Indian Journal of Public Health

: 2012  |  Volume : 56  |  Issue : 4  |  Page : 308--313

Evaluating quality of health services in health centres of Zanjan district of Iran

Ali Mohammadi1, Jamshid Mohammadi2,  
1 Department of Public Health, Faculty of Health, Zanjan University of Medical Sciences, Iran
2 Department of Parasitology, Faculty of Medicine, Zanjan University of Medical Sciences, Iran

Correspondence Address:
Ali Mohammadi
Department of Public Health, Faculty of Health, Zanjan University of Medical Sciences


To assess quality of health services in Zanjan health centres based on clients«SQ» expectations and perceptions. The study was conducted by using service quality (SERVQUAL) scale on a sample of 300 females, clients of health care centres in the district of Zanjan, selected by cluster sampling. The results indicated that there were negative quality gaps at five SERVQUAL dimensions. The most and least negative quality gap mean scores were in reliability dimension (-2.1) and tangible (-1.13) respectively. There was statistically significant difference between clients«SQ» perceptions and expectations mean scores at all of the five service quality dimensions (P<0.001). The negative quality gap level in health service dimensions can be used as a guideline for redistribution of resources and managerial attempts to reduce quality gaps and improvement of health care quality.

How to cite this article:
Mohammadi A, Mohammadi J. Evaluating quality of health services in health centres of Zanjan district of Iran.Indian J Public Health 2012;56:308-313

How to cite this URL:
Mohammadi A, Mohammadi J. Evaluating quality of health services in health centres of Zanjan district of Iran. Indian J Public Health [serial online] 2012 [cited 2022 Dec 2 ];56:308-313
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Full Text

District Health System (DHS) provides primary health cares (PHC) to defined population in Iran. The ultimate mission of DHS is the promotion of community well being. [1]

Services quality (SQ) is a key and strategic factor for the efficiency of providers, and competitive advantage, thus it should be measured and improved. [2] Health care services have a distinct position among other services due to the risky nature of service and lack of client knowledge. [3] Superior quality is the desirable target in the sensitive field of health sector, because healthy population is better disposed to achieve economical development. [4],[5],[6]

Service quality in health care is a multidimensional construct. [5],[7] Thus, most studies about quality measurement assess quality based on two perspectives: technical and functional dimensions. In technical dimension, quality is defined according to scientific standards by health professionals; in second perspective, clients have an essential role in assessment of health care quality. [8],[9],[10],[11]

Functional quality refers to the way in which health services are delivered to clients. [7]

When clients perceive high quality of health services, they are more likely to return to the same hospital in the future and recommend it to relatives and friends. [2] To maintain and improve the quality of health service, besides relying on clinical and economic criteria, managers can utilize clients' expectations and perceptions as an important tool in order to trace the weaknesses of health care system. [12] In this research, functional quality was studied by SERVQUAL model. This tool has been widely used in many service industries including education, banking, hospitals, health care and dentistry. [7],[4],[10],[11],[12],[13]

Parasurman et al., (1985) defined services quality as the degree of discrepancy between customers' expectations and their perceptions of performance of a service organization. Expectation means the wants of clients; on the other hand, perception means the consumers' evaluation of the services real experiences. [14] Babakus used the SERVQUAL to assess the magnitude of gap between patient expectations and perceptions. [15]

Most studies of client-perceived quality of services have been conducted in developed countries. [7] Little attention has been paid to the quality of PHC services in developing countries. [9]

The main aim of this paper is evaluation of quality of health services in zanjan health centers based on clients' expectations and perceptions and informing health policy-makers about the strengths and weaknesses of quality of government PHC services, as perceived by clients.

This descriptive cross -sectional study was implemented in 2009. Study population were female of services user of health centers, in the district of zanjan, in north-west of Iran. In health centers, married females, have health files and receive systematic and continuous health services (such as: continuous health care during pregnancy, immunization, family planning etc, they usually have a dominant role in taking care of their family health, hence they had experience of services from health centers and were included.

Samples were selected out of households covered by health centers. The number of household file was used to select the household whose female was to be interviewed. Random cluster sampling was utilized, and within clusters simple random (two- stage sampling) was used. Each health center with the coverage of defined population was considered as one cluster. In stage one of cluster sampling, a sample of 15 out of health centers (5 rural and 10 urban) was selected from 3o clusters. Then in stage two, 20 female with health files were selected by simple random sampling from each cluster.

For calculating sample size, range of difference between questionnaire items (-4 to 4) was used for estimating standard deviation ( s d ), and taking α = 0.01 and precise value(d) of mean difference equal with 0.4, sample size was calculated by the following formula:


Thus, sample size for either of rural and urban community was approximately equal to 150 and total sample size was equal to 300. Since population of rural community was one third (1/3) of urban community, so sample of 100 was considered to be appropriate for rural community.

Modified SERVQUAL scale was used for data collection.

The Original scale has five generic dimensions or factors and are stated as follows (2004):

Tangibles. Physical facilities, equipment and appearance of personnelReliability. Ability to perform the promised service dependably and accurately Responsiveness. Willingness of employees to help customers and provide prompt serviceAssurance (including competence, courtesy and security). Knowledge and courtesy of employees and their ability to inspire trust and confidenceEmpathy (including access, communication, understanding the customer). Caring and individualized attention that the firm provides to its customers. [16] Prior to the actual collection of the data, the questionnaire was pretested with 15 clients of health centre to clarify potential areas of misinterpretation and administration. Changes were made to adapt it to a health setting. The final SERVQUAL scale was performed with twenty two items measuring five dimensions of service quality: Reliability (five items), responsiveness (four items), assurance (four items), empathy (five items) and tangibles (four items).

Clients (females) were interviewed by one of trained interviewers. Two interviewers were university graduates and had received necessary training on interviewing techniques and were the local residents and spoke the local dialect.

The clients were first asked to rate quality of the health service delivered by health centers (client perception of current services), to do so, they were asked to select one response in each item including very good, good, average, poor, and very poor. Then they were asked to rate how important each item was to the quality of service provided (client's expectation of optimal services), in order to do this, client selected one response in each item including very important, important, moderate, less and least important. Five - point Likert scale was used, where (5) was very important/very good and (1) represented least important/very poor.

The clients were told that the most important is equal to the highest expectation and the least important is equal to the lowest expectation here. The scores of perceptions and expectations of clients in each dimension were from 1 to 5. The difference between perceptions (P) and expectations (E), (P-E=Q) represents the measure of SQ. When SQ is negative, there is service quality gap.

The clients were informed clearly about objectives and procedures of the study.

Cronbach alpha was used to calculate the reliability of measurement scale. Alpha coefficients of tangibility, assurance, responsiveness, empathy and reliability dimensions were 0.8, 0.89, 0.87, 0.84 and 0.90 respectively. All coefficients were more than the minimum level acceptable 0.7. In order to assess the content validity of the questionnaire items, a copy of it was sent to professionals with experience in health field. Their points of view were considered in developing final version of Farsi questionnaire. SPSS 11.5 for windows was used to analyze the data. Mean scores of perceptions and expectations were used to compare clients' perceptions and expectations of health service quality. The gap was calculated using SERVQUAL equation:

Service quality (Q) = perception (p)-expectation (E).

Paired-t test, Willcoxon and Friedman were used for analysis of significance of the data.

The age mean of clients was 28.4 years; age range of the clients was 15-49 years. 44.7% of the clients were housewives, 28% were employees and the rest were involved in private sector. The results indicated that there were negative quality gaps at five SERVQUAL dimensions. Clients' expectations have not been achieved at any of health services dimensions. The most negative quality gap mean was in the reliability dimension and the least negative quality gap mean was in tangibles [Table 1]. There were significant difference between clients' perceptions and expectations at all of the five service quality dimensions. (P<0.001) Also, statistically there were significant differences between negative quality gaps in the entire five service quality dimensions (Friedman test: X 2 =39.5 P<0.01) from clients point of view.{Table 1}

Wilcoxon test showed that the differences between negative quality gaps at all dimensions were significant except between assurance and tangibles, and between empathy and reliability. (P<0.01)

These dimensions with regard to theirs negative quality gaps and Wilcoxon test between dimensions, can be classified into three groups, so that the reliability dimension is placed in the first group, responsiveness and empathy dimensions are placed in the second group ,and the assurance and tangible dimensions are placed in the third group. Also, the results showed that in all of the items there were negative quality gaps. There were significant differences between perceptions and expectations of clients in all of the items of health services quality. (P<0.001) [Table 2].{Table 2}

The aim of this study was to assess the quality gap of health services using SERVQUAL instrument from the point of views of clients of zanjan health centers. As the findings show, in all of the five service quality dimensions, there were negative quality gap. Negative quality gap means the clients' expectations exceeded their perceptions, indicating dissatisfaction among the clients. Thus, there is room for improvements in all of the service quality dimensions in this study; the greatest and the least negative quality gap were in the reliability and tangible dimensions respectively.

The findings of this study confirm the results of Youssef et al., study in NHS hospitals, Lee et al., study about quality of nursing services, De man et al., study in nuclear medicine. In all of above studies, the reliability was the most important dimension of service quality. [2],[5],[7]

In the study of Youssef et al., in NHS hospitals, patients rated reliability as the most important dimension of service. [5] In the study of Lee, the highest expectations and perceptions rating were in the dimension of reliability. Patients rated the empathy, responsiveness and assurance the second to fourth, respectively. [2]

This study shows that zanjan health center clients' expectations are similar to the study of Lee et al., where patients emphasized the importance of reliability. In the study of De man et al., the reliability dimension was strongly associated with overall patient satisfaction. [7] In the study of Karydis et al., the largest quality gap was observed in dimensions of responsiveness, followed by empathy and reliability. [6] In the study of Baltussen et al., in Burkina Faso, clients of health centres perceived items related to health personnel conduct negatively, this problem rarely received attention by health planners who seem to focus more on technical aspects of quality. [17]

The results of Hansen et al., study, in Afghanistan PHC, thoroughness taking history, conducting examination and communicating with patients were the strongest determinant of clients' perceived quality; the clients were sensitive to amount of waiting time. [18]

In the study of Karassavidou et al., about SQ in Greek NHS hospitals, among the three dimensions, expectations were the highest for the human factor, the dimension that covers the issues of caring, trust, inspiring security, responsiveness and competence. [12]

In the study of Tomes et al., about SQ in UK NHS hospital, patients agreed strongly that the doctors should receive the complete case history from patients, be able to gain the trust of their patients, they would also like that their doctors to treat them with respect and explain medical matters in layman's language. [19]

In present study, the greatest negative quality gap was in the reliability dimension. This dimension indicates the ability of health centers to provide health care accurately and dependably at the first time. It also reflects the delivery of health services by promised time and keeps records without mistake. The greatest negative quality gap in this dimension and its items indicate that health care is not provided correctly and the clients await a long time before receiving health service.

Negative quality gap in other dimensions indicate that clients' expectations have not been fulfilled well. The least negative quality gap was in tangible dimensions. Studies of Duong et al., in Vietnam showed that the physical environment of health setting can impact on client-perceived quality of care. [8]

The results of Hansen et al., study showed that clients' perceptions of quality were sensitive to the waiting time and physical conditions of the health facility. Service capacity and the availability of equipment or drugs were associated with client perceptions of quality. [18]

The negative quality gap in health service dimensions can be used as a guideline for planning, policy-making and reallocation of resources, the five service quality dimensions can be classified into three priority groups for redistribution of resources and managerial attempts to reduce quality gaps, so that the reliability dimension would be the first priority, empathy and responsiveness would be placed in the second priority and tangible and assurance would be placed in the third priority.

If health policy-makers and managers of district health services consider the above mentioned priorities, the improvement of health care quality will be resulted. With regard to the view points of clients and negative quality gap in each of the service quality dimensions, the following hints are suggested for improving service quality: empowering staff for delivery of high quality health care, holding educational workshops on correct filing skills, increasing staff of health centers, and considering needs of health staff and rewarding them. It is recommended that future research focus on the measures to improve quality of health services and minimize the gaps between different aspects of services.

Due to the diversity of culture and differences of health levels in other Iranian districts, having different equipment, staff and facilities, the findings of this study may be useful for other health systems, but it cannot be generalized to all DHSs. It is recommended that other DHS in Iran carry out a similar study, so that a comprehensive model is designed for policy-making and planning.


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