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 ACKNOWLEDGEMENTS 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 Fac. of Grad. Studies, Mahidol Univ. Thesis/iv 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 6 th January to 28 th 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 vi 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 LIST OF TABLES 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 LIST OF FIGURES Figure Page 1. Conceptual framework 6 2. Patients flow of service in Kuta Blang health center 17 3. An Emerging Model-Phase 4 20 LIST OF ABBREVIATION NAD : Nanggroe Aceh Darussalam OPD : OUT-patient Department WHO : World Health Organization MoH : Ministry of Health [...]... 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) 1.2 Research questions What are factors related to patient satisfaction. .. 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. .. 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... 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... 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... units which included sub centers posts for trained midwives in villages and communitybased 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... the health care services at Kuta Blang health center in Bireuen district? 1.3 Research objectives 1.3.1 General objective To assess the levels of patient satisfaction with the services and to identify factors relating to the patient satisfaction 1.3.2 Specific objectives 1 To describe patient satisfaction at Kuta Blang health center in Bireuen district 2 To describe socio-demographic factors of patient... 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... 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. .. 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 . 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. PATIENT’S SATISFACTION WITH HEALTH SERVICES AT KUTA BLANG HEALTH CENTER IN BIREUEN DISTRICT, NANGGROE ACEH DARUSSALAM PROVINCE, INDONESIA NAZIRAH. 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,