Journal of Substance Abuse Treatment 53 (2015) 47–51
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Journal of Substance Abuse Treatment
A Satisfaction Survey of Opioid-Dependent Patients with Methadone Maintenance Treatment Zoriah Aziz, Ph.D. ⁎, Nyuk Jet Chong, M.Med.Sc. Department of Pharmacy, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
a r t i c l e
i n f o
Article history: Received 27 July 2014 Received in revised form 16 December 2014 Accepted 22 December 2014 Keywords: Opioid dependency Methadone maintenance treatment services Satisfaction Predictors
a b s t r a c t The aim of this study was to examine opioid-dependent patients' satisfaction with the methadone maintenance treatment (MMT) program in Malaysia and identify predictors of satisfaction. We used an intervieweradministered questionnaire developed and validated by Rankin Court, New South Wales, Australia. Of 502 patients approached in 11 MMT centers in Malaysia, 425 agreed to participate giving a response rate of 85%. In terms of overall satisfaction, a high percentage of respondents (85%) were satisfied with the MMT services. A logistic regression analysis showed that only “centres” and marital status were associated with overall satisfaction and that being single (OR 3.31; 95% CI 1.52 to 7.20) or married (OR 4.06; 95% CI 1.76 to 9.38) was associated with higher odds of overall satisfaction compared to being divorced or separated. An analysis of the responses pertaining to the most desired changes required at the center found dosing hours, waiting area and staff shortages to be common. The findings acquired from this survey will be useful to attain a clearer perspective on what aspects of the MMT service need to be reviewed for the improvement of service delivery. © 2015 Elsevier Inc. All rights reserved.
1. Introduction The aim of methadone maintenance treatment (MMT) in opiate dependency is to reduce the individual and social harm associated with illicit opiate use. MMT does not cure opiate dependence; rather it is a treatment that helps people to manage their opiate dependence. By reducing craving and preventing withdrawal, the addicts' preoccupation with obtaining illicit drugs is reduced sufficiently, thus enabling the users to achieve some stability in their life (Ward, Hall, & Mattick, 1999). From a social perspective MMT has been shown to be cost effective and beneficial for the treatment of opiate dependence (Simoens, Ludbrook, Matheson, & Bond, 2006). Among the benefits seen in individuals and society are reduced numbers of deaths due to drug overdose, improved family stability and employment potential, reduced transmission of diseases such as HIV and sexually transmitted diseases, and reduced criminal activities (Bennett, Holloway, & Williams, 2001; Oppenheimer, Tobutt, Taylor, & Andrew, 1994; Ward et al., 1999; Wells, Calsyn, Clark, Saxon, & Jackson, 1996). It is estimated that at least one million people in Malaysia are currently addicted to heroin and other opiates (Malaysian Psychiatric Association, 2006). They risk premature death and often suffer from HIV, hepatitis B or C, sexually transmitted diseases, and mental health
Abbreviations: CSQ-8, Client Satisfaction Questionnaire; MMT, Methadone Maintenance Treatment; SSS-30, Service Satisfaction Scale; VSSS-32, Verona Service Satisfaction Scale; VSSS-MT, Verona Service Satisfaction Scale for methadone-treated opioiddependent patients. ⁎ Corresponding author. Tel.:+60 3 79674909; fax: +60 3 79674964. E-mail address: [email protected] (Z. Aziz). http://dx.doi.org/10.1016/j.jsat.2014.12.008 0740-5472/© 2015 Elsevier Inc. All rights reserved.
problems. The MMT program in Malaysia was initiated in October 2005 with 18 facilities (Sangeeth, Hafidah, & Mahmood, 2009) and has now expanded to include 333 centers in 2012 (Ministry of Health Malaysia (MOH), 2012). However, little is known about patients' satisfaction with the delivery of those services. Patients who are dissatisfied with the MMT services may have worse outcomes than others because they may miss appointments or do not follow through on treatment plans (Fitzpatrick, 1991). The measurement of satisfaction can be difficult because there is no clear definition of satisfaction and a lack of understanding of its underlying factors (Baker, 1997). This has hindered measurement efforts and caused difficulty in the interpretation and comparing of research findings. In spite of the increased emphasis on assessing patients' satisfaction because satisfaction can affect treatment outcome, the literature regarding patients' satisfaction remains limited (Pérez de los Cobos et al., 2004). Even though there is no clear definition of satisfaction, patients' satisfaction can be viewed as patients' expectations and perceptions of how well the services fulfilled their needs. This measure is affected by their prior experiences, individual needs and expectations (Williams, 1994). A major limitation in assessing patient's satisfaction with MMT services is the limited availability of instruments designed to measure satisfaction specific to MMT service delivery. Given the lack of such a tool, satisfaction with MMT program has been assessed using other satisfaction instruments designed for other purposes such as the Client Satisfaction Questionnaire (CSQ-8) (Larsen, Attkisson, Hargreaves, & Nguyen, 1979), the Service Satisfaction Scale (SSS-30) (Attkisson & Greenfield, 1996) and the Verona Service Satisfaction Scale (VSSS-32) (Ruggeri, DallAgnola, Bisoffi, & Greenfield, 1996). The SSS-30 has several
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features that greatly limit its usefulness in assessing patients' satisfaction with MMT. The most important of these is that SSS-30 appears appropriate for use only in health or mental health outpatient services (Attkisson & Greenfield, 1994). For example, it contains items that ask patients about their satisfaction with prescription (or non-prescription) medication in helping to relieve symptoms. de los Cobos et al. (2002) adapted the VSSS-32 specifically for application in methadone treatment centers. The adapted instrument (the Verona Service Satisfaction Scale for methadone-treated opioid-dependent patients, or VSSS-MT) has 27 items and contains a mixture of open ended and 5 point Likert scale responses, addressing specific aspects of service delivery and overall quality of service ratings. The authors reported that the VSSS-MT displays a high level of internal consistency, and a satisfactory level of test–retest reliability. Despite its usability, the Rankin Court Centre, New South Wales, Australia (Kehoe, Wodak, Degenhardt, & National Drug Alcohol Research Centre, 2004) considered VSSS-MT as too long and complex for most patients' literacy skills. The Rankin Centre thus developed a validated shorter, eleven items questionnaire which we used in this study. Assessing patients' satisfaction with the MMT services is crucial because at present the trend is for health care services to be more patient oriented. Given that patients' satisfaction evaluation is important and that WHO has recommended it for improving the quality of services at MMT centers (World Health Organization, United Nations International Drug Control Programme, & European Monitoring Center on Drugs Drug Addiction, 2000), we wanted to determine patients' satisfaction with the MMT services they were receiving. Thus, the main objective of our study was to examine patients' satisfaction with the MMT services offered by MMT centers in Malaysia. We also identified factors which predicted overall satisfaction. 2. Methods 2.1. Survey centers and participants This cross-sectional study was conducted in 11 centers from four regions in Peninsular Malaysia (central, north, south and east). Eligible centers were methadone-dispensing centers that had been in operation for at least 3 months. The centers were selected based on simple random sampling while participants from each selected center were based on convenient sampling. The researchers approached potential participants in order to recruit and inform them of the purpose of the research. Potential respondents were assured of their anonymity, and oral informed consent was obtained. Subjects who showed clear signs of substance intoxication were excluded from the study. Two trained interviewers administered the questionnaires via face-to-face interview. The survey was carried out over a 2-month period. Only participants who received MMT in the month prior to the survey were included. We made one change to the questionnaire before the study. Since we intended to dichotomize the response of overall satisfaction to “satisfied” and “dissatisfied”, we changed the wording for item 11 of the original questionnaire to “Thinking about all your experiences at this centre, are you satisfied with the service?” This version of the questionnaire was piloted with a representative sample of 40 participants to assess the items for local suitability before the study began. Data from this pilot testing were not included in the analysis. 2.2. Instrument Except for item 11, we used all the items in the questionnaire developed by Rankin Court, Australia. Permission to use the questionnaire was obtained from the questionnaire developer. According to the questionnaire developer, the items in the questionnaire addressed a range of conceptual dimensions including professionals' skills and behaviors, physical environment, the amount of information provided, and overall satisfaction. Face validity of the questionnaire has also been addressed (Kehoe et al., 2004).
Eight of the eleven items explored satisfaction about the center and covered conceptual dimensions such as professionals' skills and behaviors, access and amount of information. Likert scale response categories used were terrible = 1; mostly dissatisfied =2; neither good nor bad = 3; mostly satisfactory = 4 and excellent = 5. For the purpose of data presentation we considered the response on the Likert scale as scores. We also collected socio-demographic data, age, gender, ethnicity, level of education, and marital status. 2.3. Data analysis Data were analyzed using Statistical Package for the Social Sciences (SPSS), version 21.0. Descriptive statistics such as percentages and means were used to describe the sample on the various variables. Univariate logistic regression was used to evaluate the relationships between overall satisfaction (satisfied vs. dissatisfied) and all the demographic variables. When the expected cell number was lower than five in the contingency table, Fisher's exact test was used. 2.4. Model building The dependent variable, “Satisfied” was regarded as a dichotomous variable and coded 0 = “No” response and 1 = “Yes” response. Univariate logistic regression analysis was then performed to identify variables for inclusion into the model. Statistical significance at p b 0.10 level was used to determine the significance of variables for inclusion into the model. Nominal scale variables with more than two levels (such as race and centers) were entered as k − 1 dummy variables. For the ethnic variable, Malay was treated as the reference group while for centers, center A in Kuala Lumpur was used as the reference group. For ordered categorical data with more than two levels, the variable was entered as k − 1 dummy variables with the lowest level used as the reference group. Significant variables in the univariate analysis were entered simultaneously (forced entry method) into binary logistic regression to evaluate their independent predictive value for overall satisfaction. 3. Results 3.1. Socio-demographic characteristics of the study population Of the 502 patients approached, 425 agreed to participate and completed the questionnaire representing a response rate of 85%. Except for two females, all the respondents were males. The gender distribution of the sample was reflective of the MMT population. Their age ranged from 14 to 74, with a mean age of 39.2 (SD = 2.1) years. The majority of the sample was Malay respondents (80.7%). Other socio-demographic characteristics of the study population are shown in Table 1. 3.2. Association of socio-demographic variables with overall satisfaction Table 1 compares characteristics of patients in the two groups: satisfied (i.e., responded with a “Yes”) versus dissatisfied (i.e., described their overall satisfaction with a “No”). Univariate logistic regression analysis indicated that overall satisfaction was not associated with the demographic variables of sex, age, race, and education category and length of time on MMT at significance level of p = 0.1 (Table 1). Only marital status and treatment centers were found to be statistically associated with overall satisfaction. 3.2.1. Predictors of overall satisfaction in the multivariate logistic regression Table 1 shows that only marital status and treatment centers were found to be statistically predictive of overall satisfaction and therefore were included into the multivariate model. Table 2 shows the results of the multiple logistic regression model predicting overall satisfaction with MMT services. Compared to someone who was divorced or separated, the odds of being satisfied with MMT services was about three
Z. Aziz, N.J. Chong / Journal of Substance Abuse Treatment 53 (2015) 47–51 Table 1 Demographic characteristic of MMT patients (n = 425). Characteristic Sex Male Female Age (years) ≤25 26–35 36–45 46–55 N55 Marital status Single Married Divorced/Separated Race Malay Chinese Indian Education (years) 0–6 7–9 10–11 12–17 Duration of treatment with MMT (months) b6 6–12 13–24 N24 Treatment centers A B C D E F G H I J K
n (%)
Satisfied
Dissatisfied
423 (99.5) 2 (0.5)
362 (85.6) 1 (50.0)
61 (14.4) 1 (50.0)
33 (7.8) 130 (30.6) 149 (35.1) 89 (20.9) 24 (5.6)
27 (81.8) 106 (81.5) 131 (87.9) 79 (88.8) 20 (83.3)
6 (18.2) 24 (18.5) 18 (12.1) 10 (11.2) 4 (16.7)
211 (49.6) 165 (38.8) 49 (11.5)
183 (86.7) 146 (88.5) 34 (69.4)
28 (13.3) 19 (11.5) 15 (30.6)
343 (80.7) 59 (13.9) 23 (5.4)
294 (85.7) 50 (84.7) 19 (82.6)
49 (14.3) 9 (15.3) 4 (17.4)
53 (12.5) 122 (28.7) 224 (52.7) 26 (6.1)
45 (84.9) 103 (84.4) 193 (86.2) 22 (84.6)
8 (15.1) 19 (15.6) 31 (13.8) 4 (15.4)
p-value 0.271
0.479
0.005
0.909
0.974
0.432 182 (42.8) 119 (28.0) 83 (19.5) 41 (9.6)
160 (87.9) 101 (84.9) 70 (84.3) 32 (78.0)
22 (12.1) 18 (15.1) 13 (15.7) 9 (22.0)
122 (28.7) 21 (4.9) 26 (6.1) 63 (14.8) 33 (7.8) 64 (15.1) 28 (6.6) 22 (5.2) 12 (2.8) 8 (1.9) 26 (6.1)
101 (82.8) 19 (90.5) 18 (69.2) 58 (92.1) 25 (75.8) 61 (95.3) 20 (71.4) 21 (95.5) 10 (83.3) 7 (87.5) 23 (88.5)
21 (17.2) 2 (9.5) 8 (30.8) 5 (7.9) 8 (24.2) 3 (4.7) 8 (28.6) 1 (4.5) 2 (16.7) 1 (12.5) 3 (11.5)
0.016
times higher for a participant who was single and about four times higher for those who were married. The odds ratio for the variable, treatment center (center C) was less than 1. This indicates that the odds of overall satisfaction with treatment center C was statistically lower compared to center A. On the other hand the odds of overall satisfaction with treatment center F was about four times higher compared to treatment center A, all other factors being constant. 3.2.2. Satisfaction with MMT services Table 3 shows that the satisfaction score for each item from the eleven centers varies slightly but the majority has a mostly satisfactory score (above 4.0). Treatment center F was predicted to have four times higher Table 2 Predictors of overall satisfaction in the multivariate logistic regression analysis. Variables
Odds ratio
95% Confidence interval
Marital status (single) Marital status (married) Center B Center C Center D Center E Center F Center G Center H Center I Center J Center K
3.31 4.06 1.54 0.35 2.12 0.53 3.97 0.49 4.19 0.76 1.15 1.71
1.52 to 7.20 1.76 to 9.38 0.32 to 7.32 0.13 to 0.96 0.75 to 6.02 0.21 to 1.38 1.12 to 14.07 0.18 to 1.29 0.52 to 33.66 0.15 to 3.80 0.13 to 10.03 0.46 to 6.39
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overall satisfaction compared to treatment center A. Its respondents rated all eight items as mostly satisfied (score more than 4.0). In contrast, only four items at center C have score above 4.0. The lowest score was 2.97 from center E on the item “about the way the participants were included in how the centre was run”. 3.3. Identification of things that needed change and other comments about the center Item 9 on the questionnaire was an open-ended question, which asked respondents to identify the one thing they would most like to see changed at the center. Fig. 1 shows that slightly more than onethird of the respondents did not wish for anything to change. The top three things frequently identified, as requiring change were dosing time flexibility, waiting area improvement and increase in number of staff. Respondents who highlighted this issue mostly wanted longer hours for dose administration to cater for their working hours, and they considered the waiting area to be over crowded particularly at peak hours between 8:00 and 9:00 in the morning when the process of queuing was disorganized. 3.4. Other comments regarding the MMT center Item 10 on the questionnaire was also an open-ended question. The question asked respondents for any other comments about the center. Slightly more than 50% of the participants did not give any response while the remaining respondents gave positive comments such as MMT service has helped them to manage their life, they were able to receive free methadone, and they enjoyed the activities organized by the centers. A small number of respondents felt they were safe from being questioned by the police about their addiction. 4. Discussion The response rate achieved was high (85%) suggesting that the brevity of the Rankin Court questionnaire and strong assurance on the patient's anonymity might have helped to improve the rate. The percentage of respondents who indicated that they were satisfied with the MMT service at the centers was high, and this was in agreement with most patient surveys where high satisfaction rates of 75–90% were reported (Kehoe et al., 2004). Additionally, all the treatment centers scored more than 4.0 (mostly satisfactory) for the item, which asked whether the respondents would recommend the center to friend who needed treatment. It is also encouraging to note that about half of the respondents made positive comments about the service received. Mean scores on the eight items of satisfaction covering a range of conceptual dimensions including professionals' skills and behaviors, physical environment, the amount of information provided were in the “satisfied” range for all treatment centers. However, our findings that a high proportion of respondents was satisfied with the MMT services should be interpreted with caution as high levels of patients' satisfaction may have been attributed to measurement errors such as social desirability (Kehoe et al., 2004; Nathorst-Boos, Munck, Eckerlund, & EkfeldtSandberg, 2001), patients' low expectation of service (Bickman, 1996), and patients' fear of reprisal or feeling of empathy for those providing frontline care (Beattie, Lauder, Atherton, & Murphy, 2014). Of the demographic variables examined in the univariate analysis only “marital status” and “centres” were associated with satisfaction. This association did not diminish when examined with multiple logistic regressions analysis. The variable “centres” emerged as the strongest predictor of satisfaction. This is not surprising since the treatment centers differ from each other in aspects such as the physical environment, interpersonal skills of staff and process of service delivery. Several studies showed that these aspects are positively related to patients' satisfaction (Al-Abri & Al-Balushi, 2014; Goel, Sharma, Bahuguna, Raj, & Singh, 2014; Jawaid, Ali, Rizvi, & Razzak, 2010). It is to be noted that one
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Table 3 The Likert responses for eight items exploring the overall feeling about eleven centers. Items
Centers mean (SD)
Feeling about how staff at the center treat you Feeling about the way you are included in the decisions on your treatment Feeling about the way you are included on how the center is run Feeling about the physical environment for patients Feeling about the way this center responds to complaints from patients Feeling about how effective this center has been with your problems Feeling about the amount of information this center gives you about your treatment Would you recommend this center to a friend who needed treatment?
A
B
C
D
E
F
G
H
I
J
K
4.36 (0.53)
4.14 (0.73)
3.96 (1.04)
4.44 (0.62)
3.97 (0.81)
4.52 (0.59)
3.71 (0.98)
4.36 (0.58)
4.75 (0.45)
4.63 (0.52)
4.35 (0.69)
4.22 (0.62)
4.29 (0.72)
4.15 (0.88)
4.27 (0.52)
4.03 (0.81)
4.42 (0.64)
3.79 (0.79)
4.50 (0.51)
4.42 (0.52)
4.25 (0.46)
4.27 (0.53)
3.94 (0.88)
3.71 (0.85)
3.00 (1.30)
4.14 (0.64)
2.97 (1.10)
4.47 (0.59)
3.21 (1.13)
4.23 (0.53)
4.25 (0.97)
3.75 (1.17)
3.85 (1.05)
4.25 (0.68)
4.10 (0.83)
4.12 (0.77)
3.94 (0.80)
4.06 (0.79)
4.28 (0.65)
3.82 (0.86)
4.23 (0.92)
4.75 (0.45)
3.63 (1.06)
4.12 (1.03)
3.85 (0.89)
3.90 (0.89)
3.38 (1.39)
4.16 (0.65)
3.91 (0.91)
4.31 (0.69)
3.50 (1.20)
4.14 (0.71)
4.42 (0.90)
4.13 (0.99)
4.04 (0.96)
4.30 (0.79)
4.29 (0.85)
4.42 (0.70)
4.48 (0.56)
4.30 (0.81)
4.50 (0.69)
4.14 (0.89)
4.73 (0.46)
4.50 (0.91)
4.75 (0.46)
4.46 (0.65)
4.25 (0.84)
4.00 (0.84)
3.96 (0.87)
4.21 (0.77)
4.03 (0.85)
4.48 (0.67)
3.79 (0.96)
4.36 (0.79)
4.67 (0.49)
4.00 (1.41)
4.35 (0.63)
4.91 (0.29)
4.81 (0.51)
4.81 (0.40)
4.90 (0.35)
4.94 (0.24)
4.88 (0.55)
4.46 (1.17)
4.86 (0.55)
4.88 (0.55)
4.75 (0.71)
4.81 (0.40)
treatment center (center F) has high scores for all items exploring feelings of satisfaction. One possible explanation for the high score could be that the patients' expectations of this treatment center were realistically met since there is a strong association between expectations and satisfaction (Tarantino, 2004). It is expected that there would be differences between centers (urban versus rural) in terms of participants' characteristics such as education status and ethnic background. Previous research has shown patients from rural areas are more likely to be satisfied with healthcare services compared to patients from the urban centers (Farmer, Hinds, Richards, & Godden, 2005). However, within our study, this variable (rural versus urban) was not explored as all the centers included are located in the urban area. The most frequent aspect of the service the patients would like to see changed was the flexibility of dosing i.e. hours of service. At the time of data collection, all the treatment centers provided methadone dosing between 8:00 to 11:00 am. As indicated by respondents, they would like to see longer dosing hours to include an earlier start time so that patients' work schedule would not be disrupted. Since their attendance at
No change required
38.4
Dosing flexibility
20.8
Centre/ waiting area
15.5
Staff shortages
7.2
Miscellaneous
6.0
Improve services
4.1
Queuing system
3.1
No comments
3.1
Takeaways policy
1.6
0
10
20
30
40
Percent Fig. 1. The distribution of responses on the one thing that the respondent would most like to see changed at the 11 treatment centers.
the center to receive dosing could be linked with their satisfaction with the treatment center, it is thus reasonable for the health administrators to consider this request. However, as the MMT service in Malaysia is provided free, consideration must be given to the scarcity of government resources. Interestingly about 2% of the respondents wanted the treatment centers to change their policy with regards to takeaways. At the time of writing, all treatment centers restrict methadone takeaway to patients who are believed to be free from using other narcotics by having negative urine test for a period of time specified by the individual centers. Clearer explanation of the basis for takeaway restrictions is recommended to help patients with their expectations and thus improve quality of service. Our findings should be interpreted in the light of several limitations. One, we could not establish the relationship between patient satisfaction with retention given the cross-sectional study design of our study. It has been shown that patient satisfaction with the MMT services was positively correlated with retention in treatment (Kelly, O’Grady, Brown, Mitchell, & Schwartz, 2010; Villafranca, McKellar, Trafton, & Humphreys, 2006). Two, the major limitation of patients' satisfaction data is that it cannot establish the effectiveness of a particular service because there is no direct causal link between satisfaction and effectiveness of the service (Bickman, 1996). For example, patients with low expectations of the service may be satisfied with services that are ‘ineffective’ if determined by other more objective evaluations. In contrast, patients may be unsatisfied with services that are effective but lack human courtesy. Three, the cross-sectional design of the study only provides a 'snapshot' of satisfaction and the characteristics associated with it at a specific point in time. Patients' satisfaction is likely to vary from one visit to another depending on factors such as personality of staff on duty at the time of the study and waiting time. Finally, there may be another healthcare dimension that influences satisfaction which is not covered by the questionnaire. At the time of writing, apart from the Rankin Court Instrument, only one other instrument is available to measure opioid dependent patients' satisfaction with MMT services: The Verona Service Satisfaction Scale-MT (de los Cobos et al., 2002). However, this Verona scale was too lengthy with textual complexity that it is not considered to be appropriate for routine use to assess satisfaction. However, our results have shown that the Rankin Court questionnaire may be useful as an assessment tool to provide meaningful feedback to enable service improvement at the MMT centers in
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Malaysia. This questionnaire will allow various MMT centers' performance to be compared while regular use at each center will support longitudinal assessment of improvement in the center's performance. Patients' satisfaction rating as an indicator of the quality of services provided has also been criticized because the rating may reflect unrealistic patient expectations. Although in some cases this criticism may be valid, studies involving other health services suggest that satisfaction surveys can effectively discriminate between services that are different in quality (Sheppard, 1993). It is, therefore, worth noting that positive patients' satisfaction alone is not sufficient to establish the quality of MMT services provided. However, our findings also identify aspects of the service, which can be reviewed to align with patients' expectations, and needs. 5. Conclusion The findings generated from this survey will allow MMT administrators to obtain a clearer perspective on what aspects of the MMT service should be reviewed to achieve improvement of service delivery. The identification of service areas requiring improvement will create a supportive environment and foster motivated patients who would be less likely to miss appointments or not follow through on treatment plans. The findings from this study would also be useful in establishing national level performance indicators for the MMT programs at the various MMT centers. In summary, information gathering from opioid-independent individuals about their satisfaction is essential to the quality assurance process. Acknowledgments The study was supported by the Short Term Grant (PJP/FS218/2008B) from the University of Malaya. The authors would like to thank the National Anti-drug Agency, Malaysia for giving the approval to conduct the study and the ethics clearance. We would like to thank Salmizawati Salim of the Department of Pharmacy, Faculty of Medicine for her help in data collection and Sameerah Shaik Abdul Rahman of National Pharmaceutical Control Bureau, Ministry of Health Malaysia for providing constructive comments. We are also grateful for the very useful suggestions for amendments made by two anonymous Journal of Substance Abuse Treatment reviewers. References Al-Abri, R., & Al-Balushi, A. (2014). Patient satisfaction survey as a tool towards quality improvement. Oman Medical Journal, 29(1), 3–7, http://dx.doi.org/10.5001/omj.2014.02. Attkisson, C. C., & Greenfield, T. K. (1994). Client satisfaction questionnaire-8 and service satisfaction scale-30. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcome assessment (pp. 402–420). Hillsdale, NJ, England: Lawrence Erlbaum Associates, Inc. Attkisson, C. C., & Greenfield, T. K. (1996). The Client Satisfaction Questionnaire (CSQ) Scales and the Service Satisfaction Scale- 30 (SSS-30). In L. I. Sederer, & B. Dickey (Eds.), Outcomes Assessment in Central Practice (pp. 120–127). Baltimore: Lippincott Williams and Wilkins. Baker, R. (1997). Pragmatic model of patient satisfaction in general practice: Progress towards a theory. Quality in Health Care, 6(4), 201–204, http://dx.doi.org/ 10.1136/qshc.6.4.201. Beattie, M., Lauder, W., Atherton, I., & Murphy, D. (2014). Instruments to measure patient experience of health care quality in hospitals: A systematic review protocol. Systematic Reviews, 3(1), 1–8, http://dx.doi.org/10.1186/2046-4053-3-4. Bennett, T., Holloway, K., & Williams, T. (2001). Drug use and offending: Summary results of the first year of the New-Adam Research Programme. Research Findings No. 148. London: Great Britain, Home office Research, Development and Statistics Directorate (Retrieved from http://www.dldocs.stir.ac.uk/documents/r179.pdf). Bickman, L. (1996). A continuum of care. More is not always better. American Psychologist, 51(7), 689–701, http://dx.doi.org/10.1037/0003-066X.51.7.689.
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Evaluation and Program Planning, 2(3), 197–207, http://dx.doi.org/10.1016/0149-7189(79)90094-6. Malaysian Psychiatric Association (2006). What is Drug Addiction? Retrieved 2014, April 15, from http://www.psychiatry-malaysia.org/article.php?aid=90 Ministry of Health Malaysia (MOH) (2012). Directory of methadone replacement therapy. Retrieved 2014, July 3, from http://www.pharmacy.gov.my/v2/sites/default/files/ document-upload/direktori-pusat-rtg-methadone-upload-diportal.pdf Nathorst-Boos, J., Munck, I. M., Eckerlund, I., & Ekfeldt-Sandberg, C. (2001). An evaluation of the QSP and the QPP: Two methods for measuring patient satisfaction. International Journal for Quality in Health Care, 13(3), 257–264, http://dx.doi.org/10. 1093/intqhc/13.3.257. Oppenheimer, E., Tobutt, C., Taylor, C., & Andrew, T. (1994). Death and survival in a cohort of heroin addicts from London centres: A 22-year follow-up study. Addiction, 89(10), 1299–1308, http://dx.doi.org/10.1111/j.1360-0443.1994.tb03309.x. Pérez de los Cobos, J., Fidel, G., Escuder, G., Haro, G., Sanchez, N., Pascual, C., et al. (2004). A satisfaction survey of opioid-dependent clients at methadone treatment centres in Spain. Drug and Alcohol Dependence, 73(3), 307–313, http://dx.doi.org/10.1016/j. drugalcdep.2003.11.001. Ruggeri, M., DallAgnola, R., Bisoffi, G., & Greenfield, T. (1996). Factor analysis of the Verona Service Satisfaction Scale-82 and development of reduced versions. International Journal of Methods in Psychiatric Research, 6(1), 23–38, http://dx.doi.org/10.1002/ (sici)1234-988x(199604)6:1b23::aid-mpr147N3.3.co;2-d. Sangeeth, K., Hafidah, M., & Mahmood, N. M. (2009). Projek perintis program rawatan terapi gantian (RTG) menggunakan methadone di Pusat Khidmat AADK [The pilot project of Methadone replacement therapy in the anti-drug agency service centre]. Jurnal Antidadah Malaysia, 5, 79–108 (Retrieved from http://www.adk.gov.my/ html/pdf/jurnal/2009/5_3.pdf). Sheppard, M. (1993). Client satisfaction, extended intervention and interpersonal skills in community mental health. Journal of Advanced Nursing, 18(2), 246–259, http://dx.doi. org/10.1046/j.1365-2648.1993.18020246.x. Simoens, S., Ludbrook, A., Matheson, C., & Bond, C. (2006). Pharmaco-economics of community maintenance for opiate dependence: A review of evidence and methodology. Drug Alcohol Depend, 84. (pp. 28–39)Drug and Alcohol Dependence, 84(1), 28–39, http:// dx.doi.org/10.1016/j.drugalcdep.2005.12.009. Tarantino, D. P. (2004). How should we measure patient satisfaction? Physician Executive, 30(4), 60–61. Villafranca, S. W., McKellar, J. D., Trafton, J. A., & Humphreys, K. (2006). Predictors of retention in methadone programs: A signal detection analysis. Drug and Alcohol Dependence, 83(3), 218–224, http://dx.doi.org/10.1016/j.drugalcdep.2005.11.020. Ward, J., Hall, W., & Mattick, R. P. (1999). Role of maintenance treatment in opioid dependence. Lancet, 353(9148), 221–226, http://dx.doi.org/10.1016/s0140-6736(98) 05356-2. Wells, E. A., Calsyn, D. A., Clark, L. L., Saxon, A. J., & Jackson, T. R. (1996). Retention in methadone maintenance is associated with reductions in different HIV risk behaviors for women and men. American Journal of Drug and Alcohol Abuse, 22(4), 509–521, http://dx.doi.org/10.3109/00952999609001677. Williams, B. (1994). Patient satisfaction: A valid concept? Social Science & Medicine, 38(4), 509–516, http://dx.doi.org/10.1016/0277-9536(94)90247-X. World Health Organization, United Nations International Drug Control Programme, & European Monitoring Center on Drugs Drug Addiction (2000). Evaluation of psychoactive substance use disorder treatment: Workbook 6 Client satisfaction evaluations.
Contents lists available at ScienceDirect
Journal of Substance Abuse Treatment
A Satisfaction Survey of Opioid-Dependent Patients with Methadone Maintenance Treatment Zoriah Aziz, Ph.D. ⁎, Nyuk Jet Chong, M.Med.Sc. Department of Pharmacy, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
a r t i c l e
i n f o
Article history: Received 27 July 2014 Received in revised form 16 December 2014 Accepted 22 December 2014 Keywords: Opioid dependency Methadone maintenance treatment services Satisfaction Predictors
a b s t r a c t The aim of this study was to examine opioid-dependent patients' satisfaction with the methadone maintenance treatment (MMT) program in Malaysia and identify predictors of satisfaction. We used an intervieweradministered questionnaire developed and validated by Rankin Court, New South Wales, Australia. Of 502 patients approached in 11 MMT centers in Malaysia, 425 agreed to participate giving a response rate of 85%. In terms of overall satisfaction, a high percentage of respondents (85%) were satisfied with the MMT services. A logistic regression analysis showed that only “centres” and marital status were associated with overall satisfaction and that being single (OR 3.31; 95% CI 1.52 to 7.20) or married (OR 4.06; 95% CI 1.76 to 9.38) was associated with higher odds of overall satisfaction compared to being divorced or separated. An analysis of the responses pertaining to the most desired changes required at the center found dosing hours, waiting area and staff shortages to be common. The findings acquired from this survey will be useful to attain a clearer perspective on what aspects of the MMT service need to be reviewed for the improvement of service delivery. © 2015 Elsevier Inc. All rights reserved.
1. Introduction The aim of methadone maintenance treatment (MMT) in opiate dependency is to reduce the individual and social harm associated with illicit opiate use. MMT does not cure opiate dependence; rather it is a treatment that helps people to manage their opiate dependence. By reducing craving and preventing withdrawal, the addicts' preoccupation with obtaining illicit drugs is reduced sufficiently, thus enabling the users to achieve some stability in their life (Ward, Hall, & Mattick, 1999). From a social perspective MMT has been shown to be cost effective and beneficial for the treatment of opiate dependence (Simoens, Ludbrook, Matheson, & Bond, 2006). Among the benefits seen in individuals and society are reduced numbers of deaths due to drug overdose, improved family stability and employment potential, reduced transmission of diseases such as HIV and sexually transmitted diseases, and reduced criminal activities (Bennett, Holloway, & Williams, 2001; Oppenheimer, Tobutt, Taylor, & Andrew, 1994; Ward et al., 1999; Wells, Calsyn, Clark, Saxon, & Jackson, 1996). It is estimated that at least one million people in Malaysia are currently addicted to heroin and other opiates (Malaysian Psychiatric Association, 2006). They risk premature death and often suffer from HIV, hepatitis B or C, sexually transmitted diseases, and mental health
Abbreviations: CSQ-8, Client Satisfaction Questionnaire; MMT, Methadone Maintenance Treatment; SSS-30, Service Satisfaction Scale; VSSS-32, Verona Service Satisfaction Scale; VSSS-MT, Verona Service Satisfaction Scale for methadone-treated opioiddependent patients. ⁎ Corresponding author. Tel.:+60 3 79674909; fax: +60 3 79674964. E-mail address: [email protected] (Z. Aziz). http://dx.doi.org/10.1016/j.jsat.2014.12.008 0740-5472/© 2015 Elsevier Inc. All rights reserved.
problems. The MMT program in Malaysia was initiated in October 2005 with 18 facilities (Sangeeth, Hafidah, & Mahmood, 2009) and has now expanded to include 333 centers in 2012 (Ministry of Health Malaysia (MOH), 2012). However, little is known about patients' satisfaction with the delivery of those services. Patients who are dissatisfied with the MMT services may have worse outcomes than others because they may miss appointments or do not follow through on treatment plans (Fitzpatrick, 1991). The measurement of satisfaction can be difficult because there is no clear definition of satisfaction and a lack of understanding of its underlying factors (Baker, 1997). This has hindered measurement efforts and caused difficulty in the interpretation and comparing of research findings. In spite of the increased emphasis on assessing patients' satisfaction because satisfaction can affect treatment outcome, the literature regarding patients' satisfaction remains limited (Pérez de los Cobos et al., 2004). Even though there is no clear definition of satisfaction, patients' satisfaction can be viewed as patients' expectations and perceptions of how well the services fulfilled their needs. This measure is affected by their prior experiences, individual needs and expectations (Williams, 1994). A major limitation in assessing patient's satisfaction with MMT services is the limited availability of instruments designed to measure satisfaction specific to MMT service delivery. Given the lack of such a tool, satisfaction with MMT program has been assessed using other satisfaction instruments designed for other purposes such as the Client Satisfaction Questionnaire (CSQ-8) (Larsen, Attkisson, Hargreaves, & Nguyen, 1979), the Service Satisfaction Scale (SSS-30) (Attkisson & Greenfield, 1996) and the Verona Service Satisfaction Scale (VSSS-32) (Ruggeri, DallAgnola, Bisoffi, & Greenfield, 1996). The SSS-30 has several
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features that greatly limit its usefulness in assessing patients' satisfaction with MMT. The most important of these is that SSS-30 appears appropriate for use only in health or mental health outpatient services (Attkisson & Greenfield, 1994). For example, it contains items that ask patients about their satisfaction with prescription (or non-prescription) medication in helping to relieve symptoms. de los Cobos et al. (2002) adapted the VSSS-32 specifically for application in methadone treatment centers. The adapted instrument (the Verona Service Satisfaction Scale for methadone-treated opioid-dependent patients, or VSSS-MT) has 27 items and contains a mixture of open ended and 5 point Likert scale responses, addressing specific aspects of service delivery and overall quality of service ratings. The authors reported that the VSSS-MT displays a high level of internal consistency, and a satisfactory level of test–retest reliability. Despite its usability, the Rankin Court Centre, New South Wales, Australia (Kehoe, Wodak, Degenhardt, & National Drug Alcohol Research Centre, 2004) considered VSSS-MT as too long and complex for most patients' literacy skills. The Rankin Centre thus developed a validated shorter, eleven items questionnaire which we used in this study. Assessing patients' satisfaction with the MMT services is crucial because at present the trend is for health care services to be more patient oriented. Given that patients' satisfaction evaluation is important and that WHO has recommended it for improving the quality of services at MMT centers (World Health Organization, United Nations International Drug Control Programme, & European Monitoring Center on Drugs Drug Addiction, 2000), we wanted to determine patients' satisfaction with the MMT services they were receiving. Thus, the main objective of our study was to examine patients' satisfaction with the MMT services offered by MMT centers in Malaysia. We also identified factors which predicted overall satisfaction. 2. Methods 2.1. Survey centers and participants This cross-sectional study was conducted in 11 centers from four regions in Peninsular Malaysia (central, north, south and east). Eligible centers were methadone-dispensing centers that had been in operation for at least 3 months. The centers were selected based on simple random sampling while participants from each selected center were based on convenient sampling. The researchers approached potential participants in order to recruit and inform them of the purpose of the research. Potential respondents were assured of their anonymity, and oral informed consent was obtained. Subjects who showed clear signs of substance intoxication were excluded from the study. Two trained interviewers administered the questionnaires via face-to-face interview. The survey was carried out over a 2-month period. Only participants who received MMT in the month prior to the survey were included. We made one change to the questionnaire before the study. Since we intended to dichotomize the response of overall satisfaction to “satisfied” and “dissatisfied”, we changed the wording for item 11 of the original questionnaire to “Thinking about all your experiences at this centre, are you satisfied with the service?” This version of the questionnaire was piloted with a representative sample of 40 participants to assess the items for local suitability before the study began. Data from this pilot testing were not included in the analysis. 2.2. Instrument Except for item 11, we used all the items in the questionnaire developed by Rankin Court, Australia. Permission to use the questionnaire was obtained from the questionnaire developer. According to the questionnaire developer, the items in the questionnaire addressed a range of conceptual dimensions including professionals' skills and behaviors, physical environment, the amount of information provided, and overall satisfaction. Face validity of the questionnaire has also been addressed (Kehoe et al., 2004).
Eight of the eleven items explored satisfaction about the center and covered conceptual dimensions such as professionals' skills and behaviors, access and amount of information. Likert scale response categories used were terrible = 1; mostly dissatisfied =2; neither good nor bad = 3; mostly satisfactory = 4 and excellent = 5. For the purpose of data presentation we considered the response on the Likert scale as scores. We also collected socio-demographic data, age, gender, ethnicity, level of education, and marital status. 2.3. Data analysis Data were analyzed using Statistical Package for the Social Sciences (SPSS), version 21.0. Descriptive statistics such as percentages and means were used to describe the sample on the various variables. Univariate logistic regression was used to evaluate the relationships between overall satisfaction (satisfied vs. dissatisfied) and all the demographic variables. When the expected cell number was lower than five in the contingency table, Fisher's exact test was used. 2.4. Model building The dependent variable, “Satisfied” was regarded as a dichotomous variable and coded 0 = “No” response and 1 = “Yes” response. Univariate logistic regression analysis was then performed to identify variables for inclusion into the model. Statistical significance at p b 0.10 level was used to determine the significance of variables for inclusion into the model. Nominal scale variables with more than two levels (such as race and centers) were entered as k − 1 dummy variables. For the ethnic variable, Malay was treated as the reference group while for centers, center A in Kuala Lumpur was used as the reference group. For ordered categorical data with more than two levels, the variable was entered as k − 1 dummy variables with the lowest level used as the reference group. Significant variables in the univariate analysis were entered simultaneously (forced entry method) into binary logistic regression to evaluate their independent predictive value for overall satisfaction. 3. Results 3.1. Socio-demographic characteristics of the study population Of the 502 patients approached, 425 agreed to participate and completed the questionnaire representing a response rate of 85%. Except for two females, all the respondents were males. The gender distribution of the sample was reflective of the MMT population. Their age ranged from 14 to 74, with a mean age of 39.2 (SD = 2.1) years. The majority of the sample was Malay respondents (80.7%). Other socio-demographic characteristics of the study population are shown in Table 1. 3.2. Association of socio-demographic variables with overall satisfaction Table 1 compares characteristics of patients in the two groups: satisfied (i.e., responded with a “Yes”) versus dissatisfied (i.e., described their overall satisfaction with a “No”). Univariate logistic regression analysis indicated that overall satisfaction was not associated with the demographic variables of sex, age, race, and education category and length of time on MMT at significance level of p = 0.1 (Table 1). Only marital status and treatment centers were found to be statistically associated with overall satisfaction. 3.2.1. Predictors of overall satisfaction in the multivariate logistic regression Table 1 shows that only marital status and treatment centers were found to be statistically predictive of overall satisfaction and therefore were included into the multivariate model. Table 2 shows the results of the multiple logistic regression model predicting overall satisfaction with MMT services. Compared to someone who was divorced or separated, the odds of being satisfied with MMT services was about three
Z. Aziz, N.J. Chong / Journal of Substance Abuse Treatment 53 (2015) 47–51 Table 1 Demographic characteristic of MMT patients (n = 425). Characteristic Sex Male Female Age (years) ≤25 26–35 36–45 46–55 N55 Marital status Single Married Divorced/Separated Race Malay Chinese Indian Education (years) 0–6 7–9 10–11 12–17 Duration of treatment with MMT (months) b6 6–12 13–24 N24 Treatment centers A B C D E F G H I J K
n (%)
Satisfied
Dissatisfied
423 (99.5) 2 (0.5)
362 (85.6) 1 (50.0)
61 (14.4) 1 (50.0)
33 (7.8) 130 (30.6) 149 (35.1) 89 (20.9) 24 (5.6)
27 (81.8) 106 (81.5) 131 (87.9) 79 (88.8) 20 (83.3)
6 (18.2) 24 (18.5) 18 (12.1) 10 (11.2) 4 (16.7)
211 (49.6) 165 (38.8) 49 (11.5)
183 (86.7) 146 (88.5) 34 (69.4)
28 (13.3) 19 (11.5) 15 (30.6)
343 (80.7) 59 (13.9) 23 (5.4)
294 (85.7) 50 (84.7) 19 (82.6)
49 (14.3) 9 (15.3) 4 (17.4)
53 (12.5) 122 (28.7) 224 (52.7) 26 (6.1)
45 (84.9) 103 (84.4) 193 (86.2) 22 (84.6)
8 (15.1) 19 (15.6) 31 (13.8) 4 (15.4)
p-value 0.271
0.479
0.005
0.909
0.974
0.432 182 (42.8) 119 (28.0) 83 (19.5) 41 (9.6)
160 (87.9) 101 (84.9) 70 (84.3) 32 (78.0)
22 (12.1) 18 (15.1) 13 (15.7) 9 (22.0)
122 (28.7) 21 (4.9) 26 (6.1) 63 (14.8) 33 (7.8) 64 (15.1) 28 (6.6) 22 (5.2) 12 (2.8) 8 (1.9) 26 (6.1)
101 (82.8) 19 (90.5) 18 (69.2) 58 (92.1) 25 (75.8) 61 (95.3) 20 (71.4) 21 (95.5) 10 (83.3) 7 (87.5) 23 (88.5)
21 (17.2) 2 (9.5) 8 (30.8) 5 (7.9) 8 (24.2) 3 (4.7) 8 (28.6) 1 (4.5) 2 (16.7) 1 (12.5) 3 (11.5)
0.016
times higher for a participant who was single and about four times higher for those who were married. The odds ratio for the variable, treatment center (center C) was less than 1. This indicates that the odds of overall satisfaction with treatment center C was statistically lower compared to center A. On the other hand the odds of overall satisfaction with treatment center F was about four times higher compared to treatment center A, all other factors being constant. 3.2.2. Satisfaction with MMT services Table 3 shows that the satisfaction score for each item from the eleven centers varies slightly but the majority has a mostly satisfactory score (above 4.0). Treatment center F was predicted to have four times higher Table 2 Predictors of overall satisfaction in the multivariate logistic regression analysis. Variables
Odds ratio
95% Confidence interval
Marital status (single) Marital status (married) Center B Center C Center D Center E Center F Center G Center H Center I Center J Center K
3.31 4.06 1.54 0.35 2.12 0.53 3.97 0.49 4.19 0.76 1.15 1.71
1.52 to 7.20 1.76 to 9.38 0.32 to 7.32 0.13 to 0.96 0.75 to 6.02 0.21 to 1.38 1.12 to 14.07 0.18 to 1.29 0.52 to 33.66 0.15 to 3.80 0.13 to 10.03 0.46 to 6.39
49
overall satisfaction compared to treatment center A. Its respondents rated all eight items as mostly satisfied (score more than 4.0). In contrast, only four items at center C have score above 4.0. The lowest score was 2.97 from center E on the item “about the way the participants were included in how the centre was run”. 3.3. Identification of things that needed change and other comments about the center Item 9 on the questionnaire was an open-ended question, which asked respondents to identify the one thing they would most like to see changed at the center. Fig. 1 shows that slightly more than onethird of the respondents did not wish for anything to change. The top three things frequently identified, as requiring change were dosing time flexibility, waiting area improvement and increase in number of staff. Respondents who highlighted this issue mostly wanted longer hours for dose administration to cater for their working hours, and they considered the waiting area to be over crowded particularly at peak hours between 8:00 and 9:00 in the morning when the process of queuing was disorganized. 3.4. Other comments regarding the MMT center Item 10 on the questionnaire was also an open-ended question. The question asked respondents for any other comments about the center. Slightly more than 50% of the participants did not give any response while the remaining respondents gave positive comments such as MMT service has helped them to manage their life, they were able to receive free methadone, and they enjoyed the activities organized by the centers. A small number of respondents felt they were safe from being questioned by the police about their addiction. 4. Discussion The response rate achieved was high (85%) suggesting that the brevity of the Rankin Court questionnaire and strong assurance on the patient's anonymity might have helped to improve the rate. The percentage of respondents who indicated that they were satisfied with the MMT service at the centers was high, and this was in agreement with most patient surveys where high satisfaction rates of 75–90% were reported (Kehoe et al., 2004). Additionally, all the treatment centers scored more than 4.0 (mostly satisfactory) for the item, which asked whether the respondents would recommend the center to friend who needed treatment. It is also encouraging to note that about half of the respondents made positive comments about the service received. Mean scores on the eight items of satisfaction covering a range of conceptual dimensions including professionals' skills and behaviors, physical environment, the amount of information provided were in the “satisfied” range for all treatment centers. However, our findings that a high proportion of respondents was satisfied with the MMT services should be interpreted with caution as high levels of patients' satisfaction may have been attributed to measurement errors such as social desirability (Kehoe et al., 2004; Nathorst-Boos, Munck, Eckerlund, & EkfeldtSandberg, 2001), patients' low expectation of service (Bickman, 1996), and patients' fear of reprisal or feeling of empathy for those providing frontline care (Beattie, Lauder, Atherton, & Murphy, 2014). Of the demographic variables examined in the univariate analysis only “marital status” and “centres” were associated with satisfaction. This association did not diminish when examined with multiple logistic regressions analysis. The variable “centres” emerged as the strongest predictor of satisfaction. This is not surprising since the treatment centers differ from each other in aspects such as the physical environment, interpersonal skills of staff and process of service delivery. Several studies showed that these aspects are positively related to patients' satisfaction (Al-Abri & Al-Balushi, 2014; Goel, Sharma, Bahuguna, Raj, & Singh, 2014; Jawaid, Ali, Rizvi, & Razzak, 2010). It is to be noted that one
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Table 3 The Likert responses for eight items exploring the overall feeling about eleven centers. Items
Centers mean (SD)
Feeling about how staff at the center treat you Feeling about the way you are included in the decisions on your treatment Feeling about the way you are included on how the center is run Feeling about the physical environment for patients Feeling about the way this center responds to complaints from patients Feeling about how effective this center has been with your problems Feeling about the amount of information this center gives you about your treatment Would you recommend this center to a friend who needed treatment?
A
B
C
D
E
F
G
H
I
J
K
4.36 (0.53)
4.14 (0.73)
3.96 (1.04)
4.44 (0.62)
3.97 (0.81)
4.52 (0.59)
3.71 (0.98)
4.36 (0.58)
4.75 (0.45)
4.63 (0.52)
4.35 (0.69)
4.22 (0.62)
4.29 (0.72)
4.15 (0.88)
4.27 (0.52)
4.03 (0.81)
4.42 (0.64)
3.79 (0.79)
4.50 (0.51)
4.42 (0.52)
4.25 (0.46)
4.27 (0.53)
3.94 (0.88)
3.71 (0.85)
3.00 (1.30)
4.14 (0.64)
2.97 (1.10)
4.47 (0.59)
3.21 (1.13)
4.23 (0.53)
4.25 (0.97)
3.75 (1.17)
3.85 (1.05)
4.25 (0.68)
4.10 (0.83)
4.12 (0.77)
3.94 (0.80)
4.06 (0.79)
4.28 (0.65)
3.82 (0.86)
4.23 (0.92)
4.75 (0.45)
3.63 (1.06)
4.12 (1.03)
3.85 (0.89)
3.90 (0.89)
3.38 (1.39)
4.16 (0.65)
3.91 (0.91)
4.31 (0.69)
3.50 (1.20)
4.14 (0.71)
4.42 (0.90)
4.13 (0.99)
4.04 (0.96)
4.30 (0.79)
4.29 (0.85)
4.42 (0.70)
4.48 (0.56)
4.30 (0.81)
4.50 (0.69)
4.14 (0.89)
4.73 (0.46)
4.50 (0.91)
4.75 (0.46)
4.46 (0.65)
4.25 (0.84)
4.00 (0.84)
3.96 (0.87)
4.21 (0.77)
4.03 (0.85)
4.48 (0.67)
3.79 (0.96)
4.36 (0.79)
4.67 (0.49)
4.00 (1.41)
4.35 (0.63)
4.91 (0.29)
4.81 (0.51)
4.81 (0.40)
4.90 (0.35)
4.94 (0.24)
4.88 (0.55)
4.46 (1.17)
4.86 (0.55)
4.88 (0.55)
4.75 (0.71)
4.81 (0.40)
treatment center (center F) has high scores for all items exploring feelings of satisfaction. One possible explanation for the high score could be that the patients' expectations of this treatment center were realistically met since there is a strong association between expectations and satisfaction (Tarantino, 2004). It is expected that there would be differences between centers (urban versus rural) in terms of participants' characteristics such as education status and ethnic background. Previous research has shown patients from rural areas are more likely to be satisfied with healthcare services compared to patients from the urban centers (Farmer, Hinds, Richards, & Godden, 2005). However, within our study, this variable (rural versus urban) was not explored as all the centers included are located in the urban area. The most frequent aspect of the service the patients would like to see changed was the flexibility of dosing i.e. hours of service. At the time of data collection, all the treatment centers provided methadone dosing between 8:00 to 11:00 am. As indicated by respondents, they would like to see longer dosing hours to include an earlier start time so that patients' work schedule would not be disrupted. Since their attendance at
No change required
38.4
Dosing flexibility
20.8
Centre/ waiting area
15.5
Staff shortages
7.2
Miscellaneous
6.0
Improve services
4.1
Queuing system
3.1
No comments
3.1
Takeaways policy
1.6
0
10
20
30
40
Percent Fig. 1. The distribution of responses on the one thing that the respondent would most like to see changed at the 11 treatment centers.
the center to receive dosing could be linked with their satisfaction with the treatment center, it is thus reasonable for the health administrators to consider this request. However, as the MMT service in Malaysia is provided free, consideration must be given to the scarcity of government resources. Interestingly about 2% of the respondents wanted the treatment centers to change their policy with regards to takeaways. At the time of writing, all treatment centers restrict methadone takeaway to patients who are believed to be free from using other narcotics by having negative urine test for a period of time specified by the individual centers. Clearer explanation of the basis for takeaway restrictions is recommended to help patients with their expectations and thus improve quality of service. Our findings should be interpreted in the light of several limitations. One, we could not establish the relationship between patient satisfaction with retention given the cross-sectional study design of our study. It has been shown that patient satisfaction with the MMT services was positively correlated with retention in treatment (Kelly, O’Grady, Brown, Mitchell, & Schwartz, 2010; Villafranca, McKellar, Trafton, & Humphreys, 2006). Two, the major limitation of patients' satisfaction data is that it cannot establish the effectiveness of a particular service because there is no direct causal link between satisfaction and effectiveness of the service (Bickman, 1996). For example, patients with low expectations of the service may be satisfied with services that are ‘ineffective’ if determined by other more objective evaluations. In contrast, patients may be unsatisfied with services that are effective but lack human courtesy. Three, the cross-sectional design of the study only provides a 'snapshot' of satisfaction and the characteristics associated with it at a specific point in time. Patients' satisfaction is likely to vary from one visit to another depending on factors such as personality of staff on duty at the time of the study and waiting time. Finally, there may be another healthcare dimension that influences satisfaction which is not covered by the questionnaire. At the time of writing, apart from the Rankin Court Instrument, only one other instrument is available to measure opioid dependent patients' satisfaction with MMT services: The Verona Service Satisfaction Scale-MT (de los Cobos et al., 2002). However, this Verona scale was too lengthy with textual complexity that it is not considered to be appropriate for routine use to assess satisfaction. However, our results have shown that the Rankin Court questionnaire may be useful as an assessment tool to provide meaningful feedback to enable service improvement at the MMT centers in
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Malaysia. This questionnaire will allow various MMT centers' performance to be compared while regular use at each center will support longitudinal assessment of improvement in the center's performance. Patients' satisfaction rating as an indicator of the quality of services provided has also been criticized because the rating may reflect unrealistic patient expectations. Although in some cases this criticism may be valid, studies involving other health services suggest that satisfaction surveys can effectively discriminate between services that are different in quality (Sheppard, 1993). It is, therefore, worth noting that positive patients' satisfaction alone is not sufficient to establish the quality of MMT services provided. However, our findings also identify aspects of the service, which can be reviewed to align with patients' expectations, and needs. 5. Conclusion The findings generated from this survey will allow MMT administrators to obtain a clearer perspective on what aspects of the MMT service should be reviewed to achieve improvement of service delivery. The identification of service areas requiring improvement will create a supportive environment and foster motivated patients who would be less likely to miss appointments or not follow through on treatment plans. The findings from this study would also be useful in establishing national level performance indicators for the MMT programs at the various MMT centers. In summary, information gathering from opioid-independent individuals about their satisfaction is essential to the quality assurance process. Acknowledgments The study was supported by the Short Term Grant (PJP/FS218/2008B) from the University of Malaya. The authors would like to thank the National Anti-drug Agency, Malaysia for giving the approval to conduct the study and the ethics clearance. We would like to thank Salmizawati Salim of the Department of Pharmacy, Faculty of Medicine for her help in data collection and Sameerah Shaik Abdul Rahman of National Pharmaceutical Control Bureau, Ministry of Health Malaysia for providing constructive comments. We are also grateful for the very useful suggestions for amendments made by two anonymous Journal of Substance Abuse Treatment reviewers. References Al-Abri, R., & Al-Balushi, A. (2014). Patient satisfaction survey as a tool towards quality improvement. Oman Medical Journal, 29(1), 3–7, http://dx.doi.org/10.5001/omj.2014.02. Attkisson, C. C., & Greenfield, T. K. (1994). Client satisfaction questionnaire-8 and service satisfaction scale-30. In M. E. Maruish (Ed.), The use of psychological testing for treatment planning and outcome assessment (pp. 402–420). Hillsdale, NJ, England: Lawrence Erlbaum Associates, Inc. Attkisson, C. C., & Greenfield, T. K. (1996). The Client Satisfaction Questionnaire (CSQ) Scales and the Service Satisfaction Scale- 30 (SSS-30). In L. I. Sederer, & B. Dickey (Eds.), Outcomes Assessment in Central Practice (pp. 120–127). Baltimore: Lippincott Williams and Wilkins. Baker, R. (1997). Pragmatic model of patient satisfaction in general practice: Progress towards a theory. Quality in Health Care, 6(4), 201–204, http://dx.doi.org/ 10.1136/qshc.6.4.201. Beattie, M., Lauder, W., Atherton, I., & Murphy, D. (2014). Instruments to measure patient experience of health care quality in hospitals: A systematic review protocol. Systematic Reviews, 3(1), 1–8, http://dx.doi.org/10.1186/2046-4053-3-4. Bennett, T., Holloway, K., & Williams, T. (2001). Drug use and offending: Summary results of the first year of the New-Adam Research Programme. Research Findings No. 148. London: Great Britain, Home office Research, Development and Statistics Directorate (Retrieved from http://www.dldocs.stir.ac.uk/documents/r179.pdf). Bickman, L. (1996). A continuum of care. More is not always better. American Psychologist, 51(7), 689–701, http://dx.doi.org/10.1037/0003-066X.51.7.689.
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