Final Thesis for submission

UNIVERSITY OF TRINIDAD AND TOBAGO (UTT), 2014

HEALTH SCIENCES

Masters in Health Administration (MHA)

TITLE: ASSESSMENT OF PATIENTS’ SATISFACTION OF THE MEDICAL

SERVICES OFFFERED WITHIN THE TRINIDAD AND TOBAGO DEFENCE FORCE

(TTDF)

Dexter A Horsford

PS57101

2014

University of Trinidad and Tobago | Masters in Health Administration | May 2014

11565 words

This work is being submitted in partial fulfillment of the

requirements for a Masters in Health Administration (MHA)

ABSTRACT

Objective

To investigate the personnel satisfaction of the medical

services offered within the TTDF develop appropriate

recommendations that can be used to enhance the quality and

accessibility of health care in the TTDF.

Method

The study design used was a survey research design and

conducted using a self-administered questionnaire (see

Appendix A) to determine the level of satisfaction of the

medical services offered in the TTDF. The theoretical

framework, on which this research is based, is the Primary

Provider Theory. Two hundred and fifty of the TTDF personnel

participated in the survey. The analysis was completed using

SPSS. The questionnaire was administered and collected at the


ii

major camps and bases of the TTDF when it was expected that

the majority of personnel would be on location/

Result

The results for the frequency distribution of the GSAT

Variable indicated an average of 238 personnel responded to

the survey and that there was dissatisfaction. Very satisfied

with the medical services variable had a total of 47.7% that

disagreed. The results showed that the medical care is just

perfect had 58.5% respondent disagreeing whilst 42(17.5%).

The frequency distribution indicated that 88.9% agreed things

about the medical system need to be improved. The variable-

some things about the medical care could be better had 92.9%

of the respondents agreeing. The results for the medical care

is excellent indicated that 60.6% disagree. Finally 79.6%

indicated that they agreed to dissatisfaction with some things

about the medical care. Overall there was a satisfaction rate

of 46.90 percent

Conclusion

The research question “What is the level of patient

satisfaction within the Trinidad and Tobago Defence Force and


iii

what are the factors that influence it?” was answered in the

study. The study concluded that patients’ satisfaction of the

medical services offered in the TTDF was 46.9percent which was

below the international standards of 95 percent.

Data analysis revealed

A total of 250 personnel participated in the survey with 198

male respondent and 41 female respondents. .The sample

comprised 82.8 percent male and 17.2 percent female conforming

to the general composition of the TTDF male female ratio of

90:10. One hundred and sixty-seven (167) of the respondents

were in the 25-34 age groups representing 69.6 %; with 46 from

the 25-44 age group that represents 18.4%, 26 from the 18-24

age group that represents 10.8% and 1 from the 45 and over

group a percentage of 0.1.

Recommendations

Constructing a process flow of the entire process in medical

inspection room to determine if the time can be reduced to

improve the flow for patients, if time cannot be reduced what

successful and established activities can be introduced that

can occupy the attention of the patient and reduce the

negative impact off waiting for long periods.Reviewing the


iv

policies, which govern the provision of medical services to

determine adequacy, relevance to personnel medical

needs.Institute a mandatory patients’ satisfaction survey to

help determine the extent of success or failure of the medical

system and services. Take satisfaction scores seriously as in

many jurisdictions this is mandatory

Keywords: Trinidad and Tobago Defence Force (TTDF), personnel

satisfaction, restructuring, opinions, relationship,

association.


v

ACKNOWLEDGEMENT

The Chief of Defence Staff for approving the study within the

Force

Formation Commanders for their support in conducting the

studies.

Executive Officer of the Trinidad and Tobago Coast Guard-

Lieutenant Commander Archer who’s assistance was timely when I

was faced with the possibility of low response from Coast

Guard also in lieu of the CDS approval.


vi

Majors KAK Sebastien and AD Williams who approved the study in

lieu of the CDS’s approval.

Major K Francis, Lieutenant N McIntyre and Sub-Lieutenant

Gohnity who assisted me in the gathering of the data.

My family who supported and abided with me along the entire

process.

Dexter A Horsford; R.D.

Mr.

LIST OF ABBREVIATIONS


vii

AAC Access/Availability/Convenience

AHQR Agency for Healthcare Research

CAHPS Consumer Assessment of Healthcare Providers and Systems

CDS Chief of Defence Staff

CCC Civilian Conservation Corp

CF Canadian Force

CFHS Canadian Force Health Services

CG Coast Guard

COMM Communication

CNCD’s Chronic Non-communicable Diseases

CRDAMC Carl R. Darnall Army Medical Center

DFHQ Defence Force Headquarters

DFR Defence Force Reserves

DFMO Defence Force Medical Officer

DFSI Dental Functional Status Index

DoD Department of Defence

FIN Finance

GSAT General Satisfaction

HEN Health Evidence Network

HLIS Health and Lifestyle Survey

ICE Interactive Customer Evaluation

INTER Interpersonal Aspect

MHA Masters in Health Administration


viii

MILAT Military Led Academic Training

MIR Medical Inspection Room

MYPARTMilitary Led Youth Programme of Apprenticeship and

Reorientation Training

NCQA National Committee for Quality Assurance

MHS Military Health Services

MHI Rand Mental Health Index

PSS Patient Satisfaction Survey

PSQ Patients’ Satisfaction Questionnaire

R3MMU Role 3 Multinational Medical Unit

SIP Sickness Impact Profile

SSB Support and Services Battalion

SYSP Specialized Youth Service Programme

TTA Trinidad and Tobago Army

TTAG Trinidad and Tobago Air Guard

TTCG Trinidad and Tobago Coast Guard

TTDF Trinidad and Tobago Defence Force

TECH Technical Aspect

TTR Trinidad and Tobago Regiment

UTT University of Trinidad and Tobago

Visitdrho

spVisit to the DFMO Private Office,Hospitalized

WHO World Health Organization


ix

1st Engr

BnFirst engineering Battalion

1TTR First Infantry Battalion

2TTR Second Infantry Battalion

LIST OF TABLES OR FIGURES

Table Page

Table 1: Showing the Number of Valid Response for the

Demographics Data

Table 2: Showing the Frequency of Sex

Table 3: Showing the Frequency of Age

Table4: Showing the Frequency of Marital Status

Table 5: Showing the Frequency of Education Level

Table 6: Showing the Frequency of Insurance Coverage

Table 7: Showing the Frequency of History of admission to Sick

Bay

Table 8: Showing the Frequency of Years of military service

Table 9: Showing the Frequency of Category of personnel

Table 10: Showing the Frequency of Formations

Table 11: Showing the Number of Valid Response for the General

Satisfaction (GSAT) Variables

Table 12: Frequency Of General Satisfaction (GSAT) Theme

(%)Factors influencing patient satisfaction in the TTDF

29

29

30

31

32

33

34

35

36

37

38

39

41


x

Tables13: Showing the relationship of significance between each

independent variable and general satisfaction

Tables 14: Showing the relationship of insignificance between

eachindependent variable and general satisfaction

Chart 1: Showing results of Mann-Whitney Test for Sex

Chart 2: Showing results of Kruskal-Wallis Test for History of

Admission to Sick Bay

Chart 3: Showing results of Kruskal-Wallis Test Education Levels

Chart 4: Showing results of Kruskal-Wallis Test for Insurance

Coverage

Chart 5: Showing results of Kruskal-Wallis Test for Marital

Status

Chart 6: Showing results of Kruskal-Wallis Test for Category of

Personnel

Chart 7: Showing results of Kruskal-Wallis Test for Formation

Chart 8: Showing results of Kruskal-Wallis Test for Age

Table 15: Ranks (Mann-Whitney Test) GenSatisfaction History of

admission to Sick Bay

Table 16: Ranks (Mann-Whitney Test) GenSatisfaction and Sex

Chart 1: Frequency Of General Satisfaction(GSAT) Theme

44

46

47

47

48

48

49

49

50

50

51

40


xi

TABLE OF CONTENT

SUBJECT PAGE

Abstract iiKeywords ivAcknowledgement vList of Abbreviations viList of Tables or Figures viiiIntroduction 1Literature Review 6Research Question 14Objectives 14Study Goal(S) 14Objectives of the Study 14


xii

Significance or Relevance of Study 15Methodology 16

Data Collection 22Data Analysis 23Limitations 26Strengths 27Ethical Considerations 28

Results 29Discussion 52Conclusion 57

58Recommendations 59References 61Appendices 64


xiii

INTRODUCTION

The Trinidad and Tobago Defence Force (TTDF) was established

in 1962 under the Defence Force Act 14:01 and was given the

following responsibilities:

To defend the sovereign good of the Republic of Trinidad

and Tobago;

To cooperate with and assist the civil power in

maintaining law and order;

To assist the civil authorities in times of crisis or

disaster;

To perform ceremonial functions on behalf of the State;

To provide Search and Rescue services in keeping with

national requirements and

under international agreements to;

Assist in the prevention of trafficking of narcotics and

other illegal goods;

Monitor the safety of shipping in national waters;

Assist in the development of the national community.

At the time of establishment of TTDF it comprised two

formations, the Trinidad and Tobago Regiment (TTR), comprising

one Battalion and the Trinidad and Tobago and Coast Guard


(TTCG), consisting of a Naval Arm and Air Wing. Over the past

two decades, the TTDF has been restructured from its original

composition of two formations to four formations. The Regiment

comprising of two Infantry Battalions, one Engineer Battalion

and a Logistic Battalion; an increase in personnel of the

TTCG, the formation of the Trinidad and Tobago Air Guard

(TTAG) and the restructuring of the Trinidad and Tobago

Defence Force Reserves (DFR).

This restructuring of the Force also saw increases in

personnel, equipment and infrastructure. There were also

increases in the military lead exercises locally and regional

deployment (example Haiti-1990, Grenada-2005).This also saw

the military leading the main efforts in various youth

programmes (example Specialized Youth Service Programme

(SYSP), Civilian Conservation Corp (CCC), Military Led

Academic Training (MILAT), Military Led Youth Programme of

Apprenticeship and Reorientation Training (MYPART).

Changes were in the Force were inevitable as it sought to keep

abreast of technology and the mandate of the government.

Before the changes in the Force and by extension the medical


2

department under-mention is a brief look at the department

before the changes occurred:

The main Medical Inspection Room (MIR) was at Teteron

Barracks, Chaguaramas;

At the time there was two doctors employed (DFMO) and

both operated out of Teteron Barracks;

The First Infantry Battalion situated at Camp Ogden, Long

Circular Road, St. James housed a MIR but was regarded as

all other military outstations and bases inclusive of

Camp Signal Hill, Tobago. These camps and bases were

facilitated by medical orderlies who review the men and

women of the Force with minor cases, and persons who were

classified as major were referred to Teteron Barracks to

be seen by the DFMO;

Patients also went to Teteron for referrals to

specialist, dental or optical treatment;

The MIR at Teteron had two sick-bays (male and female),

where patient confined for review and observation on

recommendation by the DFMO necessary;


3

At Camp Ogden the DFMO would have visited that location

for the sole purpose of seeing children of DF employees

at the Defence Force Children’s Clinic;

Due to the proximity of the Coast Guard (CG) Headquarters

at Staubles Bay to Teteron, the CG Medics performed most

of their duties at the Teteron Barracks;

The pharmacy is also at Teteron;

Before the expansion, the building housed two doctors’

examination rooms, patient waiting area, two sick-bays,

Medical Services Officer office, general admin office,

treatment room and storage room.

As a result of the restructuring, the medical department

expanded and its services decentralised. Some notable changes

were:

Refurbishment of the MIR at both Teteron Barracks and

Camp Ogden;

Cessation of the Children’s Clinic;

Increase in medical doctors from two to three;

One of the doctors being a serving member of the Force

(Coast Guard);


4

Utilizing the opportunity to send a serving member to

study medicine;

Expanding the type and levels of training for persons

employed in the medical department, some of the training

includes psychiatric nursing, social sciences, dietetics,

pharmacist, radiology and health administration;

Development of MIR at each of the formations that mirrors

the MIR at Teteron Barracks but at a smaller scale;

Increasing the ambulance fleet; and

Forming greater alliances with external medical service

providers.

In the TTDF, the medical practitioners’ opinions are the

foremost opinions taken into consideration to initiate any

changes of the medical services. The opinions of the

recipients were not garnered, to determine the viability or

extent of their needs. In modern studies, researchers began

considering the viewpoints of patients about health services

as an important gauge of the quality of services that may be

different or in opposition with that of health experts. As a

decisive index for evaluating and improving the quality of


5

services, consideration is given to patients’ viewpoints

concerning the way of providing health service (Ebrahimniaet

al, 2010).

“A soldier should be fighting fit” is a concept that the

military epitomizes. As serving members of the military

optimum health and physical fitness are fundamental to being

effective military personnel. These essentials ensure that

the individual is alert and able to perform at a high

efficiency level during routine duties, training or

operations. Fit individuals make strong team members and

ensure operational readiness at all times. Additionally, they

are at lower risk of becoming injured during training, or heal

more quickly than someone who is below optimum health and

unfit. Regardless of the appointment or occupational task,

military personnel can be called upon to perform difficult and

dangerous tasks, whether they are combative, peace

enforcement, peacekeeping, or aid to the civil power locally,

regionally or internationally.

Though the operational landscape has changed the need to

adequately provide for military personnel medical needs still

requires the efforts of key stakeholder. Providing for the


6

increase health care needs saw increases in the cost for

providing the services and Central Government Budgetary annual

allocation towards healthcare for the TTDF personnel.

Healthcare can be considered the provision of all services

that prevents illness and maintains health. It includes the

provision of illness treatment and management and extends to

the maintenance of the mental and physical well-being of a

person. Healthcare is, therefore, more than medical care. It

encompasses more than the availability or affordability of

medical services (Michaelet.al.).

Faced with the challenges to cater for the increased medical

needs and the situations of emerging and re-emerging diseases

the military medical services should be able to adequately

address these situations. Over the years, the standards of

the medical services of the TTDF may not have met these

challenges adequately. Additionally, the medical needs of its

personnel may not have kept abreast with the restructuring of

the Force that over the past two decades saw an increase in

personnel. An increase in personnel suffering from lifestyle

diseases, the number one cause of deaths in the Caribbean, was

noted.


7

These transformations throughout the Force also executed

changes in the medical services as follows:

An increase in medical staff (example first responders);

An increase in the budgetary allocations for medicines and

equipment;

Increases in the amount of Medical Doctor, Registered Nurses

and employment of a Register Dietitian;

Improvement in the infrastructure;

Increase in outsourcing some medical service (psychological

and psychiatric).

Not all changes were increases there was also the

discontinuation of the family clinic.

Despite the many changes, the medical services department also

had to struggle with the expressed dissatisfactions of the

recipients of the services provided, be it real or perceived.

No formal survey or research was conducted as a result of

these changes in the medical service over the past two

decades, to determine compliance, adequacy, efficiency,

effectiveness, overall confidence and satisfaction of the

system and its providers.


8

Therefore, the goal of this paper is to examine the patient

satisfaction and how it can be used to enhance the quality and

accessibility of health care in the TTDF.Ascertain what may be

the hindrances and make the appropriate recommendations for

sustainable enhancement in the service base on the findings.

The Primary Provider Theory (Aragon 2006) was the theoretical

framework, used to conduct this research. This Theory

emphasizes the importance of the patient-provider relationship

and the weight of the provider’s patient-centeredness on

outcomes.

LITERATURE REVIEW

The literature review discovered that there were no published

articles on patient satisfaction in the military both locally

and regionally. Carman (2000) pointed out that perception of

service quality is an attitude and that the attitude is a

function of some mixture of features that a patient believes

to be features of quality. Division of these features are in


9

two sets, such as functional, which include measures such as

ambiance and provider attentiveness; and technical, such as

outcome that describe the service delivery. Consequently,

there exist a relation between perceived service quality and

patient satisfaction. Fordet. al., (1997) noted that a

patient satisfaction has become known over the years as a

significant measure of the quality of care offered by health

care organizations. Donabedian (1998) indicated it was not

only essential for gathering insights into the perspective of

the customers on the delivery of the health care service but

also a key outcome of care. Low patient satisfaction may lead

to poor compliance with the likelihood for waste of resources

and suboptimal clinical outcome. As a result satisfaction of

the genuine demands of the patients should be the outcome of

all medical care (McKinley et. al., 1997).

The literature review also confirmed military forces of other

jurisdictions used satisfaction tools to access their

healthcare systems and with the results implemented desired

changes in their medical services. It also revealed there is

no published work regarding the medical services of the TTDF

or any of its formations. This deficiency highlights the need


10

to initiate comprehensive studies of the medical services, not

limited to such areas as patients’ satisfaction, compliance,

disease prevalence and immerging trends. Without such

researches suitable programmes cannot be initiated that may

meet the medical needs of the Force. Additionally budgetary

allocation may be underestimated or directed into failing

programmes.

The Canadian Force (CF) completed several researches such as

but not limited to the following:

A survey conducted in 1993 with females to determine the

impact on implant-retained oral prostheses and conventional

complete dentures. This used a completed questionnaire based

on three valid and reliable treatment outcome measures:

Dental Functional Status Index (DFSI),

Rand Mental Health Index (MHI),

Elements of the Sickness Impact Profile (SIP), (Harle and

Anderson. 1993).

In 2000, a pioneering Health and Lifestyle Survey (HLIS) was

completed which provided a baseline census for the entire CF.

The results were used to assist in prioritizing health

resource allocations; developing, assessing the success of


11

health promotion, illness prevention and intervention

programmes

A follow-up HLIS was completed in 2004 and revealed members

were apprehensive about nutrition, exercise and stress but

commonly satisfied with their profession. Four outcomes were

assessed:

Physical and mental health status of the CF;

Prevalence of behaviours that contribute to health

problems;

Degree of the employment of previous health promotion

programmes;

And the potential, utilization and satisfaction with the

CF health care system. (Kelly 2004).

Whereas, in 2006, a 27-items satisfaction survey was done to

evaluate the introduction of chiropractic services in the

military that were traditionally out-sourced and paid for by

its personnel. Subsequent to this a 3-items survey was used

to review recommendation patterns and satisfaction with the

medical services offered (Boudreau et. al., 2006).

During the period February 2006 to October 2009 the CF Health

Services (CFHS) staffed and led the Role 3 Multinational


12

Medical Unit (R3MMU). The R3MMU experiences were used to

successfully deploy a hospital as part of the earthquake

relief effort in Haiti, in 2010. The training and operating

protocols developed by the R3MMU were applied to disaster

preparedness and trauma care in Canadian civilian hospitals

(Brisebois et. al., 2011).

The US Congress (Senate Committee) in 1993 mandated a survey

under the National Defence Authorization Act for Fiscal Year

of 1993. The survey examined the Military Health Services

(MHS) beneficiaries’ satisfaction with their healthcare

options using questions from the Consumer Assessment of

Healthcare Providers and Systems (CAHPS) Health Plan Survey.

CAHPS was developed by the Agency for Healthcare Research

(AHQR) and the National Committee for Quality Assurance (NCQA)

and is a comprehensive tool for measuring consumer

satisfaction with health plans.

Introduction of TRICARE in the United States (US) occurred to

improve the access to health care system and to take advantage

of the capabilities of the managed-care industry (Schafer

2010). To improve the Department of Defence (DoD) delivery of

health care services, a TRICARE took place in 2011. In this


13

report a comparison was done between the MHS beneficiaries who

had used TRICARE and the civilian benchmark with respect to

ratings of the health plan, the health care, personal

physician and specialty care. Health plan ratings depend on

access to care and how the plan handles various service

aspects such as claims, referrals, and customer complaints.

(TMA, TMA/HPA&E, 2011).

The US Department of Defense (DoD) introduced the Interactive

Customer Evaluation (ICE) system. This system is a web-based

tool that collects feedback on services provided by various

organizations throughout the DoD. The ICE system allows

customers to submit online comment cards in providing feedback

about the service providers they have encountered at military

installations and related facilities around the world. It is

intended to improve customer service by allowing managers to

monitor the satisfaction levels of services provided through

reports and customer comments. Some benefits of ICE programme

are:

It allows DoD customers to quickly and easily provide

feedback to service provider managers;

Gives leadership timely data on service quality;


14

Allows managers to benchmark the performance of their

service providers against other DoD organizations;

Encourages communication across organizations by

comparing best practices to increase performance results;

Save money by providing managers a free tool to collect

and organization feedback data used for process

improvement (ICE 2011)

Other benefits of conducting PSS are:

That the responses are reviewed and analysed to determine

what is important to the users of the services.

Returned surveys are tied to funds that can be used to improve

services for the personnel’ improve problem areas, upgrade

amenities and expand services (Darnall Army Medical Center,

2013).

Carl R. Darnall Army Medical Center (CRDAMC, 2013) leadership

indicated that the goal for patient satisfaction was to attain

and sustain 95 percent or higher overall satisfaction rate.

Additionally in Iran there was several patients' satisfaction

studies conducted. The study was also conducted to

investigate the hospitalized patients' satisfaction with


15

hospital services in six military hospitals located in

different parts of Iran, in 2001 (Ebrahimnia et. al., 2010).

The Jewish General Hospital (2014)indicated that satisfaction

rate of 60percent showed that the hospital was doing a good

job at meeting patients’ needs and expectations. In addition

to continually seek to improve an organization should aim at a

satisfaction rate of 90 percent as attaining 100 percent is

seemingly unrealistic to achieve.

Patient satisfaction has gained significance with health

services and was identified as one of the five service quality

indicators by World Health Organization (WHO). In instances

of research, some researchers considered this as one of the

most important indicators of health services quality. The most

frequent studied groups in this field are the hospitalized

patients. The major fields of studying satisfaction with

health services are consideration of patients’ view on the

quality of hospital services.

WHO identified six main potential sources of information for

addressing quality of primary health care these are:

Household surveys.

Routine reports, from both central and peripheral levels.


16

Client records.

Direct, structured observation.

Follow-up interview.

Laboratory examinations (Roemer and Montoya-Aguilar,

1988).

Health Evidence Network (HEN) synthesis report on hospital

performance was in response to questions from decision-makers.

It provides a synthesis of the best existing evidence, as well

as a summary of the main findings and policy options related

to the issue. The principal methods of measuring hospital

performance were identified as:

Regulatory inspection,

Public satisfaction surveys,

Third-party assessment,

Statistical indicators.

The majority of which have never been tested rigorously with

evidence of their relative effectiveness mostly from

descriptive studies rather than from controlled trials (Shaw C

2003).

An important factor in the improvement of modern healthcare is

the participation of patients in the management of their


17

treatment and care. This is recognized in current health

strategies in various jurisdictions. To support this process

it is vital to recognize that the knowledge and experience of

patients receiving health care vary noticeably. A number of

them may have an infrequent or acute medical intervention that

may not develop a customer-service provider relation while

others may have a chronic or more enduring and long-term

relationship with a service provider depending on the nature

and extent of their needs.

People centred health care respects the dignity and value of

each person. It is absolutely desirable and appropriate that

the views of patients should be sought on their experiences

and expectations of health care (Irish Society for Quality and

Safety in Healthcare, 2003)

The literature review identified The Primary Provider Theory

which was developed by Dr. Stephen J. Aragon (Aragon, 2003).

This Theory hierarchically relates its satisfaction constructs

to patients expectations, conceding that the primary provider

has the greatest clinical utility to patients, followed by

time spent waiting for the primary provider, and finally the

provider’s assistant. It is a generalized theory of how the


18

patient-centeredness of health providers has an effect on the

patient’s care behaviour, during patient encounters and

related outcomes. The Theory holds that outcomes such as

satisfaction, trust, ratings of quality and various clinical

outcomes were fundamentally rooted in the patient’s

relationship with their primary provider. As an evidence-based

outcome measurement paradigm, owing to generalize nature of

the Theory it can accommodate an array of healthcare

practitioners as primary providers, including nurses, nurse

practitioners, dentists, physician assistants, allied health

practitioners, as well as physicians in their respective

settings.

The Theory emphasizes the importance of the patient-provider

relationship and the weight of the provider’s patient-

centeredness on outcomes and was based on the following nine

principles that favour patients in healthcare encounters with

their providers and support the scientific method and

Hippocratic Oath.

Clinical competency is a necessary but insufficient

condition of desired outcomes.


19

Desired outcomes require more than clinical competency

alone, because the transmission of care and clinical

knowledge require effective communication and interaction

with patients.

Patient-centeredness is an underlying ability that

influences the quality of provider's interaction with and

transmission of care to patients.

Providers' patient-centeredness influences the outcomes

of their patients.

Providers are uniquely responsible for the quality of the

transmission of their care and clinical knowledge to

patients.

Providers who are both clinically competent and patient-

centred are more likely to achieve desired outcomes.

Patients and families value the patient-centeredness of

their providers.

The patient-centeredness of the provider is more

important than the financial objectives of a patient

encounter.

Patients are the best judges of the patient-centeredness

of their providers.


20

The Primary Provider Theory holds that the patient

satisfaction occurs at the nexus of provider power and patient

expectations. More specifically, patient satisfaction is

principally the function of the underlying network of

interrelated satisfaction constructs, such as satisfaction

with the primary provider, waiting for the provider, and

satisfaction with the provider's assistant(s) or auxiliary

staff. Hierarchically related to patient-centred expectations

of provider value, the Theory specifies that primary providers

offer the greatest clinical value to patients. It is

operationalized by patient-centred measures exclusively, where

only patients judge the quality of service, and all other

judgments are immaterial. The Primary Provider Theory offers

an alternative paradigm for the measurement and realization of

patient satisfaction and it can inform patient-centred

physician practice, medical education, quality improvement,

outcome measurement, and satisfaction survey construction.


21

RESEARCH QUESTION AND OBJECTIVES:

What is the level of patient satisfaction within the TTDF and

what are the factors that influence it?

HYPOTHESIS


22

H1: There is an association between patients’ satisfaction and the

medical services offered in the Trinidad and Tobago Defence Force.

H0: There is no association between patients’ satisfaction and the

medical services offered in the Trinidad and Tobago Defence Force.

STUDY GOAL(S):

Improvement of the satisfaction levels within the Force of the

medical services offered.

To establish a bench mark for customer satisfaction of the

medical services.

To make the appropriate recommendations for sustainable

improvement in the services based on the conclusion and result

of the research.

OBJECTIVES OF THE STUDY

The main objective of the study was to determine the level of

patient satisfaction in TTDF,

To determine whether the personnel within the TTDF are

satisfied with the health care services offered.

To identify areas of dissatisfaction that needs to be dealt

with.


23

To develop recommendations that could be used to enhance the

health care services.

SIGNIFICANCE OR RELEVANCE OF STUDY

The significance of this proposed study is to help set in

place a system or systems of measuring the satisfaction of

deliverables of the medical services within the Force. This

would inform the hierarchy of its medical needs and how the

medical service can be a sustained and viable arm of the Force

in addressing it needs. Having no previous studies completed

on patient satisfaction and outcome of the medical services

within the TTDF the study can be the catalyst for future

studies within the Force on medical outcomes ad patient

satisfaction.

The evaluation system would be used to determine the needs of

the TTDF personnel. Whereby meeting these need may mean

developing new programmes, cessation of some current

programmes or realignment of others. Additionally use to


24

properly allocated resources for the acquisition of medical

goods and services, and develop a Chronic Non-communicable

Diseases (CNCD’s) Clinics for personnel diagnosed as suffering

from any of these diseases. Further for the future base on

the identified needs the establishment of a military hospital.

METHODOLOGY

The study design used was a survey research design and

conducted using a self-administered questionnaire (see

Appendix A) to determine the level of satisfaction of the

medical services offered in the TTDF. In the study all

variables were group according to the Patients’ Satisfaction


25

Questionnaire III (PSQ-III) subscales. These variables were

adapted for the study of Patients’ Satisfaction of the medical

services offered in the TTDF. The General Satisfaction (GSAT)

is the dependent variable for patients’ satisfaction and is as

follows:

General Satisfaction (GSAT)

I am very satisfied with the medical services I received

The medical care I have been receiving is just perfect

There are things about the medical system where I receive

my care from that need to be improved.

There are some things about the medical care that I

received that could be better.

All things considered the medical care I received is

excellent.

I am dissatisfied with some things about the medical care

I received.

The independent variables were:

Access/Availability/Convenience (AAC)

Can get care without any trouble in the medical

department

Easy to get medical care in an emergency


26

Usually kept waiting for a long time at the doctor’s

office

Hard to get medical care on short notice

The office hours are convenient (good).

The office should be open for more hours than it is.

Easy access to the medical specialist needed

Communication (COMM)

Doctors explain the reasons for medical tests

Allowed to say everything that I think is important.

Use of medical terms without explaining meaning.

Sometime ignored what they are told

Listen carefully to what is said

Interpersonal Aspect (INTER)

The doctor who treats me should give me more respect.

The doctors who treat me have a genuine interest in me as

a person.

Sometimes doctors make me feel foolish.

Doctors act too business like and impersonal towards me

My doctor treats me in a very friendly and courteous

manner


27

When I am receiving medical attention, they should pay

more attention to my privacy.

Doctors always do their best to keep me from worrying

In the case of Finance Aspect (FIN) one variable of the

subscale was used due to the medical services being

provided by the TTDF being free for the military

personnel. The variable used was (I have to pay for more

of my medical care than I can afford)

Time Spent with Doctor (DFMO)

Those who provide my health care sometimes hurry too much

when they treat me

The doctors usually spend plenty of time with me

Crisis in the health care (CRISIS)

There is a crisis in the health care within the Force

today.

Technical Aspect (TECH)

Doctors need to be more thorough

Doctor’s office has everything needed to provide medical

care

Sometimes doctors make me wonder if their diagnosis is

correct


28

They are careful to check everything when treating and

examining

The medical staff knows about the latest medical

development

Doctors never expose me to unnecessary risks.

The doctor lack experience with my medical problem.

Doctors rarely give advice to avoid illness and staying

healthy.

Some doubts about the ability of the doctor.

Doctors are very competent and well-trained.

The following two sets of variables were included in the

study to assist with improving the illustration of the

study results.

Ratings

Rating the services provided by the female doctor

Rating the services provided by the senior male doctor

Rating the services provided by the enlisted doctor

Rating the services provided by the Pharmacist

Rating the services provided by the Medical Orderlies

Rating the services provided by Other (State the Others)

Rating the medical facilities


29

Rating the medical services provided

Visit to the DFMO private office, Hospitalized

(Visitdrhosp)

Have you ever been hospitalized?

If ‘Yes’ were you ever visited by the DFMO.

Have you ever visited any other DFMO outside of in their

Private Office?

If ‘Yes’ how were the services provided.

The theoretical framework, on which this research was based,

was the Primary Provider Theory (Aragon, 2003) and will focus

on the following principles:

Clinical competency is a necessary but insufficient

condition of desired outcomes.

Desired outcomes require more than clinical competency

alone, because the transmission of care and clinical

knowledge require effective communication and interaction

with patients.

Patient-centeredness is an underlying ability that

influences the quality of provider's interaction with and

transmission of care to patients.


30

Providers' patient-centred influences the outcomes of

their patients.

Providers are uniquely responsible for the quality of the

transmission of their care and clinical knowledge to

patients.

Providers who are both clinically competent and patient-

centred are more likely to achieve desired outcomes.

Patients are the best judges of the patient-centeredness of

their providers that are captured in the four constructs to

patients’ expectations. Conceding that the primary provider

has the greatest clinical utility to patients, followed by

time spent waiting for the primary provider, and finally the

provider’s assistant. These principles highlight the need for

a high level of patient centeredness to achieve patient

satisfaction within the TTDF. These principles are:

Patients and families value the patient-centeredness of their

providers.

The patient-centeredness of the provider is more important

than the financial objectives of a patient encounter.

Much focus was not given to the financial aspect of the

provider patient relationship. The reason was that, in the


31

TTDF there is no cost to the patient for medical services

provided in the TTDF and families are not seen personally in

camps or bases by the TTDF Medical Officer. Additionally

personnel can claim for any monies spent outside of the Force

for medical care sought. Questionnaires were administered and

collected at the major camps and bases of the TTDF. The

researcher and assistants visited the locations when it was

expected that the majority of personnel would be on location

such as:

After Padre Hour; as all Army camps conducts Padre Hour

on Wednesdays where all personnel who are not on leave or

duties are required to attend;

Similar to the Army the Air Guard also conduct Padre Hour

but on Tuesdays;

At Coast Guard during the changing of shift where there

would be maximum personnel on station;

Commanding Officer CG Inaugural Address to the personnel

at Staubles Bay;

For the Reserves during their monthly weekend training;

For Officers and Senior Non-commissioned Officers and

Senior Ratings to be administered at the respective Mess.


32

The target population for the proposal is the TTDF that

comprises of four formations or units. The male to female

composition or ratio of the TTDF is 9:1 respectively. The

sampling size was selected using the Tables of Random Numbers,

Based on the current strength of the TTDF this figure was

three hundred and fifty-seven (357), of the enlisted personnel

from each formation in relation to the male to female ratio.

The sample size also sought to capture the years in service

and rank structure of the TTDF (see Appendix E).

Personnel excluded were those overseas on military duties or

training, and any recruits in training at the time of

administering the questionnaires. The reasons for these

exclusions were essentially due to accessibility and

availability of personnel overseas on military duties or

training to complete the questionnaire and have it returned in

a timely manner for analysing. The experiences of the recruit

in training are very limited or non-existence, as at the time

of training the only encounter in the medical department would

be that of their initial entry medical exam. Additionally

their responses may contain a high degree of respondent bias,


33

due to the recruits being instructed to complete the

questionnaire.

To accomplish this task for data collection a questionnaire

for satisfaction was designed and pre-tested before actual

use, using military personnel of the TTDF and non-military

personnel. The researcher reviewed the Defence Act-Chapter 14

of the Laws of Trinidad and Tobago; Standing Orders of the

Regiment; Coast Guard and Air Guard Regulations for documented

reference of standards. The questionnaire included questions

on patient’s satisfaction of the environment where service

provision occurred, the preliminary examinations and the

service offered by the Medical Doctor. Additionally the

questionnaire contained items related to the attitude of all

personnel working in the system.

The researcher and members of staff from the units’ medical

department administered the questionnaires to randomly

selected personnel. Persons were trained to administer the

questionnaire. Due to the uniqueness of the TTDF efforts were

made to capture a close as possible representation of the

composition of the Force, after which collecting the

questionnaires for analysis. The questionnaires after being


34

collected were secure in a secured draw at the researcher’s

office, which was located outside all military establishments.

Storage of the data was in a password protected file. After

one year, all hard copies of the questionnaires would be

shredded and properly disposed of. Personnel erroneously

placing his or her Regimental Number, Rank or Name on the

questionnaire were invited to complete another questionnaire

and destroy the void copy.

DATA COLLECTION

The questionnaire focused on the participants' level of

satisfaction with the medical services. At least twenty (20)

minutes was ideal for complete the questionnaire. The data

collected was categorized as general Satisfaction, Technical

Quality, Interpersonal Manner, Communication, and Time Spent


35

with Doctor, Accessibility and Convenience (see Appendix K).

An analysis of the quality of services from the perspective of

the participants happened in six (6) domains. These are

general satisfaction, technical quality, interpersonal

aspects, communication, time spent with the doctor and

personal spending for care or services. The responses were

designed according to Likert Five-point Scale of "strongly

agreed" (five points) to "strongly disagree" (one point).

Testing a similar questionnaire took place in Iran, and in

addition to validity, its reliability has been confirmed with

confidence coefficient of 90 percent (Ebrahimnia M. et. al,

2010).


36

DATA ANALYSIS

The data was collected using a sample size in Appendix E and

was statistically analysed using SPSS software. Frequency and

relative frequency of different levels of satisfaction were

calculated presented using frequency tables (See AppendixE).

In order to compare the levels of patients’ satisfaction with

different parts of medical services, in each part patients

were divided into two groups (satisfied and dissatisfied).

Dissatisfaction carried scores less than or equal to three,

and scores of four and greater as satisfaction with medical

services in general and in each of the studied parts. to use

the Using tests of significance and inferential statistics

such as Bivariate Correlations (Pearson product-moment

correlation coefficient) was used to test how strong the

relationship, direction of the relationship, measure of

association, and statistical significant of the relationship

(see Appendices F to I)

The Pearson product-moment correlation knew by its shorter

title of the Pearson correlation or Pearson's correlation test


37

for correlation between variables. This test produces a

coefficient called the Pearson correlation coefficient,

represented as r (that is, the italic lowercase letter r). It

measures the strength and direction of a linear relationship

between two continuous variables. Its values can range from a

positive one (+1) for a perfect positive linear relationship

to a negative one (-1) for a perfect negative linear

relationship. A value of zero (0) signifies no association

between two variables. In choosing Pearson's correlation to

analyse data, part of the process involves scrutinizing the

data to ensure that it can be analysed using Pearson's

correlation. This is accomplished if the data "passes" four

assumptions that are required for Pearson's correlation to

give a valid result, these assumptions are:

Assumption 1: At internal, or ratio level (that is, they

are continuous) the two variables should be measured.

Assumption 2: There needs to be a linear relationship

between the two variables. The best way is to visually

inspect a generated scatterplot.

Assumption 3: There should be no significant outliers as

Pearson's correlation coefficient, r, is sensitive to


38

outliers. Outliers can have an inflated power on the

value of r as this can lead to Pearson's correlation

efficient not having a value that best represents the

data as a whole.

Assumption 4: This is required for inferential statistics

(null hypothesis significance testing) and is also needed

to satisfy the assumption of bivariate normality.

To satisfy the assumptions before conducting the Pearson

product-moment correlation coefficient various preliminary

test were perform. These teats were Shapiro-Wilk's test (p>.05)

test for normality. A significant value < 0.05 violates the

assumption of normality (i.e., the test is significant at the

p < .05 level). A significant value > 0.05, indicates no

violation of the assumption of normality (i.e., p > .05)

because the Shapiro-Wilk test is testing the null hypothesis

that the data's distribution is equal to a normal

distribution. Rejecting the null hypothesis means that the

data's distribution is not equal to a normal distribution.

Other preliminary tests included visual examination of a

generated scatterplot to test for linearity. Testing and


39

adjusting for outliers which have the propensity to greatly

alter the results (LAERD 2014).

Interpreting the test of significance the properly stated

result would read: Because (test statistic) had a P-value of

(less than or greater than) 0.05; thus I can (reject or not

reject) the null hypothesis. However significance is not

synonymous with strength. Only a measure of association can

reveal the strength. Significance does not imply that the

relationship is meaningful. Significance does not mean the

relationship is not spurious (both variables are being

affected by a third unidentified variable).

The Mann-Whitney U test (also called the Wilcoxon-Mann-Whitney

test) is a rank-based nonparametric test that was used to

determine if there were differences between two groups on a

continuous or ordinal dependent variable.

In completing Mann-Whitney U test, the following four

assumptions were met. As indicated by LAERD (2013) the first

three relate to the choice of study design, whilst the fourth

reveals the nature of the data:

Assumption 1: There is one dependent variable that is

measured at the continuous or ordinal level.


40

Assumption 2: There is one independent variable that

consists of two categorical, independent groups (i.e., a

dichotomous variable).

Assumption 3: There is independence of observations, that

is, that there is no association between the observations

in each group of the independent variable or between the

groups themselves. If the study fails this assumption,

another statistical test instead of the Mann-Whitney U

test (e.g., a Wilcoxon signed-rank test) must be use

Assumption 4: Make a determination whether the

distribution of scores for both groups of the independent

variable has the similar shape or a different shape.

Since this is a critical assumption of the Mann-Whitney U

test, and will affect interpretation the data generated.

A Kruskal-Wallis test was also performed determine statistical

differences. This test is the non-parametric alternative to

the one way ANOVA and is used to determine whether there are

any statistically significant differences between the

distributions of three or more independent (unrelated) groups.

A Kruskal-Wallis test is most often used for three types of

study design:


41

Determine if there are differences between three or more

independent groups

Determine if there are differences between conditions

(with no pre-test measurement taken)

Determine if there are differences in change scores

(LAERD, 2013)

LIMITATIONS

The limitations identified would be accessing personnel whom

may be randomly selected and are not available to administer

the questionnaire to them, as a consequence of these personnel

posted on duties or training overseas. A second limitation

would be personnel who may not have access medical care at the

time of administering the survey such as enlisted personnel of

the DFR who are not on the permanent staff or who by virtue of

their status access medical care privately.

A third limitation would be utilizing new recruits who may be

training at the time of administering the questionnaire. This

category of personnel would have had minimal experiences as it

relates to accessing the medical services. Additionally their

encounter would be very limited or non-existence, for, at the


42

time of training, the only encounter in the medical department

would be that of their initial entry medical exam.

As well as an increase in respondent bias due to the recruit

responding to an instructors command to complete the

questionnaire, where coercion and undue influence or pressure

from the instruction may affect the recruit’s response.

Some limitations to the statistical test are with the Shapiro-

Wilk test larger sample sizes (e.g., above 50 cases) can lead

to a statistically significant result (i.e., data are non-

normal) even when they are normal.

Outliers are a real problem for Pearson's correlation, which

is particularly susceptible to them. The problem results in

the value of Pearson's correlation coefficient being unduly

altered, exerting a negative influence on the value of the

correlation coefficient. As such, it is important to try to

identify outliers in your data.

STRENGTHS

Logistic regression is a very strong tool to control for

confounding in epidemiological research.


43

ETHICAL CONSIDERATIONS


44

Approval to conduct the study was sought from The Chief of

Defence Staff (CDS) (see Appendix B). Subsequent to the CDS

approval Formation Commanders were communicated with, for

administering of the questionnaire (see Appendix C). Before

administering the questionnaire, participants were required to

give their written consent, after a full explanation of the

benefits and procedures was given. The Ministries of National

Security and Health was be informed of the CDS approval to

undertake the project.

Although the study undertaken was on patient satisfaction, and

the study tool used was a survey questionnaire, ethical issues

pertaining to the data collection was be addressed.

Consideration was given to confidentiality and anonymity of

patient or respondents (see Appendix D Consent Forms). All

due care was taken to protect the identity of all respondent

by not having any aspect of personnel identification place on

the form (such as personal address, identification number,

addresses – personal and email addresses, regimental number,

rank or name). Before the administering the questionnaire an

explanation on the conducting of and reason for, the process

was given to the respondents.


45

All documents were secure by the investigator. Utmost

confidentiality was adhered to, for any Regimental Number,

Rank or Name inserted in error on a questionnaire. Whereby

the insertions were blotted off with black markers or given

back to the individual before it is assessed or destroyed in

their presence and then given the opportunity to re-do another

questionnaire. Using the landline the researcher was able to

complete interviews of a sensitive nature to avoid disclosure

of participant numbers. After tabulation of the data and

documented, all responses were disposed of via shredding and

incineration. The researcher stored all tabulated data in

encrypted files that required password access. Accessing

participants’ medical files or record did not occur during

this study.


46

RESULTS

Characteristics of the Sample Demographic data

Table 1: Showing the Number of Valid Response for the

Demographics Data

Sex Age Marit

al

Statu

s

Educat

ion

Level

Insura

nce

Covera

ge

History

of

admissio

n to

Sick Bay

Years

of

milita

ry

servic

e

Catego

ry of

person

nel

Format

ion

N

Valid 239 240 237 235 235 224 239 240 229

Missi

ng11 10 13 15 15 26 11 10 21

Two hundred and fifty (250) personnel participated in the survey.

Table 2: Showing the Frequency of Sex

Frequenc

y

Percent Valid

Percent

Cumulative

Percent

University of Trinidad and Tobago | Masters in Health Administration| May 2014

47

Valid

Male 198 79.2 82.8 82.8

Female 41 16.4 17.2 100.0

Total 239 95.6 100.0

MissingSystem 11 4.4

Total 250 100.0

A frequency analysis was run and the result indicated that there

was a total of 198 (82.8 %) male and 41 (17.2 %) female

respondents. .The sample conforms to the general composition of

the TTDF male female ratio of 90:10.

Table 3: Showing the Frequency of Age

Frequenc

y

Percent Valid

Percent

Cumulative

Percent

Valid 18-24 26 10.4 10.8 10.8

25-34 167 66.8 69.6 80.4

35-44 46 18.4 19.2 99.6


48

45 and

over1 .4 .4 100.0

Total 240 96.0 100.0


Total 250 100.0

Conducting a frequency analysis the results showed that there was

one hundred and sixty-seven (167) respondents in the 25-34 age

groups representing 69.6 %; with 46 from the 25-44 age group that

representing 18.4%, 26 from the 18-24 age group that representing

10.8% and 1 from the 45 and over group representing 0.1%.

Table4: Showing the Frequency of Marital Status

Frequenc

y

Percent Valid

Percent

Cumulative

Percent

Valid Married 82 32.8 34.6 34.6

Single 146 58.4 61.6 96.2


49

Divorce 7 2.8 3.0 99.2

Separate

d1 .4 .4 99.6

Widowed 1 .4 .4 100.0

Total 237 94.8 100.0


Total 250 100.0

The results of the frequency analysis indicated that in the

marital status category 146 (61.6%) personnel were single, 82

(34.6%) were married, 7 (2.8%) were divorced and 1 (0.4%) each

from the separated and widowed categories.


50

Table 5: Showing the Frequency of Education Level

Frequenc

y

Percent Valid

Percent

Cumulative

Percent

Valid

Primary 9 3.6 3.8 3.8

Secondary/

College137 54.8 58.3 62.1

Tertiary/

University86 34.4 36.6 98.7

Others (Please

State)3 1.2 1.3 100.0

Total 235 94.0 100.0


Total 250 100.0

The results of the frequency analysis completed showed 137

personnel had attained secondary level education that represented

58.3%, 86 of the respondent attained tertiary level education

which represented 36.6%, 9 of the respondent only achieved


51

primary level education represented by 3.6% while 3 had achieved

other forms of education represented by 1.3%.

Table 6: Showing the Frequency of Insurance Coverage

Frequenc

y

Percent Valid

Percent

Cumulative

Percent

Valid

Yes 179 71.6 76.2 76.2

No 56 22.4 23.8 100.0

Total 235 94.0 100.0


Total 250 100.0

The frequency analysis indicated that one hundred and seventy-

nine (179) respondents specified that they had some form of


52

insurance this represented 71.2%, and 56 specified that they had

no insurance coverage which represented 23.8%.

Table 7: Showing the Frequency of History of admission

to Sick Bay

Frequenc

y

Percent Valid

Percent

Cumulative

Percent

Valid

Yes 94 37.6 42.0 42.0

No 130 52.0 58.0 100.0

Total 224 89.6 100.0


53


Total 250 100.0

A total of fifty eight percent (58%) or 130 of the respondents

indicated that they had never been admitted to the sickbay whilst

42% a total of 94 indicated that they were admitted to the sic-

bay.

Table 8: Showing the Frequency of Years of military service


54

Frequenc

y

Percent Valid

Percent

Cumulative

Percent

Valid

Less than 6

years78 31.2 32.6 32.6

7 to 12 years 118 47.2 49.4 82.0

Over 12 years 42 16.8 17.6 99.6

4.00 1 .4 .4 100.0

Total 239 95.6 100.0


Total 250 100.0

A frequency analysis was completed on years of military service

the results showed that 118 (49.4%) had served 7 to 12 years, 78

(32.6) less than 6years and 42 (17.6%0 over 12 years.


55

Table 9: Showing the Frequency of Category of personnel

Frequenc

y

Percent Valid

Percent

Cumulative

Percent

Valid Commissioned

Officer9 3.6 3.8 3.8

Warrant Officer 3 1.2 1.3 5.0

Senior Non-

commissioned

Officer or Senior

Ratings

17 6.8 7.1 12.1

Junior Non-

commissioned

Officer or Junior

Ratings

125 50.0 52.1 64.2


56

Other Ranks or

Ratings86 34.4 35.8 100.0

Total 240 96.0 100.0


Total 250 100.0

In the frequency analysis of category of personnel, 9 (3.8%)

respondents were Commissioned Officers, 3 (1.3%) were Warrant

Officer, 17 (7.1%) were Senior Non-commissioned Officer or Senior

Ratings, 125 (52.1%) Junior Non-commissioned Officer or Junior

Ratings and 86 (35.8%) were Other Ranks or Ratings.

Table 10: Showing the Frequency of Formations

Frequenc

y

Percent Valid

Percent

Cumulative

Percent

Valid TTR 166 66.4 72.5 72.5

CG 47 18.8 20.5 93.0


57

TTAG 13 5.2 5.7 98.7

DFR 3 1.2 1.3 100.0

Total 229 91.6 100.0


Total 250 100.0

A total of 166 respondent, represent 72.5% were from the Trinidad

and Tobago Regiment, 47 (18.8%) were from the Coast Guard, 13

(5.7%) were from the Air Guard and 3 (1.3%) were from the Defence

Force Reserves.

Levels of Satisfaction


58

Table 11: Showing the Number of Valid Response for the General

Satisfaction (GSAT) Variables

I am

very

satisfi

ed with

the

medical

service

s I

receive

d

The

medical

care I

have

been

receivi

ng is

just

perfect

There

are

things

about

the

medical

system

where I

receive

my care

from

that

need to

be

improve

d.

There

are

some

things

about

the

medical

care

that I

receive

d that

could

be

better.

All

things

conside

red the

medical

care I

receive

d is

excelle

nt.

I am

dissati

sfied

with

some

things

about

the

medical

care I

receive

d.

N Valid 241 241 242 238 234 235


59

Missi

ng

9 9 8 12 16 15

Table 12: Frequency Of General Satisfaction (GSAT) Theme (%)

Disagre

e

Uncerta

in

Agree

I am very satisfied with the medical

services I received (GSAT1)

115

(47.7)

48(19.9

)

78

(32.3)

The medical care I have been

receiving is just perfect (GSAT2)

141(58.

5)

58(24.1

)

42(17.5

)

There are things about the medical

system where I receive my care from

that need to be improved. (GSAT3)

9(3.8) 18(7.4) 215(88.

9)


60

There are some things about the

medical care that I received that

could be better. (GSAT4)

5(2.1) 12 (5) 221

(92.9)

All things considered the medical

care I received is excellent.

(GSAT5)

142(60.

6)

53

(22.6)

39

(16.6)

I am dissatisfied with some things

about the medical care I received.

(GSAT6)

23(9.8) 25

(10.6)

187

(79.6)


61

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%Chart 1: Frequency Of General Satisfaction(GSAT) Theme

Disagree

Total number of respondents who agree = 585

Total number of respondent who strongly agree = 435

Total of respondents = 585 + 435 = 1020

Average percentage of respondents that agree = (1020/585) x 20 =

34.87 percent

Average percentage of respondents that disagree = (1020/435) x 20

= 46.90 percent


62

The results for the frequency distribution of the GSAT Variable

indicated an average of 238 personnel responded to the survey and

that there was dissatisfaction. GSAT1 variable had a total of

115 (47.7%) that disagreed and 78 (32.3%) that agreed. The

results showed GSAT2 had 141(58.5%) respondent disagreeing whilst

42(17.5%) respondent agreeing. The frequency distribution

results for GSAT3 indicated that 215(88.9%) agreed and 9(3.8%)

disagreed. GSAT4 variable had 221 (92.9%) of the respondents

agreeing and 5(2.1%) disagreeing. The results of GSAT5 indicated

that 142(60.6%) disagree and 39 (16.6%) agree. Finally for GSAT6,

187 (79.6%) indicated that they agreed and 23(9.8%) disagree (see

Chart 1 above).

Factors influencing patient satisfaction in the TTDF

Tables 13: Showing the relationship of significance between each independent variable and general satisfaction

CRISIS FIN GSAT AAC TECH COMM INTER TIME

CRISIS

Pearson Correlation .302** .149* .150*

Sig. (2-tailed) .000 .026 .022

N 239 224 234


63

FIN

Pearson Correlation .302

** .134* .274** .184**

Sig. (2-tailed) .000 .043 .000 .005

N 239 228 224 233

GSAT

Pearson Correlation

.426*

* .207** .294** .180** .191**

Sig. (2-tailed) .000 .002 .000 .008 .004

N 216 222 221 216 225

AAC

Pearson Correlation .426** .305** .235** .229** .211**

Sig. (2-tailed) .000 .000 .000 .001 .002

N 216 220 220 215 224

TECH

Pearson Correlation .134* .207** .305*

* .205** .332** .207**

Sig. (2-tailed) .043 .002 .000 .002 .000 .002

N 228 222 220 225 220 229

COMM

Pearson Correlation .294** .235*

* .205** .188** .268**

Sig. (2-tailed) .000 .000 .002 .005 .000

N 221 220 225 221 230

INTER Pearson Correlation

.149* .274** .180** .229*

*.332** .188** .219**


64

Sig. (2-tailed) .026 .000 .008 .001 .000 .005 .001

N 224 224 216 215 220 221 224

TIME

Pearson Correlation .150

* .184** .191** .211*

* .207** .268** .219**

Sig. (2-tailed) .022 .005 .004 .002 .002 .000 .001

N 234 233 225 224 229 230 224

A Pearson product-moment correlation coefficient was computed to

assess the relationship between General Satisfaction, the

(Dependent Variables) and Timing (Independent Variables) of

personnel of the Trinidad and Tobago Defence Force (TTDF).

Preliminary analyses showed the relationship to be linear with

both variables normally distributed, as assessed by Shaprio-

Wilktest (p> .05). There was a positive correlation between the

two variables, r = .191, n = 225, p < 0.004, with general

satisfaction explaining 3.65% (r2 = .0365) variation in the

timing. Overall, there was a correlation between General

Satisfaction and Timing. Increases in the general satisfaction

were correlated with increases in timing. We reject the null

hypothesis but fail to reject the alternative hypothesis.


65

A Pearson product-moment correlation coefficient was run to

assess the relationship between General Satisfaction and

Communication of personnel of the TTDF. Preliminary results

showed the relationship to be linear with both variables normally

distributed, as assessed by Shaprio-Wilk test (p> .05). There

was a positive correlation between the two variables, r = .294, n

= 221, p < 0.000, with Communication explaining 8.64% (r2 =

0.0864) of the variation in general satisfaction. Overall, there

was a positive correlation between General Satisfaction composite

Variable (Dependent Variables) and Timing Composite Variable.

Increases in the General Satisfaction were correlated with

increases in Communication. Thus we can reject the null

hypothesis and fail to reject the alternative hypothesis.



Technical Ability of personnel of the TTDF. Preliminary analyses

showed the relationship to be linear with both variables normally

distributed, as assessed by Shaprio-Wilk test (p> .05). There

was a positive correlation between the two variables, r = .207, n


66

= 222, p = 0.002, with Technical Ability explaining 4.28% (r2 =

0.0428) of the variation in General Satisfaction. We can reject

the null hypothesis and accept the alternative hypothesis



Access/Availability/Convenience (AAC). There was a moderate

positive correlation between the two variables, r = .426, n =

216, p < 0.000, with AAC Variables explaining 18.15% (r2 =

0.1815). We can reject the null hypothesis and accept the

alternative hypothesis.


67

Tables 14: Showing the relationship of insignificance between each independent variableand general satisfaction

CRISIS

DEMO FIN GSAT AAC TECH COMM INTER TIME Visitdrhos

p

Ratings

CRISIS

Pearson Correlation 1 -.124 .053 -.00

5 .066 .014

Sig. (2-tailed) .086 .432 .935 .319 .832

N 240 191 225 224 229 232

DEMO

Pearson Correlation -.124 1 .041 .068 -.04

5 .006 -.017 -.044 -.051

Sig. (2-tailed) .086 .573 .366 .545 .937 .813 .557 .489

N 191 193 191 181 181 183 186 181 188

FIN

Pearson Correlation .041 1 .111 .071 .090

Sig. (2-tailed) .573 .098 .288 .174

N 191 239 224 224 231

GSAT

Pearson Correlation .053 .068 .111 1

Sig. (2-tailed) .432 .366 .098

N 225 181 224 225AAC Pearson

Correlation-.005 -.045 .071

University of Trinidad and Tobago | Masters in Health Administration | May 2014 68

Sig. (2-tailed) .935 .545 .288

N 224 181 224

TECH

Pearson Correlation .066 .006

Sig. (2-tailed) .319 .937

N 229 183

COMM

Pearson Correlation .014 -.017 .090

Sig. (2-tailed) .832 .813 .174

N 232 186 231

INTER

Pearson Correlation -.044

Sig. (2-tailed) .557

N 181

TIME

Pearson Correlation -.051

Sig. (2-tailed) .489 .005 .004 .002 .002 .000 .001

N 188 233 225 224 229 230 224 234

Visitdrhosp

Pearson Correlation -.227 -.262 -.208 -.074 .004 -.055 .065 .141 .324 1 -.660

Sig. (2-tailed) .189 .227 .232 .682 .984 .754 .715 .434 .058 .154

N 35 23 35 33 33 35 34 33 35 35 6


Ratings

Pearson Correlation -.094 .156 -.043 .211 .235 -.095 .135 -.076 -.00

4 -.660 1

Sig. (2-tailed) .620 .489 .822 .273 .212 .622 .477 .689 .983 .154

N 30 22 30 29 30 29 30 30 30 6 30**. Correlation is significant at the 0.01 level (2-tailed).*. Correlation is significant at the 0.05 level (2-tailed).



assess the relationship between General Satisfaction composite

variable and Independent composite variables (Hospitalization

and Visit to the DFMO private office) of personnel of TTDF.



Wilk test (p = .05). However there was no correlation between

the two variables, r = -.660, n = 6, p =0.154. There was no

statistically significant relationship between General

Satisfaction composite variables (Dependent Variable) and

Hospitalization and Visit to the DFMO private office variables

(Independent Variable), so we cannot reject the null

hypothesis.



Demographic Variable of personnel of TTDF. Preliminary

analyses showed the relationship to be linear with both

variables normally distributed, as assessed by Shaprio-Wilk

test (p = .05). However there was no significant correlation

between the two variables, r = .068, n = 181, p = 0.366.

Chart 1: Showing results of Mann-Whitney Test of Sex

A Mann-Whitney Test was run for Sex and the results showed

that p=.004 which is below the significance level of .05,

indicating that the Null Hypothesis should be rejected.

Chart 2: Showing results of Kruskall Wallis Test of History of

admission to Sick


72

A Kruskal-Wallis Test was run for the Demographic variable

(Age) and the results showed that p=.000 which is below the

significance level of .05, indicating that the Null Hypothesis

should be rejected.

Chart 3: Showing results of Kruskall Wallis Test of Education

Levels


(Education Level) and the results showed that p=.000 which is

below the significance level of .05, indicating that the Null

Hypothesis should be rejected.


73

Chart 4: Showing results of Kruskall Wallis Test for Insurance

Coverage

A Kruskal-Wallis Test was completed for the Demographic

variable (Insurance Coverage) and the results showed that

p=.000 which is below the significance level of .05,


Chart 5: Showing results of Kruskall Wallis Test of Marital

Status


74


(Marital Status) and the results showed that p=.001 which is



Chart 6: Showing results of Kruskall Wallis Test of Categoryof Personnel


variable (Category of Personnel) and the results showed that

p=.000 which is below the significance level of .05,


Chart 7: Showing results of Kruskall Wallis Test of Formation


75


variable (Formation) and the results showed that p=.027 which

is below the significance level of .05, indicating that the

Null Hypothesis should be rejected.

Chart 8: Showing results of Kruskall Wallis Test of Age


76


variable (Age) and the results showed that p=.000 which is



Table 15: Ranks (Mann-Whitney Test) between GAST and History

of admission to the sick bay

History of admission to Sick Bay N

Mean

Rank

Sum of

Ranks

GenSatisfac

tion

Yes 87 107.11 9319.00

No 121 102.62 12417.00

Total 208

Test Statisticsa

GenSatisfaction

Mann-

Whitney U

5036.000

Wilcoxon W 12417.000

Z -.537

Asymp. Sig.

(2-tailed)

.591

a. Grouping Variable: History of University of Trinidad and Tobago | Masters in Health Administration | May 2014

77

admission to Sick Bay

A Mann-Whitney U test was run to determine if there were

differences general satisfaction and History of admission to

sick bay. There was no statistically significantly difference

in engagement scores between males and females, U =5036, z =

-.537, p = .591, using an exact sampling distribution

for U (Dineen & Blakesley, 1973).

Table 16: Ranks(M-Whitney Test) between GAST and SexSex N Mean Rank Sum of

RanksGenSatisfaction Male 186 112.13 20857.00

Female 37 111.32 4119.00Total 223

Test Statisticsa

GenSatisfactionMann-Whitney U 3416.000Wilcoxon W 4119.000Z -.070Asymp. Sig. (2-tailed)

.944

a. Grouping Variable: SexA Mann-Whitney U test was run to determine if there were

differences general satisfaction and Sex. There was no

statistically significantly difference in engagement scores

between males and females, U =3416, z = -.o7o, p = .944, using


78

an exact sampling distribution for U (Dineen & Blakesley,

1973).

DISCUSSION

A total of 250 personnel participated in the survey with 198

male respondent and 41 female respondents. .The sample

comprised 82.8 percent male and 17.2 percent female conforming

to the general composition of the TTDF male female ratio of

90:10. One hundred and sixty-seven (167) of the respondents

were in the 25-34 age groups representing 69.6 %; with 46 from

the 25-44 age group that represents 18.4%, 26 from the 18-24

age group that represents 10.8% and 1 from the 45 and over

group a percentage of 0.1.

In the marital status category 146 (61.6%) personnel were

single, 82 (34.6%) were married, 7 (2.8%) were divorced and 1

(0.4%) each from the separated and widowed categories. A

total of 137 personnel had attained secondary level education

that represented 58.3%, 86 of the respondent attained tertiary

level education which represented 36.6%, 9 of the respondent

only achieved primary level education a3.6% while 3 had


79

achieved other forms of education represented by 1.3%. One

hundred and seventy-nine (179) respondents indicated that they

had some form of insurance this represented 71.2%, and 56

indicated that they had no insurance coverage which

represented 23.8%.

Fifty eight percent (58%) or 130 of the respondents indicated

that they had never been admitted to the sickbay and 42% a

total of 94 indicated that they were admitted to the sic-bay.

On the subject of the years of military service the results

showed that 118 (49.4%) had served7 to 12 years, 78 (32.6)

less than 6years and 42 (17.6%0 over 12 years. In the

category of personnel 9 respondents that represented 3.8% were

Commissioned Officers, 3 (1.3%) were Warrant Officer, 17

(7.1%) were Senior Non-commissioned Officer or Senior Ratings,

125 (52.1%)Junior Non-commissioned Officer or Junior Ratings

and 86 (35.8%)Other Ranks or Ratings. A total of 166

respondent, represent 72.5% were from the Trinidad and Tobago

Regiment, 47 (18.8%) from the Coast Guard, 13 (5.7%) from the

Air Guard and 3 (1.3%) from the Defence Force Reserves.

The results for the frequency distribution of the General

Satifaction (GSAT) Variable indicated an average of 238


80

personnel responded to the survey and showed a level

dissatisfaction. A total of 47.7% indicateddissatisfied with

the medical services I received. The results showed 58.5%

respondent disagreeing with the medical care is just perfect.

The frequency distribution results for GSAT3 (There are things

about the medical system that need to be improved) indicated

that 88.9% agreed. There are some things about the medical

care that could be better variable had 92.9% of the

respondents agreeing. The results indicated that 60.6%

disagree that the medical was excellent. Finally 79.6%

indicated dissatisfaction with some things about the medical

care.

This result was validated by the level of satisfaction of

46.90 percent. Further investigation would be necessary to

determine what are the root causeds for these results.

A Pearson product-moment correlation coefficient was computed

to assess the relationship between General Satisfaction, the

(Dependent Variables) and the Independent Variables of

personnel of the Trinidad and Tobago Defence Force (TTDF).




81

Wilktest (p> .05). Overall, there was a correlation between

General Satisfaction (Dependant Variable) and the Independent

Variables - AAC, TECH, COMM, INTER and TIME.

Increases in the general satisfaction were correlated with

increases AAC, TECH, COMM, INTER and TIME variables. We reject

the null hypothesis but fail to reject the alternative

hypothesis for these variables.


assess the relationship between General Satisfaction composite

variable and Independent composite variables (Hospitalization

and Visit to the DFMO private office) of personnel of

TTDF,Demographic Variable of personnel of TTDF,Interpersonal

relationships,Ratings in the health care in TTDF of personnel

of TTDF0. Preliminary analyses showed the relationship to be

linear with both variables normally distributed, as assessed

by Shaprio-Wilk test (p = .05). However there was no

correlation between the Dependent variables and Independent

variables of: Hospitalization and Visit to the DFMO private

office) of personnel of TTDF,Demographic Variable of personnel

of TTDF,Interpersonal relationships, andRatings in the health

care in TTDF. There was no statistically significant


82

relationship between General Satisfaction composite variables

(Dependent Variable) and these Independentvariables, so we

cannot reject the null hypothesis.

Analysis of variance (ANOVA) is a statistical analysis tool

used to analyse the differences between group means and their

associated procedures (such as-variation among and between

groups. The results of the Anova test run between General

Satisfaction and the following Demographic Variables

(Formation, Category of personnel, Years of military service,

History of admission to sick bay, Education, Age and Sex)

indicated that there was no significance difference between

these Demographic Variables and general satisfaction with p-

values higher than the acceptance level of .05. This is an

indication that these variables does not make a difference in

the level of patients’ satisfaction of the medical services

offered in the TTDF.

However, the results of the Anova tests indicated that there

was significance difference between Demographic Variables

(Insurance coverage and Marital Status) and General

Satisfaction with p-values lower than the acceptance level

of .05 (.038 and .047 respectively) This is an indication that


83

these may make a difference in the level of patients’

satisfaction of the medical services offered in the TTDF.

The Jewish General Hospital (2014) asserted that a patients’

satisfaction rate of 80% indicates that the intuition did a

good job. Though achieving 100% may not be practical however

intuition should endeavour to reach a satisfaction level of

95%. Carl R. Darnall Army Medical Center (CRDAMC, 2013)

administration point out that the object for patient

satisfaction was to achieve and maintain 95 percent or greater

overall satisfaction rate. In this research, the results

showed that the average rate of satisfaction by respondents

equalled 46.90% in contrast to international standards of 95%.

The reasons for the level of dissatisfaction can be attributed

to the services provided as indicated by the result. One area

that the respondents indicated that needed to be address is

the waiting time, as 25% indicated that the waiting time to

see the DFMO was too long. A frequency analysis was run and

the results indicated for that those who provide health care

sometimes hurry too much when they treat shown by a 70.7%

result. The time taken for medical assessment by DFMO was too


84

short as indicated by 74%. Additionally 80.4% indicated that

heir was a crisis in the medical services in the TTDF.

Other factors that can contribute to the low rate ofsatisfactions are:

The interpersonal aspect of care received a poor rating

by the personnel.

A total of 56.8% of respondents indicated that they were

ignored by the DFMO during their medical assessment.

It is difficult to get medical care at short notice.

Seventy seven percent indicated that more attention

should be paid to the personnel’s privacy.

Sixty six percent indicated that waiting time was too

long.

A total of 56.8% indicated that the DFMO does not explain

medical terms when they are used.

Sixty three percent indicated that the DFMO should give

personnel more respect.

Doctors act too business like and impersonal towards

personnel had a score of 46.4%.

A total of 90% of persons who were hospitalized indicated

that they were not visited by the DFMO who is required to


85

visit personnel at the hospital when they are

hospitalized.

The results showed that 70.7% indicated that providers

hurry too much in their treatment processes. While 73.9%

indicated that the DFMO does not spent sufficient time in

the assessment of personnel. Sixty seven percent

indicated that they have to spend more on medical care,

even though all services should be provided directly by

the DFMO or via referrals.

The Primary Provider Theory was supported by the results in

conducting of this research. This Theory hierarchically

relates its satisfaction constructs to patients expectations,

conceding that the primary provider has the greatest clinical

utility to patients, followed by time spent waiting for the

primary provider, and finally the provider’s assistant. As

the expectations were not greatly met the provider who has

the greatest clinical utility to the patients negatively

affected as patients were ignored by the DFMO the

interpersonal aspect were poorly rated and the time spent in

assessment was low including a long waiting time to see the

DFMO.


86

The Primary Provider Theory is a generalized theory of how the

patient-centeredness of health providers has an effect on the

patient’s care behaviour, during patient encounters and

related outcomes. The Theory holds that outcomes such as

satisfaction, trust, ratings of quality and various clinical

outcomes were fundamentally rooted in the patient’s

relationship with their primary provider. The results of the

study showed that the personnel did not have sound

relationship with the primary provider.

The usefulness of the theory and its relevance in the study

was critical as it directed the researcher to focus on the

factors that influences patient’s satisfaction. Additionally

to help determine what measures can be instituted to assist

with improvement to the health care system. It also

highlighted the fact that patients’ views can and should be

taken into consideration, to be used as drivers to better and

more effective and efficient service provision.

The greatest challenge encountered throughout the research was

ethical approval, and subsequent dissemination of the approval

to Formation Commanders. The processes used to overcome this

challenge were to constantly enquire and follow-up the stages


87

of approval. Additionally liaising with and seeking the

approval of Unit Commanders in lieu of the CDS’s approval to

administer the questionnaire. Determining the ideal time when

maximum amount of personnel were in the camps or on bases.


88

CONCLUSION AND RECOMMENDATIONS

The research question “What is the level of patient

satisfaction within the TTDF and what are the factors that

influence it?” was answered in the study. The study concluded

that patients’ satisfaction of the medical services offered in

the TTDF was 46.9percent which was below the international

standards of 95 percent. The theory coincided with the

methodology of using a PSQ and having a predominantly

quantitative method. Even though a principally qualitative

approach could have also suited the research and focus group

discussion and interviews may well have been utilized.

The results showed that personnel indicated that there was a

crisis in the medical services new questions that can be

researched are:

What is the root cause/s of the crisis and the

implication/s if not adequately addressed?

To what extent are the current policies for medical

service provision meeting for the current needs of the

TTDF?


89

To what extent are the providers not meeting the

expectation of the recipients of the medical services

provided?

What are best practices for medical innovation in the MIR

that creates higher patient satisfaction?

The extent of the objectives was met as the main objective of

the study to determine the level of patient satisfaction in

TTDF was determined by the satisfaction rate of 46.8%.

Personnel were not satisfied overall with the health care

services offered. Additionally identifying some critical

areas of dissatisfaction, which need to be dealt with over

time to improve the satisfaction levels.

RECOMMENDATIONS

Recommendations were developed that could be used to enhance

the health care services.Further to the results recommendation

that can be used to improve the overall satisfaction level

are:

Construct a process flow the medical inspection room to

determine where the time waiting can be identified. Once

completed determine if the time can be reduced to improve

the flow for patients, if time cannot be reduced what


90

successful and established activities can be introduced

that can occupy the attention of the patient and reduce

the negative impact off waiting for long

periods.Reviewing of the policies which govern the

provision of medical services to determine adequacy,

relevance and currency to personnel medical needs.

Institute a mandatory patients’ satisfaction survey to

help determine the extent of success or failure of the

medical system and services. Take satisfaction scores

seriously as in many jurisdictions this is mandatory

Institute a monitoring and evaluation mechanism to assist

with the on-going evaluation of the medical services,

providers and facilities using key performance

indicators.

Establish a sense of trust between provider and patient.

Make sure that patient feels respected, comfortable and

valued. This may require some form of training in

customer relationship and medical skills via continuous

professional development.


91

Ensure that staff is motivated to provide quality care

service, while embracing changes that may occur over

time.

Key to patient satisfaction is checking out the patients’

complaints to determine validity and help drive the

process for quality care. Additionally uncovering

patients’ actual needs.


92

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2009/07/05; Accepted 2010/03/14

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measuring patient satisfaction in health care


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javascript:__doLinkPostBack('','ss~~DE%20%22WASHINGTON%20(D.C.)%22%7C%7Csl~~rl','');

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APPENDICESAppendix A

Sample Questionnaire

Adapted from the Long-Form Patient Satisfaction Questionnaire

(PSG III) (Grant 1998- RAND)

INSTRUCTIONSOn the following pages are some things personnel say abouthealthcare. Please read each one carefully before you answer,keeping in mind the medical care you are receiving now or havereceived. (If you have not received care recently, think about


97

what you would expect if you received care today.)We areinterested in your honest opinion, your feelings, GOOD andBAD, about the medical services you have received and howstrongly do you AGREE or DISAGREE with each of the followingstatements?Please tick your responses where applicable for each question,one response only per question.You are not required to place any identification marks on theform(I.E. YOUR REGIMENTAL NUMBER, RANK, AND NAME OR ANY OTHERDISTINGUISHING FEATURES THAT ARE UNIQUE TO YOU AND CANIDENTIFY YOU).

Sex: [] Male [] Female

Age: [] 18-24 [] 25-35 [] 36-45 [] 46 and over

Marital status: [] Married [] Single [] Divorce

[] Separated [] Widowed

Education: [] Primary School [] Secondary or College []

Tertiary[] Others (State)

Insurance coverage: [] Yes [] No

History of admission to Sick Bay: [] Yes [] No

Years of military service: [] Less than 6 years [] 7 to

12 years [] Over 12 years

Category of personnel: [] Commissioned Officer

[] Warrant Officer, Fleet Chief Petty

Officer, Chief Petty Officer

[] Senior Non-commissioned Officer or

Senior Ratings


98

[] Junior Non-commissioned Officer or

Junior Ratings

[] Other Ranks or Ratings

Strong

ly

Agree

Agree Uncerta

in

Disagr

ee

Strong

ly

Disagr

ee

1. If I need medicalcare, I can get carewithout any trouble inthe medicaldepartment.

[] [] [] [] []

2. Doctors need to bemore thorough intreating and examiningme.

[] [] [] [] []

3. I am very satisfied with the medical services I received.

[] [] [] [] []

4. It is easy for me to get medical care in anemergency.

[] [] [] [] []

5. Doctors are good aboutexplaining the reasonsfor medical tests.

[] [] [] [] []

6. I am usually keptwaiting for a longtime when I am at thedoctor’s office.

[] [] [] [] []

7. I think my doctor’soffice has everythingneeded to provide

[] [] [] [] []


99

medical care.

8. The doctor who treatsme should give me morerespect.

[] [] [] [] []

9. The medical care Ihave been receiving isjust perfect.

[] [] [] [] []

10. Sometimes doctorsmake me wonder iftheir diagnosis iscorrect.

[] [] [] [] []

11. During my medicalvisit, I am alwaysallowed to sayeverything that Ithink is important.

[] [] [] [] []

12. When I go formedical care, they arecareful to checkeverything whentreating and examiningme.

[] [] [] [] []

13. It is .hard for meto get medical care onshort notice

[] [] [] [] []

Strong

ly

Agree

Agree Uncerta

in

Disagr

ee

Strong

ly

Disagr

ee

14. The doctors whotreat me have agenuine interest in meas a person.

[] [] [] [] []


100

15. Sometimes doctorsuse medical termswithout explainingwhat they mean.

[] [] [] [] []

16. For me the officehours when I can getmedical care areconvenient (good) forme.

[] [] [] [] []

17. There are thingsabout the medicalsystem where I receivemy care from that needto be improved.

[] [] [] [] []

18. The office I receivemy medical care shouldbe open for more hoursthan it is.

[] [] [] [] []

19. The medical staffthat treats me knowsabout the latestmedical development

[] [] [] [] []

20. I have to pay formore of my medicalcare than I canafford.

[] [] [] [] []

21. I have easy accessto the medicalspecialist I need.

[] [] [] [] []

22. Sometimes doctorsmake me feel foolish.

[] [] [] [] []

23. Where I get medicalcare, I have to waittoo long for emergency

[] [] [] [] []


101

treatment.

24. Doctors act toobusiness like andimpersonal towards me

[] [] [] [] []

25. There is a crisis inthe health care in theDefence Force today.

[] [] [] [] []

26. Doctors never exposeme to unnecessaryrisks.

[] [] [] [] []

Agree Uncer

tain

Disagre

e

Strong

ly

Disagr

ee

Strong

ly

Agree

27. There are somethings about themedical care that Ireceived that could bebetter.

[] [] [] [] []

28. My doctor treats mein a very friendly andcourteous manner.

[] [] [] [] []

29. Those who provide myhealth care sometimeshurry too much whenthey treat me.

[] [] [] [] []

30. The doctor I haveseen lack experiencewith my medicalproblem.

[] [] [] [] []

31. Places where I canaccess medical care in

[] [] [] [] []


102

the Defence Force areconveniently located.

32. Doctors sometimeignore what I tellthem.

[] [] [] [] []

33. When I am receivingmedical attention,they should pay moreattention to myprivacy.

[] [] [] [] []

34. If I have a medicalquestion, I can reacha doctor without anyproblem.

[] [] [] [] []

35. Doctors rarely giveme advice on ways toavoid illness andstaying healthy.

[] [] [] [] []

36. All thingsconsidered the medicalcare I received isexcellent.

[] [] [] [] []

37. Doctors listencarefully to what Ihave to say.

[] [] [] [] []

38. I have some doubtsabout the ability ofthe doctors who treatme.

[] [] [] [] []

39. The doctors usuallyspend plenty of timewith me.

[] [] [] [] []

40. Doctors always dotheir best to keep me

[] [] [] [] []


103

from worrying.Strong

ly

Agree

Agree Uncerta

in

Disagr

ee

Strong

ly

Disagr

ee

41. I find it hard toget an appointment formedical care rightaway

[] [] [] [] []

42. I am dissatisfiedwith some things aboutthe medical care Ireceived.

[] [] [] [] []

43. My doctors are verycompetent and well-trained.

[] [] [] [] []

44. I am able to getmedical care wheneverI need it.

[] [] [] [] []

45. Have you ever beenhospitalized?

Yes [] No []

46. If “Yes” were youever visited by theDFMO?

Yes [] No []

47. Have you evervisited any other DFMOoutside of in theirPrivate Office?

Yes [] No []

Excelle

ntGood Fair Poor Very

Poor

48. If “Yes “how werethe services provided?

[] [] [] [] []

Completely

Somewhat

NeitherSatisfi

Somewhat

Completely


104

Satisfied

Satisfied

ed norDissatisfied

Dissatisfied

Dissatisfied

49. How would you ratethe services providedby following:

Female Doctor [] [] [] [] []

Senior Male Doctor [] [] [] [] []

Enlisted Male Doctor [] [] [] [] []

Pharmacist [] [] [] [] []

Medical Orderlies [] [] [] [] []

Others (State) [] [] [] [] []

Completely

Satisfied

SomewhatSatisfied

NeitherSatisfied norDissatisfied

Somewhat

Dissatisfied

Completely

Dissatisfied

50. How would you ratethe medicalfacilities?

[] [] [] [] []

51. Overall how wouldyou rate the medicalservices provided?

[] [] [] [] []

52. During your MilitaryService have you seenany changes in theservices provided?

Yes[] No[]

53. If “Yes”, how do yourate the changes inthe Medical Services

[] [] [] [] []


105

you have seenimplemented?

54.State possible recommendations to improve quality of service you can rate them in order of importance:

55.If “YES” to Question 52: State the changes in the Medical Services that you have seen implemented during your career.

56.State possible areas that you think should be eliminated toimprove service quality you can rate them in order or priority:

THANK YOU VERY MUCH FOR YOURHONEST ANDVALUED OPINION.

Appendix B

Letter of request to Chief of Defence Staff

Chief of Defence StaffTrinidad and Tobago Defence ForceDefence Force Headquarters


106

Airways RoadCHAGUARAMAS November2012

REQUEST FOR APPROVAL COMPLETE A SURVEY OF PERSONNELSATIFACTION OF THE MEDICAL SERVICES OFFERED IN THE DEFENCEFORCE

1. Approval is hereby requested by Lieutenant (Ret) Dexter

A Horsford to conduct a survey of the personnel satisfaction

of the medical services offered within the Trinidad and Tobago

Defence Force (TTDF or Force).This is in partial fulfilment of

the Masters of Health Administration being read for under the

University Of Trinidad and Tobago.

2. The aim of this thesis is to review the current medical

services offered in the TTDF. To determine if compliance,

adequacy, efficiency, effectiveness and overall confidence in

the system and its providers is being met while providing

service to its serving members and their dependants. To

determine what may be the hindrances, and to make possible

recommendations for sustainable improvement in the services

base on the findings.

3. The significance of this proposed study is to help set

in place a system or systems of measuring the satisfaction of

deliverables of the medical services within the Force that


medical service can be a sustained and viable arm of the TTDF

in addressing it needs


107

4. Submitted for your consideration.

DA HorsfordLieutenant (Retired)Registered Dietitian

Enclosures:1. Copy of questionnaire to be administered.2. Copy of the proposal

Appendix C

Letter of request to Formation Commanders, Permanent Secretary

Ministry of National Security and Ethics Committee Ministry of

Health

Commanding OfficerTrinidad and Tobago ArmyArmy HeadquartersCorner of Knox and Abercrombie StreetsPORT OF SPAIN November 2012

APPROVAL TO COMPLETE A SURVEY OF PERSONNEL SATIFACTION OF THEMEDICAL SERVICES OFFERED IN THE DEFENCE FORCE

1. Approval was sought and acceded to by the Chief Of Defence

Staff, by Lieutenant (Ret) Dexter A Horsford to conduct a survey of

the personnel satisfaction of the medical services offered within

the Trinidad and Tobago Defence Force (TTDF or Force).This is in

partial fulfilment of the Masters of Health Administration being

read for under the University Of Trinidad and Tobago.


services offered in the TTDF. To determine if compliance, adequacy,

efficiency, effectiveness and overall confidence in the system and

it providers is being met while providing service to its serving


108

members and their dependants. To determine what may be the

hindrances, and to make possible recommendations for sustainable

improvement in the services base on the findings.

3. The significance of this proposed study is to help set in


deliverables of the medical services within the Force that would

inform the hierarchy of its medical needs and how the medical

service can be a sustained and viable arm of the TTDF in addressing

it needs.

4. Further approval is being sought to conduct the survey

within your formation.



Enclosure:1. Copy of Questionnaire to be administered.2. Copy of the proposal3. Chief of Defence Staff approval

Commanding OfficerTrinidad and Tobago Coast GuardCoast Guard HeadquartersStaubles BayCHAGUARAMAS November 2012

REQUEST FOR APPROVAL TO COMPLETE A SURVEY OF PERSONNEL SATIFACTIONOF THE MEDICAL SERVICES OFFERED IN THE DEFENCE FORCE




109












3. The significance of this proposed study is to help set in


deliverables of the medical services within the Force that would

inform the hierarchy of its medical needs and how the medical

service can be a sustained and viable arm of the TTDF in addressing

it needs.

4. Further approval is being sought to conduct the survey

within your formation.





110

Commanding OfficerTrinidad and Tobago Air GuardAir Guard HeadquartersPiarco Air StationNorthbank RoadPIARCO November 2012















3. The significance of this proposed study is to help set in place

a system or systems of measuring the satisfaction of deliverables of

the medical services within the Force that would inform the

hierarchy of its medical needs and how the medical service can be a


111

sustained and viable arm of the TTDF in addressing it needs.

4. Further approval is being sought to conduct the survey within

your formation.




Commanding OfficerTrinidad and Tobago Defence Force ReservesDefence Force Reserve HeadquartersMacaqueripeCHAGUARAMAS November 2012










112













your formation.




Ethical CommitteeMinistry of HealthPark and Edward Streets


113

PORT OF SPAIN November 2012





















your formation.

DA Horsford


114

Lieutenant (Retired)Registered Dietitian


Permanent SecretaryMinistry of National SecurityTemple Court 1Abercrombie StreetsPORT OF SPAIN November 2012



Staff, by Lieutenant (Ret) Dexter A Horsford to conduct a

survey of the personnel satisfaction of the medical services

offered within the Trinidad and Tobago Defence Force (TTDF or

Force).This is in partial fulfilment of the Masters of Health

Administration being read for under the University Of Trinidad

and Tobago.


services offered in the TTDF. To determine if compliance,

adequacy, efficiency, effectiveness and overall confidence in

the system and it providers is being met while providing

service to its serving members and their dependants. To

determine what may be the hindrances, and to make possible

recommendations for sustainable improvement in the services


115

base on the findings.


a system or systems of measuring the satisfaction of

deliverables of the medical services within the Force that


medical service can be a sustained and viable arm of the TTDF

in addressing it needs.


your formation.



Appendix D

Interviewer Initials: Questionnaire Number:

TO BE KEPT BY THE PARTICIPANT

University of Trinidad and Tobago


116

Centre for Health Sciences - Masters in Health

Administration

To determine quality satisfaction of the medical services

in Trinidad and Tobago Defence Force.

Questionnaire to determine satisfaction of the medical

services within the

Defence Force

Introduction:

My name is Dexter A Horsford and I am a Postgraduate student

at the University of Trinidad and Tobago. I am currently doing

a project in fulfillment of my Master's Degree in Health

Administration in the area of medical services quality

satisfaction. My project title is ‘To determine quality

satisfaction of the medical services in Trinidad And Tobago

Defence Force.’The purpose of this project is determine the

quality and standard of the medical services within the

Defence Force and if the personnel are satisfied with it.

Interviews are being carried out with medical practitioners,

pharmacist, dietitian, patients, nurses, technicians and

medical orderlies who will be asked about the quality of the

medical services if they are meeting the needs of the patients

and with the patients to determine their satisfaction. The

interview will take approximately 10 to 15 minutes of your time


117

and will be tape recorded. I am the only person who has

access to the tapes, which will be kept electronically on a

password protected computer and destroyed by me once I have

completed transcription.

Participation is voluntary and you may withdraw at any timewithout penalty. You may also refuse to answer any questionwhich makes you uncomfortable. All information provided willbe treated in a confidential manner and no names will appearon the transcribed interview, only Questionnaire Numbers.The list linking the names and questionnaire numbers will bekept in a locked drawer in a secured office, to which only Iwill have access. Once the data has been entered into acomputer and verified, the list and any identifyinginformation will be shredded.

Extracts of the interview may be used in the report, but youwill not be identified in any way. There are no risks areassociated with your participation.

This project has been approved by the MHA Postgraduate ThesisCommittee of the University of Trinidad and Tobago as well asthe Ministry of National Security, Chief of Defence Staff andFormation Commanders.

If there are any questions or concerns you have concerning

this project, please do not hesitate to contact either myself

or my supervisor:

STUDENT CONTACT INFORMATION: Dexter A Horsford

email: [email protected]

Phone: 868-626-1410 (H); 868-

726-3748 (C)

SUPERVISOR CONTACT INFORMATION:


118

mailto:[email protected]

If you have any questions or concerns about your rights as a research subject you may contact, anonymously if you wish, theMHA Postgraduate Thesis Committee Chair (Dr. Bennie Berkeley) at the University of Trinidad and Tobago at 868-642-8888, ext21468 or by email:[email protected] .

Interviewer Initials: Questionnaire

Number:

THIS COPY TO BE KEPT BY THE INTERVIEWER

Informed Consent Form:

I,________________________(print full name), hereby agree to

participate in the project outlined above. I give my permission to

be interviewed and for the interview to be tape recorded. I

understand the nature and intent of the research and have been


119

mailto:[email protected]

given the opportunity to ask questions. I understand where to

direct any future questions that I may have. I have received a copy

of the consent form.

PARTICIPANT'S STATEMENT

Participant Name: Signature:

Interviewer Name: Signature:

Date:

Interviewer Initials: Questionnaire

Number:


120

THIS COPY TO BE KEPT BY THE PARTICIPANT

Informed Consent Form:

I,________________________(print full name), hereby agree to

participate in the project outlined above. I give my permission to

be interviewed and for the interview to be tape recorded. I

understand the nature and intent of the research and have been

given the opportunity to ask questions. I understand where to

direct any future questions that I may have. I have received a copy

of the consent form.

PARTICIPANT'S STATEMENT

Participant Name: Signature:

Interviewer Name: Signature:

Date:


121

Appendix E

Thesis Sampling Size Matrix-Lt (Ret) DA Horsford

TTDF Population (N)=5040 Sample Size (S)=357

TTA=2921

57.956%

S=207

Off SNCO Cpl/LCpl Pte

3.0% 12.5% 45.5% 38.5%

6 26 95(39/56) 80

1Bn

2Bn

SSB

Eng

DFHQ

1Bn

2Bn

SSB

Eng

DFHQ

1Bn

2Bn

SSB

Eng

DFHQ

1Bn

2Bn

SSB

Eng

DFHQ

2 1 1 1 1 7 4 5 5 5 30 16 16 16 17 18 17 17 17 11

1TTR/RHQ==57 2TTR=38 SSB=38 1st Engr=38 DFHQ=34

LegendOfficer (Off)Senior Non Commissioned Officer (SNCO)Senior Rates (SR)Corporal/Leading Seaman (Cpl/LS)Able Seaman, Ordinary Seaman; Senior Aircraft Crewman, Junior Air Crewman; Private (OR)


122


CG=1423

29.266%

S=105

Off SR LS OR

3.8% 19.89% 15.68% 58.52%

4 22 17 62

Stau DFHQ Stau DFHQ Stau DFHQ Stau DFHQ

2 2 16 6 12 5 42 10

Staubles/Bases=82 DFHQ=23



123


TTAG=434

8.611%

S=31

Off WO Sgt Cpl OR

12.21% 2.30% 9.21% 16.12% 57.14%

4 1 3 5 18

AG DFHQ AG DFHQ AG DFHQ AG DFHQ AG DFHQ

3 1 1 0 2 1 3 2 12 6

TTAG=21 DFHQ=10



124


DFR (Perm Staff)=212

4.206%

15

Off WO/FCPO/CPO SSgt/PO/Sgt Cpl/LS/LCpl OR

4.72% 5.19% 13.21% 28.77% 48.11%

1 1 2 4 7

DFR DFHQ DFR DFHQ DFR DFHQ DFR DFHQ DFR DFHQ

1 0 1 0 1 1 2 2 5 2

DFR=10 DFHQ=5



125

Appendix F

Table 2 - Demographic characteristics, insurance coverage and the history of hospitalization or admitted to Sick-bay in the studied population

Variable Number PercentSex Male

Female

Age

18-2425-3536-4546 and over

EducationPrimary schoolSecondary or CollegeTertiary

Marital status

MarriedSingleDivorceSeparatedWidowed

Insurance coverage

YesNo


126

History ofadmission to Sick Bay

YesNo

Appendix G

Table 3 - The frequency of different levels of satisfaction inseven domains under studySatisfactionlevel↓Domain→

Completelysatisfied

Satisfied

Neithersatisfiednordissatisfied

Dissatisfied

Completelydissatisfied

General satisfactionItems: 3, 9, 14, 42Technical quality


127

Items: 2, 5, 7, 10, 12, 38Interpersonal mannerItems: 9, 24, 28CommunicationItems: 1, 3, 5, 28Time spent with DoctorItems: 10, 12, 29, 39Accessibility and convenienceItems: 7, 8, 13, 15, 21, 23, 41, 44(Values that would be in parentheses would be percentage and

values outside the parentheses

Would be the numbers)


128

Appendix H

Table 4 - The overall level of satisfaction or dissatisfactionof patients with the servicesOverall level↓Area→

Satisfied Satisfied Dissatisfied Level ofSignificance

General satisfactionTechnical qualityInterpersonal mannerCommunication

Time spent with DoctorAccessibility and convenience(Values that would be in parentheses would be percentage and

values outside the parentheses

Would be the numbers)


129

Appendix I

Table 5 – Univariate Statistics for subscales and constituent

items

Subscale and items Mean SD

General satisfactionItems: 3, 9, 14, 42Technical qualityItems: 2, 5, 7, 10, 12, 38Interpersonal mannerItems: 9, 24, 28CommunicationItems: 1, 3, 5, 28Time spent with DoctorItems: 10, 12, 29, 39Accessibility and convenienceItems: 7, 8, 13, 15, 21, 23, 41, 44


130

Appendix J

Table 6 -Budget (Proposed)

Expendables 500.00

Capital Expenditure 2,000.00

Total Expenditure 2,500.00

Funding would be covered by Grant and employer support.


131

Appendix K

Table 1: Abbreviated Item Content and Scale Groupings,

Questionnaire

Item Abbreviated Item Content Direction of

Variable

Placement[a] by Scale Wording Label

General Satisfaction (GSAT)

3 Very satisfied with care +

PSQ01

27 Some things could be better –

PSQ02


132

36 Medical care is excellent +

PSQ03

17 Things need to be improved –

PSQ04

9 Care just about perfect + PSQ05

42 Dissatisfied with some things –

PSQ06

Technical Quality (TECH)

12 Careful to check everything +

PSQ07

2 Doctors need to be more thorough –

PSQ08

7 Office has everything needed +

PSQ09

10 Wonder if diagnosis is correct –

PSQ10

19 Know latest medical developments +

PSQ11

30 Lack experience with my problems –

PSQ12

43 Doctors competent, well-trained +

PSQ13

38 Doubt about ability of doctors –

PSQ14

26 Never expose me to risk + PSQ15

35 Doctors rarely give advice –

PSQ16

Interpersonal Aspects (INTER)


133

24 Too business-like, impersonal –

PSQ17

40 Do best to keep me from worrying +

PSQ18

33 Should pay attention to privacy –

PSQ19

14 Genuine interest in me + PSQ20

22 Make me feel foolish –

PSQ21

28 Very friendly and courteous +

PSQ22

8 Should give me more respect –

PSQ23

Communication (COMM)

5 Explain the reason for tests +

PSQ24

15 Use terms without explaining – PSQ25

11 Say everything that’s important +

PSQ26

32 Ignore what I tell them – PSQ27

37 Doctors listen carefully +

PSQ28

Time Spent with Doctor (TIME)

39 Doctors spend plenty of time +

PSQ29

29 Hurry too much when treat me – PSQ30

Access/Availability/Convenience


134

1 Get hospital care without trouble +

PSQ31

13 Hard to get care on short notice –

PSQ32

4 Easy to get care in an emergency +

PSQ33

18 Office should be open more hours –

PSQ34

31 Care conveniently located +

PSQ35

23 Wait too long for emergency treatment –

PSQ36

34 Can reach doctor for help with medical

Question + PSQ37

41 Hard to get appointment right away –

PSQ38

16 Office hours are convenient +

PSQ39

6 Kept waiting at doctor’s office –

PSQ40

21 Easy access to specialists +

PSQ41

44 Get medical care whenever need it +

PSQ42

[a]Order of item in PSQ-III is administered in the Medical

Outcomes Study (MOS). This section of the MOS questionnaire

included 51 items; item 30 refers to beliefs about a crisis in


135

health care and is not used in scoring the satisfaction

subscales.


136

Appendix L

GANTT Chart of time line for Project


ID Task Name Duration Start Finish

12 First drraft of proposal 90 days Tue 03/04/12 M on 06/08/123 Biostatistics and Epidemiology input to develop a proposal – Year 1 (Sept 2011 – July 2012) 230 days Thu 01/09/11 W ed 18/07/124 Submission of proposal to PG Project Committee – by July 2011 30 days Fri 01/07/11 Thu 11/08/115 Proposal Grade from BS lecturer – by August 2012 30 days M on 03/09/12 Fri 12/10/126 First submission of proposal to M HA Postgraduate Thesis Committee – by beginning of Year 2 (September 2012) 30 days M on 02/09/13 Fri 11/10/137 Resubmission of proposal, with revisions (if needed) - for grading – November 2012 60 days M on 01/10/12 Fri 21/12/128 Assignment of supervisor – by January 2013 60 days Thu 29/11/12 W ed 20/02/139 Protocol completed and submitted to relevant ministry or committee – by February 2013 30 days Tue 29/01/13 M on 11/03/1310 Continue literature review, make necessary contacts at institution, desk work – by November 2012 to M arch 2013 150 days Thu 01/11/12 W ed 29/05/1311 Permission and ethical approval granted – by M arch 2013 30 days Fri 01/03/13 Thu 11/04/1312 Begin data collection – by April 2013 152 days M on 01/04/13 Tue 29/10/1313 Begin data analysis – by September 2013 30 days M on 02/09/13 Fri 11/10/1314 Begin write-up of thesis – by October 2013 30 days Tue 01/10/13 M on 11/11/1315 First draft of thesis submitted to supervisor (copy all members of M HA Postgraduate Thesis Committee) – by November 2013 28 days Fri 01/11/13 Tue 10/12/1316 Poster Presentation of project in UTT Atrium with internal and external audience – by December 2013 1 day Tue 31/12/13 Tue 31/12/1317 Final draft of thesis submitted to supervisor – by early January 2014 45 days M on 02/12/13 Fri 31/01/1418 Final thesis submitted for grading – February 2014 87 days Thu 31/10/13 Fri 28/02/14

JunJulAugSepOctNovDecJanFebM arAprM ayJunJulAugSepOctNovDecJanFebM arAprM ayJunJulAugSepOctNovDecJanFebM arQtr 2, 2011Qtr 3, 2011Qtr 4, 2011Qtr 1, 2012Qtr 2, 2012Qtr 3, 2012Qtr 4, 2012Qtr 1, 2013Qtr 2, 2013Qtr 3, 2013Qtr 4, 2013Qtr 1, 2014

2011 2012 2013 2014

137

Appendix L: Responses to questions 54, 55 and 561. 54. State possible

recommendations to improve quality of service you can rate them in order of importance:

55. If ‘YES’ to Question 52: State the changes in the Medical Services that you have seen implemented during your career.

56. State possible areas that you thinkshould be eliminatedto improve service quality you can ratethem in order of priority:

2. Access to specialists;Additional staff.

Acquisition of ambulance;Visits to bases by medical department.

3. The inclusion of a serving member as a DFMO since employed his service has beenexceptional, he ensures that you arewell informed and under stands and also carries out thorough checks whenadministering medical attention toindividuals.

4. More instructors to help out the patients till the doctor reaches;Equipment’s that are working properly.

5. Medic staff be sent for more or advance training;Bigger facility to accommodate more patients;Treat and deal with persons with ‘genuine’

Using Divon CR to treat all forms of pain only (TTCG);For smooth operations to administration process, administer cases at high


139

cases and not fake cases (put them on charge);Have a Duty NCO/SeniorRate instead of Duty Medic only;Have better drugs available (Divon CR and Panadol cannot heal all patients problem in the TTDF)

priority eliminate all ungenuine cases;Absence of a driver for the ambulance.

6. Quick service;Care of patients;Confidentiality of patients’ sickness.

7. More doctors at disposal to deal with number of patients coming to facilities.

8. Medical Orderlies needmore training;Need proper equipment;Need a doctor 24/7;Need a dentist 24/7;Need a Military Hospital or a proper health plan paid for by the government. TheMIR is a Doctor officeand nothing else.

9. Time waiting to see doctor;Manner in which some orderlies operate.

Renovation was done making more room forpatients, and air-condition placed forcomfort.

10.Medic be send to the hospital for OJT;

The sick-bay was improved and better,


140

so to deal with persons going sick, Camp Ogden and Teteron.

11.There should be more than one doctor attending to patients;Doctor hours should belonger.

12.Equality across the board.

People majority.

13.More welcoming and order in the staff;More waiting accommodations.

More medical assistance in the staff.

14.Proper respect and care from doctors whentreating patients;Medical in-confidence practice should be enforced;Correct dosage and supply with reference to quantity when issuing medicine to patient by doctors andmedics alike.The immediate dismissal and transferof medics or doctors who abuse or don’t enforce the medical in-confidence procedure;Less military approachand more medical approach from a humaneand professional stand

Proper seating and space accommodation for patients;A more sanitized environment;A faster reaction with reference to screening of patients by medics.


141

point with reference to (doctor patient/medic patient relationship).

15.Need a doctor who could be there longer;Need more medics so the screening process will be faster.

16.Have a Commissioned Doctor with better customer service for soldiers;Improve on the medics so we won’t have to pay for or look for itelsewhere;The doctor must stay alittle longer and not 1 or 2 hours.Working ambulance at each camp;Doctor at each camp location;Increase medicine for soldiers who are having babies and soldiers who have civilian wives having babies.

17.Assist soldiers in andout of uniform with extreme urgency, and also there family;Make sure machine to test be always working;Limit time frame for

Get rid of those don’t care;Place people who know what they are doing;Update machinery;Hold those accountable for


142

test and results. delinquency.18.Employing more

doctors, have them work a shift system just in case of any emergency.Equipment for saving lives must be bought and put to use (eg x-ray machine, CT Scan machines and ultra sound machines) for soldiers that need this type of services and cannot afford;Improve the transport system in the medical field also ambulance drivers should not have to look for an Orderly Officer to sign Work Ticket in emergency.

CO FundTTR Sport FundMilart/Mypart

19.The current Female DFMO should be fired because she does not pay attention to the need of sick personnel;Better screening;Upgrade of facilities;More time with the Dr;Lecture on how to stayhealthy in this stressful organization.

20.Faster service;Better facilities;

Nothing should be eliminated just improved.


143

Better quality medication.

21.The medical departmentstaff needs to change often.

22.Better trained staff;Improved and more modern equipment;Better facilities;Improved administrative procedures;Increase in medical staff;Provide the military with its own hospital and medical practitioners.

Slightly improved facilities;Increase in staff;Slightly, but not modern, better equipment.

23.More doctors;More medication.

24.Fire doctors if they do not want to work;Visit their private place.Enlist more doctors

25.Have proper medical facilities and qualified doctor.

26.Better equipment;Improved facilities.

27.Doctor at MIR every day;Medication more available.Better disposals

Medic are more able;Better service from orderlies;Better brand name medication that

Longer process to see DFMO then after you wait hours no doctor and you have to come again and again;


144

suited towards orthopaedics injuries;More vitamins.

work.

28.Doctor every day;More medics;More equipment for medics to work with;Blood test available.

Waiting long periodsto see a doctor.

29.The MI Room should operate by a first come first serve basisand not by seniority or who is your medic friend;More responsibility should be performed bythe medical staff whenhandling patients’ files to avoid misplacement.

30. Improve the space inthe waiting area;Attendance has improved a little.

31.Have a private doctor for TTDF 24 hrs and not only on a morning.They should not be a member of the service.

32.A bigger facility;More medical staff;More equipment upgraded;More access to medication.

Having to wait on a doctor to get dentalof optical device.

33.All medical personnel


145

consistently trained and kept up to date onequipment;New and functioning ambulances are needed;New equipment.

34. Drugs, the MIR and equipment

35.The TTDF have its own medical facility.

36.More staff;Update machines. Think we should have more than one doctor

37.Certified medics;Updated machine and equipment.

38.Well trained doctors;More mature staff;Better equipment.

More structure equipment

39.New doctor;Better train staff;Better equipment;Proper medication;Better facility. More doctors

Communication;The waiting period

The waiting period

40.Better MI Rooms;More qualified medics;Doctors who don’t feellike screening you or vex you came.

41.Better equipment;Better training for


146

medical orderlies.42.Let the medical staff

have lectures to TTDF of STD’s and proper hygiene.Increase the medical staff

43.Be more professional;Be more understanding.

New facilities;New equipment;More staff.

Long waiting to see doctor

44.Improvement in the procurement process toaid in medical invoices and medication.

45.More doctors;Bigger staff;Bigger facilities;Random check-up;Treating all ranks fair;Better medical attention.

46.Antibiotics should be available in the MI Room;Doctors should be accessible in the TTDF;Doctors should stop act business like whenproviding advice.

47.We should be able to get prescription medication at our medical institutions.


147

48.Medics need to be morepolite;Medics need to be further trained;MI Room needs to be more stocked with medical equipment and supplies;There need to be more than 1 doctor visitingpersonnel;Doctors need to be able to provide their services from Monday –Friday at least.

49.Doctors to be more polite and concerned about patients;Medical facilities to be improved;Doctors to listen carefully to what I have to say;Doctor to explain medical terms and things to patients.

Nothing should be eliminated just quality should be improved.

50.Need to have more staff;Need to report the doctor;Need to have a place soldiers can go and get more service.

51.More doctors trained in different fields; Get person from the outside to help


148

trained and educate person in the TTDF.

52.A doctor in camp for 24hrs;Much more Drs as well as pharmacists assigned to serve the TTDF;No more second class drugs (genuine drugs for faster wellness and relief).

53.Having the addition of2 more doctors and round the clock rotation of these doctors who should be certified;Other staff should be sent on courses so that they can be better medical officers.

54.The faster screening of patients so they can see the doctor.

The lengthy wait to see the doctor.

55.Increase size of facility;Increase staffing;More persons should beexposed to training atexternal agencies bothlocal and foreign;Improved relations with external agenciesto ensure speedy and priority treatment of military personnel.


149

56.Having more time spentwith the patients;Give proper drugsProper screen process.More medics for screening process;Attending to more ill patient first;

Long hours of waiting;No more first come first serve.

57.More doctors58.Have doctors at the

facility medical unit from 8:00 – 4:00 daily;Get doctor who are commit to serving the members of the military.

59.Better privacy, accommodation.

60.Employed more doctors and personal assistance;Improve more better machines;Must more medical insurance and cheaper;Better medicine.

61.Change female doctor. Change the female doctor her manners is not good.

62.Transport can be improved;Doctors could be more professional.

63.Let the OC mind their own business

Stop the fraternization.


150

64.Give patient more attention.

65.Training course;Confidentiality of patient.

66.Need more staff so we can see more patients on a daily basis and faster.

The facilities has been extended;New machines and things have been brought in to help the patients (beds, mattresses, etc.)

67.Need more qualified doctors;More professional training of the medical staff;Increase staff;Bigger facilities.

68.More up to date medical equipment and facilities;Faster medical treatments for emergencies.

69.Relieve the female doctor of her contract;Properly train the medical orderlies in CSR;Properly train the Orderlies in dispensing pharmaceuticals;Have more civilians towork in the medical

No area should be eliminated, but mostif not all should beimproved so as to gain better quality for soldiers.


151

room.70.MI Room to small;

Little to no emergencyprotocol;Each unit should have emergency life precaution protocol.Empathetic personnel with advanced trained skills required

The physical infrastructure and seating arrangement are much better but the medical officers’ attitude needs major adjustment.

Change the female doctor and get a more professional DFMO;Basic inefficiencies;Pharmacy lacks a lotof basic medicine.

71.Better equipment;Better seating arrangement;(If possible) separatebuilding.

72.We need to build a military hospital to eliminate this ongoingproblem;Proper training needs to be done.

73.Professionalism;Care;Love for what you do and know as a doctor;Regards and respect.

74.The doctor needs to doa physical assessment of patients and not read new medical report and judge the patient;More medics are neededin all military establishments;More equipment is


152

needed mainly defibrillators;The attitude of the doctors to wards patients should be a lot more caring. It appears that they treat us all as if we are trying to use the medical system to get free time.

75.More medical machines to conduct medical test etc.;Send members of medical staff to further their skill inthe medical field.The working area should be a bit cleaner and more organized;The doctor should havea more professional office area.

The response on carefor soldiers have improve by 50%;The quantity of medication has improved by 50%;The facility has been upgraded.

76.More training and patience.

77.More medical courses Because of the medical courses

78.Remove the female existing DFMO;Replace the female existing DFMO with a doctor that actually works to help/assist the TTDF.Recommend the AdMed card for all TTDF

Remove the waiting time mandatory;Clico Health Plan that is use by existing TTDF personnel;


153

personnel. It’s the only pre-paid insurance policy in T&T.

79.More care and attention needed.

80.More doctors;Better doctors;Doctors who care aboutthe people that they see on a day to day.

81.A doctor on call at least until 1200hrs.The sick-bay could be improved as for comfort of patient admitted.

82.People skills;Professional ethics and training;Proper facilities;Relocation and additional installations throughout the Force.

The facility should not be in any camp;Currently the femaledoctor directs soldiers to go only to West Shore Medical and states she only recognizes reports and results from that institution. This isbias and improper practice and should be reported to the NWRHA head.

83.Better equipment for the medical staff to do their jobs;Working ambulances;More effort and time spent do their jobs by


154

the doctor.84.More ambulances;

ECG equipment;More medical staff.

85.More enlisted medical staff

86.Give more training;Give more incentive.

More medication;Better and more equipment.

87.More ambulance service;Need more medical equipment.

Facility service.

88.Better CSR service;More listening by doctors of patients’ illness before diagnosis.

89.Medics take your situation for granted and more on personality than professional;Need more qualified nurses rather than medics who just have the first aid certificate;Need who is punctual and consistent not to mention efficient;The pharmacist does a great job but she needs to be provided with a wider range of drugs so she doesn’t have to substitute

Stop let officers sign your sick-leavebecause they aren’t in the medical fieldto determine whetheror not you are or aren’t really sick. In other words what the doctor says doesn’t really matter than;


155

drugs which are recommended;TTDF needs to put proper service in place when referred tospecialist whereas bills are subsidized and the best care is provided in the interest of the soldier and establishment;In the service at the public hospital.

90.More doctors;Longer hours;Doctor frequently visiting the MI Room.

91.More doctors that are willing to listen to your problems and givespecifics like the enlisted doctor.

92.Better infrastructure;Doctor should be available more;More ambulance;More qualified staff.

93.Need a doctor who is more professional whencoming to dealing withpersonnel of the Force.

We have the quantityand personnel to do the job but in a "don’t care" attitude towards individuals. People personalize things too much.

94.More doctors;


156

Doctors available every day;Doctors to physically check patients;Doctors who care aboutpatients’ well-being.

95.Be more efficient;More doctors needed inthe TTDF MI Room.

96.Expand the medical department with more equipment

Training in the medical staff;Facility upgrade wasdone.

Stop admitting patient to sick-bay.

97.Expansion Some minor small equipment

Requiring personnel abroad

98.Distribution of knowledge to those on off station

Courteous staff

99. Short waiting period100.Increase capacity101.More training for

medical staff; more modern equipment;Improved facilities.

102.Round the clock serviceable ambulance;More modernize equipment/machinery;Easy access to doctor on station;More personnel medically trained withminimum of basic firstaid.

Just improvement no areas to be eliminated.

103.Enlist additional


157

medical officers;Establish medical policy to set standards and execute medical boarding of chronically ill/injured personnel.

104.Pay closer attention to problems of ratings.

105.More doctors should beemployed;Higher skill is required;More caring doctors should be employed.

Less unskilled doctors.

106.A working ambulance;More upgrade medical equipment needed;Bigger and more spacious medical room.

TTDF stop accept sick leave from private organization.

107.Overall general facelift of the medical department.

Hostility.

108.Expansion in facilities.

Stereo types.

109.A little more understanding.

110.A proper MI Room, always have to stand around to be attended too;Proper equipment;Enough medication;Another doctor or 2 should be enlisted;


158

Better trained staff who knows how to deal with private information.

111.Better equipment. Stop victimizing juniors.

112.Ambulance;More improved medical supplies.

113.A (DFMO) on the Station

114.EquipmentStaff

115.Larger variety of medicationMore medical staff

116.More staff (well trained)More doctors on duty (more experience)

117.The medical orderlies training can be improved in such ways,where their ways of dealing with patients and the matter.Their work experience should come hand in hand with such field being trained in, for

The level/rank in which persons classed a medic.

118.Bring back a doctor atAir Guard;Ensure PT becomes a must so persons can befit and healthy.

119.The advance training The Upgrade of the


159

required and the recent training required needs to be of first priority, themedical orderly need to be properly certified for the job.More specialization interms of medical orderly.

ambulance equipment and medical room equipment.

120.Military hospital (North, Central, South, East locations);The above manned by civil doctors and nurses;Doctors on duty 24hrs at the hospital, not “on call”.


160

Table Showing Coded Responses for Question 54 (State possible

recommendations to improve quality of service you can rate them

in order of importance)

ITEMS TOTAL PERCENTAGE (%)Equipment (improved,

increase)27 22

More Staff 26 21.1Training 23 18.7More Doctors 20 16.2Ambulance (increase,

operational)10 8.1

Medication (access,

better, increase)8 6.5

Bigger facility 5 4.1Military Hospital 5 4.1


161

Table Showing Responses for Questions 55 and 56

55. If ‘YES’ to Question 52:

State the changes in the

Medical Services that you

have seen implemented during

your career.

56. State possible areas that

you think should be eliminated

to improve service quality you

can rate them in order of

priority:

1. Acquisition of ambulance;

Visits to bases by medical

department.

Using Divon CR to treat all

forms of pain only (TTCG);

For smooth operations to


162

administration process,

administer cases at high

priority eliminate all

ungenuine cases;

Absence of a driver for the

ambulance.

2. The inclusion of a serving

member as a DFMO since

employed his service has been

exceptional, he ensures that

you are well informed and

under stands and also carries

out thorough checks when

administering medical

attention to individuals.

Get rid of those don’t care;

Place people who know what they

are doing;

Update machinery;

Hold those accountable for

delinquency.

3. Renovation was done making

more room for patients, and

air-condition placed for

comfort.

People majority.

4. The sick-bay was improved and

better, so to deal with

persons going sick, Camp

Ogden and Teteron.

CO Fund

TTR Sport Fund

Milart/Mypart

5. More medical assistance in

the staff.

Nothing should be eliminated

just improved.

6. Proper seating and space

accommodation for patients;

Longer process to see DFMO then

after you wait hours no doctor


163

A more sanitized environment;

A faster reaction with

reference to screening of

patients by medics.

and you have to come again and

again;

7. Slightly improved facilities;

Increase in staff;

Slightly, but not modern,

better equipment.

Waiting long periods to see a

doctor.

8. Medic are more able;

Better service from

orderlies;

Better brand name medication

that work.

Having to wait on a doctor to

get dental of optical device.

9. The waiting period

10.Improve the space in the waiting area;

Attendance has improved a

little.

Long waiting to see doctor

11.Drugs, the MIR and equipment Nothing should be eliminated

just quality should be

improved.

12.More structure equipment The lengthy wait to see the

doctor.

13.Communication;

The waiting period

Long hours of waiting;


164

14.New facilities;

New equipment;

More staff.

No more first come first serve.

15.The facilities has been extended;

New machines and things have

been brought in to help the

patients (beds, mattresses,

etc.)

Change the female doctor her

manners is not good.

16.The physical infrastructure and seating arrangement are

much better but the medical

officers’ attitude needs

major adjustment.

Stop the fraternization.

17.Training in the medical staff;

Facility upgrade was done.

No area should be eliminated,

but most if not all should be

improved so as to gain better

quality for soldiers.

18.Some minor small equipment Change the female doctor and

get a more professional DFMO;

Basic inefficiencies;

Pharmacy lacks a lot of basic

medicine.

19.Courteous staff Stop let officers sign your

sick-leave because they aren’t

in the medical field to


165

determine whether or not you

are or aren’t really sick. In

other words what the doctor

says doesn’t really matter

than;

20.Short waiting period We have the quantity and

personnel to do the job but in

a "don’t care" attitude towards

individuals. People personalize

things too much.

21.TTDF stop accept sick leave from private organization.

Stop admitting patient to sick-

bay.

22.The Upgrade of the ambulance equipment and medical room

equipment

Requiring personnel abroad

23. Just improvement no areas to be

eliminated

24. Less unskilled doctors.

25. Hostility.

26. Stereo types.

27. Stop victimizing juniors.

28. The level/rank in which persons

classed a medic.


166


167

Appendix M: Frequency distribution Tables and Related Charts

Table of Frequency Distribution of

Access/Availability/Convenience (AAC) Subscale (%)

Disagre

e

Uncerta

in Agree

Can get care without any trouble in

the medical department (AAC1)

54

(22.6)

83

(34.9)

101

(42.5)

Easy to get medical care in an

emergency(AAC2)

80

(33.2)

83

(34.4)

78

(32.4)

Usually kept waiting for a long time

at the doctor’s office (AAC3)

52

(23.6)

30

(12.4)

159

(66.0)

Hard to get medical care on short

notice(AAC4)

49

(20.3)

46

(19.0)

147

(60.8)

The office hours are convenient

(good) (AAC5)

119

(49.2)

39

(16.1)

84

(34.7)

The office should be open for more 35 30 177


168

hours than it is (AAC6) (14.4) (12.4) (73.1)

Easy access to the medical

specialist needed (AAC7)

144

(60.3)

50

(20.9)

45

(18.8)

01020304050607080

22.6

33.223.6 20.3

49.2

14.4

60.3

34.9 34.4

12.419 16.1

12.420.9

42.532.4

6660.8

34.7

73.1

18.8

Chart represening AAC Frquency

DisagreeUncertain

Table representing frequency distribution ofCommunication Theme

Frequency distribution (%)

Disagree

Uncerta

in Agree

Doctors explain the reasons for 73 65(26.9 104(43)


169

medical tests (COMM1) (30.1) )

Allowed to say everything that I

think is important (COMM2)

64

(26.7)

37

(15.5)

139

(57.9)

Use of medical terms without

explaining meaning (COMM3)

75

(31.1) 29 (12)

137

(56.8)

Sometime ignored what they are

told (COMM4)

76

(32.2)

38

(16.1)

122(51.

7)

Listen carefully to what is said

(COMM5)

88

(37.2)

59

(24.9)

89

(37.5)

30.1 26.7 31.1 32.2 32.726.915.5 12 16.1

24.943

57.9 56.8 51.737.5

Chart showing Communication Theme Frequency distribution (%)

Disagree Uncertain Agree

Table showing frequency distribution of Interpersonal Care


170

Theme Frequency Distribution (%)

DisagreeUncertai

nAgree

The doctor who treats me should

give me more respect (INTER1)

65

(26.8)24 (9.9)

154

(63.4)

The doctors who treat me have a

genuine interest in me as a

person (INTER2)

108

(44.8)

79

(32.8)

54

(22.4)

Sometimes doctors make me feel

foolish (INTER3)

100

(42.4)

36

(15.3)

100

(42.4)

Doctors act too business like and

impersonal towards me (INTER4)

80

(33.5)

48

(20.1)

111

(46.4)

My doctor treats me in a very

friendly and courteous manner

(INTER5)

72

(30.1)43 (18)

124

(51.9)

When I am receiving medical

attention, they should pay more

attention to my privacy (INTER6)

32

(13.6)22 (9.3)

182

(77.1)

Doctors always do their best to

keep me from worrying (INTER7)

102

(44.3)

66

(28.7)62 (27)


171

0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%

26.80%

44.80%42.40%33.50%30.10%

13.60%

44.30%

9.90%

32.80%

15.30%20.10%18.00%9.30%

28.70%

63.40%

22.40%

42.40%46.40%51.90%

77.10%

27.00%

Chart showing Interpersonal Care frequency DisagreeUncertainAgree

Table frequency distribution of Ratings Theme Frequency (%)

Poor Good

Rating the services provided by the female

doctor

61

(28.1)

155

(71.4)

Rating the services provided by the senior male

doctor

28

(13.5)

179

(86.5)

Rating the services provided by the enlisted

doctor

21

(10.2)

185

(89.8)

Rating the services provided by the Pharmacist 16 199


172

(7.5) (92.5)

Rating the services provided by the Medical

Orderlies

38

(17.6)

178

(82.5)

Rating the services provided by Other (State

the Others)

26

(22.1)

92 (78)

Rating the medical facilities 89

(39.1)

139

(60.9)

Rating the medical services provided 76

(33.3)

152

(66.7)


173

0102030405060708090

100

28.1

13.5 10.2 7.517.6 22.1

39.133.3

71.4

86.5 89.8 92.582.5 78

60.9 66.7

Chart showing Ratings Theme Frequency Poor


Table showing Frequency Statistics for personnel

hospitalized and visited by the DFMO

Frequen

cy

Percen

t

Valid

Percent

Cumulative

Percent

Valid

Yes 110 44.0 47.00 47.0

No 124 49.6 53.0 100.0

Total 234 93.6 100.0

Missin

g

Syste

m16 6.4

Total 250 100.0

174

Yes No

47

53

Chart showing Have you ever been hospitalized


175


Table showing frequency of- If ‘Yes’ were you ever

visited by the DFMO

Frequen

cy

Percen

t

Valid

Percent

Cumulative

Percent

Valid

Yes 11 4.4 9.9

No 99 39.6 89.2 99.1

3.00 1 .4 .9 100.0

Total 111 44.4 100.0

Missin

g

Syste

m139 55.6

Total 250 100.0

176

10%

90%

Chart showing frequency of Visited by the DFMO

at hospital

YesNo


Table showing Frequency of ‘Have you ever visit

any other DFMO outside of in their Private Office’

Frequen

cy

Percen

t

Valid

Percent

Cumulative

Percent

Valid

Yes 61 24.0 27.0 27.0

No 161 64.4 72.5 99.5

4.00 1 .4 .5 100.0

Total 222 88.8 100.0

Missing

System

28 11.2

Total 250 100.0

177


Table for Frequency of If ‘Yes’ how were the

services provided

Frequenc

y Percent

Valid

Percen

t

Cumulat

ive

Percent

Poor 4 1.6 6.8 6.8

Good 55 22 93.2 100

Valid Total 59 23.6 100

Missing

Syste

m 191 76.4

Total 250 100

178

Poor7%

Good93%

Chart showing frequency of-How was the Doctor service

at the private office

Table showing Frequency Distribution (%) of Time variables.

Finance and Crisis Variables

DisagreeUncerta

inAgree

Those who provide my health care

sometimes hurry too much when they

treat me. (Time1)

46 (19.5

%)

23

(9.7%)

167

(70.7%)

The doctors usually spend plenty of

time with me (Time2)

175

(73.9%)

27

(11.4%)

35

(14.8%)

I have to pay for more of my medical

care than I can afford (FIN)

47

(19.6%)

32

(13.4%)

160

(67%)

There is a crisis in the health care 16 31 193


179

within the Force today. (Crisis) (6.6%) (12.9%) (80.4%)


180

Final Thesis for submission

Documents

Transcript of Final Thesis for submission