International Journal for Quality in Health Care 2003; Volume 15, Number 3: pp. 241–249
10.1093/intqhc/mzg036
Patient satisfaction with primary health care services in the United Arab Emirates STEPHEN A. MARGOLIS1, SUMAYYA AL-MARZOUQI2, TONY REVEL2 AND RICHARD L. REED1 1
Department of Family Medicine, Faculty of Medicine, United Arab Emirates University, Al Ain, 2Ministry of Health, United Arab Emirates
Abstract Objective. This study evaluated the suitability of a patient satisfaction questionnaire to survey health care consumers of traditional Arabic background. Design. A cross-sectional survey using an Arabic language questionnaire that drew upon concepts of patient satisfaction measurement in Western research literature. All participants were interviewed once by experienced interviewers to ascertain their levels of satisfaction with their health care service. Setting. Patient satisfaction was compared between the only resource-intensive clinic (RIC) in the United Arab Emirates and one resource-thrifty clinic (RTC) located in an adjacent suburb and serving essentially the same population. Study participants. A random sample of patients attending the RIC and RTC over a 5-day period. Main outcome measures. Six domains of patient satisfaction were measured. Results. Compared with the RTC (n = 125), the RIC (n = 156) scored significantly higher in continuity (P = 0.001), comprehensiveness (P < 0.001), health education (P = 0.05), effectiveness (P = 0.001), and overall satisfaction (P < 0.001), while accessibility (P = 0.130) and humaneness (P = 0.102) were not significantly different. Humaneness scored the highest and continuity the lowest at both clinics. Older people’s satisfaction was higher for comprehensiveness but otherwise the same as those who were younger. More highly educated people’s satisfaction was lower for effectiveness, but otherwise the same as those who were less educated. Men and women had equal levels of satisfaction. Conclusions. The significantly higher patient satisfaction in the RIC compared with the RTC was a strong a priori expectation, suggesting that this satisfaction questionnaire is a useful quality assurance tool in this setting. Keywords: developing country, models of care, patient satisfaction, primary care
Patient satisfaction has long been considered an important component when measuring health outcomes and quality of care [1,2]. The rising strength of consumerism in society highlights the central role patients’ attitudes play in health planning and delivery [3,4]. Furthermore, a satisfied patient is more likely to develop a deeper and longer lasting relationship with their medical provider, leading to improved compliance, continuity of care, and ultimately better health outcomes [5,6]. Health care recipients in developing and newly developed nations are particularly sensitive to perceptions of the quality of their health care delivery systems when compared with those in advanced economies [7]. This is a particularly important issue for countries on the Arabian Gulf who may have sufficient resources to provide a clinical care model similar in resource intensiveness to those present in Western countries. However, these additional costs need to be justified
and determined to be the best use of limited resources. Little evidence exists on whether these more resource-intensive models provide extra value in this environment. The United Arab Emirates (UAE), a union of seven sovereign sheikhdoms in the Arabian Gulf, was formed in 1971. It has been noted that, as recently as 1950, ‘their traditional way of life had scarcely been disturbed. There were no boundaries, and no roads, no newspapers and no telephones, indeed no electricity supply. Almost every drop of water had to be hauled from man made wells.’ [8]. Education and health development were negligible until the late 1950s. However, a relentless pace of development in the last 20 years, fuelled by petrodollars, has resulted in one of the highest per capita incomes in the world [9]. Education and health infrastructure are extensive, with each sector undergoing continuous development and expansion.
Address reprint requests to Dr S. A. Margolis, Department of Family Medicine, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates. E-mail:
[email protected] International Journal for Quality in Health Care 15(3) International Society for Quality in Health Care and Oxford University Press 2003; all rights reserved
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The largest tribal grouping in the UAE was the Bani Yas tribe, which until the 1960s lived a semi-nomadic life roaming the vast sandy deserts, which constitute most of the land area of the UAE [10]. The citizens of the UAE (known as Emirati) now comprise approximately 36% of the total UAE population, the remainder being mostly expatriate guest workers, predominantly from South Asia [11]. Despite rising wealth, Emirati people retain their strong cultural traditions and connection with the land and the desert. The UAE constitution states that health care is the right of every individual and that the state is responsible for providing health care facilities for prevention and treatment, promotion, and rehabilitation [12]. In 1986, the federal government of the UAE adopted the WHO ‘Health for All’ concept and declared that primary health care (PHC) was central to achieving this goal [12]. Consequently, by 2001, an extensive network of 105 government-funded PHC clinics had been established across the country [13], with few people living more than a short distance from their nearest clinic [14]. These PHC centres, which are funded by the Federal Ministry of Health, and in Dubai Emirate by the state Dubai Ministry of Health, show limited variation across the country. There is a relatively uniform low level of infrastructure and service provision at each of these PHC clinics [in this study termed resource thrifty clinics (RTCs)], although only smaller centres utilize offsite pathology and X-ray services. However, one PHC clinic in the inland oasis city of Al Ain, which is financed and managed by the state-based Abu Dhabi Health Authority, has a high level of human, physical, and economic resources, at a similar level to that seen in Western countries; we have termed this a ‘resource intensive clinic’ (RIC). This RIC has been designated by the health authorities as an integral component of the PHC service, with the same status and function as other less well resourced clinics. People are allocated to attend this highly resourced clinic or a clinic with fewer resources, entirely based on the geographical location of their principal place of residence. Consumer expectations have grown proportionately with the rising wealth of the population, resulting in strong societal pressure to adopt policies that satisfy heightened consumer expectations. Unfortunately, the development of structured quality assurance programmes and ongoing evaluation of health outcomes has lagged behind, leaving limited information on clinical outcomes available for decision making by policy makers. This study evaluated the suitability of a patient satisfaction questionnaire, developed for use in Western countries, to survey health care consumers of traditional Arabic background.
Methods
clinics were involved in this study: the sole RIC, and one of the 14 RTCs, which had the greatest number of shared features with the RIC. These included a similar patient population (Emirati patients comprised 100% of the patient load at the RIC and >90% at the RTC), geographic location (the clinics served adjacent and similar suburbs in Al Ain), patient numbers (the RIC had the highest number of consultations, while the RTC had the second highest in the Al Ain health district), and physical structure (both centres were housed in identical buildings, and had on-site pathology and X-ray services) [15]. The distinguishing characteristics of the two study clinics are described in Table 1, while service provision data are presented in Table 2. Of particular note is the far higher rate of consultations per doctor per clinic session in the RTC. The Emirati populations attending the two clinics were similar. As one of the two clinics did not provide services for expatriates, only Emirati citizens were included in the study. Design An Arabic language questionnaire was used in this crosssectional survey, in which all participants were interviewed once (see Appendix). The survey was administered by two Arabic-speaking people, a trained interviewer, and the second author. Makhdoom and coworkers developed the questionnaire used in this study, for an ethnically similar environment in Saudi Arabia [16]. The questionnaire covers the standard domains used in North American and European surveys by other authors, including Donabedian [1] and Ware et al. [2]: accessibility to services (seven items), continuity of care (six items), humaneness of staff (eight items), comprehensiveness of care (five items), provision of health education (five items), and effectiveness of services (eight items). Although commonly questioned in other studies, cost was specifically excluded from this one, as the health care services included in this investigation were free to the consumer. For each of these domains, Makhdoom et al. [16] developed new questions based on the published literature concerning patient satisfaction, in particular the paper by Carr-Hill [17]. These questions were then translated into Arabic, which was verified by back-translation performed by a different bilingual person who had not seen the original English language version. Any areas of disagreement in the translation were resolved by discussion between both translators and the research team. Makhdoom et al. reported that face validity was obtained from discussions with five family and community medicine consultants, while reliability was 83% for split-half testing [16]. Each item was scored using a five-point Likert scale: ‘strongly agree’, ‘agree’, ‘don’t know’, ‘disagree’, and ‘strongly disagree’. Overall satisfaction was defined as the average score for the six measured domains of satisfaction. Demographic questions concerning age, sex, marital status, level of education, and mode of transport to the clinic were also included.
Participants and setting The study was conducted in 2001 in Al Ain, an inland oasis city with a population of 250 000, located approximately 130 km from the main cities of Abu Dhabi and Dubai. Two PHC
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Study sample The study was conducted in the waiting room of the two clinics. Only Emirati citizens aged 18 years and above, who
Clinic A (resource intensive) Clinic B (resource thrifty) ............................................................................................................................................................................................................................................................................................................. Administration Tertiary care hospital Department of Primary Health Care, Ministry of Health Location Defined community Defined community Population Emirati Emirati and expatriate Building Purpose-built clinic Purpose-built clinic Medical staff Undergraduate training Primarily medical schools in Western countries Non-Western medical schools Vocational training Family physicians General Duty Medical Officers (no family medicine training) Primary language English Arabic, Urdu, Hindi Able to speak Arabic
