Abstract
Background : Planning
and utilization of health services in the elderly
group is a very important concern for both elderly
as well as health care services providers. Quality
of care is an essential need in health care delivery,
and patient satisfaction has become an integral
component of health care quality management
Objectives:
To
assess the elderly utilization and satisfaction
with primary health care services provided at
Dubai Health Authority and their associated factors.
To study associated Determinants.
Materials
and methods:
A cross sectional study was carried out in primary
health care facilities at Dubai Health Authority,
United Arab Emirates among elderly (aged 65 years
or more) similar to most developed world countries
which accepted the chronological age of 65 years
as a definition of elderly. Sample size estimation
through Utilizing EPI_INFO "6.04", applying
certain criteria was (384) participant both males
and females. Sample type was Stratified random
sample with proportional allocation.
Results
: The
study has revealed that Elderly having not enough
income were more liable to be high utilizers of
services as compared to those having enough and
more than save income (OR= 0.32; CI: 0.14-0.74).
Elderly with IHD and those with osteoporosis were
significantly more liable to be high utilizers
of services as compared to those without these
diseases (OR= 0.56; CI: 0.32-0.97 and OR= 0.36;
CI: 0.16-0.79 respectively). The study showed
that lower utilizers of these services were significantly
more satisfied than high utilizers (P<0.05).
On the other hand, there was no statistically
significant association between utilization of
services and other items of satisfaction score.
The study showed that satisfaction with services
is correlated to the income (OR= 0.24; CI: 0.20-0.88).
However, the association was not statistically
significant (OR= 0.82; CI: 0.29-2.31).
Conclusion:
the majority of the elderly at the primary health
care centres were low utilizers (Less than once/month)
of services. The significant determinants of being
less satisfied about the services provided were
being illiterate or with an educational level
less than secondary school, or having osteoporosis.
Key words: Services utilization, satisfaction,
Elderly, Dubai
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Introduction
Planning and utilization of health services in the elderly
group is a very important concern for both elderly as
well as health care services providers. (1) Quality
of care is an essential need in health care delivery,
and patient satisfaction has become an integral component
of health care quality management. (2 ,3) Patient satisfaction
has long been considered as a vital component when measuring
health outcomes and quality of care. The prevalence
of most chronic conditions rises with age, particularly
stroke, heart disease, cancer, cataracts, risk of falls
and incontinence. Integrated care models, which bridge
across health and social care, are needed to help manage
chronic conditions effectively in the community setting.(4
) The health status of older adults is evaluated by
tracking mortality and morbidity statistics, functional
status measures, amount, type, frequency of social and
health care services utilization and lifestyle behaviours
related to health. (5) The global increase in people
aged 60 years and above has attracted the attention
of the world to the magnitude of the problems of providing
health care for the elderly.(1) Elderly patients have
a disproportionately high need for usage of health care.
(4) World Health Organization set objectives for elderly
care including; prevention of unnecessary loss of function,
maintain good quality of life, keep elderly in their
own homes as long as they wish, provide support of families
or carers, and provide good quality terminal care. (
6) Because the elderly tend to have multiple disorders
and may have social or functional problems, they use
a disproportionately large amount of health care resources.
(7)
Elderly, and female in particular, report higher rates
of services utilization, (8) 8 and educated elderly
showed a higher utilization with primary health care.
(9) On the other hand poor education, poverty, lack
of drugs and basic laboratory services were identified
as a barrier to utilization of services. (10) Several
studies showed that satisfied patients are more adherent
to medical treatment and have more symptom resolution.
(11,12,13) Furthermore a satisfied patient is more likely
to develop a deeper and longer lasting relationship
with their medical provider, leading to improved compliance,
continuity of care and ultimately better health outcomes.
(13) A study conducted in Italy (2007) (14), reported
that more than 60% of the elderly patients considered
the healthcare they received to be satisfactory. Another
study conducted in Saudi Arabia (2004) (15), found that
79.0% of elderly people were satisfied with the services
provided by PHC. Although patient satisfaction has been
assessed across various patient groups and care settings,
only a few studies have been done among elderly patients.
( 16) This could indicate a low priority to the investigation
of elderly patients' view of their care.
Objectives
To assess the elderly utilization and satisfaction with
primary health care services provided at Dubai Health
Authority and their associated factors. To study associated
Determinants
Materials
and Methods
A cross sectional study was carried out in primary health
care facilities at Dubai Health Authority, United Arab
Emirates among elderly (aged 65 years or more) similar
to the most developed world countries which accepted
the chronological age of 65 years as a definition of
elderly. Elderly patients with communication problems,
such as those with severe hearing impairment, and Elderly
patients with a previous diagnosis of dementia, were
excluded. Sample size estimation through Utilizing EPI_INFO
"6.04", applying certain criteria was (384)
participants both males and females. Sample type was
Stratified random sample with proportional allocation.
Results
Table 1 shows that the only significant predictor for
high utilization of PHC services was elderly household
income. Elderly having not enough income were more liable
to be high utilizers of services as compared to those
having enough and more than save income (OR= 0.32; CI:
0.14-0.74).
Table 1: Socio-demographic characteristics as predictors
for utilization of PHC centres services: univariate
analysis
*P=0.005
Table
2 shows that among studied medical characteristics,
elderly with IHD and those with osteoporosis were significantly
more liable to be high utilizers of services as compared
to those without these diseases (OR= 0.56; CI: 0.32-0.97
and OR= 0.36; CI: 0.16-0.79 respectively).
Table 2: Medical characteristics as predictors for
utilization of PHC centres services: univariate analysis
*P=0.028; **p=0.004;
Chronic
obstructive pulmonary disease
Table 3 shows that utilization of PHC services was significantly
associated with total, effectiveness, and accessibility
items of satisfaction scores, as lower utilizers of
these services were significantly more very satisfied
than high utilizers (P<0.05). On the other hand,
there was no statistically significant association between
utilization of services and other items of satisfaction
score.
Table 3: Association between
utilization of services and satisfaction (n=384).
Table 4 shows that the
only significant predictor of satisfaction with services
was household income. Elderly having enough income were
more liable to be very satisfied with services as compared
to those having enough and more than save income (OR=
0.24; CI: 0.20-0.88). Similarly, those having not enough
income were more liable to be very satisfied with the
provided services as opposed to those having enough
and more than save income. However, the association
was not statistically significant (OR= 0.82; CI: 0.29-2.31).
Among medical characteristics shown in Table 5, only
history of osteoporosis was the only significant predictor
for satisfaction with provided services. Elderly with
history of osteoporosis were more liable to be less
very satisfied with services as compared to those without
history of osteoporosis (OR= 2.46; CI: 1.04-5.83).
Table 4: Association between socio-demographic characteristics
of elderly and total satisfaction scale: univariate
analysis
*P=0.0071
Table 5: Association between medical characteristics
of elderly and total satisfaction scale: univariate
analysis
*P=0.039;
Chronic obstructive pulmonary disease
Discussion
and Limitations
The present study also revealed that the highest percentage
of the elderly in Dubai were utilizing PHC services
less than once/month (66.4%); most of them coming for
regular treatment of chronic diseases every 3 months.
Similarly , regarding utilization of services, it was
found that among the average elderly persons over 65
years of age in Pakistan, 2009, as shown by Saleem T,
Khalid U, Qidwai study, expectations of their physicians:
findings from a tertiary care hospital in Pakistan uses
more health care services than non elderly individuals.
More than 50% of the patients were visiting their physicians
at least once every two to three months. A previous
study conducted in Alexandria 2002, (17) among elderly
patients attending different outpatient clinics, found
that most of the elderly visit the clinic once or twice/month
i.e. 12-24 visits/year. The Asir study (18 )demonstrated
that their elderly utilized PHC centres fewer times/year
than the younger adult age group. On the other hand,
a much lower rate of utilization was found among the
elderly population in Brazil 2007(19), where 72% of
them sought and received health care services at least
once/6 months. The type of illness or symptoms experienced
for the particular illness and duration are all known
to affect health service utilization.(20) A study conducted
in South Africa in 2010, (21) among patients attending
community health care centre 16 years old and above
showed that, above 45 years of age females and males
(81.8%- 75%) visited the tuberculosis clinic frequently,
followed by presence of history of diabetes (76.7% male
and 75.9% female) and hypertension, 25% for both. The
present study found that, the presence of IHD and those
with osteoporosis were significantly more liable to
be high utilizer of the services.
The present study revealed that elderly have not enough
income and has a statistically significant high rate
of utilization of pHC services at DHA. This finding
is congruent with other studies which suggest that individuals
with higher income have more tendency to use private
services (Al-Doghaithe 2003, (22)Andaleeb 2000, (23)
and Al Ghanim. (24) Elderly needing help with ADL alone
or ADL with IADL, increased their difficulty in accessing
PHC by 39% which decreased their utilization of PHC
centres as reported by a study done in the USA 2001,
(25) while our study revealed no statistical significance
between elderly with ADL or IADL and utilization of
the PHC services. This can be explained by preparation
of PHC building for easy access, presence of care giver
and way of treating (nurses, administrative, medical
record staff and physician) elderly with functional
disability by easy access and less waiting time. The
present study revealed that another significant predictor
for being a high utilizer (once or more /month) of PHC
services at DHA was being satisfied with services provided.
Asir's study (17) revealed that the majority of elderly
people (aged 60+ years) were satisfied with the services
provided (79.0%) and accordingly preferred always to
use the health services provided by the centre. An Alexandria
study (17) revealed that multiple regression analysis
utilization of other sources of medical care had a significant
negative relation to total satisfaction score of the
elderly about their facility. High degree of satisfaction
was revealed as in the overall satisfaction scale, 87.0%
of the interviewed elderly persons reported being very
satisfied while 13.% were satisfied with the PHC services
provided. This is consistent with a study conducted
in Sweden 2010, (26) among patients aged 20 years old
and above attending medical centres, which showed that
the elderly were the most satisfied group (90%) in comparison
with younger age groups (76%). Among Gulf countries,
a study was conducted in Saudi Arabia in 2001, (27)
and included patients aged 15 years old and above attending
PHC centres of Riyadh and revealed a lower rate of satisfaction
(60% among the whole group ). Another study conducted
in Kuwait in 2008, (28) among patients 16 years of age
and above attended PHC showed near satisfaction level
(67.0% elderly age group compared to 61% among adult
group).
Most satisfaction studies have revealed that satisfaction
is multi-factorial and no one factor could be claimed
to be the only contributor to satisfaction or dissatisfaction.
(29)
Although older age was significantly associated with
the risk of being less very satisfied regarding continuity
and humaneness subscale of satisfaction in the bivariate
analysis, it is not so in other subscales or in the
multivariate analysis. Moreover, patients aged 85 years
or more were more likely to be very satisfied with all
other subscales and the total satisfaction scale. This
may be explained by the fact that the study included
elderly people only and significant differences may
not be apparent between the different categories of
elderly group. Another study conducted in UAE,( 30)
has shown that age was a significant factor for the
effectiveness subscale of satisfaction. Also, Al-Eisa
(31), found that the older the patient, the higher the
satisfaction. This may be due to the elderly having
lower expectations about the service provided; hence
they have higher satisfaction than younger population.
Regarding gender, the present study found that females
were less satisfied than males with the continuity of
care, but there was no statistically significant difference.
This result is consistent with the previous studies
in Qatar 2009, (32), conducted among patients attending
PHC centre aged 16 years old and above, and Al Sakaak
(33) and Al Eisa (31) also found that males were significantly
more satisfied than females. Al-Dawood (34) identified
sex of the respondent as the most influential factor
on the level of satisfaction. Among other sociodemographic
variables, the present study demonstrated that the only
predictors of being very satisfied were the educational
status and income. According to the education status,
studies showed contradictory findings; some had a positive
effect of education and others revealed negative effect
on satisfaction. A study conducted in Dubai 2008, (35)
among patients attending Al Khawaneej health centre,
20 years old and above, showed that, the low educated
patients were very satisfied with the services provided.
A study conducted in Croatia 2001, (36) among patients
from 18 years old and above attending 47 PHC found that
less educated people were more satisfied; the researcher
proposed that less educated people may be more satisfied
as they are less demanding. While a study in Qatar,
(32) found that, those with higher education had lower
but statistically insignificant level of satisfaction
with continuity of care. On other hand the present study
also revealed that those with less than secondary education
had double to triple the risk of being less satisfied
regarding effectiveness, continuity and humaneness subscales
and the total satisfaction scale (together with the
illiterate in the total scale). Contrary to the previous
explanation regarding the relation between education
and satisfaction , it may be proposed that some of those
of lower educational level may underestimate the effort
and services provided; hence they may be less very satisfied.
A Community based sample would be more appropriate,
but was not adopted due to time constraints. Community
based sample would be also more accurate in portraying
the actual pattern of health service utilization. Moreover,
results of the present study may not be generalized
to the whole PHC, as quality of care and patient characteristics
may differ in different PHC centres. A recall bias may
also have been encountered, as the elderly may express
their satisfaction about the present or last visit to
the PHC, which may not reflect the usual quality of
services provided.
Conclusion
The majority of the elderly at the primary health care
centres were low utilizers (Less than once/month) of
services. The significant determinants of being less
very satisfied about the services provided were being
illiterate or with an educational level less than secondary
school, having osteoporosis, while presence of history
of COPD increased the liability for being more very
satisfied.
Recommendations
The integration and coordination of health and welfare
programmes and services to address effectively the various
needs of older people and to improve primary health
care systems to protect and promote healthy lifestyles,
and to tackle the chronic health problems among an ageing
population.
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