The Impact of satisfaction with care on use of prenatal services: Findings from National

Friendly AccessSM

Kirsten Wallace, MA, MSPH Linda A. Detman, Ph.D.

The Lawton and Rhea Chiles Center for Healthy Mothers and Babies

University of South Florida

APHA, Dec 2005, Philadelphia

Satisfaction and Use

Studies of satisfaction have focused on users of services

Non-users generally less satisfied with health services (Shumeli, 1997)

Studies of users No relationship between early use of PNC and

satisfaction with physician (Ivanov and Flynn, 1999) No significant relationship between satisfaction and

subsequent prenatal care (Handler et al, 2003)

Purpose

To understand the role of satisfaction with prenatal health care services in predicting completion of expected number of PNC visits.

Friendly AccessSM

Longitudinal community-based interventions Changing the culture of maternal and child health care

to improve access, use, and satisfaction Health services utilization model (Aday and Anderson,

1975) Extensive baseline data collection-secondary sources

as well as surveys with consumers and providers of maternal and child health services

Friendly AccessSM

Central Premise

Improved customer service and accessibility will lead to increased good experience and consumer satisfaction, which will, in turn, lead to increased use of preventive health services.

Methods

1,408 women in four communities Used prenatal care services Data collected on actual (observed) and expected number of

visits Expected to complete at least two visits NHW, NHB Medicaid delivery

Measures

Predisposing characteristics Literature, a priori theory

Completion of expected PNC Dichotomous measure Kotelchuck (1994) algorithm for calculating expected number of visits Self-report of completed visits (within range)

Satisfaction with care Prenatal Care Satisfaction Scale (Raube, Handler, Rosenberg, 1998) CFA, 6 constructs of satisfaction

Measures

6 satisfaction constructs Access (3 items) Administrative efficiency and interaction with office staff (6 items) Resource availability (2 items) Office/clinic environment (3 items) Provider-patient interaction (4 items) Quality of care (4 items)

(Raube, Handler, Rosenberg, 1998)

CFA found the factor structure weak, but acceptable.

Table IPredisposing Characteristics: Independent T-test for Comparison of Means between Completion Groups

Mean (s.d.)

Completed PNC

Did not complete PNC

t value (p)

Age 23.58 (5.27) 24.61 (5.33) 1.75 0.08

Parity * 2.16 (1.28) 2.43 (1.45) 2.11 0.04

* Significantly associated with failure to complete PNC (p <0.05)

Table IIPredisposing Characteristics: Prevalence and Unadjusted Odds of Failure to Complete PNC

CharacteristicsTotal

(n=1408)Did not complete

PNCUnadjusted

OR95% CI

African-American ** 41.45 11.17 1.77 (1.20, 2.60)

Not married 73.86 8.69 1.09 (0.70, 1.70)

Less than high school 37.41 9.88 1.32 (0.89, 1.94)

Patient-provider racial discordance

47.89 9.69 1.35 (0.91-2.00)

Uninsured prior to pregnancy

34.94 8.60 1.02 (0.68, 1.52)

Did not use regular care pre-pregnancy

45.66 8.80 1.08 (0.74, 1.59)

Mistimed pregnancy 46.09 7.72 1.09 (0.68, 1.76)

Unwanted pregnancy * 23.37 11.97 1.78 (1.07, 2.96)

** Significantly associated with failure to complete PNC (p <0.01)* Significantly associated with failure to complete PNC (p <0.05)

Table IIIMeasures of Satisfaction with PNC: Prevalence and Adjusted Odds of Failure to Complete Care

Satisfaction Models Model n Adjusted ORα 95% CI HL Χ2 (p) M1.Would have changed providers if it was easy **

1259 1.90 (1.28, 2.80) 4.57 (0.80)

M2. Would recommend provider **

1262 0.45 (0.28, 0.71) 12.81 (0.12)

M3. Total satisfaction score ψ *

1273 2.55 (1.33, 4.90) 5.34 (0.72)

α All models were controlled for maternal age, race, marital status, education level, parity, racial concordance, and pregnancy wanted-ness.ψ Predicting for scores of <2.5, referent is satisfaction score >=4.5

** Significantly associated with failure to complete PNC (p <0.01)* Significantly associated with failure to complete PNC (p <0.05)

Table III (contd.)

Satisfaction Models Model n Adjusted ORα 95% CI HL Χ2 (p) M4. Satisfaction with access to provider ψ 1273 1.57 (0.92, 2.66) 3.65 (0.89)

M5. Satisfaction with admin. efficiency and office staff ψ

1273 1.91 (1.05, 3.47) 6.55 (0.59)

M6. Satisfaction with resources ψ

1273 1.37 (0.80, 2.34) 12.92 (0.11)

α All models were controlled for maternal age, race, marital status, education level, parity, racial concordance, and pregnancy wanted-ness.ψ Predicting for scores of <2.5, referent is satisfaction score >=4.5

** Significantly associated with failure to complete PNC (p <0.01)* Significantly associated with failure to complete PNC (p <0.05)

Table III (contd.)

Satisfaction Models Model n Adjusted ORα 95% CI HL Χ2 (p) M7. Satisfaction with environment ψ **

1273 3.15 (1.72, 5.78) 6.42 (0.60)

M8. Satisfaction with provider interaction ψ *

1273 2.04 (1.04, 3.98) 5.72 (0.68)

M9. Satisfaction with quality of care ψ *

1273 2.96 (1.42, 6.15) 5.87 (0.66)

α All models were controlled for maternal age, race, marital status, education level, parity, racial concordance, and pregnancy wanted-ness.ψ Predicting for scores of <2.5, referent is satisfaction score >=4.5

** Significantly associated with failure to complete PNC (p <0.01)* Significantly associated with failure to complete PNC (p <0.05)

Mediation Study Conceptual Model

Continued utilization ofservices

Accessing services

Satisfaction with services

Predisposing characteristics

Measures

4 measures of Access Usually experience long waits on the phone when making

appointments Have to wait more than 2 weeks for an appointment Usually wait more than 30 minutes to see the provider Have difficulty getting (transportation) to the provider’s office

Table IV Influence of Satisfaction on the Direct Effects of 4 Measures of Access to PNC on Failure to Complete Care

Mediators Adjusted OR 95% CI% change in the

direct effect

Long phone wait * 2.07 (1.26, 3.41)

1. Total satisfaction 2.01 - 2.9

2. Satisfaction with access to provider ψ 2.08 + 0.5

3. Satisfaction with admin. efficiency and office staff ψ 2.01 - 2.9

4. Satisfaction with resources ψ 2.07 0

5. Satisfaction with access to provider ψ 1.86 - 10.1

6. Satisfaction with provider interaction ψ 2.02 - 2.4

7. Satisfaction with quality of care ψ 1.96 - 5.3

ψ Predicting for scores of <2.5, referent is satisfaction score >=4.5

* Significantly associated with failure to complete PNC (p <0.05)

Table IV (contd.)

Mediators Adjusted OR 95% CI% change in the

direct effect

Waiting >2 weeks for appointment 1.25 (0.82, 1.91)

1. Total satisfaction 1.24 - 0.8

2. Satisfaction with access to provider ψ 1.27 + 1.6

3. Satisfaction with admin. efficiency and office staff ψ 1.23 - 1.6

4. Satisfaction with resources ψ 1.24 - 0.8

5. Satisfaction with access to provider ψ 1.27 +1.6

6. Satisfaction with provider interaction ψ 1.24 - 0.8

7. Satisfaction with quality of care ψ 1.25 0

ψ Predicting for scores of <2.5, referent is satisfaction score >=4.5

* Significantly associated with failure to complete PNC (p <0.05)

Table IV (contd.)

Mediators Adjusted OR 95% CI% change in the

direct effect

Waiting >30 minutes to see provider 1.11 (0.79, 1.58)

1. Total satisfaction 1.06 - 4.5

2. Satisfaction with access to provider ψ 1.09 - 1.8

3. Satisfaction with admin. efficiency and office staff ψ 1.08 - 2.7

4. Satisfaction with resources ψ 1.12 + 0.9

5. Satisfaction with access to provider ψ 1.03 - 7.2

6. Satisfaction with provider interaction ψ 1.07 - 3.6

7. Satisfaction with quality of care ψ 1.05 - 5.4

ψ Predicting for scores of <2.5, referent is satisfaction score >=4.5

* Significantly associated with failure to complete PNC (p <0.05)

Table IV (contd.)

Mediators Adjusted OR 95% CI% change in the

direct effect

Had difficulty getting (transportation) to provider *

2.17 (1.28, 3.68)

1. Total satisfaction 2.12 - 2.3

2. Satisfaction with access to provider ψ 2.12 - 2.3

3. Satisfaction with admin. efficiency and office staff ψ 2.14 - 1.4

4. Satisfaction with resources ψ 2.15 - 0.9

5. Satisfaction with access to provider ψ 1.97 - 9.2

6. Satisfaction with provider interaction ψ 2.13 - 1.8

7. Satisfaction with quality of care ψ 2.18 + 0.5

ψ Predicting for scores of <2.5, referent is satisfaction score >=4.5

* Significantly associated with failure to complete PNC (p <0.05)

Limitations

Dichotomous measure of care utilization Misclassification overestimating completers

(conservative bias) Measurement of satisfaction Retrospective design Timing and location of data collection

Future Work

Research is needed to: Improve understanding and measurement of

“satisfaction” What does satisfaction really mean for traditionally underserved

populations?

Understand the other motivational factors that bring women to care (culture, fear, education, values, etc.)

How various barriers to care (beyond accessibility issues) interplay with motives to impact use

Study 2: Relative Importance of Barriers to PNC

Purpose

To achieve a better understanding of the role different types of barriers may play in precluding or averting a woman from using PNC services.

To determine which types of barriers are significantly related to inadequate or underutilization of PNC

Measures

Adequate Care Early and Sufficient Care

Complete expected number of visits Initiate care within first 12-15 weeks of pregnancy

Barriers Systems/structural Financial Cognitive/psychosocial Logistic

Table IBarriers to Prenatal Care

System/Structural barriersCouldn’t get an appointmentCouldn’t find a provider that would take me

Lengthy wait to contact or see the providerPoor service

Financial barriersLack of insurance or money to pay for PNC

Cognitive/Psychosocial barriersDid not need careDid not want prenatal care Family did not want prenatal care

Too many other things going on

Unwanted pregnancyFear of pregnancy or providerFear of social stigma

Logistic barriersTransportationChild care

Time/office hours for providerOther personal circumstances

Table II Adjusted Odds of Not Having Adequate PNC (n=1340)

Predictors α SE Adjusted OR 95% CI

Reported a system/structural barrier ** 0.1005 1.74 (1.20, 2.54)

Reported a financial barrier *** 0.1904 4.77 (2.76, 8.24)

Reported a cognitive/psychosocial barrier *** 0.2286 2.98 (2.15, 4.13)

Reported a logistic barrier 0.0645 1.54 (0.97. 2.43)

α Model was controlled for maternal age, race, marital status, education level, parity, and pregnancy wanted-ness. *** Significantly associated with having inadequate PNC (p <0.001)** Significantly associated with having inadequate PNC (p <0.01)* Significantly associated with having inadequate PNC (p <0.05)

Conclusion

Findings suggest that while structural barriers are an important obstacle to accessing prenatal care, financial and cognitive/psychosocial barriers may have a greater effect on a woman completing an adequate amount of care.

Implications are that improving health outcomes may depend as much on reforming educational and economic policies as on health care practices.

Acknowledgements

Association of Schools of Public Health (Grant #: S3251-23/23)

Centers for Disease Control and Prevention Community Friendly Accesssm Projects

Flint/Genesee County, MI East Tennessee Indianapolis, IN Jacksonville, FL

This project was supported under a cooperative agreement from the Centers for Disease Control and Prevention (CDC) through the Association of Schools of Public Health (ASPH) grant number U36/CCU300430-23. 

The contents of this report are solely the responsibility of the authors and do not necessarily represent the official views of CDC or ASPH.