Hong Kong Journal of Paediatrics [HK J Paediatr (New Series) 2002;7:255-262]

Department of Psychology, Victoria University, Melbourne, Australia

CM Leung ( 梁敏 ) PhD

Family Health Service, Department of Health, Hong Kong, China

HY Chan ( 陳鴻儀 ) BSc(Nursing)(Hons), M. Nursing
KY Chan ( 陳家宜 ) MBChB, MSc
AML Chung ( 鍾美玲 ) B. Nursing, Dip. Epidemiology & Applied Statistics
JCW Lai ( 黎正卉 ) B. Nursing(Hons), DPA(Health Admin)
SSL Leung ( 梁士莉 ) FRCP(Glasg), FHKAM(Paed), MPH(Hon)

Correspondence to: Dr SSL Leung

Received February 25, 2002

The aim of the present study was to understand the perception of Maternal and Child Health Centre clients in relation to their satisfaction with child health services, using a qualitative approach. The participants included 25 Chinese mothers with children from 18 to 24 months, who were current Maternal and Child Health Centre users, and their opinions were collected via focus group and individual interviews. Several themes were detected in relation to reasons for use of service, personal feelings and experiences, and suggestions for improvement. The issue of communication with staff members was the central theme. Participants appreciated two-way interaction with understanding staff members where they could get answers to their questions about their children in privacy. Satisfactory two-way communication between clients and staff members in a suitable environment could potentially alleviate feelings of anxiety, confusion, embarrassment and depersonalisation. Failure in communication could potentially aggravate feelings of anxiety, confusion and depersonalisation.

Introduction

Client oriented health care has been widely recognized. In order to improve service quality and formulate service policy, clients' views cannot be neglected.¹ Much research on clients' views about services is related to the issue of client satisfaction.

Client satisfaction can be defined in many different ways. Some regard client satisfaction as the perceived difference between clients' expectations and the actual experience.² When the experience exceeds the expectations, the experience is satisfactory and vice versa. Other researchers define client satisfaction as a multidimensional concept and study client satisfaction in terms of specific quality dimensions of the service.^3,4 The dimensions may include accessibility (convenience, bureaucracy, resource availability, continuity of care, finances), information (information gathering, information giving), tangibles (appearance of physical facilities, personnel and materials), reliability (dependability, efficacy and accuracy of service), responsiveness (promptness of service and helpfulness to clients), assurance (ability of knowledgeable and courteous staff to convey trust and confidence) and empathy (individual care and attention to customers).^2-5 Reliability is thought to be related to the outcome of the service and the other dimensions were related to the process of service delivery. Others, however, argue that the quality dimension approach may not be applicable to health services.² Instead, they argue that clients arrive at a set of service attributes which are based on their experiences of positive or negative events. The summation of the attributes gives rise to an overall service evaluation, including satisfaction.

Other researchers investigate factors contributing to client satisfaction. It is found that, in health care services, giving clients information leads to a sense of control and satisfaction with service and is also a form of empowerment.^6,7 Apart from giving information, effective reassurance has also been found to be related to client satisfaction. Similarly, discovering client's concerns and giving clients sufficient time to address their problems are also related to client satisfaction in health care settings.⁴

There are two basic issues in the investigation and measurement of client satisfaction. First, information on the elements pertaining to client satisfaction has to be obtained. Second, actual client satisfaction needs to be measured by asking the clients to evaluate those elements pertaining to client satisfaction in relation to the specific service in question.

There are two broad methods of understanding elements pertaining to client satisfaction.³ One method involves getting the service providers to identify these elements. The other method involves obtaining the information from clients about the service they have received, through qualitative method. The advantage of this latter method is that clients are in a good position to provide information on service requirement as they are the service recipients. Typically, focus groups or individual interviews are used to obtain the information and the recommended number of clients to be interviewed range from 10 to 20 people.³ The qualitative approach provides the tools to explore and understand clients' needs and expectations from the service in their own language, and to gather rich and in-depth information, which reflects the clients' perceptions and experiences.^8,9 This may uncover information, which cannot be yielded from quantitative survey and give useful insights into perceived needs and quality of service.

The aim of the present study is to understand the perception of Maternal and Child Health Centres (MCHC) clients in relation to their satisfaction with MCHC child health services, using a qualitative approach.

The MCHC service is a government run, personal health service. It provides preventive rather than curative, child and maternal health care services. The service is delivered through 50 MCHC which are widely distributed throughout Hong Kong. The target clients for child health service are children from birth to five years. The child health services include immunization, periodical physical examination, comprehensive observational service (COS) and health education activities.

Methods

The participants were 25 Chinese-speaking mothers with one of their children being 1 1/2 to 2 years of age. The participants' age range was between 26 to 46 years. Eleven of them were housewives and the others came from a wide range of occupations, including professional (n=6), executive/managerial (n=5) and sales/clerical work (n=3). The number of children in each family ranged from one to three and the age range of the children ranged from five months to 14 years old.

Participants were grouped into primary/lower secondary (n=6), upper secondary (n=9) and tertiary (n=10) educational levels. Participants were recruited through eight selected MCHC from the four regions (Hong Kong, Kowloon, New Territories East and West). According to the inclusion criteria (Chinese-speaking mothers with one child between 1?to 2 years of age) and the educational level (based on self-report of formal schooling), clinic staff identified and invited the potential participants during their visit in the set period. Their voluntary participation was stressed. Three participants from the tertiary education group were invited by personal recommendation because they were known to have strong opinions about MCHC services.

There were three focus groups with clients with tertiary education (including one group with the three special invitation participants), two focus groups of upper secondary level and one focus group of primary/lower secondary level.

An interview guide (see Appendix) was used to guide the focus group and interview discussions. A tape recorder was used to record the interview and focus group discussions. All focus group discussion and interviews were conducted in Cantonese, and transcribed fully in Chinese.

Results

The constant comparative method was used to identify categories under each question. Categories were identified and themes emerged. The themes could be summed under three major areas: reasons for use of service, personal experience and feelings, and suggestions. In the English translation of the original Cantonese quotes, the actual English words used by the participants are underlined.

Participants used MCHC for a range of services such as immunization, body weight & height measurement and health information. The following is a typical example:

In terms of the reasons for use of service, one of the frequently mentioned reasons was recommendation by health professionals or relatives, or previous personal experience with MCHC. Another reason was the convenient locations of the MCHC. Some examples of these views are:

Participants also explained that they chose MCHC services rather than private providers for various reasons. One of the reasons was the cost. Another reason was that they regarded MCHC service as more comprehensive than that provided by private providers, both in terms of a large database of normal children as reference and the scope of service offered. Furthermore, participants from tertiary and upper secondary education levels expressed the view that they have more confidence in government provided services. These views can be illustrated by the following quotes:

Participants used the full range of services provided. They trusted the recommendations of health professionals and government service.

Many of the personal experiences and feelings were related to client-staff relationship. One of the themes that emerged was staff manner. Participants were very appreciative of staff members who were gentle and willing to spend time to establish rapport with their children. However, some participants felt less satisfied with the manner of some of the staff members. The following are some typical examples:

Apart from the manner of the staff, one of the most important issues for participants in all groups was detailed explanation by staff members. This theme came up in all discussions in great detail. They were very appreciative of staff members' willingness to spend time to explain things to them. In contrast, participants felt frustrated or unhappy when staff members seemed impatient in answering their questions. They expressed their views in the following quotes:

There were many reasons why participants felt that it was important to have someone available to answer questions. First, many of them, especially the first time mothers, felt that they were inexperienced and they were often very anxious about their children. Second, all participants, whether first time mothers or not, felt that they needed detailed explanation when they perceived that they were told about possible problems with their children. The participants felt very anxious and scared when they perceived problems with their children. The following are some typical examples:

The participants were frustrated and anxious when they were not given any further explanation about their children's problems. Some also felt guilty and might start to blame themselves for their children's problems. They expressed their feelings in the following examples:

From the above, the consensus was that, to the participants, it was very important that staff should be gentle and patient in manner and be willing to spend time to explain things to them. Inadequate explanations could potentially cause a lot of anxiety, frustration and even, self-blame and guilt feelings among the participants. These issues highlighted the importance of communication between staff and clients.

Apart from the anxiety discussed in the above section, participants in all groups reported a sense of confusion when they first used the MCHC service. Though most participants became less confused by the second time they visited the MCHC, this feeling of confusion was again experienced when the participants and their children attended the COS. Most participants reported confusion about the aims, objectives and the procedure of the COS. They reported their experiences and feelings in the following quotes:

Apart from the COS, participants also commented about the procedures adopted in the MCHC. In this aspect, participants from different education levels reported very different perceptions and feelings. Participants from the primary/lower secondary education group found the procedures reasonably clear and easy to follow. Participants from the upper secondary education group found the procedures confusing the first time, but felt less confused later. However, participants from the tertiary group had very different perceptions. They felt that the procedures were unnecessarily fragmented, resulting in feelings of confusion, anxiety and depersonalisation among the participants. They were least satisfied with the procedures and expressed their feelings in the following quotes:

Apart from the procedural flow issues, participants also commented about the long waiting time. The long waiting time is related to the number of people using the service. This, in turn, leads to the issue of privacy in discussing patient matters. The participants felt that communication between staff and clients should be conducted in an environment where privacy could be ensured. These can be illustrated by the following quotes:

Overall, it is obvious that participants often experienced a sense of confusion. It is possible that this sense of confusion might again be related to the lack of adequate communication, explanation and orientation about the nature and procedures of the service offered. The lack of privacy also means that some participants might feel reluctant to discuss their concerns with staff members, which might again result in confusion. The importance of communication and the provision of facilities conducive to communication cannot be underestimated.

The theme of communication was prominent among participants' responses in terms of obtaining health information. They agreed that the system of communication with parents, explanations and reminders about immunization was good. For health information, they would like information in the form of two-way communication between staff and clients, rather than one-way health talks. They expressed their ideas in the following quotes:

Overall, participants preferred face-to-face interaction with staff, with questions and answers, as well as clear and up-to-date information.

For the physical environment, most participants found the physical environment of the centres acceptable, though there were individual comments about unsatisfactory aspects, but these comments were, nonetheless, varied, depending very much on the individual centres the participants attended.

Summing up, in terms of personal experiences and feelings, the theme of communication between staff and clients is the single strand linking up the different sub-sections. It is not unreasonable to conclude that this is the central issue in client satisfaction, in the perceptions of the participants. Participants are concerned about their children and they want to obtain information about their children and the most effective way is through talking to staff members.

For suggestions, the tertiary education group strongly asserted the need for improvement in client-staff relationship. The participants would like the service to be welcoming, friendly, personal and individualized. The following is a typical example:

For MCHC services, operations and procedures, participants' suggestions were very much related to the need for explanation and orientation. They suggested that there should be some orientation guide for parents. Furthermore, participants from the tertiary groups were very vocal about the procedures and made many suggestions regarding the change of procedures. Below are some typical examples:

In addition, participants from all groups would like more information about child health development and childcare, but participants from the upper secondary and tertiary education groups would also like to see some changes in the focus of the information, with more emphasis on psychological development. Furthermore, they would like the information to be accurate and consistent. Below are some typical examples:

In terms of the format of information dissemination, many of the participants preferred an interactive mode so they could ask staff members questions. They explained their suggestions in the following ways:

For physical environment, the participants' suggestions were very varied, depending on the individual needs of the participants as well as the environment conditions of the clinics they were attending. What was common was that participants from all groups pointed to the need for a spacious area with suitable toys for children.

Discussion

The general picture was that most participants used the full range of child health service offered by MCHC. Participants had knowledge of the services provided and had access to the range of services. This is consistent with the literature on client satisfaction where accessibility or convenience are regarded as attributes of client satisfaction.²

Participants preferred MCHC service to private providers due to cost considerations, perceived comprehensiveness of service and confidence in government provided service. There was a sense of trust towards health professionals, especially government health professionals. The sense of trust towards MCHC suggests that in the perception of the participants, there is some form of endorsement of the reliability of the service. The cost consideration is another reason mentioned. Reliability and cost considerations are also regarded as attributes of service quality and client satisfaction in the client satisfaction literature.^2,5

It is, however, recognized that the above attributes are a list of attributes discussed by the participants but for individual participants, one or a few of the attributes might be more important than the others.

In terms of client-staff relationship, the issue of communication, both verbal and non-verbal, emerged as an important factor. Good staff-client communication could alleviate client anxiety and unsatisfactory communication could potentially result in client anxiety. The themes are consistent with literature on client satisfaction which states that communication is related to staff responsiveness, staff empathy, staff friendliness, staff manner, staff attitude, humaneness and pleasantness of support that are important attributes of client satisfaction.^5,10 The present findings are also consistent with previous research which shows that provision of information to parents about their children's problems is related to decrease in parental anxiety and frustration and highlights the need for professionals to respect and listen attentively to parents' concerns.^6,11-15 Research shows that people are always anxious about screening results but the way the message is framed may affect people's response to screening results.^14,15 Information to parents must address their needs, concerns and beliefs and, as such, professionals could play an important role in empowering parents by equipping them with relevant information.

The feeling of confusion, which was related to the services and procedures, including the COS, could be alleviated by better communication and information giving, verbal or written, and attention to environmental issues conducive to communication. The findings are consistent with research which shows that lack of signage, information about procedures, and clarification of service can potentially lead to a sense of confusion and helplessness, which is related to the loss of a sense of control, insecurity and low self-esteem.^6,7,13,16 Information giving is regarded as an important element in client satisfaction.²

In addition to the feeling of confusion, participants also reported a feeling of embarrassment in relation to the lack of privacy. Participants felt reluctant or embarrassed to discuss health concerns of their children when they perceived that others might possibly hear what they said. In client satisfaction research, privacy is an important issue in clients' sense of security.¹⁶ Furthermore, participants were also concerned about the long waiting time though they admitted that this was unavoidable. This is related to the timeliness of service or the efficiency issue that is regarded in the literature as one of the categories of client expectations.³

To sum up, participants would like the information to be updated and relevant, and they liked an interactive mode of obtaining health information, preferring two-way verbal communication rather than one-way teaching. According to the client satisfaction literature, assisting clients to get the information that they want is more useful than giving them instructions in reducing anxiety and empowering health clients, so they can take a more active role in decision making about the management of their health.⁶

Physical facility is regarded as one of the evaluation dimensions of service delivery in the literature on client satisfaction.⁵ Participants' comments in this area were very varied, depending very much on their actual experience with the centres they had attended. Most of the comments were related to the specific situation in particular centres and their own personal needs. However, one common concern was the availability of a play area with toys for children. The other concern, which has been discussed above, is the lack of privacy in discussing health issues.

The participants of this study were limited to mothers who used the MCHC service. The views of the fathers could not be sought, and their views and experiences might be quite different. Similarly, parents who, for various reasons, decide not to use MCHC service, could not be reached and their opinions and perceptions could not be investigated. They might have very different perceptions from the present sample. In addition, with the group of "invited" participants, certain issues are highlighted. However, in qualitative research, this method of extreme case sampling is often adopted as these participants are more likely to provide rich information.¹⁶ In line with the principles of qualitative research, the purpose of this study was to invite a group of information rich participants to gain insights into their perceptions and experiences. Thus, the results are basically descriptive in nature, offering insights, perceptions and experiences, and any generalizations should be made with caution.

In short, the study is based on information from a small group of participants and as such, the information should not be employed for making general conclusions. Furthermore, the study is not intended as a comparison of various providers of child health services nor a judgment of the Government Child Health Service.

It is clear from the data that advice and assurance by competent staff are valued by clients and this practice should be continued and reinforced. Furthermore, staff members should be more empathetic and responsive to clients' needs and feelings in delivering test results, giving them adequate explanations and addressing their anxiety and feelings. Staff members should also be more careful in communicating findings to parents so as not to induce unnecessary anxiety. The communication between client and staff should be conducted in an environment where privacy can be ensured. In addition, information should be provided to clients, especially first time clients, to orientate them of service procedures. To improve the efficiency of the service and to reduce waiting time, streamlining procedures or adopting an appointment system might be possible options.

Conclusion

Overall, in the perception of the participants, they have knowledge of and access to MCHC services and there is a sense of endorsement of the range of service provided by MCHC. However, there are also concerns about the service, which arise out of their personal experiences while using the service. The major areas of concerns that emerged from the data include concerns about staff-client relationship, service operations and procedures, the provision of health information, the physical environment and facilities. These concerns are based on their actual experiences in using the service.

The one single theme that links up the above concerns is the theme of communication, both verbal and non-verbal. Satisfactory two-way communication between clients and staff members in a suitable environment could potentially alleviate feelings of anxiety, confusion, embarrassment and depersonalisation. Conversely, failure to do so could potentially aggravate feelings of anxiety, confusion and depersonalisation. Client-staff communication are also regarded as means of empowering the clients, giving them control over the information and the services that they would like to receive, thus promoting their self-esteem and sense of psychological security and personal control over their health.

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