Study design and setting: A cross-sectional study design was applied to assess patient satisfaction and associated factors among adult outpatient ophthalmic service users at University of Gondar Comprehensive Specialized Hospital Tertiary Eye Care and Training Center, Northwest Ethiopia between June 26 and August 5, 2020.
Source population: All adult outpatients that visited University of Gondar Comprehensive Specialized Hospital Tertiary Eye Care and Training Center to get ophthalmic service were used as a source population.
Study population: All adult outpatients attending the eye care center during the study period were assumed.
Inclusion criteria: All adult outpatients aged equal or greater than 18 years were included in the study.
Exclusion criteria: Those unable to communicate, and mentally ill were excluded from the study.
Sample size determination
The sample size was determined by using single population proportion formula;
n= (Za/2)²p(1-p)/d²
Where; n – sample size,
Z is Value of z statistic at 95% confidence interval = 1.96
P – Proportion of overall patient satisfaction towards ophthalmic service which is 57.31% taken from a study conducted in Ghana in 2017(44).
1-P = 1-0.5731= 0.4269 and
d – Marginal error 5% = 0.05
So that sample size for patient satisfaction was calculated as follows:
n= (1.96)2 (0.5731) (0.4269) = 376 / (0.05)²
Therefore, by considering 10% non-response rate, sample size for the first objective was
n = 376 + 37.6 = 414
Sampling technique
Systematic random sampling was held. Primarily the average number of patients attending the hospital seeking ophthalmic service every week was obtained by taking the previous two weeks into consideration from patient record book of the hospital. Then, based on that the average numbers of the patient were estimated as 1722 per month. So, K for this study was 5 which were obtained by taking the ratio of average patient number (1722) to total sample size (414). The first eligible individual was selected by simple random sampling using the lottery method as 3 by taking patients medical card number in to consideration. Then, every 5th element was selected by giving a piece of paper on which simple numbers were written only for contact purpose and the selected patient were told to return the piece of paper to the porters during his/her exit from Hospital after full treatment taken. Then, the porters took selected participants to data collector outside of building of the clinics. Explanation about the research purpose was given, so that participant with full willingness were included until the target sample obtained. In each next day of data collection sample unit selection were fasten to the 5th interval (for example if the number of last patients to be examined is less than 5, the next day they were taken into consideration to select eligible participants). The selections were held at the reception room by assigned porter.
Operational definitions
Satisfied: respondents who mark overall mean score of 60.00% to 100% or fulfill overall mean score (54) or more on the given items to measure satisfaction and the same approach was used to each domain of patient satisfaction.
Not satisfied: respondents who scored satisfaction score less than 60% or overall mean score on the given items to measure satisfaction and similarly applied to each domain.
Data collection tool and procedure
A pre-test was held. Cronbach’s alpha (α = 0.81) was used to assess the internal consistency of questions in the seven dimensions of PSQ-18. An adapted standardized patient satisfaction questionnaire was utilized. Pre-tested structured interviewer-administered questionnaire was translated in to the Amharic language by language experts was used to collect the data during clients exit from the clinic from selected and orally consented participants that fulfill eligibility criteria. Two research assistant public health officers and one supervisor (principal investigator) conducted the interviews.
The interview lasted a maximum of 15 minutes. The questionnaire contained the client’s background characteristics and other characteristics such as health insurance status, the type of visits, eye conditions, and also a standard tool for measuring satisfaction referred to as short-form patient satisfaction questionnaire -PSQ-18 (51). The instrument provides scoring for eighteen items which measure satisfaction with provided services. Items 3 and 17 measures general outlook, items 5,7 measures financial aspects, items 1, and 13 measures communication, items 12,15 measures waiting time, items 2,4,6,14 measures technical quality, and items 8,9,16,18 measures accessibility and convenience. Responses for each item are given on a 5-point scale ranging from strongly agree to strongly disagree.
Data quality assurance
To ensure the quality of the results the following procedures were carried out. Training was adequately given for the data collectors using standardized questionnaires. Daily supervision of the work done by assistants and rechecking of questionnaires for completeness was checked by the principal investigator.
In addition to that the questionnaire was pretested in about 21people that were 5% of total sample size at the eye clinic of Debre Tabor Hospital, South Gondar, Ethiopia to assess the appropriateness and suitability before main data collection at the proposed study site. In addition, double entry of data was done in about 5% (21) of collected data.
Data processing and analysis
The collected data were entered into EPI info version 7. Then, it was exported to SPSS version 20 for analysis. After that coding and cleaning was held to check for completeness and password was used to keep the privacy of the data. Descriptive analysis was held and satisfaction was determined by estimating patient satisfaction scores with PSQ-18 reporting means and standard deviation.
To answer the first objective of determining the level patients’ satisfaction with services provided at the eye clinic (overall satisfaction), the PSQ-18 scoring system were used. All items were scored from one to five (5 points Likert scale). This research contains 18 of PSQ-18. The Overall level of satisfaction in percentage was calculated by summing the 18 scales scores, then was divided by 90(maximum possible score) and multiplying by 100. All 18 scales scores were summed up with a maximum possible score of 90. The overall satisfaction was dichotomized, with satisfied (ranging from a score of 60% to 100%) and not satisfied score less than 60%.
To assess patient and health provider domains influencing satisfaction; firstly, satisfaction for each of the 7 dimension was estimated by the mean score of each dimension. Then categorized into two levels; that is satisfied (greater than or equal to 60%) and not satisfied (less than 60%).
A Bivariable binary logistic regression was used to assess the effects of all the domains of satisfaction and to select candidate variable for multivariable analysis model. A multivariable binary logistic regression model was applied for variables with p< 0.20 to identify final predictors of the outcome variables. Hosmer-Lemeshow model fitness test (0.74) was used to check model fitness and multi-collinearity between predictor variables were checked. The adjusted odds ratio with a 95% confidence interval was used to determine strength of association of actual predictors of the patient satisfaction and P≤ 0.05 were considered as statistically significant. Each of seven domain was quantified separately to identify areas of satisfaction. The result was presented with tables and pie chart.
Ethical considerations
Ethical clearance was obtained from the University of Gondar College of medicine and health sciences, school of medicine ethical review board. An official permission letter was obtained from the chief clinical coordinator office of University of Gondar Referral Hospital and from department of Ophthalmology and Optometry. All respondents of this study were aged 18 years and above. Informed consent was gained from respondents after a detailed explanation of the purpose, benefit and risk of the study. Participation in this study was voluntary and participants can choose not to answer any individual question or all the questions. Participants were at the freedom to withdraw from the study at any point at the time of the study. To ensure Confidentiality, the questionnaires were coded and the name of respondents’ was not included to the questionnaire. Data collected in this study was used strictly for research purposes and secured by coding and locking the data and maintained during the data collection and analysis procedure.