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

1. The Impact of satisfaction with care on use of prenatal services: Findings from National Friendly AccessSM Kirsten Wallace, MA, MSPH Linda A. Detman, Ph.D. The Lawton and Rhea Chiles Center for Healthy Mothers and Babies University of South Florida APHA, Dec 2005, Philadelphia

2. Satisfaction and Use Studies of satisfaction have focused on users of services • Non-users generally less satisfied with health services (Shumeli, 1997) Studies of users • No relationship between early use of PNC and satisfaction with physician (Ivanov and Flynn, 1999) • No significant relationship between satisfaction and subsequent prenatal care (Handler et al, 2003)

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

4. Friendly AccessSM • Longitudinal community-based interventions • Changing the culture of maternal and child health care to improve access, use, and satisfaction • Health services utilization model (Aday and Anderson, 1975) • Extensive baseline data collection-secondary sources as well as surveys with consumers and providers of maternal and child health services

5. Friendly AccessSM Central Premise • Improved customer service and accessibility will lead to increased good experience and consumer satisfaction, which will, in turn, lead to increased use of preventive health services.

6. Methods 1,408 women in four communities • Used prenatal care services • Data collected on actual (observed) and expected number of visits • Expected to complete at least two visits • NHW, NHB • Medicaid delivery

7. Measures Predisposing characteristics • Literature, a priori theory Completion of expected PNC • Dichotomous measure • Kotelchuck (1994) algorithm for calculating expected number of visits • Self-report of completed visits (within range) Satisfaction with care • Prenatal Care Satisfaction Scale (Raube, Handler, Rosenberg, 1998) • CFA, 6 constructs of satisfaction

8. Measures 6 satisfaction constructs • Access (3 items) • Administrative efficiency and interaction with office staff (6 items) • Resource availability (2 items) • Office/clinic environment (3 items) • Provider-patient interaction (4 items) • Quality of care (4 items) (Raube, Handler, Rosenberg, 1998) CFA found the factor structure weak, but acceptable.

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

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

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

12. Table III (contd.)

13. Table III (contd.)

14. Mediation Study Conceptual Model

15. Measures 4 measures of Access • Usually experience long waits on the phone when making appointments • Have to wait more than 2 weeks for an appointment • Usually wait more than 30 minutes to see the provider • Have difficulty getting (transportation) to the provider’s office

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

17. Table IV (contd.)

18. Table IV (contd.)

19. Table IV (contd.)

20. Limitations • Dichotomous measure of care utilization • Misclassification overestimating completers (conservative bias) • Measurement of satisfaction • Retrospective design • Timing and location of data collection

21. Future Work Research is needed to: • Improve understanding and measurement of “satisfaction” • What does satisfaction really mean for traditionally underserved populations? • Understand the other motivational factors that bring women to care (culture, fear, education, values, etc.) • How various barriers to care (beyond accessibility issues) interplay with motives to impact use

22. Study 2: Relative Importance of Barriers to PNC Purpose To achieve a better understanding of the role different types of barriers may play in precluding or averting a woman from using PNC services. To determine which types of barriers are significantly related to inadequate or underutilization of PNC

23. Measures Adequate Care • Early and Sufficient Care • Complete expected number of visits • Initiate care within first 12-15 weeks of pregnancy Barriers • Systems/structural • Financial • Cognitive/psychosocial • Logistic

24. Table IBarriers to Prenatal Care

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

26. Conclusion Findings suggest that while structural barriers are an important obstacle to accessing prenatal care, financial and cognitive/psychosocial barriers may have a greater effect on a woman completing an adequate amount of care. Implications are that improving health outcomes may depend as much on reforming educational and economic policies as on health care practices.

27. Acknowledgements • Association of Schools of Public Health • (Grant #: S3251-23/23) • Centers for Disease Control and Prevention • Community Friendly Accesssm Projects • Flint/Genesee County, MI • East Tennessee • Indianapolis, IN • Jacksonville, FL

28. This project was supported under a cooperative agreement from the Centers for Disease Control and Prevention (CDC) through the Association of Schools of Public Health (ASPH) grant number U36/CCU300430-23.  • The contents of this report are solely the responsibility of the authors and do not necessarily represent the official views of CDC or ASPH.