social sciences in health kontakt 18 (2016) e49–e54

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Original research article

The satisfaction with health care quality in dental

clinics in the Slovak Republic

Martin Samohýl a,*, Anna Nádaždyová b, Martin Hirjak c,

Katarína Hirošová a, Diana Vondrová a, Daniela Krajčová a,
Jana Jurkovičová a
a
Comenius University in Bratislava, Faculty of Medicine, Institute of Hygiene, Slovak Republic
b
Comenius University in Bratislava, Faculty of Medicine, Department of Stomatology and Maxilofacial Surgery,
Slovak Republic
c
St Elizabeth's College of Health and Social Sciences, Department of Public Health, Bratislava, Slovak Republic

article info abstract

Article history: In this work, the overall degree of satisfaction with the health care quality of dentists is
Received 21 July 2015 analyzed in terms of general satisfaction, technical quality, communication, interpersonal
Received in revised form and financial aspects, time spent with the doctor, and health care accessibility and conve-
17 October 2015 nience. We have used a standardized questionnaire: ‘‘Patient Satisfaction Questionnaire’’
Accepted 21 January 2016 (PSQ III, long-form). The questionnaire collection was realized in dentists' waiting rooms
Available online 2 February 2016 from November 2014 to April 2015. Completed questionnaires were obtained from 433
subjects (53.6% were men and 46.4% women). We compared two groups of respondents.
Keywords: In the first group were respondents who had not changed their dentist over the past year
Quality (n = 349), and in the second were respondents who had changed them (n = 84). The highest
Satisfaction degree of overall health care satisfaction was seen in males (2.80  0.18), and in the age group
Health care of 30–49 years (2.70  0.27). A higher degree of satisfaction with the technical health care
PSQ III quality was seen in subjects who changed their dentists (2.71  0.36). The highest degree of
Quality indicators satisfaction with the health care quality was related to the interpersonal aspect (3.29  0.47)
and to communication (3.11  0.52). The comparison of the overall health care satisfaction
between the two groups of respondents has been confirmed as statistically significant.
According to our results, we recommend the national developmental team provide support
by implementing positive changes in health care quality, and by performing an approach
known as ‘‘advanced access’’.
# 2016 Faculty of Health and Social Studies of University of South Bohemia in České
Budějovice. Published by Elsevier Sp. z o.o. All rights reserved.

* Corresponding author at: Comenius University in Bratislava, Faculty of Medicine, Institute of Hygiene, Špitálska 24, Bratislava 813 72,
Slovak Republic.
E-mail address: martin.samohyl@fmed.uniba.sk (M. Samohýl).
http://dx.doi.org/10.1016/j.kontakt.2016.01.002
1212-4117/# 2016 Faculty of Health and Social Studies of University of South Bohemia in České Budějovice. Published by Elsevier Sp. z o.
o. All rights reserved.
e50 kontakt 18 (2016) e49–e54

dentist (questions 39–43), comfort (questions 44–51) and

Introduction
overall satisfaction (questions 1–51). Answers to some ques-
tions, where strong agreement means the maximum satisfac-
The health care quality (HCQ) is a summary of the results tion with the HCQ, had to be rescaled (strongly agree – 5, agree
achieved in prevention, diagnostics and treatment, based on – 4, disagree – 2, strongly disagree – 1) to obtain a unified HCQ
medical science and practice. It is determined by the needs of score: 1 = maximum dissatisfaction with the HCQ, 5 = maxi-
the population. New information and communication tech- mum satisfaction with the HCQ. Individual groups of ques-
nologies rank among the key tools for the improvement of HCQ tions reflecting the degree of satisfaction with the HCQ were
[1]. According to Article 2.1a of Act No. 576/2004 Coll. on health evaluated as mean scores for each category. The highest
care services related to health care and on amendments to average value means the highest level of satisfaction with the
certain laws, the goal of health care is lifespan extension, HCQ.
improving the quality of life and ensuring the healthy Questionnaires were collected in dentists' surgeries from
development of future generations. National health policy November 2014 to April 2015. The selection criterion for
that respects the attributes of quality development also patients' inclusion in the study was being over 18 years of age,
ensures the long-term and continuous HCQ improvement. and their diagnosis was not taken into account. Incomplete
However, health care institutions are solely responsible for questionnaires were rejected. In total, 433 completed ques-
implementing specific actions of the management and tionnaires were collected and the response rate was 93%.
continuous improvement of HCQ [2]. The questionnaire was anonymous and a privacy policy was
Demographic characteristics, previous experiences, expec- respected.
tations, and cultural and social aspects of private life are the The sample of respondents was divided into two groups.
main factors with the greatest impact on patient satisfaction The first group consisted of patients who had not changed
in the provision of health care [3]. their dentist in the last year. The second group consisted of
A clinical audit is the most important tool for HCQ patients who had changed their dentist in the last year.
increasing. It is one of the major components that are The basic characteristics of the sample are presented in
generally considered to provide an essential contribution to Table 1. The sample consisted of 433 respondents (53.6% men,
improving the quality of patient care [4]. The time factor is the 46.4% women) with a mean age of 35.8  14.8 years. The
additional determinant of the HCQ. Successful HCQ programs majority of respondents were in the age group of 30–49 years
should be planned for long periods, last up to several decades, (41.6%). In terms of employment, most subjects were classified
and use the experiences from the continuous process of health as skilled workers (58.4%), students (22.4%) and pensioners
care improvement. (7.8%). In terms of the level of education, the largest group was
The aim of the study is to determine the overall level of represented by subjects with a secondary education (55.2%),
patient satisfaction with the health care quality at the dentist, this was followed by a university education (25.1%) and
and to find out how patients who have/have not changed their elementary education (9.7%). Over the last year, 19.4% of
dentist in the last year evaluate it. Another objective of the respondents have changed their dentist. The most common
study is to determine the level of satisfaction with the HCQ in
terms of general satisfaction, technical quality, communica-
tion, interpersonal and financial aspects, time spent with the
physician, health care accessibility and comfort. Table 1 – Basic characteristics of the sample (n = 433).
Parameters N (%)
Materials and methods Sex
Male 232 53.6
Female 201 46.4
This study analyzed both the overall satisfaction with the HCQ Age (years)
in dental clinics and also the particular categories of <30 176 40.6
satisfaction with the health care provided. 30–49 182 41.6
≥50 75 17.8
The standardized questionnaire, ‘‘Patient Satisfaction
Occupation
Questionnaire,’’ PSQ III, long-form was used [5]. The question-
Student 97 22.4
naire itself was preceded by several questions regarding basic Unemployed 7 1.6
demographic data and questions about the reasons for Not qualified 13 3.0
changing dentist. The standardized questionnaire, PSQ III, Qualified 253 58.4
consists of 51 statements focusing on the quality of the health Pensioner 34 7.8
care provided. Respondents were free to choose an answer on Other 29 6.8
Education level
a scale from 1 to 5, which signified to what extent they agreed
Elementary 42 9.7
with each statement (1 – strongly agree, 2 – agree, 3 – not sure, 4
Secondary without school-leaving exam 39 9.0
– disagree, 5 – strongly disagree). The statements in the Secondary with school-leaving exam 239 55.2
standardized questionnaire were divided into groups: general University 109 25.1
satisfaction (questions 1–6), technical quality (questions 7–16), Other 4 0.9
interpersonal aspects (questions 17–23), communication Dentist change
(questions 24–28), financial aspects (questions 29–36), time Yes 84 19.4
No 349 80.6
spent with the dentist (questions 37–38), overall attitude of the
 kontakt 18 (2016) e49–e54 e51

reason for the change was the professional approach of the significant differences in overall HCQ satisfaction were found
former dentist (36.2%). The second most common reason was between both sexes or between different age groups.
the closure of the dental practice (25.3%). With regards to occupation, the lowest overall HCQ
The data were processed by the statistical program SPSS. satisfaction was found among the unemployed (2.33  0.33)
Descriptive statistics (percentages, averages, standard devia- and unskilled workers (2.47  0.32), while the highest rate of
tions) were used. To verify the hypothesis a two-sample t-test overall HCQ satisfaction was found among students (2.71
was used to compare the HCQ satisfaction in men and women,  0.33) ( p = 0.030).
and also HCQ satisfaction in the patients who had/had not Respondents with an elementary education showed the
changed their dentist. An ANOVA test was used to compare lowest level of overall HCQ satisfaction (2.69  0.09), while the
the HCQ satisfaction in each age group and in groups highest rate of overall HCQ satisfaction was found among
organized by occupation and education level. The statistically respondents with a secondary education without school-
significant level was determined at p < 0.05. The Pareto chart leaving exam (2.77  0.09), without statistical significance.
was used to reveal the reasons of the overall health care The overall HCQ satisfaction in respondents who had
satisfaction in each category. This chart arranges the causes changed their dentist in the past year was on average 2.86
according to their importance and frequency (break point), and  0.16. However, those respondents who had not changed
assumes that 80% of the consequences were caused by only their dentist showed a significantly lower rate of overall HCQ
20% of the reasons. To construct the Pareto chart the Lorenz satisfaction (2.71  0.16) ( p = 0.000).
curve is needed, which links up the cumulative frequency Table 3 presents the comparison of HCQ satisfaction in
distribution. patients who had/had not changed their dentist. Respondents
who changed their dentist showed a significantly higher level
of satisfaction in almost all assessment categories (including
Results
overall satisfaction), except for general satisfaction and
communication. The highest rate of HCQ satisfaction among
The HCQ satisfaction in each category is presented in Table 2. all of the assessment categories was recorded in the
According to sex and age, the lowest rate of overall HCQ ‘‘interpersonal aspect’’ category.
satisfaction was among women (2.72  0.19) and in the age The HCQ satisfaction is formed of 20% (according to Pareto
group of ≥50 years (2.68  0.28). However, no statistically chart projection) by the interpersonal aspect (3.29  0.47),
communication (3.11  0.52), the time spent with the dentist
(2.86  0.58), attitude and comfort (2.64  0.34) and technical
quality (2.54  0.37) (Chart 1).
Table 2 – The overall HCQ satisfaction in dental clinics in
selected categories (n = 433).
Discussion
Parameters N (%) Overall p
satisfaction
(x  SD) In the last decade, patient satisfaction and quality of life have
Sex become an important part of the HCQ [6]. Therefore, the
Male 232 (53.6) 2.80  0.18 0.149 primary objective of this study was to determine the overall
Female 201 (46.4) 2.72  0.19 level of HCQ satisfaction at the dentist. International studies,
Age (years)
regardless of whether they were designed to ensure the quality
<30 176 (40.6) 2.69  0.27 0.897
or to evaluate health care, identified several factors associated
30–49 182 (41.6) 2.70  0.27
≥50 75 (17.8) 2.68  0.28
Occupation
Student 97 (22.4) 2.71  0.33 0.030
Unemployed 7 (1.6) 2.33  0.33
Not qualified 13 (3.0) 2.47  0.32 Table 3 – The HCQ satisfaction in two groups of
Qualified 253 (58.4) 2.68  0.33 respondents according to particular categories – mean
Pensioner 34 (7.8) 2.61  0.34 scores for each category (n = 433).
Other 29 (6.8) 2.67  0.33
Health care quality Unchanged Changed p
Education level
satisfaction dentist dentist
Elementary 42 (9.7) 2.69  0.09 0.261
(n = 349) (n = 84)
Secondary 39 (9.0) 2.77  0.09
(x  SD) (x  SD)
without
school-leaving General satisfaction 2.10  0.37 2.12  0.38 0.961
exam Technical quality 2.49  0.36 2.71  0.36 0.000
Secondary with 239 (55.2) 2.71  0.10 Interpersonal aspect 3.23  0.48 3.52  0.49 0.000
school-leaving Communication 3.12  0.52 3.11  0.52 0.983
exam Financial aspect 2.57  0.37 2.71  0.36 0.000
University 109 (25.1) 2.70  0.10 Time spent with the 2.82  0.53 3.06  0.53 0.006
Other 4 (0.9) 2.63  0.09 dentist
Dentist change Attitude 2.61  0.39 2.75  0.38 0.004
Yes 84 (19.4) 2.86  0.16 0.000 Comfort 2.68  0.32 2.87  0.33 0.000
No 232 (53.6) 2.80  0.18 Overall satisfaction 2.71  0.16 2.86  0.16 0.000
e52 kontakt 18 (2016) e49–e54
Chart 1 – Pareto chart of the HCQ satisfaction according to the mean score in each category (n = 433).
with the HCQ. These included the patient's health status and
the demographic characteristics of respondents [7].
Patient satisfaction is defined as the degree of correlation
between the patient's expectations and his perception of
received health care [8]. Quality and satisfaction with health
care is still a matter of concern for health insurance companies
when purchasing health care. Within the continuous increase
of the HCQ satisfaction, the ‘‘Model of relations and proper-
ties’’ has been created in practice. These include trust,
attentiveness, attention, diversity and social communication
[9]. Quality assessment of general health care has become a
priority in national health programs as well. Audit and
feedback from the performance indicators and the HCQ can
help improve the quality of the health care provided. However,
in some cases of quality assessment it is more appropriate to
use the smaller amount of complex indicators [10].
Patient satisfaction is an important outcome of health care.
However, this issue has only received attention in recent years
[11]. Satisfaction indicators are increasingly used to assess
physicians, nurses and service providers [12]. Satisfaction may
affect the use of health services and the relationship between
physician and patient. General patient satisfaction is subjec-
tive, because patients do not take into account the appropri-
ateness and results of therapy [13]. The Slovak Republic would
benefit from the introduction of mentorship (a process for the
informal transfer of knowledge, social capital and psychologi-
cal support) in an effort to enhance satisfaction with the
quality of health care. It should not be forgotten that activities
improving the HCQ must be adopted by patients as well as by
healthcare providers [14].
According to Chang et al. [15] demographic characteristics,
such as age and sex, influence patient health care satisfaction
to various degrees. However, the results of this study differ
from our results. We did not confirm the effect of age and
gender on patient satisfaction. Studies performed in the
countries of Eastern Europe, however, produced similar results
to the study by Chang et al. [15]. Crow et al. [16] analyzed the
results of 39 studies and concluded that intersexual differ-
ences in health care satisfaction could be distorted. Our study
showed a higher overall satisfaction rate in women (2.15
 0.38) than in men (2.11  0.38). Kimman et al. [17] achieved
similar results in their study too.
International studies of quality and patient satisfaction are
often called into question because of the lack of a universally
accepted definition of HCQ satisfaction and the unacceptable
rate scales [18]. According to Findik et al. [19], the highest level
of dissatisfaction with the HCQ was observed in younger age
groups and in patients with a lower level of education. These
conclusions are also confirmed by the study of Murakami et al.
[20]. Some authors focus their study on patients' satisfaction
with specific services provided to them [13]. The growing
importance of patient care, and sustained interest in compar-
ing patient satisfaction with health care systems in different
countries and periods suggests the need to define the
relationship between them. Most changes in the health care
system are only a reflection of patients' experiences [21]. Other
authors suggest that patient care represents only a small share
in changes of satisfaction, even after adjustments for demo-
graphic, health and institutional factors commonly associated
with patient satisfaction [22].
The degree of patient satisfaction in connection with the
communication aspect is analyzed in this paper too. Commu-
nication skills (verbal and nonverbal communication, empa-
thy, assertive behavior, line of reasoning, etc.) rank among the
most important soft skills, as they form an essential part of the
personal and professional life of a human being. Communica-
tion is one of the most important aspects in health care since it
is inherent and constant [23]. The quality of communication
between physician and patient is a multidimensional concept
that includes medical technology, psychosocial aspects and
interaction [24]. An important feature of communication
processes is the fact that they can convey messages through
 kontakt 18 (2016) e49–e54
multiple layers of verbal and nonverbal communication, and
may indirectly facilitate the analysis of health care [25].
Our study showed a lower satisfaction rate in the
‘‘communication’’ category (3.12  0.52) compared with Jaga-
deesan's study (4.46) [26]. Currently, the Internet is the
preferred medium for communicating with the physician.
Esmaeilzadeh et al. [27] confirm the direct link between
Internet use and the HCQ rate. Communication errors between
healthcare professionals and patients can lead to medical
errors with unintended consequences for a patient's condition
[28]. The approach concentrated on communication between
healthcare professional and patient is considered a valuable
strategy in creating relationships with patients, and is
considered a key aspect of HCQ improvement [29]. The
relationship between the communication skills of healthcare
professionals and HCQ confirmed the study by Brédart et al.
[30]. Satisfaction, harmony and medical treatment compli-
ance, preventive care provision and clinical outcomes are
improved by adhering to the proper principles of communica-
tion skills [31]. According to international studies, almost 50%
of patients are afraid of iatrogenic damage caused by the
doctor's lack of communication during outpatient care
admission. Typical impairments are not the result of individ-
ual negligence but the negligence of the health care institution
as a whole. Physicians often work with incomplete informa-
tion about patients' health conditions [32].
The paper also put an emphasis on the analysis of the
financial aspect of general health care. Health cost must be
included in the economic calculations of all sectors and at all
levels of governance. From the financial point of view, health
care quality was assessed as worse when compared with
studies by, for example, Nordyk et al. [33] and Winter et al. [34].
When assessing the quality of health care we also focused
on its accessibility and availability. The access to health care
services is a precondition for high HCQ. At the same time,
access to health care is considered as one of the cornerstones
of HCQ. Currently, the access to a general health care service is
considered an important strategy for reaching health for all
[35]. Health care should be available without restrictions to
every citizen and should be close to their place of residence
[36].
Conclusion
The overall satisfaction with the quality of health care was
evaluated in the sample of 433 dental clinic's patients, and
compared the differences between two subgroups: respon-
dents who had and had not changed their dentist in the last
year.
The significant difference in the overall health care
satisfaction between these two groups of respondents was
confirmed. Six statistically significant differences have been
identified in the individually assessed categories: technical
quality, interpersonal and financial aspects, the time spent
with the physician, attitude and comfort. A higher degree of
satisfaction was found in the group of respondents who had
changed their dentist in the last year.
The lowest level of overall HCQ satisfaction was found in
women (2.72  0.19), in the age group of ≥50 years (2.68  0.28),
e53
the unemployed (2.33  0.33) and among patients with an
elementary educational level (2.69  0.09).
The highest rate of satisfaction with the HCQ was seen in
the efficient interpersonal aspect and the aspect of communi-
cation.
Some recommendations result from this paper, and from
the experience acquired through the questionnaire collection:
– The need to create training programs for dentists where they
can improve their communication skills.
– Initiating the formation of a developmental team to provide
support by implementing changes concerning HCQ at
national level, and by performing an approach known as
‘‘advanced access’’. This approach would be based on the
application of knowledge from the HCQ theory and would
deal with the issue of how to shorten long waiting times.
This approach would also strive to achieve positive changes
in health care institutions.
– Introducing mentorship (i.e. the way employees are man-
aged) as an additional tool for HCQ improvement. Mentor-
ship is the relationship between a mentor and physician. It
allows the exchange of experiences and the offering of
advice to younger co-workers.
Conflict of interest
The authors declare that they are not aware of any conflict of
interest.
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