Focus Group Discussion and Questionnaire Survey in an Urban Primary Health Centre, Abu Dhabi - UAE. (A pilot study)

Author and Correspondence:
Javid Hamid Farooqi - M.B.B.S, DFM, MFM -
Monash Department of Primary Health Care,
General Authority of Health services,
Middle Region, Abu Dhabi, UAE.
E-mail: jhfarooqi@hotmail.com

ABSTRACT

Objective: To explore patient expectations of general practitioner care along with assessment of their satisfaction with various services provided in the primary health care centre.

Design: Qualitative and quantitative methods. Former included a focus group discussion and later questionnaire survey.

Results: There was overall satisfaction with the general practitioner care although dissatisfaction was expressed with few components of the services provided by the health centre. All the respondents unanimously agreed that good doctor patient relationship is very important for the satisfaction of the patients. They were of the opinion that the doctors should be communicative, compassionate and should attend to psychological and contextual determinants of the illness in addition to biomedical aspects.

Conclusion: Exploring patient expectations is very important for ensuring health care of the highest quality. There is a magical increase in the expectations of the patients and a wide gap exists between patient expectations and general practitioner perceptions of medical care. Therefore, to ensure good general practitioner care, a satisfactory balance should be achieved between patient expectations, general practitioner perceptions and priorities set by health care planners.

INTRODUCTION

General practice has represented a strong tradition of personal care comprehensive in its response to the needs of people and reasonably accessible in their neighborhood.(1) The vast majority of patients regard the general practitioner as first port of call for health regards and as the health professional who they trust to give them advice and treatment.(2) Every patient who comes for consultation has expectations based on his or her understanding of their illness.(3) The expectations of the patients towards medical care are also influenced by cultural background, beliefs, attitudes and level of understanding.(4) How far the doctor reaches an understanding of patient expectations, feelings, and social context of his illness has an impact on the successful outcome of consultations. When doctor's perceptions and patient's preferences are not concordant, it results in dissatisfaction of patients and poor outcomes of consultation. The general purpose of managing expectation is to have as little discrepancy between patient expectations and their actual experience. (5)

The last few decades have witnessed fast economic growth and rapid urbanisation in developing countries. This along with technological advances ,including revolution in information technology worldwide has led to increased demands and new expectations of patients. Now increasingly knowledgeable patients armed with the information from the media as well as guidelines developed by health planners confront physicians (6) with the expectation of quality care of highest standards. On the other hand technological innovations in medicine have shifted doctor's attention away from the personal care of the patients. They have become so much obsessed and dependent on the technology that understanding the patient, his feelings and emotions has become a thing of past. The sense of the growing gap between what patients want and what general practitioners perceive as important has resulted in increased dissatisfaction of patients with the health care system .(7)

It is now widely recognised that the views of patients are important in the measurement of quality of health care. Patient evaluation of care is increasingly seen as a valuable outcome in itself besides measures of clinical effectiveness. Patient perceptions measure quality care from patient's perspectives. Patients' evaluation of health care may reveal quality problems and provide suggestions of not only improving the quality of care but to improve clinical and functional outcomes (8). The goal of primary care systems should be delivery of the highest quality care as determined by measurable outcomes (9). All this demands further exploration of patient expectations and subsequent satisfaction of general practice care and finding ways to improve primary health services, so that these new expectations are met.

The general aim of this study was to identify patients' perceptions, experiences and expectations of services provided by general practitioners and to explore ways to improve these services.
Specific aims were:

• to identify patient perceptions of the doctor patient relationship,
• to discuss patient satisfaction with the consultation,
• to discuss patient participation in problem management,
• to consider the role of the general practitioner in health promotion,
• to obtain patient views about other services provided in health centers and how these services can be improved.

METHODS

Qualitative and quantitative methods were used. Initially focus group discussion took place, which was followed by questionnaire survey.

Focus Group

Focus group discussion took place in one of the urban health centers in Abu Dhabi serving the population of 35,000 people. An advertisement was put on the notice board and patients were invited to register their names at the reception desk. Out of 25 registered patients a homogenous group of 12 patients was selected. 8 patients confirmed participation and 4 did not attend on account of other commitments. The proceedings were audio recorded and subsequently analysed to extract relevant themes and issues.

Questionnaire Survey

The second part of the survey involved a questionnaire survey of 25 patients randomly selected according to their order of attendance at the reception desk in the same primary health centre where the focus group discussion was conducted. The target population was 25 years and above and included both nationals as well as expatriates. The instrument of study was a questionnaire which was developed after literature survey and focus group discussion. Out of 25 patients who agreed to participate only twelve agreed to continue upon receiving the detailed questionnaire.

The questionnaire was in three parts; the first covered demographic details, the second inquired about expectations of general practitioner attitudes and the final part about expectation of other services provided by the health centre. The questionnaire consisted of 23 items both categorical and non-categorical based on seven sub-scales (factors). Basic demographic information was asked from the patients using ordinal scale.

Patient expectations of general practitioner attitude was assessed by using 5 sub - scales (factors) comprising of 14 items. These subscales were:

• Doctor patient relationship.
• Communication.
• Concern about patients' social and psychological problems.
• Patient involvement in decision making.
• Health promotion.

Patients were asked to rate their responses on a 5 point likert scale. At the end information about barriers to getting good medical care were sought in two open ended question.

Data Analysis

This was done by doing the frequency analysis and factor analysis of the data collected from respondents. Mean score of each item was calculated and from this mean score each factor was determined

Focus group
A wide range of topics regarding patient expectations were discussed and valuable insight was gained about patient perceptions and experience of general practitioner care.

Doctor patient relationship
All participants agreed that good doctor patient relationship is very important for the outcome of consultations. It was a general view that attentive listening and a caring attitude is very important for developing good doctor patient relationship. All the participants agreed that they were enjoying good doctor patient relationship and were satisfied with the quality of the consultation.

Qualities of a general practitioner
Participants unanimously agreed that the most important qualities of a general practitioner are attentive listening, understanding and compassion. They expected their general practitioners to possess these qualities. Knowledge and the skills though important for being a good general practitioner were rated second.

Involvement decision making
Most of the participants expected that patients should be actively involved in management of their problems and in case there is

conflict of the opinion, the doctor should use his skills to find some common ground. They were also of the opinion that patients should be kept fully informed about their illness, drugs prescribed and their side effects.

Health promotion and education
All the participants agreed that health education was very important for health maintenance. They expected the primary health teams to be actively involved in the health education of their patients.

Other services
Participants showed overall satisfaction with the other services provided in the health centre. However, they showed dissatisfaction with the referral system, service charges and waiting time. They also wanted to receive vaccination for infectious diseases before proceeding on vacations to their native countries.

Results of questionnaire survey
Doctor patient relationship
This sub scale measures the importance of doctor patient relationship for the successful outcome of the consultation and obtained a mean score of 4.2. Frequency analysis of various items in this sub-scale showed that patients consider good doctor patient relationships very important for their satisfaction (score 4.6).

Communication
This scale measures the extent to which effective communication helps in understanding the patient and his illness and scored mean 4.2. All the respondents were of the opinion that listening attentively to the patient is as important as performing a physical exam and investigations (score 4.4). Patients were of the view that the doctor and patient speaking the same language helps in understanding the patient better (score 4.0) and wanted the doctors to keep them fully informed about their illness (score 4.2) .

Social and psychological concern
This sub scale received the highest mean score (4.6) and reflects the importance given by the patient to the interpersonal aspects of consultations. All the samples agreed that the general practitioner should not attend only to the physical disease of his patients but also attend to their psychological and social problems (score 4.4.) All unanimously agreed that providing emotional support to their patents (score 4.7) and alleviating their anxieties about the illness (score 4.6) is a part of a General Practitioner's job .

Decision making
Most of the respondents were of the view that patients should be involved in decision making and agreed that it will increase the compliance of patients (mean score 4.0).

Health Promotion
All the sample agreed that doctors should provide advice about risk avoidance to his patients (score 4.6). however the opinion was divided as to whether all the patients follow the advice of their doctors (score 3.6). Mean score for the factor was 4.1.

Satisfaction with health services facilities
This sub scale measures the Patient satisfaction with different facilities available in primary health centers. There was overall satisfaction with the various health service facilities (mean score 4.1.) The general practitioner consultation obtained the highest mean score (4.5) and dental service and waiting time lowest mean score (3.6). Two open ended questions were asked to enquire about difficulties faced by patients in getting good general practitioner care and their opinion on improving the services. Forty per cent of the respondents felt that health services were too expensive and wanted a reasonable reduction in the charges. Thirty per cent of the sample felt that big rush in the clinics was the main difficulty they were facing and wanted appointment systems to be introduced. Dissatisfaction was shown by twenty per cent of sample with referral system to secondary care hospitals and by ten percent with laboratory facilities.

DISCUSSION

The general term expectation is often used to indicate what patients hope will happen whether or not they explicitly verbalise their expectations as requests. (10) The general practitioner faces a dilemma of increased patient expectations and the need for recognising patient expectations is considered an important objective for primary care systems.

A number of studies suggest failure to identify patient expectations can lead to patient dissatisfaction with the care, lack of compliance and inappropriate use of medical resources.(11) Patient's satisfaction with the health care is the important health outcome. It has been observed that priorities of patients regarding health care have changed during the last few decades. It has also been recognised that patients may define success differently from health care professionals and patients expect their definitions, qualities and benefits recognised(2). Given the fact that an estimated 15-25% of primary care patients have unmet expectations, it is apparent that identifying the patients' agenda is an important step to improve patients' satisfaction and other health care outcomes. (10)

In order to measure patient assessment of care, various methods have been used which include in-depth interview, focus group discussions and survey. Out of these, performing a patient survey is a frequently used method for patient evaluation of general practice care(12). In this study, a patient survey was conducted in two parts using both qualitative (focus group) & quantitative method (questionnaire survey).

This study gives a valuable insight into patient expectations of general practitioner care. What emerges from this study is that although patients expressed their overall satisfaction with general practitioner care, they were not fully satisfied with some components of the service provided in the health centers.

Among scales used for measuring patients' expectations of general practitioner attitude, scale 3 got highest score. This scale measures patient perceptions of doctor's attitude to social and psychological determinants of their illness. Patients expect their general practitioner to attend to their social and psychological needs and to provide them with emotional support in difficult situations. At the start of the 21st century a vital patient centered primary care system has much to offer to a changing population with the increasing and diverse needs and expectations (9).

Stephen G.G. states "modern man's health needs require consideration of whole and is carried out with context of personal relationship to doctor and patient" (13).' MC Whinney states, "responding to sufferings is our moral obligation" (1).

The participants in the focus group viewed compassion, attentive listening and effective communication as most important qualities of general practitioners. The same was reflected in the questionnaire survey where communication scale ranked second highest. Horwood states that there are certain qualities in a doctor which encourage the healing process and the ability to listen is the most important (14). Understanding the complexity of a patient's story is important if you do not want to miss information that will prevent you oversimplifying the story to meet your personal diagnosis (15). Empathy should characterise all health care professionals because despite advancement in medical technology the healing relationship between physicians and patients remains essential to quality care.

Factors like patient involvement in decision making emerged as equally important. Most of the participants agreed that patients should be involved in decision making and felt it will increase compliance and good outcome. Starfield found agreement about the diagnosis between doctor and patient was a strong predictor of good outcomes (16). The clinical decision making process became very important and it seems crucial that patients be involved when a course of therapy is chosen, not just to improve patient satisfaction with process but to improve clinical and functional outcome (17). Checkni DC et all wrote that there is growing evidence that patients' expectations affect outcomes, allowing patients to choose treatment they believe will be helpful (18).

The emphasis of participants on health promotion and prevention was not out of place in view of the fact that illness we see today is behaviourally determined and results from too much eating, drinking and being under too much stress.

Both the surveys revealed that participants were not satisfied with same of the components of general practitioner care such as long waiting time, expensive services change, referred system. These are the genuine concerns and need to be addressed.

Overall results of both studies revealed that there was a high level of satisfaction with general practitioner care especially, although they expressed concerns about other services. William et all conclude that high reported satisfaction ratings can not be taken to indicate that patients have had or are having a good experience in relation to particular services (19). Fitzpatrich notes that the possible reason for high levels of satisfaction is that patients are usually reluctant to criticise their doctors (the so called normative effect) 20.

Key messages from this study are:

• The doctor patient relationship is very important for a good outcome of the consultation. Developing a therapeutic relationship with patients should be one of the goals of the general practitioner.
• Patients should be regarded as active partners in the management of their problems because they no longer want to be passive partners in the consultation.
• In view of the increased emphasis on behavior modification, there is a need to have a much clearer understanding of human behaviour and educating masses in this regard. Public health teams can prove more effective in this regard.
• Enhancing the role of preventive services in primary health centers needs further attention

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