Received date: December 19, 2013; Accepted date: March 13, 2014; Published date: March 17, 2014
Citation: Goel S, Sharma D, Bahuguna P, Raj S, Singh A (2014) Predictors of Patient Satisfaction in Three Tiers of Health Care Facilities of North India. J ommunity Med Health Educ S2:002. doi: 10.4172/2161-0711.S2-002
Copyright: © 2014 Goel S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Background: Satisfaction with quality of health care provision can be conceptualized as a degree of congruency between patient expectation and his perception of services and care received. Aims and objectives: This paper examines the level of satisfaction among patients attending OPD (Outpatient Department) in public health facilities in a city in Northern part of India. Methodology: The study used a cross-sectional sample survey design, wherein a total of 942 study subjects were exit interviewed. An eighty item scale was developed and validated using Delphi technique which covers six major domains of patient satisfaction. It was pilot tested in twenty subjects for development of final tool. Each item was dichotomized as “not satisfied” and “satisfied”. The composite score of each item was later computed and coded as “below average satisfaction” if it was below 0.5 and “above average satisfaction” if it was above 0.5. Binary logistic regression was performed to identify potential predictors of patient satisfaction. Results: Out of 942 study subjects, 728 (77.3%) were satisfied with the various dimensions of service provision at the health care facilities. Logistic regression model revealed that the predictors of patient satisfaction were accessibility to health facility (Odds ratio=6.6), physician care (Odds ratio=4.2), management (Odds ratio=2.9) and physical environment (Odds ratio=2.1). Display of signage’s and staff behaviour did not predict patient satisfaction. Patients attending higher level health care facilities like district hospital were more satisfied (Odds ratio=123.3) as compared to those attending community health centres (Odds ratio=26.0), polyclinic (Odds ratio=12.5) and dispensaries. The respondents in younger age group (10-19 years) were more satisfied as compared to those in age group 19-60 years (Odds ratio=0.79) and 60 years and above (Odds ratio=0.64). Similarly, literate individuals were less satisfied (Odds ratio=0.2) as compared to their counterparts. Conclusion: To conclude, there was an overall good level of satisfaction with OPD. The policy makers should focus on correlates of satisfaction namely, accessibility to health facility, physician care, physical environment and management of health care facility.
Patient; Satisfaction; Delphi; Health facility; Outpatient department
Satisfaction, like quality, is a multidimensional construct . The satisfaction with a health care facility is premised on satisfaction with multiple aspects of organization. Satisfaction with quality of health care provision can be conceptualized as degree of congruency between patient expectation of services and care and his perception of services and care received .
In the modern era, the quality of services provided by the health sector is increasingly being measured by patient’s experiences at the health facility. Several dimensions including behaviour of staff, patient physician interaction coupled with issues of administration of the health facility and physical environment are critical to the issue of patient satisfaction . Patient satisfaction is also a barometer of patient outcome and other health indicators of a facility. A satisfied patient had better adherence to treatment protocols and goes for regular follow up for his illness. Thus understanding of patient expectation and their level of satisfaction is of utmost importance for provision of good quality of health care .
Empirical evidences confirm to the fact that most public health facilities in India are very little concerned about the facilities provided to the patients and their families and in-turn their satisfaction rate. The long queues outside the outpatient departments, small and unkempt waiting areas, poor condition of toilets, unsympathetic attitude of doctor and other health care staff bear eloquent testimony to this fact. Public health facilities cover a much broader part of the society and must comply with the patient’s expectations in delivering quality services. The private care providers are only slightly better in terms of the facilities but the exploitative cost of the treatment is a deterrent for a common person in India, where nearly one third of population fall below poverty line. All these concerns make the assessment of patient’s satisfaction with public health system even more important .
In recent years, patients are becoming more aware of their rights and conscious about their health. They both deserve, and demand best health care in every aspect. Patient’s satisfaction with health care they receive is an important health outcome parameter to judge and improve quality of care. A decrease in patient satisfaction is seen wherever there is a lag between the patient’s expectations and the service received .
While there are extensive literatures on patient satisfaction with medical services in developed nations, there are, to our knowledge, very few studies in the developing nations especially in India. This may be due to the fact that most people in this part of world are bothered more about basic survival needs rather than about health services. Against this background, the present study was conducted to measure the satisfaction with health care facilities in OPD (Outpatient Department) of Chandigarh city.
This cross sectional study was carried out in public health facilities of Chandigarh city (longitude 76047’ 14E; latitude 30044’ 14N) in Northern part of India. The city serves as the capital of two states, Haryana and Punjab. As of 2011 India census, Chandigarh had a population of 960,787 with a density of about 7900 persons per square kilometre. Males constitute 55% of the population and the sex ratio is 829 females for every 1,000 males. Chandigarh has an average literacy rate of 86.77% and most health indicators are above national average.
The main study sampled patients from the six major hospitals in Chandigarh city. The target population consisted of new patients over the age of 20 years. The sample size was calculated using the formula, n=Z2 (1-α/2)pq/d2 (where Z(1-α/2)=1.96 at 95% confidence; p=prevalence of patient satisfaction, q=1-p; d=absolute allowable error). We assumed that 50% of the patients would be satisfied with the health services provided. We further set the allowable error at d=2%. Adding a 10% for incomplete answers, the required sample came to 1172. Thus, we selected a sample of 1200 patients. The sample was proportionately represented from various health facilities viz primary (dispensary), secondary (community health centres, polyclinics) and tertiary (general hospital). The study duration was six months (Sept 2010- Feb 2011).
The data was collected by two surveyors who had previous experience of data collection. They were appropriately trained in administering the questionnaire by the principal investigator, which helped to standardize the instrument. The patients were interviewed at the exit locations of the health facility at all times of the day during OPD hours so as to capture their experiences with various dimensions of care. In case, when patient was ill to be interviewed, his/her attendant was interviewed.
A literature review was initially done through various web based search engines on patient satisfaction studies conducted globally. The search engines were Pubmed, indMed, Directory of Open Access journals and Google scholar. The key words for search included “patient satisfaction” and “Out patient department”. Boolean method was used to refine the number of articles. In addition, manual search of articles was done from the institute library to collect relevant information. The search was not limited by year and country of publication. The search strategy resulted in 2208 hits in PubMed and others. Thereafter, screening of studies was then done based on title and abstract followed by evaluating full text which resulted in 20 relevant studies. The screened articles were used to develop a conceptual framework of patient satisfaction.
Thereafter, the tool was presented to a group of experts from related clinical department (medicine, surgery, obstetrics and gynaecology, community medicine). To achieve consensus Delphi technique was selected for use in this study. It is based on the assumption that a group opinion has a greater validity than an individual opinion . In the first round of Delphi technique, the conceptual framework was presented to experts of Post Graduate Institute of Medical Education and Research (PGIMER) and health care facilities in Chandigarh city for discussion on various major domains and dimensions/items within domains. The framing of questions order was also discussed. At the end of this round, the principal investigator tried to build consensus on the domains and the dimensions of the instrument. In the second round which was held after two weeks, the experts revisited the instrument for refining and final drafting. An eighty item scale was developed measuring six domains namely “accessibility”, “ display of signage’s”, “hospital management system”, “physician care”, “staff care” and “physical environment” (Table 1). The pilot testing of the instrument was done on twenty patients attending health facility (not a part of the study area) where they were interviewed using the final developed tool. The principal investigator analysed the data and found that questions were correctly interpreted by patients. The structure of questionnaire remained the same after this stage.
|Convenient hospital timings||942||627||66.6|
|Wide entrance points||942||788||83.7|
|Reception counter near main entrance||878||858||97.7|
|Easy access to the medical specialists when needed||322||226||70.2|
|Doctor can be reached for query/help||909||631||69.4|
|Lab was located at convenient place||56||54||96.4|
|Pharmacy was located at convenient place||699||695||99.4|
|Display of signage’s|
|Clear and visible sign boards||473||427||90.3|
|Signboards in regional language||941||615||65.4|
|Presence of sign board at registration counter||938||618||65.9|
|Sign board for the dressing room||6||4||66.7|
|Proper directions for various facilities||935||471||50.4|
|Doctor’s name plate displayed||937||589||62.9|
|Doctor’s qualification mentioned||878||420||47.8|
|Doctor visiting hours mentioned on signboard||937||3||0.3|
|Adequate parking space||447||414||92.6|
|Registration area was comfortable||923||857||92.8|
|Adequate sitting space||935||834||89.2|
|Fans and light working||940||926||98.5|
|Cleanliness within premises||940||817||86.9|
|Health educating posters present||904||743||82.2|
|Dressing room was not over-crowded||6||4||66.7|
|Dressing room was clean with proper disposal of dirty stuff||6||2||33.3|
|Nursing staff was present in dressing room||6||3||50|
|Frightening instruments were out of sight in Dressing room||6||3||50|
|Patient area in hospital was clean||940||770||81.9|
|Separate toilets for both sexes were there||928||835||90|
|Toilets were clean and in usable condition||208||95||45.7|
|Telephone facility was available||942||0||0|
|Complaint box was available for redressal system||940||130||13.8|
|Transport facility to be used in emergency||399||269||67.4|
|Photostat facility was available in the premises||938||0||0|
|Canteen was there within the premises||940||132||14|
|Reception counter not over crowded||875||533||60.9|
|Proper queue at reception counter||354||310||87.6|
|Separate queue for ladies/elderly||334||259||77.5|
|Availability of personnel at reception counter||873||847||97|
|Friendly payment at registration counter||766||753||98.3|
|Waiting time less before interaction with doctor||893||493||56.2|
|Personnel was available in the laboratory||56||55||98.2|
|Availability of bottles for collection of samples in lab||52||49||94.2|
|Availability of personnel in the pharmacy||700||695||99.3|
|Availability of medicines in the pharmacy||711||492||69.2|
|Proper maintenance of records||5||2||40|
|Cost of the treatment was inexpensive,||936||904||96.6|
|Treatment in dressing room was inexpensive||6||6||100|
|Reception clerk respectful||835||670||80.2|
|Proper guidance by reception clerk||846||468||55.3|
|Lab personnel behaviour was satisfactory||55||47||85.5|
|Lab report was given on time||52||52||100|
|Sample collection was in very clean conditions||49||48||98|
|Pharmacist explained prescription in a good way||456||435||95.4|
|Dressing room procedure was painless||6||2||33.3|
|Dressing room behaviour of the staff was respectful||6||4||66.7|
|Doctor gave adequate time to explain the problem||935||807||86.3|
|Patient’s examined behind screen||360||179||49.7|
|Doctor examined satisfactorily||926||812||87.7|
|Doctor treated in a friendly manner||935||781||83.5|
|Proper explanation by doctor||886||874||98.6|
|Doctor explained reason for medical test||272||205||75.4|
|Doctor gave the prescription||930||889||95.6|
|Doctor gave instructions about dosage of medicines||887||801||90.3|
|Doctor explained the side effects properly||692||156||22.5|
|Female doctor/attendant for female patient||496||366||73.8|
|Attendant for kids and disabled patients in doctors room||54||12||22.2|
|Patient trusts the doctor for confidentiality of records||730||677||92.7|
|Doctor did not hurry too much when he/she treats||902||612||67.8|
|Doctors was experienced||934||897||96.0|
|Doctors did not ignore what patient told||908||804||81.9|
|Doctor provides advice about ways to avoid illness, stay healthy||887||465||52.4|
|Doctor uses non-medical terms to explain||893||756||84.7|
|Doctor listens carefully to what the patient has to say||928||795||85.7|
|Doctor gave clear instructions about when to return||869||759||87.3|
|I think this hospital has everything needed||362||217||59.9|
|Easy for me to get medical care here||934||828||87.9|
Table 1: Descriptive statistics of items in the questionnaire.
Prior permission was sought from the hospital administrator of the concerned health care facility. Informed consent was obtained from each patient interviewed. The data was kept utmost confidential. Data was analysed using SPSS version 17 for windows. Each of the eighty items in the tool was dichotomized as “not satisfied” or “satisfied” and thereafter composite score for each item was calculated by adding up values of all patients for the particular item. Composite scores for all items in the domain and the entire questionnaire were also computed. The composite score was coded as a dichotomized response viz below average satisfied if the dimension score was below 0.5 and above average satisfied if the item score was above 0.5. The response and explanatory variables were age, sex, education, type of health facility and the six dimension of patient satisfaction viz accessibility to health facility, display of signage’s, physical environment, management, physician care and staff behaviour. The factors found significant in the descriptive analysis were included in the bivariate regression model to identify predictor factors of satisfaction. The study was approved by the Institute Ethic Committee of PGIMER, Chandigarh, India.
The response rate to the questionnaire was 74.5% (942/1200). The average age of the patients was 36.6 years (SD=13.7, range=20 years–88 years). Out of 942 study subjects, 728 (77.3%) were satisfied with the health care facilities. More teenagers (82.7%) were satisfied with the dimensions of service provision at the health care facilities as compared to middle aged (77.2%) and elderly (72.7%) (Table 2).
|10-19 years (N=75)||62(82.7)||P<0.05|
|19-60 years (N=790)||610(77.2)|
|60 and above (N=77)||56(72.7)|
|Type of facility|
|Community health centre (N=114)||59(51.8)|
|District Hospital (N=130)||24(18.5)|
|Dimensions of Satisfaction|
|Accessibility to health facility(N =934)||804(86.1)||P<0.05|
|Display of signage’s(N =545)||307(56.3)|
|Physical environment (N =379)||219(57.9)|
|Physician care(N = 942)||730(75.4)|
|Staff behaviour(N =878)||674(76.8)|
Table 2: Correlates of patient’s satisfaction in the study population.
Logistic regression model revealed that the dominant predictors of patient satisfaction were accessibility to health facility (OR=6.6), physician care (OR=4.2), management (OR=2.9) and physical environment (OR=2.1). Display of signage’s and staff behaviour were insignificant in determining the patient satisfaction. Patients attending higher level health care facilities like district hospital were more satisfied (OR=123.3) as compared to those attending community health centres (OR=26.0), polyclinic (OR=12.5) and dispensaries. The respondents in younger age group (10-19 years) were more satisfied as compared to those in age group 19-60 years (OR=0.79) and 60 years and above (OR=0.64). Similarly, literate individuals were less satisfied (OR=0.29) (Table 3).
|Parameters||All HCF||Dispensary||Polyclinic||Community health centres||District Hospital|
|Display of signage’s||0.9(0.4-1.8)||1.1(0.1-9.0)||.7(0.2-3.7)||1.3(0.4-4.2)||0.8(0.9-4.7)|
|Physical environment||2.1(1.2-3.9) *||0.7(0.1-3.3)||3.4(1.2-9.3) *||5.9(1.9-18.1) *||.1(0.0-1.4)|
|Management||2.9(1.7-5.0) *||5.1(1.1-23.5) *||2.1(0.7-6.8)||1.0(0.2-3.9)||.5(0.1-1.9)|
|Physician care||4.2(2.2-8.0) *||5.7(0.5-61.8)||.9(0.3-2.9)||4.3(1.0-18.0)||25.8(6.6-101.3)*|
|Literate||0.2(0.1-0.4) *||0.2(0.0-1.2)||0.4(0.1-1.2)||0.0(0.0-0.6) *||0.1(0.0-0.7) *|
Table 3: Association of different parameters with patient satisfaction using logistic regression.
In dispensaries health care facility management practices and literacy of the patient are significant correlates of patient satisfaction. In polyclinic, the physical environment of the health facility was significantly related to satisfaction. At Community health centre, physical environment of the health facility and literacy of the patients are significant factors affecting patient satisfaction. At district hospital, the physician care along with literacy of the patient determines patient satisfaction (Table 3).
Our results showed that most of the patients (77.3%) were satisfied with the OPD services of health care facilities. This level of satisfaction reported in our study is comparable with studies reported in India and other parts of the world. Al Emadi and Falamarzi  reported overall satisfaction rate of 75.2% among outpatient health care facilities of Qatar . Similarly, Olusina et al.  in Nigeria reported that 75% outpatients were satisfied with health care facility. A survey by De Brun et al.  in hospitals in Ireland reported higher level of satisfaction (94%) with outdoor patient services. Studies conducted in India by Puri et al., Sodani et al., Kumari et al. and Satyanarayana et al. [10-13] have reported patient satisfaction score ranging from 60%-70%. However, another survey done by Nazirah and Chompikul  reported low level of satisfaction (23%). This variation could be due to variation in the way services are delivered and differences in study populations and hence patients’ expectations. Social desirability bias may also influence satisfaction level on the higher side, if patients were interviewed at the health facility.
The present study found that patient satisfaction decreased with increasing age. Contrary to our finding; studies done by Sixma et al. , Atkinson and Haran  and Jackson et al.  have observed that the patient satisfaction scores improve with increasing age. In our study, we found illiterate individuals were more satisfied with health care facilities as compared to literate. This finding may be due to the fact that illiterates have lesser expectations with health care facilities and thus are satisfied with moderate level of facilities. Similar to our finding, some studies have also observed that less educated people tend to be more satisfied, as compared to highly educated people [15,16].
The results of logistic regression analysis showed that accessibility to health care facility, physician care and management parameters were significant predictor of patient satisfaction. Souter et al.  reported that two aspects of care which rank most highly in terms of importance by their patients were ‘the information and explanation given’ and the ‘doctor’s attitude’. Other studies have also demonstrated physician quality of service as the most important factor of patient satisfaction [7,19]. The attitudes and behaviours of health personnel are important in shaping patient satisfaction with public health care facilities. A study done Bangladesh by Aldana et al.  reported that providers behaviour towards patients, particularly respect and politeness was a powerful predictor for patient satisfaction. Another study in Tanzania  reported that staff behaviour correlates with patient satisfaction.
In conclusion there was overall good patient satisfaction level with the Outpatient Department. The policy makers should focus on correlates of satisfaction namely, accessibility to health facility, physician care, physical environment and management of health care facility.