An Exploration of Factors Influencing Level of Service Satisfaction in Eating Disordered Patients
Published in medi.philica.com
The concept of patient satisfaction has received increasing attention over the past ten years. It has become a desired measure of outcome, an attribute of quality and a legitimate health care goal (Shaw, 1986; Williams and Wilkinson, 1995). The salience of this attention to patient satisfaction can be seen with the production of the Government's "Involving Patients and the Public in Healthcare" document in September 2001 (DoH, 2001). This paper outlined the Government's vision for a more patient-centred NHS, where the voices of patients are heard through every level of the service. For this new system to succeed it must become commonplace for patients' views to be listened to and acted upon. In fact, the paper suggests that every health care trust should conduct surveys of patients' views that will then be published in the public arena. Where patient satisfaction fits into this vision is that by assessing and measuring this concept, information can be gathered that can inform both policy and, at a more service specific level, service development, taking into account the patients' needs and requirements.
Despite an abundance of satisfaction research in the literature, the evidence to date has a few limitations. First, there is a lack of consensus on the definition of patient satisfaction. Satisfaction can be seen both as an independent variable, influencing the efficacy of interventions, behaviours such as compliance and service utilisation, and also as a dependent variable, being affected by factors such as expectations, self-esteem, illness behaviours and previous experience. There have been some attempts in the literature to define such a concept. For example, Linder-Pelz (1982a) defines patient satisfaction as "patient evaluations of distinct dimensions of health care", whilst Brennan (1995) refers to it as "the appraisal, by an individual, of the extent to which the care provided has met that individual's expectations and preferences". However, in the bulk of the research, satisfaction is rarely defined and there is little clarification as to what the concept means to either the researchers or the respondents. As Sheppard (1991) points out, most researchers use a concept of satisfaction that is too vague to be of any meaningful use. As satisfaction is defined in various ways by different individuals this subjectivity has lead to problems when operationalising the concept.
The limitation due to the lack of clear definition of patient satisfaction is further compounded by a second problem: that the exact factors contributing to a patient's satisfaction are still not known. Studies measuring predictors of satisfaction have explained only a small percent of the variance - nearly always less than 20% (Jackson and Kroenke, 1997). For example, Linder-Pelz (1982a, 1982b) found that patients' expectations, values and perceived outcomes all had independent effects on satisfaction but explained only less than 10% of the total variance.
Finally, many of the instruments that have been developed are designed from the point of view of the health professionals or health service and often may not give enough emphasis to the needs of the patients. In addition, such measures were developed for research purposes and there have been difficulties transferring some of them to routine clinical use (Lelliott, 2000).
Whilst it is important to measure patients' views of the service in all health care settings, monitoring satisfaction seems to have an additional significance in the field of eating disorders. For example, although health outcomes of care have been found as the important variable in patient satisfaction (e.g., Jatulis et al., 1997), these may not be directly applicable to eating disordered patients, especially in the early stages of treatment. Many eating disordered patients, in particular those suffering from anorexia nervosa, have a fear of the treatment outcomes, such as gaining weight, and so it may be that such factors would not be associated with their satisfaction levels. It is possible that individuals suffering from eating disorders may have some unique characteristics that need to be considered in the assessment of satisfaction, which will not have been addressed in satisfaction measures previously developed for general use or with other services in mind. To date, there is very limited research that directly addresses service satisfaction of patients with eating disorders. More often, patient satisfaction is included as a small part in general surveys (e.g., Newton et al., 1993; Rosenvinge & Klusmeier, 2000) that are designed to obtain an overall view of the availability and effectiveness of treatment.
The aim of the current study was to qualitatively explore the lay constructions of what contributes to satisfaction with an eating disorder service. Although there are many forms of qualitative analysis, interpretative phenomenological analysis (IPA) (e.g., Smith, 1996) was chosen as the most appropriate. This is because IPA reflects the perspectives of the participants by engaging with the way in which they think and act. It is also grounded within a "realist" approach (Flowers et al., 1997), which means it is based on the belief that patients' speech is related to their thoughts, and that there is a connection between verbal responses to a question, cognitions and behaviour. This is in contrast to other qualitative approaches such as discourse analysis, which is based on the belief that discourse is contingent upon the situation, and is therefore difficult to map onto cognitions.
One hundred and fifty-nine current outpatients of a specialised eating disorder service were randomly selected (i.e., taking every third patient from the list of open cases) and invited to take part in the study. They were sent a covering letter and information sheet explaining the aims, methodology and intended outcomes of the research. If they decided they would like to take part they were asked to contact the researcher to arrange a suitable interview appointment. It was intended to recruit 10 participants. However, due to low response rates, only six participants were recruited. All the interviews were conducted by the first author using a semi-structured interview schedule, allowing the researcher to have some direction for the interview, whilst still providing flexibility to enable ideas and opinions of importance to the participants to be expressed and discussed. The interviews were then transcribed verbatim and various themes were identified.
Table 1 shows the demographic data (i.e., age, gender, ethnicity) of patients who took part in the study and those who did not. The data analysis suggests that there is no significant difference between the two groups. However, the data should be interpreted with caution due to the small number in the ‘participants' group.
Table 1: Comparison of participants and non-participants in terms of age, gender and ethnicity
Non-participants Participants Mann-Whitney U
Mean SD Mean SD z p
Age 32.8 (10.2) 38.8 (15.6) 1.09 0.28 (NS)
Non-participants Participants Chi-square Test
Gender Χ2 p
Female 141 6 0.51 0.48(NS)
Male 12 0
White 117 5 4.92 .30(NS)
Asian 7 0
Afro-Caribbean 1 0
Other 4 1
Unknown 24 0
Qualitative analysis of the transcription revealed five main themes, as listed in Table 2. The content of each theme is summarised as follows.
Table 2: Summary of key themes, each with examples of expressed ideas
1. Service expectations
Most of the participants revealed they had negative expectations of the service before they began their treatment (e.g., "I didn't want to come here so I was expecting the worst"). In particular, participants seemed to perceive the outcome of treatment as undesirable (e.g., "my expectation…of the service was that they were going to make me fat"). However, one of the respondents did express a more positive view (e.g., "I hoped it would solve my problems…… I was quite desperate. I was hoping to lead a normal life").
Respondents were found to attach strong feelings to service expectations, usually as a result of the uncertainty of the types of treatment they are going to receive. For example, one respondent commented, "I was quite frightened when I first came, I didn't know what to expect really"; whereas another person said, "I was apprehensive as I didn't know if I would be seeing somebody on a one-to-one basis or whether I would have to be in a group".
There were also some unrealistic initial expectations about the service and treatment outcomes. For example, one participant stated that she would like to see "a magic wand being waved". Another commented, " I probably hoped for a miracle cure before I came, possibly a little while into it as well", whilst a third participant commented that "I thought I was just going to go there, be there for a few weeks and I'd be better and I'd just be packed away and get back on with it again". However, most respondents revealed that these initial expectations were later replaced by more realistic ones as they progressed through treatment (e.g., "I was very naïve… it doesn't quite work that way" or "It certainly wasn't as daunting or scary as I thought it would be").
2. Comparisons with others
(a) Comparison with other services
Some of the participants had received help for their eating problems at other services and so made comparisons between these past services and the current one. Such information can be useful for gaining insights into patient's satisfaction and how their expectations may have been formed. Some examples of quotes in relation to this theme are "I find this [service] much better. When I've been in hospital before, I've just sort of been left to sink or swim with very little support"; " I've been an in-patient and an out-patient at [a different service], and that didn't rank too highly in my opinion so I think I was sceptical" and "The first hospital I went to everything was locked all the time, and that was quite horrible".
(b) Comparison with other patients
Equally important were the comparisons that were made with other patients both within the eating disorder service and the wider psychiatric hospital. These comments give insight into how patients perceive themselves, which may have implications for how they respond to the service. For example, some of the patients made downward social comparisons with their fellow patients, highlighting underlying self-esteem and confidence issues. One participant commented that "I think the in-patients are in a much worse situation than me … I don't really deserve to be here….They look at me and think what on earth is she doing here". Other comparisons were also made with patients from the other psychiatric wards and units (e.g., "I was frightened I would be accosted by nutters", or "There's loads of weird people out there [the waiting room]"). These comparisons highlight the mindset of the patients in that they demonstrate that the eating disordered patients don't class themselves as similar to general psychiatric patients. The general perception was that psychiatric patients were people to be wary, and even frightened of, and they felt safer having no contact with them.
3. Staff issues
(a) Level of skills
Staff members' interpersonal skills emerged as a major factor that would have a strong impact on patients' satisfaction. All the patients talked about how being made to feel welcome and comfortable in the service, and being at ease, was important to them. One respondent stated that "…the feeling that they care about you, that they want you to get better, it makes you feel comfortable", whilst another praised staff for their ability to "make you feel sort of at home". Staff members' ability and willingness to listen to patients were also highly valued. Patients wanted to feel their concerns were listened to and understood, and that they were treated as an individual rather than just given a label with presumptions being made about them. This is highlighted by comments made by a participant who valued the experience of "being treated as an individual, rather than just like everybody else, considering the nature of things…I think sensitivity to individual needs". Others remarked "feeling that they hear and understand you" and "If I wasn't listened to. If I came and they just put a label on me and said this is what we think and I didn't feel they had listened to me, that I would be dissatisfied with".
An issue related to this is that the patients wanted staff to be non-judgemental and tolerant of failure. It is not uncommon for patients with eating disorders to experience setbacks in their treatment, especially when they are not ready to take the next step in the process of change. The patients felt that for them to be happy with a service, they needed to know that this would be accepted. They also needed the staff to show empathy and be flexible in their approach. This can be best illustrated by the quote "Patience, and a tolerance of failure, as you'll go away saying you'll do things…then the hideous day comes and you haven't actually managed any of them, so being tolerant of failure. And being non-judgemental, but then I think that comes with the whole package of being tolerant".
(b) Staff Continuity
One of the major issues that contributed to patient's dissatisfaction within the service was the lack of staff continuity. This mainly applied to the out-patient psychiatric clinic rather than to individual therapy. Patients reported that seeing different medical staff on each visit was not an aspect of the service they were happy with. Having different medical staff meant that the patients found it particularly difficult to build up a trusting relationship. Others felt it was wasting time, as each visit they would be asked similar questions. One respondent remarked that " it was always somebody different…. they'd spend like two minutes before I actually got in there, quickly looking at my file and asking the same questions every single time. I just got really fed up. I just thought you don't know who I am, so therefore I wasn't prepared to offer any information". Another participant said, "It would really piss me off if I went to an appointment and nobody knew who I was. The SHOs or whatever those doctor thingies are here, they don't know who you are…."; whereas a third one commented, "…continuity, you know, having the same people and not all the chopping and changing".
4. Environmental issues
(a) Waiting area
Most of the comments on environmental issues centred around the waiting area at the main reception, with the majority of comments being negative. The patients either felt that the waiting area was dirty, smoky and generally not a nice place to be, or they were concerned about the other patients who used the area. Two examples of expressed opinions are "I would wait in the main reception … that was incredibly difficult as …I was frightened I would be accosted by nutters", and "I got scared once (in the waiting area)… as there was quite a disturbed person and I didn't know how to handle it". For some patients waiting on the eating disorder specific ward was a better arrangement (e.g., "I don't like the reception, it's full of weird people… I wouldn't sit there, so I wait on the ward") although for others this was almost as bad (e.g., "I find the unit a bit intimidating, I don't like waiting on the ward".
Comments were also made about the layout of the waiting area. It was mentioned that it was "quite confusing" as to where to wait due to a partition that separates the waiting area. As one patient mentioned, the reception is the first point of contact so it influences first impressions.
(b) Consulting / therapy rooms
A second major point regarding environmental issues was related to the consulting/therapy rooms. Patients felt rooms should be cosy, comfortable, confidential and safe, so that they could talk freely without fear of being overheard or distracted. This can be best illustrated by the comment "… if they are horrible then you tend not to be able to relax … and chat, and there have been times when there's been noises and it sort of, I'll be talking and I sort of stop because I've been distracted, then you lose your track".
(c) Location of the service
A final environmental issue was the location of the service within a psychiatric hospital. This was a topic that produced two opposing views. Half of the respondents thought the service should be located within a psychiatric hospital as it meant the disorders were treated in the best possible manner. For example, one individual felt that "it should be in a psychiatric hospital as it's not a physical thing" whereas another participant commented that she was "glad it's in a hospital as it means it is taken seriously.. you've got all the services and back-up you need in one place". On the contrary, others felt that the service being in a psychiatric setting had negative connotations (e.g., "the label "psychiatric hospital" is scary") and would bring social stigma to people who use the service (e.g., "I don't like the psychiatric hospital location, I would be mortified if anyone saw me coming in here").
5. Treatment issues
(a) Waiting time
The major treatment issue discussed that created dissatisfaction was that of waiting times, in particular, from referral to first appointment. All the respondents felt that the waiting time for their first appointment was too long. This is illustrated by the comment "I had to wait a long time to get help … which was difficult once I'd plucked up the courage to actually come". In addition, there was a general consensus amongst participants that the waiting times between appointments in the out-patient psychiatric clinic were also unsatisfactory (e.g., "once you've been seen as an out-patient and then you've got to wait, like 4 months or something, that's a long time, you've got really worried to come (the first time) then there is nothing". A further point was that if waiting times were too long at appointments then this may lead to anxiety and the patient wanting to leave.
(b) Individually-tailored treatment
A second treatment issue was the quality of treatment received. Patients wanted treatment that progressed at a pace that suited them, to minimise any pressure they may feel to make changes when they are not ready (e.g., "A realisation that everybody's pace is different"). It was also important that the treatment was individually tailored to each patient's needs and concerns where appropriate, so making the patient feel valued. For example, one participant stated that "being treated as an individual rather then just like everybody else in terms of setting goals." was important, whilst another said she would like to be "valued as an individual rather than being, just another one". Satisfaction was also expressed if the treatment was continuous for as long as it was required, and if the patients felt it was the best treatment that could be provided.
Finally, good information and communication was important to most participants in the study. It was felt that it would be a good idea to provide patients, especially those new to the unit, with information booklets or handouts that outline the structure and remit of the service, and the treatment it offers. This might reduce the anxiety of patients, especially while they are waiting for a first appointment. Another aspect highlighted as important in satisfaction was regular communication such as letters to confirm future appointments (e.g., "I've a lot of letters… I find it good that they say, you know, confirm that you are going to come, which I prefer rather than assuming, as if you aren't ready, they will contact you again. I really like that").
Additional Factor for Consideration
In addition to the five main themes, patients' personal characteristics also appear to play a significant role in service satisfaction. However, it influences how satisfaction of the service is expressed rather than actual level of satisfaction. For example, it is not surprising that an individual's level of confidence will affect their ability to express their views about a service. In fact, one participant stated that "I feel that I'm a nuisance" and "I find it difficult to complain, I've been brought up not to complain". These quotes suggest that this particular individual is unlikely to make any negative comments irrespective of the quality of the service. In contrast, other patients felt more comfortable in expressing dissatisfaction. For example, one respondent commented "I don't feel pressurised into saying nice things about the service", whereas another participant stated that "If there was something wrong I would tell you…because I do complain…I expect things to be in certain way".
The main purpose of this study was to qualitatively explore eating disorder patients' underlying concepts of satisfaction and the factors that contribute to it. As previously mentioned, due to the lack of existing satisfaction questionnaires in the field of eating disorders, a qualitative study would be useful in investigating these factors. The five themes that were identified in the current study as having an impact on patient satisfaction were service expectations, comparison to others, staff issues, environmental issues and treatment issues. These will be discussed in turn below.
Most respondents expressed a negative view on the potential outcome of treatment, which is quite different from what would be expected from patients attending other health care services. In general settings, patients usually have an expectation that the hospital treatment they are going to receive will result in a positive outcome. However, due to the nature of eating disorders such as anorexia nervosa and bulimia nervosa, what is seen as a "positive" outcome by professionals (e.g., weight gain, healthy eating patterns, etc.) may be seen as undesirable by patients. This is because these patients tend to excessively evaluate their self-worth based on their physical appearance such as weight and shape. Hence, there is a strong resistance to treatment that is designed to help them to increase and/or regulate their dietary input.
The one respondent who expressed positive service expectation was suffering from binge eating disorder, and so was hoping to gain control over her eating with a view to losing weight. In this case, her views coincide with the "positive" outcomes expected by professionals. This discrepancy in the views expressed by different patients emphasises the importance of taking the individual's eating psychopathology into consideration when measuring patients' expectation from a service.
Comparison with others
The level of service satisfaction appears to be influenced by social comparison. For example, if a patient perceives herself as undeserving of the service in comparison to other patients, her expectation of the service may be biased. This is best illustrated by the respondent with binge eating disorder who felt that she was not as "ill" as the extremely emaciated anorexic in-patients and thus was very grateful that she was offered a service.
Most respondents expressed the view that the interpersonal skills of the staff they interact with was one major factor impacting their level of satisfaction. This is consistent with other findings in the existing literature. For example, Clinton (2001) found that the second largest factor accounting for variance in satisfaction in an eating disordered population was "personal involvement" of the therapist. Similarly, Sheppard (1991) found that satisfaction was related to the extent patients felt workers listened to, and understood, their problems. Further support for these findings comes from research that has demonstrated that the attributes valued by patients in care providers include courtesy, respect, honesty, openness, friendliness, empathy, informality, non-judgmental attitude, reliability, punctuality and the ability to see the individual "behind the symptoms". (Henwood et al., 1998; Murray, 1998; Pettersen and Rosenvinge, 2002; Shepard et al., 1994).
Another staff-related factor found to be important in the current study was continuity. Overall, respondents in the current study indicated that this factor was directly linked to their satisfaction with the service. There is evidence in the literature to support the need to have continuity of care in order for patients to feel satisfied. For example, Moutoussis et al., (2000) conducted an in-depth survey of psychiatric patients and found that 14.5% thought too many people were involved in their care, with 7% complaining about the frequent changes of psychiatrists. It could be construed that, in the case where continuity is lacking, patients may feel uncertain as to who is responsible for their treatment, or may find it frustrating to repeat information at each appointment. It may also prevent the patient building up a trusting therapeutic relationship with, and developing confidence in, their doctor or therapist. All these factors may contribute to dissatisfaction with the service these individuals are receiving.
Waiting times for appointments has been found to be an important factor that influences patient satisfaction. The current results suggest that in general patients were not satisfied with long waiting times and viewed them as a negative aspect of the service. However, there is evidence in the literature to contradict this finding. For example, Fontana and Rosenheck (2001) found a positive association between waiting times and patient satisfaction. They suggested that longer waiting periods are linked to a higher level of motivation, which is associated with a predisposition to greater satisfaction. A possible explanation for the difference in the two studies could be that eating disordered patients do not normally come to a service for treatment voluntarily, but rather, they attend on the request of, or under pressure from, their family or their G.P.s. Hence persevering through long waiting periods may further decrease their motivation, resulting in dissatisfaction with the service.
Other treatment-related issues found to be important are good information about the service and efficient communication. Most of our participants expressed satisfaction regarding various means of communication such as regular letters to confirm appointments, etc. This is supported by other findings in the literature. For example, Beeforth et al., (1994) found that provision of information about services and treatments was related to satisfaction in a psychiatric population. In addition, Moutoussis et al.'s (2000) extensive survey found that 61.8% of patients wished for more printed information and 36% felt uninformed about organisations that may be of help. Similarly, Barak et al., (2001) reported that the most significant finding in their study was the correlation between initial "education" and satisfaction. When patients received information about their medication, treatment aims and procedures, and general information about the service, they reported higher levels of satisfaction.
Whilst the actual level of service satisfaction is found to be influenced by the five factors as discussed above, how it is expressed can be affected by personal characteristics of the patients. For example, if an individual is very concerned with others' perception of her, she may feel less confident in expressing any dissatisfaction about the service she receives. In contrast, other respondents in the study revealed that they would be prepared to express their dissatisfaction should they feel unhappy with the service they received. The confidence shown by these patients in expressing dissatisfaction with a service contradicts previous research findings that suggest patients in general are not able to express negative views about services, and that patient satisfaction is usually overestimated (Draper et al., 2001; Fitzpatrick and Hopkins, 1983; Lebow, 1983).
Based on the current findings, a working model of factors influencing eating disordered patients' level of satisfaction of a service was developed (see Figure 1). It is envisaged that this model can be used to inform the development of an eating-disorder-specific satisfaction questionnaire at a later stage. It was deemed important to use such a specific approach as eating disorders are very complex disorders that may raise different issues to those in other areas of mental health. In addition, although there have been many satisfaction questionnaires developed in the literature, none of them are developed specifically for the eating disordered population. Although Clinton (2001) has developed the eating disordered patient's expectations and experiences of treatment questionnaire (EDPEX), this does not seem to assess patient satisfaction directly. Assessing a service by satisfaction is believed to be a more preferable method than assessing by service quality alone (e.g., de Ruyter et al., 1997). This is because service quality taps into areas such as treatment outcomes which, as previously mentioned, may be a less important issue to eating disordered patients than to other patient groups. On the other hand, satisfaction incorporates not just service quality, but as our findings show, many other areas that are important to patients.
Figure 1: Factors Influencing Patients' Satisfaction with an Eating Disorders Service -
A Working Model
Despite the interesting findings, there are a few limitations in the present study. First, the sample size is relatively small. Only 6 people were interviewed despite the original recruitment target of 10 participants. Though not uncommon in research using eating disordered populations, this low response rate raises the key issue of how generalisable the findings are to other patients using the service, despite statistical analysis suggesting that there is no significant difference between participants and non-participants in terms of age, gender and ethnicity. A further limitation in relation to generalisability is that only out-patients were invited to participate in this study, a consideration which must be taken into account in the next phase of the research. If a satisfaction questionnaire were to be developed based on the findings of this study, then it should not be used to measure satisfaction of patients who are in day-treatment or in-patient treatment.
The third limitation of this study relates to the timing of the interviews. The individuals interviewed were current patients of the service (as opposed to those who have been discharged). As a result, there is a distinct possibility that they may have felt uncomfortable expressing their true opinions of service issues that had not satisfied them. However, judging from their responses, this may not have been an issue for these participants who freely discussed their views of the service, despite great care being taken to ensure the questions in the semi-structured interview were focused on potential areas that might contribute to their satisfaction/dissatisfaction, rather than issues specifically related to the service. A further problem associated with this factor is the temporal link between the research interview and patients' clinical appointment at the service. Jackson et al., (2001) found that if satisfaction was assessed immediately after a patient's appointment, the important factors contributing to satisfaction were different than if it was assessed two to three weeks after an appointment. In our study, the participants were asked to make an appointment for the interview at a time that suited them, which did not take into account the time of their out-patient appointments.
In conclusion, this study was a preliminary exploration of the factors underlying satisfaction from the patients' perspective. It emerged that five factors were considered important in influencing eating disordered patients' satisfaction with the service. The results from this study can be used to devise a pilot ‘eating disorder patient satisfaction questionnaire'. One important clinical implication of developing such a questionnaire is that patients' views can be monitored routinely in order to improve the quality of a service. The questionnaire can also be used for further research, for example, to investigate the association between various factors such as level of satisfaction, motivation, behavioural outcomes and drop-out rates, etc. By assessing satisfaction in this patient-centred manner, services can then make changes and improvements that are in line with what patients themselves see as important, which, will potentially have a more positive impact on treatment outcomes.
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1. Emma Vince, B.Sc., M.Sc., Ph.D., is a Research Fellow at Department of Primary Care and General Practice, University of Birmingham
2. Newman Leung, B.Sc., M.Sc., Ph.D., is a Consultant Clinical Psychologist at the Eating Disorders Service, Birmingham & Solihull Mental Health NHS Trust and an Honorary Lecturer at Department of Psychology, University of Birmingham
Information about this Article
Published on Friday 19th May, 2006 at 14:15:50.
Peer review added 25th May, 2006 at 14:21:58
This study aims to provide an initial exploration of the factors influencing eating disorder patients’ satisfaction with their treatments. I felt convinced by the authors’ rationale for saying that eating disorder patients need to be considered separately from other patient groups. In particular, the point about how professionals and patients might have very different ideas about the desirability of a “cure” is an important one that certainly seems to distinguish eating disorder treatments from almost any other form of healthcare.
Peer review added 12th August, 2006 at 12:30:10
A little question: what about the vitamin content of the food and the patient food eating satisfaction?
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