Methods: A comparative cross-sectional study was conducted from 27 March to 30 April 2010. The study included 5 private and 5 public hospitals. Participants were selected using systematic random sampling. A pre-tested and contextually prepared structured questionnaire was used to conduct interviews. Descriptive statistics, analysis of variance, factor analysis and multiple linear regressions were performed using computer software (SPSS 16.0).

Results: About 18.0% of the patients at the public hospitals were very satisfied whilst 47.9% were just satisfied with the corresponding proportions a bit higher at private hospitals. Self-judged health status, expectation about the services, perceived adequacy of consultation duration, perceived providers’ technical competency, perceived welcoming approach and perceived body signalling were determinants of satisfaction at both public and private hospitals.

Conclusions: Although patients at the private hospitals were more satisfied than those at the public hospitals with the health care they received, five of the predictors of patient satisfaction in this study were common to both settings. Thus, hospitals in both categories should work to improve the competencies of their employees, particularly health professionals, to win the interests of the clients and have a physical structure that better fits the expectations of the patients.

Contexte: Les patients ont des souhaits et des demandes explicites concernant les services lors des visites à l’hôpital. Cependant, une réponse inappropriée à leurs besoins peut entraîner l’insatisfaction du patient. Cette étude a pour but de déterminer les niveaux et les facteurs de satisfaction du patient quant aux soins ambulatoires fournis dans les hôpitaux publics et privés à Addis Abeba, en Éthiopie centrale.

Méthodes: Une étude transversale comparative a été réalisée du 27 mars au 30 avril 2010. L’étude concernait 5 hôpitaux publics et 5 hôpitaux privés. Les participants ont été sélectionnés en utilisant la technique systématique d’échantillonnage aléatoire. Un questionnaire pré-testé et mis en contexte a été utilisé pour mener à bien les entretiens. Les statistiques descriptives, l’analyse de la variance, l’analyse des facteurs et la régression linéaire multiple sont effectuées au moyen d’un logiciel informatique (SPSS 16.0).

Résultats: Près de 18% des patients des hôpitaux publics étaient très satisfaits alors que 47.9% étaient seulement satisfaits, les proportions étant légèrement supérieures dans les hôpitaux privés. L’état de santé auto-déclaré, les attentes concernant les services, la perception de la pertinence de la durée des consultations, la perception de la compétence technique des fournisseurs de soins, la perception de l’accueil et la perception du langage corporel étaient déterminants pour la satisfaction, dans les hôpitaux privés comme publics.

Conclusions: Bien que les patients des hôpitaux privés soient plus satisfaits que ceux des hôpitaux publics quant aux soins de santé qu’ils ont reçus, cinq des indicateurs de satisfaction des patients de cette étude étaient communs aux deux contextes. Ainsi, les hôpitaux des deux catégories devraient faire un effort afin d’améliorer la compétence de leurs employés, en particulier les professionnels de la santé, de concilier les intérêts de leurs clients et de disposer d’une infrastructure physique mieux adaptée aux attentes des patients.

Patients have explicit desires or requests for services when they visit hospitals. However, many cases of patient dissatisfaction can occur due to inadequate discovery of their needs.³ According to Donabedian, patient satisfaction should be investigated since it is an objective of care, a consequence of that care (outcome) that can contribute to the effects of care, as a satisfied patient is more likely to comply with advice, and it is the patient’s judgment on the care that has been provided.⁵

Moreover, there is growing consensus that assessment of the quality of hospital services should be based in part, on patients’ perceptions of overall care and patient satisfaction.⁶ The dominance of market-oriented approaches to reforms in health care delivery and cost, and the emergence of a normative perspective on clinical practice that emphasises the need to deliver patient-centred care, are also driving attention to patient perceptions of quality.^7,8,9

Different studies have pointed out that the level of satisfaction in different types of health facilities and hospitals vary. Studies in Ethiopia havereported overall satisfaction levels ranging from 52% to 57%.^10,11,12 Studies in Bangladesh showed that greater levels of satisfaction were observed in private hospitals than in training and social security hospitals.¹³ Likewise, the study conducted in Malta in 1998 showed that the expectations of private hospital patients for service were higher than those of public hospital patients.¹

Several patient characteristics have been associated with patient satisfaction including demographic factors, socio-economic status and general health status.^14,15,16 Satisfaction is also influenced by the manner with which health care is delivered. The type of health care setting and characteristics of the medical provider, such as experience, age and gender, are related to patient satisfaction.^17,18,19

Some medical-care satisfaction studies showed that people with poor health status had stronger feelings in either direction and that the most satisfied groups were those with good health or those suffering from chronic diseases.^4,20,21 But other studies showed that the patient health status was not an important factor of satisfaction.¹³

A study conducted in Kerman hospitals, a city in south-eastern Iran, showed that the effect of age on satisfaction was not significant. But a study on the experience and satisfaction of patients with health care in 2002, pointed out that age is an important factor in reported satisfaction as in the case of the findings in six regions of Ethiopia.^4,13,22,23 Ethnic origin has also been found to have a relevance to patient satisfaction.²⁴

Moreover, the Kerman hospital study cited above showed that patient satisfaction and the sex of the patient have a significant relationship; a similar finding was observed in the Wangmamyen Community Hospital study.^4,25 But a study conducted in six regions of Ethiopia showed that the sex of the patient is not a significant determinant of patient satisfaction in agreement with findings of a review of issues and concepts in 1997.^23,26

The level of education and satisfaction were found to have an inverse correlation. For instance, in the study of the six regions of Ethiopia mentioned above, educational status and marital status were observed to be significant determinants of the mean score for patient satisfaction.^4,23

The study carried out in 1998 on determinants of customer satisfaction with hospitals, showed that perceived competence of the hospital staff and their demeanour had the greatest impact on customer satisfaction. The quality of communication and the general condition of the facilities were also significant but less important in explaining customer satisfaction with hospital services.²⁷ Besides, a clean and organised appearance of a hospital, its staff, its premises, restrooms, equipment, wards and beds can influence patients’ impressions about the hospital.²⁸

Perceived waiting time is a strong predictor of patient satisfaction. If waiting time is longer than what is expected or considered inappropriate, dissatisfaction will arise no matter how long the actual waiting time.²⁹ Moreover, many studies have shown that unfulfilled expectations are related to lower patient satisfaction.^{25,30,31,32,33} However, a study that focused on unmet expectations, reported that there was little support for the relationship between fulfilment of specific expectations and patient satisfaction.²⁴ Nevertheless, studies indicated that patients have a tendency to infer the level of technical quality based on non-technical aspects.³⁴

Throughout Ethiopia, there has been a significant increment in the number of private health care facilities in large urban centres, though the majority of the population depends on government hospitals for their health care.³⁵Addis Ababa, the capital city of Ethiopia, has 442 private clinics of various categories, 150 pharmacies (135 private, 3 NGO and 15 public), 83 private drug stores, 28 health centres, 7 nucleus health centres and health stations. Under the jurisdiction of the Addis Ababa City Administration Health Bureau (AACAHB) there are 5 public and 28 private hospitals with a total of 927 beds.³⁶ By the year 2007–2008 total outpatient visits were 1 377 850 (the OPD attendance per capita was 0.60) and total inpatient admissions were 16 204 (admission rate was 5.1).³⁶ However, there is no adequate documentation of the comparison of the level and determinants of patient satisfaction with the health services provided at public and private hospitals.

The scales used in this study have been used in other studies and pre-tests of the contextually adopted tools were carried out before the actual data collection. Multiple items were used to establish appropriate measurement properties of the selected constructs. At the end of each day, supervisors of data collection checked for the appropriate recording of all entries by the data collectors by randomly taking completed questionnaires. Methods used to measure concepts at the analysis stage are also well described above.

By two population proportion formulae, taking Z a/₂ = 1.96, Z_β = 0.84 , p₁ = 0.4 and p₂ = 0.6 the calculated sample size for n₁ was 152 and for both private and public hospitals it was 304 (2 * 152). Considering a 10% non–response rate and a design effect of 2, the total sample size was 668. In the calculation, p₁ and p₂ are patient satisfaction with OPD health services in Tigray, Ethiopia and Malta, respectively.^1,37 The proportion for private hospitals was taken from a study outside the country because we did not find similar studies in Ethiopia.

After identifying all private and public hospitals, all 5 public hospitals and 5 private general hospitals selected through the lottery method were included in the study. The number of respondents from each hospital was determined based on the proportion of patients who visited the OPDs during one month prior to the start of the study. The interval of the respondents for the study in private hospitals was determined by dividing the total number of patients in the private hospitals during the last one month, by the sample size for private hospitals. The same technique was applied at public hospitals.

Factor analysis was employed for all Likert scale instruments to extract factor(s) representing each of the scales and have factor scores, which facilitate treatment of the variables as continuous during further analysis. During all factor analysis procedures, principal axis factoring with eigenvalue greater than or equal to one extraction and varimax rotation methods were employed. The factors extracted for each of the scales, which had Cronbach’s alpha value greater than 0.7, were used in a subsequent analysis. Whenever the scales had more than one factor extracted the factors were renamed according to the items contained in the factor extracted.

History of admission was relatively higher amongst public hospital service users. On the other hand, self-judged health status of private and public hospital service users was not significantly different (x² = 5.69, df = 3 p = 0.128). Public hospital respondents reported that they received recommendation from others about the current hospital services more than private hospital patients (x² = 6.97, df = 1, p = 0.008). However, private hospitals service users had higher expectation than public hospital service users about the service they should receive in their respective hospitals (x² = 22.574, df = 3, p < 0.000).

The recorded consultation duration was 7.82 (±4.78) minutes at the public hospitals with a range of 1–45 minutes. But it was 10.59 (±6.01) minutes at the private hospitals with a range of 2–45 minutes. Of the respondents at the private hospitals, 65% reported that the consultation duration was enough whilst only 46% of the respondents described the same way at the public hospitals.

Concerning the overall satisfaction with the health care provided at the public hospitals, 18.2% of the patients were very satisfied whilst 47.9% the patients were just satisfied. At the private hospitals the corresponding proportions were 26.5% and 49.2%, respectively.

Attempts made to identify determinants of patient satisfaction, revealed that common determinants of patient satisfaction at private and public hospitals were self-judged health status, expectation about the services, perceived health care providers technical competency, perceived welcoming approach and perceived adequacy of consultation duration. But perceived body signalling and perceived cleanliness of the hospitals were determinants only for public hospital patients. On the other hand, perceived health care providers’ empathy, perceived lack of experience and ability, recorded consultation duration, educational status and occupation were unique determinants of patient satisfaction at private hospitals. Most of these variables were also found to be determinants of patient satisfaction in studies carried out elsewhere.^{20,21,24, 26,28,29,31}

Previous studies presented controversial findings regarding the relationship between a self-judged health status and patient satisfaction. Some reported that it had a positive association with satisfaction,but others claimed otherwise.^13,20Still others reported that people with poor health had stronger feelings in either direction and that the most satisfied groups were those with good health or those suffering from chronic diseases.^4,22 In this study, however, it was found that a self-judged health status has positive association with patient satisfaction.

Expectation about hospital service may be influenced by previous experience of the service or based on information obtained from others. Patients at public hospitals had lower expectations about the services to be received than those at private hospitals (x² = 22.574, df = 3, p ≤ 0.005). This finding is consistent with the finding in Malta.¹ On the other hand, it is worth noting that this variable was an important determinant factor for satisfaction at both categories of hospitals of the present study and other studies carried out elsewhere previously.^{24,26,32,1,34}

It is obvious that having good communication improves the outcome of the patient-physician interaction. Non-verbal communication is part of the interaction in service provision activities and can easily be misinterpreted, and in effect has an impact on patient satisfaction. In this study, both of the non-verbal communication factors – perceived welcoming approach and perceived body signalling – were significant determinants of patient satisfaction at public hospitals and the only perceived welcoming approach at private hospitals, which is quite similar with other findings though they reported it in general form as ’nonverbal communication.’^20,28,31

Obviously, patients come to health care institutions with different health problems and they seek remedy for their problems. This puts them in need to be well heard whilst they are talking about their problems. To have an adequate consultation duration may allow health care providers to do so and know about their client and their health problems for consequent decision and effective consultation. In this study recorded consultation duration at private hospitals was 10.59 (±6.01) and at public hospitals was 7.82 (±4.78). Furthermore, 65% and 46% of the respondents of private and public hospitals respectively, reported that the consultation duration was long enough. On top of that, perceived adequacy of consultation duration was a determinant of patient satisfaction in both categories of hospitals whilst recorded consultation duration was so only at the private hospitals. This finding is consistent with that of Birhanu et al. in rural parts of central Ethiopia and implies the importance of sufficient consultation duration when providing satisfactory health services to clients in both settings.¹⁹ In order to make the services easy to get by the patients, health care providers may hurry to the next case without giving enough consultation time for the patients at hand. However, this fashion of addressing the problem of the service has its own impact on the receiver of the services and causes dissatisfaction. Moreover, hurry may undermine health care providers’ empathy, perceived technical competency and other important characteristics of the services.

Different studies indicated that patients have a tendency to infer the level of technical quality based on non-technical aspects, such as care providers’ compassion and empathy, responsiveness and service coordination amongst individual health care personnel.^{22, 27} In this study it was found that perceived technical competency (for both categories of hospitals) and perceived empathy (for private hospitals) had a positive association with patient satisfaction, this is similar with earlier findings.^22,28 On the other hand, perceived lack of experience and ability had a negative association with patient satisfaction at private hospitals.

In conclusion, although patients at the private hospitals were more satisfied than patients at the public hospitals, the majority of the identified determinants of patient satisfaction in this study were service related and common to both settings. However, perceived body signalling and perceived cleanliness of hospitals were unique determinants at public hospitals. On the other hand, perceived empathy, perceived lack of experience and ability, recorded consultation duration, educational status and occupation were unique determinants of patient satisfaction at private hospitals.

In Ethiopia, the current health system allows mixed functioning of public and private health facilities, which have raised a concern about the quality of care being delivered in both public and private facilities. In Addis Ababa there are many private and public hospitals compared to other parts of the country. However, there is no adequate documentation of the comparison of the level and setting specific determinants of patient satisfaction with the health services provided at these hospitals. The findings of this study are of practical importance to both settings by enabling health managers to look into the major areas of concern, which could result in substantial improvements in the provision of patient or client-friendly services. The findings will also help the managers to compare the situation in their facility with those of others.

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