LJM 1993-2820 1819-6357 Libyan Journal of Medicine, Vol. 5, No. 0, October 2010, pp. 1–7 sici xxx PUBMED Abbreviation Asharaf AbdulSalam

*Asharaf Abdul Salam, Faculty of Public Health, Garyounis UniversityBenghaziLibya

Amina AbdullaAlshekteria HanaAbd Alhadi MariamAhmed AneesMohammed Faculty of Public Health Garyounis University

BenghaziLibya

Libyan Journal of Medicine ORIGINAL ARTICLE Patient satisfaction with quality of primary health care Introduction: The Libyan National Health System (LNHS) is debated for the paradox of its performance versus impact. It has poor performance, but the national health statistics are good and competitive. There are concerted efforts to manage health care services and to regain the lost trust. A primary health care (PHC) system that focuses on preventive and promotive care is the core focus of LNHS efforts. Objectives: To assess patient satisfaction with quality of PHC assessed in terms of (a) customer profile, (b) patient satisfaction, and (c) health care-seeking behavior. Methodology: A sample of nine health centers and seven polyclinics from various locations in Benghazi, Libya were selected for gathering information by structured face-to-face interviews. A total of 310 beneficiaries were interviewed by using an Arabic translation of the Charleston Psychiatric Outpatient Satisfaction Scale. Results: The beneficiaries appear to be quite satisfied with the quality of services. Geographical zone, marital status of beneficiary, and type of facility are satisfaction-related factors. There are preferences for facilities located within the City Centre over those located elsewhere. There is also an interaction effect of the geographical zone and the type of facility in creating differences in satisfaction. Conclusions: A customer-friendly facility concept that emphasizes reception, physician interaction, and cordiality shall add value. Polyclinics require more attention as does the Al Slawy area. A few utility services might also be considered. exit interviews Health For All by All geographic zone administrative and environmental factors health-seeking behavior interaction effect type and location of facility place of residence Primary health care (PHC) – preventive and promotive – receives prime importance under the Libyan National Health System (LNHS). Services are offered through polyclinics, health centers, health units, and workplaces 1, free of cost and within close proximity. Following Alma-Ata Declarations, the LNHS expanded PHC services to include general medical care (for adult population and elderly), care of children, minor surgeries, rehabilitation, family planning, obstetric care, perinatal care, first aid, dispensing of pharmaceutical prescriptions, preventive programs (immunization, screening, etc.), health promotion, and school health 2. The Secretariat of Health and Environment has been designated as the nodal agency to (a) administer PHC services; (b) ensure sustainability; (c) strengthen quality; and (d) emphasize community and outreach services 3.The Libyan Health System offers PHC services through its public health care network, free of charge to all citizens. Major reforms in PHC were witnessed during 1990s in the form of National Health Strategy, National Health Decree, Health For All by All, and other actions 2. The PHC services are provided in Benghazi through 39 facilities: 10 primary health centers, 11 polyclinics, and 18 health units (Secretariat of Health, Benghazi). Based on the national motto of PHC, namely, ‘Health For All by All,’ the secretariat of health in Benghazi stresses (a) comprehensiveness; (b) equal distribution and utilization of resources; (c) integration of health development within the whole process of socioeconomic development; (d) cooperation with the other related sectors; (e) use of appropriate technology; (f) community participation and involvement; and (g) establishing a link between people and PHC units 3. There are efforts to offer high quality of care at PHC level by (a) strengthening health administration, management training and improving health information and documentation systems; (b) developing health manpower resources through continuous education; (c) fostering concepts of PHC in medical schools; (d) maintaining existing health facilities for diagnostic and therapeutic capabilities; (e) improving methods of medical supplies; (f) advocating cooperation with the international, regional, and Arab organizations; and (g) increasing financial resources by creating new sources of funding and promoting rational use of available resources 3. Through Health Decree 24 of 1994, PHC in Libya was promulgated to restructure the system and to endorse elements such as mental health, school health, occupational health, and geriatric health 2.PHC, as conceived by the International Conference held at Alma-Ata, requires full participation of all stakeholders and is offered at an affordable cost to create self-reliance and self-determination 4 in order to protect and promote the health of the world's population. These in turn facilitate attainment of the highest level of health and reduce gross inequality in health status. Quality of care is the prime consideration at this point: to offer proper services at the right time and provide the greatest health benefits with the least health risks to the greatest number of people given the available resources 5. Quality of care is ‘a property of and a judgment upon, some definable unit of care and that care is divisible into at least two parts: technical and interpersonal. At the very least, the quality of technical care consists of the application of medical science and technology in a manner that maximizes its benefits to health without correspondingly increasing its risk’ 6.Quality of care within the context of PHC has technical, non-technical, and programmatic elements. The technical aspect refers to treatment techniques and equipments used, the non-technical aspect refers to the clients’ waiting time and the staff's attitudes; and the programmatic aspect refers to policies, infrastructure, accessibility, and management. Quality might also be understood from (a) structural measures focusing on internal characteristics, (b) process measures focusing on procedures, such as diagnosis; and (c) outcome measures focusing on observed changes in health status 7. A dual perspective of quality of care considers the clients’ concerns about technical competence as essential to quality healthcare 8. From a providers’ perspective, quality means offering technically competent, effective, and safe care that contributes to an individual's well-being. Accordingly, elements that could produce an impact might include (a) client's knowledge; (b) client's health; or (c) client's satisfaction. As proposed by the above theorists, patient satisfaction is a reflection of the quality of care received. Measurement of satisfaction associated with improved clinical outcomes and administrative measures of quality 9 shall lead to identification of opportunities for improvement and competition.It was in this context of the increasing importance of the quality of PHC in the Libyan health system and its importance in determining patient satisfaction, that this current study was carried out to assess (a) customer profile, (b) customer satisfaction; and (c) health-seeking behavior. This survey was conducted during January–February 2009 at PHC facilities (health centers and polyclinics) located in various geographical zones of Benghazi. The survey included nine primary health centers and seven polyclinics selected through a lottery method and giving geographical (cluster) representation (Table 1). Health centers Polyclinics Facilities All Selected Interviews All Selected Interviews Total interviews Al Birka 4 3 40 5 3 40 80 Al Slawy 3 3 60 3 1 20 80 City Centre 3 3 110 3 3 40 150 Total 10 9 210 11 7 100 310 This survey was carried out by face-to-face interviews with the patients. The interviews were held as exit interviews within the facility premises. The Charleston Psychiatric Outpatient Satisfaction Scale (Likert-type scale) was translated into Arabic. This 15-item E5 response format (Excellent, Very Good, Good, Fair, and Poor) is intended to minimize positive response bias and optimize variability and predictive validity 9. The 15th item assesses behavioral intent to recommend the facility by using a 4-point scale (Yes Definitely, Yes Probably, No Probably Not, and No Definitely Not). Some are predictor items, such as overall quality and recommendation intent, and the other items assess administrative and environmental factors unique to the outpatient setting: helpfulness of secretariat, waiting time, amount of information received about the problem, respect for opinions, matching treatment plan with individual needs, helpfulness of services, appearance of waiting room, appearance of office, working hours, location, and parking.The survey process was standardized by allotting three man-days in each facility during the morning shift. It was decided to conduct exit interviews with as many beneficiaries as possible within these three man days by adopting a random sampling method. Instructions were laid down to the researchers in the form of a Survey Manual.Survey monitoring and data quality assurance was carried out by regular discussions with researchers, editing at field level, and centralized editing. The data were coded, computerized, cleaned, and analyzed. A total patient satisfaction score was calculated by adding the scores of all the items except items 2 and 14 (payment and billing, which are not applicable because the services are offered free), item 8 (overall quality, an anchor item), and item 15 (recommendation intent). With each of the 11 included items scored as 5 (excellent), 4 (very good), 3 (good), 2 (fair), or 1 (poor), the total score varies between 11 and 55.The data were analyzed by ANOVA (one-way and two-way), t-test, and Chi-square test. P-values <0.05 were considered significant.Data collection was carried out with approval from Faculty of Public Health, Al Arab Medical University and also after obtaining permission from the Secretariat of Health and the concerned centers. Informed consent was obtained from the patients. The patients were mostly females (64.2%), had low levels of education, were married, and worked in service-oriented jobs (Table 2). Zone Total Profile Al Birka Al Slawy City Centre ^aTwenty patients in Al Birka did not indicate educational level and are excluded from the calculation of percentage. Note: Numbers in parentheses are percentages. Age  15–24 17 (21.3) 17 (21.3) 17 (11.3) 51 (16.5)  25–59 56 (70.0) 57 (71.3) 122 (81.3) 235 (75.8)  60 +  7 (8.8) 6 (7.5) 11 (7.3) 24 (7.7) Sex  Male 24 (30.0) 34 (42.5) 53 (35.3) 111 (35.8)  Female 56 (70.0) 46 (57.5) 97 (64.7) 199 (64.2) Education^a  Primary 9 (15.0) 22 (27.5) 29 (19.3) 60 (20.7)  Middle 9 (15.0) 19 (23.8) 38 (25.3) 66 (22.8)  Secondary 20 (33.3) 25 (31.3) 50 (33.3) 95 (32.8)  Higher 22 (36.7) 14 (17.5) 33 (22.0) 69 (23.8) Marital status  Currently married 63 (78.8) 36 (45.0) 97 (64.7) 196 (63.2)  Divorced 1 (1.3) 27 (33.8) 19 (12.7) 47 (15.2)  Widowed – 2 (2.5) 8 (5.3) 10 (3.2)  Single 16 (20.0) 15 (18.8) 26 (17.3) 57 (18.4) Occupation  Teachers 7 (8.8) 2 (2.5) 11 (7.3) 20 (6.5)  Police 6 (7.5) 7 (8.8) 12 (8.0) 25 (8.1)  Other government job 30 (37.5) 32 (40.0) 49 (32.7) 111 (35.8)  Business 29 (36.3) 35 (43.8) 48 (32.0) 112 (36.1)  Unemployed – 1 (1.3) 2 (1.3) 3 (1.0)  Retired 8 (10.0) 3 (3.8) 28 (18.7) 39 (12.6) Type of family  Nuclear 68 (85.0) 58 (72.5) 113 (75.3) 239 (77.1)  Joint 12 (15.0) 22 (27.5) 37 (24.7) 71 (22.9) Size of family   ≤ 6 45 (56.3) 35 (43.8) 68 (45.3) 148 (47.7)  7–9 20 (25.0) 24 (30.0) 35 (23.3) 79 (25.5)   ≥ 10 15 (18.8) 21 (26.3) 47(31.3) 83 (26.8) Total 80 (100.0)^a 80 (100.0) 150 (100.0) 310 (100.0) The female–male ratio was highest at Al Birka and City Centre (7:3 each) than in Al Slawy (3:2). Women have been reported to be frequent users of PHC in other populations as well 10. Female-oriented issues and childhood, likely take a higher importance at PHC facilities. A higher proportion of females (20.6% as against 9.0% in males) were in the age group of 15–24 years, indicating that there was a high demand for adolescent health and reproductive health care services at these facilities.The pattern of educational status was similar in Al Slawy and City Centre, but with a slight trend to a lower level in the former. In Al Birka, 20 patients (25%) did not answer this question, which makes it unadvisable to draw conclusions regarding the seemingly higher educational level in this area.There was a high demand from married persons (Table 2). This might not relate to the national population characteristics, as the mean age at marriage remains high in Libya (33 years for males and 29 years for females) 1. More patients from Al Birka were married (78.8%) compared to the City Centre (64.7%) and Al Slawy (45.0%). Among patients from Al Slawy there was a higher proportion of divorcees (33.8%). Two-thirds (66.8%) of those who were married were females and over half (56.8%) were males. A larger proportion of divorced persons were males (30.6%) compared to females (15.2%).Though family bonds were strong in Libya, families were generally nuclear, and this was observed among the patients. The proportion of nuclear families was highest in Al Birka (85.0%), followed by City Centre (75.3%) and Al Slawy (72.5%). Half the families (52.3%) had more than six members at home. The frequency of small families (up to six members) was higher in Al Birka (56.3%) than in the City Centre (45.3%) and Al Slawy (43.8%). The total satisfaction score was calculated by summing up items 1–13 of the Charleston Scale, but excluding items 2 and 8. Two-way ANOVA, one-way ANOVA, t-test, and Chi-square test were used to identify variables affecting satisfaction.The overall average satisfaction score was 42.7. Satisfaction with PHC services is usually high 11. Geographic zone was found to be an important factor in creating satisfaction (F-value = 13.09; p=0.00). Thus, the location of the health facility was important in determining satisfaction (Table 3). Mean satisfaction level was higher in the City Centre (44.4) than in Al Slawy (a mean of 41.5) and Al Birka (40.7). Variable/Groups Number of cases Mean satisfaction F-value P-value ^aTwenty persons did not respond. Geographical zone  Al Birka 80 40.7 13.09 0.00  Al Slawy 80 41.5  City Centre 150 44.4 Marital status  Currently married 196 42.3 1.99 0.14  Widowed/Divorced 57 44.1  Unmarried 57 42.6 Education^a  Primary and middle 126 42.7 0.53 0.43  Secondary 95 42.3  Higher 69 41.9 Family size   < 6 persons 148 43.0 0.30 0.74  7–9 persons 79 42.6  10 and more persons 83 42.4 Occupation  Government sector 156 42.8 0.013 0.99  Business 112 42.6  Unemployed 42 42.7 There was no significant difference in patient satisfaction between the married and unmarried persons (F=1.99; p=0.14). Education, occupation, and family size had no relevance in creating differences in satisfaction.The effect of the type of facility, gender, and type of family on satisfaction was analyzed by an independent sample t-test (Table 4). Only the type of facility was found to produce a significant difference in satisfaction (t= − 2.04; p=0.04), with patients expressing greater satisfaction with health centers than with polyclinics. It might be inferred that health centers offer comparatively better quality of services. Variable/Groups Number of cases Mean satisfaction t-value P-value Type of facility  Polyclinic 100 41.7 −2.04 0.04  Health center 210 43.2 Sex of client  Male 111 43.4 1.58 0.12  Female 199 42.3 Type of family  Nuclear 239 42.8 0.70 0.49  Joint 71 42.3 Mean satisfaction among males and females were not significantly different (p=0.12). There was also no significant difference in satisfaction level across the three localities (Table 5). Variable/groups Satisfaction score ≤40 n (%) Satisfaction score >40 n (%) Pearson's chi-square Significance Age  15–24 21 (41.2) 30 (58.8) 3.4 0.06  25 and above 73 (28.1) 186 (71.8) Place of residence  Al Birka 34 (30.4) 78 (69.6) 3.1 0.21  Al Slawy 39 (35.5) 71 (64.5)  City Centre 21 (23.9) 67 (76.1) Comparison of satisfaction level in age groups showed that patients who were 25 years or older were significantly more satisfied (p=0.06) than those who were younger (Table 5). This indicates that younger patients had higher expectations and were more critical. These results confirm the findings of a similar study conducted in United Arab Emirates 12. Some patients sought treatment in a facility outside their zone of residence. This choice was significantly associated with the zone of residence. A higher proportion of persons from Al Birka and Al Slawy sought facilities outside their residential zone (&khgr;²=24.01; p<0.01). Half of those residing in Al Birka and over one-third of those from Al Slawy went outside their residential area (Table 6a). By contrast, only 13.6% of the City Centre residents went to another zone. Looked at from the other perspective, 49.9% of those attending facilities in the City Centre came from other zones, whereas only 8.8% of those attending Al Slawy facilities were from other zones (Table 6b). Facility Residential zone No. of patients Within the residential zone Outside the residential zone Al Birka 112 61 (54.5) 51 (45.5) Al Slawy 110 73 (66.4) 37 (33.6) City Centre 88 76 (86.4) 12 (13.6) Total 310 210 (67.8) 100 (32.2) b. Seeking facilities by the location of facility Residential zone Facility zone Number of patients From within From outside Al Birka 80 61 (76.3) 19 (23.8) Al Slawy 80 73 (91.3) 7 (8.8) City Centre 150 76 (50.1) 74 (49.9) Total 310 210 (67.8) 100 (32.2) These results indicate that in general there was more satisfaction with the facilities in the City Centre. This was supported by analysis of satisfaction among the 100 persons who attended facilities outside their zones. Those attending facilities in the City Centre were more satisfied (mean 44.6) than those going to Al Birka and Al Slawy (means 39.6 and 34.6, respectively) (Table 7). The differences in satisfaction scores are statistically significant (F-value = 18.0; p=0.00). This suggests that persons seek services in facilities with which they were more satisfied even if they were outside their residential zone. Variable/groups Mean satisfaction Number of cases F-value Significance ^aTwo patients gave no response. Geographical zone  Al Birka 39.6 19  Al Slawy 34.6 7 18.0 0.00  City Centre 44.6 74 Education^a  Primary and middle 43.8 46  Secondary 42.2 30 1.67 0.19  Higher 41.2 22 Marital status  Currently married 43.4 68  Widowed/divorced 42.3 17 0.82 0.44  Unmarried 41.3 15 Occupation  Government sector 43.1 46  Business 43.3 37 0.79 0.46  Unemployed 41.2 17 Family size   < 6 persons 44.8 45  7–9 persons 41.4 21 4.8 0.10  10 and more persons 41.2 34 Family size was also related to satisfaction (F-value = 4.8; p=0.10). Mean satisfaction was higher among those who reside in small families as compared to medium and large families (44.8, 41.4, and 41.2). Education, marital status, and occupation were not significantly associated with satisfaction.Type of facility was another variable that produced differences in satisfaction (Table 8). More satisfaction was expressed by those attending health centers (mean 43.9) than polyclinics (41.0) (t-value = − 2.4; p=0.02). These statistics indicate that those who access health centers located at zones outside their own residential zone were more satisfied. On the other hand, health centers were more satisfactory than polyclinics for those who seek care away from their homes. Variable/groups Number of patients Mean satisfaction t-value P-value Type of facility  Polyclinic 35 41.0 –2.4 0.02  Health center 65 43.9 Sex of client  Male 36 43.6 0.94 0.35  Female 64 42.5 Type of family  Nuclear 72 43.5 1.6 0.111  Joint 28 41.4 In creating differences in satisfaction, there was an interaction effect between the two types of facilities on the one hand, and the three zones in which the facilities were located, on the other hand. While both of these variables create differences in satisfaction independently, differences were also created through interaction of these two sets of variables (Table 9). The difference in patient satisfaction due to the main effect of facilities was found to be insignificant (F=2.31; p=0.128). The main effect of the zone was found to be highly significant (F=14.3; p=0.000), meaning that satisfaction varies widely across zones. The interaction of these variables in patient satisfaction was highly significant (F=31.6; p=0.000), which means that variations in patient satisfaction across zones were created through the type of facilities. Mean square F-value P-value Note: R²=0.985. Model 94,719.5 3,441.6 0.000 Facility 64.3 2.31 0.128 Zone 392.4 14.3 0.000 Interaction 869.5 31.6 0.000 Error 27.5 – – This interaction was evident from Table 8, which shows that health centers create a high level of satisfaction (mean of 43.2) compared to polyclinics (mean of 41.7). Health centers in City Centre create a satisfaction score of 45.3, which was followed by Al Birka (mean of 42.9) and Al Slawy (mean of 39.4) (Table 10). Polyclinics, on the other hand, were highly satisfactory at Al Slawy (mean of 47.8), followed by City Centre (mean of 41.9) and Al Birka (mean of 38.5). Thus, there was a disparity in the health center versus polyclinic issue in that polyclinics at Al Slawy were more satisfactory in offering quality services, whereas health centers in City Centre and Al Birka were more satisfactory. Zone/Facility n Mean satisfaction Standard deviation Al Birka  Polyclinic 40 38.5 6.13  Health center 40 42.9 6.23  Total 80 40.7 6.53 Al Slawy  Polyclinic 30 47.8 2.24  Health center 60 39.4 6.40  Total 80 41.5 6.72 City Centre  Polyclinic 40 41.9 4.80  Health center 110 45.3 4.26  Total 150 44.4 4.65 Total  Polyclinic 100 41.7 6.04  Health center 210 43.2 5.90  Total 310 42.7 5.98 Customers of the public sector PHC facilities in Benghazi expressed high levels of satisfaction. Factors related to differences in satisfaction were type and location of facility and age of customer. The decision to select a facility was associated with the place of residence. Persons seeking a facility outside of their residential zone were more satisfied. More satisfaction was expressed for health centers than for polyclinics, and there was an interaction of satisfaction between the geographical location and type of facility. The authors have not received any funding or benefits from industry or elsewhere to conduct this study. Thanks are due to Mailud El Amari for his valuable contributions in conceptualizing the project and to Diwa Pandey for editing an earlier version of this paper. Thanks are also due to the anonymous reviewers. Their comments and suggestions contributed to shaping this paper. World Health Organization. Country cooperation strategy for WHO and the Libyan Arab Jamahiriya 2005–2009. Cairo: Regional Office for the Eastern Mediterranean; 2006. Singh R, Abudejaja A, Sudani O. Libyan health service; current achievements and future challenges. Jam Med J (suppl). 2007; 7: 3–17. World Health Organization. Health system profile – Libya. Cairo: EMRO Regional Health Systems Observatory; 2007. World Health Organization. Declaration of Alma-Ata international conference on primary health care held in Alma-Ata, USSR, 6–12 September. Geneva: WHO; 1978. VerschurenPJMMasselinkH. Role concepts and expectations of physicians and nurses in hospitals Soc Sci Med. 199745 11358 DonabedianA. The definition of quality and approaches to its management, Volume 1: explorations in quality assessment and monitoring Health Administration PressAnn ArborMI1978 DimickJBBirkmeyerNJO. Measuring the quality of surgical care: structure, process or outcomes J Am Coll Surg. 2004198 6262 BruceJ. Fundamental elements of quality of care: a simple framework Stud Fam Plann. 199021 6191 PellegrinKLStuartGWMareeBFruehBCBallengerJC. A brief scale for assessing patient's satisfaction with care in outpatient psychiatric services Psych Ser. 2004198 6262 PaltiHGofinRAdlerB. Utilization of prenatal care services in larger townships in Israel Isr Med Assoc J. 20046 1382 AlshettiMMAlsyadJJ. Patient satisfaction with primary health care services in Bahrain J Bahrain Med Soc. 200618 458 MargolisSAAlmarzouqSRevelTReedRL. Patient satisfaction with primary health care services in the United Arab Emirates Int J Qual Health Care. 200315 2419