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Why are people dissatisfied with medical care services in Lithuania? A qualitative study using responses to open-ended questions


1Department of Social Medicine, Kaunas University of Medicine, Lithuania

  2Viherlaakso Centre for Health and Social Services, Espoo, Finland

Objectives. To identify and describe the main sources of dissatisfaction with medical services among the population in Lithuania.

Design. Analysis of written responses to an open-ended question as a part of a questionnaire survey.

Participants. A randomly selected group of 25-64-year-old men and women from the Utena and the Kaisiadorys regions of Lithuania. Of the 1395 survey respondents, 357 persons (25.6%) answered the question regarding the dissatisfaction with health care services.

Main outcome measures. Identification of the sources of dissatisfaction with medical care services among study participants.

Results. Twelve categories of dissatisfaction were identified that were related to three levels: shortcomings in the health care system (systemic level), deficiencies in provision and quality of services (institutional level) and deficiencies in physicians‘ attitudes, skills and work (inspanidual level).

Conclusion. Consumers‘ perceptions of medical care quality can be analysed by using information obtained from simple survey material and can be used to improve the quality of service. The causes of dissatisfaction with medical service can be traced to the development of the health care delivery system and patients‘ rights in a country.

Key words

    * dissatisfaction
    * general population
    * medical services
    * qualitative study
    * physicians‘ skills and attitudes

Over the past 20 years, the quality of health care services has become an important issue and consumer satisfaction has been recognized as a factor that contributes to quality of care. In spite of agreement on the importance of consumers‘ opinions for efforts to improve the quality of health care, there is still limited evidence concerning the mechanisms that most effectively measure views about health care quality. One method used in Western industrialized countries is patients‘ satisfaction studies, which have been used to evaluate processes in health care in order to develop a ‘customer-oriented service culture‘ [1].

Lithuania inherited the soviet model of health care provision, which is characterized by the dominance of bureaucracies over a whole society. In the soviet context, physicians assumed control over patients, and there was no movement for patients‘ rights. Patients felt compelled to make informal payments to physicians and other medical personnel [2]. As a result, present Lithuania faces problems in terms of patients‘ perceived quality of health care. Lithuania has been affected by the regional restructuring of health care, and over the last 10 years has undergone profound changes in health care. Available state revenue for the health sector has decreased due to an economic recession in the early 1990s, which had a negative impact on the development of the health sector. Since 1996 the health care system in Lithuania has been in the process of moving away from an integrated bureaucratic model towards a contractual model. Major changes in the system have been driven by the appearance of a third-party payer in the form of a statutory health insurance system and enforcement of legislation redefining property rights and the status of health care institutions [3]. In addition, health care reform in Lithuania has aimed to increase patients‘ choice, strengthen patients‘ rights and increase quality of care while maintaining accessible health care for consumers [4].

Traditionally users‘ views of health care have been evaluated through satisfaction studies. Researchers have tended to use questionnaires to assess satisfaction, but many questionnaires have been seen as problematic. As Whitfield and Baker pointed out, ‘poor questionnaires may limit the opportunity of patients to express their concerns about different aspects of care‘ [5]. A strictly formulated questionnaire might miss important aspects of the service experience. From the methodological point of view there seem to be two problems: (1) using a questionnaire to measure satisfaction may result in obtaining answers only to the questions we have asked, and (2) asking about satisfaction might result in high scores for general satisfaction but might ignore perceptions of negative experience with services. Because of these limitations, several authors have advocated alternatives for questionnaire-based satisfaction studies.

A number of authors have recommended devoting more attention to qualitative methodologies to assess the whole satisfaction-dissatisfaction phenomenon in a comprehensive and patient-oriented way, because good and validated quantitative methods are still lacking [6,7]. For example, Pichert et al. reported a qualitative analysis of 12 000 patient complaint narratives, where the reasons for complaints were classified into six categories. In this way the material could be sorted and elaborated to yield very practical advice for quality improvement [8].

The concept of ‘satisfaction‘ and the use of it in studies are problematic. Publication of satisfaction studies reached their peak in 1994, reflecting the changes in service management in the US and the UK [1]. A meta-analysis of over 100 studies showed that results of satisfaction should be interpreted carefully due to the lack of theoretical foundations on which the concept of ‘satisfaction‘ and its ‘measurement‘ are based. The validity and reliability of many studies of health care consumers‘ satisfaction have been questioned [9]. Measurement and interpretation of patients‘ satisfaction reveal several problems. Williams and colleagues identified the problems inherent in the term ‘satisfaction‘ [10]. They argue that the model for satisfaction is more complex than an expression of fulfilment of expectations. Satisfaction-and dissatisfaction-result in a process in which expectations, service experience and ‘culpability‘ of the service provider are involved. The authors demonstrated that even those service users whose needs were not met by the service would frequently express satisfaction with the service. In their study, dissatisfaction was only expressed when the following factors were present: the needs of the patient were unmet; the patient perceived the request as a ‘duty‘ of the service; the service was perceived as ‘culpable‘ of not meeting the need; and there were no mitigating factors for this ‘culpability‘ [11]. According to Williams et al. [11], dissatisfaction levels may be of more use as an indication of a negative experience, which high reported levels of satisfaction do not capture.

From the practical point of view of quality improvement, studying dissatisfaction might also be more important than studying satisfaction in the identification of system malfunctions. As Coyle pointed out, studying expressions and the meaning of dissatisfaction will provide us with information on lay beliefs about health care functioning and bases of criticism [12].

We wanted to explore the opinions about health care services among citizens in Lithuania. In this study we aimed to assess what reasons the inhabitants give for their dissatisfaction with health care services. The topic has been very little studied in Lithuania where the health care system has been extensively reorganized since 1991. To be able to describe the phenomenon with concepts used by ordinary citizens, we chose to use qualitative methods to analyse the unstructured material derived from open-ended answers in a questionnaire. We wanted to create categories that could increase understanding of the phenomenon. This, in turn, would provide us with a means to understand and improve medical care services from the point of view of the health care consumer

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