Patient satisfaction has become a critical concept in modern healthcare, although attention to this notion dates back to the 1950s (1). In recent years, assessing the quality of health services from the patients’ perspective has gained increasing importance, as it is their right to evaluate and express opinions about the care they receive (2). Measuring patient satisfaction is considered a key indicator of service quality, and improving the quality of healthcare requires an accurate understanding of the current situation and identification of existing challenges.

The success of all organizations—whether production-oriented or service-based, public or private—is influenced by numerous factors, among which satisfaction is one of the most significant (3). Over the past 25 years, incorporating patients’ views into the evaluation of healthcare services has become increasingly emphasized. In every field, understanding the clients’ perception of services plays a vital role and is essential for ensuring continuous quality improvement (4).

In healthcare systems, the first point of contact in critical situations is often the pre-hospital emergency service. Pre-hospital emergency care refers to a set of activities designed to address urgent health needs outside of hospital facilities (5). Emergency medical services (EMS) centers are regarded worldwide as one of the essential pillars of healthcare delivery, with the primary goal of providing effective, patient-centered care in the shortest possible time and in line with international scientific standards (6). As the frontline of treatment, pre-hospital emergency units manage the most urgent and life-threatening cases before patients receive any care in hospital emergency departments. Therefore, patient satisfaction with this system can significantly influence their overall satisfaction with the broader healthcare system (7–9).

Previous studies have identified several factors affecting patient satisfaction with pre-hospital emergency services, including inappropriate selection of destination hospitals, inadequate management of patient conditions, and poor communication between EMS staff and patients (7).

Emergency medical services also play a pivotal role in managing public health emergencies such as infectious disease outbreaks. COVID-19 was a significant public health challenge, officially declared a pandemic by the World Health Organization on March 11, 2020 (10). With over 7 million deaths worldwide and 146,837 confirmed deaths in Iran as of July 15, 2025 (11), this crisis imposed unprecedented challenges on national healthcare systems, far beyond those encountered under normal conditions (12).

Since the COVID-19 pandemic will not be the last epidemic, and given that failure to identify patient expectations may lead to dissatisfaction, poor treatment adherence, and inefficient use of health resources, understanding patient experiences remains essential. Considering the importance of pre-hospital emergency services as a critical component of community health during epidemics, this study was conducted to investigate the experiences and satisfaction of COVID-19 patients who were transferred to healthcare facilities by pre-hospital emergency personnel in Mazandaran Province during the pandemic.

This mixed-method study was conducted in two phases. The first phase was a descriptive-analytical, cross-sectional study.

The study population included patients with confirmed COVID-19 who received pre-hospital emergency services in Mazandaran Province during the second half of 2020 and throughout 2021.

For data collection, proportional stratified random sampling was applied. Based on the number of patients transferred from each EMS base, a quota was determined, and participants were then randomly selected across different days of the week within each stratum.

The sample size was calculated using the following formula and based on the results of Askari et al. (18):

All COVID-19 patients who were transferred to hospitals by Mazandaran pre-hospital emergency ambulances, aged over 12 years, and with an adequate level of consciousness, were eligible to participate. Inclusion also required full completion of the questionnaire.

Exclusion criteria included: failure to establish contact with the patient, unwillingness to participate, incomplete data, or inability to recall responses to the questions.

Demographic data were collected using a demographic questionnaire that included age, sex, date and time of EMS call, mission location, education level, occupation, history of chronic illness, type of illness, reason for contacting EMS, previous EMS use, number of calls, duration of services received, and patient condition at the time of contact, among others.

Patient satisfaction was assessed using a questionnaire developed by merging two validated tools: the Emergency Care Satisfaction Scale (12) and the instrument previously applied in a study evaluating patient satisfaction with pre-hospital emergency services in Yazd, Iran (13).

The final questionnaire consisted of 21 items: 19 items on a five-point Likert scale (ranging from 1 = very poor to 5 = very good) and two items on a three-point Likert scale (1 to 3). The total score ranged from 21 to 101, with higher scores indicating greater satisfaction.

Descriptive statistics, including mean, standard deviation, frequency, and percentage, were used to summarize the variables. Independent t-tests and analysis of variance (ANOVA) were performed to compare mean satisfaction scores across subgroups. Pearson correlation coefficient was applied to examine associations between continuous variables. To control for confounding factors and identify determinants of satisfaction scores, linear regression analysis was conducted. All analyses were performed using SPSS software, version 22, with a significance level set at p < 0.05.

In the second phase, qualitative content analysis was applied using Corbin’s (2015) constant comparative method to analyze participants’ experiences with pre-hospital emergency services during the COVID-19 pandemic. This method is particularly suitable for exploring new phenomena or studying a phenomenon from a novel perspective. Qualitative content analysis provides a comprehensive and condensed description of a phenomenon, resulting in categories or concepts that capture its essence (14). When limited quantitative information exists regarding perceptions of a phenomenon, qualitative design enables researchers to explore human experiences in their unique contexts (15). Data were collected directly from participants without any prior assumptions (16).

Participants were selected through purposive sampling. From the quantitative phase, patients who expressed willingness and were able to share their experiences of receiving pre-hospital emergency services in Mazandaran during the COVID-19 pandemic were recruited. Inclusion required both a desire to participate and the ability to articulate experiences. To ensure maximum diversity, participants were selected across different age groups, cities, and times of day. Sampling continued until data saturation was reached, meaning no new concepts emerged and findings became repetitive.

Inclusion criteria were sufficient awareness to answer interview questions and willingness to participate.

Exclusion criteria included failure to establish contact or unwillingness to participate.

Data on patient experiences with COVID-19 pre-hospital emergency services were gathered through in-depth, semi-structured interviews (16, 17). Semi-structured interviews were chosen as the primary strategy because they allow flexibility and depth in qualitative research. Data collection was conducted from September 2020 to March 2022. The duration of interviews ranged from 32 to 40 minutes (average: 32 minutes). A total of 34 interviews were conducted in this phase.

After obtaining necessary approvals, the researcher introduced themselves, explained the study objectives, and built rapport and trust. Upon verbal informed consent, interviews were conducted by telephone (due to pandemic-related restrictions). Using guiding questions, interviews began with broad, open-ended inquiries such as: “What was your experience of receiving services from the Mazandaran pre-hospital emergency system during the COVID-19 pandemic? What challenges or problems did you encounter in managing COVID-19?” Interviews then progressed with more specific questions based on emerging concepts and study objectives. Probing questions were used when necessary, for example: “What interventions were carried out for you from the time the EMS team arrived at your side until your admission to the hospital?”

For analysis, all interviews were transcribed verbatim immediately after repeated listening. Data were analyzed using the constant comparative method (14). In the first step, meaning units were identified, followed by open coding. Codes were then grouped based on similarities and differences, resulting in the formation of main categories and subcategories.

This study was approved by the Ethics Committee of Mazandaran University of Medical Sciences (approval code: IR.MAZUM.REC.1399.883; date: January 27, 2021). Verbal informed consent was obtained from all participants in both quantitative and qualitative phases. Participants were assured that all information collected would remain strictly confidential, anonymized, and used solely for analysis purposes. Ethical principles, including confidentiality and trustworthiness, were strictly maintained throughout both study phases. Participants were also informed of their right to withdraw freely from the study at any stage without any consequences.

A total of 503 patients participated in this study, of whom 258 (51.3%) were female and the remainder male. The mean age of participants was 57.27 ± 17.12 years. Most participants had attained university-level education. Additional demographic and clinical information is presented in Table 1.

The mean satisfaction score with pre-hospital emergency services was 81.83 ± 7.66, with scores ranging from 52 to 98. Overall, 92.8% of participants rated EMS performance as “good” or “very good.” Table 2 presents the mean satisfaction scores according to the studied variables. As shown, chronic illness status, time of EMS call, and patient condition at the time of contact were significantly associated with satisfaction scores. Patients with chronic diseases, those who called in the morning, and semi-conscious patients reported the highest levels of satisfaction.

In Table 2, the factors influencing satisfaction scores with EMS were reported using linear regression analysis. As shown, the variables of time of call and previous EMS use had a significant effect on satisfaction. The mean satisfaction score was 1.85 and 3.68 points lower for calls made in the afternoon and at night, respectively, compared with morning calls. In addition, patients who had previously used EMS reported significantly higher satisfaction scores (1.86 points) compared to those with no prior EMS use. Other variables showed no significant association with satisfaction scores.

The second phase of the study was conducted to explore the experiences of patients with COVID-19 who had utilized pre-hospital emergency services in Mazandaran during the pandemic. Based on interview responses, the most common interventions provided to patients before hospital transfer included oxygen therapy, intravenous access, patient transport by stretcher, history-taking, and medical consultation.

Regarding the use of personal protective equipment (PPE) by EMS personnel, 47% of patients reported that staff adhered to protective measures, 30% stated they did not, and 23% could not recall whether the staff used protective equipment. Concerning patient education, 20% reported receiving some form of instruction, 56% stated they did not, and 24% could not remember whether any education was provided by EMS personnel. Findings related to additional interview questions are presented in Table 3.

Participants’ experiences led to the identification of four main categories: shortage of human resources, equipment, and logistics; delays in service delivery; care beyond expectations; and non-defensive driving. The main categories, subcategories, and extracted codes are presented in Table 4.

Category 1: Shortage of human resources, equipment, and logisticsThe first and most crucial category extracted from participants’ experiences was the shortage of human resources, equipment, and logistics. This category included three subcategories: worn-out ambulances, lack of medical and consumable equipment, and inadequate human resources.

Worn-out ambulances: Participants reported that one of their significant experiences with pre-hospital emergency services was the use of old and dilapidated ambulances. For example, one participant stated:“The ambulance was very old and worn out. During the mission, it broke down, and they had to coordinate with the center to send another ambulance to transfer our patient to the hospital.”

Lack of medical and consumable equipment: Patients and their companions also mentioned shortages of essential medical and consumable supplies during the COVID-19 pandemic, such as personal protective equipment (PPE), oxygen cylinders, and ventilators. One participant noted:“Some of the equipment did not work properly. But honestly, we couldn’t expect more. With such limited resources, they really did their best.”

Inadequate human resources: Another subcategory was the shortage of EMS personnel. As one participant described:“Especially in the early days of the COVID-19 outbreak, it was tough to get an ambulance. The phone lines were often busy, and they told us their teams were on missions and we had to wait until they finished with another patient and could come to us.”

Category 2: Delays in service deliveryThe second extracted category was delays in pre-hospital emergency service delivery. This category consisted of three subcategories: delays in dispatching codes, inability to locate addresses accurately, and challenges in providing services to elderly and vulnerable groups.

Delays in dispatching codes: During the first and second waves of COVID-19, due to insufficient experience in managing the pandemic and the absence of standardized criteria for dispatching codes, EMS centers across the country faced shortages of codes and ambulances for transporting patients. As one participant explained:“We called several times, and they said there was no ambulance available. Even if we wanted to take the patient ourselves, the hospital wouldn’t admit them, saying there was no space. We were left begging and waiting until an ambulance returned from another mission.”

Inability to accurately locate addresses: This subcategory included the use of non-local staff unfamiliar with the region, inactive patient GPS systems, and a lack of precise geolocation software. For instance, one participant stated:“I wish they used local staff. They had a lot of trouble finding addresses. In our area, in the western part of the province, most of the staff were not local and didn’t know the neighborhoods well, so they arrived late to the patient.”

Challenges in serving elderly and vulnerable groups: According to participants, Mazandaran’s pre-hospital EMS lacked adequate facilities and policies for providing care to vulnerable populations and older people. One participant remarked:“During the COVID-19 outbreak, people were afraid to get close to patients. My father was alone at home after the infection, and when EMS arrived, no one was there. They did their best to take care of him, but transferring him was difficult. He refused to go, and there was no one to accompany him. I wish there were more facilities to provide home-based care in such situations.”

Category 3: Care beyond expectationsSome participants reported that pre-hospital emergency services went beyond their expected duties during the pandemic, providing care with skill and compassion. As one participant expressed:“God bless them; they did things that even a child wouldn’t do for their parents. They saved my life. The EMS staff were truly excellent.”

Category 4: Non-defensive drivingThe final category included subcategories such as high-speed and unsafe driving, and unstable fittings in the rear cabin of the ambulance. According to participants, EMS technicians often failed to follow defensive driving principles, resulting in severe shaking and discomfort in the patient cabin. As one participant described:“They drove very fast, and we were tossed around in the back of the ambulance as if everything was about to fall and collapse.”

This study aimed to assess the satisfaction of patients with COVID-19 regarding pre-hospital emergency services in Mazandaran Province. Overall, the findings demonstrated a high level of satisfaction, with 92.8% of participants rating EMS performance as good or very good. The mean satisfaction score was 81.83 out of 101, reflecting relatively high patient satisfaction with the services provided, which is consistent with the findings of Talebi et al. (9). In contrast, studies conducted in Yazd and Birjand reported moderate levels of satisfaction among EMS service recipients (18). Nevertheless, several factors, such as time of call and previous EMS use, were significantly associated with patient satisfaction.

These findings are consistent with previous studies, which have highlighted relatively high satisfaction levels with pre-hospital emergency services in both routine and crises (19). However, patient experiences in the present study also revealed significant challenges in service delivery, particularly during the COVID-19 pandemic.

Shortage of human resources, equipment, and logisticsOne of the most important findings of this study was the shortage of human resources and medical equipment in pre-hospital emergency services in Mazandaran. Patients particularly emphasized the use of outdated ambulances, lack of personal protective equipment (PPE), and shortages of medical devices. This finding is consistent with studies conducted in other countries during the COVID-19 pandemic (20, 21). For example, Sheikhi et al. (2020) also reported that shortages of protective and medical equipment were among the main challenges in delivering pre-hospital emergency services in Iran (22). Such shortages not only compromise the quality of care but also increase the risk of disease transmission to both staff and patients (23). Similarly, Heidari et al. highlighted that both individual and systemic challenges were major issues faced by pre-hospital emergency staff during the COVID-19 pandemic (24). Moreover, according to Hadian et al., EMS staff suffered from a wide range of psychiatric problems due to insufficient equipment and excessive workloads, which negatively impacted the quality of pre-hospital emergency care (25, 26).

Delays in service deliveryAnother challenge reported in this study was delays in dispatching EMS codes and difficulties in accurate address identification. This issue was particularly evident during the early waves of the pandemic, when the volume of EMS calls increased dramatically. Dispatchers responsible for telephone triage and EMS field personnel faced multiple interactive, organizational, and professional challenges (27). Other studies have similarly shown that during crises such as pandemics, pre-hospital emergency systems encounter severe difficulties in managing the high volume of requests (28, 29). In addition, the lack of familiarity of some EMS personnel with local geography further delayed response times, highlighting the need for advanced geolocation technologies and the recruitment or training of local staff.

Care beyond expectationsDespite these challenges, many patients expressed satisfaction with the care they received and reported positive experiences with the professionalism and compassion of EMS technicians. These findings demonstrate the dedication and commitment of EMS staff under the difficult circumstances of the pandemic. Similar studies have also shown that respectful and empathetic behavior by healthcare professionals can significantly enhance patient satisfaction (30).

Non-defensive drivingOne of the negative experiences reported by patients was high-speed and unsafe driving by EMS technicians, which posed risks to both patients and their companions. This highlights the need for ongoing training in defensive driving and closer supervision of EMS drivers’ performance.

Based on the findings of this study, it can be concluded that despite resource and equipment limitations, pre-hospital emergency services in Mazandaran were able to provide an acceptable level of patient satisfaction during the COVID-19 pandemic. However, improving service quality requires strengthening infrastructure, increasing human resources, ensuring adequate medical equipment, and providing specialized personnel training. Furthermore, the adoption of modern communication and geolocation technologies could help reduce response times. Ultimately, investment in infrastructure development and resource management is essential to ensure the quality of services during future crises.

This study has several limitations. First, data were collected through telephone interviews, which may have been influenced by recall bias or social desirability bias. Second, the study was conducted only in one province (Mazandaran), which may limit the generalizability of the findings to other regions. Third, certain potentially influential variables, such as patients’ socioeconomic status and EMS staff experience, were not assessed.