International Journal for Quality in Health Care 15:241-249 (2003)
© 2003 International Society for Quality in Health Care
Paper |
Patient satisfaction with primary health care services in the United Arab Emirates
1Department of Family Medicine, Faculty of Medicine, United Arab Emirates University, Al Ain
2Ministry of Health, United Arab Emirates
Objective. This study evaluated the suitability of a patient satisfaction questionnaire to survey health care consumers of traditional Arabic background.
Design. A cross-sectional survey using an Arabic language questionnaire that drew upon concepts of patient satisfaction measurement in Western research literature. All participants were interviewed once by experienced interviewers to ascertain their levels of satisfaction with their health care service.
Setting. Patient satisfaction was compared between the only resource-intensive clinic (RIC) in the United Arab Emirates and one resource-thrifty clinic (RTC) located in an adjacent suburb and serving essentially the same population.
Study participants. A random sample of patients attending the RIC and RTC over a 5-day period.
Main outcome measures. Six domains of patient satisfaction were measured.
Results. Compared with the RTC (n = 125), the RIC (n = 156) scored significantly higher in continuity (P = 0.001), comprehensiveness (P < 0.001), health education (P = 0.05), effectiveness (P = 0.001), and overall satisfaction (P < 0.001), while accessibility (P = 0.130) and humaneness (P = 0.102) were not significantly different. Humaneness scored the highest and continuity the lowest at both clinics. Older people’s satisfaction was higher for comprehensiveness but otherwise the same as those who were younger. More highly educated people’s satisfaction was lower for effectiveness, but otherwise the same as those who were less educated. Men and women had equal levels of satisfaction.
Conclusions. The significantly higher patient satisfaction in the RIC compared with the RTC was a strong a priori expectation, suggesting that this satisfaction questionnaire is a useful quality assurance tool in this setting.
Keywords: developing country, models of care, patient satisfaction, primary care
Patient satisfaction has long been considered an important component when measuring health outcomes and quality of care [1,2]. The rising strength of consumerism in society highlights the central role patients’ attitudes play in health planning and delivery [3,4]. Furthermore, a satisfied patient is more likely to develop a deeper and longer lasting relationship with their medical provider, leading to improved compliance, continuity of care, and ultimately better health outcomes [5,6].
Health care recipients in developing and newly developed nations are particularly sensitive to perceptions of the quality of their health care delivery systems when compared with those in advanced economies [7]. This is a particularly important issue for countries on the Arabian Gulf who may have sufficient resources to provide a clinical care model similar in resource intensiveness to those present in Western countries. However, these additional costs need to be justified and determined to be the best use of limited resources. Little evidence exists on whether these more resource-intensive models provide extra value in this environment.
The United Arab Emirates (UAE), a union of seven sovereign sheikhdoms in the Arabian Gulf, was formed in 1971. It has been noted that, as recently as 1950, ‘their traditional way of life had scarcely been disturbed. There were no boundaries, and no roads, no newspapers and no telephones, indeed no electricity supply. Almost every drop of water had to be hauled from man made wells.’ [8]. Education and health development were negligible until the late 1950s. However, a relentless pace of development in the last 20 years, fuelled by petrodollars, has resulted in one of the highest per capita incomes in the world [9]. Education and health infrastructure are extensive, with each sector undergoing continuous development and expansion.
The largest tribal grouping in the UAE was the Bani Yas tribe, which until the 1960s lived a semi-nomadic life roaming the vast sandy deserts, which constitute most of the land area of the UAE [10]. The citizens of the UAE (known as Emirati) now comprise approximately 36% of the total UAE population, the remainder being mostly expatriate guest workers, predominantly from South Asia [11]. Despite rising wealth, Emirati people retain their strong cultural traditions and connection with the land and the desert.
The UAE constitution states that health care is the right of every individual and that the state is responsible for providing health care facilities for prevention and treatment, promotion, and rehabilitation [12]. In 1986, the federal government of the UAE adopted the WHO ‘Health for All’ concept and declared that primary health care (PHC) was central to achieving this goal [12]. Consequently, by 2001, an extensive network of 105 government-funded PHC clinics had been established across the country [13], with few people living more than a short distance from their nearest clinic [14]. These PHC centres, which are funded by the Federal Ministry of Health, and in Dubai Emirate by the state Dubai Ministry of Health, show limited variation across the country. There is a relatively uniform low level of infrastructure and service provision at each of these PHC clinics [in this study termed resource thrifty clinics (RTCs)], although only smaller centres utilize offsite pathology and X-ray services. However, one PHC clinic in the inland oasis city of Al Ain, which is financed and managed by the state-based Abu Dhabi Health Authority, has a high level of human, physical, and economic resources, at a similar level to that seen in Western countries; we have termed this a ‘resource intensive clinic’ (RIC). This RIC has been designated by the health authorities as an integral component of the PHC service, with the same status and function as other less well resourced clinics. People are allocated to attend this highly resourced clinic or a clinic with fewer resources, entirely based on the geographical location of their principal place of residence.
Consumer expectations have grown proportionately with the rising wealth of the population, resulting in strong societal pressure to adopt policies that satisfy heightened consumer expectations. Unfortunately, the development of structured quality assurance programmes and ongoing evaluation of health outcomes has lagged behind, leaving limited information on clinical outcomes available for decision making by policy makers.
This study evaluated the suitability of a patient satisfaction questionnaire, developed for use in Western countries, to survey health care consumers of traditional Arabic background.
Methods
Participants and setting
The study was conducted in 2001 in Al Ain, an inland oasis city with a population of 250 000, located approximately 130 km from the main cities of Abu Dhabi and Dubai. Two PHC clinics were involved in this study: the sole RIC, and one of the 14 RTCs, which had the greatest number of shared features with the RIC. These included a similar patient population (Emirati patients comprised 100% of the patient load at the RIC and >90% at the RTC), geographic location (the clinics served adjacent and similar suburbs in Al Ain), patient numbers (the RIC had the highest number of consultations, while the RTC had the second highest in the Al Ain health district), and physical structure (both centres were housed in identical buildings, and had on-site pathology and X-ray services) [15].
The distinguishing characteristics of the two study clinics are described in Table 1, while service provision data are presented in Table 2. Of particular note is the far higher rate of consultations per doctor per clinic session in the RTC. The Emirati populations attending the two clinics were similar. As one of the two clinics did not provide services for expatriates, only Emirati citizens were included in the study.
|
|
Design
An Arabic language questionnaire was used in this cross-sectional survey, in which all participants were interviewed once (see Appendix). The survey was administered by two Arabic-speaking people, a trained interviewer, and the second author.
Makhdoom and coworkers developed the questionnaire used in this study, for an ethnically similar environment in Saudi Arabia [16]. The questionnaire covers the standard domains used in North American and European surveys by other authors, including Donabedian [1] and Ware et al. [2]: accessibility to services (seven items), continuity of care (six items), humaneness of staff (eight items), comprehensiveness of care (five items), provision of health education (five items), and effectiveness of services (eight items). Although commonly questioned in other studies, cost was specifically excluded from this one, as the health care services included in this investigation were free to the consumer. For each of these domains, Makhdoom et al. [16] developed new questions based on the published literature concerning patient satisfaction, in particular the paper by Carr-Hill [17]. These questions were then translated into Arabic, which was verified by back-translation performed by a different bilingual person who had not seen the original English language version. Any areas of disagreement in the translation were resolved by discussion between both translators and the research team. Makhdoom et al. reported that face validity was obtained from discussions with five family and community medicine consultants, while reliability was 83% for split-half testing [16].
Each item was scored using a five-point Likert scale: ‘strongly agree’, ‘agree’, ‘don’t know’, ‘disagree’, and ‘strongly disagree’. Overall satisfaction was defined as the average score for the six measured domains of satisfaction. Demographic questions concerning age, sex, marital status, level of education, and mode of transport to the clinic were also included.
Study sample
The study was conducted in the waiting room of the two clinics. Only Emirati citizens aged 18 years and above, who were registered with the clinic (i.e. lived within the geographic zone the clinic served), and who were themselves visiting the doctor were included. The investigators visited the clinic over a 5-day period, alternating between the morning and afternoon sessions. Every 10th patient registering to be seen by the doctor was invited to participate.
Analysis
The Statistical Package for the Social Sciences (SPSS) version 10 was used to analyse the data [18]. Each satisfaction item was scored as follows: ‘strongly agree’ and ‘agree’ = 1, ‘strongly disagree’ and ‘disagree’ = -1, and ‘don’t know’ = 0. A mean score for each of the six domains was then calculated from the individual scores for the respective items. The domain of ‘overall satisfaction’ was calculated as the mean score for the six domains.
Comparative statistics were calculated using chi-square analysis for categorical variables and one-way analysis of variance for continuous variables. Analysis of co-variance was used to calculate significance of satisfaction between the two clinics. The clinic was the fixed factor, while the co-variants were sex, age, education, marital status, and transport. The level of clinical significance was defined as P 
0.05.
Institutional Review Board approval
The project received approval from the United Arab Emirates University Faculty of Medicine and Health Sciences Research Ethics Committee, and the Ministry of Health (MOH) Research Review Committee at Tawam Hospital, both of which comply with the ethical rules for human experimentation in the Declaration of Helsinki.
Results
The response rates for participation in this survey were 95% at the RIC (156 out of 165 people approached) and 92% at the RTC (125 out of 136 people approached).
The demographics of study participants according to the clinic they attended are detailed in Table 3. The two subpopulations showed no significant variations in age (P = 0.84) or marital status (P = 0.15), although those in the RIC had a significantly higher proportion of males (P = 0.01), were better educated (P = 0.01), and were less likely to walk to the clinic (P = 0.01).
|
The surveyed patients’ satisfaction scores are detailed in Table 4. The results ranged from 0.15 to 0.76, from a possible score range of between -1.0 and +1.0. The RIC scored higher in four of the six domains and in the summary ‘overall’ domain. In particular, the domains of continuity (P = 0.001), comprehensiveness (P < 0.001), health education (P = 0.05), and effectiveness (P = 0.001) were significantly higher in the RIC, with an overall satisfaction score (P < 0.001) that was also significantly higher. Humaneness scored the highest and continuity the lowest at both clinics.
|
The details of the multivariate analysis are detailed in Table 5. There was no statistically significant relationship between the sexes, marital status, and transport mode for any of the domains of satisfaction. Age and education were statistically significant for the domains of comprehensiveness and effectiveness, respectively.
|
Older people felt that the clinic service was more comprehensive than younger people (P = 0.009), and people with higher levels of education felt that the clinic service was less effective than those who were less educated (P = 0.007). Overall satisfaction was not statistically significantly related to any of the measured demographic variables.
Discussion
This study has demonstrated the capacity of a satisfaction instrument that was originally developed in the United States, with very Western constructs, to be used effectively by traditional Arabic Emirati citizens to distinguish between a resource-intensive and a resource-poor PHC clinic. There was a strong a priori expectation that the respondents would rate the RIC higher, as the results of this survey have shown.
Why was this instrument, which was devised in a different sociocultural setting, able to work effectively in this environment? In particular, the age [6,19–21] and educational [6] gradients associated with satisfaction that have been described in North American and European patients are also evident in this cultural context. Perhaps the answer lies in the parallel rise of economic wealth, overseas travel to Western countries (including a large number of Emirati people receiving health care in North America and Europe), consumer culture, and access to world media. Almost all people in the UAE have access to an abundance of written and visual sources of information in multiple languages, while the UAE also has the 22nd highest incidence of Internet use in the world (7.61 Internet hosts/1000 people) [22]. This may have led to a process of acculturation, where the traditional Emirati sociocultural attitude towards health care has been modified to accommodate Western concepts.
Another possibility is that the questions asked in this study are inherently biased to favour a Western-style clinic. For example, no question was asked about the use of interpreters, although these were only present at one clinic. Studies in other multilingual environments have found a decline in patient satisfaction scores when an interpreter is required because the physician and patient do not share an effective common language [23,24]. In this study, however, the setting, which incorporated high involvement of interpreters in the patient–physician interaction, scored higher satisfaction.
Although no budgetary figures were available, based on the difference in resources available, the RIC was likely to be more expensive per patient encounter. This suggests that it is possible that a substantial infusion of funds to raise the standard of the lower resourced clinic would improve patient satisfaction. However, in the absence of data on clinical health outcomes, the current information addresses only part of the equation regarding health outcomes.
Other studies measuring patient satisfaction with PHC services have been conducted in the Arabian Gulf on similar patient populations. Makdoom et al., using the same questionnaire but different techniques of analysis, found higher levels of satisfaction for each domain in Saudi Arabia [16]. Humaneness scored highest and continuity lowest, as in the current study. Also, Mansour and Al-Osimy found that PHC patients in Riyadh, Saudi Arabia, were overall moderately satisfied [25]. As before, their finding of highest scores for effectiveness and humaneness and lowest score for continuity were in parallel with this study. Another study in Qatar appeared to find higher levels of satisfaction amongst the local Arabic population, but used a different set of domains [23].
Another key distinction between the two clinic settings in this study was the considerable difference in time allocated for each doctor–patient encounter. In previous studies, patient satisfaction scores were found to rise with lower volume and longer consultation management strategies. This may explain the higher satisfaction seen in our study in the responses from patients at the RIC, since this clinic provided such a format for consultations [26].
Limitations
The demographics of respondents participating in this study varied significantly between the two clinics. Although the statistical method employed accounted for this bias in apportioning statistical significance, there remains the possibility that the two clinics may have been catering to different sectors of the Emirati population. However, the strict adherence to clinic assignment by health authorities and apparent similarities in economic status of Emirati in both areas makes this less likely.
In conclusion, this study suggests that patient satisfaction measured by this questionnaire is an effective quality assurance tool in this environment, and could be used as such by health administrators in quality assurance programmes. Further studies are needed to understand exactly which aspects of the RIC led to the higher levels of satisfaction, before recommendations can be made for expanding this style of PHC service to other areas in the UAE.
Appendix: questionnaire1,2
- The distance from my home to the medical clinic is acceptable.
- Appropriate chairs are available in the waiting room.
- The time spent in the waiting room for a routine visit is acceptable.
- The operating hours of the clinic are suitable.
- The physical separation of the clinic into male and female areas is done appropriately.
- All the non-hospital medical services I require are present at the clinic.
- The clinic provides appropriate car parking facilities.
- I see the same doctor at each visit.
- I visit only this medical clinic for non-hospital-based care.
- I find it easy to be referred from the clinic to the hospital.
- The doctors at the clinic can easily access my hospital medical reports.
- I am contacted by the clinic if I fail to attend for a follow-up appointment.
- The clinic provides all my family’s vaccination needs.
- The doctors at the clinic treat me well and with respect.
- The receptionists at the clinic treat me well and with respect.
- The nursing staff at the clinic treat me well and with respect.
- The laboratory staff at the clinic treat me well and with respect.
- Medical authorities in the clinic listen to my complaints.
- The staff at the clinic respect my privacy.
- The staff at the clinic respect the traditions of my country.
- The staff at the clinic never mistreat the patients.
- The data on my file is comprehensive and accurate.
- All my family members with a file at the clinic have had a ‘check-up’.
- There are appropriate numbers of staff to perform all the tasks I require at each visit.
- At every medical checkup my temperature, weight, and blood pressure are measured.
- The doctor provides comprehensive medical examinations.
- The doctor answers all my questions.
- The pharmacist explains how to take my medication.
- The clinic provides health education materials that allow me to understand diseases, their treatment, and prevention.
- I can watch health education videos at the clinic.
- The nurse provides helpful education and advice.
- My medical file is promptly delivered to the doctor for my visit.
- The time spent with the doctor is appropriate.
- Laboratory tests are reported promptly.
- My doctor prescribes medications I can obtain at my local pharmacy.
- In my opinion, doctors working in the clinic are competent.
- I trust and appreciate the care I receive from nurses working in the clinic.
- The equipment at the clinic works properly.
- The clinic is always clean and tidy.
The authors want to thank Dr A. G. Gasim for kind permission to use his questionnaire, and Professor Earl Dunn for his assistance with the statistical analysis.
Address reprint requests to Dr S. A. Margolis, Department of Family Medicine, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates. E-mail: margolis{at}uaeu.ac.ae 
1The questionnaire provided a five-point scale: (1) yes I fully agree, (2) yes I agree, (3) I don’t know, (4) I don’t agree, (5) I don’t agree at all.
2English translation from the Arabic original.
Accepted for publication February 6, 2003.
References
- Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966; 44 (suppl.): 166–206.
- Ware JE Jr, Davies-Avery A, Stewart AL. The measurement and meaning of patient satisfaction. Health Med Care Serv Rev 1978; 1: 3–15.
- Baker R. Development of a questionnaire to assess patients’ satisfaction with consultations in general practice. Br J Gen Pract 1990; 40: 487–490.[Web of Science][Medline]
- Williams SJ, Calnan M. Key determinants of consumer satisfaction with general practice. Fam Pract 1991; 8: 237–242.
[Abstract/Free Full Text] - Larsen DE, Rootman I. Physician role performance and patient satisfaction. Soc Sci Med 1976; 10: 29–32.
- Fitzpatrick R. Surveys of patient satisfaction. II. Designing a questionnaire and conducting a survey. Br Med J 1991; 302: 1129–1132.
- Haddad S, Fournier P, Potvin L. Measuring lay people’s perceptions of the quality of primary health care services in developing countries. Validation of a 20-item scale. Int J Qual Health Care 1998; 10: 93–104.
[Abstract/Free Full Text] - Codrai R. The Seven Sheikdoms: Life in the Trucial States before the Federation of the United Arab Emirates. London: Stacey International, 1990.
- World Bank Development Indicators. Washington DC: World Bank, 2002.
- Heard-Bey F. From Trucial States to United Arab Emirates. Harlow, Essex: Longman, 1982.
- World Fact Book. Washington DC: Office of Public Affairs, Central Intelligence Agency, 2002.
- Bener A, Abdullah S, Murdoch JC. Primary health care in the United Arab Emirates. Fam Pract 1993; 10: 444–448.
[Abstract/Free Full Text] - Health Service Report 1999. Abu Dhabi: Ministry of Health, United Arab Emirates, 1999.
- Badrinath P, Al-Shboul QA, Zoubeidi T, Gargoum AS, Ghubash R, El-Rufaie OE. Measuring the Health of the Nation: United Arab Emirates Health and Lifestyle Survey 2000. Al Ain: United Arab Emirates University, 2002.
- Annual Statistical Report 2000. Al Ain: Central Statistics Department, Ministry of Health, Al Ain Medical District, United Arab Emirates, 2000.
- Makhdoom YM, Elzubier AG, Hanif M. Satisfaction with health care among primary health care centers attendees in Al Khobar, Saudi Arabia. Saudi Med J 1997; 18: 227–230.
- Carr-Hill RA. The measurement of patient satisfaction. J Publ Health Med 1992; 14: 236–49.
[Abstract/Free Full Text] - SPSS for Windows Release 11.0.0. Standard edition. Chicago: SPSS Inc, 2001.
- Dixon RA, Williams BT. Patient satisfaction with general practitioner deputising services. Br Med J 1988; 297: 1519–1522.
- Bollam MJ, McCarthy M, Modell M. Patient’s assessment of out of hours care in general practice. Br Med J (Clin Res Ed) 1988; 296: 829–832.
- Salisbury C. Postal survey of patients’ satisfaction with a general practice out of hours cooperative. Br Med J 1997; 314: 1594.
[Abstract/Free Full Text] - Arab Human Development Report. New York: United Nations Development Programme, 2002.
- Abdal Kareem A, Aday LA, Walker GM Jr. Patient satisfaction in government health facilities in the state of Qatar. J Commun Health 1996; 21: 349–358.[CrossRef][Web of Science][Medline]
- Baker DW, Hayes R, Fortier JP. Interpreter use and satisfaction with interpersonal aspects of care for Spanish-speaking patients. Med Care 1998; 36: 1461–1470.[CrossRef][Web of Science][Medline]
- Mansour AA, al-Osimy MH. A study of satisfaction among primary health care patients in Saudi Arabia. J Commun Health 1993; 18: 163–173.[CrossRef][Medline]
- Zyzanski SJ, Stange KC, Langa D, Flocke SA. Trade-offs in high-volume primary care practice. J Fam Pract 1998; 46: 397–402.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  P. M. Hansen, D. H. Peters, K. Viswanathan, K. D. Rao, A. Mashkoor, and G. Burnham Client perceptions of the quality of primary care services in Afghanistan Int. J. Qual. Health Care, December 1, 2008; 20(6): 384 - 391. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||