Received: 2014-11-22
Revised: 2015-01-29
Accepted: 2015-02-21
Satisfaction of Family Physician Plan: Viewpoint of Physicians and Health Service Consumers in Kerman, Southeast of Iran
Batoul Ahmadi1, Mohammad Hossein Pourebrahimi2, Malihe Ram Bejandi3, Ahmad Sadeghi4, Mohammad Khammarnia5, Elham Siavashi1
1 Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
2 Health Center, Kerman, Iran
3 Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
4 School of Health, North Khorasan University of Medical Sciences, Bojnurd, Iran
5 Health Promotion Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
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Abstract
Background: Family Physician plan is known as one of the most appropriate strategies to implement rural health insurance program in the form of referral system in Iran. This study aims to determine the satisfaction of family physicians and service consumers and its causes of dissatisfaction in the South of Iran. Materials and Methods: This cross-sectional study was performed in Kerman Health Network. Nineteen family physicians and 370 service consumers were selected using stratified random sampling. Data was gathered using two standardized questionnaires. Frequency tables, frequency percentage, mean graphs, Z and Freedman statistical tests were used to analyze the data. Results: Mean scores of physicians’ satisfaction were 9.10 and 4.12 in staff performance and payment system, respectively. Service consumers were satisfaction of physician delivery care (7.25), and para-medical (3.61). Moreover, most physicians were interested in per capita (31/6%).Conclusion: Family physician and health service consumers are highly satisfied. Satisfaction is an important factor for ensuring service quality and any ignorance in this regard can reduce the quantity and quality of delivered care. Physicians are recommended to respect their consumers and consider their waiting time. Meanwhile, health system managers should promote physicians’ payment. [GMJ.2015;4(2):96-102]
Keywords: Family Practice; Physician; Satisfaction; Health Care System
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Introduction
Family Physician Plan (FPP) is known as the most appropriate strategy for implementing rural health insurance program in a referral system, so this plan provides a good opportunity for urban and rural areas to gain access to health services. Similar to referral system, general physicians and their teams have full responsibility for the health of individuals and households under their coverage and are in charge of following up the individuals’ conditions after referring them to professional levels [1]. History and experience of implementing various health plans in Iran date back to 1940 [2]. However, practical experience in FPP started in 2005, although maneuvering on its implementation was the main concern for health authorities for years. FPP seeks equity in health, team-based health service provision, encouraging other development sectors to participate in health plans, public participation in health promotion, providing health services in a referral system and modification of communities’ lifestyles [3].
In this plan, family physician (FP) has the main responsibility of health team. Physicians’ satisfaction of their job is comprised of many complex factors [4]. A study in Iran concluded that 56.4% of participants were satisfied with FPP [5]. Another study pointed out that 34.52% of clients had ‘high or very high’ satisfaction regarding FPP [6]. Determining factors of job satisfaction have been mentioned as demographic characteristics (age, sex, education, race, marital status, etc.), job characteristics (fixed or extra salaries and work hours), job attitudes, employer’s characteristics, number of employees and their profession, environment, performance control and staff support [7, 8]. Furthermore, the satisfaction of health care team members can be effective in the productivity of resources, quality and quantity of services [9]. FP satisfaction is an important success factor of FPP. Some studies showed that FP satisfaction was estimated at 59.2% [3] and 95% [10] with FPP. This study aims to determine FP satisfaction and service consumers among FPPs in Kerman as the largest province in Iran.
Materials and Methods
This cross-sectional study was performed in Kerman Health Network in the South of Iran in 2012. In this study, all FP who worked in Kerman health system entered present study (13 persons in rural regions, 2 persons in urban regions upper 20000 people and 4 persons in urban region under 20000 people. Besides, for study population of service consumers used stratified random sampling. So, Kerman was divided into 19 regions according to characteristic of each region. Then 370 service consumers were selected.
Finally, questionnaires were completed by households. Family physicians also completed their questionnaires.
Two standardized questionnaires were used (reliability and validity of which were tested by Kalhor et al. in a study titled: “Satisfaction with family Physicians in 2009”) [11]. These questionnaires were designed to cover the following sections:
1. General information
2. Questions to measure satisfaction and related factors.
FP Questionnaire: Physician questionnaires had two sections: first, demographical items and second: 39 main body questions; questions 1-28 for physician satisfaction, questions 29-32 for clarity of rules and guidelines, questions 33-35 for the assessment of managers responsibility and questions 36-39 for the assessment of internal coordination.
Service consumers’ questionnaire: this questionnaire has two sections; demographic questions and 31 main body questions (questions 1-27 for the satisfaction of service consumers and questions 28-31 for the assessment of consumer identification of the service. At the beginning, necessary explanations were given to participants about satisfaction. Consent form was taken in advance. This study was approved by Ethical Committee of Tehran University of Medical Sciences.
Data were fed into SPSS software (V18). Descriptive statistics such as mean, standard deviation, frequency and percent frequency were used. One sample T-test was used for comparison of participants’ satisfaction difference with normal mean (Number 3). Since Kolmogorov–Smirnov test showed that variables had not normal distribution (P=0.71), we used nonparametric tests. Friedman test was used for assessment of the difference between satisfaction components of family physician and program.
Results
In this study, 380 questionnaires were completed by service consumers and 19 questionnaires by family physicians. Study results for health service consumers and their demographical variables are shown in Tables 1 and 2. Most service consumers were housewives with elementary education who tend to visit a same-sex physician.
According to results, health service insurance was more common (48.6%) compared to social security (21.0%) or other insurances.
The majority of service consumers were rural residents (81.0%). For the case of using pharmacy, radiology and laboratory services, 82.4%, 86.2% and 87.0% of participants were willing to use public services, respectively.
According to one sample T-test, service consumers’ satisfaction with FPP and referral system was at an optimal level (P> 0.000). In addition, Friedman test showed that the maximum and the minimum service consumers’ satisfaction were pertained to physician care and paramedical services, respectively.
A high percentage of FPs was married women aged 31-40 years old working in rural regions. In addition, most of them were contracted and had 1-5 years of work experience. Besides, they mostly had collaboration with governmental specialists in order to refer patients to them. (Table 3)
Based on one sample T-test, FPs’ satisfaction with FPP and referral system was also at an optimal level (P> 0.001). Moreover, according to Friedman test, maximum and minimum service providers’ satisfaction was related to staff performance and payment system, respectively.(Table 4)
Considering appropriate payment system, most of the physicians were interested in per capita (31.6%), salary (26.3%), fee for service (FFS) (10.5%) and fixed payment system (5.3%), respectively. Furthermore, physicians’ views on minimum population to be covered by a physician showed the following results; 2,000 (31.6%), 3,000 (26.3%), 1,000 (21.1%), 600 (10.2%), 2500 (5.3%) and 3,500 (5.3%).
Discussion
This study was aimed at assessing satisfaction levels of FP and service consumers with FPP.
Service consumers were satisfied with FPP and referral system at an optimal level. A study conducted by Alidosti et al. concluded that 56.4% of participants were satisfied with FPP [5].
Another study pointed out that 34.52% of clients had ‘high or very high’ satisfaction with FPP [6]. Other studies reached the conclusion that satisfaction with family FP on many variables, such as welfare, service provision and paramedical services [8, 10 and 12]. Regarding our study results, consumers were mostly satisfied with physician given care and patient reverence by physician. Moreover, Kersink pointed out that 58% of service recipients were satisfied with their given services [12]. Results have shown those physicians who have longer consultations and continuing care, please their patients more [12-14]. Furthermore, in another study, 77.6% of service consumers were content with trainings given by doctors to solve their health problems [8].
In this case, in order to satisfy patients, physicians have to advise them, diagnose their health problems in time and provide them with appropriate trainings, recommendations and continuing care.
In this study, consumers’ respect was identified as another important factor affecting consumers’ satisfaction. Pourshirvani found that 84.5% of subjects were satisfied with the behavior of family physicians towards their patients and other people. Interpersonal aspects of care can be affected by many variables related to physicians and patients [8,15]. These variables may include behaving courteously towards consumer, paying attention to their expectations and also considering their interests and beliefs. These factors not only make patients satisfied with their physician, but also encourage them to visit the physician and recommend it to other people such as relatives and friends, ultimately leading to increased access to doctors and positive effects on health. These findings have been proven also in other studies as well [8,13,14].
In this study, consumers were satisfied with interpersonal aspects of care more than access to care, which were also shown in a study carried out by Howard et al; however, Consumers’ satisfaction is also influenced by service accessibility. In another study most participants (54.7%) were dissatisfied with “constant and not-waiting access to physician [5]. Consumers’ satisfaction changes over time and is affected by different factors. Reasons for consumer dissatisfaction can be; lack of permanent presence of a physician at health center, insufficient number of physicians compared to patients and consequently, long waiting lines.
Trust in physicians was in the next rank. This finding was also mentioned by other studies [5, 15].
Health practices and outcomes as well as costs paid for receiving care were in the next satisfaction rank. Results of a study done by Sans-Corrales indicated an association between FP and service evaluation indicators such as satisfaction, health and cost [13]. Additionally, it has been shown that service recipients were generally satisfied with services given by health centers except for service costs [8].
Furthermore, service consumers were mostly dissatisfied with waiting time in health centers. Long waiting time for consultation in physician’s office has impacts on provider-patient interaction and on the overall satisfaction. Howard found that the majority of respondents reported less than 20 minutes for the first appointment. Also, the average number of days for an appointment was mentioned 4.7 by those patients and 70% of them agreed on having 1 to 2 days appointment waiting time in clinics [16]. Waiting time has effects not only on consumers’ satisfaction but also on their health, the latter effect being direct and crucial.
The least level of satisfaction lies at availability of paramedical services. Satisfaction with physical environment is one of the variables affecting overall satisfaction. Pourshirvani stated that 88.5% of service recipients were satisfied with the cleanliness of health centers [8]. In another study, satisfaction with performance of midwife, laboratory and pharmacy staff was 37/1%, 36/8%, and 38/3%, respectively [6]. In present study, low-satisfaction with paramedical services is related to imperfect provision of these services at health centers in Kerman and neighboring areas.
Referral process is another factor which is effective in satisfaction with family physician [17], while in 57.3% of people were dissatisfied with early referral to higher levels [5]. This is probably due to low knowledge of subjects about the program and its goals.
In general, health service consumers’ satisfaction with treatment process and service delivery varies from 47.7% to 96.7% in Iranian health centers [5]. It can be due to the unfamiliarity of people with their rights and thus, lower expectations from physicians. Of course, respecting physician has always been common in Iran and it prevents criticizing physicians and causes less expectation from them. In addition, younger people criticize physicians more than older people do. Younger people are more knowledgeable and familiar with their expectations and the rights they should ask for. Another reason can be related to curiosity and the critical spirit among the youth. Other studies have also indicated these points [5, 6, 8].
In this study, family physicians were mostly satisfied with staff performance, medication provision and clients. On the contrary, they weren’t satisfied with their job, familiarity with political and administrative authorities and payment system. In other studies, family physicians’ satisfaction was estimated at 59.2% [3] and 95% [10] with the plan.
Staff performance was the most satisfying item for FP. Another study pointed out that 95% of personnel were satisfied with family physician plan [10]. Rowan showed that their consumers have positive feelings about these assessments and stated that the private feedback about their performance is a necessary and valuable part of medical profession responsibility [18]. This was not consistent with the study carried out by Pourshirvani. Moreover, in this study, family physicians weren’t totally satisfied with urban health center staff performance [19]. Overall, satisfaction or dissatisfaction with staff performance can emerge because of several reasons such as involving employees in planning, performance feedback, speed of transferring and answering to their requests, rapid transfer of guidelines and circulars, and fair division of work.
In the study FP were highly satisfied with client as proven in Nikjou’s study in which 60/8% of physicians were satisfied with their clients [7].
Moreover, findings indicated that physicians were highly satisfied with their colleagues as it was shown in Nikjou’s study [7, 19].
Based on such results, FPs satisfaction with specialists was at an intermediate level. This is in contrast to Pourshirvani’s study in which the majority of FPs were dissatisfied with the quantity and quality of feedback by specialists [19]. In this regard, understanding the importance of referral process done by first and second health level physicians can have a significant effect on the success of this plan.
Furthermore, FPs were mostly dissatisfied with the payment system. This finding has been proved by other studies [10,19]. Physicians’ dissatisfaction with the payment system may relate to their high workload as well as the delay in payment compared to other physicians in private sectors who have higher incomes with fewer responsibilities.
Other factors apart from aforementioned factors which also affect physicians’ satisfaction include; the quantity and quality of support provided by higher levels, job security and stability, sufficient number of auxiliary staff and satisfaction with work place. Taking these factors into consideration can be largely effective in physicians’ satisfaction as an important factor and can guarantee the society’s health.
Generally, the first executive strategy to improve FPP is:
1. Creating a holistic view towards health
2. Practicing incentive mechanisms
3. Reducing patient waiting time through proper management
4. Planning to provide timely and accurate paramedical services
Conclusion
FP satisfaction is one of the most important factors in FPP success. It is bound to several variables to which health policy makers should attend. Of course, satisfaction is a general concept that changes over time and is affected by various factors. So, health authorities are expected to scrutinize items involved in satisfaction, minimize cases of dissatisfaction and provide facilities to increase satisfaction of service providers and recipients which will ultimately lead to improvement in public health.
Acknowledgement
We would like to thank Dr. Feizollh Akbari and Mr. Nozar Nakhaei as well as FP, health personnel in Kerman and participants to this study.
Conflicts of Interest
There is no conflict of interests.
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GMJ ©2013 Galen Medical Journal Fax: +98 731 2227091 PO Box 7461686688 Email:info@gmj.ir |
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Correspondence to: Department of Health Economics and Management, 4th Floor, New Building, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran Tel (Fax): (+98) 2142933055 Email Address: siavashiel@gmail.com
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GMJ.2015;4(2):96-102 |
www.gmj.ir
Table 1. Personal Characteristics of Service Recipients
|
Variable |
Number (%) |
|
Sex |
|
|
Female |
263(71.1) |
|
Male |
107(18.9) |
|
Education |
|
|
Illiterate |
73(19.7) |
|
Elementary school |
101(27.3) |
|
High school |
97(26.2) |
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Diploma and under diploma |
81(21.9) |
|
Upper diploma and above |
17(4.6) |
|
Unspecified |
1(0.3) |
|
Job |
|
|
Employee |
13(3.3) |
|
Worker |
16(4.3) |
|
Student |
3(0.8) |
|
Self-employed |
63(17.0) |
|
Housewife |
236(63.8) |
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Farmer |
28(7.6) |
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Other |
12(3.2) |
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Does it matter to visit a same sex doctor? |
|
|
Yes, it matters. |
202(54.6) |
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No, it does not matter. |
159(43.0) |
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Unspecified |
9(2.4) |
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How to get the service out of office hours? |
|
|
Wait till doctors begin working hours |
107(28.9) |
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Use “on call” physician ser- vices in urgent cases |
84(22.7) |
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Refer to a traditional clinic |
17(4.6) |
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Go to city |
154(41.6) |
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Other |
2(0.5) |
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Unspecified |
6(1.6) |
Table 2. Results of Friedman test for service recipient’s satisfaction.
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Component |
Mean ± SD |
Friedman rank |
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Patient satisfaction with physician care |
7.25 ± 0.947 |
3.98 |
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Patient reverence by physician |
6.68 ± 0.945 |
3.84 |
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Access to services |
6.03 ± 1.078 |
3.63 |
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Trust |
5.95 ± 0.924 |
3.62 |
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Health practices and outcomes |
5.49 ± 0.905 |
3.50 |
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Cost of services |
5.46 ± 1.247 |
3.42 |
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Waiting time |
5.12 ± 0.90 |
3.39 |
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Safety and well-being |
5.20 ± 1.01 |
3.37 |
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Availability of services |
4.20 ± 1.156 |
2.99 |
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Paramedical services |
3.61 ± 1.048 |
2.83 |
Table 3. Personal Characteristics of Family Physicians
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Variable |
Number (%) |
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Sex |
|
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Female |
11(57.9) |
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Male |
8(42.1) |
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Age |
|
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< 30 |
4(21.2) |
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31 - 40 |
12(63.2) |
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> 40 |
3(15.8) |
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Marital Status |
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Single |
3(15.8) |
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Married |
16(84.25) |
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work place |
|
|
Village |
13(68.4) |
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City |
2(10.5) |
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Cities with fewer than 20 thousands |
4(21.1) |
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Type of employment contracts |
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Contracted |
16(84.2) |
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Service commitment |
1(5.3) |
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Unspecified |
2(10.5) |
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Work experience as a physician (in year) |
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1-5 |
7(36.8) |
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5-10 |
8(1.42) |
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Above 10 |
3(21.1) |
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Referring to a specialist |
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Governmental |
17(89.5) |
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Private |
8(1.42) |
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Unspecified |
18(94.7) |
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Collaboration with specialists |
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|
Governmental |
11(57.9) |
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Private |
5(26.3) |
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Unspecified |
3(15.8) |
Table 4. Results of Friedman test on family physician’s satisfaction
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Component |
Mean ± SD |
Friedman Rank |
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Satisfaction with staff performance |
9.10 ± 0.696 |
3.80 |
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Satisfaction with medication provision |
8.30 ± 0.688 |
3.50 |
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Satisfaction with clients |
7.32 ± 0.834 |
3.20 |
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Satisfaction with colleagues performance |
7.05 ± 0.745 |
3.15 |
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Inter-sectoral collaboration (harmony) |
6.10 ± 0.745 |
2.85 |
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Satisfaction with facilities |
5.85 ± 0.834 |
2.80 |
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Transparency of rules and guidelines |
4.55 ± 0.761 |
2.50 |
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Satisfaction with specialists after referral |
5.12 ± 1.10 |
2.50 |
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Job satisfaction |
4.32 ± 0.681 |
2.40 |
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Familiarity with political and administrative authorities |
4.15 ± 0.910 |
2.25 |
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Satisfaction with payment system |
4.12 ± 1.04 |
2.15 |
References