Luận án TS y học: Patient’s satisfaction with health services at Kuta Blang health center in Bireuen district, Nanggroe Aceh Darussalam province, Indonesia

CHAPTER 1INTRODUCTION1.1 Rationale and justificationWith globalization has come an alarming increase in international statements and guidelines for developing about ethics, equity and health system reform. When it does not refer to specific places, times, people and condition, such thinking is of little interest international forum. All these trends in fact make the importance of the local of district health system more conspicuous. Within that system, health development is most effectively implemented through health centers, if health personal understand these to have responsibility both for maintenance of optimum health and for care of the sick in a given area population (1).Patient’s satisfaction is a component of health care quality and is increasingly being used to assess medical care in many countries in the world. Until recently, traditional assessments of medical care were done purely in terms of technical and physiological reports of outcomes. It is an established fact that satisfaction influences whether a person seeks medical advice, complies with treatment and maintains a continuing relationship with practitioners (2).Patient satisfaction has long been considered an important component when measuring health outcomes and quality of care. The rising strength of consumerism in society highlights the central role patient’s attitudes play in health planning and delivery. Further more, a satisfied patient is more likely to develop a deeper and longer lasting relationship with their medical providers, leading to improved compliance, continuity of care, and ultimately better outcomes (3). Medical care aims not only to improve health status but also to respond to patients need and wishes and to ensure their satisfaction with care. Likewise, conducting surveys to measure satisfaction with psychometrically validated questionnaires entails assessment of the quality of care organization and procedures. Patient judgment on medical care also contributes to medical outcome. In the case of ambulatory care, it has been clearly shown that satisfied patients are more likely to cooperate with treatment, to maintain a continuing relationship with a practitioner and thus enjoy a better medical prognosis. From a conceptual point of view, the construct of patient satisfaction as been defined by Isabell Gasquet Ware (4). As an "attempt to capture the personal evaluation of care that cannot be known by observing care directly" and to “Good” consider opinion of patients as a multidimensional subjective indicator of quality of care. The model most commonly, though implicitly, used in satisfaction work is the discrepancy model (degree of fulfilment of expectation is related to satisfaction level) giving to patient expectations a central role. This model, according to Sitzia “implies that concentrating upon areas of expressed dissatisfaction is more valuable than obtaining consistency of expressed satisfaction". In France, measuring satisfaction has been mandatory since 1996 and several questionnaires have been developed to evaluate inpatient care. Most existing outpatient satisfaction questionnaires have been developed to assess primary care practice, especially general practice. However, it could be hypothesized that content of questionnaires evaluating primary care physician may be different from that of questionnaires exploring hospital consultation with a specialist because of differences in patient expectations. So it could be assumed that dimensions that are very important in the case of primary care like human qualities of the physician and medical information could have a lesser importance in case of hospital consultation, while technical competency could have a more important place (5).The quality of health services can be measured by a community''''s level of satisfaction in terms of the health services received, both curative and preventive (6). The quality of health services is very much influenced by the quality of physical facilities, types of work force available, medicines, health instruments and other supportive facilities, services conferring process, and compensation received and the expectation of the consumer society. Hence the increase in physical quality and aforementioned factors are preconditions to be fulfilled. Afterwards, the process of services conferral is to be increased through increase in quality and professionalism of health resources as stated above. While the expectation of the consumer society is being adjusted through improvement in general education, health information, good communication between health providers and the public (7, 8).As the center for basic health services at the sub district level, each health center (community healthcare centers) generally has a doctor who is appointed as the head of the health center. However, the administrative duties of a health center head often reduce consultation time with patients. As a result, patients are mostly taken care of by nurses and midwives. This is a dilemma. On one hand, as a doctor assigned to a particular health center, he or she is required to contribute to the provision of health services, but on the other hand, the administrative duties of a health center head in fact interrupt their duties as a doctor (6).The health plan at provincial level emphasizes patient focused service improvement and organization development. The rate of patient satisfaction at 80% is the minimum goal for every hospital to achieve in Thailand (9). Indonesia health care delivery system consists of network of primary, secondary and tertiary facilities. An essential feature of health centers which operate at first level is the main contact among community. Based on vision of health Indonesia in 2010, 80% of health centers did not provide good quality of services (8).Health centers in Indonesia are designed to provide comprehensive, integrated health services; these include curative, promotive and preventive care, and community-based rehabilitation. There are also responsible for health development in their respective catchments area through community activities and innovative approaches. Depending on the population density, geographical area and local infrastructure, a health center catchments area is either a sub district or a Part of one. Each health center serves an average population of 30,000. They operate under the administrative authority of district administration and the district health office. The function of health center is expended through several subordinate units that include sub-center, posts for trained midwifes in village, and subordinate unit that integrated services unit (posyandu). This health center was linked to the “Village Community Resilience Body” (LKMD) to support village-based development activities (10).Patient’s satisfaction and its measurement are important as other clinical health measures and primary means of measuring the effectiveness of health care delivery as well as for policy analyst, health care managers, practitioners and users. Environment has forced health care organization to focus on Patient’s satisfaction as a way to gain and maintain market share. If you don’t know what your strengths and weakness are, you can’t compete effectively. Despite problem with establishing a tangible definition of “satisfaction” and difficulties with measurement, the concept continues to be widely used. In many instances when investigators claim to be measuring satisfaction, more general evaluation of health care services is being undertaken (11).Bireuen is the youngest district in NAD (Nanggroe Aceh Darussalam) by the rule UU No. 48 on October 1999, before it was apart of North Aceh. The total area is1.901,021 km2 consist of 17 sub district, and 581 villages. The total population is365.184 and until 2006, Bireuen district has 17 health centers, and 5 out of 17 health centers have beds for patients having serious illness. To provide services total of 142 staffs with one doctor, one nutritionist, one nurse secretary, one nurse for communicable disease ,one pharmacy assistance and for each village have one midwives and total of 40 for whole villages. The main programmes conducted in health center were focused on mother and chid health, immunization, nutrition, communicable diseases, health environment and health promotion and prevention. By National policy, a health center serves an average population of 30,000 (12, 13).Kuta Blang health center is one of the rural health centers in Bireuen sub district, which responsible for 40 villages with 20.006 populations and the average of patients visit were 60 patients per day. Health center provides free medical services to all the peoples in the village. There has been no study on patient satisfaction since the center was established; to improve quality of health care in this area the result of measuring patient’s satisfaction could be used for starting point to improve quality of services in Kuta Blang health center. A better understanding about factors relating to patient’s satisfaction can help policy and decision makers to implement programs adapted to patient’ need as perceived by patients for all health centers in Bireuen district. Therefore, this patient satisfaction study was conducted at Kuta Blang health canter, in Bireuen Aceh Province, Indonesia (12, 13).

PATIENT’S SATISFACTION WITH HEALTH SERVICES

AT KUTA BLANG HEALTH CENTER IN BIREUEN DISTRICT, NANGGROE ACEH DARUSSALAM

PROVINCE, INDONESIA

NAZIRAH

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF PRIMARY HEALTH CARE MANAGEMENT

FACULTY OF GRADUATE STUDIES

MAHIDOL UNIVERSITY

2008 COPYRIGHT OF MAHIDOL UNIVERSITY

This thesis would not have been possible without the help and support of many people First of all, I would like to thank the Provincial Health office, of Nanggroe Aceh Darussalam, for giving me this opportunity to study in the Faculty of Primary Health Care, Mahidol University, and AIHD Without their faith in my capacity, I would not have been able to partake in this course and gain knowledge in Primary Health Care Management

My heart felt gratitude goes to Assoc Prof Jirapon Chumpikul Ph.D., my major advisor, who through out entire project period was tireless to impart her knowledge of research to me and made a success

Prof Santhat Sermsri, Ph.D., was my co-advisors and they contributed many useful points during the research project relating to methodology and statistical analysis, and made the study easy and enjoyable My heartfelt thankfulness is also extended to my external advisor, Dr Ratanotai Pluburukarn, Dip Thai Board of Pediatrics, for her beneficial as well

as practical suggestions and coments offered during the thesis defend I express my thanks

to DHS1- ADB Loan INO Dinkes Prov NAD

My special thanks to all the Faculty of Primary Health Care Management, Mahidol University, AIHD, for arranging all the necessary formalities and clearances required to complete the research thesis Unless I had chance to be here, I would never have met the pleasantly energetic staffs working in this institute, especially Ms Sirilac Lyeskul, a tiny lady whose heart full given to M.P.H.M course I would like also thanks to head of Kuta Blang health center and all staffs for their encouragement and support to make this piece of work successful Last but not least, I would like to thank my beloved husband Mr Faisal and my lovely children M Khalil Al Wafi and Wifa Ufairah Hj for their kind patience and support during the study period, and also to my loving mother, sisters and brothers for their endless love and caring that helped me flourish during my study in Thailand My concern and memories to all collogues for their guidance and support Thank you very much for making me always says, “How fortunate I am!”

Nazirah

PATIENT’S SATISFACTION WITH HEALTH SERVICES AT

KUTA BLANG HEALTH CENTER IN BIREUEN DISTRICT, NANGGROE

ACEH DARUSSALAM PROVINCE, INDONESIA

NAZIRAH 5037994 ADPM/M

M.P.H.M (PRIMARY HEALTH CARE MANAGEMENT)

THESIS ADVISORS: JIRAPORN CHOMPIKUL, Ph.D., SANTHAT SRERMSRI, Ph.D

ABSTRACT This cross sectional study was conducted to assess the levels of patient satisfaction with services and to identify factors relating to patient satisfaction at Kuta Blang health center in Bireuen District, Aceh Province, Indonesia The dependent variables of patient satisfaction toward services were measured in terms of convenience, courtesy, quality of care and physical environment Using a self-administered questionnaire, data were derived from 200 patients who came to OPD services, aged 15 to 60 years old, from 6th January to

28th February 2008 Data were collected regarding socio-demographic factors, accessibility, distance, waiting time for services, information received, expectation regarding OPD services and patient satisfaction Chi-square test was performed to analyze the association between dependent and independent variables

The results concluded that the overall satisfaction was 23% The patients were most satisfied with courtesy (38%) while least satisfied with convenience (18%) There were statistically significant associations between occupation, waiting time for physician, expectation level and visiting the health center service again (p<.005)

The findings of this study are important for understanding levels of satisfaction and milestones in improving the quality of OPD services at health centers Most patients, in their comments and suggestions, highlighted the needs to improve the discipline of health care workers encourage training programs for health providers, and provide the continuing education for the experienced health providers to keep up with updated knowledge, technology and work practices

KEY WORDS: PATIENTS SATISFACTION/ HEALTH CENTER

74 pp

CONTENTS

Page

ACKNOWLEDMENTS iii

ABSTRACT iv

LIST OF TABLES vii

LIST OF FIGURES viii

LIST OF ABBREVIATIONS ix

CHAPTER 1 INTRODUTION 1.1 Rational and Justification 1

1.2 Research question 5

1.3 Research objective 5

1.4 Conceptual framework 6

1.5 Variables and operational definition 7

1.6 Limitation of the study 9

2 LITERATURE REVIEW 2.1 Background information about health center 10

2.2 The definition of satisfaction 11

2.3 Literature regarding independent variable 13

2.4 Theoretical conceptual framework 19

2.5 Components of satisfaction 21

3 RESEARCH METHODOLOGY 3.1 Research design 24

3.2 Population and study site 24

3.3 Sample size and sampling technique 25

3.4 Data collection tools and methods 26

3.5 Content validity and reliability 27

CONTENTS (Cont.)

Page

3.6 Research instrument for data collection 27

3.8 Data analysis 28

4 RESULTS 4.1 Socio-demographic characteristics of the patients 4.2 Accessibility characteristics of the patients 4.3 Patient’s expectation with health cervices at OPD Kuta Blang health center 30 32 35 5 DISCUSSION 5.1 Methodological concern 5.2 Socio-Demographic characteristics 5.3 Patient accessibility towards health cervices 5.4 Patient’s expectation towards health services at OPD 5.5 Patient’s satisfaction towards health services 47 48 49 50 51 Discussion 47

6 CONCLUSION AND RECOMMENDATION 6.1 Conclusion 53

6.2 Recommendation 54

REFERENCES 61

APPENDIX 62

BIOGRAPHY 74

Table Page

1 Reliability coefficient……… 27

2 Number and percentage of respondents by Socio-demographic characteristics……….31

3 Number and percentage distribution of the respondents classified by

accessibility……… 33

4 Overall expectation of patient towards health services at the OPD

Kuta Blang health center……… 35

5 Number and percentage of patient health problem……… 37

6 Percentage of the respondents patient satisfaction towards OPD service

regarding convenience……… 38

7 Number of percentage of patient satisfaction towards OPD service

regarding courtesy……… 38

8 Percentage of the respondents by patient satisfaction towards OPD service

regarding quality of care………39

9 Percentage of the respondents by patient satisfaction towards OPD service

Regarding physical environment……… 40

10 Total score of overall satisfaction each component……….40

11 Level of satisfaction with health service of the outpatient of Kuta Blang

Health center………41

12 Explanatory factors associated with satisfaction……….42

13 Explanatory factors not associated with satisfaction……… 43

14 Percent distribution of patient’s suggestion for improving the quality

of health center at OPD Kuta Blang health center……… 45

15 Number and percentage distribution of the respondents who would

visit the health centre again………46

Figure Page

1 Conceptual framework 6

2 Patients flow of service in Kuta Blang health center 17

3 An Emerging Model-Phase 4 20

NAD : Nanggroe Aceh Darussalam

OPD : OUT-patient Department

WHO : World Health Organization

MoH : Ministry of Health

CHAPTER 1 INTRODUCTION

1.1 Rationale and justification

With globalization has come an alarming increase in international statements and guidelines for developing about ethics, equity and health system reform When it does not refer to specific places, times, people and condition, such thinking is of little interest international forum All these trends in fact make the importance of the local

of district health system more conspicuous Within that system, health development is most effectively implemented through health centers, if health personal understand these to have responsibility both for maintenance of optimum health and for care of the sick in a given area population (1)

Patient’s satisfaction is a component of health care quality and is increasingly being used to assess medical care in many countries in the world Until recently, traditional assessments of medical care were done purely in terms of technical and physiological reports of outcomes It is an established fact that satisfaction influences whether a person seeks medical advice, complies with treatment and maintains a continuing relationship with practitioners (2)

Patient satisfaction has long been considered an important component when measuring health outcomes and quality of care The rising strength of consumerism in society highlights the central role patient’s attitudes play in health planning and delivery Further more, a satisfied patient is more likely to develop a deeper and longer lasting relationship with their medical providers, leading to improved compliance, continuity of care, and ultimately better outcomes (3)

Medical care aims not only to improve health status but also to respond to patients need and wishes and to ensure their satisfaction with care Likewise, conducting surveys to measure satisfaction with psychometrically validated questionnaires entails assessment of the quality of care organization and procedures Patient judgment on medical care also contributes to medical outcome In the case of ambulatory care, it has been clearly shown that satisfied patients are more likely to cooperate with treatment, to maintain a continuing relationship with a practitioner and thus enjoy a better medical prognosis From a conceptual point of view, the construct

of patient satisfaction as been defined by Isabell Gasquet Ware (4) As an "attempt to capture the personal evaluation of care that cannot be known by observing care directly" and to “Good” consider opinion of patients as a multidimensional subjective indicator of quality of care The model most commonly, though implicitly, used in satisfaction work is the discrepancy model (degree of fulfilment of expectation is related to satisfaction level) giving to patient expectations a central role This model, according to Sitzia “implies that concentrating upon areas of expressed dissatisfaction

is more valuable than obtaining consistency of expressed satisfaction" In France, measuring satisfaction has been mandatory since 1996 and several questionnaires have been developed to evaluate inpatient care Most existing outpatient satisfaction questionnaires have been developed to assess primary care practice, especially general practice However, it could be hypothesized that content of questionnaires evaluating primary care physician may be different from that of questionnaires exploring hospital consultation with a specialist because of differences in patient expectations So it could be assumed that dimensions that are very important in the case of primary care like human qualities of the physician and medical information could have a lesser importance in case of hospital consultation, while technical competency could have a more important place (5)

The quality of health services can be measured by a community's level of satisfaction in terms of the health services received, both curative and preventive (6) The quality of health services is very much influenced by the quality of physical facilities, types of work force available, medicines, health instruments and other

supportive facilities, services conferring process, and compensation received and the expectation of the consumer society Hence the increase in physical quality and aforementioned factors are preconditions to be fulfilled Afterwards, the process of services conferral is to be increased through increase in quality and professionalism of health resources as stated above While the expectation of the consumer society is being adjusted through improvement in general education, health information, good communication between health providers and the public (7, 8)

As the center for basic health services at the sub district level, each health center (community healthcare centers) generally has a doctor who is appointed as the head of the health center However, the administrative duties of a health center head often reduce consultation time with patients As a result, patients are mostly taken care of by nurses and midwives This is a dilemma On one hand, as a doctor assigned

to a particular health center, he or she is required to contribute to the provision of health services, but on the other hand, the administrative duties of a health center head

in fact interrupt their duties as a doctor (6)

The health plan at provincial level emphasizes patient focused service improvement and organization development The rate of patient satisfaction at 80% is the minimum goal for every hospital to achieve in Thailand (9) Indonesia health care delivery system consists of network of primary, secondary and tertiary facilities An essential feature of health centers which operate at first level is the main contact among community Based on vision of health Indonesia in 2010, 80% of health centers did not provide good quality of services (8)

Health centers in Indonesia are designed to provide comprehensive, integrated health services; these include curative, promotive and preventive care, and community-based rehabilitation There are also responsible for health development in their respective catchments area through community activities and innovative approaches Depending on the population density, geographical area and local infrastructure, a health center catchments area is either a sub district or a Part of one Each health center serves an average population of 30,000 They operate under the

administrative authority of district administration and the district health office The function of health center is expended through several subordinate units that include sub-center, posts for trained midwifes in village, and subordinate unit that integrated services unit (posyandu) This health center was linked to the “Village Community Resilience Body” (LKMD) to support village-based development activities (10)

Patient’s satisfaction and its measurement are important as other clinical health measures and primary means of measuring the effectiveness of health care delivery as well as for policy analyst, health care managers, practitioners and users Environment has forced health care organization to focus on Patient’s satisfaction as a way to gain and maintain market share If you don’t know what your strengths and weakness are, you can’t compete effectively Despite problem with establishing a tangible definition of “satisfaction” and difficulties with measurement, the concept continues to be widely used In many instances when investigators claim to be measuring satisfaction, more general evaluation of health care services is being undertaken (11)

Bireuen is the youngest district in NAD (Nanggroe Aceh Darussalam) by the rule UU No 48 on October 1999, before it was apart of North Aceh The total area is 1.901,021 km2 consist of 17 sub district, and 581 villages The total population is 365.184 and until 2006, Bireuen district has 17 health centers, and 5 out of 17 health centers have beds for patients having serious illness To provide services total of 142 staffs with one doctor, one nutritionist, one nurse secretary, one nurse for communicable disease ,one pharmacy assistance and for each village have one midwives and total of 40 for whole villages The main programmes conducted in health center were focused on mother and chid health, immunization, nutrition, communicable diseases, health environment and health promotion and prevention By National policy, a health center serves an average population of 30,000 (12, 13)

Kuta Blang health center is one of the rural health centers in Bireuen sub district, which responsible for 40 villages with 20.006 populations and the average of patients visit were 60 patients per day Health center provides free medical services to all the peoples in

the village There has been no study on patient satisfaction since the center was established;

to improve quality of health care in this area the result of measuring patient’s satisfaction could be used for starting point to improve quality of services in Kuta Blang health center

A better understanding about factors relating to patient’s satisfaction can help policy and decision makers to implement programs adapted to patient’ need as perceived by patients for all health centers in Bireuen district Therefore, this patient satisfaction study was conducted at Kuta Blang health canter, in Bireuen Aceh Province, Indonesia (12, 13)

1 To describe patient satisfaction at Kuta Blang health center in Bireuen district

2 To describe socio-demographic factors of patient on satisfaction at Kuta Blang health center in Bireuen district

3 To assess the accessibility of Kuta Blang health center

4 To asses the expectations of service at the health center according patient

perception at Kuta Blang health center

5 To determine the relationship between patient’s characteristics, expectation on services system, accessibility to the service and patient satisfaction to the service

at Kuta Blang Health Center in Bireuen District, Aceh Province, Indonesia

1.4 Conceptual framework

Independent variables Dependent variable

Figure 1 Conceptual framework

- Convenience

- Courtesy

- Quality of care

- Physical environment

1.5 Variables and operational Definition

1.5.1 Independent variable

Socio-demographic characteristics consist of age, gender, marital status,

education, and occupation

Age refers to the age of the respondent at the time of interviewing, including age, 16-60 years old The limit of age at 60 because age 60 is an old person who is still easy to communication but the age beyond 60 is probably too old to provide clear information

Marital status has five categories, is namely single, married, separated,

widowed and divorced

Educational level refers to the obtainment of schooling education of the

patients In this study education levels are categorized in 5 groups, No education/illiterate, primary school, high school, college/university, and other

Occupation is defined as the main job of the respondents categorized in 7

groups: 1 Housewife/unemployed, 2 Government service, 3 Farmer, 4 Merchant/ self-employer, 5 Laborer, 6.Unemployed and 7.Others

Accessibility to cervices means how comfortable it is to access the services in

terms relevant to information received, waiting time and service hour

Distance means the length of travel time, and expense to health center and

convenience location health center to come

Waiting time for services means an opinion of patient towards waiting time

for each section service at Kuta Blang health center such as, registration room, physical examination, treatment room, and pharmacist room

Information received means type of the information about health center

including regulation, illness, drug use, health promote and preventive care

Family income is an approximate real income of the family in month Persons

are given an open-ended question to indicate the month of family income

Physical facilities mean an opinion of patient towards general appearance of

building, place, chairs, desks, and toilet

Doctor’s service means the services provided by the health personnel, mine,

physician The doctor’s service is to provide treatments, including taking care of patients of the health center It is assumed that patient can evaluate doctor’s skills and understanding of results of the treatment

Nurse’s services means the service provided by the nurse who are working in

health center The patient can consider from ability and experience of the nurse, suggestion of how to take care of oneself, clarification diagnosis and care, and character

Pharmacist services mean the service provided by the pharmacist staff in the

drug units

Registration’s staff’s services mean the service provided by the registration

staff in the registration room

Waiting time means opinion of the patient towards the amount of waiting

time for service at Kuta Blang health center

Health problems refer to the health condition and current illness that brought

the patient to the health center

1.5.2 Dependent variable

Patient satisfaction: refers to the patients’ state of being satisfied with health

care services at the out-patient Kuta Blang health center Patient refers to the respondents who consume the health services at the OPD of the health center during the time of conducting interviews The indicators for client’s satisfaction in this study consist of four components convenience, courtesy, quality of care and physical environment

Convenience: In this study, it means accessibility of health services, taken

care well and also includes sufficiency of physical facilities

Courtesy: Means manners, speaking, and friendliness of provides by health

personnel

Quality of care: means quality of service in all levels from the patient The

quality includes capability of doctors to diagnose correctly and medical treatment, nursing skill, and use technology facilities services

Physical environment refers to features of the physical setting in which the

health services are provided Cleanliness of equipment and cleanliness of the space as health center

1.6 Limitation of the study

This study is concerned at the sub-district of Bireuen district It is there for not reflect the whole health care service of the district level The information obtained from the study population might have some variations and this study is conducted with limited resources making it impossible to include many important questions and variables

CHAPTER 2 LITERATURE REVIEW

The literature review included the following topics:

- Background information about health center

- The definition of Satisfaction

- Literature regarding to independent variables

- Theoretical conceptual framework

- Components of satisfaction

2.1 Background Information about Health Centers

A health center is a functional health organization unit which server as a center for health development, community participation development, besides providing comprehensive and integrated health service to the community within working area It is authorized and responsible for delivering health care service to the community within its working area, which is a sub district or a part of sub district (16)

Health center as a part of district health system is administratively responsibility of the head of district health office, but technically responsible to the MoH Health center as a part of national health system is a part of basic health care level in the referral system (17)

Health center is the spearhead of the national health system and one of leading element for national health development Basic health services provided at health center are: 1 Medical Treatment; 2 Health Promotion; 3 Environmental Health;

4 Maternal and Child Health; 5 Nutrition; 6 Communicable diseases (17)

At present, the following specific targets related to basic health care services

at health centers, consolidated in the government’s health policy program, are being implemented under Indonesia’s new national development policy, known as PROPENAS (fiscal 2000-2004)

- Prevention of the outbreak and spread of infectious diseases

- Reducing the instance of infection, mortality, and disease-induced disability

- Extension of areas with access to basic medical services, plus more equitable access

- Enhanced impact and efficiency of basic medical and related services

- Promotion of the use of safe and effective pharmaceuticals through medical

services and medical networks, as well as of traditional forms of treatment (18)

Health center effort consist of community health service, which focus on promotive and preventive with community group approach through outreach health service Basic medical service, which focus on the curative and rehabilitative service with individual and family approach through outpatient and referral services In certain condition and if it is possible, we can consider that health can provide inpatient services as interval before to hospital (16)

Health care has many changers over the years The objectives of health care changed with the requirements of society and the availability of resources and technology The WHO conference on supporting health for all, held in 1990, defined future development in health to be human centered A lot of stress has been made on investment in heath, patient care and patient’s right to delivery of quality health care leading to patient satisfaction (19)

2.2 The definition of satisfaction

Based on dictionary, the definition attributes the term “satisfaction” to the Latin root sati’s meaning “enough” Something that satisfies will adequately fulfill expectation, need or desire, and giving what is required, leaves no room for complaint

Two points arise from this definition First, a feeling of satisfaction with a service doesn’t imply superior service; rather that adequate or acceptable standard was achieved Dissatisfaction is defined as discontent, or failure to satisfy It is possible that consumer is satisfied unless something untoward happens, and dissatisfaction is triggered by critical event Secondly, satisfaction can be measured only against individual’ expectation needs or desires It is a relative concept: something that make one person satisfied (adequately meets their expectation) may make another dissatisfied (fall short of their expectation) (11, 2)

Patient’s satisfaction is an expression of the gap between the expected and perceived characteristics of a service Satisfaction is a subjective phenomenon and could be elicited by asking simply how satisfied or not patients may be about the service However, it has been found that, questionnaires that ask patients to rate their care in terms of how satisfied they are tend to elicit very positive ratings that are not sensitive to specific processes that affect overall quality It is recommended that patients be asked to participate on their experiences through specific questions (2)

Patient reports about satisfaction with care are thought to reflect attitudes and opinions about care that may influence other patient behaviors, such as choice of providers, amount of services used, and compliance In addition, patient satisfaction reports are behaviors in their own right (20)

Satisfaction, like many other psychological concepts, is easy to understand but hard to define The concept of satisfaction overlaps with similar themes such as happiness, contentment, and quality of life Satisfaction is not some pre-existing phenomenon waiting to be measured, but a judgment people form over time as they reflect on their experience A simple and practical definition of satisfaction would be the degree to which desired goals have been achieved Patient /Patient’s satisfaction is

an attitude – a person’s general orientation towards a total experience of health care Satisfaction comprises both cognitive and emotional facets and relates to previous experiences, expectations and social networks Meredith and Wood (1995) have described Patient’s satisfaction as ‘emergent and fluid’ It also has been important

factors influencing patients/Patients in this regard include literacy levels, intellectual and physical/sensory disability levels and difficulties with language proficiency or ethnic and cultural diversity Social elements within our society must be considered as they can very often dictate whether the consumer will provide feedback and express their satisfaction or otherwise, e.g., financial status, educational status, demographics (urban/rural), technology Previous measurements of Patient’s satisfaction overwhelmingly show that the majority of consumers, usually 80 % or more, express overall satisfaction with their care, with few respondents responding negatively to any given item Satisfaction

is, however, a relative measure which research literature shows, may be influenced by many factors that should be considered (21)

2.3 Literature Regarding To Independent Variables

2.3.1 Socio-demographic characteristics

Socio-demographic variables are related to all kinds of health care experiences that patients have, and the way that they interpret them For instance, better educated patients may participate in diagnosis and treatment decisions more then less educated patients but remain less satisfied with their degree of participation because physicians are not meeting their higher expectation Consequently, it is often difficult to interpret findings of relationships between socio- demographic and satisfaction (22)

Many researchers documented that socio-demographic variables are directly related to patient satisfaction Similarly, patient satisfaction correlates to health personal behaviour, especially those who have low income These variables are well documented by many different researchers and writers Perhaps the most consistent determinant characteristic is age, with a body of evidence from various countries to suggest that older people tend to be more satisfied with health care than younger people (23)

The other side of the of the “consensus coin” is the existence of consistent, coherent differences within demographic segments of a population A fourth task for

future health behaviour research is the determination of how various groups within a population differ in their definition Systematic study of diverse samples, of persons with different ethnic, education, socioeconomic or age characteristic, might reveal demographic diversity that would have important practical value in increasing the success of programs and improving communication between professionals and clients (20)

The study in health center, Bangkok Metropolitan Administration found the associations between socio-demographic-economic factors and patient satisfaction The results showed that education, family income, travelling time and transportation

of respondents to visit health center last year had significant associations with degree

of satisfaction (24)

It is commonly believed that satisfaction with health care may be dependent upon variables as social class, marital status, gender, and-in particular age Socio-demographic characteristics were concluded to be at best a minor predictor of satisfaction (25)

2.3.2 Accessibility to Health Center

The accessibility of health care can be assessed in various aspects: the possibility for residents to see their doctor; to use the services of health care system; the provision of population with health care resources (doctors, nurses) The evaluations of the health center territorial accessibility also depended upon the patients’ residence and the type of health center

When estimating the accessibility of health care it is important not only how long do the patients spend at the reception but also how long do they have to wait outside their doctor’s consulting-room According to the data of the survey one-third (32.9%) of the patients think that they have to wait too long for the visit to their doctor The results of the logistical regressive analysis have shown that the patients’ estimations on the time spent at the reception were largely related to the patients’ education, residence, the frequency of visits, and the type of health care The

probability that people with vocational education would point out that they have to wait for their visit to the GP for too long was 3.1 times lower in comparison with those who have primary education only; and the probability that people with university education would point out that they have to wait for their visit to the General Practice for too long was 2.2 times lower in comparison with those who have primary education only Patients who receive their health care services at private health care also more seldom ascertained that the time they spent waiting for their visit to the GP was too long; that is, the probability that they would say that the time spent at the reception was too long was 2.1 times lower compared with the patients visiting public health care

The extent to which patients are able to reach required services and treatments when they are needed and mobilize within them This includes waiting times, patients' ability to find out about, get referred to and physically get to services, accessibility for diverse populations, and the range of services provided (21)

Patients who have received their health care services in towns and patients who visit health care frequently tend to be more critical when evaluating the time spent waiting for the consultation with their GP we have come to a conclusion that the chance that the patients visiting private health care would better evaluate the waiting rooms was 5.6 times higher, and the chance of positive evaluation of GPs’ consulting rooms was 5.2 times higher in comparison with the patients who visit public health care It was established that the higher the patients’ education the bigger the possibility that the waiting rooms would be rated positively Residents of towns in comparison with the city residents tend to be more critical of the GPs’ consulting-rooms and of the health care waiting rooms Other authors point out that, when evaluating the patients’ satisfaction with the health care accessibility, it is necessary to assess the coherences between the patients’ state of health and the availability of health care evaluations (21)

2.3.3 Service system and Health Care

Health post and health center, while useful in providing a primary level

of and are limited in their capacity and services, and the skill at their disposal, and are usually available only during working hours (26)

A health system is the complex of interrelated element that contribute to health

in home, educational institution, workplace, public place and communities, as well as the physical and psychosocial environment and the health and related sectors (27)

Health centers in Indonesia are designed to provide comprehensive and integrated health services These include curative, promotive and preventive care, and community base rehabilitation They are also responsible for health development in their respective catchments areas through community activities and innovative approaches (10, 21)

Depending on the population density, geographical area and local infrastructure, a health care catchments area is either a sub district or a Part of one Each health center serves

an average population of 30.000 They operate under the administrative authority of the district administration and the district health office (10)

The function of health center is extended through several subordinate units which included sub centers posts for trained midwives in villages and community-based integrated service unit (posyandu) This health center system is linked to the

“Village Community Resilience Body “ (the LKMD) to support village-based community development activities(10)

Kuta Blang health center is one of the rural health centers in Bireuen district, Aceh province, Indonesia It is located at sub-district and one of the models of rural health center, which has service system patient flow from arrival to return home, as the bellow figure:

Figure 2: Patients flow of service in Kuta Blang health center

When patients arrived to health center (puskesmas), where they had to register, in registration unit After registration patients have to wait before obtaining individual services in poly clinic, or dental clinic, or mother and child health or family planning After the consultation or service, patients go to pharmaceutical unit or to the laboratory for diagnostic tests A few patients were referred to district hospital

2.3.4 Expectation with services

The expectations of patient are one of the determining factors of healthcare service The purpose of this study is to measure the Patients’ Expectations, based on patient's rights (28)

Patient comes to health center

Registration

Waiting room

Tuberculosis clinicDental unitMTBS unit Polyclinic unitChildren clinic

MCH and family planning Mental counselling

Pharmacy unit

Return home

From Likert-Survey in Trabzon population The analyses showed that the level

of the expectations of the patient was high on the factor of receiving information and

at an acceptable level on the other factors Statistical meaningfulness was determined between age, sex, education, health insurance, and the income of the family and the expectations of the patients According to this study, the current legal regulations have higher standards than the expectations of the patients The reason that the satisfaction

of the patients high level is interpreted due to the fact that the level of the expectation

is low It is suggested that the educational and public awareness studies on the patients’ rights must be done in order to increase the expectations of the patients (28)

Expectation make more complex of the satisfaction as an evaluative tool As patient satisfaction is a recognized component of quality Assurance, it is therefore tempting to equate “high” levels of reported satisfaction with “high” levels of quality

of care However, relating to patient satisfaction study results, it is necessary that

“expression of satisfaction should always be interpreted in the context of some understanding of the rational that underlies those expressions rather than being taken

at face value” For physician care, the hypothesis that the more a doctor performance meets a patient’s expectation, the more satisfied the patient will be with the physician’s services was strongly supported

The few later studies in which the relationship between level of patient’s expectations and overall satisfaction has been explored consistently suggested that patients with “lower expectation” tend to be more satisfied There may, however, be confounding variables which need to be considered; for example, there exist relationships between level of patient’s expectation, socioeconomic status and associated values and attitudes amongst different patient groups (29)

Patient’s satisfaction with the health care they receive isan important health outcome which has been given particular emphasis in the current review of the National Health Service.Nevertheless, the relationship between satisfaction and thequality of care received is complex and affected by patient,doctor and service factors.Recent commentators have speculated that patient expectation of care they will

receive has an importantimpact on satisfaction: patients with inappropriately high

expectations may be dissatisfied with optimal care, and thosewith inappropriately low

expectations may be satisfied withdeficient care Furthermore, observed differences

in satisfaction between people from different social classes, age, sex and culturalgroup or between different services and types of care,may be confounded by match or mismatch between expectation and the service received Based on the work of Prakash, we haveconceptualized patient expectation of care as having two aspects;

what patients expect as a result of their own or others' experiences(normative/comparative expectation) and the care they wouldlike and or hope for (idealized expectation)(30)

2.4 Theoretical Conceptual framework

In this study, the conceptual framework was derived from the Behavioural Model of Health Services Use develop by Ronald M Andersen (14)

Health beliefs are attitudes, values, and knowledge that people have about health and health services that might influence their subsequent perceptions of need and use of health cervices Health beliefs provide one means of explaining how social structure might influence enabling resources, perceived need, and subsequent use (31)

Social structure is measured by a broad array of factors that determine the status of a person in community, his or her ability to cope with presenting problems, and how healthy or unhealthy the physical environment is likely to be Measures used

to assess social structure include education, occupation, ethnicity, social networks, social interactions, and culture Measures of these concepts rightly fit into the social structure component (32)

Aday & Anderson in 1974 mentioned that patient satisfaction is the attitude towards the medical care system They proposed that patent satisfaction is probably best evaluated in the context of specific, reset and identifiable episodes of medical care seek in relevant to consider in eliciting subjective perception of access that

indicate satisfaction with the convenience of care, its coordination and cost, courtesy

of the providers, information given to the patient about dealing with their illness, and their judgment as to the quality of care received Patient satisfaction is an outcome indicator in a theoretical model of access, which indicated the use of the services

Consumer satisfaction is the health outcome affected by three key factors, including predisposing characteristics, enabling resources and need factors of the consumer In the formulation of the study conceptual framework only some factors of the model were include (15)

Environment Population characteristics Health behaviour Outcomes

Figure 3 An Emerging Model-Phase 4

Use of Health Services

Perceived Health status

Evaluated Health status Consumer Satisfaction

2.5 Components of Satisfaction

Four components of satisfaction considered by the current study Kuta Blang health center are convenience, courtesy, quality of care and Physical environment The details of these each component are the followings

2.5.1 Health care providers

Hall and Dorman reported in 1988 that satisfaction with health care services is determined by satisfaction with one’s physician, while satisfaction with the outpatient experience is determined by the quality of health care workers The satisfaction is divided into two parts: the satisfaction with technical competence and satisfaction with interpersonal skills When evaluating nurses, the patients place much more emphasis on interpersonal aspect than on perceptions of technical competence Having continuous relations with their doctors is strong predictor of overall satisfaction Prior relations between doctor and patients are major cause of disenrollment (33)

Patientsatisfaction is best considered as a multidimensional construct Patients may hold quite destined views in relation to different aspects of their health care Cleary and Mc Neil (1988) distinguish nine different dimensions of health care on which patients’ views can be obtained: the ‘art of care’ (i.e health professional’ inter personal skills), technical quality, accessibility, convenience, finance, physical environment, availability, continuity an outcome As will be evidenced below, the first category of influences, ‘the art of care’, contains elements of health care, such as health professionals’ communication skills and sensitivity to patients’ concerns that have a particularly strong influence on patient satisfaction Some evidence suggests that, so influence are such factors, patients are unable to distinguish between interpersonal skills one the on-had and technical competence on the other hand (Ware

& Snyder, 1975) (34)

One of variables repeatedly cited in providing quality of care through health promotion is the character of the patient-provider relationship, particularly that

between physician and patient Futures of this relationship that were associated with positive patient behaviours were (35):

1 The friendly and accepting attitude of the provider

2 Patient’s perceptions that the physician had spent time with them

3 Patient’s fillings that thy hade control in the interaction and input in their treat meant programs

4 Patient’s satisfaction with the care they received

5 A treatment program that was actually tailored to them as individuals

6 Situations where patients felt that information was willingly shared with them

7 Absence of formal disagreement with patients

8 Continuity of the specific provider-patient relationship

2.5.2 Convenience

Convenience meant the ease to travel to service, an opportunity of meeting the health provider, waiting time, receiving the services as wanted and

willingness of the health providers to treat patients

The convenience and characteristic of place people go for medical care provide data on whether there is differential treatment of individuals depending on where thy chance to go for cervices In addition waiting time in getting services should be as proxy indicator of convenience in any service (8) In a study at Ramathibodi hospital, it was shown that the waiting time was the most important factor influencing the satisfaction (36)

Consumer satisfaction according to Aday and Andersen (1974), thy proposed that consumer satisfaction is probably best evaluated in the context of specific, recent, and identifiable episode of medical care seeking, relevant to consider in eliciting subjective perceptions of access are satisfaction with the convenience of care, its co-ordination, and cost, the courtesy shown by providers, information given to the patient about dealing with his illness, and his judgement as to the quality of care he received (14)

2.5.3 Quality of care

Previous research studied patients satisfaction and quality of health care

in rural Bangladesh found that the quality of care was depending upon provider behaviour, especially respect and politeness aspects For patient this aspect was much more important than the technical competence of the provider Furthermore, reduction

in waiting time (on average to 30 minute) was more important to patient than a prolongation of the quite short (from a medical standpoint) consultation time (on average 2 min, 22 sec), with 75% of clients being satisfied Waiting time, with was about double at outreach services than that at fixed services, was the only element with which users of outreach services were dissatisfied (36)

Patients’ satisfaction depends not only on service quality but also on patients’ expectations Patients are satisfied when services meet or exceed their expectations If patients' expectations are low or if they have limited access to any services, they may

be satisfied with relatively poor services A poor woman in Bangladesh said "Even though they behaved badly, I have to be content” We are lucky if we can get the free medicine that they give out at the clinic Health care patients often expect poor-quality care, accept it without complaint, and even express satisfaction when surveyed Patient’s satisfaction as expressed in interviews or does not necessarily mean that quality is good; it may mean that expectations are low services Patients may say they are satisfied because they want to please the interviewer, because they are afraid of service withheld in the future, because of cultural norms against complaining, or because they respond positively to the word "satisfied” (38)

CHAPTER 3 RESEARCH METHODOLOGY

3.2 Population and Study site

The study population was outpatients of Kuta Blang Health Canter The sample of this research consisted of outpatients aged 15-60 years who visited health care visited services in January 2008 The researcher selected this age group because the patients at this age mature enough to answer questions independently The researcher interviewed their satisfaction on health care services at Kuta Blang Health Canter in Bireuen District, Aceh Province, Indonesia

3.3 Sample Size and Sampling Technique

Sample size of the patients was determined by using the following statistical formula:

6.016.0)96.1

Zα/2 = value from the standard normal (Z= 1.96 if 95 % confidence

interval required)

p = Proportion of patient’s satisfaction with service = 0.60

Cited in a research of client satisfaction with services at Health

center in Urban Banda Aceh, Indonesia 2002 (16)

d = Maximum allowed error/margin error was assumed to be 0.068

n = number of sample size

Therefore, the sample size required for this study was at least 200

Systematic random sampling was applied to draw patients in order to get information about the aspects of health care services mentioned in the study Patients ware selected with sampling interval for each day The K interval is calculated by using this formula The researcher selected one patient for every seven patient interval (39, 40):

Where:

k = sampling interval

a = average actual number of patients consumed services at the health

center per day

d = total number of days planned for data collection

n = required number of patients consumed services at the health center

3.4 Data Collection Tools and Methods

Patients who arrived, and registered to receive the service, were interviewer during registration and they were approached and requested to participate in this study The structured questionnaires were used and designed by the researcher under the guidance of advisor and co-advisor The questionnaires were translated into Indonesian language The questionnaire was divided into the following 4 sections:

Section 1 Socio-demographic such as gender, age, marital status, education,

occupation and family income were be check list and filled in the blank

Section 2 Accessibility to health center included distance, waiting time for

services, information received and service hour A score of “1” is given for “yes” answer A score of “0” is given for “no” answer

Section 3 Expectation of patients about OPD services included physical

facilities, doctor services, nurses’ services, pharmacy sector, registration services, waiting time and health problem The question was a 3 rating scale Each item was scored as follows: 3= Excellent, 2= Good, 1= Not acceptable, no expectation= missing

total score of each component was classified into two levels, using median as the cut of point

Section 4 Patient’s satisfaction with the services including: convenience,

courtesy, quality of care and physical environment Patients satisfaction was be classified into 3 scales as follows: 3 = high, 2 = moderate, 1 = low A total score of each component was classified into two levels If total score of each patient below or equal to 80%

of total score, it was classified in to low satisfaction If it was above 80% of total score it was classified into high satisfaction

3.5 Content validity and reliability

The questionnaires were pretested with 30 respondents at Kuta Blang Health center, in Bireuen district Reliability of the questionnaire was analyzed by using the Cronbrach’s coefficient.(40, 41) Content validity will be tested by the researcher, advisor and co- advisor

3.6 Research instruments for data collection

The local government and Chief of District Health Office, Indonesia approved the permission to carry out this study before data collection The data were collected

by using pretested research instrument Thirty respondents for reliability test, the data were entered into Minitab software to calculate reliability coefficients The questionnaire was translated in to Indonesia language and focused on six questions for expectation and seventeen questions for satisfaction The questionnaire was tested for reliability at one community Kuta Blang health center in Bireuen district The cronbach’s coefficient was adopted for reliability analysis of expectation and satisfaction, shown in Table1

Table 1 Reliability Coefficient

Variable Cronbach’s coefficient

Expectation 0.756091

Patient satisfaction 0.684540

After consulting with thesis advisor and co advisor in order to check content validity and continue to collect data for thesis Before collecting data four staff from subdivision of Health Service at District Health Office were selected as interviewers

and received one day training in order to understand the objectives of this research, interviewing technique and meaning of questions of this study

- Check and edit consistency of data in all variables

Frequency and percentage were calculated for predisposing characteristics (age, gender, education level, occupation, marital status), enabling factor (income), accessibility (distance, waiting time for services, information received, service hour) and the level of patient satisfaction

Chi-square test was performed to determine relationships between the independent variables and the satisfaction levels Mean, standard deviation, median, inter-quartile range and quartile deviation were calculated for patient expectation and satisfaction Frequency and percentage were used to describe the qualitative variables

in the study

CHAPTER 4 RESULTS

This cross sectional study was conducted in Bereuen District at Kuta Blang health center to describe the patient satisfaction towards outpatient medical care services A total of 200 patients were interviewed from the medical outpatient department (OPD) in Kuta Blang health center An interviewer was employed for data collection from 6th of January until 28th January 2008 not excluding public holidays All respondent were OPD patients aged 16 until 60 years who returned to OPD after previous visits The eligible respondents were asked about the basic information of socio-demographic characteristics, accessibility to health care including distance, waiting time, information OPD services and the satisfaction of patients with services,

in term of convenience, courtesy, and quality of care The respondents who came to the OPD service for utilization of health care services during the period of data collection were both males and females The study was conducted in order to measure the level of patient satisfaction with the OPD services Moreover, this study was intended to find out the relationship between the socio demographic factors, accessibility, expectation and patient satisfaction with OPD services

The results of the study were presented in the tubular and descriptive forms in the following parts:

Part 1 Socio-demographic factors

Part 2 Accessibility to health center

- Distance

- Waiting time for services

- Information received

- Service hour Part 3 Expectation of patients with health services at OPD

- Health problem

Part 4 Satisfaction with health services at Kuta Blang health center

Part 5 Association between patient satisfaction and independent variables

4.1 Socio-demographic characteristics of the patients

Socio-demographic characteristics of the patients included gender, age, marital status, education level, and occupation More than half (55 %) of them were females Patients’ age ranged from 17 to 60 years, majority of the respondents (67.5%) are in age group between 52 to 60 years old with the mean and the standard deviation of age were of 40 and 11, respectively

Most of the patients (74.5%) belonged to marriage group and (12%) were single and the remainders (14%) were in the widowed or divorced or separated Regarding education attainment, majority (42%) had colleague/ university level, only

2 percent no education Considering occupation, 31% were housewives, 26% farmers and 18.5% government offers, 16% merchant/self-employees