|Year : 2016 | Volume
| Issue : 3 | Page : 749-756
Type II diabetic patients' satisfaction with the management plan in family health centers in Port Said city, Egypt
Taghred M Farahat, Nagwa N Hegazy, Ahmed Ragheb, Wesam Yousef
Department of Family Medicine, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||11-Jul-2015|
|Date of Acceptance||20-Sep-2015|
|Date of Web Publication||23-Jan-2017|
Kornish El Nil, Damietta, 42111
Source of Support: None, Conflict of Interest: None
The aim of the study was to assess type II diabetic patients' satisfaction with the management plan in family health centers (FHCs) in Port Said city.
Diabetes mellitus is a common and potentially disabling chronic disease, with increased risk for microvascular and macrovascular complications.
Patients and methods
A cross-sectional study was carried out on 150 participants after calculation of the sample size. All diabetic participants who were registered at all FHCs were interviewed using semistructured questionnaires to obtain sociodemographic characteristics and to assess type II diabetic patients' satisfaction toward counseling and treatment plans. This was followed by a review of the family health record. The responses from the questionnaires were collected, revised, tabulated, coded, and statistically analyzed.
The study included 150 type II diabetic patients, aged 18-50 years. One-third (32.7%) of the respondents were unsatisfied with the management plan, whereas 67.3% were satisfied. The highest proportion of dissatisfaction was observed among patients with higher levels of education and low monthly income (P ≤ 0.01). Unemployed patients expressed higher grades of satisfaction compared with employed patients. Patients without health insurance in other places had higher levels of satisfaction (P ≤ 0.05).
This study concluded that 67.3% of type II diabetic patients were satisfied and 32.7% were not satisfied with the management plan in FHCs in Port Said city, Egypt.
Keywords: diabetes, management plan, process of care, satisfaction
|How to cite this article:|
Farahat TM, Hegazy NN, Ragheb A, Yousef W. Type II diabetic patients' satisfaction with the management plan in family health centers in Port Said city, Egypt. Menoufia Med J 2016;29:749-56
|How to cite this URL:|
Farahat TM, Hegazy NN, Ragheb A, Yousef W. Type II diabetic patients' satisfaction with the management plan in family health centers in Port Said city, Egypt. Menoufia Med J [serial online] 2016 [cited 2020 Apr 4];29:749-56. Available from: http://www.mmj.eg.net/text.asp?2016/29/3/749/198806
| Introduction|| |
Diabetes mellitus is one of the most common noncommunicable diseases and a major public health challenge in the world. There has been a rapid increase in the incidence of diabetes mellitus. Much of this increase occurs in developing countries and results from aging, an unhealthy diet, obesity, and a sedentary lifestyle. Despite the advances in understanding the disease and its management, the morbidity and mortality rates continue to rise  . People with diabetes are at increased risk for a number of complications, including retinopathy, renal disease, and heart disease. High-quality medical care has been shown to reduce these complications among patients with diabetes , . The American Diabetes Association  has recommended monitoring diabetes and its complications through the use of periodic tests as well as appropriate management once complications are identified. However, recent data suggest that a gap exists between recommended diabetes care and the care patients actually receive  .
Given the ever-increasing range of treatment options for diabetes, understanding treatment satisfaction for diabetes is especially important  . Treatment satisfaction is one example of patient-reported outcomes. Patient-reported outcome has been defined as any report coming from patients about a health condition and its treatment  .
Measurement of treatment satisfaction is important, as greater satisfaction has been found to be associated with higher rates of adherence and compliance with treatment regimens , . In diabetes, it has been shown that increased treatment satisfaction is associated with better glycemic control, suggesting that higher satisfaction is related to better clinical outcomes  . The quality of diabetes care is widely suboptimal , , and most interventions for diabetes depend on active involvement and participation of patients  . Thus, working through patient satisfaction may be an important way of improving care for this important public health problem. Various studies have concluded that continuity in using services , , maintenance of relationships with the provider , , and compliance with treatments are all more likely among satisfied than among unsatisfied patients.
Patients with diabetes have to pay repeated visits to primary health care (PHC) clinics, usually for the rest of their lives. These patients are usually more difficult to satisfy. This usually leads to unsatisfactory compliance and poor control of their chronic disease  .
Assessments of patient satisfaction regarding PHC physicians is important, not only as a measure of the quality of care patients receive but also for identifying potential areas for improving the content of care provided by PHC physicians  .
Patient satisfaction is one of the desired outcomes of healthcare, an element in health status, a measure of the quality of care, and as indispensable to assessments of quality as to the design and management of the healthcare system  . A satisfied patient is more likely to utilize healthcare services, comply with medical treatment, and continue with the health provider  .
In this study we aimed to assess type II diabetic patients' satisfaction with the management plan in family health centers (FHCs) in Port Said city.
| Patients and methods|| |
This was a cross-sectional study performed in Port Said city, which lies at the north of Egypt. It has three primary healthcare centers and three FHCs. The study was conducted in all the FHCs in Port Said city (Fatima Alzahraa Center, Hai-Alkweet Center, and Hai-Alarab Center). Sample size was calculated using the Open EPi (Open Source Epidemiologic Statistics for Public Health) calculation program based on the prevalence of diabetic patients in Egypt, which was 9%  , and the population of Port Said city, which was 603 787 in 2010  .
Sample size was calculated according to this equation:
n is the sample size, σ is the variance (prevalence), z = 1.96 (95% confidence interval, 2.58-99), is the mean of sample, and ΅ is the mean of the population.
According to the equation, sample size was 128 patients and it was raised to 150 patients to overcome dropout. All registered type II diabetes mellitus patients attending FHCs during the period of study were invited to participate. A month for case recruitment was allocated for each FHC wherein all the diabetic patients who attended from 10:00 a.m. to 2:00 p.m. daily for 5 days were invited to participate in the study.
The participants' distribution according to the FHC from where they were recruited was as follows:
• In the first month recruitment was from Fatima Alzahraa Center, from where 46 participants out of 75 were recruited
• In the second month, recruitment was from Hai-Alkweet Center, from where 63 participants out of 86 were recruited
• In the third month recruitment was from Hai-Alarab Center, from where 49 participants out of 57 were recruited.
Tools of the study
Interviews with patients
0All patients were interviewed using a two-part structured questionnaire.
First part: This part collected patient demographic data such as name, age, sex, occupation, socioeconomic status, special work, and duration of diabetes. The socioeconomic status was assessed on the basis of the Ibrahim and Abdel-Ghaffar  socioeconomic scoring system using five parameters (occupation, education, family size, family income, and crowdedness in the house). A modification was done on the family income to suit the recent circumstances; thus, 700 Egyptian pounds was used as the cutoff.
The patients were divided into three socioeconomic levels:
1. High socioeconomic standard: those with scores from 11 to 14
2. Middle socioeconomic standard: those with scores from 8 to 10
3. Low socioeconomic standard: those with scores below 8.
Second part: This part collected information on patient satisfaction and had two sections.
The first section contained a modified form of patient satisfaction questionnaire to assess the process of counseling with the doctor during consultation and assess doctor-patient relationship during the patient visits to the clinic. It consisted of five questions assessed on a two-point Likert scale (agree or disagree).
The second section contained a modified form of the national health services to assess patient satisfaction about the management plan and contained 15 questions: one statement to assess follow-up visits; four statements to assess patient satisfaction with patient education; five statements to assess patient satisfaction with investigations carried out; and five statements to assess patient satisfaction with treatment. Each statement was graded on a two-point Likert scale (i.e., yes = 1, no = 0).
Both questionnaires underwent validation and reliability assessment before use. A total score was calculated to assess the satisfaction of the patients, in which less than 60% was considered dissatisfied and 60% or more was considered satisfied.
Reviewing patient family medical records using a checklist
The process of diabetic care was assessed with a checklist to evaluate the indicators of diabetic care based on ten items: blood pressure, blood glucose, proteinuria, peripheral sensation, peripheral pulsation, foot examination, referral for ophthalmic examination, urea and electrolytes, and glycosylated hemoglobin  . A scoring system based on the extent of fulfillment of ten items was used to evaluate diabetic care provided by the family physician over the past year. The process of diabetic care was categorized as good (8-10 points), moderate (5-7 points), and poor (less than 4 points).
The results were collected, tabulated, and analyzed statistically using Microsoft Excel and SPSS, version 17, software programs (SPSS Inc., Chicago, Illinois, USA). Data were described as range, mean, SD, frequencies (number of cases), and relative frequencies (percentages) when appropriate. A P value less than 0.05 was considered statistically significant.
| Results|| |
Almost two-thirds (69.3%) of participants were female, and two-thirds (66.7%) of them were illiterate or had primary level of education. One-fourth (26%) of them had secondary level of education, whereas only 7.3% were university graduates. Most participants were married (79.3%) and unemployed (62%).
[Figure 1] illustrates the overall satisfaction of the respondents. Of the respondents, 32.7% were satisfied, whereas 67.3% were dissatisfied.
|Figure 1: Percentage of diabetic patients' satisfaction with the management plan.|
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[Table 1] shows that there was a significant difference between being male, illiterate, having a low socioeconomic level, having no health insurance, and being satisfied, and no statistical significant differences were found regarding marital status.
|Table 1 Comparison of patient satisfaction with respect to the management plan in the studied group |
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[Table 2] shows that 100% of the studied group underwent blood pressure, weight, and fasting blood glucose measurements at each visit, 86% underwent a foot examination at each visit, whereas a large number did undergo urea and electrolytes or glycosylated hemoglobin tests. [Figure 2] shows the average score of assessment of care process regarding investigations recorded in diabetic patients' files in the past year. [Table 3] shows that there was a highly significant difference between being illiterate, not having health insurance, and having a good process of care, whereas there was a nonsignificant difference regarding sex, age, disease duration, socioeconomic level, occupation, marital status, and having good process of care. [Table 4] shows that there was a nonsignificant correlation between patients' satisfaction with the management plan and process of care detected in their files.
|Table 2 Assessment of process of care recorded in diabetic patient files over the past year |
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|Table 3 Assessment of process of care with respect to investigations carried out in the studied group (N=150) |
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|Table 4 Correlation between satisfaction of management plan and health education, continuity of care, and process of care |
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|Figure 2: The average score of assessment of care process with respect to investigations recorded in diabetic patient files in the past year.|
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| Discussion|| |
The management of diabetes mellitus not only requires the prescription of an appropriate nutritional and pharmacological regimen by the physician but also intensive education and counseling of the patient. The chronic complications of diabetes are known to affect the quality of life of diabetic patients. Various factors like understanding of the patients about their disease, socioeconomic factors, dietary regulation, and self-monitoring of blood glucose are known to play vital roles in diabetes management  . Patient satisfaction is important in the management of chronic diseases as the effectiveness of healthcare is determined by satisfaction with the services provided  . A satisfied patient is more likely to utilize healthcare services, comply with medical treatment, and continue with the health provider. Donabedian  regarded patient satisfaction/dissatisfaction as a patient's judgment upon the quality of care in all its aspects.
Consequently, the present study aimed to assess the rate of satisfaction among diabetic patients toward the management plan at FHCs in Port Said city to identify areas of healthcare that show low satisfaction, and identify diabetic patients' characteristics associated with incomplete satisfaction.
The study showed that 32.7% of diabetic patients were satisfied with the provided healthcare at the FHCs. This finding was not in agreement with that reported by Kamien et al.  , who found that 90% of diabetic patients reported satisfaction with primary care in Australia.
In Kuwait, Al-Dousari et al.  reported that patient satisfaction ranged from 75.2 to 78.4%. However, in Mexico, Doubova et al.  reported that only half of the diabetic patients were satisfied with their provided PHC services. Ramirez et al.  noted that the proportion of diabetic patients' satisfaction ranged from 64.8 to 88.0%. In Kuwait, men (73.5%) were more satisfied with treatment than were women (26.5%), which is consistent with the findings in Sweden  and Italy  .
However, in Kuwait, Al-Dousari et al.  found that female patients experienced higher satisfaction compared with male patients. In contrast, Al-Eisa et al.  reported that male patients had significantly higher satisfaction than female patients regarding the provided healthcare services. Thiedke  pointed out that there is a controversy regarding the relation between patient's sex and his/her satisfaction. She explained this by the fact that, because of differences in sex roles within societies, results of studies about the effect of sex on patients' satisfaction are contradictory, with some studies showing that women tend to be less satisfied and other studies showing the opposite.
In the study sample of diabetic patients, highly educated patients and professionals had a lower satisfaction score compared with other patients, which is not in line with the results of another study  that reported that less-educated patients were less satisfied with diabetes treatment.
Satisfaction was negatively associated with higher income, employment, and higher educational level and this was not in line with the results of other studies ,, . These study findings show that patients' satisfaction with diabetes treatment was influenced by their sociodemographic characteristics.
Al-Doghaither  reported that an FHC physician's communication skills (i.e., length of time spent with patients, explaining and responding to their queries, offering reassurance and support, etc.) were strong and important correlates of patient satisfaction. Moreover, in Saudi Arabia, Saeed et al.  noted that about two-thirds of patients reported that careful listening of the doctor to their complaints is an important characteristic of an ideal physician. The presence of communication gaps between diabetic patients and their family physician leads to their dissatisfaction. Informing patients on different aspects of their health and about the care they need are very important for those with chronic conditions, and treating them as coparticipants in the process of decision making has been repeatedly emphasized as an important patient right  . When patients are well informed and participate in treatment decisions, their anxiety decreases and their therapeutic adherence improves, thus increasing the chances of better health outcomes  . Effective family doctor-patient communication requires sufficient consultation time  .
Doubova et al.  emphasized that patient satisfaction can greatly influence their contribution to disease management, which is important for better control of their conditions. Diabetic patients with chronic conditions receive long-term care and this should be reliable, periodic, continuous, and coordinated among different providers.
[Figure 2] shows the average total score for the process of diabetic care. It was good in 27.30% of patients, moderate in 63.30%, and poor in 9.30%, whereas [Table 2] shows the process indicators of diabetic care.
One hundred percent of the studied group had measured blood pressure, fasting blood glucose, and weight; 86% had undergone a foot examination, whereas a large number had not undergone urea and electrolytes or glycosylated hemoglobin test.
Another study conducted by Khattab et al.  and by Qureshi et al.  in Saudi Arabia aimed at auditing diabetic care in a large practice center in Riyadh. It was found that the process of care was good/fair in 66.7% and poor in 33.3%. In London a study was conducted by Chesover et al.  , which showed that the degree of process of care was good/fair in 57% of records and poor in 43%, which could be attributed to the doctor-patient relationship and continuity of care. Also, these low figures for process of care could be attributed to the high flow rate in FHCs, resulting in practicing physicians being reluctant to follow the standards of care  .
High recording rates for blood pressure (100%), blood glucose (100%), and weight (100%) could be explained by the awareness of physicians at FHCs in Port Said city of the relation between diabetes, obesity, and hypertension. In contrast, the recording rates for vision acuity or fundoscopy is 66%, reflecting the need for fundoscopy training to improve the skills of physicians in our FHCs. Recording rates of creatinine was 4% and that of glycosylated hemoglobin was 10.7%, concurring with the results in Saudi Arabia, who revealed high recording of blood pressure, blood glucose, and weight in 100% of cases but assessment of vision acuity in 44.6% of patients. This poor recording of vision acuity could be explained by the large number of patients consulting physicians daily who were less likely to refer  them to ophthalmologists. As reported in [Table 3], there was a nonsignificant relation regarding sex, age, disease duration, socioeconomic level, occupation, marital status, and having good process of care, but a highly significant relation between being illiterate, not having health insurance, and having good process of care.
These results were in contrast to those obtained by  , who found that the degree of process of care for male patients was good compared with the process of care offered to female patients. This may explained by the unwillingness of Saudi diabetic women to be examined by male physicians. In our study it is clear that continuity of care was significantly related to the process of care as satisfaction with continuous care translated into good scores for process of care. These results could be attributed to the fact that one of the principles of family medicine practice is the continuity of care and doctor-patient relationship. Thus more training in the area of doctor-patient relationship can improve the process of care  .
This study has provided important findings on several aspects of services provided to diabetic patients in FHCs, which reflect the quality of the provided healthcare. This study is expected to help policy makers and healthcare providers better understand patients' views, which can be optimally utilized in planning, controlling, and delivering healthcare services. This would eventually improve the healthcare system toward fulfillment of better patient healthcare and patient satisfaction.
| Conclusion|| |
This study concluded the following: (a) 67.3% of diabetic patients were not satisfied with the management plan in FHCs in Port Said city; (b) patients demonstrating higher satisfaction include those unemployed and patients without health insurance in other places; (c) the highest proportion of dissatisfaction was observed among patients with higher levels of education and moderate monthly income; (d) 63.3% of participants had moderate process of care; (e) there was a highly significant relation between being illiterate, not having health insurance, and having good process of care; and (f) there was a nonsignificant correlation between patients' satisfaction with the management plan and process of care detected in their files.
• To improve patient satisfaction toward the management plan in FHCs, physicians should be better trained to increase their clinical and communication skills, learn methods of active listening and empathy, give clear explanations, check the patient's understanding, negotiate a treatment plan, and check the patient's attention to compliance.
• Greater participation by the patient in the interactions improves satisfaction, compliance, and outcome of treatment.
• The importance of continuous care in family medicine should be emphasized in chronic diseases such as diabetes.
Many thanks to Prof. Taghred Mohammed Farahat, Dr Nagwa Nashat Hegazy, and Dr Ahmed Ragheb for their continuing support and unlimited generosity during the preparation of this work.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]