patient satisfaction and experience at migrant health

Patient satisfaction and experience at migrant health centres in Turkey

Abstract

A cross-sectional study of patients attending migrant health centres in 16 provinces in Turkey showed an overall satisfaction rate of 78.2% with health services. This is relatively high compared with similar studies that have evaluated services provided by a specialized unit for refugees or with sensitivity to language and cultural needs. The service with the highest satisfaction rate was psychological or social assistance (84.8%). Factors related to service and communication were significant determinants of patient satisfaction. Respondents who received explanations of their medical condition from the doctor were 8.9 times more likely to be satisfied. Respondents who felt that they had enough time with the health worker or received a comprehensive examination and respect from both doctors and nurses were more likely to be satisfied. The amount of time spent waiting to see a health worker was also a significant predictor of patient satisfaction. Some improvements in physician–patient interaction and communication are recommended to empower patients to participate in managing their treatment and overall health.

Photo coverpage: © SIHHAT Design and layout: 4PLUS4.dk

Document number: WHO/EURO:2021-2488-42244-58324

Keywords

REFUGEEPATIENT SATISFACTIONCLIENT SATISFACTIONREFUGEE HEALTH

© World Health Organization 2021

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Patient satisfaction and experience at migrant health centres in Turkey

iii

Contents

Preface ............................................................................................................................ iv

Acknowledgements .......................................................................................................... v

Abbreviations ................................................................................................................... v

Executive summary .......................................................................................................... vi

Introduction ...................................................................................................................... 1Background ........................................................................................................................................... 1Methodology ......................................................................................................................................... 3

Results ............................................................................................................................. 7Sociodemographic characteristics of participants ....................................................................... 7Access and utilization of services in MHCs .................................................................................... 8Patient experience at MHCs .............................................................................................................. 10Patient satisfaction .............................................................................................................................. 13Determinants of patient satisfaction and experience ................................................................... 16

Discussion ........................................................................................................................ 19Patient satisfaction and expectations ............................................................................................. 19Factors that determine patient satisfaction in MHCs ................................................................... 20Strengths and limitations ................................................................................................................... 21Patient feedback mechanisms .......................................................................................................... 21Recommendations .............................................................................................................................. 22

Conclusions ..................................................................................................................... 23

References ....................................................................................................................... 24

Annex 1. Patient satisfaction form .................................................................................... 28

Annex 2. Patient experience by type of facility .................................................................. 33

iv

Preface

The conflict in the Syrian Arab Republic has caused one of the world’s largest and most dynamic displacement crises, affecting millions of lives. WHO is supporting the response to the crisis through its operations in Turkey, which comprise a cross-border response from the field office in Gaziantep and a health response to refugees in Turkey, coordinated by the WHO Country Office in Ankara. In north-western Syrian Arab Republic, WHO is implementing interventions such as the delivery of vital medicines and medical supplies and providing support for the operational costs of health facilities and capacity-building of health staff. Through the Refugee Health Programme in Turkey, efforts have been made to strengthen the national health system through integrating Syrian health workers and translators, building capacity for mental health care, providing linguistic and culturally sensitive health services, and supporting home care for older refugees and those with disabilities.

Activities of the Programme are defined within the scope of the Regional Refugee and Resilience Plan 2018–2019, a broad partnership platform for over 270 development and humanitarian partners to provide coordinated support in countries bordering the Syrian Arab Republic that are heavily impacted by the influx of refugees. This platform capitalizes on the knowledge, capacities and resources of humanitarian and development actors to provide a single strategic, multisectoral and resilience-based response. Supported by several donors, WHO’s activities are complementary to the Ministry of Health-implemented SIHHAT

(Improving the health status of the Syrian population under temporary protection and related services provided by Turkish authorities) project that is funded by the European Union (EU). This project operates under the EU’s Facility for Refugees in Turkey and focuses on strengthening the provision of primary and secondary health services to Syrian migrant/refugee, building and supporting a network of migrant health centres across the country, and employing additional health personnel, including Syrian doctors and nurses.

In November 2018 the Refugee Health Programme conducted the Workshop on Refugee and Migrant Health in Turkey: Survey and Research Consultation to identify gaps in the information and evidence required for Programme development and adaptation and for informing policies on migrant health in Turkey. The Workshop brought together more than 57 national and international experts from academia, the Ministry of Health, United Nations agencies and WHO collaborating centres and led to the formulation of the Programme’s research framework. Within this framework, a series of studies was implemented in the fields of mental health, health literacy, women and child health, health workforce, and noncommunicable diseases. This study, Patient satisfaction and experience at migrant health centres in Turkey, is one of the studies implemented within the Refugee Health Programme’s research framework. It was implemented within the scope of the Improved access to health services for Syrian refugees in Turkey project with funding from the EU Regional Trust Fund in Response to the Syrian Crisis.

v

Acknowledgements

The WHO Health Emergencies team in Turkey would like to thank all stakeholders who contributed to the implementation of this study. Special thanks go to Kanuni Keklik and Özlem Kahraman Tunay of the Migration Health Department, Ministry of Health of the Republic of Turkey, and to Mr Inanc Sogut and Prof. Meliksah Ertem of the SIHHAT project, Ministry of Health of the Republic of Turkey. Thanks also go to Omur Cinar Elci, Melda Keçik, Çetin Doğan Dikmen, Pelin Cebeci, Elif Göksu, Nurtaç Kavukcu, Kadriye Küçükbalci, Mustafa Bahadir Sucakli and Altin Malaj of the WHO

Country Office in Turkey and to Oguzhan Akyildirim, Pinar Sağlik and Alev Yucel of TANDANS Data Science Consulting for their valuable contributions to designing, data collection, data analysis and the overall implementation of the study.

AuthorsThe principal authors of this report are Hanna Radysh and Monica Zikusooka, WHO Country Office in Turkey, WHO Regional Office for Europe.

Abbreviations

3RP Regional Refugee and Resilience PlanAOR adjusted odds ratioCAHPS Consumer Assessment of Healthcare Providers

and SystemsCI confidence intervalEU European UnionMHC migrant health centreMHTC migrant health training centreNHS National Health Service (United Kingdom)OR odds ratioSDGs Sustainable Development GoalsSIHHAT Improving the health status of the Syrian

population under temporary protection and related services provided by Turkish authorities (project)

UHC universal health coverage

This document was produced with the financial assistance of the European Union. The views expressed herein can in no way be taken to reflect the official opinion of the European Union.

vi

Executive summary

Universal health coverage (UHC) is a global priority and the basis for achieving other health-related Sustainable Development Goals (SDGs) (1). At the core of several international commitments, including the United Nations Global Compact on Refugees (2) and the Global Compact for Safe, Orderly and Regular Migration (3), is UHC, which was endorsed by the Sixty-first World Health Assembly in resolution WHA61.17 on the health of migrants in 2008 (4). In line with these international commitments, Turkey has taken steps to ensure access to health for its estimated 3.6 million Syrian refugees.

UHC should be embedded in a strong primary health-care system offering people-centred health services. For the Syrian refugee population in Turkey, this is pursued through a network of migrant health centres (MHCs) that provide cultural and linguistically sensitive services. This study was undertaken to assess patient experience and satisfaction with services provided in MHCs, to identify the determinants of patient satisfaction and potential areas to improve patient satisfaction or dimensions of the patient experience.

A patient survey was conducted between November 2019 and March 2020. Data was collected through face-to-face interviews using a quantitative questionnaire developed by WHO in the Yemen emergency response. The tool was adopted for this study because of its suitability to the context of the health humanitarian response in Turkey. Prior to implementation, the tool was adapted to the Syrian Arabic dialect and pre-tested. In all, 4548 patients and caregivers who received services from MHCs, extended MHCs and migrant health training centres (MHTCs) in 16 provinces participated in the study

More than 70% of respondents had arrived in Turkey after 2013, and 27.3% had arrived after 2016. Nearly two thirds (64.5%) of respondents were women. Most respondents (81.5%) were aged under 45 years, and almost a quarter of the respondents (23.7%) were illiterate. Most respondents had visited the MHC at least twice in the previous three months, and the majority had visited the MHC for a general consultation

When asked about the overall level of satisfaction with the health services that they had received at the MHC, 78.2% of all respondents said they were satisfied: 80.1% of men and 77.2% of women. Compared with the other age groups, significantly more respondents aged 60 years and over were satisfied with the health services that they had received at the MHC (P < 0.001). Higher proportions of respondents with no education and those who had arrived in Turkey in or before 2013 were satisfied compared with the other subgroups. Respondents had the highest level of satisfaction with psychological or social assistance services (84.8%), whereas lowest levels of satisfaction were for emergency services (17.6%) and dental services (8.3%). However, most respondents (89.4%) were unaware of the existence of any feedback or complaint mechanism.

Although both gender and age had a significant effect on patient satisfaction, when other factors were considered none of the patient characteristics had a significant influence on patient satisfaction. All communication and quality of service-related variables were significant predictors of patient satisfaction when all the other factors were controlled for. However, the type of MHC was not a significant predictor of patient satisfaction. The strongest service-related predictors of satisfaction were having sufficient length of consultation (adjusted odds ratios (AOR): 2.37; 95% confidence interval (CI): 1.76–3.21; P < 0.000), receiving a comprehensive examination (AOR: 2.01; 95% CI: 1.49–2.70; P < 0.000) and being treated with respect by the nurse (AOR: 2.08; 95% CI: 1.52–2.85; P < 0.000). Receiving an explanation of the medical condition from the doctor was the strongest predictor of patient satisfaction among communication-related variables (AOR: 1.98; 95% CI: 1.48–2.53; P < 0.000).

Although most patients were satisfied with services in MHCs, improvements in physician–patient interactions and communication are recommended to empower patients to participate in managing their treatment and overall health. In particular, physicians should inform patients about medicine side-effects and danger signs and consultation times should be increased, perhaps by reducing the patient-to-physician ratio. Reducing waiting

vii

times could also improve patient satisfaction. This study provides evidence that greater promotion of MHC services among refugee communities could increase their utilization and reduce the burden on secondary care facilities.

Recommendations are as follows.

• Improving patient experiences related to consultation time, waiting time and quality of physician–patient communication could improve satisfaction with MHCs. In addition, examining and addressing the causes of dissatisfaction for services that had a lower level of satisfaction would help to improve patient satisfaction.

• Implement a targeted campaign to increase the use of MHC services, especially as the Ministry of Health plans to expand the MHC network. The high level of patient satisfaction established in this study could be useful for the campaign.

• With increased service utilization in MHCs, an objective estimation of the patient-to-physician ratio based on patient records is needed to determine physician workload and its potential impact on the quality of services and patient satisfaction.

• Support physicians in MHCs to improve their communication skills. Specific emphasis on communicating with patients about medicines would cover the observed gap in patient satisfaction while improving the rational use of medicines.

• MHCs should consider implementing and promoting a variety of feedback and complaint mechanisms that can be safely accessed and used by a diverse population to gather feedback to improve services. These may include, but are not limited to, complaint boxes and toll-free telephones.

Patient satisfaction and experience at migrant health centres in Turkey 1

Introduction

UHC is a global priority and the basis for achieving other health-related SDGs (1). Under UHC, all people have access to health services when they need them, wherever they are and without financial hardship. UHC provision for refugees and migrants is the subject of several international commitments on human rights, including the United Nations Global Compact on Refugees (2) and the Global Compact for Safe, Orderly and Regular Migration (3), and was endorsed by the Sixty-first World Health Assembly in resolution WHA61.17 on the health of migrants in 2008 (4). Turkey currently hosts an estimated 3.6 million Syrians, of whom 23% are women of reproductive age and 14% are children aged 0–4 years (5). Law No. 6458 on Foreigners and International Protection provides emergency and temporary protection under Article 91 for foreigners in Turkey who have been forced to leave their country and cannot return (6). Syrian refugees in Turkey are classified as Syrians under temporary protection. In line with these international commitments, the country has taken steps to ensure access to health for its large refugee population. Globally, refugees and migrants often face challenges in accessing health care, including language and cultural differences (7–9), low health literacy (7,10), difficulties in understanding the health system (8), legal status, lack of awareness of their health rights (11) and financial limitations (7). The Government of Turkey has sought to address such challenges by expanding the capacity of its health system and developing legislation to ensure access to health care for refugees.

According to WHO, UHC should be embedded in a strong primary health-care system offering people-centred health services that “consciously adopts the perspectives of individuals, families and communities, and sees them as participants as well as beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways” (9). People-centred health services focus on individuals rather than diseases, coordinate care around people’s needs while respecting their preferences, and enable people to participate in managing their own health affairs. Further, providing integrated people-centred services is critical to achieving UHC goals, especially for disadvantaged populations. Assessments of patient experience and satisfaction with health services provide insight into the patient-centredness of services.

Background

Refugee access to health care in TurkeyIn 2015 the Government of Turkey adopted a regulation to allow Syrians registered as under temporary protection access to free emergency medical treatment and to preventive and primary health services (10). In addition to the existing primary health facilities, a network of MHCs was later introduced to provide culturally sensitive health services in their own language. The Government’s response to refugee health needs is complemented by interventions supported through the SIHHAT project, with the main objective to increase national health system capacity to provide high-quality, free-of-charge health services to Syrians under temporary protection in Turkey (10). The SIHHAT project is implemented in 29 provinces with a high population density of Syrian refugees. As of August 2020, SIHHAT had 175 MHCs that have provided 13 million primary health-care consultations (10). The health services provided through MHCs in Turkey are free of charge for registered Syrians and are expected to meet national equity standards.

Overall, a response to the needs of Syrians under temporary protection in Turkey is annually articulated in the Regional Refugee and Resilience Plan (3RP) with the health sector focusing on building resilience of the health system (12). In contributing to the 3RP objectives, WHO is implementing a refugee health programme with activities that include capacity-building for Syrian health workers, provision of quality people-centred health services for refugees, support for mental and psychosocial needs, and coordination of the Health Working Group.

2 Patient satisfaction and experience at migrant health centres in Turkey

MHC mechanismPrimary health care is the basis to achieving UHC and the SDGs (13). In Turkey, primary health care is provided through community health centres and family health centres. As part of the community health centre network, the Government of Turkey established MHCs under the SIHHAT project to meet the health needs of the Syrian population in Turkey. The MHC mechanism was planned and implemented based on the organization of primary health services in Turkey; the first MHCs were established in August 2015. The mechanism includes MHCs (or standard MHCs), extended MHCs and MHTCs. MHCs comprise several refugee health units, with each consisting of a physician and nurse pair. Extended MHCs provide additional services, including internal medicine, paediatric, obstetrics and gynaecology, oral and dental health, psychosocial support, and simple imaging and laboratory services. There are also seven MHTCs that, in addition to providing all of the services of extended MHCs, have training facilities for health workers and are jointly managed by the Ministry of Health and WHO. MHCs mainly provide services to Syrian refugees but, like all health-care facilities in Turkey, provide communicable disease prevention services (such as vaccination) and emergency health services to all people in need, regardless of nationality and registration status. Most health service providers in MHCs are Syrian nationals. Before being employed in MHCs, they are trained and oriented to work in the Turkish health-care system through a tailored adaptation training programme implemented by WHO in collaboration with the Ministry of Health. The adaptation training is delivered in MHTCs located in seven provinces: Ankara, Gaziantep, Hatay, Istanbul, Izmir, Mersin and Şanlıurfa. Through this action, the Ministry of Health and WHO aim to fill a human resources gap in the delivery of primary health services to Syrian refugees in order to increase access to quality and equitable health care for all. Up to March 2020, WHO and the Ministry of Health had trained 638 physicians, 806 nurses, 927 translators and 337 auxiliary staff who were currently providing services in 178 MHCs located in 29 provinces, and over 1 270 000 Syrian refugees had received health services in MHCs.

Patient experience and satisfactionUnderstanding patient experience and satisfaction with health services is important for monitoring and improving the quality of care. Assessments of patient satisfaction also give patients the opportunity to participate in tailoring health-care provision to their needs, which is a core principle of people-centred health services. Although definitions/concepts of patient satisfaction vary, examining patients’ views on health care and which attributes they value most can provide insights to improve the quality of care and inform strategic decision-making (14,15). In addition, satisfied patients are more likely to adhere to treatment plans, which increases the chance of good health outcomes, and to have fewer diagnostic tests and referrals, which increases the efficiency of care (14,16). Satisfied patients are also likely to return or recommend the services they have received to others, thereby helping to improve service utilization (17).

Studies on people-centred care and patient satisfaction have produced a wide body of evidence and analytical tools (18–22). For refugees, migrants and asylum seekers, high levels of patient satisfaction were found when health services were provided in specialized units or delivered with language and cultural sensitivity (18–21). Assessments have shown that multiple factors related to the health worker influence patient satisfaction, including technical expertise, interpersonal care (e.g. communication), physical environment, access (i.e. accessibility, availability and cost), organizational characteristics, continuity of care, treatment outcome, and length of consultation with the doctor (14,22). In addition, patient characteristics such as age, gender, education, socioeconomic status, marital status, race, religion, geographical characteristics, frequency of visits, length of stay in Turkey, health status, personality and expectations were also found to influence patient satisfaction, but with inconsistent strength and direction of effect (22). Although patient satisfaction is a common outcome measure in health care assessments, it may be influenced by patients’ expectations as much as by the quality of the care provided. That is, the match between patient expectations and what care is provided also influences patient satisfaction (18–25).

Within the humanitarian context, assessing the satisfaction of patients who receive services from MHCs is critical for accountability to the people most affected by the Syrian conflict. Accountability demands that actions to help people in need are driven by the needs, desires and capacities of the people affected and implemented in a respectful way. In this regard, the humanitarian sector has committed to giving affected populations the opportunity to provide feedback on the goods and services they have received through humanitarian actions (25,26).


A SIHHAT baseline survey on health needs of Syrian refugees in Turkey assessed their utilization and satisfaction with health services. Of the 869 respondents, 88% had accessed services from state/university hospitals, whereas only 29.5% had accessed services from MHCs. In all, 72% of those who had received services from hospitals were satisfied, compared with 65% of those who had attended MHCs. The main reasons given for satisfaction were the availability of medicine, quality of treatment and quality of nursing; in contrast, the main reasons given for dissatisfaction were lack of good treatment and difficulty in communicating owing to a lack of interpreters. Although this information is important for improving access, utilization and satisfaction with health services for Syrian refugees, it may have limited applicability to MHCs because of the small proportion of respondents who had used MHC services. However, the study provides a benchmark for monitoring improvements in MHCs. The present patient satisfaction survey included a larger patient sample and collected data in MHCs to ensure that respondents had recent experience of receiving MHC services.

Study aims and objectivesUnderstanding the level of patient satisfaction in MHCs is useful to ensure a people-centred approach to health service delivery. Although MHCs have been operational since 2015, evidence is lacking on patient experience and satisfaction with services from a representative sample of users. This study was undertaken to collect evidence and beneficiary feedback on services received and their expectations to improve the humanitarian response. The objectives were to:

• assess patient experience and satisfaction level with services provided in MHCs in Turkey; • identify the determinants of patient satisfaction; and • identify potential areas to improve the quality of care in terms of patient satisfaction or dimensions of the patient

experience.

MethodologyA patient survey was conducted between November 2019 and March 2020. Participants were patients and caregivers who received services from MHCs, extended MHCs and MHTCs in 16 provinces (Table 1).

Study design and populationThis cross-sectional survey targeted patients attending MHCs with more than 10 refugee health units in 16 Turkish provinces. Provinces with the highest number of patient consultations were selected to enable representative sampling of patients receiving services from MHCs. A proportional stratified sampling approach was followed to estimate the required sample size based on the number of total patient consultations in each province from 2015 until March 2019. The sample size was estimated using WinPepi (version 11.65) with a 95% CI, 0.05 error margin and 20% loss to follow-up. The final sample size was estimated at 4460 individuals, which was distributed proportionally between the 16 provinces and three types of MHC. Table 1 shows the sample distribution by province and type of MHC.


Table 1. Sample distribution by province and type of MHC

Province Sample estimation Final study population

Refugee health units (n) Patients interviewed (n)

MHCs E-MHCs MHTCs MHCs E-MHCs MHTCs

Adana 5 7 0 150 210 0 353

Ankara 1 2 1 65 130 65 202

Bursa 4 3 0 120 90 0 224

Gaziantep 3 2 1 150 100 50 451

Hatay 6 4 1 450 300 75 759

Istanbul 7 8 1 210 240 30 566

Izmir 2 1 1 116 58 58 197

Kahramanmaraş 4 5 0 120 150 0 317

Kayseri 2 2 0 60 60 0 100

Kilis 1 9 0 30 270 0 207

Konya 2 3 0 60 90 0 169

Malatya 1 1 0 30 30 0 81

Mardin 1 0 0 37 0 0 90

Mersin 3 2 1 93 62 31 224

Osmaniye 1 4 0 30 120 0 140

Şanlıurfa 4 4 1 232 230 58 468

Total sample 47 57 7 1953 2140 367 4548

4460

E-MHC: extended MHC.

Participants were recruited to the study if they were adult patients (aged > 18 years) or an immediate caregiver of a patient (child, spouse, elderly) receiving health services from the MHC on the day of the survey.

Participants were recruited in MHC reception areas on normal working days at an interval calculated from the average daily patient load of the facility. Interviewers identified potential participants, gave them detailed information about the study and confirmed that they met the inclusion criteria before inviting them to participate. Those who agreed were interviewed in areas that ensured privacy for the respondent. Of the 4665 people who met the recruitment criteria and were asked for interview, 117 refused; therefore, 4548 participants were included in the study.


Data collectionData was collected through face-to-face interviews using a quantitative questionnaire (Annex 1). Tools used in previous studies to assess patient satisfaction in different contexts include the National Health Service (NHS) Patient Reported Outcome Measures (27) and the National Institute for Health and Care Excellence quality standard on patient experience in adult NHS services (28) (United Kingdom); the Picker Patient Experience Questionnaire (29) and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Outpatient and Ambulatory Surgery Survey (30) and CAHPS Hospital Survey (31) (Agency for Healthcare Research and Quality) and a patient satisfaction tool used by WHO in the Yemen emergency (unpublished). The latter was used for this study because of its suitability to the context: it was designed and applied in a humanitarian setting. The questionnaire also addressed the need for accountability to the affected population. It included questions on the accessibility of health-care facilities (including distance from home, physical barriers, waiting time and out-of-pocket costs), overall satisfaction with the health service and the health worker–patient relationship. The questionnaire was pre-tested in a MHC in Altındağ, Ankara to ensure clarity of meaning of translated questions, questionnaire flow, content and language suitability. Following this, minor language adaptations were made to suit the Syrian Arabic dialect.

Prior to commencing data collection, interviewers received training from WHO, the Ministry of Health and Tandans Data Science Consulting.1 Data was collected in Arabic; all interviewers spoke Arabic as a first language. Interviewers used an electronic version of the questionnaire in KoBoToolbox (32) to collect data from interviews conducted in December 2019 and January 2020.

Study variablesBased on a literature review and the context of Syrian refugees in Turkey, study variables were identified and categorized into four clusters:

• patient characteristics: age, gender, education and year of arrival in Turkey; • accessibility of health services: taken as time taken to reach the MHC; • communication: health worker explains medical tests, doctor explains medical condition, health worker explains

the danger signs; and • quality of service: health worker spends enough time with the patient, health worker carries out a comprehensive

examination, health worker treats me with respect, waiting time and type of MHC.

Data cleaning and analysisData cleaning was done to identify and resolve inconsistencies and ensure completeness. A total of 15 incomplete records were removed because answers were missing for more than 60% of the questions, especially those related to satisfaction statements. Records with entry errors that could be corrected based on other entries were corrected, whereas those with errors that could not be corrected were removed. Further, responses to multiple choice questions that had the “other” option were recoded into new categories during the analysis.

Information on variables in the communication and service clusters was collected on a five-point scale (strongly disagree, disagree, neither agree nor disagree, agree, strongly agree) and re-categorized into two for analysis: the first three responses were categorized as “disagree” and the last two as “agree”. Patient responses for the statement “Overall, the health services I have been receiving are satisfactory” were also collected on a five-point scale (shown above) and re-categorized as two (disagree—unsatisfied) and (agree–satisfied) for analysis.

Descriptive analyses were conducted to describe the distribution of sociodemographic characteristics and other study variables. Patient experiences and satisfaction were analysed both overall and for the different facility types. Logistic

1 An independent consultancy based in Ankara.


regression was conducted to identify factors that influenced patient satisfaction. To fit the logistic regression models, variables with a significant influence on patient satisfaction (P < 0.05) were included, and AORs were calculated with 95% CIs. In the first model fitted, only patient characteristics (age, gender, education, year of arrival in Turkey) were adjusted, whereas in the second model all variables were adjusted by including them in the model. Data analysis was performed using IBM SPSS Statistics version 25.


Results

Sociodemographic characteristics of participantsMore than 70% of participants had arrived in Turkey after 2013, and 27.3% had arrived after 2016 (Table 2). The average household size was 5.9 people. Nearly two thirds (64.5%) of respondents were women. Most participants (81.5%) were aged under 45 years. Almost a quarter of the respondents (23.7%) were illiterate (not able to read and write) and nearly half (48.4%) had completed primary education only.

Table 2. Sociodemographic characteristics of respondents

Characteristic Number (n) Percentage (%)

Gender (n = 4533)

MenWomen

16082925

35.564.5

Age, years (n = 4533)

18–2930–4445–5960 and above

17941900

677162

39.641.914.93.6

Education level (n = 4505)

No educationCompleted primary educationCompleted secondary educationUniversity degree/equivalent or higher

10692180

762494

23.748.416.911.0

Employment status (n = 4522)

WorkingNot working

10803442

23.976.1

Year of migration (n = 4528)

≤ 201320142015≥ 2016

1205105710281238

26.623.322.727.3

Overall, about a quarter of respondents (23.9%) were currently employed, but the proportion was higher for men than for women (52.3% vs 8.2%). Regarding employment sectors, half of employed respondents (50.5%) were working in sales and services, 13.8% in agriculture and 12.4% in teaching. Most male respondents were employed in the sales and services sector (57.6%), and similar proportions of female respondents were working in the teaching (28.7%), sales and services (25.4%), and agricultural (23.8%) sectors.


Access and utilization of services in MHCsMost respondents had visited the MHC without obtaining any information about the services available in MHCs. Only 6.2% had been referred to the MHC; of theses, most (61.8%) had been referred from another MHC (Table 3). The Turkish Red Crescent was another important source of information about MHCs.

Table 3. Access to health facilities

Dimension Standard MHC Extended MHC MHTC Total

n % n % n % n %

Did you have information about this health facility before you visited?

YesNo

1141931

5.694.4

1301566

7.792.3

39699

5.394.7

2834196

6.393.7

If so, where did you get the information from?

Another MHCTurkish Red CrescentOther outreach teamOther _____

6115

830

53.513.2

7.026.3

9719

311

74.614.6

2.38.5

17778

43.617.917.920.5

175411849

61.814.5

6.417.3

In the last 3 months, how many times have you/the patient visited this health facility?

123> 3

430613473549

20.829.722.926.6

300571406431

17.633.423.825.2

141303159157

18.639.920.920.7

871148710381137

19.232.822.925.1

How did you get to the facility today?

WalkedPrivate transport or taxiPublic transportOther means

1316301408

39

63.814.619.8

1.9

942304400

62

55.217.823.4

3.6

342151256

11

45.019.933.7

1.4

2600756

1064112

57.416.723.5

2.5

How long did it take you to get here today from your home?

0–15 minutes16–30 minutes31–45 minutes> 45 minutes

1290605

8980

62.529.3

4.33.9

1001556

7869

58.732.6

4.64.0

365301

5043

48.139.7

6.65.7

26561462

217192

58.732.3

4.84.2

How much did it cost you/the patient to get here today (one way)?

< 5 TL5–10 TL≥ 10 TL

308154130

52.026.022.0

320137118

55.723.820.5

2217271

60.719.819.5

849363319

55.523.720.8

Once you arrived at the health facility, how long did you wait to be seen by a health worker?

< 20 minutes21–60 minutes61–90 minutes> 90 minutes

1366519

40136

66.325.2

1.96.6

978564

45119

57.333.1

2.67.0

428277

2431

56.336.4

3.24.1

27721360

109286

61.230.0

2.46.3


Most respondents had visited the MHC at least twice in the previous three months. Respondents aged 45–59 years had visited the MHC slightly more frequently than other age groups. More than half had walked to the MHC on the day of the interview (57.4%; Table 3). Of those who had used some other means of transport, most (55.5%) had paid transportation costs of less than 5 Turkish lira. Irrespective of the means of transport, the average time taken to reach the MHC was 19.3 minutes.

Almost one fifth of the respondents had visited the MHC to consult a specialist physician (19.2%). About two thirds of respondents (63.7%) had attended the MHC for one service, 29.3% had attended for two services and 6.9% for more than two services (Table 4). Most respondents had visited the MHC for a general consultation, followed by investigation – diagnostic tests, vaccination, and pregnancy-related (pregnancy or prenatal care) and infant-care services (Fig. 1).

Fig. 1. Overall service utilization in MHCs

Table 4. Service utilization by type of MHC

Reason/s for this visit Standard MHC Extended MHC MHTC

n % n % n %

Pregnancy-related consultation 64 3.1 122 7.1 46 6.1

Infant consultation (postnatal care) 70 3.4 51 3.0 51 6.7

Vaccination 447 21.6 294 17.2 178 23.4

General consultation 1409 68.2 1183 69.3 480 63.2

Dental care 22 1.1 21 1.2 5 0.7

Family planning 54 2.6 50 2.9 41 5.4

Investigation – diagnostic tests 713 34.5 680 39.8 290 38.2

Emergency 46 2.2 64 3.7 25 3.3

Wound care 17 0.8 7 0.4 2 0.3

Psychological or social assistance 8 0.4 20 1.2 6 0.8

Medical certificate 32 1.5 47 2.8 11 1.4

Other 0 0.0 2 0.1 0 0.0

Total 2882 100 2541 100 1135 100

0 500 1000 1500 2000 2500 3000 3500

OtherWound care

Psychological/social assistanceDental care

Medical cer�ficateEmergency careFamily planning

Infant carePregnancy-related consulta�on

Vaccina�onInves�ga�on – diagnos�c tests

General consulta�on

Respondents


Slightly more than half of the respondents (56.3%) had visited the MHC to obtain health services for themselves, 34.2% to obtain health services for their children and 8.0% to obtain health services for their spouse.

More than half (54.1%) of the respondents had attended the MHC within a day of needing health care (Fig. 2). Among those who delayed seeking health care by one day or more, the main reason was that they thought that they (or the patient) was not sick enough and would get better on their own (67.1%; Fig. 3).

Fig. 2. Time to seek care

Fig. 3. Reasons for delayed care seeking

Patient experience at MHCsParticipants were asked about their experiences at the health facility regarding services received and waiting time; interaction with physicians and nurses, receiving medication, their willingness to recommend services and intention to return. Annex 2 presents the responses by type of health facility.

Services received and waiting timeOn the day of the survey, 88.5% of respondents thought that they had fully received the health service that they needed at the MHC, and very few thought that they had partially received (6.9%) or not received (4.5%) the health service that they needed. The average waiting time to be seen by a health worker was 29.9 minutes (Table 3). Most respondents felt that they had not had to wait long to see the doctor (71.5%), but almost 20% disagreed (Fig. 4).

0

10

20

30

40

50

60

< 1 1–3 4–7 8–30 > 30

Perc

enta

ge (%

)

Time (days)

Fig 3

Fig 4

0 10 20 30 40 50 60 70 80

Worried about the cost of care

Worried about the safety of travelling to care

Didn’t think the health facility would be able to help due to lack of doctors, medicines or supplies

Appointment

Other

Didn’t think I was sick enough or thought the problem would getter better on its own

Percentage (%)

0 10 20 30 40 50 60 70 80 90 100

The doctor treats me with respect

The nurse treats me with respect

I understand the diagnosis from doctors at MHCs

The doctor spends enough time with me to answer all myquestions

The doctor spends enough time with me to explain mymedical condition

The doctor is careful to check everything when examiningme

I trust the doctor’s skills at the MHC

I trust the nurse’s skills at the MHC

The doctor explains the reason for medical tests

When I come to the MHC, I don’t have to wait long to see a doctor

The doctor told me about danger signals related to mydiagnosis to look out for at home

Percentage (%)

Agree Neutral Disagree


Physician–patient interaction and communicationOver 80% of the respondents said that the doctors and nurses had treated them with respect (Fig. 4). A similar proportion (80.0%) thought that the doctor had taken care to examined them fully and taken enough time to explain the medical condition and answer their questions. Nevertheless, almost 20% were not sure or disagreed that the doctor had comprehensively examined them or spent enough time with them. In all, 10% of respondents thought the doctor had not spent long enough examining them or explaining their medical condition. Slightly over 50% had been told about danger signs to look out for at home.

Fig. 4. Patient experience in MHCs

MedicinesMost respondents had been prescribed medicine on the day of the survey (87.0%) and 81% considered that the doctor had explained the medication use either fully or partially. Most said that they understood the purpose of the treatment and the prescribed medicines (79.5%; Fig. 5). In all, 79.4% said that they understood how to use the medicines that they had been prescribed that day; however, 12% did not understand how to use the medicines and 8.6% were not sure. Less than 50% of the respondents said that they had been informed about medication side-effects.

Fig. 5. Use of medicines

Willingness to recommend services and intention to returnBased on their experience at the MHC, 86.1% of respondents said that they would return to the facility if they needed another health service, and 83.7% said that they would recommend the health facility to other people (Fig. 6). Only 11.6% of respondents said that they would go to a private practice for further consultation after visiting the MHC.

Fig 3

Fig 4

0 10 20 30 40 50 60 70 80

Worried about the cost of care

Worried about the safety of travelling to care

Didn’t think the health facility would be able to help due to lack of doctors, medicines or supplies

Appointment

Other

Didn’t think I was sick enough or thought the problem would getter better on its own

Percentage (%)

0 10 20 30 40 50 60 70 80 90 100



I understand the diagnosis from doctors at MHCs

The doctor spends enough time with me to answer all myquestions

The doctor spends enough time with me to explain mymedical condition

The doctor is careful to check everything when examiningme




When I come to the MHC, I don’t have to wait long to see a doctor

The doctor told me about danger signals related to mydiagnosis to look out for at home

Percentage (%)


Fig 5

Fig 6

0 10 20 30 40 50 60 70 80 90 100

I understand the purpose of the treatment andprescribed medicines

I understand how to use the medicines thatwere prescribed to me today

I was informed about medication side-effects

Percentage (%)


0 20 40 60 80 100

Based on my experience here, I willrecommend this health facility to other

people

Based on my experience here, I will return tothis health facility for a service in the future

if needed

Percentage (%)



Fig. 6. Intention to return and recommendation

Patient satisfactionWhen asked about their overall level of satisfaction with the health services that they had received at the MHC, 78.2% of all respondents said that they were satisfied: 80.1% of men and 77.2% of women (Table 5). Compared with the other age groups, significantly more respondents aged 60 years and over were satisfied with the health services that they had received at the MHC (P < 0.001). Higher proportions of respondents with no education and those who had arrived in Turkey in or before 2013 were satisfied compared with the other subgroups.

Table 5. Patient satisfaction with the MHC services, by demographic characteristic

Characteristic Satisfieda Neutral Dissatisfieda P valueb

n % n % n %

Gender

MenWomen

12862257

80.177.2

240533

14.918.2

80132

5.04.5

0.017

Age, years

18–2930–4445–59≥ 60

13691475

557142

76.477.782.487.7

337334

8715

18.817.612.9

9.3

868932

5

4.84.74.73.1

0.002

Education level

No educationCompleted primaryCompleted secondaryUniversity degree/equivalent or higher

8881697

583359

83.178.076.672.8

144382129108

13.517.517.021.9

37984926

3.54.56.45.3

< 0.001

Year of arrival in Turkey

≤ 201320142015≥ 2016

976831766967

81.078.874.578.2

179176195221

14.916.719.017.9

50476748

4.14.56.53.9

0.004

Employment status

EmployedUnemployed

8272710

76.778.8

188581

17.416.9

63148

5.84.3

0.092

a Satisfied: agreed with the questionnaire statement; dissatisfied: disagreed with the questionnaire statement.b Pearson’s chi-squared test.

Fig 5

Fig 6

0 10 20 30 40 50 60 70 80 90 100

I understand the purpose of the treatment andprescribed medicines

I understand how to use the medicines thatwere prescribed to me today


Percentage (%)


0 20 40 60 80 100

Based on my experience here, I willrecommend this health facility to other

people

Based on my experience here, I will return tothis health facility for a service in the future

if needed

Percentage (%)



Overall satisfaction by type of MHCAlthough over 70% of all respondents were satisfied with the health services they had received, some variations were noted between the type of MHC (Fig. 7). A significantly higher proportion of respondents was satisfied with standard MHCs (80.0%) than with extended MHCs (79.6%) and MHTCs (70.4%; P < 0.001).2

Fig. 7. Overall satisfaction from the services received by type of facility

Overall satisfaction by type of health serviceThe overall level of satisfaction with services received at MHCs was then stratified by type of health service (Fig. 8). Respondents had the highest level of satisfaction with psychological or social assistance services (84.8%), followed by medical certificate services (82.2%) and wound care (80.8%). The lowest levels of satisfaction were for emergency services (17.6%) and dental services (8.3%), followed by reproductive health and child-care services (6.4%)

Fig. 8. Overall satisfaction by type of services received

2 Based on Pearson’s chi-squared test.

0 10 20 30 40 50 60 70 80 90 100

Standard MHC

Extended MHC

MHTC

Percentage (%)

Agree (satisf ied) Neutral Disagree (dissatisfied)

0 10 20 30 40 50 60 70 80 90 100

Emergency careDental care

Reproductive health and child careVaccination

Investigation – diagnostic testsGeneral consul tation for feeling sick

Wound careMedical certifi cate

Psychological/social assistance

Percentage (%)

Agree (satisfied) Neutral Disagree (dissatisfied)


Patient satisfaction feedback mechanismMost respondents (89.4%) were unaware of the existence of any feedback or complaint mechanism (Fig. 9).

Fig. 9. Patient awareness of a feedback mechanism

Determinants of patient satisfaction and experience Logistic regressions models were used to examine patient characteristics and factors related to MHC services (accessibility, communication and service quality) that might influence patient satisfaction.

Patient characteristicsBoth gender and age had a significant effect on patient satisfaction (Table 6). In simple logistic regression comparisons, the following groups were more likely to be satisfied with the health services they had received at MHCs: women, older people, people with lower education levels and people who had arrived in Turkey before 2013. However, none of the patient characteristics were found to significantly influence patient satisfaction in the multiple regression analysis (i.e. when other factors were added).

Table 6. Logistic regression analysis of patient characteristics that might influence patient satisfaction

Category OR 95% CI P value

Gender (Ref: women)

Men 0.85 0.73–0.98 0.027

Age, years (Ref: 18–29)

30–4445–59≥ 60

1.081.452.19

0.92–1.261.15–1.811.36–3.55

0.3410.0010.001

Education level (Ref: no education)

Completed primaryCompleted secondaryUniversity degree/equivalent or higher

0.720.670.55

0.60–0.870.53–0.840.42–0.71

0.0010.0010.000

Year of arrival in Turkey (Ref: ≤ 2013)

20142015≥ 2016

0.870.690.84

0.71–1.080.56–0.840.69–1.03

0.2020.0000.091

OR: odds ratio.

0

10

20

30

40

50

60

70

80

90

100

Standard MHC Extended MHC MHTC Total

Perc

enta

ge (%

)

Pa�ents who are aware of the feedback mechanism

Pa�ents who are not aware of the feedback mechanism


AccessibilityAccessibility was measured as the time taken for patients to reach a health facility. Using this measure, the accessibility of health services was significantly associated with patient satisfaction. Respondents with longer journey times to reach the health facility were less satisfied (P < 0.05). However, when patient characteristics were controlled for in multiple logistic regression analysis, accessibility ceased to be a significant factor (Table 7).

CommunicationPatient experiences in receiving health information were used to assess communication between the health worker and patient. Respondents who felt that medical tests, medical condition, medication side-effects and danger signs related to their health condition to look out for at home had been explained were more likely to be satisfied than those who did not (P < 0.0001). Respondents who had received explanations about their medical condition from the doctor were 8.9 times more likely to be satisfied than those who had not (odds ratio (OR): 8.93; 95% CI: 7.56–10.56; P < 0.000). All communication variables remained significant predictors of patient satisfaction when all the other factors were controlled for. Receiving an explanation of the medical condition from the doctor was the strongest predictor of patient satisfaction in this category (AOR: 1.98; 95% CI: 1.48–2.53; P < 0.000).

Quality of serviceThe influence of quality of service on patient satisfaction was assessed using the participants’ assessment of length of time spent with the health worker, adequacy of the examination, and level of perceived respect from doctors and nurses, along with the waiting time to see a health worker (from arrival at the facility) and type of MHC.

Respondents who felt that they spent enough time with the health worker, received a comprehensive examination and thought that they were treated with respect by both doctors and nurses were more likely to be satisfied (P < 0.05). The length of waiting time was also a significant predictor of patient satisfaction (P < 0.000). Respondents who received services from extended MHCs and MHTCs were less likely to be satisfied than those who received services from standard MHCs. However, when patient characteristics and other factors were controlled for, the type of MHC was not a significant predictor of patient satisfaction. Multiple logistic regression in the fully adjusted model showed that all service-related variables except for type of MHC were significant predictors of patient satisfaction. The strongest predictors of satisfaction were having a sufficient consultation time (AOR: 2.37; 95% CI: 1.76–3.21; P < 0.000), receiving a comprehensive examination (AOR: 2.01; 95% CI: 1.49–2.70; P < 0.000) and being treated with respect by the nurse (AOR: 2.08; 95% CI: 1.52–2.85; P < 0.000).

18

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0.49

0.66

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36–0

.66

0.47

–0.9

3

0.00

000.

0000

0.01

70

0.70

0.50

0.66

0.60

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37–0

.68

0.47

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4

0.00

00.

000

0.02

0

0.80

0.54

0.92

0.62

–1.0

20.

33–0

.88

0.53

–1.6

1

0.07

60.

013

0.77

7Co

mm

unic

atio

nTh

e he

alth

wor

ker e

xpla

ined

the

reas

on fo

r med

ical

test

s (R

ef: d

isag

ree)

7.53

6.36

–8.9

10.

000

7.39

6.24

–8.7

70.

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1.93

1.48

–2.5

30.

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doct

or s

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tim

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my

med

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con

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n (R

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8.93

7.56

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560.

000

8.88

7.50

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520.

000

1.7

1.24

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side

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(Ref

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823.

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.61

0.00

03.

813.

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.61

0.00

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531.

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e he

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wha

t dan

ger s

igns

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ted

to th

e di

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sis

to

look

out

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Ref:

disa

gree

)4.

533.

87–5

.31

0.00

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563.

88–5

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0.00

01.

491.

13–1

.96

0.00

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3.02

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928.

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1.72

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1.65

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0.26

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0.00

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0.58

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Discussion

Patient satisfaction is becoming an important patient-based outcome measure in health services. Efforts to improve patient satisfaction may lead to improved utilization of health services (33) and better outcomes because satisfied patients may better adhere to treatment plans and have better health-seeking behaviour (16,34). This study was conducted to evaluate the satisfaction and experience of patients who receive services in MHCs in Turkey and to investigate factors that affect the level of patient satisfaction. A total of 4548 patients in 141 MHCs in 16 provinces consented to participate in the study.

Patient satisfaction and expectationsThe study found a higher level of patient satisfaction among refugees and asylum seekers compared with previous studies that evaluated services offered by a specialized unit for refugees or delivered with sensitivity to their language and cultural needs. For example, a German study found a satisfaction level of 84% for patients who visited an integrated care facility in a reception centre for asylum seekers and refugees. In another example, an Australian study found high levels of satisfaction among Vietnamese refugees accessing specialized mental health services at a specialized unit for refugees (18). Another Australian study on an integrated health service for asylum seekers and refugees also found a high level of satisfaction, with patients placing high value on integrated care, good relationships with staff, and the availability of interpreting services and bicultural workers (19). The 2019 SIHHAT baseline survey on the health needs of Syrian refugees also found that a satisfaction rate of 65% in respondents who had accessed services from a MHC (35), and a follow-up survey in 2020 found that that this rate had increased 66.2% (36). Both studies showed that patients valued language translation services and integrated care, further indicating that migrant-sensitive health-care provision could meet patient needs and increase patient satisfaction. Although this study did not examine the contribution of language translation and integrated care to patient satisfaction in MHCs, these factors underpin the MHC mechanism in Turkey and may, therefore, explain the observed high level of patient satisfaction.

Of all three types of MHCs, respondents were most satisfied with services at standard MHCs. Patient satisfaction with MHTC services was high, but slightly lower than at the other MHCs. The apparently lower level of patient satisfaction in MHTCs might be explained by unmet patient expectations based on anecdotal evidence that patients mistakenly regard MHTCs as hospitals (whereas they are primary care facilities). The fulfilment of patient expectations (regardless of how realistic they may be) has been found to influence patient satisfaction (17,37). As such, patients who visit MHTCs expecting hospital-level medical care may be less satisfied with the primary care services that they receive instead.

In Turkey, the main barriers to accessing health care for refugees have been largely addressed through the MHC mechanism, which provides free-of-charge, culturally sensitive primary health services in their own language. Indeed, only very few respondents had delayed seeking care because they were worried about the cost or the capacity of health facilities to treat their health issue. For most of the respondents, MHCs were accessible within 15 minutes (mostly by walking) or at a transportation cost of less than 5 lira. A previous study found that accessibility to services (in terms of a convenient location) is positively associated with patient satisfaction and service utilization (38). The present study also found that patients with a shorter journey time to reach the health facility were more satisfied. However, the significance of this factor was lost in the fully controlled model, indicating that it is not very important in influencing patient satisfaction. This may be explained by the fact that the Government of Turkey purposely planned and located MHCs in areas with large Syrian refugee populations.

This study found that MHCs play a key role in addressing barriers in access to health care for refugees. Moreover, those who have accessed services are confident in their capacity to provide the necessary health care; 88.7% said


they would return for the health services in the future, and 88.1% would recommend the services to other people. Nevertheless, a SIHHAT baseline survey found that more Syrian refugees sought care from hospitals than from MHCs (35). Although the proportion of refugees seeking care from MHCs increased from 29.5% in 2018 to 36.9% in 2020 and from 1.6% to 5.3% in family health centres according to the SIHHAT follow-up survey (36), more effort could be put into further reducing pressure on hospitals. The availability of a wider range of services in hospitals could be the main pull factor for the higher utilization rates; however, it is also possible that refugees are reluctant to use MHCs because they are not fully aware of the available services or have unfounded biases.

Factors that determine patient satisfaction in MHCsHealth-care quality factors have a strong influence on patient satisfaction, including technical care, interpersonal care, physical environment, access (accessibility, availability and finances), organizational characteristics, continuity of care and outcome of care (22). This study found that the strongest predictors of patient satisfaction were the doctor taking time to explain the health condition, the health worker taking time to answer questions and receiving a comprehensive examination. Other studies have shown that the consultation time is positively associated with patient satisfaction (20,33,38,39).

Physicians must balance the time they have with patients against their other tasks such as completing electronic medical records, requesting diagnostic tests, writing prescriptions, making phone calls and sending emails. The time needed for these tasks has increased with increasing computerization and complexity in the primary care system. Owing to an ageing population and an increasing prevalence of chronic conditions and other complex clinical issues, physicians may have limited time to provide quality care and meet the expectations of all patients while effectively fulfilling other tasks. Time pressures are greater in facilities with high patient loads such as MHCs. In a WHO field assessment of the employability of Syrian health workers in Turkey (Factors affecting employability of trained Syrian health workers in Turkey, WHO Regional Office for Europe, unpublished data, 2020), physicians said that they had high workloads. Similarly, in a job satisfaction survey among health workers in MHCs, 83% and 73% of general and specialist physicians, respectively, reported seeing more than 40 patients per day on average – assuming an eight-hour day, this indicates an average consultation time of less than 12 minutes (40). Therefore, high patient loads mean that consultations could be short. Short consultations may not allow discussion of the full range of the patient’s health-care concerns and the psychosocial determinants of health, resulting in reduced patient understanding, increased dissatisfaction and poor adherence to treatment plans (41). One study argued that making primary care consultations longer (more than 30 minutes for the routine care of complex primary care patients) would probably reduce emergency room and hospital utilization, unnecessary referrals, and unnecessary diagnostic testing, and improve satisfaction levels in both patients and health workers (41). A lower patient-to-physician ratio could reduce patient waiting times and workloads for health workers and increase consultation times. Consequently, patient outcomes and satisfaction could be improved, especially in MHTCs, where patients reported the lowest satisfaction with consultation time.

Respect and recognition of patient preferences, needs and values is a core aspect of people-centred care. This study found that being treated with respect by both doctors and nurses significantly influenced patient satisfaction. Doctors and nurses who treat patients in MHCs are Syrian nationals who have been equipped with the knowledge and skills to work in the Turkish primary health-care system through an adaptation training programme jointly implemented by WHO and the Ministry of Health. As such, patients in MHCs are treated by health workers who are fellow Syrian nationals and have experienced a similar life crisis, which could lead to more empathetic and respectful interactions and, in turn, increase patient satisfaction. Consistent with this study, a positive association between respectful treatment and patient satisfaction was reported previously (42). In particular, nursing care was highlighted as having a stronger impact on care evaluation by patients (17).

Time spent waiting to see a health worker was significantly associated with patient satisfaction: patients who waited for longer were less likely to be satisfied. Other studies have also demonstrated that waiting time is negatively associated with patient satisfaction (33,39,43). The average waiting time was 30 minutes, although more patients in


extended MHCs and MHTCs reported longer waiting times. Beyond reducing patient satisfaction, longer waiting times may cause patients to leave without being seen by a doctor, thereby undermining their access to health care (44). As health facility service arrangement and patient volume may affect waiting times, improvements in these areas could reduce the average waiting time and improve patient satisfaction.

Physician–patient communication is a central aspect of diagnosis, treatment and patient support. During discussions with physicians, patients can express their health concerns and ask questions; they may also receive explanations about issues such as their medical condition, which medical tests are needed, side-effects of medications and danger signs to look out for. This study found that explanations on these topics were strong predictors of patient satisfaction. These findings are consistent with other studies that found a positive relationship between physician–patient communication and patient satisfaction (14,38,45,46). Other studies found a positive association between patient satisfaction and receiving information on their medical condition (34,42,47). Good physician communication with patients has also been established to increase patient adherence to treatment, and training physicians to better communicate with patients also increased patients’ adherence to treatment (48). In this study, patients were mostly dissatisfied with receiving information about medicine side-effects and on danger signs to look out for at home. Refugees and migrants may have specific challenges in using medicines safely, including language and communication issues, cultural issues, and limited health literacy (7). The finding that a large proportion of patients in this study say that they understand the purpose of the treatment and prescribed medicines may be a subject for further investigation because WHO estimates that half of all patients who receive medicines do not take them correctly (49). Overall, supporting physicians in MHCs to improve their communication skills could positively influence patient satisfaction and adherence to treatment.

When other factors were controlled for, sociodemographic factors were not significant predictors of patient satisfaction. In contrast, other studies suggest that sociodemographic factors may be moderate or mediate other determinants of patient satisfaction (22).

Strengths and limitationsThis study was the first assessment of patient satisfaction to be conducted in MHCs. It included a large sample of patients receiving services from MHCs in 16 provinces that host the highest number of Syrian refugees in Turkey, making the results generalizable. All steps were taken to eliminate selection bias in study participants. Conducting face-to-face interviews in MHCs may have created social desirability bias (i.e. to give responses that they think interviewers would like) but this was minimized and any negative power dynamics were addressed by using external interviewers (i.e. not employed by health facilities or the healthy system) to conduct the interviews. Respondents were patients, immediate caregivers (of patients aged under 18 years or were unable to respond) or husbands responding on behalf of their wife (because of the patriarchal structure of Syrian refugee families). Although this arrangement was not expected to affect the results (because both patient and caregiver were present at the interview), it might have had some effect on responses where the patient’s and caregiver’s views did not match.

Patient feedback mechanismsMechanisms for collecting feedback from patients on their experiences in MHCs could generate useful information to improve care and promote patient accountability. Effective feedback mechanisms would need to be diverse to meet patient preferences and abilities, known by the patients (including, on which issues feedback would be welcomed) and safe for patients to use confidentially; they would also include a system to respond to patient feedback (25,26,50). However, most patients in this study were unaware of any mechanism to provide feedback on their experience of services received. Although some MHCs may have feedback and complaint boxes, patients might not be aware of their existence or might be unable to use them (e.g. if they are illiterate). Therefore, opportunities to collect and act upon patient feedback (including managing expectations) are missed.


Recommendations • Improving patient experiences related to consultation time, waiting time and quality of physician–patient

communication could improve satisfaction in MHTCs. In addition, examining and addressing the causes of dissatisfaction with services for which the level of satisfaction was low would help to improve patient satisfaction in these areas.

• Investigate the causative factors for the preferred use of hospitals and use the findings to implement a targeted campaign to increase the use of MHC services, especially as the Ministry of Health through SIHHAT plans to expand its MHC network. The high level of patient satisfaction established in this study could be useful for the campaign

• With increased service utilization in MHCs, an objective estimate of the patient-to-physician ratio based on patient records is needed to determine the physician workload and its potential impact on the quality of services and patient satisfaction.

• Support for physicians in MHCs is needed to improve their communication skills. A specific emphasis on communicating with patients about medicines would bridge the observed gap in patient satisfaction while improving the rational use of medicines.

• MHCs should consider implementing and promoting a variety of feedback and complaint mechanisms that can be safely accessed and used by a diverse population to gather feedback in order to improve services. These may include, but are not limited to, complaint boxes and toll-free telephones.

© SIHHAT


Conclusions

The high level of patient satisfaction revealed in this study indicates the importance of integrated, culturally sensitive health services provided in the patients’ own language in MHCs. Although most patients were satisfied with services in MHCs, improvements in physician–patient interactions and communication are recommended to empower patients to participate in managing their treatment and overall health. In particular, physicians should inform patients about medicine side-effects and danger signs and consultation times should be increased, perhaps by reducing the patient-to-physician ratio. Reducing waiting times could also improve patient satisfaction. This study provides evidence that greater promotion of MHC services among refugee communities could increase their utilization and reduce the burden on secondary care facilities.

The study was implemented within the scope of the Improved access to health services for Syrian refugees in Turkey project with funding from the European Union through EU Regional Trust Fund in Response to the Syrian Crisis.


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Annex 1. Patient satisfaction form

Patient satisfaction form

STEP 1. Choose 10–20 people randomly (half male and half female, if applicable) from the beneficiaries of the activity and conduct an independent interview with each one.

Patient characteristics

PSS-01 Who is the person in need of the health service? (If the respondent comes with more than one patient, make the interview for only one patient. If the respondent is not a patient’s immediate caregiver (e.g. friend, driver), then they should not be interviewed. Skip this patient.)

1. The respondent2. Spouse3. Child4. Other, specify

NOTE. If the respondent is not the person in need of the health service, please answer the following questions on behalf of the patient.

PSS-02 Patient’s gender 1. Male2. Female

PSS-03 How old is the patient? __ years old

PSS-04 Can you read and write? 1. Yes2. No3. Declines to answer

PSS-05 What is the patient’s highest level of education?

1. Completed primary2. Completed secondary3. University degree/equivalent or higher4. Declines to answer

PSS-06 What is the total number of household members of the respondent?

PSS-07 Are you (the respondent) currently working? 1. Yes2. No3. Declines to answer

PSS-08 If working, what kind of work do you mainly do?

1. Agricultural2. Teaching3. Health4. Sales & services5. Driver6. Technical/managerial7. Student8. Declines to answer9. Other, specify _______________



PSS-09When did you come to Turkey? (year/month)

Utilization/use of health facility

PSS-10 Were you referred3 to the health facility? 1. Yes2. No3. Declines to answer

PSS-11 Who referred3 you? 1. Other MHC2. Türk Kizilay4

3. Other outreach teams4. Other _____

PSS-12 Are you here to see a specific health worker (specific person)?

1. Yes2. No

PSS-13 In the last 3 months, how many times have you/the patient visited this health facility?

______times

PSS-14 Reason/s for this visit? (Allow multiple responses)

1. Pregnancy and prenatal care2. Postnatal care3. Vaccination4. General consultation for feeling sick5. Dental care6. Family planning 7. Investigation – diagnostic tests8. Emergency care9. Wound care10. Psychological or social assistance11. Medical certificate12. Other

PSS-15 How did you get to the facility today? 1. Walked2. Private transportation or taxi3. Public transportation4. Other

PSS-16 How long did it take you to get here today from your home?

________ hours ____minutes

PSS-17 How much did it cost you/the patient to get here today (one way)?

_______Turkish lira

PSS-18 From the time you felt you or your child/spouse needed care, how long did you wait before seeking care/coming today?

1. Less than 1 day 2. 1–3 days3. 4–7 days 4. 8–30 days 5. Greater than 30 days

3 In this context, refer indicates receiving information from someone about the health facility (not referral by a physician).4 Turkish Red Crescent.



PSS-19 If you delayed seeking medical care for more than 1 day, what was the reason?

1. Didn’t think I was sick enough or thought that the problem would getter better on its own2. Worried about cost of care3. Worried about travelling to care4. Didn’t believe health facility would be able or would have capacity to help5. Other______

Patient experience

PSS-20 Have you received the health service you needed during your visit to the health facility?

1. Yes2. No3. Partially

PSS-21 Once you arrived at the health facility, how long did you wait to be seen by a health worker?

_____ minutes

PSS-22 Would you go to the private practice of the health provider for further counselling/consultations?

1. Yes2. No3. Declines to answer

Medicine provision

PSS-23 Were you/was the beneficiary prescribed medicines today?

1. Yes2. No

PSS-24 If yes, did the doctor explain to the beneficiary/relative how to use the medicine?

1. Yes2. No3. Some of them

Beneficiary satisfaction

I am going to read some things people say about medical care. Please listen to each one carefully, keeping in mind the medical care you received from this facility. We are interested in your feelings, good and bad, about the medical care you have received. Please note that the ”I” and ”me” in the statements below refer to you as the recipient of the services. How strongly do you AGREE or DISAGREE with each of the following statements?

1 – Strongly disagree

2 – Disagree

3 – Neither

4 – Agree

5 – Strongly agree

Scale

PSS-25 When I come to the health centre, I don’t have to wait a long time to see a doctor.

1 2 3 4 5

PSS-26 The doctor is careful to check everything when examining me.

1 2 3 4 5

PSS-27 The doctor explains the reason for medical tests.

1 2 3 4 5

PSS-28 The doctor spends time with me to explain my medical condition.

1 2 3 4 5



PSS-29 I understand the diagnosis from doctors in health centres.

1 2 3 4 5

PSS-30 The doctor told me about danger signals related to the diagnosis to look out for at home.

1 2 3 4 5

PSS-31 I understand the purpose of the treatment and prescribed medicines.

1 2 3 4 5

PSS-32 I understand how to use the medicines that were prescribed to me today.

1 2 3 4 5

PSS-33 I was informed about medication side-effects.

1 2 3 4 5

PSS-34 The doctor spends enough time with me to answer all my questions.

1 2 3 4 5

PSS-35–1 The doctor treats me with respect. 1 2 3 4 5

PSS-35–2 The nurse treats me with respect. 1 2 3 4 5

PSS-36–1 I trust the doctor’s skills at the health centre.

1 2 3 4 5

PSS-36–2 I trust the nurse’s skills at the health centre. 1 2 3 4 5

PSS-37 Based on my experience here, I will recommend this health facility to other people.

1 2 3 4 5

PSS-38 Based on my experience here, I will return to this health facility for a health service in future if needed.

1 2 3 4 5

PSS-39 Overall, the health services I have been receiving are satisfactory.

1 2 3 4 5

PSS-40 If you disagree or strongly disagree that the health services you have been receiving are satisfactory, please specify the reasons for your dissatisfaction? (Multiple choice)

1. Health services needed are unavailable2. Long waiting time3. Lack of medical staff4. Doctor’s incompetence5. No free medicines6. Others (specify…)

PSS-41 Did you experience any problems during your visit? If you could improve or change anything about the services provided at this health facility, what would it be?

Open

PSS-42 Do you know how you can complain if you received poor-quality services?

1. Yes2. No



STEP 2. Collect data about the site (health facility)

Health facility identification

PSS-43 Province Type answer here

PSS-44 Health facility name Type answer here

PSS-45 Type of facility 1. Standard MHCs2. Extended MHCs3. MHTCs


Annex 2. Patient experience by type of facility

Patient experience (statement) Standard MHC Extended MHC MHTC Overall (total)

n % n % n % n %

When I come to the MHC, I don’t have to wait for long to see a doctor

DisagreeNeutralAgree

331178

1549

16.18.6

75.3

375157

1165

22.19.3

68.7

15197

512

19.912.867.4

857432

3226

19.09.6

71.5

The doctor is careful to make a comprehensive examination of me


194163

1651

9.78.1

82.2

157164

1353

9.49.8

80.8

92112548

12.214.972.9

443439

3552

10.09.9

80.1



171236

1296

10.013.976.1

151233

1178

9.714.975.4

90145418

13.822.264.0

412614

2892

10.515.773.8

The doctor takes time to explain my medical condition to me


173151

1680

8.67.5

83.8

156158

1354

9.49.5

81.2

99121529

13.216.270.6

428430

3563

9.79.7

80.6

I understand the diagnosis from doctors in MHCs


158176

1648

8.08.9

83.1

126167

1359

7.610.182.3

69129545

9.317.473.4

353472

3552

8.110.881.2

The doctor told me about danger signs related to the diagnosis to look out for at home


481267

1197

24.713.761.5

440257938

26.915.757.4

235210293

31.828.539.7

1156734

2428

26.817.056.2

I understand the purpose of treatment and prescribed medicines


191189

1551

9.99.8

80.3

150151

1327

9.29.3

81.5

83118538

11.216.072.8

424458

3416

9.910.779.5

I understand how to use the medicines that were prescribed to me today


205143

1420

11.68.1

80.3

167129

1206

11.18.6

80.3

9665

475

15.110.274.7

468337

3101

12.08.6

79.4


Patient experience (statement) Standard MHC Extended MHC MHTC Overall (total)

n % n % n % n %



624249848

36.314.549.3

518221723

35.415.149.5

337101193

53.416.030.6

1479571

1764

38.815.046.3

The doctor spends enough time with me to answer all my questions


176154

1660

8.87.7

83.4

140150

1354

8.59.1

82.4

98111541

13.114.872.1

414415

3555

9.49.5

81.1



5693

1874

2.84.6

92.6

66107

1502

3.96.4

89.7

4381

626

5.710.883.5

165281

4002

3.76.3

90.0



76143

1714

3.97.4

88.7

74160

1400

4.59.8

85.7

41128556

5.717.776.7

191431

3670

4.510.085.5



127244

1651

6.312.181.7

101224

1352

6.013.480.6

56182509

7.524.468.1

284650

3512

6.414.679.0



108265

1546

5.613.880.6

93275

1267

5.716.877.5

46206470

6.428.565.1

247746

3283

5.817.476.8

Based on my experience here, I will recommend this health facility to other people


118189

1728

5.89.3

84.9

91163

1419

5.49.7

84.8

57108582

7.614.577.9

266460

3729

6.010.383.7

Based on my experience here, I will return to this health facility if I need health care in the future


100155

1768

4.97.7

87.4

77145

1439

4.68.7

86.6

37103606

5.013.881.2

214403

3813

4.89.1

86.1

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patient satisfaction and experience at migrant health

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