Abstract
Background. Patient satisfaction, the concept continues to become a crucial and commonly used indicator in the sector of health care delivery for determining the quality of health care services. Satisfaction is a highly desirable outcome of clinical care and may even be an element of health status itself. Therefore, a patient’s expression of satisfaction or dissatisfaction can be considered as a judgement on the quality of care in all of its aspects, whatever its strengths and weakness. Objective. The aim of the study is to determine patient satisfaction on the quality of care and associated factors among patients admitted in Gambella General Hospital, Gambella region, southwest Ethiopia, 2020. Methods. A facility-based cross-sectional study design was conducted, and a consecutive sampling technique was used to recruit 271 study subjects among patients admitted to Gambella General Hospital. All patients who stayed at least for five days and were discharged from inpatient wards were considered for this study. A semistructured questionnaire was used for data collection. Data were entered to Epi-data version 4.6 and exported to SPSS V21 for analysis. Binary logistic regression models were fitted to determine statistically significant associations between dependent and independent variables, and multivariable logistic regression with an AOR with a 95% confidence interval was fitted for candidate variables in binary logistic regression, and statistical significance was declared at value < 0.05. Result. The proportion of net patient satisfaction among the total of 271 respondents was 40.2% (95% CI: 34.36–46.04%). Being government employees (AOR = 0.06, 95% CI: 0.02–0.27), availability signs and direction indicators (AOR = 2.6, 95% CI: 1.18–5.54), provision of adequate information on the treatments (AOR = 2.5, 95% CI: 1.18–5.44), getting provider’s attention (AOR = 3.5, 95% CI: 1.65–7.24), and understanding of specific patient needs and concerns (AOR = 6.04, 95% CI: 2.8–12.88) were found to be significant predicators of patient satisfaction on the quality of care. Conclusion. Less than half of the patients were satisfied with the quality of service delivered in the wards of the hospital. Occupation, signs and directions to follow, getting adequate information about treatment, providers’ attention, and understanding of specific needs and concerns of the patients were the significant factors. Thus, we would recommend that the hospital management should closely work together with health professionals, supportive staff, patients, and other concerned stakeholders to improve admitted patients’ satisfaction with the quality of care. Policymakers advised to develop and institutionalize better interpersonal relations in the health system.
1. Introduction
According to the World Health Organization (WHO), quality of care is the extent to which health care services provided to individuals and patient populations improved the desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable, and acceptable or patient-centered. Since the health and wellbeing of people depend on the performance of the health system, WHO is promoting quality as a focus in health systems at this time [1].
An important and commonly used indicator for measuring the quality of health care is indirectly by asking patients to rate their satisfaction with the health services they have received or to report their experiences [2]. Satisfaction is a highly desirable outcome of clinical care in the hospital and may even be an element of health status itself. So, a patient’s expression of satisfaction or dissatisfaction can be considered as a judgement on the quality of hospital care in all of its aspects, whatever its strengths and weaknesses [3].
Despite the problems with establishing a tangible definition and measurement for patient satisfaction, Johansson defined it as a person’s subjective evaluation of cognitive and emotional reactions as a result of interaction between expectation and perception of actual care [4].
Currently, expectations of the community have increased day by day and they are beginning to question the adequacy of patient care, not only for quantity of service rendered but also for the quality that is provided by the hospitals [5]. Accordingly, the provision of health care is expected to respond directly to patients’ preferences and demands because patient satisfaction influences patient’s compliance with treatment, their seeking of medical advice, and their ability to maintain a continued relationship with providers. Also reduction of complaints against the institution and improvement of morale and job satisfaction among providers can in turn benefit both patients’ health outcomes and relationships with healthcare professionals [6].
Patient satisfaction surveys should be seen as part of a quality improvement process, which includes evaluation and dissemination of results to key players, consultation and development of plans for improvement, implementation of plans, and re-evaluation to measure gains and identify new priorities for improvement [7]. According to a study conducted in northwest Ethiopia, the proportion of overall net patient satisfaction rate was 57.8% [4]. In Ethiopia, a national effort has been made since 2000 with the purpose of establishing customer-focused institutions, rapid scaling up of health services, and enhancing the quality of care. Federal minister of health (FMOH) had focused on strengthening the management capacity of health facilities and the construction and expansion of health facilities with the health service development plans (HSDPs) [8]. Currently, efforts have been made by implementing Health Sector Transformation in Quality (HSTQ 2016–2020) to improve the quality of health services with the primary goal of satisfying patients through the delivery of relevant, safe, and optimum quality health services [9]. It is important to continuously assess the opinion of patients as well as their satisfaction level with available resources to improve the quality of health services, which can make health facilities more attractive and responsive to people’s needs and expectations.
Besides, the Gambella region has particular lifestyle, socioeconomic, cultural, geographical, and environmental features compared to most highland areas of the country [10].
Gambella General Hospital has planned to achieve 60% health service quality in the 2012 Ethiopian fiscal year within the HSTQ [11]. However, no research study has been conducted on the level of patient satisfaction with quality of care and the factors influencing it among admitted patients of Gambella General Hospital. This study contributes to a significant role for health care providers’ use in delivering services to clients, serves as a baseline for further monitoring of the changes in quality of service, and provides suggestions for targeted areas of intervention.
2. Methods
A facility based cross-sectional study was conducted in Gambella General Hospital, Gambella region, southwest Ethiopia, from March 1 to March 31, 2020. Gambella town is the capital city of Gambella region which is located 777 kilometers in the southwest of Addis Ababa. The population of the region was more than 483,017 in 2020 based on the projection of 2007 census. According to the data from Gambella regional health bureau, the region has one hundred six health posts, thirty-five health centers (31 governmental and 4 NGOs), and five hospitals (four primary and one general hospital that serves as final referral resort in the region).
All patients who were admitted to the hospital inpatient wards during the study period were considered as a source population. Study population was sampled patients who stayed at least five days in admission wards of Gambella General Hospital. Nevertheless, patients who were under 18 years of age or children, those who were alone during discharge, and patients who were unable to communicate due to their health conditions and did not have a caregiver at discharge time were excluded.
The sample size was calculated using a single population proportion formula, by considering the following assumptions: proportion of inpatient satisfaction was 52.7% from a study conducted in Zewditu Memorial Hospital, Addis Ababa, 2015 [12], using a level of confidence 95%(Zα/2 = 1.96), and considered 5% margin of error (d = 0.05). Since the source population is less than 10,000, a finite population correction formula was employed, and finally, adding 10% (24.6) potential nonresponse rate, the final sample size was 271 patients admitted to the wards of Gambella Hospital.
A proportional sample size was allocated based on the average admission rate of the four inpatient wards in Gambella General Hospital. Then, all discharged patients or their care givers in the wards were recruited using a consecutive sampling technique during the study period.
Data were collected using a semistructured questionnaire. The questionnaire has two major parts, namely, the sociodemographic and perceived inpatient satisfaction with quality of care. The inpatient satisfaction questions were composed of 5 dimensions and 35 items from a study carried out in ALERT hospital, Addis Ababa [13], which were originally adopted from the SERVQUAL model. A four-point Likert scale was used ranging from highly dissatisfied (1), dissatisfied (2), satisfied (3), and highly satisfied (4) to collect data from the respondents on their satisfaction during their stay in the hospital wards. The overall patient satisfaction was measured using two items in the questionnaire, asking the patients about how they rate the overall level of satisfaction and whether they recommend the hospital to others or not. The net patient satisfaction refers to the proportion of patients whose mean score of satisfaction is greater than 2.5. The mean score was a calculated average value of all 35 items within the five service dimensions.
Four diploma-holding nurses, who are familiar with the culture and speak the local languages in addition to Amharic, were recruited as data collectors. One nurse who had bachelor’s degree was working as a supervisor. An exit interview was conducted to collect data from inpatients admitted to different wards of the hospital during all seven working days.
Data were entered to EPI-DATA version 4.6 and exported to SPSS version 21 for analysis. The four-point Likert scale questions were minimized into two categories; both highly dissatisfied and dissatisfied answers counted as dissatisfied. Similarly, highly satisfied and satisfied answers were taken as satisfied. Binary and multivariable logistic regression models are used to identify the effect of independent variables on the outcome variable. In bivariate analysis, variables that showed statistical significant association with inpatient satisfaction at value less than 0.05 were considered as candidate variables for multivariate analysis. Independent variables, which had value less or equal to 0.05 were identified as factors associated with inpatient satisfaction toward quality of care. The strength of association between different independent variables and the outcome variable was measured through adjusted odds ratios.
The reliability of items was checked for tangibility, reliability, responsiveness, assurance, and empathy that had Cronbach’s alpha of 0.93, 0.84, 0.85, 0.94, and 0.9 separately. All were above 0.7, the recommended alpha value.
Ethical clearance was obtained from the Ethical Review Board of the Institute of Health with a reference number of IRB/00092/2020, Jimma University. Respondents were informed about the objectives of the study, and written consent was obtained. The right of respondents to participate in the study was respected. For patients whose age is less than 18 years, families or their caregivers were interviewed about satisfaction with the quality of care. The data were collected in a way to ensure confidentiality of the respondents without including the names of patients, and all information obtained was kept confidential.
3. Results
All sampled study subjects that participated provided a response rate of 100%. The mean age of respondents was 35.7 years with SD + 12.76. The majority of study participants (176, 64.9%), 203 (74.9%), and 95 (35.1%) were female, married, and had no formal education, respectively. Two hundred thirty-three (86%) of study subjects were covered service cost through out-of-pocket payment at service delivery point, while 98 (36.1%) of them earned an average monthly income of less 1000 ETB. Regarding admission, 71 (26.2%) and 113 (41.7%) of patients were admitted to the surgical ward and had a history of first admission independently. The majority of the inpatients (156, 57.6%) were kept 5–9 days in the ward, with an average length of stay being 10.5 days (Table 1).
3.1. Descriptive Analysis on the Satisfaction of Patients toward Quality of Care
Of the total study subjects, more than half (53.9%) were satisfied with the adequacy of ward space, whereas 152 (56.1%) were dissatisfied with the ventilation system of the wards. One hundred seventy (62.7%) and one hundred sixty-two (59.8%) of respondents were dissatisfied and satisfied with access to adequate water and the availability of signs and direction indicators in the hospitals, respectively. More than half (59%) of respondents were satisfied with sufficient staff availability, but the availability of prescribed drugs and supplies (69.7%) and organized admission procedure (68.6%) were the major areas of dissatisfaction. With regard to responsiveness, 60.5% of respondents were satisfied with the adequacy of visiting hours. However, only 34.7% of respondents were satisfied with the provision of prompt service by the hospital. There was also a better satisfaction response among many of the respondents with respect to assurance items. With regard to empathy, more than half of respondents were satisfied with the provider’s interest in the patient (58.3%), but most respondents were dissatisfied with the improper response to their requests (65.7%) and the way they were treated without respect and good behavior (64.6%) (Table 2).
3.2. Level of Inpatient Satisfaction toward Quality of Care
The proportion of overall satisfaction toward quality of care among admitted patients at Gambella General Hospital was 110 (40.6%). Likewise, of the total of 271 respondents, more than half of them, 151 (55.7%), did not want to recommend the hospital to a family member or friend. The final calculated net inpatient satisfaction, which refers to the proportion of respondents whose mean score of satisfaction was greater than 2.5, was 109 (40.2%) (Figure 1).
3.3. Factors Associated with Patient Satisfaction in the Wards of Hospital
In bivariate binary logistic regression, a total of 20 variables were found to fulfill the assumption of logistic regression at value of less than 0.05 selected for further analysis and entered into the final model. Accordingly, five variables independently showed a statistically significant association with the overall satisfaction status of patients at the value < 0.05 after adjusting for other variables in multiple logistic regression analysis by using the Enter method.
Government employees are 93.7% less likely to be satisfied than housewives (AOR 0.063, 95% CI: 0.015, 0.27). Similarly, merchants and students are 82% (AOR 0.18, 95% CI: 0.049, 0.67) and 81% (AOR 0.19, 95% CI: 0.055, 0.64) less likely to be satisfied as compared to housewives, respectively. The overall satisfaction among respondents who were satisfied with signs and directions was 2.6 times more likely compared to their counterparts (AOR 2.55, 95% CI: 1.18, 5.54). In addition, respondents who were satisfied with the adequacy of information the providers gave about their treatment were 2.5 times more likely to be overall satisfied as compared to those who were dissatisfied with the same item (AOR 2.53, 95% CI: 1.18, 5.44). Respondents who were satisfied with providers’ attention to the patient were 3.5 times (AOR 3.45, 95% CI: 1.65, 7.24) more likely to be overall satisfied when compared with their counterparts, and patients who weresatisfied with providers’ understanding of specific needs and concerns were six times (AOR 6.04, 95% CI: 2.83, 12.88) more likely to be overall satisfied than those who were not satisfied with the understanding of specific needs and concerns of the providers (Table 3).
4. Discussion
The findings of this study revealed that two-fifths of patients who visited the wards of Gambella General Hospital were satisfied with the quality of care. This finding is in line with a study conducted in the three hospitals of southwestern Ethiopia [14] and Nekemte Referral Hospital [15], which reported 38.7% and 35.1% satisfaction among admitted patients in wards consecutively. Even though the current finding is higher than a study done in Karapitiya Teaching Hospital, Sri Lanka (10.4%) [16], it is lower as compared to the findings from public hospitals of Addis Ababa (53%) [17], north central Nigerian Tertiary Hospital (96.1%) [18], a cross-sectional national exit survey study done in Zambia (60.9–70.3%) [19], and Jabalpur, Madhya Pradesh, India (89.1%) [20]. It is also lower than a nationwide survey conducted on patient satisfaction with nursing care in Ethiopia [21]. The possible explanation for the observed difference might be due to socioeconomic, geographic, and cultural variations; the difference in study setting and level of hospitals; and most importantly, methodological differences and variations in measurement of satisfaction.
According to the current study, only 44.3% of respondents wanted to recommend the hospital to a family or friend, which is much lower compared to studies conducted in Jimma University Specialized Hospital (84.7%) and Nnamdi Azikiwe University Teaching Hospital, Nigeria (92.7%) [22, 23]. This huge discrepancy may be due to the type of hospitals and the setting difference that both of them were university teaching hospitals with way better facility and personnel. In contrary, Gambella General Hospital is located far from the country’s capital with hot climatic conditions. Even if the government tried different strategies, it is still hard to retain professional expertise and adequate technology to give quality care.
In this study, we found that government employees were 93.7% less likely to be satisfied when compared to housewives. It is consistent with a study conducted in public hospitals in the Amhara region, northwest Ethiopia [24]. Similarly, satisfaction of merchants was 82% times less likely as compared to housewives in the current study. Moreover, this finding is consistent with a study done at Zewditu Memorial Hospital, Addis Ababa [12]. The reason might be related to employees, merchants, and students having better access to information and individual awareness of different health facilities. This leads to high expectations of the service when compared with other institutions. On the other hand, a current study showed that private employees were 82% less likely to be satisfied than housewives. However, this is not consistent with a study conducted earlier in the Amhara region, northwest Ethiopia [24]. This could be because private employees in the current study area mostly come from different places of the country to get better job opportunities. They had the opportunity to get to know different areas and better facilities on the way.
We found that the presence of signs and direction pointers affects patient satisfaction. Respondents who were satisfied with signs and direction pointers were 2.5 times more likely to be satisfied with the overall quality of care when compared to respondents who were not satisfied with signs and direction posts in the hospital compound. The finding is in line with a study conducted at Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia, which showed the presence of signs and directions increased satisfaction by 98.8% [25]. Another study in northwest Ethiopia at Gondar town also revealed that for those who did not notice signs and directions to service units, the odds of satisfaction dropped by 47% compared to those who saw signs and directions to service units [26]. The possible explanation for the decreased satisfaction could be that patients are tired and in pain when they come to the hospital, so they want things to be easy for them rather than asking people to help with everything.
The rate of satisfaction toward the overall quality of care was 2.5 times higher among respondents who were satisfied with the information they got about their treatment than their counterparts. This finding is consistent with a descriptive correlational study in Bushenyi District, Uganda [27] and a retrospective cohort study on patients’ satisfaction in child and adolescent mental health inpatient units, Turkey [28]. It is more likely because patients are most pleased with the provision of information.
A study conducted in central Saudi Arabia to measure quality of care showed that paying attention to each patient was one of the three highest predictors of patient satisfaction [29]. In the current study, patients who were satisfied with the staff’s personal attention were 3.5 times more likely to be satisfied with the overall quality of care as compared to those who were not satisfied with the staff’s attention. The reason for this dissatisfaction could be attributed to patients feeling vulnerable and insecure, so they consistently need health workers’ thoughtfulness and want to be considered and recognized the whole time.
Respondents who were satisfied with the providers’ understanding of patients’ needs and concerns were six times more likely to be satisfied with the overall quality of care when compared with respondents who were not satisfied with the same item. A previously conducted cross-sectional study at university hospitals in Ghana showed that empathy on the part of medical staff was a significant predictor of patient satisfaction [30]. Another study conducted at Mwananyamala hospital in Dar es Salaam, Tanzania, also indicated that failure to show compassion was one of the significant factors affecting satisfaction with quality of care [2]. The possible explanation may be that patients’ believed in emotional attachment and being able to share their pain makes them satisfied with the treatment process, and they will be comfortable when medical staff show emotional concern toward their needs and concerns.
This study acknowledged certain limitations; a small sample size was used, satisfaction scores were dichotomized, which possibly contributed to loss of specificity, power, and lack of observation to support the study.
5. Conclusions
Less than half of the patients who were admitted at Gambella General Hospital were satisfied with the overall quality of service delivered. Occupation, signs and directions to follow, getting adequate information about treatment, the provider paying attention to each patient, and understanding of specific needs and concerns of patients were the factors associated with patient satisfaction regarding the quality of care. Thus, we would like to recommend that it is better to put visible and easily understandable sign posts of service stations and directions in the hospital compound. Additionally, the hospital management should closely work together with health professionals, support staff, patients, and other stakeholders to build better patient-provider relations at the hospital. Policymakers advised to develop and institutionalize better interpersonal relations in the health system.
Abbreviations
| AOR: | Adjusted odds ratio |
| BSc: | Bachelor of Science |
| CI: | Confidence interval |
| COR: | Crude odds ratio |
| FMOH: | Federal Ministry of Health |
| HSDP: | Health sector development program |
| HSTQ: | Health sector transformation in quality |
| ICU: | Intensive care unit |
| IOM: | Institute Of Medicine |
| IRB: | Institutional Review Board |
| MPH: | Masters of Public Health |
| NGO: | Nongovernmental organization |
| OPD: | Outpatient department |
| SERVQUAL: | Service quality |
| SPSS: | Statistical Package for Social Studies |
| WHO: | World Health Organization. |
Data Availability
The original data are available from the authors upon request.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Authors’ Contributions
Conceptualization and design of the study was done by NA, TKC, WBS, MGG, and BG. Data were acquired by NA, TKC, and WBS. Data analysis and interpretation were conducted by NA, TKC, WBS, MGG, and BG. Funding acquisition was carried out by NA, TKC, and WBS. NA, TKC, BG, WBS, and MGG drafted and revised the manuscript. Final approval for submission was given by NA, TKC, BG, WBS, and MGG.
Acknowledgments
The authors are grateful to Jimma University for funding this research. The authors also would like to thank Gambella General Hospital administrators and staff who provided their support and valuable information on the study area. The fund of this study was totally covered by Jimma University Postgraduate and Research Office.