientcenteredness and satisfaction within the minority patient population [18]. This generalizable theory can be applied across various sectors of care and has been used in previous studies that explored how the dynamics of the provider-patient relationship influences patient satisfaction in underserved populations such as pregnant women on Medicaid [19].

Methodology

The current study was conducted using survey methodology. This method was chosen because it is effective for helping researchers increase their understanding of how an individual can influence or be influenced by the interactions that occur within his/her environment. Surveys enhance researchers’ abilities to collect sociological, demographical, and statistical data [20]. The Patient Satisfaction Questionnaire Short-Form [21] was utilized in this study to collect data on participants’ satisfaction levels in the financial aspects and accessibility and convenience dimensions.

Procedures

Site authorization letters were mailed to various inpatient and outpatient substance abuse treatment centres and parenting education programs located throughout three Southern New Jersey counties. Once authorization was granted, the researcher conducted two visits at each of the participating sites for recruitment and survey administration purposes. During survey administration, each participant was given a numerically-coded packet that contained the adult informed consent form and a demographic sheet. A survey administration script was used to facilitate the step-by-step data collection process.

Research design

The researcher hypothesized that new mothers with SUDs would report lower patient satisfaction levels in the financial aspects and accessibility and convenience dimensions than those without a SUD. The study was conducted using a descriptive research approach. A correlational research design was employed to measure differences in new mothers with SUDs and nonsubstance using new mothers’ patient satisfaction levels in the financial aspects and accessibility and convenience dimensions. This non-experimental research design was chosen because it enhanced the researcher’s ability to examine relationships amongst the variables the independent variable (IV) being diagnostic status (substance use disordered and non-substance use disordered), and the dependent (DV) variable being patient satisfaction level (higher, lower or equal to).

Participants

A power analysis was completed to estimate a reasonable sample size, and results from the analysis indicated that a sample size of 50 participants for each group would be sufficient for this study. The researcher utilized a non-probability, purposive sampling design to recruit 106 substance-using and non-substance using new mothers, ages 18-40. Participants were recruited from five substance abuse treatment and parenting education programs located throughout the three target counties. Demographic data such as SUD status, age, race, and county of residence was collected.

Measures

The PSQ-18 was used to measure the DV. This tool was originally designed to measure seven dimensions of patient satisfaction, but for the purposes of the current study, only two dimensions (financial aspects and accessibility and convenience) of the patients’ responses were analysed. The PSQ-18 is a Likert-type scale that poses questions in the form of opinions to garner a response from the participant that highlights his/her satisfaction or dissatisfaction with that dimension of care. Responses are rated as strongly agree (SA), agree (A), uncertain (U), disagree (D) or strongly disagree (SD).

A patient’s satisfaction with the financial aspects of care is assessed through his/her responses to items 5 and 7. Satisfaction with accessibility and convenience is measured via items 8, 9, 16, and 18. The statements on the PSQ-18 for the dimensions of focus are: “I feel confident that I can get the medical care I need without being set back financially” (item 5); “I have to pay more for my medical care than I can afford” (item 7); “I have easy access to the medical specialists I need” (item 8); “Where I get medical care, people have to wait too long for emergency treatment” (item 9); “I find it hard to get an appointment for medical care right away” (item 16), and “I am able to get medical care whenever I need it” (item 18).

Data analysis

Descriptive statistics and one-way ANOVA were used to analyse correlations between the independent and dependent variables. Assumptions for ANOVA were tested using homogeneity of variance. Inferential statistics were also employed in this study to enhance the researcher’s ability to generalize about the population from which the sample was drawn.

Results

Descriptive statistics were used to summarize the scores of the participants’ patient satisfaction levels in the financial aspects and accessibility and convenience dimensions highlighted in Table 1. Patient satisfaction levels were analysed based on SUD status, age, and county of residence. The mean patient satisfaction level in financial aspects was 3.66 (SD=1.06), while the mean patient satisfaction level in accessibility and convenience was 3.20 (SD=0.92). These findings indicate that new mothers with and without SUDs have higher patient satisfaction levels in the financial aspects dimension than in accessibility and convenience.

Table 1: Descriptive Statistics of Patient Satisfaction Levels.

Table 2 demonstrates the descriptive statistics for patient satisfaction levels grouped by SUD. As the table indicates, the mean satisfaction levels of participants who reported having a SUD were lower than those who did not have a SUD. Interestingly, it should be noted that new mothers with SUDs had higher patient satisfaction ratings in the financial aspects dimension (mean=3.47) than they did in accessibility and convenience (mean=2.80).

Table 2: Descriptive Statistics of Patient Satisfaction Levels by SUD.

Table 3 highlights the frequency of the participants’ ratings of each statement in the financial aspects dimension. Of the 50 participants who were diagnosed with a SUD, 50% strongly agreed and agreed with item 5, “I feel confident that I can get the medical care I need without being setback financially”, whereas 34% of participants disagreed and strongly disagreed. Approximately 72% of participants with SUDs disagreed and strongly disagreed with item 7, “I have to pay for more of my medical care than I can afford”, indicating that new mothers with SUDs have a high level of satisfaction with the financial aspects of care. Slightly more than 80% of new mothers without SUDs strongly agreed and agreed with item 5, while seventy-five percent disagreed and strongly disagreed with item 7, demonstrating that this group is also highly satisfied with the affordability of their health care.

Table 3: Frequency of Participants’ Ratings in the Financial Aspects Dimension.

Table 4 depicts the participants’ ratings in the accessibility and convenience dimension. Of the 50 participants who reported having a SUD, 48% strongly agreed and agreed with item 8, “I have easy access to the medical specialists I need”. Sixty-four percent of participants in this group strongly agreed and agreed with item 9, “Where I get medical care, people have to wait too long for emergency treatment”. Results also indicate that fifty-eight percent of participants strongly agreed and agreed with item 16, “I find it hard to get an appointment for medical care right away”, while 40% of participants disagreed and strongly disagreed with item 18, “I am able to get medical care whenever I need it”.

Table 4: Frequency of Participants’ Ratings in the Accessibility and Convenience Dimension.

It is important to note that new mothers without SUDs tended to report higher patient satisfaction ratings as it relates to accessibility and convenience. For example, 78.4% strongly agreed and agreed with item 8; 42.9% strongly agreed and agreed with item 9; 51.8% disagreed and strongly disagreed with item 16; and 12.5% disagreed and strongly disagreed with item 18.

One-way ANOVA was completed to explore differences in patient satisfaction levels by different age group. A level of significance of 0.05 was used in the ANOVA. Results in Table 5 showed that the variances of the patient satisfaction levels in the financial aspects (Levene (4, 101) =1.91, p=0.12) and accessibility and convenience (Levene (4, 101) =0.99, p=0.42) dimensions were equal or homogeneous across the different age groups of the participants. In Table 6, one-way ANOVA results showed that patient satisfaction levels in both the financial aspects (F (4, 101) =1.51, p=0.21) and accessibility and convenience (F (4, 101) =1.81, p=0.12) dimensions were not significantly different across the age groups of the new mothers.

Table 5: Test of Homogeneity of Variances Results of Patient Satisfaction Levels by Age.

Table 6: One-way ANOVA Results of Difference of Patient Satisfaction Levels by Age.

The researcher also explored differences in patient satisfaction levels in the participants by county of residence. One-way ANOVA results in Table 7 showed that the variances of the patient satisfaction levels in financial aspects (Levene (2, 103) =0.75, p=0.48) and accessibility and convenience (Levene (2, 103) =0.19, p=0.83) were equal or homogeneous across the three different counties. Results highlighted in Table 8 indicate that patient satisfaction levels in both the financial aspects (F (2, 103) =1.43, p=0.25) and accessibility and convenience (F (2, 103) =1.38, p=0.26) dimensions were not significantly different across counties.

Table 7: Homogeneity of Variances Results in Patient Satisfaction Levels by County of Residence.

Table 8: One-way ANOVA Results for Differences in Patient Satisfaction Levels by County of Residence.

Discussion

As Ford [4] noted, affordability and accessibility are two very important factors that should be considered when attempting to measure patient satisfaction. This study’s results indicate that there is a strong need for researchers to design more studies - quantitative and qualitative - to explore how these factors influence patient satisfaction in vulnerable populations like new mothers with SUDs. Perhaps special attention should be devoted to identifying the elements that negatively influence this population’s perception of accessibility and convenience and how this area can be improved. This study analysed 106 participants’ responses to the PSQ-18 to investigate whether new mothers with SUDs would report lower satisfaction ratings in the financial aspects and accessibility and convenience dimensions of patient satisfaction than those without a SUD. Findings demonstrated that new mothers with SUDs have lower levels of satisfaction in both financial aspects and accessibility and convenience than their non-substance using peers.

Although it was not formally hypothesized, it was expected that participants with SUDs would be more content with the financial aspects of care than they would with accessibility and convenience. Results supported this notion, and interestingly, it was found that both groups of participants reported higher patient satisfaction levels in financial aspects than the latter. There are sixteen FQHCs located throughout the three counties targeted in this study, so it is very possible that having access to resources provided through the FQHCs, and Medicaid or other public insurance programs increased the participants’ satisfaction with affordability. These findings support those identified in the research conducted by Mead et al. [14].

The outcomes of this study substantiate that there are underlying factors that affect new mothers with SUDs access to care, but a lack of qualitative feedback makes those factors difficult to pinpoint. Not only do results demonstrate that new mothers with SUDs have lower patient satisfaction ratings in the affordability and accessibility dimensions than their non-substance using peers, they are also indicative that patients’ long waiting room periods, limited access to medical specialists, and inability to schedule appointments when needed are deterrents to their engagement in care. Clearly, a patient’s ability to access care can affect when and how often she uses services, and her overall patient satisfaction. Per Saurman [22], “Access is about enabling a patient in need to receive the right care, from the right provider, at the right time, in the right place, dependent on context” (p. 1). Much of what could change these women’s perceptions and experiences for the better are deeply seeded in the perceptions and behaviours of their providers, and in the resources, that are available to them. Therefore, it is imperative that health care providers be mindful that pregnancy is not only a motivator for seeking treatment, but it is also a stressor that compounds these women’s existing physical, mental, and behaviourals health conditions. Providers should work with their patients to establish realistic, patient-centered treatment goals and expectations [23]. They should also be more willing to help their patients identify and access the resources that they need to ensure continuity of care, and to help improve their satisfaction with health care accessibility and convenience.

Limitations and recommendations for future research

A major limitation of this study was associated with its research design. This study’s quantitative format did not offer the researcher the ability to gain an understanding of how the participants’ lived experiences affected their perceptions of care and influenced their patient satisfaction levels. Another limitation was that the researcher was unable to recruit an equal number of participants from each of the three target counties. Hence, the small, unequally distributed sample made it difficult to generalize this study’s findings across populations. The results of the current study would have been more impactful if the researcher had solely recruited new mothers on Medicaid receiving health care services at a FQHC and analysed their responses to the PSQ-18.

Demographic data such as type of insurance coverage and type of practice where care was received (i.e., clinic, private practice, emergency room, etc.,) would have added depth to the analyses, but that information was not collected for this study [23].

Future qualitative research studies should be conducted to explore pregnant and new mothers with SUDs’ lived health care experiences. It is worth exploring the broader challenges that influence motivational components such as readiness, willingness, and ability to access care in pregnant and new mothers with SUDs, and the factors that have an impact on their treatment initiation, engagement, and adherence with services. Doing so could expand the breadth of knowledge in substance abuse research by uncovering more of the elements that negatively influence patients’ treatment-seeking behaviours, and provide professionals with a more comprehensive understanding of their needs.

Conclusion

There are a number of barriers that impede new mothers with SUDs from engaging in and complying with health care services. Stigma, discrimination, isolation, social rejection, provider bias, and even self-stigmatization are just a few challenges that negatively affect these women’s ratings in the social-interactive dimensions of patient satisfaction. This study demonstrated that although new mothers with SUDs reported overall lower levels of satisfaction with financial aspects and accessibility and convenience than their non-substance using peers, they often had higher ratings in the financial aspects dimension of care. Outcomes indicate that health care satisfaction extends far beyond the patient’s social interactive experiences, and that accessibility and affordability are two major contributors to overall satisfaction that should not be overlooked. Although the findings suggest that new mothers with SUDs report higher levels of satisfaction in the financial aspects of care, their opinions are very likely to change because of the looming threat of the AHCA, which is bound to push this vulnerable population even further back into the shadows of poor health care affordability, accessibility, and engagement.

References

1. Bandara S, Bachhuber M, Barry CL (2017) Insurance coverage and treatment use under the affordable care act among adults with mental and substance use disorders. Psychiatric Services.
2. Johns Hopkins Bloomberg School of Public Health (2017) More with mental illness, substance use disorders have health insurance. Science Daily.
3. Castro R (2017) The American health care act would cause nearly half a million New Jerseyans to lose health coverage. New Jersey Policy Perspective.
4. Ford VL (2016) Measuring patient satisfaction in new mothers with substance use disorders: A correlative investigation. Heal Sci J 10: 1-8.
5. Ford RC, Sivo SA, Fottler MD, Dickson D, Bradley K, et al. (2006) Comparing hospital staff and patient perceptions of customer service: A pilot study utilizing survey and focus group data. Heal Ser Man Res 19: 52-66.
6. Fottler MD, Ford RC, Roberts V, Ford EW (2000) Creating a healing environment: The importance of the service setting in the new consumer-oriented health care system. J Heal Care Man 45: 91-107.
7. Otani K, Waterman B, Dunagan WC, Ehinger S (2012) Patient satisfaction: How patient health conditions influence their satisfaction. J Heal Care Man 57: 276-292.
8. Scotti DJ, Harmon J, Behson SJ (2007) Links among high-performance work environment, service quality, and customer satisfaction: An extension to the health care sector. J Heal Care Man 52: 109-124.
9. Lobo A, Duarte P, Carvalho A, Rodrigues V, Monteiro MJ,et al. (2014) The association of equity, accessibility, and price with primary health care user’s satisfaction. Wes J Nur Res 36: 191-208.
10. Mpinga EK, Chastonay P (2011) Satisfaction of patients: A right to health indicator? Health Policy 100: 144-150.
11. Stone R (2015) Pregnant women and substance use: Fear, stigma, and barriers to care. Heal Jus 3: 1-15.
12. Clement S, Schauman O, Graham T,Maggioni F, Evans-Lacko S,et al. (2015) What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychol Med 45: 11-27.
13. Galle A, Van Parys A, Roelens K, Keygnaert I (2015) Expectations and satisfaction with prenatal care among pregnant women with a focus on vulnerable groups: A descriptive study in Ghent. BMC Wom Heal 15: 1-12.
14. Mead H, Andres E, Regenstein M (2014) Underserved patients’ perspectives on patient-centered primary care: Does the patient-centered medical home model meet their needs. Med Care and Res Rev 71: 61-84.
15. Otani K, Kurz R, Harris L, Byrne F (2005) Managing primary care using user satisfaction measures. J Heal Care Man 50: 311-325.
16. Rao K, Peters D, Bandeen-Roche K (2006) Towards patient-centered health services in India: A scale to measure patient perceptions of quality. Int J Qual Heal Care 18: 414-421.
17. Aragon SJ (2003) Commentary: A patient-centered theory of satisfaction. Am J Med Qual 18: 225-228.
18. Ford VL (2014) Are they content with care? A correlation study on new mothers diagnosed with substance use disorders and patient satisfaction (Doctoral Dissertation).
19. Aragon SJ, Richardson LJ, Lawrence W (2013) Nurses’ patient-centeredness and perceptions of care among Medicaid patients in hospital obstetrical units.
20. https://www.rand.org/topics/survey-research-methodology.html
21. Marshall GN, HaysRD (1994) The patient satisfaction questionnaire short-form (PSQ-18).
22. Saurman E (2015) Improving access: modifying Penchansky and Thomas’s theory of access. Journal of Health Services Research andPolicy 21: 1-4.
23. Walz GR, Bleuer C (2015) Treating pregnant women with substance abuse issues in an obgyn clinic: Barriers to treatment. pp: 1-8.