Vol. 29, No. 3, pp. 295-301
Printed in Great Britain
Journal of Public Health Medicine
Satisfaction with health services among the
Pakistani population in Middlesbrough,
England*
Rajan Madhok, Aqueela Hameed and Raj Bhopal
Abstract
Background Little is known about the quality of the health
care available to ethnic minority groups. In the absence of
empirical data, the National Health Service (NHS) is often
criticized for failing to meet their needs. We assessed
whether the Pakistani population in Middlesbrough used,
and was satisfied with, a range of health services.
Methods This was a cross-sectional survey of an age, sex and
socio-economically stratified sample of Pakistani people.
Data were collected by interview in the home.
Results Satisfaction among those who had used NHS
services was high. For example, 94 per cent were satisfied
with general practitioner (GP) care, 93 per cent with help from
the GP receptionist, and 97 per cent with the care from
hospital doctors. The most dissatisfaction was with casualty,
and accident and emergency services (19 per cent), the care
received from the nurses in hospital, and with information
given about the condition or treatment (both 12 per cent).
When services were not used, lack of knowledge or need, not
dissatisfaction, was the dominant problem. Of 34 hospital
patients, 19 were informed about 'Asian' meals. Sixty-five
per cent (11 of 17) of those who had such meals were
satisfied. Dissatisfaction was mainly because of taste and
quality of food. Only three of 63 (5 per cent) hospital in- or
out-patients were informed of the availability of a professional interpreter, and none used the service. Fifteen (four
men and 11 women; 25 per cent) said they would have used
the interpreting service if they had known of it.
Conclusions Pakistani patients reported surprisingly high
levels of satisfaction with health services. Policies on
culturally sensitive meals and interpretation services, however, were not properly implemented. Locally, the findings
are encouraging. Nationally, the message is that high levels
of satisfaction with services among ethnic minority groups
are potentially achievable.
Keywords: ethnicity and health, quality of health care,
satisfaction, Pakistani community
Introduction
To meet health care needs equitably requires an understanding
of cultural variations among population subgroups, and
adaptation of services.1 The National Health Service (NHS)
has committed itself to meeting the particular needs of ethnic
minority groups (for example, see Patient's Charter), and the
NHS Ethnic Health Unit was set up specifically for this.1 The
NHS is often criticized for not making adaptations, with the
implication, sometimes explicit, that this amounts to institutional racism.2"6 To quote from Ethnicity and health in
England1 (p. 55): 'minority ethnic patients also face the
potential obstacles of racism (overt or indirect), discrimination,
language and communication difficulties, and stereotyping
attitudes'. Most studies, however, show that ethnic minority
groups utilize NHS services about as much as or, particularly for
general practice services, more than the ethnic majority.7 The
empirical research record on the quality of service offered to
ethnic minority groups is sparse,7 with some studies indicating a
lower quality of service.8
People with ancestral origins in the countries of the Indian
Subcontinent who identify their ethnic origin as Pakistani are
Britain's third largest ethnic minority (0.9 per cent of the
population in the 1991 Census).9 Their religion, culture, social
and economic circumstances have an impact on their health care
needs. For example, most Pakistanis practise Islam, and
followers of this religion are forbidden consumption of alcohol
and pork, and are required to eat halal meats. Their main
languages, other than English, are Urdu and Punjabi. Many
Tees Health Authority, Middlesbrough TS7 ONJ.
Department of Epidemiology and Public Health, University of Newcastle
upon Tyne, Newcastle upon Tyne NE2 4HH.
Rajan Madhok, 'Consultant in Public Health Medicine, 2Honorary Lecturer
in Public Health Medicine
Tees Health Authority, Middlesbrough TS7 ONJ.
Aqueela Hameed, Health Care Co-ordinator for Ethnic Minorities
Department of Epidemiology and Public Health, University of Newcastle upon
Tyne, Newcastle upon Tyne NE2 4HH
Raj Bhopal, Head and Professor of Epidemiology and Public Health
Address correspondence to Professor R.S. Bhopal.
2
"A note on terminology. In the absence of an agreed nomenclature for race
and ethnicity this paper uses some words in their contemporary meaning or
when referring to the work of others, as used in the literature. For example,
'Asian' and 'South Asian' refer to people whose ancestral origins are in the
Indian Subcontinent, and 'white' refers to people of European ancestry.
'Pakistani' refers to people whose birthplace or ancestry is in Pakistan, or who
self-identify as Pakistani.
© Oxford University Press 1998
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JOURNAL OF PUBLIC HEALTH MEDICINE
Pakistani communities in Britain are comparatively poor with
high rates of unemployment.9 Disease patterns are in many
respects similar to those for socio-economically comparable
populations (the biggest killers are heart disease, cancers and
respiratory disease) but there are some notable differences such
as more haemoglobinopathy, and infections. These factors have
challenging implications for the NHS.1'7'9
Research on ethnic minorities has focused on diseases10'"
and not quality of health services. A comparative study of
in-patient care in Middlesbrough hospitals showed that 'Asian'
and 'non-Asian' people had similar experiences in most
respects but 'Asians' reported more problems with hospital
food, communication and the lack of women doctors.12 The
Trusts were contracted to provide appropriate services for
ethnic minorities especially in relation to food and interpreters.
This study extended observations to a wider range of
services. One key aim was to address an issue which has rarely
been considered in relation to ethnic minority groups:
satisfaction with services. Of 5101 papers listed in MEDLINE
(1966-June 1997) in relation to patient satisfaction, fewer than
20 contained the keywords 'race' or 'ethnicity'. This database
and others including CINAHL (1982-1997), Healthspan (1975
to present) and PSYCLT (1974 to present), and the core
biomedical collection (1993 to present), gave only one directly
relevant reference, our earlier study,12 and a few studies of
indirect relevance.
Setting and methods
In 1991, Middlesbrough had 140 849 residents of whom 6219
(4.4 per cent) were from ethnic minority groups; 3646 (2.6 per
cent) were of Pakistani origin, the largest ethnic minority group
in the borough.13 Most Middlesbrough Pakistanis originate
from the Mirpur part of the Punjab in Pakistan and speak the
Mirpuri dialect of Punjabi.
Middlesbrough residents receive primary care services from
approximately 148 general practitioners (GPs), and acute
hospitals and community services are provided by two NHS
Trusts. The Trusts are contracted to provide services sensitive
to the cultural and religious requirements of the ethnic
minorities, especially in relation to ethnic food and interpreters.
More details on the local health context have been published.12
The Health Authority's initiative on ethnic minority health
provided resources to interview a maximum of 126 subjects.
Our aim was a sample which was heterogeneous in terms of
social and economic status, age and sex.
Twenty-five electoral wards in Middlesbrough were ranked
using the four variables: ownership of car, ownership of home,
overcrowding and unemployment, in accordance with the study
by Townsend et al.14 For practical reasons relating to the
efficiency of the name search and in home interviewing (see
below) we excluded four wards containing, according to Census
data, ten or fewer Pakistani residents. The remaining wards
(w = 21) were categorized into three strata: the most prosperous
{n = l, the number of people in each ward ranged from 16 to
93), less prosperous wards (n = 7, the number of people ranged
from 62 to 399) and the least prosperous wards (« = 7, the
number of people ranged from 82 to 1624). Because of the
small numbers of Pakistani people in the top strata all seven
wards were selected, whereas alternate wards from the middle
and bottom strata were sampled (three from each). The electoral
registers for these 13 wards were searched for Pakistanisounding names. Potential subjects were identified from the
registers by scanning for Muslim names, a tested technique.15'16
The Family Health Services Register gave subjects' date of
birth and sex.
Potential subjects were stratified by three age groups (18-29
years, 30-44 years and 45-64 years) and sex. No more than one
person per household was selected. An equal number (63) of
males and females in each of the three sets of wards and age
groups were randomly drawn. The sample consisted of 126
people, 42 from each of the three sets of wards, and from each
age stratum.
Letters in English and Urdu sent by A.H. informed subjects
about the survey and that an interviewer would visit their home.
Permission to do the survey was obtained by the interviewers at
the home visit. Interviews were held at subjects' homes.
Interviews were conducted by one of two interviewers (of the
same sex as the respondent) fluent in English, Punjabi and
Urdu. A questionnaire, partly based on previous studies,17'18
focused on knowledge and utilization of, and satisfaction with,
certain primary, community and secondary health services.
Details on religion, education, employment status, housing
tenure, overcrowding at home, car ownership and total
household income were collected. (The questionnaire was
pilot tested and modified.)
The questionnaire was in English, with the interviewers
translating it at interview if needed. The quality and comparability of the verbal translation into Punjabi or Urdu was
checked by a professional interpreter and both A.H. and the
interpreter agreed that the translations were comparable with
the English. Training was provided to the two interviewers in
posing questions and recording responses.
The questions on satisfaction mostly focused on specific
experiences. For example, the question on general practice was
only asked of people who had been to the GP within the last
year (104) and was: "Thinking about your last visit to your GP,
how satisfied were you with: The care you received from the
GP?; The care you received from the nurse?' (if applicable);
etc.
The corresponding stem question for hospital services,
based on experience of admission in the previous two years,
was: 'Thinking about your last admission (to hospital), how
satisfied were you with ...?' In this case the denominator was
34, the number of people who had been admitted.
Mostly answers were recorded on a five-point scale (very
satisfied, satisfied, no opinion, dissatisfied, very dissatisfied) but
are presented on a three-point scale for simplicity and because
PAKISTANI POPULATION SATISFACTION WITH HEALTH SERVICES
very few people used the very dissatisfied category. If any
dissatisfaction was expressed, reasons for this were sought in an
open question. The questions on the family planning service
and on 'Asian' food simply asked about satisfaction with a yes/
no answer, and an opportunity to explain why not.
The interviews took place from July to September 1993.
Approval was obtained from the local ethical committee. The
local community health council was consulted and the purpose
of the study was communicated through the Pakistani news
media and local ethnic minority groups.
297
sample of 126, the 18 non-respondents were replaced by the next
individual from the appropriate stratified list (all participated).
The personal characteristics of the subjects are shown in Table 1.
Self-reported ability to understand, speak, read and write
languages is shown in Table 2. Almost all men and about twothirds of women reported being able to read and write English
adequately. Fluency in speaking but not writing Punjabi was
common.
Experience of health services
Utilization of health services
Results
The initial response rate was 85.7 per cent (108/126). Five
declined to be interviewed, others were in Pakistan (n = 4), had
moved house (n = 3), were unavailable (n = 3), were not
Pakistani (n = 2) or had died ( « = 1 ) . To achieve the target
Table 3 shows that use of health services was common, and that
over 80 per cent of respondents had visited the GP in the last
year at least once. Use of other primary care services, including
family planning, and cervical screening, was also common. A
sizeable minority had experience of secondary care services.
Very few had attended parentcraft classes.
Table 1 Characteristics of the study subjects (numbers, with percentages to the
nearest integer given in parentheses, unless otherwise noted)
Characteristic
Men
(n = 63)
Women
[n = 63)
Age
Mean (SD, range)
34(12.6, 18-63)
34(13, 18-64)
18(29)
44(70)
1 (1)
13(21)
44(70)
6(9)
63 (100)
61 (98)
22 (35)
39 (62)
2(3)
18(29)
44(70)
1 (1)
24 (7, 7-36)
19(9,2-36)
1 (2)
21 (33)
7(11)
12(19)
3(5)
8(13)
8(13)
3(5)
0
6(10)
12(19)
3(5)
3(5)
1 (2)
3(5)
4(6)
1 (2)
30 (48)
5(8)
20 (32)
20 (32)
7(11)
11 (17)
0(0)
9(14)
19(30)
16(25)
1 (2)
5(8)
13(21)
Home owners
63(100)
60 (95)
Car owners
41 (65)
23 (37)
Marital status
Single
Married
Widowed, single or divorced
Religion
Islam
Country of birth
UK
Pakistan
Elsewhere
Number of years in UK (for overseas born)
Mean (SD, range)
Employment status
Retired
Full-time work (employee)
Part-time work (employee)
Self-employed
Waiting to start job
Unemployed
Full-time education
Long-term sick
Looking after the home
Education status
Primary school
Secondary school
College
Polytechnic
University
None
298
JOURNAL OF PUBLIC HEALTH MEDICINE
Table 2 Ability to adequately understand, speak and read and write languages (n = 63 each for
men and women) (numbers, with percentages given in parentheses)
Understand
Read and write
Speak
Language
Men
Women
Men
Women
Men
Women
English
Punjabi
Urdu
62 (98)
59 (94)
52 (83)
52 (83)
62 (98)
54(86)
62 (98)
56 (89)
47 (75)
46 (73)
60 (95)
44(70)
61 (97)
(0)
34 (54)
43 (68)
0(0)
38 (60)
Sixty-three (50 per cent) respondents had been to either inpatient or out-patient/casualty hospital services in the previous
two years. There, only three were informed of the availability of
a professional interpreter, and none of these three used the
service. Fifteen (four men and 11 women) of the remaining 60
people said they would have used the interpreting service if
they had been informed of it. There were some differences by
age, with, as is predictable, lesser use of services by the younger
age group. For example, whereas, overall, 82.5 per cent of the
sample had seen a GP or practice nurse in the last year, the
figure for the 18-29 year group was 73.8 per cent.
Satisfaction with services
Table 4 shows a high level of satisfaction, particularly with
primary care. Dissatisfaction was expressed by 10 per cent or
more of respondents only for accident and emergency services,
the care received from nurses in hospital and information given
about the condition or treatment in hospital. Very few people
indicated they were very dissatisfied; for example, only one
person was very dissatisfied with each type of care received
from the GP, the help from receptionists and the information
given about treatment on the last visit.
When services were seldom used, lack of knowledge, not
dissatisfaction with past experience of health services, was the
apparent problem. Of the 16 people who used the family
planning service at the community health clinic, 15 were
generally satisfied, and one did not answer. People were asked
why they did not avail themselves of family planning services.
The specific reasons given for not attending were: not
applicable (34), no knowledge (14), language barrier (4), fear
or embarrassment (3), inconvenient times (3), staff may not
understand the implications for family planning of culture or
religion (1) and lack of transport (1); others said that they were
trying for a family or could not be bothered. Of the 38 people
who attended the GP for family planning, 36 were satisfied.
Of the 39 women who may potentially have benefited from
parentcraft classes only two went, one being satisfied and the
other not (because of a language barrier). Reasons for not going
included: no knowledge of the service (24), no time (6),
language barrier (4), not bothered (3).
Failure to use other services, such as not having a cervical
smear and not having a breast examination by a health
professional, were also explained in terms of lack of knowledge
or perceptions of their importance, not dissatisfaction.
Table 3 Utilization of health services (n = 63 each for men and women)
(numbers, with percentages given in parentheses)
Health service
Men
Seen a GP or practice nurse during the past year
once or twice
three to five times
six or more times
51 (81)
16(25)
21 (33)
14(22)
Women
53
11
19
23
(84)
(17)
(30)
(37)
Admitted as an in-patient in the past two years
16(25)
18 (29)
Attended an out-patient department in the past two years
24 (38)
24 (38)
Attended a casualty or A&E department during the past year:
once or twice
three to five times
9(14)
1 (2)
6 (10)
0 (0)
Had a cervical smear test
na
45 (71)
Had a breast examination
na
23 (37)
Used family planning services
5(8)
11 (17)
Attended parentcraft sessions
0(0)
2 (3)
na, not applicable.
299
PAKISTANI POPULATION SATISFACTION WITH HEALTH SERVICES
Table 4 Satisfaction with aspects of health services (only asked of those who reported having used the
service) (numbers, with percentages given in parentheses)
Health service
Very satisfied/
satisfied
No opinion
Dissatisfied/
very dissatisfied
GP
Care received from GP
Care received from nurse
Help received from receptionists
Information given about condition or treatment
Facilities in waiting room
98 (94)
33 (77)
96 (93)
93 (89)
95(91)
1 (1)
9(21)
2(2)
4(4)
4(4)
5(5)
1 (2)
5(5)
7(7)
5(5)
In-patient
Care received from doctors
Care received from nurses
Information given about condition or treatment
Information given about hospital procedures
Surroundings of ward
Entertainment facilities in the hospital
Privacy and visiting arrangements
33
30
30
29
31
27
29
0(0)
0(0)
0(0)
2(6)
1 (3)
4(12)
2(6)
1 (3)
4(12)
4(12)
3(9)
2(6)
3(9)
3(9)
0(0)
0(0)
0(0)
1 (2)
1 (2)
0(0)
1 (2)
0(0)
0(0)
3(6)
0(0)
3(19)
Out-patient
Care received from doctors
Care received from nurses
Help received from receptionists
Information given about the condition or treatment
Facilities in waiting room
Casualty or A&E department
Of 34 people admitted to hospital, 19 were informed about
'Asian' and halal meals. Two did not order them. Sixty-five per
cent (11 of 17) of those who actually had Asian vegetarian or
halal meals were satisfied with them. The reasons for
dissatisfaction were poor taste and quality of foods (five
responses), and insufficient quantity (one).
Finally, the respondents' satisfaction with this kind of
survey was gauged indirectly by asking whether the Health
Authority should do more surveys of this kind. Of 126
participants, 122 said yes.
Discussion
Pakistani patients in Middlesbrough use NHS services (in
line with previous reports1'7'9) and are generally satisfied with
them. The latter finding is a surprise given recent observations
critical of the NHS response to the care of ethnic minority
groups, 2 " 7 and in the light of specific studies showing either a
lower quality of care 8 or professionals' concern about the
workload created by 'Asian' patients, 19 " 21 as reflected in the
Jarman Index which is used to calculate deprivation
payments to GPs. 20 This finding of satisfaction resonates
with our earlier work demonstrating that only in a small
number of ways was the hospital in-patient experience of
'Asians' worse than for 'non-Asians'. 12 Before discussing the
implications we consider the crucial issues of context,
sampling and methods.
(97)
(88)
(88)
(85)
(91)
(79)
(85)
44(98)
47(100)
46(100)
43 (92)
47 (98)
13(81)
Context, sampling and methods
The Middlesbrough area has a relatively low proportion of
ethnic minority groups, and most of them are of 'South Asian'
ancestry. Ethnicity and health in England warns that relatively
small ethnic minority communities may be most isolated and
disadvantaged in terms of health care.1 The local health
authority has had an interest in the health of ethnic minority
groups and a responsible committee acting since 1988 to
improve services. Many of the local doctors are from the 'South
Asian' community, although as Ahmad has pointed out this
may not guarantee positive attitudes towards ethnic minority
patients. 19
The focus of this study on Pakistanis, and a sampling
strategy which sought heterogeneity within this population,
was deliberate. First, we hoped to avoid the criticism that
ethnic minority groups, including the group often labelled
'Asians', are heterogeneous. 22 Second, we wanted to avoid
focusing on only the economically deprived members of
ethnic minority groups, often living in a few areas of the inner
city, for they are different from the ethnic minority population
as a whole. 23 Third, we were conscious that because of its
size and relative economic deprivation, the priority was to
study the Pakistani ethnic minority populations in the area. We
acknowledge that obtaining representative samples of ethnic
minority patients is difficult and that sampling frames,
including the electoral register, may be inaccurate. 23 The
resulting bias is unknown but needs to be acknowledged. We
300
JOURNAL OF PUBLIC HEALTH MEDICINE
also acknowledge that there is a need for larger studies to
explore differences in health service utilization and satisfaction in different age and socio-economic strata.
This study did not incorporate a 'white' comparison group,
which, from the perspective of the paradigm of comparative
research, may be seen as a weakness. Although this decision
was mainly because resources were limited, and because the
funds were assigned for ethnic minority groups, there is some
justification. A comparison 'white' population would have
helped to assess equity but, arguably, might have implied that
the appropriate levels of utilization and satisfaction for the
Pakistani community would be those of the 'white' majority.24
Might our results be generalized? We claim no more than
that our findings are likely to be valid for the local Pakistani
community, and that the results and methods may have
applicability to similar populations in other parts of the country
with populations with characteristics similar to Middlesbrough.
The data in Tables 1 and 2 should permit others to assess
whether their Pakistani populations are similar to those studied
here, and whether the data can be meaningfully generalized.
Middlesbrough has a 'settled' Pakistani community, with most
of the respondents reporting adequate knowledge of English.
Compared with the Health Education Authority (HEA) national
survey, more of our respondents spoke English (86 per cent
versus 72 per cent). The proportions born in the United
Kingdom were similar to those reported in the HEA survey and
the 1991 Census. The local health authority has shown interest
in the issue of ethnicity and health for some years, including
commissioning our earlier study12 and this one. We do not see
other distinguishing features to make this community unusual.
Gauging satisfaction is not easy. Respondents may be
reluctant to admit dissatisfaction and an overall rating of
satisfaction may hide dissatisfaction with specific aspects of
services.25 In this study the use of the home interview, by a
person of the same sex and ethnic group as the respondent,
and in the language of the respondents' choice, was probably
a safeguard against the possibility that dissatisfaction would
not be expressed. In addition, the questioning on a range of
services and probing on a few was at least a partial safeguard
against the problem of overall satisfaction amid specific
criticism.
Interpretation and implications
One interpretation of ourfindingsis that the expectations of this
Pakistani community are low. This interpretation, although
negative, may hold some truth but questions the quality of
the perceptions of the respondents, and the good work of the
Health Authority and health professionals. The alternative
interpretation is that the findings reflect good performance by
the service.
There are few comparable studies to help judge between
interpretations. Smaje has reviewed the literature.7 He cited a
study by Judge and Solomon which reported that 'non-white'
respondents were less satisfied with services than 'whites'
(Ref. 7, p. 106) but it is hard to derive meaning from such crude
categories of race or ethnicity. Pilgrim et al. reported that there
were no clear differences by ethnic group and generally high
levels of satisfaction with GP services in Bristol. The
exceptions were Chinese and Vietnamese, who were least
satisfied (Ref. 7, p. 106). In a qualitative study, Donovan found
more satisfaction among Asians than among Caribbeans
(Ref. 7, p. 106-107). McGovern and Hemmings found levels
of satisfaction in relation to mental health services among
Caribbean patients and their relatives to be only slightly lower
than among white patients.26 Two other studies concerning use
and satisfaction with maternity services used categories of
Caucasian and non-Caucasian,27'28 a categorization which
makes meaningful interpretation impossible. Smaje concluded:
'the evidence arguably suggests that attitudes to and satisfaction with health services do not differ vastly between minority
and majority populations.'7
Since Smaje's review, the HEA's national survey of
minority groups9 has been published. Interpretation is somewhat difficult because the UK population sample was selected
on different criteria than the ethnic minority groups, which
were essentially inner city populations. On four indicators the
UK population sample reported higher quality of consultation
with a GP than the minority groups but the differences were
small. For example, 81 per cent of the Pakistani population
were 'happy with the outcome of the visit to a GP' compared
with 88 per cent of a UK sample.
Satisfaction probably reflects the quality of interpersonal
care. In a study in the United States, Hispanic and AfricanAmerican patients with asthma expressed high levels of
satisfaction with their care, but there was a gap between the
care they actually received and guideline recommendations.29
In this study, policies on culturally sensitive meals were
incompletely promoted and interpretation services were
seldom offered. The implication for local services is to sharpen
up the implementation of existing policies. Despite the
complexities of providing culturally appropriate services, an
acceptable level of satisfaction can be achieved. The message for
the NHS nationally is not that satisfaction among ethnic minority
groups has been widely achieved but that it can be. 'South Asian'
groups do utilize NHS services, and uptake rates are similar to or
greater than in the population as a whole.''7'30~33 The need now
is to focus on the quality of service, of which satisfaction is a
gauge 25
Acknowledgements
We are grateful to the Pakistani people of Middlesbrough for
their support of the study, to Parveen and M. Yaqub Mughal for
interviewing, to Nusrat Hussain for checking the quality of
verbal translation of the questionnaire, Sandra Green for her
help with the analysis and Tees Health Authority for their
financial assistance.
PAKISTANI POPULATION SATISFACTION WITH HEALTH SERVICES
301
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Beevers DG, eds. Ethnic factors in health and disease.
20 Jarman B. Identification of underprivileged areas. Br Med J
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Accepted on 4 March 1998