Level of patient’s satisfaction in gynaecological practice at a south west Nigerian specialist hospital

The health sector occupies an enormously important position in ensuring sustainable overall socio-economic advancement in developing countries. Healthy people make a healthy nation and also contribute to economic growth. Satisfaction is the contentment one feels when one has fulfilled a desire, need, or expectation. Poor quality is costly to clients, to programmes and to the society overall. People's perception about quality of care often determines whether they seek and continue to use services. This study evaluated the level of patient’s satisfaction in gynaecological practice at the state specialist hospital Akure. This study is a descriptive cross-sectional study. Questionnaires of the Likert-like form was used to obtain information from consenting patients on various factors that determines or have effect on their level of satisfaction while accessing gynaecological care services at the gynaecology clinic of State Specialist Hospital, Akure. Systematic sampling method was used to recruit patients by selecting every second patient serially as they present. Three hundred and eight consenting gynaecological patients were recruited into the study. Data was analysed with the Statistical Package for Social sciences (SPSS) 20.0. Majority of the respondents 295 (95.7%) were satisfied with the morning time clinic schedule. More percentage of respondents were very satisfied with attending doctor being male (52.9%) than if the attending doctor was female (26.3%). Most patients (53.3%) were not satisfied with having to go outside the hospital to get some of their investigations done. Most patients (44.6%) were not satisfied with the level of availability of drugs in the hospital as they still go out to buy drugs. Vast majority of the respondents (89.2%) were either satisfied or very satisfied with the behavior and competence of the attending doctors and nurses. In conclusion, client's satisfaction is reflected by their happy expression about the care they receive, where and how they access the care. There is need for health care givers to continue and improve on aspects of care that gives patients satisfaction and discourage those that make the patients dissatisfied.


INTRODUCTION
Healthcare providers and programmes worldwide have increasingly recognized that the quality of care they provide determines their overall success in attracting the clients and meeting their needs. Poor quality is costly -to clients, to programmes and to the society overall. People's perception about quality of care often determines whether they seek and continue to use services (Fitzpatrick, 1991).
Governments own most of the tertiary hospitals in developing countries, therefore they are expected by patients, to provide all necessary things to make service delivery in these hospitals efficient and effective. Hospital personnel including gynaecological specialist should be available and adequate, equipment and facilities to enhance service delivery should also be provided. The personnel should be well remunerated and have satisfactory working environment so that they will be able to render services that will satisfy their clients (Vujicic, International  Human resource factors that affect patients' level of satisfaction with gynaeclogical services include unavailability or inadequacy of doctors, nurses, and other relevant personnel. When they are available, their occasional negative attitudes and behaviours, lack of empathy of the service providers and their generally callous and casual demeanour including their aggressive pursuit of monetary gains, their poor levels of competence, their occasional disregard for the suffering that patients endure without being able to voice their concerns (Ortola et al., 1993) goes a long way in affecting patients level of satisfaction while accessing care. None incorporation of the views of the users in the management of the health services -will lead to unsatisfied users (Vahdat et al., 2014;House of Commons Health Committee, 2006), so also long travel and waiting times and lack of drugs.
Prevailing sociocultural norms of the community can also influence women's views on reproductive health (Bastiaens et al., 2007), wellbeing, and notions of illness, clinical requirements and the type of service delivery system in which a woman is being asked to participate and factors related to quality of care. Factors of sociocultural norms are the beliefs and attitudes of patients towards prevention of diseases, people seeking allopathic gynaecological care as last resort, lack of financial power (Bingham et al., 2001) and lack of knowledge of preventability/curability of gynaecological conditions (Agurto, 2001). Some belief that gynaecological conditions are related to sexually transmitted diseases or sins. Many exercise fears stemming from negative images of cancer and gynaecological care (Agurto, 2001), so also fears that gynaecological treatment would leave women sexually disabled (PATH, 1998), husbands emotional and financial disposition and lack of support (PATH, 2002) as in infertility investigation.
Health system operational factors include location of service points in relation to where majority of those needing gynaecolgical care are located or staying where coverage currently does not exist (Agurto, 2001). Transportation costs and distance have effects on screening participation and loss to follow-up (PATH, 1998(PATH, , 2002. Structure of the service delivery system like multiple visits for screening, confirmatory diagnosis, treatment, and follow-up, compounding both financial and opportunity costs to women and contributing to high attrition rates. Other operational factors may relate to quality of care like lack of women-centered quality services. Client-centered high-quality services (Herdman and Sherris, 2000;Bingham et al., 2002;AVSC International, 1995;Lazcano-Ponce et al., 1999) are such services that result in satisfied women.
Gender of the attending professional may also be a factor. Some women feel ashamed when male providers examine them especially when confidentiality is lacking. Omotayo et al. 61 In some cultures and religion, husband may only agree to their wives' receiving cervical cancer screening service only if a female provider performs the examination (PATH, 2002). Physical aspects of the facility like appearance and cleanliness of the clinic and provider (PATH, 2002) and instruments, clinic arrangements to assure maximum privacy during the examination of patients also matters. Barriers related to post-treatment care include compliance to some specific instruction and lack of facility and expertise for women needing more advanced care. Omission of counseling on need for follow-up and its schedule, possibility of recurrence of ailment, need to screen siblings and lack of adequate information for patients about prognosis can all be source of dissatisfaction for patients.
Some of the things that can be done to enhance patients satisfaction with gynaecological services include support and empowerment of gynaecological patients, Jettisoning the professionals 'expert' approach and replace with 'exchange model' (Loeffler et al., 2013). Improving the client-provider relationship greatly affects client satisfaction (Agurto, 2001;Lazcano-Ponce et al., 1999). General education of the populace by mobile campaigns to distant communities, offering screening and immediate treatment during the same visit, improving the referral system, and seeking out women who have not returned for follow-up will also help.
The process of informed consent, and the respect for privacy and confidentiality all are important factors that influence a woman's experience with care. Patients always want to enjoy confidentiality (Bord et al., 2013) in all their dealing with gynaecological services, comment on, challenge or complain about services or service delivery.
Post treatment counseling and including male partners in post-treatment counseling when possible is essential. Language barriers must be overcome and adopt one-onone communication between women and their providers rather than group counseling sessions (PATH, 2002;Buskens and Bradley, 2002). Use of functional tracking systems prevent loss to follow up. Women appreciated being addressed by their names, and wanted providers to speak simply, softly, and gently, and avoid brusque behavior. Programs must try to ensure that facilities are clean and welcoming and provide adequate privacy for clients (PATH, 2002;Lazcano-Ponce et al., 1999).
The level of satisfaction with the gynaecological services received by a patient can determine whether the patient will patronize the health care service again or not. Therefore, all appropriate efforts must be made to ensure that patients are satisfied. An ongoing quality-of-care training program for health care providers is essential for improving service delivery (Herdman and Sherris, 2000;Winkler et al., 2001). Training can help health workers understand the importance of a satisfied client and develop goals for improving performance. Although many of these steps will require some additional investment, the benefits should justify the modest added costs.

Objective
This study evaluated the level of patient's satisfaction in the various processes of accessing gynaecological care services at State Specialist Hospital, Akure.

Study design
This study is a descriptive cross-sectional study. It is an observational study that surveyed level of satisfaction in randomly selected gynaecological patients at a particular period.

Methods
Ethical clearance was secured from the ethics and research committee of the hospital. Questionnaires of the Likert-like form was used to obtain information on various factors that patients feel have one effect on their level of satisfaction with gynaecological services at the gynaecology clinic of State Specialist Hospital, Akure. Systematic sampling method was used to recruit patients by selecting every second patient serially as they present. Three hundred and eight (308) consenting gynaecology patients were recruited into the study. Data was analysed with the Statistical Package for Social sciences (SPSS) 20.0

Sample size calculation
The study is a descriptive study. The following formula was used to calculate the sample size.
Where Zcrit is standard normal deviate corresponding to chosen Confidence interval. For Confidence interval of 95%, it is 1.96 P is pre-study estimation of proportion measured. D is the width of confidence interval. This gave 292. Adding the allowance for attrition of 16, total sample size becomes 308.

RESULTS
The majority 66.6% of the patients interviewed were in the age group 20-39 years. Only 10 patients (3.2%) were teenagers while 9 patients were older than 60 years.  (Table 1).
More than half of the respondents 164 (53.2%) were very satisfied with the morning time clinic schedule (Table  2) while 131 (42.5%) were satisfied and 13 (4.2%) were dissatisfied with morning clinic. When asked of their views about afternoon clinic, 18 (5.8%) and 39 (12.7%) said they were very satisfied and satisfied respectively, 109 (35.4%) were dissatisfied. One hundred and forty two (46.1%) were undecided (Table 2) when asked in different questions, two hundred and fifty eight respondents (83.7%) were either very satisfied or satisfied with the attending doctor being male while 241 (78.2%) were either very satisfied or satisfied with the attending doctor being female. However, more percentage of respondents were very satisfied with attending doctor being male (52.9%) than if the attending doctor was female (26.3%) ( Table 2).
Majority 143 (46.4%) of the respondents were indifferent at the information that their complaints will require surgery as mode of management. 29 (9.4%) were very satisfied and 69 (22.4%) were satisfied if their complaints require surgery while 61 (19.8%) were dissatisfied while 6 (1.9%) were very dissatisfied with possible surgery for their complaints (Table 2).
When the view of the respondents were sought about the general hospital surrounding's neatness, 77 (25%) said they were very satisfied, 183 (59.4%) were satisfied, 32 (10.4%) were dissatisfied while 32(1.0%) were very dissatisfied. Thirteen (13) indicated indifference ( Table 3). Majority of the respondents 138 (44.8%) indicated dissatisfaction with accessing prescribed medications in the hospital, 36 (11.7%) were indifferent while others were satisfied (Table 3). More than 44% were dissatisfied with the time spent on payment for hospital card. About 60.7% of respondents were either very satisfied or satisfied with duration of consultation. Most patients, 44.6 and 52.3%, were not satisfied with having to go outside the hospital to either buy drugs or get their investigations done respectively (Table 3).
Vast majority of the respondents were either satisfied or very satisfied with the behavior and competence of the attending doctors and nurses (Table 4).

DISCUSSION
Majority of the respondents were in the age group 20-39 years. This is the age group that account for the bulk of 4(z crit ) 2 p(1-p) N = D 2 Values are given as absolute number of respondents and corresponding percentages. women in reproductive age, similar to 20-29 years reported in another Nigerian study (Oguntoyinbo and Aboyeji, 2011). Therefore complaints relating to reproductive system are expected to be more from this age group. The Yoruba ethnic group accounts for the majority of the respondents because the area of study is Yoruba speaking area though there are still few from other tribes. More than half of the respondents were graduates while a few were without formal education this made the understanding of the concept of this study and getting required information easy for majority of the respondents. The bulk of the patients seen in the Gynaecology clinic were referred from the Out Patient Department (OPD) this is because of the specialist nature of the gynaecology clinic while about 15% came on selfreferral. About Thirty percent (30%) of the respondents presented with inability to conceive. This constitute the commonest presentation at the gynaecology clinic of the hospital at the time of this study and is in contrast with 10 to 15% in the developed countries (Alvarez, 2006) but in Africa the prevalence is higher 20 to 46% due to high rate of associated conditions like unsafe abortion, sexually transmitted diseases and puerperal pelvic infections (Idrisa, 2005). Majority of the respondents (53.2%) prefer morning time clinic. Difficulty in transportation back home after clinic was the commonest reason cited. This is in conformity with a British study that reported that higher percentage of patients prefer morning clinic to afternoon clinic (Churchill et al., 2003). Most other specialist clinics are also scheduled for morning time. Two hundred and fifty eight respondents (83.7%) were either very satisfied or satisfied with the attending doctor being male while 241 (78.2%) were either very satisfied or satisfied with the attending doctor being female. This outcome is in consonance with that of an American study that discovered that majority of patients 66.6% had no gender bias when selecting an obstetrician gynaecologist and that there was no statistical difference in patient satisfaction based on physicians sex (Johnson et al., 2005). Only few of the respondents indicated dissatisfaction if their complaints will require surgery.
Majority are satisfied with surgery probably because many gynaecological complaints are associated with swelling and the believe that when surgery is done, the problem will be over once and for all may make patients more comfortable with their complaints requiring surgery. A very significant percentage were not satisfied with waiting to pay for card. This has earlier been noted in a Ghanaian study where waiting time was noted as a major source of patients dissatisfaction (Yeboah and Thomas, 2009). Majority of the respondents were either satisfied or very satisfied with the behavior and competence of the attending doctors and nurses. This is similar with the findings of 82.7% patient's satisfaction with doctors' ways of examining them in an Ethiopian study (Assefa et al., 2011).

Conclusion
Patient's satisfaction is reflected by their happy expression about the general facility, doctor's consultations, efficiency of the health care system they patronize and also by consistent regular utilization by majority. It is imperative to regularly find out things that are being done in gynaecological practice that are affecting patient's level of satisfaction negatively and those that give them required satisfaction with the aim of improving on the positive and discarding the negative.

RECOMMENDATION
We must ensure that our patients are satisfied with the services we provide. The hospital should keep-it-up in the areas of service delivery that currently gives patients satisfaction while all efforts must be made to improve upon those that give patients dissatisfaction as shown in this study such as drug provision and investigation facilities.