An investigation on the quality of midwifery services from the viewpoint of the clients in Isfahan through SERVQUAL model.

BACKGROUND: Quality of care is of great importance in health services as these services have the important mission to preserve health, and to give care to the society. The present study aimed to investigate the quality of midwifery services from the viewpoint of the clients, under coverage of health care centers in Isfahan, through SERVQUAL model.
MATERIALS AND METHODS: This descriptive and analytical study was conducted on 218 subjects in 2014. Study population comprised the women referring to midwifery services clinics in health care centers in Isfahan. Data of the subjects (n = 218) were collected by SERVQUAL model containing the dimensions of tangibles, reliability, responsiveness, assurance, and empathy. Data were analyzed by paired t-test, Spearman and Pearson correlation coefficients, and independent t-test through SPSS 20.
RESULTS: There was a negative gap in all five relevant dimensions of giving services. The widest gap was in the mean of dimension of tangibles (-1.5), and the narrowest gap was in the dimension of assurance (-0.9). There was no significant association between the scores of expectations and perceptions, and age, education level, occupation, and marital status.
CONCLUSIONS: The obtained negative gap showed that the level of service receivers' perception from existing condition was far from their expectation, and there was a wide gap between attaining their satisfaction with midwifery services and their expectation and reaching their appropriate level of services.

INTRODUCTION

Customer's satisfaction, quality, and care are global subjects that affect all the organizations. Most of the organizations, for improving customer's satisfaction and, consequently, their own survival, are willing to evaluate the strategies of their service quality, and so, the customer is considered the key indicator in this evaluation.[1] The quality of care is a judgment that is made by the customer after receiving the service and comparing their expectations with the received service.[2] One of the principle characteristics of desirable management is accepting customer's perceptions and expectations as the main factor for determining the quality.[3]

Expectations are customers' demands, meaning that what they feel a service provider must present. Perceptions are a costumer's experiences or, in other words, the current status. The distance between costumer's expectations and perceptions indicates the quality of service.[4] The difference between costumer's expectations and perceptions is called service quality gap.[5] By determining the gap between costumers' perceptions and expectations of the quality of provided services, the process of service provision could be improved and costumer's satisfaction, as a very sensitive element in today's field of competition, could be provided.[6]

Zithmal believes that expectations of services is affected by different factors such as individual needs, communication with others, past experiences, and society's environmental conditions; therefore, customers in different countries have different levels of expectations.[4]

Parasurman considers the following factors effective in determining the quality of service: The ability to provide right, in-time, and reliable services; the ability of responding to customer's problems and complaints rapidly and increase the speed of services; creating confidence and trust in costumers; having sufficient professional skills and qualification; paying attention to and regarding human dignity in behaviors; and neat and tidy appearance for tangible elements like facilities and staff clothing.[7]

One of the methods to determine the quality of services is to evaluate costumers' satisfaction, and one of the tools for evaluating and analyzing service quality gap is to study the difference between costumer's expectations and perceptions using SERVQUAL method. This method was presented by Parasuraman, Zithmal, and Berry in the mid-80s. This tool evaluates the quality of services by comparing costumer's expectations and perceptions in different dimensions. SERVQUAL model is the most important tool for measuring service quality. This model has a questionnaire that measures the quality of services in five quality dimensions of tangibles, reliability of services, responding, assurance, and empathy.[48]

Quality in the field of health services has a special place because the critical duty and mission of protecting the health and lives of the society is the responsibility of this part and any mistake could be irreparable; on the other hand, health services are related to a vast part of the society[9] ad providing flawless and professionally standard services must be common in the society.[4] Most of the clients and patients, because of increased level of knowledge about health and medicine and also to prevent the increase in health service expenses, demand services with desirable quality.[10]

Different studies have been conducted to evaluate costumers' satisfaction for improving the quality of provided services using SERVQUAL model in different sections including industry,[11] service department,[12] restaurants,[13] municipalities,[14] higher education,[15] and banks.[16] Inside and outside Iran, in the field of health service also, this model has been used in some sections, including the following places: Tehran,[8] Zahedan,[17] Zanjan,[7] Yazd,[18] and Isfahan[19] in Iran and Singapore,[20] Korea,[21] Malaysia,[22] Sana of Yemen,[23] Ghana,[24] and England[25] outside Iran; but less attention has been paid to evaluation of service quality in different sections of primary health care of health centers, including the midwifery section.

In this regard, some cases could be mentioned: Sharifi Rad et al. evaluated the service quality gap of primary health services in health centers of Isfahan. Results showed that patients' expectations were way much beyond their perception of the current condition.[26] Agha Mollaei et al. conducted a study on the expectations and perceptions of primary health service receivers about the quality of services in health centers of Bandar Abbas. Results showed that patients did not have similar perception of different dimensions of quality of service and these differences should be considered in the programs for improving the quality of services.[27] Aron et al. conducted a study about the quality of medical services in health care centers of Ghana. Results showed that patients' expectations were not fulfilled during treatment.[24] Anbori et al. evaluated the satisfaction and loyalty of patients of private hospitals in Sana, Yemen. Their results revealed that to increase the loyalty of patients, improving the quality of provided services was necessary.[23]

The aim of the present study was to evaluate the quality of services of midwifery in the health centers of Isfahan, because women, as the mothers of families, are the pillar of health in families and their mortality, disability, and behaviors would affect all the health dimensions of the family, and the threats for the health of mothers would be a threat for the health of other age groups too. By determining the expectations and perceptions of midwifery service receivers, the policy makers, planners, and service providers could be informed about the strengths and weaknesses of the quality of midwifery services and this could be a starting point for improving the quality of services.

MATERIALS AND METHODS

The present study was a descriptive, comparative, cross-sectional study that was conducted on women who referred to the midwifery section of the health centers of Isfahan. Inclusion criteria were being able to at least read and write, having the ability to answer the questionnaire, having a medical file at the health center, and willingness to participate in the study, and the exclusion criterion was unwillingness to participate in the study.

In the present study, considering the formula for sample size (z1= 95%, z2= 80%, d = 2s), the number of samples required was calculated to be 218. For sampling, from the main two health centers of Isfahan, based on the covered population, 15 centers were randomly selected, and then, at each center, random sampling was conducted.

For gathering data, the standard SERVQUAL questionnaire by Parasuraman et al. was used.[28] The standard SERVQUAL questionnaire has 22 questions that evaluate the quality of provided services in five dimensions of tangibles (4 questions), reliability (5 questions), responding (4 questions), assurance (4 questions), and empathy (5 questions). This questionnaire was completed by the participants, once before receiving the service to evaluate their expectations (evaluation of desirable situation) and once after receiving the service to evaluate their perceptions (evaluation of current situation). The questionnaire had two parts; the first part contained demographic characteristics of the service receiver and the second part was the standard SERVQUAL questionnaire for evaluating the expectations and perceptions of participants about the quality of the provided service. Questions were scored based on 5-point Likert scale from “completely agreed” (5) to “completely disagreed” (1). Various studies have used SERVQUAL questionnaire in Iran previously and its reliability and validity have been approved.[3526] In one of the studies, Chronbach's α of expectation questions was 0.8 and of perception questions was 0.9.[3]

Data were analyzed using SPSS 20; frequency distribution, mean, standard deviation, paired t, Pearson correlation, Spearman correlation, and independent t tests were used for analysis. To determine the quality of the provide care (quality gap), the score of perception was subtracted from the score of expectations. Negative score (negative gap) indicated a gap between the current status and desirable status (low quality of services) and positive score indicated a positive gap that means providing ideal services (high-quality services). A score of zero means no gap existed.

Ethical considerations

The present study was approved by the ethics committee of Isfahan University of Medical Sciences before execution and all the ethical issues were regarded at all the stages of the study.

RESULTS

In this study, 201 women who referred to the midwifery section of selected health centers of Isfahan were selected and their average age was 31.8 ± 7.3 years, which ranged from 18 to 61 years. Most of the participants had diploma and were married housewives.

The mean scores of expectations, perceptions, and quality gap in the midwifery section of Isfahan health centers separately for each dimension are shown in Table 1. The mean score of expectations of all the participants was higher than their score of perception in all the aspects; the highest score of expectations belonged to reliability dimension and the lowest score belonged to responding dimension. In the perception part, the highest score belonged to reliability and the lowest score belonged to tangibles.

Table 1

Dimensions of midwifery service quality and mean scores for clients’ expectations and perceptions

As shown in Table 1, the highest difference in the mean scores (quality gap) was in the field of tangible quality of services and the least difference was in the field of service quality assurance.

As shown in Table 2, comparing the age and educational level in five dimensions of service quality by Spearman and Pearson correlation coefficients showed no significant relation between the scores of expectations and perceptions of the quality of midwifery services, and age and educational level.

Table 2

Mean scores for clients’ expectations and perceptions and demographic characteristics (age and educational level)

As can be seen in Table 3, independent t-test showed no significant relation between the mean scores of expectations and perceptions, and employment and marital status.

Table 3

Mean scores for clients’ expectations and perceptions and occupation and marital status

DISCUSSION

The main aim of the present study was to evaluate the quality of provided services at the midwifery sections of Isfahan health centers using SERVQUAL model. Results showed that negative gap existed in all the five dimensions of service quality (tangibles, reliability, responding, assurance, and empathy); meaning that the performance of midwifery staff has not been satisfactory for patients.

In this regard, Noor'ain et al. reported a significant negative relation between patients' satisfaction and the quality of provided services in Malaysia.[22] Another study revealed a gap between the expectations and perceptions of ICU patients and the gap was positive. Patients' score of perceptions was higher than their score of expectations; however, this positive difference could be due to short time of their hospitalization in the ICU (24 h) or their special condition.[29]

In the present study, the greatest gap was seen in the tangibles dimension. In this regard, Sharifi Rad et al., also in Isfahan, reported that the greatest gap belonged to the tangibles dimension.[26] The greatest gap in the study of Roohi et al. from Gorgan,[3] Agha Mollaei et al. from Bandar Abbas,[27] and Papanikolaou and Zygiaris from Greece[30] was in the empathy dimension, in the study of Mohammadi and Shoghli from Zanjan[4] and Lee and Yom in Korean hospitals[21] was in the reliability dimension, in the study of Tarig et al. from Khartoum, Sudan[31] was in the assurance dimension, and in the study of Kebriaei et al. from Kashan[5] was in the responding dimension. In the study of Butt and de Cyril conducted in Malaysia, the highest negative score of service quality belonged to responding and reliability dimensions.[32] Anbori et al., in a study conducted in hospitals of Sanaa, found that the greatest service quality gap belonged to responding, assurance, and empathy dimensions.[23]

In this study, the least service quality gap or, in other words, the most appropriate dimension of service quality was the assurance dimension. In this regard, Sharifi Rad et al.,[26] Ameryoun et al.[8] and Agha Mollaei et al.[27] also reported that the least service quality gap belonged to the assurance dimension. Also, the least service quality gap in the studies of Tarahi et al.[6] and Roohi et al.[3] belonged to the reliability dimension, in the studies of Mohammadi and Shoghli[4] and Lee and Yom[21] to the tangibles dimension, and in the study of Anbori et al.[23] to the tangibles and reliability dimensions.

In this study, there was no significant relation between the scores of expectations and perceptions and some demographic characteristics like age, marital status, employment status, and educational level.

In the study of Agha Mollaei et al. also, the relation between service quality gap and age, educational level, and employment was not significant.[27] In the study of Tarahi et al.,[6] the mean score of service quality gap had a reverse correlation with the age of patients, but showed no significant relation with their educational level. In the study conducted by Gholami et al.,[33] there was a significant relation between patients' age and educational level, and their expectations and perceptions; meaning that as the patients' mean of age and educational level increased, the negative service quality gap also increased and patients with higher education believed that negative gap existed in all dimensions except empathy. Also, the study of Kebriaei et al.[5] found a significant relation between patients' expectations and perceptions, and their age and educational level and the relation was reverse. Gorji et al.[34] reported no significant relation between patients' expectations and perceptions, and their age, marital status, employment status, and educational level, but the relation between educational level and expectations was significant.

On comparing the results of the present study and other similar studies, it was found that different characteristics of patients, different facilities of health organizations, and the diverse nature of services have led to dissimilarity of the results. Health organization administrators could not lean on traditional methods and personal knowledge and experiences for planning and governing their own organizations and providing quality services for their customers.[35] Therefore, it is necessary for the administrators to prioritize the programs for different sections of their organizations for increased customer satisfaction and improving the quality of their organization's services by discovering the lowest and highest expectations and perceptions of customers about the current and the desirable condition.[27]

Considering that the mentioned studies have been conducted on different groups with different organizational conditions and also knowing that the study has been conducted on a special group, the results of this study are not generalizable to other fields of health system and medical services and organizations. It is recommended that in every city, for improving the quality of their organization, all the administrators of health centers should try to determine the expectations of patients at different sections of their center and conduct periodical studies based on their organizational condition and improve the quality of their organization by insisting on patients' ideas and expectations and receiving their feedback.

CONCLUSIONS

Negative gap between the expectations and perceptions of patients indicates that patients' perception of the current situation is lower than their expectations and there is a long distance to satisfaction of patients of midwifery section and reaching the desirable condition. On the other hand, this negative gap was not similar in all the dimensions of quality, and since the greatest service quality gap in the midwifery section of Isfahan health centers belonged to the tangibles dimension, the administrators of this organization should reform the physical environment, provide up-to-date and sufficient facilities, and pay special attention to the hygiene of equipment.

Financial support and sponsorship

This study was financially sponsored by the research deputy of Isfahan University of Medical Sciences.

Conflicts of interest

There are no conflicts of interest.