This study relied on convenience sampling of patients from a nonprofit Federally Qualified Health Center (FQHC) serving marginalized community members from June 2022 to July 2022. There was no existing user of the patient portal as the study was conducted prior to the full launch to improve the design of the patient portal. The access to the digital survey was published on the clinic’s website and the recruitment material was available at the clinic’s waiting room with a QR code directing to the digital survey. The survey took about 7 minutes to finish. Those who agreed had the chance to opt into a drawing for 20 gift cards (US $25 each). All questions were translated into Spanish by certified translators and double-checked by a native Spanish speaker graduate research assistant.

The survey asked questions regarding participants’ access to electronic devices and the internet, barriers to using a patient portal, willingness to adopt such a portal, preference mode of communication with health care providers, and preferred features in the current clinic’s portal. To determine the participants' preferred language, participants were asked what their primary language was, and more specifically, what language they speak most of the time. Potential barriers were identified from previous literature as well as input from the clinical staff’s experience [4,6,11,18,19]. For the full survey instrument, please see Multimedia Appendix 1.

Grounded in the Theory of Planned Behavior, a psychological framework focused on behavior prediction, which states intention as the strongest predictor to behavior measured by the attitude toward the behavior, perceived behavioral norms, and perceived behavioral control shown in [20] (Textbox 1). Measures were adopted from previous studies [20-22] and modified to fit the research context of interest and participants’ literacy level per clinic staff’s feedback.

A series of independent-sample t tests and χ² analyses were performed to identify differences among English- and Spanish-speaking participants. A logistic regression analysis was performed to investigate the relationship between attitudes, perceived behavioral control, and perceived behavioral norms with the intention to adopt the patient portal. Age and gender were controlled in the logistic regression.

The University of Texas at Austin Institutional Review Board determined this study as exempt and did not require further review (STUDY00002291). Participants reviewed and acknowledged informed consent materials prior to completing the electronic survey. To compensate participants, each person was entered into a drawing to win one of the 20 gift cards (US $25 each). For privacy and confidentiality, all study data were deidentified.

The differences between English-speaking and Spanish-speaking participants revealed further insights such as Spanish-speaking participants’ lower willingness to exchange electronic information than English-speaking participants. Even so, compared to English-speaking participants, Spanish-speaking participants prefer in-person communication with their physicians. This finding, in conjunction with the language barrier, supports previous research where more emphasis on portal training for patients with LEP is needed to increase comfort and combat distrust [4].

Historically, patient portal uptake has been challenging due to a lack of access to technology [6]. However, the findings of this study revealed many patients have good internet access and device availability. Despite adequate access to the technology, only 65% of participants said they envisioned themselves signing up for and using the patient portal. While this is a fairly strong intention response, there are still barriers worth acknowledging, such as a stronger preference for in-person communication with their physician, concerns about privacy, language difficulties, lack of comfort with portals, and poor design. The most prominent barrier reported was the preference for in-person communication with their doctor, highlighting an opportunity for physicians and staff to emphasize the potential benefit of completing administrative tasks through portal use such as scheduling appointments, sending secure messages, and reviewing lab results.

Many studies have investigated the uptake of patient portals in Hispanic populations; however, often in specialized areas of care such as asthma or with small sample sizes [8,12,19]. Few have investigated patients’ willingness to adopt an electronic portal and assess potential barriers while specifically exploring the impact of language preferences and measuring behavioral intention. This study successfully fills such a gap, as it surveyed English- and Spanish-speaking participants from a community clinic in a Southwestern city to identify patient portal uptake barriers based on language preferences and measured differences in their intention to sign up and use the portal. Understanding the existing barriers is the first step in strategizing ways to overcome obstacles patients experience when considering a patient portal.

The Theory of Planned Behavior is criticized for simply measuring the intentions to predict actual behavior; however, this study uniquely addresses this by simultaneously identifying barriers and measuring patients’ attitudes and perceptions (perceived norms and perceived behavioral control) toward portal adoption. The first notable limitation is that while this study did not measure actual adoption of the clinic’s patient portal, the findings still provide insight into the challenges faced by a multilingual patient population. Specifically, by understanding attitudes and perceptions along with language preference differences, we can tailor approaches and predict how patients with higher perceived behavioral control and more positive attitudes toward the patient portal were most likely to adopt and use the portal. The second limitation is the reliance on convenience sampling limiting the ability to make broad generalizations from the findings; however, the strength of this study is that it helps understand the need for further assessment on ways to increase perceived behavioral control and positive attitudes toward patient portals through in-person relationships, particularly among patients with LEP.

The study’s findings identify areas for health care organizations to focus on when seeking to increase patient portal uptake among a linguistically diverse population. Future research can investigate in-person preferences as well as communication surrounding privacy concerns, which were the top 2 barriers expressed by participants in this study. Empowering patients to have more autonomy over their health and decision-making leads to a more meaningful experience with their physicians, which can tackle low health literacy–related barriers. Yet, understanding these differences based on language preference confirms that a more targeted approach is needed. These findings add to the current body of literature by revealing that barriers such as lack of access require more investigation, as even with adequate access to internet and technology, there is still a need for patients to feel secure with the level of privacy and ease of use regarding portal design.

To understand the willingness to adopt an electronic portal and examine differences between language preferences, this study presented survey findings from a FQHC regarding access to electronic devices and the internet, and identified barriers to using a patient portal. We conducted a series of independent-sample t tests and χ² analyses to identify differences among English- and Spanish-speaking participants. A logistic regression analysis was performed to investigate the relationship between attitudes, perceived behavioral control, and perceived behavioral norms with the intention to adopt the patient portal. Despite adequate access to technology, only 65% of participants said they envisioned themselves using a patient portal. English-speaking patients were more willing to exchange electronic information with their health care providers. Spanish-speaking patients reported language as a significant barrier to portal use. Finally, patients with more positive attitudes and higher perceived behavioral control are more likely to sign up and use the patient portal. These findings can inform strategies to achieve a more meaningful experience between physician and patients with potential to tailor approaches to patients based on preferred language.