Patient satisfaction in Kazakhstan

Patient satisfaction in Kazakhstan: Looking through the prism of patient healthcare experience

Ilya Seleznev, Raushan Alibekova, Alessandra Clementi*

NazarbayevUniversitySchoolofMedicine,Nursultan,Kazakhstan

ARTICLE INFO

Articlehistory:

Received20September2019 Receivedinrevisedform2May2020 Accepted4May2020

Keywords:

Patientsatisfaction Qualityofhealthcare Deliveryofhealthcare Patientacceptanceofhealthcare Qualitymeasurements Surveys

ABSTRACT

Objectives: This study aimed to explore therelationship between patient satisfaction and patient experienceafterexposuretoinpatienthospitalization.

Methods:Across-sectionalself-completedsurveyatthebedsideintheInpatientdepartmentsofthe UniversityMedicalCenterhospitals(UMC)inNur-Sultancity,Kazakhstanwassubmitted.Atotalof153 patientscompletedthesurveyfromSeptember2017toJune2018.ThesurveyusedthePickerPatient ExperiencequestionnairevalidatedinRussianandKazakhlanguages.

Results:Themajorityofpatientsweresatisfiedwiththeirhospitalstay(90.8%).Onlyself-ratedhealth status was associated with overall satisfaction (OR 1.922, 95 % CI 1.09 3.37). Patient experience assessmentrevealedanassociationofphysicalcomfortandrespectforpatientpreferenceswithoverall satisfaction(OR0.101,95%CI0.01 0.91andOR0.317,95%CI0.11 0.92).

Conclusions:Study findingssupportthatpatientsatisfactionis anexaggeratedimage ofhealthcare performance.Groupswithnegativeexperiencehaveshownloweroverallsatisfactioninthedimensions

‘physicalcomfort’and‘respectforpatientpreferences’.

Practiceimplications:Improvingpatientcenteredcommunicationandpaincontrolinclinicalpractice mayleadtotheimprovementinpatientsatisfaction.

©2020TheAuthor(s).PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1.Introduction

HealthcareinKazakhstanhasbeenundergoingactivereforms toachieveinternationalstandardsinhealthcaresincethecountry’s independence.Recentpublicationshighlightedthatbothpatient experienceandpatientsatisfactionareintegralcomponentsofa high-qualityhealthsystemframeworkandtargetforimprovement inthetransitiontohigh-qualityhealthsystemsinlow-incomeand middle-incomecountries[1].

Although patient satisfaction and patient experience are distinct entities, they showed to have variable degrees of association in different hospital systems and hospital settings whenmeasuredobjectively[2–5].

Previous studies demonstrated that patients are generally satisfiedwithcare[6].Somestudiesshowedassociationsbetween patient satisfaction and patient characteristics: age, ethnicity, spokenlanguage,levelofeducation,healthstatus[5,7–11].Other studies demonstrated associations of specific aspects of care extrapolatedfrompatientexperience[2,4,5,9].

Manytools weredevelopedand appliedat thenationaland cross-nationlevelsforvariablehospitalsettingsthatcapturethe patientexperienceandpatientsatisfaction[12].Todate,assess- mentof patient-centeredcarein Kazakhstansubstantiallylacks dataandcontainsveryfewpublishedreportsonthequalityofcare in Kazakhstan. No literature specifically targets measure of experience in inpatient care through standardized valid and reliablemethods.

Inthisstudy,weadopteda15-itemPickerPatientExperience QuestionnairedevelopedbyPickerInstituteEurope[13]tofitthe bilingual setting of the local population. This study aimed to investigatetheassociationofoverallpatientsatisfactionincluding sociodemographiccharacteristics and patient experiencein the hospitalsetting. Addressing patientsatisfactionthrough patient experience would set the direction for patient-centered care.

Experience surveys on their own have not shown to improve experiencedirectly,but ratherprovideareasof focustopursue improvementsthroughcampaigns,incentives,andpenalties[14].

2.Methods

Thedatawascollectedfromtheinpatientdepartmentsofthe UniversityMedicalCenter(UMC)tertiarycarehospitalnetworkin Nur-Sultan, former Astana, after approval from the ethics

*Correspondingauthorat:NazarbayevUniversitySchoolofMedicine,NUSOM Building,KereyZhanibekKhansstreet5/1,Nursultan,010000,Kazakhstan.

E-mailaddress:alessandra.clementi@nu.edu.kz(A.Clementi).

https://doi.org/10.1016/j.pec.2020.05.004

0738-3991/©2020TheAuthor(s).PublishedbyElsevierB.V.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/

4.0/).

ContentslistsavailableatScienceDirect

Patient Education and Counseling

j o u r n al h o m e p a g e : w w w . el s e v i e r . c o m / l o c a t e / p a t ed u c o u

committeesofNazarbayevUniversityandUMC.Theaimsofthe study were explained to each participant and oral informed consentwasobtained.Patientswererecruitedbyasingleresearch assistantfromtheinpatientwardsonthedayofdischargeinthe period September 2017 - June 2018 on a consecutive basis.

Participantswerelegallycompetentadults (18yearsand older) and citizens and permanent residents of thecountry. All were preparingfordischargeonthedayofrecruitment,afterplanned hospitalizationorhavingreceivedemergencycare.

Exclusioncriteriawerepatientswhohadundergonepalliative or intensivecare and anyonewithindicatorsof altered mental status.Theabovecriteriawerefollowedthroughdischargereview with ward staff responsible for a discharge procedure. During surveyadministration,subjectswereallowedtimetorespondand returned the self-completed survey. No identifiable data was collectedfromthepatients.

The survey includedtwenty-five questions, fifteen of which wereadoptedfromthePickerPatientExperience Questionnaire (PPE-15)andninequestionsforsociodemographiccharacteristics [13].Eachquestioncorrespondstooneofthesevendimensionsof patienthospitalexperienceincluding:

1)Informationandeducation(Question1–2) 2)Coordinationofcare(Q3)

3)Physicalcomfort(Q10) 4)Emotionalsupport(Q4 8-9)

5)Respectforpatientpreferences(Q5 6-7) 6)Involvementoffamilyandfriends(Q11–12) 7)Continuityandtransition(Q13 14-15)

The fifteen questions from PPE-15 were translated and culturallyadaptedinamultistepprocessfollowingtheguidelines for thecross-culturaladaptationofself-reportmeasures[15]. A pre-test of 23 patientswas performed for comprehension and question understanding. Internal consistency reliability in the presentstudywashigh,Chronbach’sα=0.714and0.701inRussian andKazakhlanguages,respectively.

Demographic data included questions aboutage, education, nationality, spoken language, residency, hospital stay funding, lengthofhospitalstayandself-ratedhealthstatus.

Overallpatientsatisfactionwasevaluatedonafive-pointscale ranging from “not at all satisfied” to “very satisfied”. We dichotomized the outcome variable by distinguishing patients whowere“verysatisfied”fromthose“lesssatisfied”[16].

Questions from the PPE-15 were coded as dichotomous variablesidentifyingthepresenceorabsenceofnegativeexperi- enceinsevendimensions.Bivariateanalysisofsociodemographic factors,patientexperienceandoverallsatisfactionasadependent

Table1

DistributionofdemographiccharacteristicsofpatientsbysatisfactionlevelwithhealthservicesattheUniversityMedicalCenterhospitalsinAstana/Nursultan(n=153).

Patient-specificcharacteristic Totaln^a(%) NotSatisfiedn(%) Satisfiedn(%) p-value

Age 0.843

25 4(2.8) 2(50.0) 2(50.0)

26 35 17(12.0) 9(52.9) 8(47.1)

36 45 23(16.2) 11(50.0) 11(50.0)

46 55 25(17.6) 11(45.8) 13(54.2)

56 65 44(31.0) 17(43.6) 22(56.4)

>65 29(20.4) 10(34.5) 19(65.5)

Gender 0.895

Female 102(67.1) 42(43.8) 54(56.2)

Male 50(32.9) 22(44.9) 27(55.1)

Educationallevel 0.304

Incompletegeneral 3(2.0) 1(33.3) 2(66.7)

Generaleducation 35(23.0) 18(52.9) 16(47.1)

Specializedsecondary 54(35.5) 18(34.6) 34(65.4)

Undergraduateandhigher 60(39.5) 27(48.2) 29(51.8)

Ethnicity 0.154

Kazakh 100(65.8) 41(44.1) 52(55.9)

Russian 41(27.0) 21(51.2) 20(48.8)

Other 11(7.2) 2(18.2) 9(81.8)

Spokenlanguage 0.760

Russian 57(37.3) 23(40.3) 34(59.7)

Kazakh 28(18.3) 12(46.2) 14(53.8)

BothRussianandKazakh 67(44.1) 29(46.8) 33(53.2)

Funding 0.321

Governmentalquota 143(94.7) 60(44.1) 76(55.9)

Insurance 3(2.0) 0(0.0) 3(100.0)

Self-funded 5(3.3) 3(60.0) 2(40.0)

Lengthofstay 0.350

1weeks 96(63.2) 44(48.9) 46(51.1)

2weeks 52(34.2) 19(36.5) 33(63.5)

1month 4(2.6) 1(33.3) 2(66.7)

Region 0.247

Astanaandvicinity 80(52.6) 37(48.7) 39(51.3)

Otherregions 72(47.4) 27(39.1) 42(60.9)

Healthstatus 0.036*

Verypoor 1(0.7) 1(100.0) 0(0.0)

Poor 1(0.7) 1(100.0) 0(0.0)

Fair 47(31.3) 24(53.3) 21(46.7)

Good 61(40.7) 28(49.1) 29(50.9)

Verygood 25(16.7) 6(24.0) 19(76.0)

Excellent 15(10.0) 4(26.7) 11(73.7)

bChi-squaredtestorFisherexacttest.

aTotalcountsmayvarybecauseofmissingvalues.

* Statisticallysignificantatp<0.05level.

variablewasperformedusingChi-squaretestandFisher’sexact test.Multivariablelogisticregressionanalysiswasconductedusing overallsatisfactionasadependentvariable.Likelihood-rationtest wasappliedtotestthegoodnessoffitofthefinalmodel.Analyses wereperformedinSPSSV.23.0.

3.Results

A total of 153 patients returned the questionnaire with an overallresponse rate of 83 %.Among those 80.4 % (n=123)of respondentshave completed thequestionnaires in theRussian language,and19.6%(n=30)intheKazakhlanguage.Themajority

ofparticipantswereverysatisfied(56.2%,n=82)orsatisfied(34.3

%,n=50)withtheprovidedservices.

The sociodemographic characteristics of participants are summarized in Table 1. The mean age of participants was 53 years (SD 13.8) predominantly females 67.1 % (n=102). Most respondentswereeducatedhavinga‘generaleducationleveland above’comprising98%(n=149),the44.1%ofparticipants(n=67) were bilingual. Ethnical distribution in collected sample was Kazakh 65.8 % (n=100), Russian 27.0 % (n=41) and other ethnicities 7.2 % (n=11). No significant difference in overall satisfactionwasfoundamongdifferentagegroupsandbasedon gender,levelofeducation,spokenlanguage,funding,lengthofstay Table2

Relationshipbetweensatisfactionlevelandpatientexperiencerepresentedasdichotomousvariable^a.

Question Notsatisfied^b% Satisfied% p-value

1 Doctors’answerstoquestionsnotclear 0.077

No 55(41.3) 78(58.7)

Yes 9(69.2) 4(30.8)

2 Nurses’answerstoquestionsnotclear 0.460

No 57(43.2) 75(56.8)

Yes 7(53.8) 6(46.2)

3 Staffgaveconflictinginformation 0.045*

No 54(42.2) 77(58.8)

Yes 10(71.4) 4(28.6)

4 Doctordidn’tdiscussanxietiesorfears 0.027*

No 45(39.1) 70(60.9)

Yes 19(61.3) 12(38.7)

5 DoctorssometimestalkedasifIwasn’tthere 0.240

No 57(42.5) 77(57.5)

Yes 5(71.4) 2(28.6)

6 Notsufficientlyinvolvedindecisionsabouttreatmentandcare 0.029*

No 13(30.2) 30(69.8)

Yes 49(50.0) 49(50.0)

7 Notalwaystreatedwithrespectanddignity 0.079

No 56(41.8) 78(58.2)

Yes 6(75.0) 2(25.0)

8 Nursesdidn’tdiscussanxietiesandfears 0.366

No 34(48.5) 50(59.5)

Yes 27(48.2) 29(51.8)

9 Noteasytofindsomeonetotalktoaboutconcerns 0.005*

No 32(35.2) 59(64.8)

Yes 31(59.6) 21(40.4)

10 Staffdidnotdoenoughtocontrolpain 0.005*

No 35(39.8) 53(60.2)

Yes 9(90.0) 1(10.0)

11 Familydidn’tgetopportunitytotalktodoctor 0.004*

No 48(38.4) 77(61.6)

Yes 13(76.5) 4(23.5)

12 Familynotgiveninformationneededtohelprecovery <0.001*

No 43(35.8) 77(64.2)

Yes 19(79.2) 5(20.8)

13 Purposeofmedicinesnotexplained 0.042*

No 54(40.3) 80(59.7)

Yes 6(85.7) 1(14.3)

14 Nottoldaboutmedicationsideeffects 0.036*

No 36(37.9) 59(62.1)

Yes 24(57.1) 18(42.9)

15 Nottoldaboutdangersignalstolookforathome 0.097

No 38(38.4) 61(61.6)

Yes 22(53.7) 19(4.3)

a“No”responsesuggestabsenceofaproblem,“Yes”responsesuggestpresenceofaproblem.

b Chi-squaredtestorFisherexacttest.*Statisticallysignificantatp<0.05level.

Table3

Multivariablelogisticregressionmodelofassociationsbetweenpatientsatisfactionandindependentvariables.

Variable AdjustedOddsRatio 95%ConfidenceInterval p-value

Healthstatus 1.922 (1.09 3.37) 0.023*

Notsufficientlyinvolvedindecisionsabouttreatmentandcare 0.317 (0.11 0.92) 0.036*

Staffdidnotdoenoughtocontrolpain 0.101 (0.01 0.91) 0.041*

Familydidn’tgetopportunitytotalktodoctor 0.233 (0.05 1.01) 0.052

*Statisticallysignificantatp<0.05level.

orgeographicalregion.Themajorityofthepatientsreportedself- ratedhealthstatusas“good”andabove67.4%(n=101).Patients withbetterself-reportedhealthstatushaveshownsignificantly higheroverallsatisfaction(p=0.036).

Lowerlevelsofoverallsatisfactionwereidentifiedinsixoutof seven dimensions among patients with negative experiences (Table2).Statisticallysignificantdimensionswerecoordinationof care(p=0.045),physicalcomfort (p=0.005),emotional support (p=0.027 and p=0.005), respect for patient preferences (p=0.029), involvement of family and friends (p=0.001 and p<0.001),continuityandtransition(p=0.042andp=0.036).

Finally,multivariablelogistic regression(Table3)hasshown thatself-ratedhealthstatuswasassociatedwithoverallsatisfac- tion.Moreover,oneunitincreaseinself-ratedhealthstatuswas showntoincreasetheoddsofbeingsatisfiedby92.2%(OR1.922, 95 % CI 1.09 3.37). Physical comfort and respect for patient preferences were also associated with the overall experience.

Wherenegative experience in these dimensions decreased the oddsof beingsatisfiedby 89.9%and 68.3%(OR 0.101, 95%CI 0.01 0.91andOR0.317,95%CI0.11 0.92).

4.Discussionandconclusion 4.1.Discussion

Thisisthefirststudytoassesstherelationshipbetweenpatient experience and overall satisfaction of hospitalized patients in Kazakhstan. Study results agree with previous research that satisfactionisgenerallyhigh[2,6].

Previousreportssuggestedthatageisanimportantpredictorof overallpatientsatisfaction[2,17].Inourstudy,ageacrossdifferent groups did not reveal significant difference in overall patient satisfaction according to studies from Sweden and HongKong [3,5]. Incontrasttoourfindings, theSwedishstudyhighlighted thatforeignlanguage,femalegender,andhighereducationwere factorsassociatedwithlowersatisfaction,butbetterhealthstatus havedemonstratedhigheroverallpatientsatisfaction.

Our findings agree with earlier reports suggesting that relatively low rates of negative experience lead to lower satisfaction [2]. Physical comfort appears to be one of two dimensionsassociated withsatisfaction. It isworth notingthat most patients (n=101) experienced pain during hospital stay, approximatelytenpercentreportedpoorpain control(datanot shown). The presence of pain at the discharge leads to lower patient satisfaction. Similar findings weredemonstrated in the outpatient setting, where poor symptomatic control leads to decreasedsatisfaction[18].

This study emphasized the importance of patient decision making, time spent at discharge, and options given for post- hospital care. Lack of respect for patient preferences was the second dimension less likely to result in overall satisfaction.

SimilarfindingsweredemonstratedinHongKong,usingthesame measurementscale,whererespectforpatientpreferenceswasa predictorofpatientsatisfaction[5].Physicalcomfortandpatient preferences are integral parts of patient-centered care, where activecollaborationbetweenpatientandcareprovidershouldbe established.OnereportfromAstana,Kazakhstansuggestedthat patient’sperceptionofhealthcareisheavilydoctor-oriented.The samereportshowed highersatisfactionwithcommunicationin patientswhovaluedapatient-orientedapproach[19].Ourfindings highlighttheneedofapatient-centeredapproachtopatientcare andeffectivedoctor-patientcommunication.

Several limitations were present during the study. A cross- sectional study design limited the establishment of a causal relationship.Besidesstudydesign,thesamplesizewasrelatively small. This study has limited generalizability. Patients were

recruited from a singlehospital complex. Unlikecity hospitals, UMCisatertiarydegreehospitalnetwork.

4.2.Conclusion

Our evidence suggests that patient satisfaction presents an optimistic picture, and one that is impacted upon by multiple factors.

Theresultsofourstudyshowedthatoverallpatientsatisfaction is associated with health status, physical comfort and patient preferences.

4.3.Practiceimplication

Areasidentifiedthroughpatientexperiencemaybetargetedto achieve improvementinthedeliveryofhealthcareina patient- centeredmanner.Specialfocusinfuturestudiesshouldbeputon theimprovementofpatient-centeredcommunicationandpatient comfort.

CRediTauthorshipcontributionstatement

Ilya Seleznev: Formal analysis, Methodology, Investigation, Writing - original draft. Raushan Alibekova: Investigation, Supervision, Methodology,Formal analysis, Writing - review &

editing. AlessandraClementi: Conceptualization, Methodology, Supervision,Writing-review&editing,Projectadministration.

References

[1]M.E.Kruk,A.D.Gage,C.Arsenault,K.Jordan,H.H.Leslie,S.Roder-DeWan,etal., High-qualityhealthsystemsinthesustainabledevelopmentgoalsera:time forarevolution,LancetGlob.Health6(2018)1196–1252.

[2]C.Jenkinson,Patients’experiencesandsatisfactionwithhealthcare:resultsof aquestionnairestudyofspecificaspectsofcare,Qual.Saf.HealthCare11 (2002)335–339.

[3]Ely Wong, Mcm Leung, AwlCheung, Chk Yam, Ek Yeoh, S.Griffiths,A population-basedsurveyusingPPE-15:relationshipofcareaspectstopatient satisfactioninHongKong,Int.J.Qual.HealthCare4(2011)390–396.

[4]OaBjertnaes,IsSjetne,HhIversen,Overallpatientsatisfactionwithhospitals:

effectsofpatient-reportedexperiencesandfulfilmentofexpectations,Brit.

Med.J.Qual.Saf.21(2012)39–46.

[5]K.Kandelaki,G. Marrone,C.S.Lundborg,I.Schmidt,I. Björkman,Patient- centrednessasaqualitydomaininSwedishhealthcare:resultsfromthefirst nationalsurveysindifferentSwedishhealthcaresettings,Brit.Med.J.Open6 (2016)e009056.

[6]R.Fitzpatrick,A.Hopkins,Problemsintheconceptualframeworkofpatient satisfactionresearch:anempiricalexploration,Sociol.HealthIlln.5(1983) 297–311.

[7]M.Rahmqvist,Patientsatisfactioninrelationtoage,healthstatusandother backgroundfactors:amodelforcomparisonsofcareunits,Int.J.Qual.Health Care13(2001)385–390.

[8]BcSun,EjOrav,TaBrennan,DwRucker,J.Adams,Hr.Burstin,Determinantsof patientsatisfactionandwillingnesstoreturnwithemergencycare,Ann.

Emerg.Med.35(2007)426–434.

[9]R. Crow, H. Gage,S. Hampson, J. Hart,A. Kimber,L. Storey, etal., The measurementofsatisfactionwithhealthcare:implicationsforpracticefroma systematicreviewoftheliterature,HealthTechnol.Assess.6(2002)1–224.

[10]A.A.Saeed,B.A.Mohammed,M.E.Magzoub,A.H.Al-Doghaither,Satisfaction andcorrelatesofpatients’satisfactionwithphysicians’servicesinprimary healthcarecenters,SaudiMed.J.6(2001)1–92.

[11]JanetH.Y.Ng,BronyaH.K.Luk,Patientsatisfaction:conceptanalysisinthe healthcarecontext,PatientEduc.Couns.102(2019)790–796.

[12]AmGarrat,E.Solheim,K.Danielsen,NationalandCross-nationalSurveysof PatientExperiences:AStructuredReview,NorwegianKnowledgeCentrefor theHealthServices,Oslo,2008Report7-2008.

[13]C. Jenkinson, A. Coulter, S. Bruster, The Picker patient experience questionnaire:developmentandvalidationusingdatafromin-patient surveysinfivecountries,Int.J.Qual.HealthCare14(2002)353–358.

[14]A.DeCourcy,E.West,D.Barron,Thenationaladultinpatientsurveyconducted intheEnglishNationalHealthServicefrom2002to2009:howhavethedata beenusedandwhatdoweknowasaresult?BMCHealthServ.Res.(12)(2012) 1–12.

[15]D.E. Beaton, C.Bombardier, F.Guillemin,M.B. Ferraz,Guidelinesfor the processofcross-culturaladaptationofself-reportmeasures,SpineJ.25(2000) 3186–3191.

[16]K.Collins,A.O’Cathain,Thecontinuumofpatientsatisfaction-fromsatisfied toverysatisfied,Soc.Sci.Med.57(2003)2465–2470.

[17]P.D.Cleary,S.Edgman-Levitan,Healthcarequality.Incorporatingconsumer perspectives,J.Amer.Med.Assoc.278(1997)1608–1612.

[18]JlJackson,J.Chamberlin,K.Kroenke,Predictorsofpatientsatisfaction,Soc.Sci.

Med.(2001).

[19]A.Zhumadilova,B.J.Craig,M.Bobak,Patient-centeredbeliefsamongpatients andprovidersinKazakhstan,OchsnerJ.18(2018)46–52.