SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE

2019, VOL. 37, NO. 4, 468–475

https://doi.org/10.1080/02813432.2019.1684430

RESEARCH ARTICLE

Patients’ ideas, concerns, expectations and satisfaction in primary health

care – a questionnaire study of patients and health care professionals’
perspectives
Joel Freilicha,c, Eivor Wikingb, Gunnar H Nilssond and Christina Olssonb,d
a
Roslags N€asby Health Care Center, Stockholm County Council, Stockholm, Sweden; bMo€rby Academic Primary Health Care Center,
Stockholm County Council, Stockholm, Sweden; cDepartment of Learning, Informatics, Management and Ethics (LIME), Karolinska
Institutet, Stockholm, Sweden; dDepartment of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet,
Stockholm, Sweden

ABSTRACT ARTICLE HISTORY

Objective: Explore the perceptions of patients and health care professionals about patients’ Received 17 January 2019
ideas, concerns, expectations (ICE), and satisfaction in consultations with general practitioners Accepted 8 September 2019
(GPs), district nurses (DNs) and physiotherapists (PTs).
KEYWORDS
Design: Cross-sectional questionnaire study of participants in planned consultations.
Primary health care; patient
Setting: Five primary health care centers and two rehabilitation centers in Stockholm, Sweden. centeredness; general
Subjects: Pairs of patients and GPs (n ¼ 156), patients and DNs (n ¼ 73), and patients and practitioner; district nurse;
PTs (n ¼ 69). physiotherapist
Main outcome measures: Multiple-choice questions about patients’ ICE and satisfaction.
Results: Approximately 75% of patients and GPs reported that patients’ thoughts and explana-
tions about their symptoms emerged during the consultation. For patient-DN pairs, the figure
was 60%, and for patient-PT pairs, 80%. A majority of patients reported not having concerns
and anxiety about the investigation/treatment, whereas health care professionals thought
patients were more concerned. One-third of patients consulting GPs and PTs expected to
receive a reason/explanation for their symptoms. Figures were lower for the DNs. About 70% of
patients were satisfied with the consultation.
Conclusions: Most patients expressed their ideas, a minority had concerns, and a minority
expected an explanation of their illness. Patients and health care professionals rated patient sat-
isfaction high, but health care professionals tended to believe patients were less satisfied than
patients reported they were.
KEY POINTS
 Patient surveys show that important aspects of patient-centeredness remain weak in Swedish
primary health care; for example, shared decision-making.
 In this study of planned consultations, few patients expected to receive an explanation of
their symptoms, but most were satisfied with the consultation.
 Health care professionals thought patients’ experiences were more negative than they were.
 This discrepancy was observed in responses to questions about patients’ concerns, expecta-
tions and satisfaction.

Introduction
outcomes, such as unwanted prescriptions and non-
A patient-centered consultation starts with eliciting adherence to treatment [3]. It is therefore important
the patient’s perspective. Most patients have a particu- that health care professionals explore patients’ ideas,
lar agenda, which often includes ideas about the concerns and expectations (ICE) early in the consult-
cause of the consultation [1]. In many cases, they also ation [3–5].
have an explanation of why they do not feel well In patient-centered consultations, health care pro-
[1,2]. Earlier studies have shown that patients do not fessionals aim to share understanding and decision-
always express their entire agenda in consultations, making with patients [6]. This involves empathy with
which can lead to misunderstandings and poor and respect for the patient. Patient-centeredness may

CONTACT Joel Freilich [email protected] MMC/System Safety in Health Care, Department of Learning, Informatics, Management and Ethics (LIME),
Karolinska Institutet, Stockholm 17177, Sweden
ß 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
 SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE 469

lead to increased patient satisfaction [7,8], better the centers agreed to participate in the study, but one
adherence to treatment [9,10], less need for investiga- dropped out after a few months because of the heavy
tions and fewer prescriptions [11,12], fewer referrals workload at the center. One of the PHC centers had
[13], better health outcomes [10,14] and less health all three categories of professionals, and five had GPs
care utilization [13,15]. and DNs but no PTs. Two rehabilitation centers only
Swedish health care policy calls for patient-centered had PTs. Only fully trained specialist physicians in fam-
care [16]. However, an analysis of Swedish National ily medicine were included in the study.
Patient Survey data from the mid-2000s showed defi- In northeastern Stockholm, socioeconomic status is
ciencies in involving Primary health care (PHC) generally high, and Swedish is the most commonly
patients in planning their care [17]. Moreover, a 2017 used language. The population of the three municipal-
survey found that patients older than 65 years in ities represented in this study has a higher educational
Sweden were receiving less information and shared level than most other areas in Stockholm and Sweden
less in decision-making than previously and in Europe as a whole.
as a whole [18]. It is therefore important to investigate
how care can become more patient-centered for
Questionnaires
patients in Sweden.
PHC serves as the foundation of health care sys- Two questionnaires were developed: one for patients,
tems, and many patient consultations take place there. which asked about their experiences, and one for
Most studies have focused on patients’ experiences of health care professionals, which asked about patients’
consultations [1–4,7], but it is also important to gain experiences. The questions were based on items in
insight into the experiences of health care professio- questionnaires used in earlier studies of patient-cen-
nals, since achieving concordance is a central part of teredness [20–25]. Because none of the previously
patient-centered consultations. Few previous studies existing questionnaires addressed all the items we
have examined patients and health care professionals’ wanted to include in this study, we developed the
experiences of patients’ ICE and satisfaction in the study-specific questionnaires. A research group that
same consultations [19]. included GPs, district nurses, physiotherapists, and
The aim of this study was to explore the percep- senior researchers revised, translated and adapted the
tions of patients and health care professionals about questions to Swedish PHC. The questions addressed
patients’ ICE and satisfaction in consultations with background factors and ideas (questions 2 and 3),
general practitioners (GPs), district nurses (DNs) and concerns (questions 5–8), expectations (questions 9–11
physiotherapists (PTs), the largest groups of health and 13–14) and satisfaction (questions 16–20) (Tables
care professionals in PHC. 2 and 3). Response alternatives were ‘yes’, ‘partly’, ‘no’
and ‘I don’t know’. Questions 1, 4, 12 and 15 were
Method open-ended and were not included in this study but
will be part of a forthcoming qualitative study. The
Design questionnaires were tested on pairs of patients and
This study is a cross-sectional questionnaire study of health care professionals (3 GPs and 3 patients, 3 DNs
patients and health care professionals who took part and 3 patients, and 3 PTs and 3 patients). The patients
in planned consultations. and health care professionals deemed the questions
understandable, so no changes were made to them.

Setting
Sampling and ethics
The study was conducted at five PHC centers and two
rehabilitation centers in northeast Stockholm from 1 All managers and participating professionals provided
February 2015 to 31 July 2015. Ten of the 28 PHC cen- oral informed consent before the study started. The
ters in the northeast area of Stockholm were invited receptionists also gave patients oral and written infor-
to participate in the study. Invitations were made by mation about the study prior to inclusion, highlighting
telephone and via in-person visits from one of the the voluntary and anonymous nature of participation.
researchers. The research group was familiar with the The receptionists at the centers consecutively invited
centers in the area, and the 10 PHC centers were Swedish-speaking adult patients to participate. They
chosen because their staff situation was stable and were to invite as many patients as possible during the
they had shown previous interest in research. Six of study period who were booked for consultations with
470 J. FREILICH ET AL.

Table 1. Gender, age distribution and number of participants in 298 consultations with general practitioners (GP), district nurses
(DN) and physiotherapists (PT).
GP (n ¼ 156) DN (n ¼ 73) PT (n ¼ 69)
Patient GP Patient DN Patient PT
W M U W M U W M U W M U W M U W M U
Age (years) 98 55 3 88 66 2 34 33 6 60 10 3 47 22 0 55 14 0
20–49 40 5 56 6 5 7 20 11 19 2 41 1
50–70 59 94 21 42 26 27
>70 52 40 22
M: men; W: women; U: unanswered/unknown gender or age.

GPs, DNs and PTs and to keep track of the number of 19 who consulted DNs, and 9 who consulted PTs). The
patients who declined to participate. Only patients majority of respondents were women. Most patients
attending planned consultations were invited, not who consulted GPs and DNs were 50 years.
those attending acute care consultations. It was not Of the health care professionals, GPs had the most
possible to include acute care consultations because equal gender distribution. On average, PTs were
such consultations are too short for both patients and younger than GPs and DNs.
professionals to have time to provide reflections about The most common causes of consultations with
patients’ ICE. GPs were musculoskeletal, circulatory, and psycho-
After obtaining patients’ oral informed consent, the logical problems; with DNs, were related to wound
receptionist provided them with two anonymous dressing, blood pressure measurement, and medical
questionnaires with matching codes: one for the supplies; and with PTs, were for musculoskel-
health care professional and one for the patient. The etal problems.
codes enabled the researchers to match the responses This study analyzed data at the group level to
from the same consultation. Immediately following the investigate patterns in responses from patients and
consultation, patients and health care professionals health care professionals.
were to separately complete their questionnaires and
return them to the receptionist. The coded anonym- Ideas, concerns and expectations
ous surveys were returned by the patients to the
receptionist, either handed in or left in a sealed box. Three-quarters of the patients and a corresponding
The receptionist kept the completed questionnaires in percentage of GPs reported that patients’ thoughts
sealed boxes until the researcher collected them. The and explanations about their symptoms emerged dur-
participating centers were of varied size and recruited ing the consultation (Table 2, question 2). Around 60%
of patients and DNs reported that the patients pre-
different numbers of participants. The length of time
sented their thoughts and explanations. The highest
questionnaires were distributed and collected also var-
figure was observed for PT consultations, where over
ied by center.
80% of patients felt that their thoughts and explana-
The study was approved by the Regional Ethics
tions emerged during the consultation. Approximately
Review Board in Stockholm, Sweden, Dnr 2014/
70% of patients and health care professionals reported
1851-31.
that patients’ questions about health were answered
(question 3).
Results A minority of patients reported that they had con-
cerns about the cause of their illness (7–14%; Table 2,
Study population
question 5) or investigation/treatment (4–7%, question
A total of 724 questionnaires were distributed, and 6). On the other hand, 25% of GPs perceived that their
641 were returned by patients and health care profes- patients had concerns about the cause of their illness;
sionals and collected from the centers by one of the in DNs and PTs the numbers were lower, but a total
researchers. These questionnaires included responses of 44% of DNs and 46% of PTs partly agreed that the
from 156 pairs of patients and GPs, 73 pairs of patient had such concerns (question 5). In 11% to
patients and DNs, and 69 pairs of patients and PTs (a 33% of consultations, patients reported that they had
total of 298 consultations) (Table 1). Thirty-five presented their concerns (question 7).
patients who were invited declined to participate or About a third of patients consulting GPs (31%) and
returned a blank questionnaire (7 who consulted GPs, PTs (32%) expected to receive an explanation for their
Table 2. Question number and content, and distribution in percentages of answers from 298 patient consultations with general practitioners (GP), district nurses (DN) and physio-
therapists (PT) regarding related ideas, concerns and expectations.
GP (n ¼ 156) DN (n ¼ 73) PT (n ¼ 69)
Patients GP Patients DN Patients PT
Question area,
number and content Yes Partly yes No D/U Yes Partly yes No D/U Yes Partly yes No D/U Yes Partly yes No D/U Yes Partly yes No D/U Yes Partly yes No D/U
Ideas
2 If patients’ thoughts and 75.6 8.3 9.0 7.1 73.1 22.4 2.6 1.9 63.0 5.5 9.6 21.9 60.3 20.5 4.1 15.1 84.0 8.7 5.9 1.4 68.1 26.1 4.4 1.4
explanations about their
symptoms emerged during the
consultation
3 If patients’ questions about 70.0 17.9 3.8 8.3 76.3 19.9 1.9 1.9 68.5 8.2 5.5 17.8 74.0 16.4 6.9 2.7 79.7 17.4 2.9 – 69.6 27.5 – 29
health
were answered
5 If patients thought there was 7.1 19.2 62.8 10.9 25.0 26.9 44.3 3.8 6.8 6.8 69.9 16.5 5.5 43.8 42.5 8.2 14.5 17.4 58.0 10.1 17.4 46.4 36.2 –
something frightening that
might cause their symptoms
Concerns
6 If patients had concerns and 7.1 14.7 72.4 5.8 9.0 18.6 71.8 0.6 5.5 6.8 80.9 6.8 2.7 28.8 54.8 13.7 4.3 11.6 79.7 4.3 8.7 27.5 56.5 7.3
anxiety regarding
investigation/treatment
7 If patients’ concerns were 23.1 16.7 41.0 19.2 17.3 18.6 63.5 0.6 10.9 13.7 56.2 19.2 4.1 21.9 68.5 5.5 33.3 17.4 37.7 11.6 14.5 31.9 52.2 1.4
presented
8 If patients had other concerns 10.3 11.5 68.6 9.6 10.3 11.5 68.6 9.6 12.2 11.0 59.0 17.8 15.1 31.5 50.7 2.7 11.6 10.1 69.6 8.7 23.2 30.4 43.5 2.9
Expectations
9 If patients had any expectations 31.4 16.7 40.4 11.5 40.4 30.8 28.2 0.6 12.3 12.3 59.0 16.4 20.5 17.8 52.1 9.6 31.2 31.2 26.1 10.1 44.9 29.0 23.2 2.9
about receiving a reason/an
explanation for their
symptoms
10 If patients felt they were 95.5 – – 4.5 95.6 3.8 0.6 0 87.6 5.5 1.4 5.5 90.4 1.4 2.7 5.5 98.6 – – 1.4 97.1 2.9 – –
respected and taken
seriously
11 If patients’ expectations for the 87.8 8.3 1.3 2.6 76.9 19.2 2.6 1.3 83.6 5.5 2.7 8.2 68.5 20.5 – 11.0 88.4 5.8 1.4 4.3 71.0 24.7 2.9 1.4
consultation were fulfilled
13 If patients received help with 84.0 9.6 0.6 5.8 80.8 17.9 1.3 – 76.7 2.7 1.4 19.2 74.0 16.4 1.4 8.2 85.5 11.6 – 2.9 65.2 33.4 1.4 –
what they expected
14 If patients thought there 3.8 2.6 84.6 9.0 30.8 9.0 59.6 0.6 1.4 1.4 79.5 17.7 15.1 5.5 76.7 2.7 1.4 4.3 88.4 5.8 20.3 13.0 66.7 –
was anything that should
have been done at the
consultation but was missed
D/U: Don’t know/unanswered.
SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE
471
 472 J. FREILICH ET AL.

symptoms. The figures were lower for DNs (12%;

yes no/No D/U Yes yes no/No D/U Yes yes no/No D/U Yes yes no/No D/U Yes yes no/No D/U Yes yes no/No D/U
Table 3. Question number and content, and distribution in percentages of answers from 298 patient consultations with general practitioners (GP), district nurses (DN) and physio-

1.4

1.4

1.4

2.9

2.9
Table 2, question 9). A high percentage of patients felt

Partly Partly

1.4

5.9

1.4

1.4
–
their expectations for the consultation had been ful-
PT
filled (84–88%, question 11) and that they were

2.9 82.6 16.0

2.9 65.3 31.9

7.2 59.4 33.3

4.3 63.8 31.9

2.9 56.5 39.2

respected and taken seriously (88–98%, question 10).
PT (n ¼ 69)

These figures are in line with those of the health care

professionals. Few patients felt something was missed
during their consultation, whereas a higher percentage
Partly Partly

1.4
–

–
Patients

of health care professionals perceived that patients

felt this way (question 14).
2.9

8.7

4.4

5.8

6.8 87.0 10.1

4.1 94.2

5.5 88.4

5.5 87.0

6.8 89.9
Questions about satisfaction
The majority of patients reported that they were satis-
Partly Partly

2.7

1.4

2.7

1.4

fied with the way the health care professional

DN

behaved towards them, with the information and

13.7 72.6 20.6

13.7 54.8 38.3

1.,8 61.7 30.1

1.4 75.3 16.5

5.5 75.3 17.9

emotional support they received, and with shared

DN (n ¼ 73)

decision-making (74–94%, Table 3, questions 16–19).

The highest proportion of satisfied patients was
observed in PT consultations. A lower percentage of
Partly Partly

1.4

1.4

2.7
Patients

all groups of health care professionals than patients

0

reported that patients were satisfied with the consult-

1.4

9.6

8.2

4.1

6.9

ation (questions 16–20).

84.9

0.6 75.3

74.0

1.3 78.1

0.6 84.9
–

Discussion
Partly Partly

1.3

0.6

0.6

0.6

0.6

This study explored patients’ ICE and satisfaction as

GP

expressed by patients and health care professionals

4.5 66.6 32.1

5.7 66.0 32.8

5.1 66.6 32.8

5.1 68.6 29.5

5.1 66.0 32.8

who had taken part in the same PHC consultation. We

GP (n ¼ 156)

found that most patients had expressed their ideas,

but fewer had presented their concerns. A relatively
low number expected to receive an explanation for
Partly Partly

1.3

1.3

1.3

0.6
–

their symptoms, but most felt their overall expecta-

Patients

tions had been met. Health care professionals tended

3.8

80.8 12.2

9.0

5.8

8.3

to believe patients were less satisfied than patients

91.7

84.6

87.8

86.0
Yes

reported they were.

If patients were satisfied with how they were

emotional support during the consultation

behaved towards during the consultation

If patients felt involved in decisions about

Ideas
If patients felt they received sufficient

The number of patients who expressed their own

investigations and treatment

ideas (their own thoughts and explanations) about

If patients were satisfied with
the consultations a whole
If patients felt they received

their illness was higher than in an earlier study in

enough information
therapists (PT) related satisfaction.

which doctors failed to elicit about half of patients’

problems [26]. The relatively low numbers who
expressed their ideas in DN consultations could stem
D/U: Don’t know/unanswered.

from the purpose of the consultations (e.g. blood

pressure measurement, wound dressing). Fewer
patients may have felt it was relevant to express their
Question number

own ideas about their illness during such consulta-

and content
Satisfaction

tions. The highest numbers of patients who presented

their ideas were found in the group who consulted
16

17

18

19

20

PTs. This could be because patients often consult PTs

 SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE 473

for musculoskeletal problems, and the causes of such were more satisfied with shared medication-related
problems can be difficult to determine. Moreover, decision-making than patients of GPs or pharmacist
patients typically consult PTs repeatedly for the same prescribers [35]. It also seems inconsistent with the
cause, providing patients with several opportunities to findings of the 2017 survey that showed that older
tell their story. patients in Sweden shared less in decision-making
than older patients in other countries in Europe [18].
One potential explanation for the seeming inconstancy
Concerns
is that the survey covered all forms of health care, not
It is possible that the relatively low percentage of only PHC. Continuity of care delivery and the more
patients in our study (23%) and in a previous study of natural environment in PHC might facilitate shared
GP trainees (35%) [11] who presented concerns about decision-making.
their illness during consultations may originate in the We hypothesize that the relatively high proportion
planned nature of the consultations in both studies. of patients who were satisfied with shared decision-
That is, patients may have brought up their concerns in making may be related to the high socioeconomic sta-
earlier consultations. The same may be true of patients tus of our study area. Previous studies indicate that
consulting PTs (33%), whereas the corresponding high socioeconomic status is linked to a preference for
results for DNs (12%) may have to do with the nature a more active role in shared decision-making [32,36].
of the consultation, as described previously. Thus, patients in our study area may have taken more
initiative to discuss decisions with the health care pro-
fessionals. However, this is just a hypothesis, and fur-
Expectations
ther study would be needed to test it.
Overall, patients felt their expectations had been met. Our main finding was the discrepancy between
However, only about a third of patients consulting patients’ reported satisfaction and health care profes-
GPs and PTs expected to receive an explanation of the sionals’ perceptions of patient satisfaction. We
cause of their illness. Perhaps this is because we observed this finding in all three professions. There
studied planned (mainly follow-up) consultations, so could be many reasons for the discrepancy. For
patients may already have received such an explan- instance, health care professionals may have wanted
ation. The lower proportion of patients consulting DNs to bring up more topics than time permitted, or they
(12%) who expected to receive an explanation for may not have had the opportunity to check that the
their illness may reflect the non-complex nature of patient’s needs had been met. Previous studies show
many of these consultations. that PHC professionals experience a great deal of job
stress [37–39], and misperception of patients’ experi-
Satisfaction ences might be a preventable source of such stress.

Overall, a high percentage of patients and health care

professionals reported that patients were satisfied Strengths and weaknesses
with the consultation as a whole. Earlier studies that The focus on both patients’ and health care professio-
focused on patients’ perspectives have found that nals’ perspectives of the same consultation is unusual,
contextual factors (e.g. shorter waiting times and care as is the inclusion of consultations with three different
continuity) [27–30], patient characteristics (e.g. age kinds of primary health care professionals. Another
and functional status) [31,32], and factors related to strength is the fairly large number of respondents.
the consultation are associated with patient satisfac- Moreover, the inclusion of multiple health care centers
tion. Consultation-related factors include receiving an may make the results more generalizable. On the
explanation of the illness [21,31–33], receiving emo- other hand, all participating centers were located in a
tional support [31], and feeling respected by and part of Stockholm characterized by higher socioeco-
experiencing good communication with the health nomic status than the country as whole, which nega-
care professional [34]. tively affects generalizability.
Many patients in the current study (74–87%) were The main limitation of the study was the use of an
also satisfied with opportunities for shared decision- unvalidated questionnaire, which affects the validity
making regardless of which kind of health care profes- and reliability of the results. It is not clear whether
sional they consulted. This contrasts with the results study participants grasped the concepts of ICE that lay
of a previous study that found that patients of nurses behind the questions, and differing understanding of
474 J. FREILICH ET AL.

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