Luận Án TS Y học: Patient satisfaction with health services at the outpatient department of Indira Gandhi memorial hospital, male’ Maldives.

PATIENT SATISFACTION WITH HEALTH SERVICES AT THE
OUTPATIENT DEPARTMENT OF INDIRA GANDHI MEMORIAL
HOSPITAL, MALE’ MALDIVES.






ASMA IBRAHIM






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.
I express my deep sincere of gratitude to Associated Professor Jiraporn

Chompikul, my major advisor, who offers me her endless support and remarkable
kindness from the beginning until the completion of my thesis. I also would like to
express my sincere thanks to my co-advisor, Associated Professor Sirikul Isaranurug,
for her constructive comments and suggestions.
I would like to acknowledge and pay my special thanks to Ministry of Health
Maldives for offering me this scholarship.
My special thanks go to my sponsor, World Health Organization (WHO) for
giving me this great opportunity to achieve my goals from this MPHM course and
gain precious experience from here. I would never forget endless support given by
MPHM staffs working in this institute, especially Ms. Sirilak Leyeskul and her
elegant staffs.
I eager to say “Thank you very much” to my all classmates who always inspire
me, especially Dr In Sokhanya and Dr. Kazi Asadur Rahman. Without your help I
might not be successful to achieve this.
I would also like to express my thanks to three Senior Staff Nurses who
participated in the process of data collection and give their valuable time to complete
the process with limited time. I thank to all my friends in Indira Gandhi Memorial
Hospital (IGMH) for encouraging me during data collection.
Lastly of all, I would like to thanks to my devoted husband and beloved
mother, brothers and sisters for their encouragement and support to make this
successful.
Asma Ibrahim
Fac. of Grad. Studies, Mahidol Univ. Thesis /
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PATIENT SATISFACTION WITH HEALTH SERVICES AT THE OUTPATIENT
DEPARTMENT OF INDIRA GANDHI MEMEORIAL HOSPITAL, MALE’
MALDIVES.

ASMA IBRAHIM 5037998 ADPM/M

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

THESIS ADVISORS: JIRAPORN CHOMPIKUL, Ph.D., SIRIKUL ISARANURUG,
M.D., Dip. Thai Board of Pediatrics


ABSTRACT

A cross-sectional study was conducted on patient satisfaction with health
services at the outpatient department of Indira Gandhi Memorial Hospital, Male’
Maldives, with the aim determining the relationship between satisfaction and
explanatory factors. Suggestions and comments from the patients were also revealed
in this study.
Using a structured questionnaire, data were derived from 251 patients using
the OPD services. Descriptive statistics were used to describe satisfaction level and
independent variables while the relationships between these factors were determined
by Chi-square test.
The average score of patient satisfaction was 3.5 and 10.4% of the patients
were highly satisfied with health services. Patients were highly satisfied with courtesy
(45.8%), quality of care (44.2%), physical environment (41.8%), convenience
(24.7%), and out of pocket cost (23.5%). Regarding predisposing factors, attitude
were significantly associated with level of satisfaction (p=0.002). The majority of the
patients was concerned about waiting time to seek a doctor’s service and counter
services are being delayed due to not enough staff being available.
Strategies emphasizing improving the image of the hospital should be
continuously implemented while the attitude of the patients could change with good
reputation of hospital. Patient satisfaction surveys can be conducted in each unit to get
the real picture for further strategies.

KEY WORDS: PATIENT SATISFACTION / OUTPATINET DEPARTEMNT /
HEALTH SERVICES


76 pp.

CONTENTS

Page
ACKNOWLEDGEMENTS iii
ABSTRACT iv
LIST OF TABLES vii
LIST OF FIGURES viii
LIST OF ABBREVIATIONS ix
CHAPTER
1 INTRODUCTION
1.1 Rationale and Justification 1
1.2 Research Questions 4
1.3 Research Objectives………………………………………… 4
1.4 Conceptual framework 5
1.5 Operational definition of study variables 7
1.6 Limitation of the study 10
2 LITERATURE REVIEW
2.1 Patient satisfaction ………………………………………… 11
2.2 Theoretical model 14
2.3 Factors related to satisfaction 17
2.4 Health services in the Maldives 18
3 RESEARCH METHODOLOGY
3.1 Research design 22
3.2 Study site 22

3.3 Study population 22
3.4 Sample size determination 23
3.5 Sampling technique 24
3.6 Data collection tools 25
3.7 Pre-test 29

vi
CONTENTS (cont.)

Page

3.8 Data collection procedure 30
3.9 Data analysis 30
3.10 Ethical consideration 31

4 RESULTS
4.1 Socio-demographic characteristics of the patients 32
4.2 Expectation towards health services at OPD 36
4.3 Patient attitude towards health services at the OPD 36
4.4 Patient satisfaction towards health services at OPD 37
4.5 Association between independent and dependent variables 39
4.6 Patient’s comments and suggestion 43
5 DISCUSSION
5.1 Methodological concern 45
5.2 Patient satisfaction towards health services of IGMH
hospital………………………………………………… 46
5.3 Socio-demographical factors…………………………… 48
5.4 Patient attitude towards health services of IGM hospital 50
5.5 Patient expectation towards health services of IGMH
hospital ……………………………………………… … 51

5.6 Comments and suggestions from the patients…………… 51
6 CONCLUSION AND RECOMMENDATION
6.1 Conclusion 54
6.2 Recommendations 56
REFERENCES 59
APPENDIX 63
BIOGRAPHY 76
LIST OF TABLES

Table Page

1 Total number of patients per day in each unit…………………………………… 24
2 Measurement and classification of variables …………………………………… 28
3 Socio-demographic characteristic of the patients ………………………………. 34
4 Overall expectation of patient towards health services at the OPD
of IGM hospital ………………………………………………………………… 36
5 Overall attitudes of the patients towards health services at the IGM hospital… 37
6 Number and percentage of patients by overall satisfaction for each component 38
7 Overall satisfactions towards health services at OPD………………………… 39
8 Association between attitude and satisfaction …………………………………. 40
9 Association between expectation and satisfaction …………………………… 40
10 Association between satisfaction and socio-demographic factors …………… 42
11 Patient’s comments and suggestion for improving the quality of health
services at the OPD of IGM hospital 44
12 Frequency and percentage of patient’s attitude towards health services at OPD of
IGM hospital by item of question…………………………………………….…. 70
13 Frequency and percentage of the patients expectation towards health services at
OPD of IGM hospital ……………………………………………………… …. 71
14 Frequency and percentage of the patients satisfaction towards health services at
OPD of IGM hospital ………………………………………………………… 72

15 Frequency and percentage of overall patient’s satisfaction with 75 cut-off
point 75

LIST OF FIGURES

Figure Page

1 Conceptual framework 6
2 Andersen’s behavioral model 16
3 Service system of OPD 21



LIST OF ABBREVIATIONS

ANC : Antenatal Care
CI : Class interval
ENT : Ear Nose and Throat
ICCU : Intensive Coronary Care Unit
IGMH : Indira Gandhi Memorial Hospital.
NTC : National Thalassemia Center.
OPD : Out Patient Department.
PNC : Postnatal Care
STO : State Trading Organization
TBA : Traditional Birth Attendance.

Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) /
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CHAPTER 1
INTRODUCTION

1.1 Rationale and justification

For every hospital, patients are the main users. The primary function of the
hospital is patient care. It is one of the yardsticks to measure the success of services
that it produces. Effectiveness of the hospital relates to provision of good patient care
as intended. According to Swamy (1975) patient satisfaction is the real testimony to
the efficiency of hospital administration. As the hospital serves all the members of the
society, the expectations of the users differ from one individual to another individual
because everyone carries a particular set of thoughts, feelings and needs. Hence
determination of patient’s real feelings is very difficult. It is the responsibility of the
administrator team. "Put yourself in your patient's shoes," was a proverb that explains
how to proceed with a patient (1).

Consumer satisfaction is generally defined as the consumer’s view of services
received and the results of the treatment. It has been used by program evaluators to
enhance health care providers’ ability to render services that meet consumers need
(2). Society now acknowledges the importance of the views of users in developing
services, and the healthcare sector has used a range of methods to identify the views
of patients and the public (3). Dansky and Miles (1997) state that from a management
perspective, client satisfaction with health care is important for various reasons. First,
satisfied patients are more likely to maintain a consistent relationship with a specific
provider. Second, by identifying sources of patient satisfaction, an organization can
address system weakness, thus improving its risk management. Third, satisfied
patients are more likely to follow specific medical regimens and treatment plans.
Finally, patient satisfaction measurement adds important information on system
performance, thus contributing to the organization’s total quality management (4).

Asma Ibrahim Introduction /

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Research on patient satisfaction with medical care can be traced back to the
late 1960s. Over 40 years, an overwhelming number of publications on the topic have
appeared. At first, research focused on patient satisfaction as a condition to be
satisfied in order to reach desirable clinical outcomes, such as appointment keeping or
compliance with recommended treatment. Gradually, interest shifted to patient
satisfaction as a dependent variable. Nowadays, hardly any hospital will fail to
incorporate in-patient satisfaction rating into their evaluation of care (5).

According to the South African Black Population study 76% rely on public
hospitals and the facilities are overcrowded, understaffed and under resourced,
contributing to waiting time of more than 1 hour to see a health provider (6). Thomas
et al investigated patient
satisfaction in a oncology outpatient clinic in Middlesex
University in Enfield UK and reported that out of 252 patients 92% were "always" or
"usually" reassured as a consequence of their visit. This study also confirmed the fact
that clinical staffs are one of the most important sources of satisfaction. Similar Italian
and British studies also reported strong and weak points of their services that were
brought out by patient satisfaction surveys and took measures to rectify the problem
areas.
The health care system is basically a service based industry and customer
satisfaction is of utmost importance just as in other service-oriented sectors (7).

Maldives is a developing country and most efforts in health services seek to
provide basic health care needs to all citizens adequately and equally. There was a
paucity of reliable and valid satisfaction measures. In addition, no studies have
investigated the relationship between the component of patient satisfaction and health
status. The Indira Gandhi Memorial Hospital serves as the major tertiary referral
hospital. It also serves as the focal point for entry to health service for the people of
the whole country. This hospital is situated in Male, the capital of Maldives. The

hospital, with its wide ranging departments and modern diagnostic facilities, are
manned by qualified and experienced medical personnel. The IGMH policy is to
deliver an affordable and wide-ranging health care service to Maldivians. To achieve
this IGMH has been conducting several methods to enhance their services; however
they need to go through a long path to reach the goal. The customer image of the
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) /
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hospital still desired better quality of services appropriately throughout whole
country. OPD problems like overcrowding, delay in consultation, lack of proper
guidance and many others lead to patient dissatisfaction. Some departments had
conducted client satisfaction and comments surveys. According to the statistics of
Maldives, no standard survey has been conducted in IGMH in terms of patient
satisfaction. The reason to choose OPD for this study was that IGMH provides
services to the whole country. It is often called shop window that leads to glide in
both new and old patient, which hold back the long run sustainability of any hospital.

The government considers that the enjoyment of the highest attainable level of
health is a basic right of every citizen. The mission is to protect the health of the
people and supportive environment for health and provide preventive, curative and
rehabilitative services through an affordable and accessible health system. Health
care has been changing over the years. The objectives of health care changed with the
requirements of society and the availability of resources and technology. The WHO
Alma Ata conference on supporting Health for All, held in 1990, defined future
development in health to be human centered (8).

It is now a global trend in healthcare development toward integrating
subjective user satisfaction into the evaluation of medical service quality (9). Most
countries are focusing their attention on the cost and access to health care because it
needs to be distributed appropriately and equitably (10). Consumer expectations have
grown proportionately with the rising wealth of the population, resulting in strong

societal pressure to adopt policies on satisfying consumer expectations (11). Medical
care aims not only to improve health status but also to respond to patient needs and
wishes and to ensure their satisfaction with care (12). Patient satisfaction surveys are
an instrument in monitoring hospital’s quality of care relation to cost and services. It
is a significant indictor of quality of care. To evaluate and improve the quality of care
provided, it is of vital importance to investigate the quality of care in the context of
health care. Satisfaction might be influenced by socio-economic factors, accessibility
to the services and the experience towards the health services (13).
Asma Ibrahim Introduction /

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IGMH is a government hospital which covers total male population in the
nearby islands and referrals throughout the country. Out of a total 156 doctors
throughout the country, 89 are specialists. There are 442 nurses who include ward,
staff, specialized and assistant nurses. The IGMH capacity is 236 beds with one
Operation Theater, one Intensive Coronary Care Unit (ICCU), one labor room, one
scan room, one X-ray department and CT scan room. In- patients are admitted in 5
main wards namely, Gynecological, medical, surgical, ENT (Ear, Nose & Throat),
Eye & Orthopedic in one ward, pediatric ward and also 5 private wards. There are 9
rooms in each private ward.

In this patient satisfaction study the researcher aimed to determine the patient
satisfaction with OPD services at IGMH. Patient satisfaction included 5 subscales:
convenience, courtesy, quality of care, out of pocket cost and physical environment.
They are indicators of how the patients are satisfied with services. Other than this,
independent variables such as predisposing factors (age, sex, marital status, education
level, occupation and attitude) enabling factors (family income and health insurance)
and need factors (health problems and expectation) were determined for their
relationship to satisfaction with health care. In addition patient opinions and
suggestion on improvement from patients were analyzed thoroughly.

1.2 Research questions

1. What is the level of patient satisfaction towards health services at the
outpatient department of IGMH?
2. What are the factors related to patient satisfaction with health care
services?

1.3 Research objectives

1.3.1 General objectives
To assess the satisfaction of patients who have utilized the OPD
services provided by IGMH and to identify factors related to patient’s satisfaction.
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) /
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1.3.2 Specific objectives.

1. To assess the level of satisfaction with the services provided by the
outpatient department.
2. To determine the relationship between socio-demographic factors
and the level of satisfaction.
3. To identify the relationship between patient’s attitude and the level
of satisfaction
4. To find out the relationship between enabling factors and the
satisfaction level.
5. To determine the relationship between need factors towards the
services and the satisfaction level.
6. To describe the patients opinions and suggestion on improving the
services in the outpatient department at Indira Gandhi Memorial Hospital.

1.4 Conceptual framework

For this study, the conceptual framework was derived from Ronald M.
Andersen Behavioral Model. Andersen’s behavioral model organized an array of
correlates of health and health care behavior from the different literature in sociology,
psychology, economics and medicine into predisposing, enabling and need predictors
of families’ use of physician and hospital services. According to Andersen (1968) the
amount of health services used by a family will be a function of the predisposing and
enabling characteristics of the family and its need for medical care (14). These three
factors mentioned in Andersen’s model were used to plan the conceptual framework
for this research. (Details in chapter 2)






Asma Ibrahim Introduction /

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Conceptual framework

Independent variables Dependent variable

Figure 1 Conceptual framework







Predisposing factors

Demographic factors
- Age
- Gender
Social structure
- Marital status
- Education level

- Occupation
- Number of visits to hospital
Health belief
- Attitude
Enabling factors
- Family income
- Type of payment

Need Factors

- Health problems
- Expectation
Patient Satisfaction towards
health services at OPD

- Convenience
- Courtesy
- Quality of care
- Out of pocket cost
- Physical environment
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) /
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1.5 Operational definition of study variables

Dependent variable

Patient satisfaction
It refers to the patients’ value judgments and succeeding reactions to the
stimuli they perceive in the health environment just before, during, and after the
course of their clinical visit. The indicator for client’s satisfaction in this study

consists of convenience, courtesy, out of pocket cost, quality of care and physical
environment.

Convenience refers to the availability of health care provider and receiving the
services as wanted and willingness of providers.

Courtesy refers to the way providers express their respect and politeness shown to the
patients (e.g. doctors, nurse and pharmacy assistance and other health care personnel).

Quality of care refers to the superiority of care that patients perceive from doctors in
terms of knowledge and skills to diagnose and treatment and quality of equipment.

Out of pocket cost refers to the amount of money spend out of pocket for
registration, investigation and medication.

Physical environment refers to the features of the setting in which the health services
are provided. This includes pleasantness of atmosphere, clear sign and direction,
enough toilet and clean drinking water.

The answer of each question is measured by using Likert scales. In the present
study the answers are ranked in 5 scales as;
Very satisfied = 5, satisfied = 4, neutral = 3, dissatisfied = 2 and very dissatisfied =1.
The scores are summed and then divided into two groups.
Asma Ibrahim Introduction /

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High satisfaction considered above 80% of total score and for low satisfaction
considered as equal or below to 80% of total score.

Independent variables

Age: is a real age of respondent up to birthday at the time of study. The age range is
16 -65 years. At 16 years is the secondary school leaving age and 65 years is the
retirement age, at these category respondents able to answer questions independently.
Age group will be divided in to three categories by using class interval:
- 16- 32 years
- 33- 49 years
- 50- 66 years
Gender: refers to the characteristics of the respondent as male and female.
Gender will be divided into two categories:
- Male
- Female
Marital status refers to the respondent was single, married, divorce/separated and
widowed. Marital status will be divided in to four categories:
- Single
- Married
- Divorce/separated
- Widowed
Educational level refers to the highest level of educational background of the
respondent. Educational level will be divided in to six categories:
- No education –no formal education
- Primary school – from grade 1 to 7
- Secondary school – from grade 8 to 10
- Higher secondary school– from grade 11 to 12
- Higher education- from a college or university
- Others
Occupation refers to the main job of respondent to earn for his living. It will be
divided in to six categories:
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) /
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- Civil servants
- Private sectors
- Self-employed
- Unemployed
- Student
- Others
Number of visit to hospital during last 6 months refers to the total number of visits
to the hospital by the patient during last 6 months. The respondent for this study have
been utilized the services more than once before 6 months. Therefore it was divided
into two groups. The cut-off point as > median and < median score. Median score
used because the data was not normally distributed.

Attitude refers it is a hypothetical construct that represents an individual's like or
dislike for an item. In this attitude meant as cognitive perception of a patients towards
services that they get from hospital. To measure attitude of the respondents a set of 5
questions would be asked. Whether they agree or disagree with the statement, Likert
scale was used as above;
Strongly agree = 5
Agree = 4
Not sure = 3
Disagree = 2
Strongly disagree = 1
Total score was computed and categorized as good fair and poor attitude.
Since the data was not normally distributed, percentile was used as a cut-off point to
categorize into three groups; good, fair and poor.

Family income refers to the respondent’s family income earned per month. (Nuclear
family) It was an open-ended question.
It was divided into 3 groups for data analysis by using class interval:
- 1000 – 17333 RF

- 17334 – 33667 RF
- 33668 – 50001 RF
Asma Ibrahim Introduction /

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Type of payment refers how patient would pay for the health services. It was divided
into four categories; private scheme, government scheme, insurance schema and
others.

Health problems refer to the general condition of the patient.
It was assessed by asking an open-ended question and identifies the present health
problem of the patient.

Expectation refers to the state of expecting or looking forward to an event at the
hospital. He or she might expect to get treatment as soon as possible without delay.
Expectation would be measured in terms of waiting time, quality of care and
accessibility of services with multiple choice questions. To know expectation of
patient 5 questions were asked and got mean score for each respondent to calculate
descriptive statistics to find percentile to categorize into three groups; high, medium
and low expectation.

1.6 Limitations of the study.

The main constrain was due to limited time to complete required sample size.
Ethical committee review took about 2-3 weeks to get permission. The planned
duration for data collection was 18 days, but due to limited time it has been changed
to 10 days.
When study was conducted hospital launched new software for registration.
The system got delayed and was not able to consult the doctors on time. Therefore
some patients went back home due to inconvenience on the first day that changed to

new system. The patients were not happy with new system and patient had gone
through many problems during that time. Some patients hesitate to answer the
questionnaire. Due to this the researcher was not able to collect data through
interviewer. Some doctors gave pre information about the survey so the researcher
gains more co-operations from the patients.
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) /
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CHAPTER 2
LITERATURE REVIEW

The literature review included the following topics:

- Patient satisfaction
1) Meaning and scope of satisfaction
2) Benefits of patient satisfaction
3) Measurement of satisfaction
- Theoretical model
- Factors related to satisfaction
- Health services in the Maldives

2.1 Patient satisfaction

2.1.1 Meaning and scope of satisfaction
Patient satisfaction was initially perceived as being related to issues
around access to medical infrastructure and nursing care (15).Patient satisfaction is
generally defined as the consumer's view of services received and the results of the
treatment. The importance of patient satisfaction has had a long history of debate,
beginning over two millenniums ago in ancient Rome. Plato suggested in a statement
that since the doctor "cuts us up, and orders us to bring him money as if he were
exacting tribute he should be put under rigid control," and that this could be done by

calling an assembly of the people and inviting opinions about "disease and how drugs
and surgical instruments should be applied to patients" (2). To evaluate and improve
the quality of care provided, it is vitally important to investigate the quality of care in
the context of health care. Patient satisfaction is a significant indicator of the quality
of care. Consequently, quality work includes investigations that map out patient
satisfaction with nursing care. To improve quality of nursing care, the nurse needs to
Asma Ibrahim Literature Review /
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know that factors influence patient satisfaction (16). Fitzpatrick (1991) states that
since 1984 the objectives of the Australian federal evaluation policy have emphasized
efficiency, effectiveness and accountability. Patient satisfaction has been used as an
indicator of accountability. Satisfaction was seen, therefore, as a surrogate indicator
justifying and validating health care initiatives (17). Health care organizations are
operating in an extremely competitive environment, and patient satisfaction has
become a key indicator, gaining and maintaining market share. Without acceptable
levels of patient satisfaction, health plans may not get full accreditation and will lack
the competitive edge enjoyed by fully accredited plans (8). According to Jones (1978)
satisfaction surveys are the main sources of feedback from patients about the health
care services and as such they inform purchasing decisions, stimulate proposals to
restructure service delivery and can be used to evaluate the effects of policy change
(18).

2.1.2 Benefits of patient satisfaction

Patient satisfaction is important to the process of health care for a
number of reasons. Patients who are dissatisfied with their health care change health
care providers or "doctor shop" more frequently,
- more frequently disenroll from prepaid health plans,
- adhere less well to medical regimens prescribed by their doctors,
- and willingness to seek malpractice litigation (19).

According to the Fitzpatrick, (1990) satisfied patients are more likely to follow
planned care and make better use of health services. Therefore patient satisfaction
was seen, as a substitute indicator justifying and validating health care initiatives. And
also it has been used to evaluate patient controlled analgesia (18).
In August 2003, Press Ganey reported on one study of nearly 2 million patient
surveys- the largest study of patient satisfaction ever conducted. He stated that "…the
Baby Boom generation…as a whole is less satisfied than patients in the adjacent age
groups. Members of the Baby Boom generation have been described as distrustful of
institutions, more informed than others, and harder to please because of their high
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) /
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expectations”. In fact, studies show that is likely already happening. The upshot is that
healthcare is, or soon will be, facing a market that has increasing choice and very
demanding expectations. It will pay healthcare marketers to sharpen their pencils
when it comes to creating satisfaction (20).

2.1.3 Measurement of satisfaction

Measuring patient satisfaction are being used as surrogate expressions of
is users’ preferences about the range and type of health services they want, as a way
of quantifying the quality of medical and nursing care as patient focused outcome
measures (18). An increased focus on enhancing relationships with patients can result
in a reduction in medical errors (21).

- Convenience
Lebow (1983) consider that all inquiries into both the felt adequacy of
treatment and of surrounding setting are specific aspects that may include reactions to
the quality of care, to its helpfulness, its cost and continuity, the availability and
accessibility of the practitioner, and the reaction to supporting services (17).

Rubin (1993) and Drain (2001) both concluded that patient satisfaction studies enable
patients to select health care clinicians, facilities or insurance plans: less satisfied
patients are more likely to seek health care elsewhere (18).

If receipt of care, guidance and support were to help patients make genuinely
informed choices about interventions, it would be likely to impact on operational
delivery of services. A study by James (1992) describes a nurse who worked
previously in an acute hospital setting and then moved to another job in hospice. Soon
after starting work in that hospital, the nurse described that she left her old job due to
busy routines which can get in the way of and undermine effective communication.
Hospitals were established in response to an identified need for environments better
suited for terminally ill patients, for whom palliative care rather than curative
treatment was appropriate (22). Communication between patients and practioner is a
central part of health care. Effective communication is essential, for practioners to
Asma Ibrahim Literature Review /
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understand the nature of the disease and the way patient thinks about the illness.
Failure to communicate effectively leads to numerous adverse effects; including
patient not understand the test result and fails to reassurance (23).

- Quality of care
Hospitals are emphasizing enhanced quality of care along with the improvement
of technology. Researchers explained the quality of health services in seven factors.
They are efficiency, effectiveness, efficacy, optimality, legitimacy and equity.
Therefore adaptation of modern quality service from manufacturing and other
servicing industry has changed the situation of quality of care. The combination of
conventional and modern health care techniques had lead to the modern era of quality
health care management (24).Perhaps the most important lesson for physicians was to
take the time and effort to draw patients’ expectations. Stimson and Webb (1975)
suggest that satisfaction is related to the perception of the benefits of care and the

extent to which these are the patient’s expectations (25). When physicians recognize
and address patient expectations, satisfaction is higher not only for the physician; it
may help to remember that patients often show up at a visit desiring information more
than they desire a specific action (26).

- Out of pocket cost
The survey of seven countries conducted by the commonwealth fund shows
that Americans have the highest out-of-pocket coats and the most difficulty paying
medical bills. Even though they have the most expensive health-care system, they are
more likely to skip care because of cost and experience with medical errors. Patients
in Canada, the Netherlands, and the United Kingdom rarely reported not getting
needed medical care because of costs (27).

2.2 Theoretical model
In this study a theoretical framework for viewing health services utilization is
presented, emphasizing the importance of the:
Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) /
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- Characteristics of health services delivery system
- Changes in medical technology and social norms, treatment and illness
- Individual determinants of utilization.
These three factors are specified within the framework of impact on health care
system (28).

Andersen’s behavioral model was used for the construction of the conceptual
framework for present study. The model has been used to display and test complex
causal models of health care-seeking behavior and to simply order any array the
relevant predictors and indicators of utilization.

Predisposing variables include those that describe the propensity of family members

to use services- including family composition such as age, gender and marital status.
Social structure includes education, employment, social class and ethnicity. Health
beliefs are attitudes, values, and knowledge that people have about health and health
services that might influence their succeeding perceptions of needs and use of health
resources. People who believe strongly in the value of health care or physicians might
be more likely to seek care than those who do not have these beliefs.

The enabling factors describe the means individuals have available to them for the
use of services.

- Resources specific- income, savings and health insurance.
- Community attributes- physician and hospital bad ratio, geographic location
and community attitude towards medical care.

Need factors to determine health status or cause of illness are the most immediate and
important causes of health use.
Among the predisposing characteristics, age and gender represents biological
imperatives suggesting the likelihood that people will need health care.