Volume 8 No 1 2020 V2.indd


14 International Journal of Integrated Health Sciences 

(puskesmas).  The prolanis is a program that 
organized various activities to control the 
chronic diseases, prevent it from reaching  
complications, and finally increasing the 
health status of the elderly.3

The success of the prolanis is still not 
satisfactory.  The compliance level is still 
low.4 The monitoring of the patient’s blood 
sugar levels and the treatment compliance 
are not optimal.5 One of the causes of this low 
compliance is satisfaction.4
     Patient satisfaction is one of the indicators 
of the quality of care. It indicates the success 
of the health providers to meet the patient’s 
expectations of the health care they received.6  
The satisfaction level can be measured 
through an instrument known as Service & 
Quality (SERVQUAL).7,8 The study about the 
satisfaction level of the elderly on the prolanis 
by using SERVQUAL has not been carried out. 
Based on this information, the purpose of this 
study was to identify the satisfaction level of 
the elderly on the health services provided by 
the prolanis in the puskesmas. 

Original Article

Elderly Satisfaction on Chronic Disease Management Program at 
Public Health Center, Bandung City, West Java, Indonesia

Correspondence: 
James Maladi Akbar, 
Faculty of Medicine Universitas Padjadjaran, Indonesia
e-mail: maladiakbarjames@yahoo.co.id

James Maladi Akbar,1 Sharon Gondodiputro,2 Ardini Saptaningsih Raksanagara2

1Faculty of Medicine Universitas Padjadjaran, Indonesia
2Department of Public Health Faculty of Medicine Universitas Padjadjaran, Indonesia

 Abstract 
 
 Objective: To identify the satisfaction level of the elderly on the health 

services provided by The Chronic Disease Management Program 
(prolanis) at the  Public Health Center (puskesmas).

  Methods: A descriptive quantitative study with a cross-sectional approach 
had been carried out to 112 elderly from 8 puskesmas in Bandung City, 
West Java, Indonesia. This study was conducted from August until 
November 2019. The variables in this study were 5 dimensions of the 
SERVQUAL. The collected data were analyzed using percentages and the 
Importance-Performance matrix.

  Results: The satisfaction level of the elderly on the health services 
provided by the prolanis was 92%. The dimension that has the highest 
satisfaction level was the assurance dimension  (94,6%) and the lowest 
one was the tangibles dimension (84,8%). The result of the importance-
performance matrix showed that assurance, responsiveness, and empathy 
dimensions needed to be maintained to reach the patient’s satisfaction.  

 
 Conclusions: The elderly satisfaction on the health services provided by  
 the prolanis is high in every dimension of the SERVQUAL.
                  
  Keywords: Chronic disease management program, elderly, Importance-
          Performance matrix, satisfaction, SERVQUAL

Received:
January 9, 2020

Accepted:
May 27, 2020

pISSN: 2302-1381; 
eISSN: 2338-4506; 
http://doi.org/10.15850/
ijihs.v8n1.1935
IJIHS. 2020;8(1):14–21

Introduction

Indonesia has an increase in the total 
population of the elderly. It is reported that 
in 2019  there was 25.64 million elderly in 
Indonesia (9.60%) and this percentage is 
predicted to increase each year.1 The aging 
process causes the elderly more susceptible 
to disease. The overall morbidity rate both 
in urban and rural areas in three consecutive 
years from 2013 to 2015 was 24.8%, 25.05%, 
and 28.62%, respectively. Stroke, malignancy, 
asthma, and diabetes mellitus type 2 are the 
common diseases occurred.2  The Indonesian 
Social Security Agency in the health sector, 
developed a Chronic Disease Management 
Program (prolanis) for the National Health 
Insurance (JKN) participants, conducted 
especially at the public health center 



International Journal of Integrated Health Sciences 15

James Maladi Akbar, Sharon Gondodiputro, et al.

Methods

This study was a descriptive study with a 
cross-sectional method, conducted from 
August 2019 to November 2019 in Bandung 
City, West Java Indonesia. The total number 
of puskesmas that provided prolanis was 16 
puskesmas and from that number, 50% (8 
puskesmas)  were selected by simple random 
sampling. The inclusion criteria were elderly 
aged 60 years and over, willing to participate in 
the study, able to communicate well, and came 
for treatment at the puskesmas, whereas the 
exclusion criteria were elderly that did not take 
the interview completely.  The total samples 
were calculated by using sample formula for 
categorical descriptive study, with α=5%, 
and p value=0.88.9 Based on that formula, the 
total samples needed in this study were 112 
respondents. Before determining the number 
of elderly in each puskesmas, the researchers 
requested data on the presence of the elderly 
for 3 months in each selected puskesmas. This 
data was used as a denominator in calculating 
the number of samples in each puskesmas. The 
number of respondents in each puskesmas was 
calculated by the number of elderly visits at 
the puskesmas (n) divided by the total number 
of elderly visits to the 8 puskesmas (N) and 
multiplied by the number of samples needed. 
On the day of data collection, the number of the 
elderly present was uncertain, therefore the 
respondents were selected using consecutive 
sampling, a sampling technique in which 
every subject meeting the criteria of inclusion 
was selected until the required sample size 
was achieved.  Permission to do the study 
was obtained from three institutions, namely 
the Bandung City Mayor Office, Bandung City 
Health Office, and the selected puskesmas. 
This study had received the ethical clearance 
from the Health Research Ethics Committee of 
Universitas Padjadjaran Bandung, Indonesia 
under the ethical clearance 1036/UN6.KEP/
EC/2019. 

The questionnaire of the  SERVQUAL 
consisted of 22 statements and divided into 
5 dimensions, namely tangibles, reliability, 
assurance, responsiveness, and empathy7,8, 
and was developed by the Departement of 
Public Health Faculty of Medicine Universitas 
Padjadjaran in 2011, based on the SERVQUAL 
by Parasuraman. It was tested to 53 
respondents from Bandung City. A content and 
construct analysis were carried out. The result 
of the Cronbach’s alpha was between 0,801 
and 0,977 for each dimension.10  The tangibles 
dimension consisted of 4 statements, namely 

visually appealing rooms; complete facilities; 
employees who have a neat, professional 
appearance; and complete medical 
equipment. The reliability dimension consists 
of 5 statements, namely, providing services 
as promised; dependability in handling 
customers’ problems; simple procedures; 
providing services at the promised time; and 
prompt administrative services. The assurance 
dimension consisted of 4 statements, namely 
health providers who instill confidence 
in customers; making customers feel 
safe; respect the customers;  and health 
providers who have the knowledge to answer 
customer questions. The responsiveness 
dimension consisted of 4 statements, 
namely keeping customers informed about 
when services will be performed; prompt 
service to customers; willingness to help 
the customers; and readiness to respond to 
customers’ requests. The empathy dimension 
consisted of 5 statements, namely giving 
customers individual attention without any 
discrimination; convenient business hours;  
health providers who understand the needs 
of their customers; having the customer’s 
best interest at heart; and health providers 
who deal with customers in a caring fashion.10 
Each statement had two columns namely 
“expectation” and “reality” columns that 
had a score ranging from 1 to 10. Prior to 
data collection, the selected respondents 
were given explained about the purpose and 
procedure of the study. After they understood 
and agreed to participate in this study, they 
signed the informed consent form.  The 
researcher read and explained the meaning of 
each statement one by one to the respondents 
and the respondents chose the right score for 
each statement both for the “expectation” and 
“reality” aspects. 

The average score of the “expectation” and 
the “reality” was calculated by adding up the 
total score of “expectation” or “reality” divided 
by the number of samples. The satisfaction 
level was calculated by dividing the “reality” 
average score with the “expectation” average 
score and multiplied by 100%. Satisfied if  the 
percentage reached  ≥ 80%, and dissatisfied  if 
the percentage was <80%.11

The collected data were statistically 
analyzed using Fisher’s exact test or 
Kolmogorov-Smirnov test to identify the 
difference of satisfaction according to the 
characteristics of the respondents.
     The importance and performance matrix 
had 2 components, those were the x-axis 
(performance/reality axis) and the y-axis 



16 International Journal of Integrated Health Sciences 

Table 1 Respondent’s Characteristics and Satisfaction

Characteristic Frequency(n=112) (%)
Dissatisfied
(n=9) (%)

Satisfied
(n=103) (%) p-value

Age (years old) 
60–69
>70 

70 (62.5)
42 (37.5)

           
3 (4.3)

6 (14.3)
67 (95.7)
36 (85.7) 0.078*

Education
≤ Elementary School
Junior high school
Senior high school
>Senior high school

44 (39.3)
26 (23.2)
27 (24.1)
15 (13.4)

3 (6.8)
2 (7.7)
1 (3.7)

3 (20.0)

41 (93.2)
24 (92.3)
26 (96.3)
12 (80.0)

0.831**

Marital status
Not married
Married
Divorce

1 (0.9)
60 (53.6)
51 (45.5)

0 (0.0)
5 (8.3)
4 (7.8)

1 (100)
55 (91.7)
47 (92.2)

1.000**

Occupation
Retired
Employed

88 (78.6)
24 (21.4)

6 (6.8)
3 (12.5)

82 (93.2)
21 (87.5) 0.400*

Disease
       Hypertension
       Diabetes mellitus
       Hypertension and Diabetes mellitus

49 (43.8)
34 (30.4)
29 (25.9)

5 (10.2)
0 (0.0)

4 (13.8)

44 (89.4)
34 (100)
25 (86.2)

0.889**

Notes: *Fisher’s exact test; ** Kolmogorov-Smirnov test

(importance/expectation axis).12 The value of 
the x-axis was the “reality” average score and 
the value of the y-axis was the “expectation” 
average score.12 This matrix created using 
IMB SPSS 22.0. Both axes create a Cartesian 
diagram that had four quadrants. (Figure 1). 

Quadrant I showed customers feel that 
the health services provided by the prolanis 
was high, but the performance was low. 
The quality of health services that entered 

Main Priority (I) Maintain Achievement 
(II)

Low Priority (III) Overload (IV)                                            X

Y

Figure 1 Importance-Performance Matrix

this quadrant should be prioritized to be 
improved because of the high importance 
and low satisfaction. Quadrant II showed the 
area in which health services at the prolanis 
needed to be maintained to make sure that 
the customers were still satisfied with the 
health services provided because the level 
of importance and performance were both 
high. Quadrant III showed a low priority 
area because of the low importance and low 
performance. The performance of the prolanis 
was low,  and the importance perceived by the 
customer was also low. This situation did not 
mean that the organization did not have to 
enhance the quality of their services. They still 
had to provide health care better than before.  
Quadrant IV was categorized as overload area 
because there were factors that were not 
important for consumers (low importance 
level), but the organization provided the 
health care with a high performance.12,13

Results

The study on the satisfaction level of the 
elderly on the health care provided by the 
prolanis in Bandung City has been conducted 
using SERVQUAL questionnaires with total 
respondents of 112 elderly. Table 1 showed 

Elderly Satisfaction on Chronic Disease Management Program at Public Health Center, Bandung City



International Journal of Integrated Health Sciences 17

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James Maladi Akbar, Sharon Gondodiputro, et al.



18 International Journal of Integrated Health Sciences 

that most of the respondents were aged 
60-69 years old, low education, married, 
retired, and had hypertension. There was no 
difference in satisfaction level satisfaction for 
all characteristic variables (p-value ≥0.05).

This study discovered that the satisfaction 
level was very high.  The dimension that 
had the highest satisfaction level was the 
assurance dimension (94,6%) and the lowest 
was the tangibles dimension (84,8%; Table 2).

This study revealed that there were 
differences in the total satisfaction and in 
every dimension that existed in the eight 
puskesmas. In the puskesmas number 2, the 
total satisfaction was high, but in the tangibles 
and reliability dimensions, the satisfaction 
was low. Puskesmas number 4 had the lowest 

level of satisfaction compared to the other 
puskesmas (Table 2).

This study discovered that tangibles 
and reliability dimensions placed inside 
the quadrant III, which means that both 
dimensions had a low priority to be improved, 
while assurance, responsiveness, and empathy 
dimensions placed inside the quadrant II 
which means the health providers needed to 
maintain the health service quality in these 
three dimensions (Figure 2). 

Every statement in every dimension was 
plotted also into the Importance-Performance 
Matrix. This study discovered that “the 
complete medical equipment” statement 
(tangibles) placed in the first quadrant.  
Moreover, the “simple procedures” statement 

Figure 2  Importance-Performance Matrix for  5 Dimensions of Satisfaction 
                       Notes: 1. Tangibles; 2. Reliability; 3. Responsiveness; 4. Assurance; 5.Empathy

Figure 3 Tangibles and Reliability Importance-Performance Matrix

Elderly Satisfaction on Chronic Disease Management Program at Public Health Center, Bandung City



International Journal of Integrated Health Sciences 19

Figure 4 Assurance, Responsiveness, and Empathy Importance-Performance Matrix

(reliability) placed in the first quadrant as well 
(Figure 3).

Regarding the assurance dimension, this 
study discovered that the statement about 
“health providers who knew to answer customer 
questions” placed in the  first quadrant (Figure 
4).

Discussion

Prolanis is a health service system that involves 
patients, as members of the JKN, primary health 
facilities, and The Indonesian Social Security 
Agency in the health sector,  who suffer from 
chronic diseases, especially hypertension 
and diabetes mellitus. Six prolanis activities 
consist of: (1) medical consultation; (2) health 
education; (3) SMS gateway reminder; (4) home 
visit; (5) physical exercise (gymnastics) and; 

(6) monitoring health status.3  The goal of the 
prolanis is to encourage participants to come to 
the puskesmas for monitoring and treating their 
diseases so that they achieve optimal quality of 
life and prevent complications.3 
      Patient satisfaction is one of the indicators 
for measuring the quality of health care 
services. Measuring the level of satisfaction 
is very important as satisfaction might affect 
adherence to treatment for chronic diseases 
such as hypertension and diabetes mellitus.14 
Moreover, assessing the level of satisfaction 
can give information on whether the services 
provided by the puskesmas are in accordance 
with the customer expectation.6 This study 
discovered that most of the respondents were 
satisfied with the health services provided at 
the prolanis in every dimension, however, the 
tangible dimension had the lowest satisfaction 

James Maladi Akbar, Sharon Gondodiputro, et al.



20 International Journal of Integrated Health Sciences 

level compared to the other dimensions of 
SERVQUAL. Moreover, the responsiveness, 
assurance, and empathy dimensions placed in 
the Quadrant II of the importance-performance 
matrix which means that the quality of those 
dimensions should be maintained.12,13

From the tangible dimension, the main 
component that needed to be improved is the 
availability of medical equipment such as the 
insulin syringe. In Indonesia, hypertension 
and diabetes mellitus are chronic diseases 
that have become the primary concern for 
the public health sector.15 The hypertension 
prevalence in Indonesia is quite high as many 
as 8.6–10%16, while the diabetes prevalence 
is as many as 4,6%.17 The management 
of hypertension and diabetes without 
complications is the authority of doctors 
who work at the puskesmas, therefore the 
availability of medicines and insulin syringes 
need to be considered.  

The reliability dimension placed inside the 
quadrant III of the importance-performance 
matrix which means that this dimension had a 
low priority to be improved, however, there is 
one component of the reliability dimension that 
should be improved, namely the procedures 
at the prolanis was complicated, not a simple 
one, especially when the puskesmas referred 
them to the hospital. This is in accordance 
with the study by Nurheda et al., that the 
respondents were not satisfied because they 
had not been served promptly and tended to 
be convoluted.18 

The ability of the health providers to 
answer the patients’ questions is a component 
of the assurance dimension placed in the 
quadrant I. A study conducted by Andrew H. 
Van de Ven  et al discovered that patients will 
feel satisfied if the health providers were able 
to explain about the condition of illness, the 
treatment given and the side effects of  the 
medicine given to the patients.19 

     This study discovered that tangible and 
reliability dimension, and several components 
in other dimensions placed inside the 
quadrant III. This quadrant described that 
the respondents had a low expectation and 
the performance of the health care provided 
at the prolanis was low.13the purpose of this 
paper is to measure service quality provided 
to surgical and medical inpatients at Kerman 
Medical Sciences University (KUMS Compared 
to other quadrant, dimensions or statements 
placed in this quadrant showed a low priority 
to be intervened.12,13 Sanam Roder-DeWan 
et al. stated that the low expectation of the 
patients, made them feel satisfied with the low 
quality of the health services. There was no 
demand to improve the quality of the health 
services and in the end the health providers 
will not make efforts to enhance the quality of 
their health services.20  

This study has some limitations. This 
study did not link the satisfaction level with 
treatment adherence. There were lots of 
statements in the SERVQUAL questionnaire 
that require a considerable amount of time to 
answer by the respondents. This causes some 
of the elderly were suspected of not answering 
them in accordance with their choices.

The conclusion of this study is the 
satisfaction level of the elderly on the health 
care provided at the prolanis is high. The 
dimension with the highest satisfaction level 
is the assurance dimension (94,6%) and the 
lowest in the tangibles dimension (84,8%). 
The responsiveness, assurance, and empathy 
dimensions should be maintained so that the 
elderly satisfied with the health care provided, 
however, some of the components of tangible 
and reliability dimensions should be improved. 
Further study needed to be conducted to 
analyze the relationship between satisfaction 
level and the treatment adherence of patients 
with hypertension and diabetes.   

Elderly Satisfaction on Chronic Disease Management Program at Public Health Center, Bandung City

1. BPS-Statistics Indonesia. Statistik penduduk 
lanjut usia 2019. Jakarta; 2019. 

2. Indonesian Ministry of Health. Riset kesehatan 
dasar 2018. Jakarta: Badan Penelitian dan 
Pengembangan Kesehatan Kemenkes RI; 2018. 

3. Rosdiana AI. Implementasi program 
pengelolaan penyakit kronis (Prolanis). Higeia 
J Public Heal Res Dev. 2017;1(3):140–50. 

4. Asfiani LV, Ilyas Y. Level of adherence and its 
determinants of Prolanis attendance in type 

2 Diabetes Mellitus participants at five BPJS 
primary health care in Bekasi 2016. J Indones 
Heal Policy Adm. 2017;2(2):6–13. 

5. Raraswati A, Heryaman H, Soetedjo NNM. Peran 
program Prolanis dalam penurunan kadar gula 
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6. Xesfingi S, Vozikis A. Patient satisfaction with 
the healthcare system: Assessing the impact 

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