UNDERSTANDING PATIENT SATISFACTION AND DISSATISFACTION WITH HEALTH CARE MEI-O HSIEH and JILL DONER KAGLE
Patient satisfaction or dissatisfaction is a complicated phenomenon that is linked to patients' expectations, health status, and personal characteristics, as well as health system characteristics. This article presents a cross-sectional study of the relationship among these factors using data collected from a large sample of university employees. The primary hypothesis, that patients' expectations would be the best predictor of satisfaction, was supported by the data. Health status, personal characteristics, and health system characteristics were not strong predictors. The findings suggest that patients may base their evaluations on sophisticated expectations and that those expectations vary from one sociodemographic group to another. Implications for social work practice in health care are highlighted.
The consumer revolution in health care has had many beneficial effects. Patients now are actively involved in decision making, not just by choosing among health plans and providers but also by participating directly in judgments about their treatment. Patients also are asked routinely to evaluate the quality of the services they receive. One side effect of this revolution is a growing scholarly interest in evaluation and a deeper understanding of the increased involvement of patients in their own health care. Many social workers have assumed that there is a direct relationship between a patient's experiences with and evaluation of health care services. Like other health care providers, these social workers have believed that patients would be satisfied with good services and dissatisfied
with poor services. However, research indicates that actual experience is only one of several factors that determine whether a patient is satisfied or dissatisfied with his or her health care. A patient's expectations, personal characteristics, health status, and health plan also play important parts. Moreover, certain aspects of a patient's ex-' perience with health care appear to be more influential in his or her evaluation than others. Understanding patient satisfaction, a term generally used to connote the level of satisfaction or dissatisfaction, can be very useful for social workers. Such understanding can assist social workers in interpreting and using the results of evaluations to improve their own practice and the practices of others in the health care system. It also can help them recognize
CCC Code: 0360-7283/91 $3.00 © 1991, National Association of Social Workers, Inc.
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influences on patients' attitudes and behaviors that they otherwise might overlook. For example, patient satisfaction is associated with subsequent compliance with medical recommendations (Linder-Pelz, 1982; Weiss, 1988; Zimmerman, 1988); that is, a patient who is satisfied with his or her health care is more likely to comply with the medical regimen. Social workers who recognize this relationship may be better able to overcome noncompliance, a problem that not only increases the cost of health care (Levy, 1978) but alsojeopardizes the life and health of the patient. This article familiarizes social workers with what is currently known about patient satisfaction and presents and interprets the findings of a study on the relationship between patient expectations and patient satisfaction.
LITERATURE REVIEW A person brings to any evaluation process a set of expectations that are derived from beliefs about ideal or anticipated situations (Miller & Turnbull, 1986). These beliefsmay be associated with the person's demographic characteristics, such as age, gender, and ethnicity, or with the person's knowledge and experience (Korsch, Gozzi, & Francis, 1968). In general, patients' evaluations of their health and mental health care tend to be favorable (Lebow, 1983a). However, the research in both health and mental health care indicates that satisfaction is influenced by expectations. Patients have certain positive expectations of the care that they will receive. When experience fulfills these expectations, patients are likely to be satisfied; when experience fails to meet expectations, patients may be dissatisfied (Duckro, Beal, & George, 1979; Larsen & Rootman, 1976; Martin, Sterne, & Hunter, 1976; Noyes, Levy, Chase, & Udry, 1974). Much of the research -in health and mental health has examined the relationship between patient satisfaction and the conduct of the provider (Lebow, 1983b). In one of these studies, Korsch et al. (1968) found that mothers who perceived pediatricians to be friendly expressed a higher level of satisfaction with care following a visit. Moreover, the mothers who expected to learn the cause and nature of their children's illnesses but did not were likely to be dissatisfied. 282
Similarly, Noyes et al. (1974) found that if gynecologypatients' positive expectations of their physicians were fulfilled, they were more likely to be satisfied. Larsen and Rootman (1976) found that the more a physician's role performance met a patient's expectations, the more satisfied the patient was with the physician's services. Linder-Pelz (1982) found a statistically significant relationship between a patient's expectation of physician's conduct and both general satisfaction and satisfaction with the physician's conduct, but not between expectation of physician's conduct and satisfaction with convenience. These findings indicate that a patient whose positive expectations of the physician's behavior are met is more likely to be satisfied with physician and with his or her health care in general. However, these studies also suggest that patient satisfaction is multidimensional and that satisfaction with one aspect of care may not carry over to other aspects of care. In addition to patient expectations, researchers also have linked sociodemographic factors, health status, and mode of service delivery to patient satisfaction with health care. Although one study found a negative relationship between age and patient satisfaction (Hulka, ]upper, Daly, Cassel, & Schoen, 1975), most have found that elderly patients are more likely to indicate that they are very satisfied with their health care than are younger groups (Linn, 1975; Linn & Greenfield, 1982). Most studies have found patient satisfaction to be unrelated to the patient's gender (Hulka, Zynanski, Cassel, & Thompson, 1971; Linn, 1975; Linn & Greenfield, 1982). However, some studies have reported that women are more satisfied with their health care than are men (Hulkaet al., 1975; Ware, Davies, & Stewart, 1977). Socioeconomic status also has been the subject of some interest. Some studies have reported that low-income patients are more skeptical and less satisfied with medical care than are other groups (Hulka et al., 1975; Suchman, 1964). The patient's health status also has been found to correlate with ratings of satisfaction. Typically, patients who report that they are in poor health also report lower levels of satisfaction (Linn & Greenfield, 1982; Patrick, Scrivens, & Charlton, 1983; Stratmann, Block, Brown, & Rozzi, 1975).
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The relationship between patient satisfaction and mode of service delivery, usually fee for service (FFS) versus prepaid group practice (PPG), also has been studied. Research findings indicate that patients who receive services under FFS arrangements generally report higher levels of satisfaction than do those who use PPGs (Davies, 1983; Tessler & Mechanic, 1975; Ware, Curbow, Davies, & Robins, 1981). When satisfaction is broken down into different aspects of care, PPG enrollees report less satisfaction with travel time and the length of time between making an appointment and the appointment date; however, they report higher satisfaction with health care costs (Davies, 1983; Richardson, Shortell, & Diehr, 1976; Tessler & Mechanic, 1975). These studies suggest that different groups have different expectations and different perceptions of the health care system. It is unlikely that older patients, women, members of higher socioeconomic groups, those who are in good health, and those who select FFS modes of service all perceive health care more favorably because they receive better health care. It is more likely that their satisfaction is linked to different expectations and to having their positive expectations fulfilled.
developed and tested by Ware, Snyder, and Wright (1976). Respondents rated their expectations and their levels of satisfaction using a five-point Likert-type scale. A random sample of 650 was selected from the complete list of 10,573 faculty and staff members employed by a large Midwestern university in February 1988. Nineteen of those selected were eliminated from the study because they did not reside within a 50-mile radius of the community or because they had retired. In March 1988, a questionnaire was sent to a sample of 631 faculty and staff; four weeks later, those who had not responded received a second mailing. The questionnaire was divided into five sections: (1) health information, including health plan and health status; (2) the anticipation scale; (3) the satisfaction scale; (4) the importance scale, which asked the respondent to rate the importance of various dimensions of the anticipation and satisfaction scales; and (5) demographic information. The members of the sample were asked to complete and return the questionnaire by mail. The two mailings produced a return of 401 usable questionnaires, a return rate of 63.5 percent (Hsieh, 1988).
METHOD
The reliability of the anticipation scale was 0.87; the reliability of the satisfaction scale was 0.91. These two scales also were subjected to principal components factor analysis to derive their a posteriori dimensions. After these analyses, the authors analyzed selected sociodemographic factors, health experiences, selfreported health status, and the derived anticipation factors for their ability to predict specific dimensions of and overall levels of satisfaction. Because the results of oblique and orthogonal rotations were very similar, only the orthogonal rotation was selectedfor presentation in this article. Factor loadings equal to or greater than .50 were included, as is standard practice. Four factors with eigenvalues greater than 1 were extracted from the data provided on the anticipation scale (Table 1). These factors accounted for 51.7 percent of the explanatory power of the 19
Sample and Data Collection This study used a cross-sectional design to examine the relationships between patients' expectations, personal characteristics, health status, and mode of service delivery and their satisfaction with health care (Hsieh, 1988). The authors treated patient expectations and patient satisfaction as multidimensional constructs. Patient satisfaction was defined as a patient's attitudes toward health care received and was measured with an a priori six-dimensional satisfaction scale. Patient expectation was defined as a patient's practical, rather than idealized, anticipation of future health care and was measured with a similar six-dimensional anticipation scale (Hsieh, 1988). Most of the items on the satisfaction scale and the anticipation scale were rephrased items from the Patient Satisfaction Scale
Results of Reliability Tests and Factor Analysis of Scales
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Table 1. Factor Loadings for Items on the Expectation Scale Factor
Factor Loading
Physician's conduct and convenience Uses up-to-date technology Checks on previous problems Explains what to expect regarding treatment Is available each visit Is kind and considerate Examines me thoroughly Enough specialized medical service is in the area Parking is convenient Waiting time No long wait in doctor's office No long wait for an appointment Preparation and resources for future care Enough specialists are in the area Physician encourages regular checkups Physician explains medical problems Cost and risk of care Medical insurance coverage is adequate Amount paid for care is reasonable Physician takes no risks in treatment
individual items. (The 20th item, asking for the patient's general expectation, was excluded from analysis.) The four factors, given names that connote the prominent included items, are expectation of physician's conduct and convenience, expectation of waiting time, expectation of preparation and resources for future care, and expectation of the cost and risk of health care. Using the same method, the authors extracted four factors from the data provided by the satisfaction scale (Table 2). These factors accounted for 61.0 percent of the explanatory power of the 19 items. (Again, the 20th item was excluded.) The four factors identified were satisfaction with physician's conduct, satisfaction with the availability of health resources, satisfaction with accessibility, and satisfaction with the financial coverage of care.
FINDINGS Characteristics of the Respondents The sociodemographic characteristics of the total population of 10,573 faculty and staff, the total sample of 631, and the 401 respondents who returned usable questionnaires were 284
.74:277 .69603 .69291 .69026 .67076 .61997 .53555 .52871 .83163 .82353 .74:536 .56089 .54:981 .604:67 .6034:7 .59971
compared (Table 3). The groups were clearly similar. The respondent group was almost equally divided between males and females. About the same proportion of white people to nonwhite people appeared in the respondent group as in the population as a whole. However, because a large percentage of the university staffand faculty were white, minority groups were underrepresented in this study. Information about age, reported by 396 respondents, showed that the sample was relatively young. The modal category (30.8 percent, n = 122) was between 26 and 36 years old. About a quarter (25.5 percent, n = 101) of the respondents were faculty members; 19.6 percent (n = 78) were academic professionals, and 54.8 percent (n = 217) were nonacademic staff. Most of the respondents (94.3, n = 378)werefull-time employees of the university. As might be expected, the education level was high in this sample. Respondents having a doctoral degree were the modal group (25.5 percent, n = 101). Most of the respondents were currently married (71.9 percent, n = 285). The distribution of family income was close to normal (skewness = .038). The number of respondents having an income of $25,000 to $34,999
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 4/NOVEMBER 1991
Table 2. Factor Loadings for Items on the Satisfaction Scale Factor Loading
Factor Physician's conduct Gives me information Examines me thoroughly Explains medical problems adequately Checks on previous problems Advises me about how to avoid illness Encourages me to have regular checkups Uses up-to-date technology Respects me Takes no risk in treatment Availability of health resources Availability of specialized medical services Availability of specialists Accessibility No long wait in doctor's oflice No long wait for an appointment Doctor available to answer questions Financial coverage Amount paid for service Coverage by medical insurance plan
.82828 .82245 .80932 .75396 .74403 .61848 .61043 .61036 .52105 .80820 .74967 .87411 .83721 .55996 .81031 .78157
Table 3. Sociodemographic Distributions of the Population, the Sample, and the Respondents Population Variable Gender Female Male Race/ethnicity White Nonwhite Full- or part-time employment 65
Sample
Respondents
n
%
n
%
n
%
4,892 5,681
46.2 53.8
302 348
46.0 54.0
208 193
51.9 48.1
9,176 1,397
86.8 13.2
578 72
88.9 11.1
365 32
91.9 8.1
530 10,043
5.0 95.0
33 617
5.1 94.9
23 378
5.7 94.3
2,216 2,702 5,655
21.0 25.5 53.5
156 155 339
24.0 23.8 52.2
101 78 217
25.5 19.7 54.8
637 3,188 3,078 2,176 1,341 153
6.0 30.2 29.1 20.6 12.7 1.4
32 195 203 131 79 10
5.0 30.0 31.2 20.2 12.1 1.5
19 122 118 82 49 6
4.8 30.8 29.8 20.7 12.4 1.5
was 87 (22 percent), which was the modal group. The mean number of family members who were dependent on the yearly family income was 2.56.
Demographics and Patient Satisfaction Women rated continuity as more impor4.14, tant (M = 4.32) than did men [M
UNDERSTANDING PATIENT SATISFACTION AND DISSATISFACTION WITH HEALTH CARE
285
= 2.61, P < .01], reported higher levels of anticipation of preparation and resources for future care (M = .11) than did men [M = - .11,1(391) = 2.16, P < .05], and reported higher levels of satisfaction with physician's conduct (M = .10) than did men [M = - .11, 1(390) = 2.10, P < .05]. In general, women (M = 16.70) were more satisfiedthan were men (M = 15.96), as shown by their weighted composite satisfaction score [1(379) = 1.97, P < .05]. Different ethnic groups reported different levels of satisfaction with availability of health resources (I = - 3.11, dj = 377, P < .005). Nonwhite respondents (M = - .53) tended to be more dissatisfied with the availability of health resources than were white respondents (M = .04). Age was associated with satisfaction with physicians' conduct [F(5, 371) = 2.80,p < .01], accessibility of care [F(5, 371) = 2.97, P < .01], average satisfaction [F(5, 381) = 2.51, P < .05], and the weighted composite satisfaction score [F(5, 370) = 2.49, P < .05]. The extreme age groups were more satisfied with physician's conduct, but slightly less satisfied with accessibility, and had higher scores on general satisfaction and weighted composite satisfaction measures. When post-hoc contrasts were conducted between two extreme age groups and the remaining age groups, extreme age groups were significantly different from the other three age groups on satisfaction with accessibility
1(397)
(I = 2.09, df = 371, P < .05). Plan Enrollment and Patient Satisfaction Findings of z-tests showed that respondents enrolled in the university's FFS plan reported a higher level of satisfaction with physician's conduct (M = .28) than did respondents enrolled in PPG plans [;\1 = .04, 1(378) = 2.15, P < .05]. Respondents who had been enrolled in the FFS plan also cared less about the cost and risk of care. In general, PPG respondents were more conscious of the cost and risk of care. The mean score on expectation of cost and risk of care for the FFS group was - .62, compared with .08 for the PPG group. The I-test was statistically significant
[1(389) 286
-4.07, P < .0001].
Health Status and Patient Satisfaction The findings suggest that respondents who reported relatively poor health did not expect the cost of care to be reasonable IF(3, 389) = 5.37, P < .001]. They also did not expect to be satisfied with the care they received [F(3, 396) = 4.87, P < .005]. These respondents were less satisfied with accessibility [F(3, 389) = 6.78, P < .0001] and rated their general satisfaction lower than did other respondents [F(3, 388) 10.81, P < .0001].
Patient Expectations and Satisfaction Previous research has found strong relationships between patients' levels of satisfaction and gender, age, family income, number of doctor's visits in the previous year, FFS versus PPG enrollment, and self-reported health status. These sociodemographic and health factors, along with the four expectation factors, were included in multiple-regression analyses in the present study. Dummy variables were created for gender (two levels), number of doctor's visits in the previous year (fivelevels), health status (four levels), and health insurance plan (two levels). Age and income were treated as interval data. In predicting satisfaction with physicians' conduct, only the type of health insurance plan was included in the equation. PPG enrollment was negatively associated with satisfaction with physicians' conduct. The model predicted 20.7 percent of the variance (Table 4). The number of doctor's visits during the previous year was included in the equation predicting satisfaction with the availability of health resources. All four expectation factors were also in the equation. A respondent who had visited a doctor one to three times tended to be more satisfied with the availability of health resources (Table 4). The expectation of preparation and resources for future care was negatively associated with higher levels of satisfaction with the availability ofhealth resources. In contrast, a respondent's expectation of waiting time predicted satisfaction with accessibilitybest. Respondents who were enrolled in PPGs were less satisfied with access. When the PPG variable was included, expectation
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 4/NOVEMBER 1991
Table 4. Predictors of Specific Dimensions of Patient Satisfaction Predictor Satisfaction with physician's conduct, [R .455, R2 = .207, N = 370, F(5. 364) = 18.988 ***] Anticipated conduct and convenience Anticipated preparation and resources Anticipated waiting time PPG Anticipated cost and risk Constant Satisfaction with availability of health resources, [R = .425, R2 = .182, N = 370, F(5.1M) = 16.166***] Anticipated preparation and resources Anticipated conduct and convenience Anticipated cost and risk Anticipated waiting time Doctor visits (1-3 times) Constant Satisfaction with accessibility of care, [R = .372, R2 = .139, N = 370, f(". j",,) = 14,671***] Anticipated waiting time Anticipated conduct and convenience Anticipated preparation and resources PPG Constant Satisfaction with financial coverage of care, [R = .494, R2 = .244, N = 370, F(4.365) = 29.50**] Anticipated cost and risk PPG Anticipated preparation and resources Doctor visits (1-3 times) Constant NOTE:
SE
b
SE of b
Beta
.325*** .217*** .150** -.520** .132* .471**
.047 .047 .047 .152 .047 .142
.323 .217 .150 - .166 .134
.254*** .231*** .176*** -.141** .216* - .128
.047 .048 .047 .047 .095 .069
.256 .230 .180 - .141 .108
.300*** .139** - .117* -.367* .333*
.048 .049 .049 .153 .144
.301 .138 - .118 - .117
.291** .764** .212** -.229* -.558**
.047 .149 .046 .092 .148
.292 .241 .216 - .113
standard error.
*p < .05. "p < .005. • "p < .0001.
of cost and risk of care became less important in predicting satisfaction with accessibility (Table 4). With respect to satisfaction with financial coverage, two major predictors were included: the expectation of the cost and risk of care and the expectation of preparation and resources for future care. In addition, two control variables (the health plan and the number of doctor's visits in the previous year) were included. Respondents who were enrolled in PPGs were more satisfied with financial coverage than those in the FFS plan. However, if a respondent had been to a doctor one to three times in the
previous year, he or she tended to be less satisfied with this dimension of care (Table 4). Overall satisfaction was measured by a single item asking general satisfaction with care and by the average score of the remaining 19 items. All four expectation factors were included when predicting the single-item measure of general satisfaction. However, when a respondent reported his or her health status as fair, the score was reduced by .133 standardized unit; PPG membership reduced it another .097 unit (Table 5). Health status and the number of doctor's visits in the previous year influenced the average satisfaction score.
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287
Table 5. Predictors of Single-Item Measure: Overall Satisfaction and Average Satisfaction Predictor Overall satisfaction, [R = .467, R2 = .218, N = 369, F(6,362) = 16.791***] Anticipated conduct and convenience Anticipated cost and risk Anticipated preparation and resources Health status Anticipated waiting time PPG Constant Average satisfaction, [R = .635, R2 = .403, N = 369, F(9.359) = 26,890***] Anticipated conduct and convenience Anticipated preparation and resources Anticipated cost and risk Anticipated waiting time Doctor visits (none) Health status (excellent) Health status (good) Health status (fair) Doctor visits (1-3 times) Constant NOTE:
SE
=
b
SE of b
Beta
.229*** .229*** .209*** -.424** .086* -.280* 4.124***
.043 .044 .043 .150 .043 .139 .131
.247 .253 .226 - .133 .094 -.097
.208* .184* .161 * .086* -.270** .789*** .704*** .595** - .112* 3.100*
.025 .024 .024 .024 .081 .173 .172 .185 .056 .168
.348 .310 .277 .146 - .162 .661 .594 .291 -.095
standard error.
*p < .05. **p < .005. ***p < .0001.
DISCUSSION The study summarized in this article had a large sample and a high response rate (Hsieh, 1988). Although the respondents were younger and better educated than the general population, their views were similar to those of other groups sampled in previous research. First, their level of satisfaction with health care was strongly associated with their expectations. In line with previous research (Korsch et aI., 1968; Larsen & Rootman, 1976; Linder-Pelz, 1982; Noyes et al., 1974), this study indicates that those who have their positive expectations of the health care system fulfilled were apt to express satisfaction with services. Second, patients' expectations of their physicians' conduct and the convenience of services was the best predictor of their overall level of satisfaction. For example, a patient who expected that his or her physician would use upto-date technology, that he or she would see the same physician on each visit, and that parking would be convenient was more likely to express overall satisfactionwith servicesreceived. Third, patients' satisfaction with specificdimensions of 288
their health care was directly associated with their specific expectations. That is, satisfaction with cost was linked with expectations of cost, satisfaction with accessibilitywas linked with expectations of accessibility, and so on. This means that patients had a relatively sophisticated set of expectations and evaluated health care accordingly. A positive evaluation of one dimension of care did not necessarily carry over to another aspect of care; a patient may have expressed satisfaction with one dimension and dissatisfaction with another dimension of care. Overall, sociodemographic factors, health status, and mode of service delivery were not strong predictors of patient satisfaction. However, the data suggest that different subgroups may have had differing expectations and levels of satisfaction with their health care. For example, women were more concerned with future care and continuity of services and were more satisfied with their health care than were men. Members of minority groups were less satisfied overall and less satisfied in particular with the availability of health services. The oldest (over 55) and youngest (under 25) groups were more
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 4/NOVEMBER 1991
satisfied overall but were less satisfied with accessibility of services than other groups. Those who received services through an FFS arrangement were more satisfied overall than those enrolled in PPGs; however, the latter group was more cost conscious and more satisfied with the cost of care. Those who reported relatively poor health had less positive expectations and were less satisfied than were other groups. These findings, particularly the dissatisfaction of minority group members with the availability of services, warrant further investigation.
PATIENT SATISFACTION AND SOCIAL WORK Social workers can use their knowledge of patient satisfaction and its relationship to expectations and other factors in several ways. They may use this knowledge when they design and interpret the findings of evaluations of health care and social services. Clearly, evaluation questionnaires should measure expectations as well as satisfaction with services received and should include both global and specificquestions about the various dimensions of service. Similarly, in interpreting the results of evaluation studies, social workers should be sensitive to the influence of expectations and other factors on a patient's levels of satisfaction with services. Social workers in health care also may use this knowledge in their practice with clients. Patient satisfaction appears to affect clients' behavior in three areas: (1) care seeking, (2) adherence to medical advice, and (3) action against a provider (Ware & Davies, 1983). Patients who are satisfied with their care are more likely to schedule routine checkups and to seek care when they are ill. They are also more likely to comply with their medical regimen, meet appointments, follow physicians' instructions, and take prescribed medications (Linder-Pelz, 1982; Weiss, 1988; Zimmerman, 1988). Finally, satisfied patients are less apt to change providers, disenroll from their health plans, or take punitive action. Thus, understanding the factors that influence patient satisfaction may assist social workers in contributing to their clients' health and quality of life as well as in influencing their organizations and other providers. Social workers can
help patients develop realistic and positive expectations of their health care, they can help patients communicate their expectations to providers, and they can encourage health providers to recognize and meet those expectations.
About the Authors Mei-O Hsieh, PhD, is Associate Professor, Department of Sociology, National Chengchi University ofTaiwan, Taipei, Taiwan. jill Doner Kagle, PhD, ACSW, LCSW, is Associate Professor, University of Illinois School of Social Work, 1207 West Oregon Street, Urbana, IL 61801.
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SSAGES: Working with Children with Learning Disabilities by Elizabeth Dane
Children with learn ing disabilities require understanding, knowledge , and skilled intervention . Painfu l Passages helps social workers , administrators, educators, and parents respond creatively and effectively to these needs.
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 4/NOVEMBER 1991
Patient satisfaction or dissatisfaction is a complicated phenomenon that is linked to patients' expectations, health status, and personal characteristics, as well as health system characteristics. This article presents a cross-sectional study of the relationship among these factors using data collected from a large sample of university employees. The primary hypothesis, that patients' expectations would be the best predictor of satisfaction, was supported by the data. Health status, personal characteristics, and health system characteristics were not strong predictors. The findings suggest that patients may base their evaluations on sophisticated expectations and that those expectations vary from one sociodemographic group to another. Implications for social work practice in health care are highlighted.
The consumer revolution in health care has had many beneficial effects. Patients now are actively involved in decision making, not just by choosing among health plans and providers but also by participating directly in judgments about their treatment. Patients also are asked routinely to evaluate the quality of the services they receive. One side effect of this revolution is a growing scholarly interest in evaluation and a deeper understanding of the increased involvement of patients in their own health care. Many social workers have assumed that there is a direct relationship between a patient's experiences with and evaluation of health care services. Like other health care providers, these social workers have believed that patients would be satisfied with good services and dissatisfied
with poor services. However, research indicates that actual experience is only one of several factors that determine whether a patient is satisfied or dissatisfied with his or her health care. A patient's expectations, personal characteristics, health status, and health plan also play important parts. Moreover, certain aspects of a patient's ex-' perience with health care appear to be more influential in his or her evaluation than others. Understanding patient satisfaction, a term generally used to connote the level of satisfaction or dissatisfaction, can be very useful for social workers. Such understanding can assist social workers in interpreting and using the results of evaluations to improve their own practice and the practices of others in the health care system. It also can help them recognize
CCC Code: 0360-7283/91 $3.00 © 1991, National Association of Social Workers, Inc.
281
influences on patients' attitudes and behaviors that they otherwise might overlook. For example, patient satisfaction is associated with subsequent compliance with medical recommendations (Linder-Pelz, 1982; Weiss, 1988; Zimmerman, 1988); that is, a patient who is satisfied with his or her health care is more likely to comply with the medical regimen. Social workers who recognize this relationship may be better able to overcome noncompliance, a problem that not only increases the cost of health care (Levy, 1978) but alsojeopardizes the life and health of the patient. This article familiarizes social workers with what is currently known about patient satisfaction and presents and interprets the findings of a study on the relationship between patient expectations and patient satisfaction.
LITERATURE REVIEW A person brings to any evaluation process a set of expectations that are derived from beliefs about ideal or anticipated situations (Miller & Turnbull, 1986). These beliefsmay be associated with the person's demographic characteristics, such as age, gender, and ethnicity, or with the person's knowledge and experience (Korsch, Gozzi, & Francis, 1968). In general, patients' evaluations of their health and mental health care tend to be favorable (Lebow, 1983a). However, the research in both health and mental health care indicates that satisfaction is influenced by expectations. Patients have certain positive expectations of the care that they will receive. When experience fulfills these expectations, patients are likely to be satisfied; when experience fails to meet expectations, patients may be dissatisfied (Duckro, Beal, & George, 1979; Larsen & Rootman, 1976; Martin, Sterne, & Hunter, 1976; Noyes, Levy, Chase, & Udry, 1974). Much of the research -in health and mental health has examined the relationship between patient satisfaction and the conduct of the provider (Lebow, 1983b). In one of these studies, Korsch et al. (1968) found that mothers who perceived pediatricians to be friendly expressed a higher level of satisfaction with care following a visit. Moreover, the mothers who expected to learn the cause and nature of their children's illnesses but did not were likely to be dissatisfied. 282
Similarly, Noyes et al. (1974) found that if gynecologypatients' positive expectations of their physicians were fulfilled, they were more likely to be satisfied. Larsen and Rootman (1976) found that the more a physician's role performance met a patient's expectations, the more satisfied the patient was with the physician's services. Linder-Pelz (1982) found a statistically significant relationship between a patient's expectation of physician's conduct and both general satisfaction and satisfaction with the physician's conduct, but not between expectation of physician's conduct and satisfaction with convenience. These findings indicate that a patient whose positive expectations of the physician's behavior are met is more likely to be satisfied with physician and with his or her health care in general. However, these studies also suggest that patient satisfaction is multidimensional and that satisfaction with one aspect of care may not carry over to other aspects of care. In addition to patient expectations, researchers also have linked sociodemographic factors, health status, and mode of service delivery to patient satisfaction with health care. Although one study found a negative relationship between age and patient satisfaction (Hulka, ]upper, Daly, Cassel, & Schoen, 1975), most have found that elderly patients are more likely to indicate that they are very satisfied with their health care than are younger groups (Linn, 1975; Linn & Greenfield, 1982). Most studies have found patient satisfaction to be unrelated to the patient's gender (Hulka, Zynanski, Cassel, & Thompson, 1971; Linn, 1975; Linn & Greenfield, 1982). However, some studies have reported that women are more satisfied with their health care than are men (Hulkaet al., 1975; Ware, Davies, & Stewart, 1977). Socioeconomic status also has been the subject of some interest. Some studies have reported that low-income patients are more skeptical and less satisfied with medical care than are other groups (Hulka et al., 1975; Suchman, 1964). The patient's health status also has been found to correlate with ratings of satisfaction. Typically, patients who report that they are in poor health also report lower levels of satisfaction (Linn & Greenfield, 1982; Patrick, Scrivens, & Charlton, 1983; Stratmann, Block, Brown, & Rozzi, 1975).
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 4/NOVEMBER 1991
The relationship between patient satisfaction and mode of service delivery, usually fee for service (FFS) versus prepaid group practice (PPG), also has been studied. Research findings indicate that patients who receive services under FFS arrangements generally report higher levels of satisfaction than do those who use PPGs (Davies, 1983; Tessler & Mechanic, 1975; Ware, Curbow, Davies, & Robins, 1981). When satisfaction is broken down into different aspects of care, PPG enrollees report less satisfaction with travel time and the length of time between making an appointment and the appointment date; however, they report higher satisfaction with health care costs (Davies, 1983; Richardson, Shortell, & Diehr, 1976; Tessler & Mechanic, 1975). These studies suggest that different groups have different expectations and different perceptions of the health care system. It is unlikely that older patients, women, members of higher socioeconomic groups, those who are in good health, and those who select FFS modes of service all perceive health care more favorably because they receive better health care. It is more likely that their satisfaction is linked to different expectations and to having their positive expectations fulfilled.
developed and tested by Ware, Snyder, and Wright (1976). Respondents rated their expectations and their levels of satisfaction using a five-point Likert-type scale. A random sample of 650 was selected from the complete list of 10,573 faculty and staff members employed by a large Midwestern university in February 1988. Nineteen of those selected were eliminated from the study because they did not reside within a 50-mile radius of the community or because they had retired. In March 1988, a questionnaire was sent to a sample of 631 faculty and staff; four weeks later, those who had not responded received a second mailing. The questionnaire was divided into five sections: (1) health information, including health plan and health status; (2) the anticipation scale; (3) the satisfaction scale; (4) the importance scale, which asked the respondent to rate the importance of various dimensions of the anticipation and satisfaction scales; and (5) demographic information. The members of the sample were asked to complete and return the questionnaire by mail. The two mailings produced a return of 401 usable questionnaires, a return rate of 63.5 percent (Hsieh, 1988).
METHOD
The reliability of the anticipation scale was 0.87; the reliability of the satisfaction scale was 0.91. These two scales also were subjected to principal components factor analysis to derive their a posteriori dimensions. After these analyses, the authors analyzed selected sociodemographic factors, health experiences, selfreported health status, and the derived anticipation factors for their ability to predict specific dimensions of and overall levels of satisfaction. Because the results of oblique and orthogonal rotations were very similar, only the orthogonal rotation was selectedfor presentation in this article. Factor loadings equal to or greater than .50 were included, as is standard practice. Four factors with eigenvalues greater than 1 were extracted from the data provided on the anticipation scale (Table 1). These factors accounted for 51.7 percent of the explanatory power of the 19
Sample and Data Collection This study used a cross-sectional design to examine the relationships between patients' expectations, personal characteristics, health status, and mode of service delivery and their satisfaction with health care (Hsieh, 1988). The authors treated patient expectations and patient satisfaction as multidimensional constructs. Patient satisfaction was defined as a patient's attitudes toward health care received and was measured with an a priori six-dimensional satisfaction scale. Patient expectation was defined as a patient's practical, rather than idealized, anticipation of future health care and was measured with a similar six-dimensional anticipation scale (Hsieh, 1988). Most of the items on the satisfaction scale and the anticipation scale were rephrased items from the Patient Satisfaction Scale
Results of Reliability Tests and Factor Analysis of Scales
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283
Table 1. Factor Loadings for Items on the Expectation Scale Factor
Factor Loading
Physician's conduct and convenience Uses up-to-date technology Checks on previous problems Explains what to expect regarding treatment Is available each visit Is kind and considerate Examines me thoroughly Enough specialized medical service is in the area Parking is convenient Waiting time No long wait in doctor's office No long wait for an appointment Preparation and resources for future care Enough specialists are in the area Physician encourages regular checkups Physician explains medical problems Cost and risk of care Medical insurance coverage is adequate Amount paid for care is reasonable Physician takes no risks in treatment
individual items. (The 20th item, asking for the patient's general expectation, was excluded from analysis.) The four factors, given names that connote the prominent included items, are expectation of physician's conduct and convenience, expectation of waiting time, expectation of preparation and resources for future care, and expectation of the cost and risk of health care. Using the same method, the authors extracted four factors from the data provided by the satisfaction scale (Table 2). These factors accounted for 61.0 percent of the explanatory power of the 19 items. (Again, the 20th item was excluded.) The four factors identified were satisfaction with physician's conduct, satisfaction with the availability of health resources, satisfaction with accessibility, and satisfaction with the financial coverage of care.
FINDINGS Characteristics of the Respondents The sociodemographic characteristics of the total population of 10,573 faculty and staff, the total sample of 631, and the 401 respondents who returned usable questionnaires were 284
.74:277 .69603 .69291 .69026 .67076 .61997 .53555 .52871 .83163 .82353 .74:536 .56089 .54:981 .604:67 .6034:7 .59971
compared (Table 3). The groups were clearly similar. The respondent group was almost equally divided between males and females. About the same proportion of white people to nonwhite people appeared in the respondent group as in the population as a whole. However, because a large percentage of the university staffand faculty were white, minority groups were underrepresented in this study. Information about age, reported by 396 respondents, showed that the sample was relatively young. The modal category (30.8 percent, n = 122) was between 26 and 36 years old. About a quarter (25.5 percent, n = 101) of the respondents were faculty members; 19.6 percent (n = 78) were academic professionals, and 54.8 percent (n = 217) were nonacademic staff. Most of the respondents (94.3, n = 378)werefull-time employees of the university. As might be expected, the education level was high in this sample. Respondents having a doctoral degree were the modal group (25.5 percent, n = 101). Most of the respondents were currently married (71.9 percent, n = 285). The distribution of family income was close to normal (skewness = .038). The number of respondents having an income of $25,000 to $34,999
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 4/NOVEMBER 1991
Table 2. Factor Loadings for Items on the Satisfaction Scale Factor Loading
Factor Physician's conduct Gives me information Examines me thoroughly Explains medical problems adequately Checks on previous problems Advises me about how to avoid illness Encourages me to have regular checkups Uses up-to-date technology Respects me Takes no risk in treatment Availability of health resources Availability of specialized medical services Availability of specialists Accessibility No long wait in doctor's oflice No long wait for an appointment Doctor available to answer questions Financial coverage Amount paid for service Coverage by medical insurance plan
.82828 .82245 .80932 .75396 .74403 .61848 .61043 .61036 .52105 .80820 .74967 .87411 .83721 .55996 .81031 .78157
Table 3. Sociodemographic Distributions of the Population, the Sample, and the Respondents Population Variable Gender Female Male Race/ethnicity White Nonwhite Full- or part-time employment 65
Sample
Respondents
n
%
n
%
n
%
4,892 5,681
46.2 53.8
302 348
46.0 54.0
208 193
51.9 48.1
9,176 1,397
86.8 13.2
578 72
88.9 11.1
365 32
91.9 8.1
530 10,043
5.0 95.0
33 617
5.1 94.9
23 378
5.7 94.3
2,216 2,702 5,655
21.0 25.5 53.5
156 155 339
24.0 23.8 52.2
101 78 217
25.5 19.7 54.8
637 3,188 3,078 2,176 1,341 153
6.0 30.2 29.1 20.6 12.7 1.4
32 195 203 131 79 10
5.0 30.0 31.2 20.2 12.1 1.5
19 122 118 82 49 6
4.8 30.8 29.8 20.7 12.4 1.5
was 87 (22 percent), which was the modal group. The mean number of family members who were dependent on the yearly family income was 2.56.
Demographics and Patient Satisfaction Women rated continuity as more impor4.14, tant (M = 4.32) than did men [M
UNDERSTANDING PATIENT SATISFACTION AND DISSATISFACTION WITH HEALTH CARE
285
= 2.61, P < .01], reported higher levels of anticipation of preparation and resources for future care (M = .11) than did men [M = - .11,1(391) = 2.16, P < .05], and reported higher levels of satisfaction with physician's conduct (M = .10) than did men [M = - .11, 1(390) = 2.10, P < .05]. In general, women (M = 16.70) were more satisfiedthan were men (M = 15.96), as shown by their weighted composite satisfaction score [1(379) = 1.97, P < .05]. Different ethnic groups reported different levels of satisfaction with availability of health resources (I = - 3.11, dj = 377, P < .005). Nonwhite respondents (M = - .53) tended to be more dissatisfied with the availability of health resources than were white respondents (M = .04). Age was associated with satisfaction with physicians' conduct [F(5, 371) = 2.80,p < .01], accessibility of care [F(5, 371) = 2.97, P < .01], average satisfaction [F(5, 381) = 2.51, P < .05], and the weighted composite satisfaction score [F(5, 370) = 2.49, P < .05]. The extreme age groups were more satisfied with physician's conduct, but slightly less satisfied with accessibility, and had higher scores on general satisfaction and weighted composite satisfaction measures. When post-hoc contrasts were conducted between two extreme age groups and the remaining age groups, extreme age groups were significantly different from the other three age groups on satisfaction with accessibility
1(397)
(I = 2.09, df = 371, P < .05). Plan Enrollment and Patient Satisfaction Findings of z-tests showed that respondents enrolled in the university's FFS plan reported a higher level of satisfaction with physician's conduct (M = .28) than did respondents enrolled in PPG plans [;\1 = .04, 1(378) = 2.15, P < .05]. Respondents who had been enrolled in the FFS plan also cared less about the cost and risk of care. In general, PPG respondents were more conscious of the cost and risk of care. The mean score on expectation of cost and risk of care for the FFS group was - .62, compared with .08 for the PPG group. The I-test was statistically significant
[1(389) 286
-4.07, P < .0001].
Health Status and Patient Satisfaction The findings suggest that respondents who reported relatively poor health did not expect the cost of care to be reasonable IF(3, 389) = 5.37, P < .001]. They also did not expect to be satisfied with the care they received [F(3, 396) = 4.87, P < .005]. These respondents were less satisfied with accessibility [F(3, 389) = 6.78, P < .0001] and rated their general satisfaction lower than did other respondents [F(3, 388) 10.81, P < .0001].
Patient Expectations and Satisfaction Previous research has found strong relationships between patients' levels of satisfaction and gender, age, family income, number of doctor's visits in the previous year, FFS versus PPG enrollment, and self-reported health status. These sociodemographic and health factors, along with the four expectation factors, were included in multiple-regression analyses in the present study. Dummy variables were created for gender (two levels), number of doctor's visits in the previous year (fivelevels), health status (four levels), and health insurance plan (two levels). Age and income were treated as interval data. In predicting satisfaction with physicians' conduct, only the type of health insurance plan was included in the equation. PPG enrollment was negatively associated with satisfaction with physicians' conduct. The model predicted 20.7 percent of the variance (Table 4). The number of doctor's visits during the previous year was included in the equation predicting satisfaction with the availability of health resources. All four expectation factors were also in the equation. A respondent who had visited a doctor one to three times tended to be more satisfied with the availability of health resources (Table 4). The expectation of preparation and resources for future care was negatively associated with higher levels of satisfaction with the availability ofhealth resources. In contrast, a respondent's expectation of waiting time predicted satisfaction with accessibilitybest. Respondents who were enrolled in PPGs were less satisfied with access. When the PPG variable was included, expectation
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 4/NOVEMBER 1991
Table 4. Predictors of Specific Dimensions of Patient Satisfaction Predictor Satisfaction with physician's conduct, [R .455, R2 = .207, N = 370, F(5. 364) = 18.988 ***] Anticipated conduct and convenience Anticipated preparation and resources Anticipated waiting time PPG Anticipated cost and risk Constant Satisfaction with availability of health resources, [R = .425, R2 = .182, N = 370, F(5.1M) = 16.166***] Anticipated preparation and resources Anticipated conduct and convenience Anticipated cost and risk Anticipated waiting time Doctor visits (1-3 times) Constant Satisfaction with accessibility of care, [R = .372, R2 = .139, N = 370, f(". j",,) = 14,671***] Anticipated waiting time Anticipated conduct and convenience Anticipated preparation and resources PPG Constant Satisfaction with financial coverage of care, [R = .494, R2 = .244, N = 370, F(4.365) = 29.50**] Anticipated cost and risk PPG Anticipated preparation and resources Doctor visits (1-3 times) Constant NOTE:
SE
b
SE of b
Beta
.325*** .217*** .150** -.520** .132* .471**
.047 .047 .047 .152 .047 .142
.323 .217 .150 - .166 .134
.254*** .231*** .176*** -.141** .216* - .128
.047 .048 .047 .047 .095 .069
.256 .230 .180 - .141 .108
.300*** .139** - .117* -.367* .333*
.048 .049 .049 .153 .144
.301 .138 - .118 - .117
.291** .764** .212** -.229* -.558**
.047 .149 .046 .092 .148
.292 .241 .216 - .113
standard error.
*p < .05. "p < .005. • "p < .0001.
of cost and risk of care became less important in predicting satisfaction with accessibility (Table 4). With respect to satisfaction with financial coverage, two major predictors were included: the expectation of the cost and risk of care and the expectation of preparation and resources for future care. In addition, two control variables (the health plan and the number of doctor's visits in the previous year) were included. Respondents who were enrolled in PPGs were more satisfied with financial coverage than those in the FFS plan. However, if a respondent had been to a doctor one to three times in the
previous year, he or she tended to be less satisfied with this dimension of care (Table 4). Overall satisfaction was measured by a single item asking general satisfaction with care and by the average score of the remaining 19 items. All four expectation factors were included when predicting the single-item measure of general satisfaction. However, when a respondent reported his or her health status as fair, the score was reduced by .133 standardized unit; PPG membership reduced it another .097 unit (Table 5). Health status and the number of doctor's visits in the previous year influenced the average satisfaction score.
UNDERSTANDING PATIENT SATISFACTION AND DISSATISFACTION WITH HEALTH CARE
287
Table 5. Predictors of Single-Item Measure: Overall Satisfaction and Average Satisfaction Predictor Overall satisfaction, [R = .467, R2 = .218, N = 369, F(6,362) = 16.791***] Anticipated conduct and convenience Anticipated cost and risk Anticipated preparation and resources Health status Anticipated waiting time PPG Constant Average satisfaction, [R = .635, R2 = .403, N = 369, F(9.359) = 26,890***] Anticipated conduct and convenience Anticipated preparation and resources Anticipated cost and risk Anticipated waiting time Doctor visits (none) Health status (excellent) Health status (good) Health status (fair) Doctor visits (1-3 times) Constant NOTE:
SE
=
b
SE of b
Beta
.229*** .229*** .209*** -.424** .086* -.280* 4.124***
.043 .044 .043 .150 .043 .139 .131
.247 .253 .226 - .133 .094 -.097
.208* .184* .161 * .086* -.270** .789*** .704*** .595** - .112* 3.100*
.025 .024 .024 .024 .081 .173 .172 .185 .056 .168
.348 .310 .277 .146 - .162 .661 .594 .291 -.095
standard error.
*p < .05. **p < .005. ***p < .0001.
DISCUSSION The study summarized in this article had a large sample and a high response rate (Hsieh, 1988). Although the respondents were younger and better educated than the general population, their views were similar to those of other groups sampled in previous research. First, their level of satisfaction with health care was strongly associated with their expectations. In line with previous research (Korsch et aI., 1968; Larsen & Rootman, 1976; Linder-Pelz, 1982; Noyes et al., 1974), this study indicates that those who have their positive expectations of the health care system fulfilled were apt to express satisfaction with services. Second, patients' expectations of their physicians' conduct and the convenience of services was the best predictor of their overall level of satisfaction. For example, a patient who expected that his or her physician would use upto-date technology, that he or she would see the same physician on each visit, and that parking would be convenient was more likely to express overall satisfactionwith servicesreceived. Third, patients' satisfaction with specificdimensions of 288
their health care was directly associated with their specific expectations. That is, satisfaction with cost was linked with expectations of cost, satisfaction with accessibilitywas linked with expectations of accessibility, and so on. This means that patients had a relatively sophisticated set of expectations and evaluated health care accordingly. A positive evaluation of one dimension of care did not necessarily carry over to another aspect of care; a patient may have expressed satisfaction with one dimension and dissatisfaction with another dimension of care. Overall, sociodemographic factors, health status, and mode of service delivery were not strong predictors of patient satisfaction. However, the data suggest that different subgroups may have had differing expectations and levels of satisfaction with their health care. For example, women were more concerned with future care and continuity of services and were more satisfied with their health care than were men. Members of minority groups were less satisfied overall and less satisfied in particular with the availability of health services. The oldest (over 55) and youngest (under 25) groups were more
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 4/NOVEMBER 1991
satisfied overall but were less satisfied with accessibility of services than other groups. Those who received services through an FFS arrangement were more satisfied overall than those enrolled in PPGs; however, the latter group was more cost conscious and more satisfied with the cost of care. Those who reported relatively poor health had less positive expectations and were less satisfied than were other groups. These findings, particularly the dissatisfaction of minority group members with the availability of services, warrant further investigation.
PATIENT SATISFACTION AND SOCIAL WORK Social workers can use their knowledge of patient satisfaction and its relationship to expectations and other factors in several ways. They may use this knowledge when they design and interpret the findings of evaluations of health care and social services. Clearly, evaluation questionnaires should measure expectations as well as satisfaction with services received and should include both global and specificquestions about the various dimensions of service. Similarly, in interpreting the results of evaluation studies, social workers should be sensitive to the influence of expectations and other factors on a patient's levels of satisfaction with services. Social workers in health care also may use this knowledge in their practice with clients. Patient satisfaction appears to affect clients' behavior in three areas: (1) care seeking, (2) adherence to medical advice, and (3) action against a provider (Ware & Davies, 1983). Patients who are satisfied with their care are more likely to schedule routine checkups and to seek care when they are ill. They are also more likely to comply with their medical regimen, meet appointments, follow physicians' instructions, and take prescribed medications (Linder-Pelz, 1982; Weiss, 1988; Zimmerman, 1988). Finally, satisfied patients are less apt to change providers, disenroll from their health plans, or take punitive action. Thus, understanding the factors that influence patient satisfaction may assist social workers in contributing to their clients' health and quality of life as well as in influencing their organizations and other providers. Social workers can
help patients develop realistic and positive expectations of their health care, they can help patients communicate their expectations to providers, and they can encourage health providers to recognize and meet those expectations.
About the Authors Mei-O Hsieh, PhD, is Associate Professor, Department of Sociology, National Chengchi University ofTaiwan, Taipei, Taiwan. jill Doner Kagle, PhD, ACSW, LCSW, is Associate Professor, University of Illinois School of Social Work, 1207 West Oregon Street, Urbana, IL 61801.
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SSAGES: Working with Children with Learning Disabilities by Elizabeth Dane
Children with learn ing disabilities require understanding, knowledge , and skilled intervention . Painfu l Passages helps social workers , administrators, educators, and parents respond creatively and effectively to these needs.
HEALTH AND SOCIAL WORKIVOLUME 16, NUMBER 4/NOVEMBER 1991
