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Health research methodology : a guide for training in research methods. 2nd ed..

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Introduction to Health Research Methods: A Practical Guide 3rd Edition

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• ISBN-10 1284197565
• ISBN-13 978-1284197563
• Edition 3rd
• Publisher Jones & Bartlett Learning
• Publication date February 20, 2020
• Language English
• Dimensions 7.1 x 0.5 x 9 inches
• Print length 404 pages
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• Publisher ‏ : ‎ Jones & Bartlett Learning; 3rd edition (February 20, 2020)
• Language ‏ : ‎ English
• Paperback ‏ : ‎ 404 pages
• ISBN-10 ‏ : ‎ 1284197565
• ISBN-13 ‏ : ‎ 978-1284197563
• Item Weight ‏ : ‎ 1.12 pounds
• Dimensions ‏ : ‎ 7.1 x 0.5 x 9 inches
• #4 in Medical Research (Books)
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Research Methods for Health Sciences

How to create an account and enroll in the course?

Research Methods Homepage

   .

Welcome to the Research Methods for Health Sciences course. This course provides students with the knowledge and skills necessary to design a research project and present it in the form of a research proposal.

The Research Methods for Health Sciences course is sponsored by the University of the Incarnate Word . Like all NextGenU.org courses, the Research Methods for Health Sciences course is competency-based, referencing competencies from the Health Services Research Doctoral Core Competencies (2018) , Development of the Learning Health System Researcher Core Competencies , and WHO-ASPHER 2020 . It uses learning resources from accredited, world-class organizations such as the U.S. Centers for Disease Control and Prevention (CDC) , the U.S. National Institutes of Health , and the World Health Organization .

The Research Methods for Health Sciences course was developed in collaboration with the University of the Incarnate Word and was designed by Hugo Rojas, MD, MSc, DiplEd; Pablo Baldiviezo, MD, DiplEd; Carolina Bustillos, MD, DiplEd; Felix Emeka Anyiam MPH, MScPH, DataSc., Ph.D.; Jean Pierre Musabyimana MSc; Genikka Camille Gabral, B.ED, MSc; Glenda Niles PhD.

For publications on NextGenU.org’s courses’ efficacy, see “A Novel Integration of Online and Flipped Classroom Instructional Models in Public Health Higher Education” (2014), BMC Medical Education , “Building Public Health Capacity through Online Global Learning,” (2018), Open Praxis , or on NextGenU.org’s publication page .   Subscribe to our newsletter to be notified of future updates, new courses, and to be part of our community.

There are 6 modules to complete, which provide an introduction to:

Module 1: Introduction to Research Methods

Module 2: research questions, research objectives, and hypotheses, module 3: quantitative studies, module 4: qualitative and mixed studies, module 5: literature reviews and critical appraisals of research, module 6: scientific skills.

The completion time for this course is estimated at 143 hours, consisting of 27 hours of learning resources, 55 hours for time to study content and assimilation, and 61 hours of participating in learning activities and quizzes, to assist the learners in the synthesis of learning materials. This course is equivalent to 3 credit hours.

The course requires the completion of all activities i.e., quizzes, peer activities , discussion forums , and a final assignment that are needed to complete the course. At the end of each module, there is a practice quiz of ten (15) multiple-choice questions. After you’ve completed each lesson, quiz, peer activity, and learning activity, you will have access to a final exam consisting of fifty (50) multiple-choice questions and a chance to evaluate this course. The final exam will be designed so that participants can have multiple opportunities to answer correctly until the required score of 70% or higher is obtained. Once you’ve passed that last test, you will be able to download a certificate of completion from NextGenU.org and our course’s co-sponsoring organizations (listed above). We keep all of your personal information confidential, never sell any of your information, and only use anonymized data for research purposes. Also, we are happy to report your testing information and share your work with anyone (your school, employer, etc.) at your request. 

Engaging with this course:

You may browse this course for free to learn for your personal enrichment; there are no requirements. To register in this course, it is required that learners have obtained a college-level/bachelor's degree.  

To obtain a certificate, a learner must first register for the course and then successfully complete:

• All reading requirements,
• All quizzes and pass with a score of 70% with unlimited attempts,
• All peer activities,
• All discussion forums,
• Final assignment,
• The final exam with a minimum score of 70% and a maximum of 3 attempts, and
• The self and course evaluation forms.

To obtain credit:

• Complete all requirements listed above for the certificate, and
• Your learning institution or workplace should approve the partner-university-sponsored NextGenU.org course for educational credit, as they would for their learner taking a course anywhere.  

NextGenU.org is happy to provide your institution with:

• A link to and description of the course training, so they can see all its components, including the co-sponsoring universities and other professional organization co-sponsors; 
• Your grade on the final exam;
• Your work products (e.g., case study activities) and any other required or optional shared materials that you produce and authorize to share with them;  
• Your evaluations -- course, and self-assessments;
• A copy of your certificate of completion, with the co-sponsoring universities and other organizations listed.

To obtain a degree, NextGenU.org co-sponsors degree programs with institutional partners. To obtain a full degree co-sponsored with NextGenU.org, registrants must be enrolled in a degree program as a student of a NextGenU.org institutional partner. If you think that your institution might be interested in offering a degree with NextGenU.org, contact us .

We hope that you will find this a rewarding learning experience, and we count on your assessment and feedback to help us improve this training for future students.

Here are the next steps to take the course and earn a certificate.

• Complete the registration form.
• Take the pre-test .
• Begin the course with Module 1: Introduction to Research Methods. In each lesson, read the description, complete all required readings and any required activities, as well as take the corresponding quizzes.

Instructional Goals covered in this module:

• Understand research terminologies and the scientific method.
• Analyze the theoretical basis of research paradigms and health models.
• Describe the ethical principles of research, ethical challenges, and informed consent.

Module 1: Lesson 1: The History of Research and Evolution of Key Terminologies

Student learning outcomes:.

• Describe terms such as epistemology, empirical research, variables, units of analysis, and others.
• Describe the concept and process of the scientific method.
• Give specific examples of how the scientific method has contributed to the development of modern society.

Click here to start this lesson

Required Learning Resources and Activities

Read the entire page. (28 minutes)

University of Southern California -  2020

Read the entire page except for the "References" section. (35 minutes)

PLOS Computational Biology -  2019

Read the key takeaway titles under Roots of the Scientific Method. (11 minutes)

Stanford Encyclopedia of Philosophy -  2015

Read the following sections: 8. Technological Revolution” and 9. Sustainability Revolution. (33 minutes)

University of Southampton, United Kingdom -  2021

Read the entire webpage and watch the entire video The video explores how science leads to new developments of addiction medicines. (60 minutes)

In this activity, you will select a date or an event in the given “development of modern society” timeline and will analyze how the scientific method has contributed to the selected date/event.

Step 1: Review

Review this timeline of human conditions: milestones in evolution and history . Select one date or event under sections “8. Technological Revolution” and “9. Sustainability Revolution.”

Step 2: Analyze

Analyze the role of the scientific method in the emergence and development of the selected event/date. Focus on the following key questions:

• What is the most prominent or distinctive feature/ element of the selected event/ date?

Example: 2019 - first case of COVID-19 coronavirus (Wuhan, China, 1/12/2019) → pandemic, triggering unprecedented lockdowns of nations and societies worldwide.

• Is the event deemed to be a positive event or a negative event?
• How is the scientific method utilized or related to this event? Give specific examples.
• Does the use of scientific methods have a positive impact on the event? Give specific examples.

Step 3: Respond

Write a 300-500 word discussion post that answers all the questions in Step 2.

Step 4: Share

To share your work, click on the “Reply” button under this post and paste your work in the “Message” box. Make sure to reference others’ intellectual property when necessary. All references should follow 7th Edition APA formatting. For further instructions, see the resource on the Himmelfarb Health Sciences Library: APA citation resource (N.B. references are excluded from word counts).

Step 5: Interact

To complete the activity, you will need to reply to at least two posts made by your peers in a respectful and professional manner. Be sure that your post engages your peers' ideas by including a reflection on their comments, sharing ideas on other potential difficulties and parties involved, or asking thought-provoking questions. If a peer comments on your posting, please reply. To post a reply, click “Reply” on a particular discussion, write your feedback and then click on “post to forum.”

Recommended Additional Readings

Read the information under the headings "Scientific Method" and "Discourse on scientific method". (16 minutes)

Stanford Encyclopedia of Philosophy -  2021

Module 1: Lesson 2: Research Theory: Paradigms, Methodologies, and Designs in Health Research

• Differentiate the concepts of paradigm, method, and design in research theory.
• Identify the most significant characteristics of the positivist, post-positivist, constructivist, and critical research paradigms.
• Discuss the strengths and weaknesses of the positivist, post-positivist, constructivist, and critical research paradigms.
• Examine the most significant aspects of ontology, epistemology, and methodology according to different research paradigms.

Read the content under the heading "Introduction" and "Research Paradigms" until the end of the article. (64 minutes)

The Qualitative Report. - 2017

Read the entire article. (34 minutes)

Life Science Journal -  2013

Read content under the following headings: "Abstract, Introduction, Paradigm, Post-Positivist Paradigm, Social Constructivist Paradigm, Critical Theory Paradigm". (21 minutes)

British Journal of Social Work -  2015

Read the content under Section 2 on page 26: "What Are the Essential Elements of a Research Paradigm? Pertinent Literature". (14 minutes)

International Journal of Higher Education -  2017

In this activity, you will select a research problem. You will create a video presentation explaining the different approaches to study the problem from different paradigms, including how ontology, epistemology, and methodology differ. For each paradigm, you will make a comment on the strengths and weaknesses of each.

Review the components of Module 1 Lesson 2, especially the four common research paradigms in medical education: positivist, post-positivist, constructivist, and critical research. After reviewing, select a particular health issue of your interest. 

Health issue: Assessing COVID-19 Vaccine Hesitancy in the US population.

2.1: Select four research paradigms and think of examples about how each of them can help you discover different aspects of a health issue of your choice.

2.2: Now, select one paradigm and reflect on how ontology, epistemology, and methodology differ according to your selected paradigm. The table in this link and the following questions will help you to complete this task:

Ontology: What is out there to know? / What is reality?

Epistemology: How can I know reality?

Methodology: How do I acquire knowledge?

Step 3: Create

Create a 5-minute video presentation that includes:

Your examples on how each research paradigm would help you discover different aspects of the health issue of your choice.

How ontology, epistemology, and methodology differ for a selected paradigm. Use examples related to your selected health issue to illustrate your arguments.

Feel free to use slides for the presentation. You can use the free version of Loom to record and share your video.

Step 4: Self-Analysis and Enhancement

Before you submit, engage in an introspective self-analysis by systematically reviewing each component of your work. Reflect on what aspects of your work were executed well and what could be enhanced. Proceed to refine these elements in your work. 

Step 5: Submit

Post a shareable link to your presentation in the forum. To share your work, click on the “Reply” button under this post and paste your link in the “Message” box. Make sure to reference others’ intellectual property when necessary. All references should follow 7th Edition APA formatting. For further instructions, see the resource on the Himmelfarb Health Sciences Library: APA citation resource (N.B. references are excluded from word counts).

Module 1: Lesson 3: Research Ethics and Integrity

• Discuss the importance of informed consent in public health research.
• Explain the ethical principles in public health research and their importance.
• Describe the core values of integrity in research.
• Summarize the history of research ethics, the Nuremberg Code, and the Belmont Report.
• Using the example of substance abuse research, discuss ethical challenges in research with potentially vulnerable participants.

Read the entire article. (8 minutes)

International Journal of Occupational Safety and Health - 2020

Read from page 1 to page 5. (11 minutes)

National Institute of Environmental Health Sciences - 2013

Read the entire page. (5 minutes)

National Institutes of Health -  2016

Read the entire article. (35 minutes)

National Academy of Sciences -  2017

Read entire page. ( 46 minutes)

National Institute of Environmental Health Sciences - 2021

Read the entire article. (10 minutes)

JAMA Network American Medical Association - 2017

Read all sections except for Acknowledgment and References. ( 16 minutes)

American Public Health Association - 2018

Read the entire article. (21 minutes)

Journal of Medical Ethics and History of Medicine -  2014

Read the entire article. (22 minutes)

NCBI - 2018

Read the entire article. (20 minutes)

Therapeutic Innovation & Regulatory Science - 2018

For this activity, you will reflect about the unique risks that arise in research with individuals with substance use disorder and link them with the ethical principles of research.

Step 1: Reflect

Review the readings listed below and reflect on how unique risks in research with individuals with substance use disorders are related to specific principles of ethical research and core values and guiding norms of integrity research.

• Guiding Principles for Ethical Research
• Foundations of Integrity in Research: Core Values and Guiding Norms
• Ethical Issues in Research Involving Participants With Opioid Use Disorder

Step 2: Respond

Write a 250-450 word post in which you:

• Select one or two unique risks that arise in research with individuals with substance use disorders
• Explain how these unique risks are related to the guiding principles for ethical research and the core values and guiding norms of integrity research 
• Discuss how these principles, values, and norms, can reduce risks when working with these potentially vulnerable populations

Step 3: Share

Step 4: Interact

• The activity Course Registration is marked complete
• The activity Pre-Test is marked complete

To access the quiz, click on the name of the quiz provided above. On the following screen, click the "Preview quiz now" button to respond to the questions.

• Formulate research problems, questions, aims, objectives, and hypotheses that are clear and practicable.

Module 2: Lesson 1: Research Problems and Research Questions

• Define a research problem and a research question.
• Describe the characteristics of clear and practicable research problems and research questions for quantitative, qualitative, and mixed methods research.
• Formulate clear and practicable quantitative and qualitative research problems and research questions.

Read the entire page. (2 minutes)

University of London - 2014

Read the entire article.  (17 minutes)

International Journal of Research (IJR)-2014

Read the entire article. (18 minutes)

Stanford University - 2016

Read the entire article. (19 minutes)

Journal of Indian Association of Pediatric Surgeons - 2019

Read the entire Document except the "References" part. (19 minutes)

American Scientific Research Journal for Engineering, Technology, and Sciences (ASRJETS) - 2021

Read the entire page and the next page for qualitative research questions. (16 minutes)

Mavs Open Press Open Educational Resources from the University of Texas at Arlington - 2018

In this activity, you will write a research problem statement keeping in mind that it will be used to work on the activities in the entire course, including the final assignment. Then, you will write qualitative and quantitative research questions for your identified problem.

Review this Learning Resource .

Think about a health issue that you might be interested in studying and complete the following:

• Write a problem statement that:
• Reflects a need
• Is based on factual evidence
• Is meaningful; has testable hypotheses
• Has a relevant and manageable problem 
• Using this to guide you, write between 3 and 5 research questions to guide your study of the problem. Ensure that you have a combination of qualitative and quantitative questions.

Module 2: Lesson 2: Research Aims and Research Objectives

• Define a research aim and research objective.
• Differentiate research aims and research objectives.
• Give examples of research objectives and research aims that are clear and practicable for qualitative and quantitative research.
• Write research aims and objectives that are clear and practicable.

Read the following sections: Aims, Objectives, and Conclusion. (10 minutes)

Nurse Researcher - 2016

Read the entire journal article. (26 minutes)

Sage - 2013

Based on the research problems and questions developed in M2 L1, you will write qualitative and quantitative research aims and objectives.

Review the learning resources for Lesson 2.

• Write the aim(s) of your research. Ensure that it clearly states what you want to achieve by the end of the research project.
• List your research objectives:
• Write between 3-5 research objectives
• Make sure to have a combination of qualitative and quantitative objectives
• Remember that they should be SMART (specific, measurable, achievable, realistic, and time-constrained)

Step 3: Self-Analysis and Enhancement

Step 4: Submit

To submit your work, click on the “Reply” button under this post and paste your work in the “Message” box. Make sure to reference others’ intellectual property when necessary. All references should follow 7th Edition APA formatting. For further instructions, see the resource on the Himmelfarb Health Sciences Library: APA citation resource (N.B. references are excluded from word counts).

Module 2: Lesson 3: Research Hypotheses

• Describe the common types of research hypotheses for health research.
• Differentiate qualitative and quantitative research hypotheses.
• Formulate clear and practicable quantitative and qualitative research hypotheses.

Read the entire page. (1 minute)

Austin Peay State University - 2021

Read the content under the heading "Quantitative Research Questions and Hypotheses" on pages 132 to 136, and "Mixed Methods Research Questions and Hypotheses" on pages 138 to 143. (30 minutes)

Sage Publishing. - 2008

Read the following sections:  Abstract 3.3.What Is a Research Hypothesis? 3.4. Analogical Arguments in Support of Using Hypotheses 3.5. Can a Hypothesis Be “Tested” in Qualitative Research? 4. The Process of Developing and Using Hypotheses in Qualitative Research. (15 minutes)

MDPI or Multidisciplinary Digital Publishing Institute - 2019

Read the content under the sections: "Formulating Hypotheses" and "Variables of Interest". (7 minutes)

University of Central Arkansas - 2013

In this activity, you will build on previous work and write quantitative and qualitative research hypotheses for your research proposal.

Review the Section on Formulating Hypotheses .

Recalling your research problem, which you formulated in Module 2 Lesson 1:

• Write at least two hypotheses to predict the result of your research. Make sure to have at least one qualitative and quantitative hypothesis. 
• For each hypothesis, write a 50-150 word paragraph explaining the rationale for the prediction.

Read entire table. (2 minutes)

Xavier University - 2012

• Develop a quantitative study design, including a strategy for sampling and data collection, hypothesis testing, and data analysis.

Module 3: Lesson 1: Quantitative Study Designs

• Understand the hierarchies of quantitative study designs.
• Understand the levels of evidence based on study designs.
• Describe the concept and classification of descriptive study designs.
• Discuss the strengths and weaknesses of descriptive study designs such as cross-sectional studies, case reports, and case series.
• Select a descriptive study design to address a given research question.
• Describe the concept and classification of analytic study designs, including observational and experimental studies.
• Break down the different observational study designs (cross-sectional, case-control, and cohort studies).
• Describe the concept of quasi-experimental studies.
• Describe the concepts of randomization and experimental study designs.
• Examine the different types of clinical trials.
• Discuss the strengths and weaknesses of common observational and analytical study designs.
• Select a quantitative study design to address a given research question.

Read the entire document. ( 16 minutes)

Australian Journal of Advanced Nursing - 2016

Read the entire document. ( 8 minutes)

Walden University - 2021

Read the section under overview of the design tree. (8 minutes)

University of Oxford - 2009

Read the entire article. ( 15 minutes)

Journal of Health Specialties - 2015

Read the entire article. (12 minutes)

Perspectives in Clinical Research - 2019

Read the entire article EXCEPT for these sections: Standards of research and reporting and Conclusion. (35 minutes)

Biochemia Medica - 2014

Read the content under cross-sectional, case-control design and cohort stduy design. (32 minutes)

HealthKnowledge - 2018

Read the following components of the Review section: Cross-sectional, Case-control, and cohort studies. ( 6 minutes)

Cureus Journal of Medical Science -  2020

Read pages 6-11 of the manuscript. (19 minutes)

Journal of Clinical Epidemiology - 2017

Read entire page including the hyperlinked page: Random Assignment. (8 minutes)

Office of Research Integrity by U.S. Department of Health and Human Services -  2017

Read the entire page. (17 minutes)

American Cancer Society - 2021

In this activity, you will analyse a given set of research questions and will discuss the strengths and weaknesses of studying one of the questions with at least 2 types of descriptive and analytical study designs.

Review the learning resources for this lesson.

Analyze the following research questions:

• Is there a correlation between diet and stomach cancer survival in people aged 50-65?
• How effective is immunotherapy in the fight against breast cancer?
• What are the perceptions of residents in rural communities about vaccinations?
• Are middle/low-income countries more likely to have low rates of COVID vaccine uptake?
• Was there an increase in mental health disorders as a result of lockdown measures imposed in Italy between March and May 2020?
• Select one question from the list above.
• Write a post of 250-350 words in which you:
• Choose at least 2 types of study designs (descriptive and/or analytical) that can be used to answer this question.
• Discuss the strengths and weaknesses of utilizing each study design to answer the research question.

To complete the activity, you will need to reply to at least one post made by your peers in a respectful and professional manner. Be sure that your post engages your peers' ideas by including a reflection on their comments, sharing ideas on other potential difficulties and parties involved, asking thought-provoking questions or making suggestions. If a peer comments on your posting, please reply. To post a reply, click “Reply” on a particular discussion, write your feedback and then click on “post to forum.”

In this activity, you will continue to build upon previous work by selecting a study design for the quantitative component of your research proposal.

Review the research questions which you wrote in Module 2 Lesson 1. Select the quantitative question(s).

Choose the best quantitative study design which will help you to answer the question(s). Write a 200-350 word post in which you:

• Summarize the selected design for the chosen questions
• Give a rationale for its selection

Before you submit, engage in an introspective self-analysis by systematically reviewing each component of your work. Reflect on what aspects of your work were executed well and what could be enhanced. Proceed to refine these elements in your work.

Module 3: Lesson 2: Sampling and Data Collection for Quantitative Research

• Understand the uses of probability and non-probability sampling methods.
• Give examples of probability and non-probability sampling methods.
• Determine a sampling strategy and sample size for a quantitative study.
• Describe the data collection methods in quantitative research.
• Determine a data collection method for a quantitative study.

Read the entire document. ( 51 minutes)

People's University - 2016

International Journal of Academic Research in Management - 2016

Read the entire article. (23 minutes)

Indian Journal of Continuing Nursing Education - 2017

Read the entire document. (5 minutes)

For this activity, you will determine a sampling strategy, sample size, and data collection strategy for the quantitative component of your research proposal.

Recalling the quantitative research questions, design, and objectives already designed, write a post of 200-350 words in which you explain:

• Sampling strategy with a description of the study population
• Sample size along with:
• Justification for the calculation strategy
• Margin of error and confidence level
• Data collection strategy

Module 3: Lesson 3: Quantitative Data Analysis: Hypothesis Testing and Tests of Significance

• Describe the process of quantitative data analysis.
• Explain the different data measurement scales (nominal, ordinal, interval, ratio).
• Differentiate between continuous and discrete data.
• Explain the purpose of hypothesis testing.
• Explain the components of hypothesis testing (null hypothesis, alternative hypothesis, Type I Error, Type II Error, and power).
• Describe the meaning of a test of significance.
• Define the different tests of significance (Chi-Square, T-Test, ANOVA, F-Statistic, etc).
• Differentiate the different tests of significance (Chi-Square, T-Test, ANOVA, F-Statistic, etc).
• Define probability value (P-value).
• Give examples of the use of P-value in a research context.
• Determine a data analysis strategy for a given research question.

University of Southern California - 2021

Read the entire page. ( 9 minutes)

Read the entire page. (16 minutes)

Annals of Cardiac Anaesthesia -  2018

Read the following sections:  -Introduction -Nominal -Ordinal -Ratio -Interval and watch the videos that accompany each. (11 minutes)

University of Nottingham School of Health Sciences - 2016

Read the entire document. (11 minutes)

NextGenu.org - 2019

Read the entire document. (4 minutes)

Read the entire document. (24 minutes)

University of Dallas 

Read the entire document.  (20 minutes)

University of West Georgia

Read the entire document. (45 minutes)

UCLA - 2021

Read the entire page. (40 minutes)

Food and Agriculture Organization of the United Nations

Read the entire page. ( 6 minutes)

Boston University School of Public Health - 2019

Read the entire article. (5 minutes)

Sociedade Brasileira de Pneumologia e Tisiologia: Continuing Education: Scientific Methodology - 2015

In this activity, you will write the first part of the "Data Analysis" section of your research proposal. It will include a description of the type of data you expect to collect in the quantitative component and the analysis strategy(ies) you plan to utilize.

Review the following resources from the lesson’s readings:

• Analyzing Quantitative Data for Evaluation
• Quantitative Methods - Organizing Your Social Sciences Research Paper
• Scales of Measurement and Presentation of Statistical Data 

Write the first few paragraphs of the Data Analysis section of your proposal. Your post should be 200-350 words long. Ensure that you include:

• Type of data to be collected
• Appropriate data analysis strategy(ies) to be used for each type of data

Read the content under the heading Introduction, The Meaning of Significance Tests, Z-M's Criticism of Significance Tests to page 265. (19 minutes)

Econ Journal Watch - 2012

• Develop a qualitative study design, including a strategy for sampling, data collection, and data analysis.

Module 4: Lesson 1: Qualitative Study Designs

• Describe the concept and defining characteristics of qualitative research.
• Categorize the different qualitative study designs (grounded theory, ethnography, phenomenology, participatory action research, case study, and historical studies).
• Discuss the strengths and weaknesses of qualitative research.
• Determine an appropriate qualitative design to address a given research question.

Read the entire document. ( 21 minutes)

Public Health U -  2020

Geriatrics, Gerontology and Aging -  2017

Read section: Types of Qualitative Research Designs. (10 minutes)

International Journal of Preventive Medicine - 2021

Read entire page. (12 minutes)

Australian Institute of Family Services - 2015

Read Section: 3. Qualitative Research Approaches and Methods. (12 minutes)

Journal of Education and Learning: Canadian Center of Science and Education -  2016

For this activity, you will analyse a given set of research questions, discussing the strengths and weaknesses of studying the question with at least 2 types of qualitative research designs.

• How do cancer survivors perceive their quality of life after chemotherapy and radiation treatment?
• Does early intervention in obese children result in healthy body weight as adults?
• Is vaccine hesitancy more prevalent among immigrant populations in rural areas?
• Do mental health disorders increase with substance abuse? 
• Choose at least 2 types of qualitative study designs (phenomenology, grounded theory, case study, ethnography, participant action research, historical study) that can be used to answer this question.

To complete the activity, you will need to reply to at least one post made by your peers in a respectful and professional manner. Be sure that your post engages your peers' ideas by including a reflection on their comments, sharing ideas on other potential difficulties and parties involved, asking thought-provoking questions, or making suggestions. If a peer comments on your posting, please reply. To post a reply, click “Reply” on a particular discussion, write your feedback and then click on “post to forum.”

In this activity, you will start working on the qualitative component of your research proposal. You will select a study design from the ones addressed in this lesson to study your qualitative research questions.

Review the research questions which you wrote in Module 2 Lesson 1. Select the qualitative question(s).

Choose the best qualitative study design which will help you to answer the question(s). Write a 200-350 word post in which you:

• Summarize the selected design

To submit your work, click on the “Reply” button under this post and paste your work in the “Message” box. Make sure to reference others’ intellectual property when necessary. All references should follow 7th Edition APA formatting. For further instructions, see the resource on the Himmelfarb Health Sciences Library: APA citation resource (N.B. references are excluded from word counts). 

Module 4: Lesson 2: Sampling and Data Collection for Qualitative Research

• Describe the common sampling strategies for qualitative research (purposeful, convenience, snowballing, quota).
• Explain the common qualitative research methods (interviews, focus groups, observation, document reviews, and visual methods).
• Determine the sampling and data collection methods to address a given research question.

Read pages 1-3 from "Introduction" to "Purposive Sampling Methods". (14 minutes)

American Journal of Theoretical and Applied Statistics - 2015

Read content under "Introduction" and "On Snowball Sampling". (10 minutes)

PLoS One - 2018

Read content under Non-probability Sampling and Types of Non-probability sampling. (12 minutes)

Radford University - 2021

Watch the entire video.  (12 minutes)

Center for Research Quality - 2015

In this activity, you will continue working on the qualitative component of your proposal by defining a sampling and data collection method that matches your preferred study design.

Recalling the qualitative research questions and objectives already designed, write a post of 150-250 words, in which you explain:

• Sampling strategy 
• Sample size and justification
• Data collection method

Module 4: Lesson 3: Qualitative Data Analysis

• Describe the concept and defining characteristics of qualitative data analysis.
• Describe the main approaches to qualitative data analysis (deductive, inductive, thematic, and content analysis).
• Determine a qualitative data analysis strategy to address a given research question.

Read from the content under the heading "Research Designs" on page 365 to the heading "Mixed Methods" on page 369. (22 minutes)

Sage Publishing -  2014

Read the entire page. (4 minutes)

NSW government website -  2020

Read content under "Data Analysis". ( 11 minutes)

Qualitative Research Journal - 2018

Read from "Introduction" to "When to use thematic analysis". (12 minutes)

Medical Teacher - 2020

Read the entire page. (14 minutes)

Columbia Public Health - 2021

For this activity, you will select a data analysis strategy for the qualitative component of your proposal and provide a justification/rationale.

Based on your qualitative research questions, select the most appropriate data analysis strategy/strategies and write a 200-350 word post in which you include:

• The type of data to be collected
• The strategy/strategies you will use to analyse it
• A justification for your selection.

Module 4: Lesson 4: Mixed Methods Research

• Describe what is meant by mixed research methods.
• Identify the characteristics of common mixed research designs (convergent, sequential, triangulation, explanatory, exploratory, embedded).
• Outline the advantages and shortcomings of employing mixed method designs.

Read Section 2: Mixed Method Research Defined. (5 minutes)

International Journal of Science and Research (IJSR) - 2013

Read the entire document. (22 minutes)

Read Sections 4,5,6 of the paper. ( 8 minutes)

Journal of Literature, Languages and Linguistics -  2019

Based on your experience working on the peer activities so far, for this activity, you will provide 3 advantages and 3 disadvantages of using a mixed methods approach.

Review the resources from this lesson, particularly this article .

Write a post of 150-250 words in which you discuss:

• 3 advantages of using a mixed method approach
• 3 disadvantages of using a mixed method approach

To complete the activity, you will need to reply to at least two posts made by your peers in a respectful and professional manner. Be sure that your post engages your peers' ideas by including a reflection on their comments, sharing ideas on other potential difficulties and parties involved, asking thought-provoking questions, or making suggestions. If a peer comments on your posting, please reply. To post a reply, click “Reply” on a particular discussion, write your feedback and then click on “post to forum.”

• Appraise the importance and application of literature reviews for health sciences research.
• Conduct a systematic search and critical appraisal of research.

Module 5: Lesson 1: Types and steps of Literature Reviews

• Explain the narrative, scoping, and systematic reviews of literature and meta-analysis.
• Differentiate the types of systematic reviews and their importance (Rapid review, Narrative review, Meta-analysis, Mixed methods/mixed studies)
• Explain the steps to conduct a systematic review and meta-analysis.
• Reflect on the contributions of each type of review for the advancement of health sciences research.

Watch the entire video. (10 minutes)

National Collaborating Centre for Methods and Tools - 2016

Read whole article. (31 minutes)

BMC Medical Research - 2018

Public Health U - 2020

Read the entire page. (7 minutes)

Duke University: Medical City Library

Read the entire document. (10 minutes)

Canadian Academy of Child and Adolescent Psychiatry - 2011

Read the entire article. (14 minutes)

Temple University - 2021

For this activity, you will use one of the quantitative and qualitative research questions developed in your previous peer activities. For each question, you will write a short reflective paragraph on how each type of literature review addressed in the module could help answer the research question (narrative, scoping, systematic review, meta-analysis).

For each of your research questions, write a paragraph of between 100-200 words in which you reflect on how each of the types of literature reviews can help you to answer the research question.

To complete the activity, you will need to reply to at least two  posts made by your peers in a respectful and professional manner. Be sure that your post engages your peers' ideas by including a reflection on their comments, sharing ideas on other potential difficulties and parties involved, asking thought-provoking questions or making suggestions. If a peer comments on your posting, please reply. To post a reply, click “Reply” on a particular discussion, write your feedback and then click on “post to forum.”

Module 5: Lesson 2: The Systematic Search and Critical Appraisal of Research

• Understand the concept and defining characteristics of systematic searches.
• Explain the steps and best practices to conduct a systematic search.
• Apply the techniques for a systematic search for the research question of interest.
• Describe the importance of critical appraisal of research.
• Describe the commonly used tools for critical appraisal of research (CASP and JAMA).
• Reporting a critical appraisal and systematic review in general.
• Apply the tools to critically appraise a research paper.

Read this section of the document: CREATING A SYSTEMATIC SEARCH STRATEGY. (26 minutes)

Journal of the Medical Library Association - 2018

Read the section: Why is critical appraisal needed? (2 minutes)

The Royal College of Surgeons of England - 2017

Read the entire page. (20 minutes)

University of South Australia

For this activity, you will conduct a systematic search based on one of your research questions and  share the results within the platform (process and databases employed, search terms, number of results).

After completing the systematic search, you will then select a research paper from the results. Based on the tools studied in the module, you will identify an appropriate tool to assess the paper and provide a rationale for using that particular tool. 

Review the learning resources for this module.

Step 2: Search

Assume you are doing a systematic review as part of your thesis:

• Select a research question of your preference and design search terms to conduct a systematic search. Make sure that the terms make good use of operators such as (), AND, OR, “”, and others.
• Select at least two databases of your preference. You can use open databases such as ERIC, PubMed, or Google Scholar.
• Insert your search terms, assess the results, and make adjustments to the terms until you feel satisfied with the number and quality of results obtained.

Step 3: Assess

From your results, select any research paper of your preference and get ready to make a critical appraisal.

• Choose a tool/checklist to assess the paper. Feel free to use the tools mentioned in the course readings or identify any other of your preference.
• Use your selected tool to assess the paper.

Step 4: Report

Prepare a 400-700 word report in which you include details under the following headings:

• Systematic Search
• Research Question
• Search Process utilized (logical and clear)
• Database(s) used
• Search Terms used
• Number of results obtained in each database
• Critical Appraisal
• Write a rationale for your tool selection and the main observations you have made about the paper. Make sure to include positive and negative aspects.

Step 5: Self-Analysis and Enhancement

Step 6: Submit

• Write and present scientific research, following appropriate style and referencing standards.

Module 6: Lesson 1: Scientific Writing

• Distinguish between scientific and regular writing.
• Implement scientific writing principles in research products.
• Describe the strategies for effective oral communication.
• Demonstrate oral communication skills in presenting research products.

Read the entire article. (56 minutes)

The Pennsylvania State University-2018

Read the entire article. (11 minutes)

PLOS Computational Biology - 2015

University of Nebraska-Lincoln - 2016

Read entire document. (14 minutes)

University of Leeds - 2015

Read entire document. (10 minutes)

University of Colorado Denverr - 2014

Read the entire page. (10 minutes)

University of Waterloo - 2013

Harvard Division of Continuing Education - 2020

Module 6: Lesson 2: Plagiarism and Referencing Styles

• Describe the concepts of intellectual property and plagiarism.
• Explain the common recommendations to avoid plagiarism in academic writing.
• Identify the different referencing styles and their uses.
• Apply a referencing style to cite and reference research studies.

Read entire document. (30 minutes)

World Intellectual Property Organization - 2020

Read the entire page. (8 minutes)

University of Michigan - 2020

Read entire page. (15 minutes)

Trent University - 2021

Memorial University of Newfoundland - 2012

Read the entire page. (15 minutes)

University of California - 2021

In this activity, you will write a few introductory paragraphs for your research proposal that will follow scientific writing principles and a referencing style of your preference.

Using the following as a guide, write the introductory paragraphs to your Research Proposal. Include the following:

• Problem statement and the background
• The relevance and contribution of your planned project
• Reference list, stating the referencing style used

Watch the entire video. (4 minutes)

University of Reading - 2019

Final Assignment

Click here to start this Final Assignment

For the Final Assignment, you will add to the work that you have already completed to prepare your research proposal. You will then create a 10-minute video presentation of your research proposal. 

Review your submissions for the previous activities in the course. Pay close attention to any feedback suggested by your peers.

Step 2: Create

Create your thesis proposal using the materials developed for the peer activities in this course. You can decide to propose a mixed methods approach or to use only a quantitative or qualitative approach. The proposal should have an extension of 3-4 pages and use the following outline:

• Introduction (background, relevance, contribution)
• Research Problem
• Research Questions
• Research Aim and Objectives
• Methods (specify the qualitative and quantitative components in each category if the study follows a mixed methods approach)

Study design, including a justification for the proposed design 

Inclusion and Exclusion Criteria

Data collection and analysis

Use the following as a formatting guide:

• Font: Arial or Calibri
• Font Size: 11-point
• Spacing: 1.5
• Headings: bold, flush left (Methods will have level 2 headings: flush left, bold, italics)

Step 3: Present

Prepare a 10-minute video presentation of your research proposal. You are free to use slides to present the information.  You can use the free version of Loom or any other screen recording software to record and share your video.

To share your work, click on the “Reply” button under this post, then upload your written research proposal and paste a shareable link to your video in the “Message” box. Make sure to reference others’ intellectual property when necessary. All references should follow 7th Edition APA formatting. For further instructions, see the resource on the Himmelfarb Health Sciences Library: APA citation resource (N.B. references are excluded from word counts).

To complete the activity, you will need to reply to at least one post made by your peers in a respectful and professional manner, using the items in this Rubric to guide you. Provide a rationale for the grade you have provided, as well as comments or suggestions for improvement. You may use the following as a guide:

Item A is  .…. because….  My suggestions for improvement are…. Item B is  .…. because….  My suggestions for improvement are…. Item C is  .…. because….  My suggestions for improvement are…. Item D is  .…. because….  My suggestions for improvement are…. Item E is  .…. because….  My suggestions for improvement are…. Item F is  .…. because….  My suggestions for improvement are…. Item G is  .…. because….  My suggestions for improvement are…. Item H is  .…. because….  My suggestions for improvement are….

If a peer comments on your posting, please reply. To post a reply, click “Reply” on a particular discussion, write your feedback and then click on “post to forum.”

Click here to start Final Examination

• The activity Quiz: Module 1 is marked complete
• The activity Quiz: Module 2 is marked complete
• The activity Quiz: Module 3 is marked complete
• The activity Quiz: Module 4 is marked complete
• The activity Quiz: Module 5 is marked complete
• The activity Quiz: Module 6 is marked complete
• The activity Discussion Forum 1: Scientific Method and the Development of Modern Society (200 minutes). is marked complete
• The activity Asynchronous Learning Activity 1: A video presentation explaining the approaches to studying a research problem using different paradigms and their strengths and weaknesses (200 minutes). is marked complete
• The activity Discussion Forum 2: Informed Consent (210 minutes). is marked complete
• The activity Asynchronous Learning Activity 2: Research Problem Statement and Questions (120 minutes). is marked complete
• The activity Asynchronous Learning Activity 3: Research Aims and Objectives (120 minutes). is marked complete
• The activity Asynchronous Learning Activity 4: Research Hypotheses (120 minutes). is marked complete
• The activity Discussion Forum 3: Selecting Appropriate Study Designs (180 minutes) is marked complete
• The activity Asynchronous Learning Activity 5: Quantitative Study Design Selection (120 minutes). is marked complete
• The activity Asynchronous Learning Activity 6: Quantitative Data Collection (120 minutes). is marked complete
• The activity Asynchronous Learning Activity 7: Quantitative Data Analysis (200 minutes). is marked complete
• The activity Discussion Forum 4: Qualitative Study Designs (180 minutes) is marked complete
• The activity Asynchronous Learning Review 8: Qualitative Research Design (120 minutes). is marked complete
• The activity Asynchronous Learning Activity 9: Qualitative Data Collection (120 minutes) is marked complete
• The activity Asynchronous Learning Activity 10: Qualitative Data Analysis (200 minutes) is marked complete
• The activity Discussion Forum 5: Mixed Methods (120 minutes). is marked complete
• The activity Discussion Forum 6: Literature Reviews (200 minutes). is marked complete
• The activity Asynchronous Learning Activity 11: Systematic Search and Assessment (200 minutes). is marked complete
• The activity Asynchronous Learning Activity 12: Introduction of Research Proposal (180 minutes). is marked complete
• The activity Final Assignment (480 minutes) is marked complete
• You belong to Public Health U

To take the final exam, you must complete all quizzes and complete all the required activities. The final exam consists of 50 questions, and you will have 100 minutes to complete it. When the time is over, you will have two minutes to submit your attempt before it expires, and your progress is discarded. You will not be able to answer additional questions in the grace period.

To access the exam, click on the name of the exam provided above. On the following screen, click the attempt quiz button to respond to the questions.

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• A Respondus electronic test bank , created by the authors, is available and can be used on PCs. The test bank contains multiple choice, true/false, short answer, and essay questions for each chapter and provides you with a diverse range of pre-written options as well as the opportunity for editing any question and/or inserting your own personalized questions to effectively assess students’ progress and understanding. Respondus is also compatible with many popular learning management systems so you can easily get your test questions into your online course.
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• Features coverage of current and emerging issues developed from the ground up by experienced health research methods professionals currently practicing in the field
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• Includes diverse and numerous case studies in each chapter
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• Offers citations in each chapter to direct readers who are interested in more in-depth coverage of particular techniques and issues to appropriate sources
• Includes a Suggested Resources section at the end of each chapter offering additional resources for further research on important topics

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SIMILAR ITEMS (based on metadata)

• Open access
• Published: 24 April 2024

Feasibility of a quality-improvement program based on routinely collected health outcomes in Dutch primary care physical therapist practice: a mixed-methods study

• LSF Smeekens 1 ,
• AC Verburg 1 ,
• MJM Maas 1 , 2 ,
• R van Heerde 1 ,
• A van Kerkhof 3 &
• PJ van der Wees 1  

BMC Health Services Research volume  24 , Article number:  509 ( 2024 ) Cite this article

Metrics details

This study evaluates the feasibility of a nine-month advanced quality-improvement program aimed at enhancing the quality of care provided by primary care physical therapists in the Netherlands. The evaluation is based on routinely collected health outcomes of patients with nonspecific low back pain, assessing three feasibility domains: (1) appropriateness, feasibility, and acceptability for quality-improvement purposes; (2) impact on clinical performance; and (3) impact on learning and behavioral change.

A mixed-methods quality-improvement study using a concurrent triangulation design was conducted in primary care physical therapist practice. Feedback reports on the processes and outcomes of care, peer assessment, and self-assessment were used in a Plan-Do-Study-Act cycle based on self-selected goals. The program’s appropriateness, feasibility, and acceptability, as well as the impact on clinical performance, were evaluated using the Intervention Appropriate Measure, Feasibility Intervention Measure, Acceptability Intervention Measure (for these three measure, possible scores range from 4 to 20), and with a self-assessment of clinical performance (scored 0–10), respectively. The impact on learning and behavioral change was evaluated qualitatively with a directed content analysis.

Ten physical therapists from two practices participated in this study. They rated the program with a mean of 16.5 (SD 1.9) for appropriateness, 17.1 (SD 2.2) for feasibility, and 16.4 (SD 1.5) for acceptability. Participants gave their development in clinical performance a mean score of 6.7 (SD 1.8). Participants became aware of the potential value of using outcome data and gained insight into their own routines and motivations. They changed their data collection routines, implemented data in their routine practice, and explored the impact on their clinical behavior.

Conclusions

This explorative study demonstrated that a quality-improvement program, using health outcomes from a national registry, is judged to be feasible.

Impact statement

This study provides preliminary evidence on how physical therapists may use health outcomes to improve their quality, which can be further used in initiatives to improve outcome-based care in primary physical therapy.

Peer Review reports

High-quality health care is defined as care that is safe, timely, equitable, effective, efficient, and patient centered [ 1 ]. Against a background of rapidly increasing healthcare costs, service restrictions, and differences in quality, there is an increasing need for initiatives to improve quality of care [ 2 ]. This has led the Royal Dutch Society for Physical Therapy (KNGF) to initiate the ‘Quality in Motion’ program, which aims to improve the effectiveness and patient centeredness of care in physical therapist practice by providing therapists with feedback on health outcomes [ 3 ]. Outcome measures include patient-reported outcomes (PROs), which are used to assess aspects of a patient’s health status coming directly from the patient. Patient-reported outcome measures (PROMs) are questionnaires or single-item scales used to assess PROs [ 4 ], and can be used to support quality improvement [ 3 ]; however, there is a clear lack of understanding about how physical therapists can best utilize feedback about PROs to improve quality of care [ 5 , 6 , 7 ].

Nonspecific low back pain (NSLBP) is one of the most common health conditions in primary physical therapist practice [ 8 , 9 ]. Based on health outcomes from a clinical registry and consensus among stakeholders (i.e., physical therapists, researchers, patients, and health insurers), Verburg et al. [ 4 ] developed a core set of PRO-based quality indicators for patients with NSLBP in primary physical therapist practice. The set was found to be useful for quality-improvement initiatives, and stakeholders reported that it added value for routine practice [ 3 , 4 ]. These outcomes can be aggregated across patients in clinical registries, providing data for managing clinical quality, benchmarking and public reporting across organizations, and in clinical research; however, their aggregated use for quality improvement was found to be suboptimal [ 10 , 11 , 12 ]. An earlier study found that electronic health record (EHR) compatibility and therapist knowledge of the PROMs are the two key barriers to wider PROM use [ 13 ], with similar issues reported in other professions [ 14 , 15 ].

Feedback interventions, particularly when provided by a colleague both verbally and in writing [ 16 ], have shown promise in improving physical therapist practice [ 17 , 18 ]. Correspondingly, feedback reporting on processes and outcomes of care has been identified as an effective intervention that can support the exchange of best practices and mutual learning [ 16 , 18 , 19 ]. Additionally, involving peers as feedback providers in peer assessment creates meaningful learning experiences and is associated with behavioral change and measurable performance improvement in healthcare professionals [ 20 , 21 , 22 ]. Maas et al. [ 23 ] showed that peer assessment using video recordings of client communication and clinical records is an effective feedback intervention method in enhancing commitment to change and improving the clinical performance of physical therapists. Furthermore, feedback interventions seem to be more effective in changing clinical behavior when including clear targets and an action plan [ 16 ]. Accordingly, the Plan-Do-Study-Act facilitates systematic testing of changes in real-world settings, allowing for rapid learning and adaptation. This approach has been effectively utilized in various healthcare studies to enhance clinical outcomes and process efficiencies [ 24 ]; however, most physical therapists are not familiar with such quality-improvement interventions based on health outcomes [ 25 ].

The aim of this study is therefore to evaluate the feasibility of an advanced quality-improvement program for physical therapists in primary care. The evaluation involves feedback, peer assessment, and self-assessment in a rapid improvement Plan-Do-Study-Act cycle, using the routinely collected health outcome data of patients with NSLBP.

Study design and setting

The program feasibility was evaluated through an explorative quality-improvement study using a mixed-methods approach in a concurrent triangulation design [ 26 ]. The following program feasibility domains were addressed [ 27 ]: (1) appropriateness, feasibility, and acceptability for quality-improvement; (2) impact on clinical performance; and (3) impact on learning and behavioral change. We used the Standards for QUality Improvement Reporting Excellence (SQUIRE) Guidelines [ 28 ]. The evaluation was conducted between January and October 2022. We tested our program in a convenience sample of Dutch primary care physical therapists organized in a regional network of communities of practice (the Cooperation of Physical Therapists Nijmegen; CFN).

Participants

All physical therapy practices within the CFN network ( n  = 30) were approached to recruit therapists for the study. Invitations were extended via a digital newsletter, which included the goals of the study and contact details of the first author (LS). Physical therapists willing to participate received detailed study information by email and were screened for eligibility using the inclusion criteria below. Participation was voluntary. All participants provided written informed consent.

Inclusion criteria

Licensed Dutch physical therapists were eligible to participate in this study if they provided primary care to patients with NSLBP aged 18 years or older [ 3 , 4 ]. They also had to evaluate selected outcomes as part of a standard clinical routine in patients with NSLBP using the following PROMs (associated domain): Numeric Pain Rating Scale (NPRS) (pain intensity), Patient Specific Functioning Scale (PSFS) (physical activity), Quebec Pain Disability Scale (QBPDS) (physical functioning), Global Perceived Effect (GPE-DV) (perceived treatment effect), and STarT Back Screening Tool (SBST) (profile grouping based on risk of poor outcome) [ 3 , 4 ]. Physical therapists collected outcomes using these PROMs, which were directly recorded into their EHRs. These data were transferred to the national data registry of the Royal Dutch Society for Physical Therapy (KNGF). Additionally, to facilitate meaningful participation in the quality-improvement program, particularly during peer assessment sessions and outcome discussions, it was essential for participants to have contributed sufficient data to the national clinical registry from January 2021 to November 2021 (a minimum requirement of five patients with a closed treatment episode). An episode was considered closed when the physical therapist closed the episode in the EHR, or if six weeks had passed after the last visit. Informed consent for delivering data to the national clinical registry was obtained from every patient. This approach ensured that participants could engage with actual data reflective of their clinical practices rather than hypothetical scenarios, fostering deeper learning and reflection on professional conduct and patient care. The requirement for therapists to have already been actively collecting and submitting data as part of their clinical routine underlines the study’s aim to engage therapists who were not only familiar with the use of PROMs, but who also had sufficient data to enable a meaningful analysis and discussion within the context of the quality-improvement program.

The quality-improvement program content

The nine-month program consisted of a rapid improvement cycle comprising multiple consecutive steps and quality-improvement interventions. In step 1, participants were offered the opportunity to complete an e-learning module on using data in clinical practice [ 29 ]. In step 2, personal data exports were extracted from the national clinical registry. Participants received feedback reports on the processes and outcomes of their care in step 3 [ 30 , 31 , 32 ], then attended peer assessment meetings in step 4 [ 18 , 23 , 33 ], In step 4, the therapists drafted a rapid improvement Plan-Do-Study-Act cycle and individual quality-improvement goals [ 6 , 34 , 35 ], and in step 5, they performed a self-assessment of their clinical performance [ 36 ]. See Additional File 1 for further details of the program. The process and outcome indicators of the PROMs for patients with NSLBP were used in the program (see Additional File 2 ) [ 3 , 4 ].

Evaluation of program feasibility and outcome measures

The program’s perceived appropriateness, acceptability, and feasibility for quality-improvement purposes were evaluated using the Dutch versions of the Intervention Appropriate Measure (IAM), the Feasibility Intervention Measure (FIM), and the Acceptability Intervention Measure (AIM), respectively [ 37 ], which have been demonstrated to be valid and reliable tools [ 37 ]. Each measure consists of four items scored on a five-point Likert scale, with higher scores indicating better appropriateness, acceptability, and feasibility, respectively (scoring range: 4–20 for each tool). The impact on clinical performance was evaluated using self-assessment checklists [ 36 ] (steps 5 and 7 of the quality-improvement program), while the impact on learning and behavioral change was qualitatively determined during the peer assessment (steps 4 and 6). We used a parallel approach in collecting the quantitative and qualitative data, giving equal weight to both methods.

Data collection

Participants were invited by email to attend the peer assessment meetings. A script (see Additional Files 5 and 6 ) for each meeting was designed by the research team, addressing different quality-improvement interventions. A participatory evaluation strategy was used, allowing an assessment of the impact of the program on learning and behavioral change during the actual implementation [ 38 ]. The peer assessment meetings lasted 100–120 min and were conducted face-to-face by an external coach (RvH) using open-ended questions, which facilitated group discussion and knowledge development. A safe environment was encouraged within each peer group [ 20 , 22 ]. The peer assessment meetings were audio-taped, video-recorded, and subsequently transcribed verbatim. Written informed consent was obtained from all participants. The identities of the participants were considered confidential; therefore, the transcripts of the meetings were processed anonymously. Participants were asked to complete a self-assessment checklist halfway through the program, at the end, and six months after via email. Likewise, participants completed the IAM, FIM, and AIM at the end of the study, following the second peer assessment meeting.

Data analysis

Quantitative analysis.

The mean scores and standard deviations (SDs) of the IAM, FIM, and IAM were calculated. For the quality-improvement program to be considered appropriate, feasible, and acceptable [ 37 ], a minimum mean score of 15 out of 20, averaged over all participants, was required for each measure. The mean scores and SDs were calculated separately for the self-assessment checklists at three timepoints. For the quality-improvement program to be considered to impact the development of clinical performance, a minimum mean score of 5 out of 10 was required [ 36 ], averaged over all competed self-assessment checklists. Our comparative analysis focused on the mean scores and differences in process and outcome indicators between two periods: the pre-improvement period (the 12 months before the start of the study) and the quality-improvement period (the nine months after the study began). The latter period integrates data from both the initial and subsequent phases of the quality-improvement program, reflecting insights consolidated from the two feedback reports received by the participants during the program (Fig.  1 ). Our analysis focused exclusively on complete case episodes with both baseline and endpoint measurements to ensure the integrity and applicability of the data for participation in the quality-improvement program. All quantitative data were analyzed using SPSS Statistics, version 26 (IBM, Armonk, New York, USA).

The structure of the quality-improvement (QI) program QI = quality improvement; PDSA = Plan-Do-Study-Act

Qualitative analysis

Transcripts of the peer assessment meetings were read in detail, and a directed content analysis was used to study them [ 39 , 40 ]. A codebook was developed in advance, informed by the research questions. Text fragments were labeled according to these a priori codes, which were further refined during the coding process. Meaningful text fragments that could not be labeled were coded inductively. The transcript analysis was supported by ATLAS.ti version 8.4 [ 41 ]. Two researchers (LS and AvK) independently coded the transcripts, discussed the codes to reach consensus, and created the codebook, allocating codes into categories based on their similarities [ 42 ]. A researcher (MM) with ample experience in peer assessment and qualitative research guided this process. Kirkpatrick’s model, which was designed to evaluate the impact of an educational program, was used to allocate the identified categories to four domains: reaction, learning, behavior, and results (see Additional File 7 ) [ 43 ]. Preliminary findings after both peer assessment meetings and the final codes, categories, and the allocation of categories to the domains were discussed by the research team (LS, MM, RvH, AV, and PvdW) in several meetings. A member checking procedure was conducted by sending a summary with preliminary results to all participants after the first meeting to increase the credibility of the results. To optimize the transferability of the results, we aimed to saturate the information by recruiting at least three peer groups.

In total, 10 physical therapists from two different practices participated in the program. Two mixed-practice peer groups were formed, each consisting of five participants. The participants’ characteristics are outlined in Table  1 .

Quantitative results

Table  2 provides an overview of the appropriateness, feasibility, and acceptability of the program, as well as the perceived development in clinical performance. All predefined criteria regarding the minimum score on the IAM, FIM, AIM, and the self-assessment checklists were met.

The mean process and outcome indicator scores for the three data periods are compared in Table  3 . All process indicators improved substantially during and after the quality-improvement cycle, with mean improvements ranging from 9 to 26%.

Qualitative results

We conducted four peer assessment meetings, two for each peer group. After analyzing the qualitative data, the codes were classified into eight major categories. These categories were allocated to the four domains of Kirkpatrick’s model of evaluation (see Table  4 ). Quotes are numbered and labeled by peer group (see Table  5 ).

Domsain: reaction

Program appreciation; suggestions for program improvement.

Participating in a quality-improvement program based on routinely collected health outcomes was novel for most participants. In general, the therapists considered the program’s content meaningful, pleasant, acceptable, and accessible (Q1-G2), and proposed several advancements to increase future program experiences and satisfaction (Q2-G1)(Q3-G1).

Domain: learning

Awareness and insight.

Most participants became more aware of the existing data and the possibilities for analyzing and comparing them. They developed an understanding of the clinical relevance of the data presented, and identified possible explanatory factors by interpreting and clarifying the data (Q4-G1). Participants also gained insight into how to appropriately design data collection, the importance of proper data collection methods (Q5-G1), and potential areas for implementing data in routine practice.

Participants became more aware of data collection throughout the quality-improvement cycle, but acknowledged the lack of a standardized, valid, and reliable data collection method (Q6-G1). Before the quality-improvement program, most participants did not routinely use data to guide and improve their practice, despite dedicating considerable effort to its collection (Q7-G1).

The evolving knowledge gained from the quality-improvement cycle led participants to realize that routinely implementing data can enhance their clinical practice, and more importantly can significantly benefit patients (Q8-G2). Some participants openly argued that using data will not improve the quality of their physical therapy. They challenged the perceived value of the data in comparison with their own expertise and discussed the required time investment in relation to the perceived returns.

Motivational change

Collecting and using data with the objective of improving quality of care for the patient was not a common mindset among participants. Instead, data collection was performed to meet obligatory external requirements and was not considered a priority. However, as the quality-improvement cycle continued, most participants reported a shift to more intrinsically motivated efforts for collecting data (Q9-G2).

Domain: Behavior

Intentions for behavioral change.

Participants were encouraged to reflect on their own clinical behavior and reported feeling motivated to change their routine practice. All participants planned to improve their process indicators and data collection routines, particularly by allowing patients to complete their own questionnaires. Some participants proposed integrating the data into their practice and investigating its impact on their clinical behavior (Q10-G2).

Demonstrated behavioral change

All participants revised the extent and approach of their data collection. Most participants successfully applied some form of data use in routine practice, such as to evaluate treatment progress, to guide treatment and decision-making processes, as input for taking patient histories, for patient empowerment, for goal setting with the patient, and to complement or contradict their own assumptions (Q11-G2). Although they changed their data collection routines, two participants admitted they still rarely used data to support their clinical behavior (Q12-G1).

Barriers to and facilitators of behavioral change

Participants identified several barriers and facilitators that hindered or helped them to achieve their intended behavioral changes (Q13-G2)(Q14-G2)(Q15-G1) (see Table  6 ). These factors impacted the quantity of data collected, influenced the data collection protocols used, and shaped efforts to integrate data into routine practice.

Domain: results

Goal attainment.

The majority of participants set goals related to processes and collection routines. Seven of the 10 participants accomplished their personal targets regarding improving process indicators (Q16-G2). All participants achieved their objectives around changing data collection routines. One participant openly debated the benefit of goal attainment on the added value and quality of care for the patient (Q17-G1).

This study explored the feasibility of a quality-improvement program designed to enhance the quality of primary care physical therapists. The program uses health outcomes from a national registry and incorporates feedback, peer assessment, and self-assessment in a Plan-Do-Study-Act cycle. We found that the participants considered the program an appropriate, feasible, and acceptable intervention for quality-improvement purposes, and found it beneficial for improving their clinical performance. All participants improved the completeness of the data they collected. They also gained insights into the potential value of using outcome data in clinical practice, as well as in examining their routines and motivation. Participants recognized the importance of handling data, revised their data collection methods, began to implement data use into their routine practice, and observed the impact on their clinical behavior. They acknowledged the added value of using data when formulating clear treatment targets, monitoring treatment processes, motivating patients, and, on an aggregated level, improving the quality of care. While most participants reacted positively to the program and acknowledged its added value, they faced significant challenges, such as the complexity of integrating systematic data collection into daily practice, external pressures to meet specific outcome benchmarks, and the need for more knowledge and skills in data interpretation and application. These factors sometimes hindered the full realization of the program’s benefits and highlighted areas for improvement that should be addressed to improve the program before wider implementation.

Comparison to similar studies

This study builds upon previous research that highlighted the potential value of outcome data in quality-improvement initiatives [ 4 , 24 ]. When evaluating the potential value of feedback, peer assessment, self-assessment, and Plan-Do-Study-Act cycles in physical therapist care, most previous studies did not use aggregated real-world data from clinical registries. Maas et al. [ 23 ] and Steenbruggen et al. [ 36 ] incorporated feedback, peer assessment, and self-assessment in comprehensive quality-improvement programs aimed at the professional development of physical therapists, using client records, video recordings of client communication, and the tracer methodology, respectively. Both programs were found to be feasible and led to improvements in clinical performance [ 23 , 36 ]. The results of the present study support and extend previous findings of these quality-improvement strategies in physical therapist practice.

During the initial peer assessment meeting, the participants gained new knowledge and became more conscious of their own behavior. These findings are consistent with previous research indicating that peer assessment promotes learning, increases self-awareness [ 22 , 44 ], and builds self-concept [ 45 , 46 ]. Additionally, participants developed a critical perspective regarding their daily routines and expressed a desire to change their behavior. A similar enhanced commitment to change was reported by physical therapists who underwent cycles of peer assessment and self-assessment [ 23 ]. These findings are in line with theories of health behavior, which suggest that all behavioral change begins with recognizing one’s own behavior [ 47 ], and with the intention to change [ 48 ].

Another important finding was the observed shift in motivation for collecting data. Prior to the quality-improvement program, data were often collected in a non-validated manner, driven by external factors such as health insurers, and were not used to improve patient care. This is consistent with previous findings that the use of feedback in quality improvement is hindered by a perceived political motive for public reporting rather than improved patient care [ 7 ], by financial incentives from health insurers [ 49 ], and by a lack of experience and skills [ 7 , 50 ]. Instead of collecting data to meet an external goal, most participants moving along the quality-improvement cycle reported a shift to a more intrinsic motivation. This could be attributed to participants giving new meaning to collecting and handling data in their daily practice, and establishing their own personal values. These findings are consistent with Ryan and Deci’s self-determination theory, which states that the basis for intrinsic motivation and behavior is formed by people finding a rationale within themselves [ 51 ]. Indeed, participants in the current study emphasized the importance of having clear self-directed motives for data collection as a key driver of behavioral change. Consistent with this, healthcare providers previously reported being more likely to take steps for quality improvement in response to the feedback of aggregated PROMs if they perceived these data to be credible and beneficial for improving patient care [ 19 ]. Throughout the quality-improvement cycle, learning and understanding of data management continued to be developed through experience and reflection, in line with Dewey’s experiential learning theory [ 52 ].

All participants made self-initiated behavioral changes during the program, which was believed to be supported by the application of knowledge gained by following the Plan-Do-Study-Act cycle [ 24 ]. Setting specific targets and making an action plan may increase the effectiveness of feedback and facilitate behavioral changes [ 18 ]. In the present study, feedback was provided by a colleague, more than once, both verbally and in writing to further increase its effectiveness. The participants were largely successful in changing their data-collection procedures; however, there is still room for improvement in the use of data in routine daily practice. Previous studies have shown that clinicians find PROMs useful for supporting the therapeutic process [ 19 ]; however, it took more time or effort to develop these application skills than was available within the timespan of the program. This assumption is supported by the feedback intervention theory, which assumes that the effectiveness of feedback is lower when the ‘task novelty’ and ‘task complexity’ are higher [ 53 ]. Indeed, participants mentioned a lack of knowledge and skills regarding data application as important barriers to its use. Feeling competent is very important for accomplishing behavioral change, according to the self-determination theory [ 51 ]. Correspondingly, previous research indicated that healthcare providers need more support and guidance on how to structurally implement data into their daily practice [ 19 ].

Strengths and limitations

In this explorative study, an innovative theory- and evidence-based quality-improvement program was developed and implemented in daily physical therapy practice. Integrating multiple proven quality-improvement interventions, combined and informed by outcome data, clearly contributed to the inventive character of this program. Using a participatory strategy for the evaluation of program feasibility during the implementation enhanced the evaluation relevance, as well as providing valuable information regarding the program’s beneficial features and suggestions for improvements from the direct perspectives of the intended end-users. Using both qualitative and quantitative data in a concurrent triangulation design also contributed to the rigor of this study.

This study has several limitations. First, although we intended to include three peer groups for data saturation, only two were ultimately recruited. This could have impacted the validity and transferability of the results. Despite this, the two peer groups provided us with rich data that were deemed sufficient for program evaluation and feasibility study purposes [ 54 ]. Second, the peer groups were comprised of physical therapists selected based on the amount of data they collected. As all participants needed to meet external requirements regarding data collection, they could be seen as early adopters. The voluntary participation and external motivation of the participants may have influenced the results and may limit generalizability to other physical therapists. Third, indicative of its exploratory nature, the study’s sample size was limited, but was deemed sufficient to address our research questions. Additionally, the gender distribution among participants, with nine out of 10 being male, does not reflect the typical gender distribution in primary care physiotherapy in the Netherlands. This discrepancy was unintentional, emerging from the recruitment process, but could nevertheless constitute a selection bias, and underscores the need for caution when generalizing findings across diverse physiotherapy contexts. Lastly, although the coach promoted a safe environment during the group meetings, they were not anonymous, and participants may have felt unable to talk openly. Alongside the fact that the assessments could not be blinded, this may have introduced social desirability bias.

Implications for research and practice

Our findings can be used by national physical therapist bodies and other stakeholders in the field to develop initiatives for improving outcome-based care. This program is well suited for use in primary physical therapy care as it integrates with the peer assessment methodology commonly used in many practices. Such integration minimizes the opportunity costs usually associated with new initiatives by leveraging existing peer-learning and feedback structures, making it a feasible and cost-effective strategy for quality improvement [ 55 ]. Additionally, recommendations for advancing the national clinical data registry may further improve the usability for end-users and future researchers, who may wish to study whether the findings are also generalizable to other primary care physical therapist practices. In this study, feedback reporting appeared to support the establishment of quality-improvement goals, and future research could investigate the value of these strategies in evaluating results and changing clinical practices. The sustainability of the observed participant’s behavioral changes and their translation of their revised data-collection routines into quality improvements in care require further consideration. Future studies could improve the program’s feasibility by directly addressing the identified facilitators. Additionally, the program’s impact on patient outcomes should be explored in a full-scale study with long-term follow up.

This explorative study demonstrated that a quality-improvement program incorporating feedback, peer assessment, and self-assessment in a Plan-Do-Study-Act cycle, and using health outcomes from a national registry, was deemed feasible for quality improvement. The implementation of the program led to knowledge development, perceived improvements in clinical performance, and a change in the behavior of the physical therapists regarding data handling in their routine practice.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Acceptability Intervention Measure

Cooperation of Physical Therapists Nijmegen

Electronic health system

Feasibility Intervention Measure

Global Perceived Effect

Intervention Appropriate Measure

Royal Dutch Society for Physical Therapy

• Nonspecific low back pain

Numeric Pain Rating Scale

Patient-reported outcome measures

Patient-reported outcomes

Patient Specific Functioning Scale

Quebec Pain Disability Scale

STarT Back Screening Tool

Standard deviation

QUality Improvement Reporting Excellence

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Acknowledgements

The authors express their gratitude to the participating physical therapists from the regional network of the Cooperation of Physical Therapists Nijmegen (CFN).

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Concept/idea/research design: LS, AV and PvdW Data analysis: LS, AvK and MM Project management: LS and AV Writing of the manuscript: LS and AV Peer assessment coach: RvH Approval of final manuscript: LS, MM, RvH, AV and PvdW.

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Smeekens, L., Verburg, A., Maas, M. et al. Feasibility of a quality-improvement program based on routinely collected health outcomes in Dutch primary care physical therapist practice: a mixed-methods study. BMC Health Serv Res 24 , 509 (2024). https://doi.org/10.1186/s12913-024-10958-5

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A New Use for Wegovy Opens the Door to Medicare Coverage for Millions of People with Obesity

Juliette Cubanski , Tricia Neuman , Nolan Sroczynski , and Anthony Damico Published: Apr 24, 2024

The FDA recently approved a new use for Wegovy (semaglutide), the blockbuster anti-obesity drug, to reduce the risk of heart attacks and stroke in people with cardiovascular disease who are overweight or obese. Wegovy belongs to a class of medications called GLP-1 (glucagon-like peptide-1) agonists that were initially approved to treat type 2 diabetes but are also highly effective anti-obesity drugs. The new FDA-approved indication for Wegovy paves the way for Medicare coverage of this drug and broader coverage by other insurers. Medicare is currently prohibited by law from covering Wegovy and other medications when used specifically for obesity. However, semaglutide is covered by Medicare as a treatment for diabetes, branded as Ozempic.

What does the FDA’s decision mean for Medicare coverage of Wegovy?

The FDA’s decision opens the door to Medicare coverage of Wegovy, which was first approved by the FDA as an anti-obesity medication. Soon after the FDA’s approval of the new use for Wegovy, the Centers for Medicare & Medicaid Services (CMS) issued a memo indicating that Medicare Part D plans can add Wegovy to their formularies now that it has a medically-accepted indication that is not specifically excluded from Medicare coverage . Because Wegovy is a self-administered injectable drug, coverage will be provided under Part D , Medicare’s outpatient drug benefit offered by private stand-alone drug plans and Medicare Advantage plans, not Part B, which covers physician-administered drugs.

How many Medicare beneficiaries could be eligible for coverage of Wegovy for its new use?

Of these 3.6 million beneficiaries, 1.9 million also had diabetes (other than Type 1) and may already have been eligible for Medicare coverage of GLP-1s as diabetes treatments prior to the FDA’s approval of the new use of Wegovy.

Not all people who are eligible based on the new indication are likely to take Wegovy, however. Some might be dissuaded by the potential side effects and adverse reactions . Out-of-pocket costs could also be a barrier. Based on the list price of $1,300 per month (not including rebates or other discounts negotiated by pharmacy benefit managers), Wegovy could be covered as a specialty tier drug, where Part D plans are allowed to charge coinsurance of 25% to 33%. Because coinsurance amounts are pegged to the list price, Medicare beneficiaries required to pay coinsurance could face monthly costs of $325 to $430 before they reach the new cap on annual out-of-pocket drug spending established by the Inflation Reduction Act – around $3,300 in 2024, based on brand drugs only, and $2,000 in 2025. But even paying $2,000 out of pocket would still be beyond the reach of many people with Medicare who live on modest incomes . Ultimately, how much beneficiaries pay out of pocket will depend on Part D plan coverage and formulary tier placement of Wegovy.

Further, some people may have difficulty accessing Wegovy if Part D plans apply prior authorization and step therapy tools to manage costs and ensure appropriate use. These factors could have a dampening effect on use by Medicare beneficiaries, even among the target population.

When will Medicare Part D plans begin covering Wegovy?

Some Part D plans have already announced that they will begin covering Wegovy this year, although it is not yet clear how widespread coverage will be in 2024. While Medicare drug plans can add new drugs to their formularies during the year to reflect new approvals and expanded indications, plans are not required to cover every new drug that comes to market. Part D plans are required to cover at least two drugs in each category or class and all or substantially all drugs in six protected classes . However, facing a relatively high price and potentially large patient population for Wegovy, many Part D plans might be reluctant to expand coverage now, since they can’t adjust their premiums mid-year to account for higher costs associated with use of this drug. So, broader coverage in 2025 could be more likely.

How might expanded coverage of Wegovy affect Medicare spending?

The impact on Medicare spending associated with expanded coverage of Wegovy will depend in part on how many Part D plans add coverage for it and the extent to which plans apply restrictions on use like prior authorization; how many people who qualify to take the drug use it; and negotiated prices paid by plans. For example, if plans receive a 50% rebate on the list price of $1,300 per month (or $15,600 per year), that could mean annual net costs per person around $7,800. If 10% of the target population (an estimated 360,000 people) uses Wegovy for a full year, that would amount to additional net Medicare Part D spending of $2.8 billion for one year for this one drug alone.

It’s possible that Medicare could select semaglutide for drug price negotiation as early as 2025, based on the earliest FDA approval of Ozempic in late 2017 . For small-molecule drugs like semaglutide, at least seven years must have passed from its FDA approval date to be eligible for selection, and for drugs with multiple FDA approvals, CMS will use the earliest approval date to make this determination. If semaglutide is selected for negotiation next year, a negotiated price would be available beginning in 2027. This could help to lower Medicare and out-of-pocket spending on semaglutide products, including Wegovy as well as Ozempic and Rybelsus, the oral formulation approved for type 2 diabetes. As of 2022, gross Medicare spending on Ozempic alone placed it sixth among the 10 top-selling drugs in Medicare Part D, with annual gross spending of $4.6 billion, based on KFF analysis . This estimate does not include rebates, which Medicare’s actuaries estimated to be  31.5% overall in 2022  but could be as high as  69%  for Ozempic, according to one estimate.

What does this mean for Medicare coverage of anti-obesity drugs?

For now, use of GLP-1s specifically for obesity continues to be excluded from Medicare coverage by law. But the FDA’s decision signals a turning point for broader Medicare coverage of GLP-1s since Wegovy can now be used to reduce the risk of heart attack and stroke by people with cardiovascular disease and obesity or overweight, and not only as an anti-obesity drug. And more pathways to Medicare coverage could open up if these drugs gain FDA approval for other uses . For example, Eli Lilly has just reported clinical trial results showing the benefits of its GLP-1, Zepbound (tirzepatide), in reducing the occurrence of sleep apnea events among people with obesity or overweight. Lilly reportedly plans to seek FDA approval for this use and if approved, the drug would be the first pharmaceutical treatment on the market for sleep apnea.

If more Medicare beneficiaries with obesity or overweight gain access to GLP-1s based on other approved uses for these medications, that could reduce the cost of proposed legislation to lift the statutory prohibition on Medicare coverage of anti-obesity drugs. This is because the Congressional Budget Office (CBO), Congress’s official scorekeeper for proposed legislation, would incorporate the cost of coverage for these other uses into its baseline estimates for Medicare spending, which means that the incremental cost of changing the law to allow Medicare coverage for anti-obesity drugs would be lower than it would be without FDA’s approval of these drugs for other uses. Ultimately how widely Medicare Part D coverage of GLP-1s expands could have far-reaching effects on people with obesity and on Medicare spending.

• Medicare Part D
• Chronic Diseases
• Heart Disease
• Medicare Advantage

news release

• An Estimated 1 in 4 Medicare Beneficiaries With Obesity or Overweight Could Be Eligible for Medicare Coverage of Wegovy, an Anti-Obesity Drug, to Reduce Heart Risk

This paper is in the following e-collection/theme issue:

Published on 24.4.2024 in Vol 8 (2024)

Patient Satisfaction With the Health Care Services of a Government-Financed Health Protection Scheme in Bangladesh: Cross-Sectional Study

Authors of this article:

Original Paper

• Md Zahid Hasan 1, 2 , MSS   ; 
• Md Golam Rabbani 1 , MSS   ; 
• Orin Akter 1 , MSS   ; 
• Gazi Golam Mehdi 1 , MSS   ; 
• Mohammad Wahid Ahmed 1 , MSS   ; 
• Sayem Ahmed 3 , PhD   ; 
• Mahbub Elahi Chowdhury 1 , PhD  

1 Health Systems and Population Studies Division, icddr,b, Dhaka, Bangladesh

2 Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom

3 Health Economics and Health Technology Assessment, School of Health & Wellbeing, University of Glasgow, Glasgow, United Kingdom

Corresponding Author:

Md Zahid Hasan, MSS

Health Systems and Population Studies Division

68, Shaheed Tajuddin Ahmed Sarani

Dhaka, 1212

Phone: 880 01673163613

Email: [email protected]

Background: Since 2016, the government of Bangladesh has been piloting a health protection scheme known as Shasthyo Surokhsha Karmasuchi (SSK), which specifically targets households living below the poverty line. This noncontributory scheme provides enrolled households access to inpatient health care services for 78 disease groups. Understanding patients’ experiences with health care utilization from the pilot SSK scheme is important for enhancing the quality of health care service delivery during the national-level scale-up of the scheme.

Objective: We aimed to evaluate patient satisfaction with the health care services provided under the pilot health protection scheme in Bangladesh.

Methods: A cross-sectional survey was conducted with the users of the SSK scheme from August to November 2019. Patients who had spent a minimum of 2 nights at health care facilities were selected for face-to-face exit interviews. During these interviews, we collected information on patients’ socioeconomic characteristics, care-seeking experiences, and level of satisfaction with various aspects of health care service delivery. To measure satisfaction, we employed a 5-point Likert scale (very satisfied, 5; satisfied, 4; neither satisfied nor dissatisfied, 3; dissatisfied, 2; very dissatisfied, 1). Descriptive statistics, statistical inferential tests ( t -test and 1-way ANOVA), and linear regression analyses were performed.

Results: We found that 55.1% (241/438) of users were either very satisfied or satisfied with the health care services of the SSK scheme. The most satisfactory indicators were related to privacy maintained during diagnostic tests (mean 3.91, SD 0.64), physicians’ behaviors (mean 3.86, SD 0.77), services provided at the registration booth (mean 3.86, SD 0.62), confidentiality maintained regarding diseases (mean 3.78, SD 0.72), and nurses’ behaviors (mean 3.60, SD 0.83). Poor satisfaction was identified in the interaction of patients with providers about illness-related information (mean 2.14, SD 1.40), availability of drinking water (mean 1.46, SD 0.76), cleanliness of toilets (mean 2.85, SD 1.04), and cleanliness of the waiting room (mean 2.92, SD 1.09). Patient satisfaction significantly decreased by 0.20 points for registration times of 16-30 minutes and by 0.32 points for registration times of >30 minutes compared with registration times of ≤15 minutes. Similarly, patient satisfaction significantly decreased with an increase in the waiting time to obtain services. However, the satisfaction of users significantly increased if they received a complete course of medicines and all prescribed diagnostic services.

Conclusions: More than half of the users were satisfied with the services provided under the SSK scheme. However, there is scope for improving user satisfaction. To improve the satisfaction level, the SSK scheme implementation authorities should pay attention to reducing the registration time and waiting time to obtain services and improving the availability of drugs and prescribed diagnostic services. The authorities should also ensure the supply of drinking water and enhance the cleanliness of the facility.

Introduction

Globally, more than half of the population encounters difficulties in accessing essential health care services, with the majority residing in low- and middle-income countries (LMICs) [ 1 ]. These nations experience substantial challenges in financing health care [ 2 - 5 ]. Consequently, health care financing in these countries heavily relies on out-of-pocket spending by households, leading to increased financial distress on families during their illness [ 2 , 3 , 6 ]. In many instances, the most affected are those in poverty, and they lack access to health care services when they are unwell [ 7 ]. Similar to other LMICs, out-of-pocket spending for health care in Bangladesh is notably high. Recent evidence indicates that 68.5% of the total health care expenditure is shouldered by households through out-of-pocket payments [ 8 ]. Another recent study reported that such high out-of-pocket payments resulted in 24.6% of households experiencing catastrophic health expenditure when estimated using the 10% threshold of the budget share method. Furthermore, in 2016, over 8.5 million people were pushed into poverty due to health care expenses [ 9 ]. Moreover, the incidence of catastrophic health expenditure is more concentrated among the poorest households (16.5%) compared to the richest (9.2%) [ 10 ]. To reduce the burden of health care among the population and progress toward universal health coverage, the Government of Bangladesh has developed the Health Care Financing Strategy 2012–2032, intending to provide financial protection for health care to all citizens by 2032 [ 11 ]. As a component of this strategy, the Health Economics Unit of the Ministry of Health and Family Welfare of the Government of Bangladesh has been implementing a social health protection scheme known as “Shasthyo Surokhsha Karmasuchi (SSK)” since 2016. Although there is a comprehensive plan to cover the entire population of the country within the financing scheme, the current implementation is limited to a noncontributory scheme focusing on the below-poverty-line population. The scheme is being piloted in 3 subdistricts: Kalihati, Madhupur, and Ghatail under Tangail District. The scheme has enrolled almost 1,00,000 households that have access to inpatient health care services from Upazila Health Complexes (UzHCs) of the respective Upazilas (subdistricts) and district hospitals. Participation in the scheme is mandatory for households identified as being below the poverty line, and their enrollment is noncontributory, meaning that these enrolled households are not required to pay any fees for services. Notably, the scheme does not offer purchasing services to the above-poverty-line population. The government established a pool fund, allocating BDT 1000 (US$12) per household per year as a premium (BDT 84.5 = US$ 1, August 2019, Bangladesh Bank). This measure ensures access to inpatient health care services for the enrolled below-poverty-line households, covering 78 different disease groups. The annual coverage limit for each household is BDT 50,000 (US $592). Under the scheme, inpatient health care is delivered through UzHCs, serving as the first access point for the insured beneficiaries to receive health care services. Through a structured referral system, the beneficiaries can also access services at the Tangail District Hospital. The scheme ensures that insured patients receive free diagnostic services and medicines through hospitals, contracted diagnostic centers, and pharmacies. The SSK management authority, scheme operator, hospitals, contracted diagnostic centers, and pharmacies play crucial roles in the implementation of the scheme [ 12 ].

Although the scheme provides free inpatient care services to the member households, the health care utilization under the SSK scheme is notably low. A study revealed that less than half of the beneficiary households used health care services under the SSK scheme [ 13 ]. Several factors may contribute to this low utilization rate. For instance, quality of care might be a significant factor among the various important determinants of health service utilization. Quality of service is recognized as one of the key components in achieving universal health coverage by its definition [ 14 ]. Traditionally, the quality of health care services was primarily assessed based on professional practice standards. However, in the recent decades, patients’ perceptions of health care have emerged as an important indicator for evaluating the quality of health care services. Various studies have demonstrated that health service utilization is closely linked with users’ perceptions of the quality of health care provided [ 15 - 17 ]. Consequently, patient satisfaction is considered as an important aspect of performance improvement of the delivered health care services, alongside clinical effectiveness. It is a multidimensional aspect where patients’ perceptions and attitudes shape their overall health care–seeking experience [ 18 , 19 ]. Several factors, including registration time and process, waiting time to obtain health care services, interpersonal communication, and availability of basic amenities within health care facilities, can influence patient satisfaction with health care services [ 20 - 23 ]. Increased utilization and satisfaction of any insurance scheme are associated with improved quality of health care services. However, the literature provides mixed evidence. For example, a study in India found no significant difference in satisfaction levels between insured and uninsured hospitalized patients [ 24 ]. Conversely, regarding the overall quality of care provided under the National Health Insurance Scheme of Ghana, a significant portion of insured patients reported higher satisfaction compared with uninsured patients [ 25 ]. Evidence from Nigeria indicated that most patients were satisfied with the service delivery of their national health insurance scheme [ 26 - 28 ]. In Ethiopia, a study revealed that approximately 55% of enrollees were satisfied with the community-based health insurance scheme [ 29 ], whereas another study from the same country indicated that over 90% of households were satisfied with the community-based health insurance scheme [ 30 ]. Different Vietnamese studies have reported poor satisfaction among beneficiaries regarding service coverage and quality of care under national health insurance [ 31 , 32 ]. A recent study conducted on a self-financed health insurance scheme in Bangladesh showed that, overall, members of the scheme were satisfied with the health care services; however, their satisfaction levels could be improved in several aspects of health care service delivery [ 33 ].

Despite the pilot implementation of the SSK scheme since 2016 and its low utilization, no research has been conducted on service users’ experiences and levels of satisfaction with the scheme. Gaining a better understanding of beneficiaries’ experiences and levels of satisfaction with the health care service provided under the pilot SSK scheme is crucial. This insight can help identify the gaps in the quality of health care services provided. Such evidence will be useful for the key stakeholders of the health protection scheme, allowing them to make necessary changes in the service delivery process and related aspects to enhance the quality of health care services provided under the scheme. As a result, this study was conducted to address 2 central research questions: (1) What is the level of satisfaction among the beneficiaries of the SSK scheme? and (2) What are the factors influencing their satisfaction level? In addressing these research questions, this study aimed to assess patients’ levels of satisfaction with the services offered by the SSK scheme in Bangladesh.

Study Design

A cross-sectional exit patient survey was designed to gain insights into the experiences of insured patients with various aspects of the service delivery process and the quality of services provided under the pilot SSK scheme. Every second patient who had been admitted for at least 2 nights at a scheme-designated facility was selected and interviewed at the time of discharge.

Study Setting and Sample

The study was conducted in the UzHCs of Kalihati, Madhupur, and Ghatail Upazilas (subdistricts), and Tangail District Hospital of Tangail District. Insured inpatients were interviewed after discharge from the health care facilities. The survey of the respondents took place between August 18 and November 16, 2019, on working days, from Saturday to Thursday. Every second discharged inpatient from the male and female wards was interviewed. To ensure the quality of the data, a maximum of 4 patients were interviewed each day at an SSK hospital. A total of 438 discharged inpatients aged 18 years or older were interviewed from 3 UzHCs (Kalihati, n=128; Madhupur, n=176; and Ghatail, n=134) and Tangail District Hospital (n=88).

Data Collection Process

A semistructured questionnaire was designed and pretested before data collection. Face-to-face interviews were conducted with the insured patients and, in certain cases, with attendants of patients at the time of discharge. An attendant was considered as a respondent when the patient was not involved with the various dimensions of the service delivery process during the inpatient episode owing to the physical condition.

The questionnaire covered demographic and socioeconomic details of the respondents and households, health care utilization, and various dimensions of satisfaction related to the SSK scheme. These dimensions included the registration process at the SSK booth, the dignity of patients during treatment, clear communication with health care providers, privacy during treatment, the quality of basic amenities, the availability of drugs and supplies, and the availability of prescribed diagnostic services.

Four experienced research assistants were employed for patient recruitment and conducting the interviews. Prior to the interviews, written informed consent was obtained from all participants, and their participation was entirely voluntary. Completed interviews were cross-checked among the interviewers and further reviewed by the supervisor to ensure data quality and to address any associated issues, if needed, during the data collection.

Study Variables

We collected information on various background characteristics of the patients, including age, sex, education level, current employment status, current marital status, and family size. For measuring satisfaction levels, we considered several dimensions of health care delivery under the SSK scheme.

The first dimension was hospitalization-related factors. It included self-reported illnesses and length of stay. Self-reported illnesses were categorized into 3 groups: communicable, noncommunicable, and others (ie, obstetrics and injury). Communicable diseases encompass illnesses caused by viruses or bacteria that spread through contact, bodily fluids, blood products, insect bites, or the air. Noncommunicable diseases, on the other hand, are those that do not transmit between individuals and often necessitate long-term treatment.

The second dimension was service utilization–related aspects. It included waiting time for registration, waiting time to obtain health care services, behavior of health care providers (including physicians, nurses, and other staff, such as ward boys and cleaners), interaction of health care providers with patients, privacy during diagnostic services, and confidentiality of the health care provided.

The third dimension was facility environment and basic amenity–related factors. It included cleanliness of health facilities, waiting rooms, and toilets, and availability of drinking water.

The satisfaction measurement items demonstrated a satisfactory level of internal consistency, as indicated by an overall Cronbach α coefficient of 0.77 out of 1.0 [ 34 ].

Satisfaction Measurements

Patient satisfaction was measured with a collective outcome of 14 different items. The selection of items for measurements was devised based on a literature review of patient satisfaction with the insurance scheme as well as previous systematic reviews [ 26 , 27 , 33 , 35 - 40 ]. The existing literature has examined various aspects of health service delivery from the patients’ viewpoints, encompassing domains such as patient-provider interactions, the physical environment, and internal management processes. We selected items that revolved around these domains as they encompassed the most influential satisfaction constructs. The 14 items are presented in Textbox 1 .

Each considered item was rated on a 5-point Likert scale (very satisfied, 5; satisfied, 4; neither satisfied nor dissatisfied, 3; dissatisfied, 2; very dissatisfied, 1). The total satisfaction score of respondents for all items ranged from a minimum of 14 to a maximum of 70. Furthermore, we included an item in the questionnaire to assess the overall satisfaction (on a scale of 5) with the services at the SSK facility.

Satisfaction items

• How will you rate the behavior of the authority of Shasthyo Surokhsha Karmasuchi (SSK) at the registration booth?
• What is your opinion about the time taken for completing registration?
• What is your opinion about the waiting time before consultation with the service provider?
• How will you rate the behavior of the service provider during your treatment at this hospital?
• How will you rate the behavior of nurses during your treatment at this hospital?
• How will you rate the behavior of the aya/ward boy during your treatment at this hospital?
• How will you rate the interaction with the service provider about your illness and treatment?
• How will you rate the doctor’s attitude toward listening to your problems?
• How will you rate the privacy maintained during diagnostic tests?
• What is your opinion about the privacy maintained during consultation?
• What is your opinion about the cleanliness of this hospital?
• How will you rate the cleanliness of the waiting room of this hospital?
• How will you rate the cleanliness of the toilets of this hospital?
• What is your opinion regarding the availability of drinking water in the hospital?

Statistical Analysis

We analyzed the data using Stata version 16 (StataCorp) [ 41 ]. We performed both descriptive analysis and statistical inferential tests to measure the association between dependent and independent variables. In the descriptive analysis, background characteristics of the study participants and health care facility utilization–related characteristics were presented in terms of frequency (n) and percentage (%) with 95% CIs. Moreover, we performed a t -test for variables with 2 categories and 1-way ANOVA for variables with more than 2 categories to test the significant differences in average satisfaction levels across the demographic and socioeconomic characteristics related to the SSK scheme.

To identify factors associated with patients’ average scores for satisfaction with the services under the SSK scheme, a linear regression analysis was performed. We estimated the satisfaction level for each patient by taking the average of the reported satisfaction levels in the 14 items. In the univariate unadjusted regression model, the dependent variable was the mean satisfaction score and the independent variables were age, gender, education, employment status, marital status, family size, self-reported illness, length of hospitalization, registration time, waiting time to obtain services, status of receiving drugs and supplies, and status of receiving diagnostic services. However, in the multivariate regression model, we included independent variables that had a significant association with the satisfaction score (ie, P values ≤.05) in the univariate regression models. We considered P values of <.05 as statistically significant in our analysis.

Ethics Approval

This study was approved by the Research Review Committee and Ethical Review Committee of the icddr,b (protocol#: PR-17047). Participants in the study were recruited and interviewed after obtaining written informed consent, and their participation was voluntary.

Descriptive Statistics

A total of 438 patients aged 18 years and above were interviewed at the studied facilities ( Table 1 ), and 60.1% (263/438) of the patients were female. According to education level, 60.9% (267/438) of patients had no education, whereas 24.2% (106/438) and 14.8% (65/438) had primary and secondary levels of education, respectively. Moreover, 67.8% (297/438) of patients were not involved with income generation. In terms of marital status, 83.3% (365/438) of patients were married. Moreover, 54.1% (237/438) were from a household consisting of more than 4 members.

According to self-reported diseases, 62.6% (274/438) of patients reported the reason for hospitalization as noncommunicable disease, 30.8% (135/438) reported the reason as communicable disease, and 7.0% (29/438) reported the reason as other health problems (ie, obstetrics and injury). Regarding the length of hospitalization, 47.5% (208/438) of patients were admitted for 3-4 days, 34.5% (151/438) were admitted for 2 days, and 18.0% (79/438) were admitted for more than 4 days. Among the respondents, 66.2% (290/438) mentioned that they had completed their registration process within 15 minutes, and 58.9% (258/438) waited for 15 minutes or less to get services. The majority of patients (347/438, 79.2%) received all prescribed medicines and supplies free from the SSK pharmacy. Regarding laboratory services, 74.4% (326/438) of patients reported that they received diagnostic services as prescribed. More details of the descriptive statistics are shown in Table 1 .

Level of Satisfaction by Different Items

Patient satisfaction with the items considered while using the SSK scheme is shown in Table 2 . A total of 14 satisfaction items were used to examine patient satisfaction. The highest average score on satisfaction was related to “privacy maintained during diagnostic tests” (mean 3.91, SD 0.64), followed by “physicians’ behaviors” (mean 3.86, SD 0.77), “services at the SSK registration booth” (mean 3.86, SD 0.62), “confidentiality maintained about diseases” (mean 3.78, SD 0.72), and “services from nurses” (mean 3.6, SD 0.83). Among service-related items, a lower level of satisfaction was reported for the interaction of service providers with patients (mean 2.14, SD 1.4). Among the items in the environment and basic amenities domain, comparatively higher satisfaction was found for the cleanliness of the health facility (mean 3.43, SD 0.76), followed by the cleanliness of the waiting room (mean 2.92, SD 1.09) and toilets (mean 2.85, SD 1.04). The lowest level of satisfaction was reported for the availability of drinking water (mean 1.46, SD 0.76).

a SSK: Shasthyo Surokhsha Karmasuchi.

Overall Patient Satisfaction With Health Care Services at SSK Facilities

Considering the response to the overall patient satisfaction with the services at SSK facilities, 8.5% (37/438) reported being very satisfied and 46.6% (204/438) reported being satisfied with the services received under the SSK scheme. On the other hand, 31.3% (137/438) of respondents reported feeling neither satisfied nor dissatisfied. Moreover, 8.9% (39/438) were dissatisfied and 4.8% (21/438) were very dissatisfied ( Multimedia Appendix 1 ).

Patient Satisfaction by Socioeconomic and Hospital Service Utilization Characteristics

Patient satisfaction levels significantly varied across different groups of age, sex, marital status, illness type, registration time, waiting time, status of receiving drugs, and status of getting diagnostic tests ( Table 3 ). Patients aged between 45 and 64 years were comparatively more satisfied (mean 3.28, 95% CI 3.21-3.34) with services under the SSK scheme, and the difference in the satisfaction level across the age groups was statistically significant ( P <.001). Male patients were significantly ( P =.01) more satisfied (mean 3.24, 95% CI 3.17-3.31) than female patients. Married and widowed, divorced, or separated individuals were more satisfied than unmarried individuals, and the difference was statistically significant ( P <.001). However, there was no significant difference in satisfaction by education level, employment status, or household size.

Patients with noncommunicable diseases had a higher satisfaction level (mean 3.22, 95% CI 3.17-3.28) than patients with other illnesses, and the difference in the satisfaction level was statistically significant ( P =.008). Satisfaction scores decreased with increases in the length of hospitalization, registration time, and waiting time. The satisfaction level was significantly ( P =.006) higher among patients who received all prescribed drugs from the scheme (mean 3.20, 95% CI 3.15-3.26). Similarly, the satisfaction level was higher among patients who received all prescribed diagnostic or laboratory services compared with other groups (mean 3.22, 95% CI 3.17-3.27), and the difference in the satisfaction level across the groups was statistically significant ( P <.001).

a One-way ANOVA.

Determinants of Patient Satisfaction With Services Provided Under the SSK Scheme

Our analysis demonstrated noteworthy associations between satisfaction scores and various factors ( Table 4 ). The satisfaction score was significantly higher by 0.13 points in patients aged between 45 and 64 years than in patients aged between 18 and 44 years. Additionally, the satisfaction score was significantly higher by 0.34 points in married patients than in unmarried patients. Moreover, the satisfaction score was significantly higher by 0.15 points in patients seeking care for noncommunicable diseases than in patients seeking care for communicable diseases. We found a significant negative association of the satisfaction score with extended registration and waiting time for obtaining services. Conversely, a positive association was observed with the status of receiving all drugs, supplies, and diagnostic services. The satisfaction score was significantly lower by 0.18 points in patients with a registration time of 16-30 minutes and by 0.33 points in patients with a registration time of >30 minutes than in patients with a registration time of ≤15 minutes. Similarly, the satisfaction score was significantly lower by 0.30 points in patients who waited for 16-30 minutes to obtain services and by 0.36 points in patients who waited for >30 minutes to obtain services than in patients who waited for ≤15 minutes to obtain services. Moreover, the satisfaction score was significantly higher by 0.13 points in patients who received the complete course of prescribed medicines from the SSK pharmacy than in patients who received partial medicines and supplies. Likewise, the satisfaction score was significantly higher by 0.26 points in patients who received partial diagnostic services and by 0.28 points in patients who received full diagnostic services than in patients who were not prescribed diagnostic services.

a The dependent variable is the average satisfaction score of 14 items.

b The number of observations was 438, R-square value was 0.319, and adjusted R-square value was 0.293.

c N/A: not applicable.

Principal Results and Comparison With Prior Work

We found that 55.1% (241/438) of patients were either very satisfied or satisfied with the services provided by the SSK health protection scheme. The mean satisfaction score was 3.17 out of 5, which means that, on average, the satisfaction level among the patients was slightly above the level of neither satisfied nor dissatisfied. Regarding the 14 considered items for measuring satisfaction, most of the patients were either very satisfied or satisfied with services at the SSK center (368/438, 84.0%), physicians’ behaviors (366/438, 83.6%), and privacy maintained during diagnostic services (297/364, 81.6%). On the other hand, majority of the patients were either very dissatisfied or dissatisfied with the availability of drinking water (409/438, 93.4%) and interaction with health care providers (293/438, 66.9%) regarding the illness. In multiple regression analysis, we found that receiving prescribed drugs and diagnostic services, the waiting time for registration, and the waiting time for getting treatment were the strongest predictors of patient satisfaction.

Health financing schemes are becoming popular to maintain and improve the health of the population in LMICs [ 2 , 6 , 42 ]. The SSK health protection scheme has been introduced to increase the access of the poor population to inpatient health care services and ensure financial protection against expenditure to alleviate poverty or extreme poverty induced by out-of-pocket payments for health care in Bangladesh. Although several studies have been conducted on patient satisfaction with health care utilization in different settings in Bangladesh [ 33 , 43 - 46 ], patient satisfaction with services under the SSK health protection scheme has not been studied thus far. The mean satisfaction score in our study was higher than that in a study conducted to assess satisfaction with the service quality of UzHCs among the uninsured population (3.17 vs 2.75) [ 44 ]. The SSK scheme provides health care to members through selected UzHCs; however, compared with nonmembers, insured patients are supposed to receive all prescribed medicines and diagnostic services from private providers contracted by the scheme [ 13 ]. The situation is different for other UzHCs where the SSK scheme is not being implemented. The availability of medicines and diagnostic services under the SSK scheme might have increased the satisfaction level among the insured patients.

Our study showed that patient satisfaction was the highest regarding the privacy and confidentiality maintained by providers during diagnostic tests and the patients’ diseases. The finding is similar to that in a study conducted in Bangladesh [ 33 ] among the beneficiaries of a community-based health insurance scheme. Another study conducted among adult patients at a general hospital in Ethiopia also reported that patient privacy and confidentiality maintained by health care providers were significantly associated with higher satisfaction levels [ 47 ]. Our study found that patients were satisfied with providers’ behaviors, particularly physicians’ and nurses’ behaviors, which influenced the overall level of patient satisfaction. Although not directly comparable, the proportion of patients satisfied with the behavior of providers was higher than the proportion reported in a study conducted in rural Bangladesh (84% vs 69%) [ 45 ]. Previous studies have also reported that the behavior of health care providers toward patients is directly connected with patient satisfaction [ 33 , 43 , 48 ].

Regarding interactions with health care providers, our study found that two-thirds of patients were not satisfied. This might be the result of patients not knowing about their illnesses from physicians during their treatment episodes. It is evident from the literature that patients’ satisfaction levels are influenced by healthy interpersonal communication with health care providers as this maintains a better physician-patient relationship [ 43 ]. A previous study conducted in Bangladesh showed that more than half of the surveyed patients could not ask questions to their providers about their illness [ 49 ]. However, as all patients in our study were inpatients and stayed at the facility for at least 2 days, it is unlikely that patients could not ask their providers about their illness.

Patient experiences with the cleanliness of health facilities and toilets and the availability of drinking water were not positive. Previous studies revealed that the health facility environment and cleanliness were crucial aspects of patient satisfaction [ 33 , 50 - 52 ]. Moreover, evidence indicates that since environmental contamination is directly connected with nosocomial infection, the physical environment can lead to the dissatisfaction of patients at health facilities instead of increasing satisfaction [ 33 , 50 - 52 ].

We found that patient age was significantly associated with the level of satisfaction. Another study conducted in Bangladesh [ 44 ] reported significant variation in the average satisfaction score across patient age, which is similar to our findings. Two other studies conducted among beneficiaries of health insurance schemes also reported similar findings that age was significantly associated with the level of satisfaction [ 30 , 53 ]. Lower waiting times for registration and health care were significantly associated with patient satisfaction. The findings are consistent with the findings that prolonged waiting times for registration and services are associated with lower client satisfaction [ 54 , 55 ]. Patients who received care for noncommunicable diseases were significantly more satisfied than patients having communicable diseases. This might be because people having noncommunicable diseases require regular medications, which are common and available through the contracted pharmacy. Such availability of medicines might have increased patient satisfaction. Similarly, SSK beneficiaries who received all prescribed medicines and diagnostic services were significantly more satisfied. According to the benefits package of the SSK scheme, patients should receive all prescribed medicines and diagnostic services for 78 disease groups. However, 20.8% (91/438) of patients reported that they received partial medicines and 8.7% (38/438) reported that they received partial diagnostic services. It might have happened that some of the prescribed medicines or diagnostic tests were not correlated with the 78 disease categories and therefore were not provided under the scheme. However, evidence indicates that medicines and diagnostic tests are associated with higher out-of-pocket expenditure and lead to falling into poverty [ 9 , 56 , 57 ]. Scheme beneficiaries are provided free essential medicines and free diagnostic services, and they have a low chance of incurring treatment costs and experience low risks of catastrophic health expenditure, impoverishment, and further impoverishment [ 9 ], thus increasing their satisfaction with the services under the scheme. However, other variables, such as education level, employment status, family size, and length of hospitalization, were not significantly associated with satisfaction levels. This might be because the SSK scheme targets the below-poverty-line population having relatively similar socioeconomic characteristics; thus, their perceptions of satisfaction do not vary across these factors. These findings are consistent with the findings of other studies conducted in India [ 24 ] and Turkey [ 37 ].

This is the first study to explore patient satisfaction with the pilot SSK scheme in Bangladesh. Furthermore, we included patients from all 4 facilities under the SSK scheme rather than selecting them purposively. The findings of this study will help SSK implementation authorities to understand the patient experience of the service delivery process and the quality of health care provided under the SSK scheme.

Limitations

The design of this study was observational in nature, which did not allow us to establish any causal inference with satisfaction and other characteristics under the SSK scheme without a control group. The study only focused on the point of view of the beneficiaries, and we did not explore the providers’ views in this context. The survey collected self-reported satisfaction information from patients, which is highly susceptible to social desirability bias as patients might give responses that please health care providers instead of truly reflecting their satisfaction. However, we interviewed patients at hospital premises in the absence of any providers to minimize such bias.

Conclusions

Our findings demonstrate that more than half of the patients were overall satisfied with the services provided under the SSK scheme. However, there is room for improvement in several dimensions, such as the cleanliness of the waiting room and toilets and the availability of drinking water. Furthermore, attention should be paid to minimizing the waiting time for registration and accessing health care services, and improving providers’ skills on interaction with patients. The results of this study could help stakeholders make necessary changes in the identified determinants of satisfaction related to health service delivery of the SSK scheme. Such changes will enhance the quality of services as well as increase utilization of the scheme in the target population, ultimately advancing progress toward achieving universal health coverage.

Acknowledgments

This study received support from the United States Agency for International Development (USAID) under the terms of USAID’s Research for Decision Makers (RDM) activity cooperative agreement number AID-388-A-17-00006. The views expressed herein do not necessarily reflect the views of the US Government or USAID. The icddr,b acknowledges with gratitude the commitment of the USAID to its research efforts and funding for this study. icddr,b is also thankful to the Governments of Bangladesh, Canada, Sweden, and the United Kingdom for providing core and unrestricted support. Furthermore, the authors are grateful to Health Economics Unit, Ministry of Health and Family Welfare of the Government of Bangladesh, for its cooperation during this study. All authors declared that they had insufficient or no funding to support open access publication of this manuscript, including from affiliated organizations or institutions, funding agencies, or other organizations. JMIR Publications provided article processing fee (APF) support for the publication of this article.

Data Availability

The data sets generated or analyzed during this study are available from the corresponding author upon reasonable request.

Authors' Contributions

MZH, MGR, and MEC contributed to conceptualizing, analyzing, writing, revising, and finalizing the manuscript with the support of OA, SA, GGM, and MWA. All authors have read, revised, and approved the final version of the manuscript.

Conflicts of Interest

None declared.

Overall satisfaction with the inpatient care services under the Shasthyo Surokhsha Karmasuchi (SSK) scheme.

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Abbreviations

Edited by A Mavragani; submitted 10.06.23; peer-reviewed by MA Islam, S Bidmon; comments to author 13.09.23; revised version received 07.10.23; accepted 22.11.23; published 24.04.24.

©Md Zahid Hasan, Md Golam Rabbani, Orin Akter, Gazi Golam Mehdi, Mohammad Wahid Ahmed, Sayem Ahmed, Mahbub Elahi Chowdhury. Originally published in JMIR Formative Research (https://formative.jmir.org), 24.04.2024.

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