Parents’ satisfaction with physiotherapy services for neuropediatric outpatients in government and private hospitals in the United Arab Emirates: a cross-sectional study

Background Healthcare, like other industries, emphasizes performance, quality, and consumer experience while also attempting to reduce costs. However, high-quality healthcare remains paramount for vulnerable and ill patients. This study aimed to investigate parents' and caregivers' level of satisfaction with physiotherapy services provided to neuropediatric outpatients on the United Arab Emirates (UAE). Methods This descriptive cross-sectional study included 103 parents/caregivers of children with neurological disabilities that were randomly selected from different Emirates Health Services Hospitals in the UAE. Data was collected using the long-form Patient Satisfaction Questionnaire (PSQ-III). Results The overall mean satisfaction was 159±7.73 (out of 250 points). Communication (20.36/25), interpersonal factors (20.17/35), and doctor-patient time (20.17/35) had the highest mean satisfaction scores (8.06/10). The lowest mean satisfaction scores were for access/availability/convenience (34.60/60), technical quality (33.17/50), and economic elements (23.83/40). Conclusion Despite participants’ overall satisfaction scores being positive, some service domains require improvement to improve satisfaction, specifically the access/availability/convenience, technical quality, and economic elements. These areas should be prioritized by service providers and managers to improve patients’ experiences and clinical outcomes.


Introduction
Many industries worldwide, including healthcare, have increasingly prioritized performance, quality, and user satisfaction while simultaneously attempting to reduce costs.Healthcare providers deliver vital services to vulnerable and critically ill patients, along with essential preventative and health promotion services.Several healthcare organizations worldwide have launched quality improvement initiatives to improve patient satisfaction and prevent negative experiences, but it is becoming increasingly important to implement effective strategies to provide quality care that is also costefficient. 1,2tisfaction is known as a belief and attitude regarding certain or specific services provision of an institution. 3,4Patient satisfaction is considered the most important indicator for health service quality assessment. 5Parental and patient satisfaction become a well-established outcome indicator for assessing the quality of healthcare system. 4,6arental satisfaction is determined by how effectively parents 'expectations of ideal care are balanced with how they actually feel about real available care. 7,8According to the numerous studies, poor communication and lack of information are the most serious parent/patient complaint. 9,10Even when therapists try to explain the patient condition, their terminology is often misunderstood.So, Listening to parents is very important in process of communication. 11ong the most widely used patient satisfaction tool is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.Many organizations use the HCAHPS as a key performance indicator. 12However this tool is general and nature and is of limited use for specific and specialized services like the physiotherapy service. 13Consistent with global trends, the United Arab Emirates (UAE) has prioritized the development of a world-class healthcare system to serve its population.To achieve this, the UAE government introduced new quality criteria and mandated that all healthcare institutions receive accreditation from national and international agencies. 14rthermore, healthcare organizations in the UAE consistently undergo evaluation against comprehensive quality outcomes to assess their efficiency and determine funding and reimbursement.For example, the Department of Health in Abu Dhabi uses a healthcare quality index called "Muashir" to measure the performance of healthcare organizations against pre-set key performance indicators.Distinguished facilities receive a rating from one to five domains, which is made public and used to allocate funding to these institutions. 15This system means that the operation of these healthcare organizations depends on their achievement of quality outcomes, which results in competition among organizations to perform better and attract more funding.This approach is not implemented universally across the UAE, as healthcare services are managed federally through the Ministry of Health and Prevention (MOHAP) or locally by local health authorities.However, many local health authorities have recognized the successful implementation of Muashir and are considering rolling out this approach across their healthcare institutions.
To support physiotherapists to make a maximum contribution to developing healthcare services for their patient population in the UAE, elements of their practice that contribute to patient satisfaction need to be identified.Identifying these elements can form the basis for planning and implementing relevant measures to improve available services.At the clinical level, physiotherapy patients who are satisfied with their treatment tend to interact well with their therapist, remain loyal to them, and seek further treatment when necessary. 16en initiating treatment, physiotherapists meet with their patients (and patients' parents/caregivers in pediatric cases) for a consultation to develop an appropriate treatment plan. 17The fulfilment of this plan should lead to patient satisfaction; however, many systemic, process, and outcome factors could affect the execution of the treatment plan and thereby affect patient satisfaction.This means it is essential to clarify aspects that impact patient satisfaction in these services.Therefore, the present study explored patient satisfaction in the context of rehabilitation healthcare (physiotherapy) services in the UAE, as the principal investigator is a clinician working in pediatric rehabilitation services.This study was conducted to determine parents'/caregivers' level of satisfaction with the physiotherapy services provided to their children in the physiotherapy departments of private and government hospitals in the UAE.

Study design
This study used a cross-sectional correlational design.Participants completed self-report questionnaires that assessed the satisfaction of parents/caregivers of children attending rehabilitation services and other relevant variables.

Participants
We included Parents or caregivers of children that had physical disabilities and neurological problems who were receiving rehabilitation sessions in physiotherapy departments in government and private hospitals in the UAE.Parents/caregivers were invited to participate if they were able to read and understand English and had a child aged between 5 months and 16 years that was a neuropediatric patient who had received at least 12 physiotherapy sessions.Parents and caregivers of patients who were admitted to hospital (inpatients) were excluded from this study.In addition, we did not include patients from all physiotherapy specialties as their needs may differ, which would impact their satisfaction.
Convenience sampling was used to recruit parents/caregivers of children receiving rehabilitation services.All major hospitals for children's rehabilitation governed by the Emirates Health Services authority were contacted to obtain approval to conduct this study.Those settings that responded and approved this study were approached to assist with recruitment and all eligible parents/caregivers in these settings were invited to participate.Data were collected from 103 parents/caregivers of children with various neurological disabilities attending rehabilitation services at different Emirates Health Services facilities.
The sample size was calculated depending on the proportion (78%) stated in a previous study addressing the same research question [48].The appropriate sample size with sufficient power of 80% (alpha= 0.05) was calculated by the Epi Info, a program developed by the Centers for Disease Control and Prevention.

Data collection procedure
The long form of the Patient Satisfaction Questionnaire (PSQ-III) was used in this study (English language version), which was validated in previous studies. 18,19The scale is open access and available for researchers use through the authors website. 20The scale was found to be reliable, with Cronbach's alpha coefficients of 0.92 for the whole scale and 0.74-0.89for the subscales. 17The PSQ-III is a 50-item survey that measures global satisfaction with medical care as well as satisfaction with seven specific aspects of care: general satisfaction, technical quality, interpersonal manner, communication, financial aspect of care, time spent with doctor, and accessibility of care.
Respondents are asked to rate their satisfaction with the medical care they received, with responses on a scale from 1 to 5 (strongly agree to strongly disagree) that indicate to what extent they agreed with each statement. 18An open-ended comments option was added at the end of the structured questionnaire to accommodate qualitative information from participants regarding their suggestions for service improvements.We also collected information on the children's age, gender, and the duration they had received physiotherapy treatment.
Participants were parents or caregivers who usually accompanied children to their physiotherapy session.They were selected following contact with the heads of the physiotherapy departments in different government and private hospitals via electronic communications that explained the study purpose.A link to the electronic questionnaire (PSQ-III) was distributed to eligible parents/caregivers through their preferred communication channel.

Ethical consideration
Ethical approval was obtained from the Research Ethics Committee of the University of Sharjah [approval no: REC-21-04-28-02-S], and the ethical committee of the Ministry of Health and Prevention [Approval Reference No: MOHAP/ DXB-REC/JJJ/No.57/2021] on April 2021.Before recruiting participants, written informed consent which included information of the study's purpose, was obtained from all eligible participants.Each parent who expressed interest to participate in this study was instructed to read, understand, and sign the consent form.Furthermore, the integrity and confidentiality of all data collected during the study were assured by local institutional policies.Participants were informed that they had their right to withdraw at any time without prejudice and no incentives were offered at any point in the study.

Statistical analysis
Data were analyzed using SPSS Software.Descriptive statistics were used to describe participants' demographics and levels of satisfaction.Continuous variables were expressed as means and standard deviation, while categorical variables were expressed as counts and percentages.Correlational analysis was performed to assess the association between demographic variables and the satisfaction score.

Results
Before proceeding with data analysis, the reliability of the study questionnaire was assessed to ensure valid and reliable results.The reliability of the scale used in this study was assessed and returned a Cronbach's alpha value of 0.7, which is considered acceptable reliability value.

Sociodemographic characteristics
In total, 103 parents/caregivers participated in this study, of which 44.7% (n=46) had female children receiving rehabilitation and the remaining (55.3%, n=57) had male children receiving rehabilitation.The majority of participants had children that were scheduled for a long duration of physiotherapy treatment (i.e., >12 sessions).The mean age of the children was 57AE48 months (4.75 years).Table 1 presents sociodemographic details of participants' children.
Table 3 shows the level of satisfaction with each PSQ-III item.In the general satisfaction domain, most (97.1%)participants agreed that some aspects of the medical care that they received could be improved.However, most (94.2%)participants were satisfied that their child was treated by medical staff who were aware of the latest medical developments.Regarding the interpersonal aspect domain, most (90%) participants indicated that the doctors always tried to prevent them worrying.In terms of communication, most (89.3%)participants reported that when they visited the doctor, they were always free to express concerns and believed that this was important.A majority (68.9%) of participants sometimes worried about having to pay a large medical bill.In addition, most (88.3%)participants reported that the doctors usually spent plenty of time with their children, and 88.3% noted that they could easily get hospital care without any trouble.
We also assessed the correlations between the child's age and parents' /caregivers' satisfaction scores.These variables showed a significant, negative, and weak correlation, which indicated that satisfaction tended to decrease as the child's age increased.A nonparametric Mann-Whitney U test was used to assess differences in parents'/caregivers' satisfaction scores by the child's sex and physiotherapy duration.This analysis showed that there were no significant differences between these groups in terms of their satisfaction scores.

Discussion
Parents' and caregivers' satisfaction with their child's rehabilitation intervention is necessary for the sustainability of services.Conducting patient satisfaction surveys can help enhance clinical practice, and can also provide relevant data for The physiotherapist answered all my questions 103 (100.0)0 (0.0) (0.0) The therapist rarely gave me advice about ways my child could avoid further problems and stay healthy 5 (4.9) 1 (1.0) (94.1) The physiotherapist acted business-like and impersonal toward my child the marketability of healthcare services and quality of care delivered. 19,21Patients are considered users of healthcare services, meaning patient satisfaction is an important tool to evaluate the quality of services provided.In this study, the overall level of satisfaction with neuropediatric rehabilitation services was high, but a lower level of satisfaction was observed when specific aspects of care were assessed.This suggested that it is not possible to assess the level of patient satisfaction by simply asking patients if they were happy with the services that they received.
We found no significant differences in parents'/caregivers' satisfaction by the child's sex and physiotherapy duration.However, this finding may be because our sample size was insufficient to allow these comparisons.Similarly, a previous study revealed patient satisfaction was not affected by their age, educational status or occupation. 22In contrast, other studies showed that age, sex, ethnicity, education, and occupation were the main predicators of overall patient satisfaction.For example, a study from Nigeria reported that the communication and access/availability/convenience domains were strongly associated with sex; however, there was no sex-based difference in satisfaction with the time spent with doctor, technical quality, interpersonal financial, and general satisfaction domains. 23However, we found that age was the best predictor of satisfaction in the majority of satisfaction dimensions, whereas the Nigerian study reported patients' age was not a determinant of their satisfaction with services they received. 23 the present study, the satisfaction of parents\caregivers differed across various areas examined in the questionnaire.
The mean total satisfaction score (63.8%, 159.49/250) showed that the majority of participants had a good level of satisfaction with the physiotherapy treatment that their children received at the government and private hospitals run by Emirates Health Services.A previous study reported the mean overall score for patient satisfaction with physiotherapy care was 68.2%, which was consistent with our results. 24However, other studies reported lower levels of satisfaction for various reasons.A study from Nepal found that patients' general satisfaction was relatively low (39%), although this was attributed to the unavailability of certain desired facilities. 25Participants in our study were satisfied with the time the therapist spent with their child (80.6%) in each session.This finding was expected because therapists in the participating services typically spend 45-60 min in one treatment session with their patients.Our participants indicated that their satisfaction was increased when the therapist spent a long time with their child and explained the treatment plan.
In contrast to our results, a study from Dubai reported that 40% of parents/caregivers were dissatisfied with the time that their children spent with the therapist.Those authors suggested that this dissatisfaction could be explained by the therapists' heavy workloads or the patients' condition not requiring a long time for treatment. 26other study conducted in Katsina State, Nigeria, found patients reported low satisfaction with the time spent with the doctor because there was a large number of surgeries completed and patients felt they did not receive proper interaction. 23evious studies focused on psychological issues related to pediatric practice revealed that parents/caregivers were interested in knowing more about their children's psychological problems and good communication was a powerful predictor of satisfaction.Good communication during medical visits was reported to significantly influence parents'/ caregivers' satisfaction, functional status, and patient compliance. 27This was consistent with our finding that most (81.4%)participants were satisfied with the therapist because there was good communication between the therapist and parents/caregivers.This was consistent with the results of other studies that found the highest level of satisfaction was reported for the communication domain. 28One study suggested that communication had the highest mean satisfaction score because patients appreciated their therapists' listening ability. 24e interpersonal and access/availability/convenience domains had the lowest scores in our study (57.6% and 57.7%, respectively).This was consistent with a previous study that also showed these two domains had the lowest mean satisfaction scores. 23Financial aspects also had a low satisfaction score in our study (59.6%)Some of our participants were not satisfied with the financial domain because they felt that they were not protected from financial hardship.Others noted they were required to pay for services from their own pocket, which could expose them to future financial issues.
We faced some challenges that might have affected this study, particularly parents'/caregivers' reluctance to complete the questionnaire and the small sample size because of the COVID-19 pandemic (Coronavirus disease of 2019).In addition, the questionnaire was not translated into Arabic, which makes it difficult to generalize the findings and might have contributed to the small sample size.However, a reasonable number of parents/caregivers completed the survey, and our findings may help in identifying reasons for dissatisfaction with neuropediatric rehabilitation services, as well as which domains require improvement and what improvement they may need.

Conclusions
In conclusion, this study sheds light on the crucial aspect of parents' satisfaction with physiotherapy treatment for neuropediatric outpatients in the UAE.The findings underscore the overall positive satisfaction reported by parents and caregivers regarding various aspects of physiotherapy services, particularly in communication, interpersonal factors, and doctor-patient time.However, it is evident that there are areas in need of improvement, notably access/availability/ convenience, technical quality, and economic elements.These findings emphasize the importance of continuous assessment and enhancement of healthcare services to meet the evolving needs of patients and their families.Addressing the identified areas of concern is paramount to enhancing patient experiences and ultimately improving clinical outcomes.Therefore, it is imperative for service providers and managers to prioritize these domains in their efforts to optimize the quality of care provided to neuropediatric outpatients and ensure the delivery of patient-centered healthcare in the UAE.

Underlying data
Harvard Dataverse: "Replication Data for: Parents' satisfaction with physiotherapy services for neuropediatric outpatients in Government and Private Hospitals in the United Arab Emirates: a cross-sectional study" https://doi.org/10.7910/DVN/QBANIG. 29he data set contains the underlying data:

Bhamini Krishna Rao
Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka, India The manuscript titled "Parents' satisfaction with physiotherapy services for neuropediatric outpatients in government and private hospitals in the United Arab Emirates: a cross-sectional study" presents a valuable exploration of parental satisfaction with physiotherapy services for children with neurological disabilities in the UAE.The study design, which utilizes a cross-sectional correlational approach, is appropriate for the research objectives and provides a comprehensive overview of the satisfaction levels among parents and caregivers.
The methods section is detailed and well-structured, clearly outlining the study design, participant recruitment, data collection, and analysis procedures.The choice of the Patient Satisfaction Questionnaire (PSQ-III) is justified and its reliability is well-documented, making it a suitable tool for this study.The ethical considerations are thoroughly addressed, ensuring the integrity and ethical soundness of the study.However, providing more details on the sampling process, including the selection criteria and any potential biases, would enhance the transparency and replicability of the methodology.
The results are presented clearly and concisely, with comprehensive tables that effectively illustrate the key findings.The analysis is robust, and the interpretation of the data is logical and consistent with the study's objectives.The sociodemographic characteristics of the participants are well-documented, providing important context for understanding the results.The correlation analysis between demographic variables and satisfaction scores is particularly useful, highlighting the factors that influence parental satisfaction.Including more detailed subgroup analyses could provide additional insights into these factors.
The discussion effectively interprets the results in the context of existing literature, highlighting both the strengths and areas needing improvement in the physiotherapy services.The identification of areas requiring improvement, such as access, technical quality, and economic elements, is particularly valuable for informing future service enhancements.The discussion could be further enriched by exploring potential strategies for addressing these areas and by discussing the implications of the findings for policy and practice in more detail.Additionally, a comparison with similar studies in other regions could provide a broader perspective on the findings and underscore the study's relevance in a global context.
In conclusion, this study sheds light on the crucial aspect of parents' satisfaction with physiotherapy treatment for neuropediatric outpatients in the UAE.The findings underscore the overall positive satisfaction reported by parents and caregivers regarding various aspects of physiotherapy services, particularly in communication, interpersonal factors, and doctor-patient time.However, it is evident that there are areas in need of improvement, notably access, technical quality, and economic elements.These findings emphasize the importance of continuous assessment and enhancement of healthcare services to meet the evolving needs of patients and their families.Addressing the identified areas of concern is paramount to enhancing patient experiences and ultimately improving clinical outcomes.Therefore, it is imperative for service providers and managers to prioritize these domains in their efforts to optimize the quality of care provided to neuropediatric outpatients and ensure the delivery of patient-centered healthcare in the UAE.

Suggestions for Improvement:
The abstract can be reorganized to suit the title of the study by giving importance to parents whose children receive long term rehabilitation services.
The introduction can emphasize more on how caregiving is difficult in neuropediatric population rather than giving too much importance to general aspects of patient satisfaction Provide more details on the sampling process and potential biases in the methods section.Include more detailed subgroup analyses in the results section to provide additional insights into factors influencing satisfaction.The results section can highlight parents' or caregivers' characteristics and then compare it with the patient satisfaction scores.Explore potential strategies for improving areas of low satisfaction in the discussion.
Compare findings with similar studies in other regions to provide a broader context.Include specific recommendations for future research and practice in the conclusion.Recommendation: Approve for indexing with minor revisions.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Yes Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Pediatric neurorehabilitation, Neonatal intensive care unit , pelvic floor dysfunction and physiotherapy I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
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1 ) 1 )
The therapist always does their best to keep me from worrying 103 (100.0)0 (0.0) (0.0) When my child receives medical care, the physiotherapist should pay more attention to our privacy.101 (98.1) 0 (0.0) (2.0)During my child's initial visit, the physiotherapist took time to listen to my explanation about my child'During my child's medical visits, I am always allowed to say everything that I think is important 100 (97.1) 3 (2.9)(0.0)The physiotherapist sometimes ignored what I told them 1 (1.0) 0 (0.0) (99.1)The physiotherapist listened carefully to what I had to say 102 (99.0) 1 (1.0) (0.0) I was allowed to contribute to my child's care 26 (25.2) 1 (1.0) (73.8)

Table 1 .
Sociodemographic characteristics of participants' children.

Table 2 .
Total and domain satisfaction scores.

Table 3 .
Satisfaction scores for all items.

the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests:
Satisfaction data -with items recoded.tab:Thisfile contains the socio-demographic and QoL variables.Data are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).evaluation of quality of physical therapy services provided in Federal Medical Centre, Yenagoa, Bayelsa State.Yen.Med.J. 2021; 3(2): 116-123.28.Adhikari M, Paudel NR, Mishra SR, et al.: Patient satisfaction and its socio-demographic correlates in a tertiary public hospital in Nepal: a cross-sectional study.BMC Health Serv.Res.2021;21(1): 135.PubMed Abstract|Publisher Full Text|Free Full Text 29.Al-Yateem N: Replication Data for: Parents' satisfaction with physiotherapy services for neuropediatric outpatients in Government and Private Hospitals in the United Arab Emirates: a cross-sectional study.Harvard Dataverse.2024;V1.UNF:6:Xi +hkuwus7MBMEgHNzqnKw== [fileUNF].Publisher Full Textaddressing these areas and discussing the implications for policy and practice in more detail.6. Comparing the findings with similar studies in other regions would offer a broader perspective.7. The conclusion succinctly summarizes the main findings and their implications, emphasizing the need for ongoing assessment and improvement of physiotherapy services.Including specific recommendations for future research and practice would strengthen the conclusion.No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
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