The satisfaction of the user in health services evaluation: essay on the imposition of problems

Monique Azevedo Esperidião Lígia Maria Viera-da-Silva About the authors

ABSTRACT

User satisfaction surveys are currently placed as one of the main strategies for participation, protection and defense of the rights of users of public services, despite the existence of a set of evidences reported in the international literature more than four decades ago, question the legitimacy of such approaches. The present essay aims to contribute to the understanding of some neglected aspects of the meaning of user satisfaction surveys and their results, particularly the paradox of high satisfaction found as a result of these surveys. This phenomenon will be analyzed through an analogy with opinion polls, discussing the hypothesis that the high satisfaction, described in the literature, may represent an artifact of research resulting from a problematic imposition, in the sense discussed by Bourdieu (1973) and Champagne (1998). The answers obtained do not necessarily correspond to social representations or perceptions regarding the services, but to the reactions of the users to the research situation, being characterized as a forced response to the conditions of the surveys.

KEYWORDS
Consumer behavior; Health services research; Patient Satisfaction

Introduction

This essay aims to contribute to the understanding of some neglected aspects of the meaning of surveys about user satisfaction and its results, particularly on the paradox of high satisfaction found as a result of these surveys. This phenomenon will be analyzed by means of an interrogation about its conditions of production and reproduction within the collective health field, in the sense of Bourdieu11 Vieira-da-Silva LM. Gênese Sócio-Histórica da Saúde Coletiva no Brasil. In: Lima NT, Santana JP, Paiva J. Saúde Coletiva: a Abrasco em 35 anos de história. Rio de Janeiro: Fiocruz; 2015. p. 25-48.,22 Vieira-da-Silva LM. Salud Colectiva brasilena: arquitectura y dinamica de un campo. In: Castro R, Suarez HJ, organizadores. Pierre Bourdieu en la sociologia Latinoamericana: Campo y Habitus. 1. ed. Morelos: Universidad Nacional Autonoma de México; 2018. p. 143-166..

By means of an analogy with the opinion polls, it is intended to discuss the hypothesis that the high satisfaction reported in the literature may represent a research artifact resulting from the forced response to a problematic imposition, as discussed by Bourdieu33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980. and Champagne44 Champagne P. A ruptura com as pré-construções espontâneas ou eruditas. In: Merllié D. Iniciação à prática sociológica. Petrópolis: Vozes; 1998.. The answers obtained may not correspond to social representations or perceptions related to services, but would represent reactions to a research situation.

The 'total quality' business culture, which has been widespread in Japan since the 1950s, had privileged 'customer satisfaction' as the gold standard of service and product quality, aiming at customer loyalty and at 'return to the company'. The idea of the Japanese kaizen, implying continuous improvement in production processes, encompassed not only manufacturing, engineering or business management areas, but, also, the health area.

The health literature soon incorporated satisfaction as an indicator of quality of care66 Cleary DP, Mcneil JB. Patient satisfaction as an indicator of quality care. Inquiry. 1988; 25(1):25-36., and, in the late 1970s, in the United States and England, there was an increase in the satisfaction surveys of health service users, as an expression of the movement of consumerism and the 'total quality' culture, with the introduction of elements of competition in their health systems. The studies were, at that moment, related to consumer satisfaction and studies on work satisfaction77 Evrard Y. La satisfaction des consommateurs: état des recherches. Revue Française du Marketing. 1993; 144:53-65..

In Brazil, the first publications on user satisfaction were also from the 1970s and were aimed at evaluating the quality of nursing care.

The user's point of view in the evaluation of governmental public policies in Brazil spread from the 1990s, with the creation of the Unified Health System (SUS) and the incentive to the participation of users in health policies. In the following decade, the satisfaction studies gained strength, with the Brazilian Administrative Reform and the incorporation of measures of the business field in public management. In 2002, the National System for Evaluating Satisfaction of Public Service Users was implemented, which institutionalized the Standard Satisfaction Survey Instrument (IPPS), disseminating the evaluation of satisfaction with public services in different areas.

Currently, user satisfaction surveys have been placed as one of the main strategies for the participation, protection and defense of the rights of users of public services (Law nº 13.460, of June 26, 2017). Such an emphasis, adopted by the Temer government, may be related to the incorporation of business conceptions in public management, which ignore a set of evidences, reported in the international literature for more than four decades, questioning the validity of such approaches.

The interaction of the user with the health services

The relationships between health service users and professionals are mediated by the position they occupy in the social space, their trajectories and many circumstances related to the process of social construction of the health problem, as well as the historical conditions that have made possible those specific relationships88 Vieira-da-Silva LM. Saúde e espaço social. In: Nogueira RP, organizador. Determinação social da saúde e Reforma Sanitária. Rio de Janeiro: Cebes; 2010. p. 180-200..

It is very different the relationship between an elderly patient with a severe pain, in a public emergency, attended by a young doctor, at the beginning of the career, and a young patient, doing a preventive examination with an experienced doctor in a private practice. There are endless combinations imaginable in view of the variety of possible positions in the social space, as well as the segmentation of public and private health services.

The contact of the user with the health services includes considering several interpersonal relationships: from the receptionist to the doctor, through their reaction to the care amenities (comfort, type of building, refrigeration, among others), their perception about the quality of the consultation and the access to general inputs, among them, medicines. Depending on the position and trajectory of the individuals, including relations of gender, generation, ethnicity, among others, the way of experiencing the passage through the service will be differentiated, with implications in the way of judging and evaluating such services and professionals. The judgment of the user in relation to his/her experience in a health service depends on his/her habitus, the system of dispositions that guide his perceptions99 Bourdieu P. A Distinção: crítica social do julgamento. Porto Alegre: Zouk; São Paulo: Edusp; c2006., the adjustment of his/her habitus to that situation and, also, the distance with respect to the habitus of health professionals.

Of these relationships, the most important would be those between patients and health professionals, such as the doctor-patient relationship. The exchange between the doctor and the patient, however, will always be uneven. It is an exchange where, no matter how socially positioned the patient is, he/she cannot fully reciprocate. The social distances will confer different characteristics to the way of interaction between doctor and patient, as well as the communication between the patient and the doctor1010 Boltanski L. As classes sociais e o corpo. Rio de Janeiro: Graal; 2004..

Moreover, the distance from the need for health, that is, the fact that the patient is ill and needing medical care gives the relationship a dimension that is often asymmetrical, dependent on medical knowledge, which, at times, interferes with the way of judging. Even among doctors this relationship can be asymmetric and influenced by the characteristics of gender, generation, specialty and position in the medical field and social space.

In this way, these relations can be symmetrical or asymmetrical, depending on the position that the doctor and the patient occupy in the social space, and, consequently, the capital they accumulate, in particular, economic and cultural capital, as well as the encounter of the habitus due to their trajectories.

The quality of the medical consultation will also depend on a set of factors, since the prior indication by someone of the confidence of the users, such as a family member or other doctor, including aspects such as ease of access, time of duration, quality of care and resolutivity1111 Bastos GAN, Fasolo LR. Fatores que influenciam a satisfação do paciente ambulatorial em uma população de baixa renda. Rev Bras Epidemiol. 2013; 16(1): 114-124..

In an earlier study on the relationship between social position and the choice of doctors and services1212 Esperidião MA, Vieira-da-Silva LM. Posição social e julgamento dos serviços de saúde pelos usuários. Saúde Soc. 2016 jun; 25(2):381-391., it was found that the choice of doctors by interviewees with greater global capital (economic and cultural) was linked to technical and symbolic criteria, while agents of popular classes evaluated the service according to the access. It was analyzed that the positioning in relation to the service corresponds to an unconscious adjustment of the needs to the possibilities of the users. The implications of the social distance between doctors and patients in the choice and judgment of health services are discussed.

The judgment of the user

The interaction of users with health services has been investigated through different research approaches, such as studies aimed at the 'social representations' of users1313 Martins PC, Cotta RMM, Mendes FF, et al. De quem é o SUS? Sobre as representações sociais dos usuários do Programa Saúde da Família. Ciênc Saúde Colet. 2011; 16(3):1933-1942., research on the perception of the user1414 Santiago RF, Mendes ACG, Miranda GMD, et al. Qualidade do atendimento nas Unidades de Saúde da Família no município de Recife: a percepção do usuários. Ciênc Saúde Colet. 2013 jan; 18(1):35-44. or studies on the doctor-patient relationship1515 Pereira MGA, Azevêdo ES. A relação médico-paciente em Rio Branco/AC sob a ótica dos pacientes. Rev Assoc Med Bras. 2005 jun; 51(3):153-157.. Studies on access, accessibility and use also sometimes record the experience of users and their perception about services1616 Azevedo ALM, Costa AM. A estreita porta de entrada do Sistema Único de Saúde (SUS): uma avaliação do acesso na Estratégia de Saúde da Família. Interface. 2010 dez; 14(35):797-810.. But it is, undoubtedly, the studies about the satisfaction of users with health services that are more frequent about the judgment of the user, especially those aimed at inferring about the quality of care, being incorporated in the evaluation of the services of several countries for at least four decades, existing a considerable effort in the development of research instruments to measure it1717 Gill L, White L. A critical review of patient satisfaction. Leadership Health Serv. 2009; 22(1):8-19..

User satisfaction, broadly, has been defined as a notion that refers to the assessment of care received, considering as its determinants especially the expectation of the patient and previous experience with similar services1717 Gill L, White L. A critical review of patient satisfaction. Leadership Health Serv. 2009; 22(1):8-19.. This definition has been criticized, in particular, with respect for the low theoretical and conceptual development of the expression patient satisfaction. The reviewed studies have little standardization, low reliability and uncertain validity1717 Gill L, White L. A critical review of patient satisfaction. Leadership Health Serv. 2009; 22(1):8-19..

Although satisfaction continues to be used as a synonym for (and as a proxy for) quality of service, there are studies that problematize this connection. Some authors1717 Gill L, White L. A critical review of patient satisfaction. Leadership Health Serv. 2009; 22(1):8-19. suggest that satisfaction should be used as an indicator of the perceived quality of health services, which in itself is a conceptually distinct construction of quality of care. On the other hand, recent studies show that the concept of satisfaction is multidimensional, subjective and does not always measure the quality of care, which corresponds to an important contribution to the understanding of this theme1818 Mishima SM, Campos AC, Matumoto S, et al. Satisfação do usuário sob a perspectiva da responsividade: estratégia para análise de sistemas universais. Rev Latino-Am Enferm. 2016; 24:1-7..

It is observed that the majority of empirical studies published, both in the international context1919 Shill J, Taylor DM, Ngui B, et al. Factors associated with high levels of patient satisfaction with pain management. Acad Emerg Med. 2012 out; 19(10):1212-1215.

20 Jao K, Taylor DM, Taylor SE, et al. Simple clinical targets associated with a high level of patient satisfaction with their pain management. Emerg Med Australas. 2011 abr; 23(2):195-201.

21 Guzik A, Menzel NN, Fitzpatrick J, et al. Patient satisfaction with nurse practitioner and physician services in the occupational health setting. AAOHN J. 2009; 57(5):191-197.
-2222 Estcourt S, Hickey J, Perros P, et al. The patient experience of services for thyroid eye disease in the United Kingdom: results of a nationwide survey. Eur J Endocrinol. 2009 set; 161(3):483-487. and in Brazil2323 Hollanda E, Siqueira SAV, Andrade GRB, et al. Satisfação e responsividade em serviços de atenção à saúde da Fundação Oswaldo Cruz. Ciênc Saúde Colet. 2012 dez; 17(12):3343-3352., presents as results high user satisfaction, regardless of the service situation and the methodology used. In the United States of America, user satisfaction scores range from 90% to 100% approval2424 Stewart DE, Dang BN, Trautner B, et al. Assessing residents' knowledge of patient satisfaction: a cross-sectional study at a large academic medical centre. BMJ Open. 2017 ago; 7(8):1-7.. There is high satisfaction, even when expectations about services are negative. These results have been associated with several research designs and instruments and data collection, such as the use of focus groups2525 Trad LAB, Bastos ACS, Santana EM, et al. Estudo etnográfico da satisfação de usuário do Programa de Saúde da Família (PSF) na Bahia. Ciênc Saúde Colet. 2002; 7(3):581-589., in-depth interviews2626 Zaicaner R. Satisfação da clientela: um objetivo a ser alcançado pelo serviço público de saúde [dissertação]. São Paulo: Faculdade de Saúde Pública, Universidade de São Paulo; 2001.-2727 Gerschman S, Veiga L, Guimarães C, et al. Estudo de satisfação dos beneficiários de planos de saúde de hospitais filantrópicos. Ciênc Saúde Colet. 2007; 12(2):487-500. and surveys2828 Gentil RM, Leal SM, Scarpi MJ. Avaliação da resolutividade e da satisfação da clientela de um serviço de referência secundária em oftalmologia da Universidade Federal de São Paulo - UNIFESP. Arq Bras Oftalmol. 2003; 66(2):159-165.

29 Silva LMP, Muccioli C, Belfort JR. Perfil socioeconômico e satisfação dos pacientes atendidos no mutirão de catarata do Instituto da Visão - UNIFESP. Arq Bras Oftalmol. 2004; 67(5):737-744.

30 Ventura LO, Brandt CT. Projeto Mutirão de Catarata em centro de referência oftalmológico, em Pernambuco: perfil, grau de satisfação e benefício visual do usuário. Arq Bras Oftalmol. 2004; 67(2):231-235.
-3131 Costa PG, Aoki L, Saraiva FP, et al. Toxina botulínica no tratamento de distonias faciais: avaliação da eficácia e da satisfação dos pacientes ao longo do tratamento. Arq Bras Oftalmol. 2005; 68(4):471-474..

In order to explain the phenomenon of high satisfaction, the sensitivity of the methods to discriminate between satisfied and dissatisfied patients and the relevance of the selected dimensions for the study of satisfaction has been questioned3232 Carr-Hill RA. The measurement of patient satisfaction. J Public Health Med. 1992; 14(3):236-249.. Survey-type studies are the most criticized, as well as dichotomous questions about satisfaction3333 Esperidião MA, Trad LAB. Avaliação de satisfação de usuários: considerações metodológicas. Ciênc Saúde Colet. 2005; 10(supl). and direct approaches3232 Carr-Hill RA. The measurement of patient satisfaction. J Public Health Med. 1992; 14(3):236-249.. The instruments of general satisfaction, or indices of global satisfaction, are also considered as possible generators of the phenomenon of high satisfaction3434. Leichner P, Perrealut M. Developpmente et validation d'une echelle multi- dimensionelle de satisfaction de patients de services d'hospitalisation en psychiatrie. Rapport Final. Montréal: Société canadienne d'évaluation; 1990..

It refers, as well, to the acquiescence bias, related to the enumeration of the questions in the questionnaire or to the satisfaction scale3535 Locker D, Dunt D. Theoretical and methodological issues in sociological studies of consumer satisfaction with medical care. Soc Science Med. 1978; 12(4):283-292.,3636 Ross CK, Steward CA, Sinacope JM. The importance of patient preferences in the measurement of health care satisfaction. Medical Care. 1993; 31(12):1138-1149.. It is highlighted the tendency of the user to agree with the first item of the scale, regardless of its content, influencing the level of satisfaction in the order of the items, that is, for more, if the items are ordered positively, or less, in the situation inverse3737 Ware JE, Snyder MK, Wright WR, et al. Defining and measuring patient satisfaction with medical care. Evaluation Program Planning. 1983; 6:247-263.. According to some authors, this bias is more evident among older or lower income users3737 Ware JE, Snyder MK, Wright WR, et al. Defining and measuring patient satisfaction with medical care. Evaluation Program Planning. 1983; 6:247-263.

38 Fitzpatrick R, Hopkins A. Problems in the conceptual framework of patient satisfaction research: an empirical exploration. Sociol Health Illness. 1983; 5(3):297-311.
-3939 Owens DJ, Bachelor C. Patient satisfaction and the elderly. Soc Science Med. 1996; 42(11):1483-1491..

The reluctance of users to express negative opinions, or the bias of gratitude3939 Owens DJ, Bachelor C. Patient satisfaction and the elderly. Soc Science Med. 1996; 42(11):1483-1491., has been described as an explanation for high satisfaction. Courtesy norms, such as social obligations to show respect for authority (to health professionals and the researcher) or to understand criticism as a comment that demonstrates social inconvenience may be associated with the positive pattern of satisfaction responses4040 Atkinson S, Medeiros RL. Explanatory models of influences on the construction and expression of user satisfaction. Soc Science Med. 2009 jun; 68(11):2089-2096.. The omission of negative questions and critiques by users is frequently verified in the evaluation of public services, as well as in situations where the user has a great affinity with care providers, such as in inpatient cases4141 Bernhart MH, Wiadnyana IGP, Wihardjo H, et al. Patient Satisfaction in developing countries. Soc Science Med. 1999; 48:989-996.. Pugh et al.4242 Pugh R, Scharf T, Williamns C, et al. Obstacles to using and providing rural social care in Santiago de Chile. J Health Soc Behavior. 1998; 29:199-213. argue that satisfaction is greatest in 'disempowered' groups.

Since the 1990s, there is a growing literature suggesting that expressions of satisfaction may not represent user ratings3939 Owens DJ, Bachelor C. Patient satisfaction and the elderly. Soc Science Med. 1996; 42(11):1483-1491.. That is, the assessment carried out by the user on the service is not described in terms of 'satisfaction' or 'dissatisfaction'. The term 'satisfaction' does not belong to the linguistic repertoire used by users in evaluating a service4343 Williams B, Coyle J, Healy D. The meaning of patient satisfaction: An explanation of high reported levels. Soc Science Med. 1998; 47(9):1351-1359., implying the need for prior investigation of their understanding of the term 'satisfaction'4444 Williams B. Patient satisfaction: a valid concept? Soc Science Med. 1994; 38(4):509-551..

Given the assumption that satisfaction expression does not represent how users evaluate health services, some authors began to investigate how users evaluate services, identifying cognitive and affective devices related to the service judgment process4343 Williams B, Coyle J, Healy D. The meaning of patient satisfaction: An explanation of high reported levels. Soc Science Med. 1998; 47(9):1351-1359.,4444 Williams B. Patient satisfaction: a valid concept? Soc Science Med. 1994; 38(4):509-551..

According to the model of Williams et al.4343 Williams B, Coyle J, Healy D. The meaning of patient satisfaction: An explanation of high reported levels. Soc Science Med. 1998; 47(9):1351-1359., users evaluate health services through two processes: the first, related to the perception about the service obligation to attend to the presented problem; and the second, in case of failure to comply with this obligation, if the service is to blame for the negative experience of the user.

For these authors, the expression of satisfaction does not necessarily reflect a positive evaluation. Patients feel satisfied regardless of the good quality of care received, and dissatisfaction is manifested only in extremely negative events.

The question about why patients are satisfied in health units where service delivery is known to be of low quality motivated the study of Aktinson and Medeiros4545 Singly F. L´enquête et ses methods: Le questionnaire. Paris: Armand Colin; 2005.. The authors investigated how satisfaction is constructed and expressed, based on the verification of three current theoretical assumptions in the literature: expectations, contextual dynamics and mediator filters (guilt and obligation). For them, the lack of information (low expectation), coupled with the reluctance to give negative answers (elements of contextual dynamics), produce a high satisfaction as an artificial response. On the other hand, the concept of mediator filters (derived from the model of Williams4343 Williams B, Coyle J, Healy D. The meaning of patient satisfaction: An explanation of high reported levels. Soc Science Med. 1998; 47(9):1351-1359.) proposes that users construct an evaluation that considers quite broad aspects, so that the high level of satisfaction expressed in this sense is real. The research, thus, reinforces current theses regarding low expectations, reluctance to give negative responses and two-step evaluation (filters).

These many hypotheses about the reasons for high satisfaction represent important efforts in the deconstruction of 'satisfaction'. However, with some exceptions, they assume the existence of an opinion of the user, expressed in terms of dissatisfaction vs. satisfaction as the product of the judgment of the health services. On the other hand, these approaches have also not been developed within a social theory capable of articulating partial explanations or providing others that make sense within the space of use of care services and practices, in particular situations and conjunctures.

The approaches are of the cognitivist type, making considerations about the way the user perceives the service (mental models), without the understanding of how such models of perception are constructed. The explanation of the social processes involved in the judgment of services has been insufficiently investigated.

Also, aspects related to the interest of the researcher and the various agents involved in the production of the studies, as well as devices related to the way of interrogating the user are not well established. Before accounting for satisfaction responses, one must ask the question itself: who asks, how asks, who answers and what relationship is established between investigator and investigated.

The imposition of problematic

The imposition of problematic was discussed by Bourdieu33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980. and Champagne44 Champagne P. A ruptura com as pré-construções espontâneas ou eruditas. In: Merllié D. Iniciação à prática sociológica. Petrópolis: Vozes; 1998. as a phenomenon linked to opinion polls. Opinion polls have interested sociology to the extent that they have legitimated themselves on the political stage by presenting themselves as 'an appearance of science'44 Champagne P. A ruptura com as pré-construções espontâneas ou eruditas. In: Merllié D. Iniciação à prática sociológica. Petrópolis: Vozes; 1998.. Commissioned by the authorities, opinion polls are conducted to assess the opinions of the citizens (voting intentions, opinions on particular issues) and play the role of legitimating the assumptions they are supposed to make and formalizing political common sense44 Champagne P. A ruptura com as pré-construções espontâneas ou eruditas. In: Merllié D. Iniciação à prática sociológica. Petrópolis: Vozes; 1998..

Bourdieu33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980. was also interested in the assumptions and social effects of opinion polls. In an article published in 1973, he challenged three hidden assumptions of the polls: the first is to suppose that all people have opinions on all subjects. The second, is to assume that all opinions are equivalent, and the latter, is that there is a consensus on the problems. In this case, it is observed that the same question is asked to all the interviewees, which, according to Bourdieu, implies the hypothesis of existence of consensuses on the problems exposed there; on the relevance of problems; and on the questions that should be asked.

Bourdieu33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980. observes that the scientific analysis of opinion polls shows that there are no problems that present themselves equally to all; there are no questions that are not reinterpreted according to the interests or non-interests of the people to whom they are put. This way, according to the author, it is fundamental to ask which question the different categories of respondents believe to respond.

What the author calls 'problematic imposition' is one of the most pernicious effects of the opinion poll, which

consists precisely in ordering people to respond to questions that have not been posed or, still, to answer to a different question than the question raised, and interpretation only registers misunderstanding33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980.(141).

Thus, the problems raised by opinion polls are interested problematics. Bourdieu33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980. considers that the interests that sustain these problems are political interests, exercising control over the meaning of the answers and about the meaning given to the publication of the answers. This implies the 'illusion' that public opinion is the mere addition of individual opinions, that public opinion would be the average of the opinions, or average opinion, "collected in a situation of isolation in which the individual furtively expresses an isolated opinion"33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980.(140), while "in real situations, opinions are forces and relations between opinions are conflicts of forces between groups"33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980.(140). Thus, he argues that the fundamental effect of opinion research is to convey the idea that there is a unanimous public opinion constituted to legitimize a policy and strengthen the relations of force that underlie it33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980..

Bourdieu11 Vieira-da-Silva LM. Gênese Sócio-Histórica da Saúde Coletiva no Brasil. In: Lima NT, Santana JP, Paiva J. Saúde Coletiva: a Abrasco em 35 anos de história. Rio de Janeiro: Fiocruz; 2015. p. 25-48., therefore, considers that public opinion 'does not exist', in the sense given by those responsible for the polls. There would, rather, be an artifact produced from a statistical aggregation and an imposition of problematic, considering that there are,

on the one hand, opinions mobilized, opinions constituted, pressure groups mobilized around a system of interests; and on the other hand, dispositions, that is, opinion in the implicit state, which by definition, is not an opinion if one understands something that can be formulated in discourse with a certain pretension to coherence33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980.(151).

Satisfaction as an imposition of problematic

Polls on the satisfaction of the user are similar to opinion polls. They are based on an implicit philosophy of the registration of the real, which presupposes, first of all, that satisfaction is a data of reality, produced after the use of the service, and that it is only a matter of measuring it. Secondly, that users have an opinion and that it would be enough to give the floor to a representative sample of individuals and register their answers to know and understand the social world44 Champagne P. A ruptura com as pré-construções espontâneas ou eruditas. In: Merllié D. Iniciação à prática sociológica. Petrópolis: Vozes; 1998..

Likewise, the interview situation of an inquiry that seeks to measure satisfaction with this variety of possibilities of interactions reproduces class relations and may correspond to an imposition of problematic.

Thus, answers about satisfaction depend, in part, on how the questions are posed and, partly, on the relationships established between the user and the professional, and, subsequently, on the user and the interviewer. It is not known that there is probably a group that oscillates between the approval and disapproval of the services and, also, a group that has no opinion on the issue, even if class provisions somehow guide the issuance of a judgment.

They are characterized, also, by researches of pragmatic interest capable of being used to legitimize governmental actions, insofar as they result in the assessment of the majority opinion of those who are for or against a particular system, program or action.

Final comments

The present essay discusses the hypothesis that the high satisfaction described in the specialized literature can be a product of the relationship between the way and the conditions of interrogating the user and the possibilities of response of the user related to their position in the social space.

The simplistic and, almost always, positive images that users have of health services presented by satisfaction surveys should be replaced by a complex and multiple representation of service experiences that require a variety of investigative strategies for their apprehension.

On the other hand, this type of opinion poll, sometimes, masks important criticism of services. It is necessary to minimize the effects of imposition of problematic in the surveys that seek to assess the perceptions of the users about health services, as well as to avoid the class ethnocentrism of the researcher, through epistemological surveillance, minimizing the symbolic violence present in the situation of search.

According to Singly4545 Singly F. L´enquête et ses methods: Le questionnaire. Paris: Armand Colin; 2005., from a methodological point of view, it is possible to reduce the effects of problematic imposition by means of strategies such as including in the questionnaire the option 'no opinion' or putting the question in two times, allowing, thus, an intermediary filter between existence and the statement of the opinion. These measures challenge the assumption that all individuals have an opinion on all subjects. Moreover, to establish a balance between the positive and negative modalities of response and allow the user to respond to more than one possibility of response, in the case of structured instruments. In this case, the school attitude in providing answers is avoided.

These considerations, however, refer us to the way of questioning the satisfaction or perception of the user about the service. In fact, the answers to a questionnaire are influenced by the way the questions are written and in the order in which they are placed. However, this type of analysis suggests that there is a 'good' way of asking questions in order to get 'true' opinions33 Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980.. For Champagne44 Champagne P. A ruptura com as pré-construções espontâneas ou eruditas. In: Merllié D. Iniciação à prática sociológica. Petrópolis: Vozes; 1998., there are no 'good questions', but more or less approximate interpretations of the meaning that should be given to the answers to the questions.

The exercise of reflexivity by the researcher and the search for non-violent interviews4646 Bourdieu P, Accardo A, Balazs G, et al. A miséria do mundo. Petrópolis: Vozes; 1998. represent ways of reducing the asymmetrical and, often, of domination, relations present in such research. The reduction of the symbolic violence present in the research situation requires a methodical and active listening, the exercise of reflexive reflexivity, capable of "perceiving and controlling in the field, in the very condition of the interview, the effects of the social structure in which it is performed"4646 Bourdieu P, Accardo A, Balazs G, et al. A miséria do mundo. Petrópolis: Vozes; 1998.(694).

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References

  • 1
    Vieira-da-Silva LM. Gênese Sócio-Histórica da Saúde Coletiva no Brasil. In: Lima NT, Santana JP, Paiva J. Saúde Coletiva: a Abrasco em 35 anos de história. Rio de Janeiro: Fiocruz; 2015. p. 25-48.
  • 2
    Vieira-da-Silva LM. Salud Colectiva brasilena: arquitectura y dinamica de un campo. In: Castro R, Suarez HJ, organizadores. Pierre Bourdieu en la sociologia Latinoamericana: Campo y Habitus. 1. ed. Morelos: Universidad Nacional Autonoma de México; 2018. p. 143-166.
  • 3
    Bourdieu P. A opinião pública não existe. In: Thiollent MJM. Crítica metodológica: Investigação social e enquete operária. São Paulo: Polis; 1980.
  • 4
    Champagne P. A ruptura com as pré-construções espontâneas ou eruditas. In: Merllié D. Iniciação à prática sociológica. Petrópolis: Vozes; 1998.
  • 5
    Berwick DM. Sintomas do stress no sistema de serviços de saúde. In: Berwick DM, Godfrey AB, Roessner J. Melhorando a qualidade dos serviços médicos, hospitalares e da saúde. São Paulo: Makron Books; 1994. p. 1-13.
  • 6
    Cleary DP, Mcneil JB. Patient satisfaction as an indicator of quality care. Inquiry. 1988; 25(1):25-36.
  • 7
    Evrard Y. La satisfaction des consommateurs: état des recherches. Revue Française du Marketing. 1993; 144:53-65.
  • 8
    Vieira-da-Silva LM. Saúde e espaço social. In: Nogueira RP, organizador. Determinação social da saúde e Reforma Sanitária. Rio de Janeiro: Cebes; 2010. p. 180-200.
  • 9
    Bourdieu P. A Distinção: crítica social do julgamento. Porto Alegre: Zouk; São Paulo: Edusp; c2006.
  • 10
    Boltanski L. As classes sociais e o corpo. Rio de Janeiro: Graal; 2004.
  • 11
    Bastos GAN, Fasolo LR. Fatores que influenciam a satisfação do paciente ambulatorial em uma população de baixa renda. Rev Bras Epidemiol. 2013; 16(1): 114-124.
  • 12
    Esperidião MA, Vieira-da-Silva LM. Posição social e julgamento dos serviços de saúde pelos usuários. Saúde Soc. 2016 jun; 25(2):381-391.
  • 13
    Martins PC, Cotta RMM, Mendes FF, et al. De quem é o SUS? Sobre as representações sociais dos usuários do Programa Saúde da Família. Ciênc Saúde Colet. 2011; 16(3):1933-1942.
  • 14
    Santiago RF, Mendes ACG, Miranda GMD, et al. Qualidade do atendimento nas Unidades de Saúde da Família no município de Recife: a percepção do usuários. Ciênc Saúde Colet. 2013 jan; 18(1):35-44.
  • 15
    Pereira MGA, Azevêdo ES. A relação médico-paciente em Rio Branco/AC sob a ótica dos pacientes. Rev Assoc Med Bras. 2005 jun; 51(3):153-157.
  • 16
    Azevedo ALM, Costa AM. A estreita porta de entrada do Sistema Único de Saúde (SUS): uma avaliação do acesso na Estratégia de Saúde da Família. Interface. 2010 dez; 14(35):797-810.
  • 17
    Gill L, White L. A critical review of patient satisfaction. Leadership Health Serv. 2009; 22(1):8-19.
  • 18
    Mishima SM, Campos AC, Matumoto S, et al. Satisfação do usuário sob a perspectiva da responsividade: estratégia para análise de sistemas universais. Rev Latino-Am Enferm. 2016; 24:1-7.
  • 19
    Shill J, Taylor DM, Ngui B, et al. Factors associated with high levels of patient satisfaction with pain management. Acad Emerg Med. 2012 out; 19(10):1212-1215.
  • 20
    Jao K, Taylor DM, Taylor SE, et al. Simple clinical targets associated with a high level of patient satisfaction with their pain management. Emerg Med Australas. 2011 abr; 23(2):195-201.
  • 21
    Guzik A, Menzel NN, Fitzpatrick J, et al. Patient satisfaction with nurse practitioner and physician services in the occupational health setting. AAOHN J. 2009; 57(5):191-197.
  • 22
    Estcourt S, Hickey J, Perros P, et al. The patient experience of services for thyroid eye disease in the United Kingdom: results of a nationwide survey. Eur J Endocrinol. 2009 set; 161(3):483-487.
  • 23
    Hollanda E, Siqueira SAV, Andrade GRB, et al. Satisfação e responsividade em serviços de atenção à saúde da Fundação Oswaldo Cruz. Ciênc Saúde Colet. 2012 dez; 17(12):3343-3352.
  • 24
    Stewart DE, Dang BN, Trautner B, et al. Assessing residents' knowledge of patient satisfaction: a cross-sectional study at a large academic medical centre. BMJ Open. 2017 ago; 7(8):1-7.
  • 25
    Trad LAB, Bastos ACS, Santana EM, et al. Estudo etnográfico da satisfação de usuário do Programa de Saúde da Família (PSF) na Bahia. Ciênc Saúde Colet. 2002; 7(3):581-589.
  • 26
    Zaicaner R. Satisfação da clientela: um objetivo a ser alcançado pelo serviço público de saúde [dissertação]. São Paulo: Faculdade de Saúde Pública, Universidade de São Paulo; 2001.
  • 27
    Gerschman S, Veiga L, Guimarães C, et al. Estudo de satisfação dos beneficiários de planos de saúde de hospitais filantrópicos. Ciênc Saúde Colet. 2007; 12(2):487-500.
  • 28
    Gentil RM, Leal SM, Scarpi MJ. Avaliação da resolutividade e da satisfação da clientela de um serviço de referência secundária em oftalmologia da Universidade Federal de São Paulo - UNIFESP. Arq Bras Oftalmol. 2003; 66(2):159-165.
  • 29
    Silva LMP, Muccioli C, Belfort JR. Perfil socioeconômico e satisfação dos pacientes atendidos no mutirão de catarata do Instituto da Visão - UNIFESP. Arq Bras Oftalmol. 2004; 67(5):737-744.
  • 30
    Ventura LO, Brandt CT. Projeto Mutirão de Catarata em centro de referência oftalmológico, em Pernambuco: perfil, grau de satisfação e benefício visual do usuário. Arq Bras Oftalmol. 2004; 67(2):231-235.
  • 31
    Costa PG, Aoki L, Saraiva FP, et al. Toxina botulínica no tratamento de distonias faciais: avaliação da eficácia e da satisfação dos pacientes ao longo do tratamento. Arq Bras Oftalmol. 2005; 68(4):471-474.
  • 32
    Carr-Hill RA. The measurement of patient satisfaction. J Public Health Med. 1992; 14(3):236-249.
  • 33
    Esperidião MA, Trad LAB. Avaliação de satisfação de usuários: considerações metodológicas. Ciênc Saúde Colet. 2005; 10(supl).
  • 34.
    Leichner P, Perrealut M. Developpmente et validation d'une echelle multi- dimensionelle de satisfaction de patients de services d'hospitalisation en psychiatrie. Rapport Final. Montréal: Société canadienne d'évaluation; 1990.
  • 35
    Locker D, Dunt D. Theoretical and methodological issues in sociological studies of consumer satisfaction with medical care. Soc Science Med. 1978; 12(4):283-292.
  • 36
    Ross CK, Steward CA, Sinacope JM. The importance of patient preferences in the measurement of health care satisfaction. Medical Care. 1993; 31(12):1138-1149.
  • 37
    Ware JE, Snyder MK, Wright WR, et al. Defining and measuring patient satisfaction with medical care. Evaluation Program Planning. 1983; 6:247-263.
  • 38
    Fitzpatrick R, Hopkins A. Problems in the conceptual framework of patient satisfaction research: an empirical exploration. Sociol Health Illness. 1983; 5(3):297-311.
  • 39
    Owens DJ, Bachelor C. Patient satisfaction and the elderly. Soc Science Med. 1996; 42(11):1483-1491.
  • 40
    Atkinson S, Medeiros RL. Explanatory models of influences on the construction and expression of user satisfaction. Soc Science Med. 2009 jun; 68(11):2089-2096.
  • 41
    Bernhart MH, Wiadnyana IGP, Wihardjo H, et al. Patient Satisfaction in developing countries. Soc Science Med. 1999; 48:989-996.
  • 42
    Pugh R, Scharf T, Williamns C, et al. Obstacles to using and providing rural social care in Santiago de Chile. J Health Soc Behavior. 1998; 29:199-213.
  • 43
    Williams B, Coyle J, Healy D. The meaning of patient satisfaction: An explanation of high reported levels. Soc Science Med. 1998; 47(9):1351-1359.
  • 44
    Williams B. Patient satisfaction: a valid concept? Soc Science Med. 1994; 38(4):509-551.
  • 45
    Singly F. L´enquête et ses methods: Le questionnaire. Paris: Armand Colin; 2005.
  • 46
    Bourdieu P, Accardo A, Balazs G, et al. A miséria do mundo. Petrópolis: Vozes; 1998.

History

  • Received
    16 July 2018
  • Accepted
    23 Sept 2018
  • Publication
    Oct 2018
Centro Brasileiro de Estudos de Saúde RJ - Brazil
E-mail: revista@saudeemdebate.org.br