Assessment of Patients Satisfaction in Accredited and Non–Accredited Primary Health Care Facilities in Nabaroh Health District

Zagazig University
Faculty of Medicine
Public Health and Community
Medicine Department
Assessment of Patients Satisfaction in Accredited and
Non–Accredited Primary Health Care Facilities in
Nabaroh District
Thesis
Submitted as a partial fulfillment of the Requirements of
Master Degree in Family Medicine
By
Mohammad Mamdouh Mohammad Al-Shishtawy
(M.B.B.Ch., 2005)
Faculty of Medicine – Mansoura University
Family Medicine Resident – Nabarouh Health District
Under Supervision of
Prof. Abd El-Lateef Saleh Ali
Professor of Public Health and Community Medicine
Faculty of Medicine – Zagazig University
Prof. Abdalla Hassen Mohammed
Professor of Public Health and Community Medicine
Faculty of Medicine – Zagazig University
Faculty of Medicine
Zagazig University
2015

‫و‬ ‫عليه‬ ‫هللا‬ ‫صلي‬ ‫هللا‬ ‫رسول‬ ‫قال‬‫سلم‬:
‫ن‬ِ‫إ‬(‫ه‬ َ‫هللا‬‫ب‬ِ‫ُح‬‫ي‬‫ا‬‫ه‬‫ذ‬ِ‫إ‬‫ه‬‫ل‬ِ‫م‬‫ه‬‫ع‬‫م‬ُ‫ك‬ُ‫د‬‫ه‬‫ح‬‫ه‬‫أ‬‫ا‬‫ل‬‫ه‬‫م‬‫ه‬‫ع‬‫ن‬‫ه‬‫أ‬)ُ‫ه‬‫ه‬‫ن‬ِ‫ق‬‫ُت‬‫ي‬
‫وسلم‬ ‫عليه‬ ‫هللا‬ ‫صلي‬ ‫هللا‬ ‫رسول‬ ‫صدق‬
‫البيهقي‬ ‫رواه‬ ،‫شريف‬ ‫حديث‬

AKNOWLEDGEMENT
First of all, thanks to Allah who guided me through this work.
I would like to express my deepest gratitude and most
sincere thanks to Prof. Abd El-Lateef Saleh Ali, Professor of
Public Health & Community Medicine, Faculty of Medicine,
Zagazig University, for his patience, time, valuable help and
advice in every step of this work.
It is pleasurable to express my deepest thanks to Prof.
Abdalla Hassen Mohammed, Professor of Public Health &
Community Medicine, Faculty of Medicine, Zagazig University,
for his great and continuous effort, support, time and precious
advice during the supervision of this work.

DEDICATION
This work is dedicated to:
My father and my mother for their continuous help and support,
My wife, My dear daughter Taleen and all My family.
Mohammad Mamdouh M. Al-Shishtawy

I
Contents
Title Page
List of Tables II
List of Figures IV
List of Abbreviations V
Introduction 1
Aim of the work and Objectives 3
Review of Literature 4
Definitions 7
Primary Health Care 11
Accreditation 13
Factors affecting patient satisfaction 19
Value of patient satisfaction 36
Measuring patient satisfaction 38
Patient satisfaction and quality of life 40
Improving patient satisfaction 44
Subjects and Methods 49
Results 55
Discussion 71
Conclusion 81
Recommendations 82
Summary 84
References 88
Appendix 110
Arabic Summary 114

II
List of Tables
NO.
Title Page
I The eight categories measured in accreditation process in
Egyptian MOH
16
II Scoring System for Socio– economic Status 51
1 General satisfaction in different Primary Health Care Units
(PHC) in Nabarouh District
56
2 Satisfaction score about Reception Services in different
Primary Health Care Units (PHC) in Nabarouh District
57
3 Satisfaction score about Physicians’ Performance in different
58
4 Satisfaction score about Nurses’ Performance in different
59
5 Satisfaction score about Accessibility of Place and Time in
different Primary Health Care Units (PHC) in Nabarouh
District
60
6 Satisfaction score about Unit Environment in different
61
7 Satisfaction score about Health Care Services in different
62
8 Satisfaction score about Patients’ Rights in different Primary 63

III
Health Care Units (PHC) in Nabarouh District
9 General satisfaction in Accredited and Non-Accredited
64
10 Satisfaction score in Accredited and non-accredited units 65
11 General satisfaction in Rural and Urban Primary Health
Care Units (PHC) in Nabarouh District.
66
12 Satisfaction score in rural and urban units 67
13 Distribution of the studied subjects according to their
satisfaction score according to their Socio-economic
Standards
68
14 Distribution of the studied subjects according to their
satisfaction score in relation to their Age.
69
15 Satisfaction score according to socio-demographic
characteristics of the studied subjects.
70

IV
List of Figures
NO.
Figure Page
1 Patient participation is a legitimate method of
evaluating health services
46
2 The European Foundation for Quality Management
(EFQM) Model
47

V
List of Abbreviations
CMS Centers for Medicare & Medicaid Services
ED Emergency Department
EFQM The European Foundation for Quality Management
GP General Practitioner
HIVBP Hospital Inpatient Value-Based Purchasing
IMCI Integrated Management of Child Illness
ISQUA International Society for Quality of Health Care
MOH Ministry Of Health
MOHP Ministry Of Health and Population
NGO Non-Governmental Organization
PHC Primary Health Care
PHCC Primary Health Care Center
PHCU Primary Health Care Units
PSRS Patient Satisfaction Rating Scale
QAAP Quality Assurance and Accreditation Project
TQM Total Quality management
WHO World Health Organization

1
Introduction
Family medicine is the high quality primary health care (PHC). Family
medicine depends on the availability of well-trained family physicians as
members of health care teams in the community, so measuring health care
quality is an important issue in family medicine. Two of the simple rules of
Institute of Medicine of the National Academies to fulfill quality state that
"customization based on patients’ needs and values" is needed and that "the
patient is the source of control" of interaction with the health care providing
system. Further in its target of "crossing the quality chasm", it identified
providing patient-centered care as one of important aims of health care system
(Institute of Medicine of the National Academies, 2001).
Patient’s satisfaction is the extent to which a patient's expectations or needs
are achieved by the available service or the range of fulfillment of patient health
hopes (Branson et al., 2003).
Factors affecting patient satisfaction such as age, health status and
socioeconomic status are the most effective factors for determining satisfaction
level (Branson et al., 2003).
Continuous assessment of the clients’ satisfaction of the delivered services is
particularly an important issue for a country as Egypt which is going on the
steps of applying the total quality management and accreditation of its health
care facilities (Abd El-Hamid et al., 2005).
Primary care teams are usually quite different from each other, largely due to
the independent status of the general practitioners (GP) and the nature of the
population that they serve. Many of the studies therefore warned that the result

2
may not be generalized to other practices. (Mangen and Griffith, 1982; Bond
and Thomas, 1992; Lewis, 1994; Mahon, 1996).
Developing strong patient relationships with high levels of satisfaction is not
that easy, but it is a realistic goal. Physicians can find ways to improve the
doctor-patient relationship by examining what works in other fields, such as
sales. In other words, the physician has to recognize the opportunity for
invention, reframe it in a way that makes it meaningful to the patient and
generate a sufficient sense of urgency to push the patient to take action. At the
same time, the physician has to maintain cooperation with the patient, based on
trust and understanding (Pawar, 2005).
Health represents the real wealth of any community and is a definite measure
for social and economic development. Health care faces major challenges
arising from the complexity of the provision process and its extreme sensitivity
to adverse outcomes. In Egypt health has never been seen as a priority and this
fact led to severe deteriorations during the last decades. Today, Egypt is facing
a scattered Health care sector in terms of service provision with a very high
burden on out of pocket spending and deeply prone to corruption (Hunter and
Hausler, 2011).
This study was carried out in Nabaroh District, Dakahellia, Egypt. Patient
satisfaction was never assessed in this district before.

Aim of the
work and
Objectives

3
Aim of the work
The aim of this work is to help improving patients’ satisfaction in
Nabaroh Primary Health Care units.
Objectives
1- Assess patients’ satisfaction in Primary Health Care in Nabaroh district.
2- Detect the causes and underlying factors of patients’ dissatisfaction.
3- Compare between patients’ satisfaction in accredited and non-accredited
units.
4- Compare between patients’ satisfaction in rural and urban units.
Study questions:
 What is the level of satisfaction of patients visiting Primary Health
Care facilities in Nabarouh district ?
 Which parts of health care components cause satisfaction and
which parts cause dissatisfaction ?
 What is the difference between patient satisfaction in accredited
and non accredited units ?
 What is the difference between patient satisfaction in rural and
urban health care facilities ?

4
Review of Literature
The need to improve quality in health care delivery is increasing. The
Centers for Medicare & Medicaid Services (CMS), hospitals, and insurance
providers alike are striving to better define and measure quality of health care.
A major component of quality of health care is patient’s satisfaction.
Furthermore, patient satisfaction is critical to how will patients do; research has
identified a clear link between patient’s outcomes and patient’s satisfaction
scores (Morris et al., 2014).
Patient’s satisfaction is a key determinant of quality of care and an
important component of pay-for-performance metrics. Under the CMS and
Hospital Inpatient Value-Based Purchasing (HIVBP) program, Medicare
reimbursements are linked to patient satisfaction and surveys completed by
patients (Morris et al., 2014). In recent years increasing emphasis has been
placed upon issues concerning the evaluation of health care (Garrido et al.,
2005).
Historical review:
Measuring and reporting on patient’s satisfaction with health care has
become a major topic. The number of medline articles featuring “patient
satisfaction” as a key word has increased more than 10-fold over the past two
decades, from 761 in the period 1975 through 1979 to 8,505 in 1993 through
1997 (Spoeri and Ullman, 1997).
Patient’s satisfaction measures have been added to reports of hospital and
health plan quality, and hundreds of consultants make a good living selling
software packages to health care providers eager to assess their customers'
reactions by telephone, fax, and modem. Hundreds of patient’s satisfaction

5
reports sit on the desk of every health care administrator in America. During
this flurry of activity, three fundamental questions emerge: Is patient’s
satisfaction worth measuring ? How can it best be measured ? And how can we
use the results ? These three questions form a framework for evaluating the
place of patient’s satisfaction according to the whole medical process
(Rosenthal and Harper, 1994).
For many years, patient’s satisfaction has been widely studied.
Considerable effort has gone into developing survey instruments to measure
patient’s satisfaction. Until the recent drive toward accountability, there were
two major uses of such instruments: first, in research studies in which patient’s
satisfaction was considered an outcome, either to assess the value of a new
intervention or to identify patient characteristics that appear to influence quality
assessment; second, by health plans, hospitals, and other providers to assess the
satisfaction of their members or patients with their services. The results of such
surveys were rarely reported publicly, except in advertising campaigns (Sofaer
and Firminger, 2005).
Despite its large use, the patient satisfaction was initially considered as a
difficult concept to be measured and interpreted. An unanimous consensus on
the definition of satisfaction with health care is not already fully achieved due to
the multi-dimensional and subjective nature of this concept, which is affected
by individuals’ expectations, needs or desires. For example, when users have
limited knowledge of opportunities and low expectations of service quality,
high satisfaction scores may be recorded even though poor standards of care
have been ensured (Baker, 1997).
Factors influencing dissatisfaction could be somehow different from
factors generating satisfaction. While on one side an adequate or acceptable
standard of quality should be considered a must, on the other side, a feeling of

6
satisfaction might result from a high quality service even if not matching the
required standards.
Moreover, when something negative happens consumers might be satisfied
or not; for instance, this depends on whether the negative event is caused by the
health professionals or it is not due to their behavior. Thus, it is possible that
what makes one person satisfied might make another one dissatisfied (Williams
et al., 1998).
This confusion related to the “patient’s satisfaction” concept enhance the
argumentation among researchers, health professionals and managers. In recent
years, new approaches have also been evaluated and adopted in order to
introduce more objective measures of the service’s quality. For instance,
researchers ask people to report in detail their experience with health service
using reporting and rating scales. The obtained results could be considered more
helpful in order to identify weaknesses in the delivery and organization of the
health services. Sometimes, also patients’ willingness to use again and/or
recommend services (e.g., hospital, general practitioner, etc.) is investigated as a
reliable proxy of overall evaluation both in not for profit and in market-based
health systems (Jenkinson et al., 2002).

7
Definitions
Satisfaction, like many other psychological concepts, is easy to understand
but hard to define. The concept of satisfaction overlaps with similar themes
such as happiness, contentment, and quality of life. Satisfaction is not some pre-
existing phenomenon waiting to be measured, but a judgment people form over
time as they reflect on their experience. A simple and practical definition of
satisfaction would be "the degree to which desired goals have been achieved".
Patient satisfaction is multifaceted and a very challenging outcome to
define. Patient’s expectations of care and attitudes greatly contribute to
satisfaction; other psychosocial factors, including pain and depression, are also
known to contribute to patient satisfaction scores. Historically, physicians,
especially surgeons, have focused on surgical technique and objective outcomes
as measures of “patient’s satisfaction”, while patients place great value on the
surgeon-patient interaction (Morris et al., 2014).
Cleary and McNeil (1988) suggested that more personal care will result in
better communication and more patient involvement, and hence better quality of
care, but the data on these issues are weak and inconsistent.
Meredith and Wood (1995) have described patient satisfaction as
emergency. It also has been described as a particularly passive form of
establishing consumer’s views. Satisfaction is achieved when the patient’s
perception of the quality of care and services that they receive in health care
setting has been positive, satisfying, and meets their expectations.
Ahmad et al. (2011) reported that patients’ satisfaction is a serious subject
for health care providers. Mixture in patients’ demographics also frames and
models their perceptions about hospital facilities and services. They investigated
the changes brought in the patients’ agreement of patients who were admitted in

8
various wards in the public sector hospitals and found that female patients were
more satisfied than male patients with reference of treatment and
administration.
Larsson and Widle-Larsson (2010) have found association between
perceptions of the quality of care with patient satisfaction. According to
Chassin and Gaivin (2010), national accountability center is a common place to
measure health care quality and use these measurements to encourage the
enhancement of health services, and raise transparency.
There are a number of definitions of primary health care currently in use.
The following definition endorsed by the Australian Health Ministers' Council
in 1988 and widely used since then, takes as its starting point the WHO 1978
Alma-Ata declaration (WHO and UNICEF, 1978):
"Primary health care seeks to extend the first level of the health system
from sick care to the development of health. It seeks to protect and promote the
health of defined communities and to address individual problems and populates
health at an early stage. PHC services involve continuity of care, health
promotion and education, integration of prevention with sick care, a concern for
population as well as individual health, community involvement and the use of
appropriate technology (Fry and Furler, 2000).
Primary health care is also seen as a philosophy, an approach and a level of
service delivery (Campbell et al., 2003).
Another definition is essential health care; based on practical, scientifically
sound, and socially acceptable method and technology; universally accessible to
all in the community through their full participation; at an affordable cost; and
geared toward self-reliance and self-determination (WHO and UNICEF, 1978).

9
As a philosophy, PHC is based on the overlap of mutuality, social justice and
equality (Fry and Furler, 2000).
As a strategy, PHC focuses on individual and community strengths (assets)
and opportunities for change (needs); maximizes the involvement of the
community; includes all relevant sectors but avoids duplication of services; and
uses only health technologies that are accessible, acceptable, affordable and
appropriate (WHO and UNICEF, 1978).
Primary health care needs to be delivered close to the people; thus, should
rely on maximum use of both lay and professional health care practitioners
(Kirkham et al 2006). PHC is fully participatory and involved the community in
all aspects of health and its subsequent action (Wass, 2000).
Sweeney et al. (2003) and Lin et al. (2004) defined quality according to
both providers' definition of quality which is mainly technical; that is
performance according to the set standard of practice. As well, health care
consumers' definition; that is effectiveness, acceptability, accessibility,
affordability, and equity.
Rafeh (2001) explained patient rights as the concept that emphasizes the
rights of patients to respect and dignity, the right to know about their health, and
the right to privacy and confidentiality. It also assesses clients’ satisfaction.
While patient care is the extent to which patients receive appropriate care. This
care focuses on compliance with clinical practice guidelines, and appropriate
diagnosis, assessment, treatment, follow-up, and patient counseling. Rafeh
(2001) defined patient safety as the extent to which the facility provides a safe
environment to its patients, staff, and clients. It emphasized both clinical and
environmental safety. Clinical safety includes having an infection control
program and employee health safety regulations.

01
Through integration of the concepts of empowerment, community-action
and transformative learning, health teams will be able to learn how best to
transform the present sick-cure medical system of primary care into a model of
PHC which reflects values and works with the community on opportunities for
change (Ramsden et al., 2003).
According to (WHO and UNICEF, 1978), Component of primary health
care are:
1. Education for the identification and prevention/control of prevailing
health challenges.
2. Proper food supplies and nutrition; adequate supply of safe water and
basic sanitation.
3. Maternal and child care, including family planning.
4. Immunization against the major infectious diseases.
5. Prevention and control of locally endemic diseases.
6. Appropriate treatment of common diseases using appropriate
technology.
7. Promotion of mental, emotional and spiritual health.
8. Provision of essential drugs.

00
Primary Health Care
Primary health care is the first level of health care where people live and
work, often used interchangeably with primary medical care as its focus is on
preventive services provided predominantly by general practioners as well as by
practice nurses, primary/community health care nurses, early childhood nurses
and community pharmacists (Fry and Furler, 2000).
The WHO and UNICEF (1978) declaration of Alma Ata stated that PHC
was the key to achieving “Health for all by the year 2000” and that it should be
an integral part of a country's health care scheme. Also, primary care is seen as
an increasingly important substitute for hospital care with a growing number of
elderly in the population and greater emphasis on patient autonomy and
independence (Calnan et al. et al, 1994).
Primary health care incorporates primary care, but has a broader focus
through providing a comprehensive range of generalist services by
multidisciplinary teams. These teams include not only general practioners and
nurses but also allied health professionals and other health workers, such as
multicultural health workers and indigenous health workers, health education,
promotion and community development workers. PHC services provide
services not only at the level of individuals and families but aslo at the level of
communities (Beasley et al., 2007).
The primary health care facility is professionally and ethically responsible
for ensuring that the care provided at the facility is satisfactory to patients and
providers. The facility must have a formal process for collecting information
and reviewing the degree of patient and provider satisfaction with the care
provided. This process includes a plan to inform patients and staff about the
data collection process and results. This process also involves the designation of

01
a person/committee who reviews the findings and consults with the appropriate
facility staff. The issues that require the intervention of the administration of the
facility for improvement are brought to their attention (Rafeh, 2001).
Primary health care shifts the emphasis of health care to the people
themselves and their needs, reinforcing and strengthening their own capacity to
shape their lives. Hospitals and primary health centers then become only one
aspect of the system in which health care is provided. (WHO and UNICEF,
1978).
In Egypt there are two types of health care facilities responsible for the
PHC:
1. Primary Health Care Units (PHCU), known under the health sector
reform program as Family Health Units. These units provide basic
outpatient preventive and curative services.
2. Primary Health Care Centers (PHCC) known under health sector reform
as Family Health Centers. These centers also provide basic outpatient
preventive and curative services in addition to services in specialty areas
such as obstetrics and gynecology, pediatrics, and internal medicine.
Centers may have a limited number of inpatient beds. (Rafeh, 2001)

01
Accreditation
Accreditation is a formal process by which a recognized body, usually a
non-governmental organization (NGO), assesses and recognizes that a health
care organization meets applicable pre-determined and published standards.
Accreditation standards are usually regarded as optimal and achievable, and are
designed to encourage continuous improvement efforts within accredited
organizations. An accreditation decision about a specific health care
organization is made following a periodic on-site evaluation by a team of peer
reviewers, typically conducted every two to three years. Accreditation is often a
voluntary process in which organizations choose to participate, rather than one
required by law and regulation (Rooney and van Ostenberg, 1999).
The accreditation process generally involves three specific steps:
(i) A self‐evaluation process conducted by the facility, the
administrators, and the staff of the institution or academic program,
resulting in a report that takes as its reference the set of standards and
criteria of the accrediting body.
(ii) A study visit conducted by a team of peers, selected by the accrediting
organization, which reviews the evidence, visits the premises, and
interviews the academic and administrative staff, resulting in an
assessment report, including a recommendation to the commission of
the accrediting body.
(iii) An examination by the commission of the evidence and
recommendation on the basis of the given set of criteria concerning
quality and resulting in a final judgment and the communication of
the formal decision to the institution and other constituencies, if
appropriate (Cullen et al., 2003).

04
Duration of Accreditation:
Accreditation decisions are limited in time. The duration of validity of the
accreditation license is established by the accrediting body, which generally
holds the right to suspend or to renew the license, upon the satisfactory
resolution of any identified issues (University of Sussex, 1999).
In 1997, the Minisrty Of Health and Population adopted a Health Sector
Reform Program, a new PHC strategy to reform the health system in phases
over a period of 15–20 years. Previously, Egypt had made significant progress
in many aspects of primary care. Despite their success, these programs have
fragmented the delivery system into many specialized, vertical programs. Under
the new reform strategy, the MOHP is committed to building an integrated
service delivery system for primary care and preventive services centered on the
family medicine approach. This new strategy aims to use scarce resources
efficiently and benefit people who are most in need: the underserved, the poor,
and those at high risk, particularly women and children (Rafeh, 2001).
The Egyptian MOHP has initiated an accreditation program which assesses
the performance of PHC clinics to make sure that it is up to the national
standards for quality of health service provision and grant accreditation
accordingly (Abdel Latif et al., 2013).
The main purpose of such accreditation process is to improve the health
services by making primary care providers more accountable. Accreditation
period would not exceed two years as none of the facilities are fully accredited;
i.e. achieving 100% of the set standards, accordingly, inspections from MOHP
every one or two years would assess the services and management quality to
measure the impact of the accreditation process (Egyptian MOHP, 2007). It is
up to the health clinic to decide if they seek full accreditation or gradual

05
accreditation through making incremental changes in the system and procedures
over a period of time (Booth et al., 2013).
In 2007 the Egyptian accreditation standards for primary health care were
accredited by the International Society for Quality of Health Care (ISQUA); the
“accreditors of the accreditors”, the vision of the Egyptian MOHP back then
was to achieve accreditation by 2020. The vision is to apply all standards to all
public health clinics in order to achieve high quality of health care. It is worth
mentioning that these qualities were revised by different national stakeholders;
and tailored to suit the Egyptian society norms, laws and practices. (Egyptian
MOHP, 2007).
According to Rafeh (2001) one of the first tasks in the design of the
accreditation program was the development of the key dimensions of quality
that should be assessed in the accreditation program. The criteria for selecting
the dimensions are based on their relative importance in defining quality of
services in the Egypt. After thorough discussions among MOHP officials, eight
categories were selected as the most important to measure in the accreditation.
The eight categories that will be included in the assessment can be summarized
in table (I).

06
Table (I): The eight categories measured in accreditation process in
Egyptian MOH (Rafeh, 2001)
1- Patient Rights
 Right for information
 System to assess patients’
complaints
 System to assess patients’
satisfaction
 Right to choose
5- Management of Information
 Accuracy and validity of data
 Accuracy and completeness of
medical records
 System to review and maintain
 medical records
 Confidentiality of records
2- Patient Care
 History and physical
 Diagnostic tests
 Treatment
 Patient education
 Referral and follow-up
6- Quality Improvement Program
 System to monitor and improve
the quality of care
3- Safety
 Environment
 Clinical
 Sterilization
 Infection control
 Employee health
7- Family Practice Model
 Prevention
 Continuity of care
 Referral system
4- Support Services
 Pharmacy
 Laboratory
 Radiology
 Emergency
 Housekeeping
 Laundry
 Kitchen
8-Management of the Facility
 Management approach
 Human Resource development

07
Benefits of accreditation:
1. Provides a framework to help create and implement systems and
processes that improve operational effectiveness and advance positive
health outcomes (Alkhenizan and Shaw, 2011).
2. Demonestrates credibility and a commitment to quality and
accountability (Kaminski, 2012).
3. Decreases liability costs, identifies areas for additional funding for
health care organizations and provides a platform for negotiating this
funding (Peter et al., 2010).
4. Sustains improvements in quality and organizational performance
(Flodgren et al., 2011).
5. Supports the efficient and effective use of resources in health care
services (Mate et al., 2014).
6. Enables on-going self-analysis of performance in relation to standards
(Greenfield et al., 2014).
7. Ensures an acceptable level of quality among health care providers
(René et al., 2006).
8. Enhances the organization’s understanding of the continuity of care
(Pomey et al., 2010).
9. Promotes a quality and safety culture (Ladha-Waljee et al., 2014).
10. Promotes the sharing of policies, procedures, and best practices among
health care organizations (Davis et al., 2007).

08
11. Provides a team building opportunity for staff and improves their
understanding of their coworkers functions (Davis et al., 2007).
12. Improves patients’ health outcomes (El-Jardali et al., 2013).
13.Enhances the reliability of laboratory testing (CAEAL, 2001).
14.Decreases variances in practice among health care providers and
decision-makers (Salmon et al., 2003).
15. Drives compliance with medication reconciliation (Colquhoun and
Owen, 2012).
16. Promotes capacity-building, professional development, and
organizational learning (Greenfield and Braithwaite, 2008).
17. Improves the organization’s reputation among end-users and enhances
their awareness and perception of quality care, as well as their overall
satisfaction level (Bird et al., 2005; Al Tehewy et al., 2009).

09
Factors affecting patients’ satisfaction
When including patient satisfaction mechanisms in health care systems, the
options should take account of the capacity of users to understand what is being
asked of them and to communicate their opinions and feelings effectively.
Previous measurements of patient satisfaction overwhelmingly show that
the majority of consumers, usually 80% or more, express overall satisfaction
with their care, with few respondents responding negatively to any given item.
Satisfaction is, however, a relative measure which research literature shows may
be influenced by many factors that should be considered.
Patient satisfaction metrics are used as internal comparators to determine
progress in improving care and provide external benchmarks for competitive
markets positions, which, if favorable, can be linked to greater profitability by
attracting more patients (Woodring et al., 2004).
it has been argued that evaluation of health care should not only focus
upon measures of clinical effectiveness and economics, but also upon the
measurements of social acceptability to the consumers of health care (Calnan et
al., 1994).
Continuous assessment of the clients satisfaction of the delivered services
is particularly important issue for a country as Egypt which is going on the steps
of applying the total quality management and accreditation of its health care
facilities (Abd El-Hamid et al., 2005).
Every human being carries a particular set of thoughts, feelings and needs.
By getting to know the patients a little more and to get their views on the care,
one ought to know what the patients consider as good care (Sultana et al.,
2009).

11
Mckinley (2001) has studies about factors affecting satisfaction and found
relation between patients’ expectations and the attained satisfaction. Andaleeb
(2001) concluded in his study that the greater the responsiveness, assurance and
tangibility of health care providers, the higher the satisfaction level reached.
Soleimanpour et al (2011) reported that a patient’s satisfaction is a major health
problem now.
Research of patient’s satisfaction in advanced, as well as, in developing
countries has many common and some unique variables and attributes that
influence overall patient’s satisfaction (Ahmad et al., 2011).
Patient satisfaction is associated with continuity of care, the doctor's
communication skills (Weiss and Ramsey, 1989), the degree of the patient
centeredness (Roter et al., 1987) and the congruence between desired
intervention and that received by the patient (Brody et al., 1989). Other factors
influencing satisfaction with medical care include confidence in the system and
a positive outlook on life in general (Weiss, 1988). Finally, satisfaction is the
judgment of the patient on the care that has been provided (Baker, 1991) and
the physician remains a key element in patient satisfaction (Janice and
Anbesaw, 1997).
Nasir et al. (2012) identified factors affecting patients’ satisfaction in line
with the health care services provided by hospital. They concluded that the
patients were in general satisfied with the services provided by the Aga khan
hospital in Pakistan. It also showed that greater part of the respondents were
satisfied with the health personnel’s when they consulted for medical needs.
Though this study have found some gray areas (such as pharmacy services,
billing services) in the system that can be changed to improve service. The
strengths of the organization as highlighted by patients must be continuing,

10
though some services need more focus, while planning and managing the health
care system like pharmacy and billing department services.
(A) Patient-related factors:
Hall and Dornan (1990) stated the importance of patients' demographic
and social factors in patient satisfaction, while Sixma et al. (1998) concluded
that demographics represent 90 percent to 95 percent of the variance in rates of
satisfaction.
Patient perspective was also included in the performance evaluation
frameworks to observe whether organizations achieved all the three goals
assigned to them by the World Health Organization (WHO): good health for the
population, fair payment systems and responsiveness to the public. Indicators
which consider patients’ perspective aim at monitoring whether health services
meet the overall needs of patients and are really patient-centred (Crow et al.,
2002).
Important factors influencing patients in this regard include literacy levels,
intellectual and physical/sensory disability levels and difficulties with language
proficiency or ethnic and cultural diversity. Social elements within each society
must be considered as they can very often dictate whether the consumer will
provide feedback and express their satisfaction or otherwise, e.g., financial
status, educational status, demographics (urban/rural) and technology.
1- Age:
Al-Bashir and Armstrong (1991) investigated the relationship between
reported satisfaction and age and confirmed the conventional wisdom: older
respondents were significantly more satisfied. Older respondents generally
record higher satisfaction; possible explanations include lower expectations of

11
health care and reluctance to articulate their dissatisfaction (Owens and
Batchelor, 1996).
Various explanations are advanced for the reason why older people
generally report higher satisfaction, and research is required to investigate these
further. It may reflect generational or lifecycle effects: that older people are
more stoical and accepting than the young, or that they engender more respect
and care from their providers. Alternatively, it may be a cohort effect and that
they have lower expectations based on prior experiences when standards were
lower (Al-Bashir and Armstrong, 1991).
There are particular circumstances that may explain findings that do not
support the trend. In one study, satisfaction was polarised, being highest in the
very young age group as well as among the oldest (Hsieh and Kagle, 1991).
Kane et al. (1997) focused on hospital inpatients. They showed that
younger surgery patients were more satisfied 6 months after discharge than
those who were older. They also showed that health status correlated with
satisfaction.
In another study, older patients reported more sources of dissatisfaction
with their hospital stay, but this was exclusively due to their extensive
communication problems (Pilpel, 1996). Results, however are inconsistent and
sometimes contradictory, for example, (Cleary et al., 1992) found that older
patients consistently tend to report higher levels of satisfaction than do younger
ones. Kathryn et al. (2004) concentrated heavily on interpersonal aspects of
care, which may have resulted in the lower recorded satisfaction among elderly
patients.

11
2- Gender, ethnicity, and socio-economic status:
Evidence about the effects of gender, ethnicity, and socio-economic status
is equivocal due to the small amount of literature available on each (Crow et al,
2002).
Harvey et al. (1999) investigated the relationship between race or ethnicity
and satisfaction. This was found to be significant. In 73.3% of this study, black
and other visible minority groups were found to be less satisfied. On the
contrary in a study of chronically sick outpatients, non-white people
(terminology used by article) were more satisfied (Kerr et al., 1998).
Rogut et al. (1996) showed significant differences between various
minority groups. In an investigational study in Switzerland, non-Swiss
ambulatory patients were found to be less satisfied with the care they received
than the indigenous population (Etter and Perneger, 1997).
Several indicators of socio-economic status were used across the studies.
In general, the findings about the relationships between socio-economic
indicators were inconsistent and inconclusive. The effect of level of education
on satisfaction was considered by 31 investigators. Education was not found to
have a significant influence on satisfaction in 15 (48.3%) studies. Higher levels
of education were associated with significantly less satisfaction in 11 (35.4%)
studies, and significantly more satisfaction in five (16.2%). The differences
between manual and non-manual workers or between social classes was
investigated in 15 studies. No significant differences in satisfaction were
observed by 12 studies of them (Annandale and Hunt, 1998).
3- Health status:
Wilson et al. (1995) examined the relationship between health status and
satisfaction. The majority involved large numbers of participants in varied

14
settings. Many methods were used by the investigators. There is evidence that
poorer physical health status, disability, low quality of life, and psychological
distress are associated with lower levels of reported satisfaction.
Al-Bashir and Armstrong (1991) showed that the existence of a long-term
health problem (in contrast to acute distress and pain) did not affect satisfaction
in general practice, although there is evidence that patients’ preferences vary
according to their health status.
In a study of satisfaction with medical care in general, Hall et al. (1990)
showed that people with poor health had stronger feelings in either direction,
and that the most satisfied groups were those with good health or those
suffering a chronic disease. Diagnosis in the emergency room was not
predictive of satisfaction.
Esteban de la Rosa et al. (1994) found that health status is not
significantly related to satisfaction. On the other hand Linder-Pelz and Stewart
(1986) found that health status affected satisfaction in the manner of the more
sick people were less satisfied
Hall and Milburn (1998) have found that sicker patients and those
experiencing psychological stress are less satisfied, with the possible exception
of some chronically ill groups. He differentiated between the experience of
sickness and experience of health service, treatment or other factors as causes of
dissatisfaction.
Among hospitalised patients, poorer health is generally associated with
lower satisfaction and reporting more problems with care (Krupat et al., 2000).
Perceived improvement in health has been linked to satisfaction, although
Covinsky et al. (1998) found satisfaction in elderly patients to be positively

15
associated with health status on discharge, rather than with improvements in
health status over the hospital stay.
Changes in health status have been shown to influence reported
satisfaction over longer periods. Among patients undergoing surgery, those
reporting the greatest absolute or relative improvements in symptoms 6 months
after discharge were the most satisfied (Kane et al., 1997).
Patients with migraine who had the longest history of illness were most
dissatisfied by their consultations and experienced the least symptom
improvement after 1 year. Thought there is a need to create a model which
separates between the effect of health status on satisfaction during illness, and
in the follow-up period (Schlesinger et al., 1999).
4- Patient’s expectation:
The meeting of patient’s expectations are assumed to play a role in the
process by which an outcome can be said to be satisfactory or unsatisfactory.
Expectations are an important influence on the patient’s overall measurement of
satisfaction with a health care experience. Patient satisfaction is influenced by
the degree to which care fulfils expectation (Mahon, 1996).
Avis et al. (1995) investigated the relationship between expectations of
various types (including desires, values, entitlements) prior to the health care
encounter and satisfaction after it. There is evidence from the USA of a positive
relationship between satisfaction and expectations: consumers with expectations
of high-quality care reported higher levels of satisfaction and were more likely
to return to and recommend their providers than people with lower expectations.
In the UK, however, satisfaction could not be explained entirely in terms of
meeting expectations.

16
Williams (1994) suggested that a link between satisfaction and fulfilment
of patient’s expectations is not necessarily the case, since it is possible that the
patient’s evaluation of a service may be largely independent of actual care
received.
In a theoretically-based investigation of social psychological variables,
values and feelings of entitlement were not related to satisfaction, although
expectations were. Social psychological variables accounted for a small (<10%)
and variable proportion of the explained variation in satisfaction in the study,
depending on the model used (Linder-Pelz and Stewart, 1986).
There is some support for the discrepancy model: satisfaction is highest
when favourable experiences match favourable expectations and lower when
negative occurrences reinforce negative expectations or contradict positive
ones. Good and bad “surprises” experienced in hospital have been observed to
affect satisfaction, with bad events more significant than good ones (Nelson and
Larson, 1993).
Gottlieb et al. (1994) showed links between disconfirmation of
expectations and perceived quality of care, and between perceived quality of
care and satisfaction, but did not establish a direct connection between
disconfirmation and satisfaction.
Sixma et al. (1998) uncovered a positive relationship between satisfaction
reported after an encounter and previously recorded levels of satisfaction. This
relationship held even for patients consulting with a doctor who was new to
them.
This consistency could be explained by patients’ predispositions:
Respondents reporting more satisfaction with life in general, or greater

17
confidence in the medical care system, recorded significantly higher satisfaction
with their physicians than those who did not (Robbins et al., 1993).
When the relationship between health service utilization and satisfaction
was examined, a self-regulating system was uncovered. Satisfied patients were
observed to visit their primary care providers more often, but higher numbers of
visits were seen to result in reduced satisfaction (Mirowsky and Ross, 1983).
Mirowsky and Ross (1983) speculated that the reason underlying this
relationship is the rising probability that patients’ expectations will not be met
as the number of visits increases. Patients may become dis-illusioned, and
doctors may seek to deter or cease frequent attendees.
There is confirmatory evidence in another US study showing that women
who made more visits to their health care provider were more likely to want to
disenrol from their health plan (Kerr et al., 1998). On the other hand, negative
expectations about a health care provider that are based on no prior experience
were associated with low reported satisfaction, but this was reversed over time
as positive experiences accumulated (Ross et al., 1981).
Harvey et al. (1999) investigated the relationship between satisfaction and
the extent to which patients’ pre-consultation expectations, desires or
preferences for treatment were met by their doctors. In most cases satisfaction
was enhanced when the patients’ wishes were met, or dissatisfaction arose when
they were not.
However, Kenny (1995) found that consumers’ expectations were not well
formed. Dissatisfaction with a consultation may negatively affect symptom
resolution later. The apparent relationship between favourable evaluations and
giving patients what they want or expect creates a challenge for providers when
consumers’ desires or expectations are inappropriate or unrealistic. In such

18
circumstances, fostering satisfaction will be contingent upon doctors’
communication skills and the extent to which the consumer is open to reasoned
argument. There is a constant need to educate consumers about appropriate
care, and to manage their ideals and expectations about what can realistically
and practically be provided.
5- Prior experience of satisfaction:
Crow et al. (2002) identified that satisfaction was linked to prior
satisfaction with health care and granting patients’ desires (e.g. for tests). In the
last years, several health care services have adopted multidimensional
evaluation systems in order to monitor the outcome of health programs as well
as the performance of organizations.
(B) Physician-related factors:
Physicians can promote higher rates of satisfaction by improving the way
they interact with their patients (Haviland et al., 2005).
1- Patient–professional relationship:
There is consistent evidence across settings that the most important health
service factor affecting satisfaction is the patient-practitioner relationship,
including information and technical competence (Crow et al, 2002).
Schlesinger et al. (1999) confirmed the high importance that consumers
attach to interaction factors and the quality of the patient–practitioner
relationship in general when they are evaluating care.
McCann and Weinman (1996) investigated the characteristics of patient–
doctor interactions in order to identify the features most closely associated with
satisfaction. They investigated the effect of training doctors in communication

19
or psychosocial skills and of encouraging patients to participate more actively in
consultations.
Although doctor training had a significant positive effect on satisfaction, a
leaflet provided to patients did not, possibly because such an approach is
insufficiently proactive and personal. There is no evidence that the gender or
age of physicians had a consistent effect on satisfaction (McCann and
Weinman, 1996).
Greater satisfaction with female doctors amongst female patients than
amongst male patients was reported (Comstock et al., 1982). Smith et al. (1995)
found that trained female doctors seemed to be better on disclosure and empathy
than their male counterparts.
There is contradictory evidence on the effect of physician age. It has been
suggested that when patients do not have a choice of physician they prefer
middle-aged, white, non-Catholic, male doctors in Netherlands (Hjortdal and
Laerum, 1992).
There is general evidence that physicians’ interpersonal skills affect
satisfaction, and that a personalised approach is appreciated by consumers
(DiMatteo et al., 1998). Rowland-Morin and Carroll (1990) showed a link
between the use of intervals of silence in the interview and satisfaction during
the consultation.
Affective behaviour by the physician was consistently related to
satisfaction, although this was variously described by Ben-Sira (1990) in terms
of warmth and respect, friendliness, trust, courtesy, empathy, supportiveness,
sensitivity and understanding. Shared laughter and chatting with patients have
been associated with higher satisfaction.

11
With respect to information gathering and giving, most evidence showed
that satisfaction correlated positively with physician feedback and discussions
about treatment (Stiles et al., 1979).
Giving better information about drug regimens was shown to improve
compliance. The provision of general health promotion advice also generated
satisfaction (Wartman et al., 1983).
Information collection by physicians, by means of chart reviews or history
taking, has been observed to have a negative impact on satisfaction. However,
physician listening, undertaking a physical examination, and explaining
patients’ problems were noted to be positively related to satisfaction.
Expressions of physician control, including dominating the conversation,
reduced reported levels of satisfaction. A directing style has been found to be
more satisfactory for patients with physical problems, but in general partnership
arrangements were preferred (Krupat et al., 2000).
2- Control:
Physicians can also improve patient satisfaction by attenuation of some
control over the encounter. Cecil and Killeen (1997) have found that when
physicians exhibited less dominance by encouraging patients to express their
ideas, concerns and expectations, patients were more satisfied with their visits
and more likely to adhere to physicians' advice.
3- Choice of service provider:
Choice of service provider is associated with higher satisfaction. Care
provided under fee-for-service arrangements generates greater satisfaction than
that delivered with prepaid schemes. Gate keeping organisations, where patients
have little or no choice in their treatment or are assigned treatment, score
relatively poorly on satisfaction (Crow et al., 2002).

10
4- In-hospital satisfaction:
Bruster et al. (1994) investigated satisfaction with in-hospital care and
identified the most important dimensions of hospital care contributing to
satisfaction. They illustrated the importance to patients of the care afforded by
human resources, particularly nurses, and of interpersonal communication. In-
hospital satisfaction in the USA has been reported to be lower in teaching
hospitals and government-run hospitals than in private hospitals. Patient
satisfaction has been shown to be adversely affected by nursing strain and
exhaustion.
Satisfaction was used as a focal outcome measure in a study done by
Thomas et al. (1996) that evaluated different methods of organising nursing
care from the patient’s perspective.
5- Hospital outpatient care:
Bishop et al. (1991) explored this issue. Professional standards and
interpersonal relationships are of prime importance to patients.
6- Decision making:
Patient satisfaction can also be influenced by physicians' medical decision
making. Patients expressed a preference for physicians who recognized the
importance of their social and mental functioning as much as their physical
functioning (Sherbourne et al., 1999).
7- Time spent:
Time spent during a visit plays a role in patient satisfaction, with
satisfaction rates improving as consultation length increases. Time spent
chatting during the consultation was also related to higher rates of satisfaction.
Physicians with high rate practices were more efficient with their time but had

11
lower rates of patients satisfaction, offered fewer preventive services and were
viewed as less sensitive in the doctor-patients relationship (Zyzanski et al.,
1998).
With regard to consultation time, longer consultations were associated with
higher satisfaction (Kvamme and Hjortdahl, 1997). Anderson and Zimmerman
(1993) showed no association, but average consultation times in the USA that
caused satisfaction are longer than in the UK.
Interestingly, Lin et al. (2001) showed that while physicians felt that they
ran out of time and rushed 10 percent of the time, patients felt that way only 3
percent of the time. Patient satisfaction was identical whether the physician did
or did not feel rushed. This suggested that physicians may be more sensitive to
feelings of being rushed and their feelings may not reflect the actual time spent
during the visit.
According to Umar et al. (2011) the performance of health care facilities
can evaluate patient satisfaction as reducing waiting time is needed to ensure
effective health care delivery system.
8- Technical skills:
Chang et al. (2006) have looked at patients' assessment of their physicians'
technical skills and its effect on satisfaction. In this survey of patients, better
communication skills were linked to higher patient satisfaction but technical
expertise and skills did not affect the satisfaction.
However, Fung et al. (2005) found that when forced to make a trade-off,
participants expressed a strong preference for physicians who have high
technical skills. Patietns also indicated that a physician's ability to make the
correct diagnosis and craft an effective treatment plan were more important than
his or her bedside manner (patient care).

11
9- Appearance:
Patients also appear to respond to a physician's appearance. Patients
indicated that they preferred "semiformal" attire and a smile. Next, in order of
preference, were "semi-formal" dress without a smile, a white coat, a formal
suit, jeans and casual dress. They were less comfortable with facial piercings,
short tops, or earrings on men. In addition, most patietns wanted to be called by
their first name, be introduced to the doctor by this full name and title, and see a
name badge (Lill and Wilkinson, 2005).
(C) System-related factors:
Patient satisfaction is not simply a product of the patient's demographics
and the physician's skills. It is also affected by the system in which care is
provided (Wolosin, 2005).
1- The clinic team:
Although it is clear that patients' first concern is their doctor, they also
value the team with which the doctor works. Otani et al. (2005) found that
while physician care was most influential to patients' satisfaction, the
compassion, willingness to help and promptness of the physician's staff were
next in importance.
In another survey, nurses were the next most important source of
satisfaction, ahead of access-to-care issues. Patients who had remained in a
practice for more than 15 years attributed their loyalty to their physician first
and to the "team concept" second (Brown et al., 1997).
In the Emergency department (ED), the role of gatekeeper is considered
the treatment of the patient. ED should have to provide quality service to attain
customer’s satisfaction. For monitoring and evaluating health care quality of life

14
and patients’ satisfaction both are essentials. Patients’ attitudes and behaviors
towards hospitals has become an important issue in the competitive industry of
health care and it depends upon the hospital’s brand image (Joseph and Nichols
2007).
Iliyasu et al. (2010) stated that the surveys of total quality management
have become common and very important in the development field.
2- Referrals:
Effective referrals play a role in patient satisfaction. Rosemann et al.
(2006) looked at referrals from the standpoint of the family physician, the
referral physician and the patient, and found that satisfaction with the referral's
outcome was higher when the family physician initiated the referral.
In a survey of cancer patients, Norman et al. (2001) found that they valued
their family physician highly and wanted to maintain contact with them, even
when they were receiving cancer care elsewhere.
Similarly, in a study of patients treated for recurring headaches, Bekkelund
and Salvesen (2001) revealed that those who self-referred to a neurological
were less satisfied than those whose primary doctor had referred them.
3- Continuity of care:
Continuity of care, one of the pillars of family medicine, is felt to have
suffered under managed care. While it is unclear to what degree patients in
general value continuity of care, it is clear that patients who have been followed
by their physician for more than two years are more satisfied with their care;
particularly when they are able to see their own physician (Donahue et al.,
2005).

15
4- Quality of care:
The lack of quality within the Egyptian health care sector is a big issue.
Most public institutions have very bad reputation when it comes to quality of
service. The little number of private hospitals that have a good reputation are
only accessible to the very wealthy part of the population due to high costs of
services without ceilings. Generally, the quality issue had resulted in a loss of
trust in the (especially the public) sector. Basically, hospitals are not keeping
records that document quality (Hunter and Hausler, 2011).
5- Governance and transparency:
Worldwide, the absence or inadequacy of governance and transparency has
not only hindered the overall performance of the health care industry but also
deprived the sector from valuable investment opportunities deemed critical for
its sustainability and growth. Hence, it is crucial to introduce the concepts of
governance and transparency for development to be enabled.
Transparent and properly governed health care organizations with clearly
defined roles, responsibilities and segregated duties should achieve high levels
of efficiency and performance that can meet the demands of today’s consumers
and other stakeholders. Such organizations will also boost their ability to attract
potential investments, so will a more transparent market. Transparency will
raise the quality and the competition within a health care sector by disclosing
information. At the same time, transparency will give patients the chance to
choose and compare services and prices. Finally, corruption will be diminished
to a great extent (Hunter and Hausler, 2011).

16
Value of patients’ satisfaction
Patient’s satisfaction is a powerful driver of outcomes such as the ability of
the patient to choose a plan or a provider, patient complaints, grievances and
claims (Halperin, 2000), the level and seriousness of malpractice claims, or,
perhaps most important, actual health and functional status outcomes (Taylor et
al., 2002). Patient’s satisfaction predicts both compliances (Ayatollahi, 1999)
and utilization (Weisman et al., 2011) and may even be related to improved
health. It also contributes to the atmosphere prevailing in a PHCC (Fitzpatrick,
1991).
Patients who are dissatisfied are more likely to switch physician and
medical groups, which could lead to decrease viability of the medical practice
(Robbins et al., 1993; Kerr et al., 1998). High levels of satisfaction predict
important aspects of care including the probability of following medical advice
(Bartlett, 2002), participating in self-health maintenance (Hudak and Wright,
2000), the strength of the patient-physician relationship and continuity of care.
Patient satisfaction is one of the several ways to evaluate the quality of
care, an outcome variable in its own right, and is an indicator of weaknesses in
the service. Previous literature shows that satisfaction level can be dependent on
many factors other than the quality of service delivery, it may subject to factors
like patients’ demographics (Holikatti, 2012; Young et al., 2000).
Patient satisfaction can be used to investigate the areas having flaws or
deficiencies in quality of services. Previous studies have explored methods to
improve service quality in outpatient departments by analyzing outpatient
satisfaction regarding waiting times, courtesy and interpersonal skills,
professionalism, access, coordination of care, education and information
provision, emotional support, technical quality of care, and overall quality and

17
satisfaction (Pothier and Frosh, 2006; Rao et al., 2006; Bergenmar et al.,
2006; Chandra et al, 2006).
Patient satisfaction is an important aspect of health care quality and can be
used for monitoring of some aspects of quality (Cleary and McNeil, 1988). It is
an important tool to measure the performance of providers, managed care
organization and health care system. Health plans are also using satisfaction
ratings to modify payment and capitation rates, provide bonuses, and identify
outlier at both medical group and individual physician levels (Gold and
Wooldridge, 1995). Finally, purchasers are basing contracting decisions at least
in part on patient satisfaction reports. Indeed, the Quality Assurance and
Accreditation Project (QAAP) has recently required a standardized patient
satisfaction survey for plans seeking accreditation (Kerr et al., 1999).
Patient satisfaction metrics are used as internal comparators to
determine progress in improving care and provide external benchmarks for
competitive markets positions, which, if favorable, can be linked to greater
profitability by attracting more patients (Woodring et al., 2004).
The reform of the medical systems must respond to the individual's needs,
taking into consideration, in the democratic process, their expectations
regarding health and the medical care domains. The opinions and options of the
individual, must exercise a decisive influence on the way the health services are
conceived and the way they work. The individuals must assume the
responsibility of their own health. (Ljubljana Charter, 1996)

18
Measuring patients’ satisfaction
The patient’s satisfaction measurements have been generally used in order
to provide researchers, health managers and professionals with valuable
information for understanding patients’ experience, promoting patient’s
compliance with treatment, identifying the weaknesses in services and
evaluating health service performance (Sitzia and Wood, 1997).
One of the critical success factors when measuring patient satisfaction is
that the process is planned effectively. It is important to identify clear objectives
and link them with the appropriate method of evaluation (Hudak et al., 2003).
A critical aspect in the patient satisfaction’s measurement is that models
and instruments sometimes reflect the providers’ perspective rather than the
patients’ one. For example, the patient capability to evaluate health services and
professionals’ skills is frequently questioned, even when these items receive
high satisfaction rates (Rao et al, 2006).
According to Hopkins and Fitzpatrick (1993), patients are less capable of
judging technical competence because of a real informative asymmetry and in
any case they are more reserved in expressing critical comments with regard to
the abilities of doctors. As a consequence, the high satisfaction scores observed
may depend on the confidence in doctors’ capabilities.
Instead, Coulter (2006), argued that well designed questionnaires allow to
assess both the technical competence and interpersonal skills of health
professionals. Although the debate on the use of patient satisfaction as an
outcome measure is still open, it has been observed that satisfied patients are
more compliant and more likely to participate in their treatment. In fact, a
satisfied patient is more aware of his care pathway and more willing to follow
the physician prescriptions (Norquist, 2009).

19
The assessment of patient satisfaction with the process of care is an
important measure of the care quality and it allows to identify the phases of the
process to be improved. Questionnaires using report style questions allow to
observe how the care is delivered (Leeper et al., 2003).
Lantz et al., (2005) and Marchisio et al., (2006) have highlighted that
satisfaction strongly increases when care is provided in accordance with the
clinical standard procedures. Furthermore, the patients’ point of view may help
managers to evaluate activities such as the purchase of new technologies or the
test of new medical treatments.
In the USA, the results of standardized measures of client satisfaction are
used with other indicators in the process of accrediting managed care
organisations, and in “report cards” to inform both suppliers and purchasers of
health care about consumer views of alternative plans. With so much at stake,
large sums of money are invested in researching the health care market (Weiss
and Senf, 1990).
Planning an evaluation to measure patient satisfaction:
Those involved in planning an evaluation to measure patient’s satisfaction
should consider a number of key questions grouped as follows:
 Questions to consider before identifying patients who will be invited to
participate in the evaluation.
 Questions to consider when you are ready to begin involving patients.
 Evaluation questions (Hudak et al., 2003).

41
Patients’ satisfaction and quality of life
Quality of life is an important concept since it allows development to be
analyzed on a measure broader than standard of living. There are varying ideas
concerning what constitutes desirable change for a particular society, and the
different ways that quality of life is defined by institutions therefore shapes how
these organizations work for its improvement (Patthira, 2011).
The term quality of life is used to evaluate the general well-being of
individuals and societies. The term is used in a wide range of contexts,
including the fields of international development, health care, and political
science (Gregory et al., 2009).
Quality of life should not be confused with the concept of standard of
living, which is based primarily on income. Instead, standard indicators of the
quality of life include not only wealth and employment, but also the built
environment, physical and mental health, education, recreation and leisure time,
and social belonging (Gregory et al., 2009).
Infante et al. (2004) determined patients’ own definitions of quality of
care. They are typically small-scale, qualitative studies using patient interviews
and focus groups. This methodological choice is understandable. They have
elicited a wide range of specific definitions offered by patients themselves. In
some cases, they have categorized these specific definitions into several
categories or dimensions and named them using terms familiar to health
professionals. The categories are patient-centered care, access, communication
and information, courtesy and emotional support, technical quality, efficiency of
care/organization, and structure and facilities.
 Patient-centered care: Patients defined quality through what has been
termed patient-centered care.

40
 Access: There are concerns about access, such as having doctors, nurses,
and staff who make themselves available and accessible to the patient;
having access to specialists; having care that is affordable; having
convenient places and times for visits; having providers who make home
visits; having access to gender-concordant, professionally trained, and
culturally appropriate interpreter services; having access to urgent care;
and having help from staff in navigating the health system.
 Communication and information: This category includes open
communication and information flow; providers with good interpersonal
communication skills such as listening carefully and attentively and
explaining complex technical information clearly; provision of information
on clinical status, progress, prognosis, and processes of care; provision of
information on what to expect; prompt communication of test results;
complete and accurate translations, including written prescription labels in
the patient’s native language; and education to facilitate patient autonomy,
self-care, and health promotion.
 Courtesy and emotional support: Patients recognition of quality is based
on the social and emotional characteristics of interactions with providers
and office staff.
 Efficiency of care/effective organization: Patients expected care to be
efficient, with coordination between the many individuals and
organizations involved in their care, such as multiple providers within a
hospital, between generalists and specialists, across facilities, and between
their providers and their health plans.
 Technical quality: Patients mentioned features that can easily be related
to what clinicians often refer to as the technical quality of care. Patients

41
expressed a desire for technically knowledgeable, competent, and
experienced providers who are well educated; provide effective treatments,
accurate diagnoses, and diligent and efficient services and treatment; and
present themselves in a professional manner. In one study patients said
they wanted providers to “strive for excellence.” Patients also defined
quality as having good health outcomes and improved quality of life.
 Structure and facilities: Patients evaluate quality of the health care
organizations’ structures and facilities, including easy access, parking
availability, safety and security in and around the facility, cleanliness and
comfort, quality of food provided, a quiet and pleasant environment, a
variety of clinical services available, and use of up-to-date technology such
as computers (Infante et al., 2004).
Quality health care together with Total Quality management (TQM) have
emerged as a watchword for health care in the 1990s. TQM focuses on quality
as a key to managerial excellence. It is defined as a cost-effective management
system for integrating the continuous quality improvement efforts of people at
all levels in an organization to deliver products and services that ensure
customer satisfaction. This definition implies that TQM is a total and
continuous process (Willeumier, 2004).
The so called Joiner triangle neatly captures the essential elements of
TQM:
1. The customers as the defining factor in determining quality.
2. Team work as a means of unifying goals.
3. Scientific approach based on data collection and analysis as a means of
achieving continuous improvement (Morgan, 1994).

41
One of the main aims of TQM is meeting customer requirements,
exceeding customer expectations and getting things right every time. There was
a link between quality of health care and patients satisfaction. The other major
driver of attention to patients has been, in fact, the movement toward patient-
centered care. Specialization led to fragmentation of care, an increasingly
noticeable absence of care coordination, and little recognition that the patient
was a whole, multi-faceted human being. In spite of growing evidence of the
significant effect of psychosocial and behavioral factors in the onset and
presentation and prognosis of many illnesses, a biomedical model remained
dominant in medical practice. As chronic disease became more prevalent, the
need for ongoing, productive relationships between patients and physicians and
other providers became more critical. Yet evidence has grown that what is
termed patient adherence to medical advice was sketchy at best, often because
of failures in the physician-patient relationship. So, late twentieth-century
medical civilization had an increasing number of discontents (Sofaer and
Firminger, 2005).

44
Improving patients’ satisfaction
When asked to identify the physician in charge of their care at the time of
discharge, up to 90 percent of medical inpatients are unable to correctly name
their treating physician.
Many patients are admitted to hospitals directly from the ED, and hospital
admission from the ED has been associated with a decreased ability of patients
to identify their treating physicians (Morris et al., 2014).
The acuity of some injuries does not always permit patients and physicians
to establish a strong patient-physician relationship prior to management. Even
in these settings, however, appropriate pre-operative discussions are necessary
to address the patient’s concerns and priorities, due to the distinct differences
that exist between patients and physicians regarding expectations and outcomes.
Ultimately, when patient’s expectations are met, patients are more satisfied and
have better outcomes (Morris et al., 2014).
Patients’ satisfaction can be an important tool to improve the quality of
services. It can play an increasingly important role in the growing push toward
accountability among health care providers over-shadowed by measures of
clinical processes and outcomes in the quality of care (Afzal et al., 2014).
Evaluation of patients’ satisfaction should form a part of continuous
improvement. Patients’ satisfaction, as a method of evaluating health services is
essential. Whilst satisfaction with delivered services is important, focusing on it
alone fails to address customer needs. Understanding the difference between
customer needs and customer satisfaction is crucial to the organisation’s success
in quality management (Hudak et al., 2003).

45
Quality of care is considered a multidimensional concept that has been
given different meanings. Researchers, health care providers, governments, and
consumers may all define health care quality differently (Willeumier, 2004).
Quality improvement program is one of the most important components to
be measured in the accreditation process. Since performance improvement is
one of the main objectives of the program, it is imperative that the accreditation
survey assesses the extent to which the facility has an organized process or a
system to improve the quality of care. This includes assessing the extent to
which systems are developed to identify problem areas, mechanisms to analyze
these problems, and systems for improving services (Rafeh, 2001).
There are a number of suggested models to assist the integration of
patient/client satisfaction. Examples include the quality improvement cycle
(figure 1); it lays out a road map for continuous improvement. The European
Foundation for Quality Management (EFQM) model (figure 2) identifies the
leadership commitment necessary to facilitate system wide quality improvement
(Hudak et al., 2003).

46
Figure (1): Patient participation is a legitimate method of evaluating
health services.
Managing patient’s expectations and psychosocial factors, such as pain and
depression, that can drive patients’ satisfaction can be difficult. Individualizing
patient pre-operative counseling and shared decision-making can help to
identify patient-specific factors, such as chronic pain and depression, that may
negatively impact patient satisfaction scores. By setting appropriate pre-
operative expectations and managing pain and depression, physicians can help
patients achieve good outcomes (Morris et al., 2014).

47
Figure (2): EFQM Model
Kroenke and Jackson (1998) supported the idea that patients who get
better are satisfied with their care, but those who were still symptomatic were
still worried, had unmet expectations and had lower satisfaction.
In a patient satisfaction survey of inpatient physician performance, Stelfox
et al. (2005) showed an inverse relationship between satisfaction and risk
management episodes.
Physicians can find practical take-away lessons, such as the following:
 Treat patients with dignity and icnlude them in decision making.

48
 Work with a team you can be proud of and invest in their ongoing
development.
 Elicit patients' concerns by asking questions such as "what do you
think is going on?" or "what are you afraid of?".
 Dress in semiformal attire; and do not forget to smile.
Lastly, while it may not be as easy as the above lessons, find pleasure in
what you do. Physicians who report high professional satisfaction have patients
who are more satisfied with their care (Haas et al., 2000).

94
Subjects and Methods
This study was carried out to assess patient satisfaction in Primary Health
Care (PHC) Facilities in Nabaroh District - Dakahallia Governorate - Egypt and
to compare between patient satisfaction in accredited and non-accredited units
and patient satisfaction in urban and rural health care units
Technical Design:
The technical design included the study design, study setting, study subjects
and data collection tools.
1. Study design:
A descriptive cross-sectional design was used in carrying out the study.
2. Study settings:
This study was conducted in 2013 on PHC facilities of Nabaroh. Nabaroh
District in Dakahallia Governorate includes 20 PHC units (17 rural and 3 urban
units), 5 units of the rural units are accredited, no urban units are accredited yet
allover Egypt.
Working hours in these facilities starts at 8 am and ends at 2 pm daily except
Friday. Number of working physicians in every unit vary from 1 to 3 according
to served population. Rate of customers usually ranges from 50 to 150 patients
per day.
3. Study subjects:
A sample of one urban PHC facility (Nabaroh Child Health Care Center) and
four rural PHC facilities, two accredited (Taneekh and Met-Abbad) and two not
accredited (Kafr Al-Dakroory and Banoub) were randomly selected.

05
Samples were selected from the attendants of PHC facilities of Nabaroh
district. The sample size was calculated using Epi-info software (version 6.04)
(Dean et al., 2001), assuming that the prevalence rate of patients’ satisfaction is
40% (Said et al., 2009) at 95% confidence interval and power of 85% and the
population size of about (232,000). The calculated sample size was 256 cases.
Allowing for a non response rate of 10%, the sample size increased to be 282
cases to be taken from rural and urban PHC units.
A sample of 57 individuals was taken from the selected urban health center
and a random sample of 57 individuals was taken from each selected rural
health unit.
Inclusion criteria:
Out-patient clinics consumers (either the patient himself or the companion of
the diseased child) who were attending these facilities during the selected days
were included in this study until the required number of consumers was
reached, whether they were regular users or not.
4. Data collection tool:
Data were collected using a questionnaire sheet which is a modification of
Patient Satisfaction Rating Scale (PSRS) developed by Adam and Elsawi
(2000), including questions about: reception, physicians, nursing, accessibility,
environment, health care services and patient’s rights. This modification was
made by the researcher to make this PSRS suitable for PHC units, tested by
pilot study and was revised by the supervisors. This modification was made so
as to make the scale suitable for the units of the primary health care as the
original scale was designed for hospitals. Questions about different hospital
departments and inpatient wards were replaced with question about different
health care services. Questions about patient follow up, post-operative care and

05
other hospital services like radiology and specialized clinics were removed.
This tool consisted of two parts:
The first part: questions to assess patient satisfaction. It included 49 items
represented as follow: reception service (2 items), physicians (19 items), nurses
(6 items), accessibility in time and place (2 items), health care environment (9
items), the available services within the PHC facility (4 items) and patients'
rights (7 items). Responses were measured on a five points rating scale ranged
from excellent, very good, good, fair and poor ( Appendix 1 )
The second part: questions to collect socio-economic data related to the
study subjects; education, occupation, income and crowding index. They were
determined by modified scoring system from El- Sherbini and Fahmy
classification (1983). As shown in table (II) ( Appendix 2 ). Questions to
determine other aspects of socio-demographic data; name, gender, age,
residence, marital status and number of unit visits ( Appendix 3 ).
Table (II): Scoring System for Socio– economic Status.
Educational Level Score Answer
 Illiterate 5
 Read & Write 2
 Moderate Education (Basic – Secondary) 3
 High Education (University and Above) 9
Occupation Score Answer
 Not Working/house wife 5
 Unskilled manual worker/farmer 2
 Skilled worker 3
 Employee e.g.: secretarial worker, teacher, nurse 9
 Professional class e.g.: physician, engineer, lawyer 0

02
Crowding Index Score Answer
 5 or more / bedroom 5
 4 / bedroom 2
 2 or 3 / bedroom 3
 1 / bedroom 9
Income Score Answer
 Insufficient 5
 Just Sufficient 2
 Sufficient and More 3
High socioeconomic standard > 12
Moderate socioeconomic standard 8 – 12
Low socioeconomic standard < 8
Scoring system:
Responses of patients to the 49 statements were put in a 5-points Likert
Scale including excellent (5 scores), very good (4 scores), good (3 scores), fair
(2 scores) and poor (1 score). Then for every dimension, the percent score was
calculated by dividing the total score of every one by the maximum score × 100.
The level of patient satisfaction was evaluated as following:
Less than 60% = unsatisfied
From 60% to 80% = partially satisfied
More than 80% = strongly satisfied
Operational design:
It included two stages, namely pilot study and field work stage.
Pilot study:
Pilot study was conducted at May 2013 to assess the feasibility and the time
needed to fill out the sheet. It was conducted on 25 patients from different PHC

03
facilities. They were excluded from the main study sample. Data obtained from
the pilot study were analyzed and accordingly necessary modifications were
done. The time needed for filling the sheet was ranged from 5 - 15 minutes.
Fieldwork stage:
The actual fieldwork started in June 2013, and was completed in December
2013. It was done one day per week from 10 a.m. to 1 p.m. and this timing was
chosen as it is the rush hours at which the peak of service utilization occure. In
each one of these days, a different facility from the selected ones was visited. So
every one of the selected facilities (4 rural, 1 urban) was visited 4 times at least
during the study period i.e. once every 5 weeks. Visits to each selected facility
were tried to be done at different days of the week in order to ensure complete
week coverage.
After securing official permissions and taking verbal consent from patients,
data were collected via personal interviews with the patients after the end of
their consultation, explaining the purpose of the study to them, then asking them
and recording their answers by the researcher himself in the sheet. Filling the
sheet took 5 - 15 minutes for each patient. This operation was done in the family
club room in each unit without attendance of any of the employee of the health
care facility to avoid their effect on the customers opinion. Customers who were
hesitating whether to participate or not were reassured again and again and were
persuaded, so finally no one refused to participate.
Administrative Design and Ethical Aspects
To carry out the study, the necessary official permissions were obtained from
the Health Directory in Nabaroh Health District, also from the Managers of the
selected PHC units. An informed verbal consent was also obtained from every
patient who accepted to participate in this study before filling the sheet. They
were reassured about the strict confidentiality of any obtained information, and
that the study results would be used only for the purpose of research. The study

09
procedures were free from any harmful effects on the participants as well as the
service provided.
Data Management:
Data entry and analysis were done using SPSS 15.0 statistical software
package. Presentation of the data was done by:
1. Calculating frequencies and percentages for each dimension i.e. for
reception service, physicians' performance, nurses' performance, health
care environment, health care services (pharmacy, laboratory, vaccination
service, ante-natal care and family planning services) and patients' rights.
Chi-square test was used for comparisons between distributions of
patients as regard general satisfaction score according to different five
targeted units. It was considered statistically significant at P-value < 0.05.
2. Calculating frequencies and percentages for general satisfaction in
accredited and non-accredited PHCU.
3. Calculating frequencies and percentages for general satisfaction in rural
and urban PHCU.
4. Calculating frequencies and percentages for satisfaction score in
accredited and non-accredited units in relation to different dimensions.
5. Calculating frequencies and percentages for satisfaction score in rural and
urban units in relation to different dimensions.
6. Calculating frequencies and percentages for general satisfaction in the
five targeted PHCU.
7. Calculating frequencies and percentages for satisfaction score according
to socio-economic standards.
to Age.
to socio-demographic characteristics of the studied subjects.

55
Results
This study was carried out to assess patients’ satisfaction in PHCU in
Nabaroh district, compare between patients’ satisfaction in accredited and non-
accredited PHCU, compare between patients’ satisfaction in rural and urban
PHCU and give recommendations for improving patients’ satisfaction in PHCU.
The study results will be described under the following parts:
Part 1 (tables 1-8): General satisfaction score in the five selected PHCU,
satisfaction score of each separate compartment of health service (reception
service, doctors' performance, nurses' performance, accessibility of time and
place, health care environment, services provided by PHC Facilities and
patients' rights) in the five selected PHCU.
Part 2 (tables 9-12): General satisfaction score in accredited and non-
accredited selected PHCU, satisfaction score of each separate compartment of
health service in accredited and non-accredited selected PHCU, general
satisfaction score in rural and urban selected PHCU and satisfaction score of
each separate compartment of health service in rural and urban selected PHCU.
Part 3 (tables 13-15): Distribution of the studied subjects according to
their satisfaction score in relation to their age and socio-demographic
characteristics.

55
Table 1: General satisfaction in different Primary Health Care Units
(PHCU) in Nabarouh District (57 Cases in each Unit).
Group Unsatisfied Partially
satisfied
Strongly
satisfied
No. % No. % No. %
Nabrouh Child Care 5 8.8 50 87.7 2 3.5
Banoub 2 3.5 55 96.5 0 0.0
Tanneekh 3 5.3 50 87.7 4 7.0
Kafr Al-Dakroory 49 86.0 8 14.0 0 0.0
Mit-Abbad 1 1.8 43 75.4 13 22.8
Total 60 21.1 206 72.3 19 6.7
2
= 209.28  < 0.05.
This table shows that 21.1% of the surveyed customers were generally
unsatisfied while only 6.7% of them were strongly satisfied. The highest
unsatisfied proportion (86%) was present in Kafr Al-Dakroory followed by
Nabarouh Child Care Center (8.8%). The highest strongly satisfied proportion
was in Mit-Abbad (22.8%) while no one (0.0%) was strongly satisfied in
Banoub and Kafr Al-Dakroory.

55
Table 2: Satisfaction score about Reception Services in different
Primary Health Care Units (PHCU) in Nabarouh District (57 Cases in
each Unit).
satisfied
Strongly
satisfied
No. % No. % No. %
Banoub 0 0.0 31 54.4 26 45.6
Tanneekh 4 7.0 32 56.1 21 36.8
Kafr Al-Dakroory 31 54.4 16 28.1 10 17.5
Mit-Abbad 3 5.3 26 45.6 28 49.1
Total 38 13.3 136 47.7 111 38.9
2
= 107.90 P < 0.05
This table shows that only 13.3% of the surveyed customers were unsatisfied
about the reception services. The highest unsatisfied proportion was in Kafr Al-
Dakroory (54.4%) while the highest proportion of strongly satisfied was in Mit-
Abbad (49.1%) followed by Nabarouh Child Care (45.6%) and Banoub
(45.6%).

55
Table 3: Satisfaction score about Physicians’ Performance in different
each Unit).
satisfied
Strongly
satisfied
No. % No. % No. %
Banoub 4 7.0 52 91.2 1 1.8
Tanneekh 1 1.8 38 66.7 18 31.6
Kafr Al-Dakroory 46 80.7 11 19.3 0 0.0
Mit-Abbad 1 1.8 31 54.4 25 43.9
Total 56 19.6 175 61.4 54 18.9
2
= 206.44 P < 0.05
This table shows that only 19.6% of the surveyed customers were unsatisfied
about physicians’ performance with the highest proportion in Kafr Al-Dakroory
(80.7%). It also shows that 18.9% of the surveyed customers were strongly
satisfied and the highest proportion (43.9%) was in Mit-Abbad while no one
(0.0%) was strongly satisfied in Kafr Al-Dakroory.

55
Table 4: Satisfaction score about Nurses’ Performance in different
each Unit).
Group
Unsatisfied Partially satisfied Strongly satisfied
No. % No. % No. %
Banoub 10 17.5 45 78.9 2 3.5
Tanneekh 13 22.8 39 68.4 5 8.8
Kafr Al-Dakroory 50 87.7 7 12.3 0 0.0
Mit-Abbad 8 14.0 36 63.2 13 22.8
Total 104 36.5 157 55.1 24 8.4
2
= 105.65 P < 0.05
This table shows that 36.5% of the surveyed customers were unsatisfied
about Nurses’ Performance with the highest proportion in Kafr Al-Dakroory
(87.7%) followed by Nabarouh Child Care (40.4%). Only 8.4% of the surveyed
customers were strongly satisfied about nurses’ performance and the highest
proportion (22.8%) was in Mit-Abbad.

56
Table 5: Satisfaction score about Accessibility of Place and Time in
different Primary Health Care Units (PHCU) in Nabarouh District.
Group
No. % No. % No. %
Banoub 2 3.5 35 61.4 20 35.1
Tanneekh 3 5.3 31 54.4 23 40.4
Kafr Al-Dakroory 11 19.3 21 36.8 25 43.9
Mit-Abbad 4 7.0 32 56.1 21 36.8
Total 21 7.4 153 53.7 111 38.9
2
= 19.71 P < 0.05
This table shows that only 7.4% of surveyed customers were
unsatisfied about accessibility of place and time in the selected PHCU
with highest proportion (19.3%) in Kafr Al-Dakroory. This table shows
that 38.9% of the surveyed customers were strongly satisfied and the
highest proportion (43.9%) was in Kafr Al-Dakroory.

56
Table 6: Satisfaction score about Unit Environment in different Primary
Health Care Units (PHCU) in Nabarouh District (57 Cases in each Unit).
Group
No. % No. % No. %
Banoub 3 5.3 54 94.7 0 0.0
Tanneekh 14 24.6 37 64.9 6 10.5
Kafr Al-Dakroory 57 100.0 0 0.0 0 0.0
Mit-Abbad 0 0 40 70.2 17 29.8
Total 83 29.1 179 62.8 23 8.1
2
= 227.35 P < 0.05
This table shows that 29.1% of the surveyed customers were
unsatisfied about unit environment and the highest proportion (100%)
was in Kafr Al-Dakroory, while 8.1% of the surveyed customers were
strongly satisfied and the highest proportion (29.8%) was in Mit-Abbad.

56
Table 7: Satisfaction score about Health Care Services (Pharmacy, Lab.,
Vaccinations, Ante-Natal and Family Planning Services) in different
each Unit).
satisfied
Strongly
satisfied
No. % No. % No. %
Banoub 10 17.5 45 78.9 2 3.5
Tanneekh 8 14.0 43 75.4 6 10.5
Kafr Al-Dakroory 33 57.9 24 42.1 0 0.0
Mit-Abbad 20 35.1 31 54.4 6 10.5
Total 89 31.2 182 63.9 14 4.9
2
= 43.65 P < 0.05
about health care services in the selected PHCU and the highest proportion
(57.9%) was in Kafr Al-Dakroory. Only 4.9% of the surveyed customers were
strongly satisfied and the highest proportion (10.5%) was in Tannekh and Mit-
Abbad.

56
Table 8: Satisfaction score about Patients’ Rights in different Primary
Health Care Units (PHCU) in Nabarouh District (57 Cases in each Unit).
satisfied
Strongly
satisfied
No. % No. % No. %
Banoub 14 24.6 43 75.4 0 0.0
Tanneekh 10 17.5 36 63.2 11 19.3
Kafr Al-Dakroory 48 84.2 9 15.8 0 0.0
Mit-Abbad 1 1.8 33 57.9 23 40.4
Total 112 39.3 136 47.7 37 13.0
2
= 154.98 P < 0.05
about patients’ rights and the highest proportion (84.2%) was in Kafr Al-
Dakroory while 13% of the surveyed customers were strongly satisfied and the
highest proportion (40.4%) was in Mit-Abbad.

56
Table 9: General satisfaction in Accredited and Non-Accredited
Primary Health Care Units (PHCU) in Nabarouh District.
satisfied
Strongly
satisfied
Total
No. % No. % No. %
Accredited Units 4 3.5 93 81.6 17 14.9 114
Non-Accredited Units 56 32.7 113 66.1 2 1.2 171
Total 60 21.1 206 72.3 19 6.7 285
2
= 49.43  < 0.05.
This table shows that un-satisfaction was significantly higher (32.7%) in
non-accredited PHCU than in accredited units (3.5%). Partial satisfaction and
strong satisfaction were higher (81.6% and 14.9%, respectively) in accredited
than in non-accredited units (66.1% and 1.2%, respectively).

55
Table 10: Satisfaction score in Accredited and Non-Accredited units
No of
Cases
Unsatisfied Partially
satisfied
Strongly
satisfied
2 P
Value
No. % No. % No. %
Reception services
Accredited Units 114 7 6.1 58 50.9 49 43.0 8.56 < 0.05
Non-Accredited Units 171 31 18.1 78 45.6 62 36.3
Total 285 38 13.3 136 47.7 111 38.9
Physicians’
performance
Total 285 56 19.6 175 61.4 54 18.9
Nurses’ performance
Total 285 104 36.5 157 55.1 24 8.4
Acc. Of place & time
Accredited Units 114 7 6.1 63 55.3 44 38.6 0.48 > 0.05
Total 285 21 7.4 153 53.7 111 38.9
Unit environment
Total 285 83 29.1 179 62.8 23 8.1
Health Care Services
Total 285 89 31.2 182 63.9 14 4.9
Patients’ Rights
Total 285 112 39.3 136 47.7 37 13.0
This table shows that the highest unsatisfied proportion (39.3%) was as
regard patients’ rights followed by nurses’ performance (36.5%) and health care
services (31.2%). Un-satisfaction was significantly lower in accredited units
than non-accredited units in all items except accessibility of place and time. It
also shows that the highest strongly satisfied proportion was as regard reception
services (38.9%) and accessibility of place and time (38.9%) with significantly
higher satisfaction in accredited units than non-accredited units in all aspects
except accessibility of place and time.

55
Table 11: General satisfaction in Rural and Urban Primary Health Care
Units (PHCU) in Nabarouh District.
Group Unsatisfied Partially satisfied Strongly satisfied Total
No. % No. % No. %
Rural Units 55 24.1 156 68.4 17 7.5 228
Urban Units 5 8.8 50 87.7 2 3.5 57
Total 60 21.1 206 72.3 19 6.7 285
2
= 8.52  < 0.05.
This table shows that 24.1% of the surveyed customers were generally
unsatisfied in the selected rural PHCU meanwhile only 8.8% of the surveyed
customers were generally unsatisfied in the selected urban PHC unit and this
difference was statistically significant.

55
Table 12: Satisfaction score in rural and urban units
No of
Cases
Unsatisfied Partially
satisfied
Strongly
satisfied
2 P
Value
No. % No. % No. %
Reception service
Rural Units 228 38 16.7 105 46.1 85 37.3
10.98 <0.05Urban Units 57 0.0 0.0 31 54.4 26 45.6
Total 285 38 13.3 136 47.7 111 38.9
Physicians
performance
Rural Units 228 52 22.8 132 57.9 44 19.3
8.14 <0.05Urban Units 57 4 7.0 43 75.4 10 17.5
Total 285 56 19.6 175 61.4 54 18.9
Nurses
performance
Rural Units 228 81 35.5 127 55.7 20 8.8
0.54 >0.05Urban Units 57 23 40.4 30 52.6 4 7.0
Total 285 104 36.5 157 55.1 24 8.4
Acc. Of place &
time
Rural Units 228 20 8.8 119 52.2 89 39.0
3.52 >0.05Urban Units 57 1 1.8 34 59.6 22 38.6
Total 285 21 7.4 153 53.7 111 38.9
Unit environment
Rural Units 228 74 31.1 131 57.5 23 10.1
15.29 <0.05Urban Units 57 9 31.6 48 84.2 0 0.0
Total 285 83 31.2 179 62.8 23 8.1
Health care
services
Rural Units 228 71 31.1 143 62.7 14 6.1
3.74 >0.05Urban Units 57 18 31.6 39 68.4 0 0.0
Total 285 89 31.2 182 63.9 14 4.9
Patients’ rights
Rural Units 228 73 32.0 121 53.1 34 14.9
25.48 <0.05Urban Units 57 39 68.4 15 26.3 3 5.3
Total 285 112 39.3 136 47.7 37 13.0
This table shows that un-satisfaction proportion was significantly higher in
rural units in relation with reception services and physicians’ performance while
it was significantly higher in urban units in relation with unit environment and
patients’ rights. The highest un-satisfaction proportion was about patients’
rights in urban units (68.4%) and the highest strong satisfaction proportion was
about reception service in the urban units (45.6%). No one showed un-
satisfaction about reception services in the selected urban PHCU. No one
showed strong satisfaction about the unit environment or health care services in
the selected urban PHC unit.

Assessment of Patients Satisfaction in Accredited and Non–Accredited Primary Health Care Facilities in Nabaroh Health District

Assessment of Patients Satisfaction in Accredited and Non–Accredited Primary Health Care Facilities in Nabaroh Health District

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