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, 2020: An Institution-Based Cross-Sectional Study

Background: Patient satisfaction is explained as “the extent to which patients are happy with their health care, both inside and outside of the doctor’s oce”. Observed complain and limited evidence on patient satisfaction specic to ophthalmic services. So, aimed to assess the overall patient satisfaction and associated factors among adult outpatient ophthalmic service users at University of Gondar Comprehensive Specialized Hospital, Eye Care and Training Center, Ethiopia, 2020. Methods and materials: An institution-based cross-sectional study was conducted from June 26 to August 5 with a sample size of 414. A systematic random sampling technique was used to select participants. An interviewer administered questionnaire was employed to collect the data. The data was analyzed by SPSS 20. Descriptive statistics such as frequency cross tabulation test was carried out to translate data into information. P-value less than 0.05 was considered as statistically signicant. Result: A total of 403 participants with 97.34% response rate were included in this study. Their mean age was 46.67±16.21 years. The majorities were males (59.8%). The overall patient satisfaction was 57.1% at 95% CI :( 52.1%-61.5%). The top three sub-domains with greater score of satisfaction were general outlook (67.5%), communication with providers (64.5%), and interpersonal manner (61.5%). The least satisfaction score was to waiting time (45.9%) sub domain. Being unmarried (AOR = 2.51, 95% CI 1.21-5.23) and earning a monthly income of Ethiopian Birr ≥ 2500 (AOR = 5.90; 95% CI: 2.11-16.5) were associated with the patient satisfaction. Conclusion: The result infers that nearly sixty percent of the study participants were satised. While improving each sub-domain of patient satisfaction, waiting time and nancial aspect need greater by the hospital The hospital policymakers


Background
Quality of care is "the degree to which health care services provided to individuals and patient populations improves desired health outcomes and to achieve that health care must be safe, effective, timely, e cient, equitable and patient-centered.¹ ² It is poor globally and nowadays quality healthcare is a global concern⁴ . The universal health costs and the weight of poor health is scaling up due to less than average quality of health care . It has been affected through patient related factors like income, education and provider factors such as competency, motivation and others . "Patient satisfaction" is explained as "the extent to which patients are happy with their healthcare, both inside and outside of doctor's o ce." ¹ . It is measured in various ways like access to care, convenience, and patient-provider relationship¹¹. It was indicated to determine the level of health care delivery, analyze the existing situation and carryout important strategies using patient satisfaction¹². Accessibility and technical quality, reduced waiting time, improved communication and interaction between the health care provider and patients as a strategy¹³. Various studies done among ophthalmic service users indicated the overall satisfaction Page 3/20 between (35.2% -98.3%) ¹³ ¹ ² ⁴³ ⁴ , which is inconsistent. The observed complains and limited evidence on patient satisfaction speci cally an institution-based towards ophthalmic services in Ethiopia.
The aim of current study was patient satisfaction and associated factors among adult outpatient ophthalmic service users as a quality measure.
At least 1 billion from estimated 2.2 billion blindness and/ visual impairment globally were due to preventable and treatable causes (14). While there is limited and little veri cation on quality eye care service including patient satisfaction to plan evidence-based strategies for high-quality eye health service (21,22). So, this work may ll the gap and provide information on the current topic and its allied factors for service providers, advocators and policymakers. Because, health care quality improvement does not happen accidentally without consumer participation.

Methods
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% con dence 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). 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 rst 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 5 th 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 5 th 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 de nitions
Satis ed: respondents who mark overall mean score of 60.00% to 100% or ful ll 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 satis ed: 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 ful ll eligibility criteria. Two research assistant public health o cers 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 nancial 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 rst 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 ve (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 satis ed (ranging from a score of 60% to 100%) and not satis ed score less than 60%.
To assess patient and health provider domains in uencing satisfaction; rstly, satisfaction for each of the 7 dimension was estimated by the mean score of each dimension. Then categorized into two levels; that is satis ed (greater than or equal to 60%) and not satis ed (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 nal predictors of the outcome variables. Hosmer-Lemeshow model tness test (0.74) was used to check model tness and multicollinearity between predictor variables were checked. The adjusted odds ratio with a 95% con dence interval was used to determine strength of association of actual predictors of the patient satisfaction and P≤ 0.05 were considered as statistically signi cant. Each of seven domain was quanti ed 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 o cial permission letter was obtained from the chief clinical coordinator o ce 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, bene t 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 Con dentiality, 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.

Results
Socio-demographic and economic characteristics of the study participants

Service related satisfaction sub-domains
The result of this study indicated that the mean score ofgeneral outlook of the provided service by users was (M = 3.14;  (Table  3)  Two-third (67.5%) of participants were satis ed with the general outlook sub-domain of eye care service with a mean score of 3.14. The MSS is lower than the results of previous studies done in non-comparable settings in India (3.69) ² and Jordan (3.20) ⁴ while higher than that of Uganda (2.70) ³¹. The discrepancy may be due to the difference in data collection tools, variation in the service provided and socio-economic variation among participants. The result infers that the medical care received by respondents was not just perfect.
Nearly half (51.9%) of respondents were satis ed with the nancial aspect with a mean satisfaction score of 2.77. Meaning, still half of the service users have been waiting for nancial support from the facility and other stakeholders. However, this mean satisfaction score is lower than the MSS of the study result in a parallel setting in Ghana (3.06)⁴⁴ and outreach based study at Jimma, Ethiopia (4.46)² . This may be justi ed by variation in socio-economic characteristics of the study subjects and the usual free service provision at outreach sites. It denotes that some of the service users are still set back due to the affordability issue.
In comparison to the present study (64.5%), the communication sub-domain had a higher proportion in a similar study done in Nigeria (92%) ⁴ . In non-parallel settings in Haryana, India (80.9%) ²² using multi stage sampling technique and Gaur et al (78.8%) ² using linear regression model also revealed a better proportion of satisfaction. Difference in the study results may be due to dissimilarity in sampling and analysis techniques. However, it is promising than previous work in similar setting in Ghana (58.8%) ⁴⁴, but the MSS(3.10) is lower than the study conducted in Jordan (3.40) ⁴ and outreach based study at Jimma, Ethiopia (4.63) ² . The survey tools used and analysis approach variation may explain the difference. The result suggests that nearly one-third of service users were examined and tested without explanation about what was did for them.
The proportion and MSS to sub-domain interpersonal manner was 61.5% and 2.94 respectively. This result is lower than outcomes obtained from studies performed in Iran 87.9% ¹ and Calabar, Nigeria 98.6% ¹ . The reason for the disparity may be due to dissimilarity in the study population. Non-analogous studies that were conducted at India Gaur et al (67%) ² using 500 study participants among different outpatient department attendants including Ophthalmology has shown a better proportion of satisfaction than the present work; but another study in India (56.8%) ²² using nominal regression model revealed a smaller proportion of satisfaction. It might be justi ed by the difference in sample size and analysis technique. In relation to outreach based study at Jimma, Ethiopia (3.3) ² , the MSS of the present study is lower but nearly similar to that of Ghana (2.91) ⁴⁴. The variation in the analysis model and categorization difference may be the reason for the discrepancy. The result signi es that the service providers are friendly and courteous when helping their patients to the explained level while being exposed to the selfoptimistic response of participants. ; Uganda (2.80)³¹ and outreach based study at Jimma, Ethiopia (3.75)² . The difference may be due to variation in the study population; the difference in measurement tools and the unbalanced emphasis of stakeholders at different sites and departments. It might indicate that there is a problem in the eye care service provision with easy access to specialists and the community cannot easily nd the service whenever they need it.
In the present study, unmarried respondents were 2.5 times more likely satis ed when compared to ever married participants. The result may denote the greater socio-economic burden on the ever married group. In previous research conducted in Ghana in a parallel setting ⁴⁴ marital status is not associated with overall patient satisfaction. The same applies to studies done in Jimma University Hospital, Ethiopia ³⁴; Dessie Referral Hospital, Ethiopia ³ , and Felege hiwot Referral Hospital, Ethiopia ³ . The similarity in the results may be due to the same categorization and methodology applied. However, being married was positively associated with overall patient satisfaction in the study done in Serbia ⁴ . The disparity may be due to variation in the study population.
The odds of patient satisfaction was 5.9 higher among those earning an average monthly income of ≥2500 when compared to those earning monthly income of < 500. It suggests that nancial support from the service provider and other stakeholders may ll the gap in the future. In opposite, monthly income was not associated with the interest variable in a study done in University of Gondar Comprehensive Specialized Hospital, Ethiopia ⁴¹. The sample size difference may justify the discrepancy.
Generally, poor health is still a concern due to less than average quality of healthcare globally . The ndings of this study suggest clinicians to explain examinations and tests as well as to improve a friendly and courteous approach. It infers the hospital manager to set a quality improvement plan to ful ll necessarily advanced instruments and solve the affordability issue while the concern of waiting time at the center. It also denotes policymakers and other stakeholders to solve the problem of unbalanced eye care provision centers to the population on its need. Social desirability bias has been its short come.

Conclusion
The overall patient satisfaction of this study is 57.1%, infers that nearly sixty percent of the study population was satis ed. Hence, the Hospital proceed on proving regular eye care service while improving each sub-domains of patient satisfaction. However, it needs extra focus on areas of major dissatisfaction (waiting time followed by nancial aspect). Those earning a monthly income of greater than 2500 and unmarried may pay the treatment fee easily because of less burden when compared to those earning a monthly income of less than 2500 and married respectively. The study was funded by University of Gondar and funding was for data collection, Processing and write up.

Availability of data and materials
The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.

Authors' contributions
The principal investigator, MML wrote the abstract, result, and discussion. MSH wrote the introduction section and methodology. MMT had written a conclusion and declarations. Then, all authors have reviewed the manuscript.

Ethics approval and consent to participate
The study was approved by University of Gondar College of medicine and health sciences, school of medicine ethical review board in accordance with Ethiopian national research ethics review guideline. Informed consent was gained from respondents after a detailed explanation of the purpose, bene t and risk of the study. Con dentiality of the data was kept strictly.