Users ’ Perception and Satisfaction of Current Situation of Home Health Care Services in Jordan

Background: The healthcare system in Jordan is evolving and has to continuously respond to the changing risk profile of the population. The purpose of this study was to examine perception of users and providers of the quality of home health care services. Methods: A descriptive design was used to collect data from a convenience sample of 82 users of home health care services. Results: Users had low to fair satisfaction (30.5% 69.5%) about the quality of care provided, had moderate satisfaction (72.0% to 81.7%) about the information received, and had low to fair satisfaction about education related to goal of treatment and medication (46.4% 53.3%). Users had high level of agreement (>70%) that health agencies provided interpersonal care. Conclusion: The ability of the frail people to choose from a variety of cost-effective long-term care services is limited.


Introduction
Continuity of care became an urged issue due to fragmentation of care.Specialization and multidisciplinary approaches increased the likelihood that patients are seen by number of health care professional during their testament journey.According to Haggerty et al. [1], policy reports and charters worldwide called for integration and enhancement of continuity of care.Continuity is especially important in chronic or complex clinical diseas-es that require management from several providers who could potentially work at cross purposes [1].Therefore, home care services have dramatically increased in many countries around [2]. "Home care", "home health care", and "in-home care" are terms used interchangeably to refer to any type of care given to a person in their own home.More recently, there is a growing movement to distinguish between "home health care" meaning skilled health care and "home care" meaning non-medical care.Home care aims supporting people with various degrees of dependency to remain at home rather than use residential, long-term, or institutional-based nursing care [3].Home care providers render services in the clients' own home.These services may include combined professional health care services and life assistance services.Professional home health services could include medical and/or psychological assessment and intervention; wound care, medication teaching, pain management, disease education and management, physical therapy, speech therapy, and occupational therapy [4] [5].Home health care is usually less expensive and more convenient than hospital or skilled nursing facility [1].In general, the goal of home health care is to help patients get better, regain their independence, and become as self-sufficient as possible [2].
The healthcare system in Jordan is evolving and has to continuously respond to the changing demographics, epidemiologic and risk profile of the population [6].Demographic, epidemiological, social, and cultural trends in Jordan as in other countries are changing the traditional patterns of care.According to Tarricone & Tsouros [7] rates of care-dependent older people and noncommunicable diseases will increase rates of chronic illness and disability.The shift of care of complex health conditions to home care demands high level of competence among care providers.A previous study showed that that nursing staff in home care were less competent than nurses working in nursing homes.A significant number of home care nursing staff, reported insufficient knowledge in palliative care, patient transfers, oral care, nutrition, range of motion, medication and pressure ulcer [8].Furthermore, home care was staffed by aide and practical nurses that performed delegated medical tasks on daily basis [9].Other studies also showed that staff competence development was needed in mental illnesses [10] and dementia [11].
Moreover, the literature addressed the need for a link with the secondary care when caring for complex health care conditions at home [9] [12] [13].These studies highlighted the need to perform thorough assessment of users, and to assure matching the needs of the users as measured by their level of functioning, ability to perform ADLs, and other health and social needs, with the level of service and the preparedness of the organization and the care givers.In Jordan, there are no legislations, policies or guidelines that govern home health care services, therefore; these services are neither regulated nor monitored and their accountability to the users of the services is not defined.
Thus, there is an urgent need to explore the current status of the home health care sector in Jordan and to evaluate the patterns and barriers of utilization of home health care services from providers and users perspectives.The purpose of this study was to examine perception of users' perception and satisfaction of current situation of home health care services in Jordan.The specific objectives were: 1) Users' perception of current situation of home health care services in Jordan.
2) To assess users' satisfaction of quality of care provided by home health care services in Jordan.

Methods
Design: This is descriptive study using convenience sample of 82 family member/users to assess users' perception and satisfaction of current situation of home health care services in Jordan.Data was collected using a self report format of data collection from families/users of home health care services.Data from families/users were collected in regards to perception of quality of care provided by home health care agencies.
Sample and settings: The study used a convenience sample of 82 family/users of registered home health care agencies at the Ministry of Health in Jordan.Inclusion criteria for family member/user was included those who receive/received home care services at the agency for at least one month.Other than deceased users, there were no other exclusion criteria to maximized variation in data collection.Data was collected from the period Jan 2012 to May 2012.
Data collection procedures: Approvals from the ethics and Academic Research Committee at Philadelphia University were obtained prior to data collection.The Ministry of Health was contacted to provide contact list of the registered and licensed home health care agencies in Jordan.The adapted and translated HHCAHPS (Consumer Assessment of Healthcare Providers and Systems) was pilot tested using 10 users of home health care.The managers of all home health care agencies registered and licensed by the Ministry of Health were invited to participate in the study.They served as the liaison to facilitate the contact list of the users of the services who either choose the services or were referred by medical doctors.The research team (Principal Investigator and Co-investigators) contacted all subjects and screened them to determine their eligibility for the study.Those who met the inclusion criteria were invited to participate in the study and asked to sign the informed consent form.Families/users of home health care services who met the inclusion criteria were informed that data will be collected through self-administered questionnaire that measures their perception of quality of care provider by the home health care agencies.They were informed where to pick and return the package that included two forms; the demographic form and the Home Health Care CAHPS survey.The package also included a cover letter that includes information about the purpose of the study and what was expected from them and where to return the packages, and that the study is anonymous.In addition, the cover letter included contact information of the principal investigator and co-investigator for any further information and for answering the questions related to the study.The interested participants were asked to sign the cover letter in which a statement made at the end of the cover letter says explicitly that their participation in the study was voluntarily and their decision is of their own choice without any direct or indirect influence.Human participants' right to confidentiality, privacy and safety were securely protected throughout the project.Files were kept in locked cabinets at the Jordanian Nursing Council.All projects' electronic versions were kept only in the primary investigator's computer.No names or any identifying information were used that may cause harm to participants at any stage of participation.An approval from the Academic Research Committee at Philadelphia University was obtained prior to data collection at the beginning of the research project.
Measurement: Data were collected using self-administered questionnaires adapted from the Home Health Care CAHPS survey (HHCAHPS) [14].This questionnaire was translated into Arabic by a professional translator and back translated by another translator into English; discrepancies were compared and checked to assure sameness in the meanings on all items.HHCAHPS measures the perception of quality of home health care provided.The Home Health Care CAHPS Survey questionnaire includes the two types of questions contained on all CAHPS instruments-those dealing with reports of specific experiences and those asking for opinions and ratings.The Home Health Care CAHPS Survey instrument contains 34 items that cover topics such as access to care, communications, and interactions with the agency and with agency staff.There are two global items; one asks the patient to rate the care provided by the Home Health Agency (HHA), and the second asks the patient about his or her willingness to recommend the HHA to family and friends.The HHCAHPS was designed to measure the experiences of people receiving home health care from Medicare-certified home health care agencies.This instrument was developed by the Agency for Healthcare Research and Quality (AHRQ) in conjunction with Center for Medicaid and Medicare Services (CMS).The tool is used globally as reference for quality assessment and measurement for health care services.In this study tool showed good reliability with Cronbach's alpha of 0.79.
Potential covariates: Gender, age, citizenship, medical diagnoses, length of time of use of the home health care services, type of service used, health condition, and health insurance and method of payment.
Data analysis plan: The computer program, SPSS Windows (version 17.0) was used to describe the variables of the study using central tendency measures (means, and medians) and the dispersion measures (standard deviation and ranges).The estimated descriptive statistics were compared to normative samples in the literature.

Users' Characteristics
A total of 82 users completed and returned the questionnaire.The majority of users (see Table 1) were above the age of 60 years (54.8%,n = 44), while about 11% (n = 9) were below the age of 30 years.51.2% of them (n = 42) were males, and 48.8% (n = 40) were females.About 46% (n = 38) have bachelor and graduate level of education, while 23.2% (n = 19) have high school level of education.Most of the users were Jordanian citizens about 76%, n = 62), while the non-Jordanians were 24% (n = 20).The majority of user were not living alone (86.6% (n = 71), and do not have health insurance.More than 90% of the users were diagnosed with heart problems, lung problem, and diabetes.Their use of the home health services vary from one week to more than 8 years; however, the highest reported period was more than six months and less than one year (18.3%), and the lowest was less than one week (1.2%, n = 1).Most of the users sought home health services for nursing care (61.0%, n = 50) and specialized health care services (25.6%, n = 21).

Users' Perception about Information Provided by Home Health Care Agencies
In relation to information, the results (Table 2) showed that users have reported high level of satisfaction about the type of introductory information that had been provided to them when they started their treatment courses with the institution; 72.0% to 81.7% of users reported that the institution provided them with such information and appropriate education.However, users had lower satisfaction about the follow up information.Most of users were not satisfied about the type of education they received from health care agencies.The analysis showed that 53.7% (n = 44) reported that they had low to fair agreement that home health care agencies educated them about the goal of treatment and medication time, 62.2% (n = 51) had low to fair agreement that they received pain information, and 46.2% (n = 38) reported low to fair agreement that they received information about the side effects of their medication.In general, the users reported that although they felt moderately satisfied about the information received at the beginning of treatment course, they had low satisfaction about health information provided to them during the follow up services.
Regarding the interpersonal aspect of care, the analysis (see Table 3) showed that the "usually" and "always" agreement responses of clients for items related to interpersonal aspects of care ranged from 73.1% "Care providers are aware and knowledgeable of recent developments in home care" to 85.2% "Care providers respect clients." Although most response rates seem satisfactory, the rates might be considered debatable as the aspects such as respect, listening, insight and awareness, notification, explanation and clarification are the core elements of quality of health care services that should be maximized to the utmost levels.Moreover, 12.2% (n = 10) of users reported that they have never received any explanation from the health care providers about their health care services.

Users' Perception of Quality of Home Health Care Services
Regarding the quality of home health care services as perceived by clients, the results (Table 4) showed that users had some problems related to the quality of care received from home health care agencies.Users agreement responses ranged from 30.5% (n = 25) "During the last two months of care, had you faced any problems in the care that was provided to you from this institution" to 69.5% (n = 57) "During the last two months of care, have you taken a new treatment, or has been there any change in any of your treatments you are receiving."Although 76.8% (n = 63) of the users reported that they will advise the institution that provides them with home health  services to others, only 64.2% (n = 43) of them reported that they have received the type of assistance they asked for in the same day and 33.8% (n = 24) of them reported that they did not.Moreover, 48.8% (n = 40) of the users reported that their evaluation for their health is "Possibly bad" to "surely bad", while only 13.4% (n = 11) reported that their health is excellent.Particularly, 44.5% (n = 37) of the users reported that their emotional status is possible too bad and 15.8% (n = 13) of them reported that emotional status as excellent.

Differences in Users' Evaluation of Home Health Care Services Related to Demographic Characteristics
The analysis shows (Table 5) that the mean score of users' evaluation of HHCS was 7.60 (SD = 2.90).About 25% of the users had a score of 6.0 or below and 25% of them had a score of 10.0 or above.This means that 50% of the users had a score between 6.0 and 10.0 and this would be considered moderate to high level of general satisfaction of HHCS provided by agencies.To investigate whether users' evaluation has been affected by demographic and personal characteristics of the users, nonparametric statistical analysis is conducted as sample size was small and distribution of samples was not normal.The analysis (see Table 5) shows that there was no significant difference in users evaluation of health care provision in regards to gender (U = 728.5,p = 0.78), citizenship (U = 438.0,p = 0.096), and whether they live alone or not (U = 241.5,p = 0.900); while there is significant difference in regards to source of information (U = 310.5,p > 0.001).In addition, the analysis shows that there is no significant difference in users' evaluation of health care provided between those who recommend agencies and those who do not (U = 25.0,p = 0.245), while there was a significant difference between those who have health insurance and those who do not (U = 213.0,p = 0.033).Using Kruskal Wallis test (see Table 6) to investigate differences in users' evaluation of health care provided in regards to users' age group and evaluation to their health physically and psychologically; the analysis shows no significant difference in regards to age groups and general users' evaluation to their psychological health; while there was significant difference in regards to users' evaluation to their physical health (chi square = 10.89,p = 0.028).Moreover, difference in users' evaluation to health care provided by HHC agencies has been inves- tigated in regards to users' health problems and health status.The analysis shows there was no significant difference in users' evaluation to health care provided by HHC agencies in regards to their type of health problem they sought care for or to their current evaluation of their health status (p > 0.05).On the other hand, the analysis shows that there is a significant difference in regards to source of information between those who recommended HHC agencies and those who did not (chi-square = 23.50,p < 0.001), while there were no significant differences in regards to levels of users' physical health evaluation (chi-square = 8.34, p = 0.074) and levels of users' psychological health evaluation (chi-square = 7.41, p > 0.05).
The results indicate that differences in users' evaluation to provided health care at HHC agencies are related to factors as source of information (internal versus external resources) and health insurance status.All other variables were statistically non-significant although there were significant differences between the subgroups of variables.For example males mean score was higher than females, those who are not living alone have higher mean score than those who live alone, and those who will not advise the agency had higher mean score than those who will.The mean differences have impression that all these factors have a role in deciding the quality of care provided and may serve as indicators for quality of care provided by HHCS (Home Health Care Services) agencies.In addition, patients' health problems and the current health status of the patients that serve as reasons to seek HHC did not show any effect on the users' evaluation for HHCS (Home Health Care Services) or their evaluation for their health.In conclusion, although users' satisfaction level of the provided HHCS (Home Health Care Services) was moderate to high, it was significantly higher among those who reported their evaluation to internal sources than those who reported their evaluation to external sources.In other word, there is a possibility of social bias in reported users' evaluation.

Discussion
Many health care treatments that were once offered only in a hospital or a doctor's office can now be done in home.Home health care is usually less expensive, more convenient, and just as effective as a hospital or skilled nursing facility [3].The literature underlined the core goal of home health care as to provide treatment for an illness or injury, and that home health care help patients get better, regain their independence, and become as self-sufficient as possible.This study, in general, found that patients receiving care from Jordanian home health care agencies are, generally, not satisfied.Patients had low perception of quality of information received related to their treatment plans and in overall level of quality of care.However; patients reported high level of satisfac- tion about the quality of interpersonal care.The results in study had some agreement with reports from interna-tional studies.For example, Riccio [15] found that 20% of patients rated their satisfaction with home health nursing care as satisfied, 71% were undecided, and 9% were dissatisfied.Also that study found that patients were most dissatisfied with teaching which agrees with the results from this study.In addition, Gasquet and colleagues [16] found that patients had small-to-moderate satisfaction about medical/nursing care and information received at home care agencies.Moreover, Fadyl and colleagues [17] maintained that the patients receiving home care identified the main quality indicators for home health care services to be technical competence of care service and professionals, human approach to service provision, context-appropriate response to needs.One explanation to for the results in this study can be interpreted in terms of lived experience with chronic and debilitating disease.This infers that users of home health care services are aware and willing to evaluate the quality of care provided and that they expect.In another word, while users find that home-based care enriched their experiences, the level of competency and high expectation of care might contribute to low level of satisfaction about the quality of care received.The low level of satisfaction, as reported, may have negative impact on users' willingness and desire to use home health care services, and that the ultimate goal for home health care services is jeopardized increasing the cost of health care services.One of the causes for the growth in home care services is the preference for home care by the users [18].However, low satisfaction may affect users' preference for selecting home health care services.Furthermore, patients in this study had low satisfaction about the level and type of information they received questioning the competency of health care providers.The results agrees with previous international studies that found that patients had low satisfaction about level of information received [16], and that health care providers lack the knowledge and skills to provide a quality of care [8] [9].This has not been only addressed by patients, but also recognized by providers themselves who have reported needs for competency staff development training programs [10] [11].
The interpersonal aspects of care, such as caring, respect, and kindness and listening were characterized as the "human side" of provider-patient relationships.In this study, the users reported high satisfaction of level of caring, respect, and kindness that they received from the providers at home care agencies.According to Wickizer and associates [19], satisfaction with interpersonal aspects of care reflects the patients' overall treatment experience.While, Donabedian [20] reported that satisfaction with interpersonal care enhanced patient outcomes and considered a significant indicator for quality of care.
One limitation for this study is the limited access to users of home services, and that home health care agencies in Jordan are centralized in large cities limiting the access to users.

Conclusion
In Jordan, the ability of the frail people and disabled people to choose from a variety of cost-effective long-term care services has been limited by many factors including the lack of health insurance coverage for home care services, lack of quality home health care services, and accessibility.This study found that patients had low level of satisfaction, exempting the interpersonal care aspects, about services provided by home health care agencies.Therefore, home health care agencies should develop continuous quality improvement programs to raise the standard of care provided to clients and increase their level of satisfaction.Also, they should perform periodic clients' satisfaction surveys to identify dissatisfaction areas and develop proper interventions to minimize them.Home health care agencies should develop written policies and procedures, health information system, patients' education and orientation programs, continuous quality improvement programs, and continuous training programs.

Table 1 .
Demographic and personal characteristics of users of home health care services (N = 82).
* HHC services: Home Health Care Services.

Table 2 .
Users' perception of type of information services provided by Home Health Care Services Institutions (N = 82).

Table 3 .
Users' perception of the interpersonal aspects of care provided at home health care agencies (N = 82).

Table 4 .
Users' perception of quality of services provided by home health care agencies (N = 82).

Table 5 .
Differences in users' evaluation of health care provided by agency in relation to selected demographic and personal characteristics (N = 82).

Table 6 .
Differences in users' evaluation of health care provided by agency in relation to selected demographic and personal characteristics (N = 82).