When care is provided by a health facility to patient, it is important to take into account of how that care is viewed and valued by the patient. Components of patient satisfaction consist of: structural (access, physical setting, costs, convenience, etc.), technical (knowledge, quality of care, competence of staff, etc.), and interpersonal (communication, empathy, education, etc.) aspects of care. Information on these aspects from the perspective of patients is useful for better understanding about utilization of eye care services.[2–4] Patient-based assessments of medical care are also an important measure of service quality.[2–7] Patient satisfaction depends on personal care given by the provider, availability of medical personnel on a continuous basis outcome of treatment, the way health care is delivered, the type of health care setting, and patient characteristics such as age, gender education, socio economic status, etc.[10–14] Little research has been carried out on patient satisfaction with primary health or eye care services in India.
Primary health care is an approach to achieve both the Millennium Development Goals and the bigger goal of universal access to health through acceptable, accessible, appropriate, and affordable health care. The vision center (VC) is one such model of primary eye care initiated and practiced by the LV Prasad Eye Institute.[17–19] In brief, the VC is a strategy to control avoidable blindness. It identifies the major causes of visual impairment and blindness. The VCs are located either in small towns or in villages.
Each VC is staffed by a Vision Technician (VT). Potential technicians are selected from the community in which they will serve, with a minimum education of high school diploma. Training requires 1 year and includes refraction assessment, slit lamp evaluation, and appanation tonometry. VTs are trained to handle three primary eye care functions (recognizing eye problems, refraction, and prescribing spectacles and referral). Based on the location of the VC; technicians see 8–20 patients a day on an average and also help to do mass screenings in the community and in schools.
We have previously reported the comparison of patient satisfaction with VCs located in two types of rural settings of Andhra Pradesh. Since the VC model is now a core strategy to address the needs of eye care in needy areas, this paper aims to figure out the number of key domains or factors of VC model and as well as explore the relationship between predictor variables and patient satisfaction with VC model.
Materials and Methods
This paper is carried as part of the PhD thesis work of the lead. The details of study methodology and questionnaires were reported previously. In brief, we used retrospective, comparative, small sample study design with structured and unstructured questionnaires to obtain data from 136 patients on patient satisfaction between October and December 2007 from the two rural VCs serving the communities in Easily Accessible Rural locations (ERL) and two Remote Rural Locations (RRL).
RRL is a small village with around 5000 populations with no market. ERL is a large village with around 20,000 populations with a well-developed market. The study questions and methodology are presented in Fig. 1.
Using our field experience and qualitative data on VCs, we presumed that there would be a minimum of 10% difference in the effectiveness of service delivery of the VCs of ERL over the VCs of RRL (with a margin of error at 5%). Accordingly, a sample of 136 subjects was needed in this study. To obtain 136 eligible patients, we sampled every fourth patient on the list with the starting point for the sample being randomly selected from the list of the first four patients [Fig. 1].
The selection criteria for the 136 sampled patients included: (a) patients above 16 years who received eye screening and spectacles at least 6 months prior to the study (b) patients who lived within 10 km distance (since majority patients come from 10 km and also because of study logistics) from the VC locations. The ethics committee of L V Prasad Eye Institute approved this study. We obtained informed consent of the participated subjects after explanation of the nature and possible consequences of the study.
We defined patient satisfaction as ‘positive evaluation of specific aspects of health care facility’,[18–20] assessing responses on 5-point Likert scale from 0 (very dissatisfied) to 4 (very satisfied). Assessment of patients’ satisfaction includes ratings of the two VCs’ facilities for the services received and the outcome of the use of spectacles.
Development of questionnaire
The details about how the questionnaires were developed and administered on sample patients have been reported previously. In brief, the initial questionnaire with 16 items (developed from qualitative data) was piloted on 60 patients who accessed the VCs that were not part of the study. At the pilot stage, the questionnaire was verified and reduced to 12 items to suit the context of VC-based eye care services. The Cronbach's α statistic method was used to determine the internal consistency of the 12 items of the questionnaire (Cronbach's α=0.767 for 12 items). Cohen's Kappa Statistic method was used to find the agreement between the two investigators for each item used to assess patient satisfaction (N=60 patients) and the Kappa values ranged from 0.71 to 0.87 for all the items, except two items: Quality (0.41) and affordability of the VCs’ services (0.46). After the pilot, the Field Investigators were retrained and the repeated agreement was found to be satisfactory. The near final questionnaire was repeated three times and was translated to the local language. Two trained investigators interviewed the 127 of the 136 sampled patients at their residences 6 months after their visit to the VCs using the final questionnaire.
Two-step analysis was used to assess the determinants of patient satisfaction. First, items were grouped into factors using factor analysis. Second, these factors were used as dependent variables in the linear regression models to explain variance in-patient. We considered 12 items used for assessing patient satisfaction (outcome variable) for factor and reliability analysis. Independent variables were excluded as these were included in linear regression models to examine the associations between factors and demographic and socio economic items.
The stage-wise data reduction of 12 variables produced three reliable factors (1.)VT; (2.) location of VC; and (3.) access to the services of VC comprised four, three, and five variables, respectively. The author has considered these factors as the three components of dependent/outcome variables, that is, patients’ satisfaction. These were used in linear regression to build explanatory models for patients’ satisfaction. The linearity of the relationship between dependent and independent variables and no serial correlation were the assumptions used to justify the use of linear regression models. The linear regression models were adjusted for the demographic characteristics of the patients–geographical area, age, gender, perceptions of travel convenience, and ease in identifying the VC building. The author has considered <0.05 as the level of significance. The SPSS16th (SPSS Inc, Chicago, IL, USA) was used for the data analysis.
A total of 127 patients from the two VCs at ERL and the two VCs at RRL were interviewed (9 sampled patients were not available). The total participation rate was 93%.The characteristics of the two samples were compared in Table 1. The number of females (n=61) was almost equal to the number of males (n=66) in both the samples. The mean ages were 52.7±9.4 for ERL setting and 53.0±10.9 for RRL setting and was not significantly different (P=0.625). The three factors obtained from factor analysis were entered in three linear regression models to explain the association of patient demographics with patient satisfaction of VC services.
The Table 2 shows the stage-wise data reduction of 12 variables has allowed us to extract three reliable factors that comprised four, three, and five variables, respectively. The Factor-1 (services of the VT) consists of four variables namely – (a) amount of time spent with the VT,(b) personal care received from the VT, (c) information and guidance received from the VT, and (d) overall impression about the behavior of the VT at the VC. This factor explains 29.0% of patients’ satisfaction. The Factor-2 (access to the location of the VC) yielded two variables – (a) transport convenience and(b) ease to identify the VC location, and thus explains 13.9% patients’ satisfaction. Lastly, the Factor-3 (services of VC facility) consists of six variables – (a) the waiting time at the VC,(b) the cost of spectacles at the VC,(c) the quality of spectacles received at the VCs’, (d) the value placed on VCs’ services, (e) the affordability to access the VT's services as compared with other providers, and (f) spectacles’ dispensing time at the VC. Factor-3 explains 18.5 % of patients’ satisfaction. The three components together accounted for 61.50% of the total variance and can explain the patients’ satisfaction with the VCs’ services in the rural settings of the Indian State of Andhra Pradesh.
The three linear regression models [Table 3], refer to an association between Factor 1, Factor 2, and Factor 3 and patients’ characteristics as presented below:
- Factor-1, labeled as ‘Service of VT’: The adjusted R2 for Factor-1 was 0.61; F1,124=144.36, P<0.001, using the stepwise method. The respondents who had ‘difficulty to travel to the place of VC’ had 0.47 units of lower satisfaction levels with the ‘VT's Services’ as compared with those who felt they had ease in traveling to the place of VC facility (P=<0.001).The respondents’ perceived severity of eye problem was associated with patients’ satisfaction. Those who reported ‘somewhat blurred ‘as the eye problem had 0.2 units of lower satisfaction level with the ‘VC's Services’ as compared with those who felt they had severe eye problem (P=<0.002). The respondents’ perceived ability to pay was associated with patients’ satisfaction. Those patients who perceived that they can afford to pay for eye care services had 0.3 units decreased satisfaction level with ‘VT's Services’ as compared with those who cannot afford to pay for eye care services (P<0.004).
- Factor-2, labeled as ‘Access to Location of VC’: The adjusted R2 for Factor-2 was 0.18; F1,124= 29.5, P<0.001 using the stepwise method. The significant variable is shown below. The respondents’ difficulty to identify the building of VC had 0.4units decreased patients’ satisfaction as compared with those who had no difficulty to identify the VC building (P<0.001).
- Factor 3, labeled as ‘ Services of VC’: The adjusted R2 for Factor-3 was 0.36; F1,124=45.6, P<0.001, using the stepwise method.The significant variables are:The respondents’ traveling area (geographical setting to which they had to travel to access VC facility) was associated with patients’ satisfaction. Those who had to travel less distance (<5kms) to the center had 0.4 units of increased satisfaction level with the services of VC as compared with those who had to travel more distance. (P=<0.001).
The respondents who perceived ‘difficulty to travel to the place of VC’ had 0.24 units of decreased satisfaction levels with the services of VC as compared with those who felt they had ease in traveling to the place of VC facility (P=<0.001).
This paper addresses the issue of what determines patient satisfaction with primary eye care services through the concept of VC from the perspective of the patient. Three components of VC model; VT (Factor-1), location of VC (Factor-2) and access to the services of VC (Factor-3), respectively, explained 61.5% cumulative variance of patient satisfaction. Three linear regression models predicted the association between patients’ characteristics and the three components of patients’ satisfaction.
According to the first model (adjusted R2 value = 0.61; F1,124=144.36, P<0.001), the VT components with which the patients were satisfied were: (a) convenience of transportation to access the VT's services, (b) personal care (good listening, good behavior, and empathy), and (c) the duration of time spent with the patient. Communication of information to patients appears to be the source of satisfaction with vision care similar to the findings reported in a study. These results are consistent with a prior study in which a good doctor-patient relationship was associated with general satisfaction.
The reason for this association is that a good patient–VT relationship is an essential component of primary eye care. This finding is consistent with other reports. This evidence also suggests that the satisfaction with the VCs’ services depends on multiple conditions such as the perceived severity of eye problem by the patient and the good outcome of services, (positive impact of appropriate refraction by the VT and the quality of spectacles) the way services are delivered (personal care with empathy) and the ease with which patients are able to access the services (transportation). Communication, respect and patient engagement in provider-patient relationship are important in determining patient's satisfaction. This finding was similar to the report that mentioned patients were more satisfied with their empathetic providers.
In the second model (R2=0.18; F1,124=29.5; P<0.001), the level of satisfaction with the component – ‘Location of VC’ was significantly higher among the patientswho had ease to identify the VC building as compared with those who had difficulty in identifying the VC facility. According to one study, the site of the clinic was reported to be associated with patient satisfaction. The access to facility was reported to be an important source of satisfaction.[2318–20]
Finally, even though the clinical settings for the VC were the same in both the settings of RRLs and ERLs, the satisfaction of the patients with the component – ‘Access to VC facility’ was significantly different as explained by the third model (R2=0.25; F1,124=42.6). Those who were able to access the VC facility with ease and had to travel less were significantly more satisfied with the VCs’ services. This finding implies that the patients’ inclination in utilizing the VCs’ services increases with the increased convenience in accessing the facility. This is particularly important since 42% of total 127 sampled patients had expressed discomfort in accessing the VCs [Table 1].
In our study, we did not find any significant difference in satisfaction levels among men and women.
This data indicate that patients expect the VT at the VC to be (a) an effective communicator, (b) a provider of personal care with empathy, and (c) a guide for giving appropriate information and education. This data corroborates with the statement that ‘Patient Satisfaction’ is assumed to be the fulfillment of expectations. and the quality of communication between the VT and patients is associated with patient satisfaction. Using this data, one can argue that a combination of factors such as good VT, transport convenience, ability to pay, etc. can enhance higher patient satisfaction and this in turn could lead to higher patient participation, which needs to be tested further.
There are several potential limitations to this study. It is found that the general satisfaction with the items used in this study needs to be standardized using a larger sample size. The questionnaire items used in this study could measure only over 61.5% of satisfaction indicating that there are unmeasured items that should have been in the instrument.Further studies are required to comment on the remaining 40% of unmeasured aspects such as cultural acceptance, patients’ expectations of eye care delivery, awareness levels and health status, etc., might influence patient satisfaction. Although statistically significant, the difference in the percentage of patients who were satisfied was small and may not suggest clinical difference. The study results may not be generalized due to its small sample size. Besides this, the participants were approached after 6 months of use of services and may have affected by recall bias. Moreover, the respondents were restricted to only four VCs, which could also be a potential source of selection bias.
In conclusion, this study data on patient satisfaction can be useful for service providers to evaluate the quality care, as an outcome variable, and as a method for quality improvement of VC services.
We are thankful to Brien Holden Vision Institute, Sydney, Australia and Hyderabad Eye Research Foundation of L V Prasad Eye Institute, India for supporting this study. We are thankful to Dr. Bob Biggar for guidance and feed back in developing the manuscript and Ms.SunithaVemuri for editing the paper. We also thank Mr.Ilaiah and Mr. Santosh, for the field investigation. We are thankful to the Vision Technicians and subjects for participation in the study. We are indebted to the Lavelle Fund for the Blind, USA, Latter Day Saints Charities, USA, and Sight Savers International, UK, to support the Vision Center program in Andhra Pradesh, India.
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Source of Support: Brien Holden Vision Institute, Sydney, Australia and Hyderabad Eye Research Foundation of L V Prasad Eye Institute, India.
Conflict of Interest: None declared