1. Background
Health and security are among the primary rights of a society, whose securement falls on the government. In accordance with the fourth national economical-social-cultural development plan, all the necessary arrangements for the family physician-based health insurance and referral system must be provided by the end of this program (1).
Nowadays, family physicians in various countries, such as North America, Western Europe, and Canada, are responsible for the provision of health services with the help of health teams. The national health systems in Britain, Canada, South Korea, and Chili are based on the referral system level and family physicians (2, 3). Family physicians provide all sorts of services including preventive, educational, promotional, and managerial services related to health at medical centers (4). The family physician program, based on family physicians and referral systems, attempts to create and improve national referral systems, increase responsiveness in health markets, increase access to health services, reduce unwanted and unnecessary costs, and increase service coverage. The family physician is responsible for providing health services for the entire society in accordance with defined limitations and without any prejudice towards age, gender, financial-social traits, and disease risk (5). The family physician program in Iran was first piloted in the Fars and Mazandaran provinces. However, the program was not fully carried out due to financial crisis in the country (6). Also, the program’s coverage in Shiraz increased from 23% to 84% during a 7-month period (7). Overall, the satisfaction levels with the program in urban and rural regions of Shiraz were 54.5% and 69.2%, respectively (8). Moreover, 76.41% of the study subjects from the Markazi province were content with the family physician program (9). The family physician program resulted in decreased mortality of infants and children throughout Iran (10).
Today, most organizations seek to improve customer satisfaction and, consequently, their own durability, through the evaluation of their services and by selecting customer satisfaction as a key index (11). The ultimate objective of quality evaluation is to promote the outcome and effectiveness of various programs, or in other words, the promotion of service quality and health care (12). The simplest way one can evaluate the family physician’s services is by evaluating the satisfaction of the service recipients (13). In today’s world, the issue of customers has found a significantly important stand in case of healthcare and medical services. The reason for this is that a customer’s inclination or unwillingness towards a service can significantly influence the permanence of the service provider organization (14). The evaluation of patient satisfaction can be looked at as a tool for assessing the quality of healthcare services (15). A survey by Doyle consisting of 55 reviews indicated patient satisfaction as a significant index in evaluating the quality of service (16).
Therefore, it was concluded that customer satisfaction, which in the case of family physician services involves the satisfaction of service recipients regarding various services provided by the family physician team, is a significant factor contributing to the increased performance of the team. Evaluating the amount of satisfaction is, therefore, a major index in the development and growth of healthcare services. Studies have indicated the effectiveness of patient satisfaction in the amelioration of health services (17-20). The study results have shown that patient satisfaction in return causes patients to refer other individuals, including friends and other patients in need of service to the same service provider hospitals or health centers (21). Out of 378 studies conducted on the relationship between patient experience and outcome of treatment, 312 studies confirmed a positive relationship between the 2 parameters (16). Also, a study on the population of Jiroft indicated that 66% of patients refused to return to the same doctor due to a lack of knowledge on the part of the family physician (22).
Despite the importance of quality of service and customer satisfaction, and the significance of their evaluation in improving health services, and considering that the family physician project in Iran was launched in 2005, studies evaluating the quality of service and customer satisfaction among the population are still limited. The lack of such studies may result in potential problems in the implementation of this program. Thus, the present study sought to investigate customer satisfaction alongside the assessment and identification of current issues in the area of health.
2. Methods
For the present cross-sectional analytical descriptive study, 218 service recipients of the family physician programs in Khusf and Birjand, during year 2015, were selected as the study population. The precise number of subjects needed (218) was attained by considering a standard deviation of 0.97 for the satisfaction score, according to a study conducted by Ahmadi Kashkoli et al. (23) wherein an error rate of 5% and precision of 0.13 resulted in a study population of 218 individuals. Considering that the program took place at health centers in the rural regions of cities with populations of more than 20,000 and all the health centers of both the urban and rural regions of cities with populations of less than 20,000, the study subjects were selected from 12 rural health centers in Birjand and Khusf. The selection procedure was as follows, questioners initially referred to health centers on the 5th of November from 8 AM to 1 PM, and questionnaires were filled according to that day’s referrals per quota of each center’s population coverage using simple non-statistical sampling (Table 1).
Table 1.Samples Selected from the Family Physician Health Centers of Birjand and Khusf
| City | Health Center | Population Covered | Number of Selected Samples |
|---|---|---|---|
| Birjand | Amirabad | 17000 | 63 |
| Shakhan | 5000 | 18 | |
| Gazar | 4000 | 15 | |
| khong | 4000 | 15 | |
| Marak | 3000 | 11 | |
| Khorashad | 2200 | 8 | |
| Ghyuk | 2500 | 9 | |
| Khousf | Urban center | 10000 | 37 |
| Majan | 4500 | 17 | |
| Taghab | 3500 | 13 | |
| Khour | 1700 | 6 | |
| Gol | 1800 | 6 | |
| Total | 59200 | 218 |
The applied questionnaire was designed by Alibabaei et al. (24) and had 51 questions with 8 categories, including quality (4 questions), performance (6 questions), effectiveness (7 questions), accessibility (13 questions), timeliness (5 questions), applicability (4 questions), stability (5 questions), and facilities (7 questions). The questions were scored according to the Likert scale from strongly disagree to strongly agree. The overall score for each category was computed by averaging the scores of each category. Consequently, the overall score for each category and the total score of the questionnaire was from 1 to 5. The questionnaire has been justified by the opinion of 12 experts. Cronbach’s alpha coefficient for the Ali Babayi study was computed as 0.938, indicative of its reliability (24). The Cronbach’s alpha coefficient for the overall score, quality, performance, effectiveness, accessibility, timeliness, applicability, stability, and facilities for the present study were obtained as 0.91, 0.87, 0.88, 0.79, 0.90, 0.88, 0.81, 0.78, and 0.83, respectively.
The present study is the conclusion of a research project conducted under the supervision of the Birjand University of Medical Sciences (code 4589). The ethical considerations were approved by the Birjand University of Medical Sciences (code IR.bums.REC.1394.411).
The information analysis was performed using descriptive methods, including frequency distribution, central indices, scattering, and inferential methods, such as multiple analysis of variance (ANOVA), independent t-tests, and ANOVA for normal variables, including performance, respect, timeliness, and facilities. The Mann-Whitney and Kruskal-Wallis tests were performed for variables of quality, accessibility, effectiveness, and stability. The data were analyzed with a 5% error rate using the SPSS (version 18) software.
3. Results
For this study, 218 individuals were selected and studied. Of the study samples, 38.2% were male, and 61.5% had a below-diploma education. Of the study samples, 77.5% were married, 75.7% had rural insurance, 53.8% were middle-aged, and 77.2% were residents of rural regions with health centers. The overall satisfaction score of the study samples for the family physician services was obtained as 3.58, with quality and facilities contributing to the highest and lowest scores, respectively (Table 2).
Table 2.Frequency Distribution for Demographic Characteristics and Satisfaction with the Family Physician Program Amongst Service Recipient
| Variable | No. (%) |
|---|---|
| Gender | |
| Male | 83 (38.2) |
| Female | 134 (61.8) |
| Education | |
| Illiterate | 31 (14.4) |
| Below-diploma | 134 (61.5) |
| Diploma | 43 (19.7) |
| College degree | 9 (4.3) |
| Marital status | |
| Married | 169 (77.5) |
| Other | 49 (22.5) |
| Insurance | |
| Rural | 165 (75.7) |
| Other | 53 (24.3) |
| Type of rural region | |
| With health home | 168 (77.2) |
| Without health home | 50 (22.8) |
| Age | |
| Young | 80 (36.7) |
| Middle-aged | 117 (53.8) |
| Senior | 21 (9.5) |
| Service recipient satisfaction* | |
| Quality | 3.92 ± 0.69 |
| Accessibility | 3.74 ± 0.69 |
| Performance | 3.62 ± 0.66 |
| Effectiveness | 3.38 ± 0.81 |
| Respect | 3.68 ± 0.75 |
| Timeliness | 3.57 ± 0.83 |
| Stability | 3.63 ± 0.70 |
| Facilities | 3.19 ± 1 |
| Total | 3.58 ± 0.66 |
The subscale satisfaction scores (scores for each category of the questionnaire) were evaluated based on demographic variables. The results indicated that the mean satisfaction score and the score of their corresponding subscales were significantly higher in females compared to males (P < 0.05). The level of education also had significant effects on the satisfaction with stability and timeliness of services, and the Tukey test results indicating a high score for satisfaction with the timeliness of services among individuals with college degrees compared to those with diplomas. With regards to stability, the results of the Mann-Whitney test indicated that individuals with diplomas had higher scores compared to illiterate individuals and those with degrees lower than a diploma, and the individuals with college degrees scored higher than those with diplomas (P < 0.05). Moreover, the satisfaction scores among the residents of rural regions with health centers were significantly higher. The age category also had significant effects on all the subscales of the questionnaire, except accessibility, timeliness, and facilities. The Tukey tests showed that seniors scored higher on the category of performance in comparison to middle-aged individuals. The seniors also scored higher with regards to the respect subscale (P < 0.05). The results of the Mann-Whitney test for the 3 subscales of quality, effectiveness, and stability indicated a higher score amongst seniors compared to young and middle-aged individuals (P < 0.05) (Table 3).
Table 3.Comparison of the Mean Scores for Each Category of the Family Physician Services Questionnaire According to Demographic Variables in Birjand and Khusf During Year 2015a
| Variable | Qualityb | Accessibilityb | Performancec | Effectivenessb | Respectc | Timelinessc | Stabilityb | Facilitiesc |
|---|---|---|---|---|---|---|---|---|
| Gender | ||||||||
| Male | 3.75 (3.25 - 4.25) | 3.5 (3 - 4) | 3.44 ± 0.58 | 3 (2.57 - 3.57) | 3.37 ± 0.63 | 3.33 ± 0.78 | 3.33 (3 - 3.83) | 2.89 ± 0.92 |
| Female | 4 (3.5 - 4.5) | 4 (3.5 - 4.25) | 3.74 ± 0.68 | 3.57 (3 - 4) | 3.88 ± 0.75 | 3.72 ± 0.83 | 3.83 (3.3 - 4.17) | 3.38 ± 1.01 |
| Significance | 0.04 | 0.008 | 0.001 | < 0.001 | < 0.001 | 0.001 | < 0.001 | < 0.001 |
| Education | ||||||||
| Illiterate | 4 (3.5 - 4.75) | 4 (3.25 - 4.5) | 3.82 ± 0.59 | 3.5 (3.14 - 4.14) | 3.96 ± 0.72 | 3.82 ± 0.72 | 3.75 (3.5 - 4) | 3.34 ± 0.94 |
| Below-diploma | 4 (3.5 - 4.25) | 3.75 (3 - 4) | 3.57 ± 0.67 | 3.14 (2.71 - 4) | 3.65 ± 0.74 | 3.53 ± 0.83 | 3.5 (3 - 4) | 3.25 ± 1.03 |
| Diploma | 4 (3.25 - 4.25) | 3.75 (3.25 - 4) | 3.58 ± 0.63 | 3.57 (3 - 3.86) | 3.58 ± 0.73 | 3.37 ± 0.87 | 3.5 (3 - 3.83) | 2.91 ± 0.89 |
| College-degree | 4 (3.75 - 4) | 3.75 (3.75 - 4) | 3.76 ± 0.71 | 3.14 (3 - 3.86) | 3.92 ± 0.65 | 4.13 ± 0.68 | 4 (3.5 - 4.33) | 3.22 ± 0.95 |
| Significance | 0.69 | 0.45 | 0.24 | 0.21 | 0.11 | 0.02 | 0.02 | 0.22 |
| Marital status | ||||||||
| Married | 4 (3.5 - 4.5) | 3.75 (3.25 - 4.25) | 3.62 ± 0.65 | 3.29 (2.71 - 3.86) | 3.69 ± 0.74 | 3.56 ± 0.84 | 3.67 (3.17 - 4) | 3.19 ± 0.97 |
| Other | 4 (3.75 - 4.25) | 3.5 (3.25 - 4) | 3.61 ± 0.68 | 3.29 (3 - 4) | 3.65 ± 0.75 | 3.58 ± 0.80 | 3.5 (3 - 4) | 3.19 ± 1.12 |
| Significance | 0.98 | 0.34 | 0.92 | 0.31 | 0.70 | 0.88 | 0.98 | 0.98 |
| Insurance | ||||||||
| Rural | 4 (3.5 - 4.5) | 3.75 (3.25 - 4) | 3.62 ± 0.65 | 3.29 (2.71 - 4) | 3.68 ± 0.73 | 3.57 ± 0.80 | 3.5 (3 - 4) | 3.19 ± 1.04 |
| Other | 4 (3.75 - 4.25) | 3.75 (3.25 - 4.25) | 3.63 ± 0.69 | 3.29 (3 - 3.86) | 3.69 ± 0.79 | 3.55 ± 0.93 | 3.8 (3 - 4) | 3.21 ± 0.87 |
| Significance | 0.90 | 0.66 | 0.95 | 0.83 | 0.94 | 0.86 | 0.85 | 0.87 |
| Type of rural region | ||||||||
| With health home | 4 (3.5 - 4.5) | 4 (3.5 - 4.25) | 3.75 ± 0.63 | 3.57 (3 - 4) | 3.82 ± 0.72 | 3.70 ± 0.78 | 3.83 (3.33 - 4.08) | 3.37 ± 1.01 |
| Without health home | 3.75 (3.25 - 4) | 3 (2.75 - 3.75) | 3.21 ± 0.61 | 2.71 (2.29 - 3.29) | 3.18 ± 0.63 | 3.05 ± 0.85 | 3.17 (2.83 - 3.5) | 2.61 ± 0.82 |
| Significance | 0.01 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 | < 0.001 |
| Age categoryd | ||||||||
| Young | 4 (3.5 - 4.25) | 3.75 (3.5 - 4) | 3.63 ± 0.57 | 3.75 (3.5 - 4) | 3.66 ± 0.72 | 3.57 ± 0.75 | 4 (3.17 - 4) | 3.13 ± 1.10 |
| Middle-aged | 4 (3.5 - 4.25) | 3.75 (3 - 4) | 3.56 ± 0.68 | 3.75 (3 - 4) | 3.60 ± 0.73 | 3.49 ± 0.87 | 3.86 (3 - 4) | 3.14 ± 0.92 |
| Senior | 4.75 (4 - 5) | 3.88 (3.5 - 5) | 3.94 ± 0.65 | 3.88 (3.5 - 5) | 4.23 ± 0.63 | 3.96 ± 0.77 | 4 (3.67 - 4.25) | 3.62 ± 0.96 |
| Significance | 0.002 | 0.29 | 0.05 | 0.04 | 0.002 | 0.06 | 0.007 | 0.13 |
aValues are expressed as median (Q1 - Q3) or mean ± SD.
bObtained using non-parametric Mann-Whitney and Kruskal-Wallis tests due to non-normal distribution of dependent variable.
cObtained by T-test and ANOVA.
dYoung category (under 30), middle aged (30 - 59 years old), senior (above 60 years old).
Multiple ANOVA was applied for identifying effective variables on recipient satisfaction. The results indicated that age, gender, and residency in rural regions with health centers had significant effects on overall satisfaction with the family physician services (P < 0.01), with impact values of 5%, 10%, and 15%, respectively. Overall, these variables contributed to 25.2% of the changes in the satisfaction scores (Table 4).
Table 4.Predictors of Satisfaction with the Family Physician Program Among Service Recipients in Khusf and Birjand During Year 2015
| Variable | SS | MS | Fisher Statistics | Significance | Effect Size |
|---|---|---|---|---|---|
| Age | 3.23 | 1.62 | 4.81 | 0.01 | 0.05 |
| Gender | 7.17 | 7.17 | 21.30 | < 0.001 | 0.10 |
| Rural region | 11.37 | 11.37 | 33.81 | < 0.001 | 0.15 |
4. Discussion
The family physician program is one of the most important and effective methods for increasing accessibility to health services for the society, which not only provides the necessary health services but also prevents and reduces the abuse of people’s needs for the services offered by various providers (25). Evidence shows that the patients satisfied with their treatment are more likely to refer to the same service provider (26, 27). Thus, the patient satisfaction with the family physician services positively affects their behavior and causes the patients to refer to the same service providers on an ongoing basis (28).
Various research studies have investigated the issue of patient satisfaction with the family physician services. The present study investigated satisfaction with the family physician program in 8 categories, including quality, accessibility, effectiveness, performance, respect toward recipients, timeliness, stability, and facilities. It investigated the effects of parameters, such as age, gender, and education, on the study factors.
The mean satisfaction score of the service recipients in the present study was obtained as 3.58 ± 0.66 (range: 1 to 5). The mean satisfaction score in Ahmadi Kashkoli et al.’s study on 500 patients from 3 hospitals of Tehran using a standard 32-query questionnaire was obtained as 3.54 ± 0.97 (range: 1 to 5). Although the study design and applied tools for these 2 studies are different, the results of the latter study are consistent with results of the present study (23).
The mean score for accessibility was higher than average, as 77% of the patients were satisfied with accessibility. Therefore, accessibility to the family physician services is relatively high. Although the cultural accessibility was high for the present study, it seems to lack potency from the geographical perspective as 22.8% of the individuals resided in regions without health centers.
The mean score for respect towards the service recipients was also higher than average with 77% of the patients satisfied with the services provided. Therefore, respect for patient rights was also high in the present study, which was consistent with the results of a study conducted in the Ajab Shir region (24).
In the present study, 74% of the subjects were satisfied with the stability of services. This index is one of the most significant factors for evaluating patient satisfaction with the services, whose substantiation requires coordination between the service providers and various health sectors in order to provide continuous services. In a study in America, the stability of services was reported at a high-level of importance, where the mean score for satisfaction with stability was higher than average. This result was consistent with those obtained by another study (29) for the American population, Ali Babayi for the population of Ajab Shir (24), and Shabani for the population of Ardabil (30).
The mean score of satisfaction with facilities was not significantly different from the average value, and only half of the recipients were satisfied with the service facilities. Thus, it can be concluded that the family physician program has been performed on a mediocre level with regards to facilities for services.
The mean score for satisfaction with the effectiveness of services was also not significantly different from the average score, concluding in a mediocre performance with regards to the service effectiveness on the part of the family physician program.
Performance is another important factor in evaluating different health programs. The results of a study on the Mexican population indicated that the occupational satisfaction of family physicians and the quality and performance of services are closely related (31). A study from England showed that satisfaction with accessibility, performance, effectiveness, stability, time spent during consultation, timeliness, and patient-doctor relations were related (32). Considering that the mean score for satisfaction with performance in the present study was higher than average, it can be concluded that the performance was at a relatively high level (24).
The results of the present study showed that gender, age, and residency in rural regions with health centers had significant effects on patient satisfaction.
The mean satisfaction score among females was significantly higher than males, which is consistent with the results of Alibabaei et al. (24) for the population of Ajab Shir, and Maharlouei et al. (33) for the population of Shiraz. However, this result is not consistent with those obtained by Khosravi et al. in Bardesir (34), Ebrahimpoor et al. in Bardeskan (35), Ghorbani in Sabzevar (36), and Khadivi et al. in Isfahan (37).
In this study, the seniors scored higher with regards to overall satisfaction. This finding is consistent with the results of Ghorbani for the population of Shiraz (38). Bagheri et al. (39) showed in their study of the population of Mazandaran that an increase in age resulted in an increase in satisfaction. Honarvar (40) showed in a study on the population of Shiraz that individuals older than 51 were more satisfied with the family physician program. Wetmore et al. (41) and Baettig et al. (42) showed that older individuals were more satisfied with health services. The present study showed a direct and significant relationship between satisfaction with respect to patients on the part of the family physician and the patient age. Lower satisfaction among the younger individuals may be due to their higher level of education, which results in higher awareness and, consequently, higher expectations. On the other hand, older individuals expect less, are more flexible, and communicate better with family physicians compared to younger individuals (43).
The overall mean satisfaction score was higher than average, placing the family physician services at a relatively high level.
According to the service recipients, the mean satisfaction score for the service facilities in regions with health centers was significantly higher. It is evident that the accessibility and vicinity to regions with health centers increase patient satisfaction.
The limitations of the present study include lack of time spent on filling the questionnaires on the part of the patients, which resulted in unreliable or rather unrealistic answers. On the other hand, the patient satisfaction with services was significantly related to the patient’s awareness of his/her own rights. Owing to this fact, individuals lacked the ability to judge realistically, which is why many studies on patient satisfaction reporting a high level of satisfaction included many cases where patients’ needs were not actually satisfied. Also, different studies used different tools with various variables for assessing patient satisfaction. Thus, a direct comparison of results was not possible.
4.1. Conclusion
According to the study results, the service recipients were generally satisfied with the family physician program. However, the program is lacking in cases of service facilities and service effectiveness. Therefore, the program requires improvement. It is recommended that more in-depth research be performed on various factors affecting patient satisfaction with the family physician services using qualitative methods and in-depth interviews with physicians, health boards, and referrals. It is also recommended that various agents and health authorities make further efforts to improve the facilities and effectiveness of the services provided by the family physician program in order to increase patient satisfaction.
