1. Dr. Nada Al Emadi, MBBS, ABFM
Specialist in Family medicine
Primary Health Care - Qatar

2. Dr. Samya Falamarzi, MBBS, ABFM
Consultant in Family medicine
Primary Health Care - Qatar

3. Dr. Mohamed Ghaith Al-Kuwari, MBBS, ABCM, FFPH (UK), FPHM
Consultant in Public Health medicine & Health Promotion
Primary Health Care - Qatar

4. Dr. Amna Al-Ansari, MBBS, ABFM
Specialist in Family medicine
Primary Health Care - Qatar

Correspondence:
Dr. Nada Al Emadi
Primary Health Care Department
P.O. Box 3050
Doha - Qatar
E-mail: Nadaalemadi@yahoo.com

INTRODUCTION

Satisfaction, is defined as a psychological state resulting when the emotion surrounding disconfirmed expectations is coupled with consumer's prior feelings about the consumption experience.⁽¹⁾ Patient satisfaction has become an important indicator of quality of primary care and health care performance.^(2,3)
Patient satisfaction with health care is important for several reasons. Firstly, satisfied patients are more likely to maintain consistent relationships with their care provider. Secondly, by identifying source of dissatisfaction, the primary care administration can address system weakness, thus improving their services⁽⁴⁾. Thirdly, satisfied patients are more likely to develop a deeper and longer lasting relationship with their medical provider leading to improved compliance, continuity of care and ultimately better health outcomes.^(5,6)
It is reported that low patient satisfaction is associated with lower trust in caregivers and greater chance of physician changes resulting in less continuity of care,⁽⁷⁾ while, high patient involvement in care has been associated with higher trust and satisfaction.^(8,9)
Patients' satisfaction surveys have a long history in the assessment of consultation and patters of communication^(10,11) and are amongst the best means of assessing the interpersonal aspect of care.⁽¹²⁾ Many studies measuring patient satisfaction with primary health care services have been conducted in many countries with a wide range of methods used; questionnaire with Likert scale has been accepted as the simplest method.^(13-15)
In Qatar there are 21 health centres with ongoing building of new centres, and renewing and expanding the old ones. A previous Qatari study in patient satisfaction based on self administered survey of patients receiving care in one hospital and one primary health centre revealed that respondents were more satisfied with the services provided through the hospital. This may be due to the fact that the hospital had more modern facilities and medical specialists⁽¹⁶⁾. Starting from the previous study, we found it is important to study patient satisfaction with the primary care services at national level and by using a more validated measurement tool. Therefore this study aims to measure patient satisfaction with primary health care centers in the state of Qatar and to identify the socio-demographic factors affecting their satisfaction.

This cross-sectional study was carried out in all the twenty-one health centres in Qatar in August and September 2008. Most of the health centres are serving large numbers of patients and offering variable health services from prevention of diseases to treating them.
The study included both male and female adult patients attending the primary health care centres from all nationalities. Subjects were selected by using systematic random sample by taking every tenth patient according to their order of attendance at the reception desk, between August and September 2008.
The data were collected by using Arabic and English questionnaire, which were conducted by experienced interviewers. This questionnaire was developed by Makhdoom et al in Saudi Arabia⁽¹⁷⁾ and it covers the standards domains used in North American and European surveys including the Donabedian survey⁽¹⁸⁾. It includes six sections: accessibility to the services (7 items), continuity of care (6 items), and humanity of staff (8 items), comprehensiveness of care (5 items), provision of health education (5 items) and effectiveness of services (8 items).for each of these domains Makhdoom⁽¹⁷⁾ developed new questions based on the published literature about patient satisfaction, especially the paper by Carr-Hill.⁽¹⁹⁾ The questions were translated into Arabic then retranslated by a different bilingual person who had not seen the original English version. The research team and the translators had resolved any areas of disagreement by discussion. Makhdoom et al⁽¹⁷⁾ reported that face validity was obtained from discussions with five family and community consultants and reliability was 83% for split half testing. The response was rated in a 5 point Likert scale 'strongly agree', 'agree', 'don't know', 'disagree', and 'strongly disagree'. The overall satisfaction was defined as the average score of the six measured domains of satisfaction.
The questionnaire also included questions about socio-demographic characters such as sex, age, nationality, marital status, job, education level and the income.
A verbal consent was taken from the patient before starting to fill in the questionnaire. An experienced bilingual interviewer in each of the health centres supervised and assisted the patients to fill in or understand the questionnaire in a private room.
The statistical package of the social sciences (SPSS) version 14.0 was used to analyse the data. Mean, standard deviation and frequency distribution were calculated. Multiple comparisons were carried out by One-Way Analysis Of Variance (ANOVA). We studied t-tests wherever applicable; correlation-coefficient has been calculated to see the association among different aspects-value (a=0.05) and were set to indicate satisfaction significance level. Satisfaction level has been calculated through all the indices of care. If the total of indices is 0.5 to 2 it represents (satisfied), -0.499 to 0.499 it represents (don't know) and -0.5 to -2 has been taken as (dissatisfied). The score 0.5 to 2 has been taken into consideration of overall satisfaction.

Out of the 315 questionnaires that were distributed, 282 were completed, making a response rate of 89.5%. Of all participants, males were 127 (45%) and females were 155 (55%). The age in the range between 18-40 years forms 65.6 % of the sample.
As shown in Table (1), the great majority of the sample were married 218 (77.3%) and Qatari's represented just 104 (36.9%). 131 (46.5 %) of the sample were graduates and 188 (66.7%) were employed. 202 (71.6 %) participants have satisfactory income.
The overall satisfaction was 75.2%. The highest score of satisfaction for the aspect of services was for accessibility to the health services (98%) and the lowest was for comprehensiveness of care (92.6%), as shown in Table (2).
Table (3) shows the satisfaction according to demographical characteristics of the client. Regarding gender of the patient, there was no statistically significanct difference in all aspects of care but observationally, females were less satisfied than males with continuity of care. Patients between 18-40 years were less satisfied with continuity of care while patients >60 years were more satisfied with all aspects of care. There was significant difference in satisfaction between Qatari and non-Qatari patients. Non-Qatari were more satisfied with accessibility to services (p-value < 0.01), continuity of care (p-value < 0.03), and comprehensiveness of care (p-value < 0.04).
Table (4) illustrates the relationship between satisfaction and socio-economic determinants of the patients. Single patients were less satisfied with the continuity of care and the divorced patients were less satisfied with the previous aspect and provision of health education, while the widowed were more satisfied in all aspects of care. According to marital status, there was no statistical difference among all the categories. The students and housewives were less satisfied with continuity of care (p-value < 0.04). Also continuity of care got low satisfaction from the secondary, university, post graduate and lo- income patients.

*Statistically significant

*Statistically significant

Primary health care is essential in delivering health services that are curative and integrated (20). Identification of patient requests, needs, and judgment on health care received is the starting point of a patient centred approach (21,22). Therefore, patient satisfaction is considered as an important measure to evaluate the quality of health services and can predict both compliance⁽²³⁾ and utilization⁽²⁴⁾ that is associated with the continuity of care⁽¹³⁾, the doctor's communication skills⁽²⁵⁾ and confidence in the medical system.⁽²⁶⁾
This study assessed the overall patient satisfaction level for health care services provided by primary health care centers in Qatar at the national level; and it showed that overall satisfaction was 75.2%. This level of satisfaction is within the range of levels reported by similar studies in the Arabian Gulf countries, which have showed variable level and determinants of patients' satisfaction with primary health centres. For instance, Al-Faris et al⁽²⁷⁾ showed that the overall satisfaction with Riyadh health centres was 90%. Another Saudi study done by Al-Sakkak⁽²⁸⁾ to evaluate the services in PHC affiliated to Riyadh military hospital showed the overall satisfaction level was 64.2%, while in Kuwait a study done in the Capital Health Region, the overall satisfaction was relatively high (99.6%).⁽¹⁵⁾
In Egypt, a study done to compare patients' satisfaction with primary health care services in two districts in Lower and Upper Egypt found that the overall satisfaction level was similar in both districts, at about 98%.⁽¹⁴⁾
Accessibility is one of the principles of health for all, as stated in the Alma Ata declaration on primary health care in 1978⁽²⁹⁾. Meng et al⁽³⁰⁾ reported that accessibility is the strongest predictor of overall satisfaction with quality of health care. In our study the highest score of satisfaction for the aspect of care was for accessibility to the health services (98%), which includes the distance to the PHC, appropriate chairs in the waiting areas, proper waiting time, proper working hours and availability of parking areas. The relation of distance from home on patient satisfaction and utilization of services was reported in many studies where utilization is increased by travelling shorter distance to PHC centres.⁽³¹⁾ Only waiting time significantly influenced satisfaction as found by Janice C and David et al.⁽³²⁾ In a Saudi Arabian study 87% of patients were satisfied with the accessibility to health care centres.⁽³³⁾ The comfortable physical environment is an important factor for patient satisfaction and increases the willingness to return and thus enhances the continuity of care.^{(20,27,34,35)}
While the lowest satisfaction was for comprehensiveness of care (92.6%), which includes accurate data in the files, available of appropriate number of staff and provision of comprehensive medical examination. Inadequate number of staff could play a role in delaying the provision of health services. In addition the need for efficient file recording systems is important to enhance the quality of services. Other studies that have been conducted in the Arabian Gulf on similar patient populations like in U.A.E⁽³⁶⁾ where it was found that humaneness scored the highest and continuity the lowest. Similarly, researchers in Saudi Arabia have found that humaneness and effectiveness got the highest score and lowest score was for continuity.⁽²⁰⁾ In his study, Al-sakkar⁽²⁸⁾ has found that accessibility and continuity got the lowest score.
Weiss⁽¹²⁾ found that patient background characteristics are among the most difficult to relate to the level of satisfaction. Most of satisfaction studies showed variable determinants of satisfaction, which revealed that satisfaction is multi-factorial and no one factor could be claimed to be the only contributor to satisfaction or dissatisfaction^(37-39).
In our study we found that females were less satisfied than males with the continuity of care, but there was no statistically significant difference. Our result is consistent with the previous studies in Qatar and neighbouring countries. Abdul-Kareem⁽¹⁶⁾, Al-Sakaar⁽²⁸⁾, and Al-Eisa⁽¹⁵⁾ found that males were significantly more satisfied than females. Al-Dawood⁽⁴⁰⁾ identified sex of the respondent as the most influential factor on the level of satisfaction.
Although age was not statistically significant, but observationally, patients > 60 were more satisfied with all aspects. This may be explained by the fact that the patient has become less demanding when older. Al-Eisa⁽¹⁵⁾ found that the older the patient, the higher the satisfaction. Khyat et al⁽⁴¹⁾ found that age between 17-44 years was consistently less satisfied than those of age 45-years or more. A study from the Emirates has shown that age was a significant factor for the domains of comprehensiveness and effectiveness.⁽³⁶⁾
In agreement with the previous study in Qatar, this study revealed that non-Qatari patients were more satisfied, which was statistically significant with accessibility, continuity and comprehensiveness of care.⁽¹⁶⁾ However Saudi studies⁽²⁰⁾ didn't find such difference in satisfaction between Saudis and non Saudis. This may be due to easy accessibility and low cost of health services in Qatar compared to non-Qatari's countries.
The students and housewives were less satisfied with the continuity of care which was significant. However in some previous regional studies, Makhdoom et al⁽¹⁷⁾ and Al Faris et al⁽²⁷⁾ found that being a housewife was the factors associated with higher satisfaction.
According to the education status, studies provide contradictory findings. Educational level has a positive and sometimes negative effect on satisfaction^(11,26,42). Babic-Banaszak et al⁽⁴³⁾ found that less educated people were more satisfied, as they are less demanding. Another studies also reported that highly educated people may be more critical⁽²⁷⁾. In our study observationally but not statistically, significance of the secondary, university and post graduate patients were less satisfied with continuity of care.
One of the limitations in the current study was the questionnaire used, which didn't investigate the correlation between the health status of the patients and their level of satisfaction as such correlation was reported by previous studies.^(44,45)
In conclusion, the overall satisfaction was relatively low. The highest score of satisfaction for the aspect of services was for accessibility to the health services and the lowest was for comprehensiveness of care. Non-Qatari patients were more satisfied with services compared to Qatari patients. Students and housewives are less satisfied with the current primary care services. A further qualitative study may be required to explain the role of citizenship and employment status on satisfaction level.

The research team extend their sincere thanks to the individuals participated in this study, Medical research centre-H.M.C, for giving permission to conduct this study. Also, we appreciate efforts of Dr. Rajvir Singh, Medical research centre in analysing the data.

1. Oliver RL. Measurement and evaluation of satisfaction process in retail settings. Journal of Retailing.1981, 57(3):25-48.
   
2. Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality care. Inquiry. 1988 spring, 25(1):25-36.
   
3. Vuori H. Patient satisfaction-an attribute or indicator of the quality of care? QRB Qual Rev Bull. 1987, 13(3):106-8.
   
4. Dansky KH, Miles J.Patient satisfaction with ambulatory health care services: waiting time and filling time. Hosp health serv admin 1997; 42(2):165-77.
   
5. Larsen DE, Rootman I. Physician role performance and patient satisfaction. Soc Sci Med 1976, 10:29-32.
   
6. Pascoe GC. Patient satisfaction in primary health care a literature review and analysis Evaluation and program planning. 1983, 6(3/4):185-97.
   
7. Keating NL, Green DC, Koa AC, Gazmararian JA, Wu VY, Cleary PD. How are patients' specific ambulatory care experiences related to trust, satisfaction, and considering changing physicians Gen Intern Med. 2002,17(1): 29-39.
   
8. Hickson GB, Clayton EW, Entman SS, Miller CS, Githens PB, Whetten-Goldstein K, Sloan FA. Obstetricians' poor malpractice experience and patients' satisfaction with care. JAMA 1994, 272(20):1583-7.
   
9. Stelfox HT, Ghandhi TK, Orav EJ, Gustafson ML. The relation of patient satisfaction with complaints against physicians and malpractice law suits. Am J Med 2005, 118(10):1126-33.
   
10. Davis AR, Ware JE. Involving consumers in quality of care assessment. Health Affairs 1988; spring 33-48.
    
11. Fitzpatrick R. Surveys of patient satisfaction: Important general considerations Br Med J 1991; 302:88-9.
    
12. Donabedian A. The quality of care: how can it be assessed? J Am Med Assoc 1988; 260:1743-8.
    
13. Williams SJ, Calnan M. Key determinants of consumer satisfaction with general practice. Fam pract 1991; 8:237-242.
    
14. Gadallh M, Zaki B. Patient satisfaction with primary health care services in two districts in lower and Upper Egypt. Eastern Mediterr Health J 2003; 9(3): 422-430.
    
15. Al-Eisa, Al-Mutar, patints' satisfaction with primary health care services at capital health region, Kuwait. Middle East Journal of Family Medicine2005; 3(2):10-16.
    
16. Abdul Kareem A, Aday LA, Walker GM Jr. Patient satisfaction in government health facilities in the state of Qatar. .J commun Health 1996,21:349-358
    
17. Makhdoom YM, Elzubier AG, Hanif M. Satisfaction with health care among primary health care centers attendees in Al Khobar,Saudi Arabia.Saudi Med J 1997;18:227-230.
    
18. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966; 44(suppl.) 166-206.
    
19. Carr-Hill RA. The measurement of patient satisfaction .J Publ Health Med 1992; 14:236-49.
    
20. Mansour AA, Al-Osimy MH.A study of satisfaction among primary health patients in Saudi Arabia. J Commun Health 1993:18:163-173.
    
21. Joos SK, HickamDlt and Boarders LM. Patient desires and satisfaction in general medicine clinics. Public Health Rep 1993; Nov-Dec 108 (6):75-9.
    
22. Baker R. The reliability and criterion validity of patients' satisfaction with their general practice. Family Practice 191; 8: 171-177.
    
23. Kincey J, Bradshaw P, Ley P .Patients' satisfaction and reported acceptance of advice in general practice. J R Gen Pract 1975; 25: 558-566.
    
24. Roghmann K, Hengst A, Zastowny T. Satisfaction with medical care: its measurement and relation to utilization. Med Care 1979; 17:461-477.
    
25. Weiss GL, Ramsey CA.Regular source of primary medical care and patient satisfaction. Qual Rev Bull 1989; 15: 180-184.
    
26. Weiss GL. Patient satisfaction with primary medical care. Evaluation of sociodemographic and predispositional factors. Med Care 1988; 26: 383-392.
    
27. Al-Faris EA, Khoja TA, Falouda M, Saeed A A. Patients' satisfaction with accessibility and services offered in Riyadh health centres. Saudi Med J 1996; 17 (1):11-17.
    
28. Al-Sakkak MR, Al-Nowaiser NA. Patient satisfaction with primary health care services offered in Riyadh health centres. Saudi Med J 2008; 29(3): 432-436.
    
29. Primary health care: report of the international conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978 joint sponsored by the World Health Organization and the United Nations Children's Fund. Geneva, World Health Organization, 1978.
    
30. Meng YY, Jatulis DE , McDonald JP , Legorreta AP .Satisfaction with access to and quality of health care among Medicare enrollers in a health maintenance organization. Western journal of medicine. 1997, 166(4):242-7.
    
31. Saeed A, Effect of distance on the utilization of health services. CAMS Newsletter 1985; 1:7-9.
    
32. Jannice C, David L, Anbesaw W.Patient and physician satisfaction with an outpatient care visit. Fam Practice 1997; Nov (5): 418-425.
    
33. Ali M, Mahmoud ME. A study of patient satisfaction with primary health care services in Saudi Arabia. J commun health, 1993, 18(1):49-54.
    
34. Leppanen T, Toyry E, Vehvilainen-Julkunen K. Patients' viewpoint about the most important aspects of the Human Caring Scale. Hoitotiede 1997; 9:178-185.
    
35. Gregory P, Malka E, Kostis J, Wilson A, Arora J, Rhoads G. Impact of geographic proximity to cardiac revascularization services on service utilization. Med Care 2000; 38: 45-57.
    
36. Margolis SA, Al.Marzouqi S .Patient satisfaction with primary health care services in the United Arab Emirates. Int J Qual Health Care 2003; 15:241-249.
    
37. Baker R. Use of psychometrics to develop a measure of patient satisfaction for general practice. In Fitzpatrick R, Hopkins A, eds, Measurement of Patients' Satisfaction with Their Care. London: Royal College of physicians of London, 1993,57-75.
    
38. Hulka BS, Kupper LL, Daly MB et al. Correlates of satisfaction and dissatisfaction with medical care: a community perspective. Med Care 1975; 13: 648-658.
    
39. Zastowny TR, Roghmann KJ, Cafferata GL. Patient satisfaction and rhe use of health services: exploration in causality. Med Care 1989; 27: 705-723.
    
40. Al-Dawood KM,Elzubier AG.Patients' expectations and satisfaction in a teaching hospital outpatient clinic, Al Khubar, Saudi Arabia. Saudi Med J 1996; 17:245-250.
    
41. Khayat K, Sulter B .Patient satisfaction surveys have a market research tool for general practices. Brt Med J 1994; 44:215-219.
    
42. Ware JE, Davis-Avery A, Stewart AL. The measurement and mean of patient satisfaction. Health Med Care Serv Rev 1978; 1: 2-15.
    
43. Babic-Banaszak A, Kovacic L, Mastilica M, Babic S, Ivankovic D ,Budak A. The Croatian health survey- patent's satisfaction with medical service in primary health care in Croatia. Collegiums Antropologicum 2001;25(2): 449-58.
    
44. Al-Mandhari AS, Hassan AA, Haran D. Association between perceived health status and satisfaction with quality of care: evidence from users of primary health care in Oman. Fam Pract 2004; 21(5): 519-27.
    
45. Al Qatari G, Haran D.Determinants of users' satisfaction with primary health care settings and services in Saudi Arabia. Int J Qual Health Care 1999; 11(6):523-31.