PATIENT’S SATISFACTION WITH HEALTH …mulinet11.li.mahidol.ac.th/e-thesis/5037994.pdfFac. of Grad....

PATIENT’S SATISFACTION WITH HEALTH SERVICES

AT KUTA BLANG HEALTH CENTER IN BIREUEN

DISTRICT, NANGGROE ACEH DARUSSALAM

PROVINCE, INDONESIA

NAZIRAH

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF PRIMARY HEALTH CARE MANAGEMENT

FACULTY OF GRADUATE STUDIES

MAHIDOL UNIVERSITY

2008

COPYRIGHT OF MAHIDOL UNIVERSITY

ACKNOWLEDGEMENTS

This thesis would not have been possible without the help and support of many

people. First of all, I would like to thank the Provincial Health office, of Nanggroe Aceh

Darussalam, for giving me this opportunity to study in the Faculty of Primary Health Care,

Mahidol University, and AIHD. Without their faith in my capacity, I would not have been

able to partake in this course and gain knowledge in Primary Health Care Management.

My heart felt gratitude goes to Assoc. Prof. Jirapon Chumpikul Ph.D., my major

advisor, who through out entire project period was tireless to impart her knowledge of

research to me and made a success.

Prof. Santhat Sermsri, Ph.D., was my co-advisors and they contributed many useful

points during the research project relating to methodology and statistical analysis, and made

the study easy and enjoyable. My heartfelt thankfulness is also extended to my external

advisor, Dr. Ratanotai Pluburukarn, Dip. Thai Board of Pediatrics, for her beneficial as well

as practical suggestions and coments offered during the thesis defend. I express my thanks

to DHS1- ADB Loan INO Dinkes Prov. NAD.

My special thanks to all the Faculty of Primary Health Care Management, Mahidol

University, AIHD, for arranging all the necessary formalities and clearances required to

complete the research thesis. Unless I had chance to be here, I would never have met the

pleasantly energetic staffs working in this institute, especially Ms. Sirilac Lyeskul, a tiny

lady whose heart full given to M.P.H.M. course. I would like also thanks to head of Kuta

Blang health center and all staffs for their encouragement and support to make this piece of

work successful. Last but not least, I would like to thank my beloved husband Mr. Faisal

and my lovely children M. Khalil Al Wafi and Wifa Ufairah Hj for their kind patience and

support during the study period, and also to my loving mother, sisters and brothers for their

endless love and caring that helped me flourish during my study in Thailand. My concern

and memories to all collogues for their guidance and support. Thank you very much for

making me always says, “How fortunate I am!”

Nazirah

Fac. of Grad. Studies, Mahidol Univ. Thesis/iv

PATIENT’S SATISFACTION WITH HEALTH SERVICES AT KUTA BLANG HEALTH CENTER IN BIREUEN DISTRICT, NANGGROE

ACEH DARUSSALAM PROVINCE, INDONESIA

NAZIRAH 5037994 ADPM/M

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

THESIS ADVISORS: JIRAPORN CHOMPIKUL, Ph.D., SANTHAT SRERMSRI, Ph.D.

ABSTRACT

This cross sectional study was conducted to assess the levels of patient satisfaction

with services and to identify factors relating to patient satisfaction at Kuta Blang health

center in Bireuen District, Aceh Province, Indonesia. The dependent variables of patient

satisfaction toward services were measured in terms of convenience, courtesy, quality of

care and physical environment. Using a self-administered questionnaire, data were derived

from 200 patients who came to OPD services, aged 15 to 60 years old, from 6th January to

28th February 2008. Data were collected regarding socio-demographic factors, accessibility,

distance, waiting time for services, information received, expectation regarding OPD

services and patient satisfaction. Chi-square test was performed to analyze the association

between dependent and independent variables.

The results concluded that the overall satisfaction was 23%. The patients were most

satisfied with courtesy (38%) while least satisfied with convenience (18%). There were

statistically significant associations between occupation, waiting time for physician,

expectation level and visiting the health center service again (p<.005).

The findings of this study are important for understanding levels of satisfaction and

milestones in improving the quality of OPD services at health centers. Most patients, in

their comments and suggestions, highlighted the needs to improve the discipline of health

care workers encourage training programs for health providers, and provide the continuing

education for the experienced health providers to keep up with updated knowledge,

technology and work practices.

KEY WORDS: PATIENTS SATISFACTION/ HEALTH CENTER 74 pp.

CONTENTS

Page

ACKNOWLEDMENTS............................................................................................ iii

ABSTRACT............................................................................................................... iv

LIST OF TABLES..................................................................................................... vii

LIST OF FIGURES....................................................................................................viii

LIST OF ABBREVIATIONS.................................................................................... ix

CHAPTER

1 INTRODUTION

1.1 Rational and Justification.........................................................................1

1.2 Research question.................................................................................... 5

1.3 Research objective....................................................................................5

1.4 Conceptual framework............................................................................. 6

1.5 Variables and operational definition.........................................................7

1.6 Limitation of the study............................................................................. 9

2 LITERATURE REVIEW

2.1 Background information about health center.......................................... 10

2.2 The definition of satisfaction................................................................... 11

2.3 Literature regarding independent variable............................................... 13

2.4 Theoretical conceptual framework.......................................................... 19

2.5 Components of satisfaction..................................................................... 21

3 RESEARCH METHODOLOGY

3.1 Research design........................................................................................24

3.2 Population and study site......................................................................... 24

3.3 Sample size and sampling technique....................................................... 25

3.4 Data collection tools and .methods......................................................... 26

3.5 Content validity and reliability................................................................ 27

vi

CONTENTS (Cont.)

Page

3.6 Research instrument for data collection................................................. 27

3.8 Data analysis.......................................................................................... 28

4 RESULTS

4.1 Socio-demographic characteristics of the patients

4.2 Accessibility characteristics of the patients

4.3 Patient’s expectation with health cervices at OPD Kuta Blang health center

30

32

35

5 DISCUSSION

5.1 Methodological concern

5.2 Socio-Demographic characteristics

5.3 Patient accessibility towards health cervices

5.4 Patient’s expectation towards health services at OPD

5.5 Patient’s satisfaction towards health services

47

48

49

50

51

Discussion.....................................................................................................47

6 CONCLUSION AND RECOMMENDATION

6.1 Conclusion..............................................................................................53

6.2 Recommendation....................................................................................54

REFERENCES.........................................................................................................61

APPENDIX.............................................................................................................. 62

BIOGRAPHY........................................................................................................... 74

LIST OF TABLES

Table Page 1 Reliability coefficient………………………………………………………...........27

2 Number and percentage of respondents by Socio-demographic characteristics……….31

3 Number and percentage distribution of the respondents classified by

accessibility………………………………………………………………………...33

4 Overall expectation of patient towards health services at the OPD

Kuta Blang health center……………………………………………………..........35

5 Number and percentage of patient health problem…………………………..........37

6 Percentage of the respondents patient satisfaction towards OPD service

regarding convenience……………………………………………………….........38

7 Number of percentage of patient satisfaction towards OPD service

regarding courtesy………………………………………………………………...38

8 Percentage of the respondents by patient satisfaction towards OPD service

regarding quality of care…………………………………………………………39

9 Percentage of the respondents by patient satisfaction towards OPD service

Regarding physical environment…………………………………………...........40

10 Total score of overall satisfaction each component…………………………….40

11 Level of satisfaction with health service of the outpatient of Kuta Blang

Health center……………………………………………………………………41

12 Explanatory factors associated with satisfaction……………………………….42

13 Explanatory factors not associated with satisfaction…………………………...43

14 Percent distribution of patient’s suggestion for improving the quality

of health center at OPD Kuta Blang health center………………………..........45

15 Number and percentage distribution of the respondents who would

visit the health centre again……………………………………………………46

LIST OF FIGURES

Figure Page

1. Conceptual framework...........................................................................................6

2. Patients flow of service in Kuta Blang health center............................................17

3. An Emerging Model-Phase 4................................................................................20

LIST OF ABBREVIATION

NAD : Nanggroe Aceh Darussalam

OPD : OUT-patient Department

WHO : World Health Organization

MoH : Ministry of Health

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

CHAPTER 1 INTRODUCTION

1.1 Rationale and justification

With globalization has come an alarming increase in international statements

and guidelines for developing about ethics, equity and health system reform. When it

does not refer to specific places, times, people and condition, such thinking is of little

interest international forum. All these trends in fact make the importance of the local

of district health system more conspicuous. Within that system, health development is

most effectively implemented through health centers, if health personal understand

these to have responsibility both for maintenance of optimum health and for care of

the sick in a given area population (1).

Patient’s satisfaction is a component of health care quality and is increasingly

being used to assess medical care in many countries in the world. Until recently,

traditional assessments of medical care were done purely in terms of technical and

physiological reports of outcomes. It is an established fact that satisfaction influences

whether a person seeks medical advice, complies with treatment and maintains a

continuing relationship with practitioners (2).

Patient satisfaction has long been considered an important component when

measuring health outcomes and quality of care. The rising strength of consumerism in

society highlights the central role patient’s attitudes play in health planning and

delivery. Further more, a satisfied patient is more likely to develop a deeper and

longer lasting relationship with their medical providers, leading to improved

compliance, continuity of care, and ultimately better outcomes (3).

Nazirah Introduction /2

Medical care aims not only to improve health status but also to respond to

patients need and wishes and to ensure their satisfaction with care. Likewise,

conducting surveys to measure satisfaction with psychometrically validated

questionnaires entails assessment of the quality of care organization and procedures.

Patient judgment on medical care also contributes to medical outcome. In the case of

ambulatory care, it has been clearly shown that satisfied patients are more likely to

cooperate with treatment, to maintain a continuing relationship with a practitioner and

thus enjoy a better medical prognosis. From a conceptual point of view, the construct

of patient satisfaction as been defined by Isabell Gasquet Ware (4). As an "attempt to

capture the personal evaluation of care that cannot be known by observing care

directly" and to “Good” consider opinion of patients as a multidimensional subjective

indicator of quality of care. The model most commonly, though implicitly, used in

satisfaction work is the discrepancy model (degree of fulfilment of expectation is

related to satisfaction level) giving to patient expectations a central role. This model,

according to Sitzia “implies that concentrating upon areas of expressed dissatisfaction

is more valuable than obtaining consistency of expressed satisfaction". In France,

measuring satisfaction has been mandatory since 1996 and several questionnaires

have been developed to evaluate inpatient care. Most existing outpatient satisfaction

questionnaires have been developed to assess primary care practice, especially general

practice. However, it could be hypothesized that content of questionnaires evaluating

primary care physician may be different from that of questionnaires exploring hospital

consultation with a specialist because of differences in patient expectations. So it

could be assumed that dimensions that are very important in the case of primary care

like human qualities of the physician and medical information could have a lesser

importance in case of hospital consultation, while technical competency could have a

more important place (5).

The quality of health services can be measured by a community's level of

satisfaction in terms of the health services received, both curative and preventive (6).

The quality of health services is very much influenced by the quality of physical

facilities, types of work force available, medicines, health instruments and other


supportive facilities, services conferring process, and compensation received and the

expectation of the consumer society. Hence the increase in physical quality and

aforementioned factors are preconditions to be fulfilled. Afterwards, the process of

services conferral is to be increased through increase in quality and professionalism of

health resources as stated above. While the expectation of the consumer society is

being adjusted through improvement in general education, health information, good

communication between health providers and the public (7, 8).

As the center for basic health services at the sub district level, each health

center (community healthcare centers) generally has a doctor who is appointed as the

head of the health center. However, the administrative duties of a health center head

often reduce consultation time with patients. As a result, patients are mostly taken

care of by nurses and midwives. This is a dilemma. On one hand, as a doctor assigned

to a particular health center, he or she is required to contribute to the provision of

health services, but on the other hand, the administrative duties of a health center head

in fact interrupt their duties as a doctor (6).

The health plan at provincial level emphasizes patient focused service

improvement and organization development. The rate of patient satisfaction at 80% is

the minimum goal for every hospital to achieve in Thailand (9). Indonesia health care

delivery system consists of network of primary, secondary and tertiary facilities. An

essential feature of health centers which operate at first level is the main contact

among community. Based on vision of health Indonesia in 2010, 80% of health

centers did not provide good quality of services (8).

Health centers in Indonesia are designed to provide comprehensive, integrated

health services; these include curative, promotive and preventive care, and

community-based rehabilitation. There are also responsible for health development in

their respective catchments area through community activities and innovative

approaches. Depending on the population density, geographical area and local

infrastructure, a health center catchments area is either a sub district or a Part of one.

Each health center serves an average population of 30,000. They operate under the


administrative authority of district administration and the district health office. The

function of health center is expended through several subordinate units that include

sub-center, posts for trained midwifes in village, and subordinate unit that integrated

services unit (posyandu). This health center was linked to the “Village Community

Resilience Body” (LKMD) to support village-based development activities (10).

Patient’s satisfaction and its measurement are important as other clinical

health measures and primary means of measuring the effectiveness of health care

delivery as well as for policy analyst, health care managers, practitioners and users.

Environment has forced health care organization to focus on Patient’s satisfaction as a

way to gain and maintain market share. If you don’t know what your strengths and

weakness are, you can’t compete effectively. Despite problem with establishing a

tangible definition of “satisfaction” and difficulties with measurement, the concept

continues to be widely used. In many instances when investigators claim to be

measuring satisfaction, more general evaluation of health care services is being

undertaken (11).

Bireuen is the youngest district in NAD (Nanggroe Aceh Darussalam) by the

rule UU No. 48 on October 1999, before it was apart of North Aceh. The total area is

1.901,021 km2 consist of 17 sub district, and 581 villages. The total population is

365.184 and until 2006, Bireuen district has 17 health centers, and 5 out of 17 health

centers have beds for patients having serious illness. To provide services total of 142

staffs with one doctor, one nutritionist, one nurse secretary, one nurse for

communicable disease ,one pharmacy assistance and for each village have one

midwives and total of 40 for whole villages. The main programmes conducted in

health center were focused on mother and chid health, immunization, nutrition,

communicable diseases, health environment and health promotion and prevention. By

National policy, a health center serves an average population of 30,000 (12, 13).

Kuta Blang health center is one of the rural health centers in Bireuen sub district,

which responsible for 40 villages with 20.006 populations and the average of patients visit

were 60 patients per day. Health center provides free medical services to all the peoples in


the village. There has been no study on patient satisfaction since the center was established;

to improve quality of health care in this area the result of measuring patient’s satisfaction

could be used for starting point to improve quality of services in Kuta Blang health center.

A better understanding about factors relating to patient’s satisfaction can help policy and

decision makers to implement programs adapted to patient’ need as perceived by patients

for all health centers in Bireuen district. Therefore, this patient satisfaction study was

conducted at Kuta Blang health canter, in Bireuen Aceh Province, Indonesia (12, 13).

1.2 Research questions

What are factors related to patient satisfaction toward the health care services at

Kuta Blang health center in Bireuen district?

1.3 Research objectives

1.3.1 General objective

To assess the levels of patient satisfaction with the services and to identify

factors relating to the patient satisfaction.

1.3.2 Specific objectives

1. To describe patient satisfaction at Kuta Blang health center in Bireuen district.

2. To describe socio-demographic factors of patient on satisfaction at Kuta Blang

health center in Bireuen district.

3. To assess the accessibility of Kuta Blang health center.

4. To asses the expectations of service at the health center according patient

perception at Kuta Blang health center.

5. To determine the relationship between patient’s characteristics, expectation on

services system, accessibility to the service and patient satisfaction to the service

at Kuta Blang Health Center in Bireuen District, Aceh Province, Indonesia.


1.4 Conceptual framework

Independent variables Dependent variable

Figure 1 Conceptual framework

Predisposing Factors

Socio-demographic factor - Age - Gender - Marital Status - Educational - Occupation

Enabling factor: Family Income Accessibility - Distance - Waiting time for services - Information received - Service hour

Need factors

Expectation of patients about services - Physical facilities - Doctor services - Nurses services - Pharmacist services - Registration staff services

- Waiting time Health problem

Patient’s satisfaction toward services at Bireuen health center - Convenience

- Courtesy

- Quality of care

- Physical environment


1.5 Variables and operational Definition

1.5.1. Independent variable

Socio-demographic characteristics consist of age, gender, marital status,

education, and occupation.

Age refers to the age of the respondent at the time of interviewing, including

age, 16-60 years old. The limit of age at 60 because age 60 is an old person who is

still easy to communication but the age beyond 60 is probably too old to provide clear

information.

Marital status has five categories, is namely single, married, separated,

widowed and divorced.

Educational level refers to the obtainment of schooling education of the

patients. In this study education levels are categorized in 5 groups, No

education/illiterate, primary school, high school, college/university, and other.

Occupation is defined as the main job of the respondents categorized in 7

groups: 1. Housewife/unemployed, 2. Government service, 3. Farmer, 4. Merchant/

self-employer, 5. Laborer, 6.Unemployed and 7.Others.

Accessibility to cervices means how comfortable it is to access the services in

terms relevant to information received, waiting time and service hour.

Distance means the length of travel time, and expense to health center and

convenience location health center to come.

Waiting time for services means an opinion of patient towards waiting time

for each section service at Kuta Blang health center such as, registration room,

physical examination, treatment room, and pharmacist room.

Information received means type of the information about health center

including regulation, illness, drug use, health promote and preventive care.

Family income is an approximate real income of the family in month. Persons

are given an open-ended question to indicate the month of family income.


Physical facilities mean an opinion of patient towards general appearance of

building, place, chairs, desks, and toilet.

Doctor’s service means the services provided by the health personnel, mine,

physician. The doctor’s service is to provide treatments, including taking care of

patients of the health center. It is assumed that patient can evaluate doctor’s skills and

understanding of results of the treatment.

Nurse’s services means the service provided by the nurse who are working in

health center. The patient can consider from ability and experience of the nurse,

suggestion of how to take care of oneself, clarification diagnosis and care, and

character.

Pharmacist services mean the service provided by the pharmacist staff in the

drug units.

Registration’s staff’s services mean the service provided by the registration

staff in the registration room.

Waiting time means opinion of the patient towards the amount of waiting

time for service at Kuta Blang health center.

Health problems refer to the health condition and current illness that brought

the patient to the health center.

1.5.2 Dependent variable

Patient satisfaction: refers to the patients’ state of being satisfied with health

care services at the out-patient Kuta Blang health center. Patient refers to the

respondents who consume the health services at the OPD of the health center during

the time of conducting interviews. The indicators for client’s satisfaction in this study

consist of four components convenience, courtesy, quality of care and physical

environment.

Convenience: In this study, it means accessibility of health services, taken

care well and also includes sufficiency of physical facilities.


Courtesy: Means manners, speaking, and friendliness of provides by health

personnel.

Quality of care: means quality of service in all levels from the patient. The

quality includes capability of doctors to diagnose correctly and medical treatment,

nursing skill, and use technology facilities services.

Physical environment refers to features of the physical setting in which the

health services are provided. Cleanliness of equipment and cleanliness of the space as

health center.

.

1.6 Limitation of the study

This study is concerned at the sub-district of Bireuen district. It is there for not

reflect the whole health care service of the district level. The information obtained

from the study population might have some variations and this study is conducted

with limited resources making it impossible to include many important questions and

variables.

Nazirah Literature Review /10

CHAPTER 2

LITERATURE REVIEW

The literature review included the following topics:

- Background information about health center

- The definition of Satisfaction

- Literature regarding to independent variables

- Theoretical conceptual framework

- Components of satisfaction

2.1 Background Information about Health Centers

A health center is a functional health organization unit which server as a center

for health development, community participation development, besides providing

comprehensive and integrated health service to the community within working area. It is

authorized and responsible for delivering health care service to the community within its

working area, which is a sub district or a part of sub district (16).

Health center as a part of district health system is administratively

responsibility of the head of district health office, but technically responsible to the

MoH. Health center as a part of national health system is a part of basic health care

level in the referral system (17).

Health center is the spearhead of the national health system and one of leading

element for national health development. Basic health services provided at health

center are: 1. Medical Treatment; 2. Health Promotion; 3. Environmental Health;

4. Maternal and Child Health; 5. Nutrition; 6. Communicable diseases (17).


At present, the following specific targets related to basic health care services

at health centers, consolidated in the government’s health policy program, are being

implemented under Indonesia’s new national development policy, known as

PROPENAS (fiscal 2000-2004).

- Prevention of the outbreak and spread of infectious diseases.

- Reducing the instance of infection, mortality, and disease-induced disability

- Extension of areas with access to basic medical services, plus more

equitable access.

- Enhanced impact and efficiency of basic medical and related services

- Promotion of the use of safe and effective pharmaceuticals through medical

services and medical networks, as well as of traditional forms of treatment (18).

Health center effort consist of community health service, which focus on

promotive and preventive with community group approach through outreach health

service. Basic medical service, which focus on the curative and rehabilitative service

with individual and family approach through outpatient and referral services. In

certain condition and if it is possible, we can consider that health can provide

inpatient services as interval before to hospital (16).

Health care has many changers over the years. The objectives of health care

changed with the requirements of society and the availability of resources and

technology. The WHO conference on supporting health for all, held in 1990, defined

future development in health to be human centered. A lot of stress has been made on

investment in heath, patient care and patient’s right to delivery of quality health care

leading to patient satisfaction (19).

2.2 The definition of satisfaction

Based on dictionary, the definition attributes the term “satisfaction” to the

Latin root sati’s meaning “enough”. Something that satisfies will adequately fulfill

expectation, need or desire, and giving what is required, leaves no room for

complaint.


Two points arise from this definition. First, a feeling of satisfaction with a

service doesn’t imply superior service; rather that adequate or acceptable standard

was achieved. Dissatisfaction is defined as discontent, or failure to satisfy. It is

possible that consumer is satisfied unless something untoward happens, and

dissatisfaction is triggered by critical event. Secondly, satisfaction can be measured

only against individual’ expectation needs or desires. It is a relative concept:

something that make one person satisfied (adequately meets their expectation) may

make another dissatisfied (fall short of their expectation) (11, 2).

Patient’s satisfaction is an expression of the gap between the expected and

perceived characteristics of a service. Satisfaction is a subjective phenomenon and

could be elicited by asking simply how satisfied or not patients may be about the

service. However, it has been found that, questionnaires that ask patients to rate their

care in terms of how satisfied they are tend to elicit very positive ratings that are not

sensitive to specific processes that affect overall quality. It is recommended that

patients be asked to participate on their experiences through specific questions (2).

Patient reports about satisfaction with care are thought to reflect attitudes and

opinions about care that may influence other patient behaviors, such as choice of

providers, amount of services used, and compliance. In addition, patient satisfaction

reports are behaviors in their own right (20).

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 /Patient’s satisfaction is

an attitude – a person’s general orientation towards a total experience of health care.

Satisfaction comprises both cognitive and emotional facets and relates to previous

experiences, expectations and social networks. Meredith and Wood (1995) have

described Patient’s satisfaction as ‘emergent and fluid’. It also has been important


factors influencing patients/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 our 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), technology. Previous measurements of Patient’s 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 (21).

2.3 Literature Regarding To Independent Variables

2.3.1 Socio-demographic characteristics

Socio-demographic variables are related to all kinds of health care

experiences that patients have, and the way that they interpret them. For instance,

better educated patients may participate in diagnosis and treatment decisions more

then less educated patients but remain less satisfied with their degree of participation

because physicians are not meeting their higher expectation. Consequently, it is often

difficult to interpret findings of relationships between socio- demographic and

satisfaction (22).

Many researchers documented that socio-demographic variables are directly

related to patient satisfaction. Similarly, patient satisfaction correlates to health

personal behaviour, especially those who have low income. These variables are well

documented by many different researchers and writers. Perhaps the most consistent

determinant characteristic is age, with a body of evidence from various countries to

suggest that older people tend to be more satisfied with health care than younger

people (23).

The other side of the of the “consensus coin” is the existence of consistent,

coherent differences within demographic segments of a population. A fourth task for


future health behaviour research is the determination of how various groups within a

population differ in their definition. Systematic study of diverse samples, of persons

with different ethnic, education, socioeconomic or age characteristic, might reveal

demographic diversity that would have important practical value in increasing the

success of programs and improving communication between professionals and

clients (20).

The study in health center, Bangkok Metropolitan Administration found the

associations between socio-demographic-economic factors and patient satisfaction.

The results showed that education, family income, travelling time and transportation

of respondents to visit health center last year had significant associations with degree

of satisfaction (24).

It is commonly believed that satisfaction with health care may be dependent

upon variables as social class, marital status, gender, and-in particular age. Socio-

demographic characteristics were concluded to be at best a minor predictor of

satisfaction (25).

2.3.2 Accessibility to Health Center

The accessibility of health care can be assessed in various aspects: the

possibility for residents to see their doctor; to use the services of health care system;

the provision of population with health care resources (doctors, nurses). The

evaluations of the health center territorial accessibility also depended upon the

patients’ residence and the type of health center.

When estimating the accessibility of health care it is important not only how

long do the patients spend at the reception but also how long do they have to wait

outside their doctor’s consulting-room. According to the data of the survey one-third

(32.9%) of the patients think that they have to wait too long for the visit to their

doctor. The results of the logistical regressive analysis have shown that the patients’

estimations on the time spent at the reception were largely related to the patients’

education, residence, the frequency of visits, and the type of health care. The


probability that people with vocational education would point out that they have to

wait for their visit to the GP for too long was 3.1 times lower in comparison with

those who have primary education only; and the probability that people with

university education would point out that they have to wait for their visit to the

General Practice for too long was 2.2 times lower in comparison with those who have

primary education only. Patients who receive their health care services at private

health care also more seldom ascertained that the time they spent waiting for their

visit to the GP was too long; that is, the probability that they would say that the time

spent at the reception was too long was 2.1 times lower compared with the patients

visiting public health care.

The extent to which patients are able to reach required services and treatments

when they are needed and mobilize within them. This includes waiting times, patients'

ability to find out about, get referred to and physically get to services, accessibility for

diverse populations, and the range of services provided (21).

Patients who have received their health care services in towns and patients

who visit health care frequently tend to be more critical when evaluating the time

spent waiting for the consultation with their GP we have come to a conclusion that the

chance that the patients visiting private health care would better evaluate the waiting

rooms was 5.6 times higher, and the chance of positive evaluation of GPs’ consulting

rooms was 5.2 times higher in comparison with the patients who visit public health

care. It was established that the higher the patients’ education the bigger the

possibility that the waiting rooms would be rated positively. Residents of towns in

comparison with the city residents tend to be more critical of the GPs’ consulting-

rooms and of the health care waiting rooms. Other authors point out that, when

evaluating the patients’ satisfaction with the health care accessibility, it is necessary to

assess the coherences between the patients’ state of health and the availability of

health care evaluations (21).


2.3.3 Service system and Health Care

Health post and health center, while useful in providing a primary level

of and are limited in their capacity and services, and the skill at their disposal, and are

usually available only during working hours (26).

A health system is the complex of interrelated element that contribute to health

in home, educational institution, workplace, public place and communities, as well as

the physical and psychosocial environment and the health and related sectors (27).

Health centers in Indonesia are designed to provide comprehensive and

integrated health services. These include curative, promotive and preventive care, and

community base rehabilitation. They are also responsible for health development in

their respective catchments areas through community activities and innovative

approaches (10, 21).

Depending on the population density, geographical area and local infrastructure, a

health care catchments area is either a sub district or a Part of one. Each health center serves

an average population of 30.000. They operate under the administrative authority of the

district administration and the district health office (10).

The function of health center is extended through several subordinate units

which included sub centers posts for trained midwives in villages and community-

based integrated service unit (posyandu). This health center system is linked to the

“Village Community Resilience Body “ (the LKMD) to support village-based

community development activities(10).

Kuta Blang health center is one of the rural health centers in Bireuen district,

Aceh province, Indonesia. It is located at sub-district and one of the models of rural

health center, which has service system patient flow from arrival to return home, as

the bellow figure:


Figure 2: Patients flow of service in Kuta Blang health center

When patients arrived to health center (puskesmas), where they had to

register, in registration unit. After registration patients have to wait before obtaining

individual services in poly clinic, or dental clinic, or mother and child health or family

planning. After the consultation or service, patients go to pharmaceutical unit or to the

laboratory for diagnostic tests. A few patients were referred to district hospital.

2.3.4 Expectation with services

The expectations of patient are one of the determining factors of

healthcare service. The purpose of this study is to measure the Patients’ Expectations,

based on patient's rights (28).

Patient comes to health center

Registration

Waiting room

Tuberculosis clinic

Dental unit

MTBS unit

Polyclinic unit

Children clinic

MCH and family planning

Mental counselling

Pharmacy unit

Return home


From Likert-Survey in Trabzon population. The analyses showed that the level

of the expectations of the patient was high on the factor of receiving information and

at an acceptable level on the other factors. Statistical meaningfulness was determined

between age, sex, education, health insurance, and the income of the family and the

expectations of the patients. According to this study, the current legal regulations have

higher standards than the expectations of the patients. The reason that the satisfaction

of the patients high level is interpreted due to the fact that the level of the expectation

is low. It is suggested that the educational and public awareness studies on the

patients’ rights must be done in order to increase the expectations of the patients (28).

Expectation make more complex of the satisfaction as an evaluative tool. As

patient satisfaction is a recognized component of quality Assurance, it is therefore

tempting to equate “high” levels of reported satisfaction with “high” levels of quality

of care. However, relating to patient satisfaction study results, it is necessary that

“expression of satisfaction should always be interpreted in the context of some

understanding of the rational that underlies those expressions rather than being taken

at face value”. For physician care, the hypothesis that the more a doctor performance

meets a patient’s expectation, the more satisfied the patient will be with the

physician’s services was strongly supported.

The few later studies in which the relationship between level of patient’s

expectations and overall satisfaction has been explored consistently suggested that

patients with “lower expectation” tend to be more satisfied. There may, however, be

confounding variables which need to be considered; for example, there exist

relationships between level of patient’s expectation, socioeconomic status and

associated values and attitudes amongst different patient groups (29).

Patient’s satisfaction with the health care they receive is an important health

outcome which has been given particular emphasis in the current review of the

National Health Service. Nevertheless, the relationship between satisfaction and the

quality of care received is complex and affected by patient, doctor and service factors.

Recent commentators have speculated that patient expectation of care they will


receive has an important impact on satisfaction: patients with inappropriately high

expectations may be dissatisfied with optimal care, and those with inappropriately low

expectations may be satisfied with deficient care. Furthermore, observed differences

in satisfaction between people from different social classes, age, sex and cultural

group or between different services and types of care, may be confounded by match or

mismatch between expectation and the service received. Based on the work of

Prakash, we have conceptualized patient expectation of care as having two aspects;

what patients expect as a result of their own or others' experiences

(normative/comparative expectation) and the care they would like and or hope for

(idealized expectation) (30).

2.4 Theoretical Conceptual framework

In this study, the conceptual framework was derived from the Behavioural

Model of Health Services Use develop by Ronald M. Andersen (14).

Health beliefs are attitudes, values, and knowledge that people have about health

and health services that might influence their subsequent perceptions of need and use of

health cervices. Health beliefs provide one means of explaining how social structure might

influence enabling resources, perceived need, and subsequent use (31).

Social structure is measured by a broad array of factors that determine the

status of a person in community, his or her ability to cope with presenting problems,

and how healthy or unhealthy the physical environment is likely to be. Measures used

to assess social structure include education, occupation, ethnicity, social networks,

social interactions, and culture. Measures of these concepts rightly fit into the social

structure component (32).

Aday & Anderson in 1974 mentioned that patient satisfaction is the attitude

towards the medical care system. They proposed that patent satisfaction is probably

best evaluated in the context of specific, reset and identifiable episodes of medical

care seek in relevant to consider in eliciting subjective perception of access that


indicate satisfaction with the convenience of care, its coordination and cost, courtesy

of the providers, information given to the patient about dealing with their illness, and

their judgment as to the quality of care received. Patient satisfaction is an outcome

indicator in a theoretical model of access, which indicated the use of the services.

Consumer satisfaction is the health outcome affected by three key factors,

including predisposing characteristics, enabling resources and need factors of the

consumer. In the formulation of the study conceptual framework only some factors of

the model were include (15).

Environment Population characteristics Health behaviour Outcomes

Figure 3 An Emerging Model-Phase 4

Health care system

External

environment

Predisposing Enabling Need

Characteristics resources

Personal

Health

Practices

Use of

Health

Services

Perceived

Health status

Evaluated

Health status

Consumer

Satisfaction


2.5 Components of Satisfaction

Four components of satisfaction considered by the current study Kuta Blang

health center are convenience, courtesy, quality of care and Physical environment.

The details of these each component are the followings.

2.5.1 Health care providers

Hall and Dorman reported in 1988 that satisfaction with health care

services is determined by satisfaction with one’s physician, while satisfaction with the

outpatient experience is determined by the quality of health care workers. The

satisfaction is divided into two parts: the satisfaction with technical competence and

satisfaction with interpersonal skills. When evaluating nurses, the patients place much

more emphasis on interpersonal aspect than on perceptions of technical competence.

Having continuous relations with their doctors is strong predictor of overall

satisfaction. Prior relations between doctor and patients are major cause of

disenrollment (33).

Patient satisfaction is best considered as a multidimensional construct. Patients

may hold quite destined views in relation to different aspects of their health care.

Cleary and Mc Neil (1988) distinguish nine different dimensions of health care on

which patients’ views can be obtained: the ‘art of care’ (i.e. health professional’ inter

personal skills), technical quality, accessibility, convenience, finance, physical

environment, availability, continuity an outcome. As will be evidenced below, the

first category of influences, ‘the art of care’, contains elements of health care, such as

health professionals’ communication skills and sensitivity to patients’ concerns that

have a particularly strong influence on patient satisfaction. Some evidence suggests

that, so influence are such factors, patients are unable to distinguish between

interpersonal skills one the on-had and technical competence on the other hand (Ware

& Snyder, 1975) (34).

One of variables repeatedly cited in providing quality of care through health

promotion is the character of the patient-provider relationship, particularly that


between physician and patient. Futures of this relationship that were associated with

positive patient behaviours were (35):

1. The friendly and accepting attitude of the provider

2. Patient’s perceptions that the physician had spent time with them

3. Patient’s fillings that thy hade control in the interaction and input in their treat

meant programs

4. Patient’s satisfaction with the care they received

5. A treatment program that was actually tailored to them as individuals

6. Situations where patients felt that information was willingly shared with them

7. Absence of formal disagreement with patients

8. Continuity of the specific provider-patient relationship

2.5.2 Convenience

Convenience meant the ease to travel to service, an opportunity of

meeting the health provider, waiting time, receiving the services as wanted and

willingness of the health providers to treat patients.

The convenience and characteristic of place people go for medical care

provide data on whether there is differential treatment of individuals depending on

where thy chance to go for cervices. In addition waiting time in getting services

should be as proxy indicator of convenience in any service (8). In a study at

Ramathibodi hospital, it was shown that the waiting time was the most important

factor influencing the satisfaction (36).

Consumer satisfaction according to Aday and Andersen (1974), thy proposed that

consumer satisfaction is probably best evaluated in the context of specific, recent, and

identifiable episode of medical care seeking, relevant to consider in eliciting subjective

perceptions of access are satisfaction with the convenience of care, its co-ordination, and

cost, the courtesy shown by providers, information given to the patient about dealing with

his illness, and his judgement as to the quality of care he received (14).


2.5.3 Quality of care

Previous research studied patients satisfaction and quality of health care

in rural Bangladesh found that the quality of care was depending upon provider

behaviour, especially respect and politeness aspects. For patient this aspect was much

more important than the technical competence of the provider. Furthermore, reduction

in waiting time (on average to 30 minute) was more important to patient than a

prolongation of the quite short (from a medical standpoint) consultation time (on

average 2 min, 22 sec), with 75% of clients being satisfied. Waiting time, with was

about double at outreach services than that at fixed services, was the only element

with which users of outreach services were dissatisfied (36).

Patients’ satisfaction depends not only on service quality but also on patients’

expectations. Patients are satisfied when services meet or exceed their expectations. If

patients' expectations are low or if they have limited access to any services, they may

be satisfied with relatively poor services. A poor woman in Bangladesh said "Even

though they behaved badly, I have to be content”. We are lucky if we can get the free

medicine that they give out at the clinic. Health care patients often expect poor-quality

care, accept it without complaint, and even express satisfaction when surveyed.

Patient’s satisfaction as expressed in interviews or does not necessarily mean that

quality is good; it may mean that expectations are low services. Patients may say they

are satisfied because they want to please the interviewer, because they are afraid of

service withheld in the future, because of cultural norms against complaining, or

because they respond positively to the word "satisfied” (38).

Nazirah Research Methodolog /24

CHAPTER 3

RESEARCH METHODOLOGY

3.1 Research design

A cross-sectional study was conducted in Kuta Blang Health Canter in

Bireuen district, Aceh Province, Indonesia. The interview questionnaire was the tool

in collecting data for assessing the patient satisfaction towards the services in Kuta

Blang sub district community at Bireuen. The interviews were held at the health

center where the patients received medical care.

3.2 Population and Study site

The study population was outpatients of Kuta Blang Health Canter. The

sample of this research consisted of outpatients aged 15-60 years who visited health

care visited services in January 2008. The researcher selected this age group because

the patients at this age mature enough to answer questions independently. The

researcher interviewed their satisfaction on health care services at Kuta Blang Health

Canter in Bireuen District, Aceh Province, Indonesia.


3.3 Sample Size and Sampling Technique

Sample size of the patients was determined by using the following statistical

formula:

( )2

2 12/d

PPn −Ζ=

α

( )( )2

2

068.06.016.0)96.1( −××

=n

200=n

Where :

Zα/2 = value from the standard normal (Z= 1.96 if 95 % confidence

interval required)

p = Proportion of patient’s satisfaction with service = 0.60

Cited in a research of client satisfaction with services at Health

center in Urban Banda Aceh, Indonesia 2002 (16).

d = Maximum allowed error/margin error was assumed to be 0.068

n = number of sample size

Therefore, the sample size required for this study was at least 200.

Systematic random sampling was applied to draw patients in order to get

information about the aspects of health care services mentioned in the study. Patients

ware selected with sampling interval for each day. The K interval is calculated by

using this formula. The researcher selected one patient for every seven patient interval

(39, 40):

k = dna×

k = 2220060

×

k = 7


Where:

k = sampling interval

a = average actual number of patients consumed services at the health

center per day

d = total number of days planned for data collection

n = required number of patients consumed services at the health center

3.4 Data Collection Tools and Methods

Patients who arrived, and registered to receive the service, were interviewer

during registration and they were approached and requested to participate in this

study. The structured questionnaires were used and designed by the researcher under

the guidance of advisor and co-advisor. The questionnaires were translated into

Indonesian language. The questionnaire was divided into the following 4 sections:

Section 1. Socio-demographic such as gender, age, marital status, education,

occupation and family income were be check list and filled in the blank.

Section 2. Accessibility to health center included distance, waiting time for

services, information received and service hour. A score of “1” is

given for “yes” answer. A score of “0” is given for “no” answer.

Section 3. Expectation of patients about OPD services included physical

facilities, doctor services, nurses’ services, pharmacy sector,

registration services, waiting time and health problem. The question

was a 3 rating scale. Each item was scored as follows:

3= Excellent, 2= Good, 1= Not acceptable, no expectation= missing

total score of each component was classified into two levels, using

median as the cut of point.

Section 4. Patient’s satisfaction with the services including: convenience,

courtesy, quality of care and physical environment. Patients

satisfaction was be classified into 3 scales as follows: 3 = high, 2 =

moderate, 1 = low. A total score of each component was classified

into two levels. If total score of each patient below or equal to 80%


of total score, it was classified in to low satisfaction. If it was above

80% of total score it was classified into high satisfaction.

3.5 Content validity and reliability

The questionnaires were pretested with 30 respondents at Kuta Blang Health

center, in Bireuen district. Reliability of the questionnaire was analyzed by using the

Cronbrach’s coefficient.(40, 41) Content validity will be tested by the researcher,

advisor and co- advisor.

3.6 Research instruments for data collection

The local government and Chief of District Health Office, Indonesia approved

the permission to carry out this study before data collection. The data were collected

by using pretested research instrument. Thirty respondents for reliability test, the data

were entered into Minitab software to calculate reliability coefficients. The

questionnaire was translated in to Indonesia language and focused on six questions for

expectation and seventeen questions for satisfaction. The questionnaire was tested for

reliability at one community Kuta Blang health center in Bireuen district. The

cronbach’s coefficient was adopted for reliability analysis of expectation and

satisfaction, shown in Table1.

Table 1 Reliability Coefficient

Variable Cronbach’s coefficient

Expectation 0.756091

Patient satisfaction 0.684540

After consulting with thesis advisor and co advisor in order to check content

validity and continue to collect data for thesis. Before collecting data four staff from

subdivision of Health Service at District Health Office were selected as interviewers


and received one day training in order to understand the objectives of this research,

interviewing technique and meaning of questions of this study.

3.7 Data analysis

After the data collection was completed and entered by using Epi Data 3.0

program and Minitab version 13 for data analysis. Steps were to be as follows:

- Each item was coded and checked consistency of coding in all questionnaire

forms

- Entering data

- Check and edit consistency of data in all variables

Frequency and percentage were calculated for predisposing characteristics

(age, gender, education level, occupation, marital status), enabling factor (income),

accessibility (distance, waiting time for services, information received, service hour)

and the level of patient satisfaction.

Chi-square test was performed to determine relationships between the

independent variables and the satisfaction levels. Mean, standard deviation, median,

inter-quartile range and quartile deviation were calculated for patient expectation and

satisfaction. Frequency and percentage were used to describe the qualitative variables

in the study.


CHAPTER 4

RESULTS

This cross sectional study was conducted in Bereuen District at Kuta Blang

health center to describe the patient satisfaction towards outpatient medical care

services. A total of 200 patients were interviewed from the medical outpatient

department (OPD) in Kuta Blang health center. An interviewer was employed for data

collection from 6th of January until 28th January 2008 not excluding public holidays.

All respondent were OPD patients aged 16 until 60 years who returned to OPD after

previous visits. The eligible respondents were asked about the basic information of

socio-demographic characteristics, accessibility to health care including distance,

waiting time, information OPD services and the satisfaction of patients with services,

in term of convenience, courtesy, and quality of care. The respondents who came to

the OPD service for utilization of health care services during the period of data

collection were both males and females. The study was conducted in order to measure

the level of patient satisfaction with the OPD services. Moreover, this study was

intended to find out the relationship between the socio demographic factors,

accessibility, expectation and patient satisfaction with OPD services.

The results of the study were presented in the tubular and descriptive forms in

the following parts:

Part 1 Socio-demographic factors

Part 2 Accessibility to health center

- Distance

- Waiting time for services

- Information received

- Service hour

Part 3 Expectation of patients with health services at OPD

- Health problem

Nazirah Results /30

Part 4 Satisfaction with health services at Kuta Blang health center

Part 5 Association between patient satisfaction and independent variables

4.1 Socio-demographic characteristics of the patients

Socio-demographic characteristics of the patients included gender, age, marital

status, education level, and occupation. More than half (55 %) of them were females.

Patients’ age ranged from 17 to 60 years, majority of the respondents (67.5%) are in

age group between 52 to 60 years old with the mean and the standard deviation of age

were of 40 and 11, respectively.

. Most of the patients (74.5%) belonged to marriage group and (12%) were

single and the remainders (14%) were in the widowed or divorced or separated.

Regarding education attainment, majority (42%) had colleague/ university level, only

2 percent no education. Considering occupation, 31% were housewives, 26% farmers

and 18.5% government offers, 16% merchant/self-employees.

.


Table 2 Number and Percentage of the Respondents by Socio-Demographic

characteristics

Socio-demographic

characteristics

Number

n = 200

Percentage

(%)

Sex

Male 90 45.0

Female 110 55.0

Age (years)

17-28 32 16.0

29-51 135 67.35

52-60 33 16.5

Mean =40.12 Median= 40.00 SD=11.04 Min=17.00 Max=60.00

Marital status

Single 24 12.0

Married 149 74.5

Widowed 17 8.5

Divorced/separated 10 5.5

Education

No education 4 2.0

Primary school 54 27.0

High school 38 19.0

College/University 84 42.0

Other 20 10.0

Occupation

Housewife 62 31.0

Government officers 37 18.5

Farmer 53 26.0

Merchant/self-employee 32 16.0

Laborer 9 4.0

Nazirah Results /32

4.2 Accessibility characteristics of the patients

In Table 3, the accessibility as regard to the family income per month in

rupiah, family income was classified into three groups using percentile or quartile as

the cut of point.. First group is Rp.1,500,001 to Rp.3,000,000, second group is

between Rp.500,000 to 1.500.000 and the third group is Rp.200,000 to Rp.499.999.

The lowest monthly family income of the patients was Rp.200,000, the highest was

Rp.3,000,000. Currency 235 rupiah equivalent to one Baht.

Regarding to distance from home to the health center, most of the respondents

(78.5%) agreed that the health center was near (less than 3 Km). Almost all

respondents, (98.5%) answered that the health center ease to reach. With regard to

travel time 71% spent only 10 to20 minutes to reach the health center.

Considering transportation, majority used motorcycles, 17.5% of the

respondents went to health center by walking, 35% used bicycle. Moreover, 98.5% of

the respondents felt convenience to come to health center. Majority (97%) answered

that waiting time for registration is not very long. Minority (33%) felt that waiting

time for physician examination is not very long. Almost all respondents 98% received

information of service procedure at the health center.

Regarding the regulation of getting health services 66% of patients knows

about it and 34%of patients do not know about the regulation information.

With regard to receiving information type of examination 88.5% of the

respondents received information, however, for promoting and prevention 75.5% of

the respondents got the information (detail in Table 3).


Table 3 Number and percentage distribution of the respondents classified by

accessibility

Predisposing characteristics Number Percent

n = 200 (%)

Family income(Rupiah)

200,000-499,000 36 18.0

5000,000-1,500,000 131 65.5

1,500,001-3000,000 33 16.5

Median = 950,000 QD=500,000 Min = 200,00 Max = 300,000

Distance to health center(km)

1-2 157 78.5

3-15 43 21.5

Median = 2.0 QD = 1,5 Min=1.0 Max=15

Health center ease to reach

Yes 197 98.5

No 3 1.5

Travel time (minute)

5-9 48 24.0

10-20 142 71.0

21-60 10 5.0

Median = 15 QD = 5 Min = 5 Max = 60

Nazirah Results /34

Table 3 Number and percentage distribution of the respondents classified by

accessibility (cont.)

Predisposing characteristics Number Percent

n=200 (%)

Means of transportation

On foot 35 17.5

Bicycle 70 35.0

Motor cycle 94 47.0

Car 1 0.5

Convenience to come to HC

Yes 197 98.5

No 3 1.5

Waiting time for registration is not long

Yes 194 97.0

No 6 3.0

Waiting time for physician is not long

Yes 134 67.0

No 66 33.0

Information about procedure

Yes 196 98.0

No 4 2.0

Information about health center regulation

Yes 132 66.0

No 68 34.0

Type of examination

Yes 177 88.5

No 23 11.5


4.3 Patient’s expectation with health cervices at OPD Kuta Blang health center

Patients were asked about their expectation to awards health services provided

by the OPD of Kuta Blang health center. There were six questions in the expectation

section, including inters personal manner of service providers, quality of care and

expectation to the waiting time of service provision (registration, physician,

examination and receiving drug).

The overall expectation of patients towards health service at the OPD of Kuta

Blang health center was shown in Table 4 below. This expectation was computed by

dividing into three levels as high, moderate and low expectation. By using percentile

as cut-off point; > Q3 as high, Q3- Q1 as moderate and <Q1 as low expectation.

Table 4 Overall Expectation of the respondents towards health services at the OPD

Kuta Blang Health center

Expectation Frequency Percent

High expectation 10 5.0

Moderate expectation 155 77.5

Low expectation 35 17.5

Median=2.0 QD=0.1 Max=2.8 Min=1.2

As shown in Table 4 most of the patients (5%) has high expectation and re

than half were having (77.5%) moderate expectation and (17.5%) low expectation

towards health services at OPD Kuta Blang Health center. The minimum score was

equal to 1.1 while maximum score was 2.8. The median was 2.0 with quartile

deviation 0.1.

Table16 in the appendix had shown that majority of patient’s answer that they

expected good quality of care (78.5%). Majority (86%) expected that good manner of

the physician that would be expressed to patients during visiting OPD; good manner

of the nurses expressed to the patients during services was also expected from the

Nazirah Results /36

majority (84%). Most of the patients expected good manner of the pharmacist and

registration staff. For waiting time of service provision (registration, physician,

examination, and receiving drug) 78% of the patients expected short time.

4.3.1 Health problem

Regarding to the previous of health problem, 67.5% of the patients had

diseases. The previous health problem that brought the patients to OPD Kuta Blang

health center were categorized in to three groups acute, chronic and no previous

health problem.

Acute health problem were group of illness or health problem such as common

cold (CC), fever, headache, allergy, dermatitis, upper respiratory infection, and

gastro-intestinal tract diseases etc. Chronic health problem included diabetes mellitus,

hypertension, and musculo-skeletal diseases. The statistics presented in Table 5

showed that 74.0 percent of the patients came to the health center with acute health

problems and only 26 percent with chronic problems.

Majority (64, 5%) of the patients visited in Kuta Blang health center for 1-7

times and 33% visited between 8-14 times. Only 2.5 percent visited OPD Kuta Blang

health center 15-20 times.


Table 5 Number and percentage of patient health problem

Number Percent Predisposing characteristics

n=200 (%)

Health Problem

Have any health problem before this

visit

No 65 32.5

Yes (specify) 135 67.5

Acute health problem 109 54.5

Chronic health problem 26 13.0

No previous health problem 65 32.5

How many time visited HC

1 - 7 129 64.5

8 - 14 66 33.0

15 - 21 5 2.5

Median=5 QD=4 Min=1 Max=20

The current problem that bring patient

came to HC

Acute health problem 148 74.0

Chronic health problem 52 26.0

4.4 Satisfaction with health care services at Kuta Blang health center

Many factors influence the level of satisfaction as mentioned in conceptual

framework, the study attempted to see the satisfaction in four different perspectives:

convenience, courtesy, quality of care and physical environment. In this section, 17

questions were asked about 4 aspects of satisfaction. The score 3 was given for high

satisfaction, score 2 for moderate satisfaction and score 1 for low satisfaction.

Nazirah Results /38

Table 6 Percentage of the respondents patient satisfaction towards OPD service

regarding convenience

Level of satisfaction

n = 200 Patients satisfaction

Good Fair Poor

Convenience

To access at the registration 19.5 76.0 5.5

Enough seats at the waiting room

physical examination

25.5

74.0

2.5

Service hour 12.5 82.0 5.5

Waiting room at the pharmacy section 24.5 71.5 4.0

The first section of satisfaction was about the convenience as shown in Table

6. This section comprised of four questions on the access at the registration, waiting

room before get the physical examination, service hour, and the waiting room at the

pharmacy section. Majority fairly satisfied with convenience to access the services.

Table 7 Percentage of patient satisfaction towards OPD service regarding courtesy


n=200

Patients satisfaction

Good Fair Poor

Courtesy

Doctor respect and friendly 38.5 60.5 1.0

Nurse respect and friendly 35.0 61.0 4.0

Pharmacist respect and friendly 36.0 63.0 1.0

Registration respect and friendly 31.0 62.5 6.5

Courtesy of other staff 22.5 75.0 2.5


As shown in Table 7, the section on courtesy consisted of five questions: the

respect and friendliness of doctor, respect and friendliness nurse, respect and

friendliness pharmacist, respect and friendly registration staff and courtesy of staff

during examination and treatment. Nearly 39% of the patients highly satisfied with

the respect and friendly manner of the doctor. Majority moderately satisfied with

courtesy of health personal.

Table 8 Percentage of the respondents by patient satisfaction towards OPD service

regarding quality of care

Level of satisfaction n=200 Patients satisfaction

Good Fair Poor

Quality of care

Doctor very competent and well trained 21.0 71.0 7.0

Doctor good about explaining the reason

for medical test

21.0 70.5 8.5

Nurse skill in using medical equipment

and very cooperative

29.0 60.0 11.0

Pharmacists explain clearly and

accurately on drug prescription

21.0 70.5 8.5

Registration services are skilful and

systematic careful

26.0 65.5 8.5

Regarding Quality of care as shown in Table 8, this section comprised of five

questions. Skillful and systematic careful registration services gained higher satisfied

among the other components.

Nazirah Results /40

Table 9 Percentage of the respondents by patient satisfaction towards OPD service

regarding physical environment


n=200 Patients satisfaction

Good Fair Poor

Physical environment

The location of services clean and enough

space to use

25.0 54.0 21.0

Atmosphere of this OPD is good 14.5 70.5 15.0

Facilities and equipment OPD tidy and

clean

17.0 62.0 21.0

The last section of satisfaction was about the physical environment as shown

in Table 9. This section comprised of three questions, about the location of services is

clean and enough space to use received high score of satisfaction. Atmosphere of this

OPD gained high satisfaction only 14.5%. For tidy and clean facilities and equipments

the health center received high satisfaction only 17%. Twenty five percent of the patients

highly satisfied with clean location and enough space to use.

Table 10 Total score of overall satisfaction and each component

satisfaction Total score

Min Max Median QD

Overall satisfaction 51 17.0 47.0 36.0 3.0

Convenience 12 4.0 12.0 8.0 0.5

Courtesy 15 5.0 15.0 10.0 1.5

Quality of care 15 5.0 15.0 10.0 1

Physical environment 9 3.0 9.0 6.0 1

Satisfaction was determined by using scores of: overall satisfaction, convenience,

courtesy, quality of care and physical environment. The level of Satisfaction was classified


into to two groups: high and low. The total score of convenience, courtesy, quality of care,

and physical environment were calculated for each aspects of satisfaction. Descriptive

statistics was used for calculated the cut-off point. The percentage >80% was considered as

high and ≤ 80% was considered as low satisfaction. The result of satisfaction shows in

Table 10.

Table 11 Level of satisfaction with health services of the outpatient of Kuta Blang

health center


n=200 Patients satisfaction

High Low

Overall satisfaction 46 (23.0) 154 (77.0)

Convenience 36 (18.0) 164 (82.0)

Courtesy 76 (38.0) 124 (62.0)

Quality of care 61 (23.0) 139 (69.5)

Physical environment 53 (26.5) 147 (73.0)

Table 11 shows number and percentage of the respondents by overall satisfaction

with OPD services. When considered with overall satisfaction 23% of the patients highly

satisfied and 77% of the patients were lowly satisfied with the services. When each

component of satisfaction was considered, 18% of the patients were highly satisfied with

convenience and more than three quarter (82%) of the respondents had low satisfaction

with convenience. Courtesy was the most highly satisfied (38%). While quality of care 23%

were highly satisfied and 69.5% of the patients were lowly satisfied. For physical

environment only 26.5% were highly satisfied and 73% lowly satisfied respectively.

4.5 Association between patient satisfaction and independent variables

To find out the association between predisposing factors, enabling factors and need

factors of the patients and the satisfaction, Chi-square test was performed.

Nazirah Results /42

Table 12 Explanatory factors associated with satisfaction

Satisfaction level χ2 P-

High Low Value Independent

Variable n = 46 % n=154 %

Occupation 15.76 0.003 Housewife 21 33.9 41 66.1 Government service 3 8.1 34 91.9 Farmer 17 32.1 36 67.9

Laborer /employee 4 6.3 28 93.7 Merchant 1 12.5 15 87.5 Waiting time for physician

4.87 0.027

Yes 9 27.6 57 72.4 No 37 13.6 97 86.3 Expectation Level 9.50 0.009 High 6 13.4 4 2.59 Moderate 30 65.21 125 81.16 Low 10 21.73 25 16.23 Visit the health center service again

0.002*

No sure - - 28 100 Yes 46 26.74 126 73.26

* The Fisher exact test

As shown in Table 12, the association between occupation, waiting time for

services, expectation level and satisfaction level of patient were detected by Chi-square test

while other independent variables were not. Regarding predisposing factors, there was

significantly associated only between occupation and satisfaction (p value = 0.003). The

higher level of satisfaction shows with housewife with 33.9% among all groups. Because

they were more prone to visit health center more than other groups since they are the people

who take care of family as a whole.

There was significant association between waiting time for physicians and

satisfaction level (p-value=0.027). Among the patients who said that they have to wait for


the doctor, 27.6% were highly satisfied and the patients whom did not have to wait only

13.6% were highly satisfied.

For expectation significantly associated with satisfaction. The patient satisfaction

was associated with expectation (p-value=0.005) and thought of revisit the health center

(p-value=0.002). The proportion of the patients who expected an excellent service was

higher than those with lower expectation. The patients who thought to visit the health center

again, 26.74% were highly satisfied with the services while none of those who were not

sure felt highly satisfied.

Table 13 Explanatory factors not associated with satisfaction



Variable n=46 % n=154 %

Gender 0.603 0.437

Male 23 25.56 67 74.44

Female 23 20.91 87 79.09

Age (years) 3.450 0.179

17 - 28 6 18.18 27 81.82

29 - 51 36 12.50 99 87.50

52 - 60 4 26.67 28 73.33

Education 1.968 0.374

No education/Illiterate 16 20.51 62 79.48

High school 12 31.57 26 68.42

College/University 18 21.42 66 78.57

Family income per month 2.642 0.267

200,000 – 499,999 9 25.00 27 75.00

500000 – 1,500,000 33 25.19 98 74.81

1,500,001 – 3,000,000 4 12.12 29 87.89

Nazirah Results /44

Table 13 Explanatory factors not associated with satisfaction (cont.)



Variable n=46 % n=154 %

How far from resident to HC 0.598 0.440

1 to 2 km 38 24.20 119 75.80

3 to 15 km 8 18.60 35 81.40

HC ease to reach 0.910 0.587*

Ease - - 3 100

Not ease 46 23.35 151 76.65

Travel time 0.205

5 to 9 minute 12 25.00 36 75.00

10 to 20 minute 34 23.94 108 76.06

21 to 60 minute - - 10 6.49

Information received 3.599 0.165

procedure/regulation 8 27.6 21 72.4

Type of examination 12 15.8 64 84.2

Promotion and prevention 26 27.4 69 72.6

*Fishers exact test

Considering the relationship between the socio-demographic factors, gender,

age in year, marital status, education, enabling factor it was found that family income,

and for accessibility; distance, and information received were no association with

satisfaction (Table.13).


Table 14 Percent distribution of Patient’s suggestions for improving the quality of

health center at OPD Kuta Blang health center

Suggestions Frequency Percentage

1 Improve the discipline of health personnel 43 21.5

2 Improve the interpersonal manner of nurse 23 11.5

3 Improve the quality of physical examination 21 10.5

4 Improve the cleanliness of toilets 20 10.0

5 Improve the quality of drugs 18 9.0

6 Need more doctor and specialist 10 5.0

7 Need a dentist 9 4.5

8 Need a rubbish box 8 4

9 Improve the cleanliness and tidiness of health center 7 3.5

10 Build flower park 5 2.5

11 Provide cafeteria in the area health center 5 2.5

12 Provide enough park area 5 2.5

13 Provide immunization every day 4 2

14 Provide enough drinking water 3 1.5

15 Provide a television in the waiting room 2 1

16 Provide doctors and nurses stand by in the Emergency room 2 1

Regarding patient’s suggestions and comments, almost all patients provided

suggestions and comments on what should be improved for better quality of health

services as shown in Table 14. Most of the (21.5%) patients commented on to

improve the discipline of health personnel. Then they were commented on to improve

the interpersonal manner of the nurse (11.5%). To improve the quality of physical

examination and to maintain cleanliness of the toilet 10% of the patients suggested.

Moreover comments and suggestion were given to improve the whole image of the

hospital.

Their ideas were concerned about doctors and nurses should be more polite

and friendly when interacting with patients. They should receive patient with smile

and speak with nice in a courteous manner. In point of their view needs one more

doctors to provide services for this village. Therefore increase number of doctors, one

Nazirah Results /46

dentist and specialist, doctor should be available in emergency situation or stand by to

provide services at any time, especially for the afternoon session and public holidays.

Table 15 Number and percentage of the respondents who would visit the health

center again

Visit the health center again in case of

sickness.

Number

n=200

Percentage

(%)

No - -

Yes 172 86.0

Not sure 28 14.0

Table 15 shows that most (86.0%) of the respondents would visit the health

center again and only 14.0% of them were not sure. Since there was no other health

center in the village near by so they were happy with services. And the facilities were

free of charge for the people of the whole village.


CHAPTER 5

DISCUSSION

The objectives of this cross-sectional descriptive study were to evaluate the

levels of satisfaction towards the health care services provided at the outpatient

Department of Kuta Blang health center at Bireuen district, Nanggroe Aceh

Darussalam Indonesia; and to determine the relationship between general

characteristics of patients, accessibility to the services, expectation of patients and

satisfaction with the services. A total of 200 patients attended to the outpatient Kuta

Blang health center were systematic randomly selected and interviewed by using

structured questionnaire during 6 January until 28 February, 2008 except public

holidays. The descriptive statistics and Chi-square test were applied for the analysis.

The discussion was presented as follows:

1. Methodological concerned

2. Socio-demographic characteristics

3. Patient accessibility towards health cervices

4. Patient’s expectation towards health services at OPD

5. Patient’s satisfaction towards health services

5.1 Methodological concern

This study was conducted during the office hour so that information bias from

the respondents could be inevitable since the surrounding of the health center may

make the patients felt reluctant to complain for fear of unfavorable treatment and

services. In this study, staffs providing services in the health center were not selected

to be interviewers because their personalities and recognition could influence the

patients.

To obtain the good quality of data, the interviewers had to be well-trained and

properly selected. Subdivision health workers were trained to assist the researcher in

Nazirah Discussion /48

the process of data collection in order to minimize bias that can be occurred because

of the characters of interviewers. During data collecting her/his performance should

be very simple. Nevertheless the researcher monitored along the process of the data

collection with the intention that the mistakes or incomplete filled questionnaire could

correct on time.

5.2 Socio-Demographic characteristics

With regard to the patient’s gender, it was found that most of them were

females (55%), and there were few males (45%) utilizing services of health. However

it did not matter if the patients were males or females since the satisfaction was not

significantly associated with the gender. It might be due to health services were not

specific services of interest in both gender for examples, female should take care of

their health and are more interested in cosmetics or beauty services while male is

probably more interested in services of the sports or automobile.

The youngest patient was 17 years old and the eldest one was 60 years old.

The mean age was 40 years and the standard deviation was 11. The majority of the

patients were from age group 52 to 60 years followed by 29 to 51 years and the last

group 17 to 28 years old patients. The highest percentage of patients was age group 52

to 60 years (67 %) of the total respondents. The younger and older groups were

almost same with 16% and 16.5% respectively. The level of satisfaction was almost

same in all age groups and there was no significant association between age and

satisfaction. The result was opposite to the study by Al-Bashir M, et. al (1991), in

with he concluded that old aged patients had high level of satisfaction as compared to

younger.

Regarding marital status, it was found that most of respondents were married,

(74.5%) very few people were still single at this age (12%). Finally statistically it can

be concluded that there was no significant association between marital status and

satisfaction. The result was almost same with the study carried out by Tran Thi Nga in

Fac. of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) / 49

2002, which concluded that there was no association between marital status and

satisfaction.

Even though the result was statically not significant, patients who belonged to

college group (78.5%) more satisfied than high school (68.4%) and no education

(79.4%). This result was different from the study of Partha P.R. who found that clients

with low level of education more satisfied than the high level education. This finding

was also supported by the study of Tangmankongworakoon, in which she indicated

that the clients who graduated at the higher level were satisfied less (42). Therefore it

can be concluded that education was one of the factors that influence on the level of

satisfaction because higher educated client have the chance to know more advanced

medical care and would have higher expectation.

In occupation category, the housewife group was found to be more satisfaction

than laborer. Statistical association was significant with p-value of 0.003, the reason

might be that the health center provides free services for all people and house wife

usually acquired health center services than laborer. The result of the study is similar

with the finding in study by Roy (2002) which also showed association between

occupation and satisfaction. The reason may be owing to high satisfaction among the

laborer might be because of their less expectation and quality of services (43).

Gregory (1988) said that the most difficult investigation was to detect the

association between patient’s socio-economic demographic characteristics and the

level of satisfaction. While socio-economic demographic variables have been studies

on numerous occasions, a consistent picture of their effects on patients’ satisfaction

had not emerged. This might be due to the fact that many studies had varied widely in

the nature of the sample and their specific background characteristics and culture (44).

5.3 Patient accessibility towards health cervices

The relationship between accessibility and patient satisfaction was assessed by

using Chi-square test. The major factor used for accessibility analysis were regarding

Nazirah Discussion /50

need factor while family income per month, the highest income group were the one

earning between Rp.500.000 to 1.500.000 (rupiah), which means that almost more

and half patients belonged to moderate income group but there was no association

between income and satisfaction. This result was opposite to the study conducted by

Partha P.R. who found clients with lower income reported higher level of satisfaction

with the medical care services (43).

The distance to health center, the residence to health center ease to reach was

not associated with satisfaction. This result was opposite with many previous studies,

e.g.Gadalah (7), Suryadi (45). It has been proven that easy to access to health facility

can be satisfaction to the patient.

Regarding the association between waiting time for physician was significantly

associated with satisfaction at (p=0.027). From the result it was found that 27% of the

patients were highly satisfied with waiting time, and 13% who says that waiting time for

physician was long. While higher percentage of patient was with low satisfaction than

higher satisfaction level. The result was similar to Amin Khan’s study; the association with

waiting time was significantly associated with satisfaction (46).

5.4 Patient’s expectation towards health services at OPD

In this study, the results of overall expectation showed that 5% of high

expectation group had high satisfaction, more that half 30% had moderate

expectation group with high satisfaction and 10% was low expectation with high

satisfaction. The association between expectation was significantly associated with

satisfaction level at P=0.029. This indicates that the patients with high expectation

more satisfied with health services than those who are with low expectation. It could

also be implied that patients got better health services than what they expected. In

previous studies also mentioned about expectation as the determinant for satisfaction.

The patients with lower expectation tend to be more satisfied and for the physician

care there was evidence to support the hypothesis that the more doctors’ performance

met the patient’s expectation the more satisfied the patient would be with the


physician’s services. (42). The finding of this study might be related to the hypothesis

by Larsen Roadman (1976) that the patient exposed the services of doctor’s

performance meets the patient’s expectation, the more satisfied the patient will be

with the physician’s service (47).

5.5 Patient’s satisfaction towards health services

The patient satisfaction was assessed in terms of convenience, courtesy,

quality of care and physical environment. The satisfaction was measured from the

point of view of the respondents who came to OPD services at time of the interview.

The overall satisfaction with health services at health center shows that 23%

was highly satisfied and 77% were lowly satisfied. Regarding the components of

satisfaction the convenience was 18%, courtesy 38%, quality of care 23%, and

physical environment 27% sowed high satisfaction rate. The percentage with low

level of satisfaction, for convenience 18%, followed by quality of care 23%, and

physical environment 26%, the last courtesy 38%. Percentage of the respondents with

higher satisfaction rate was lower than that of higher satisfaction. According to most

of the study showed that medical care service would develop according to the needs

and wants of patients. For this purpose the providers were needs to understand the

expectation of the patients. Fitz Patrick (1991) in measurement of client satisfaction

asserts that clients evaluate their medical care on number of different and separate

aspects. How many dimension clients distinguish in their evaluation of care was not

universally agreed, but several studies asses client view separately. The key

dimension was quality of care, personal aspect of care, convenience, physical

facilities, and expenses of medical care and out come of care (48).

The finding was lower than a similar study on client satisfaction with service

at health center in urban Banda Aceh, Indonesia by Alamsyah (49) in which 60% of

client were satisfied. A similar study in Bangkok, Thailand on patient satisfaction

toward the service of health center by Smutraprapoot (24) showed 65.5 % the

respondents were highly satisfied. Another study of client satisfaction with service at

Nazirah Discussion / 52

Kiaracondong health center in urban Bandung, Indonesia by Ruhanshah (17) revealed

that 34.5% respondent highly satisfied. The different satisfaction might be due to the

operational definitions and the way of measuring the studied factors. In addition

different cultures express satisfaction in different way. The low proportion of

satisfaction with the service in this study, in some degree might be due to the fact that

most of the respondents were more openly expressed their dissatisfaction.


CHAPTER 6

CONCLUSION AND RECOMMENDATION

6.1 Conclusion

Patient satisfaction is the essential indicator that reflects the service quality at

any level of health services. Kuta Blang health center in Breuen district has not ever

conducted patient satisfaction survey. However, the whole picture of satisfaction

towards services of the health center had not been documented. This study was

conducted in one outpatient unit of the health center. The study on the patient

satisfaction was an effective means of evaluating the performance of health center

from the view of the patients. The in formation obtained through this type of the study

was valuable to remove discrepancies which are distorting the patient satisfaction so

as to make this health center and OPD more attractive for the patients.

The patient’s satisfaction was studied in terms of convenience, courtesy,

quality of care, and physical environment. They were evaluated by using by Likert’s

scale and the satisfaction was classified into high and low using Thailand standard.

A structured questionnaire was used as study instrument for data collection. There

were four sections in the questionnaire; general information regarding the patients,

accessibility include distance, waiting time, information received, patients expectation,

patients satisfaction towards health services, and patients suggestions/comments to improve

the quality of health cervices at the OPD of Kuta Blang health center. Cronbrach’s alpha

coefficients for the reliability test of questionnaire were 0.75 and 0.68 for expectation

section and satisfaction section respectively.

Nazirah Conclusion and Recommendation /54

Systematic random sampling was applied to select patients from the OPD of

the health center; data collection was conducted from January 6 to February 28, 2008.

There were 200 patients participated in this study. The results were presented by using

frequency, percentage, minimum, maximum, mean, median, standard deviation,

quartile deviation; Chi-square test was performed to determine an association between

dependent and independent variables.

The result revealed that the female were more utilized at outpatient

department; with mean age was 40 years. Around 74.5% of the patients were married,

and educational levels were from college/university (42%). In the category of

occupation: 31% were housewife. Mean monthly family income was 1.177.750

rupiah, and the highest percentage was 500.000 rupiah to 1.500.000 rupiah. The

average time to reach health center was 10 minute to 20 minute and average distance

to health center was 1 km to 2 km. But majority of them came to outpatient service

with the acute health problem.

Overall level of patient’s satisfaction to the services provided, 77% had low

level satisfaction and high level satisfaction only 23%. Regarding on each category of

cervices provided: courtesy (38%), and the second physical environment (26.5%) the

third quality of care (23%), the last convenience (18%).

The study on patient satisfaction showed that the determination of the

satisfaction of the satisfaction is very complex. It involves trust, patient characteristics

and need as well as their perception to physicians and interpersonal skill, together

with their perception whether or not they are responding appropriately to the

treatment.

When the provider (doctor, nurse) were trusted and respected by he patients,

their behavior should support and keep this condition because once people established

faith with one health services, they continue it for long time until their trust was lost.

Good understanding between the health center and patient usually ways for good


participation. The increase in the service facilities was not the only solution, quality

must also be considered.

Many finding of this study may be useful for future improvements. Patient’s

satisfaction assessment should be regular assessment at all health centers that should

be conducted at least once a year. It will be helpful to know the problems of the

patients and improve the quality of care, ultimately earning good reputation and

prestige for the institution.

6.2 Recommendation

6.2.1 Recommendation for outpatient department services

This study found important information of the outpatient department of

Kuta Blang health center. There were some recommendations for improving the

quality of services that the investigator wants to make as follows:

The health care services

The health care service is the important part, which should be improved by

the health center because it is the basic service. Good or bad of health care service can

influence the level of the satisfaction. The health center should encourage the training

programs for the health providers and provide the continuing education for the

experienced health providers to keep up work update knowledge and technology.

Physical facilities

The health center should improve the physical facilities services such as sitting

arrangement in the waiting room, television program to give health information, and if

possible, to give some educational entertainment’s for patients/visitors. Likewise, the

health center should improve the physical examination room and medical equipments

along with providing one more doctor.

Nazirah Conclusion and Recommendation / 56

6.2.2 Recommendation for the future research

The basic objectives behind in each research were to find out the real

problem, study was systematically to find out means to solve it. In patients

satisfaction it should take into consideration on persons’ expectations, patients

medical conditions, survey items might attempt to better discriminate.

To minimize bias for the research in the future it should be better to interview

patient in community since the real data would get at home environment. Highlight

the component of primary health care for further improvement of health center

services. The times spent with the physician were a significant predictor of patient

satisfaction. Therefore health center needs to consider this point to minimize the

waiting time for physician in future. These results suggests that shortening patient

waiting times reduce the expense of time spent by the patients to improve patient

satisfaction scores would be counter-productive. The complaints and suggestion for

service improvement might be expressed more genuinely and high satisfaction may be

lower than those when studied within the surrounding of the health center. The

attitudes of the people, cultural setting and religion may differ from community to

community. This may result in different in level of satisfaction.

For the future research, satisfaction of each health care service at health

centers should be measured in order to improve the quality of care at each unit.

Fac.of Grad. Studies, Mahidol Univ. M.P.H.M. (PHC Management) /57

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Health] Bangkok : Faculty of Graduate Studies, Mahidol University; 2001.

46. Mandokhail AK. PAtient satisfaction towards outpatient Departement (OPD)

Services of Medicine in Banphaeo Autonomous Hospital Samut Sakhon

Province, Thailan: [M.P.H.M.Thesis in Primary Health Care Management].

Nakhon Pathom: Faculty of Graduate Studies, Mahidol University; 2002.

47. Larsen DE, Rootman I. Physician role performance and patient satisfaction.

Social Science & Medicine. 1976; 10: 29-32.

48. Fitzpatrick Ray: Surveys of patient satisfaction; I-Important General

consideration. Bitish Medical Jurnal. 1991;302:887-89.

49. Alamsyah T.Client Satisfaction with Services at Health Canters in urban

Banda Aceh Indonesia. [M.P.H. Thesis in Urban Health]-Bangkok :

Faculty of Graduate Studies , Mahidol University ; 2000.

Nazirah Appendix /62

APPENDIX


APPENDIX A

QUESTIONNAIRES

ID: [ ] [ ] [ ]

Questionnaire

This questionnaire is prepared for thesis writing purpose of MPH (Master

Public Health) course, and evaluating level of Patient satisfaction with services at

Kuta Blang Health Center. Your response will be kept secret and will not be exposed

to any other purpose. Your cooperation in completing the questionnaire is greatly

appreciated.

Date of Interview :______/ _ __ _ / 2008

Name of interviewer: ………………………..

Please mark “√” into or fill in the blank as appropriate answer according to you.

Section 1. Socio-demographic factor

1. Gender

1. Male 2. Female

2. How old are you by this year (Years Completed)? :…………………(In years)

3. What is your marital status?

1. Single 2. Married

3. Widow/Widower 4. Divorced/Separated

4. What is your educational and qualification?

1. No education/Illiterate 2. Primary School

3. High School 4. College/University

5. Other (specify)………………………………………………..


5. What is your current occupation?

1. Housewife 2. Government Service 3. Farmer

4. Merchant/Self-employee 5. Laborer 6. unemployed

7. Other (specify)…………………………………………

Section 2. Accessibility to health Center

Distance

6. Family income per month Rp: …………………

7. How far from you resident to health centre? ………….km

8. Distance from your residence to health centre ease to reach

1. Yes 2. No

9. How long (in travel time)? ................. minutes

10. What is your mean or transportation to come to this health centre?

1. On foot 3. Motor cycle

2. Bicycle 4. Car

11. Health centre location is convenience to come to your residence

1. Yes 2. No

Waiting time for services

12. The waiting time for registration is not very long

1. Yes 2. No

13. The waiting time for physician’s examination is not very long

1. Yes 2. No

Information received

14. Received enough information about steps of service procedure

1. Yes 2. No

15. Received enough information about health regulation?

Yes 2. No

16. Received enough information about types of examination

1. Yes 2. No

17. Received enough information about health promotion and prevention

1. Yes 2. No


Section.3 Expectation of patients with health cervices at OPD Kuta Blang

health center

18. What is your expectation to the quality of care that serve you at the OPD?

1. I expected that the quality of care might not be acceptable

2 . I expected that the quality of care might be good

3. Expected that the quality of care might be excellent

4. I do not have any Expected

19. What is your expectation to the manner of the physician that would be expressed to you during visiting the OPD?

1. I expected that the manner of the physician might not be acceptable

2. I expected that the manner of the physician might be good

3. I expected that the manner of the physician might be excellent


20. What is your expectation to the manner of the nurses that would be expressed to

you during care services?

1. I expected that the manner of the nurses might not be acceptable

2. I expected that the manner of the nurses might be good

3. I expected that the manner of the nurses might be excellent


21. What is your expectation to the manner of the pharmacist that would be expressed

to you during receiving the medicine?

1. I expected that the manner of the pharmacist might not be acceptable

2. I expected that the manner of the pharmacist might be good

3. I expected that the manner of the pharmacist might be excellent


22. What is your expectation to the manner of service providers at registration that

would be expressed to you?

1. I expected that the manner of the service providers might not be acceptable

2. I expected that the manner of the service providers might be good

3. I expected that the manner of the service providers might be excellent



23. What is your expectation to the waiting time of service provision (registration,

physician’s examination, and receiving drug) that would be expressed to you?

1. I expected that the waiting time might not be acceptable

2. I expected that the waiting time might be reasonable

3. I expected that the waiting time might be short


Health problem

24. Before this visit, did you have any health problem/illness such as DM,

hypertension, heart disease, rheumatoid arthritis, gastritis, accident, others, etc.?

1. No

2. Yes (if yes, please specify…………………………………….……………)

25. Have you visited or been at health centre before?

How many times have you visited this health center (include this visits)?

..................times

26. What is the current problem that brings you to the health centre today?

………………………………………………………………………….


Section4. Satisfaction with health services at Kuta Blang health centre

For the following statement, please mark [√ ] the answer relevant to your perception

Level of satisfaction Statements

Good Fair Poor

Convenience

27. It is convenient to access at the

registration

28. There are enough seats at the waiting

room before you get the physical

examination

29. Service hour is convenience

30. Convenience at the waiting room at

the pharmacy section

Courtesy

31. Doctor at health centre treats the

patient with respect and friendly

32. Nurses at health centre treat the

patients with respect and friendly

33. Pharmacist at the health centre treat

the patients with respect and friendly

34. Registration staff at health centre treat

the patients with respect and friendly

35. Courtesy of other staff

Quality of care

36. The doctors are very competent and

well-trained

37. Doctor at health centre is good about

explaining the reason for medical test


38. Nurse skill in using medical

equipment and very cooperative

39. Pharmacists explain clearly and

accurately on drug prescription

40. Registration services are skillful and

systematic careful

Physical environment

41. The location of services is clean and

enough space to use

42. The atmosphere of this OPD is good

43. Facilities and equipment at OPD tidy

and clean

44. Other comments or suggestions to improve the quality of services a………………………………………………………………………………………….

b…………………………………………………………………………………………

c………………………………………………………………………………………….

d…………………………………………………………………………………………

45. Would you visit the health center service again in case of sickness?

1. No 2. Not sure 3. Yes

Thank you very much


APPEENDIX B

NOMOR IDENTIFIKASI: [ ][ ][ ]

KUESIONER

Daftar pertanyaan ini disiapkan utnuk tujuan penulisan thesis MPH, dan eavaluasi tentang kepuasan pasien terhadap pelayanan di Puskesmas Kuta Blang. Jawaban anda akan dijaga kerahsiaannya dan tidak akan disebarluaskan untuk tujuan apapun . Kerjasama anda dalam meyelesaikan kuesioner ini sangat kami hargai. Tanggal wawancara :___/ / 2008 Nama pewawancara :……………………………………. Berilah tanda “√” dalam kotak yang tersedia sesuai dengal pilihan anda.

Bagian 1. Sosio-Demografi factor

1. Jenis Kelamin 1. Laki-laki 2. Perempuan

2. .Berapakah usia anda?:…………………(dalam tahun)

3. Status perkawinan? 1. Belum menikah 2. Menikah 3. Janda/Duda/ 4. Cerai/berpisah

4. Apakah status pendidikan anda? 1. Buta huruf 2. Sekolah dasar 3. Sekolah menengah pertama 4. SMA 5. Akademi/Universitas 6. Lainnya (jelaskan)………….

5. Apakah pekerjaan anda sekarang? 1. Ibu Rumah tangga/tidak bekerja 2. PNS 3. Petani 4. Pedagang/bekerja sendiri 5. Buruh pekerja kasar 6. Lainnya (jelaskan)…………………………………………

Bagian 2. Akses ke Puskesmas Jarak

6. Berapakah penghasilan rata-rata keluarga per bulan? Rp……………………..

7. Berapkan jarak dari rumah anda ke Puskesmas ? …….. km

8. Apakah mudah dijangkau? 1. Ya 2. Tidak

9. Berapa lama pejalanan(waktu tempuh) ke puskesmas?………….menit


10. Ditempuh dengan menggunakan ........ ?

1. Jalan kaki 2. Sepeda 3. Sepeda motor 4. Mobil

11. Apakah Letak puskesmas mudah terjangkau dari tempat tinggal ibu/bapak 1. Ya 2. tidak

Waktu tunggu untuk mendapatkan pelayanan

12. Waktu tunggu untuk pendaftaran/registrasi tidak terlalu lama

1. Ya 2. Tidak

13. Waktu tunggu untuk mendapatkan pelayanan pemeriksaan kesehatan terlalu

lama?

1. Ya 2. Tidak

Informasi pelayanan yang diterima

14. Mendapat cukup informasi tentang langkah dan prosedur dalam pelayanan?

1. Ya 2. Tidak

15. Apakah jadwal pelayanan di Puskesmas memadai bagi anda?

1. Ya 2. Tidak

16. Mendapat cukup informasi tentang jenis pemeriksaan dan pelayanan?

1. Ya 2. Tidak

17. Mendapat cukup informasi tentang promosi kesehatan dan cara preventif?

1. Ya 2. Tidak

Bagian.3 Harapan pasient terhadap pelayanan kesehatan di OPD puskesmas

Kuta Blang

18. Apa harapan anda terhadap kualitas dan fasilitas pelayanan di OPD

1. Harapan saya terhadap kualitas dan fasilitas tidak dapat di terima 2. Harapan saya terhadap kualitas dan fasilitas bagus 3. Harapan saya terhadap kualitas dan fasilitas Sangat bagus 4. Tidak punya harapan

19. Apa harapan anda terhadap sikap dokter selama melakukan pelayanan

1. Harapan saya terhadap sikap dokter tidak dapat di terima 2. Harapan saya terhadap sikap dokter selama melakukan pelayanan bagus

3. Harapan saya terhadap dokter selama melakukan pelayanan sangat bagus 4. Tidak punya harapan


20. Apa harapan anda terhadap sikap perawat selama melakukan pelayanan

1. Harapan saya terhadap sikap perawat tidak dapat di terima 2. Harapan saya terhadap sikap perawat selama melakukan pelayanan bagus 3. Harapan saya terhadap sikap perawat selama pelayanan sangat bagus 4. Tidak punya harapan

21. Apa harapan anda terhadap pelayan apotik selama melakukan pelayanan

1. Harapan saya terhadap pelayan apotik tidak dapat di terima 2. Harapan saya terhadap pelayan apotik bagus 3. Harapan saya terhadap pelayan apotik sangat bagus 4. Tidak punya harapan

22. Apa harapan anda terhadap pelayan staf di bagian regirtrasi

1. Harapan saya terhadap pelayan apotik tidak dapat di terima 2. Harapan saya terhadap pelayan apotik bagus 3. Harapan saya terhadap pelayan apotik sangat bagus 4. Tidak punya harapan

23. Apa harapan anda terhadap waktu tunggu/antri untu mendapat pelayanan

(registrasi, pemeriksaan dan untuk mendapat obat) pernyataan anda?

1. Harapan saya terhadap waktu tunggu tidak dapat di terima 2. Harapan saya terhadap waktu tunggu layak 3. Harapan saya terhadap waktu tunggu singkat 4. Tidak punya harapan

Masalah kesehatan

24. Sebelumnya apakah anda mempunyai masalah terhadap kesehatan seperti

penyakit DM, Hipertensi, penyakit jantung, gastritis, kecelakaan atau lainnya?

1. Tidak 2. Ya, penyakit apa?……………....................

25. Sebelumnya pernahkah anda mengunjungi PKM?

Berapa kali termasuk kunjungan ini……… kali

26. Apa masalah kesehatan anda hari ini………….................................................

..................................................................................................................................


Bagian.3 Kepuasan pasien terhadap pelayanan kesehatan di puskesmas

Kuta Blang

Untuk penyataan berikut ini, tandailah [√ ] pada jawaban yang berhubungan dengan persepsi anda

Tingkat kepuasan Sistim Pelayanan

Puas Cukup Tidak puas

Kenyamanan

27. Punya kemudahan dalam melakukan registrasi/ pendaftaran

28. Apakah cukup tempat duduk di ruang tunggu sebelum pemuriksaan kesehatan

29. Jam pelayanan.kesehatan ada kemudahan

30. Ruang tunggu cukup luas/ nyaman saat menunggu obat

Kesopanan

31. Dokter di PKM memperlakukan pasien dengan sopan dan ramah

32. Perawat memperlakukan pasien dengan penuh perhatian dan sopan

33. Staf apotik memperlakukan pasien dengan penuh perhatian dan sopan

34. Setaf di ruang registrasi PKM memperlakukan pasien dengan ramah

35. Umumnya seluruh staf PKM sopan dan ramah.

Kualitas pelayanan

36. Dokter trampil dan bijaksana dalam bertindak

37. Dokter menjelaskan dengan baik alasan dari pemeriksaan

38. Perawat trampil dalam mempergunakan alat kesehatan dan ramah terhadap pasien

39. Staf apotik menjelaskan dengan baik cara minum obat.

40 Staf bagian registrasi sistimatik dan trampil

Yang berhubungan dengan keadaan sekitar

41. Lokasi PKM dan sekitarnya bersih dan ruangannya cukup

42. Suasana di OPD nyaman (tidak ribut)

43. Fasilitas juga peralatan di OPD bersih dan rapi


44. Usul atau saran lainnya untuk meningkatkan qualitas pelayanan

a…………………………………………………………………………………………

b………………………………………………………………………………………....

c…………………………………………………………………………………………

d…………………………………………………………………………………………

45. Apakan anda akan mengunjungi lagi Puskesmas ini bila anda sakit?

1. Tidak 2. Tidak yakin 3. Ya

Terima kasih

Nazirah Biography /74

BIOGRAPHY

NAME : Nazirah

NATIONALITY : Indonesia

DATE OF BIRTH : September, 20 1969

PLACE OF BIRTH : Banda Aceh

INSTITUTION ATTENDED : Syiah Kuala University,

Medical Doctor, 1989 – 1999

Mahidol University

Master of Primary Health Care

Management, 2007 - 2008

WOKING EXPERIENCE 2000 – 2002: Volunteer doctor Head of Health

Center, Simpang Mamplam, in Bireuen District,

Indonesia

2002 – 2003: Staff in district health offices

2003 – 2004: Medical technic at Peusangan

Health center

2005 – 2006: Head of Health center in Bireuen

District

2006 – Present: Staff in district health offices

PERMANENT ADDRESS Jl. Pendidikan, Lorong: S. M. A no.44

Lhokseumawe, Aceh Utara, Indonesia

Tel. 001-645-44086

e-mail: [email protected]

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