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Sami speakers are less satisfied with general practitioners' services.

OBJECTIVES: The government’s Action Plan for Health and Social Services states as a goal that the Sami population’s encounter with health and social services should be just as good as what the rest of the population experiences. The goal of this study is to investigate patient satisfaction with the municipal GP service in areas with both a Sami and Norwegian population. STUDY DESIGN: A cross-sectional population study using questionnaires. METHODS: The data were taken from the population based study of health and living conditions in areas with both Sami and Norwegian populations (SAMINOR) in which respondents were asked about their satisfaction with GP services in their municipalities. This population survey was carried out in the period 2002–2004. The analyses include 15,612 men and women aged 36-79. RESULTS: The Sami-speaking patients were less satisfied with the municipal GP service as a whole than were the Norwegian speakers; RR 2.4 (95% CI 2.1–2.7). They were less satisfied with the physicians’ language skills; RR 5.8 (95% CI 4.8-7.0); and they felt that misunderstandings between physician and patient due to language problems were more frequent; RR 3.8 (95% CI 3.3-4.3). One-third expressed that they did not wish to use an interpreter. CONCLUSIONS: The results indicate that it is necessary to place greater emphasis on the physicians’ language competency when hiring GPs in municipalities within the Administrative Area for the Sami Language. This could improve satisfaction with the physicians’ services.


INTRODUCTION
The government's Action Plan for Health and Social Services to the Sami Population in Norway, 00-00, states as a goal that the Sami population's encounter with the health and social services should be as good as that as the rest of the population. In 199 the Sami Language Act was passed. In accordance with this Act, those who wish to use the Sami language to take care of their own interests, vis-à-vis local and regional public health and social institutions, should have the right to receive such services in the Sami language (1). The area of application of this Act is called the Administrative Area for the Sami Language.
The Plan for Health and Social Services (), points out that the Sami population experiences big problems in their encounters with health and social services. Language obstacles complicate examination, diagnosis, treatment, nursing, care and user information. Lack of knowledge about Sami culture among health and social service personnel often results in an unsuccessful follow-up of Sami users ().
Little research and few studies have been done on these matters, but some smaller qualitative and quantitative user surveys from areas with a Sami population do exist. Most of our knowledge about these topics is based on the practical experience of health and social workers in Sami areas (1).
By comparing Sami-and Norwegianspeaking users of the health services, we wished to investigate whether there were any differences in their satisfaction with the municipal physicians' services.

MATERIAL AND METHODS
On request from the Ministry of Health and Social Affairs, the Centre for Sami Health Research at the University of Tromsø in cooperation with the National Institute of Public Health, carried out the health and living conditions survey (SAMINOR), 00-00. All municipalities in the Administrative Area for the Sami Language were included: Karasjok, Kautokeino, Porsanger, Nesseby, Tana and Kåfjord. Other municipalities or districts were included if the number of persons with Sami-language affiliation constituted at least % of the population at the 1970 Census (). In Finnmark County, the survey included Lebesby, Kvalsund, Loppa and Alta; in Troms County, the municipalities of Kvaenangen, Storfjord, Lyngen, Lavangen and Skånland; and in Nordland County, the municipalities of Evenes and Tysfjord as well as the districts of Hattfjelldal, Majavatn (Grane) and Vassdalen (Narvik). In the Trøndelag region, Røyrvik municipality and the districts of Trones and Furuly (Namsskogan), Vinje (Snåsa) and Brekken (Røros) were included (Fig. 1).
It was decided that all inhabitants of the ages 6-79 (born between 19 and 1968), as well as all 0-year-olds, should be invited to participate. In total, 8,071 persons received an invitation to participate; of these, 8 were excluded and the 0-year-olds were left out of the analyses. Out of the total number of 7,10, the response rate was 60.1%, or 16,. Those who only spoke the Kven language (9), another foreign language () or had not answered the question of language (266) were left out. The final selection constituted 1,61 persons.

Questionnaire and variables
The Survey on Health and Living Conditions included both a questionnaire and a clinical survey linked to cardiovascular screening. The questionnaire was sent together with an invitation. The form included, among other things, questions about the population's perception of health care services, their ethnicity and their language (see www.fhi.no, Helseundersøkelser/SAMINOR).
The main question was: How satisfied are you with the municipal physicians' service as a whole? Respondents were also asked how satisfied they were with their physician's language skills, and whether language problems could lead to misunderstandings between physician and patient. Finally they were asked whether their physician, to a sufficient extent, offered them an interpreter when the need arose. For this question, respondents had an Patient satisfaction with GP service additional fifth option they could tick off: "I do not like to use an interpreter." Several other questions concerning satisfaction with physicians' services were asked, but given the limited length of this article, we have decided to leave them out.
In this survey, ethnic affiliation was defined on the basis of self-reported home language; that is, Sami only, Norwegian only, or both.
In order to investigate the number of physicians per person within the population during the survey period, the relevant physicians' offices were contacted by telephone. The physicians were asked which language(s) they spoke: Norwegian, Sami and Norwegian, or Norwegian and some other foreign language.
All participants involved in our study gave informed written consent. The Regional Committee for Research Ethics and the Norwegian Data Inspectorate approved the study.

Statistical analyses
The SAS v 9.1 software (SAS Institute Inc, Cary, NC, USA) was used for both data processing and analyses. The data were analysed using frequency counts, cross-tabulations and the Cochran-Mantel-Haenszel test for chi-square (χ ) and relative risk (RR), with a 95% confidence interval. Adjustments were made for age, gender and geographic area.
The response variable was categorised as a dichotomous variable in which "very satisfied" and "satisfied" were lumped together as "satisfied." Similarly, the categories "discontented" and "very discontented" merged into one as "discontented." The "don't know" responses were taken out of the calculations.

RESULTS
The results are based on 1,61 men and women aged 6-79 who participated in the present study. A total of 17% spoke Sami as their home language. Within areas geographically belonging to the Administrative Area for the Sami Language, 8% said they had Sami as their home language as opposed to .0% outside this area (Table I).
When asked about their satisfaction with the municipal physicians' services as a whole, a vast majority answered that they were satisfied or very satisfied. Clear geographic differences emerged. Outside the Administrative Area, 87% of the Norwegian-speaking and 79% of the Sami-speaking patients were satisfied. Among those who lived within the Administrative Area, 7% of the Sami-speakers said they were very satisfied or satisfied. Among the Norwegian-speakers in the same area, 79% said they were satisfied. The difference between the linguistic groups was statistically significant both inside and outside the Administrative Area; p<0.0001 (Table II).
When we compared overall satisfaction with the municipal GP services between the Sami-speakers and the Norwegian-speakers, we found that the Sami-speakers were less satisfied, RR 2.4 (95% CI 2.1-2.7). The findings showed clearly significant differences when we adjusted for age, gender and whether they lived within or outside the Administrative Area.
When asked how satisfied they were with the physician's language skills, the Samispeakers were less satisfied than the Norwegian-speakers, RR .8 (9% CI .8-7.0). When we looked at those who considered themselves bilingual and compared them with the Patient satisfaction with GP service Norwegian-speakers, the differences were less for all questions (Table III).
Out of the total selection, 90% answered that misunderstandings between physician and patient due to language problems rarely or never occurred. Approximately 10% said that misunderstandings occurred often or now and then, most frequently among the Sami-speakers, RR .8 (9% CI .-.) (Table IV).
When asked if their physician readily enough offered them an interpreter when the need arose, 8% of the Sami-speakers answered yes, while 6.6% felt that the physician fell short in this respect. One-third did not answer the question, and one-third said that they did not like to use an interpreter (Table V).

DISCUSSION
The main findings in this study are that the Sami-speaking patients are less satisfied with the municipal physicians' service as a whole. The share of discontented respondents, both Sami-and Norwegian-speakers, is highest in the Administrative Area for the Sami Language.

Patient satisfaction with GP service
The Sami-speaking patients are less satisfied with the physician's language skills and feel that misunderstandings between physician and patient occur more frequently as a result of language difficulties. A large number of respondents do not wish to use an interpreter at all.

Patient satisfaction
In the literature, it is debated what patient satisfaction is actually a measurement of. Is it a measurement of the quality of the services, of traits in the patients and their expectations of these services, or is it an exposition of the rela-  Patient satisfaction with GP service tional circumstances in the encounter between physician and patient? All these aspects affect the degree of satisfaction, but the quality of the services and the relational circumstances in the encounter between patient and physician are more important than the patient's individual traits (). U.S. studies show that 90% of the users are satisfied with the health care services (). In Great Britain, a similar number is found (6). In Norway, Lian and associates carried out a study on patient experiences in the primary GP service before and after the personal GP reform, 000-00 (7). When asked about satisfaction with primary GP services as a whole, 91% replied that they were satisfied, while 9% said they were discontented. If we compare these figures with our data, we arrive at completely identical percentages for the Norwegian-speaking population. On the other hand, the discontented constitute a much larger proportion in the Samispeaking population (%). A discontent rate of one-third is exceptionally high. It is difficult to say anything specific about the reasons for this discontent, since these results come from a cross-sectional study, which has certain limitations. But we will discuss some possible explanations for these findings.
Previous studies have shown that continuity in GP services is an important factor for the degree of satisfaction (), which may also be a contributing factor to our results. In our study, we have established clear geographical differences. Within the Administrative Area, a higher proportion of the Norwegian-speakers are also less satisfied, and we see differences in satisfaction on a municipal level. It is known that in some municipalities within the Administrative Area, it has been difficult to hire physicians. This leads to unstable GP coverage and poor continuity. Several respondents in these areas also state that they have not been assigned a personal GP.

Language
Another reason may be communication problems, since many of the Sami-speaking patients in this study expressed discontent with the GP's language skills, and felt that misunderstandings could occur between physician and patient on linguistic grounds. Similar results have also been established in other smaller surveys conducted in Skoganvarre, Karasjok and Kautokeino (2). These findings may not be so astounding if we bear in mind that the language barrier is the biggest cultural gap between a physician and a patient, and that communication between patient and physician is of major significance in a clinical practice.
The total number of GP positions in the municipalities within the Administrative Area was during the survey period. There was 1 (%) Sami-speaker, 17 (71%) Norwegianspeakers and (1%) foreign-language GP's. One position was vacant. We may assume that the Sami-speaking patients have even greater communication problems with foreign GP's than they do with Norwegian physicians.

Interpreter
Many who felt they needed an interpreter were not offered one. Some expressed that did they did not like to use an interpreter. In primary health care it has been common that patients bring family members or use the GP office staff as interpreters (1). This may be the reason that so many do not wish to use an interpreter, and it is possible that improved organisation of the interpreting service would result in more patients wishing to make use of this offer.

Patient satisfaction with GP service
This is the first major survey that has been carried out in areas with a Sami and Norwegian population. The participation rate was 60%, which is satisfactory for this kind of survey. A methodological weakness existed in the fact that it was a cross-sectional study, with limitations concerning the ability to explain causal connections that are inherent in such studies. Additionally, there was a low response percentage for some of the questions.

Conclusions
The main results of this study are: • Sami-speaking patients are less satisfied with the municipal physicians' services than Norwegian-speakers. Patient satisfaction is lowest in the Administrative Area for the Sami Language.
• The Sami-speakers are also less satisfied with the physician's language competency.
• Sami-language competency should be viewed as significant when hiring physicians in these areas.
This survey shows that resources should be allocated towards recruiting Sami-speaking GPs for central Sami settlement areas. In the short term, this can be solved by establishing a "recruitment package" that offers financial compensation for Sami language and cultural competency. The long-term goal should be to educate more Sami-speaking GPs by increasing the admission of Sami-speaking students into the University of Tromsø. This work has already been started. Expansion of the interpreter service is a third alternative, but many do not wish to use an interpreter when they go to see their physician.