Client satisfaction among outpatients of Eastern zone general hospitals of Tigray, Northern Ethiopia, 2020
2 Department of Surgery, College of Medicine and Health Science, Adigrat University, Tigray, Ethiopia
3 Department of Public Health, College of Medicine and Health Science, Mekelle University, Mekelle University, Tigray, Ethiopia
Received Date: Jun 18, 2021 / Accepted Date: Jul 02, 2021 / Published Date: Jul 09, 2021
Citation: Gebrezgi ZA, Desye B, Gebremedhin H, et al. Client satisfaction among outpatients of Eastern zone general hospitals of Tigray, Northern Ethiopia,2020. J Health Pol Manag. 2021;4(4):1-6.
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Introduction: Client satisfaction is important to measure the quality of care that contains understanding the need of clients, and providing services accordingly. It may play its own role in the utilization of hospital services.
Objective: To investigate client satisfaction among outpatients of Eastern zone general hospitals of Tigray, Northern Ethiopia, 2020.
Methodology: Hospital based cross-sectional study design was used among outpatients of the eastern zone general hospitals of Tigray, from September up to December 2019. Sample size was estimated to be 273 and selected with the systematic random sampling method. Collected data was entered and analyzed using SPSS version 21. Binary logistic regression was used to check the association between dependent and independent variables.
Results: Overall client satisfaction was 41.4% with Mean ± SD, 1.19 ± 0.17. Client satisfaction was more than 75% with 11(84.6%) of satisfaction tool measurements, whereas with information provision by health workers and doctor examination was to be 36.3% and 73.6% respectively. Marital status (AOR=0.469 at 95%CI=(0.229, 0.957), time to be x-rayed (AOR=0.065 at 95%CI=(0.022, 0.191), presence of ordered drugs in the institution (AOR=9.037 at 95%CI=(3.761, 21.713) and time taken by nurses after doctor (AOR=6.277 at 95% CI=(1.613, 24.430) were found to be statistically significant.
Conclusion and recommendations: Overall satisfaction of this study was rated as low. Patients were low satisfied with information provision by health workers and the doctor examination. The hospital staffs, clients, and board of the hospital should work on the availability of drugs, time for x-ray, and low satisfaction areas. Health professionals should give the patients adequate information about the hospital services.
Client satisfaction; General hospitals; Outpatients
Client satisfaction is basic for a good hospital service that provides information for health care professionals how patients are getting their expectations. Recently, client satisfaction is very helpful for how to provide and improve health care services. In general, it is a fundamental parameter for health service management [1,2].
Hospital service may be measured by client’s satisfaction. Many institutions are using client satisfaction for increasing health professional’s accountability. Findings stated that satisfied clients can properly utilize medicine and advising of health care providers. Besides, clients may likely to come back for extra health care services and will be helpful for enhancing health institution income [3,4].
Different studies relating client satisfaction in Ethiopia showed that long time taking for different health care services, lack of secret room, very delayed results, absence of medicines in health institutions, and absence of risk information for clients are the main frequent health care quality obstacles that diminish client satisfaction [5-7].
World Health Organization showed that Ethiopian health service coverage and utilization is about 86.7% and 32%, respectively. The low rate utilization includes lack of fundamental and potential services and cost unaffordability. Hence, client satisfaction is a fundamental tool to estimate the health institution performance so that health care service is provided by health and non-health professionals [8-10].
Enhancing the health institutions performance is the main method to lessen the prevalence of infectious and noninfectious diseases. As providing health care quality service is one of the key indicators for good health institution performance, it will be very essential for achieving Millennium Development Goal .
Studies showed that recipient information service upgraded the performance of health institutions driving health care providers while their good effort result is reported, included in planning, evaluating of the institution performance and clients’ will be self-assured so that their worries are being considered .
Client satisfaction affects healthcare organizations ‘image and has a direct effect on client confidence, which may bring about enhancing health care service utilization and exchanging of business issues. Client confidence and trust on the organizational service may influence clients’ views on their health service providers’ so that they will hesitate on their professional knowledge and skills. Clients with high satisfaction are very confident to explain their disease signs and symptoms to their health care service providers [13,14].
It will be very crucial to conduct research studies and simple surveys to know the status of client satisfaction and how the health institution is performing. This is especially important to assess the availability and accessibility of medical supplies, how the health care service is provided, what problems are there that can diminish the service, and to dig out important solutions for the problems that are obstacles to the enhancing of health care quality service .
Studies showed that health institution clients are highly influenced by the exchange of messages with their health care providers. Associated factors like age, educational status, marital status, sex of clients, occupational status, availability of services (like availability of drugs, X-ray service, and laboratory service in the hospital), the away doctor examines the patient, privacy, confidentiality, waiting time for the services, perception of empathy, hospital set up, showing politeness and respecting, giving chance clients to explain their feelings like that of patient centered service, competent skills and knowledge of professionals are mostly found predictors that can compromise the health care quality service and diminish client satisfaction. Different Studies showed that different findings on client satisfaction and predictors [16-31].
Although eastern zone Tigray general hospitals are struggling and providing health care services to satisfy their clients, their outpatient client satisfaction is unknown and there was not a study conducted. Therefore, we plan to assess client satisfaction among outpatients of Eastern zone general hospitals, Tigray, Northern Ethiopia.
Methods significance of the study
This study will give data about the outpatient client satisfaction of Eastern zone general hospitals, Tigray region. It will also provide information about what predictors are influencing the health care service and to set a recommendation based on the findings. And this will inform the responsible bodies what work must be done to achieve the required goals. Moreover, it will be helpful for hospital managers to plan and evaluate the service.
General objective: To investigate client satisfaction among outpatients of Eastern zone general hospitals of Tigray, Northern Ethiopia, 2020.
1. To assess client satisfaction among outpatients of Eastern zone general hospitals.
2. To identify associated factors affecting client satisfaction among outpatients of Eastern zone general hospitals.
Study area and period
This study was done in Eastern zone. Tigray from January to March, 2020. Eastern zone Tigray is demarked to the south by Mekelle capital city of Tigray, to the east by Afar region, to the northern by Eretria, and to the west by Tigray Central zone. Eastern zone has one federal university, two general hospitals, six primarily hospitals, 12 health centers, 6 private clinics, and 20 health posts. Eastern zone general hospitals have around ten specialists, 6 master health officers, 8 general practitioners,25 BSC nurses, 8 health officers, 30 clinical nurses, 2 anesthetists, 24 midwifes, 8 pharmacists, 10 laboratory professionals,4 environmental health professionals and 2 radiologists .
All clients visiting Eastern zone Tigray general Hospitals.
All clients visited the outpatient department of Eastern zone Tigray General Hospitals.
Clients who were randomly selected among outpatients of Eastern zone Tigray General Hospital
Hospital based cross-sectional study has been deployed.
Sample Size determination and sampling techniques
Sampling formula with percent of patient satisfaction (P) 80.1%, margin of error 5%, Confidence level of 95%, Z-value=1.96, n=sample size:
n=Z2p (1-p)/d2=(1.96)2 (0.801) (0.199)/(0.05)2=248
Thus, using the 10% nonresponse rate, the total sample size was 273.
Total sample was allocated to the two general hospitals proportionally based on their patient flows. Accordingly, 160 and 113 samples were allocated to Adigrat and Wukro general hospitals, respectively. The proportionated sample size of each hospital was allocated to the four units (Medicine, Surgical, Pediatrics and Gynecology and obstetrics) equally. Then, each study unit was selected with a systematic random sampling technique.
Inclusion: Clients visiting the outpatient departments of Eastern zone Tigray general hospital.
Exclusion: Clients severely ill and unable to respond and were interviewed questions.
Dependent: Client satisfaction.
Independent: Sociodemographic characteristics, free/paying, doctor-patient relationship (politeness and respecting), distance, existence/availability of drugs and supplies. In addition, to time for services like the registration room, laboratory, examination room, and radiology investigation.
Data collection materials: Structured questionnaire was adapted from similar references but some adjustments have been done on the objective of the current study and based on the service delivery of the study area. Questionnaire equipped in English, translated into the local language Tigrigna and then to English for uniformity. Six Health Management Information System professionals were employed for data collection. Data was collected from all areas that gave outpatient services [21,28,30].
Data management and quality control: A one-day training was provided to data collectors aimed the objectives, contents of the study, and how to approach the study units. Before the actual study, 5% of the total sample size was pretested. After the pretest, editing of the questionnaire was done. Collected data was coded, cleaned, and assured if all questionnaires are completed.
Data analysis: Data was entered and analyzed using SPSS version 21. Descriptive data was presented using frequencies and percentages. Client satisfaction was categorized into satisfied (satisfied, strongly satisfied) and dissatisfied (dissatisfied, neutral, and strongly dissatisfied) for appropriateness of checking associations. After the rectal scales have been categorized into satisfied and dissatisfied, binary logistic regression was used to check the association between dependent and independent variables.
Client satisfaction: Is a parameter used to measure either customers are getting their expectations. After satisfaction specific questions were entered in to SPSS, the five rectal scales were categorized into satisfied and not satisfied, and then the total mean score of satisfaction was calculated to decide the cut-off client satisfaction. Those who scored above the mean were categorized as satisfied and below the mean not satisfied .
Outpatient: A hospital service is planned for the accommodation of health providers and their colleagues to give medical and primarily health care services .
Low client satisfaction: Client satisfaction with a mean score of below 75% .
High client satisfaction: Client satisfaction with a mean score of above or equal to 75% .
Ethical research committee of College of Medicine and Health Sciences provided us an ethical paper. We have also taken a supportive letter from the college to the general hospital. Purpose and content of the research was clarified to the patient/care takers of the study subjects and written consent was obtained.
From the 273 participants, 190(69.6%) were males; most of the Clients (63.7%) were above 35 years old. Majority of respondents 172(63%) were diploma and above. Regarding their marital status, the majority 155(56.7%) was single. Most of the clients (44.3%) were unemployed, 61(22.3%) were merchants, while the others are farmers and employed. About 174 (63.7%) of the clients came from Urban areas. Of the total respondents, 20% were new visitors. About 90% were paying clients (Table 1 and Figure 1).
|Diploma and above||172||63|
|Frequency of visit|
TABLE 1:Socio demographic characteristics of the clients among outpatients of Eastern zone general hospitals of Tigray, Northern Ethiopia,2020 (n=273)
Outpatient satisfaction rate of the service was 113(41.4%) with Mean ± SD, 1.19 ± 0.17. Of the total, 273 respondents were highly satisfied with time spent to see a health worker, courtesy and respect, privacy during examination, access to latrines, cleanliness of latrines, queue process, confidentiality information about patient problems, general cleanliness of the hospital, general satisfaction and overall waiting time to get the services (Table 2). Whereas clients were lowly satisfied with information provision about the service by health professionals, the doctor examination and information provision about the service by health workers. Of the total clients, 248 (91%) got prescription paper for drugs and supplies. Of those with prescription 145 (58.6%) were satisfied with the availability of prescribed drugs (Table 2).
|Characteristics||Satisfied (%)||Dissatisfied (%)||Mean ± SD|
|Information provision by health workers||99(36.3%)||174(63.7%)||1.08 ± 0.27|
|Time used to be served by health professionals||244(89.4%)||29(10.6%)||1.43 ± 0.49|
|Courtesy and respect||207(75.8%)||66(24.2%)||1.43 ± 0.47|
|Doctor examination||201(73.6%)||72(26.4%)||1.24 ± 0.43|
|Privacy during examination||246(90.1%)||27(9.9%)||1.28 ± 0.30|
|Access to latrines||235(86.1)||38(13.9%)||1.4 ± 0.49|
|Cleanliness of latrines||252(92.3%)||21 (7.7%)||1.59 ± 0.49|
|Queue process||219(80.2%)||54(19.8%)||1.45 ± 0.49|
|Confidentiality||209(76.6%)||64(23.4%)||1.2 ± 0.41|
|Information about patient problem||237(86.8%)||36(13.2%)||1.49 ± 0.50|
|Overall waiting time to get the services||262(96%)||11(4%)||1.56 ± 0.49|
|Availability of drugs (n’’=248)||145(58.6%)||128(39.8%)||1.38 ± 0.49|
|General cleanliness of hospital||232(85%)||41(15%)||1.46 ± 0.50|
|General satisfaction of the service||214(78.4%)||59(21.6%)||1.4 ± 0.49|
|Overall client satisfaction||113(41.4%)||160(58.6%)||1.19 ± 0.17|
TABLE 2:Client satisfaction among outpatients of Eastern Zone General hospitals of Tigray, Northern Ethiopia, 2020 (n=273)
Factors associated with client satisfaction among outpatients
Factors associated with client satisfaction who visited outpatient service, eastern zone general hospitals, significant variables on bivariate analysis, marital status, education, occupational status, time taken to be x-rayed, existence of prescribed drugs, time taken before or seen a doctor and time taken to be served by a nurse after a doctor has seen at p-value<0.2. Under multivariate analysis, marital status, time taken to be x-rayed, existence of prescribed drugs, and time taken to be served by nurses after the doctor has seen were declared to have significant association with the outcome variable (Table 3).
|Variable||Satisfied||Dissatisfied||COR (95%CI)||AOR (95%CI)|
|Married||6||10||0.917(0.316, 2.657)||0.162(.023, 1.132)|
|Divorced||12||7||0.321(0.119, 0.862)||0.369(0.108, 1.257)|
|Widowed||40||43||0.591(0.344, 1.018)||0.469(0.229, 0.957)*|
|01-Aug||16||43||7.391(2.054, 26.588)||1.054(0.100, 11.063)|
|Diploma and above||79||43||3.237(0.992,10.567)||0.199(0.022,1.792)|
|Availability of drugs in the hospital||Yes||8||79||1||1|
|Time taken to be x-rayed||<1 hr||78||126||1||1|
|Time taken before seen by doctor||<1 hr||65||67||1||1|
|Time taken to be served by nurse after a Dr.||<1 hr||73||70||1||1|
Note: P-value<0.2 at bivariate analysis, p-value<0.05 at multivariate analysis.
TABLE 3:The mean ± SD of liver enzymes (ALP, ALT and AST) activities in pregnant women who were HIV seropositive on HAART (test group)across the trimesters of pregnancy
Participants who were widowed had 53% times less satisfaction (AOR=0.469 at 95%CI=(0.229, 0.957) than those who were single. Participants who had got x-ray service within 1-2 hours had 93.5% times less probable satisfaction (AOR=0.065 at 95%CI=(0.022,0.191) than individuals who had got service less than one hour. Participants who had got prescribed drugs in the hospital pharmacy had 9.037 times more probable satisfaction as compared to those who had not got the prescribed drugs 9.037(AOR=9.037 at 95%CI=(3.761,21.713). Participants who had got nurse service in less than two hours after the doctor has seen, were 6.277 times more satisfied than individuals who had got the service after two hours 6.271(AOR=6.277 at 95% CI=(1.613, 24.430).
Outpatient client satisfaction has been rated 41.4% with a Mean ± SD of 1.19 ± 0.17. Current finding is almost similar to findings from Gondar University referral hospital 47.6%, Debrebirhan referral hospital 49.2%, west Amhara region 39.3%, public hospitals Amhara region 40.7%, Felege Hiwot Referral Hospital 44.9%, public health facilities of Jigjiga 41.7% (Ethiopia) and Nigeria 45% in which they are rated as low patient satisfaction [18-24].
However, the current finding is higher than the finding of St. Paulus Medical College, Addis Ababa Ethiopia 19% . This divergence might be due to the variance in client expectation, time of study, the type of study participants on which the study participants in St. Paulos hospital focused on women’s satisfaction with intrapartum care so that pain, long stay of time in the hospital and longtime duration of admission might have decreased the satisfaction of the mothers.
This study finding is lower than research findings of public hospitals of Ethiopia like Mekelle patients admitted to Obstetrics and Gynecology Wards 79.7% and elective surgical patients 88.3%, outpatient department of hospitals in the capital city of Ethiopia 89.3%, Gondar university referral and teaching hospital 98.1%, Hawassa university teaching hospital (client satisfaction emergency department 86.7%, patient satisfaction outpatient services 80.1%) [26-31]. The high difference, the result of patient satisfaction between the mentioned studies over the current study finding could be due to the more quality and availability of medical equipment, good infrastructure, the availability of higher medical expert, accessibility of services in which most of the patients may be from towns that can easily access the service and availability of apparent students that can minimize the work load in the teaching hospitals.
Moreover, this research finding is also lesser than research findings in Nigeria, 86.8%, Tanzania 91%, Vietnam 82.5% [32-34]. The reason for the discrepancy could be the socio-economic difference, type of study population, difference in the availability of medical equipment, and difference in the service quality expectations of the population. The other reason could be the type of service differences on which the current study focuses on the general service of the outpatient department, whereas the studies did in Tanzania and Vietnam focus on specific services of family planning and HIV treatment respectively and a study in Nigeria focus on inpatient service. Although study findings in Nigeria 53%, Uganda 53.9%, Kenya 64.9%, and in Ethiopia (Mizan-Aman, Bonga and Tepi Hospitals 61.3%, adult satisfaction nursing care selected hospitals of Ethiopia 52.75%, treatment study in Addiss Ababa 67%, radiological service in Hawassa teaching hospital 71.6% and Mekelle 72%) are rated as low patient satisfaction [35-43], they are still higher than this research finding. The reason could be, the staffs of the general hospitals of eastern zone Tigray might have been less committed to the providing of the services and may not follow the hospital guidelines and protocols.
In this study, it showed that there was an association between marital status with outpatient satisfaction. Participants who were widowed were 53% times less satisfied (AOR=0.469 at 95%CI=(0.229, 0.957) as compared to those who were single. A study done in West Amhara, Ethiopia also showed that association clients who are divorced were 4.26 times less satisfied than those who were single. (AOR: 4.26, 95% CI: 1.11–16.26, P: 0.034) . However, the current research finding is inconsistent with research findings in Kenya  in which it showed that sociodemographic characteristics had no significant association with patient satisfaction. The reason for the inconsistency could be the sociocultural differences.
In this study, participants who had got x-ray service within 1-2 hours were 93.5% times less satisfied (AOR=0.065 at 95%CI=(0.022,0.191)) than that had got service less than one hour. A study conducted in Hawassa University teaching and referral hospital patient satisfaction towards radiological services showed that there was association between waiting time for x-ray service and patient satisfaction. Clients that had less duration to be examined not more than one hour (30 min-1 hr) have been four times more probable satisfied than clients that served after 2 hours (AOR=4.12, 95% CI: 1.4–11.62) .
In the current study, Participants that bought ordered drugs in the health institution had 9.037 times higher probable satisfaction than clients that did not get ordered drugs 9.037(AOR=9.037 at 95%CI=(3.761,21.713). Study findings done in Addiss Ababa St. paulos hospital (AOR: 1.62,95 CI: 1.13,2.23)  and a comparative cross-sectional study among private wing and regular services (AOR: 0.0.14,95%CI=0.004,0.58)  showed positive association between availability of drugs and patient satisfaction. Moreover, studies done in Mulago Hospital, Uganda  and Kenya  showed that there is a positive association between availability of drugs and client satisfaction.
In this study, participants who had got nurse service in less than two hours after the doctor has seen, were 6.277 times more satisfied than that they have been serviced after two hours 6.271(AOR=6.277 at 95% CI=(1.613, 24.430)). Study findings done in Ethiopia showed that high duration time to wait for health care service was associated with client satisfaction (Gondar AOR:0.12, 95% CI=0.04,0.33, comparative cross-sectional study Addis Ababa AOR:0.22,95%CI=0.07,0.073, Mekelle AOR:0.01,95%CI=0,002,0.07 ). Studies done in Uganda and Nigeria revealed that patients who had got service after two hours for services at the facility and after one hour for surgical outpatient department service were dissatisfied. Moreover, different study findings in Ethiopia (St. Paulos Addis Ababa , and Hawassa ), Kenya , and Vietnam  stated that hospital clients who waited for a long duration of time to get service were less satisfied.
Limitations of the Study
Clients may favor the hospital service by thinking that health professionals may not give them good services if they report as they were dissatisfied.
Outpatient client satisfaction rate was below the expected 113(41.4%) with Mean ± SD, 1.19 ± 0.17. Ten of the thirteen client satisfaction measurement tools indicate highly satisfaction of patients with time spent to see health professionals, courtesy and respect by health workers, privacy during examination, access to latrines, cleanliness of latrines, queue process, confidentiality information about patient problems, general cleanliness of the hospital, general satisfaction all services and duration of time to be served. Whereas clients’ satisfaction was low with information regarding services by health professionals and the way doctor examines the patients. Marital status, presence of ordered medicines and supplies in the health institution, time taken for x-ray and time taken to be served by nurses after the doctor has seen the patient are predictors for clients’ satisfaction among outpatients of eastern zone general hospitals.
To the general hospitals
1. The Hospitals should provide information to the clients about the services they are served.
2. The Hospitals should reduce long waiting time and prepare time protocols.
3. The hospitals should conduct a study on client satisfaction to know how the services are provided.
To the board of hospitals
The boards of hospitals should have discussions with the community, Nongovernmental, and government organizations to improve the satisfaction of clients.
Availability of data
Data is found with a corresponding author and any one can find it by requesting.
Conflict of Interest
Authors revealed that there has not been a conflict of interest.
Authors added contributions based on their work divisions for producing this research article.
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