Sauti Za Wananchi “voice of the people”: patient satisfaction on the medical wards at a Kenyan Referral Hospital

Introduction Patient satisfaction is one indicator of healthcare quality. Few studies have examined the inpatient experiences in resource-scarce environments in sub-Saharan Africa. Methods To examine patient satisfaction on the public medical wards at a Kenyan referral hospital, we performed a cross-sectional survey focused on patients’ satisfaction with medical information and their relationship with staffing and hospital routine. Ratings of communication with providers, efforts to protect privacy, information about costs, food, and hospital environment were also elicited. Results Overall, the average patient satisfaction rating was 64.7, nearly midway between “average” and “good” Higher rated satisfaction was associated with higher self-rated general health scores and self-rated health gains during the hospitalization (p = 0.023 and p = 0.001). Women who shared a hospital bed found privacy to be “below average” to “poor” Most men (72.7%) felt information about costs was insufficient. Patients rated food and environmental quality favorably while also frequently suggesting these areas could be improved. Conclusion Overall, patients expressed satisfaction with the care provided. These ratings may reflect modest patients’ expectations as well as acceptable circumstances and performance. Women expressed concern about privacy while men expressed a desire for more information on costs. Inconsistencies were noted between patient ratings and free response answers.


Introduction
Patient satisfaction is one indicator of healthcare outcomes and a measure of healthcare quality. Research suggests that satisfied patients are more likely to comply with prescribed treatments, provide information to healthcare providers, and continue using medical services [1,2]. Few studies, however, have examined the experiences of inpatients in sub-Saharan Africa. Patient satisfaction is likely highly dependent on a number of factors including patient expectations, demographics, and psychosocial traits as well as healthcare worker traits and the hospital environment [3].
Moreover, patient satisfaction may be influenced by cultural background, self-interest, gratitude, and even the -Hawthorne effect‖ which postulates the additional attention implicit in satisfaction data-gathering leads to a more positive perception of services [3][4][5]. The objective of this study was to examine patient satisfaction on the public medical wards at a Kenyan referral hospital. In particular, the goal was to examine the level of patient satisfaction with respect to the quality of medical information provided and the patients' relationships with healthcare providers and the daily hospital routine.

Study design and setting
This was a cross-sectional survey performed over 3 weeks in May 2013 via one-on-one patient interviews on the public medical wards of Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya.
MTRH is an approximately 750-bed national referral hospital for western Kenya. Divided into men's and women's wards, the medical wards together admit approximately 400 patients monthly. These wards are largely populated by those in the lowest socioeconomic strata as those with means largely choose private wards or hospitals [6]. On these wards, patients often reside two per bed, lying head- Patients were excluded if they were unable or unwilling to consent or participate in the 10-15 minute interview (ie. critically ill, confused, unable to communicate, language barrier) or if they were prisoners, younger than 18 years old, or discharged yet still on the wards awaiting financial release. If the patient was not present in his/her bed, the research team tried to find the patient before moving on to the next randomly selected bed. Patients were only eligible to respond to the survey on a single occasion. All interviewers performing the surveys were fluent in Kiswahili, English, and the tribal language most common locally.

Data collection
Interviews were structured around a modified 16-question Echelle de Qualité des Soins en Hospitalisation (EHQ-S) survey with additional questions focused on the patient knowledge of the healthcare providers' names, perspective on communication with the providers, understanding of hospital costs, and perspective on the hospital's food, cleanliness, and efforts to ensure privacy [7].
The EQS-H is one well-known and validated scale used to assess in patient satisfaction in various settings. Through validation studies in other settings, it has been reduced to 16 items covering 2 domains of patient satisfaction: quality of medical information and relationship with staff and daily hospital routine [7]. Each domain consists of 8 items with each rated on a five-point Likert scale. The final 3 questions of the medical information subset focus specifically on discharge information as the EHQ-S is generally used at the time of discharge or afterwards [8,9].

Results
During the study period, 45 men and 45 women completed the survey with 195 beds randomly chosen excluded: 29 beds had patients who had previously participated in the study, 98 beds had patients either unable or unwilling to consent, 39 beds were either unoccupied or the interviewer was unable to locate patient, 11 beds were occupied by patients either <18 years old or prisoners, 14 beds had patients discharged but awaiting financial release, and 4 beds were excluded for unclear reasons. One survey was misplaced during the study with an additional randomly selected bed on a subsequent day chosen.

Study population
Compared to the women, the men surveyed were older, and the men were also more likely to be married, employed outside the home, and to be insured ( Table 1). Not reaching statistical significance, the men also were also more likely to have completed some secondary school and had a shorter length of stay at the time of being surveyed. Women though generally rated their health status slightly higher. More than two-thirds of both lived in rural areas. Furthermore, similar percentages of men and women interviewed shared a bed during their hospitalizations.

Overall patient satisfaction ratings
The average patient's overall satisfaction rating for this population was approximately midway between -average‖ and -good‖ ( Figure   1). or -very poor‖. The ratings of women who did not share a bed were not significantly different from the men including when compared to those who did and did not share a bed (Figure 2)

Discussion
Patient satisfaction is one aspect in assessing the quality of care.   Even in high-income settings, there is concern about the interpretation of patient satisfaction with questions to its correlation with health outcomes [13]. Generally, patient satisfaction surveys consistently report high levels of patient satisfaction [14,15].
Moreover, as researchers have demonstrated, patient-described experiences do not always correlate with their evaluations of the very services that produced those experiences. As Williams et al wrote, -high satisfaction ratings do not necessarily mean that patients have had good experience in relation to the service‖.
Rather it may reflect a general sense that healthcare providers are -doing the best they can‖ [16]. Moreover, there may be a tendency due to gratitude, fear, or culture to withhold critical and negative comments [4,14]. Additionally, patient satisfaction measurements have been found to vary with patient socio-demographic variables [17,18]. They also have been found to vary with respect to length of stay, previous admissions, timing of response to questionnaire, clinical outcome, and current health status [17,19].
Our study had a number of limitations.

Conclusion
Patients on the public medical wards expressed a general consensus that the care they were receiving was above average. They did so in a setting where resources are limited, patient-to-staff ratios are often quite high, and space requirements lead to patients often sharing beds. This patient consensus can be seen as a validation of the care provision currently; however, we also see it at as a sobering reflection on the current level of expectations for care provision by these patients. As stated above, their evaluations may reflect a general consensus that everyone is -doing the best he can‖ in a difficult system [16]. Likewise, positively reported patient satisfaction should not be used to cover over hidden problems of care provision such as lack of resources, non-adherence to guidelines, or other areas for improvement in care [20]. In the end, while overall expressing general satisfaction, our patients also noted areas for improvement, including privacy and information with respect to hospital costs. Areas for future research and exploration include the means to best elicit and evaluate patient satisfaction in this setting and the variables that shape their expectations and ratings.    Health Status 5.8 (3-10, SD 1.9) 6.5 (3-10, SD 1.7) -0.7 (p=0.054) 6.2 (3-10, SD 1.8) *At least partial secondary education completed. †Missing insurance information for 7 female patients. ‡Missing residential information for 3 male patients. §Only included those patients that shared beds in this calculation