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European Journal of Economics, Finance and Administrative Sciences ISSN 1450-2275 Issue 48 (2012) EuroJournals, Inc. 2012 http://www.eurojournals.com/EJEFAS.

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The Role of Demographics in Patients Perceptions towards the Quality of Health Care Services Provided at Public Hospitals in Damascus
Abdulhamid Al-Khalil Higher Institute of Business Administration (HIBA), Damascus, Syria Ali Bassam Mahmoud Higher Institute of Business Administration (HIBA), Damascus, Syria Tel: +963-933-439287 E-mail: elguitarrista@live.com; http://hiba.edu.sy/ Abstract The assessment of health care service quality is considered one of the important indicators utilized by decision makers in the process of enhancing and developing the quality of the health care services provided through hospitals. This study aims at assessing patients perception towards the quality of health care services provided at the public hospitals affiliated to the Syrian ministry of health in Damascus. The results of (677) valid questionnaires revealed that patients had perceived positively the three dimensions of health care service quality which are: Health Care, Health Personnel, and Health Facilities. It was also found that female lower educated patient would hold less positive perceived quality for the health care services than other categories of patients do. Recommendations are discussed later.

Keywords: Health Marketing, Quality, Health care service Perceived Quality.

1. Introduction
Though it has been too long since the concept of quality in general was first investigated, however, research work regarding quality within the health sector is still debatable and comparatively new especially for developing countries like Syria, as the features of the concept of quality in the health sector were first unwrapped in 1980 when it became necessary to apply the concept of quality within services (Al-Bakri, 2005). Patients opinions about health care services are considered important when it comes to assess the quality of the health care service (Jenkinson, Coulter, Bruster, Richards, & Chandola, 2002), let alone the role of the experience of getting health care services in patients behaviors regarding committing to medication rules, and keeping loyal to the health care service provider (Sofaer & Firminger, 2005; Wilde-Larsson & Bergstrom, 2005). Syria has achieved impressive health improvements in the last four decades. People in Syria are now living longer, leading healthier lifestyles and enjoying higher coverage and better quality of health care services than ever before. A variety of indicators ranging from life expectancy, infant mortality and maternal mortality confirm this trend. In this regard, Syria has been a model country and a good example in its commitment to provide health care to all citizens. Nevertheless the health status of the

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population of Syria was harmfully influenced by numerous factors, but especially by a lasting economic crisis, the consequences of war in the surrounding countries and a wide range of economic and diplomatic sanctions. In this context, the Syrian government invests incremental big amounts of money in the public health sector every year. For example, in 2009, 4.89% of the Syrian general budget was utilized to the ministry of health (Health Indicators, 2009). Doing that expenditure, the Syrian government is mainly aiming to improve the quality of health care services provided by the public hospitals. Previous researches have referred in many studies to patients evaluation as a major indicator to the quality of the health care services (e.g. Naidu, 2009; Caro & Garcia, 2007; Rose, Che , Abdul, & Ng, 2004). So there is an obstrusive need to investigate the plite of health care services in public hospital in Syria, given the scarcity of studies within this area of research in Syria.

2. Literature Review
The term of perceived quality has been handled in many researches for the last few decades aiming at defining and measuring it (e.g. Parasuraman, Zeithaml, & Berry, 1985; Parasuraman, Zeithaml, & Berry, 1994a; Parasuraman, Zeithaml, & Berry, 1988; Haddad, Potvin, Roberge, Pineault, & Remondin, 2000; Gill & White, 2009; Elleuch, 2008). The perceived quality of health care service has been defined by sevral authors (e.g. Kotler & N.Clarke, 1987; Sulek, Lind, & Marucheck, 1995). However, most of the definitions of health care service quality are sharing one common point, which refers to the patients subjective evaluation of the health care service. Consiquently, we can say that health care perceived quality represents the beliefs that patients hold about health care service being provided. This defintion goes along with the approach that adopted by many researchers to evalute the perceived quality for health care seriveces. This approach is based on employing patients opinion to generate an assessment for the quality of health care services (Calnan, 1988; Palmer, 1991; Donabedian, 1992; Fitzpatrick, 1991; Reerink & Sauerborn, 1996; Andaleeb, 2000). That is, patient satisfaction is considered one of the most important indicators regarding the quality of health service. In this respect, patient satisfaction has been deemed by many researchers to help predicting patients loyalty and prospective intentions towards the hospital (e.g. Naidu, 2009; Gill & White, 2009). Haddad, Potvin, Roberge, Pineault, & Remondin (2000) have suggested some potential advantages for considering patients evaluations in measuring health care service qualty. The most prominent advantages of using patients opinion measuring the quality of the health care service are (Haddad, Potvin, Roberge, Pineault, & Remondin, 2000): Inexpensive approach to assess health care service quality. The ability to measure the perceived quality directly once patients get the health care service. No need for medical records. It is worth to say that the roles of some demographic variables in perceiving health care quality have been investigated by some researchers. It was found that some of these factors exhibited significant predictions for perceived quality (e.g. Narang, 2011; Baltussen, Ye, Haddad, & Sauerborn, 2002).

3. Hypotheses
As one goal of the process of modernizing the health sector in Syria is to improve the quality of health care services provided at hospitals affiliated to the Syrian ministry of health (Project of health sector modernization - Syria, 2011), we can state the first hypothesis as follows: H1: Patients will significantly evaluate the quality of health care services as positive. It was mentioned above that significant variances in the perception of health care service could be regarded to some demographic variables, given that; the following hypothesis can be stated:

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H2: The perception of patients towards health care service quality will vary significantly according to gender, education, age, and income.

4. Research Method
Aiming at collecting data for the present study, a cross-sectional survey was conducted using the tool of questionnaire. The questionnaire consisted of two sections. Section 1 contained the demographic questions, whereas section 2 held a 20-item multi-dimensional scale measuring health care service perceived quality with responses ranged from 1 to 4, this scale was developed by Haddad, Founier, & Potvin (1998). Fifteen items were extracted after the validation process. All Damascus public hospitals that have internal medicine departments were chosen for this study. They are 3 hospitals: Dimashk, Ibn Nafis, and Al Hilal Al Ahmar (see table 1). There are approximately 5-7 rooms in each of the internal medicine departments; and in each room there will be 4-5 patients. We went to each hospital two days a week and interview the patients in rooms 1-2 and 3 on the first day and in rooms 4-5-6 on the second day. In this manner, we should have been able to get about 24-30 patients from each hospital each week. Over a period of ten weeks, this should have given me a potential sample of about 300 from each hospital (allowing for having to discard patients who have stayed more than a week in the hospital and for non-response, this gives 200). We changed the days we went to each hospital each week: for example in the first week we shall go to Hospital 1 on Days 1 and 2, Hospital 2 on days 3 and 4, and Hospital 3 on days 5 and 6. In the second week we shall go to Hospital 2 on Days 1 and 2, Hospital 3 on Days 3 and 4 and Hospital 1 on Days 5 and 6; and so on.
Table 1: Hospitals involved in the present study

Hospitals Damask Hospital Ibn Nafis Hospital Al Hilal Al Ahmar Hospital Specialized Doctors # 23 22 18 Resident Doctors # 22 20 14 Nurses # 10 5 5 Inpatients # (monthly) 95 81 55 Beds # 44 24 18 Rooms # 7 6 5 Abdominal echo, ECG, SPO2, Abdominal echo, ECG, Abdominal echo, ECG, upper and lower endoscopy, SPO2, upper and lower SPO2, upper and lower Equipment available bronchoscope, sterilization endoscopy, bronchoscope, endoscopy, bronchoscope, machines sterilization machines sterilization machines Controlling water and power consumption, improving hygiene, periodic furniture Efforts to enhance maintenance, define the shortage in medical equipment and fill it, cooking and catering quality controlling, patients consumption controlling. Source: A pre-field trip held for the present study. Quality factors

Since the scale of health care services perceived quality was originally developed in cultures that could differ from the Syrian context. So the present study held a validation process for the respective scale through the following steps: a) Double translation (English Arabic); b) Factorial validity (see table 2); c) Reliability (see table 3). Table 2 shows the results of the factorial analysis. Items measuring health care services perceived quality load on 3 factors, with loading values higher than .3 and eigenvalues greater than 1 (Nunnally, 1978).

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Table 3 shows the results of reliability test using the statistic of cronbach's alpha to assess the internal consistency for the measure used in this study. We notice that all cronbach's alpha values are acceptable, since they are higher than .6 (Nunnally, 1978).
Table 2: factorial analysis
Dimension Medical Personnel Quality

Item In your opinion, are the "doctors" in the "hospital" capable of finding out what is wrong with the patients? In your opinion, are the drugs that the "doctors" in the "hospital" prescribe to patients...? In your opinion, patients can obtain drugs from this "hospital"... The patients cared for in this "hospital"... Doctors treatment with patients (Openness) Doctors treatment with patients (Mercy) Doctors treatment with patients (Respect) The time that the "doctors" devote to their patients is... In your opinion, the time that the "doctors" take to explain to their patients about their illness is... In your opinion, the people who work in this "hospital" are... The distance from your home to the "hospital"... is In your opinion, the number of "doctors" in this "hospital" is... In your opinion, the equipment in the "hospital" is ... for detecting diseases In your opinion, the waiting rooms, examination rooms, and "hospital" rooms... are the quality of equipment Eigenvalue % of Variance Cumulative %

Health Care Quality 0.772 0.698 0.515 0.546

Health Facilities Quality

0.634 0.694 0.673 0.525 0.533 0.461 0.443 0.394 0.703 0.729 2.51 16.73 16.73 2.297 15.314 32.045 0.744 1.96 13.069 45.113

Table 3:

Reliability Test
Number of items 4 6 5 Alpha 0.610 0.724 0.675

Dimension Health Care Quality Medical Personnel Quality Health Facilities Quality

5. Data Description
We can see from table 4 that our sample consisted of slightly more men (54.4%) than women (45.6%). According to the educational level, the majority of the respondents were at the level of high school (54.4%), with age ranged between 31 years and above (57.5%), and a monthly income ranged between 10,000 and 30,000 SYP.
Table 4:
Variable Gender

Data Description
Values Male Female Total Illiterate High School Bachelor Frequency 368 309 677 48 368 159 Frequency % 54.4 45.6 100 7.1 54.4 23.5

Education

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Table 4:

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Data Description - continued
Postgraduate Total Less than 20 Years 20- 30 Years 31 Years and above Total Less than 10,000 SYP 10,000- 30,000 SYP More than 30,000 SYP Total 102 677 69 219 389 677 286 369 22 677 15.1 100 10.2 32.3 57.5 100 42.2 54.5 3.2 100

Age

Income

6. Hypotheses Testing
6.1. H1 Looking at table 5, we can notice that patients have reported significantly positive evaluation regarding the three dimensions of health care service perceived quality, since mean values were all significantly above the neutral value (2.5), i.e. Health Care Quality (t = 26.026), Medical Personnel Quality (t = 13.338), and Health Facilities Quality (t = 7.905).
Table 5: Results of testing H1
Mean 3.093 2.834 2.701 SD 0.592 0.651 0.663 Neutral Value 2.5 2.5 2.5 T-Test 26.062** 13.338** 7.905** P-Value 0.000 0.000 0.000

Dimension Health Care Quality Medical Personnel Quality Health Facilities Quality ** Significant at 1%

So we come to the result that H1 is fully supported. This finding is consistent with the efforts of the Syrian government in the respect of reforming the public health sector. 6.2. H2 Table 6 exhibits the results of testing H2 in respect to gender. It is indicated that males have more favorable evaluation regarding Health Care Quality than females do (t = 2.2361). This result is consistent with (Baltussen, Ye, Haddad, & Sauerborn, 2002). This finding can be explained through the fact that in the sample of the sample of the present study (See table 7) males with higher education (40.2%) are more than higher educated females (36.6%), given the results of some previous studies that higher educated subjects tend to show more positive evaluations towards health care service than lower educated subjects do (e.g. Baltussen, Ye, Haddad, & Sauerborn, 2002).
Table 6:
Dimension Health Care Quality Medical Personnel Quality Health Facilities Quality * Significant at 5%

Results of testing H2 (Gender)


Mean Male 3.1399 2.8433 2.6951 > Female 3.0380 2.8220 2.7087 T-test 2.2361* 0.4238 -0.2664 P-value 0.026 0.670 0.790

Table 8 exhibits that higher educated subjects tend to evaluate the three dimensions of health care services quality more positively than lower educated subjects do. This finding goes along with the previous literature (e.g. Baltussen, Ye, Haddad, & Sauerborn, 2002; Narang, 2011).

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Table 7:

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Cross-tabulating gender with education
Level of Education * the gender of patient Cross-tabulation The gender of patient male female Lower Education 59.80% 63.40% Higher Education 40.20% 36.60%

Level of Education

Table 8:

Results of testing H2 (Education)


Multiple Comparisons (J) level of education Mean Difference (I-J) high school or lower bachelor postgraduate illiterate bachelor postgraduate illiterate high school or lower postgraduate illiterate high school or lower bachelor high school or lower bachelor postgraduate illiterate bachelor postgraduate illiterate high school or lower postgraduate illiterate high school or lower bachelor high school or lower bachelor postgraduate illiterate bachelor postgraduate illiterate high school or lower postgraduate illiterate high school or lower -.19452-.40409-** -.39461-** 0.19452 -.20957-** -.20009-* .40409** .20957** 0.00948 .39461** .20009* -.00948-.20380-.29632-* -.256330.2038 -.09251-.05253.29632* 0.09251 0.03999 0.25633 0.05253 -.03999-.18841-.37311-** -.35147-* 0.18841 -.18471-* -.16306.37311** .18471* 0.02164 .35147* 0.16306

Tukey HSD Dependent Variable The perceived quality of health care

(I) level of education illiterate

Sig. 0.130 0.000 0.001 0.130 0.001 0.012 0.000 0.001 0.999 0.001 0.012 0.999 0.171 0.029 0.109 0.171 0.436 0.887 0.029 0.436 0.962 0.109 0.887 0.962 0.241 0.003 0.012 0.241 0.016 0.118 0.003 0.016 0.994 0.012 0.118

high school or lower

bachelor

postgraduate

The perceived quality of health personnel

illiterate

high school or lower

bachelor

postgraduate

The perceived quality of health facilities

illiterate

high school or lower

bachelor

postgraduate

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Table 8:

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Results of testing H2 (Education) - continued
bachelor -.021640.994

** Significant at 1% * Significant at 5%

Table 9:

Results of testing H2 (Age)


ANOVA

Dimension The perceived quality of health care The perceived quality of health personnel The perceived quality of health facilities

F 0.406 1.624 0.666

Sig. 0.666 0.198 0.514

Table 10: Results of testing H2 (Income)


ANOVA Dimension The perceived quality of health care The perceived quality of health personnel The perceived quality of health facilities F 0.743 2.922 2.245 Sig. 0.389 0.088 0.135

Tables 9 and 10 show that age and income don't impact the perception of the three dimension of health care service quality. So we conclude that H2 is partially supported, since among demographic variables being considered in the present study, only gender and education play significant roles in predicting the perception of health care service quality.

7. Discussion
In overall perspective, the results of the present study indicate that patients hold favorable evaluations towards the quality of the health care service being provided at the public hospitals affiliated to the Syrian ministry of health in Damascus. This means that patients at the respective hospitals positively perceive doctors abilities to diagnose health problems, and prescribe the suitable medication, let alone the respectful and merciful behaviors of doctors in dealing with patients. That would be giving better opportunities for patients to heal up, besides to the good availability of drugs at hospitals. On the other side, this positive perception of health care service quality could be also due to the almost free of charge medication offered to patients by public hospitals in Syria. This will lower the perceived cost that patients sacrifice to meet their medication needs. However, in case of having the Syrian ministry of health turning those hospitals into autonomous or semi- autonomous ones requiring patients to pay fees for medication, it is recommended to enhance the quality of health care services at those hospitals, so they can compete with other private hospitals. Having patients surveyed periodically regard their satisfaction could be effective in enhancing the quality of the health care services at this stage. Gender and education were found to predict the perceived quality of health care service. That is, female lower educated patients could perceive less positively the quality of the health care. So it is advised for public hospitals to pay more attention to this category of patients. This could be done through some practices like offering well specialized medical staff, and a stay in separated rooms from other categories of patients, as well as using simpler language and tools in explaining the conditions especially to those with lower education. A worth to be mentioned limitation is related to having the present study conducted in the internal medicine departments of public hospitals affiliated to the ministry of health in Damascus. That is, we might get different results if our investigation had been conducted in departments other than

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internal medicine ones, or even in hospitals affiliated to the Syrian ministry of health, however located in provinces other than Damascus.

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