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Level of Patient Satisfaction with Inpatient Services and Its Determinants: A

Study of a Specialized Hospital in Ethiopia

Article in Journal of Environmental and Public Health · August 2020

DOI: 10.1155/2020/2473469

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Journal of Environmental and Public Health
Volume 2020, Article ID 2473469, 12 pages
https://doi.org/10.1155/2020/2473469

Review Article
Level of Patient Satisfaction with Inpatient Services and Its
Determinants: A Study of a Specialized Hospital in Ethiopia

Nebsu Asamrew,1 Abduilhafiz A. Endris ,2 and Musse Tadesse2

1
Health Service Quality Directorate, Addis Ababa Regional Health Bureau, Addis Ababa, Ethiopia
2
Public Health Emergency Management Center, Ethiopian Public Health Institute, P.O. Box: 1242, Addis Ababa, Ethiopia

Correspondence should be addressed to Abduilhafiz A. Endris; abduilhafizhassen@gmail.com

Received 18 September 2019; Revised 24 July 2020; Accepted 31 July 2020; Published 13 August 2020

Academic Editor: Jonathan Haughton

Copyright © 2020 Nebsu Asamrew et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Background. The health care industry is undergoing a rapid transformation to meet the ever-increasing needs and demands of its
patient population. Level of patients’ satisfaction is an important health outcome, which is regarded as a determinant measure for
quality of care. This study was performed with the aim of assessing the level of patient satisfaction with inpatient services and its
determinants in Black Lion Specialized Hospital, Addis Ababa, Ethiopia. Methods. A facility-based cross-sectional study was
conducted from November 25th to December 20th, 2015, using 398 randomly selected patients. Ethical clearance was obtained
from the Jimma University research review board, and verbal consent was also received from the study participants during data
collection time. A pretested structured interview questionnaire was used to collect data from study participants. The collected data
were handled by using SPSS statistical software. Before analysis, relevant explanatory variables were identified using factor analysis
with varimax rotation, and bivariate analysis was carried out using linear regression for every independent variable with the
outcome variable independently. Explanatory variables scoring p value <−0.05 were used for the final model after checking the
assumption. Study findings are presented by using tables, graphs, and description. Results. A total of 398 patients were participated
in the study, yielding a response rate of 100%. A total of 46.2% (95% CI: 41.2%–51.1%) patients were satisfied by the services they
received in the hospital. Patient and health care provider interaction and general facility amenity-related domains were found to
explain 96.4% of the variability in the net overall satisfaction score. Good quality services provided by hospital physicians,
availability of laboratory and radiology services, pain management services, and inpatient pharmacy services of the hospital had
positive influences. Besides toilet cleanliness, availability of rooms for accommodation and dietary service had significant relation
with level of patient satisfaction. Quality of the inpatient pharmacy service had a great influence on satisfaction; a unit increase in it
resulted in 2.3 (95% CI: 2.1–2.5) times increment in patient satisfaction level at p ≤ 0.001. For final predictors, regression estimates
for level of satisfaction moved from very dissatisfied to very satisfied when service improves by a unit. Conclusion. Overall patients’
satisfaction is lower than other studies in the nation. A great opportunity is there to improve patient’s satisfaction level if the
service quality is improved around the time of patient and health care provider interaction and facility amenity services. Besides,
improving the health literacy of service providers and devising a strategy to routinely assess satisfaction level of patients in the
facility is critical. On top of this, providing tailored on-the-job training for health care workers in the facility is a crucial step in
order to improve their knowledge and skills to render patient-centered quality service to improve their patients’ satisfaction. Using
a checklist during service delivery may improve client patient interaction and ensure the standard. Facility design dimension can
be considered for future research activities.

1. Background and demands of its patient population [1, 2]. Quality of

health services was traditionally based on professional
1.1. Introduction. Health care quality is becoming a global practice standards; however, over the last decade, patient’s
issue, which occasioned the health care industry to undergo perception about health care has been predominantly be-
a rapid transformation to meet the ever-increasing needs coming an important indicator for measuring the quality of
2 Journal of Environmental and Public Health

health care [3]. On top of this, patient satisfaction is be- component of the health system for continuous quality
coming a critical component of performance improvement improvement process [30]. On top of this, following in-
and clinical effectiveness [2, 4–6]. creased levels of competition and the emphasis on con-
Recent practices in the health system showed that health sumerism, measuring patient satisfaction has become an
authorities are considering the patient as the best judge who important measurement for monitoring health care per-
accurately assesses and provides inputs to help in the overall formance of health plans.
improvement of quality health care provision through the Therefore, this study is aimed at measuring the level of
rectification of the system weaknesses [1, 2, 6]. The regu- patient satisfaction and its determinants in one of the
latory and accreditation mandates imposed by agencies such specialized hospitals in Addis Ababa so as to identify the
as the Joint Commission on Accreditation of Healthcare critical dimensions, which has a greater influence on patient
Organizations (JCAHO) and the National Committee on satisfaction level related to inpatient services in Ethiopian
Quality Assurance (NCQA) showed that quantifiable patient context.
satisfaction data as a critical component of performance
improvement and clinical effectiveness programs are re-
quired [7, 8]. 1.2. Justification of the Study. In the context of Ethiopian
Patient satisfaction, which is a perception and an attitude health sector reform, health facilities are striving to improve
that a consumer can have or view towards a total experience the efficiency, effectiveness, and quality of services provided.
of health care, is a multidimensional aspect, which repre- Among the range of indicators that has been used to measure
sents a vital key marker for the quality of health care delivery quality health service delivery and to track its change over
[1, 2, 4, 9]. Furthermore, level of patient satisfaction is an time in Ethiopia, routine measuring of patient satisfaction
internationally accepted factor, which needs to be studied level for improvement is the recommended approach for
routinely to complement other methods of quality assess- health care providers at all level [30]. On top of this, im-
ment and assurance for smooth functioning of the health proving the patient’s satisfaction level by identifying the
care system [2, 3, 5, 9–11]. This wholistic approach can help major responsible factors for improvement is the integral
to better meet patients’ needs and improve quality of health component of continuous quality improvement process and
service delivery by identifying and understanding of its efficient way.
determinants through a continuous quality improvement It is generally agreed that satisfaction data’s play a sig-
process [3, 10, 12]. nificant role in improving the strategy and tactics of health
Various dimensions of patient satisfaction have been care providers in delivering health care services for clients.
identified, health care services ranging from admission to In addition to its role in improving quality health service
discharge process, waiting time to receive care, as well as delivery, measurement of patient satisfaction plays an im-
from medical care to interpersonal communication [13–16]. portant role in the growing push toward accountability
It has also been reported that the interpersonal and technical among health care providers, which has a significant role in
skills of health care provider are the two unique dimensions developing and delivering high-quality health care in the
involved in a patient assessment of hospital care [17–20]. hospital with the involvement of patients in the management
General amenities of the facility in terms of availability, its of their problem and treatment [9, 11, 31]. It is also viewed as
quality, and structural design were also among the identified an established indicator for quality of care, despite it was
dimensions, which significantly affect the patient satisfaction overshadowed by measures of organizational aspects in the
level [2, 21, 22]. quality of health care equation [30].
Additionally, sociodemographic and economic status of Different studies also indicated that a satisfied patient
the patients and their expectations of care and attitudes has complied with the medical treatment prescribed, service
towards the health care system were among the dimensions provider recommendation, and continually using medical
identified to have direct influence on satisfaction level; other services at a specific health provider, which might result with
psychosocial factors, including pain and depression, are also the enhanced disease healing process and healthier and
known to contribute to patient satisfaction level scores happier clients, who are contributing to the development of
[9, 23–29]. the country [14, 32].
In Ethiopia, the health care services are limited and of
poor quality, which is a direct reflection of the countries 2. Methods
socioeconomic status. This takes the lion share for the higher
morbidity and mortality of the population due to the 2.1. Study Setting, Sample Size, and Sampling Procedures.
emerging and reemerging infectious and chronic health This study was conducted at one of the specialized gov-
problems in the nation. The lower life expectancy rate of the ernmental hospitals in Addis Ababa, Ethiopia, aimed at
peoples in the nation is a clear indication for this. assessing the level of patient satisfaction and its determi-
Considering this major bottleneck for the health system, nants. A facility-based cross-sectional study design was
the Ethiopian government has focused on improving the applied to understand patient’s satisfaction level by the
health care organizations and quality of health service de- services provided in the facility. All admitted patients at
livery to the population in recent years. In such efforts Black Lion Specialized Hospital during the study period
towards improving the quality health care service delivery, were used as source population for this study. All admitted
measuring the level of patient satisfaction is an integral patients at different wards who stayed for 48 hrs and above
Journal of Environmental and Public Health 3

during the time of data collection were the study population. inpatient pharmacy service, abundancy on supply
During the data collection, patients who were selected and and availability of drugs in the hospital, laboratory
fulfilled the inclusion criteria for the study among the ad- and radiology services of the hospital, and the
mitted patients were included in the study. Those seriously hospital pain management were considered.
ill, laboring mothers, and pediatric patients without parents/
(iv) General facility amenities of the hospital-related
guardian were excluded from the study.
variables
The total sample size of this study was determined using
a single population proportion formula by taking the as- Under this category, availability of rooms for ac-
sumptions that the overall net patient satisfaction to be 62% commodation, dietary service given by the hos-
[33], 95% CI and a 5% margin of error (d), and expected a pital, toilet, ward and bed services, and cleanliness
nonresponse rate of 10%. This resulted in a total of 398 were considered.
samples for the study. Available bed capacity of wards and
available patients during the study period was used to al-
locate the total sample size in each ward to ensure the 2.3. Data Collection Materials and Procedures. A structured
proportional allocation of samples from all service providing questionnaire developed by reviewing other similar studies
ward of the hospital. Health Management Information [12, 33–38] was used for questionnaire development, which
System (HMIS) report of the hospital made on October 2015 we used to assess the level of patient satisfaction with in-
was used to know the total available beds per ward and patient services in Black Lion Specialized Hospital. To ensure
estimate the patients per ward. Systematic random sampling the required information is collected with greater under-
technique was used to ensure the random selection of standing, local language was used during data collection. To
participants with every three intervals to recruit study facilitate this, the data collection questionnaire was first
participants. Lists of patients from the patient register of an developed in English, then translated to Amharic language,
individual ward were used as the sampling frame for and back to English for its consistency. Three diploma level
selection. health professionals were used for data collection, and one
first degree level health professional with three years of
experience and one of the principal investigators acted as a
2.2. Study Variables supervisor during the data collection. The data collection
team was briefed about the objective and methodology of the
2.2.1. Dependent Variables. Level of patient satisfaction with study and trained on the data collection process by the
inpatient service was considered the dependent variable. principal investigators. To avoid social desirability bias, both
the data collectors and supervisors were recruited from other
2.2.2. Independent Variables health facilities. Admitted patients were interviewed being
on their bed. To ensure the quality of the collected data, the
(i) Sociodemographic variables collected data have been collected by the supervisors to
Sociodemographic variables including sex, age, review for clarity and completeness check on a daily basis.
marital status, living with status of the study
participant, educational status, occupational sta-
tus, religion, ethnicity, permanent residence of the 2.4. Measurements
patient, and financial income status of the re- 2.4.1. Patient Satisfaction. Considering that patient satis-
spondents were considered. Besides, presence of faction is a collective outcome of different kinds of services
caretaker during hospital admission was also provided in the hospital, the level of patient satisfaction in
considered. this study was measured by using 19-item questions, which
(ii) Service utilization-related information variables is composed of three dimensions. Service utilization, patient
and health care provider interaction, and facility-related
Information regarding waiting time to get required information were the three different dimensions assessed.
service in the facility (as stated by the participant), Each item has a 5-point Likert scale ranging from 1 (very
official visiting hours of the facility, information’s dissatisfied) to 5 (very satisfied).
received regarding the services provided by the
hospital, admitting processes of the hospital for
inpatient service, activities performed to ensure 2.4.2. Overall Patient Satisfaction. This is measured by using
privacy of the patient, measures taken to assure one item in the questionnaire stating “How do you rate your
confidentiality, and availability of signboards overall level of satisfaction regarding the health service you
displayed inside the hospital were collected. received in this hospital?”
(iii) Patient and health care provider interaction
variables
2.4.3. Net Overall Patient Satisfaction. Mean value of
Health education provided by health workers, participants’ level of satisfaction which was computed
nursing care received during their stay, perceived from the entire questions under the three dimensions
quality of physician service received, quality of (service utilization, patient and health care provider
4 Journal of Environmental and Public Health

Table 1: Operational definitions used.

S. no Variable Definition used
Perception of the patients regarding the outcome of care and the extent it meets their needs and
(1) Patient satisfaction
expectations
(2) Inpatients Patients who had a hospital stay greater than 48 hours in the facility
(3) Service departments Service area serving inpatients in the facility during their stay in the hospital
The time interval between the departure from registration for inpatient service and seen by a doctor
(4) Waiting time
to receive service

interaction, and facility-related information) was used methodological issues. During the data collection, names of
(Table 1). the participants were kept anonymous by using a study
record number only. It is believed that there is no anticipated
harm for the patients except for their time scarification at the
2.5. Data Processing and Management. The collected data time of data collection.
were entered and analyzed using SPSS version 21 statistical
software. After data cleaning was completed, descriptive
3. Results
statistics including frequencies and percentages were used to
describe the study participants. Before fitting to the model for 3.1. Sociodemographic Characteristics. A total of 398 patients
analysis, required assumption for the model in use was done. were participated in the study making a response rate of
Statistical tests for normality such as Shapiro–will and Kol- 100%. Of the total study participants, 231 (58.0%) and 211
mogorov–Smirnov were performed. During checking for the (53.0%) were female and married, respectively. The median
assumption for linear regression, the dependent variable was age of study participants was 34 years. One hundred twenty
not normally distributed, and a two-step transformation was (30.2%) study participants had primary education and 69
performed to ensure its normality. To reduce the load of the (17.3%) of them have no formal education. The median
independent variables and select critical variables, factor income of the study participants was 1,500.00 Ethiopian Birr
analysis with varimax rotation was performed, variables with (ETB), and 273 (68.6%) of the participants were from a rural
greater than 0.443 rotated component matrix value were part of the country (Table 2).
considered, and bivariate analysis was performed for every
independent variable with the outcome variable indepen-
dently. Finally, explanatory variables which had a statistically 3.2. Hospitalization Characteristics. About 249 (62.6%)
significant association with the dependent variables at study participants were admitted for the first time to the
p < 0.05 were considered for the final linear regression model. hospital, and 222 (55.8%) of the respondents were paying for
the hospital service. Among study participants, 239 (60.1%)
of them stayed in the hospital for less than 15 days (Table 3).
2.6. Data Quality Management. Quality of the data for the
study was assured throughout the study period starting from the
designing phase of a data collection instrument. Simplicity of 3.3. Level of Patient Satisfaction with Different Service
the questions for understanding and relevance of variables in Categories. Among the three service categories used to as-
the study were considered during preparation followed pre- sess the net overall satisfaction rate of patients, the majority
testing, and modification of the questionnaire based on the of the patients were satisfied with the services under patient
findings was performed accordingly. Before actual data col- and health care provider interaction and facility-related
lection, training was given for data collectors and the supervisor information. This study finding showed that almost half of
on the techniques of data collection, proper categorization, and the study participants were satisfied with waiting time to get
coding of data. During data collection, the assigned supervisor service 190 (47%), 228 (57.3%) with official visiting hours of
and principal investigator checked the collected data on a daily the hospital, 207 (52.0%) with information provided on the
basis for its completeness, accuracy, and clarity. Cronbach alpha available service by the staffs, 194 (48.7%) with admission
was calculated for all independent variables together in order to processes of the hospital, 169 (42.5%) and 219 (55.0%) with
demonstrate the reliability of the variables to measure the measures taken to assure confidentiality and privacy of the
overall satisfaction level of the patients during analysis stage. The patients, respectively, and 187 (47.0%) with signboards
Cronbach alpha analysis indicated that reliability for variables available inside the hospital (Table 4).
included in the study was 0.81. In patient and health care provider interaction, a total of
235 (59.0%) patients claimed that they were satisfied with the
physician service. The highest very dissatisfaction propor-
2.7. Ethical Considerations. Ethical approval was obtained tion in this study was registered regarding the observed
from the Ethical Review Committee of Jimma University, cleanness status of the toilets in the facility. A total of 42
College of Health Sciences. Verbal consent was also obtained (10.6%) study participants claimed that they were very
from the study participants before the data collection after dissatisfied with the cleanness of toilets in the facility
providing clear information on the study objective and other (Table 4).
Journal of Environmental and Public Health 5

Table 2: Sociodemographic characteristics of study participants in Black Lion Specialized Hospital (BLSH), Addis Ababa, Ethiopia,
December 2015 (N � 398).
Variables Categories Frequency Percentage (%)
Male 167 42.0
Sex
Female 231 58.0
≤34 years 199 50.0
Age
>34 years 199 50.0
Single 128 32.2
Married 211 53.0
Marital status
Divorced 34 8.5
Widowed 25 6.3
Yes 361 90.7
Presence of caretaker
No 37 9.3
No formal education 69 17.3
Elementary/1–8th grade 120 30.2
Educational status Secondary school 95 23.9
Vocational/diploma 66 16.6
Degree and above 48 12.1
Government employee 83 20.9
Private/NGO 132 33.2
Farmer 56 14.1
Occupational status Student 48 12.1
Daily laborers 16 4.0
Merchants 54 13.6
Others 9 2.3
Orthodox 224 56.3
Protestant 82 20.6
Religion
Muslim 86 21.6
Others 6 1.5
Amhara 150 37.7
Oromo 142 35.7
Ethnicity Tigre 46 11.6
Gurage 49 12.3
Other 11 2.8
Addis Ababa 124 31.2
Amhara 70 17.6
Oromiya 124 31.2
The region they come
Tigray 35 8.8
SNNP 38 9.5
Others 7 1.8
Urban 273 68.6
Residence
Rural 125 31.4
Less than 1000ETB 152 38.1
1000–2500ETB 173 43.5
Financial income status of the respondents
2500–5000ETB 71 17.8
Greater than 5000ETB 2 0.6

3.4. Overall Net Patient Satisfaction Level. Regarding the 27.1% of the variability in the net overall satisfaction score.
overall satisfaction level with the hospital service, around Among the sociodemographic and hospitalization character-
150 (37.7%) patients were satisfied with the service provided istics measuring variables to measure the net overall satisfaction
by the hospital, and an equivalent number of study par- level, patient’s age, marital status, and presence of caretaker
ticipants were neither satisfied nor dissatisfied. Besides, 8.5% during admission shows independent association with net
of the respondents were very satisfied with the service, and overall satisfaction level at p < 0.05. The net satisfaction level of
around 0.5% of the respondents were very dissatisfied with study participants aged >34 increased by 3.45 (95% CI: −1.33 to
the service provided by the hospital service (Figure 1). 5.55) as age increased by one unit. The net satisfaction score of
study participants who have their own caretaker in their hospital
3.5. Patients Satisfaction by Sociodemographic and Hospi- stay was increased by 4.66 (95% CI: −1.05 to 8.27) when
talization Variables. In this study, the sociodemographic and compared with study participants without a caretaker in their
hospitalization characteristics variables were found to explain hospital stay.
6 Journal of Environmental and Public Health

Table 3: Hospitalization characteristics of study participants in Black Lion Specialized Hospital (BLSH), Addis Ababa, Ethiopia, December
2015 (N � 398).
Variables Categories Frequency %
<7 days 140 35.2
7–14 days 99 24.9
14–21 days 79 19.8
21–28 days 25 6.3
Number of days of hospital stay 28–35 days 26 6.5
35–42 days 11 2.8
42–49 days 5 1.3
49–56 days 1 0.3
>56 days 12 3.0
New 249 62.6
Admission type
Repeat 149 37.4
Free 176 44.2
Payment status
Paying 222 55.8
Medical ward 75 18.8
Surgical ward 56 14.1
Gynecology and obstetrics 88 22.1
Ward
Orthopedics 27 6.8
Pediatrics 85 21.4
Oncology 67 16.8

Table 4: Satisfaction levels of study participants in Black Lion Specialized Hospital (BLSH) with different service categories, Addis Ababa,
Ethiopia, December 2015 (N � 398).
Variables Very dissatisfied Dissatisfied Neutral Satisfied Very satisfied
Services utilization-related information
Waiting time to get service 32 (8.0%) 114 (28.6%) 26 (6.5%) 190 (47.7%) 36 (9.0%)
Visiting hours 8 (2.0%) 61 (15.3%) 36 (9.0%) 228 (57.3%) 65 (16.3%)
Information on the service 21 (5.3%) 99 (24.9%) 48 (12.1%) 207 (52.0%) 23 (5.8%)
Admission processes 27 (6.8%) 108 (27.1%) 43 (10.8%) 194 (48.7%) 26 (6.5%)
Privacy 19 (4.8%) 63 (15.8%) 38 (9.5%) 219 (55.0%) 59 (14.8%)
Measures taken to assure confidentiality 26 (6.5%) 124 (31.2%) 42 (10.6%) 169 (42.5%) 37 (9.3%)
Signboards 27 (6.8%) 105 (26.4%) 40 (10.1%) 187 (47.0%) 39 (9.8%)
Patient and health care provider interaction
Health education provided by the health workers 23 (5.8%) 140 (35.2%) 42 (10.6%) 165 (41.5%) 28 (7.0%)
Nursing care 14 (3.5%) 47 (11.8%) 29 (7.3%) 242 (60.8%) 66 (16.6%)
Physician service 11 (2.8%) 39 (9.8%) 33 (8.3%) 235 (59.0%) 80 (20.1%)
Inpatient pharmacy services 25 (6.3%) 126 (31.7%) 38 (9.5%) 175 (44.0%) 34 (8.5%)
Availability of drug and supply 10 (2.5%) 67 (16.8%) 22 (5.5%) 236 (59.3%) 63 (15.8%)
Laboratory and radiology services 25 (6.3%) 72 (18.1%) 43 (10.8%) 216 (54.3%) 42 (10.6%)
Pain management 20 (5.0%) 65 (16.3%) 30 (7.5%) 224 (56.3%) 59 (14.8%)
Facility amenity-related information
Room accommodation 10 (2.5%) 67 (16.8%) 22 (5.5%) 236 (59.3%) 63 (15.8%)
Dietary service given by the hospital 28 (7.0%) 79 (19.8%) 45 (11.3%) 205 (51.5%) 41 (10.3%)
Toilet cleanliness 42 (10.6%) 124 (31.2%) 33 (8.3%) 164 (41.2%) 35 (8.8%)
Ward cleanliness 8 (2.0%) 51 (12.8%) 57 (14.3%) 225 (56.5%) 57 (14.3%)
Bed cleanliness 6 (1.5%) 45 (11.3%) 30 (7.5%) 242 (60.8%) 75 (18.8%)

3.6. Patient’s Satisfaction by Service Utilization-Related In- regression estimates of satisfaction level moved from very
formation, Patient-Health Care Provider Interaction, and dissatisfied to very satisfied, which means that an improvement
Facility-Related Information Variables. The relationship be- of listed services to satisfy the clients can potentially have an
tween service utilization-related variables, patient and health improvement in the net satisfaction score of patients.
care provider interaction variables, and facility-related infor-
mation variables with net overall satisfaction is quantified in
Table 5. These variables were found to explain 96.5% of the 3.7. Final Predictors of Patient Satisfaction in Black Lion
variability in the net overall satisfaction score. For almost all Hospital. The variables included in the final model
variables in these domains, when facility service improves, the explained 96.4% of the variability in net overall patient
Journal of Environmental and Public Health 7

40 37.7 37.7
35

Percentage of study participants

30

25

20
15.6
15

10 8.5

5
0.5
0
Very dissatisfied Dissatisfied Neither satisfied Satisfied Very satisfied
nor dissatisfied
Level of satisfaction
Figure 1: Level of overall net patient satisfaction of study participant of Black Lion Specialized Hospital (BLSH), December 2015.

Table 5: Relationship of net overall patient satisfaction level with services of BLSH, Addis Ababa, Ethiopia, December 2015.
95% CI
Variables B p value
Lower B Upper B
Services utilization-related information
Information on services provided 5.957 5.157 6.757 <0.001
Admitting processes of the hospital 5.213 4.419 6.006 <0.001
Waiting time to receive service 1.891 1.016 2.766 <0.001
Official visiting hours for service 2.814 1.773 3.855 <0.001
Available signboards in the facility 5.313 4.558 6.068 <0.001
Patient and health care provider interaction
Nursing care 4.664 3.691 5.637 <0.001
Physician service 5.561 4.590 6.533 <0.001
Health education 2.834 1.937 3.732 <0.001
Laboratory and radiology services 5.478 4.676 6.280 <0.001
Pain management 5.576 4.765 6.387 <0.001
Inpatient pharmacy services 5.084 4.322 5.846 <0.001
Facility-related information
Toilet cleanliness 5.292 4.601 5.984 <0.001
Ward cleanliness 6.942 6.033 7.850 <0.001
Room accommodation 6.565 5.741 7.390 <0.001
Bed cleanliness 7.375 6.467 8.282 <0.001
Dietary service 1.861 0.938 2.784 <0.001

satisfaction. Physician service, laboratory and radiology 1.164–1.682 at a p value less than 0.001. Pain management
services, pain management, inpatient pharmacy service, for patients was also a strong predictor of patient satisfac-
toilet cleanliness, room accommodation, and dietary service tion. In a unit, increase in pain management score will lead
were strong predictors of patient satisfaction. Table 6 pro- to 1.379 increases in the patient satisfaction score with a 95%
vides the regression estimates and the relative effect of each CI of 1.141–1.617 at a p value of less than 0.001. From all
predictor variable for net overall patient satisfaction with all predictor variables, inpatient pharmacy services have a
variables, which were included for the final multilinear significant change in the satisfaction score of patients in
regression model. BLSH. A unit increase in the inpatient pharmacy will in-
From the variables categorized into three parts, none of crease the satisfaction score of patients by 2.311 unit with a
the variables under service utilization-related indicators were 95% CI of 2.118–2.504 at a p value of less than 0.001.
predictors of net overall satisfaction. Majority of variables From the third category (i.e., facility amenity-related
under patient and health care provider interaction variables variables), three variables (toilet cleanliness, room accom-
(physician service, laboratory and radiology services, pain modation, and dietary service) were significant predictors of
management, and inpatient pharmacy service) were signifi- net overall satisfaction of patients in BLSH. From these
cant predictors of net overall satisfaction of patients. variables, toilet cleanliness was a strong predictor variable of
As it is indicated in the table, a unit increases in phy- net overall satisfaction score. A unit improvement in toilet
sician service score will lead to 1.423 unit times increase in cleanliness will increase the satisfaction level of patients by
the net overall satisfaction score with a 95% CI of 1.500 unit with a 95% CI of 1.300–1.700 at a p value of less
8 Journal of Environmental and Public Health

Table 6: Final predictor variables of net overall patient satisfaction in BLSH, Addis Ababa, Ethiopia, December 2015 (N � 398).
95% confidence interval
Variables (categories) Unstandardized B-coefficient p value
Lower B Upper B
Age
≤35.5 years —
>35.5 years 0.05 0.662
Presence of caretaker
No —
Yes 0.00 0.975
Marital status
Single 0.141 0.079 1.625
Married 0.091 0.072 1.253
Divorced 0.034 0.015 1.139
Widowed 0.044 0.021 1.027
Services utilization-related information
Information services 0.902 0.653 1.152
Admitting processes 1.147 0.922 1.373
Waiting time 0.978 0.786 1.169
Visiting hours 0.872 0.608 1.135
Signboards 1.039 0.815 1.263
Patient and health care provider interaction
Nursing care 1.157 0.919 1.395
Physician service 1.423 1.164 1.682 <0.001∗∗
Health education 1.006 0.811 1.201
Laboratory and radiology services 0.706 0.478 0.935 <0.001∗∗
Pain management 1.379 1.141 1.617 <0.001∗∗
Inpatient pharmacy services 2.311 2.118 2.504 <0.001∗∗
Facility-related information
Toilet cleanliness 1.500 1.300 1.700 <0.001∗∗
Ward cleanliness 1.233 0.946 1.52
Room accommodation 1.311 1.043 1.58 <0.001∗∗
Bed cleanliness 1.225 0.92 1.529
Dietary service 1.211 1.008 1.413 <0.001∗∗
∗∗
Variables having p value <0.001 and found to be strong predictors of the final model.

than 0.001. Room accommodation had also a significant Different study findings revealed that the relevance of
change in net overall satisfaction score of study participants. information services given for patients, proper admitting
The net overall satisfaction score of study participants in- processes, short waiting time to receive service, and ensuring
creased by 1.311 unit when there is a unit improvement in privacy and confidentiality for services provided by the
room accommodation with a 95% CI of 1.300–1.700 at a p hospital had statistical association in other studies. On the
value of less than 0.001. Similarly, a unit improvement in other hand, different literatures also indicate that quality of
dietary service showed that 1.211 unit satisfaction level communication and interpersonal skills is also the key in-
improvement with a 95% CI of 1.008–1.413 at a p value of dicator for patient satisfaction [13–20]. But none of the
less than 0.001 (Table 6). variables were found to be significant for patient satisfaction
in our study. This may be due to the difference in the type
4. Discussion and level of hospital, patients flow, patient-level expecta-
tions, and priority of required services of the patients. Black
Our study finding shows that the proportion of overall net Lion Hospital is one of the specialized hospitals in the
patient satisfaction rate is 46.2%. This level of satisfaction nation, which is responsible to receive referral patients from
was higher when compared with other interventional study all over the nation, and the type of conditions to be managed
performed in Debre Markos Hospital, Ethiopia, which is in this hospital is very serious, which needs specialized
25% before the intervention [39]. But, compared with other service. Besides, there are many services which are found in
studies performed on patient satisfaction in Jimma Spe- this hospital only. Considering these, clients may prioritize
cialized Hospital, Debre Berhan Hospital, and other study receiving care rather than the amount of time they spent to
performed in Bahir Dar Felege Hiwot Hospital, the overall receive. So that, the clients who are coming to this facility
satisfaction level was low, which is 61.9%, 57.7%, and 57.8%, may expect to wait longer time duration and compromised
respectively [33–36]. This discrepancy may be due to the other facility-related services. This trend may be perceived as
level of the hospital and/or workers capacity and motivation normal compared with the quality of clinical services they
status of the health workers to attain higher patients’ needs. want to receive, which may be their priority as it is indicated
Journal of Environmental and Public Health 9

in our finding that a total of 180 (45.2%) participants wanted Based on this study finding, a unit improvement in
improvement in laboratory and pharmacy services. toilet cleanliness will have an average of 1.500 times
Majority of variables under patient and health care increment in the net overall satisfaction rate of patients in
provider interaction domain (physician service, laboratory the hospital with 95% CI (1.300–1.700) at a p value of less
and radiology services, pain management, and inpatient than 0.001 and a unit increase in dietary services score
pharmacy service) were significant predictors of net overall also increase patient satisfaction by 1.211 unit with 95%
satisfaction of patients. From this domain, inpatient phar- CI (1.008–1.413) at a p value of less than 0.001. Other
macy service was the strong predictor variable of net overall study findings in other areas also showed that dietary
satisfaction score of the patients. service, cleanness of toilet and bed were an important
The net overall satisfaction of study participants predictor of patient satisfaction [33, 34, 36, 40, 42–45].
satisfied with physician service in the facility had 1.423 This result can be supported by the finding that, the
unit times greater satisfaction score with the service (95% highest “very dissatisfaction” level among patients
CI (1.164–1.682)) at p < 0.001. A unit increase in the (10.6%) were with toilet cleanness problem. Almost 50%
quality of laboratory and radiology services score will of participants were dissatisfied with the toilet service of
lead to 0.706 unit times increase in net overall satisfaction the hospital. Our study finding is also similar with the
level of patients with a 95% CI of 0.478–0.935 at a p value study done in Bangladesh. Which indicate that a common
of less than 0.001. Our study finding is also in line with complaint of patients was against cleaner and sweepers of
other studies performed in other different areas the hospital that they do not clean the hospital toilet and
[33, 37, 40]. Pain management for patients is also strong bathroom regularly [34]. The possible reason for their
predictors of patient satisfaction in our study, which is complaint from patients’ sides maybe, they believe that
against the study finding performed in other study areas receiving adequate food timely, clean toilet service and
[28]. Based on this study finding, the net overall satis- good quality accommodation are the bases for psycho-
faction score of patients increases by 1.379 when there is a logical satisfaction and healing process. Besides, they may
unit increase in the pain management with a 95% CI of fear to develop health care -acquired infection due to the
1.141–1.617 at p < 0.001. poor sanitation of the facility which can debilitate their
Regarding inpatient service of the facility, about half of health status.
(52.5%) of the participants were satisfied with the service In this study, none of the sociodemographic charac-
they received in the hospital. This finding is lower than the teristics of the patients were found to be a predictor for the
study performed in India on patient satisfaction in a tertiary net overall satisfaction of the patients. Other similar studies
care teaching hospital, which shows about 69% of respon- on the influence of sociodemographic characteristics on
dents were satisfied by the pharmacy service they received patients’ satisfaction also showed that there is no consistent
from the hospital. The possible explanation for this differ- relationship between patient satisfaction with age, race,
ence may be due to the difference in developmental status of gender, education, or income. However, some other studies
the two countries. India is more developed country than found that older patients were more likely to report satis-
Ethiopia and might have a strong health system structure faction compared with younger patients and that females
with numerous pharmaceutical factories, which may be the were more likely to express satisfaction than males
reason for the abundant availability of drugs in the facility [26, 27, 35].
that can satisfy the patients need. But it is almost similar with In general, this study found that patient and health care
other study performed in Jimma Specialized Hospital, in provider interaction domain and general facility amenity-
which 54% of patients were satisfied by the drug availability related domains of patient satisfaction were found to explain
and supply in the inpatient pharmacy. 96.4% of the variability in the net overall satisfaction score of
Inpatient pharmacy service is found to be the highest the patients. Another new domain dimension of patient
predictor of patient satisfaction in our study. The finding satisfaction including facility design domain should be
shows that a unit increase in the inpatient pharmacy considered for future research.
services increases patient satisfaction level by 2.311 unit
with a 95% CI of 2.118–2.504 at p < 0.001. Another prior 5. Recommendations
study conducted in a similar facility (Black Lion Hospital)
before four years also revealed that the main reasons for Continuous quality improvement is linked to the use of
patient’s dissatisfaction in the hospital was the poor timely and useful feedback from clients. Patients constitute
quality services they received from pharmacy, radiology, the hospital’s direct client. The overall satisfaction is an
and laboratory department of the hospital, which can important aspect of the service itself, and it is considered to
significantly indicate the persistence of the problem in the be an important outcome measure for health services. Pa-
facility after four years [12, 33–35, 38, 41, 42]. tient care is not considered to be of high quality unless the
From the general facility amenity-related domain, three patient is satisfied.
variables (toilet cleanliness, room accommodation, and Improving patient satisfaction is one of the key indi-
dietary service) were significant predictors of net overall cators of quality of care and indicator of quality health
satisfaction of patients in BLSH. From these variables, toilet service. Based on this study finding, we recommend the
cleanliness was a strong predictor variable of net overall following strategies to improve patient satisfaction in the
satisfaction score of the patients. hospital.
10 Journal of Environmental and Public Health

(i) The hospital managers should routinely assess the 6. Conclusion

patients’ satisfaction status and provide tailored
on-the-job training to their professionals in the Based on the study finding, around 46.2% of the patients
facility in order to improve their skill for en- were satisfied by the services they received in the hospitals,
hancing patients’ satisfaction. and 15.6% of the patients reported that they were dissatisfied
(ii) Managers of the hospital should devise a mecha- by the hospital services. The remaining 37.7% of the re-
nism to improve the performance of staff and spondents were neither satisfied nor dissatisfied with the
monitor the implementation process in order to service provided in the hospital service. Based on this
take appropriate improvement and action. finding, the overall patient satisfaction is low compared with
other health facilities in the nation and compared with the
(iii) Periodic assessment of health services and average standard level expected. Majority of variables under
further study in other dimensions of patient patient and health care provider interaction variables and
satisfactions including facility design dimen- facility amenities have higher prediction capacity for the net
sion, which can explore from the user’s satis- overall satisfaction of patients. Physician service, laboratory
faction perspective, is recommended as a and radiology services, pain management, inpatient phar-
fundamental initiative in the improvement of macy service, cleanliness of the toilet, room accommodation,
the performance of health care delivery in the and dietary service of the hospital were significant predictors
facility. of net overall satisfaction of patients in Black Lion Spe-
(iv) Hospital reformation and modern hospital ad- cialized Hospital.
ministration system could be considered to im-
prove the level of patient satisfaction.
Data Availability
(v) The hospital should improve the general facility
amenities including the meal need of the patient The data used to support the study are available from the
and the cleanliness of the toilet. corresponding author upon request.
(vi) Considering that service unavailability is a major
source of patient dissatisfaction, a system should Conflicts of Interest
be in place to ensure the availability of hospital-
specific tracer drugs in the hospital on a daily basis, The authors declare that there are no conflicts of interest.
and there should be drug information service in
the hospitals as recommended by Ethiopian
Hospital Reform Implementation Guideline.
Authors’ Contributions
(vii) Improving the client-patient interaction should The work presented here was carried out in collaboration
be addressed by using an appropriately designed between all authors. NA and AA prepared the protocol; NA,
checklist which considers the norm of the AA, and MT participated in fieldwork, data organization,
community and other client needs, and a and cleaning; NA, AA, and MT carried out the data analysis,
standard checklist for communication can po- interpretation, and write-up of the manuscript. All authors
tentially improve the satisfaction level of pa- read and approved the final manuscript.
tients regarding service delivery of different
departments.
Acknowledgments
(viii) Improving the health literacy status of service
providers in the facility should be addressed by The authors would like to thank School of Public Health,
providing on-the-job trainings related to deter- Jimma University, for providing this opportunity to conduct
minants of patients as soon as possible to support this study. Staff and supervisors working at the university
the compassionate and respectful care initiative of who had a contribution in this work also deserve the authors’
the hospital. gratefulness for their support. The authors would also like to
(ix) Last, we want to emphasize that this research extend their special thanks to Black Lion Specialized Hos-
identifies a number of indicators that are im- pital administration and staff for their willingness during the
portant to improve the quality of hospital ser- study period. Finally, the authors’ sincere thanks go to the
vices and patient satisfaction in Black Lion team (supervisors and data collectors) and study participants
Specialized Hospital. Since the study is con- for their willingness to participate in the study.
ducted in one government medical hospital in
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