Study on Patient Satisfaction in the Government Allopathic Health Facilities of Lucknow District , India

Background: The outcome of any disease is influenced by the decisions to seek care, timely arrival at appropriate diagnostic and treatment services and the receipt of adequate care from service providers. Satisfaction in service provision is increasingly being used as a measure of health system performance. Satisfaction manifests itself in the distribution, access and utilization of health services. Objectives: To determine the areas and causes of low satisfaction among the patients and suggest methods for improvement. Materials and Methods: Multistage stratified random sampling was used to select the government allopathic health facilities of Lucknow district and systematic random sampling for the selection of the patients for the interview. Results: The accessibility was difficult in 42% patients and waiting time more than 30 min for 62.5% of those attending the tertiary level health facility. The satisfaction with the duration of the outpatient department (OPD) (64.6%) and the presence of signboards (46.6%) was also found to be low. The overall satisfaction regarding the doctor-patient communication was more than 60% at all the levels of health care facilities but that with the examination and consultation was less than 60% at the primary level as compared to more than 80% elsewhere. The most important motivating factor for the visit to the tertiary (48.2%) and secondary level (71.9%, 67.1%) of health facilities was the faith on doctors or health facility. Conclusions: The level of patient satisfaction is severely deficient in several areas and needs improvement for the achievement of optimal health of the people.


Introduction
The quality of service in health means an inexpensive type of service with minimum side effects that can cure or relieve the health problems of the patients. (1)It is easier to evaluate the patient's satisfaction towards the service than evaluate the quality of medical services that they receive. (2)Therefore, a research on patient satisfaction can be an important tool to improve the quality of services. (3,4)her industries have been paying attention to customer satisfaction for years."Health care is the only industry -service or manufacturing -that for years has left the customer out of it.This is an absolutely prehistoric thinking.To ignore the input from the patient, to ignore the customer, to say the customer's desires are irrelevant is not living with reality". (3)alth care consumers today, are more sophisticated than in the past and now demand increasingly more accurate and valid evidence of health plan quality.Patient-centered outcomes have taken center stage as the primary means of measuring the effectiveness of health care delivery.It is commonly acknowledged that patients' reports of their satisfaction with the quality of care and services, are as important as many clinical health measures.Health care organizations are operating in an extremely competitive environment, and patient satisfaction has become a key to gaining and maintaining market share.
Patient satisfaction with the healthcare services largely determines their compliance with the treatment and thus contributes to the positive infl uence on health.This study was therefore undertaken with the aim to fi nd out the level of patient satisfaction related to different parameters of quality health care including the prescription at public health facilities in the Lucknow district, a centrally Original Article placed, capital city of the most populous Indian state -Uttar Pradesh. (5)Being the capital city of Uttar Pradesh, it leads in the provision of health care to its people.It has various health care facilities providing different levels of health care.While it has Sanjay Gandhi Post Graduate Institute for providing superspeciality care, it has the renowned King George Medical University with its state-of-art Trauma centre for the tertiary level health care.The health system is also supported by the district hospital (DH), community health centers (CHC) and the primary health centers (PHC) for the secondary and primary level of care, respectively.

Materials and Methods
Study design: The study design was cross-sectional.
Study population: The present study was conducted among the patients attending the outpatient department (OPD) of government health facilities of Lucknow district.
Period of study: The period of survey was from May 2006 to August 2006.

Sampling
Sampling frame: The sampling frame consisted of all the allopathic public health facilities of Lucknow district at the tertiary level, secondary level, and the primary level.The "public health facilities" in the present study implies all the Government health facilities.
Sample size: The sample size was calculated using the formula, n = Z 2 (1-α/2) pq/d 2 (where Z (1-α/2) = 1.96 at 95% confi dence; p = prevalence of patient satisfaction, q = 1-p; d = absolute allowable error.For this study, we presumed maximum variability, hence p = 0.5; q = 0.5; d =5%.Sample size thus yielded was of 384.Adding a 10% for incomplete answers, the total number came out to be 422.As the interview was to be taken at four types of public health facilities i.e., Medical College (MC), DH, CHC and PHC, the calculated sample size was multiplied by 4 to obtain the sample size of 1688.The data was analyzed for 1625 patients only who had provided the complete answers.
Sampling technique: Multi-stage stratified random sampling technique was used to select representative patients attending the public health facilities of Lucknow district.At fi rst stage i.e., at the tertiary level, MC was selected.At the second stage i.e., at the secondary level, Balrampur DH and two CHCs were randomly selected.At third stage i.e., at the primary level, two PHCs each under the two selected CHCs were randomly selected.
Further at the MC, the sampling population (844) was interviewed from the 10 most frequented OPDs (Medicine, General surgery, Obstetrics and Gynecology, Paediatrics, Orthopedics, Otorhinolaryngology, Ophthalmology, Cardiology, Neurology, Tuberculosis and Chest diseases) according to probability proportion to size based on the past year's OPD attendance.
At the DH, a total of 422 patients with 105 patients from each of the OPDs of Medicine, General surgery, Obstetrics and Gynecology and Paediatrics were interviewed.Similarly, 105 patients were interviewed from each of the two randomly selected CHCs and 53 new patients from each of the four PHCs, respectively.Inclusion criteria: A "new" or "referred" patient attending the OPD of the respective health care facility.
Exclusion criteria: Patients working in the health care facility and follow-up patients attending the OPD of the respective health care facility were excluded from the study.
Selection of patient: The patients attending the OPD of the respective health care facility were selected for the interview by systematic random sampling.Depending upon the previous attendance of the particular department and the time taken to complete the interview, a random number was chosen and every n th patient was selected for the interview.This process was continued till the required sample size was completed.
Tools of data collection: Permission to conduct the study was taken from the superintendents of the concerned health care facility.All the patients were interviewed after they had consulted the doctor.Informed verbal consent was taken from all the participating patients before the start of the interview after telling them about the objective of the study and the approximate time that will be involved in the completion of the interview.The prescribing doctor was largely kept unaware of the procedure, except in unavoidable circumstances, to avoid the bias in their behavior with the patient.
A quantitative structured interview schedule was used to record information taking the key elements of sociodemographic characteristics of the patients attending the outpatient health care facility, patient satisfaction regarding accessibility of health services, waiting area and waiting time, examination room and clinical consultation and the drug prescription.Adding the numerators of all the variables taken into consideration and dividing it by the sum of all the denominators of the variables calculated the overall satisfaction regarding a particular aspect.The satisfaction was graded as unsatisfactory (0-20%), satisfactory (20-40%), good (40-60%), very good (60-80%) and excellent (80-100%).

Analysis
Data was tabulated on Microsoft Excel sheet and analysed using the software Epi Info version 6 and Microsoft Excel (Analysis toolpak) for Windows.Discrete data was analysed using Pearson's Chi-square test for normal distribution.P values <0.05 were considered signifi cant.

Results
We observed in the present study that, the primary level health facilities were the most easily accessible (88.3%), affordable (76.1%), required less travel time.About one third of those attending the tertiary health facility were unsatisfi ed with the duration of the OPD [Table 1].
Enquiries about the waiting area and waiting time in the public health facilities revealed a signifi cantly high satisfaction with respect to the presence of signboards (100%), waiting time of less than 30 minutes (99.5%) and overcrowding (32.8%) in the patients attending the primary level health facilities, while that regarding the availability (2.9%) and cleanliness of the toilets (2.9%) was miserable.On the other hand, the satisfaction regarding the waiting area (92.9%), availability of seats (81.4%), availability (44.7%) and cleanliness of the toilets (31.3%) was highest at the tertiary level health facilities [Table 2].
The overall satisfaction regarding examination and consultation were signifi cantly higher at the tertiary (81.6%) and secondary (81.3%) level, as compared to the primary level health facilities (59.6%).Absence of a separate place for examination at the primary level resulted in high dissatisfaction [Table 4].History taking about the allergy to drugs was equally poor in all the health facilities (0.6%) while that about the use of other drugs (30.3%) as well as information imparted about the side effects (1.9%) and about returning immediately (19.7%) due to the adverse effects of drugs was higher at the MC in comparison to other facilities, but unsatisfactory on the whole.A signifi cantly greater proportion of the patients attending the PHC wanted a change in the form of the drugs (40.9%) as well as expected tonics (45.8%) [Table 5].
Regarding the time spent in seeking medical care as perceived by the patient in various public health facilities, it was observed that the average waiting time for registration at the tertiary care health facility (8.1 ± 9.1 minutes) was highest followed by secondary level health facility and least at the primary level (3.8 ± 2.8 minutes).
It can be observed from [Table 6] that the most important motivating factor for the visit to the tertiary and secondary level of health facilities was the faith on doctors or health facility, followed by the availability of specialists (43%, 63%).On the other hand, the proximity of the health facility to the residence (67.1%), followed by faith on doctors or health facility (55.4%) and cost-effectiveness (34.3%) were more important at the primary level.

Discussion
The present study was an attempt to assess the level of satisfaction of the patients with the various aspects of health care in the allopathic government health facilities of Lucknow district.Very few similar studies have been done and therefore we lack the data for comparison.Yet, the fi ndings of the survey are quite helpful if they are transformed into actions for improving the quality of health care.
Accessibility is one of the principles of Health for All, as stated in Alma Ata declaration on primary health care. (6)lthough, the large catchment area of the tertiary health facilities make it less accessible, yet people travelled  by the public automated transport for more than an hour to reach there to receive specialized services.Our fi ndings are consistent with those of Gadallah et al, (7) with respect to the accessibility and the traveling time.
The affordability of the cost involved in reaching the health facility by almost all signifi es the readiness of the patients to pay for their health.The demand for evening OPD services can be an important fi nding regarding the reforms that need to be made for making the health services more user-friendly.The decreased level of satisfaction with the duration of the OPD at the tertiary level could be attributed to a number of factors such as short duration of four hours, compounded by late arrival, relative lack of appropriate signboards and misleading of the ignorant patients by people from private agencies,   P-values <0.05 are signifi cant, *Association of variables between tertiary and secondary level, † Association of variables between secondary and primary level, ‡ Association of variables between tertiary and primary level adding to the cost and suffering.
The registration time and waiting time at the primary level was different to the observation of Dr. Syed Mohamed Aljunid (8) in his study in Malaysia where the patients waited for 52 minutes on an average.Differences in satisfaction with long waiting time as compared to other studies by Dr. Syed Mohamed Aljunid, (8) van Uden et al (9) and Mahfouz et al, (10) could be attributed to the differences in the perceptions and expectations of the people.Reduction of the waiting time by triage of the patients and sending them to the appropriate doctor would save their time and also provide appropriate treatment.The waiting time and area could also be utilized to provide health education to the people.The unsatisfactory availability of drinking water (45.7%) and toilet facilities (37.4%) as well as the cleanliness of the toilets (27.3%) were similar to those of Srilatha Sivalenka (11) and Peerasak Lerttrakarnnon et al, (12) who also found these as the major areas of concern in their study.
The satisfaction regarding the listening of the complaints and the behavior of the doctors and the paramedical staff was similar to that recorded by Peerasak Lerttrakarnnon et al, (12) in their study, while it was higher than that reported by Janko Kersnik et al, (13) who found it to be 69.1% and 56.9%, respectively.Our fi ndings regarding physical examination corroborate with those of Janko Kersnik et al, (13) who observed a satisfaction of 55.3%.The relatively low satisfaction at the primary level health facilities might result in loss of faith and non-compliance with the treatment.The average consultation time was similar to that observed by Desta et al, (14) Hazra et al (15) and Mallet et al, (16) while it was considerably less from that of Pati (17) (7 min) and Guyon et al, (18) (54 s).
Serious medication errors could result from inappropriate history taking prior to and inadequate instructions while prescribing the drugs as observed in our study.A proper drug dispensing system may help the patients overcome the dissatisfaction regarding the form and duration of the drugs to prevent noncompliance as well as avoid grave consequences of the medication errors.
Improvement of the skills of doctor-patient communication and other relevant areas would go a long way to enhance the level of satisfaction of the patients, considering the fact that most of the patients were drawn to the health facility because of their faith.The cost effectiveness of the services provided would also go a long way to maintain the bond between the doctors and the patient for the achievement of the optimal level of health of the people.

Limitations
Due to non-availability of similar studies in India, the sample size was calculated taking the percentage of patient satisfaction as 50%.But, since it provides us with maximum variability, the sample size is considered appropriate.The responses of the patients depend upon their personality and their perceptions.Some may be satisfi ed with average services while others may be dissatisfi ed with even the best.The results also need to be compared with the other major group of health providers' i.e., private practitioners to evaluate the differences in the quality of health care but could not be done due to the paucity of resources.

Conclusions
An attempt to evaluate the level of patient satisfaction related to different parameters of quality health care at the health facilities has provided us with the certain areas that need corrective efforts to improve hospitals' service quality.Infrastructure and architectural corrections need to be made to enhance the comfort and satisfaction of the patients.There is a need to channelize the patients through the hierarchical levels of health care to prevent undue burden on the tertiary health facilities.Certain improvements are also needed in the waiting area by making it informative and comfortable.Also, there is an imperative need to communicate effectively with the patients about their disease and the treatment specially the largely ignored and the most effi cient preventive aspect to allay their fears, remove misconceptions, comply with the treatment and develop confi dence in the health system for achieving the standards of good health.

Kumari,
et al.: Patient satisfaction in the government health facilities

Table 1 : Patient satisfaction regarding accessibility of health services in the government health facilities
P-values <0.05 are signifi cant, *Association of variables between tertiary and secondary level, † Association of variables between secondary and primary level, ‡ Association of variables between tertiary and primary level, § Numbers in italics are the denominator for that variable

Table 2 : Patient satisfaction regarding waiting area and waiting time in the government health facilities
P-values <0.05 are signifi cant, *Association of variables between tertiary and secondary level, † Association of variables between secondary and primary level, ‡ Association of variables between tertiary and primary level

Table 3 : Patient satisfaction regarding doctor patient communication in government health facilities
-values <0.05 are signifi cant, *Numbers in italics are the denominator for that variable, † Association of variables between tertiary and secondary level, ‡ Association of variables between secondary and primary level, § Association of variables between tertiary and primary level P