附录1外文文献（英文）
Factors affecting public dissatisfaction with urban family physician plan: A general population based study in Fars Province[1]
Abstract
Background:Understanding the level of public satisfaction with a family physician plan as well as the relevant factors in this respect, can be employed as valuable tools in identifying quality of services.
Objective:To determine the factors affecting public dissatisfaction with an urban family physician plan in Iran.
Methods:This cross-sectional study was conducted from January 2014 through June 2015 on Fars Province residents in Iran, selected based on cluster sampling method. The data collection instrument was comprised of a two-part checklist including demographic information and items related to dissatisfaction with the family physician plan, specialists, para-clinic services, pharmacy, physicians on shift work, emergency services, and family physician assistants. Data were described by SPSS 20.
Results:In this study, 1,020 individuals (524 males, 496 females) were investigated. Based on the results, the most frequent factor affecting dissatisfaction with physicians was their single work shifts and unavailability (53%). In terms of dissatisfaction with family physiciansrsquo; specialist colleagues and para-clinic services, the most common factors were related to difficulty in obtaining a referral form (41.5%) and making appointments (21.6%), respectively. Given the level of dissatisfaction with pharmacies, the significant factor was reported to be excessive delay in medication delivery (31.6%); and in terms of physicians on shift work and emergency services, the most important factor was lower work hours for family physicians (9.2%).
Conclusion:It seems that, the most common causes of dissatisfaction with the urban family physician plan are due to the short duration of services, obtaining a referral form and making appointments, and providing prescribed medications.
Keywords: Satisfaction, Family Physician, Referral System
Discussion
Nearly eight years after the onset of the rural family physician plan and its achievements in terms of increased community health and public satisfaction, authorities and policy-makers decided to expand such a plan in the urban system. Therefore, the urban family physician plan was implemented in the provinces of Fars and Mazandaran in 2012. After 2.5 years of implementation of the urban family physician plan, the level of satisfaction in participants was measured in a research study and the results showed that the level of satisfaction with the plan in 15.8% of participants was high, 31.3% of individuals had an average level of satisfaction, and 31.1% had low satisfaction in this respect. With regard to the rights of individuals in the family physician system and their expectations of the plan, a questionnaire was designed in collaboration with policy-makers and directors of the family physician plan, in order to identify the causes of dissatisfaction in the group with a low level of satisfaction (31.1%). In the present study, seven items including family physician competence, time for examination and listening to patientrsquo;s descriptions, access to family physician if required, complexity of referral system, waiting times to receive services, rate of referrals to family physicians, ways to deal with clients in different sectors of the family physician plan (family physicians, specialists, para-clinic services, pharmacy, physicians on work shift and emergency services, colleagues and assistants of family physicians) were investigated. The results of this study indicated that the most frequent cause of dissatisfaction with family physicians was associated with single work shifts and unavailability of physicians particularly on weekends, and visit time limits after 8 p.m. (53%) which was higher than such dissatisfaction level with rural family physicians. The second cause of dissatisfaction was identified as long waiting times to receive services (51%); while, in Slovenia, access to physician services and waiting times for services were recognized as the most and the least frequent factors affecting satisfaction with the family physician plan, respectively. Moreover, 51.6% and 49.1% of Slovenian respondents expressed their satisfaction with counseling time and possibility of raising patient problems with family physicians, respectively. However, in the present study, only 7.7% of participants were dissatisfied with inappropriateness of the method adopted and the time spent to listen to patientsrsquo; descriptions. Such findings revealed the strength of physicians in this field that was consistent with the results of studies conducted in the US as well as those in the rural family physician plan. Difficulty in obtaining a referral form was taken into account as the most common cause of dissatisfaction (41.5%) with specialists, which could reflect weaknesses in culture-building in terms of the referral system among individuals. It should be noted that a very efficient referral system is also dominating in developed countries and there are also concerns about lack of control over bureaucracy and access to specialists, but this issue has not led to any public dissatisfaction. However, insistence and urges by patients for some unnecessary services has become a challenge in the rural family physician plan. The results of previous studies showed that 56% of the referrals were not based on physiciansrsquo;willingness but urges made by patients. This demonstrated that trust and belief in the performance of family physicians was low in society and further investigations have also confirmed this. According to research studies, communication skills training for physicians could hav
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