Evaluation of patients' satisfaction after laparoscopic surgery in a tertiary hospital in Cameroon (Africa)

Introduction Access to laparoscopy is low in Cameroon where customers' satisfaction has not been reported so far. We assessed patients' satisfaction with the process of care during laparoscopic surgery in a new tertiary hospital. Methods A questionnaire was addressed to consenting patients (guardians for patients under 18) with complete medical records who underwent laparoscopy at the Douala Gynaeco-Obstetric and Paediatric Hospital (Cameroon) from November 1, 2015 to July 31, 2016. The following modified Likert's scale was used to assess satisfaction: very weak: 0-2.5; weak 2.6-5; good: 5.1-7.5; very good: 7.6-10. Only descriptive statistics were used. Results Response rate was 90% (45/50). Of the 45 respondents, 39 (86.7%) were female, 14(31.1%) were referred and 39 (86.7%) paid by direct cash deposit. Mean age was 36.8±11.9 years. Laparoscopies were carried out in emergency for 3 (6.7%) patients. Digestive abnormalities indicated 13 (28.9%) laparoscopies while gynaecologic diseases accounted for 32 (71.1%) cases. Perception of the overall care process was good with a mean satisfaction score of 6.8 ± 1.4. Scores in categories were: 0% (Very weak); 13.3% (weak); 57.8% (good) and 28.9% (very good). Specifically mean satisfaction scores were: 7.8 ± 1.0 with doctors' care; 7.1 ± 1.3 with hospital administration; 7.0 ± 1.2 with nursing and 4.7 ± 1.4 with the costs. Main complaints were: long waiting time (73.3%), constraining geographical access (66.7%) and expensiveness (48.9%). Conclusion Patients were globally satisfied with the process of care but financial and geographical barriers should be addressed.


Introduction
Over the past two decades, patients' satisfaction (PS) has emerged as an important indicator of health care quality [1,2]. PS can relate to the outcome of care (treatment) and/or to the perception of the process of care [3]. This applies to surgical care but is particularly true for laparoscopic surgery which has been proven to be superior to traditional open surgery in terms of minimal perioperative morbidity, lower overall costs, better cosmesis, reduced blood lost, reduced postoperative pain and hospital stay duration, with consequent quick postoperative recovery [4,5]. Laparoscopy has been introduced in Cameroon in 1992 and is currently practiced in five public and eight private hospitals [6][7][8][9][10][11]. To the best of our knowledge, no study has evaluated the satisfaction of patients with the process of care during laparoscopic surgery. In general, few studies have evaluated patients' satisfaction with health care in Cameroon, while it is a routine activity in developed countries [12,13]. In view of improving the process of care for patients undergoing laparoscopic surgery in Cameroon, we assessed their satisfaction in a tertiary hospital one year after its opening.

Study design and site:
We carried out a cross-sectional study at the Douala Gynaeco-Obstetric and Paediatric Hospital (DGOPH).
This hospital was opened in September 2015. It is the largest health facility dedicated to mother and child's care in Cameroon (central Africa).
Sampling and procedure: Our sample was convenient. We consecutively included all consenting patients (legal guardians for those under 18) who underwent laparoscopic surgery from November 1, 2015 to July 31, 2016. Patients with incomplete medical records were excluded. Data were collected through a selfadministered questionnaire on the following items: doctors' care, nursing, administrative procedures and cost. Participants were also asked to list their main complaints. Following a modified Likert's scale, participants were asked to score their satisfaction from 0 to 10 ("very weak": 0-2.5; "weak" 2.6-5; "good": 5.1-7.5; "very good": 7.6-10). Then a technical form was used to retrieve the followings parameters: age, sex, gravidity and parity (for women), marital status, mode of payment, occupational status, referral status, previous abdominopelvic surgery (laparoscopy or laparotomy), pregnancy status during laparoscopic surgery and its indication. Written informed consent was obtained prior to participation from adult participants and from either parents or legal guardians of nonadult participants. Confidentiality was observed.

Results
During the study period, 56 patients underwent laparoscopic surgery. For 6 of them, medical records were incomplete and 5 did not consent to participate (90% response rate).

Baseline characteristics of patients and indications of
laparoscopic surgeries: Table 1 shows patients' characteristics.
Patients' satisfaction and complaints after laparoscopic surgery: Figure 1 shows the overall satisfaction of patients on a scale of 0 -10. Mean satisfaction score was 6.8 ± 1.4. Table   3 illustrates the specific levels of patients' satisfaction and Table   4 lists their main complaints.

Discussion
Women predominated in our study (39/45; 86.7%). This is due to the fact that the study took place in a hospital dedicated to women and child health. The majority of participants was employed (32/45; Page number not for citation purposes 3 71.1%); this is understandable given that the study took place in the economic capital of the country. Infertility was the most frequent indication of laparoscopy (19/45; 42.2%). Similar findings are commonly reported in Cameroon for at least two reasons: laparoscopy was introduced in Cameroon three decades ago by gynaecologists; laparoscopic procedures indicated for infertility belong to the second levelof the European Society for Gynaecological Endoscopy classification for which local laparoscopic surgeons and gynaecologists are generally proficient [7,14]. The level of overall satisfaction was either good or very good for 39 (86.7%) patients. This proportion seems high for a hospital in Cameroon where public health facilities are frequently described as "'patient-unfriendly"' [15]. The newness of the hospital in which the study was carried out, its referral status and the relatively small sample size may provide an explanation. More specifically, the average level of satisfaction with the costs was low (4.7 ± 1.4) and 22 (48.9%) participants complained about expensiveness. This is certainly due the very poor coverage (1%) by health insurance in Cameroon where most patients have to pay by direct cash deposit like in other in low-income African countries [15,16]. It has been proven that in those countries, access to health services is inadequate because of financial barriers [17]. Indeed, over the past three decades, direct cash payment by users has partially replaced state funding of health care in Cameroon and sub-Saharan Africa [16]. Implementing low-cost laparoscopic surgery programme may reduce the costs of surgery [17]. Mean satisfaction scores with doctor's care, nursing and hospital administration were all above 7/10. This is contrary to the wide-spread poor perception of the quality of health care by users in sub-Saharan Africa [18].
Nevertheless, 33 (73.3%) complained of long waiting time. This was partly due to the fact that only one surgical team was available for each specialty (gynaecological and digestive). Even in developed countries the waiting time for elective laparoscopies is long [19].

Conclusion
Patients were satisfied with the process of care during hospital stay for laparoscopic surgery. The costs, long waiting time and constraining geographic access were the main complaints.
What is known about this topic  Patients' satisfaction with laparoscopic surgery is good in developed countries where it is regularly assessed to maintain good quality of care;  Satisfaction of Cameroonians patients with surgery in general and with laparoscopy in particular has not been assessed (to the best of our knowledge).

What this study adds
 Our study gives a first appraisal of patients' satisfaction with laparoscopic surgery (they are globally satisfied);  Expensiveness and poor geographical accessed are the main grievances reported by patients after laparoscopy.

Competing interests
The authors declare no competing interests.  Tables and figure   Table 1: Baseline characteristics of patients (N = 45)