Abstract
Background
The percentage of Omani physicians from total number of physicians working in the Sultanate tripled from 9% in 1999 to 27% in 2006 and is expected to increase to 50% by 2010. The study aimed to asses community attitudes towards Omani doctors and to investigate the different socio-demographic variables related to these attitudes.
Method
It was done in two selected Primary Health Care (PHC) facilities by simple random technique in Batinah region. Face-to-face interview was made on 305 randomly selected samples of PHC customers by trained researchers from Sultan Qaboos University (SQU). Omani Doctors Acceptance Scale (ODAS) was adapted and used to assess participants acceptance of the communication skills of the Omani doctor, care to the patient, absence of language barrier, competence level, preference to be seen by doctor from the same sex, embarrassment from seeing an Omani doctor, qualification, experience, knowledge and skills of the Omani experience of the Omani doctor, and trust on the Omani doctor. Chi squared tests of significance was used in analysis.
Results
Males reported more satisfaction about communication skills of the Omani doctors, whereas female respondents reported higher likelihood of being embarrassed from the latter. Elder age cohort, those reported ever treated by an Omani doctor, married respondents, and those of lower level of education were more likely to report higher level of acceptance than others. Those aged 26-40 and those above 40 years of age were 2.41 and 3.41 times higher than the youngest age cohort respectively. Similarly, older age cohort reported having more trust than the middle age respondents relatively to the youngest age group.
Conclusion
The current study showed an accepted level of acceptance to Omani doctors. Looking for crucial issues in patient-doctor relationships as acceptance, satisfaction, trust, gender preference especially for PHC doctors ensure the continuity of care.
Introduction
Ministry of Health (MoH) relentlessly prepared five-year health development plans since 1976. That has lead to significant achievement quantitatively and qualitatively. Because 60-70% of the recurrent budget is spent on human resources, the ministry considers human resources development as one of the main priorities in all its development plans and advocates Omanization as a national policy of self-reliance. The percentage of Omani physicians from total number of physicians working in the Sultanate tripled from 9% in 1999 to 27% in 2006 and is expected to increase to 50% by 2010.1,2 Therefore, consumers’ satisfaction, and trust in Omani doctors of both genders is crucial. Yet, no previous study was conducted investigating such important issue. Such results will help decision makers in Ministry of Health and in academia to plan for and implement different educational programs and strategies for both the under and post- graduate medical students that ultimately would improve community acceptance of Omani doctors. As a valid example, the Medical school in Sultan Qaboos University introduced the communication skills course to the 4th year medical students in 2005. The Aim of our work was to assess community attitudes towards Omani doctors and to investigate the different socio-demographic variables related to these attitudes.
Methodology
This study was done in 2 randomly selected primary healthcare facilities out of 34 facilities by simple random technique in Batinah region. Face-to-face interview was made on 305 randomly selected samples of Primary Health Care (PHC) customers by trained interviewers’ second and third year medical students from College of Medicine and Health Sciences, Sultan Qaboos University. They were given three days training course by the first author with role play to enforce the skills of asking questions properly. Data collection was done in 2 weeks in August 2006 and individual interviews took 15-20 minutes to be conducted.
The questionnaire was developed to fit the situation in our setting. Using a number of questions adapted from previous studies examining the domains of patient’s autonomy,3-5 professional expertise and humanism. It was rephrased after consulting community members in order to be modified for the present study. It was composed of two sections. The first section assesses the participant’s demographic and service utilisation data that include the age, gender, educational level, marital status, main source of healthcare, self-rated health status, number of visits per year, and ever consult an Omani doctor the year prior to the study. The second tool used was the Omani doctors acceptance scale which was composed of 12 questions that comprehensively assessed participants acceptance of the communication skill of the doctor, care to the patient, absence of language barrier, competence level, preference to be seen by doctor from the same sex, embarrassment from seeing an Omani doctor, qualification, experience, knowledge and skills of the Omani doctor, and trust on the Omani doctor. Using Likert scale, participants were given five options to answer each question that ranged between strongly agree to strongly disagree. The questionnaire was tested on a pilot of 150 participants from PHC centres in the same region not participated in the study. Data collection, through face-to-face interview, was made by the same group of students participated in the main study. The interviewers were trained to read out the items of the questionnaire and to code the responses with precision and reliability. The forms were collected daily by the first author for data entry into the computer, and SPSS version 10.0 was used for data analysis by the corresponding author.
Results
The 12 items Acceptance scale used in the study showed a high alfa Chronback’s reliability score, 0.78. The sample mean (SD) age of consumers in years was 30.16 (11.86), with the majority aged 18- 40 years (84.6%). Around 54% were of male sex, 57% of the overall samples were married, 27% had secondary or above education, and 52.4% reported paying 1-5 visits the last year prior to the survey. The mean (SD) reported number of visits per year for the overall sample was 8.69 (7.98) with a median of 5 annual visits with, astonishingly, no significant gender difference (Table 1).
Table 1. Socio-Demographic Characteristics of the Study Sample.
| Characteristics | Frequency | Percentage |
|---|---|---|
| Age, (N=274) | ||
| Mean±SD | 30.16± 11.86 | |
| 18-25 years | 133 | 48.5 |
| 26-40 years | 96 | 35.0 |
| >40 years | 45 | 16.4 |
| Gender, (n=305) | ||
| Male | 165 | 54.1 |
| Female | 140 | 45.9 |
| Marital status, (N=302) | ||
| Unmarried (single, divorced, widowed) | 130 | 43.0 |
| Married | 172 | 57.0 |
| Ever treated by Omani doctors, (N=305) | ||
| No | 70 | 23.0 |
| Yes | 235 | 77.0 |
| Self-rated health status, (N=302) | ||
| Not good, needs chronic care | 179 | 59.3 |
| Good | 123 | 40.7 |
| Education, (N=300) | ||
| Uneducated | 37 | 12.3 |
| Moderately educated | 180 | 60.0 |
| Highly educated | 83 | 27.7 |
| Healthcare visits, (N=252) | ||
| Mean±SD | 8.69±7.98 | |
| 1-5 visits | 132 | 52.4 |
| 6-10 visits | 37 | 14.7 |
| >10 visits | 83 | 32.9 |
(N=305)
Table 2 showed the distribution of the 12 items of the acceptance scale gender wise. Males reported more satisfaction about communication skills of the Omani doctors, whereas female respondents reported higher likelihood of being embarrassed from these doctors. The gender wise distribution of upper 30% scorers in the acceptance scale of Omani doctors used showed male gender preponderance for accepting Omani doctors than females.
Table 2. Cross-Tabulation of Acceptance Questionnaire Items with Respondents’ Sex.
| Questions | Gender | p value | ||||
|---|---|---|---|---|---|---|
| Male | Female | |||||
| n | % | n | % | |||
| Q1. | Communication | |||||
| No | 20 | 39.2 | 31 | 60.8 | ||
| Yes | 145 | 57.1 | 109 | 42.9 | 0.019 | |
| Q2. | Honesty | |||||
| No | 33 | 47.1 | 37 | 52.9 | ||
| Yes | 132 | 56.2 | 103 | 43.8 | 0.184 | |
| Q3. | Language communication | |||||
| No | 24 | 42.9 | 32 | 57.1 | ||
| Yes | 141 | 56.6 | 108 | 43.4 | 0.062 | |
| Q4. | Satisfying level | |||||
| No | 39 | 50.0 | 39 | 50.0 | ||
| Yes | 126 | 55.5 | 101 | 44.5 | 0.400 | |
| Q5. | Dealing with the same gender | |||||
| No | 38 | 55.1 | 31 | 44.9 | ||
| Yes | 127 | 53.8 | 109 | 46.2 | 0.853 | |
| Q6. | Embarrassment feeling | |||||
| No | 129 | 60.3 | 85 | 39.7 | ||
| Yes | 36 | 39.6 | 55 | 60.4 | 0.001 | |
| Q7. | Doctor’s level | |||||
| No | 56 | 48.3 | 60 | 51.7 | ||
| Yes | 109 | 57.7 | 80 | 42.3 | 0.11 | |
| Q8. | Qualification | |||||
| No | 37 | 45.1 | 45 | 54.9 | ||
| Yes | 128 | 57.4 | 95 | 42.6 | 0.057 | |
| Q9. | Having adequate experience | |||||
| No | 63 | 53.8 | 54 | 46.2 | ||
| Yes | 102 | 54.3 | 86 | 45.7 | 0.944 | |
| Q10. | Having adequate medical knowledge | |||||
| No | 66 | 55.5 | 53 | 44.5 | ||
| Yes | 99 | 53.2 | 87 | 46.8 | 0.702 | |
| Q11. | Having adequate skills | |||||
| No | 55 | 53.9 | 47 | 46.1 | ||
| Yes | 110 | 54.2 | 93 | 45.8 | 0.965 | |
| Q.12 | Trust | |||||
| No | 24 | 45.3 | 29 | 54.7 | ||
| Yes | 141 | 56.0 | 111 | 44.0 | 0.157 | |
Table 3 showed the cross-tabulation of degree of satisfaction with some of the socio-demographic variable selected. Elder age cohort, those reported ever treated by an Omani doctor, married respondents, and those of lower level of education were more likely to report higher level of acceptance than others.
Table 3. Distribution of the Overall Acceptance Score on the Socio-Demographic. Characteristics of the Sample (N=305).
| Characteristic | Overall Acceptance score | All | p-value | ||||
|---|---|---|---|---|---|---|---|
| Low (Lower 70%) | High (Upper 30%) | ||||||
| n | % | n | % | n | % | ||
| Age group | 0.001 | ||||||
| 18-25 years | 108 | 81.2 | 25 | 18.8 | 133 | 100 | |
| 26-40 years | 61 | 63.5 | 35 | 36.5 | 96 | 100 | |
| >40 years | 25 | 55.6 | 20 | 44.4 | 45 | 100 | |
| Gender | 0.656 | ||||||
| Male | 114 | 69.1 | 51 | 30.9 | 165 | 100 | |
| Female | 100 | 71.4 | 40 | 28.6 | 140 | 100 | |
| Marital status | <0.001 | ||||||
| Unmarried (single, divorced, widowed) | 107 | 82.3 | 23 | 17.7 | 130 | 100 | |
| Married | 107 | 62.2 | 65 | 37.8 | 172 | 100 | |
| Ever treated by Omani doctors | 0.015 | ||||||
| No | 57 | 81.4 | 13 | 18.6 | 70 | 100 | |
| Yes | 157 | 66.8 | 78 | 33.2 | 235 | 100 | |
| Self-rated health status | 0.930 | ||||||
| Good | 126 | 70.4 | 53 | 29.6 | 179 | 100 | |
| Not good, needs chronic care | 86 | 69.9 | 37 | 30.1 | 123 | 100 | |
| Education | 0.035 | ||||||
| Uneducated | 21 | 56.8 | 16 | 43.2 | 37 | 100 | |
| Moderately educated | 125 | 69.4 | 55 | 30.6 | 180 | 100 | |
| Highly educated | 66 | 79.5 | 17 | 20.5 | 83 | 100 | |
| Healthcare visits | 0.351 | ||||||
| 1-5 visits | 98 | 74.2 | 34 | 25.8 | 132 | 100 | |
| 6-10 visits | 23 | 62.2 | 14 | 37.8 | 37 | 100 | |
| >10 visits | 61 | 73.5 | 22 | 26.5 | 83 | 100 | |
PS: don’t sum always to 305 due to missing cells in some variables.
However, in multivariate analysis, only getting old predicted higher acceptance level in the logistic regression model where those aged 26-40 and those above 40 years of age were 2.41 and 3.41 times higher than the youngest age cohort respectively. Similarly, age predicted trusting Omani doctors, where older age cohort reported having more trust than the middle age respondents relatively to the youngest age group (OR= 2737.72, 1.52 respectively). As regards gender preference of PHC doctors, the logistic regression model showed that only marital status predicted health provider gender preference. Married respondents were more likely, than singles, divorced or widowed respondents, in favor of the same gender as health providers, OR= 2.91. (Data not shown in table)
Discussion
The study highlighted the Omani health care consumers’ acceptance level to their nationals’ doctors of both gender. Generally, the acceptance was high and showed non significant variations according to socio-demographic variables except for its increase with age. Trust also showed the same trend with age. PHC doctors’ gender preference was more likely among married which could imply consulting doctors in gynecological and/or private body parts problems. Our results showed that ever being treated by Omani doctor increased significantly the level of respondents’ acceptance to the later. Because of the cross-sectional nature of the current study design, temporality could not be proven and it would be difficult to deduct whether having lower level of acceptance to Omani doctors was a constraint for consumers to be managed by Omani doctors, or not passing the experience lowers their acceptance level.
The study showed that age predicted trust in Omani doctors. Younger generation have a relatively lower level of trust. That could be explained through the need of younger more educated generation for a wider provider choice than old clients. Limited provider choice is believed to undermine trust and provider choice has been identified as strongly associated with physician trust.6 Studies7-9 have identified that the amount of physician choice is a predictor of, or was strongly associated with, provider trust. Trust as a quality of healthcare measure7,10,11 is important in medical treatment relationships and better health outcomes. Trust affects many important health attitudes, behaviours, and outcomes including medication adherence,8,12 therapeutic effects,13 patientphysician communication, health promotion efforts disputes, likelihood of malpractice claims14,15 and transaction costs.16 The relatively lower trust and acceptance among younger respondents and those of higher level of education should be rectified through health educational programs aiming to improve young and/or more educated community attitudes towards Omani doctors. The community should be sensitized to the importance of time needed for junior Omani doctors to improve their skills and gain medical experience.
Albeit there was no significant gender difference in reporting of number of visits to health facilities, previous studies showed higher female gender preponderance.17 Hence, overcoming female respondents’ feelings of embarrassment on consulting Omani doctors revealed in the results should be overcome. Reasons for such barrier should be explored by conducting further qualitative studies. In addition, educational programmes should be directed towards female consumers into strengthen the doctor-patient relationship regardless of the health provider’s gender. Although bias still tends to be against women in academic obstetrics/gynaecology and is felt especially by women who aspire to leadership positions in academic medicine, there is an increasing sentiment among patients, physicians, and the public that women truly are more qualified to be obstetrician/gynaecologists. That is because only a woman can experience or know the issues faced by other women.18 From this viewpoint, then, women make better obstetrician/gynaecologists than men by virtue of their sex alone. Such sex discrimination against male physicians is insidious but pervasive throughout the field of women’s health and occurs in large part because of current social beliefs and stereotypical thinking.18 Our study found that married respondents were more likely, than singles, divorced or widowed respondents, to be in favour of the same gender as health providers. Another survey conducted in community based institutions in Toronto, Canada in order to determine preference for the gender of PHC doctors under various scenarios showed that same gender preference was evident, gender-sensitive examinations (gynaecological and private body parts examination, family and emotional problems, and gender ailments).19
Conclusion
To conclude, the current study showed a good level of acceptance to Omani doctors. Looking for crucial issues in patient-doctor relationships as acceptance, satisfaction, trust, gender preference especially for PHC doctors ensure the continuity of care. Continuity of care is the cornerstone of primary health care. It is now well known that continuity of care leads to a better knowledge of the patient and enhances the patient’s compliance, satisfaction and care, especially among chronic patients.20-22
Acknowledgement
The authors would like to thank Fatma Al-Khuzairi, Amani Al-Saidi, Ali Al-Belushi, and all medical students from College of Medicine & Health Sciences at Sultan Qaboos University who participated in data collection for both pilot and main studies.
References
- 1.Ministry of health. Oman. Annual Health Report 2006. Directorate General of Planning, Ministry of health, 2007.
- 2.Ministry of health. Oman. The seventh five–year plan for health development 2006-2011: the National strategic plan 2007.
- 3.Baker R. The reliability and criterion validity of a measure of patients’ satisfaction with their general practice. Fam Pract 1991. Jun;8(2):171-177 10.1093/fampra/8.2.171 [DOI] [PubMed] [Google Scholar]
- 4.Ramsay J, Campbell JL, Schroter S, Green J, Roland M. The General Practice Assessment Survey (GPAS): tests of data quality and measurement properties. Fam Pract 2000. Oct;17(5):372-379 10.1093/fampra/17.5.372 [DOI] [PubMed] [Google Scholar]
- 5.Schattner A, Rudin D, Jellin N. Good physicians from the perspective of their patients. BMC Health Serv Res. 2004; 12;4:26. [DOI] [PMC free article] [PubMed]
- 6.Chu-Weininger MY, Balkrishnan R. Consumer satisfaction with primary care provider choice and associated trust. BMC Health Serv Res. 2006; 23:6:139. [DOI] [PMC free article] [PubMed]
- 7.Hall MA, Dugan E, Zheng BY, Mishra AK. Trust in physicians and medical institutions: what is it, can it be measured, and does it matter? Milbank Q 2001;79(4):613-639, v 10.1111/1468-0009.00223 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Thom DH, Ribisl KM, Stewart AL, Luke DA, The Stanford Trust Study Physicians Further validation and reliability testing of the Trust in Physician Scale. Med Care 1999. May;37(5):510-517 10.1097/00005650-199905000-00010 [DOI] [PubMed] [Google Scholar]
- 9.Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. Patients’ trust in their physicians: effects of choice, continuity, and payment method. J Gen Intern Med 1998. Oct;13(10):681-686 10.1046/j.1525-1497.1998.00204.x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Thom DH, Hall MA, Pawlson LG. Measuring patients’ trust in physicians when assessing quality of care. Health Aff (Millwood) 2004. Jul-Aug;23(4):124-132 10.1377/hlthaff.23.4.124 [DOI] [PubMed] [Google Scholar]
- 11.Hall MA, Camacho F, Dugan E, Balkrishnan R. Trust in the medical profession: conceptual and measurement issues. Health Serv Res 2002. Oct;37(5):1419-1439 10.1111/1475-6773.01070 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Piette JD, Heisler M, Krein S, Kerr EA. The role of patient-physician trust in moderating medication nonadherence due to cost pressures. Arch Intern Med 2005. Aug;165(15):1749-1755 10.1001/archinte.165.15.1749 [DOI] [PubMed] [Google Scholar]
- 13.Hall MA. Law, medicine, and trust. Stanford Law Rev 2002. Nov;55(2):463-527 10.2307/1229596 [DOI] [PubMed] [Google Scholar]
- 14.Boehm FH. Building trust. Fam Pract News 2003;33:12 [Google Scholar]
- 15.Lichtstein DMaterson BJ Spicer DW. Reducing the risk of malpractice claims. Hosp Pract 1999;34:69 . 10.3810/hp.1999.07.152 [DOI] [PubMed] [Google Scholar]
- 16.Thom DH. Physician behaviours that predict patient trust. J Fam Pract; 2001: 50 323 328. [PubMed]
- 17.Green CA, Pope CR. Gender, psychosocial factors and the use of medical services: a longitudinal analysis. Soc Sci Med 1999. May;48(10):1363-1372 10.1016/S0277-9536(98)00440-7 [DOI] [PubMed] [Google Scholar]
- 18.Adams KE. Patient choice of provider gender. J Am Med Womens Assoc 2003;58(2):117-119 [PubMed] [Google Scholar]
- 19.Ahmad F, Gupta H, Rawlins J, Stewart DE. Preferences for gender of family physician among Canadian European-descent and South-Asian immigrant women. Fam Pract 2002. Apr;19(2):146-153 10.1093/fampra/19.2.146 [DOI] [PubMed] [Google Scholar]
- 20.McWhinney IR. Continuity of care in family practice. Part 2: implications of continuity. J Fam Pract 1975. Oct;2(5):373-374 [PubMed] [Google Scholar]
- 21.Weiss GL, Ramsey CA. Regular source of primary medical care and patient satisfaction. QRB Qual Rev Bull 1989. Jun;15(6):180-184 [DOI] [PubMed] [Google Scholar]
- 22.Weyrauch KF. Does continuity of care increase HMO patients’ satisfaction with physician performance? J Am Board Fam Pract 1996. Jan-Feb;9(1):31-36 [PubMed] [Google Scholar]