research proposal on patient satisfaction

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The Association Between Patient Satisfaction and Patient-Reported Health Outcomes

Affiliations.

1 Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
2 Center for Healthcare Advancement and Outcomes, Miami Cardiac and Vascular Institute, Baptist Health South Florida, Miami, FL, USA.
PMID: 31535008
PMCID: PMC6739681
DOI: 10.1177/2374373518795414

Objective: Although patient satisfaction is increasingly used to rate hospitals, it is unclear how patient satisfaction is associated with health outcomes. We sought to define the relationship of self-reported patient satisfaction and health outcomes.

Design: Retrospective cross-sectional analysis using regression analyses and generalized linear modeling.

Setting: Utilizing the Medical Expenditure Panel Survey Database (2010-2014), patients who had responses to survey questions related to satisfaction were identified.

Participants: Among the 9166 patients, representing 106 million patients, satisfaction was rated as optimal (28.2%), average (61.1%), and poor (10.7%). Main Outcome Measures: We sought to define the relationship of self-reported patient satisfaction and health outcomes.

Results: Patients who were younger, male, black/African American, with Medicaid insurance, as well as patients with lower socioeconomic status were more likely to report poor satisfaction (all P < .001). In the adjusted model, physical health score was not associated with an increased odds of poor satisfaction (1.42 95% confidence interval [CI]: 0.88-2.28); however, patients with a poor mental health score or ≥2 emergency department visits were more likely to report poor overall satisfaction (3.91, 95% CI: 2.34-6.5; 2.24, 95% CI: 1.48-3.38, respectively).

Conclusion: Poor satisfaction was associated with certain unmodifiable patient-level characteristics, as well as mental health scores. These data suggest that patient satisfaction is a complex metric that can be affected by more than provider performance.

Keywords: health-care outcomes; patient satisfaction; provider performance.

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Conflict of interest statement

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Flowchart of study participant selection…

Flowchart of study participant selection process.

Distribution of eligible patients with…

Distribution of eligible patients with one diagnosis from 2010 to 2014 across the…

Distribution of satisfaction across disease…

Distribution of satisfaction across disease categories.

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Published: 24 May 2022

Patient satisfaction with health care at a tertiary hospital in Northern Malawi: results from a triangulated cross-sectional study

Frank Watson Sinyiza 1 ,
Paul Uchizi Kaseka 1 ,
Master Rodgers Okapi Chisale 2 , 3 ,
Chikondi Sharon Chimbatata 1 ,
Balwani Chingatichifwe Mbakaya 4 , 5 ,
Pocha Samuel Kamudumuli 6 ,
Tsung-Shu Joseph Wu 2 , 7 &
Alfred Bornwell Kayira 1

BMC Health Services Research volume 22 , Article number: 695 ( 2022 ) Cite this article

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Metrics details

In 2016 the Malawi government embarked on several interrelated health sector reforms aimed at improving the quality of health services at all levels of care and attain Universal Health Coverage by 2030. Patient satisfaction with services is an important proxy measure of quality. We assessed patient satisfaction at a tertiary hospital in Northern Malawi to understand the current state.

We conducted exit interviews with patients aged ≥ 18 years using a 28 statement interviewer administered questionnaire. Patients were asked to express their level of agreement to each statement on a five-point Likert scale – strongly disagree to strongly agree, corresponding to scores of 1 to 5. Overall patient satisfaction was calculated by summing up the scores and dividing the sum by the number of statements. Mean score > 3 constituted satisfaction while mean score ≤ 3 constituted dissatisfaction. A χ 2 test was used to assess the association between overall patient satisfaction and demographic variables, visit type and clinic consulted at alpha 0.05. Patient self-rated satisfaction was determined from a single statement that asked patients to rate their satisfaction with services on a five-point Likert scale. We also asked patients to mention aspects of hospital care that they did not like. Responses were summarized into major issues which are presented according to frequencies.

Overall patient satisfaction was 8.4% (95% CI: 5.2 − 12.9%). Self-rated patient satisfaction was 8.9% (95% CI: 5.5 − 13.4%). There was no significant association between overall patient satisfaction and all predictor variables assessed. Patients raised six major issues that dampened their health care seeking experience, including health workers reporting late to work, doctors not listening to patients concerns and neither examining them properly nor explaining the diagnosis, shortage of medicines, diagnostics and medical equipment, unprofessional conduct of health workers, poor sanitation and cleanliness, and health worker behaviour of favouring relatives and friends over other patients.

Conclusions

We found very low levels of patient satisfaction, suggesting that quality of services in the public health sector is still poor. It is, therefore, critical to accelerate and innovate the Ministry of Health’s quality improvement initiatives to attain Malawi’s health goals.

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Introduction

Malawi aspires to achieve Universal Health Coverage (UHC) by 2030 [ 1 ]. But a 2016 situation analysis of the health sector in Malawi identified low quality of care as a major setback to achieving UHC and improving population health outcomes [ 2 ]. Based on recommendations of this report the Malawi government has since 2016 been undertaking several health sector reforms to improve the quality of health services at all levels of care by improving and strengthening leadership and governance, human resource capacity, clinical practice, client safety, people-centered care and supply chain systems [ 1 ]. In 2018, the Ministry of Health and Population (MoHP) designated patient or client satisfaction with services as one of the main indicators for monitoring improvements in the quality of services in public health facilities in Malawi, and encourages the conduct of patient satisfaction surveys disaggregated by service type and facility type every two years [ 3 ]. The target is that by 2022 at least 80% of patients or clients seeking health care in public facilities should be satisfied with the health services provided [ 3 ].

Patient satisfaction, defined as the congruence between patient expectations of optimal care and the perception of the actual care received [ 4 ], is however not without limitations when used as an indicator for quality of care. According to the Donabedian quality of care model, health care quality encompasses the technical competencies of the providers as well as the interpersonal process through which that care is provided [ 5 ]. Technical quality of care is judged against the best in practice which is known or believed to produce the greatest improvements in health [ 5 ]. But Donabedian argues that due to limitation in medical knowledge most patients cannot competently assess the technical skills of their provider, and may therefore have low or no expectations on the technical quality of care [ 5 ]. As such, their satisfaction scores may only indicate the interpersonal skills of the provider and good health care outcomes. But even if the health care outcome is not good the quality of care given will still be judged as good if it conformed to best practice permitted by the science and technology of the day. Therefore satisfaction or dissatisfaction with care does not necessarily equate to receipt of good or bad quality of technical care.

Nonetheless, in recent decades, there has been a major shift in health care practice from the traditional way of defining quality of health care in terms of the technical standards to one that includes patient’s perception and judgement about the services received [ 6 ]. Patient perception about the quality of and trust in the health care services received has a huge bearing on their continued utilisation of health care and compliance with care regimens and suggested lifestyle modifications, which in turn affects treatment outcomes [ 7 ]. Donabedian, in his quality of care model, corroborates the importance of good interpersonal relationship between the provider and the patient because the interpersonal process serves as the vehicle by which technical care is implemented and on which its success depends [ 5 ]. Furthermore, beyond technical and interpersonal quality aspects of care, patient satisfaction has been reported to be influenced by availability and accessibility of health care providers, medicines and diagnostics; cost of services; and physical environment [ 8 , 9 , 10 ]. Studies have also demonstrated a direct connection between quality of services and patient satisfaction with services [ 11 , 12 , 13 ], making it an important indicator of health system performance improvement.

Four studies have previously assessed client or patient satisfaction in Malawi. All of them were done before the year 2016 and three of them reported satisfaction levels of more than 85% [ 14 , 15 , 16 ] which is higher than MoHP set target of 80% by the year 2022. The other study found that at least 75% of hospitalized stroke patients surveyed at discharge were satisfied with the care they received [ 17 ]. All four studies assessed satisfaction with either a specific service provided by a specific group of providers, one hospital unit or a specific group of patients, and mainly focused on the technical aspects of care. Perhaps this explains why MoHP set a target of 80% by the year 2022 knowing pretty well that studies done way earlier had demonstrated higher levels of client/patient satisfaction with the services. Motivated by these deficiencies and in responding to MoHP’s call for regular patient satisfaction surveys as a way of obtaining important feedback from clients and patients on the quality of services in public health facilities we assessed patient satisfaction with health care at a tertiary hospital in Northern Malawi.

Study design and setting

This was a descriptive cross-sectional study. It was carried out at Mzuzu Central Hospital (MCH) between January, 2021 and February, 2021 during the second surge of COVID-19 cases in the country. MCH is tertiary hospital located in Mzuzu City, Northern Malawi. It is a 410 bed capacity hospital and serves as the referral facility for six health districts that constitute the Northern Region and serving a population of 2,289,780 people [ 18 ]. Ideally the hospital provides specialist health services at the regional level. In practice, however, around 70% of the services it provides are either primary or secondary [ 19 ]. This is mainly due to unavailability of proper primary and secondary level health facilities in Mzuzu city and the surrounding areas and lack of a gate-keeping system [ 19 ]. Daily bed occupancy is at 410 and about 50 inpatients are discharged from hospital daily. Hospital records showed that the facility also treats about 500 patients daily on an outpatient basis.

Data collection, management and analysis

We conducted exit interviews with patients aged 18 years and above shortly after having been discharged from hospital (for inpatients) or after they had completed consultation and received treatment. Interviewer administered structured questionnaire was used to collect data from patients. The questionnaire was adapted from the Patient Satisfaction Questionnaire (PSQ-III) and the Patient Satisfaction Questionnaire Short Form (PSQ-18) (an abbreviated version of PSQ-III), both of which are validated and reliable tools for assessing patient satisfaction with medical care [ 20 , 21 ]. The adaption process involved rephrasing some statements to reflect the local context, dropping items that were not applicable locally, and substituting such items with those that were locally relevant. All new additions were based on literature. We engaged non-Mzuzu Central Hospital staff as interviewers to encourage free expression by patients. Interviewers had professional training in nursing and medicine. They were dressed in civilian clothes and interviews were conducted at a private place, away from identifiable hospital staff. Interviewers were trained in data collection tools and procedures before deployment.

The questionnaire consisted of 28 statements grouped into six domains of care: (1) Communication (4 statements), (2) Relational conduct (5 statements), (3) Technical skills/competence (5 statements), (4) Personal qualities/attributes (3 statements), (5) Availability and accessibility (6 statements), and (6) Physical environment (5 statements). Statements under communication domain solicited information from patients on whether health care providers provided adequate and patient tailored information on the investigations being done and eventual diagnosis, and adequately addressed patient concerns. Relation conduct domain comprised statements seeking information on whether patients were treated with respect by providers and were adequately involved in decision making. Statements under technical skills domain gathered information on whether providers demonstrated a masterly of their job. The personal attributes domain statements probed whether patients were treated courteously, and with privacy and empathy by providers. Statements under availability and accessibility domain solicited information on whether doctors were readily available and accessible to patients at the hospital and whether medicines, diagnostic services and functional medical equipment were also available. The physical environment domain asked patients to rate the adequacy, cleanliness and tidiness of sanitary facilities and hospital surroundings as well as the state of hospital infrastructure and room space.

Patients were asked to indicate their level of agreement to the statements on a five-point Likert scale: (1) Strongly disagree, (2) Disagree, (3) Not sure, (4) Agree, and (5) Strongly agree. The questionnaire contained a mix of statements expressing both positive and negative sentiments in a random order to minimize acquiescence bias. Together, the 28 statements provided a composite measure of satisfaction which we call Overall Patient Satisfaction. The questionnaire also contained one more question “ On the overall, how satisfied are you with the services you have received? ” with responses on a five-point Likert scale – very dissatisfied to very satisfied. The objective of this question was to solicit patients’ own subjective assessment of their health care seeking experience, herein referred to as Self-rated Satisfaction. The questionnaire further contained an open-ended question asking patients to mention any areas or aspects of care that needed improvement at the hospital. This question solicited inputs from patients so as to understand what constitutes quality health care from their perspective.

Data were entered in Microsoft excel 2016, cleaned and then imported into STATA V.13.0 (StataCorp) for analysis. But before any analysis could begin responses to all negatively framed statements were first re-coded so that all scores (1, 2, 3, 4, 5 corresponding to strongly disagree, disagree, not sure, agree and strongly agree) were in the same sense (i.e. the higher the score the higher the level of satisfaction). Overall patient satisfaction was calculated by summing up individual satisfaction scores across the six domains of care to get an overall score and then dividing this overall score by the total number of statements in the six domains. This calculation brought the overall scores back into the scale of 1 to 5. An overall mean score of more than 3 was treated as ‘Satisfied’ while an overall mean score of 3 or less was treated as ‘Unsatisfied’. This analysis was repeated for each domain to calculate domain specific overall satisfaction. Overall patient satisfaction was dichotomized because very few patients were satisfied with the care they received and splitting it further would have scattered the data even more, making it unlikely to observe any association between satisfaction and predictor variables.

For self-rated satisfaction responses very dissatisfied, dissatisfied and not sure constituted dissatisfaction whereas satisfied and very satisfied formed satisfaction. The response ‘Not sure’ was categorized on the dissatisfaction side because we felt that that was patients’ polite way of saying the services were not good. We believe if patients were happy with the services received they would not hesitate to say so. Patients’ responses to an open ended question were reviewed and summarized into major issues.

Descriptive statistics were performed to summarize patient characteristics. Overall patient satisfaction was the main outcome of analysis. A Chi square (χ 2 ) test of independence was used to test the association between overall patient satisfaction and demographic variables, visit type and hospital clinic/department consulted. A χ 2 test was performed for all cross tabulations where the sample size (n) was greater than the number of cells multiplied by 5 and where the expected value in 80% of the contingency cells was greater than 5 and no cell had the expected value of less than 3. Where this condition was not met a Fisher’s exact test was performed instead. A p-value of 0.05 or less was considered statistically significant. A binary logistic regression was not a good fit for the data at alpha 0.05 (i.e. Prob > chi2 was greater than 0.05) so we had to stick to the χ 2 .

A total of 225 patients were interviewed, representing 100% of the target sample size. Of these, 126 (56.0%) were female and the majority (38.7%) were in the 20–29 years age group. Half (50%) of the patients had completed secondary level education. The majority of patients resided in the Northern Region (77.8%), were treated as outpatients (58.7%) and were seen at the general outpatient department (44.4%) (Table 1 ).

Overall patient satisfaction was 8.4% (95% CI: 5.2 − 12.9%), but ranged from as low as 4.9% for health worker attributes to as high as 27.1% for availability and accessibility of health workers and health services. Self-rated patient satisfaction was 8.9% (95% CI: 5.5 − 13.4%) (Table 2 ).

A Chi square or Fishers’s exact test was used to explore associations between overall patient satisfaction and demographic characteristics of participants and other variables. None of the variables examined had a statistically significant association with overall patient satisfaction (Table 3 ).

The top six areas of improvement cited by patients are that health workers should report to work on time at 29.8% followed by a plea that doctors should listen to patients’ concerns, examine them thoroughly and explain their findings and diagnosis, including the reasons for doing blood tests and other examinations at 17.8% (Table 4 ). “Doctors should come to work on time and examine patients properly” , said a 27 year-old male when asked what he thought could have been done differently to improve his experience at the hospital. While a 35 year-old female had this to say “Doctors should pay attention to patients and examine them properly based on their complaints ”.

Third was an observation that the hospital should improve its stocks of essential medicines, diagnostics and medical furniture at 14.7%, which was followed by an earnest call that health workers must conduct themselves professionally at 12.9% (Table 4 ). “Doctors should minimize chatting with colleagues and on their phones when attending to us” said a 21 year-old woman when asked what should improve at the hospital to make her experience better. Another 20 year-old female responded “ Stock enough drugs in the pharmacy and provide more chairs on the outpatient queues so that we can observe social distance during this era of COVID-19” .

On fifth position, there was a call from 6.7% of patients that hospital management has to improve cleanliness in the hospital’s sanitary facilities and regularly maintain the physical infrastructure. Finally at number six, 4.0% of patients bemoaned the behaviour of some health workers who favour or prioritise their relatives and friends over other patients and pleaded that heath workers should change this discriminatory behaviour (Table 4 ). When asked what she thought should have been done differently in order to improve her experience at the hospital a 60 year old female said “improve sanitation in the toilets” while 63 year old woman said “stop prioritizing relatives and friends of health workers and treat us all equally”.

Seventy two patients (32%) contradicted their initial responses and said they were satisfied with the services they received when prompted to suggest what could be improved at the hospital (Table 4 ). When asked to mention areas that needed improvement at the hospital so as to make their experience better next time they come to seek care a 42 year old male said “I’m satisfied with the services” . An 18 year old female said “The hospital should keep up the good work it is doing” while a 36 year old female said “There’s improvement on abuse of patients and that should continue”.

We assessed patient satisfaction in six domains of care (communication, rational conduct, technical competence, personal qualities, availability and accessibility, and physical environment) and calculated an overall measure of patient satisfaction. We also report patient self-rated satisfaction with the services they received and patient suggested areas of improvement for better service delivery at the hospital. To our knowledge this is the first study in Malawi to have taken a multi-pronged approach to assessing patient satisfaction, and to have assessed satisfaction holistically and not focussing on a specific service or hospital department.

Both overall patient satisfaction self-rated satisfaction were low (8.4% and 8.9% respectively), suggesting that the quality of services in public hospitals is still not satisfactory. If this study had included family members of patients who died in hospital the service ratings would have been even poorer considering the fact that patients who survive often tend to rate services as satisfactory [ 22 ]. It is encouraging to note, however, that our measured overall satisfaction was not different from patient self-rated satisfaction, giving confidence in the tool that we used to objectively assess patient satisfaction. Therefore, instituting improvements in the domains of care that we assessed may lead to increased satisfaction with care among patients.

Previous studies reported high levels of satisfaction with health care services in Malawi. In a study investigating client satisfaction with cervical cancer screening all women (100%) reported being satisfied with the services, with 68.3% reporting being very satisfied [ 14 ]. Creanga and colleagues found patient satisfaction levels of more than 85% with perinatal care [ 15 ]. 97% (97%) of women were satisfied with reproductive health services at Gogo Chatinkha Maternity Unit in Blantyre, Malawi [ 16 ] while more than 75% of stroke patients were said to be satisfied by the care they received in four tertiary hospitals in Malawi [ 17 ]. All of the above studies have fundamental differences from our study. While we attempted to assess the hospital as a system, encompassing as many dimensions of care that might lead to patient satisfaction (or otherwise) as possible, they focused on a specific service provided by specific staff in a particular unit or department of the hospital. Taking such a narrow approach one is likely to find higher levels of satisfaction. In Nigeria and Uganda studies that assessed a particular service or one aspect of care provided by the hospital or clinic reported higher levels of satisfaction (91.6% and 93.8% respectively) [ 23 , 24 ].

The hospital, however, is a much broader sand complex system. In navigating such a system patients may encounter several frustrations along the way, including having to interact with multiple providers with varying technical competencies and personal manners, and from different professional backgrounds. In resource constrained countries like Malawi patients are also faced with limited access to the doctor, frequent stock outs of essential medicines and limited diagnostics services. Studying patient experiences with the health care system from such a broader perspective one may find lower levels of satisfaction. In Ethiopia and Uganda, studies that took a similar approach to our own and measured patient satisfaction in a similar manner found lower levels of satisfaction with nursing care among hospitalized patients (40.7% and 49.2%) [ 25 , 26 ], inpatient services (46.2%) [ 27 ] and outpatient services (50.0%) [ 28 ]. Even though our results are still far lower than these the trend is apparent, and the observed discrepancies could be due differences in study sites. We are, therefore, of the view that when assessing patient satisfaction with hospital care taking a holistic approach is the best way to draw out true hospital ratings from the people it endeavors to serve better.

Further, this study was conducted in the midst of the COVID-19 pandemic. COVID-19 has had significant impact on the delivery of other essential health services in Sub-Saharan Africa, including Malawi. It led to shortage of human and material resources due to staff and money being redirected to tackle the epidemic [ 29 , 30 ]. COVID-19-related stressors such as physical exhaustion, alarming deaths of COVID-19 patients and the fear of contracting infection and subsequently passing it to family members took a huge toll on mental health of health workers [ 31 , 32 ], which in turn may have affected how providers related with patients. Globally, COVID-19 lockdowns disrupted supply chains and lead to acute shortage of medicines and other essential health commodities in Malawi [ 33 , 34 ]. In addition, the global scramble for essential health commodities such as masks and other protective equipment (PPE) led to severe shortages of these items in third world countries like Malawi [ 35 ]. Without appropriate and adequate PPE it was difficult for health workers to maintain good provider-patient interactions and discharge their duties comfortably. A combination of these factors may have plummeted health care provider and hospital ratings in the eyes of the patient.

We examined the association between overall patient satisfaction and independent variables listed in Table 1 using a Chi square or Fishers’s exact test, as appropriate. Initially, the plan was to fit a binary logistic regression but when we attempted to fit such a model with either of the variables individually or together the model itself was insignificant at alpha 0.05. As such we had to explore the association using basic statistical tests (Chi square or Fisher’s exact) which too did not reveal any association at 5% level of significance. Maseko et al. found no association between client satisfaction with cervical cancer screening and age, education level or marital status [ 36 ] while Nabbuye-Sekandi and colleagues reported higher levels of satisfaction among clients with primary or secondary education compared with those that had no formal education [ 28 ]. They also found greater levels of satisfaction among clients who attended certain specialized clinics (HIV treatment and research clinic) than among those who attended general outpatient clinics [ 28 ]. Sharew et al. reported the opposite of what Nabbuye-Sekandi et al. had reported. In their study they found that patients with at least primary education were 80% less satisfied compared with those without any formal education [ 26 ]. So, failure by our study to find any significant associations between satisfaction and demographic variables, visit type and department or clinic consulted could mean that indeed there is no association, or simply a failure by our study to detect these associations owing to few events (only 8.4% of patients were satisfied and therefore could not achieve adequate distribution for optimal comparison).

Patients raised various issues that dampened their health care seeking expereince at the hospital. Top on the list were health workers reporting late to work, that doctors do not listen to patients’ concerns and that they do not take time to examine patients thoroughly and explain the findings, shortage of medicines and diagnostics, and unprofessional conduct of health workers. Five of the top six items raised by patients were already included in the questionnaire we used to objectively assess patient satisfaction, giving reassuarance that the tool we used touched on issues that patients considered important. A small proportion of patients also raised some important issues that the hospital should consider improving if it is to appeal to its clientele. Concerns that health workers are favouring or prioritizing their relatives and friends over ordinary patients by aiding them to skip the queue, the revelation that some health workers are soliciting bribes from patients, and the need for adequate physical space so that patients can observe social distance while waiting on the queue during the COVID-19 pandemic must be seriously looked into. None of the issues raised were related to the technical aspects of quality of care. Nonetheless, these are the things that patients are able to observe and upon which they base their evaluation of the performance of the hospital. Therefore, while aiming to improve the technical quality of care particular attention must be paid to the nontechnical aspects of it as well.

When asked to mention areas that the hospital should improve to meet their expectations a substantial proportion of patients (32%) had nothing specific to point a finger at other than to contradict their earlier statements and say they were satisfied with the care they had received. Of these, 98.6% were not satisfied with the care they received by our measured overall satisfaction, and all of them (100%) reported not being satisfied in their self-rated satisfaction. Forty-two (58.3%) of them had completed at least secondary education. This contradictory result is interesting. We suspect that despite many of them having good education they still lacked knowledge on their rights with regard to health care, and therefore had no expectations of the quality of services they ought to receive. Without expectations it is difficult to judge the actual care received, and hence unable to point out a single thing that was not right in the services they received.

Patient satisfaction was very low, suggesting that patients were not happy with the quality of services they received. This is a strong message to policy makers and health managers to improve the quality of services and patient experience in public hospitals. To stay true to its commitment of improving population health outcomes and achieve UHC by 2030 through provision of quality services the Malawi government has to step up and accelerate current initiatives meant to improve quality of services or innovate its quality improvement approaches. Furthermore, the Malawi health system has to get better prepared for future pandemics because these tend to reverse the gains made in previous years. In addition, the Malawi government and development partners should consider sensitizing citizens on their rights and responsibilities enshrined in the Malawi service charter on patients’ and health service providers’ rights and responsibilities so that they know what to expect from and what is expected of them during a health care seeking encounter. Until there is congruence between expectations of ideal care and the actual care received it will be difficult for patients to rate the services as satisfactory or not. So even if the Malawi government is to make investments to improve quality of care and patient experience in its facilities future patient satisfaction surveys may still fail to detect changes in levels of satisfaction as patients may not be able to distinguish between optimal and suboptimal care.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Email: [email protected].

Abbreviations

Ministry of Health and Population

Universal Health Coverage

Personal Protective Equipment

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Acknowledgements

The authors are sincerely grateful to Pingtung Christian Hospital and Luke International Norway (LIN) for funding this study.

The study was funded by Pingtung Christian Hospital, Taiwan through Luke International Norway (LIN), Malawi, Grant Number: PS-IR-108001. The funder played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.

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FWS conceptualized and designed the study. TJW provided inputs to the manuscript and funding acquisition. PUK, MRC, CSC, BCM, PK and ABK refined the study design and contributed to the development of the study protocol. PUK supervised data collection. FWS, PUK, MRC, BCM and ABK devised the data analysis plan. ABK analysed and interpreted the data, and wrote the manuscript. All authors read and approved the final manuscript.

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Correspondence to Alfred Bornwell Kayira .

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The study was approved by Mzuzu University Research and Ethics Committee (MZUNIREC). Permission to conduct the study was also obtained from Mzuzu Central Hospital Research Committee. Written informed consent was obtained from patients before interviews could proceed. For illiterate participants written informed consent was obtained from literate legal guardians. Patients were assured of confidentiality of information they provided and that this would have no bearing on the care they would receive at the hospital in future visits. Information obtained from patients was handled by authorized personnel only. All study methods were performed in accordance with MZUNIREC regulations and guidelines.

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Sinyiza, F.W., Kaseka, P.U., Chisale, M.R. et al. Patient satisfaction with health care at a tertiary hospital in Northern Malawi: results from a triangulated cross-sectional study. BMC Health Serv Res 22 , 695 (2022). https://doi.org/10.1186/s12913-022-08087-y

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Research Proposal on Elderly Patient Satisfaction in CVGH with regards to Nursing care given

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Cross-Sectional Study of Clients’ Satisfaction With Outpatient and Inpatient Services of Public Health Facilities of a North Indian State

Associated data.

Supplemental material, Questionnaire for Cross-Sectional Study of Clients’ Satisfaction With Outpatient and Inpatient Services of Public Health Facilities of a North Indian State by Manmeet Kaur, Abu Bashar, Tarundeep Singh and Rajesh Kumar in Health Services Insights

Satisfaction with health care services is a desired outcome of health care delivery. Nonetheless, there is scant information on client satisfaction with services provided in public health facilities in India. A cross-sectional study of persons attending public health facilities in Punjab, North India, was carried out in 2016. All district hospitals, subdistrict hospitals, 2 community health centres (CHCs), and 6 primary health centres (PHCs) were randomly selected from each of the 22 districts. A 60-item pre-tested and validated questionnaire was used to collect data. Participants (3278 outpatient department [OPD] and 1614 inpatient department [IPD]) visiting health care facilities were interviewed. Majority of OPD participants were satisfied with registration process, care providers, and personal issues like safety and security at the health facilities. Major domains of dissatisfaction were long waiting time and concern shown for patients during lab tests and x-rays. Most IPD participants were satisfied with care received from nurses and doctors, availability of medicines, and hospital environment. Domains of dissatisfaction were cleanliness of rooms and bathrooms and quietness at night. Varying levels of satisfaction were observed for experiences during stay, information about new medicine being given, pain control, and locomotion to bathroom or using bedpan. Around 71% were likely to recommend the health facility to others. Satisfaction with public health facilities is context dependent. Lack of drugs and supplies, poor information about medicines, long waiting time, poor cleanliness, lack of privacy, and peace were the major reasons for dissatisfaction in our study.

Introduction

Patients’ or clients’ satisfaction with health care is an integral component of quality monitoring in health care systems:

Providers must get first-hand information from their clients, which should help them to reorient their services by adopting a more client centred approach, transforming their attitude and introducing a convivial ambience at health service outlets based on feedback of their clients. 1

Donabedian defined patient satisfaction as patient-reported outcome measure while the structures and processes of care can be measured by patient-reported experiences. 2 Moreover, quality assurance and accreditation process in most countries requires that satisfaction of clients be measured on a regular basis. 3

Quality of health services has been traditionally based on professional practice standards. However, in recent times, patient’s perception about health care has been increasingly accepted as an important measure of quality of health care and a critical component of performance improvement and clinical effectiveness. 4 Donabedian emphasised that client satisfaction is of fundamental importance as a measure of quality of care because it gives information on provider’s success at meeting those client values and expectations, on which client is the ultimate authority. 5 , 6

Patients’ evaluation of care is a realistic tool to provide opportunity for improvement of care, enhancing strategic decision making, reducing cost, meeting patients’ expectations, framing strategies for effective management, monitoring performance of health plans, and provide benchmarking across health care institutions. 2 , 7 - 9 In addition, patient satisfaction reflects patients’ involvement in decision making and their role as partners in improving the quality of health care services. 7 , 10 There is a significant correlation between measuring patient satisfaction and patients’ compliance to treatment and continuity with health care providers. 11 - 13

Majority of existing patient satisfaction studies have assessed overall satisfaction levels and paid little attention to satisfaction with specific domains of health care delivery. Domains of satisfaction have been viewed as multidimensional, which includes hospital structure, medical processes, and outcome of health care services. 14 In recent years, the World Bank and other donors have been advising developing countries to ensure that limited resources not only have an optimal impact on population’s health at affordable cost but also that health services are client-oriented. 15 - 18

Most research done on patient satisfaction with health services in India has been confined to family planning services. In this background, this study was conducted to measure the clients’ satisfaction with outpatient and inpatient services of public health facilities in a north Indian state.

Material and Methods

The study was conducted in North Indian state of Punjab, situated between 29″30′N to 32″32′N latitude and 73″55′E to 76″50′E longitude with a total population of 28 million (Census 2011). Information was collected from users or clients seeking health care from public institutions: district hospitals (DHs), subdistrict hospitals (SDH), community health centres (CHCs), and primary health centres (PHCs). At each selected hospital/health facility, exit interviews were carried out using a structured study tool/interview schedule from persons seeking outpatient and inpatient health care. Each of the districts usually has one DH and one SDH, which represent secondary care institutions, and multiple CHCs and PHCs, which represent primary care institutions. Hence, all DHs and SDHs were included in the sample and 2 CHCs and 6 PHCs were randomly selected from the list of CHCs and PHCs in each of the 22 districts. The study was conducted between September 2015 and August 2016.

Sickness rate in Indian population at any given time averages around 10%. Assuming that these 10% population seeks outpatient department (OPD) health care, with power of 80% and precision of 5%, and 10% non-response rate, a sample size of 150 was required for each district. Hospitalisation rates in a population vary between 1% and 5% of the population. Assuming 5% hospitalisation, a sample size of 74 individuals from inpatient was arrived for each district. Hence, the total sample for each district was 150 + 74 = 224, and a sample of 224 × 22 = 4928 was required at the state level ( Table 1 ).

Sampling framework for the clients’ satisfaction survey in Punjab.

Type of facility	Number of patients from OPD	Number of patients from IPD
DH	30	20
SDH	30	20
2 CHCs	2 × 15 = 30	2 × 5 = 10
6 PHCs	6 × 10 = 60	6 × 4 = 24
Total	150	74
Grand total (for each district)	224

Abbreviations: CHCs, community health centres; DH, district hospitals; IPD, inpatient department; OPD, outpatient department; PHCs, primary health centres; SDH, subdistrict hospitals.

From each of the institutions and health facilities, persons seeking care were selected through simple random sampling technique so as to represent the surgical and nonsurgical departments including emergency. In case of paediatric patients, adult caretakers were interviewed regarding their experiences in the hospital. Those clients who were mentally challenged/under influence of any drug or alcohol, or hearing impaired or unable to communicate due to any other reasons were excluded.

Development of clients’ satisfaction tool

Four focussed group discussions (FGDs) were held in different settings of the state: 2 rural and 2 urban, one involving high-income group and other involving low-income group each to identify common issues in the health care institutions which determine or affect satisfaction with the services.

Existing scales were reviewed and adapted. Additional items were added to address issues identified during FGDs. A panel of experts (academicians, researchers, and health care providers) was then constituted to identify appropriate items to formulate the tool. The finalised tool for OPD participants had a 5-point Likert-type scale where questions and responses were categorised as excellent, good, fair, poor, and very poor. These 5 points were assigned scores from least favourable to most favourable (1-5). Each sub-component of the scale addressed different aspects of care giving, for example, experiences in the registration area, experience with nurses, experience and satisfaction with doctors, availability of medicines and infrastructure, and surrounding environment of the health facility. Similarly, for inpatient department (IPD) participants, a 4-point (always, usually, sometimes, and never) Likert-type scale questions were included in the scale. Five dimensions of perceived quality were identified – medicine availability, medical information, staff behaviour, doctor behaviour, and hospital infrastructure and relevant sections in tool were devoted to capture information on each of them.

The tool was developed in English with back-and-forth translated to Punjabi, the local language. The developed questionnaire was pilot tested in health facilities in neighbouring territory of Chandigarh for validity and reliability. Minor adjustments were made based on the pilot testing to ensure that all relevant domains had been covered and the language and format of questions were unambiguous.

Data management and analysis

Data were analysed using Statistical Package for Social Sciences (SPSS) version 14.1. Descriptive analysis was employed to determine patients’ level of satisfaction. Level of satisfaction was categorised into 5 categories for OPD participants and 4 categories for IPD participants and percentage scores of each category were calculated.

Ethical considerations

Written consent was obtained after intended participants were informed about the purpose and procedures of study. Privacy and confidentiality of data was ensured by masking personal identifiers like name and address and assigning a unique ID to each respondent. The questionnaires were digitised and field investigators filled in the answers as given by the participants online on tablet computers/mobile phones. This also ensured that the data recorded by investigators could not be accessed by anyone except authorised individuals. The study protocol was approved by the institute ethics committee (IEC) of Postgraduate Institute of Medical Education & Research, Chandigarh vide letter no PGI/IEC/2015/1129 dated July 21, 2015, Project no. P-229.

A total of 3278 patients or their caregivers from OPD and 1614 from IPD were interviewed for the study. Majority of patients belonged to rural areas (58.7% of IPD and 58.3% of OPD participants) and were females (57.4% for IPD and 50.1% for OPD). Different occupational groups seemed to use public health facilities in the similar proportions for IPD and OPD except professionals who used IPD more often than OPD. Younger age groups appeared to use IPD more often whereas the older age groups appeared to use OPD more often ( Table 2 ).

Sociodemographic characteristics of the study participants (N = 4928).

Variables	Sociodemographic characteristics	IPD (N = 1614) N (%)	OPD (N = 3278) N (%)
Place of residence	Rural	947 (58.7)	1911 (58.3)
	Urban	667 (41.3)	1367 (41.7)
Age (y)	18-30	632 (39.2)	143 (4.4)
	31-40	454 (28.1)	893 (27.2)
	41-50	244 (15.2)	880 (26.8)
	51-60	188 (11.6)	517 (15.8)
	Above 60	96 (5.9)	513 (15.6)
Gender	Female	924 (57.2)	1644 (50.1)
	Male	690 (42.8)	1634 (49.9)
Marital status	Married	1412 (87.5)	2557 (78.0)
	Single	202 (12.5)	721 (22.0)
Educational level	Below primary	381 (23.6)	846 (25.8)
	Up to middle	254 (15.7)	501 (15.3)
	Secondary	358 (22.2)	648 (19.8)
	Higher secondary	407 (25.2)	751 (22.9)
	Diploma/graduation and above	214 (13.3)	532 (16.2)
Occupation	Professional	286 (17.7)	235 (7.2)
	Farmer	156 (9.7)	428 (13.1)
	Skilled worker	258 (16.0)	470 (14.3)
	House wife	731 (45.3)	1159 (35.4)
	Retired	24 (1.5)	56 (1.7)
	Business person	153 (9.5)	400 (12.2)
	Unemployed	0 (0.0)	154 (4.7)
	Student	6 (0.3)	376 (11.5)
Religion	Hindu	624 (38.7)	1247 (38.0)
	Sikh	944 (58.5)	1906 (58.1)
	Others	46 (2.8)	125 (3.8)
Caste/category	General	641 (39.7)	1423 (43.4)
	Other backward castes	313 (19.3)	744 (22.7)
	Scheduled castes	638 (39.5)	1068 (32.6)
	Not applicable	22 (1.5)	38 (1.5)
Type of house	Kaccha house	158 (9.8)	178 (5.4)
	Kaccha-pacca house/pacca house	1456 (90.2)	3100 (94.6)
BPL Card	Yes	181 (11.2)	346 (11)
	No	1433 (88.8)	2932 (89)
Monthly household income (in INR)	0-7000	400 (24.8)	702 (21.4)
	7001-15 000	902 (55.9)	1674 (51.1)
	15 001-30 000	282 (17.5)	784 (23.9)
	30 001-60 000	30 (1.8)	118 (3.6)

Abbreviations: BPL, below poverty line; INR, Indian National Rupees; IPD, inpatient department; OPD, outpatient department.

Outpatient department

Participants had mean age of 34.6 ± 12.6 years, majority had education above secondary level (60%), were married (87%), housewives (35.4%), and above poverty line (89%). Around 75% of the participants had monthly household income above 7000 INR ( Table 2 ).

Less than 5% of the OPD participants rated speed of registration as either poor or very poor. Similarly, very few were dissatisfied with courtesy of the staff in the registration area with less than 3% rating them as either poor or very poor. Majority were also satisfied with other domains of registration like comfort of the waiting area, waiting time before going to check-up room, comfort and pleasantness of the check-up room, friendliness/courtesy of the nurse/assistant, concern the nurse/assistant showed for the problem, and waiting time in the exam room before being seen by the care provider ( Table 3 ).

Rating of different aspects of registration process by OPD participants.

	Variables	Excellent N (%)	Good N (%)	Fair N (%)	Poor N (%)	Very poor N (%)
1.	Speed of registration	904 (27.6)	1305 (39.8)	909 (27.7)	144 (4.4)	16 (0.5)
2.	Courtesy of staff in the registration area	958 (29.3)	1336 (40.7)	883 (26.9)	97 (2.9)	4 (0.1)
3.	Comfort and pleasantness of the waiting area	913 (27.8)	1084 (33.1)	1069 (32.6)	200 (6.1)	12 (0.4)
4.	Length of wait before going to check-up room	890 (27.2)	1249 (38.1)	893 (27.2)	227 (6.9)	19 (0.6)
5.	Comfort and pleasantness of the check-up room	953 (29.1)	1174 (35.8)	963 (29.4)	179 (5.5)	9 (0.3)
6.	Friendliness/courtesy of the nurse/assistant	1050 (32.0)	1470 (44.8)	664 (20.2)	89 (2.8)	5 (0.2)
7.	Concern the nurse assistant showed for your problem	1043 (31.8)	1149 (35.1)	947 (28.9)	132(4.0)	7 (0.2)
8.	Waiting time in the exam room before being seen by the care provider	951 (29.0)	1162 (35.4)	1000 (30.5)	149 (4.5)	16 (0.6)

Abbreviation: OPD, outpatient department.

Majority of the participants were satisfied with various aspects of care provision like friendliness/courtesy of the care provider, explanations the care provider gave about the problem, concern the care provider showed for the questions or worries, care provider’s efforts to include the patient in decisions about the treatment, information the care provider gave about medications and follow-up care, and so on ( Figure 1 ).

An external file that holds a picture, illustration, etc.
Object name is 10.1177_1178632920929969-fig1.jpg

Rating of the various domains of care received from the care provider by the OPD participants.

OPD indicates outpatient department.

Overall, majority (80%) were satisfied with the care received from the care providers with less than 3% being either completely or somewhat unsatisfied.

Majority of the participants were satisfied with the various personal issues like convenience of hospital/health facility hours, sensitivity shown to the needs and concern shown for privacy. However, around 7% of the participants rated the degree of safety/security at the hospital/health facility as poor or very poor ( Figure 2 ).

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Rating of various domains of personal issues and laboratory/radiology services by the OPD participants.

A total of 693 (21.1%) out of the 3278 OPD participants availed laboratory/radiology services from the concerned health facilities. Major domains of dissatisfaction were waiting time for lab tests (51.2% rating it as either poor or very poor), waiting time for x-rays (58.8% rating it as either poor or very poor), concern shown for patient’s comfort during the lab tests (47.3% rating it as either poor or very poor), and concern shown for patient’s comfort during x-ray (31.9% rating it as either poor or very poor) ( Figure 2 ). However, majority were satisfied with the dealing of staff during the lab/radiology tests with only around 7% only being unsatisfied.

In the OPD, majority were satisfied with the politeness of the hospital staff as only 1.8% of the participants rated it as poor or very poor. Only 6% of the respondent rated overall cleanliness of the hospital/health facility as poor or very poor. Similarly, majority (72.2%) rated the overall care received during the visit as either good or very good and only 4.8% of the participants said that their likelihood of recommending the hospital to others was poor or very poor ( Figure 3 ).

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Various experiences of the IPD participants during hospital stay.

IPD indicates inpatient department.

Inpatient Department

Mean age of participants from IPD was 36.56 ± 21.23 years with majority being in age range of 31 to 50 years. Around 59% of participants had education above secondary level. About 11% of participants were below poverty line (BPL) and monthly household income was more than INR 7000 for approximately more than 75% of the participants ( Table 2 ).

Majority (78.2%) of participants reported to be satisfied with overall care received from nurses with less than 3% being unsatisfied ( Figure 3 ). The nurses treated the participants with courtesy, listened to them carefully, and explained the things in an understandable way and participants got help as soon as wanted from the nurses as less than 1% of total participants answered to these questions as never ( Table 4 ).

Rating of different domains of care received from nurses and doctors and of the hospital environment by the IPD participants.

	Variables	Always N (%)	Usually N (%)	Sometimes N (%)	Never N (%)
1.	How often did nurses treat you with courtesy and respect?	731 (45.3)	739 (45.8)	130 (9.9)	14 (0.9)
2.	How often did nurses listen carefully to you?	798 (49.4)	706 (43.7)	99 (6.0)	13 (0.9)
3.	How often did nurses explain things in a way you could understand?	836 (51.8)	626 (38.8)	138 (8.5)	14 (0.9)
4.	How often did you get help as soon as you wanted it from hospital staff?	829 (51.4)	632 (39.2)	142 (8.7)	11 (0.7)
5.	How often did doctors treat you with courtesy and respect?	801 (49.6)	728 (45.1)	80 (4.9)	5 (0.3)
6.	How often did doctors listen carefully to you?	889 (55.1)	667 (41.3)	53 (3.3)	5 (0.3)
7.	How often did doctors explain things in a way you could understand?	881 (54.6)	570 (35.3)	157 (9.7)	6 (0.4)
8.	How often your room and bathroom were kept clean?	650 (40.3)	761 (47.1)	168 (10.4)	35 (2.2)
9.	How often was the area around your room quiet at night?	939 (58.2)	567 (35.1)	97 (6.0)	10 (0.7)

Abbreviation: IPD, inpatient department.

Similarly, majority (80%) of the participants reported satisfaction with the overall care received from the doctors with less than 2% being unsatisfied. The doctors treated the participants with courtesy and respect, listened to them carefully, and explained things in an understandable way to the patients ( Table 4 ).

Around 2% of participants reported that room and bathrooms were never clean and another 10% reported them to be clean sometimes only. Similarly, around 1% and 6% of the participants replied that area around their room was never or only sometimes quiet at night, respectively ( Table 4 ). Overall, only 46% of the participants were satisfied with the hospital environment.

With domains of other experiences during hospital stay, out of 130 patients who required help going to bathroom or using a bedpan, 23.1% of the participants told that they never got help from nurses or other hospital staff and around 21% replied as getting the help sometimes only. Similarly, among the 658 patients requiring medicines for pain, around 1% and 6% of them reported to have never having pain well controlled and having pain controlled sometimes, respectively. Out of 729 participants who said they were given medicines which they had not taken before, around 5% and 14% of participants replied that they were never and sometimes only told what the medicine was for, respectively. Around 35% of the participants who were given any new medicines replied that they were not told about the possible side effects of the medicines in a way they could understand. However, 84% of the inpatient participants were satisfied with the availability of medicine in the hospital/health facility and around 71% of them were likely to recommend the hospital/health facility for admissions to others ( Table 4 )

Measurement of patients’ satisfaction is important for improving services and strategising goals for all health care organisations. 19

In our study, majority (97%) of OPD participants were satisfied with overall care received. This is much higher than found in some of the other studies from developing world. 20 - 26 Previous studies from India have reported patient satisfaction score ranging from 60% to 88%. 27 - 31 Higher level of satisfaction among the OPD participants in our study may be attributable to availability of free medicines and low cost of laboratory tests. Politeness and courtesy are context and culture specific and cannot be directly compared across cultures. However, it is important that the clients perceive the behaviour of service providers as acceptable.

A vast majority (98%) of the participants in our study were satisfied with overall politeness of the hospital/health facility staff and around 95% of the OPD participants were likely to recommend the hospital/health facility to others. In a study to assess the level of satisfaction of patients attending a public tertiary hospital in Nigeria, 78.5% of the participants were satisfied with the hospital services and 91.7% were likely to recommend the health facility to a friend. 22 In another study to assess degree of clients’ satisfaction among patients attending government health facilities in rural Bangladesh, only 68.9% of the participants expressed satisfaction with the provider’s usual behaviour. 23

Around 7.5% of OPD participants were dissatisfied with long waiting time for consultation. In the study to evaluate patients’ satisfaction with quality of care provided at National Health Insurance Scheme (NHIS) clinic of a tertiary hospital in South-Eastern Nigeria, 48.3% of participants were dissatisfied with long waiting time. 24 In a study from Bangladesh, 28.2% of users were not satisfied with the time they waited to receive care. 23 In another study to assess client satisfaction with health services of a specialised tertiary care Centre in Ethiopia, dissatisfaction was reported to be highest (46.9%) by participants with waiting time. 25

In our study, majority (98%) of OPD participants were satisfied with overall care received from care provider and majority (97%) were also satisfied with time the care providers spent with patients. In a study assessing satisfaction of patients with primary health care services in Saudi Arabia, 16.7% of satisfied and 38.9% of dissatisfied clients complained that physicians did not satisfactorily explain their health problems and treatments. 26 In contrast, 96% of OPD participants in our study were satisfied with explanation the care provider gave to them about their problems and 95% could understand the words used by care providers.

In our study, majority (97.2%) of the OPD participants found the hospital/health facility hours convenient. Around 95% were satisfied with concern shown for their privacy. This is in contrast to a study from Bangladesh where a significant proportion of users (34.2%) were unsatisfied with the length of time the facilities were open to the public and only 45.1% of the clients were satisfied with the privacy maintained at the health facility. 23

With inpatient services, 78% of participants reported to be satisfied with overall care received from nurses and 80% of participants reported to be either completely or somewhat satisfied with care received from the doctors. In the study by Rajkumari and Nula 32 done in a tertiary care health facility from North East India and by Malangu and Westhuisen 33 done in a DH of South Africa, 32.5% and 50% of the patients, respectively, were satisfied with the overall inpatient care which is lower than seen in our study. In another study by Mishra and Mishra 34 conducted in a tertiary care private hospital of North India, the nursing services satisfied 80% of the participants while 92% were satisfied with explanation about disease and treatment by doctors. However, in the same study, behaviour of nurses, doctors, and orderlies satisfied 92%, 92%, and 83% of people, respectively. 34 The somewhat higher level of satisfaction with the behaviour of nurses and doctors in the above study compared to ours might be due to differences in the study populations and the different study settings.

Another study done among patients admitted to obstetrics and gynaecology wards of public hospitals of Ethiopia reported overall satisfaction rate of 79.7% similar to our findings. 35 However, concerning hospital staff informing to clients what the medicine was before giving new medicine, describing possible side effects of the medications in ways clients could understand, and cleanliness of toilet and washroom were the areas in which clients were dissatisfied in the study similar to our findings. 35

With respect to hospital environment, around 46% of participants were satisfied with hospital environment, with 12% reported problem with cleanliness of toilets and rooms and 7% reported problem with quietness during night. Similar findings were reported by Mishra and Mishra 34 in their study in which only 49% of the inpatients were satisfied with cleanliness of the toilets. However, in the study by Malangu and Westhuisen, 33 80% of participants were happy with cleanliness of wards, bedding and ablution facilities, as well as safety at night. The results of this study confirm that perception and judgement of quality are highly individualistic, dynamic and consequently client satisfaction has an important reflection on the quality of health care process.

Conclusions and Recommendations

Majority of patients using outdoor and indoor services were satisfied with the care received and the behaviour of the received and behaviour of hospital staffs. Registration process needs to be streamlined to reduce waiting time and delays. In laboratory services, particularly the waiting time may be reduced and patients’ comfort during lab tests and x-ray may be improved for improving satisfaction of clients. Majority of participants, both OPD and IPD, agreed that behaviour of hospital staff was good, doctors and nurses spent adequate time with patients, and detailed information about illness and treatment was provided to them by doctors. Attention should be given to the perceived feeling of lack of personal security and cleanliness at health facilities. Before prescribing a new medicine to a patient, the possible side effects and purpose of giving the medicine should also be explained to them. Finally, a system for clients’ feedback may be institutionalised at all health facilities to improve quality of care.

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Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the National Health Mission Research, Punjab. The funders had no role in the conduct of study and writing of manuscript of publication.

Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Contributions: MK: Conceptualization, Data collection and analysis, Manuscript writing and approval; AB: Data collection and analysis, Manuscript writing and approval; TS: conceptualization, Data collection and analysis, Manuscript writing and approval; RK: conceptualization, Data collection and analysis, Manuscript writing and approval.

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Supplemental material: Supplemental material for this article is available online.

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