Published by : PROFESSIONAL MEDICAL PUBLICATIONS
|July - September 2007||
Expectations of primary care patients
in rural Karnataka
Padmashree S1, Anton N. Isaacs2
Objective: To study the expectations and satisfaction levels of patients attending a primary care service in a rural area of Karnataka state, India.
Methodology: The study was conducted at the clinic of the Community Health Training Centre of St. Johnís Medical College, Bangalore. One hundred six successive patients were interviewed on expectations of treatment and charges while they waited for the consultation. They were interviewed a second time on satisfaction with treatment and charges while they were leaving the centre after consultation.
Results: Patients were aware of what type of treatment they wanted and most expectations of treatment were met. However, overall levels of satisfaction were not significantly associated with met expectations for treatment, but were dependent on met expectations for charges.
Conclusion: Primary Care physicians must always be aware of the socio-economic status of their patients, while prescribing treatment.
KEY WORDS: Expectations, Satisfaction, Primary Care, India.
Pak J Med Sci July - September 2007 Vol. 23 No. 4 534-537
1. Padmashree S,
2. Anton N. Isaacs,
1-2: St. Johnís Medical College and Hospital,
Bangalore - India.
Dr. Anton N. Isaacs
Department of Community Health,
St. Johnís Medical College,
Bangalore Ė 560034.
* Received for Publication: March 28, 2007
* Accepted: June 4, 2007
The term expectations is often used to indicate what patients hope will happen, whether or not they explicitly verbalize this expectation as a request.1 Patients often have a specific agenda when visiting a health care facility.2 However, if this agenda differs from that of the treating physician and consequently goes undetected, it may result in a lower level of satisfaction with care.3 Further, since good clinical outcomes depend to a large extent on patient compliance, which in turn is dependent on patient satisfaction, the latter has to be seen as a prerequisite of good quality care4 and therefore becomes an important component while evaluating health care systems. Although research on patient satisfaction with primary care services has become standard in Western countries, the concept in developing countries, including India, is relatively new. We investigated the expectations of patients visiting a primary health institution in Mugalur, a sub centre of the Sarjapura Primary Health Centre, and their level of satisfaction following consultation.
PATIENTS AND METHODS
Setting: The study was conducted at the Community Health Training Centre (CHTC) at Mugalur village, which is about 30 kilometres from Bangalore City. This centre serves as the base for all rural programmes of the department of Community Health at St. Johnís Medical College, Bangalore. It also provides primary health care to a rural population of about twenty five thoushand on a Not for Profit basis. The centre is run by a postgraduate resident in Community Health.
Subjects: One hundred six contiguous patients presenting with a new problem to the general health clinic were chosen for the study.
While patients waited to see the doctor, they were informed of the conduct of the study and its purpose which was to investigate what their expectations regarding treatment and charges were and whether those expectations were fulfilled or not. After obtaining informed consent, a medical intern interviewed the subjects and subsequently requested them to proceed for the consultation. The interview schedule included demographic details, patientís presenting complaints and expectations of both treatment and charges.3
Further questions were administered after the patient completed the consultation and was about to leave the centre. These questions covered details of treatment received, actual charges and level of satisfaction with the consultation. Treatment and charges that were expected and received were recorded verbatim and compared. The investigators were not involved in the treatment of these patients. SPSS software ver.10 was used for analysis of the data. Pearson X2 tests were used to examine associations between expectations and demographic characteristics as well as that between expectations and satisfaction levels. ĎMet expectationsí were defined as those expectations for treatment or charges that were realized.
All 106 subjects agreed to take part in the study. Demographic characteristics of the study group are shown in Table-I. 7th standard was selected as the cut off for educational status since that was highest class in the local school. Patients with fever, musculoskeletal conditions and animal bites, expected injections as part of their treatment. However, those with respiratory, gastrointestinal and eye symptoms did not expect injections (X2 =8.84, df=1, P=0.003).
Seventy nine (74.5%) patients received treatment that they had expected and of them, fifty one (48.1%) received more than they had expected. Fifty three (91.4%) of the patients who expected an injection, received it and of those who did not expect an injection, 48 (90.5%) did not receive it (X2 =12.33, df=1, P<0.001). Educational status was significantly associated with met expectations for treatment (X2 =4.35, df=1, p<0.04) although, age, sex and income were not. 58.5% of patients expected to pay less than 20 rupees for consultation and treatment and 30% expected to pay between 21 and 60 rupees. Almost 75% of patients were charged in accordance with their expectations. Increasing age was significantly associated with met expectations for charges (X2 = 9.22, df =3, p<0.027), although sex, educational status and income were not. Moreover, those whose expectations for treatment were met, also had met expectations for charges (X2 =6.25, df=1, p=0.012). 99% were satisfied with the treatment of which 67% were "Happy" or "Very Happy" at the end of the consultation. Satisfaction levels were significantly associated with met expectations for charges (Table-II) but not with met expectations for treatment (X2 =4.59, df=3, p=0.2).
This study was carried out on a sample of rural patients who were predominantly dependant on agriculture for their livelihood. A majority of them had not completed middle school but felt that injections were necessary for painful somatic complaints, fever and animal bites unlike gastrointestinal, respiratory and ophthalmic symptoms, which did not automatically warrant injections. There is a widespread perception among rural communities that injections are a sure and definitive cure for most types of pain and so, many patients presenting to primary health centres with such symptoms, request an injection. This understanding has probably been influenced by prescribing patterns of both private general practitioners as well as medical officers of the surrounding Primary Health Centres.
Injections that are prescribed are more often than not, those of Non Steroidal Anti Inflammatory Drugs and Vitamins. Most general practitioners oblige patients with injections, more so, if patients request it. Ethical issues can come into play if injections requested by patients and prescribed by physicians, cause adverse effects.
As expected, those who were educated had a better idea of the treatment that was necessary. However, surprisingly, increasing age was not associated with met expectations for treatment. This could probably be due to the fact that a large proportion of subjects were not educated. Nevertheless, as indicated in our findings, individuals tend to be more money conscious as they grow older. Those who had an idea of the kind of treatment that was necessary, were also familiar with the charges for that treatment and these individuals were mostly more educated than the others. Unlike secondary or tertiary care services which are utilized mostly by middle and higher income individuals, the lowest socio-economic classes of society are perhaps the only ones who depend on primary care providers for medical care. The rigours of daily hard physical labour could result in considerable somatic symptoms requiring adequate rest. However, the inability to stay away from work due to poverty might possibly be the reason for individuals seeking injections which give quick relief. Regular users of these services would therefore know what to expect and how much it would cost.
Whether their expectations for treatment were met or not was not as important to these individuals as the met expectations for charges. This was probably due to the fact that being from the lower socioeconomic strata, there were severe constraints on the money available for medical care. Primary Care physicians must therefore be always conscious about the socio-economic status of their patients, while prescribing treatment.
Although, there is reason to believe that the high levels of expressed satisfaction were justified, there could be other reasons for almost 100% reported satisfaction. The subjects were aware that the interviewer was working at the centre and therefore may not have wanted to displease her. Poverty and illiteracy can render individuals unable to voice their true feelings in the presence of those belonging to the higher socio-economic classes and may perhaps volunteer to express only those feelings which are perceived to be acceptable by those who are more educated and well-off. Some authors also suggest that high levels of expressed satisfaction may indicate an absence of opinion.5
There are many limitations to this study. Firstly, this is a pilot study and the findings described here cannot be applied to the entire population that utilizes conventional primary health care services in India. It merely indicates the trends in patientsí expectations and satisfaction with services. Secondly, it may be presumed that only patients who are satisfied with a certain health care service will continue to utilize it. Therefore, most patients attending the centre would be satisfied clients. This has been pointed out by other authors as well.6 Finally, the main focus of this study was on expectations for injections. Other expectations like emotional support from the doctor and explanation of the "illness" which, along with prescribing patterns of primary care physicians are possible topics for future research in similar settings.
Conflict of Interest: None Declared
Contribution of authors: PS proposed the topic for the study contributed to the study design and carried out the study. ANI contributed to the study design, wrote the proposal and analysed the data. AI and PS wrote the manuscript.
1. Kroenke K. Patient expectations for care: How hidden is the agenda? Mayo Clin Proc 1998;73:191-3.
2. Price JH, Desmond SM, Losh DP. Patientsí expectations of the family physician in Health Promotion. Am J Prev Med 1991;7:33-9.
3. Kravitz RL, Cope DW, Bhrany V, Leake B. Internal Medicine patientís expectations for care during office visits. J Gen Intern Med 1994;9:75-81.
4. Williams B. Patient satisfaction: a valid concept? Soc Sci Med 1994; 38:509-16.
5. Brody DS, Miller SM, Lerman CF, Smith DG, Lazaro CG, Blum MB. The relationship between patientís satisfaction with their physicians and perceptions about interventions they desired and received. Med Care 1989;27:102-35.
6. Al Qatari G, Haran D. determinants of userís satisfaction with primary health care settings and services in Saudi Arabia. Int J Qual Health Care 1999;11:523-31.
HOME | SEARCH | CURRENT ISSUE | PAST ISSUES
Room No. 522, 5th Floor, Panorama Centre
Building No. 2, P.O. Box 8766, Saddar, Karachi - Pakistan.
Phones : 5688791, 5689285 Fax : 5689860