The Relationship between Fulfilling Privacy Needs and Service Satisfaction in Adolescents with Chronic Illness Conditions in the Inpatient Room

Privacy needs for adolescents with chronic disease conditions are important, including secure information, psychological information, and social privacy. Violations against privacy will bring discomfort, stress, and dissatisfaction. Patients' satisfaction is one of the most important indicators that show the quality of ward services that include the dimensions of tangibility, reliability, responsiveness, assurance, and empathy. This study was conducted to analyze the relationship between the fulfillment of privacy needs and service satisfaction in adolescents with hospitalized chronic conditions. This correlational study was conducted using a cross-sectional approach. Samples were 72 adolescents aged 12-21 years with chronic disease conditions were selected using the consecutive sampling method. Data of this study were collected using questionnaires. Bivariate data analysis was performed using chi-square analysis. The results showed that the most unfulfilled need for privacy security was information privacy (70.8%), followed by psychological privacy (63.9%), physical privacy (58.3%), and the least unfulfilled one was social privacy (51.4%). Respondents were most dissatisfied with the dimension of empathy (87.5%), followed by assurance (84.7%), reliability (83.3%), tangibility (80.6%), and responsiveness (76.4%). This study also confirmed a meaningful relationship between service satisfaction with information privacy (p-value <0.001) and physical privacy (p-value 0.021 <0.05). Whereas service satisfaction is associated with neither psychological privacy nor social privacy. The role of nurses is very important in carrying out patient-centered care, especially


INTRODUCTION
Adolescence is a critical period in every individual's life, marked by significant biological, physical, psychological, and emotional changes.Adolescence is a period when an individual experiences significant changes in social roles, social relationships, and social expectations, which is the basis for the function of maturity.Adolescents are individuals with an age range of 12-21 years (Sanders, 2013).Many behaviors and health conditions affect health in adolescence, one of which is a chronic disease.Adolescence is a transition from childhood to adulthood that goes from childhood to adulthood, dependence to independence.This matter shows a sense of autonomy and a desire to build their identity (Sumartini & Maretha, 2020) Adolescents with chronic disease conditions as much as 10-20% in the world and as much as 20-30% in western countries, one of which is in the UK around 800,000 adolescents have Asthma, 63,000 have epilepsy, 35,000 suffer from diabetes mellitus, 2,500 have arthritis, and 2,200 have cancer annually.Teenagers in Indonesia suffer from Asthma as much as 15.2%, suffer from diabetes mellitus as much as 2.1%, suffer from heart failure as much as 0.3%, suffer from cancer as much as 1.6%, and suffer from arthritis as much as 18.1% (RISKESDAS, 2013).The number of adolescents in Lebak Regency is 32,598, about 3,627 adolescents/year are treated at Dr. A Hospital is one of them with chronic disease conditions including Asthma as much as 3.4%, diabetes mellitus by 3%, epilepsy as much as 3.5%, cancer as much as 5%, arthritis as much as 1.4%, heart disease as much as 3.8%, and chronic failure kidneys as much as 3.6% (Rangkasbitung, 2017).
Adolescents with chronic disease conditions experience changes in physical, cognitive, social, emotional, psychological development and decreased involvement in school, reducing the quality of life of adolescents (Nurhidayah et al., 2016).Physical changes that occur have a negative impact on the appearance and function of the body, one of which is the side effect of the treatment being undertaken by adolescents with cancer which has affected their appearance due to hair loss, changes in body weight, and amputations.Thus, the negative impact on appearance affects the body image of adolescents.
According to (Atoui et al., 2015), physical development changes impact bodily functions that cause conditions with physical limitations that are restrictions on participating in normal activities accompanied by psychological changes with the emergence of sadness and frustration among adolescents creating an isolated environment.The reduced involvement of adolescents in school will reduce their ability to socialize in group activities with peers, reduce participation inclass learning activities, sports activities, and experience difficulty concentrating.
The theory of psychosocial development, according to Erikson (1968) in (Zhang, 2015) adolescents have a psychosocial developmental stage of identity.Identity is a unity that gives a person to lead to satisfaction in life and to recognize and be recognized as a unique individual (Kroger, 2015).Satisfaction is one of the most important indicators that show the efficiency and quality of inpatient services at the hospital because patients act as contributors, reformers, and targets in determining service quality.
The quality of health services is the level of perfection of health services that can satisfy health service users in accordance with norms, ethics, and law.Patient satisfaction at the hospital can be measured using service quality with the SERVQUAL model, which consists of five dimensions: tangibles, reliability, responsiveness, assurance, and empathy (Fan L. et al., 2017).This cross-sectional study conducted by (Wei et al., 2015) aims to develop a reliable and practical questionnaire to assess patient satisfaction in hospitalization in China, saying that four factors affect satisfaction, including the quality of doctor care, the quality of nurse care, quality of environment and facilities, and comprehensive quality with a Cronbach alpha coefficient for each dimension> 0.7 and correlation between subscales 0.72 -0.83 with a satisfaction level of 89.6%.Meanwhile, according to (Batbaatar et al., 2017), the factors that affect satisfaction include factors of health care service providers and patient characteristics.Interpersonal care is a factor that influences increasing adolescent satisfaction in respecting patients by maintaining privacy has a major effect on patient satisfaction as much as 41%.Teenagers will feel valued, confident, comfortable, and able to make decisions that lead to positive results, namely their satisfaction while undergoing treatment at the hospital.
The quality of service that is effective and better in providing satisfaction is illustrated by meeting the patient's needs (Al-Abri & Al-Balushi, 2014).Adolescents with chronic diseases have educational needs, information needs, leisure time needs, physical space needs, interaction needs with medical personnel, and the needs of special youth wards, which are very important and must be managed in privacy (Al-Yateem et al., 2016;Moruno Miralles et al., 2016).The need for privacy is a basic right that every individual has by providing a sense of security against disturbances that arise in a person's personality, such as disorders of the mind, feelings, and body.The special care performed by health workers in carrying out examination procedures sometimes violates patient privacy.Privacy is a person's feeling of identity, dignity, freedom, and personal space that will cause anxiety, distrust and lead to judgment if there is a violation against the patient.The impact of this violation of the need for privacy causes discomfort and stress.However, privacy also has a positive impact on adolescents by directly creating trust in health service providers that affects adolescent behavior towards the quality of health and safety care services and improves welfare (Jamalimoghadam et al., 2019).
The above statement is supported by research conducted by (Jamalimoghadam et al., 2019) which states that nurses in caring for adolescents without paying attention to privacy will have a negative impact on mental stress, anxiety, and shame.In addition to the mental impact, it will affect physical health and youthful lack of trust in nurses in the treatment process at the hospital.Meanwhile, most of the nurses in carrying out their care have less knowledge, skills and attitudes in giving respect to adolescents.Adolescents consider the need for privacy is very important, which is one of their hopes for health care providers to build trust and comfort in the care environment (Daley et al., 2017).Teens have expressed disappointment with service providers regarding unattended privacy.So that education is needed for all staff about the privacy needs of adolescents.This research is in line with research conducted by (Ama-Amadasun, 2016) which states that as many as 60% of nurses do not maintain confidentiality regarding patient medical information.
Research on the relationship between privacy and satisfaction will be investigated by the differences in research locations, namely in the inpatient room and adolescents with chronic disease conditions.Fulfilling the privacy needs is very important to increase service satisfaction for adolescents with chronic disease conditions to achieve prosperity in the inpatient room.If the need for privacy is not met, it will cause discomfort and stress to the teenager while being treated.Therefore, this study was conducted to see the relationship between fulfilling privacy needs and service satisfaction in adolescents with chronic disease conditions in the inpatient room.

Research Design
The method in this research is using quantitative methods with a correlational study type with a cross-sectional design.The research was conducted to find the relationship between the independent variables, namely the fulfillment of privacy needs, with the dependent variable, namely service satisfaction in adolescents with chronic disease conditions in the inpatient room.

Population and Sample
The population in this study were 243 adolescents (12-21 years) with chronic disease conditions, namely asthma, diabetes mellitus, arthritis, epilepsy, cancer, heart disease, and chronic renal failure based on medical records in 2017 in the inpatient room at one public hospital.The sample in this study were adolescents with chronic disease conditions such as Asthma, diabetes mellitus, arthritis, epilepsy, cancer, heart disease, and chronic kidney failure in the inpatient room at one public hospital as many as 72 respondents, sampling size with categorical descriptive formula and sample technique with consecutive sampling.The research process was carried out from March 2019 -June 2019.

Instrument
The research was conducted using two instruments, namely the Privacy questionnaire and a service satisfaction questionnaire.Privacy questionnaire This privacy needs questionnaire looks at whether the privacy needs are met or not met, including four dimensions: information privacy, physical privacy, psychological privacy, and social privacy.The value of validity 0,361 and reliability 0,7.The privacy questionnaire is a questionnaire that has been used abroad and has been developed by (Sarenko, 2013).The questionnaire consisted of 25 statements covering information privacy as many as 8 statement items, seven physical privacy statement items, 6 statement items for psychological privacy, and 4 statement items for social privacy.The service satisfaction questionnaire used is a satisfaction questionnaire which will be used based on the theory of service quality or SERVQUAL from Parasuraman and Berry (1985) which was made by the researchers themselves.To see service satisfaction on the satisfaction questionnaire by looking at the level of conformity between expectations and reality.The level of conformity is the result of a comparison between the value of reality, and expectation.The service satisfaction questionnaire consists of 40 statement items of reality and 39 items of statement of expectation in five dimensions consisting of tangibles of 7 items of statement of reality and seven items of statement of expectation, reliability of 8 items of statement of hope, and eight items of statement of expectation, eight items of statement of expectation and eight items of responsiveness.Statement of expectation items, assurance eight items of statement of expectation and eight items of statement of expectation, and empathy of 8 items of statement of hope and eight items of statement of expectation.The questionnaire with back-translation technique this technique is done by translating the instrument from the original source language into the target language, after that it is translated back to the source language by a translator who does not know the original wording.

Data analysis
Univariate analysis using frequency distribution and presentation.The data normality test used the Kolmogorov Smirnov test (n> 50).The results obtained from the p-value data of the four sub-variables and variables from fulfilling adolescents' privacy needs with chronic disease conditions in the inpatient room is smaller than 0.05, so it can be concluded that all data are not normally distributed.Therefore, in categorizing it, the Cut-off criteria are used based on the Median value because the median value for privacy needs is 50.Bivariate analysis is an analysis conducted to see the relationship between two variables.The bivariate analysis in this study was to determine whether there was a relationship between fulfilling privacy needs and service satisfaction in adolescents with chronic disease conditions in the inpatient room.The type of statistical test used is chi-square.

Ethics Clearance
Research ethics must be carried out in research aimed at protecting the rights (autonomy) of respondents.In general, there are three ethical principles in research, namely the principle of benefit, the principle of respecting human rights (respect human dignity), and the principle of justice.This research has been declared to have passed the ethical test from the research ethics committee of the University of Padjadjaran Bandung on November 8, 2018 with the number 1249/UN6.KEP/EC/2018.

RESULTS
Table 1 shows that the largest percentage of patients were male (53%) and female (47%).For age, the highest percentage of patients was 16 years old (26%), the second-largest was 17 years old (22%), and the third-highest was 15 years (13%).The youngest age was 12 years (6%), and the highest was 21 years (3%).Based on the medical diagnosis suffered by adolescents, the highest percentage had a medical diagnosis of Asthma (32%), the second and third most were CHF and DM (24% each).The length of hospitalization passed by the patient was seven days (24%), the second-highest was three days (17%), and the third-highest was 4 and 5 days (15% respectively).For the duration of being diagnosed, new patients were diagnosed (28%), the second most had been diagnosed since two years earlier (26%), and the third most had been diagnosed since three years ago (17%).More than half of the patients were not treated for the first time (69%), and the remaining 31% were treated for the first time (31%).Table 2 shows that most of the respondents stated that their privacy needs were not fulfilled (79.2%), and the rest were stated that their privacy needs were fulfilled (20.8%).The following table presents the fulfillment of privacy needs seeing from each sub variable.It is known that more than half of the respondents are not fulfilled in fulfilling their information privacy needs (70.8%), more than half of them are not fulfilling their physical privacy needs (58.3%), more than half of respondents are not fulfilling their psychological privacy needs (63.9%), and more than half of the respondents did not meet the needs of the fulfillment of social privacy (51.4%).This shows that the four sub-variables to fulfill the need for privacy are declared unfulfilled in more than half of the respondents.Based on Table 3, it is known that more than half of the respondents were declared unsatisfied with the services provided (86.1%), and the rest were stated to be satisfied with the services provided (13.9%).In the following table, Service Satisfaction is presented as seen from each sub variable.Based on Table 4, it is known that the majority of respondents were declared dissatisfied with the tangibles dimension (80.6%), the majority of respondents were declared dissatisfied with the reliability dimension (83.3%), the majority of respondents were declared dissatisfied with the responsiveness dimension (76.4%),The majority of respondents were stated to be dissatisfied with the assurance dimension (84.7%), and the majority of respondents stated that they were dissatisfied with the empathy dimension (87.5%).This shows that the majority of respondents are not satisfied with the five sub-variables of service satisfaction.Based on Table 5, it is known that of the 62 respondents who were dissatisfied with the service, the majority were categorized as not having their privacy needs to be met (88.7%), while of the ten respondents who expressed satisfaction with the service, the majority were categorized as having their privacy needs met (80%).This is confirmed by the p-value obtained from the Chi-Square test of <0.001, which is much smaller than 0.05, which can be concluded that there is a significant relationship between fulfilling privacy needs and service satisfaction.If the fulfillment of privacy needs is met, it will be closely related to respondent satisfaction with the services received.it is known that of the four dimensions of the need for privacy, two of them are stated to have a significant relationship with service satisfaction, namely the dimensions of information privacy and the dimensions of physical privacy.

DISCUSSION Fulfilling the Privacy Needs of Adolescent Chronic Disease Conditions in the Inpatient Room
The privacy needs of adolescents with chronic disease conditions in the inpatient room were measured using the Privacy instrument questionnaire, which was modified by the researcher covering four dimensions of privacy, namely information privacy, physical privacy, psychological privacy, and social privacy.The results showed that the fulfillment of adolescent privacy needs with chronic disease conditions in the inpatient room, for the most part, did not meet their privacy needs as much as 79.2% of respondents.Meeting the privacy needs consists of 4 dimensions: information privacy, physical privacy, psychological privacy, and social privacy.Adolescents with chronic disease conditions in this study had the most privacy needs that were not fulfilled, namely information privacy as much as 70.8%, followed by psychological privacy as much as 63.9%, physical privacy with 58.3%, and the least being met was social privacy as many as 51, 4%.
The results show that information privacy that is not fulfilled is more than the research, namely 52.2%.The research which was conducted in one public hospital shows that adolescents with chronic disease conditions prefer to keep their condition a secret because confidential information is very important for adolescents who are being cared for as well as being the basis for the availability of adolescents to get treatment.The research showed that as many as 63.9% of adolescents with chronic conditions had not fulfilled their psychological privacy.
The fulfillment of physical privacy needs is not fulfilled, namely as much as 63.5%.The need for physical privacy that was not fulfilled in this study occurred because the nurses did not knock on the door or the nurses did not ask permission as much as 81.1% and the nurses did not close the curtains around the patient's bed or the door that was left open at the time of the examination on the patient as much as 40%.Physical privacy is not fulfilled due to the patient's inconvenience while undergoing treatment, including not closing doors or curtains during procedures, not avoiding unnecessary touching of the patient's body, not closing parts of the patient's body that are not required to be examined, not knocking on the door when entering the room patients, and do not ask permission when they want to do an examination or treatment (Valizadeh & Ghasemi, 2020).
The research shows that the social privacy of adolescents with chronic disease conditions was 51.4% which was not fulfilled.These results indicate that physical privacy in adolescents with chronic disease conditions is most fulfilled compared to the dimensions of information, psychological and physical.Research by (Ferri et al., 2015) shows that 26.5% of their social privacy is not fulfilled.

Service Satisfaction in Adolescents with Chronic Diseases Conditions in the Inpatient Room
The results showed that service satisfaction in adolescents with chronic disease conditions in the inpatient room, more than half of the respondents were not satisfied with the services provided as much as 86.1%.Service satisfaction in this study includes five dimensions, namely tangibles, reliability, responsiveness, assurance, and empathy.Respondents were the most dissatisfied in the empathy dimension as much as 87.5%, the second-order of assurance dimensions was 84.7%, the third-order was the reliability dimension of 83.3%, the fourth order was the tangibles dimension as much as 80.6%, and the fifth was the responsiveness dimension as much as 76.4%.
This study showed that there were fewer patients who were dissatisfied at the time of being hospitalized.Patient satisfaction is an indicator of the quality of care that affects various factors and strongly influences adherence to health care, especially for adolescents (Dagnew et al., 2015).Research conducted by (Alghamdi, 2014) shows results with a value of β = 0.476, namely that the empathy dimension has a major influence on patient satisfaction.Meanwhile, the research results showed that most adolescents with chronic disease conditions are not satisfied with the dimension of empathy.This is due to the nurse's lack of concern for the patient is feeling and understanding what the patient needs when he is hospitalized.
Adolescents will feel satisfied in undergoing treatment in the inpatient room on the Assurance dimension if the nurse guarantees the confidentiality of adolescent information, friendliness, and the ability to build patient trust in nurses.Adolescents undergoing treatment usually feel uncomfortable disclosing health problems and worry about confidentiality, especially for adolescents with chronic disease conditions.However, adolescents will reveal their health problems if nurses build trust so that they will build trust in adolescents (Dagnew et al., 2015).
It can be seen from the results of research conducted by (Dagnew et al., 2015) showing that as many as 73.7% of patients were satisfied with the nurse's attitude in ensuring the confidentiality of information about the patient's health condition, as many as 79% of patients were satisfied because the nurse was doing the treatment.Behave in a friendly manner, and the patient's trust has been built because privacy has been guaranteed with a value of 2.9 times (AOR = 2.9, 95% CI: 1.4, 5.6).This research shows that there are fewer dissatisfied patients compared to the research conducted in the hospital, which is only 15.3% of adolescents with chronic disease conditions who are satisfied with the assurance dimension.Patient satisfaction on the Reliability dimension if the nurse promises treatment to the patient with the nurse's skills to convince the patient.Research conducted by (Dagnew et al., 2015) showed that 66.7% of patients were satisfied with the skills of nurses and did not doubt it during treatment.This shows that the results are more satisfactory than the research conducted.
The Tangibles dimension in this study shows that 30.5% of adolescents with chronic disease conditions are dissatisfied with the physical environment of the treatment room.This shows that there are fewer dissatisfied patients compared to the research conducted in the hospital.The results of research conducted by researchers showed that 76.4% were dissatisfied with the Responsiveness dimension.Research conducted shows the results of adolescents with chronic disease conditions are less dissatisfied than other satisfaction dimensions.Patient satisfaction is the patient's perception of effective, useful, and beneficial health services as well as the patient's assessment of nurses in meeting patient needs.

The Relationship between Fulfilling Privacy Needs and Service Satisfaction in Adolescents with Chronic Disease Conditions in the Inpatient Room
The bivariate analysis results using the Chi-Square test found a significant relationship between fulfilling privacy needs and service satisfaction (p = <0.001).The research results mean that if the fulfillment of privacy needs is met, it will be closely related to respondent satisfaction with the services received.

Dimensions Relationship between Information Privacy Needs and Service Satisfaction
Information privacy has a very significant relationship with service satisfaction (p-value <0.001),where respondents who are not satisfied with the majority of services have their information privacy not fulfilled (80.6%).In comparison, respondents who are satisfied with the majority of services have their information privacy needs fulfilled (90%).
This study is in line with the research conducted by (Nayeri & Aghajani, 2010) in Iran, which shows that information privacy has a relatively strong and significant relationship with patient satisfaction with a p-value <0.0001,where the patient's information privacy is not fulfilled (58.6%).).This happens because information about the patient's health is known by other people from conversations between nurses and patients heard by other patients.(Kaushansky et al., 2017) show that as many as 49% of patients consider that with chronic disease, information about their condition is essential to keep private because they have poor health conditions compared to healthy adolescents so that they feel embarrassed if known by others.

The Relationship between the Dimensions of Meeting the Need for Physical Privacy and Service Satisfaction
Physical privacy has a significant relationship with service satisfaction (p-value 0.021 <0.05),where respondents who are not satisfied with the majority of services have no physical privacy (64.5%).In contrast, respondents who are satisfied with the majority of services have their privacy needs fulfilled physically (80%).
This study is in line with the research conducted by (Nayeri & Aghajani, 2010) in Iran, which shows that physical privacy has a relatively strong and significant relationship with patient satisfaction with a p-value <0.0001, in which patients whose physical privacy is not fulfilled (50.0%) ).This study is supported by a cross-sectional study in Iran conducted by (Hajbaghery, 2014) which shows the results that the patient's physical privacy is fulfilled at a moderate level of 64.2%, so that patient satisfaction is also at a moderate level.
The research results conducted by (Valizadeh & Ghasemi, 2020) show that respecting patient privacy can lead to satisfaction in patients who are in the inpatient room, accelerate the healing process, and reduce hospitalization time.The results showed that as much as 50.8% of physical privacy was not fulfilled, as many as 56.3% said that nurses never closed the curtains during physical examinations or treatments.This research is the same as research conducted by (Valizadeh & Ghasemi, 2020), it was found that only 36.48% of adolescent physical privacy needs were met because, during the examination, the curtains were not closed so that other patients could see when they were examined or care.

The Relationship Dimensions of Psychological Privacy Needs Fulfillment with Service Satisfaction
Psychological privacy is stated to have no significant relationship with service satisfaction (p-value 1,000> 0.05), where respondents who are satisfied or dissatisfied with the majority of services do not have their psychological privacy needs met.
Psychological privacy plays a role in giving patients the opportunity to maintain values, emotions, and thoughts without feeling judged by others, especially health care providers and is involved in the autonomy of decisions to restore self-image, dignity, respect, and value from the patient.Patients with bad conditions, one of them with chronic disease conditions, will have a source of strength over the condition if their individual values are maintained (Sarenko, 2013).Research conducted by (Valizadeh & Ghasemi, 2020) showed that 78% of patients' psychological privacy was not fulfilled when involved in decision making.

The Relationship Dimensions of Meeting Social Privacy Needs with Service Satisfaction
Social privacy is stated to have no significant relationship with service satisfaction (p-value 1,000> 0.05), where respondents who are satisfied or dissatisfied with the majority of services do not have their social privacy needs met.
Research conducted is not in line with research conducted by (Nayeri & Aghajani, 2010) in Iran, which shows that social privacy has a relatively strong and significant relationship with patient satisfaction with a p-value <0.0001,where patients who are not fulfilled social privacy are 32%.Social privacy is an individual control in an interaction, one of which is in health services by paying attention to the frequency, duration, and scope of interaction (Akyüz & Erdemir, 2013).

Implications for Nursing Services
The implication of the results of this study for nursing services for children is to provide information about the relationship between fulfilling privacy needs and service satisfaction for adolescents with chronic disease conditions in the inpatient room.The results of this study can be used as a basis in developing a nursing care plan in an effort to meet patient needs, one of which is the need for privacy which not only pays attention to information privacy but other privacy also includes physical, psychological, and social privacy by implementing patient center care (PCC), namely patient-focused to improve service satisfaction of adolescent chronic disease conditions.

CONCLUSIONS
Based on the results, it can be concluded that service satisfaction in adolescents with chronic disease conditions in the inpatient room was categorized as dissatisfied (86.1%), fulfilling the privacy needs of adolescents with chronic disease conditions in the inpatient room the majority of the unfulfilled category (79.2%) and there is a significant relationship between fulfilling privacy needs and service satisfaction for adolescents with chronic disease conditions.Adolescents who have their privacy needs met tend to be satisfied with the services received (p = 0.000 <0.05)., E., & Erdemir, F. (2013).Surgical patients' and nurses' opinions and expectations about privacy in care.Nursing Ethics, 20(6), 660-671.