Introduction

Autism Spectrum Disorder (ASD) is a chronic neurodevelopmental disorder highlighted by impairments in social interaction, verbal and nonverbal communication, and a limited range of activities and interests. American Psychiatric Association, 2013. Autism is a group of developmental disorders marked by difficulties communicating verbally and emotionally, as well as social reciprocal connection and stereotyped, repetitive, or atypical actions or interests. It is referred to as a spectrum of illnesses since its symptoms can appear in several ways and at different levels of severity. [1] Parenting children with ASD can be stressful on an emotional, emotional, financial, and physical level. When compared to parents of generally developing children or children with other disabilities, studies have consistently found higher levels of psychological distress among parents of children with ASD. [2] Frustration, distress, anxiety, possibly guilt and shame, powerlessness, and sometimes refusal may happen when parents become knowledgeable of their autistic children's communicational and relational features. Having a child with special needs, however, is not always a difficult experience. The family is asked to learn new skills, and the presence of the autistic child activates previously unnoticed elements in the family structure [3].

Six quality domains were identified by the Institute of Medicine (IOM): safety, timeliness, effectiveness, efficiency, equity, and patient/family-centeredness. The Institute of Medicine (IOM) established a standard definition of quality as “The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. It has also been defined as “the totality of features and characteristics of a service that bear on its ability to satisfy a given need” [4]. The World Health Organization emphasized the importance of quality in healthcare delivery, as measured by effectiveness, cost, and social acceptability standards. [5] Many studies have concluded that various factors influence service quality. They had originally identified ten different dimensions of service effectiveness, which were later reduced to five broad dimensions [6]. The following were the five broad dimensions:

• Tangibles: is defined as the Resources and capabilities, manpower, and equipment
• Reliability: is defined as the capacity to provide accurate service on timetable and at the same degree of quality every time.
• Responsiveness: Which is defined as the desire to provide prompt and helpful service to the customers.
• Assurance: defined as the Customers' faith and confidence, as well as the efficiency and honesty of personnel.
• Empathy includes offering all users unique, individual care.

A larger and holistic concept that is paper will assess the families of children with ASD satisfaction is in addition to measuring the quality of health treatments for ASD children in Jordan. To address the issue of healthcare quality, in truth, defining the quality of healthcare is more difficult than it appears. Different conceptions of quality are acknowledged as both possible and legitimate.

Objectives of the study

The proposed study is to assess the quality of care for young children with autism and continuously causes a rise in patient satisfaction with healthcare services. The goals are to use the SERVQUAL tool to assess levels of patient satisfaction periodically [7]. Assessing the service quality; involving the facility's management and health providers to their patients' demands; and demonstrating an increase in patient satisfaction through the usage of this instrument.

Method

Procedure

A descriptive cross-sectional research design was used in this study. For assessing the quality characteristics of healthcare services for young children with autism in Jordan. The demographic characteristics of the participants were the basis of the first section of the questionnaire and the second section had 21 questions that reflected the five dimensions of service-quality characteristics established from [8] SERVQUAL's model and extensively covered all areas of healthcare services. (Table 1).

Description of the Questionnaire

A SERVQUAL scale-based questionnaire has been developed. The SERVQUAL tool evaluates service quality on five dimensions: dependability, responsiveness, assurance, empathy, and tangibility. The goal of using this measure regularly is to assess patient satisfaction with services by tracking these service quality dimensions.

Sample Size

The study sample consisted of (122) out of (366) parents of ASD students who are provided with health care services in governmental, voluntary, international and private education centers in the northern Jordan governorates (Irbid, Mafraq, Jerash and Ajloun), according to the Supreme Council for the Affairs of Persons with Disabilities for the year. (2021).

Ethical approval

Institutional approval was obtained from the Albalqa’a university's Institutional Review Board. All of the families who were enrolled in the study gave their informed consent, and the research was carried out in compliance with the Helsinki Declaration's ethical criteria.

Translation procedure

The survey questionnaire was written in English and then translated into Arabic by an independent, bilingual, professional translator who spoke Arabic as a first language. There was no monetary remuneration granted to the participants. The questionnaire takes nearly 8–10 min to finish and includes multiple-choice questions.

Result

Sample’s characteristics

This research consisted of a total of 122 respondents. The sample's average age was (35) years (SD=10.2), with respondents ranging in age from 18 to 41. The vast majority of respondents (69.9%) were married, and the majority (30.3%) had a diploma. About half of the respondents (51.6%, n=94) were unemployed. Almost 55.7 percent of those who took part had incomes below 500 JD. The proportion of respondents (83.7 percent, n=154) said their children with Autism Spectrum Disorder were cared for mostly by their mothers. The rest stated that caregiving obligations were shared by both fathers and mothers. Tables (2 and 3) below shows the study sample and demographic characteristics of the parents :

The five-point Likert scale was adopted to correct the study tools, by giving each of its paragraphs one degree out of its five degrees (strongly agree, agree, neutral, disagree, strongly disagree), and it is represented digitally (5, 4, 3, 2, 1) on Ranking, and the following scale has been adopted to analyze the results: From 1.00 - 2.33 Low, From 2.34- 3.67 Medium, From 3.68-5.00 large. The scale was calculated by using the following equation: (The upper limit of the scale (5) - the lower limit of the scale (1)) / The number of required categories (3)=(5-1)/3=1.33. then add the answer (1.33) to the end of each category.

The first question: What is the degree of quality of health services in special education centers for children with autism from the point of view of parents in Jordan? To answer this question, the arithmetic averages and standard deviations of the degree of health services quality in special education centers for children with autism spectrum disorder were extracted from the parent's point of view in Jordan, and the table below illustrates this. This study adopted a qualitative cross-sectional research method. In investigating the quality of healthcare services provided to young children with autism in Jordan. A questionnaire based on the SERVQUAL scale has been designed. (Table 4) below shows this:

Table (3) shows that the arithmetic averages ranged between (3.45-3.52), where the confidence in dealing came in the first place with the highest arithmetic average of (3.52), while the credibility in dealing came in the last rank with an arithmetic average of (3.45), and the average Arithmetic degree of health services quality in special education centers for children with autism disorder from the point of view of parents in Jordan as a whole (3.48).

The second question: “Are there any statistically significant differences at the significance level (a = 0.05) in the degree of quality of health services in special education centers for children with autism from the point of view of parents in Jordan that are due to the variables (kinship relationship, age group, educational level, and are you employee, marital status, and monthly income level)?" To answer this question, the arithmetic means and standard deviations of the degree of quality of health services in special education centers for children with autism disorder were extracted from the point of view of parents in Jordan according to the variables of kinship, age group, educational level, whether you are an employee, marital status, monthly income level, and the (Table 5) below illustrate this.

x = arithmetic means z = standard deviation

Table (4) shows an apparent variation in the arithmetic averages and standard deviations of the degree of quality of health services in special education centers for children with autism from the point of view of parents in Jordan due to the different categories of kinship variables, age group, educational level, whether you are an employee, marital status, and level of Monthly income.

And to show the significance of the statistical differences between the arithmetic averages, the analysis of variance was used multiple variance analysis. (Table 6) illustrates this.

The following table (5) shows:

• There are no statistically significant differences (a = 0.05) due to the effect of kinship in all areas and the total degree.
• There are no statistically significant differences (a = 0.05) due to the effect of the educational level in all areas and the total score.
• There are no statistically significant differences (a = 0.05) due to the effect of whether you are an employee in all fields except for devices, facilities, and equipment, credibility in dealing and the total score, and the differences came in favor of the employee.
• There are no statistically significant differences (a = 0.05) due to the effect of social status in all areas and the total score.
• There are no statistically significant differences (a = 0.05) due to the effect of the level of monthly income in all areas and the total score.
• There are no statistically significant differences (a = 0.05) due to the effect of the age group in all fields and the total degree except for devices, facilities, and equipment, and to show the statistically significant pairwise differences between the arithmetic averages, dimensional comparisons were used using a verbal method (Scheffe) as shown in the (Table 7).

A function at the significance level (a=0.05). It is evident from the table (6) that there are statistically significant differences (a=0.05) between 23-30 and 40 or more, and the differences are in favor of 23-30.

Discussion

Discussing the results related to the first question: What is the quality level of health services provided to children with autism spectrum disorders in special education centers from the point of view of parents in Jordan? The results of this question showed that the arithmetic averages of the level of health services provided to children with autism spectrum disorder were moderate in all areas and in the tool as a whole, and researchers attribute this to the fact that the level of satisfaction in general with the services provided to children with autism spectrum disorder is low or moderate, including services In addition, most centers for children with autism spectrum disorder do not fully provide health services within the center, but rather rely on referral to hospitals or agencies that provide health services, Parents do not feel that there is adequate health care for their children inside the centers, and there are no advanced and appropriate facilities and equipment in the centers for children with autism spectrum disorder through which appropriate health care is provided, in addition to the parents’ lack of sympathy for workers and health care providers with their children with a spectrum disorder. Autism within the center, and the centers’ lack of keenness to provide the service on time, in a good and appropriate manner, and the centers do not inform the parents about the date of providing the service unless the family has visited the center and asked to know this, and workers and health service providers are very busy with the auditors or their families and do not provide Prompt help, As there were no changes in parents' perceptions of health care quality aspects related to any of the demographic variables, according to the statistical analysis. The results of this study agree with the results of the discussing the results related to the second question: Are there statistically significant differences at the significance level (a=0.05) in the level of quality of health services provided to children with an autism spectrum disorder in special education centers from the point of view of parents in Jordan that are due to the variables (relaxation, age group, educational level, are you an employee, marital status, and monthly income level)?

The results of this question showed that there were no statistically significant differences due to the effect of kinship in all fields and the total degree, And the absence of statistically significant differences due to the effect of the age group in all fields and the total degree except for devices, facilities, and equipment. It was found that there were statistically significant differences between the age group (23-30) and (40 and more) and the differences came in favor of the age group (23-30).

It was also found that there were no statistically significant differences due to the effect of the educational level in all fields and the total degree, and the absence of statistically significant differences due to the effect of Are you an employee in all fields except for devices, facilities and equipment, and credibility in dealing and the total degree, and the differences came in favor of the employee. The results showed that there were no statistically significant differences due to the effect of social status in all fields and the total degree, and no statistically significant differences due to the effect of the level of monthly income in all fields and the total degree.

The researchers attribute this to the fact that there is no difference between the father and the mother, regardless of their age group, in evaluating the degree of quality of health services provided to children with an autism spectrum disorder in the centers, because the father and mother live with the experience and have the same suffering and complaints, and health services are usually sought from Before father and mother together, however, parents in the younger age group (23-30) believe that the devices, equipment, and facilities are not adequately provided for their children with autism spectrum disorder, because this age group is more attached, informed and searched on websites and more in search of experiences and health services for their children. Health services need to be improved and improved in the field of materials, devices, and facilities, and the health services available in centers for children with autism spectrum disorder are received by all families, regardless of their educational level, monthly income, or social status, in addition to the fact that they live in one environment and culture The health services available to them are available to all the medical, nursing and administrative services provided in these centers were satisfactory to some extent for the caregivers, and the majority of the participants in this study were females with a percentage of (52.5%), and their ages ranged between 31-40 years, with a percentage of (34.3%), and that (30.3%) of the respondents to this study are holders of a bachelor's degree and have a low income. It can also be noted here that the conditions of private centers in Jordan in terms of those responsible for serving children receiving similar educational programs, whether before or during the service, in addition to the fact that the owners of private centers are non-specialized people whose goals are profit, and they hardly provide the minimum conditions that allow They have the right to license these centers and practice this profession he explains the absence of differences according to these variables. As for the explanation of the existence of differences in favor of the employee in the field of facilities, devices, equipment, and credibility in dealing, this is because most of the families, whether they are fathers or mothers, our employees, and work and thus know them about tools, devices, and equipment through what They share with others concerns and problems related to health services, in addition to the fact that they are also more familiar with the facilities, devices, and equipment that their children with autism spectrum disorders need. The results of this study are consistent with the results.

Study Limitations:

Objective Limits: Assessing the quality of health care services for young children with autism disorder in Jordan: a SERVQUAL approach.

Human Limits: parents of ASD students on Special Care Centers.

Temporal Limits: the first semester. 2021/2022

Spatial Limits: the northern governorates of H.K. of Jordan (Irbid, Mafraq, Jerash, and Ajloun)

Tool: sequometeric characteristics represented in validity and reliability.

Recommendations

According to the study, all centers should strive for a modest degree of perceived healthcare service quality practices and overall caregiver satisfaction. The following are the most important recommendations:

A. It is suggested that the administration of rehabilitation institutions maintain their dedication to providing prompt medical treatments to patients. Furthermore, healthcare workers must do everything possible to deliver patient-centered care.

B. It is suggested that the administration of rehabilitation facilities build an improved appointment system to address the issues of overcrowding in clinics and excessive working hours.

C. It is suggested that the administration of rehabilitation centers pay more attention to patients' concerns, respond more quickly to complaints, and pay special attention to their treatment.

D. It is advised that the administration of rehabilitation institutions provide appropriate waiting areas and restrooms for attendants and patients.

E. employees' communication skills in interacting with caregivers and the level of reaction to their demands should be developed in rehabilitation clinics, giving them empathy and safety.

F. It is advised that the administration of rehabilitation centers conduct regular surveys to analyze patient perceptions and contentment, which can then be used to improve the quality of health treatment and overall patient satisfaction.

G. It is recommended that the administration of rehabilitation clinics provide staff with incentives and training courses that will improve their job happiness and retention.

H. The instrument for assessing perceived healthcare quality and satisfaction among carers is trustworthy and valid. According to the study, rehabilitation institutions might use this technology to increase their quality improvement efforts.

Sources of funding

 No funding

Community Participation

Parents are considered the basis for following up the provision and evaluation of various programs and services for their children with intellectual disabilities and autism spectrum disorder in special education institutions and centers and they are from the community participating in this study, as they are the ones who mobilized the tool prepared for this purpose.

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