Previous research has documented parents’ satisfaction levels regarding the anticipation and assessment of pediatric care quality, which in turn influences regulatory or operational practice changes [1-13]. On average, pediatric patients visit outpatient medical centers or primary care providers 31 times between birth and age 21 for basic pediatric development and growth assessments [14]. Because children’s intellectual and emotional development varies by age, their interactions with healthcare professionals can cause nervousness and possible trauma–especially if they undergo repeated hospital visits, treatment procedures, and hospitalizations. Such experiences can lead to fear, pain, and helplessness, making pediatric patients feel defenseless. Furthermore, this emotional sequence may delay diagnostic and treatment procedures, subsequently affecting both patient and parental satisfaction.

Healthcare professionals should find ways to address these emotional and psychological challenges to improve patient outcomes and to prevent future mental health issues [14-16]. According to research, healthcare-induced anxiety in children may lead to serious mental health problems later in life [17]. Meanwhile, hospital staff have considerable influence yet sometimes overlook patients’ points of view. Hospital management, responsible for enhancing quality, recognizes that patients’ and parents’ views on care quality are an essential component of providing excellent healthcare. Therefore, patients’ experiences in medical centers should be evaluated and integrated into all phases of the healthcare process, as only patients can accurately report their own views on care procedures and outcomes.

Patient feedback is a critical source of information for a patient-centered healthcare institution. Patients’ primary concern is receiving treatment and care that meet their needs; thus, healthcare providers seek to enhance service quality, especially under market competition and accountability pressures. Patient satisfaction is often used as a proxy for existing quality management and certification methods in healthcare industries [2,14]. It has also become a recognized indicator for measuring the delivery of quality care from the patient’s perspective. However, the methods or instruments used to measure patient satisfaction may not be fully applicable to certain populations—such as children who may have difficulty expressing their views.

It is important to distinguish overall patient satisfaction—which includes all aspects of care and facilities—from satisfaction with examinations performed by pediatricians, focusing on the care provided during clinical visits. Such a distinction helps identify specific areas in need of improvement. Although pediatricians are the primary providers, they usually examine children with a nurse present. Therefore, this study also provides insights into how the caring behavior of healthcare workers can be improved when delivering child health services. In pediatric outpatient clinics, nurses are critical for creating a supportive environment during medical consultations. While pediatricians conduct examinations, nurses contribute to care quality and patient interactions. This study aims to provide insights into how to improve nurses’ roles as intermediaries between doctors, children, and parents, as nurses help foster a calming atmosphere that reduces children’s anxiety and increases their comfort during visits and examinations.

From the hospital management perspective, patient satisfaction at the pediatric clinic–often represented by the mother–must be well managed. This satisfaction affects hospital performance, especially in private hospitals. The attitudes and intentions these parents exhibit can yield favorable outcomes for the hospital, including the willingness to recommend the hospital and intentions to revisit when needed, both of which are particularly crucial for private institutions. Hospitals influence patients’ future healthcare choices through the satisfaction they provide. In academic contexts, a favorable outcome for the hospital is often described as positive behavioral intention on the part of patients. Positive behavioral intentions among hospital staff can also enhance performance and improve patient outcomes. Studies have shown that mothers have specific expectations regarding nurses' attitudes toward both patients and themselves, such as tolerance for maternal stress and collaboration in caring for their child [18,19], all of which support hospital performance. In this study, behavioral intention serves as the dependent variable, with relevant independent variables explaining it.

Several tools exist for assessing parents’ satisfaction with care. These tools generally demonstrate good psychometric properties and are sensitive to various hospital-site variables. Collaboration among medical professionals, children, and parents is central to successful Family Centered Care (FCC). Assessing parental satisfaction helps identify critical areas for improving care standards [6]. Buchanan and Brock [20] in 1989, an ethics specialist focusing on pediatric issues, notes that adults play a role in providing children more opportunities to make healthcare decisions as they grow in their judgment, thereby improving their ability to act independently as adults. Successful interactions between healthcare providers and pediatric patients lay the groundwork for children to take greater responsibility for themselves. Dokken and Sydnor-Greenberg [21] in 2000 suggests that healthcare workers should communicate more frequently with children and actively seek their input. However, young patients are rarely asked about their own medical experiences. Most research on pediatric patients’ experiences relies on parents’ evaluations of their children’s care, with only a few studies examining children’s or adolescents’ own ratings [22].

Recent studies have explored various dimensions of patient satisfaction, including collaborative decision-making between parent, child, and clinician. The German ZAP (German for “Zufriedenheit in der Arztpraxis”) outpatient satisfaction questionnaire was introduced in 1999 as a standardized tool for measuring process-related patient satisfaction in outpatient settings. Child ZAP, specifically used in pediatric care, evolved into a psychometrically sound instrument for capturing patients’ perspectives on care processes. It includes two perspectives: the parent’s appraisal of the child-physician interaction (proxy report) and the parent’s assessment of their own interaction with the physician (self-report). Child ZAP has also been adapted for use in multiple languages (with Polish, Arabic, Croatian versions) and different clinical settings, such as ambulatory care, pediatric outpatient post–heart transplantation, and dental care clinics [2]. Having the mother assess the physician’s interaction with her child (aged 5 years and older) provides a valuable measure of overall care quality.

In Indonesia, no specific methods have been identified or employed to assess parental or child engagement in pediatric and adolescent healthcare settings. Medical professionals continue to rely on parents to act on behalf of their children and evaluate the quality of care. Further research is needed to determine how accurately parents capture and represent children’s and adolescents’ anxieties, needs, preferences, and satisfaction during healthcare encounters. Child ZAP was chosen from among various tools because it examines both how parents perceive the physician’s interaction with the child and how parents assess their own relationship with the pediatrician. This approach should also be recognized by nurses assisting the pediatrician, as their attention may help put pediatric patients at ease. Consequently, nurses must understand their active role during pediatric assessments.

The proposed framework in this study, developed using the Child ZAP instrument, consists of seven elements (child interaction, child-information, child-decision making, parents-information, parents-decision making, parents-organization facilities, professional attitude) and investigates their relationships with behavioral intention and overall parental satisfaction. This study examines how parental satisfaction with a child’s examination relates to overall parental satisfaction, behavioral intention, and potential moderating factors. First, we aim to determine whether parental satisfaction with the child’s examination, as measured by Child ZAP, positively influences overall parental satisfaction. Second, we explore whether parental satisfaction with the child’s examination affects behavioral intention, with possible implications for future healthcare decisions. Additionally, we seek to determine whether overall parental satisfaction mediates the relationship between parental satisfaction with the child’s examination and behavioral intention.

Furthermore, we investigate whether overall parental satisfaction mediates the relationship between parental satisfaction with the child’s examination and behavioral intention. We also examine whether the child’s age moderates the relationship between parental satisfaction with the child’s examination and overall parental satisfaction. Finally, we explore whether the mother’s age moderates the relationship between parental satisfaction with the child’s examination and behavioral intention.

This study makes two key contributions that could improve healthcare administration. First, because it is the first study to validate Child ZAP in an Indonesian context, the tool can be applied to other pediatric healthcare services in Indonesia. Second, integrating Child ZAP’s seven dimensions into a behavioral intention model demonstrates that effectively implementing Child ZAP domains can positively influence pediatric clinic performance.

This research aimed to test and evaluate six hypotheses in the model, all of which were supported. The results indicate that parental satisfaction with a child’s examination (as HOC) is positively and significantly related to overall parent satisfaction and behavioral intention. The parent’s satisfaction with the child’s examination is adapted from the Child ZAP or Kinder ZAP in German. This study reinvents the concept of child examination by Bitzer et al. [2] in 2012 and is the first to adopt the original ZAP in pediatric outpatient settings in Indonesia. The preliminary version of the Child ZAP included six scales (24 items) for parent assessment of parent-physician interaction (self-report), three scales (14 items) for parent assessment of child-physician interaction (proxy report), and three global items (overall physician satisfaction, trust in the physician, and quality of care). The findings of this study confirm that the Child ZAP is valid for measuring parental satisfaction with children’s examinations in the Indonesian context.

Over time, the doctor-patient interaction has evolved into a more equal collaboration, shifting from compliance to cooperation. This change can validate patients’ needs while empowering them to take responsibility for their health improvement journey. Meanwhile, doctors can better understand their patients on physical, psychological, and sociological levels. Children should be included in and benefit from this movement toward strengthening doctor-patient communication, as their societal roles and positions have changed. Amid these advancements, children also want to participate in decision-making.

Most studies have not sufficiently examined the perspectives of children and parents regarding satisfaction with patient care and service. Their focus has often positioned the parent, rather than the child, as the primary patient. This study addresses that gap by highlighting the importance of child interaction and child information.

This study was found to align with a Polish study conducted by Krzywdzińska et al. [28] in 2017, which involved 362 parents of children up to 18 years of age. The correlation between scales in the child models showed similar results in both the Polish research and the present study, specifically a low correlation value for child interaction with decision-making [29]. These findings underscore the importance of child interaction and child communication dimensions in the examination process. Previous evidence indicates that communication skills in pediatrics must effectively involve healthcare providers, children, and/or their caregivers. Pediatric patients require a distinct approach tailored to their developmental milestones at every step, making pediatric care more challenging than adult care.

The study highlights the vital role of nurses in pediatric care by facilitating interactions between pediatricians and children, alleviating fear, building rapport, and engaging children during examinations. Nurses ensure child-centered care by preparing the child, managing equipment, and supporting examinations through observations that complement pediatricians’ findings. They also reinforce follow-up care, address parental concerns, and enhance continuity of care, thereby fostering trust and improving long-term outcomes. In addition, nurses implement techniques aligned with child-centered principles to ensure children feel understood and comfortable. This approach aligns with the American Academy of Pediatrics’ stance that excellent communication is the cornerstone of care, addressing the needs of the patient and family while focusing on patient- and family-centered care [30]. In pediatric care, communication is uniquely challenging because it involves the interplay between parents, children, and doctors, requiring nurses to act as critical facilitators who bridge gaps and ensure effective collaboration. By emphasizing the multidimensional role of nurses in pediatric outpatient settings, this study underscores their significance in creating a supportive environment for children and families while validating the Child ZAP dimensions that capture these relational dynamics during medical examinations by pediatricians.

This study shows that there are three key components to effective physician-parent-child communication: (1) accuracy in the pediatrician’s delivery of health information, in both quantity and quality; (2) interpersonal awareness and sensitivity to emotional attitudes, reflecting the physician’s attention to and involvement in the emotions and concerns of caregivers and pediatric patients; and (3) partnership-building, demonstrated by the ways the doctor encourages parents/caregivers. According to this study, “information” showed the highest path coefficient toward overall satisfaction. This finding is consistent with a study conducted in Romania on children and their parents, which highlights the value of pediatricians’ soft communication skills. Although communication is perhaps the most prevalent technique in medicine, it is often overlooked in medical schools, where the focus is typically on healthcare procedures. Thus, communication abilities must be cultivated and practiced to improve doctors’ capacity to interact effectively with patients, especially younger ones [30].

Involvement in the examination differs from shared decision-making. Because children are still developing their autonomy and interpersonal skills, they are not equal decision-makers. However, children learn, practice, and develop these skills through clinical interactions, gradually leading to greater participation over time [31]. In this study, most children were between 5 and 7 years old, a stage when they are developing communication capabilities. Although the Child ZAP questionnaire includes categories that evaluate parental and child involvement in decision-making processes, it may lead to missing data, particularly for younger children. This study demonstrates that a child’s age increases the moderating effect of parent satisfaction on the child’s evaluation of overall parental contentment. This finding aligns with earlier research showing a positive correlation between ease of understanding and child age, reinforcing the recommendation to use this questionnaire scale primarily for children aged 5 or 6 and older.

While this research model demonstrates strong explanatory and predictive capabilities, it has certain limitations. Because the study was conducted in a private hospital, most parents had high incomes and education levels, enabling them to seek private care for mild symptoms. Therefore, the model needs testing in public pediatric clinics. In addition, respondents were not categorized by their children’s disease types. Some conditions require more complex examinations (e.g., use of a spatula or vaccinations), suggesting a need for further research based on specific disease types. Furthermore, 65% of participants were preschool children, whereas only 12% were 13 or older. Since preschoolers and adolescents may differ significantly in their perspectives and responses, grouping all children under 18 together could skew the results. Future studies should consider stratifying participants by age group to better capture these developmental differences and their impact on outcomes.

The findings of this study affirm that parental satisfaction in pediatric examination and treatment can predict behavioral intentions within a private hospital’s pediatric clinic. Parental satisfaction can be distinguished between satisfaction with the child’s examination by a pediatrician and overall satisfaction generated by other service factors. Satisfaction during child examinations needs to be measured dimensionally because it offers more precise insights into how doctors interact with children, considering their emotional state. Both types of satisfaction serve as valuable input for hospital management, supporting improvements that benefit from positive behavioral intentions. These findings are also useful for pediatricians and nurses, guiding them toward a more comprehensive understanding of child healthcare services. They highlight how pediatric nurses enhance communication and interaction during examinations by assisting pediatricians and acting as key intermediaries between children, parents, and the medical team. Nurses ensure children’s emotional and psychological needs are met during clinical interactions. Their efforts to create a positive, supportive environment directly affect parental satisfaction, underscoring their significance in achieving the favorable behavioral intentions identified in this study.

This research also demonstrates that ZAP, with its seven dimensions, is valid for comprehensively measuring satisfaction during pediatric examinations. The ZAP domain can serve as an independent variable in a structural satisfaction model to predict behavioral intention. Following empirical testing and validation, this study aligns with Patient-Centered Care (PCC) principles by advocating for stronger child engagement during examinations. Consequently, the Indonesian version of ZAP can be employed in future studies to assess interactions among doctors, pediatric patients, and parents in Indonesia, thereby improving the delivery of quality care.