1. Background
According to the world tourism organization (WTO), the total number of world tourists in 1950 amounted to approximately 25 million and in 2000 to 700 million. In 2006 and 2007, it reached 842 and 905 million tourists, respectively. Among the above-mentioned tourists, 51% were from Europe, 22 % from Asia and Oceania, 20% from America, 3% from Africa, and 4 % from the Middle East (1). Health and medical globalization have formed a new form of tourism termed health tourism. Health tourism includes medical tourism, wellness tourism, and treatment tourism (2). It is one of the sectors experiencing the highest growth; as a result there are many countries legally and practically planning to obtain the highest share of the market (3, 4). This sector in tourism has a big share in the world economy. Nowadays, health tourism enjoys an annual income of approximately $60 billion. Up to 2012, more than 4.4 billion of this income was spent in countries such as Malaysia, Thailand, Singapore, and India. Health tourism in India reached $2 billion in 2012 and Singapore attracted one million medical tourists annually, therefore increasing its GDP to more than $1.6 billion. Malaysia hopes to increase its market share in a five-year period to approximately $590. Health tourism in Thailand and South Korea earned more than 4 billion up to 2012 (5-9).
Regarding unique touristic attractions of Lorestan province like natural sceneries and historical sites, it has immense potential in the attraction of tourists, creating jobs, and making money for its local people. In this regard, special focus on health and medical tourism is of great importance. Turning the very important and strategic matter into reality would be impossible unless there is long-term planning under the supervision of provincial Medical University as well as co-operation coming from involved sectors such as cultural heritage, handicrafts, tourism organizations, and other relevant organizations. In health tourism, the patients and their family’s perspectives towards quality of provided services in hospital centers, including quality of clinical and welfare services, plays a major role in the promotion of this important and money-making industry (10). As a result, the current study was carried out to investigate the perspective of tourists (people who traveled on holiday to Lorestan province to receive medical care) regarding services provided at the hospitals of Lorestan University of Medical Sciences.
2. Methods
A qualitative case study method was applied in this research. There was an open-ended questionnaire and it was asked from the respondents to provide comments, suggestions or necessary criticism about quality of services. The answers to the question from 600 questionnaires distributed among 12 hospitals in Lorestan province were extracted and analyzed. All the participants were chosen of non-indigenous patients that were referred to receive medical care of hospitals in Lorestan province during the New Year holiday. Data were collected during the Norouz vacation (21st of March to 1st of April, 2015). The researcher himself attended the hospitals and observed and examined the patient’s conditions personally. This qualitative study was conducted using content analysis approach to explore factors affecting tourists’ satisfaction of services provided in hospitals of Lorestan province. The analyzed texts were re-analyzed several times, breaking down each text, the contents or themes as the smallest meaningful units were extracted, coded, and categorized. In some cases, participants quotations, related to each of the major and minor themes, were recorded. Extraction of the themes and sub-themes and categorization was done by 2 independent researchers and in problematic and confusing cases; the case was resolved using a third party researcher. In order to increase the rigor of the study, the triangulation method was also implemented. It was used at various times, places (different hospitals), and for different participants (patients and their families). In order to fill the gap between what respondents meant and what the researchers understood, respondent validation and member check was used. The researcher used second reference to participants and reuse of their corrective ideas in order to check data credibility and acceptability. The samples were chosen from various social economical classes with different educational levels and different groups to evaluate the transferability of data. For ethical considerations, the researcher first introduced himself to the participants and provided an explanation of the study and its aims, then asked them to answer the questionnaire and fill the consent form. An assurance of the confidentiality of the information was given. The participants had the choice of attending or leaving the study at any time.
3. Results
3.1. Characteristics of the Participants
A total of 600 patients were studied, 326 (54.4%) males and 274 (45.6%) females. Overall, 15.8% were single, 81.7% were married and 2.5% of the participants had other conditions. Furthermore, 56% of the patients were referred to hospitals of Lorestan province for the first time, and 38.9% of the participants had a level of education lower than high school diploma, and the lowest frequency was for those with a PhD degree (1 person). In the hospitalization ward, most patients were in the pediatric department of the hospital with a percentage of 20.8% and the lowest number was 3 people from the maternity ward. The results of other demographic characteristics are shown in Table 1.
Table 1.Demographic Characteristics of the Studied Samples
| Variable | Percentage | Frequency | |
|---|---|---|---|
| Gender | Male | 54/4 | 326 |
| Female | 45/6 | 274 | |
| Admission times | First time | 56 | 336 |
| 2 to 3 times | 44 | 264 | |
| Marital status | Single | 15/8 | 95 |
| Married | 81/7 | 490 | |
| Othersa | 2/5 | 15 | |
| Schooling level | Less than high school diploma | 38/9 | 233 |
| Diploma | 25/5 | 153 | |
| Associate degree | 12/8 | 77 | |
| BS | 18/4 | 110 | |
| MA | 4/3 | 26 | |
| Ph.D. | 0/1 | 1 | |
| Hospitalization ward | Female internal ward | 8/6 | 52 |
| Female Surgery | 11/5 | 69 | |
| Male internal ward | 14/5 | 87 | |
| Male surgery | 8 | 48 | |
| Pediatricb | 20/8 | 125 | |
| Maternity | 0/5 | 3 | |
| Dialysis | 4/1 | 25 | |
| Emergency | 13/6 | 81 | |
| ICU | 7/9 | 47 | |
| CCU | 10/5 | 63 |
aPeople who are divorced or widowed.
bIn pediatric ward, questions were answered by accompanied (Child Parent).
3.2. Hospital Problems in a Tourists’ View
The results showed that the hospitals main problems in the Losartan province from a tourists’ point of view was in nine main themes and 26 sub-themes. The major findings of the study indicate various problems at different levels. The main themes included personnel and equipment, responsiveness, abilities of medical staff, availability of medical staff, issues related to the welfare status, public hygiene, the overall condition of the hospital wards, admission, discharge and patient appointments, and managerial issues. Some of the problems and quotes raised by the participants are mentioned. The number of resident physicians in the hospitals of the province was not enough, one of the participants had expressed that “There was no children specialist during holidays. When there are no heart specialists, internal specialists do their functions”. One of the respondents complained of inappropriate responsiveness to patients and their family and expressed that “physicians and nurses behaved very badly with patients. They did not respect patient’s personality”. Another respondent was displeased of the sanitation status of the section room. “Rooms are full of flies and mosquitos; we even saw cockroaches here”.
“Service crew rarely comes for cleaning, and when they come, clean hastily and leave as soon as possible. They sort of pretend that they are doing their duty”.
The problems mentioned by the respondents were delays and lack of coordination on admission; lack of qualified personnel in hospital management posts. “At the time of admission, there was too much paperwork. The patient was bothered up to death”. “University Managers should come and check the condition. It is for 4 days we have brought a child, who had an accident; he has not been operated yet”. Table 2 indicates major problems (main themes, sub-themes and quotations) extracted from the participants’ viewpoints in the hospitals under the supervision of Lorestan University of Medical Sciences.
Table 2.Major Problems in Hospitals from the Viewpoints of Tourists
| No. | Theme | Sub-Theme | Quotations |
|---|---|---|---|
| 1 | Personnel and equipment | Shortage of experienced physicians | “There are a few experienced physicians. General physicians visit the patients instead.” |
| Shortage of nurses | “There is no children specialist during holidays. When there are no heart specialists, internal specialists do their functions.” | ||
| Shortage of diagnostic equipment | “No MRI facilities, we have to go to another city for MRI. Sonography unit is closed on holidays.” | ||
| “Most of the medical equipment are old and worn out.” | |||
| 2 | Responsiveness | Inappropriate responsiveness to patients and their family | “Physicians and nurses behave very badly with patients. They do not respect patient’s personality”. |
| “Patients’ family is not allowed to stay with the patient, if so, there is no suitable room for staying”. | |||
| Violation of patient privacy | “You need go to the nursing station so many times for some small thing to be done, at the end, it is done frowningly”. | ||
| Patients in emergency conditions are not taken care by medical staff rapidly. | |||
| “Hospital Guardian behaves very badly with patients and their relatives”. | |||
| Shared WC (Toilet) for ,males and females, causing discomfort to patients and their relatives | |||
| 3 | Abilities of medical staff | Inadequate skills of physicians, nurses and para-meds | “There is no good specialist here” |
| “They do not have the simple skill of an injection, nursing assistants are better at injecting than nurses”. | |||
| “Most of the physicians are in-experienced, it is as if the patients are lab cases and physicians are here to learn” | |||
| 4 | Availability of medical staff | Inaccessibility on urgency situations | “They are sometimes not in their workplace. After patient's death, they will be available”. |
| Delay in delivering medical services | “Sometimes serum finishes, but there is no one to drag it”. | ||
| Absence from workplace on work hours | “Specialized physicians do not visit; you have to go to their office”. | ||
| 5 | Issues related to the welfare status | Lack of a perfect place to attendant patients resting Unsuitability of patient's room | “No facilities for the patient’s attendants, no room to lie down for an hour”. |
| Shortage of places to play and entertain children | “In this hospital there are no facilities for kids entertainment”. | ||
| The inappropriate nutritional status of patients | |||
| Inappropriateness of prayer room | Hospital food is very bad. A healthy person cannot eat it, let alone an ill one”. | ||
| Lack of Basic facilities such as refrigerator, TV in the patient room | “We bring blankets to the hospital ourselves; and sleep on the floor, no facilities are provided by the hospital”. | ||
| Inadequacy of parking space | |||
| 6 | Public hygiene | Insects in hospital wards | “Rooms are full of flies and mosquitos; we even saw cockroaches here”. |
| Sanitation status of the section room was inappropriate | “Service crew rarely comes for cleaning, and when they come, they clean hastily and leave as soon as possible. They pretend to do their duty”. | ||
| Being dirty of bed linen and beds | “Waste baskets are not emptied on time”. | ||
| 7 | The overall condition of the hospital wards | Emergency, ICU, pharmacy, dialysis, maternity wards | “Clinical ward (dialysis, ICU, maternity and etc.) amenities are very limited and sometimes closed”. |
| “Response time is long at the emergency department”. | |||
| “Receiving medicine from the pharmacy takes too long; Even more than an hour”. | |||
| 8 | Admission, discharge and Patient appointments | The major problems at the time of initial reception, preparing documents | “Queuing system is very weak”. |
| Problems on meeting time and place | “At the time of admission, there was too much paperwork. The patient was bothered up to death”. | ||
| Delays and lack of coordination on discharge | “There was no exact time for meeting”. | ||
| “Men are present in women and children’s units for long periods, which make women really annoyed”. | |||
| 9 | Managerial issues | Lack of monitoring and inspection by managers | “To who should we offer suggestions, nobody cares”. |
| Lack of accountability of managers | “Nobody cares and we have filled so many of these questionnaires (suggestions and recommendations)”. | ||
| Managers’ lack of full time presence at the workplace | “There are so many problems that even I do not have the patience to list”. | ||
| Lack of qualified personnel in hospital managerial posts | “There are no signposts in the hospital; you are easily lost”. | ||
| University Managers should come and check the condition. It is for 4 days we have brought a child, who had an accident; he has not been operated yet”. |
4. Discussion
There are fundamental problems in all aspects of the province’s hospitals that include infrastructure problems, management, equipment, and manpower that have been causing dissatisfaction for medical tourists. Several factors effect recipients’ satisfaction of services and their change is dependent on the service provider. The most important factors include behavior, warmth and proximity of communication, understanding and acceptance of the patient’s needs and expectations by service providers, and meeting the needs of service recipients (11).
The results of this study showed that there were 10 determinants of global patient satisfaction. Thereby, both medical and service elements of the hospital were important dimensions. The outcome of treatment was overall the most salient predictor of global patient satisfaction followed by nursing and physicians’ kindness (12).
Because of its qualitative aspect, the present study has claimed many tangible problems encountered by attending health services’ seekers. As indicated here, many of the problems could easily be resolved by appropriate management interventions and without imposing any extra expenses. Some other problems could be resolved with little cost and few of the problems need some costly and time consuming interventions.
Managers’ awareness of the problems experienced by patients in the hospitals is a very good tool in order to solve these problems. Problems, such as lack of appropriate response from personnel, availability of personnel, improper conditions in general sanitation, lack of discipline and order, problems in reception, meeting and leaving, and management problems are among problems, almost all of which can be resolved without any expenses.
Such problems are solvable within an organization using small organizational and administrative changes such as management practices, proper planning or changes in practices and procedures. The second type are the kind of problems, which require low expenses, including improper conditions in the units and in-experienced medical staff; these could be overcome by little intervention practices in training the staff. A small group of problems require larger expenses. These problems are shortage in personnel and equipment, the removal of which is out of the control of hospital managers; therefore they require planning in upper managerial levels.
Some studies have been done to assess satisfaction in the health and medical system. Sahebzadeh et al. in a descriptive cross-sectional study tried to evaluate the satisfaction level of elderly patients admitted to public hospitals affiliated to Isfahan University of Medical Sciences. The researchers of the study claimed that the average satisfaction score in the communication dimension was lower in comparison to the financial dimension, professional quality, and interpersonal behavior (13), which better matches with the results of the current study. The reason is that one of the major problems quoted by dissatisfied patients was that of improper personnel responding to the patients and their companions, which mostly relates to the manners in communication. From quoted dissatisfactions, the highest rate belonged to the nursing crew. Apart from nurses, there are physicians and security guards’ misbehavior. In another study, Mortazavi et al. studied patients’ satisfaction level about services and cares provided before and after operation in Babol’s educational hospitals. The results of the study showed that the overall satisfaction from nursing services before and after the operation was at an acceptable level (14), which is in contrast with the results gained from the current study. The difference could be linked to the methods by which the studies are carried out, since Mortazavi’s study had a cross-sectional descriptive design using a questionnaire, however, the latter was done using qualitative content analysis and the problems were deeply examined and extracted. The results showed that one of the major problems was medical staff’s improper behavior, especially nurses in hospitals.
Jalali et al. evaluated the satisfaction level of patients admitted to the teaching hospitals of Kermanshah. The results of this cross-sectional study showed that overall satisfaction with respect to patients’ rights was at an average level (15). The results of the current study showed that there are major dissatisfactions in this regard in the hospitals, some of which are ignorance of privacy rights of patients and unsuitable behavior with patients and their companions. It is however interesting to know that such problems could easily be solved by various programs, such as training the health sector staff, and increasing their commitment in this regard. Nemati et al, in a study entitled “evaluation of patient satisfaction level of care services in teaching hospitals” expressed that the highest level of satisfaction was towards needs’ provision of the patients and the lowest to the satisfaction rate with accessibility of health care staff when needed (16). The results of this study were mostly in line with the results of the current study, because inaccessibility of health care staff was also mentioned in this study as a major issue. The inaccessibility includes lack of access on urgency, delay in provision of services, and absence from workplace during work hours (6, 17).
Concerning the fact that the attitude of service recipients, including patients and their families, about quality of provided services in medical tourism is of great importance in the promotion and development of this money-making sector, awareness about service recipients’ ideas is also an important and vital matter and decision-making without awareness of problems would be a futile effort. It is certain that considering problems quoted by patients and their families could have major effects on satisfaction level and as a result good outcomes from services as well as introduction of the best service providers among other providers (18). Gaining the attention of medical tourists could lead to financial resources (7) and empower economic benefits at the provincial level coupled with related job creation, all of which cause an increased level of social welfare and enhanced social satisfaction. Of course, planning is one of the most important and basic activities for the elimination of existing problems to attract medical tourists (19).
4.1. Conclusion
In conclusion, using inferences coming from patients’ points of view, it could be concluded that there are a large number of problems in the current hospital system, however, these problems could be corrected and resolved using accurate and suitable planning, which can in its turn result in increased satisfaction level in service recipients. It is hoped for authorities to pay greater attention to more important studies and try to solve problems and prevent such problems in the future by a comprehensive and faultless planning. It is because customer satisfaction is directly related to the quality of services and it is a continuous and consistent issue, which should be under the focus of attention at all times.
