Patient satisfaction with malaria care among pregnant women and mothers of under 5 children in Ibadan, Southwest Nigeria


 Background Patient satisfaction is as an important measure of program assessment and health system performance. In our study, we assessed patient’s satisfaction with malaria care among pregnant women (PW) and mothers of children less than five years of age (MU5) in Ibadan, Nigeria. Methods A cross-sectional design, patient satisfaction with malaria care was assessed among 1,373 participants (818 PW and 555 MU5) with the anti-malarial care they received in a comprehensive hospital in Ibadan, Nigeria. Data on patient satisfaction was obtained using a validated eighteen-item questionnaire (PSQ-18) and analyzed using the standard satisfaction scales and quantitative scores. Results Overall, more than half of the participants (79.5% of PW and 78.8% MU5) were well satisfied with malaria care. The least satisfaction i.e., 41.4% among PW (mean satisfaction score = 3.06±1.2) and 45.1% (mean 3.16±1.3) among MU5 was reported on the clinical technical quality of (Sometimes doctors make me wonder if their diagnosis is correct). Furthermore, general satisfaction (based on satisfactions with technical quality, inter-personal attitude, communication, cost, accessibility or convenience and time spent with the doctor) was inversely associated with parity of PW (OR for PW with one child = 0.51, 95% CI: 0.34-0.75 with reference to pregnant women who have had more than one child) in multivariate analyses. Among MU5, general satisfaction was associated with extreme poverty (OR = for the poorest = 0.30, 95% CI: 0.10-0.90, with reference to the richest). Conclusion Socio economic status plays significant roles in mothers’ satisfaction with health care access, level of care received and most importantly their prospective health seeking behaviour. Important aspect, such as patient’s perception of being well treated by the health care provider should be a key consideration for formulate a patients’ centred strategy to improve malaria cares in Oyo state and Nigeria at large.

Conclusion Socio economic status plays signi cant roles in mothers' satisfaction with health care access, level of care received and most importantly their prospective health seeking behaviour. Important aspect, such as patient's perception of being well treated by the health care provider should be a key consideration for formulate a patients' centred strategy to improve malaria cares in Oyo state and Nigeria at large.

Background
Despite an unprecedented success in malaria control worldwide, malaria continues to be the leading cause of childhood and maternal mortality in Nigeria. Africa's most populous country, accounted for 27% of malaria cases and 24% of malaria deaths globally in 2016 [1]. According to the recent Nigeria Malaria Indicator Survey (NMIS), the country has demonstrated progress in reducing malaria prevalence among children less than 5 years old, from 42% in 2010 to 27% in 2015 [2]. The national malaria response supports the promotion of insecticide-treated mosquito nets (ITNs), indoor residual spraying (IRS), intermittent preventive treatment for pregnant women (IPT) and prompt diagnosis and treatment [3].
Despite these efforts in controlling malaria, the rate of progress is not uniform across the country. Some of the challenges responsible for the variance and slow-progress in reducing malaria burden to preelimination levels and achieving zero malaria-related mortality include weaknesses in the Nigerian health care system [2,4].
Identifying weaknesses in health care systems using patient-centered approaches is important for improved and strategic health care planning [5]. Over the past years, patient satisfaction surveys have gained increasing attention as meaningful and essential source of information for identifying operational gaps and developing an effective intervention for quality improvement in healthcare delivery [6,7]. Patient satisfaction refers to the patient's perception of care received compared with the care expected [8]. There are very few published studies on patient satisfaction with malaria care in sub-Saharan Africa, particularly in Nigeria. More studies are needed to inform policy makers on the needs of patients and to in uence the development of strategic plans for provision of improved health care services [7]. The Nigerian national malaria policy launched in February 2015 stated the country's aim is to provide cost effective and equitable malaria elimination services while ensuring transparency, accountability and patient satisfaction [9]. The present study set out to evaluate the level of satisfaction with malaria health care services among pregnant women and mothers of children under 5 years of age in Ibadan, South West Nigeria.

Study design and setting
This cross sectional study was conducted between May and September, 2016 at the Adeoyo maternity hospital, which is the largest secondary maternity hospital in Ibadan, Oyo State, Nigeria [10]. Ibadan is the second most populated city in Nigeria's southwest region with total population of about 2,550,593 based

Study Population And Sampling
This study population included consenting pregnant women and mothers of children under 5 years old. Women who resided in Ibadan and presented to the antenatal clinic or outpatient children's clinic for care based on self-reported malaria symptoms were eligible to participate in the study. A three-stage sampling technique used in the selection of study participants; rst stage included the random selection of Ibadan from the list of local government areas in Oyo state. The second stage involved the random selection of Adeoyo maternity hospital as the study site from lists of maternity hospitals in Ibadan northeast LGA.
Lastly, at the third stage, study participants were randomly selected from the study site and enrolled into the study.

Data Collection
Data was collected using a validated eighteen-item patient satisfaction questionnaire (PSQ-18) [13].
Socio demographic information was collected using a modi ed validated demographic health survey (DHS) questionnaire [14]. Eligible study participants were randomly selected and interviewed by study trained research assistants using both the DHS questionnaire and PSQ-18 after signed informed consents were obtained.

Data analysis
Based on a documented guide for PSQ-18 analyses [13,15], all items in the PSQ-18 forms were scored using means and standard deviation such that high mean scores re ect higher satisfaction with malaria care. In addition, each item in the PSQ-18 was worded such that; 'Agree or strongly agree' = 'Satisfaction' for Items 1, 2, 3, 5, 6, 8, 11, 16 and 18. Similarly, 'Disagree or strongly disagree' = 'Satisfaction' for Items 4,7,9,10,12,13,14,16 and 17. Further, seven different scales of satisfaction (dependent variables) were derived from each item in the PSQ-18 as follows: General Satisfaction (Items 3 and 17); Technical Quality (Items 2, 4, 6, and 14); Interpersonal Manner (Items 10 and 11); Communication (Items 1 and 13); Financial Aspects (Items 5 and 7); Time Spent with Doctor (Items 12 and 15); Accessibility and Convenience (Items 8, 9, 16, and 18). The levels of satisfaction for the respective scales were presented both as percentages and as mean ratings (out of ve) such that higher means indicate higher satisfaction levels with that scale of satisfaction.
Ordinal logistic regression was used to explore signi cant predictors of satisfaction from the respondent characteristics (independent variables). A bivariate logistic regression analysis was rst conducted for all independent variables, and only those found to be statistically signi cant using signi cance level (P value) set at < 0.05 were included in the nal multivariate ordinal logistic regression analysis. Wealth status that was one of the explanatory variables was computed from availability of household assets and income data collected from the modi ed DHS questionnaire. Wealth status of the study participants was ranked in percentages and then categorized into wealth quintiles as poorest (0-20%), poor (21-40%), middle (41-60%), rich (61-80%), and richest (81-100%). Data analyses were conducted with the Statistical Package of Social Sciences (SPSS) version-25.

Socio-demographic and clinical characteristics
Mean age of the pregnant women in the study was 29.0 years ± standard deviation (SD) of 5.2 years. The mean age of mothers of children under 5 years of age was 30.0 ± 5.2 years. The predominant age group between both maternal groups in the study was women aged 25-34 years of age (69.5% of all participants). Majority of the respondents (60.9%) were within the lower upper socio-economic class. Most respondents (90.8%) were married and living in their matrimonial homes. Slightly above half (51.6%) of the respondents attained secondary education. Almost eighty percent of the respondents have had more than one child (Table 1).  Satisfaction level of the 7 domains derived from the raw scale is presented in Table 3. General satisfaction to malaria care was 79.5% with mean score 3.91 ± 0.5 among pregnant women and 78.8% (mean 3.87 ± 0.5) for mothers of children less than 5 years old. For other measures of satisfaction, pregnant women and mothers reported the following: satisfaction with technical quality 63.2% (mean 3.55 ± 0.3) and 64.6% (mean 3.57 ± 0.3) respectively; Interpersonal manner, 90.0% (mean 3.91 ± 0.4) and 83.8% (mean 4.02 ± 0.3), respectively; satisfaction to communication, 78.5% (mean 3.89 ± 0.5) and 80% (mean 3.97 ± 0.6), respectively; satisfaction to nancial aspect of care, was 72.5% (mean 3.81 ± 0.5) and 71.9% (mean 3.79 ± 0.6), respectively; satisfaction to time spent with doctor, 69.4% (mean 3.72 ± 0.5) and 73.2% (mean 3.82 ± 0.5), respectively; and satisfaction to accessibility and convenience, 68.7% (mean 3.93 ± 0.6) and 78.1% (mean 4.03 ± 0.4), respectively (Table 3).  Association of patients' satisfaction with malaria care

Discussion
The current study is the rst to use the PSQ-18 tool to evaluate patient satisfaction with malaria care in the Nigeria and Sub-Sahara Africa. Satisfaction of patients with health care has been described as the degree to which a patient's desired expectations, goals and or preferences are met by the health care provider and or service [16]. Some studies [17,18] have shown that patients are more likely to take appropriate preventive measures and adhere to their treatment plan if they were satis ed with level of care they were offered. The ndings from our study showed varying level of satisfaction for some of the items on the PSQ-18 and to each of the seven sub scales of the tool by study respondents. We observed that for each item of the PSQ-18, our study respondents were poorly satis ed with items of the PSQ that re ects on the technical quality of the health care providers. A considerable proportion of this study respondents reported dissatisfaction with the technical aspects of malaria care, as they were unsure of the professional ability of the medical staff to manage them. A similar nding was previously reported by by Farley et al in 2014 [19]. Furthermore, in the present study, a little above half of the respondents reported dissatisfaction with waiting for too long before getting medical attention, an observation than has been reported in other parts of Nigeria and therefore suggests a systemic weakness in the national health care provision system [20,21].
Good satisfaction was reported in the present study for items on the PSQ-18 that relate to level of communication and interpersonal manner by the health care providers as well as accessibility and convenience to health care. Our study ndings corroborate with ndings from a 2014 evaluation of patient satisfaction with surgical outpatient services in a smaller hospital located in Southern Nigeria [22] where high satisfaction level was found for interpersonal manner of health care providers. Poor satisfaction with nancial aspects of surgical outpatient services care was reported in the other study but this is signi cantly not comparable to our study mainly because wealth status was not measured by the authors in the latter study. Also, our study showed no signi cant relationship for nancial aspects of malaria as a domain for satisfaction with malaria care. We observed that the level of satisfaction among each of the seven scales of satisfaction derived from the 18 items in PSQ ranged from 63.2 to 89.95% vs 64.55 to 83.80% among pregnant women and mothers of children under 5 years of age respectively (Table 3). This is commendable because these proportions are well over average which indicates that good level of satisfaction for all seven patient satisfaction sub scales which include general satisfaction, technical quality, interpersonal manner, communication, nancial aspects, time spent with health care provider, and lastly, accessibility and convenience to health care. Similar positive patients satisfaction level was found when compared to other studies which used the PSQ-18 tool and other data collection tool in assessing other health care service in South Eastern Nigeria [23]; other African geographical settings such as North West Ethiopia [24], Tanzania [25], and Egypt [26].
Multivariate analysis to determine association between some socio demographic characteristics and each of the seven scales for patient satisfaction with malaria care showed some signi cant relationships. First, we observed that pregnant women with average wealth quintile were more satis ed with convenience and accessibility to malaria care than pregnant women in the wealthiest quintile.
Income level as a socio economic factor has been shown to in uence decision on convenience and accessibility to malaria care [27]. Also observed in our study was that good satisfaction with the clinical technical quality was among pregnant women with low educational status. This provides empirical evidence for the review by Ricci who suggested that low levels of education leads to low knowledge on malaria due to inability to understand written health education materials, such as posters and yers [28].
Furthermore, we found that the women pregnant with their rst child in our study were seen to be less likely generally satis ed with malaria care, nancial aspects of care and time spent with doctor. Marital status was associated with satisfaction with the doctor's interpersonal manner and level of communication; greater odds of satisfaction was seen among the married pregnant women. Positive attitude of multiparous mothers compared to rst time mothers has been documented to be associated with expectations based on previous experiences with child delivery [29]. Satisfaction from our study supports ndings from recent study conducted to assess antenatal care satisfaction in few northern states in Nigeria revealed that nancial cost, health care provider behavior and attitude positively in uences maternal satisfaction with health care [30]. The latter study aimed to identify the modi able factors associated with pregnant women's satisfaction with antenatal care ANC at government health facilities in Nigeria. They found an association between patient satisfaction and both the perceived quality of clinical aspects of care and interpersonal interactions of providers. Important clinical care quality factors were: patients trust in their providers' medical decisions, and the number of clinical examinations patients received. Providers' interpersonal interactions of signi cance were providers' nondiscriminatory behavior regardless of patient's socioeconomic status, their concern for patients' wellbeing (empathy), responsive provision of services (respect for patients' time and privacy) and effective communication at consultation (a component of treatment facilitation). In Kenya, satisfaction of pregnant women with the free maternal healthcare services has been documented [31].

Limitations
Although the PSQ-18 that was used to collect data for this study is a valid, reproducible questionnaire [32], potential limitation to this study was response bias. The responses of individuals recruited at a hospital could be in uenced by the health condition that brought them to seek health care. Study participants were recruited based on their self-reported malaria symptoms that in uenced them to seek health care.

Conclusion
This study found an above average level of satisfaction for each of the seven sub-scales measuring satisfaction with malaria care interventions. Level of satisfaction with malaria was particularly high for the sub scale on health care provider's interpersonal manner and communication. Low satisfaction was observed for the subscale on technical quality of clinical services as perceived by the study respondents.
Patient satisfaction can sometimes be very subjective; however, because of the large sample size and methodical approach of the current study, we recommend that health care providers and stake holders take note of the ndings herein. Low satisfaction is indicative of unmet health service delivery in the prevention and treatment of malaria. Clinicians and health service providers need to be more attentive and responsive to the expectations of patients seeking for malaria care. The policy implications of ndings from this study emphasizes the need for conscientious effort to improve on health care delivery and on women's socio-economic empowerment programs taking into consideration the roles played by mothers in the malaria control and treatment activities. Only human participants were involved in the study. The participants enrolled in the study voluntarily gave informed consent to participate after gaining an understanding of the purpose and procedure of the study.

Consent to publish
Not applicable Availability of data and materials The dataset produced by the current study is available from the corresponding author upon request