International Journal of Pediatric Otorhinolaryngology 78 (2014) 348–353
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International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
A questionnaire-based study on parental satisfaction with a universal newborn hearing screening program in Kuala Lumpur, Malaysia Rafidah Mazlan a,b,*, Tan Lee Ting a,b, Siti Zamratol-Mai Sarah Mukari a, Asma Abdullah b a b
Audiology Programme, School of Rehabilitation Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Department of Otorhinolaryngology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 October 2013 Received in revised form 7 December 2013 Accepted 10 December 2013 Available online 18 December 2013
Objectives: The present study aimed to determine levels of parents’ satisfaction associated with the universal newborn hearing screening process in a university hospital setting in Kuala Lumpur, Malaysia. Methods: Parents whose babies had undergone a hearing screening test at the Pusat Perubatan Universiti Kebangsaan (Universiti Kebangsaan Malaysia Medical Center), Kuala Lumpur, Malaysia, participated in this study. In this study, the original English version of the Parent Satisfaction Questionnaire with Neonatal Hearing Screening Program (PSQ-NHSP) was translated and adapted into Malay language. Thus, this self-administered Malay version of PSQ-NHSP was used to measure parents’ satisfaction on information of newborn hearing screening program, personnel in charge of the hearing testing, hearing screening activities, and overall satisfaction. Results: Of the 200 questionnaires distributed, 119 parents (59.5%) responded. Overall, more than 80% of parents were satisfied with the program. The highest percentage of satisfaction (95.6%) was related to the contents of an information leaflet. However, parents were not satisfied with items measuring communication aspect of personnel in charge of the hearing screening. In specific, 38.1% of parents were not satisfied with the explanations and information provided by the screeners on the test procedures, while 26.1% of parents found that the information they received on the test results was insufficient. Conclusions: The findings of the present study revealed that parents were generally satisfied with the UNHS program. However, further intervention is required to improve the communication aspects of the personnel in charge of the hearing testing. Results suggest that the questionnaire is easily employed and effective tool for assessing parental satisfaction with newborn hearing screening programs. Additionally, this study has demonstrated the survey tool to be useful in identifying areas that need changes or improvements. ß 2013 Published by Elsevier Ireland Ltd.
Keywords: Newborn hearing screening Parent satisfaction
1. Introduction Parent satisfaction with treatment is particularly important in the case of young children. Parents are seen as their representatives and, therefore, represent the child’s’ point of view. The differences between the perception of parents and health care providers, as reported in [1], indicate the need for parental satisfaction measurement in the health care setting. This study maintains that health care providers often under or overestimate parent needs and satisfaction, which further stresses the need to assess parent satisfaction.
* Corresponding author at: Audiology Programme, School of Rehabilitation Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia. Tel.: +60 3 2691 4230; fax: +60 3 2698 6039. E-mail address: [email protected] (R. Mazlan). 0165-5876/$ – see front matter ß 2013 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.ijporl.2013.12.014
To date, parent satisfaction has been accepted as an important outcome measure to evaluate the success of the programs in many pediatric health care service programs [2,3]. According to Bernheimer et al. [4], measuring parent satisfaction is important in pediatric health care service programs because parents play a major role in their child’s life. Their decisions are fundamental to the success or failure of the child’s treatment in many cases. For example, there is evidence that satisfied parents will co-operate more effectively, show greater compliance with their child’s treatment and are more likely to return to the service [5]. Moreover, information obtained from parental satisfaction measurement has been proved as useful in identifying service shortfalls, monitoring and guiding service developments. Measuring parent satisfaction has been recommended by the Joint Committee on Infant Hearing (JCIH) as one of the important outcome measures when evaluating and monitoring the success of universal newborn hearing screening programs (UNHSPs) [6]. Despite this recommendation, many investigators
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have concentrated on achieving other outcomes measures recommended by the JCIH such as conducting hearing screening on at least 95% of infants during their birth admissions or before one month of age, keeping the referral rate less than 4% following the initial screening, and having at least 70% of infants who fail hearing screening return for follow-up [7,8]. However, there is a growing interest in assessing parent satisfaction with UNHSPs in recent years [9–13]. Fox and Minchom [9] surveyed 177 women whose babies had their hearing screened with the Newborn Hearing Screening Wales, Wales, United Kingdom. In this study, a close-ended questionnaire with a Likert-type response scale, ranging from strongly agree to strongly disagree was utilized to measure mother’s satisfaction with the information provision given by the screeners, the staff attributes, the test, and the overall satisfaction. In general, the majority of parents (>90%) reported high level of satisfaction with the program. However, findings from this particular study revealed that mothers were less satisfied with the information provision than the staff attributes and the test itself. In 2007, MacNeil et al. [10] conducted a satisfaction survey on families whose children received hearing screening in Massachusetts. They reported that 88% of 748 families whose babies passed the initial hearing screening test were satisfied with the overall service they received from the program. In another study conducted by Mazlan et al. [11], the majority of parents (>95%) were satisfied with all aspect of the Infant Hearing Screening Program provided by The Hear and Say Centre in Brisbane, Australia (i.e. information, personnel in charge of the hearing testing, appointment activities, and overall satisfaction). Using the translated version of the questionnaire used in Mazlan et al. [11], Nunez-Batalla et al. [12] and Shojaee et al. [13] evaluated their UNHS programs at Spain and Iran, respectively. Nunez-Batalla et al. [12] found that more than 90% of 112 Spanish parents reported high level of satisfaction with each measured dimension in their study. Similarly, Shojaee et al. [13] reported that the majority of 138 parents in their study were satisfied with the aspects of overall satisfaction (90.6%), personnel in charge of hearing testing (60.1%) and appointment activities (58%). In summary, it is apparent that parent satisfaction is rapidly becoming an important outcome measure, as well as an indicator of the success of UNSHPs. Moreover, the application of a questionnaire that has been specifically developed for UNHSPs provides valuable information regarding features of the program that most meet parent needs and those aspects that require change or improvement. As of yet, assessing parent satisfaction with UNHSPs remains a largely neglected area in Malaysia. Therefore, the present work aims to evaluate parents’ satisfaction with a UNHSP that their babies received in a university hospital in Kuala Lumpur, Malaysia.
discharged from the program and those with refer results will be scheduled for re-screening within a month at the Audiology Unit of UKMMC using DPOAE and automated auditory brainstem response tests. Those who failed the re-screening will be immediately scheduled for a diagnostic auditory brainstem response test.
2. Methods
2.3. Procedure
2.1. Participants
This study was approved by the human ethics committees of the Universiti Kebangsaan Malaysia. Participants were approached to participate only after their babies completed the screen. The researcher described the survey study to all potential participants and provided them with an information sheet, a consent form and the translated questionnaire. Participants were asked to complete the questionnaire immediately post screening or before the hospital discharge, and returned it in a seal envelope to their attending midwives. Participants were also informed that their participation was voluntary and that their decision would not affect their babies’ future management.
The participants were the parents whose babies had received hearing screening at the maternity wards, Department of Obstetrics and Gynecology, Pusat Perubatan Universiti Kebangsaan Malaysia (National University of Malaysia Medical Center, UKMMC), Kuala Lumpur, Malaysia. In this study, only the parents of well babies born between January and March 2012 were included. Parents whose babies have not been screened were excluded from the study. In total, 119 parents voluntarily participated in this study. During the 3 months data collection period, the UNHS in UKMMC screened 1127 well nursery newborns with an average screening rate of 90%. UKMMC established its UNHSP in 2003 [14]. All babies born in this hospital will receive hearing screening prior to hospital discharge using distortion product otoacoustic emission (DPOAE) test. Babies who passed the initial DPOAE screening will be
2.2. The survey instrument The satisfaction survey was carried out using a previously published questionnaire, the Parent Satisfaction Questionnaire with Neonatal Hearing Screening Program (PSQ-NHSP) developed by Mazlan et al. [11]. The development and validation process of the PSQ-NHSP are described in detail elsewhere [11]. Briefly, the original PSQ-NHSP comprised 22 close-ended items that measures four dimensions of parents’ satisfaction: information (3 items), personnel in charge of hearing testing (8 items), hearing screening activities (7 items), and overall satisfaction (4 items). Five response options from strongly disagree to strongly agree, were provided for these close ended items. Scoring of the items ranged from 1 to 5, with 1 being attributed to the most negative response, and 5 to the most positive. Apart from the close-ended items, the PSQ-NHSP also contained a dichotomous, two multiple-choice items, and three open-ended items. Before the actual study started, the questionnaire was translated and adapted into the Malay language through the standard ‘‘forward–backward’’ procedure. Two independent audiologists translated the items and the response categories and a provisional version was provided. Subsequently, it was back translated into English by two linguists, and following a careful cultural adaptation the final version was provided. An initial version of the questionnaire was then created, which was pilot tested on a group of 20 mothers to analyze the comprehensibility and clarity of items and features related to the psychometric properties of the instrument. Results from the pilot study showed the questions and response options were easy to understand and simple to complete by all participants. However, removal of one item in the domain of hearing screening activities, ‘I was satisfied with the waiting time for the appointment’, was recommended because all participants commented that they had not experienced such situation during the hearing screening process. After eliminating this particular item, the Malay version of PSQ-NHSP consists of 27 items. In specific, the Malay version of PSQ-NHSP contains one dichotomous, two multiple-choice, 21 close-ended and 3 open-ended items which follow in chronological order of the hearing screening process.
2.4. Data analysis In this study, data were analyzed using the Statistical Package for the Social Sciences (SPSS 17.0) software. During the data analysis, all negative items in the Malay version of PSQ-NHSP
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Table 1 Descriptive statistics for each item in the questionnaire. Scoring of the items ranged from 1 to 5, with 1 being attributed to the most negative response, and 5 the most positive. Items
Information The content of the information sheet (brochure or leaflet) was sufficient The information about the program was difficult to understanda The information about the program was very useful Total Personnel in charge of the hearing testing I was satisfied with the interval between the initial hearing screening and the follow-up appointment The tester did not give clear information about the follow-up appointmenta Now that I have had the follow-up appointment, I know what must be done next concerning my child’s hearing The information I received regarding the testing procedure was not sufficienta The information on the results of the test was sufficient The tester was knowledgeable about the program The tester was skillful with the equipment The tester was not approachablea The tester was gentle with my baby during the testing procedure Total
Mean
Standard deviation (SD)
Agree/ strongly agree (%)
Neutral (%)
Disagree/ strongly disagree (%)
68 (57.1) 68 (57.1) 68 (57.1)
3.93 3.87 4.19 4.00
0.56 0.64 0.50
89.8 2.9 95.6
5.8 19.1 4.4
4.4 78.0 0.0
54 (45.4)
3.87
0.52
87.0
9.3
3.7
55 (46.2) 56 (47.1)
3.69 3.70
0.74 0.74
10.9 71.5
14.5 19.6
74.6 8.9
n (%)
118 119 118 110 117 105
(99.2) (100) (99.2) (92.4) (98.3) (88.2)
3.13 3.34 3.70 3.71 3.84 3.86 3.65
1.06 0.93 0.70 0.67 0.78 0.73
38.1 58.8 72.0 65.5 8.5 80.0
12.7 15.1 21.3 32.7 13.8 14.2
49.2 26.1 6.7 1.8 91.0 5.8
Hearing screening activities I had the chance to ask more about the program I had the chance to ask more about the test procedure I had the chance to ask more about the results of the test The testing period was not appropriatea The testing site for this program was not appropriatea Total
119 118 118 116 115
(100) (99.2) (99.2) (97.5) (96.6)
3.50 3.49 3.54 3.60 3.69 3.56
0.94 0.94 0.86 0.83 0.84
67.2 67.0 67.9 13.0 10.4
13.4 13.5 16.9 20.6 19.1
19.4 19.5 15.2 66.4 70.5
Overall satisfaction Overall, I was satisfied with the program I was not satisfied with the test processa I will recommend this program to friends or relatives I will not use the same service in futurea Total
119 119 119 119
(100) (100) (100) (100)
3.85 3.80 4.03 4.05 3.93
0.66 0.78 0.48 0.64
80.6 8.4 91.6 2.5
15.2 16.9 7.6 10.1
4.2 74.7 0.8 87.4
n = total number of participants answered each item. a Negatively worded item.
(items 4, 9, 11, 15, 20, 22, 24, 26) were reverse coded. Descriptive statistics included the frequency, percentage, mean and standard deviation of all items in the questionnaire were computed to establish the level of parent satisfaction with the NHSP. Additionally, a cumulative percentage of two disagreement levels (disagree and strongly disagree) of more than 20% were calculated to identify areas associated with a high level of dissatisfaction [15]. The three open ended questions were analyzed and categorized manually, which involved organizing the responses into common themes. Where possible, all comments were grouped into the four dimensions of satisfaction which are information, personnel in charge of hearing testing, hearing screening activities, and overall satisfaction. Those responses that were not associated with any of the dimensions of satisfaction were categorized under ‘others’ comments. In regard to the psychometric properties of the Malay version PSQ-NHSP, Cronbach’s alpha analysis was used to measure its internal consistency reliability, while Spearman’s rank correlation was performed to evaluate the content validity of the questionnaire. 3. Results Two hundred questionnaires were distributed during the data collection period, and 119 (59.5%) mothers responded. In response to a multiple-choice item of ‘how did they hear about the program’, 84 mothers (70.6%) reported that they knew about the program from midwives, 31 (26.1%) from doctors, and 4 (3.3%) from friends and relatives. With regard to another multiple-choice item which ask about the results of their baby’s
hearing test, 54 mothers (45.4%) reported that their newborns passed the initial hearing screening, 56 (47.1%) indicated that their newborns required further testing, and 9 (7.5%) did not know their babies’ test results. The descriptive statistics of each item in the questionnaire are summarized in Table 1. The mean scores of the overall satisfaction items ranged from 3.80 to 4.05 which represent a level of satisfaction between satisfied and very satisfied. In this dimension, item ‘I will recommend this program to friends or relatives’ received the highest rating (91.6%) and has the lowest percentage of disagreement level of 0.8%. In regard to the information dimension, of the 119 mothers whose baby received a hearing screening, only 68 participants (57.1%) reported that they received the brochure prior the screening process. Mean scores for information items ranged from 3.87 to 4.19 (SD range = 0.50–0.64), with item, ‘The information about the program was very useful’ received the highest rating (95.6%) among all the items in the questionnaire. Furthermore, the percentage of disagreement for items in the information dimension ranged from 0% to 4.4%, indicating high levels of parent satisfaction with this aspect of the program. Mean scores for items in the personnel in charge of the hearing testing dimension ranged from 3.13 to 3.86 (SD range = 0.52– 1.06). As shown in Table 1, the percentage of disagreement for all items in this dimension was less than 20% except for two items measuring communication aspect of personnel in charge of the hearing testing. The highest percentage of disagreement (38.1%) was related to item ‘the information I received regarding the testing procedure was not sufficient’. In addition, about 26% of the
R. Mazlan et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 348–353 Table 2 Summary of responses to ‘‘one thing which you were more than satisfied about’’. Satisfied with Information Easy to understand Personnel in charge of hearing testing Friendly staff Approachable, caring and gentle tester Hearing screening activities The test did not upset my baby Others Early detection of hearing loss Total
Comments frequency n (%)
20 (26.0) 5 (6.5) 9 (11.7)
Table 3 Summary of responses to ‘‘one thing which you were less than satisfied about’’.
Personnel in charge of hearing testing Inadequate explanation of the test procedure and test results Hearing screening activities Lack of parent–screener communication Total
Suggestions
Comments frequency n (%) 14 (56.0)
3 (12.0) 8 (32.0) 25 (100)
41 (53.2) 77 (100)
participants were not satisfied with item ‘the information on the results of the test was sufficient’. Mean scores for the hearing screening activities items ranged from 3.49 to 3.69 (SD range = 0.83–0.94). Furthermore, the cumulative percentage of the two disagreement levels for all items was less than 20%, indicating that parents were generally satisfied with this dimension. In regard to the open-ended items, 93 (78.1%) questionnaires contained comments. Forty one participants (44.1%) provided at least one comment while 55.9% of participants made more than one comment. Tables 2–4 detail the responses obtained for each of the open-ended items in the questionnaire. A total of 77 comments were received for the open-ended item relating to one area that participants were satisfied with the program (see Table 2). As shown in Table 2, most positive comments were not related to any of the dimensions. In specific, 41 participants (53.2%) were satisfied with the fact that the hearing loss can be detected early. Table 3 shows a summary of the 33 comments offered by participants in regard to any dissatisfaction with the program. Similar dimensions of satisfaction as obtained from satisfied comments (i.e. personnel in charge of hearing testing and appointment activities) contributed to dissatisfaction responses. Most comments (66.7%) were related to personnel in charge of the hearing testing, in particular, the communication aspect of the screener. Participants also expressed dissatisfaction with a lack of communication between parent and screener during the hearing screening process. Participant’s suggestions for changes and improvements to the program are shown in Table 4. A total of 25 suggestions were made, with the most common suggestions were related to the personnel in charge of the hearing testing dimension. The internal reliability of the Malay version of PSQ-NHSP was assessed by determining the Cronbach’s alpha values. The results showed that the revised questionnaire has excellent internal consistency reliability with a total Cronbach’s alpha of 0.90. Additionally, the Cronbach’s alpha coefficients were above 0.7 for all dimensions of satisfaction. In specific, alphas for information, personnel in charge of the hearing testing, hearing screening activities, and overall satisfaction were 0.72, 0.80, 0.81, and 0.82, respectively.
Dissatisfied with
Table 4 Summary of participant suggestions for changes and improvements to program.
Personnel in charge of hearing testing Provide more detailed explanation on the test procedure and results Appointment activities More appropriate room for testing More flexible on the follow-up date Total
2 (2.6)
351
Comments frequency n (%) 22 (66.7)
11 (33.3) 33 (100)
In regard to its content validity, the results of Spearman’s rankorder correlation analysis showed moderately positive correlation between overall satisfaction and all measured dimensions, with correlation values ranging from 0.58 to 0.70. 4. Discussion The present study aimed to evaluate parents’ satisfaction with a UNHS program in a university hospital in Kuala Lumpur, Malaysia. The results suggest that parents were generally satisfied with the program, with more than 80% of them responded with either ‘agree’ or ‘strongly agree’ to items measuring the overall satisfaction. The overall satisfaction levels in the present study compare very favorably with those obtained in other programs. For instance, 80–95% of parents were satisfied with the overall service provided by the Newborn Hearing Screening Wales, Wales, United Kingdom [9], while over 95% of parents were satisfied with the Infant Hearing Screening Program at The Hear and Say Centre, Brisbane, Australia [11]. The present study also found that parents were satisfied with the specific dimensions of satisfaction; information, personnel in charge of hearing testing, and hearing screening activities. However, there was variability in the degree of satisfaction depending on the dimension. For the information dimension, only 68 of the 119 (57.1%) participants in the present study received the written information brochure prior to the NHSP. More than 90% of this group reported that they were satisfied for the majority of items representing this dimension. This result suggests that parents are generally satisfied; however, the fact that only 57.1% of parents actually received the information is an issue that need to be addressed by the program. It was not possible however to directly compare results from this particular dimension of satisfaction with results from other hearing screening programs, as some studies did not include this aspect in their surveys [9,10]. The only similar work is by Watkin et al. [16] and Mazlan et al. [11]. In both studies, high level of satisfaction with the contents of an information leaflet was reported, with more than 90% of parents responding that they were satisfied or very satisfied with this aspect of the service. In regard to other dimensions of satisfaction, personnel in charge of the hearing testing and hearing screening activities, parents in the present study were generally satisfied with all items contained in these two dimensions. However, parents were dissatisfied with two aspects of the program. In specific, assessments of disagreement scores indicate that parents reported high levels of dissatisfaction with the communication aspect of personnel in charge of the hearing testing. The dissatisfaction levels for explanations provided by the screener on the testing procedures and the test results were 38.1% and 26.1%, respectively. Therefore, this is an area that warrants further attention and targeted intervention, possibly through avoiding jargon or medical terminology when communicating with parents, listening carefully or by spending sufficient time with the parents. Dissatisfaction
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with screener’s explanations expressed by the parents has also been reported in Fox and Minchom [9]. In this particular study, item ‘I was given enough information to decide whether my baby should be tested’ received the lowest rating from 77% of the participants. A further aim of the present study was to obtain qualitative feedback from parents by seeking their responses to the openended items included in the questionnaire. Inclusion of openended items in the present study allowed parents to express issues that may not have been considered important by the researcher, but are relevant to the participants. The majority of participants (78%) responded to the open-ended items included in the questionnaire. It seems clear that parents did not hesitant to criticize particular aspects of services and make suggestions to improve the current service. For the open-ended item that sought parents’ views on one thing that they were satisfied with in the program, the most frequent positive comments received for this item were related to the fact that hearing loss can be detected early (53%). This finding indicates that parents agreed on the importance of early detection of hearing loss in newborn babies. It is interesting to note that personnel in charge of the hearing testing received the most frequent negative comments for another open-ended item that asked parents to indicate one thing that they were dissatisfied with in the program. The fact that both close-ended statements and open-ended question focused on the same area, that is, on personnel in charge of the hearing testing, highlights the needs to address this issue. Additionally, the lack of parent–screener communication indicates that parents in the present study supported the concept of family-centered approach during the screening process. Existing research suggests that communication styles of professionals is the most important issue shaping parent experiences, with ‘good’ professional communication was marked by being clear, jargon-free explanations that use examples in context, sensitive toward parents’ emotional needs, involve parents in testing procedures, honesty and openness [17]. In regard to the open-ended item about how the service might be improved, 25 suggestions were made. The area that received the most frequent comments (56%) was the communication aspect of personnel in charge of the hearing testing dimension. Specifically, parents wanted more detailed information in areas of the testing procedures and the test results. ‘More appropriate testing room’ and ‘more flexible on the follow-up date’ were suggestions reported by parents about hearing screening activities. One of the difficulties with studies of parents’ satisfaction is the tendency for participants to report high levels of satisfaction, regardless of the nature of the service being evaluated [18]. This makes it difficult to identify the particular concerns that give rise to dissatisfaction among some participants. The high levels of agreement with close-ended items highlight the importance of including open-ended items in the questionnaires. Some parents may not wish to give a service a ‘bad mark’ in response to a general question, but will be prepared to offer suggestions for improvements. Strength of the present study was its use of items from a reliable and validated measure of parents’ satisfaction (i.e. PSQ-NHSP) together with ratings of three dimensions of satisfaction of the service being evaluated. This approach overcame two problems that have tended to hinder previous research investigating satisfaction with other types of pediatric health care service programs [2,19]. First, it seems reasonable to argue that parent satisfaction is a multidimensional concept that reflects parents’ judgements about several characteristics of the services they have received. However, many measures of satisfaction are unidimensional and provide little opportunity for parents to comment on the different characteristics that contribute to overall satisfaction.
Second, although global ratings provide a useful summary of parent satisfaction, they do not provide information that can be employed to address the concerns causing dissatisfaction among some parents. In the present study, it was possible to use the ratings from items representing the three dimensions of satisfaction to identify aspects of service that need changes or improvements. In addition, the use of open-ended items was also important as it allowed the identification of particular concerns of parents and thus indicated areas for service improvement. An important area that the present study did not investigate is the relationship between satisfaction and the demographic variables of the parents. Byalin [2] found a significant relationship between parents’ age and their satisfaction with services received by their children. Brannan et al. [20] found a positive correlation between parents’ age and their satisfaction with certain service aspects. Other researchers have found no relationship between satisfaction and demographic variables of the parents [21]. Available parent demographic details were very limited in the present study (i.e., race and employment status), and further investigation is necessary to clarify this issue. 5. Conclusion Overall, parents reported being satisfied with the UNHSP services they are receiving in the university hospital. However, issues related to the communication aspect of personnel in charge of the hearing testing requires further investigation and intervention in an effort to improve and sustain the program. Additionally, this study has demonstrated the survey instrument to be useful in identifying key areas that require improvement in the UNHSP process. Funding This study was supported by the Universiti Kebangsaan Malaysia Research and Ethics Committee (NN-124-2011). Acknowledgements The authors are grateful to the parents who kindly participated in this survey. The authors would also like to thank the staff of the maternity wards for their time and assistance during the study. References [1] R. Bradford, Staff accuracy in predicting the concerns of parents of chronically ill children, Child Care Health Dev. 17 (1991) 39–47. [2] K. Byalin, Assessing parental satisfaction with children’s mental health services, Eval. Prog. Plan. 16 (1993) 69–72. [3] K. Brown, E. Sheehan, M. Sawyer, J. Raftos, V. Smyth, Parent satisfaction with services in emergency department located at a paediatric teaching hospital, J. Paediatr. Child Health 31 (1995) 435–439. [4] L.P. Bernheimer, R. Gallimore, T.S. Weisner, Ecocultural theory as a context for the individual family service plan, J. Early Interv. 14 (1990) 219–233. [5] H. Bragadottir, D. Reed, Psychometric instrument evaluation: the pediatric family satisfaction questionnaire, Pediatr. Nurs. 28 (2002) 475–484. [6] JCIH, Year 2000 position statement: principles and guidelines for early hearing detection and intervention programs, Pediatrics 106 (2000) 798–817. [7] L. Cox, M. Toro, Evolution of a universal infant hearing screening program in an inner city hospital, Int. J. Pediatr. Otorhinolaryngol. 59 (2001) 99–104. [8] L. Dalzell, M. Orlando, M. MacDonald, A. Berg, M. Bradley, A. Cacace, et al., The New York State universal newborn hearing demonstration project: ages of hearing loss identification, hearing aid fitting, and enrollment in early intervention, Ear Hear. 21 (2000) 118–130. [9] R. Fox, S. Minchom, Parental experiences of the newborn hearing screening programme in Wales: a postal questionnaire survey, Health Expect. 11 (2008) 376–383. [10] J.R. MacNeil, C. Liu, S. Stone, J. Farrel, Evaluating families’ satisfaction with early hearing detection and intervention services in Massachusetts, Am. J. Audiol. 16 (2007) 29–56. [11] R. Mazlan, L. Hickson, C. Driscoll, Measuring parent satisfaction with a neonatal hearing screening program, J. Am. Acad. Audiol. 27 (2006) 253–264.
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Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
A questionnaire-based study on parental satisfaction with a universal newborn hearing screening program in Kuala Lumpur, Malaysia Rafidah Mazlan a,b,*, Tan Lee Ting a,b, Siti Zamratol-Mai Sarah Mukari a, Asma Abdullah b a b
Audiology Programme, School of Rehabilitation Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia Department of Otorhinolaryngology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 12 October 2013 Received in revised form 7 December 2013 Accepted 10 December 2013 Available online 18 December 2013
Objectives: The present study aimed to determine levels of parents’ satisfaction associated with the universal newborn hearing screening process in a university hospital setting in Kuala Lumpur, Malaysia. Methods: Parents whose babies had undergone a hearing screening test at the Pusat Perubatan Universiti Kebangsaan (Universiti Kebangsaan Malaysia Medical Center), Kuala Lumpur, Malaysia, participated in this study. In this study, the original English version of the Parent Satisfaction Questionnaire with Neonatal Hearing Screening Program (PSQ-NHSP) was translated and adapted into Malay language. Thus, this self-administered Malay version of PSQ-NHSP was used to measure parents’ satisfaction on information of newborn hearing screening program, personnel in charge of the hearing testing, hearing screening activities, and overall satisfaction. Results: Of the 200 questionnaires distributed, 119 parents (59.5%) responded. Overall, more than 80% of parents were satisfied with the program. The highest percentage of satisfaction (95.6%) was related to the contents of an information leaflet. However, parents were not satisfied with items measuring communication aspect of personnel in charge of the hearing screening. In specific, 38.1% of parents were not satisfied with the explanations and information provided by the screeners on the test procedures, while 26.1% of parents found that the information they received on the test results was insufficient. Conclusions: The findings of the present study revealed that parents were generally satisfied with the UNHS program. However, further intervention is required to improve the communication aspects of the personnel in charge of the hearing testing. Results suggest that the questionnaire is easily employed and effective tool for assessing parental satisfaction with newborn hearing screening programs. Additionally, this study has demonstrated the survey tool to be useful in identifying areas that need changes or improvements. ß 2013 Published by Elsevier Ireland Ltd.
Keywords: Newborn hearing screening Parent satisfaction
1. Introduction Parent satisfaction with treatment is particularly important in the case of young children. Parents are seen as their representatives and, therefore, represent the child’s’ point of view. The differences between the perception of parents and health care providers, as reported in [1], indicate the need for parental satisfaction measurement in the health care setting. This study maintains that health care providers often under or overestimate parent needs and satisfaction, which further stresses the need to assess parent satisfaction.
* Corresponding author at: Audiology Programme, School of Rehabilitation Sciences, Faculty of Health Sciences, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia. Tel.: +60 3 2691 4230; fax: +60 3 2698 6039. E-mail address: [email protected] (R. Mazlan). 0165-5876/$ – see front matter ß 2013 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.ijporl.2013.12.014
To date, parent satisfaction has been accepted as an important outcome measure to evaluate the success of the programs in many pediatric health care service programs [2,3]. According to Bernheimer et al. [4], measuring parent satisfaction is important in pediatric health care service programs because parents play a major role in their child’s life. Their decisions are fundamental to the success or failure of the child’s treatment in many cases. For example, there is evidence that satisfied parents will co-operate more effectively, show greater compliance with their child’s treatment and are more likely to return to the service [5]. Moreover, information obtained from parental satisfaction measurement has been proved as useful in identifying service shortfalls, monitoring and guiding service developments. Measuring parent satisfaction has been recommended by the Joint Committee on Infant Hearing (JCIH) as one of the important outcome measures when evaluating and monitoring the success of universal newborn hearing screening programs (UNHSPs) [6]. Despite this recommendation, many investigators
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have concentrated on achieving other outcomes measures recommended by the JCIH such as conducting hearing screening on at least 95% of infants during their birth admissions or before one month of age, keeping the referral rate less than 4% following the initial screening, and having at least 70% of infants who fail hearing screening return for follow-up [7,8]. However, there is a growing interest in assessing parent satisfaction with UNHSPs in recent years [9–13]. Fox and Minchom [9] surveyed 177 women whose babies had their hearing screened with the Newborn Hearing Screening Wales, Wales, United Kingdom. In this study, a close-ended questionnaire with a Likert-type response scale, ranging from strongly agree to strongly disagree was utilized to measure mother’s satisfaction with the information provision given by the screeners, the staff attributes, the test, and the overall satisfaction. In general, the majority of parents (>90%) reported high level of satisfaction with the program. However, findings from this particular study revealed that mothers were less satisfied with the information provision than the staff attributes and the test itself. In 2007, MacNeil et al. [10] conducted a satisfaction survey on families whose children received hearing screening in Massachusetts. They reported that 88% of 748 families whose babies passed the initial hearing screening test were satisfied with the overall service they received from the program. In another study conducted by Mazlan et al. [11], the majority of parents (>95%) were satisfied with all aspect of the Infant Hearing Screening Program provided by The Hear and Say Centre in Brisbane, Australia (i.e. information, personnel in charge of the hearing testing, appointment activities, and overall satisfaction). Using the translated version of the questionnaire used in Mazlan et al. [11], Nunez-Batalla et al. [12] and Shojaee et al. [13] evaluated their UNHS programs at Spain and Iran, respectively. Nunez-Batalla et al. [12] found that more than 90% of 112 Spanish parents reported high level of satisfaction with each measured dimension in their study. Similarly, Shojaee et al. [13] reported that the majority of 138 parents in their study were satisfied with the aspects of overall satisfaction (90.6%), personnel in charge of hearing testing (60.1%) and appointment activities (58%). In summary, it is apparent that parent satisfaction is rapidly becoming an important outcome measure, as well as an indicator of the success of UNSHPs. Moreover, the application of a questionnaire that has been specifically developed for UNHSPs provides valuable information regarding features of the program that most meet parent needs and those aspects that require change or improvement. As of yet, assessing parent satisfaction with UNHSPs remains a largely neglected area in Malaysia. Therefore, the present work aims to evaluate parents’ satisfaction with a UNHSP that their babies received in a university hospital in Kuala Lumpur, Malaysia.
discharged from the program and those with refer results will be scheduled for re-screening within a month at the Audiology Unit of UKMMC using DPOAE and automated auditory brainstem response tests. Those who failed the re-screening will be immediately scheduled for a diagnostic auditory brainstem response test.
2. Methods
2.3. Procedure
2.1. Participants
This study was approved by the human ethics committees of the Universiti Kebangsaan Malaysia. Participants were approached to participate only after their babies completed the screen. The researcher described the survey study to all potential participants and provided them with an information sheet, a consent form and the translated questionnaire. Participants were asked to complete the questionnaire immediately post screening or before the hospital discharge, and returned it in a seal envelope to their attending midwives. Participants were also informed that their participation was voluntary and that their decision would not affect their babies’ future management.
The participants were the parents whose babies had received hearing screening at the maternity wards, Department of Obstetrics and Gynecology, Pusat Perubatan Universiti Kebangsaan Malaysia (National University of Malaysia Medical Center, UKMMC), Kuala Lumpur, Malaysia. In this study, only the parents of well babies born between January and March 2012 were included. Parents whose babies have not been screened were excluded from the study. In total, 119 parents voluntarily participated in this study. During the 3 months data collection period, the UNHS in UKMMC screened 1127 well nursery newborns with an average screening rate of 90%. UKMMC established its UNHSP in 2003 [14]. All babies born in this hospital will receive hearing screening prior to hospital discharge using distortion product otoacoustic emission (DPOAE) test. Babies who passed the initial DPOAE screening will be
2.2. The survey instrument The satisfaction survey was carried out using a previously published questionnaire, the Parent Satisfaction Questionnaire with Neonatal Hearing Screening Program (PSQ-NHSP) developed by Mazlan et al. [11]. The development and validation process of the PSQ-NHSP are described in detail elsewhere [11]. Briefly, the original PSQ-NHSP comprised 22 close-ended items that measures four dimensions of parents’ satisfaction: information (3 items), personnel in charge of hearing testing (8 items), hearing screening activities (7 items), and overall satisfaction (4 items). Five response options from strongly disagree to strongly agree, were provided for these close ended items. Scoring of the items ranged from 1 to 5, with 1 being attributed to the most negative response, and 5 to the most positive. Apart from the close-ended items, the PSQ-NHSP also contained a dichotomous, two multiple-choice items, and three open-ended items. Before the actual study started, the questionnaire was translated and adapted into the Malay language through the standard ‘‘forward–backward’’ procedure. Two independent audiologists translated the items and the response categories and a provisional version was provided. Subsequently, it was back translated into English by two linguists, and following a careful cultural adaptation the final version was provided. An initial version of the questionnaire was then created, which was pilot tested on a group of 20 mothers to analyze the comprehensibility and clarity of items and features related to the psychometric properties of the instrument. Results from the pilot study showed the questions and response options were easy to understand and simple to complete by all participants. However, removal of one item in the domain of hearing screening activities, ‘I was satisfied with the waiting time for the appointment’, was recommended because all participants commented that they had not experienced such situation during the hearing screening process. After eliminating this particular item, the Malay version of PSQ-NHSP consists of 27 items. In specific, the Malay version of PSQ-NHSP contains one dichotomous, two multiple-choice, 21 close-ended and 3 open-ended items which follow in chronological order of the hearing screening process.
2.4. Data analysis In this study, data were analyzed using the Statistical Package for the Social Sciences (SPSS 17.0) software. During the data analysis, all negative items in the Malay version of PSQ-NHSP
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Table 1 Descriptive statistics for each item in the questionnaire. Scoring of the items ranged from 1 to 5, with 1 being attributed to the most negative response, and 5 the most positive. Items
Information The content of the information sheet (brochure or leaflet) was sufficient The information about the program was difficult to understanda The information about the program was very useful Total Personnel in charge of the hearing testing I was satisfied with the interval between the initial hearing screening and the follow-up appointment The tester did not give clear information about the follow-up appointmenta Now that I have had the follow-up appointment, I know what must be done next concerning my child’s hearing The information I received regarding the testing procedure was not sufficienta The information on the results of the test was sufficient The tester was knowledgeable about the program The tester was skillful with the equipment The tester was not approachablea The tester was gentle with my baby during the testing procedure Total
Mean
Standard deviation (SD)
Agree/ strongly agree (%)
Neutral (%)
Disagree/ strongly disagree (%)
68 (57.1) 68 (57.1) 68 (57.1)
3.93 3.87 4.19 4.00
0.56 0.64 0.50
89.8 2.9 95.6
5.8 19.1 4.4
4.4 78.0 0.0
54 (45.4)
3.87
0.52
87.0
9.3
3.7
55 (46.2) 56 (47.1)
3.69 3.70
0.74 0.74
10.9 71.5
14.5 19.6
74.6 8.9
n (%)
118 119 118 110 117 105
(99.2) (100) (99.2) (92.4) (98.3) (88.2)
3.13 3.34 3.70 3.71 3.84 3.86 3.65
1.06 0.93 0.70 0.67 0.78 0.73
38.1 58.8 72.0 65.5 8.5 80.0
12.7 15.1 21.3 32.7 13.8 14.2
49.2 26.1 6.7 1.8 91.0 5.8
Hearing screening activities I had the chance to ask more about the program I had the chance to ask more about the test procedure I had the chance to ask more about the results of the test The testing period was not appropriatea The testing site for this program was not appropriatea Total
119 118 118 116 115
(100) (99.2) (99.2) (97.5) (96.6)
3.50 3.49 3.54 3.60 3.69 3.56
0.94 0.94 0.86 0.83 0.84
67.2 67.0 67.9 13.0 10.4
13.4 13.5 16.9 20.6 19.1
19.4 19.5 15.2 66.4 70.5
Overall satisfaction Overall, I was satisfied with the program I was not satisfied with the test processa I will recommend this program to friends or relatives I will not use the same service in futurea Total
119 119 119 119
(100) (100) (100) (100)
3.85 3.80 4.03 4.05 3.93
0.66 0.78 0.48 0.64
80.6 8.4 91.6 2.5
15.2 16.9 7.6 10.1
4.2 74.7 0.8 87.4
n = total number of participants answered each item. a Negatively worded item.
(items 4, 9, 11, 15, 20, 22, 24, 26) were reverse coded. Descriptive statistics included the frequency, percentage, mean and standard deviation of all items in the questionnaire were computed to establish the level of parent satisfaction with the NHSP. Additionally, a cumulative percentage of two disagreement levels (disagree and strongly disagree) of more than 20% were calculated to identify areas associated with a high level of dissatisfaction [15]. The three open ended questions were analyzed and categorized manually, which involved organizing the responses into common themes. Where possible, all comments were grouped into the four dimensions of satisfaction which are information, personnel in charge of hearing testing, hearing screening activities, and overall satisfaction. Those responses that were not associated with any of the dimensions of satisfaction were categorized under ‘others’ comments. In regard to the psychometric properties of the Malay version PSQ-NHSP, Cronbach’s alpha analysis was used to measure its internal consistency reliability, while Spearman’s rank correlation was performed to evaluate the content validity of the questionnaire. 3. Results Two hundred questionnaires were distributed during the data collection period, and 119 (59.5%) mothers responded. In response to a multiple-choice item of ‘how did they hear about the program’, 84 mothers (70.6%) reported that they knew about the program from midwives, 31 (26.1%) from doctors, and 4 (3.3%) from friends and relatives. With regard to another multiple-choice item which ask about the results of their baby’s
hearing test, 54 mothers (45.4%) reported that their newborns passed the initial hearing screening, 56 (47.1%) indicated that their newborns required further testing, and 9 (7.5%) did not know their babies’ test results. The descriptive statistics of each item in the questionnaire are summarized in Table 1. The mean scores of the overall satisfaction items ranged from 3.80 to 4.05 which represent a level of satisfaction between satisfied and very satisfied. In this dimension, item ‘I will recommend this program to friends or relatives’ received the highest rating (91.6%) and has the lowest percentage of disagreement level of 0.8%. In regard to the information dimension, of the 119 mothers whose baby received a hearing screening, only 68 participants (57.1%) reported that they received the brochure prior the screening process. Mean scores for information items ranged from 3.87 to 4.19 (SD range = 0.50–0.64), with item, ‘The information about the program was very useful’ received the highest rating (95.6%) among all the items in the questionnaire. Furthermore, the percentage of disagreement for items in the information dimension ranged from 0% to 4.4%, indicating high levels of parent satisfaction with this aspect of the program. Mean scores for items in the personnel in charge of the hearing testing dimension ranged from 3.13 to 3.86 (SD range = 0.52– 1.06). As shown in Table 1, the percentage of disagreement for all items in this dimension was less than 20% except for two items measuring communication aspect of personnel in charge of the hearing testing. The highest percentage of disagreement (38.1%) was related to item ‘the information I received regarding the testing procedure was not sufficient’. In addition, about 26% of the
R. Mazlan et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 348–353 Table 2 Summary of responses to ‘‘one thing which you were more than satisfied about’’. Satisfied with Information Easy to understand Personnel in charge of hearing testing Friendly staff Approachable, caring and gentle tester Hearing screening activities The test did not upset my baby Others Early detection of hearing loss Total
Comments frequency n (%)
20 (26.0) 5 (6.5) 9 (11.7)
Table 3 Summary of responses to ‘‘one thing which you were less than satisfied about’’.
Personnel in charge of hearing testing Inadequate explanation of the test procedure and test results Hearing screening activities Lack of parent–screener communication Total
Suggestions
Comments frequency n (%) 14 (56.0)
3 (12.0) 8 (32.0) 25 (100)
41 (53.2) 77 (100)
participants were not satisfied with item ‘the information on the results of the test was sufficient’. Mean scores for the hearing screening activities items ranged from 3.49 to 3.69 (SD range = 0.83–0.94). Furthermore, the cumulative percentage of the two disagreement levels for all items was less than 20%, indicating that parents were generally satisfied with this dimension. In regard to the open-ended items, 93 (78.1%) questionnaires contained comments. Forty one participants (44.1%) provided at least one comment while 55.9% of participants made more than one comment. Tables 2–4 detail the responses obtained for each of the open-ended items in the questionnaire. A total of 77 comments were received for the open-ended item relating to one area that participants were satisfied with the program (see Table 2). As shown in Table 2, most positive comments were not related to any of the dimensions. In specific, 41 participants (53.2%) were satisfied with the fact that the hearing loss can be detected early. Table 3 shows a summary of the 33 comments offered by participants in regard to any dissatisfaction with the program. Similar dimensions of satisfaction as obtained from satisfied comments (i.e. personnel in charge of hearing testing and appointment activities) contributed to dissatisfaction responses. Most comments (66.7%) were related to personnel in charge of the hearing testing, in particular, the communication aspect of the screener. Participants also expressed dissatisfaction with a lack of communication between parent and screener during the hearing screening process. Participant’s suggestions for changes and improvements to the program are shown in Table 4. A total of 25 suggestions were made, with the most common suggestions were related to the personnel in charge of the hearing testing dimension. The internal reliability of the Malay version of PSQ-NHSP was assessed by determining the Cronbach’s alpha values. The results showed that the revised questionnaire has excellent internal consistency reliability with a total Cronbach’s alpha of 0.90. Additionally, the Cronbach’s alpha coefficients were above 0.7 for all dimensions of satisfaction. In specific, alphas for information, personnel in charge of the hearing testing, hearing screening activities, and overall satisfaction were 0.72, 0.80, 0.81, and 0.82, respectively.
Dissatisfied with
Table 4 Summary of participant suggestions for changes and improvements to program.
Personnel in charge of hearing testing Provide more detailed explanation on the test procedure and results Appointment activities More appropriate room for testing More flexible on the follow-up date Total
2 (2.6)
351
Comments frequency n (%) 22 (66.7)
11 (33.3) 33 (100)
In regard to its content validity, the results of Spearman’s rankorder correlation analysis showed moderately positive correlation between overall satisfaction and all measured dimensions, with correlation values ranging from 0.58 to 0.70. 4. Discussion The present study aimed to evaluate parents’ satisfaction with a UNHS program in a university hospital in Kuala Lumpur, Malaysia. The results suggest that parents were generally satisfied with the program, with more than 80% of them responded with either ‘agree’ or ‘strongly agree’ to items measuring the overall satisfaction. The overall satisfaction levels in the present study compare very favorably with those obtained in other programs. For instance, 80–95% of parents were satisfied with the overall service provided by the Newborn Hearing Screening Wales, Wales, United Kingdom [9], while over 95% of parents were satisfied with the Infant Hearing Screening Program at The Hear and Say Centre, Brisbane, Australia [11]. The present study also found that parents were satisfied with the specific dimensions of satisfaction; information, personnel in charge of hearing testing, and hearing screening activities. However, there was variability in the degree of satisfaction depending on the dimension. For the information dimension, only 68 of the 119 (57.1%) participants in the present study received the written information brochure prior to the NHSP. More than 90% of this group reported that they were satisfied for the majority of items representing this dimension. This result suggests that parents are generally satisfied; however, the fact that only 57.1% of parents actually received the information is an issue that need to be addressed by the program. It was not possible however to directly compare results from this particular dimension of satisfaction with results from other hearing screening programs, as some studies did not include this aspect in their surveys [9,10]. The only similar work is by Watkin et al. [16] and Mazlan et al. [11]. In both studies, high level of satisfaction with the contents of an information leaflet was reported, with more than 90% of parents responding that they were satisfied or very satisfied with this aspect of the service. In regard to other dimensions of satisfaction, personnel in charge of the hearing testing and hearing screening activities, parents in the present study were generally satisfied with all items contained in these two dimensions. However, parents were dissatisfied with two aspects of the program. In specific, assessments of disagreement scores indicate that parents reported high levels of dissatisfaction with the communication aspect of personnel in charge of the hearing testing. The dissatisfaction levels for explanations provided by the screener on the testing procedures and the test results were 38.1% and 26.1%, respectively. Therefore, this is an area that warrants further attention and targeted intervention, possibly through avoiding jargon or medical terminology when communicating with parents, listening carefully or by spending sufficient time with the parents. Dissatisfaction
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with screener’s explanations expressed by the parents has also been reported in Fox and Minchom [9]. In this particular study, item ‘I was given enough information to decide whether my baby should be tested’ received the lowest rating from 77% of the participants. A further aim of the present study was to obtain qualitative feedback from parents by seeking their responses to the openended items included in the questionnaire. Inclusion of openended items in the present study allowed parents to express issues that may not have been considered important by the researcher, but are relevant to the participants. The majority of participants (78%) responded to the open-ended items included in the questionnaire. It seems clear that parents did not hesitant to criticize particular aspects of services and make suggestions to improve the current service. For the open-ended item that sought parents’ views on one thing that they were satisfied with in the program, the most frequent positive comments received for this item were related to the fact that hearing loss can be detected early (53%). This finding indicates that parents agreed on the importance of early detection of hearing loss in newborn babies. It is interesting to note that personnel in charge of the hearing testing received the most frequent negative comments for another open-ended item that asked parents to indicate one thing that they were dissatisfied with in the program. The fact that both close-ended statements and open-ended question focused on the same area, that is, on personnel in charge of the hearing testing, highlights the needs to address this issue. Additionally, the lack of parent–screener communication indicates that parents in the present study supported the concept of family-centered approach during the screening process. Existing research suggests that communication styles of professionals is the most important issue shaping parent experiences, with ‘good’ professional communication was marked by being clear, jargon-free explanations that use examples in context, sensitive toward parents’ emotional needs, involve parents in testing procedures, honesty and openness [17]. In regard to the open-ended item about how the service might be improved, 25 suggestions were made. The area that received the most frequent comments (56%) was the communication aspect of personnel in charge of the hearing testing dimension. Specifically, parents wanted more detailed information in areas of the testing procedures and the test results. ‘More appropriate testing room’ and ‘more flexible on the follow-up date’ were suggestions reported by parents about hearing screening activities. One of the difficulties with studies of parents’ satisfaction is the tendency for participants to report high levels of satisfaction, regardless of the nature of the service being evaluated [18]. This makes it difficult to identify the particular concerns that give rise to dissatisfaction among some participants. The high levels of agreement with close-ended items highlight the importance of including open-ended items in the questionnaires. Some parents may not wish to give a service a ‘bad mark’ in response to a general question, but will be prepared to offer suggestions for improvements. Strength of the present study was its use of items from a reliable and validated measure of parents’ satisfaction (i.e. PSQ-NHSP) together with ratings of three dimensions of satisfaction of the service being evaluated. This approach overcame two problems that have tended to hinder previous research investigating satisfaction with other types of pediatric health care service programs [2,19]. First, it seems reasonable to argue that parent satisfaction is a multidimensional concept that reflects parents’ judgements about several characteristics of the services they have received. However, many measures of satisfaction are unidimensional and provide little opportunity for parents to comment on the different characteristics that contribute to overall satisfaction.
Second, although global ratings provide a useful summary of parent satisfaction, they do not provide information that can be employed to address the concerns causing dissatisfaction among some parents. In the present study, it was possible to use the ratings from items representing the three dimensions of satisfaction to identify aspects of service that need changes or improvements. In addition, the use of open-ended items was also important as it allowed the identification of particular concerns of parents and thus indicated areas for service improvement. An important area that the present study did not investigate is the relationship between satisfaction and the demographic variables of the parents. Byalin [2] found a significant relationship between parents’ age and their satisfaction with services received by their children. Brannan et al. [20] found a positive correlation between parents’ age and their satisfaction with certain service aspects. Other researchers have found no relationship between satisfaction and demographic variables of the parents [21]. Available parent demographic details were very limited in the present study (i.e., race and employment status), and further investigation is necessary to clarify this issue. 5. Conclusion Overall, parents reported being satisfied with the UNHSP services they are receiving in the university hospital. However, issues related to the communication aspect of personnel in charge of the hearing testing requires further investigation and intervention in an effort to improve and sustain the program. Additionally, this study has demonstrated the survey instrument to be useful in identifying key areas that require improvement in the UNHSP process. Funding This study was supported by the Universiti Kebangsaan Malaysia Research and Ethics Committee (NN-124-2011). Acknowledgements The authors are grateful to the parents who kindly participated in this survey. The authors would also like to thank the staff of the maternity wards for their time and assistance during the study. References [1] R. Bradford, Staff accuracy in predicting the concerns of parents of chronically ill children, Child Care Health Dev. 17 (1991) 39–47. [2] K. Byalin, Assessing parental satisfaction with children’s mental health services, Eval. Prog. Plan. 16 (1993) 69–72. [3] K. Brown, E. Sheehan, M. Sawyer, J. Raftos, V. Smyth, Parent satisfaction with services in emergency department located at a paediatric teaching hospital, J. Paediatr. Child Health 31 (1995) 435–439. [4] L.P. Bernheimer, R. Gallimore, T.S. Weisner, Ecocultural theory as a context for the individual family service plan, J. Early Interv. 14 (1990) 219–233. [5] H. Bragadottir, D. Reed, Psychometric instrument evaluation: the pediatric family satisfaction questionnaire, Pediatr. Nurs. 28 (2002) 475–484. [6] JCIH, Year 2000 position statement: principles and guidelines for early hearing detection and intervention programs, Pediatrics 106 (2000) 798–817. [7] L. Cox, M. Toro, Evolution of a universal infant hearing screening program in an inner city hospital, Int. J. Pediatr. Otorhinolaryngol. 59 (2001) 99–104. [8] L. Dalzell, M. Orlando, M. MacDonald, A. Berg, M. Bradley, A. Cacace, et al., The New York State universal newborn hearing demonstration project: ages of hearing loss identification, hearing aid fitting, and enrollment in early intervention, Ear Hear. 21 (2000) 118–130. [9] R. Fox, S. Minchom, Parental experiences of the newborn hearing screening programme in Wales: a postal questionnaire survey, Health Expect. 11 (2008) 376–383. [10] J.R. MacNeil, C. Liu, S. Stone, J. Farrel, Evaluating families’ satisfaction with early hearing detection and intervention services in Massachusetts, Am. J. Audiol. 16 (2007) 29–56. [11] R. Mazlan, L. Hickson, C. Driscoll, Measuring parent satisfaction with a neonatal hearing screening program, J. Am. Acad. Audiol. 27 (2006) 253–264.
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