Climate change is the greatest environmental challenge facing the world today. Rising global temperatures will bring changes in weather patterns, rising sea levels and increased frequency and intensity of extreme weather.

Since the 1980s, the outcomes of climatic change on human health have received more attention. WHO expects the excess risk from climate change to more than double by 2030. Although these estimates are highly uncertain, they make the point that the potential impacts of future climate change on human health are likely to be considerable (Huntingford, Hemming, Gash, Gedney, & Nuttall, 2007).

There are several mechanisms by which climate can affect health. Extremes of temperature and rainfall, such as heat waves, floods and drought, have direct immediate effects on mortality as well as longer term effects. For example, populations that have experienced flooding may suffer from sustained increases in common mental disorders. Climate change is also likely to affect biodiversity and the ecosystem goods and services that we rely on for human health. Changes in temperature and rainfall may also affect the distribution of disease vectors, e.g. those of malaria and dengue, and the incidence of diarrhoeal diseases. Climate can affect levels of air pollutants, for example tropospheric ozone pollution may be higher in some areas of Europe, and lower in others but the relationships are still imperfectly understood. Sea level rise is likely to threaten low lying coastal populations, particularly in countries where economic conditions do not allow construction of sea defences and other counter measures. There are also concerns that flooding, drought and environmental degradation associated with climate change may lead to population displacement and more environmental refugees (Haines, Kovats, Campbell-Lendrum, & Corvalan, 2006).

The impact of global warming is already evident in Indonesia and will likely worsen due to further human-induced climate change (WWF, 2007). The combination of high population density and high levels of biodiversity, together with a staggering 80,000 kilometres of coastline and 17,500 islands, makes Indonesia one of the most vulnerable countries to the impacts of climate change especially for health population. This paper will discuss the climate change have a negative impacts to population health in Indonesia.

1. The Effects of Climate change for health population in Indonesia

Climate change is the increase in the average temperature of the earth’s near-surface air and oceans in recent decades, and its projected continuation.

The World Health Organization (WHO) latest report stated that climate change would bring severe risks to developing countries such as Indonesia and have negative implications for achieving the health-related Millennium Development Goals (MDG) and for health equity. (IRIN, 2008).

Observations of short-term variations in climate or weather show that even small temperature increases and precipitation changes can result in measurable impacts on malaria, diarrhoeal episodes and injuries related to floods, and malnutrition. Knowledge of these relationships allows approximate estimates of the health effects of past and future climate change to be made.

2.1. Climate change and infection diseases

A growing number of studies present evidence for the effects of observed climate change on vector borne and other infectious diseases.

Changes in climate that can affect the transmission of vector-borne infectious diseases include temperature, humidity, altered rainfall, soil moisture and sea level rise (Haines, Kovats, Campbell-Lendrum, & Corvalan, 2006). These diseases, according to the WHO report, include some of the significant killers, including malaria, dengue fever and other infections carried by insect vectors. The latest data from the Health Ministry for 2007 show 700 deaths from malaria and 1,570 from dengue fever, but many more go unrecorded (IRIN, 2008).

Communities in Indonesia have traditionally considered the transition from the dry to wet season, the pancaroba, as a dangerous period, and older people would caution the young to take extra care. Climate change will heighten the risk for young and old alike by allowing mosquitoes to spread to new areas. This was demonstrated in the 1997 El Niño, when mosquitoes moved to higher altitudes in the highlands of Papua. Higher temperatures could also cause some viruses to mutate as may already have happened with the dengue virus, making the disease more difficult to treat. Dengue cases in Indonesia have also been found to increase significantly in La Niña years (Figure 1).

Other health problems caused by climate change include acute respiratory infections, bronchial asthma, bronchitis, and eye and skin irritation. The 1997 fires in eight provinces resulted in around 9 million cases of respiratory infections (UNDP Indonesia, 2007).

2.2. Climate change and Malnutrition’s

Food security in Indonesia will be threatened by climate change. Perhaps the largest concern for Indonesia with regards to the impacts of climate change is the risk of decreased food security. Climate change will alter precipitation, evaporation, run-off water and soil moisture; hence will have effects on agriculture and thus food security (Agus, Martha, Ria, Rizka, & Wisnu, 2007).

Poor communities are thus likely to suffer as a result of climate change. A clear illustration of the effects of climatic disaster on poor communities comes from Indramayu in West Java a district that, during an El Niño, usually experiences a drought. Figure 2 shows the levels of poverty in a normal year, 2001, compared with an El Niño in year 2003. This will be the combined result of climate changes along with rises in the prices of food and fuel.

Figure 2. Proportion of households living in poverty in Indramayu, West Java, Indonesia, 2001 and 2003.

Source: UNDP Indonesia, 2007

The poorest regions are also likely to suffer food shortages. In Nusa Tenggara Timur, West Timor, East Sumba and the islands east of Flores, many communities are already acutely vulnerable to climatic variations with poor soils that degrade during the erratic rainfall and longer droughts of El Niño years. More than one third of the population in many of these areas are below the poverty line. In the El Niño years of 2002 and 2005, around one quarter of children under five suffered from acute malnutrition, compared to 8 to 12 percent in a non-El Niño year. In Belu district, Nusa Tenggara Timur, for example the district with the lowest rainfall in Indonesia a long drought followed by crop failure has had severe consequences. Malnutrition is widespread across the province between 32 and 50 percent (Johan & Damayanti, 2007).

2.3. Climate change and health environment

There is some evidence for changes in frequency of weather extremes over recent decades. Many health outcomes are sensitive to isolated extreme events (e.g. heavy rainfall and high temperatures).

Changing rainfall patterns are reducing the availability of water for irrigation or for drinking. In Lombok and Sumbawa islands, between 1985 and 2006, the number of water sources for irrigation and drinking water fell from 580 to 180. Meanwhile, the islands are also suffering from ‘season breaks’ droughts during wet seasons which have now become much more common, leading to crop failure. Across the country, many more rivers now have much lower flows, such as the Ular in North Sumatra, the Tondano in North Sulawesi, the Citarum in West Java, the Brantas in East Java, the Ciliwung-Katulampa in West Java, the Barito-Muara Teweh in Central Kalimantan, and the Larona-Warau in South Sulawesi (WWF Indonesia, 2007). In coastal areas, the loss of groundwater combined with rising sea levels will also allow more sea water to intrude contaminating water resources for both drinking and irrigation.

More than 100 million people in Indonesia lack access to safe drinking water. Contaminated water is a major cause of such illnesses as diarrhoea, the second leading cause of death for children under age 5 in the country (McConnell, 2007). Up to 75 percent of people in Klaten lack clean water for drink. The effects on their health are diarrhoeal and skin infections (IRIN, 2008). The incidence of diarrhoea, which if untreated can kill people.

2.4. Disaster and health population post disaster

Disasters have a variety of health impacts. These range from immediate effects of physical injury and morbidity and mortality through to potentially long lasting effects on mental health.

Indonesia, a sprawling archipelago nation, is one of the world’s largest contributors of carbon dioxide emissions, thanks to the rapid pace of deforestation. But experts say the country is also at risk of becoming one of the biggest victims of climate change. Rising sea waters especially pose a threat to coastal cities like Jakarta, which has sunk at least 7 feet in the last three decades because of excessive ground water extraction (cnn.com, 2008). Following floods, increases in diarrhoeal and respiratory diseases are reported.

Heavy rains in the first week of February 2007 caused massive flooding in the Indonesian capital of Jakarta, affecting more than 340,000 people, damaging public utilities and disrupting livelihoods. All five districts of Jakarta were affected by the flooding as well as Tangerang and Bekasi, two cities close to Jakarta.

In a large study undertaken in Indonesia in 1992-1993, flooding was identified as a significant risk factor for diarrheal illnesses caused by Salmonella enterica serotype Paratyphi A (paratyphoid fever). In a separate evaluation of risk factors for infection with Cryptosporidium parvum in Indonesia in 2001-2003, case-patients were >4x more likely than controls to have been exposed to flooding. In Aceh Province, Indonesia, a rapid health assessment in the town of Calang 2 weeks after the December 2004 tsunami found that 100% of the survivors drank from unprotected wells and that 85% of residents reported diarrhea in the previous 2 weeks (Medscape, 2007).

In flood conditions, there is potential for increased fecaloral transmission of disease, especially in areas where the population does not have access to clean water and sanitation. Published studies (case-control studies, cross-sectional surveys, outbreak investigations, analyses of routine data) have reported postflood increases in cholera, cryptosporidiosis, nonspecific diarrhea, poliomyelitis, rotavirus, and typhoid and paratyphoid. In Indonesia, Vollaard et al. (2004) found flooding of the home to increase paratyphoid fever, with an odds ratio of 4.52 (95 percent confidence interval (CI): 1.90, 10.73), and Katsumata et al. (27) found it to increase the risk of cryptosporidiosis, with an odds ratio of 3.08 (95 percent CI: 1.9, 4.9) (cited in Mike, Kovats, Wilkinson, Few, & Matthies, 2005).

Leptospirosis is an epidemic-prone zoonotic bacterial disease that can be transmitted by direct contact with contaminated water. Rodents shed large amounts of leptospires in their urine, and transmission occurs through contact of the skin and mucous membranes with water, damp soil or vegetation (such as sugar cane), or mud contaminated with rodent urine. Flooding facilitates spread of the organism because of the proliferation of rodents and the proximity of rodents to humans on shared high ground. In Jakarta, Indonesia Ministry of Health (MoH) reports that as of 21 February 2007, the number of positive leptospirosis patients has increased to 112, while four people have died (OCHA, 2007).

3. Climate change and Public Health Roles in Indonesia

3.1. Adaptation For Health

Many of the other forms of adaptation for health will involve strengthening existing systems for primary and curative health care expanding health awareness campaigns to encourage people to pay more attention to hygiene and the storage of water.

Combating the spread of disease will need closer surveillance of disease patterns. In floods, this will include monitoring for cholera. Over the longer term, it will mean monitoring the changing distribution of mosquito-borne diseases while ensuring that households are able to protect themselves, such as through the use of insecticide-treated mosquito nets.

Some examples of public health adaptation strategies to climate variability and change are given in Table 1

Table 1. Summary of public health adaptation measures in relation to the health impact of climate change.

Source: Haines, Kovats, Campbell-Lendrum, & Corvalan, 2006.

For preventing the immediate physical impact of disasters, in some cases such as floods, the risks can be reduced by reforestation. In Madiun, for example, the government is planning to reforest hundreds of hectares of agricultural land on the slopes of the Wilis volcano to reduce the risks of landslides following heavy rainfall (Prijosusilo, 2007) but all communities need to establish the zones that are at highest risk of flooding and landslide and make plans for early warning systems for evacuation. The public health workers have to makes public health education post floods to protect people from diseases such as health promotion to people for boil the water drink, emergency preparedness, check list for post flood activities and surveillance for flood effects, with long term follow up.

The air quality and vector borne diseases can be control by give early warnings for population at risk, daily air pollution measurement, monitoring of vectors and reservoir hosts and integrated surveillance for human and animal diseases. Health adaptations for food borne diseases are maintenance food hygiene measures and doing integrated surveillance for human and animal diseases.

3.2. Public health roles

The professional and academic health communities have appropriate roles to play in all three types of interaction between health and climate change, as follows. (1) Investigation of the effects of climate change on health will remain an important arena of research and is needed to assist in the establishment of the priorities for mitigating climate change in comparison with other societal needs. Additionally, the health community has an appropriate role in the promotion of activities to mitigate greenhousegas emissions, both at the institutional and clinical levels (Stott R, 2006). (2) Assessment and promotion of interventions to reduce greenhouse-gas emissions that also promote other health objectives (co-benefits) while avoiding negative effects are also important roles for the health community. (3) Finally, by adjusting its own priorities in recognition of the coming risks to health from the climate change to which we are already committed, the health community continues to best serve one of its primary purposes, promoting the public’s health. Here, one of the major messages for the community to convey is the importance and effectiveness of reducing vulnerability in the most threatened populations (Haines, et al. 2007).

1. Conclusions

The impacts of observed changes in climate are already evident in Indonesia and will likely worsen due to further human-induced climate change. Rising concentrations of greenhouse gases will continue to raise the surface and ocean temperatures, change precipitation patterns, increase sea levels, and cause various other impacts from more frequent forest fires to increased health risks.

Human health in Indonesia will be adversely affected by climate changes and its associated effects both directly (e.g., deaths due to heat waves, floods, and storms) and indirectly (e.g., increases in infections and diseases and less available food). Direct effects, such as higher temperatures, changes in precipitation and sea-level rise can cause more frequent and severe heat waves, floods, extreme weather events, and prolonged droughts and lead to increased injury, illness, and death. Indirect effects, which are more difficult to attribute to climate change, may include more widespread vector-borne infections (e.g., malaria and dengue), an expansion of water borne diseases, such as diarrhoea, an increase in infectious diseases, poor nutrition due to food production disruption, ill health due to social dislocation and migration, and increased respiratory effects from worsening air pollution and burning. Rising temperatures can compound the effects of poverty and poor hygiene on bacterial proliferation, leading to diarrhoeal disease and endemic morbidity and mortality (Checkley et al., 2000).

The challenge for public health workers in Indonesia is to create appropriate and effective adaptation strategies to minimize the effect of climate change with health population. Action needs to take place at all levels; from international, to national, to local and community-based efforts.

1. References List

Agus P. S., Martha, M., Ria, N. B., Rizka E. S., & Wisnu, R. (2007). Indonesia and Climate Change: Working Paper on Current Status and Policies. World Bank: Indonesia.

Checkley, W., L.D. Epstein, R.H. Gilman, D. Figueroa, R. Cama, J.A. Patz and R.E. Black. 2000. Effects of El Niño and ambient temperature on hospital admissions for diarrhoel diseases in Peruvian children. Lancet 355: 442-450.

Haines A, et al. (2007). Policies for accelerating access to clean energy, improving health, advancing development, and mitigating climate change. London School of Hygiene an Tropical Medicine, London, UK. Retrieved May 25, 2008, from the Griffith library database.

Haines, A., Kovats, R.S., Campbell, L. D., & Corvalan, C. (2006). Climate change and human health: Impacts, vulnerability and public health. Journal of the royal institute of public health, 120, 585–596. Retrieved May 20, 2008, from the Griffith library database.

Huntingford, C., Hemming, D., Gash, J.H.C., Gedney, N., & Nuttall P.A. (2006). Impact of climate change on health: what is required of climate modellers. journal of transactions of the royal society of tropical medicine and hygiene, 101, 97-103. Retrieved May 20, 2008, from the Griffith library database.

IRIN, (2008). INDONESIA: Climate change brings new disease threats. UN Office for the Coordination of Humanitarian Affairs. Retrieved May 15, 2008, from Google database.

Johan, K & Damayanti, S. (2007). Food and nutritional security assessment; Initial impact analysis of the 2006/2007 crop season in comparison to 1997/1998 and 2002/2003 El Niño events for the Eastern NTT region. Jakarta, CARE International Indonesia.

McConnell, K. (2007). United States Helps Bring Clean Water to Indonesian Families. Retrieved April 26, 2008, from the Google database.

Medspace.com. (2007). Communicable diseases associated with natural disasters. Retrieved April 26, 2008, from the Google Scholar database.

Mike, A., Kovats, R. S., Wilkinson, P., Few, R., & Matthies, F. (2005). Global health impacts of floods: Epidemiologic evidence. Journal of Epidemiologic Reviews, 27, 36-46. Retrieved May 20, 2008, from the Griffith library database.

OCHA. (2007). Indonesia: Floods in JABODETABEK (Jakarta-Bogor-Depok-Tangerang-Bekasi). United Nations Office for the Coordination of Humanitarian Affairs: Jakarta, Indonesia. Retrieved April 26, 2008, from the Google database.

Prijosusilo, B. (2007). Can traditional rice farmers help combat climate change. in The Jakarta Post, May 8, 2007. Retrieved April 26, 2008, from the Google database.

Stott, R. (2006.) Healthy response to climate change. Journal of BMJ, 332, 85-87. Retrieved May 20, 2008, from the Griffith library database.

UNDP Indonesia. (2007). The other half of climate change; Why Indonesia must adapt to protect its poorest people. Retrieved May 15, 2008, from www.undp.or.id.

WWF Indonesia, 2007. Strategi Adaptasi Lokal: Upaya Pengarus utamaan pada rencana kebijakan pembangunan. WWF Indonesia.

Data Sources/Study Setting. Survey of 557 outpatients using a self-administered questionnaire over a 10-day period at a general hospital in Sungnam, South Korea. Data Collection. Patients answered questions related to two main constructs, patient satisfaction and health care service quality. The health care service qualitymeasures (30 items) were developed based on the results of three focus group interviews and the SERVQUAL scale, while satisfaction (3 items) was measured using a previously sevalidated scale.

Study Design. Confirmatory factor analysis was used to assess the construct validity of the service quality scale by testing convergent and divergent validity. A structural equation model specifying the four service quality dimensions as exogenous variables and patient satisfaction as an endogenous variable was estimated to assess the relative impact of each of the service quality dimensions on satisfaction. This was followed by a multigroup LISREL analysis that tested the invariance of structural coefficients across three groups with different frequencies of outpatient visits to the hospital.

Principal Findings. Findings support the causal relationship between service quality and satisfaction in the context of the South Korean health care environment. The four service quality dimensions showed varying patterns of impact on patient satisfaction across the three different outpatient groups.

Conclusion. The hospitalmanagement needs to be aware of the relative importance of each of the service quality dimensions in satisfaction formation of outpatients, which varies across different hospital utilization groups, and use this in strategic considerations.

Key Words. Outpatient satisfaction, service quality, visit frequency pattern, measurement validation

By : Woo Hyun Cho, Hanjoon Lee, Chankon Kim, Sunhee Lee, and Kui-Son Choi

1.1. Definition

Social Marketing is applies marketing techniques to social psychology theories in order to bring about population-wide behavior change. The most commonly used technique is mass media promotion, which borrows heavily from traditional marketing and the ‘four Ps of marketing’ – product, price, place and promotion (Egger, Spark et al., 1990 cited in Baum, F. 2008).

1.2. Social Marketing in Public Health

To confront the chronic disease epidemic that threatens to determine human health in the twenty-first century, public health practice must begin to focus on far more than providing basic medical care. To establish a favorable environment for human well-being, public health practitioners must concentrate on affecting social change by helping to modify individual behaviors and lifestyles, improve social and economic conditions, and reform social policies. (Siegel, M & Lotenberg, L.D. 2007).

Behavior-based health promotion starts from the premise that in developed countries the major killers are diseases or injuries that are linked to lifestyle, sometimes called the diseases of affluence, and that modification of the lifestyle linked to disease or injury will be beneficial to people’s health.

Like a sample in South Africa social marketing techniques are being used as part of the fight again HIV/AIDS and other STDs, as well as unwanted teenage pregnancy. LoveLife was launched in September 1999 by a consortium of leading South African public health organization in partnership with a coalition of more than a hundred community-based organizations, the South Africa government, major South African media groups and private foundations. The lovelife campaign uses social marketing to support a range community based initiatives, such as youth leadership program and campaigns to establish appropriate youth health services. Its general message is to encourage South African youth to adopt positive lifestyle options (Baum, F. 2008).

2. 2. Case Studies (social marketing program to reduce a number of people smoking in Indonesia)

2.1. Background

Tobacco use has been identified as an important risk factor for many non-communicable diseases both in developed and developing countries. To date, about one-third of the world’s population smokes, mostly in China, India and Indonesia. These three Asian countries with large populations have been the main targets for tobacco companies’ expansion (Market, J.E. 2005). The three leading tobacco companies in Indonesia produced 146 billion cigarettes in 2004. The acquisition of 97% of HM Sampoerna, Indonesia’s third largest tobacco company in 2004, by Philip Morris International in 2005 intensifies the threat to tobacco control efforts in Indonesia (Aurora, L. 2005). As one of the top five tobacco-consuming countries in the world, Indonesia is lagging behind in terms of the Framework Convention of Tobacco Control signature and ratification. The reluctance of the Indonesian government to promptly adopt this global strategy as national policy aimed at reducing tobacco supply and demand has created an opportunity for the expansion of the tobacco industry (WHO, 2003). Even in the latest amendment of government regulation about tobacco control, sanctions for violation on production, advertisements and sales were eliminated (Achadi, A., Soerojo, W., Barber, S. 2005) and no laws prohibiting the sale of cigarettes to minors exist (cited in Nawi, N. L., Weinehall & Ohman, A. 2007).

. Given its large population and smoking prevalence, Indonesia ranks fifth among countries with the highest tobacco consumption globally at 182 billion sticks per year. Consumption has increased rapidly since the 1960s. Between 1970 and 1980, a 159% increase coincides with the mechanization of the clove cigarette industry. With a doubling of the GNP per capita in real terms between 1980 and 1997, tobacco consumption rose by 8.2% per year for a cumulative increase of 139%. Quite remarkably, the rise in consumption continued even after the economic crisis of 1997. Adult smoking prevalence rose from 26.9% to 31.5% between 1995 and 2001, reflecting an increase among males from 53.4% to 62.2%. Regionally, the highest male smoking rates are Gorontalo province (69%) in the northernmost tail of Sulawesi Island compared with the lowest in Bali (45.7%). East Java and Lampung provinces experienced steep increases in prevalence between 1995 and 2001 exceeding 60%, and relatively low educational levels could be a contributing factor. Female smoking prevalence more than doubled between 1995 and 2001 in Papua, East Kalimantan, Central Java and Bali provinces, although nationwide rates remain below 2%. The vast majority of smokers (68.8%) started their habit before 19 years of age (cited in Achadia, A., Soerojob, W., & Barber, S. 2004).

2.2. Social marketing program anti smoking in Indonesia

Indonesian government has developed some policies concerning smoking issue, including legislation approach, campaigns, and research. The legislation includes regulation about tobacco advertising; health warning on tobacco packages; safe tar and nicotine standard; smoke-free smoking areas in public places, schools, and workplaces; community involvement; training and supervision; fines for disobeying the regulations; tobacco price and taxes.

Indonesia Ministry of Health has developed anti-smoking programs, which are focused on educating people to understand more about the negative effect of smoking on health. The government has developed quit smoking programs that provide services to help smokers to quit smoking (MOH 2000).

One of program social marketing for anti-smoking in Indonesia is put health warning on the cigarette packages. Health warnings on cigarette packages have been implemented since 1991. The health warning reads that “Smoking can cause cancer, heart attacks, impotence and harm pregnancy and fetal development”. The health warnings must be placed on and comprise at least 15% of the wide of the package. The health warning on cigarette packages have objective to educate people to understand more about the negative effect of smoking on health and reducing a number people smoking in Indonesia.

The another programs doing by Ministry of Health is spread poster and leaflet in public space such as School, Government office, Airport, Bus Station, Market, etc.

2.3. Evaluation of Social marketing program to reduce number of people smoking in Indonesia

Research by Public Health Faculty of Indonesia University has found that health warning on cigarette packages not effective to reduce number of people smoking in Indonesia. The health warning on cigarette packages has not effective because that message to small and put in back side on cigarette packages (MOH Indonesia, 2008).

Social marketing Program with put health warning on cigarette packages in Indonesia has been not effective because the shape of the message only a small writing without pictures to explain negative impact of smoking. Based on survey by Public Health faculty of Indonesia University, 42,5% respondent not believe contents on health warning, 20% respondent say that health warning is not clear and 25% respondent is not care that message because they has to become addicted with smoking. 78% respondent say that the health warning on cigarette packages have to show pictures and put in the back and front of cigarette packages to becomes effective for educate people the negative impact of smoking (Cited in MOH Indonesia, 2008).

Programs social marketing to reduce a number of people smoking until now is not effective in Indonesia. This is because the cigarette promotion strategies are stronger than anti smoking promotion strategies. There is lack of government support regarding tobacco control programs. As a policy maker, government plays a vital role for policy implementation. Indonesian governments do not really manage the tobacco control seriously. They have a weak policy regarding limitation of cigarettes advertising. Most countries have regulation to ban the smoking advertising in any media, but Indonesia only restricts it. It seems that governments provide regulations that still don’t affect the tobacco industries. Supported by huge financial resources tobacco manufacturers develop their promotion strategies as widely as they can. They use television, posters, sponsorship, billboard, etc to promote their cigarettes. They develop their promotion strategies as subtly as they can. As an example, some schools accept donations from tobacco manufactures for several school activities. The anti smoking promotion strategies that are conducted by ministry of health are not comparable to the cigarette promotion strategies.

3. 3. Conclusion

Indonesia Ministry of Health has developed anti-smoking programs, which are focused on educating people to understand more about the negative effect of smoking on health is not effective. This is because there lack of government support regarding tobacco control programs. The cigarette promotion strategies by cigarette industries are stronger than anti smoking promotion strategies by ministry of health. The anti smoking promotion strategies that are conducted by ministry of health are not comparable to the cigarette promotion strategies.

Patient opinions are important because dissatisfaction suggests opportunities for improvement. Patient satisfaction can lead to a higher rate of patient retention which affects customer loyalty (Nelson et al. 1992, Cited in Cho, W.H. Lee, H. Kim, C. Lee, S. and Choi, K.S. 2004).

Past research on patient satisfaction has also found a linkage between satisfaction and hospital utilization. Several studies presented evidence for an inverse relationship between satisfaction and the frequency of patient visits (Linn, Linn, and Stein 1982; Pascoe & Attkinsson 1983; West 1976). Given the prevailing view in the consumer behaviour literature that patient satisfaction has positively affects to loyalty. (Nelson et al. 1992, Cited in Hannele, H. Pekka, L. Kaija, N. 2001).

Hospitals in the developed world recognize the importance of delivering patient satisfaction as a strategic variable and a crucial determinant of long-term viability and success (Davies and Ware 1988; Makoul et al. 1995; Royal Pharmaceutical Society 1997 cited in fahad, F. A. 2005).

The SERVQUAL scale is a multiple-scale questionnaire that measures expectations and perceptions of service quality and evaluates the different aspects of quality under 5 dimensions: tangibles, reliability, responsiveness, assurance, and empathy. This model was adapted in 1990 for use in healthcare settings , and is now considered a suitable instrument for measuring the quality of care in hospital services. (Babakus & Mangold, 1990. Cited in Araceli, G. Susana, P. and Enrique, RG. 2005). The SERVQUAL dimensions such as Tangibles: The appearance of physical facilities, equipment, personnel, and communication materials, Reliability: The ability to perform the promised service dependably and accurately, Responsiveness: The willingness to help customers and to provide prompt service, Assurance: The knowledge and courtesy of employers and their ability to convey trust and confidence, Empathy: The provision of caring, individualized attention to customers.

Several studies have found a positive relationship between patient satisfaction with health care and willingness to revisit the hospital (Atkins et al., 1996; Lee, 1998; Lee, 2001; Lumby and England, 2000; Scarding, 1994; Zifko-Baliga and Kramp, 1997. Cited in Aie, M. L. Hee, Y.Yo. (2007). Given the prevailing view in the consumer behaviour literature that patient satisfaction has positively affects to loyalty. (Nelson et al. 1992, Cited in Hannele, H. Pekka, L. Kaija, N. 2001).

It is very important to clarify the factors influencing the patients satisfaction with medical services, very little research has been performed in this area. Thus it is necessary to clarify this relationship, because this research can be used by management of Hospital as a basis for establishing strategies to improve patient satisfaction and thus lead them to visit the hospital again.