Theoretical Framework

Patients satisfaction is an attitude or a person`s general orientation towards a total

experience of health care. Satisfaction comprises both cognitive and emotional facets and

relates to previous experiences, expectations and social networks (Keegan et al, 2002).

Expectancy-value theory of Linder-Pelz (1982) postulated that satisfaction was mediated

by personal beliefs and values about care as well as prior expectations about care. Linder-Pelz

identified the important relationship between expectations and variance in satisfaction ratings

and offered an operational definition for patient satisfaction as positive evaluations of distinct

dimensions of healthcare. The Linder-Pelz model was developed by Pascoe (1983) to take into

account the influence of expectations on satisfaction and then further developed by Strasser et

al. (1993) to create a six-factor psychological model: cognitive and affective perception

formation; multidimensional construct; dynamic process; attitudinal response; iterative; and

ameliorated by individual difference.

Linder-Pelz, S. (1982): Toward a Theory of Patient Satisfaction. Social Science and

Medicine; 16: 577-582.

Determinants and components theory of Ware et al. (1983) propounded that patient

satisfaction was a function of patients subjective responses to experienced care mediated by

their personal preferences and expectations. Determinants of satisfaction are examined in

relation to the literature on expectations, and demographic and psychosocial variables. These

are distinguished from the multidimensional components of satisfaction as aspects of the

delivery of care, identified by many authors.

 Ware, J.E., Snyder, M.K., Wright, W.R. and Davies, A.R. (1983), Defining and

measuring patient satisfaction with medical care, Evaluation and Program Planning, Vol. 6 Nos

3-4, pp. 247-63.

Healthcare quality theory of Donabedian (1980) proposed that satisfaction was the principal

outcome of the interpersonal process of care. He argued that the expression of satisfaction or

dissatisfaction is the patients judgement on the quality of care in all its aspects, but particularly

in relation to the interpersonal component of care.

Donabedian, A. (1980), The definition of quality and approaches to its assessment,

Explorations in Quality Assessment and Monitoring, Vol. 1, Health Administration Press, Ann

Arbor, MI.

Performance theory suggests that patients satisfaction is not affected by prior patient

expectations at all. Actual performance and the treatment outcome effectively affect patient

satisfaction. Actual performance will overwhelm any psychological response tendencies related

to expectations (Oliver & Desabro, 1998). Higher patient satisfaction can be expected to result

in a better clinical outcome and lower patient satisfaction is associated with poor clinical

outcomes (Oliver & Desabro). Basically, what the theory means is, though patients have

expectations, level of patient satisfaction is influenced highly by the quality of care provided and

the outcomes of the care. Patients pretreatment expectations cannot inhibit the level of patient

satisfaction, as it is overcome by the high-quality care offered and a superior treatment

outcome.

The expectancy-disconfirmation theory contends that patients form expectations of their

treatment outcomes even before the treatment. It proposes that the consumer compares his or

her perception about a product or a service against a repurchase comparison level or standard.
In a health care setting, patients tend to compare the actual outcomes with that of the perceived

outcomes (Oliver & Desabro, 1998). It proposes that if ones expectations are higher, the less

likely that service could meet or exceed them, and the result would be reduced satisfaction or

dissatisfaction. On the contrary, the higher the perceived level of performance, the more likely

the expectations would be exceeded, resulting in increased satisfaction.

Fulfillment theory views patient satisfaction in a somewhat different way from

performance theory. This theory contends that patient satisfaction is the difference between

actual outcome and some other ideal or other desired outcomes. This theory hypothesizes that

satisfaction would vary positively with the extent to which perceived outcomes concurred with

the pretreatment expectations (Linder-Pelz, 1982). The patients perception on whether the

outcome of a treatment is either good or bad is based on the expectations the patient had

before treatment and would influence the patients satisfaction. This means that there would be

positive satisfaction if the outcome of the treatment matched with the pretreatment expectations

of the patient.

Linder-Pelz, S. (1982), Toward a theory of patient satisfaction, Social Science &

Medicine, Vol. 16 No. 5, pp. 577-82.

Social-equity theory differs from the other stated theories. It refers that if a patient

perceives that his/her treatment outcome is comparatively and fairly the same when compared

to that of his/her counterparts, then he/she is supposed to be satisfied. Individuals compare their

gains with those of other consumers and with those of the service provider (Newsome & Wright,
1999). Patients tend to compare their treatment results with those who undergone the same

treatment procedures for a similar condition in the same health care setting or any other health

care setting. If the other patient had acquired better treatment services and the outcome in that

patient is found superior to that of the first patient, the first patients more likely get dissatisfied.

The Primary Provider Theory contends that patient satisfaction occurs at the nexus of

provider power and patient expectations. It is principally the function of an underlying network of

interrelated satisfaction constructs satisfaction with the primary provider, the amount of time a

patient has to wait for the provider, and satisfaction with the providers assistant. According to

this theory primary providers offer the greatest clinical utility to patients (Aragon, 2003). The

theory is mainly operated by patient centered measures exclusively, where only patients judge

the quality for service and other judgments are totally irrelevant. So, this theory concludes that

patients level of satisfaction is inherently influenced by the primary care provider.

It appears that the level of satisfaction varies with the disease condition. Hence,

satisfaction is generally higher in patients with acute conditions than in those with chronic

conditions (Hills R et. al, 2007), possibly because those with acute conditions are more

optimistic about their outcome. Patients age also appears to be an important factor, with older

patients reporting more satisfaction (Casserley-Feeney SN et. al., 2008).

Furthermore, a lower satisfaction level may be associated with an increase in the

waiting time for treatment, inadequate waiting area facilities, a low level of faith on the
therapist/health facility, and ineffective communication with the patient about his/her disease

condition (Kumarito et. al., 2009).

Other than patient and physiotherapist related factors, patient satisfaction is also

associated with the organization and infrastructure of the physiotherapy treatment facility. Well-

organized physiotherapy care is a determinant of high patient satisfaction. Patients are more

satisfied if the physiotherapy service is easy to access (in terms of location, parking, and clinic

hours), involves helpful administrative staff, and is associated with low waiting times, and the

premises are of a high standard. Patient satisfaction was also associated with the type of facility,

where patients were more satisfied in a private clinic than in a government hospital, possibly

because of better resources in private clinics in particular, the therapist time.

These theories suggests that patients level of satisfaction is influenced by different

factors like quality care, treatment outcomes, provider power, waiting time, equality in treatment,

and staff members. The factors mentioned in these theories together with various other

influencing factors were integrated in the patient satisfaction instrument. The first three theories,

Performance Theory, Expectancy Disconfirmation Theory and Fulfillment Theory mainly focus

on the treatment outcome in a patient, irrespective of patients prior expectations. Social Equity

Theory talks about patients being treated equally. According to Primary Provider Theory, patient

satisfaction is influenced by the primary provider, waiting time, and the staff assisting the

provider. The Expectancy-Value Theory, Determinants and Components Theory, and the

Healthcare Quality Theory addresses the satisfaction of the patient as to care.

 The above mentioned theories in correlation to patients level of satisfaction as to

Physical Therapy explains that it is based on what is the patients subjective responses to

experience care mediated by their personal preferences and expectations about care from

where it is judged based on the quality in all its aspects including the facility, services and

treatment provided, but in particularly in relation to the interpersonal component of care.

Based on the given theories and concepts, the researchers came up the paradigm of the

study. Figure 1 presents the paradigm of the study. The basis of the formulation of the paradigm

is with respect to the assumed cause (independent variable) and assumed effect (dependent

variable). The assumed causes are characteristics of the patients status, demographic and

clinical profile and level of satisfaction of patients towards Physical Therapy. And the assumed

effect is based on the patients status corresponding to Physical Therapy treatment, facilities

and services.