Satisfaction with Service Delivery in Clients Referring to Urban Health Centers Affiliated to Shaheed Beheshti University of Medical Sciences and Health Services: A Qualitative Study

Abstract

Background and Purpose: Delivery of health services should be based on the needs and demands of each population. This can solve health problems and, finally, lead to clients’ satisfaction. This qualitative study was conducted to assess satisfaction with service delivery in clients referring to urban health centers affiliated to Shaheed Beheshti University of Medical Sciences and Health Services.

Materials and Methods: With respect to research aims, distribution of centers with various locations, different socioeconomic conditions of the subjects and various delivered services, 233 clients were selected by purposive sampling method from 21 urban health centers affiliated to Shemiranat, North, and East health centers supervised by the university in Tehran.

Data were collected by semi-structured interviews and the voice of the subjects was recorded with their permission by the researchers. Questions were divided into two sections: demographics in the first part and information concerning research aims including physical environment, personnel communication and service delivery of the centers in the second part. Data were analyzed by frequent listening to statements of the subjects and verbatim transcribing as well as storing them in the computer.

Results: Findings showed that the majority of subjects were satisfied with physical environment of the centers while having some critiques about other aspects. With respect to clients’ satisfaction with personnel communication, most of them were satisfied while some of them expressed their nuisance from certain behaviors of personnel. Regarding clients’ satisfaction with service delivery, most of them expressed their moderate satisfaction with some delivered services.

Conclusion and Recommendations: As a whole, findings indicated a general dissatisfaction with service delivery, time wastage, too-long waiting, inadequate period of activity as well as attention to clients, and insufficient health education. Further studies concerning the quantity and quality of services delivered by the health centers are warranted.

Key words: Clients’ satisfaction, Service delivery, Urban health centers

Introduction

Since the General Assembly of the UN in 1948, healthcare has been recognized as a right with respect to Universal Declaration of Human Rights. This right was subsequently included in the Declaration of Patient Rights. In fact, evidence increasingly shows that having alternatives in different health programs for individuals’ plays an important role in their satisfaction and dissatisfaction with healthcare. Surprisingly, studies show that about %44-%58 of American employees have no rights in choosing health plans. A national survey for determining the influences of selection right in the US on 1204 randomly-selected employees less than 65 years of age showed that %42 of respondents had no right to choose their health programs and the less they had the right of selection, the more their dissatisfaction with these programs and healthcare was. It was emphasized that those subjects who had selected certain programs because of their cheapness were dissatisfied due to the limitation of delivered services (1).

Currently, the quantity and quality of health service delivery should be based on clients’ needs and demands. Promoting service delivery irrespective of people’s opinion would be inappropriate and occasionally impossible. Bond (1992) believed that health institutions should respect clients’ needs, wishes, desires and opinions. Attending to evaluation of health service delivery by clients can lead to correction of deficiencies and their final satisfaction with services of health institutes (2). Increasing clients’ satisfaction with the quality of health services results in greater productivity and benefit in health organizations (3). Some scholars believe that opinions and behavioral patterns of people should be determined prior to healthcare planning (4). Regarding the lack of attention to clients’ views, Thomson and Koh (1994) held that dissatisfaction results from inappropriate response to clients’ needs. This can lead to frustration, hopelessness, anger, permanent anxiety as well as abnormal and sometimes ill behaviors in the clients. All these problems can be projected to families, relatives, and friends by the clients with final pessimism about the care delivered by health professionals (5).

Lofferrie (1996) argued that clients satisfaction reflects the quality of services provided and its assessment as an important indicator in evaluating outcomes is a method in determining clients’ views about the condition of services (6). In addition, assessing and identifying clients’ satisfaction is a basis to develop service delivery, which, in turn, can reinforce their satisfaction. Since there is no accurate information about clients’ opinions regarding healthcare provision nationwide, the researchers decided to conduct this study to find specific results regarding clients’ satisfaction, which can then be used for better health planning.

Materials and Methods

This is a qualitative study in the form of phenomenology. Qualitative studies are conducted to understand human behaviors (7). Qualitative findings provide objective and subjective data from interviewees. Donagha (1984) believed that gathering subjective information is a difficult task, which can be performed by interviewing (8). In qualitative studies, theory evolution from specific to general is possible and these investigations often provide explanations based on present realities for different events (9). Phenomenological approach uses dialogues and interviews to form ideas from experiences of individuals. Individuals’ experiences about a specific subject lead to a deep understanding of concepts from participants’ perspectives. Additionally, in this method, people’s ideas as the background of real experience are revealed (10, 11).

In this research, the population under study was those clients referring to urban health centers affiliated to Shaheed Beheshti University of Medical Sciences and Health Services. 233 subjects were selected by purposive sampling method from 21 urban health centers (affiliated to Shemiranat, North, and East centers) of the university. The subjects were selected by considering the aims of the study, geographic distribution of the centers, socioeconomic status of the residents, and the variety of services provided.

Semi-structured face-to-face interviews were used to collect data. Questions were divided into two parts. In the first part, demographic information (age, sex, education, occupation, number of children, number and reason of visits…) was collected and in the second part, specific questions regarding the aims of the study were asked. Before interviewing, the researchers visited the subjects to explain the aims and process of the study and to appoint a date for the interview. Interviews were tape-recorded with the permission of subjects and, in case of their disapproval, they were either questioned orally to write their replies or excluded from the study.

Analyzing Qualitative Data

To analyze the collected data, Collaizi method was used as follows:

1. Explaining the phenomenon under study by participants;
2. Collecting data from participants;
3. Reading and reviewing the data;
4. Returning to original transcripts and significant statements;
5. Proper categorizing and summarizing significant statements;
6. Organizing and controlling categories;
7. Writing cluster of themes for each category;
8. Returning to transcripts for determining the validity of categories;
9. Incorporating new data in relevant categories.

The recorded interviews were then analyzed at the appropriate time as soon as possible by frequent listening to the contents for complete understanding. The whole content were then transcribed verbatim and loaded in the computer. Considering different methods for data analysis in qualitative studies, the researchers used Word Perfect software to encode the collected data. Accordingly, all significant statements resulted from interview analysis were typed in a special form and categorized into cluster of themes. Certain and appropriate letters were then designated for the clusters and the resulted outcomes were discussed.

Findings

Demographic findings include age, sex, educational level, occupation, number of children, frequency and reason of visits in the subjects (Tables 1, 2: at bottom of page).

In analyzing qualitative findings related to the aims of the study, relevant factors such as 1- physical condition of the centers (waiting salon; appearance of building, rooms, …); 2- personnel communication (responsibility and responsiveness of staff from entrance of clients to the centers until their departure); and 3- the quality of health services (vaccination, family planning, maternity and child health, health education) and treatment services (medical procedures, dentistry, pharmacy, injection and dressing) were assessed.

In the first, second, and third part of the analysis, urban health centers affiliated to Shemiranat, North, and East centers were evaluated respectively. General opinions of clients referring to health centers affiliated to urban health center of Shemiranat were: 1- improving the quantity and quality of dentistry services; 2- increasing the speed of service delivery and decreasing waiting time in some centers; 3- increasing the types of drugs needed for clients in pharmacies of the centers; 4- increasing working hours and making the activity of some centers around the clock; 5- having medical laboratory and some specialties such a gynecology in the centers.

Similarly, the views of clients referring to health centers affiliated to urban health center of North included: 1- improving the quantity and quality of dentistry services; 2- increasing the speed of service delivery and decreasing waiting time in some centers; 3- increasing the types of drugs needed for clients in pharmacies of the centers; 4- adding some specialties (e.g. gynecology and pediatrics) and making the working hours of some centers around the clock; 5- improving communication skills of personnel with clients; 6- improving physical condition of some centers; 7- delivering better laboratory services in all centers.

The opinions of clients referring to health centers affiliated to urban health center of East were: 1- decreasing wastage of time due to service delivery delay; 2- increasing the number of personnel in some centers to speed up service delivery; 3- improving physical environment in some centers; 4- improving advertising activities to introduce health services of the centers to society; 5- improving communication skills of personnel with clients; 6- improving the quantity and quality of dentistry, pharmacy, and midwifery services; 7- supervising personnel activities by supervisors more than before.

Discussion

Findings showed that the majority (%24.03) of clients were between 30 – 35. In Shabravy’s study (1992) about clients’ satisfaction with the health services in 140 health centers in Riyadh city, the majority (%30.2) of clients were between 30 – 40 and female (%94.42) with high school diploma (%29.18) (12). In another study, it was also shown that most clients (%84.6) were female with high school diploma (%34.4) (13). These findings are similar to those of our study.

Results also showed that the majority (%80.68) of subjects were housewives, which is similar to findings of the other study in which %45.3 were housewives (12). Most subjects (%25.32) in the study had only one child. This may be attributed to the effects of family planning programs in health centers or mass media. %31.33 of the clients had no medical insurance while, in a similar study, only %19.6 had no insurance (13). This may be due to low income of most clients in our study. The majority (%56.82) of subjects used the services of the centers from 1 to 3 years, which is somehow similar to findings of the mentioned study in which most clients (%87.7) had a history of previous visits (13). However, the duration of visits has not been identified in any corresponding study.

The results also showed that most clients (%23.43) came to the centers due to vaccination of their children while, in the corresponding study, the majority (%32.80) came to visit a physician (13). Concerning clients’ satisfaction with physical environment, findings, generally, indicated that most of them were collectively satisfied while having some critiques about it since they spent relatively short time in the centers and this factor was not so important for them, but they wanted a better appearance for these places.

With respect to clients’ satisfaction with personnel communication during their presence in the centers, most of them were satisfied and only complained about some insulting behaviors in this regard. They ignore these insulting and rude behaviors because of low-cost and free services delivered and the availability of centers. In the previously-mentioned study and without stating the behaviors in detail, supporting findings showed that %77.8, %80.6, %61.1, %83.3, %86.1, and %75 of clients were satisfied with the behaviors of admission; pharmacy; injection and dressing; vaccination; maternity and child health as well as family planning; and dentistry personnel respectively (13). In a study about communication in health, Johnson (1999) noted that research in this field has been in low priority and studies have only focused on problems. Since there are differences between healthcare workers and clients in social class, experience and knowledge, communication models should be devised for each society (14).

Concerning the delivery of different health services, the relative majority of subjects were generally satisfied while having some suggestions and critiques about it. With respect to the contents of interviews and analysis of the statements, it seems that one of the important reasons for clients’ satisfaction is the lack of knowledge regarding the rights of patients as health consumers and the other one despite enough explanation concerning confidentiality and anonymity and isolation of interview location may be a sense of uncertainty and insecurity to express the true feelings.

Conclusion

The results showed that, in general, clients were more satisfied with health services than treatment services (medicine, dentistry, pharmacy, injection, and laboratory). The reasons for dissatisfaction with dentistry were inadequate services; with medicine, lack of experience in physicians and absence of various specialties; with pharmacy, lack of needed drugs prescribed by physicians of the centers; with injection, presence of some male personnel for female patients; and with laboratory, lack of this service in all centers and the resulting inability to perform all diagnostic tests and wastage of much time. The reasons for dissatisfaction especially in vaccination and family planning departments included time wastage, too long waiting, insufficient working hours and lack of attention to patients without any health education. All of the above can create pessimism toward healthcare delivered by professionals.

Finally, the results showed that, according to the clients, general satisfaction resulted from appropriateness of facilities, availability of the centers for distance, cheap and free medical services, endeavor of employees as far as possible, and delivery of suitable services by some healthcare workers or physicians of the centers. However, despite the satisfaction expressed by clients, there is an urgent need to study about the quantity and quality of services in healthcare centers affiliated to the university to promote the present situation and to make clients come to the centers not only for the above reasons. This reveals the importance of improving managerial indicators in these centers more.

Advantages of the Present Research

By being qualitative and having detailed interviews about the problems of urban health care centers, this study is the first one of its type and can pave the way of future studies in this field and in making required tools for assessing satisfaction in such clients. Suggestions based on research findings include:

1- Informing clients about their rights by posters and pamphlets prepared by health centers or mass media is essential because knowing these rights makes people familiar with their expectations and demands and while improving the quality of services, provides the opportunity for clients to offer better suggestions.

2- Informing society about healthcare system, its ranking, and job description of employees in each rank, … is vital to enable people to make their demands compatible with this structure (with respect to suggestion of clients to be provided with the services of specialists in urban health centers, the first rank, which shows the lack of knowledge in people about the services that should be delivered in this rank).

3- Holding periodic or monthly illuminative sessions by provincial healthcare centers for all types of employees in healthcare centers concerning “communication and the quality of service delivery” is crucial to solve present problems and provide solutions by employees themselves for increasing cooperation.

4- Holding weekly or even daily sessions for employees in urban healthcare centers for exchanging views and new information or stating current problems and trying to solve them in time is very important, which can be so effective in improving service delivery by the employees especially if it is supported by officials.

5- Encouraging employees in a proper manner to motivate active and responsible people more and, therefore, increase clients’ satisfaction would be very effective.

Acknowledgements

We would like to express our gratitude to respectful deputy of research in Shaheed Beheshti University of Medical Sciences, Dr. Jorjani, and to all respectful officials of Shemiranat, North, and East healthcare centers as well as clients for their sincere cooperation.

References:

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Table 1: Frequency distribution of clients by age, sex, level of education and occupation.

Table 2: Frequency distribution of clients by number of children, frequency of visit and reason of visit.

Dr Yaghmayie, F. (1) Ph.D.

Dr Mahfoozpour, S. (2) Ph.D.

1,2: Faculty members in Shaheed Beheshti University of Medical Science and Health Services . School of Nursing and Midwifery

Faculty members in *Shaheed Beheshti University of Medical Science and Health Services* . School of Nursing and Midwifery

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