Patient satisfaction of primary care services in Gulf Cooperation Council Countries: A scoping review

Abstract Patient satisfaction (PS) is an essential element in evaluating and improving healthcare systems. Few studies have gathered evidence about patient satisfaction with primary care (PC) services in the Gulf Cooperation Council (GCC) countries. Therefore, it is important to review the existing literature examining PS with PC services in the GCC countries. This scoping review was conducted for primary data studies published between 2000 to March 2022. Out of 4461 screened articles, 37 met the inclusion criteria. Most studies were conducted in Saudi Arabia and were of cross sectional methodology. PS with primary care in the GCC is affected by multiple provider‐related and patient‐related factors and users are generally satisfied with the service provided. Future research should focus on the effects of the factors that were not explored and validate the existing results.


| BACKG ROU N D
2][3] The patient's thoughts and satisfaction with the service provided are essential in evaluating the service quality.PS can be defined as "the extent of agreement between what a patient expects to receive from the healthcare experience and the perception of the level of care they receive". 4 contributes to healthcare services' structure, process, and output. 5valid way to learn patients' opinions about the health system is to systematically review the existing literature for studies that measure PS.With the increase in patient focus in the health field, there has been a significant increase in PS evaluation studies. 6,7wever, the scoping review of PS is still quite limited, specifically those conducted about PS with primary care (PC) services in the Gulf Cooperation Council (GCC) countries.A systematic review about PS in Saudi Arabia (one of the GCC countries) found that there was a contradiction between the patients' responses to the surveys on the domains of PS and their actual experience where patients reported that they were satisfied with primary care centers; however, they frequently attended the emergency department directly.The authors claimed that this indicated that patients were unlikely to be fully satisfied with the primary healthcare center services. 8A primary healthcare center in the GCC countries is a patient's first point of contact with the medical care system.The GCC countries share similar cultures and healthcare systems with some differences.

| Objective
This scoping review aims to examine the nature and range of studies examining PS with PC services in the GCC countries.To the best of the researcher's knowledge, this is the first study that examines the nature and range of studies related to PS with PC services in the GCC countries.

| Review protocol
A scooping literature review was followed using Arksey and O'Malley framework 9 to systematically summarize the nature and range of PS studies in the GCC countries in PC centers.It started with identifying the research question, then identifying relevant studies, and then went through the study selection process (Table 1).

| Search strategy
Search terms were initially used in Medline and applied to other databases.Field experts (clinicians and quality specialists) were consulted in the search terms selection process.Additionally, the terms used in other satisfaction-related systematic reviews informed the search terms used in this review (Table 2).Terms appearing as keywords and subject headings were combined to search for studies that examined PS in primary health care in the Gulf region.The search was conducted in March 2022.

| Sources of data
Six databases (Table 1) were searched using the search terms.The papers included were empirical studies that examined PS with PC centers in any GCC countries published in peer review journals on or after the year 2000, whether in English or Arabic.Studies that examined satisfaction in hospital settings or satisfaction with specific clinical interventions or procedures were excluded (Table 3).

| Data extraction and data synthesis
Data were extracted and synthesized using tables to summarize and answer the review questions.The headings of tables summarizing the determinants of PS were developed following the systematic review by Batbaatar et al. 10 The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) were used to guide the screening and selection process. 11,12Title screening was conducted by one reviewer, while two reviewers conducted the abstract and full-text screening.Any disagreement between the reviewers regarding the abstract screening was resolved by the third reviewer.TA B L E 1 Application of Arksey and O'Malley framework. 9Identifying the research question: What is the existing evidence regarding PS of PC services in GCC countries.

| Technical care
This represents healthcare providers' practice concerning their competency, ethics, and confidentiality. 10Four studies indicated that overall technical care could contribute to patients' level of satisfaction with healthcare services provided in PC settings. 20,25,29,33e ability of a health provider to discuss health problems (including psychological aspects), 20,[28][29][30]35 how to take medications correctly, 22,36,37 and advice to promote healthy living 13,29,30,37 were seen as important competencies related to increasing PS with the services provided.
PS was also shown to be affected by the qualification of a PC provider, as the satisfaction scores were more positive towards family physicians compared to general practitioners. 13,15,20,37This was found to be significantly related to the fact that visiting a family physician allowed the patient to follow up with the same doctor. 20,28her studies showed that PS was significantly affected when visiting consultant physicians and those with nonsurgical specialties. 23,38tients also favored having specialized doctors in their primary centers. 19,23,39The comprehensiveness of the services provided to patients, including full physical examination and accurate and upto-date medical history, were also reported as important elements of PS. 14,24,34

| Physical environment
The physical environment was also reported to affect PS.Cleanliness of PC centers, 25,44,46 comfortable design and layout, 36,46 enough space in reception and waiting area and their locations within the center, 22,29,46 availability of air ventilation and air conditioning, 29 comfortable furniture in waiting area, 39,46 and availability of public toilets 46 were reported as factors that may enhance patients' experience in health facilities and improve their level of satisfaction with health services.
Differences between rural and urban regions were found to be significant concerning the cleanliness and design of the PC centers.
A study showed that patients in rural regions were significantly more likely to state that the PC was not very clean than those from urban regions. 13Moreover, patients in urban regions were likelier to report that it is very easy to get around and within the PC center than patients in rural regions. 131.4| Access (accessibility, availability, and affordability) Access to healthcare is concerned with helping people command appropriate healthcare resources to preserve or improve their health. 43,45 Furthermore, one study has shown that implementing a triage system significantly reduces waiting time and increases the level of PS. 16 However, another study showed that access and utilization of PC services significantly varied between urban and rural areas in relation to opening days/hours and distance. 13It was found that respondents from urban regions were significantly more likely to want the center to open early mornings, with those from rural regions most likely to want the center to open for extra days; whereas the distance was significantly more likely to present a problem to those residing in rural regions compared to those from urban regions. 13Moreover, patients in urban regions were likelier to report that it is very easy to get around and within the PC center than patients in rural regions.The availability of health services and the sufficient number of healthcare staff were important determinants of PS. 10 Patients were more satisfied when there was an adequate number of clinical staff, including lab and pharmacy staff. 41Availability of specialized services 22 and other services such as laboratory tests, the follow-up appointment system, and referral to the hospital, if needed, were an enhancer of PS in different studies. 29,30,44Moreover, the availability of medicines and adequate pharmacy supplies increased PS. 22,29,32 The affordability of healthcare services and their relation to PS was found to be contradictory in some studies.One study reported that paying for prescribed medicines was not significantly related to PS as patients have not had to pay for medicines. 13Another study found that overall satisfaction ratings were significantly related to the type of PC (public or private). 42

| Organizational characteristics
This is related to the operation of services and staff within the PC.
Satisfaction with the appointment system was reported in different studies with an improvement in appointment booking after Electronic Medical Records (EMR) implementation. 34,47Implementation of EMR was also shown to improve other determinants such as technical care (e.g., physician performance), access (e.g., waiting time), interpersonal care (e.g., communication), continuity (e.g., seeing physician of choice), and outcome (e.g., medical care). 21,47,48Walk-in clinics also showed a high satisfaction rate; however, patients favored having an appointment system run concurrently with the existing walk-in system. 49tegrating PC with hospitals improved PS and experience. 50The study showed that, after the integration of PC with local hospitals, there was a significant improvement in satisfaction levels in every functional domain, such as overcrowding at the registration counters, overall improvement in PC cleanliness, improved overall general behavior of the staff, and promptness of services. 50th regards to staff operation, on the contrary, satisfaction was seen as high with laboratory, pharmacy, radiology, and dental staff and services as well as with physicians, 29 while seen as not significantly related to receptionists' communication. 31

| Continuity
Continuity of care could be determined by services such as seeing and following up with the same doctor, referral to a hospital, and accessing hospital records from the PC centers. 14,22,27,34,51Patients were more likely to express the desire to consult the same physician, especially if they have chronic conditions such as hypertension, diabetes, asthma, 35 or psychological problems. 51A study indicated that relational continuity (where the care provided by one or more named healthcare professionals with whom the patient can develop a therapeutic and interpersonal relationship) improved the patients' medical conditions and the quality of services. 35

| Efficacy/outcome of care
None of the retrieved studies investigated PS concerning outcomes for care except one. 21Patients were seen as satisfied with the outcome of care after the implementation of the EMR system, which was related to adherence to treatment, resolution of symptoms, and improvement of functional status. 21

| Patient-related characteristics results section
Most patient-related factors were discussed in the included papers; however, religion, length of stay, and personality factors were not discussed.Nationality was added to the race theme, as mentioned by some studies.

| Age
Most of the older population were satisfied, 21,26,27,30,32,36,38,41 which they reported for physicians' rapport, 38 pharmacy services, 36 and the implementation of EMR. 21However, a study showed dissatisfaction with physicians' services. 29Regarding younger age groups, they were dissatisfied with physicians' services, 30 consultations, 33 and pharmacy services 36 ; and they were satisfied with opening hours, available appointment times, 18 and waiting times. 45

| Education
35][36]38,41,45 Some studies linked higher satisfaction with PC services 34 and recognized the importance of continuity of care. 35Others associated higher education with low satisfaction with general services, 21 consultation length, 33 and pharmacy service, 36 and they were less likely to receive continuity of care, resolve their personal and psychological problems and comply with physicians' recommendations. 35Other studies associated low education status with higher satisfaction rates for PC services [25][26][27]41,45 and physician rapport. 38 Onthe contrary, those with low education levels were dissatisfied with general services 34 and physician services.29,30

| Socio-economic status
41,45 Numerous studies discussed satisfaction among high-income participants, 26,29,30,33,37,41,45 in which some showed satisfaction with physicians' services 29,30 and consultations, 33 and one showed dissatisfaction with general services. 26Mixed evidence was shown in the association between low income and satisfaction, where studies showed that those with low income showed high satisfaction in the services 26,41 and low satisfaction in physicians consultations 33 and physician services. 30ere was also mixed evidence regarding the association between employment status and satisfaction.Some studies showed that unskilled laborers had high satisfaction rates in general 26,31 and physician services. 30In addition, one study showed that the unemployed had high satisfaction in general services, 41 and another showed low satisfaction rates in physician services. 29Only one study demonstrated that retired or not working participants have high satisfaction rates. 34Students were more dissatisfied with the services in general 31,34 and physician services, 30 and only one study showed they were satisfied. 26

| Marital status and race/nationality
Numerous studies explored the association of satisfaction with marital status. 15,25,26,29,31,34,41,45Higher satisfaction was seen more among married in the general services 31,34 in waiting times 45 and physician services. 29Other studies also demonstrated high satisfaction rates among divorced, 25,26 single, 41 and widowed participants. 25ree studies mentioned the effect of nationality on satisfaction. 15,36,39One study showed that satisfaction is higher among nationals, 39 and another showed that satisfaction is also higher among nationals, but the difference was not statistically significant. 36

| Geographic characteristics
The geographic location was discussed, with the location being rural or urban, and the location or proximity of the PC center to the participants' homes and mixed evidence was found.Both urban and rural residents had concerns about different views and needs regarding the accessibility to the centers. 13Other studies showed a difference in satisfaction according to the center's location, 13,26,28,30,34,50 where some linked longer distances between patients' residences and the center with low satisfaction. 13,26,28,30As mentioned earlier, differences in satisfaction were seen between rural and urban regions concerning cleanliness, getting around the center, and working hours. 13

| Visit regularity, health status, and expectations
Only one study discussed visit regularity, in which satisfaction was inversely related to the number of visits to the center and its pharmacy. 36Satisfaction was also linked to individual health status.Good health was associated with higher satisfaction 39,42,46 ; however, one study associated having a chronic illness with high satisfaction. 38 addition, other studies linked satisfaction with personal or family medical history. 26,42Only one study associated satisfaction with individual satisfaction with life. 39Only one study discussed the patients' expectations, showing that PC physicians knew about them and worked hard to achieve them. 35

| DISCUSS ION
5][56] Furthermore, this review showed the importance of technical factors as a determinant of satisfaction with PC services, which is similar to the literature that showed an association of satisfaction with the time spent with the physician, 57-59 confidentiality, 59 and comprehensiveness of care, 59 and other technical factors. 10,60,61Moreover, as in other studies, [58][59][60][61][62] communication skills, respectfulness, humaneness, and trust in the care provider was linked with satisfaction.[62][63][64][65] Regarding patient-related characteristics, this review found that being old and female is linked to higher satisfaction, which is also similar to the evidence in the literature. 57,58,62,66These results can be explained by the fact that the older population have greater time than the younger population to receive health services 67 and the differences in care received by the older population. 68The gender differences can also be explained by the differences in the expectations between males and females about the quality of services provided 69 and that females tend to use health services more frequently than males. 70though this review showed that being married is linked to higher satisfaction, there is mixed evidence on the effect of marriage, which might be explained by the cultural and social differences between the population in GCC and the western countries.This review showed that students had higher satisfaction rates, which adds to the contradictory evidence about the effect of education. 10,57,60 in other studies, 10 the high-income class in this review was associated with higher satisfaction.Mixed evidence was found on the effect of educational factors, which is different from the literature as it associated a positive association between education level and satisfaction, 10,57 which can be explained by the small number of results that evaluated the association in this review. 13This review found mixed evidence on the effect of geographic location on satisfaction, in terms of being rural or urban and how far the center is from the population residents, which is also similar to other studies as some in the literature. 10,71e evidence showed that the frequency of visits, poor health status or having chronic diseases, matching patients' expectations, and good care outcome is associated with higher satisfaction 10,58,62,66 ; however, this review found a lack of evidence regarding their effect on satisfaction as few studies discussed the above-mentioned factors.Surprisingly few studies examined the effect of nationality on satisfaction, despite the high number of non-nationals among the GCC populations. 72is review has several strengths, to our knowledge this is the first review that examines the PS with PC services in the GCC.
Furthermore, it showed a lack of evidence in specific satisfactionrelated areas, such as the relation with nationality, health status, and care outcome.On the contrary, this review has some limitations; as with any review, there is a chance of missing some data, especially since the gray literature was not reviewed, and the search was limited to the year 2000 and after.Almost all the included studies were cross sectional, which can affect the causality relation between satisfaction and the determinants.

| CON CLUS ION
This is the first scoping review that examined the nature and range of studies investigating the satisfaction of PC services and the factors influencing it in the GCC.Despite the increasing number of articles examining PS in PC services in GCC over years, this number is relatively low given the importance of satisfaction on health outcomes.The review showed that satisfaction with PC services in GCC is affected by multiple factors related to the healthcare provider and the patients.The review demonstrated that the effects of nationality, health status, and care outcomes on patient satisfaction were not examined calling for future research to examine these areas.

Table 2
2. Identifying relevant studies: Cumulative Index to Nursing and Allied Health Literature (CINHAL), EMBASE, MEDLINE (EBSCOhost, OVID, Web of Science), and PubMed were searched using the search terms in Table 1. 3. Study selection: inclusion and exclusion criteria in

E 2 Search terms. Search terms for primary health care AND search terms for satisfaction AND search terms for users AND search terms for GCC countries
Inclusion and exclusion criteria.

1
Flowchart of search and selection process using PRISMA. 13 Included studies.
TA B L E 4