University of Ghana http://ugspace.ug.edu.gh SCHOOL OF NURSING AND MIDWIFERY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA PATIENTS’ SATISFACTION WITH THE QUALITY OF HEALTH CARE SERVICES AT THE MAMPROBI POLYCLINIC BY FELICIA MENSAH (10552151) THIS THESIS IS SUBMITTED TO UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PHILOSOPHY IN NURSING AND MIDWIFERY DEGREE JULY, 2017 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services DECLARATION I, Felicia Mensah hereby declare that; this thesis is the result of my own original work, except for other people’s work which were used and have been duly acknowledged at the reference section. This thesis has therefore never been presented to the university or any other university for the award of any degree. FELICIA MENSAH ……………………… …………. (10552151) SIGNATURE DATE DR. KWADWO AMEYAW KORSAH ……………………… …………. (SUPERVISOR) SIGNATURE DATE MS. PARTICIA AVADU ……………………. …………. (SUPERVISOR) SIGNATURE DATE i University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services DEDICATION This research work is dedicated to my Late husband Mr. Desmond Cudjoe and my family for their immense support throughout my graduate studies at University of Ghana. This work is also dedicated to my friends who support me in difficult times. . ii University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services ACKNOWLEDGEMENT I could not have started this program without the support, encouragement and motivation of my late husband, Mr. Desmond Cudjoe. I am indebted to my supervisors: Dr. Kwadwo Ameyaw Korsah and Ms. Patricia Avadu of the University of Ghana Nursing and Midwifery School for their significant inputs, suggestions and direction during the supervision work. I wish to acknowledge Dr. Lomotey and Dr. Mrs. Lomotey, my Principal Nursing Officer Mrs. Agnes Opuni-Boateng for their motivations and directives. My appreciation also goes to Ghana Health Service and Mamprobi polyclinic administrators for their official permission and guide during my data collection. Moreover, I am grateful to the patients for their time and concern to respond to issues in my instrument. I cannot also afford to leave out wonderful people like: Augustina Kende, Peter Kobina Asare Mensah, Jacob Halm, Frank Agyei-Bediako, David, Charles and my siblings who were of tremendous assistance during my thesis. Finally, my special gratitude goes to my mother Mrs. Eva Mensah and my father Mr. P.K.O Mensah for their sacrifice, prayers and support to my education. I wish to acknowledge the authors and publishers whose work or publication were used to complete this thesis. God bless them. iii University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services TABLE OF CONTENTS CONTENT PAGE DECLARATION ......................................................................................................................... i DEDICATION ........................................................................................................................... ii ACKNOWLEDGEMENT ......................................................................................................... iii TABLE OF CONTENTS .......................................................................................................... iv LIST OF TABLES .................................................................................................................... ix LIST OF FIGURES .................................................................................................................... x LIST OF ABBREVIATIONS ................................................................................................... xi ABSTRACT ............................................................................................................................. xii CHAPTER ONE ......................................................................................................................... 1 INTRODUCTION .................................................................................................................. 1 1.0 Background to the Study ...................................................................................................... 1 1.1 Statement of the Problem ..................................................................................................... 6 1.2 Purpose of the Study ............................................................................................................. 9 1.3 Research Objectives ............................................................................................................. 9 1.4 Research Questions .............................................................................................................. 9 1.5 Significance of the Study .................................................................................................... 10 1.6 Researcher’s Motivation ..................................................................................................... 10 1.7 Operational Definition of Terms ........................................................................................ 11 CHAPTER TWO ...................................................................................................................... 12 LITERATURE REVIEW ..................................................................................................... 12 Introduction .............................................................................................................................. 12 Theoretical framework ............................................................................................................. 12 iv University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 2.1 Perception of quality of health care .................................................................................... 20 2.2 Patient satisfaction with health care ................................................................................... 23 2.3 Barriers to patients’ satisfaction with health care ............................................................... 29 2.4 Effect of patient satisfaction with health care on health seeking behaviour ...................... 32 2.5 The Perception of Patients .................................................................................................. 35 2.6 The Values of Patients ........................................................................................................ 36 2.7 Summary ............................................................................................................................. 37 CHAPTER THREE .................................................................................................................. 38 METHODS ........................................................................................................................... 38 3.0 Introduction ........................................................................................................................ 38 3.1 Research Design ................................................................................................................. 38 3.2 Research Setting ................................................................................................................. 39 3.3 Target Population ............................................................................................................... 40 3.4 Inclusion criteria ................................................................................................................. 41 3.5 Exclusion criteria ................................................................................................................ 41 3.6 Sample size ......................................................................................................................... 41 3.7 Sampling technique ............................................................................................................ 42 3.8 Data collection tool ............................................................................................................. 43 3.9 Data collection procedure ................................................................................................... 44 3.10 Piloting ............................................................................................................................. 45 3.11 Data analysis ..................................................................................................................... 45 3.12 Methodological Rigour ..................................................................................................... 47 3.13 Ethical consideration ........................................................................................................ 49 3.14 Data Management ............................................................................................................. 50 v University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services CHAPTER FOUR .................................................................................................................... 51 FINDINGS ............................................................................................................................... 51 4.0 Introduction ........................................................................................................................ 51 4.1 Demographic Characteristics of Participants ..................................................................... 51 4.2 Organisation of Themes...................................................................................................... 52 4.3 Patients’ satisfaction with healthcare ................................................................................. 53 4.3.1 Patient’s Expectations .................................................................................................. 54 4.3.2 Satisfaction with healthcare ......................................................................................... 58 4.3.3 Dissatisfaction with health care ................................................................................... 59 4.4 Hospital Environment (Tangibility) ................................................................................... 61 4.4.1 Appearance of the hospital personnel .......................................................................... 61 4.4.2 Cleanliness of the environment .................................................................................... 63 4.4.3 Availability of drugs and other logistics ...................................................................... 65 4.5 Facilitators/barriers to patients’ satisfaction ....................................................................... 67 4.5.1 Reliability ..................................................................................................................... 68 4.5.1.1 Standard of care ..................................................................................................... 68 4.5.1.2 Staff commitment .................................................................................................. 71 4.5.2 Empathy and Responsiveness ...................................................................................... 74 4.5.2.1 Attitudes of staff towards patients ......................................................................... 74 4.5.2.2 Waiting time .......................................................................................................... 77 4.5.2.3 Response to complaints ......................................................................................... 79 4.5.3 Assurance ..................................................................................................................... 81 4.5.3.1 Privacy and confidentiality.................................................................................... 81 4.5.3.2 Health promotion................................................................................................... 82 4.6 Effects of patients’ satisfaction on their health seeking behaviour .................................... 83 vi University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 4.6.1 Willingness to encourage others to use the Polyclinic................................................. 84 4.6.2 Intentions to use the clinic in the future ....................................................................... 85 4.7 Needs/Suggestions of patients ............................................................................................ 87 4.7.1 Needs of Patients ......................................................................................................... 87 4.7.2 Suggestions of patients ................................................................................................ 90 4.8 Summary of findings............................................................................................................ 91 CHAPTER FIVE ...................................................................................................................... 93 DISCUSSION OF FINDINGS ................................................................................................. 93 5.0 Introduction ........................................................................................................................ 93 5.1 Patients’ satisfaction with health care ................................................................................ 93 5.2 Hospital Environment (Tangibility) ................................................................................... 96 5.3 Facilitators/barriers to patients’ satisfaction ....................................................................... 98 5.4 Effects of patients’ satisfaction on their health seeking behaviour .................................. 102 5.5 Meeting Needs/Suggestions of patients to improve service quality ................................. 103 5.6 Usefulness of the SERVQUAL model in the study ......................................................... 104 CHAPTER SIX ...................................................................................................................... 106 SUMMARY, IMPLICATIONS FOR NURSING, LIMITATIONS, CONCLUSION AND RECOMMENDATIONS ....................................................................................................... 106 6.0 Introduction ...................................................................................................................... 106 6.1 Summary of the Study ...................................................................................................... 106 6.2 Implications ...................................................................................................................... 107 6.3 Limitations ........................................................................................................................ 108 6.4 Conclusion ........................................................................................................................ 109 6.5 Recommendations ............................................................................................................ 109 REFERENCE ......................................................................................................................... 112 vii University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services APPENDICES ........................................................................................................................ 128 Appendix A : Ethical Clearance ............................................................................................. 128 Appendix B: Interview Guide................................................................................................. 129 Appendix C: Consent form ..................................................................................................... 133 Appendix D: Introductory letter ............................................................................................. 137 Appendix E: Summary of Demographic characteristics of Participants ................................ 138 Appendix F: Thematic Code Frame ....................................................................................... 139 viii University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services LIST OF TABLES Table 1: Themes and Sub-themes…………………………………………………………..53 ix University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services LIST OF FIGURES Figure 1: Adapted SERVQUAL model showing the 5 dimensions of quality................... 14 x University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services LIST OF ABBREVIATIONS ENT Ear and Nose Throat GHS Ghana Health Service IOM Institute of Medicine IRB Institutional Review Board MOH Ministry of Health NHIS National Health Insurance Scheme OPD Out-Patients Department SERVPERF Service Performance SERVQUAL Service Quality SPSS Statistical Package for Social Science WHO World Health Organisation xi University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services ABSTRACT Patients have become aware of the need for quality health care, and as a result, the satisfaction of patient is considered as an outcome of health care services delivered, as well as a measure of its quality. Good health in any society or community depends on the quality of health care services delivered. In addition to this, the socioeconomic status of participants, their life style/culture and their environment, play a role in ensuring good health of participants. Researchers’ observation shows that patients are dissatisfied with care being rendered to them. This study, therefore, aims at exploring patients’ satisfaction with health care services. The SERVQUAL model was used as a framework for the study. The Mamprobi Polyclinic was chosen as the site for the study. Participants for the study were selected through a purposive sampling technique from patients who attended the out -patients department (O.P.D) of the polyclinic and both genders were included. In all twelve participants, based on saturation of the study were used. Data were collected, using a semi-structured interview guide accompanied by probes to aid further exploration. Data analysis was done by thematic content analysis, and this was carried out concurrently with data collection. During the study, ethical issues were addressed by ensuring confidentiality and anonymity of all participants. In all five major the findings emerged. Three of them were related to the construct of the model. Namely; patients’ satisfaction with health care, hospital environment and facilitators/barriers to patients’ satisfaction. The remaining two were from the objectives of the study; these were the effect of patients’ satisfaction with their health seeking behaviours and needs/suggestions of patients to improve service quality. At the end of the study, it was recommended that health care providers should be trained on interpersonal skills. In conclusion, the study stressed the need for improvement in the staff strength and physical environment of the polyclinic to ensure patient satisfaction with health care services. xii University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services CHAPTER ONE INTRODUCTION 1.0 Background to the Study The service sector is a rapidly growing area as far as the world economy is concerned, and health service organisations are playing very important roles to champion these advancements (Pakdil & Harwood, 2005; Dagger, Sweeney & Johnson, 2007). On the corporate level, the delivery of quality service is regarded as a pivotal strategy for success and survival in modern times (Reichheld & Sasser, 1990; Zeithaml, Parasuraman & Berry, 1990). This is grounded on the fact that, quality is difficult to replicate or copy; hence it has become a strategic differentiator for the accomplishment of distinctive advantage by service firms (Cheng Lim & Tang, 2000). In modern times, hospitals are faced with not only complex issues of regulating activities in their centres and market forces but also have to grapple with matters akin to service quality (Cheng Lim, Tang & Jackson,1999). This is because, patients continuously display a strong desire for greater care and quality service delivery from health care providers (Downey-Ennis &Harrington, 2002). They are not just recipients of health services but are stakeholders in the delivery of quality health services through their evaluation of care. (Iftikhar, Allah, Shadiullah, Habibullah, Muhammad & Muhammad, 2011; Clever, Jin, Levinson, & Meltzer, 2008). Services offered in the health sectors unlike other service sectors must be done with extraordinary professionalism because the level of professional output can make a difference between life and death (Ministry of Health [MOH], 1997). Patients today, crave not only for 1 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services medical services but also hotel services (comfortable rooms, courteous and empathetic personnel) in whichever health facility they attend. (Yamoah & Adom, 2014). Good life and good health is a vital aspect of the progress and development of society (Bowling, 2014). In any society or community, good health depends on the quality of health services delivered. In addition to this, the socioeconomic status of participants, their life style/culture and their environment, play a role in ensuring good health of participants. An effective and efficient health services delivery will in no small way from the above influential factor through effective health care interventions such as health education, proper management of disease conditions, affordability, accessibility and cost effectiveness help improve the lives of the patients. Therefore, to maintain good health of the population, the health care systems/institutions must ensure an effective and quality health services delivery that meet client/patient needs and expectation, and for that matter clients satisfaction. Quality is measured as an indication of thing (material goods and personality), the significant character of a product or a person, high level of excellence and public standing. This dimensions must first be defined and measured to control and improve it. Ghylin et al., 2008). Perceived quality is said to affect one's satisfaction with services provided. According to Ovretveit (2003), quality comes in three fold namely; client, professional and management quality. Client quality talks about what clients want from the services. Professional quality points out whether services meet the requests of the clients. Do services properly transport the skill and procedures necessary to meet client’s needs/ satisfaction? Management quality deals with the use of resources within the limits and directives set by higher authorities and customers with to ensure efficient and productive services. The combined definition of quality health care looks at these three elements (Ovretveit, 2003). 2 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Quality health services/system gives patients what they want and need at the lowest cost. An attempt by organisations to improve its products and processes regarding meeting the expectations of its customers is an important aspect of quality improvement. Customer satisfaction is one aspect of quality improvement initiatives. However, patient satisfaction in healthcare has no agreement between the literature and how the concept should be defined. Quality measurement model by Donabedian defines patient satisfaction as a measurement of patient-reported result whereas measurement of structures and processes of care is based on patient-reported experiences (Oyvind, Ingeborg & Hilde, 2011). Patient satisfaction explanation emerged from various writers having diverse opinions. Patient satisfaction according to Ahmed et al. (2011) looked at attitudes towards care or aspects of care (Iftikhar, Allah, Shadiullah, Habibullah, Muhammad & Muhammad, 2011). Dissatisfaction occurs when health care services received by the patient is weak and uneven with expectation. However, satisfaction is assured when services received goes in line or beyond patient’s expectations (Laohasirichaikul et al., 2011). In other words, the usage of a service by customers is believed to cause an optimistic feeling which are revealed to be by their satisfaction (Cronin, Brady & Hult, 2000). Mohan et al. (as cited in Rama & Kanagaluru, 2011) talk about patient satisfaction as the patients’ emotional feelings and their view of healthcare services delivered. Other authors equally defined patient satisfaction to be the degree of agreement with patient expectations of ideal care and their perceptions of actual care received (Iftikhar et al., 2011). When patients are satisfied with health care, they will return to a health facility and recommend the place to their families and friends (Aliman and Mohamad, 2013). It is worth- noting that, patient satisfaction is not a single concept, but rather it addresses both values and perceptions. Values are the measurement of those occurrences 3 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services patient experience. Perceptions have to do with patients' beliefs about events that, reflect what happened (Kravitz, 1998). Health care supervisors have moved towards focused method of changing patient satisfaction surveys to a quality improvement tool for general organisational performance. Around the world, various actions have been taken to assess perceived quality of health care and patients’ satisfaction to improve quality of health care services patients’ receive. Patient satisfaction measures and provides healthcare supervisors with valuable information about the structures, process, and outcomes of care (Donabedian, 1988). Measuring satisfaction in Germany has been vital since 2005 as a division of quality management reports (Schoenfelder, Klewer & Kugler, 2011). Since 2002, Department of Health (DOH) from 2002, launched a national survey program were all NHS trusts in England conducted an annual survey on patient satisfaction and reported the results to their managers (Jenkinson, Coulter & Bruster, 2002). Patient satisfaction measurement is a legitimate indicator of improving the services and strategic goals for all healthcare organisations (Elaine, Gail & Richard, 2002). In 2011, Otani, Herrmann and Kurz (2011) conducted a study of hospitals in the United States of America where they identified the impact of nursing care, physician care and physical environment on patient satisfaction. Results gathered showed that all attributes were statistically important and positively related to overall satisfaction. It came to light that courtesy and respect of healthcare providers impacted greatly on patient satisfaction while communication and explanation followed as the second most important aspect of satisfaction. 4 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services When patients are satisfied with health care, they become adherent and loyalty to recommendations from physicians (Zolnierek & Dimatteo, 2009), however, research suggested a questionable connection between patient satisfaction, health care quality and outcomes (Sequist et al., 2008). In Ghana, there have been many health care reforms or programmes implemented with the target of improving health care delivery. In 2005, Ghana implemented the National Health Insurance Scheme (NHIS) to ensure proper and universal access to quality health care (Ministry of Finance, 2003). Customers’ satisfaction and quality of health care services have an impact on the overall success of health care organisations, giving it more importance recently, furthermore a sign by which managers make organisational changes and improvements in performance. Patient satisfaction considers the outcome of health care services delivered as well as a measure of its quality. Identification and comprehending what affects clients satisfaction with health care services received is a reasonable critical approach for attracting healthcare clients to a particular hospital and hence increasing profits (Wang, Chang, Liu & Chen, 2007; Otani & Kurz 2004). Several intellectuals speak out that, enhancement in the quality of hospital services increases patient satisfaction and consolidates customer loyalty (Karassavidou, Niki & Chrissoleon, 2009; Arasli, Haktan & Turan, 2008). In general, patient’ satisfaction is necessary for health care delivery because globally, health care service is becoming increasingly essential to equate health care and other services provided by the non-health institutions. Providers of other types of services are morally, and duty bound to give quality service to their clients. This is also a professional and legal obligation. Consequently, health care as a provision of a critical service to the community and 5 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services the population as a whole cannot be an exception. Health facilities need to always monitor and assess patient satisfaction with health care services to ensure improvement in service delivery and obtain some feedback to facilitate the work of health professionals and policy makers (Bara et al., 2002). It is therefore important for health facilities in Ghana to comprehend and measure customer’s expectations in a direction to identify any gaps in service delivery to ensure satisfaction (Negi, 2009). The service quality (SERVQUAL) model by Parasurman, Zeithaml and Berry (1988) will be employed in this study. Five service quality dimensions were identified in the model name; tangibles, reliability, responsiveness, assurance and empathy. According to Parasurman et al.,(1988), these dimensions predict patient’s perceived quality of service rendered which in turn determine overall patient satisfaction with health care. These dimension were used to assess patient satisfaction with the quality of health care in one of the polyclinics in Accra, the capital of Ghana. 1.1 Statement of the Problem Middle-income countries are struggling with some issues in their health sector. They include: poor health care service, the high cost of treatment and expense for additional services and inadequate health experts is a worry for patients on a daily basis (Fomba, Yang, Zhou, Liu & Xiao, 2010). For too long, commitment to improving quality health care has remained rhetorical in middle-income countries particularly in sub-saharan africa, and poor quality health services are still the only option for many communities in this region (Gold & John, 2013). Middle-income countries have greatly been affected by the exodus of a health 6 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services care professional to developed countries ignoring evident health threats in the continent (Naicker, Plange-Rhule, Tutt & Eastwood, 2009). In Ghana, health division has been endorsed among the best performing compared to next-door countries within West African sub-region. However, there are still objections concerning the performance of health sector regarding patient satisfaction with health care services. Donor agencies have similarly shown concerns about the low professional production in the area of health despite enormous investments of funds into the sector (Abor, Abekah-Nkrumah, & Abor, 2007). The health sector hindrance is not peculiar to simply patients as there are also high levels of dissatisfaction with working conditions in the middle of health professionals leading to high turnover for better opportunities (Fomba et al., 2010). This is ultimately likely to affect negatively on the general quality of health care service provided and patient satisfaction. In 2005, the Ghana National Health Insurance Scheme (NHIS) was implemented to provide a more uniform healthcare delivery method (NHIS, 2011). Consequently, its implementation led to major increases in facility attendance by clients without a corresponding improvement in health infrastructure, equipment and human resource. This placed undue pressure on the existing health facilities (Mensah, Brown, Croft & Geenlund, 2005; Korsah, 2015). Some accredited healthcare facilities in Ghana alleged that NHIS had negative effect on health services delivered whiles others regarded the scheme to be discriminatory in favour of higher level health facilities (Dalinjong & Laar, 2012) Health care delivery should not be compromised as patients have become enlightened through technology about the need for quality health care and value for money anytime they 7 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services visit the hospital. Technology has become an eye opener for the patient to uncover what was covered from them in the past and gain more insight into their conditions and well-being. Patients demand is an important driver for the embracing of technology as consumers have become more empowered and more demanding about the kinds of treatment they want. (Liddell, Adshead, & Burgess, 2008). Personal observation by the researcher has shown that patients at the Mamprobi Polyclinic complain bitterly about the care they received from the health facility. Patients also spend long waiting hours at the polyclinic due to late reporting of staff to work. Sometimes patients are forced to buy medicines from outside the hospital due to a shortage of medicine in the facility. Personal interview with some of the patients in the facility shows that some of them are dissatisfied with the services received from the facility. However, not many studies have been done in Ghana to assess patient perception of health service quality and satisfaction with health care. A few studies done in the past have shown that the quality of health services in Ghana is inadequate (Ghana Health Service, 2003; Ministry of Health [MoH], 2007). Recently, a study by Aggrey and Appiah in 2014, assessed the impact of clients’ perceived quality on health care utilization in Kumasi. However, they only focused on clients on the NHIS. No model was also applied in this work. The associations among patient perception of health service quality, satisfaction with health care and outcomes have not been studied among all categories of patients. Therefore, this study will assess patients’ perception of health service quality at the Mamprobi Polyclinic including patient satisfaction with health care and its effect on their health seeking behaviour. 8 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 1.2 Purpose of the Study Patient satisfaction is very essential in the measurement of healthcare services as it measures patients’ perceptions with regards to the quality of healthcare and service they receive. The purpose of this study was to explore patients’ satisfaction with health care service received at the Mamprobi Polyclinic. 1.3 Research Objectives The specific objectives of the study were to; 1. Determine patients’ satisfaction with quality of health care 2. Explore how the hospital environment influences patients’ satisfaction with health care. 3. Identify the barriers /facilitators to patients’ satisfaction with quality of health care 4. Find out effect of patient satisfaction with health care on health seeking behaviour 5. Identify the needs of patients to improve patients’ satisfaction with health care system. 1.4 Research Questions This study seeks to find answers to the following research questions 1. What is satisfaction with quality of health care among patients? 2. What are the influences of hospital environment on patients’ satisfaction with health care? 3. What are the barriers or facilitators to patients’ satisfaction with quality of health care? 4. What are the effects of patient satisfaction with health care on health seeking behaviour? 9 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 5. What are patients’ suggestions on ways to improve their satisfaction with the health care system? 1.5 Significance of the Study Findings from the study will immensely be beneficial in the following ways; It will provide reliable feedback from patients regarding health care to enable health personnel deliver quality services that maximizes patients’ satisfaction. The study will unmask gaps in the delivery of health services. Understandings gained will enable policy makers and health administrators to commit more funds in the health sector for significant achievements. Additionally, it aids as feedback especially for health administrators with respect to patients’ perception on health care service. Such feedback can adequately place health facility to achieve competitive advantage over other health facilities. The outcome of the study will serve as a future reference point for further educations of public health and other medical students. This research will contribute to the literature of patients’ satisfaction with health care services in polyclinics. 1.6 Researcher’s Motivation There have been recent increases in complaints about health workers on the media and how dissatisfied patients are with the care health professionals provide them. Common complaints have been on the negative attitude of health workers towards patients, undue delay of patients at health facilities for health care services and poor health care. This has motivated the researcher to assess patients’ perception about health care service quality and patients of satisfaction with health care provided. 10 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 1.7 Operational Definition of Terms Satisfaction: Extent to which health care services meet the expectation of the client or an evaluation of an emotion. Quality: The worth health care service provided talk about the patients’ acceptable standards of care delivered to them at the various facilities Perception: Patients’ opinion or view about health care services Patient/ Client: Persons accessing health care services from the Mamprobi Polyclinic Tangibles: Physical surrounding/environment of the hospitals understudy. Responsiveness: Staffs readiness to help patients and provide prompt healthcare service Reliability: Staffs ability to provide service dependably. Empathy: Caring attitude staff to patients at the hospital. Assurance: The knowledge and courtesy as well as the trust of staff to patients. 11 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services CHAPTER TWO LITERATURE REVIEW Introduction Review of literature in this chapter looks at patients’ satisfaction with health care services. The chapter is divided into two sections. The first section describes the theoretical framework used to guide the study followed by a review of studies related on patient satisfaction and a summary of the literature review. Search engines employed for the literature in this study includes SceinceDirect, emerald insight, PubMed and Google Scholar. Mesh words used during the search include patient satisfaction, quality health care, health care and service quality. Empirical studies on patients’ satisfaction were organized based on the objectives of the study. Theoretical framework SERVQUAL Model was used as the theoretical framework to guide the study SERVQUAL Model SERVQUAL model; a multi-item scale developed to assess customer perceptions of service quality in service and retail businesses. Zeithaml, Parasuraman and Berry (1990) defined service quality as perceived by customers as “the extent of discrepancy between customers’ expectations or desires and their perceptions”. Their exploratory qualitative studies on quality or service delivery resulted in a great deal of knowledge about service quality from a customer perspective about how customers define and evaluate service quality. Findings from their qualitative studies supported the view that “… the key to ensuring good service quality is meeting or exceeding what customers expect from the service” (Zeithaml et al., 12 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 1990). This means that in case a customer has an expectation of what constitutes excellent service quality before receiving service and the actual service exceeds the expectation, then the customer will evaluate the service quality as excellent. On the contrary, if the actual service falls short of the expectation, then the customer will evaluate the service quality as something less than excellent. Ten dimensions by which customers use to judge the quality of the service delivered by the provider were derived from their exploratory qualitative study. They were labelled as: “tangibles, reliability, responsiveness, competence, courtesy, credibility, security, access, communication, and understanding the customer” (Zeithaml et al., 1990). Following the exploratory study, the SERVQUAL developers began a quantitative research project to develop an instrument for measuring customers’ perceptions of service quality. The SERVQUAL customer perception tool which was developed through this process consisted of 22 statements to ascertain the general expectation of customers concerning a service and 22 matching statements to measure customers’ assessment of a specific organization within the service industry. They developed 97 items that corresponded with the 10 dimensions of service quality that were identified during the exploratory research phase. The qualitative testing phase resulted in the elimination of roughly “two-thirds” of the original items and the consolidation of several overlapping quality dimensions into five new, combined dimensions (Zeithaml et al., 1990). The five new dimensions identified were: tangibles; reliability; responsiveness; assurance and; empathy. 13 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Reliability Responsiveness Service Patient Quality satisfaction Assurance Empathy Tangibles Figure 1: Adapted SERVQUAL model showing the 5 dimensions of quality The SERVQUAL Dimensions Reliability Reliability represents the ability to perform service dependably and accurately. This comprises the reliability of the service provider in providing the service and also whether services are provided as promised, performing services right the first time, sincerely solving patient‘s problems and provision of services at the right time (Parasuraman et al., 1988). Reliability reflects the service provider’s consistency and certainty in terms of performance. It is the most important dimension for the consumer of services. Health administrators must invest in extra resources consistently for reliability of services to be achieved. Abu-Kharmeh (2012) indicated that, reliability placed last among the five SERVQUAL dimensions that was 14 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services used to measure service quality in Jordanian hospitals. Nonetheless, reliability remains a key SERVQUAL dimension in evaluating service quality Responsiveness Responsiveness or responsibility is the willingness of staff to help and `respond to customer need. This assesses whether company employees helpful and capable of providing fast service. This helps in measuring company and employee receptiveness towards clients. This aspect focuses on whether health care providers are helpful with patient care and offer prompt service. Patients at this dimension are informed of the exact service that will be rendered, the promptness of service given to patients, willingness of hospital staff to help patients and the commitment of hospital staff in responding to patients request even when busy (Parasuraman et al., 1988). Assurance Assurance represents the ability of staff to inspire confidence, trust and gives patients the feeling of safety. Thus the understanding and politeness of employees and their ability to inspire trust and confidence in service users. Friendly interactions according to Curry and Sinclair (2002), are likely to increase patients‘satisfaction with health care and improve their access to information relating to their condition and treatment. The interaction of health professional with patients also offers some kind of psychological healing to alleviate their suffering (Ayimbillah Atinga, 2012) 15 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Empathy Empathy is the extent to which caring individualized service is given. The ability of an individual to experience another person’s feelings. Thus it involves the provision of careful and personalized thoughtfulness to service users. To the patients, quality health care services requires among other things such as meeting their emotional needs, having healthcare providers that respect and know their health beliefs, showing respect to them, listening to them and anticipate their needs and giving equal care for all (Sofaer & Firminger, 2005). Tangibles Tangibles represent the physical facilities, equipment, and staff appearance. It includes the good condition in which the service provider’s physical installations, equipment, people and communication material are. However, since there is no physical element to be assessed in services, clients often trust the tangible evidence that surrounds it when making their assessment. The tangible dimension has been described with different names such as: physical environment and Infrastructure (Karassavidou et al., 2009; Yogesh & Satyanarayana, 2012), physical environment (Reidenbach & Sandifer-Smallwood, 1990) physical environment (Arasli et al., 2008), and pleasantness of environments (Otani & Kurz, 2004). A very clean, safe and well-layed-out environment of the health facility can significantly improve the patient‘s mood, satisfaction with health care services. These dimensions largely looks at the human side of service delivery (responsiveness, reliability, assurance, and empathy) and the tangibles of service. Service quality measurement 16 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services is therefore based on how consumers assess the service delivery process and outcome of the service (Parasuraman et al, 1985). According to Parasuraman et al. (1985), when expectations are met (or exceeded) then service quality has occurred and when not met then there is a break in service. For each statement a gap mark is calculated as perception score minus expectation score. Positive gap score indicates that expectations of customers have been met or exceeds and a negative score also indicates that expectations was not met. For service quality to be good, it must therefore exceed or meet expectation of consumers with regards to services provided (Parasuraman et al, 1985). Significance of SERVQUAL model The SERVQUAL model has extensively been applied and is highly valued (Buttle, 1996). According to Chunulaka (2010), SERVQUAL facilitates understanding of what customer value is all about and enables an organization to better position itself to meet the needs and expectation of patients. A study by Rohini and Mahadevappa (2006) stated that, the model is a consistent and dependable tool that recognised five diverse dimensions of service quality and authenticates those dimensions in other service situations. Babakus and Mangold (1992) revelation showed that, SERVQUAL is a reliable and an effective model in the hospital setting. O‘Connor, Trinh and Schewchuk (2001) therefore identified the SERVQUAL instruments as an appropriate tool for analysing gaps comprehending patient expectation among health care stakeholders. The SERVQUAL as a tool in measuring the differences between patients’ preferences and their actual experiences was adopted by Pakdil and Harwood (2005). The SERVQUAL instrument has a standardized analysis procedure to facilitate explanations of results in hospitals, this has been the 17 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services views of researchers like Rohini and Mahadevappa (2006). Qin and Prybutok (2009) further argued that all the five dimensions of the SERVQUAL instrument are significant and reliable in a health care setting. Mangkolrat (2008) in measuring patient satisfaction enumerated the benefits of using seven SERVQUAL approach. They followed as: views of clients about service encounters were elicited e.g. client position, expectations, satisfaction, Specific areas of excellence and weaknesses are identified with SERVQUAL. It addresses the service gaps which can serve as a basis for formulating strategies and tactics in order to ensure the fulfilment of expectations, Alerts management to consider the perception of both management and customers, it is able to prioritize areas of service weaknesses. It provides benchmarking analysis for organizations in the same industry and the SERVQUAL model can trace the trend of customers‘relative importance, expectations and perceptions, if applied periodically. Justification for the Model Selection The SERVQUAL model by Parasuraman et al. (1988) was selected for this study. It has been applied across various industries including the health sector. National Health Service (NSH) hospitals in the United Kingdom (UK) carried out an investigation of patient’s satisfaction by using the SERVQUAL model to aid in a study conducted by Youssef, (1996) using the five SERVQUAL dimensions .Reliability emerged as the most significant predictor of patients’ overall satisfaction. This was closely followed by empathy as the second important dimension, then responsiveness and assurance. The least important out of the five SERVQUAL dimension was tangibility. Yesilada & Direkor, (2010) also used the SERVQUAL model to compare the quality of healthcare services amongst public and private hospitals in Northern Cyprus. The revealed three significant dimensions; reliability, empathy 18 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services and tangibles were identified. This findings by Yesilada & Direkor (2010) is similar to that of Youssef (1996). Curry and Sinclair (2002) used the SERVQUAL model to assess the quality of physiotherapy services in three physiotherapy services in Dundee, Scotland. Compared to Yesilada and Direkor, (2010) who assessed the five dimensions of quality in both public and private hospitals. Jabnoun and Chaker (2003) earlier on also carried out a similar study to that of Yesilada and Direkor, (2010) where they established a link between public and private hospitals in the United Arab Emirate. Factor analysis resulted in five dimensions; empathy, tangibles, reliability, administrative responsiveness and supporting skills. Significantly, they identified differences between private and public hospitals in terms of overall service quality in empathy, tangibles, reliability and managerial responsiveness dimensions. Their findings point out that, public hospitals were perceived to be effective than private hospitals on service quality. Ajarmah and Hashem (2015), used the SERVQUAL model to evaluate patient satisfaction by comparing the services rendered at accredited and non-accredited hospitals in Jordan. Patient satisfaction was measured using the SERVQUAL scale (tangibility, reliability, responsiveness, assurance and empathy). The results showed considerable evidence that accreditation significantly improves patients' satisfaction. A study by Wong, (2002) pointed out that, three dimensions namely: responsiveness, assurance and empathy of SERVQUAL model were significant factors than the other two dimensions (reliability and tangibles) affecting overall patient satisfaction. Abu-Kharmeh (2012), maintained the five SERVQUAL dimensions of: tangible, responsiveness, assurance, 19 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services empathy and reliability to evaluate the quality of healthcare services in the Hashemite Kingdom of Jordan. Related studies/empirical studies 2.1 Perception of quality of health care Quality is a multi-faceted concept defined in different ways. At a wide level, quality reflects the extent to which health care service or product produces a desired outcome (Runciman, Merry & Walton, 2007). It serves as a guiding principle in assessing how well the health system is performing. According to World Health Organization (WHO, 2006), health system must pursue to make progresses in six areas or dimensions of quality. To ensure that, these dimensions required are ensured, quality health care must be effective, efficient, accessible, patient-centred, equitable and safe. Patient perception about quality of health care is essential for many reasons. Most importantly for hospitals to establish a patient oriented quality health service and not only focusing merely on the patient’s disease (Dayasiri & Lekamge, 2010). The reputation of health care institutions is uplifted due to improvement in service quality gained. Patient satisfaction is also a valuable competitive tool, to increase staff motivation. Recently researches done has shown that, service satisfaction can enhance patients’ quality of life significantly (Dagger & Sweeney, 2006). To the patients, quality health care is when needs are met and delivered courteously and on time (Brown, Franco, Rafeh & Hatzell, 1998). In sum, relieve of symptoms and illness 20 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services prevention effectively are the services clients want. This is because, satisfied clients comply more with treatment and continuously use health services. The dimensions of quality that relates to clients satisfaction equally affect the health and well-being of the community (Naidu, 2009). Hence,the focus of patients and community members are on effectiveness, accessibility, interpersonal relations, continuity, and amenities (which is the most important dimensions of quality) (Naidu, 2009; Mohammad, 2013). These dimensions work independently and interdependently to influence patient perception of health care services (Naidu, 2009; Parasuraman et al, 1985). Generally, client perception of effectiveness is when desired or expected outcome is achieved (Runciman et al., 2007). Therefore client perception of quality of health service delivery depends on the extent to which their expected outcomes are met. In addition to effectiveness of health care services, easy accessibility of health care services that meet clients’ expected outcome is perceived as being of a higher quality (Zeithaml et al, 1990). Positive attitude refers to empathy and responsiveness of health care providers toward clients, making them feel accepted and cared for, and which also increases client perception of health service quality (Chaniotakis, & Lymperopoulos, 2009; Naidu, 2009; Zeithaml et al, 1990). This determines the level of assurance that clients have about the services provided. The continuous provision of effective and easily accessible health care services by friendly health care providers also increases client perception of health service quality positively. (Alrubaiee & Alkaa'ida, 2011; Ayimbillah Atinga, Abekah-Nkrumah & Ameyaw Domfeh, 2011). 21 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Continuous provision of effective health care services reflects reliability of health services provided. The availability of proper hospital amenities within the serene and neat environment makes clients feel more comfortable, and also enjoy services provided (Ayimbillah Atinga, Abekah-Nkrumah, & Ameyaw Domfeh, 2011). These are known as tangibles that enhance comfort among clients within the health facility (Naidu, 2009). A study by Turkson (2009) assessed patients’ perception of quality healthcare delivery in rural districts in Ghana at Komenda-Edina-Eguafo-Abrem District as the study setting. This was a mixed method study which employed both qualitative and quantitative approaches. Turkson, (2009) explored perceptions of patients about quality of healthcare received and identified areas for likely intervention to help improve patient satisfaction with health care delivery in the district. In his study, a total of 803 patients were purposively selected and interviewed after their visit to the hospital facilities using a pretested questionnaire, in thirteen communities a focus group discussions was conducted (Turkson, 2009). However, no model was applied in this study. Quantitative data was used Statistical Package for Social Sciences (SPSS) version 11.0 for windows and data from interviews were analysed qualitatively using the content analysis approach. The study revealed that, most respondents were females and 32 years represented mean age of respondents. Turkson, 2009 showed that, those who waited for less than an hour before registration to receive their card formed majority. This was followed closely by patients who had to wait less than two hours and others more than two hours. Majority found the waiting time to be reasonable. The period from which patients had to wait for their cards before being attended to by medical assistant was 52.2%, which was less than an hour and the other waited for more 22 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services than an hour. Respondents gave their rating in proportion for the following cleanliness of the various facilities and their surroundings were, clean was the highest followed directly by very clean and fairly clean with the last as very dirty. A conclusion drawn saw that quality of healthcare as measured by the indicators used were generally observed to be high except in patients who were not told about their diagnosis or instructions on what to do about their illness (Turkson, 2009). 2.2 Patient satisfaction with health care A major determinant of quality health care delivery is patient satisfaction (Naidu, 2009). A discussion was put forward by Kotler (2003) saying that satisfaction is a person's feelings of liking or disappointment as a result of comparing a product's perceived performance (or outcome) in relation to their expectations. Based on this review, customer satisfaction is defined as the effect of cognitive and affective assessment, where certain comparison standard is linked to the actually perceived performance (Giese & Cote 2000). When the expected performance is more than perceived performance then, customers become dissatisfied. Alternatively, if the expectation exceeds perceived performance, customers turn to be satisfied. Otherwise, if the perceived performance is equal to expectations, customers are in an indifferent or neutral stage. According to Gustafsson (2005), customer satisfaction as a customer's overall evaluation of the performance of an offering to date. This general satisfaction has a strong positive consequence on customer loyalty intentions across a wide range of service and product groups. Kotler (2003), give details that the satisfaction judgment is associated to all the experiences made with a certain business relating to its known products, the sales process, and the after- sale service. The ability to 23 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services satisfy the customer after sales purchase depends on the offer's performance with regard to the customer's expectation; Customers form their expectation from previous buying experience, and word of mouth from associates and friends, and marketers' and competitors' information and promises. Patient satisfaction is seen as both an outcome and an indicator and may offer a simple first step into understanding quality of care. To understand and measure customer’s expectations it is vital to identify any gaps in service delivery so as to ensure satisfaction (Negi, 2009). In a mixed method study involving a purposive sample 803 patients in the the Komenda-Edina-Eguafo-Abrem District in Ghana, Turkon (2009) assessed patient satisfaction with quality of health care. The study revealed that, respondents who were satisfied or very satisfied with the care received during their visit to the health facility formed majority. Respondents’ satisfaction levels and proportions were described as follows, very satisfied (26.5%), satisfied (62.8%), fairly satisfied (6.4%), dissatisfied (1.4%), very dissatisfied (0.2%) and no response (2.7%). The authors concluded that the overall level of satisfaction was high and commendable. Aggrey and Appiah (2014) assessed the influence of clients’ perceived quality on health care utilization. In this cross-sectional study, 400 clients from ten health facilities in the Bantama sub-metro in the Kumasi metropolis of Ghana took part. Both qualitative and quantitative data were collected and analysed. Data was collected through interviewing using semi-structured questionnaires using SPSS and analyzed descriptively using frequencies and means and inferentially using independent t-test and Chi-square test. Majority of the respondents were of the view that their level of satisfaction of health care is good with a few going the extra mile to express their satisfaction as excellent. This was due to the positive 24 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services perception they had about the health care services provided at the facility. However, others expressed their levels of satisfaction to health care as very poor, poor and average respectively. Xesfingi and Vozikis (2016) investigated patient satisfaction, and also the relationship between patient satisfaction of healthcare system and a set of socio-economic and healthcare provision indicators. 31 countries for the years 2007, 2008, 2009 and 2012. Their findings suggested a strong positive correlation between patient satisfaction level and the availability of healthcare personnel especially physicians’ .their study also revealed that the older a patient was, the more satisfied he or she was with the country’s healthcare system. Mohan and Kumar (2011), examined satisfaction of patients with respect to selected hospital related services. A sample of 150 patients at different educational backgrounds were selected and studied with reference to various factors that influence the satisfaction of patients. The study attempted to identify factors which are the combination of pharmacy, laboratory, radiology, blood bank and laundry & linen services. Gender analysis of patient satisfaction with respect to various hospital services revealed that, both male and female patients were highly satisfied with cleanliness, and least satisfied with behavior of staff and charges for medicines. In another Ghanaian study, Peprah (2014) employed the SERVQUAL model to assess determinants of patients’ satisfaction at Sunyani Regional Hospital using a quantitative approach. In this cross-sectional study, a pretested questionnaire was administered to 212 randomly sampled patients. The associating factors with patients’ satisfaction at the Sunyani Regional Hospital were categorized into six main components. One key factor that influences patients’ satisfaction is empathy. The patients felt that their satisfaction level about the service 25 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services delivery would probably go high when they are treated with utmost care and given individualized attention. The finding pointed out that the rudeness of nurses and other staff, the ability of the hospital to provide individualized attention to the aged and physically challenges, understanding the specific needs of patients, and keeping patients informed about when service will be performed were other factors under empathy dimension that determined patients’ satisfaction. Other factors extracted were the politeness of staff, the willingness of nurses to answer patients’ questions, patients being given enough time to tell the doctor their problem and the feeling of being secure at the hospital. These factors among others were also utmost in determining the satisfaction of patients of Sunyani Regional Hospital. Furthermore, reliability of the hospital was identified as another factor that contributed immensely to patients’ satisfaction. Thus, the ability of the hospital to perform the promised service reliably and accurately. Patients expected that service delivered was without time wasting, the level of service remained the same all times (day and night), patients had enough time to tell the doctor their problems, and the hospital delivered 24 hour service. The result further showed that the third factor affecting patients’ satisfaction was tangibility. By this dimension, the provision of direction / written material that are easy to read and understand, how easy to locate the hospital, attractiveness and cleanliness of the hospital all the time, the neatness and smartness of the staff and the availability of up-to-date equipment play a crucial role in determining the satisfaction of patients (Peprah, 2014). According to Peprah (2014), communication or interpersonal relationship at Sunyani Regional hospital was the fourth component or factor associated with patients’ satisfaction. Patients were of the view that they felt satisfied with service delivered whenever the doctor patiently told them their diagnosis, clearly explained what was wrong before giving any 26 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services treatment, and was ready to answer their question. Also whenever the pharmacist gave them detailed information or instruction about their medicines, it made them happy and satisfied with the service. Another interesting finding of the study was that the reputation of the hospital was also recognized as a factor affecting patients’ satisfaction. Patients were of the view that a hospital with good reputation is capable of assuring of quality service delivery. According to them, they feel save and secured about the services of a hospital with a good reputation. The responsiveness of the hospital in terms of how it responded to emergency cases was also identified as the last component associated with the satisfaction level of patients in Sunyani Regional Hospital. From the analysis, whenever the hospital reacted promptly to the needs of patients and emergency cases, it made them recognize the willingness of the hospital to help them and therefore, the patients felt satisfied about the service delivery. Various authors have not arrived at a consensus regarding the definition of patient satisfaction with regards to health care however, numerous definitions have been given on the concept. Some authors have conceptualised patient satisfaction in the context of vital non- clinical services that accelerates patients. Jenkinson, Coulter, Bruster, Richards & Chandola, (2003) and Iftikhar et al. (2011) for example, defined patient satisfaction to a large extent as attitudes towards care or aspects of care. For Rama et al. (2011) patient satisfaction is the patients’ emotions, feelings and their perception of delivered healthcare services. This further suggest that, delivering quality healthcare requires a comprehensive approach as patients are not only concerned about physician care, admission process, physical environment and cleanliness but also in the courtesy, respect and attention they are accorded (Schoenfelder, Klewer & Kugler, 2011; Rafii, Hajinezhad & Haghani, 2008 ; Choi, Lee, Kim & Lee, 2005). 27 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services A study conducted by Otani, Herrmann and Kurz (2011) indicates that, courtesy and respect exhibited by healthcare personnel impact more on patient satisfaction while communication and explanation are the second most important determinants of care for patients. In contrast, a study conducted hospitals in Ireland revealed that, effective communication and clear explanation had the strongest effect in improving the overall patient satisfaction among other attributes of care (Sweeney, Brooks, & Leahy, 2003). Other authors however have conceptualized patient satisfaction as a degree of congruency between patient expectations of ideal care and their perceptions of real care received (Iftikhar et. al., 2011). The quest to meet the needs of patients requires the effort of all stakeholders in the health fraternity. The role of doctors for instance is very pivotal in attracting patients to a health facility. According to Rocque and Leanza (2015), patients’ consultation encounter with a doctors has a positive correlation with their decision to re-visit a facility. Patients among other things desire quality time and attention from nurses in relation to their care. (Molazem, Falahati, Jahanbin, Jafari & Ghadakpour, 2014; Jolaee, Nasrabadi, and Yekta, 2004; Kalyani, Sharif, Ahmadi, and Iman, 2013) .Out-patients often develop a feeling of inner assurance and harmony when they observe nurses standing or being by their side willing to attend to their needs. (Molazem, Falahati, Jahanbin, Jafari & Ghadakpour, 2014)These findings adequately offers enough basis to support claims that the delivery of quality services is not the duty of specific health practitioners but all personnel within the health fraternity. The authors concluded that a number of factors influence patients satisfaction including attitudes of nurses toward patients, the capacity to deliver prompt service without wasting time, ability to disseminate information to patients, the availability of up-to-date equipment, the hospital’s ability to render 24 hour service, response to emergency cases, the 28 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services patience of the doctor to clearly explain what was wrong with patients before giving treatment, providing patients with detail information about their medication, and attractiveness and cleanliness of the hospital. The need for these factors to be given the necessary attention to help deliver services that meet the needs and expectations of patients was underscored. 2.3 Barriers to patients’ satisfaction with health care Aggrey and Appiah (2014) in their cross-sectional study also assessed the influence of clients’ perceived quality on health care utilization in the Kumasi metropolis. In this mixed method approach they found that majority of the respondents (40.2%) were of the view that on the average, they spend more than three hours when they visit health facilities per day. Only 8.7% of the clients spent less than an hour at the health facility averagely. Those who spent between 1-2 hours and 2-3 hours on their visit to health facility for a particular day are 22.1% and 29.0% correspondingly. The in-depth-interview from the study also revealed that the delay (time wasted) in health facilities might be due to insufficient workers, increased workload, conversation among health staffs and long queues, insufficient doctors, increased workload of doctors and long queues. Majority of the participants in the in-depth interview disclosed that they do not get their laboratory results easily done. Notwithstanding, the respondents opined that the non-insured spend much longer time at the facility because they have to go through a lot of procedures. Despite the time wasted, they expressed that they prefer NHIS to “cash and carry” with regards to time spent at the health facility. According to Aggrey and Appiah (2014), about 80% of the clients in the qualitative study further disclosed that they face problems when they have to collect their medicines from the pharmacy or dispensary. The participants indicated that they spend so much time as a 29 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services result of unprofessionalism on some part of the dispensers. Others disclosed that there are drug shortages sometimes and this causes delay. Some participants further disclosed that they are not given all prescribed drugs at the dispensary and this they attributed to the fact that, the NHIS does not cover all drugs and some drugs are sometimes not available at the health facility so they have to buy from a private pharmacy. However, for the effectiveness of the drugs; majority (75.4%) accept that the drugs prescribed to them are effective with 13.7% of the clients going the extreme ends to express much more satisfaction that the drugs are very effective when used. Notwithstanding, 8.1% of the respondents are at the other side of the coin. Left to them alone, one could say, the drugs rendered to them are ineffective. Also, 2.8% of the clients expressed their views in a dilemma manner not knowing whether the drugs are very effective, effective or inefficient. Turkson (2009), in his mixed method study, also assessed patients’ satisfaction with the quality of healthcare delivery in the Komenda-Edina-Eguafo-Abrem District in Ghana. Out of the 13 communities were focus group discussions was held, findings show that quality of services was acceptable in most of the facilities. However, specific issues identified had the potency to impact service utilisation and quality of care. Firstly, ranges of drugs given were restricted to main painkillers, vitamins and anti-malarial drugs. Staffs were inadequate, so the few available were overworked and exhausted affecting their performance. Self-medication was encouraged since referral was too many and expensive. To reduce referrals, they suggested taking qualified medical doctors visit on specified days. There was also the need to make available ambulances or vehicles especially to help transport referred cases. Also, some health workers were perceived as rude, unfriendly, unapproachable or impatient, or did not 30 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services respect patients. Favouritism was sometimes practised to the chagrin of other patients. As a result of this, the respondents advocated respect for all. Janicijevic, Seke, Djokovic, and Filipovic (2013), studied the impact that the satisfaction level of health workers had on patients’ satisfaction. Questionnaires were used to mobilise responses from 18,642 healthcare workers and 9,283 patients across 50 secondary healthcare institutions in Serbia. Data were analysed quantitatively. Moreover, findings indicate that healthcare worker satisfaction has an impact on patient satisfaction. Jalil, Zakar, Zakar and Fischer, (2017) examined the association between patient satisfaction and five dimensions of medical interaction: technical expertise, interpersonal aspects, communication, consultation time, and access/availability. A cross-sectional mixed methods study was undertaken involving 1164 patients. Findings of the study indicated that several factors involving doctors’ incompetence, such as inappropriate handling of critical cases, inaccurate diagnose, excessive reliance on medical tests, the absence of physical examination, non-availability of specialist doctors, and experimentation by trainee doctors were the basis for patient dissatisfaction. Arasu (2014) examined the key influences of patient satisfaction and how it is measured in an inpatient facility. A literature search was done through PubMed and Google Scholar to determine specific areas needing improvement. Out of 30 articles that met all search Criteria, the most frequently mentioned areas of dissatisfaction include: food, wait time, follow up/discharge, facility, medical personnel interaction, and activities/program. A further breakdown of specific points of dissatisfaction for each factor was determined by 31 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services frequently mentioned specifics. The systematic review confirmed the concept that patients greatly value access, time, and medical personnel interaction. Also, only emergencies were treated on weekends; no service was rendered. Medical assistants were not available over the weekends in certain facilities. Waiting times were longer, especially at the dispensary or when going for an injection. When seeking medical help, the suggested ideal total waiting time was one hour. There was the need to make available an Information or Complaints reception desk to help clients. They suggested that health personnel should be effectively directed to reduce illegal charges. Conclusively, the attitude of some staff and unavailability of some drugs at the pharmacy were their concern. Patients perceived a poor attitude of some health workers, long waiting times, the high cost of services, inadequate staff, the policy of payment for health services, frequent referrals to hospitals, and lack of ambulances at facilities as being detrimental to effective delivery of quality healthcare. The author indicated that these should be addressed to improve the quality of care. 2.4 Effect of patient satisfaction with health care on health seeking behaviour In India, Mahmood, Ali, Faisal and Kumar (2014) used a quantitative approach to assess the public’s attitude towards seeking healthcare and their satisfaction with health services. This is a descriptive cross sectional study which was carried out in private and public hospitals in Karachi and Hyderabad. A questionnaire based survey was conducted to measure the health seeking behaviour and the factors influencing it. The Chi-square test was used to determine the association of variables. Majority of the patients (56%) visit the doctor’s clinic 32 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services to seek health care services. Around 78% patients prefer to seek professional help for their health related issues. However, majority of the patients (58%) are not satisfied with their experience as it doesn’t meet their expectation. Result showed a significant association of cost of care being a barrier to health seeking behaviour (p= 0.0001) suggesting that the financial burden of utilizing health care services hinder the respondent from seeking medical help for their health problems. There was also a significant association of participant health seeking behaviour with satisfaction from healthcare service (p= 0. 001) suggesting that those who were satisfied with their previous experiences with health care services tend to be more inclined to seek help for their health problem in future. Salam, Alshekteria, Abd Alhadi, Ahmed and Mohammed (2010) assessed patient satisfaction with the quality of primary health care Benghazi, Libya and its effect on health seeking behaviour using a quantitative approach. From January and February 2009, a survey was conducted at nine health centres and seven polyclinics all located in different geographical zones of Benghazi. The Charleston Psychiatric Outpatient Satisfaction Scale was used to assess patient satisfaction with the quality of health care. Inferential statistical tests such as ANOVA (one-way and two-way), t-test, and Chi-square tests were used to test the association between patient satisfaction and demographic variables and health seeking behaviour. It was established that some patients search for treatment from another facility outside their zone of residence (Salam et al., 2010). This choice was significantly associated with the zone of residence. From Al Birka and Al Slawy, a higher proportion of persons sought facilities outside their residential zone. Half of those residing in Al Birka and over one- 33 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services third of those from Al Slawy went outside their residential area. By contrast, only 13.6% of the City Centre residents went to another zone. About half of attendants in the City Centre facilities came from other zones. Whereas only 8.8% of those attending Al Slawy facilities were from other zones. In general, these result shows that patients were more satisfied with the facilities in the City Centre. An analysis of satisfaction among the 100 persons who attended facilities outside their zones supports this results. Those attending facilities in the City Centre were more satisfied (mean 44.6) than those going to Al Birka and Al Slawy (means 39.6 and 34.6, respectively). The differences in satisfaction scores are statistically significant (F-value = 18.0; p = 0.00) which suggests that persons even seek services outside their residential zone were more satisfied. In a cross-sectional study involving 400 patients in the Bantama sub-metro in the Kumasi metropolis, Aggrey and Appiah (2014) assessed the influence of clients’ perceived quality of health care utilisation. Both qualitative and quantitative approaches were used in this study. Data were collected using a structured questionnaire and an interview guide. It was identified that the over-arching reason (51.19%) for clients commending the scheme to a friend was that, the NHIS is cost friendly (affordable). The next scale of order for recommending the scheme to a friend is the respect accorded to them by health staff (22.62%); followed by the excellent services rendered to them (16.37%) and finally the ease of accessing health care under the scheme (9.82%). 34 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Turkson (2009) used a proxy for satisfaction with care given to the facility as to whether or not a respondent was willing to recommend a facility to a friend or to go back to a facility. This mixed method study involving a purposive sample 803 patients in the Komenda- Edina-Eguafo-Abrem District in Ghana. He established that almost 94% of respondents were ready to recommend the facility to their friends or to return to the facility. Notably, dissatisfied patients are unlikely to follow instructions on taking medications or might not come for follow-up care or discourage family members and friends from seeking health care services. 2.5 The Perception of Patients Patient satisfaction is an attitude which is incumbent on the quality of service a patient received. This attitude in turn impacts on his or her loyalty to a facility where health service was patronised. Loyalty created values very pivotal to a health facility. Although patient satisfaction is not the only patient satisfaction element in ensuring loyalty, it is an important determiner (Fan, Burman, McDonell, & Fihn, 2005). It is worth-noting that a myriad of factors streamlines the expectations of patients. They include: word of mouth communication, experience, and external marketing. A patient’s expectation of an effective treatment, for instance, is based on a testimony he or she received from a family member or relative. When a patient may be dissatisfied with a past medical experience such as: prolonged waiting or delayed responses, however, a single appointment that goes smoothly may alter the perception of the patient making him, or she indicate a feeling of satisfaction. Publicity materials such as brochures, billboards, and photographs depicting a caring doctor may lead a patient to opt for a health facility based on perceived expectation of quality (Fan et al., 2005). 35 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 2.6 The Values of Patients Patients’ satisfaction or dissatisfaction is underpinned by some factors. Access for instance to a health facility is of great value to patients. It deals with the patients arranging for and obtaining the needed care. Also, patients with busy day schedules may make time for health services mostly in the evenings hence the availability of services during evening hours is a satisfaction issue to patients (Le May, Hardy, Taillefer & Dupuis, 2001). One of the most crucial commodities for most people is time; delays in healthcare delivery include: waiting time, travel time, or the ease of completing a medical task such as filling a prescription. Delays are often observable in the reception and treatment rooms. Although delays will naturally occur, the manner in which they are handled determines how patients perceive them. Proper handling of delays includes: providing an explanation of the delay and minimising total waiting time in the reception and treatment room. Patients become relaxed when a delay was communicated to them. When patients see medical personnel preparing for an examination, delays become more bearable given some progress being made to curtail it (Le May et al., 2001). Time wasting is most critical to a patient in emergency situations. The perceived value of health care drastically reduces upon the idea that a particular service is not available at a stipulated time. For a situation, the patients are likely to choose another competitor to obtain health care in the future. (Urden, 2002; de Bronk art, 2011). There is the tendency among doctors and paramedics to use jargons in explaining disease conditions to patients. Such explanations are often done in a rash. This gets patients very frustrated and leaves them more confused. Such patients are likely to seek a second opinion from another health professional. In addition to sufficient time in the consulting rooms, patients greatly value all their questions being answered (Saultz & Albedaiwi, 2004). 36 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 2.7 Summary The literature review above has shown that there has been much research undertaken on the quality of healthcare delivery, the expectation of patient, perceptions of health care quality and equity in healthcare. In general, perceived quality depends on the degree to which expectations are met. The more client perception of health service quality was achieved, the higher client satisfaction was felt. Thus reflecting a direct relationship between perceived service quality and satisfaction with health care among clients. Similarly, client satisfaction with health care has a direct connection with their health seeking behaviour. Increase levels of satisfaction with health care lead to more positive health seeking behaviour and vice versa. However, barriers to patient satisfaction with health care services are factors that hinder clients’ realisation of expected outcomes in accessing health care services. It also reflects situations whereby empathy and responsiveness among staff, in addition to tangibles, are poor. Information on the number of patient satisfaction surveys carried out in Ghana is inadequate. Moreover, surveys do not give reasons to their answer making it difficult to justify the result gotten from other studies. Studies in Ghana on patient perception of quality of health care employed a quantitative approach. Only one known study used a mixed method approach which is not enough. Also, to that, no model was applied. The only known study that applied the SERVQUAL Model used a quantitative approach, indicating a gap in qualitative assessment of patient perception of health service quality with the application of a model. This void is what this study seeks to fill. 37 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services CHAPTER THREE METHODS 3.0 Introduction This chapter describes the methodological processes of this study. This includes the research design, research setting and target population. A description of the sample and sampling technique was provide including the tool for data collection and process, data analysis process and ethical issues. 3.1 Research Design The research design used referred to as the blueprint for carrying out a study which has total control over all factors with the tendency to influence the validity of the findings (Burns & Grove, 2009). An exploratory descriptive approach was used to guide this study. According to Fain (2017), qualitative approach to research provides one with the opportunity to acquire a deeper understanding and rich descriptions of people’s experiences of the phenomenon under study. According to Denzin and Lincoln (2000), qualitative research includes a realistic interpretive approach to the world. Qualitative researchers study things in their natural settings, attempt to make sense of them and interpret phenomena regarding the meanings people bring to them. This helps to provide insights into the problem, therefore, helping one to discover or expand in knowledge. The main goal of qualitative research is to acquire additional understanding and help explore the depth, richness, and complication that characterise the phenomenon being studied. 38 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services The explorative descriptive approach to research involves investigating the full nature of phenomena rather than simply observing and explaining the phenomena, and this provides an insight into comprehension of an issue or situation (Polit, Hungler, & Beck, 2001). The flexibility of data sources such as the use of secondary data, interviews and discussions, in addition to its focus on understanding a phenomenon rather that making definite conclusions are some of the advantages of the exploratory approach to research. An exploratory descriptive research design helped the researcher to have an objective and accurate description of the phenomenon under study (Polit & Hungler, 2013). It provides a general overview of the concept and the way certain phenomenon occurs, thus helping to describe and providing answers to certain life experiences. The exploratory qualitative design helped the researcher to explore and describe patients’ satisfaction with health care services received at the Mamprobi Polyclinic in Greater Accra. 3.2 Research Setting The study was conducted at Mamprobi Polyclinic which is amongst the polyclinics in the northern part of the Ablekuma Sub-Metropolis. In August 1972, Ministry of Health (MOH) in Ghana established the facility to provide medical care to individuals within the Mamprobi community and its environs. Within Ablekuma Sub-Metropolis Mamprobi polyclinic is the biggest of the public polyclinics. The polyclinic provides a comprehensive curative and preventive healthcare service to the general public as well as training of students in public health care and general practice. An out-patients care services is offered at the polyclinic, which are as following: nutritional rehabilitation services, eye care services, pharmacy services, ante-natal and maternity 39 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services services, medical laboratory services , community psychiatry services; oral health (dental) services, reproductive and child health (RCH) services (including adolescent health and counselling services), x ray services, ENT ( ear, nose and throat) services. A bed capacity of 55, staff strength of 169 accordingly two specialists, three medical officers, one psychiatric officer, six physician assistants, 55 general nurses, 46 midwives, three psychiatric nurses, two community mental health officers, 40 enrolled nurses and 11 health care assistants. The facility offers 24 hours general out-patient health care services. There are two wards within the facility (labour and recovery ward) and an emergency unit. The recovery and labour ward provide 24-hour health care services which include detention, admission and observation of general patients and pregnant women. The facility is a centre for a research study. One of the busiest units in the facility is the out-patient department (OPD). The unit has five consulting room for consultation which is operational throughout the week. A specialised clinic runs in addition to general medical consultations that is HIV clinic, hypertensive clinic as well as diabetic clinic and gynaecology clinic. The ENT, eye unit, emergency unit and the recovery ward are all within the OPD. High patronage and the fact that the polyclinic is the largest public health facility within the Ablekuma Sub-Metropolis was the reason for selection of Mamprobi Polyclinic. 3.3 Target Population The target population is the number of subjects or people that was recruited for a study (Korb, 2012). The target population for this study include all patients accessing health care services at the Mamprobi Polyclinic. 40 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 3.4 Inclusion criteria The criteria for inclusion are patients above 18 years of age and receiving treatment at the Mamprobi Polyclinic. Those above 18 years are considered as matured to give voluntary consent regarding their participation. Only patients who have accessed health care at the polyclinic were included in the study since such individuals are in a better position to give well-informed opinions about health care delivery at the polyclinic. This was to ensure that participants can remember their experiences and observation in general with regards to health care services received at the polyclinic. This places them in the position to be able to give an accurate account of their observation on health care services they received from the polyclinic. 3.5 Exclusion criteria Seriously ill patients on admission to the facility was excluded from the study. Patients below 18 years and patients who have come from other facilities to buy medicines including those who have been referred from other facilities for medical laboratory or x-ray services was excluded from the study. This is because this category of patients have not had enough interactions with the staff of the polyclinic and enough experience with health care services provided in Mamprobi Polyclinic. Seriously ill patients may also be too weak for interactions with staff of the clinic and might not be able to speak. Those below 18 years were excluded given the fact that maturity age of voting in Ghana is 18 years and above. 3.6 Sample size The sample is a subset of subjects obtained from the target population to denote the population for the study (Nieswiadomy, 2008). It was estimated that saturation will occur at 41 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services the 20th participant (Guest, Bunce & Johnson, 2006). In other words, when there is no new information forthcoming, saturation is said to have occurred (Walker, 2012). Saturation refers to the collection and analysis of data through the general process until it reaches a point where no new or relevant insights emerge from the data being collected (Bryman, 2012). Data saturation concept is important because it addresses the issue of whether a study is centred on the adequate sample to demonstrate content validity (Francis et al., 2010). However, the actual sample size was determined after the contents of the themes and subthemes of the data collected were satisfactorily met and subsequent interviews provided redundant data. For this study, saturation was reached at the twelve interview hence the sample size of the study was 12. 3.7 Sampling technique Purposive sampling technique was employed to select participants for the study. This is a form of non-probability sampling technique whereby subjects or participants are selected based on certain properties that are of interest to the researcher. This sampling technique enabled the researcher to select the participants based on their specific understanding of the phenomenon under study and to share that knowledge with the researcher (Speziale, Streubert & Carpenter, 2011). In this study, only patients, above 18 years of admission including those accessing health care services at the OPD of the Mamprobi Polyclinic were selected for the interview. This was done with the assistance of the staffs at the Records department, OPD and recovery ward. These staff served as contact persons who helped the researcher to identify patients at 42 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services the OPD and those on admission who qualified for the inclusion into the study and introduce them to the researcher. The researcher informed them about the study. They were informed and were engaged in an interview about their views on the health care services provided at the facility in addition to how the interview was conducted. Those who decided to take were recruited for the study; consent form was signed indicating their willingness to be part of the study. 3.8 Data collection tool In this study, data collection was carried out by the use of a semi structured interview guide (Appendix B). The guide used open-ended questions to solicit views of participants regarding health care services at the polyclinic (DiCicco-Bloom & Crabtree, 2006). This approach allowed the researcher to have an in-depth discussion with the interviewees. It was very flexible and provided the interviewee's opportunity to freely express themselves and provide in-depth information concerning their experiences of the phenomenon under study. Furthermore, the researcher is also allowed the opportunity to seek clarifications by asking follow up questions (Kusi, 2012), which also ensures flexibility on the side of the researcher by asking the same questions in different ways to confirm responses from the research participants. The interview guide was in two parts. The first part focuses on demographic data of participants which comprise age, sex, the highest level of education, employment status and religion. The second part of the interview guide looks at (1) satisfaction with health care services, (2) how patient satisfaction with health care services affect their health seeking behaviour, (3) facilitative factors for patient satisfaction in health care setting; (4) barriers to 43 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services patients’ satisfaction with health care delivery system and; (5) how to improve patients’ satisfaction with health care system. The first part of the interview guide is intended to help establish rapport with the research participant to get rich and appropriate data from the subsequent sections of the interview guide. 3.9 Data collection procedure Ethical clearance from the Institutional Review Board (IRB) of the Noguchi Memorial Institute, Legon and the Greater Accra Regional Health Directorate of the Ghana Health Service was obtained to conduct the study. An introductory letter from the school of nursing and midwifery, University of Ghana, Legon, was sent to the management of the Mamprobi Polyclinic to introduce the researcher to them, inform them about the study and seek permission to collect data for the study. The nurse in-charge at the recovery ward and OPDs of the Mamprobi Polyclinic served acted as a contact person to introduce the researcher to the patients. OPD staffs helped the researcher identify patients who qualified for the study. Those who were selected and agreed to take part in the study signed a consent form as an evidence of their consent to participate in the study. Arrangement was made with the nurse manager in-charge of the polyclinic for an office that was used as the venue for the interviews. The interviews began with questions on socio-demographic characteristics of the participants to establish rapport with them before going on with questions on the purpose of the study. The interviews then continued with open ended questions on the subjected matter under study and participants were permitted to speak uninterruptedly on the subject matter. Subsequent 44 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services probing questions were asked for a further exploration of emerging themes. This was done after the researcher listened attentively and noted down issues which needed to be revisited for clarification. Each interview session lasted for 30 to 45 minutes. The interviews were conducted either in English, “Twi” or “Ga” for the participants. A digital audio recorder was used to record each interview and observations made were recorded in a field note. 3.10 Piloting The interview guide was piloted at the out patients department of the Dansoman polyclinic. Dansoman polyclinic was chosen for the piloting because, it provided similar health care services to patients. It also falls under Ablekuma Sub Metropolis just as the study area and they share similar characteristics. The interview guide was piloted with two participants of the polyclinic, no new modification was added but researcher gained insight to probe further for data. 3.11 Data analysis Data collected that is the field notes, and the interviews were analysed using thematic content analysis approach by Miles & Huberman (1994). The thematic content analysis is a type of qualitative analysis approach to analysing classifications and presents themes or patterns that relate to the data and using interpretations in dealing with diverse subjects in the data (Boyatzis, 1998). The thematic content analysis, therefore, extends away from the counting of explicit words or phrases and focuses on identifying and describing both implicit and explicit ideas (Namey Guest, Thairu, & Johnson, 2008). The thematic content analysis approach was more appropriate for this study because it provided flexibility in the use 45 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services of both inductive and deductive approaches and the opportunity to code and categorise data into themes (Miles & Huberman, 1994). Thematic content analysis approach according to Miles & Huberman (1994) has three stages; data reduction, data display and data conclusion, thus drawing or verifying conclusions. These stages are not separate from each other but overlapping and are complementary. The first phase, data reduction phase, involves sharpening, sorting, focusing, discarding and organising data in such a way that conclusions can be drawn and verified (Miles & Huberman, 1994). It involves selecting, simplifying and transforming the data (Miles & Huberman, 1994). All interviews conducted in vernacular were translated into English by the researcher. The data was transcribed verbatim. Verbatim transcription of interviews carried out in “Twi” and “Ga” was done in consultation with an expert in “Twi” and “Ga”. The analysis was done immediately after transcription in a bid to determine the stage at which saturation occurred. As part of the data reduction process, transcribed data was coded. Coding allowed the researcher to analyse the whole data by identifying the most significant meaning to understand what the data meant (Miles & Huberman 1994; Halldorson, 2009). Coding was done by reading the transcripts over and over to get a feel of texts by handling the data several times (Ryan & Bernard, 2003). Reading over the transcript several times allowed the researcher to appreciate the complete picture, create meaning and connections between the participant's thoughts, ideas and the data collected through observations. After that similar sentence, statements and phrases or words were identified and tagged with common words or phrases, as codes, depicting their meanings. 46 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services The second phase, data display, involved organising, compressing and assembling of information to make sense of the data that was collected. Data display therefore helped in the organisation of data and the arrangement of concepts and the thoughts of the participants (Miles & Huberman, 1994). Sentences that have been highlighted or coded was then arranged into smaller segments or themes. Data display helped one to view the data more clearly to avoid data overload and to making sense of the data collected by displaying related concepts (Halldorson, 2009). This was done using a table to display the themes and sub themes that emerge from the data and its relationship with the constructs of the SERVQUAL model. The last phase was the drawing of conclusions which involved grouping or establishing categories of information that could go together and identify interrelations among factors and variables. After which, conceptual coherence and consistency of the themes are assessed and then fit into the theoretical framework of the study. This was done by aligning the themes and sub themes with the constructs of the SEVQUAL model. The themes and sub themes were presented and then supported by verbatim quotes from the participants known as exemplars. (Korsah, 2015) 3.12 Methodological Rigour The trustworthiness criteria recommended by Lincoln and Guba (1985) was employed in this study to ensure methodological rigour. This includes credibility, transferability, dependability and conformability. Credibility refers to how true the data collected conform to what the participants said. This is in preference to internal validity. The researcher ensured credibility through 47 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services prolonged engagement in the subject matter and member checking by taking the final report back to the participants and determining whether they felt that it is accurate (Creswell, 2003). Dependability refers to the reliability of the study. Lincoln and Guba (1985) underscored the close connection between credibility and dependability, by stressing that in practice, working towards credibility helps in ensuring dependability. To ensure dependability, a detail report of the processes involved in the study has been provided to enable a future researcher to repeat the work, and if possible, to gain the same results. To this end, the research design and its’ implementation, detail explanation of the data gathering process and activities carried out in the field have been spelt out. Confirmability is in preference to the objectivity of the study. This comprises processes carried out to make sure that results from the research are the same as experiences and ideas from the participants rather than characteristics and likings of the researcher. Confirmability was ensured through triangulation of the methods and keeping of audit trail. Triangulation involved a combination of field notes and interviews. By so doing, data from the interviews in addition to data from field notes on observations made on the field was analysed. Secondly, the researcher left a well-documented audit trail to make it possible for others to scrutinise the data and other supporting documents. This makes the reader follow the course of the research step-by-step through the decisions made and procedures described. Transferability refers to external validity or generalizability of the study. It was established through the creation of vivid descriptions that, another researcher can read and easily apply in another context (Speziale, Streubert & Carpenter, 2011). Detailed descriptions have been portrayed exactly as presented by the participants to ensure transferability. This 48 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services comprises enough related data about the research to enable the reader make such a transfer. The following additional information has been provided to ensure transferability; detail description of the research setting and the calibre of persons contributing to the study, details explanation of inclusion and exclusion criteria, sample size, data collection methods employed, number and length of the interview period and duration over which data was collected. 3.13 Ethical consideration First, ethical clearance was soughed from two institutions: Institutional Review Board (IRB) of the Noguchi Memorial Institute, Legon as well as Ghana Health Service Ethic Review Committee. Management of the Mamprobi Polyclinic were notify about the study by way of giving them an introductory letter from the school of Nursing and Midwifery, University of Ghana, Legon. The outline of the study (aims, methods and benefits) was explained to participant and they were asked to show consent to partake in the study by signing a consent form. All participants were educated on the fact that they had the liberty to pull out of the study at any point in time if they felt uncomfortable without any action taken against them. That is to say, withdrawing from the study was not going to affect the care they required from the hospital. In the collection of data, privacy of the participant was ensured by conducting the interview in a place identified and approved by the participant, for instance in their homes or in an office that was assigned to the researcher in the hospital. All data gathered was not available to the public only the researcher and the supervisors had access to safeguard secrecy of all information given by the participants. 49 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services In ensuring anonymity, any form of identifying information including name of participants including was excluded. Instead of the names of participants, pseudonyms was used to in order to ensure anonymity. 3.14 Data Management Data collected is being kept in the researchers’ custody for five years in a personal safe of the researcher. A password was put on all appliances that was used for the interview. Access will be made available to my supervisor. Pseudonyms was assigned to participants. Demographic data was separated from the interviewed data. 50 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services CHAPTER FOUR FINDINGS 4.0 Introduction This chapter is about the findings from the data gathered from the participants in this study. Data analysis took into consideration the field notes that were recorded whilst collecting data which also helped in understanding the generated data. The findings were organised based on the objectives and constructs of the SERVQUAL model. Five major themes emerged with their corresponding sub-themes. Verbatim quotes have been used to support the findings under the various themes and sub-themes. Pseudonyms were given to the participants to ensure anonymity. 4.1 Demographic Characteristics of Participants Twelve (12) participants who have used the Mamprobi Polyclinic were recruited to participate in this study. They were recruited from the out-patient and in-patient departments of the polyclinic. The profiles of the participants are shown in table 3 (Appendix F). Seven of them were females whilst 5 were males with one (1) married, two (2) divorced, one (1) cohabiting and seven (7) not married. The age ranges of participants were from 22 to 54 years: seven (7) were between the ages of 20 to 29; three (3) were between the ages of 30 to 39; one (1) was between the ages 40 to 49 and two (2) were between the ages of 50 to 59. Two (2) of them were students, four (4) were government employed and six (6) of them were self- employed. They belonged to the Ga, Akan and Ewe ethnic groups and most of them could speak English and ‘Twi’ together with their local languages. Six (6) of them were Gas, five 51 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services (5) were Akans and one (1) Ewe. Their educational level ranged from junior high to tertiary level. On the number of years they have been using the polyclinic, seven (7) of them have been using the facility from one month to ten (10) years and four of them have used it for more than ten (10) years. All of them were Ghanaians. 4.2 Organisation of Themes The emerged themes in the study were organised to provide answers to the research questions and were in conformity with the objectives and constructs of the SERVQUAL model which underpinned the study. The themes were: patient’s satisfaction with healthcare, influence of the hospital environment on patient’s satisfaction with healthcare, barriers/facilitators to satisfaction with healthcare, effect of satisfaction with healthcare on health seeking behaviour, and needs/suggestions of patients. The table 1 below shows details of the themes and sub-themes that emerged from the findings. The findings are described in the subsequent section after the table. 52 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Table 1: Themes and Sub-themes Themes Sub-themes Patients’ satisfaction with health care • Patient’s Expectations • Satisfaction with healthcare • Dissatisfaction with healthcare Hospital Environment(tangibility) • Appearance of the hospital personnel • Cleanliness of the environment • Availability of drugs and other logistics Facilitators/barriers to patients’ satisfaction • Reliability ❖ Standard of care ❖ Staff commitment • responsiveness and empathy ❖ Attitudes of staff towards patients ❖ Waiting time ❖ Response to complains • Assurance ❖ Privacy and confidentiality ❖ Health promotion Effects of patients satisfaction on health • willingness to encourage others to use seeking behaviours the Polyclinic • Intentions to use the clinic in the future. Meeting needs/suggestions from patients to • Needs of Patients improve service quality • Suggestions of patients 4.3 Patients’ satisfaction with healthcare The first research question sought to describe patient’s satisfaction with healthcare. This is the extent to which patients were satisfied with the healthcare provided at the Polyclinic. It was noted from the study that patient’s satisfaction was partly depended on their expectations of healthcare and partly on how patients are served. They were either satisfied or dissatisfied with the healthcare services provided at the Polyclinic. Three sub-themes emerged 53 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services under this theme namely: patient’s expectations, satisfaction with healthcare and dissatisfaction with healthcare. 4.3.1 Patient’s Expectations This sub-theme covers the patients’ anticipation of healthcare services which included the care rendered and the people who render the care as well as the environment in which the care is rendered. All participants accessed healthcare for some reasons and expected that their needs for seeking healthcare will be met by the healthcare givers. Participants expected that they would be healed as they take their medications ordered by the doctors. A few expressed that they expected the doctors to give them medicines that are effective to cure their diseases but had thought that the national health insurance scheme (NHIS) is not able to cover such drugs because of the cost. Concerning this, Akosua and Kofi had this to say: “I expect that whatever problem I had before I came, by seeing the doctor and he or she assessing me after that whatever drugs I am being given, taking it I will feel comfortable.” Akosua, age 27years “As a patient, I expect to recover as soon as I take my medications given to me by the doctor. If I take it and I do not get well, then my coming here was in vain. So I expect them to write good medicines for me. I heard sometimes the good medicines are not given because the health insurance cannot cater for those kind of medications. But we expect them to give us good medicines so that we will be healed.” Kofi, age 30 years Kofi expected a speedy recovery immediately after adhering to treatment regimen. He saw no reason for utilising health care services if the medicines ordered by the doctor 54 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services are ineffective in making him recover. He was very worried about some medicines he considered effective but was not ordered by the doctor because the NHIS does not cover such drugs. Another patient eagerly commented that: “Yes, I do have confidence because if he or she doesn’t know what he or she is doing, in the first place he or she will never be here in the first so I do have that trust in them.” Ama, age 51 years This was emphasized by Kwaku: Yes. For that, once I leave the house and come here, I know they …that is the job they have learnt. They know more about it; so when I come, at least I have that confidence that whatever problem I bring, they can help with it: Kwaku, age 22 years In addition, most of the participants like Kwaku and Ama had confidence in the medical treatment and so expected that as the staffs have been trained in their respective areas, they will be able to care for them as such. Still on patients’ expectations, another participant retorted: “As I said earlier on, I am a sick person. I have come to the hospital. I expect workers here to receive me nicely. But at times, they will shout at you and you being sick. In a way, you have some psychological em….I do not even know how to put it. You become bored with everything which can even intensify your condition” Akua, age 28 years This participant expected the staff at the facility to receive her nicely and have good attitudes towards her. She believed that when she is received in such a way, her problems are half solved psychologically. She saw the negative attitudes of staff towards the patients as a 55 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services psychological trauma which intensified their ailments. She also believed that the positive attitudes of staff towards patients could improve their condition. Yaa emphasised on the same issue: “What I would like about this place is for the staff to welcome and treat us well. When you come here with your ailment, they should speak calmly with you and advise you if the need be. If they do that, it can help alleviate one’s condition even when he/she has not yet taken medication. It is not good to yell at people when they come here.” Yaa, age 37 years Yaa looked worried as she expressed her concerns. It was noted that she had experienced negative attitudes of staff previously and was not pleased with it. She expressed the need for the staff to treat patients nicely with patience and this may comfort patients even without medication or treatment. Another patient was also concerned about the response of the staffs to their problems. She shared this: “And then welcoming patients too. The patients come; sometimes you do not even have to wait for the patient to come to you to ask questions. Sometimes, you see the patient walking around or something, you rather approach the person (the patient) and ask “Please what do you want? Are you looking for someone?” The approach; I think they should improve on it. Sometimes, they will not ask you; but you the patient asking the nurse too, it will be a problem. So I think they should improve.” Abena, age 27 years This participant added that the staffs should be proactive in rendering care to them (patients). According to her patients expected the staff to approach them when they see them in search of something and not to wait for the patients to lodge complains before they respond. 56 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services It was observed that, participants having these expectations in mind, evaluated that their expectations were either met or unmet. A few of them shared that their expectations for healthcare services were met. Afia and Abena passionately shared that: “Yes. For the doctors, I think they always meet it. Because the drugs they prescribe, sometimes, when I take them, I feel….within a short period, I feel okay.” Afia, age 37 years “They meet my expectations. When I take their medications, I feel comfortable as early as possible and that is what I expect.” Abena, age 27 years However, a considerable number of them shared that their expectations were not met. They said that their conditions have not improved. One participant expressed: “Yeah, not that met…because now, the same problem I am facing, that is the same thing I am coming here with. Ok, I have problem with my abdomen (abdominal pain); but anytime I come here, they do not attend to that one; they give me something else.” Adwoa, age 22 years This participant made it clear that her expectations were not really met because her abdominal pains for which she has being seeking healthcare has not being relieved although they give her medicines to take. Ama hurriedly added when she was asked whether her expectations have been met: “My expectation…..the reason why I came here, that is not what they are seeking to do. Look at how they even receive us…it is not fair.” Ama, age 51 years According to the 51 year old Ama, her expectations of how the staff should welcome them have not been met because some of the staffs give them attitudes which she considered unfair. 57 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 4.3.2 Satisfaction with healthcare This sub-theme was the extent to which participants were content or happy with the health care services rendered to them at the facility. A few of the patients were satisfied with the healthcare quality at the Polyclinic. They said it is a good clinic because they serve them well and meet their expectations. Some of them said that they were satisfied because of the positive attitudes of some of the staff. “Ok, Mamprobi Polyclinic is a good clinic. I am satisfied with their care. The medications they give to me are good. They treat us nicely too…the doctors are good and some of the nurses…mmm….I am satisfied with their care.” Abena, age 27 years Adwoa on patients’ satisfaction with health care happily expressed that: “Ok, to me, the OPD, I will tell you about the lady there. Anytime I see her, when I see her, I feel okay. I feel like am okay. I am relieved. And coming to the doctor too, the questions he asks me, that also make me know that where I am, I am okay. So with this, I am satisfied with their care.” Adwoa, age 22 years She was always comfortable seeing a particular staff because of how the staff treats her anytime she utilised health care services at the polyclinic. She was also satisfied with how the doctor probes to know her condition. One participant shared that: “For the cleanliness of the environment, as I said, I am very pleased with the current turn of events. I am very satisfied with the state of the environment apart from the treatment they give to us. I am pleased.” Afia, age 37 years Afia was also satisfied with the services not only because of the positive attitudes of the staff or the fact that she was healed after accessing care but with the cleanliness of the hospital environment. 58 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 4.3.3 Dissatisfaction with health care This was the extent to which participants were discontent not pleased with the quality health care at the Polyclinic. It was observed from the analysis of the data gathered that, most of the participants were not satisfied with the health care at the Polyclinic. To this end, they shared their experiences with the health care at the Polyclinic. Some were not satisfied because of the negative attitude of some staffs such as making calls or texting messages whilst attending to the patients. They also reported that they are not satisfied with the health care provided at the facility especially with the unavailability of some medications and the non-functioning of some equipment. Yaa seriously and unhappily responded when she was asked how satisfied she was with the health care provided at the facility. She had this to say: “Please, I am not satisfied with the quality of care provided here. This is because they do not treat us well. You see, I may come to the hospital because I am unwell. So the nurse has to treat me well in order to alleviate my condition. But when you come here, the treatment meted out by the nurse will sadden you. Even the medical condition you came here with would be worsened. Do you get me? So, the way they treat us leaves much to be desired. They have to take good care of us. We came here because we are sick. When you come, you expect the nurse to attend to you. For instance, if I have a temperature, the nurse should check it for me and see if I am okay generally. But that is not what happens. They would lay you down and be making phone calls. It is not nice. So, we plead with them to take good care of us. They should take very good care of us.” Yaa, age 37 years To her, the response of the nurses to their problem is not as expected of the nurses. As a concerned patient, she spoke against the nurses attitudes of being with their phones whilst at work. 59 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Similarly, another participant who was 27 years old and has been visiting the polyclinic for health care services for the past 15 years said: “Okay, as I said, the nurses should be talked to. So that at least, they should be taught on how to approach patients, and how to talk to patients. I am not satisfied with that…it is not good. And then with pharmacy especially, they have to re-stock most of the drugs (especially at night). Sometimes they will tell you they do not have drugs. And then they should also check on some of their machines at the lab.” Yaw, age 27 years Yaw was concerned about the unavailability of drugs in some instances and the faulty machines at the laboratory for which he had to go outside for hospital to have her investigations done. Two of the participants had similar opinion as they expressed their dissatisfaction with the health care. They had this to say: “They make us waste too much time here and I am highly dissatisfied with that. I am not okay with that…they should get more nurses. So that when we come, they will attend to us as early as possible…we do not want to waste our time here…we have a lot to do.” Kwaku, age 22 years “Sometimes because they do not have some specialists…gynecologist…we have to meet them by arrangements and I am sometimes not able to make it up with the time of meeting. A hospital like this should have their own doctors. I am not satisfied with this aspect...they need to get more staffs.” Akosua, age 27 years Kwaku and Akosusa stated that they were highly dissatisfied with the health care because of the time they waste at the facility. They shared their views on how sometimes they have to wait for doctors to report to work. They said that, the polyclinic does not have specialists such as gynecologists and so they meet one of them by arrangements. They added that the nurses are few so it makes them waste unnecessary time at the facility. To this end, they shared that the polyclinic should get their own specialists and recruit more staffs especially nurses to attend to them. 60 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Having shared the satisfaction of the patients on the health care at the polyclinic, the next section focuses on the influence of the health environment on patient’s satisfaction with health care at the polyclinic. 4.4 Hospital Environment (Tangibility) The second research question sought to identify how the hospital environment influences patient’s satisfaction with health care. In response to this, the theme that emerged was hospital environment (tangibility). This covers the appearance of the physical facilities, equipment, appearance of personnel and communication materials at the polyclinic as defined by the SERVQUAL model. Four sub-themes emerged under this theme namely: appearance of the hospital personnel, cleanliness and availability of drugs and other logistics. 4.4.1 Appearance of the hospital personnel This sub-theme is about how participants viewed the hospital personnel and how they expected them to look or dress. The appearance of the personnel was important to the patients. They shared their views with how they expected the staffs to appear at the hospital so that they can easily approach them and tell them their needs. Most of them commented that they were happy with the way the staffs appear in general and how they dress. Kofi emphatically stated that the nurses appeared nicely which can be seen in his statement on account of the appearance of the hospital personnel: “Their appearance...perfect. I am okay with everyone. They dress nicely and they do not have any awkward appearance.” Kofi, age 30 years 61 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Abena also shared a similar view: “Yes, their dressing for all of them, I have never seen any of the nurses here dressed improperly…they are important to me…and the doctors. The rest are just helping them to work…so my focus is on them. You know, I always say that…yes…they are well-dressed.” Abena, age 27 years Abena recounted that the nurses and the doctors always dressed well and to her, they were her focus and thought that other workers are just there to support the nurses and doctors. However, a few of them shared their displeasure in how some of the staffs especially the nurses dressed and appeared. They said that the appearance of some of the nurses make them (nurses) not easily approachable. One participant shared her observation: “Ok, some of the nurses, with their dressing, their appearance, how their faces look, you may not be able to even approach them. And how they are straight, when they are even coming to work; how they look…to me, it’s very very bad.” Adwoa, age 22 years A participant who was not happy with the way some of the nurses appeared asked questions and answered herself: “Are nurses supposed to put on long nails? Are nurses supposed to paint their lips? Are nurses supposed to wear short uniforms? Are nurses supposed to…No!! They do not have to appear that way. How can we approach someone like that? Ama, age 51 years The polyclinic has staffs who work as a team to promote the health of all individuals who use the facility. The appearance of these staffs was of much concern to the patients especially the nurses and doctors. The appearance of some staffs made it difficult for patients to interact with them. It also made some patients kept some information from some of the staffs. 62 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 4.4.2 Cleanliness of the environment This sub-theme is about the degree to which the hospital environment is kept clean. Most of the participants responded that the environment is very clean and does not look frightening. This study found that the orderlies were always at work ensuring that the environment was very clean. They spoke about the neatness of the washrooms and how satisfied they were with how neat it was looking. The views of three of the participants on the cleanliness of the environment are shown in the quotes below. Kwadwo had this to say concerning the cleanliness of the facility: “As for the cleanliness, it is good. Because anytime I come, I see the workers in the garden who are cleaning or working on the garden. The staffs too are mopping the floor all over. So I think that one…they are doing a good job over there; the cleaners. I always come in the morning; between 6:00am and 6:30am over here; so I see the workers cleaning, so I think it is okay.” Kwadwo, age 48 years The above statement was emphasized by another patient who also had this to say: “Please, the environment here is very clean. The other day when I came, I was happy. For instance, the washroom now is in great shape and I was satisfied when I used it. These days, in fact, frankly speaking, the cleaning of the environment is in order. Even where we sleep, the mattresses and the beds are wonderful. So the cleanliness of the environment is superb.” Yaa, age 37 years Similarly Afia also had this to say: “For the cleanliness of the environment, as I said, I am very pleased with the current turn of events. I am very satisfied with the state of the environment. I am pleased.” Afia, age 37 years These three participants appeared to be satisfied with the way the environment is clean and neat. They had no issues with the cleanliness of the environment and praised the staffs for their efforts. 63 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Three of the participants were not that pleased with the cleanliness of the environment. One said that she does not see the orderlies around at night to clean the place when people vomit or when the floor was dusty. “I think when you come at night, those who are supposed to clean the place, I do not know…you wouldn’t see them around. And you see people vomiting all around and at times you would just leave it and go. And at times, the rubbish would be overflowing and mosquitoes, especially at night. You complain to the nurses and they would be like they have also reported to the appropriate quarters.” Akua, age 28 years Another shared that, although the orderlies clean well, they do not finish the cleaning early which distracts them a little: “Sometimes, the cleaners are good though. When they clean the place, you know they have cleaned it. But sometimes, they delay small. Sometimes, you know cleaning you have to do it very early in the morning; latest by 8:00am, the place should be cleaned up. But here, sometimes after 10:00am, they are now cleaning; you will see them now cleaning. Sometimes, you go to the washrooms and the place is so messed up. Sometimes, even we the patient’s hygienated, we have to find means to come out of the ward before we get access to a better washroom because the washrooms inside the ward; to be frank, to be fair…it is bad.” Abena, age 27 years Another participant shared that the washrooms do not look neat at all: “And also their facilities here, when you get to the washroom, it’s very very disgusting. It’s like the floor….everything; it is very very bad. Yeah, it’s not enough. It is very very bad. It is bad.” Adwoa, age 22 years Cleanliness of a facility is one concern in quality of care. Participants shared their concerns with the cleanliness of the facility. It was noted that the facility was not clean to some people 64 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services whilst it was clean to most of them. This could be related to how each participants label what is called clean. It can also be the time or day they used the facility. 4.4.3 Availability of drugs and other logistics This is about how drugs and other logistics were easily accessible by participants. A significant few number of the participants shared their experiences with drug availability at the facility. Among these few participants, some said that there were some times that they had to take drugs from the pharmacy but that drug was not available there and so had to buy it from outside which was an extra cost they had to bear. One participant said: “Okay, if I may say, satisfied. Ok, sometimes, when I see the doctor, some of the times, they prescribe the medicine for me and I go to the dispensary and they say they haven’t got some of the medicine so I have to go outside and buy it on my own.” Kwadwo, age 41 years Another participant shared that, there was a time they had to take medicine from another patient for her in an emergency situation because the facility did not have that drug at that particular time. Please, when I came here the other day, there was no paracetamol among the drugs they gave me. But I had a strong headache and needed to take paracetamol. They went around looking for some, but to no avail. So, there was one lady, also a patient, who had some of this medicine. They went for it and gave it to me to take. Yaa, age 37 years Abena added with a soft tone that: “To be frank, there is one woman there. I don’t know if she is there now. There is one…she is a little bit old. I do not know whether she dislikes me or something. Sometimes, I will come with my health insurance paper. She will just look at me and then tell me that you have to buy all the drugs outside. I just wonder because even with the prescription, you would see paracetamol. Those drugs….there are some drugs you are just familiar with: the paracetamol, and 65 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services then the b-co. and others. And then, this woman will just look at me and just tell me that you would just have to get all these drugs at the pharmacies outside. As if she does not like me.” Abena, age 27 years According to Abena there were some times that they needed medicine in an emergency situation and there was not any at the polyclinic pharmacy. She has also noted a staff there which she believes might have personal issues with her (Abena). It was found that there are some times that participants got to the laboratory for investigations to be carried out on them but some machines were not functioning. A 24 year old Akua had something to say about the malfunction of some machines used at the laboratory for investigations: “Mostly their lab, most times you go there, they will tell you some of their machines there are not working; so you have to go outside. And at times, it is a bit uncomfortable because when you go outside the facility, mostly they don’t use the health insurance.” Akua, age 24 years A few of the participants also shared that there were some times that the beds were not enough for patients. Some said that, sometimes, they have to stand for a while before they can have chairs to sit on as they join the queue to see the Physician. Adwoa had this to say: “I once came here before. That was then. I was sick. I came and was admitted here. But the bed was not enough. There was not a place….like emergency place.” Adwoa, age 22 years Another participant who had a similar experience shared that: 66 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services “This thing…their seats are not enough. So when I come, I have to stand up for other people to sit. And talking about the washroom, they need to have facilities for the patients.” Kofi, age 30 years The polyclinic has a pharmacy which is stocked with medicines for patients’ treatment. However, as noted by patients, sometimes, some medicines were not available which they had to buy it from outside. The polyclinic has few beds which patients also complained about. Having presented the findings on how the hospital environment influence patients’ satisfaction with health care services, another major theme that emerged was facilitators/barriers to patients’ satisfaction. The findings for that have been presented in the ensuing section. 4.5 Facilitators/barriers to patients’ satisfaction In response to the third research question which was “what are the facilitators/barriers to patient’s satisfaction with health care?” the theme that emerged was facilitators/barriers to patients’ satisfaction with health care. This was the participant’s perceptions of the health service related factors that facilitates or impedes their satisfaction with the health care services provided at the polyclinic. It was found that these factors were relative, thus a factor which made a certain patient satisfied caused another to be dissatisfied. Three sub-themes emerged namely: reliability, responsiveness and empathy as well as assurance. These were in line with the constructs of the SERVQUAL model which was the organising framework for the study. 67 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 4.5.1 Reliability In the SERVQUAL model, reliability is the ability to perform the promised service dependably and accurately. Therefore, reliability was the participants’ perceptions of how the staffs at the polyclinic performed the guaranteed services consistently and correctly. These facilitated or hindered participants’ satisfaction of health care services at the polyclinic. Participants shared their experiences with the standards of care and the commitment of the staff to their various roles. 4.5.1.1 Standard of care Participants shared their experiences with the health care service standards at the polyclinic. Most of them saw the standards of care as poor with regards to the poor records keeping, poor documentation, negligence and referring patients to specific places to do their laboratory investigations. Most of them responded that the standard has not been maintained, thus it keeps changing from good to poor. It was noted from participants that some doctors direct them to some specific private laboratories to have their investigations there without reasons. Participants were very worried about this and was noted as a barrier to satisfaction with health care. One of them observed: “It is on and off because sometimes you go and the services have improved and other times too they are back to their normal way. When I say the normal way it is the normal bad way we see them. Sometimes most of the doctors I have gone to give me direction to a laboratory outside. They told me to go outside to have my laboratory tests done and they show me where to go … they did not give me reasons, they just told me to go”. Kwaku, age 22 years 68 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services According to Kwaku, standards are not really maintained at the polyclinic because he observed that a time there was improvement but it has dropped again. In addition to that, it was found that patients noted the standards of records keeping at the polyclinic to be poor. Concerning this, Ama said that: “I think in the year 2000 my folder was misplaced so I asked that a new folder be prepared for me and it was done. So, from the year 2000 down to four or five years that one too was misplaced so the third one which was prepared for me I told them I would not leave it with records …That is bad filing system.” Ama, age 51 years Ama described the filing system at the polyclinic as bad and so took a decision to take her folder home and keep it herself. This was because there were some occasions where her folder got missing and she had to make new ones to replace them all. Another participant shared her experience on the same issue: “Sometimes, you have to go back to OPD to see if your folder has not been brought here. Sometimes, you need to …you go through stress. Abena, age 27 years Abena saw this process of tracing folders as stressful as she had to sometimes search for her folder. She appeared worried as she expressed her concerns. Akosua, saw this same process as time wasting. She had this to say: “The only problem I have is with the ‘ermm’ the record section when you are going to withdraw your folder. Sometimes you have problems there who ever is there they tell you like they cannot find your folder and stuff so it takes quite a long time sometimes you can come quite early maybe like around 5:00am in the morning then you end up getting your folder like around 8:00am or 9:00am.” Akosua, age 27 years 69 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services It was noted that few of the participants had problems with the documentation of the staffs after they had attended to them. They said that some of the staffs make mistakes in writing down their vital signs after checking it. A participant shared his experience: “But one thing I noticed was that the last time I came there, one of the nurses, even the temperature, instead of her to say 37°C, she mentioned 137. So I do not know what the nurse is thinking about. Maybe, she is having problems in the house or whatever. I don’t know. But instead of 37°C, she mentioned 137. So I said it was not 137; it was 37°C. Yes, and after I finished, another patient also came. And instead of her to mention the actual number, she mentioned the wrong number again until the nurse who was sitting on the chair said no, it was not like that. So I do not know what is wrong with that nurse over there.” Kwadwo, age 48 years Another participant added that one does not have access to his or her folder until the next visit so in case of wrong documentation, you may only see it in that one’s next visit when he or she gets access to the folder: “Yeah, maybe I may think if I tell them they will know. Especially too, whenever they write, you would never see it until my next visit before I would check what have they written over there and before I get to know that they have shoot my BP to this level. But I do not see anything today.” Abena, age 27 years However, one patient described the standard of health care received from the polyclinic as normal: It is not to a very high standard. It is normal. I think they can improve on it. Akua, age 28 years The polyclinic uses the traditional filing system where the folders of the patients are kept at the records department. Patients queue every day for their folders before they are made to see 70 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services the physician. The patients were not satisfied with the time they had to spend at the records department and the misplacement of some folders. They therefore suggested that their folders will be given to them to keep it to avoid the challenges associated with the traditional filing system. 4.5.1.2 Staff commitment This is about how responsible and loyal staffs were to their patients. Most of the participants shared that sometimes the staff do not perform their services as expected of them. According to the participants, some of the staffs neglect their duties and rather make the relatives of the patients render the care they are supposed to render. A participant added that negligence of some staffs led to the death of his church member. On this account, Kwabena, a 54 year old participant had this to share: “At one time, I came here with a patient, a church member’s grandmother. So, we rushed her here only to be told that she is suffering from cholera. So she was sent to the back and there was a wooden structure there with some benches or whatever it is. So we were just there and we were informed that something was going on so we rushed. We saw her shivering or shaking so we held her up and then she started coughing. She coughed for some time before we realised she was just shaking and then she was gone. Meanwhile there were nurses sitting down there doing nothing.” Kwabena, age 54 years Kwabena shared how a church member of his died at the polyclinic. According to him, the woman was rushed there but the nurses sat unconcerned. Kwaku also had this to say on the staff attitudes: “Well then, most times you don’t even have the mouth to talk when you come nurses will be sitting conversing after your vitals have been taken. Then they will be sitting saying they are waiting for a doctor to come before they can carry the entire folders then you will be taken care off. Instead of probably, something that they have to get up and arrange” Kwaku, age 22 years 71 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services A similar view was shared by Ama: “We were sitting far and we were seeing them going up and about. They were not doing what they were supposed to do. When the patient needs water we are called to bring water meanwhile that’s their work … You understand me. They see themselves higher far higher than their level” Ama, age 51years Others shared that the staffs at the out-patient department (OPD) sometimes chatted with their friends whilst patients were waiting to be served. Patients were much displeased with such attitudes. According to the participants, some of the staffs especially the nurses instead of involving the patients as they wait for the Physician, they will be chatting with the excuse of waiting for the Physician to report to duty. Participants expected the nurses to keep them informed of whatever was happening such as informing them that the Physician is not around and that they should wait a little. Still on staff commitment Kwabena shared his opinion: “Most of the times you do not even have the mouth to talk when you come… nurses will be sitting conversing after your vitals have been taken. Then they will be sitting saying they are waiting for a doctor to come before they can carry the entire folders then you will be taken care off. Instead of probably, something that they have to get up and arrange. Sometimes we will be sitting and emergency cases will be coming hmm, now they sometimes will be sitting unconcern. I have witnessed it on two occasions and have even taken the names of those nurses of which I can actually give them out to you now as I sit here.” Kwabena, age 54 years Another participant vehemently stated that the staff are not committed to their work. For instance, they will not inform them why doctors have delayed coming to the consulting room. This was how she stated it: “They are not very committed. As I said, at times you come; probably the nurses may do their work and they come and there is no doctor around. Instead 72 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services of the nurse probably coming to tell us that “O this and this, maybe there are no doctors around; you would have to wait for some time,” no one would tell you anything. They would just leave you sitting idle. And then you go and ask them questions and they start shouting at you.” Akua, age 28 years However, a few of the participants said that the staffs were committed. One participant said that it depends on the staff you meet, but in general she was pleased with the commitment of the staff towards their work. “They are very committed…. I think they really like what they are doing so they try their possible best to assist.” Akosua, age 27 years “I think it depends on the person you meet…however in general, they are very committed to the work they are doing. Anytime you come, they receive you nicely.” Afia, age 37 years According to Afia, some of the staffs are committed and others are not committed. So her take on the issue was that it depends on the staff that one will meet on a particular day. “Oh…so far so good. They are doing their best. To me, they are very committed…you know it is not easy working on human beings because we have a lot of expectations but I like the work they are doing.” Adwoa, age 22 years In all, most of the participants responded that the staffs were not accurate and dependable in discharging their responsibilities. Another sub-theme that emerged under facilitators/barriers is empathy and responsiveness which has been presented in the ensuing section. 73 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 4.5.2 Empathy and Responsiveness This is about the provision of individualised attention to patients, the willingness to help patients and the provision of prompt service. Participants shared their experiences in these aspects of the health care at the polyclinic. Patients spoke about the attitudes of staffs towards them, the time they have to wait before they attended to and how nurses respond to their (patients) needs which falls under empathy and responsiveness in the SERVQUAL model. The findings after analysis of the data gathered from the participants have been presented below. All these either facilitated or hindered patients’ satisfaction with the health care. 4.5.2.1 Attitudes of staff towards patients Participants shared their observations concerning the attitudes of the staff towards the patients. These were positive and negative attitudes as identified from participants shared experiences. A few of the participants pointed out that the staffs had positive attitude towards them. Some of the few participants said that the staffs interact with them well and that gives them some relief and hope. They also noted that sometimes the attitudes of the staffs depend on the attitudes of the patients. Participants stated that some patients are not friendly and that can influence the attitudes of the staff towards them. Akosua shared: “They do interact a lot with patients… so with that too …I mean when you are open to them they will attend to you properly.” Akosua, age 27 years 74 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services In another positive note to praise the staff on positive attitudes, a participant had this to express: “Some of the staff display empathy. For instance, not all the nurses are rude. Some of them are very good. Some are really good. When you come and meet nurses who treat patients well, it calms your nerves and helps in alleviating your condition, even if it is blood pressure. Those who are nice will assure you of good care and ask how you are faring. The other day I came here, the nurse I met was really nice. She engaged me in a hearty chat, assuring me of excellent care and asking me not to worry.” Yaa, age 37 years It appeared Akosua and Yaa were satisfied with the attitudes of the staff. They were pleased with the interactions which went on between the staff and themselves. Although they were pleased with the attitudes of the staff, it appeared in their shared experiences that it is not all the staffs who had positive attitudes towards patients. The good attitude of some of the staffs made a participant happy and felt like going back to the polyclinic which was noted to have influenced the health seeking behaviour of the patient. “As I said earlier… as I said, some of the nurses are very… nice and…as I said, some of the nurses are very nice and they always help you out when you have problems and other things…so at times, I always feel like coming here irrespective of the fact that there are some bad nuts in it. Akua, age 28 years “What they do that meets my expectation is supposing I come here, upon seeing me……the other day for instance when I came here, the lady I met befriended me and treated me nicely. So, if the staff does that, even when I go home, I would still be singing their praises.” Afia, age 37 years Despite the good attitudes of some staffs, most of the participants spoke about the negative attitudes of some of the staffs towards them when they sought for healthcare services. Some of the participants said that the negative attitudes some staffs gives to them intensifies 75 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services their (patients) health condition. They complained of the staffs screaming at them which even scared them. Kwaku and Yaw had this to say: “You see, when someone is sick and you try to give the person hope that it will be well definitely the person will feel that it will be well but if you don’t do that and u give the person a bad face an unsmiling face you are rather increasing the person disease or health problem which sometimes is also bad” Kwaku, age 22 years “For those who are rude, their screaming alone would worsen your medical condition. Do you get me? So, that is what they do which does not make us happy.” Yaw, age 27 years Ama emphasised with a sad looking face: “The other day, when I came with blood pressure, I was asked to see the doctor. So, they took my folder to her. Instead of the nurse to offer me a seat and explain to me that there was no issue with me, she yelled at me as soon as I opened the gate asking me to leave because there was no issue.” Ama, age 51 years This 51 year old hypertensive patient was not offered a seat but had a share of the negative attitudes of staff as she was shouted at to leave the place. She almost wept as she spoke which implies that the experience was harsh to her. A participant felt that, some nurses’ negative attitudes towards the patients are as a result of discrimination. They thought the nurses discriminate against the patients who are illiterates. Some were scared because of the negative attitudes of some of the nurses. “The screaming is a major issue. You know, when you come here for some time, you kind of become familiar with how the nurses behave. The way they yell at you..go..go. Do this and that. And it is even worse for those of us with little or no education. When they see us and we do not speak English, they sideline us and focus on those who can communicate in the Queen’s language. And when going to see the doctor, those who can communicate in English are given preferential treatment and allowed to see the doctor before us. So, if they call me right now for instance, it’s a little scary because they may throw all 76 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services sorts of questions at me in the English language even though I may not be able to speak it.” Kofi, age 30 years Two of the participants said some of the staffs at the polyclinic are rude and they think such negative attitudes only happen at the public facilities. “Yeah, because you know at times when you go to other facilities like private clinics, the way they attend to you, they treat you nicely and everything. At times, you are very happy with the service at other places. But when you come to this place, some of the workers here are rude.” Akua, age 28 years “I keep on coming to this place; I have actually met terrible issues. Ok some “eerrr” nurses attending to us were very very poor. Some of the nurses look at themselves far beyond the level they are... they are rude. So what they are supposed to do as nurses probably I do not understand the definition of the nursing itself.” Kwabena, age 54 years In these two narratives, the participants were not pleased with the attitudes of the staff towards them as they sought for health care. They rated the staff attitude as very poor and were displeased with their attitudes as nurses. They wondered whether those nurses understand nursing. 4.5.2.2 Waiting time This was about the time participants spent before they were attended to at the polyclinic in each department. Most of the participants were not comfortable with the long hours they spent at the hospital before they got the needed attention. They complained of the time they have to wait before they got the attention of the staffs especially the Physicians. “At times, there is a bit of delay, an hour or 30 minutes before any doctor will appear. Sometimes when you go, at the opening, they will tell you that a doctor has not come yet, so you have to exercise patience, waiting until the doctor comes.” Kwadwo, age 48 years 77 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Kwadwo also had this to say: “Like the day, I went there for instance I had to wait because they were saying doctors were not around and some nurses were trying to take care of their family member and their friends before us (patients) so the health care service was very poor by then.” Kwaku, age 22 years Akua shared that sometimes, patients have to wait for the physicians for a long time before they will report to the consulting room to attend to them. She appeared worried as she spoke. She put it this way: Hmm, for some time now, at times you come here. Especially with the doctors; at times you come here and you have to wait and wait and wait; and there are no doctors around. At the end of the day, you would have to go to a different facility. So in a way, this place is not all that reliable. Akua, age 28 years Others also commented on the time they spend at the records unit before they are given their folders to go for consultation. One of them said: “But even when I come, people normally complain. At the records unit...today when I went, the people were complaining bitterly that they are wasting their time. To me, they have to think about the people there...the records unit.” Adwoa, age 22 years In this participant’s narration, she presented others’ experiences with the waiting time aside her own and the complaints she heard others making. It appeared patients were resentful about the long waiting hours before having their folders at the records unit. 78 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 4.5.2.3 Response to complaints This is how the staffs reacted to the complaints of patients. Concerning this, a few of the participants said they were nicely attended to and received prompt attention from the staffs when they lodged their complaints or when the staffs observed their (patients) conditions. These can be found in the quotes below: “As I was saying earlier, when it comes to human behavior, all fingers are not equal. The other day for instance, when I came, the doctor I met did not let us follow the regular queue. You know you have to be in a queue before you can be attended to. But, when the doctor realised how high my blood pressure was, she asked one nurse to take my folder. She even asked them to warm water for me. They attended to me earlier because the pressure was too high. But for others, whether your pressure is going up or down, they simply do not care. They will let you remain in a queue even if that will endanger your life. That is what I do not like” Yaa, age 37 years “Yeah. I do not have any problem with that. I am satisfied. Because what I tell them that is what they do.” Kwadwo, age 48 years However, most of the participants said that some of the staffs do not bother when they lodge complains or when the staffs observe that they need something. Some of the participants made their own arrangements to see physicians themselves. Others decided to give some few staffs who responded to them some token to motivate them to keep responding to them on their subsequent visits. Two participants shared: “They will not even border. They will not border! For several times, I have actually made my own arrangement to see a doctor when I come because when you go in there it’s like you will not be well attended to. Ones in a while you meet a nurse, a God-fearing nurse who will just attend to you nicely and such nurses when am finished with and about to leave then I call them aside and give them something small and say take it because of the way you have handled me.” Kwabena, age 54 years 79 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Ama also commented on the same issue this way: “Mmmm…sometimes you may be asked to do something and you do not know where to go. When you ask them too, they will not mind you…their minds are set on something else and not the work they are there to do.” Ama, age 51 years These two patients were dissatisfied with the response of the staff to their complaints. It appeared from their responses that the staffs do not respond to patients when they need directives on the actions patients have to take. A participant added that some staffs at the records department do not concentrate on their work which caused patients to waste much time before getting their folders. “He was not concentrating on the patients. And so, we had to sit there for so long before getting our folders.” Abena, age 27 years Others complained about poor reception of some nurses who rather concentrated on attending to persons known to them first before seeing to others. A participant shared: “Like the day, I went there for instance I had to wait because they were saying doctors were not around and some nurses were trying to take care of their family member and their friends before us (patients) so the health care service was very poor by then.” Kwaku, age 22 years This made the patients waste time waiting for their turn to be attended to at the polyclinic. Some also complained of how slow some doctors work. Some of the doctors are very slow; very very slow Yaw, age 27 years 80 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services All these had an influence on patients’ satisfaction with health care at the Mamprobi Polyclinic. Having looked at the responsiveness and empathy, another sub-theme that emerged under facilitators/barriers to patients’ satisfaction with health care was assurance. This has been presented in the next section. 4.5.3 Assurance This is about the knowledge and courtesy of staffs and their ability to convey trust and confidence. The findings of the study revealed that participants were not afraid of sharing their health histories with the staffs that have to know. They were assured of privacy and confidentiality. Others also spoke of the health promotion guidelines the staffs especially the nurses give when they access services. The findings on assurance have been categorised into privacy and confidentiality as well as health promotion. 4.5.3.1 Privacy and confidentiality According to the participants, the staffs do well with regards to privacy and confidentiality issues. Almost all the participants said they trust the staffs for that and that they have not heard of any discussion of what they share with them outside. They also said that screens are always in place to provide privacy and maintain the individuality of patients. Below are the quotes from some participants: “I do not think any of the staffs will take our issues outside. They care for a whole lot of people, and I do not believe that they can take what we discuss with them out. They are secretive.” Akosua, age 27 years Kofi also emphasised on the privacy and confidentiality: “Oh when the doctor or a nurse wants to check something at your private part, they will put something there to block others from seeing looking at you. 81 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Besides, I have not heard any of our issues outside, they have some attitudes, but for this one, I do not think they will do that.” Kofi, age 30 years “They always have a screen to block others from looking at you…and when you are talking to them too it is one after the other. We go to them one after the other…I mean the nurses and the doctors.” Yaw, age 27 years It seemed participants were satisfied with the way the staff maintain individuality as they cared for them and trusted that their matters would not be discussed outside. It was only two participants who although they have not experienced the odds of privacy and confidentiality, thought that it could happen since the staffs are human beings and are liable to gossiping. “Well…I do not know of that but are they not human beings?...they will, by all means, tell others. Especially if someone has HIV/AIDS…do you think they will not discuss with their friends outside? So they can gossip about us, but I have not heard of such.” Yaa, age 37 years Afia also added: “For screening, they do so that others will not look at us…but for our issues we cannot tell. It is possible for them to disclose our information…you see…anything at all can happen.” Afia, age 37 years It appeared the two participants did not trust the staff with regards to confidentiality. They had a divergently thought that their secrets might be exposed. 4.5.3.2 Health promotion It was found from the analysis of the data that patients were happy with the health education the nurses give at the out-patient department while they waited to be attended to. 82 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services “Well, if I may say, sometimes when we are outside, some of the nurses would come and talk to us that we should watch our behaviour in the house, what to do and some of the sicknesses like hypertension and all those kind of things. Whenever they are teaching us, at least I am okay with that. At least, it does not keep us boring. It keeps us. At least we are listening to something which you can even take good care of yourself. I am happy about that.” Kwadwo, age 48 years “They sometimes talk to us but not always…sometimes they speak about family planning which is good. Sometimes to nothing (giggled)…they will not say anything and we will just be there.” Ama, age 51 years “I think they do it on some days…not every day…however, it is good. I wish they will always educate us on certain things.” Abena, age 27 years In all, the patients’ shared experiences on facilitators/barriers or factors likely to promote or hinder patients’ satisfaction have been presented. The next section focuses on effects of patients’ satisfaction on their health seeking behaviour which was another theme that emerged when data was analysed. 4.6 Effects of patients’ satisfaction on their health seeking behaviour As much as most of the findings of this study are in line with the constructs of the model, effects of patients’ satisfaction on their health seeking behaviour fell out the model. However, it seemed to be significant to the study. In response to the fourth research question which sought to find out the effects of patients’ satisfaction on their health seeking behaviour, the theme that emerged was: effects of patients’ satisfaction with health seeking behaviour. It was found that the subsequent use of services could be influenced by the current use of health care services. Two sub-themes emerged namely: willingness to encourage others to use the Polyclinic and intentions to use the clinic in the future. 83 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 4.6.1 Willingness to encourage others to use the Polyclinic Most of the participants said they would recommend the facility to others base on some conditions but not really because they were satisfied with the health care at the facility. Some participants stated that they would have loved to recommend the hospital to others, but they are bothered about how their referee will be treated. Another one said that she becomes dissatisfied at times but would have wished to recommend to others. Two participants shared their views: “I would have loved to, but at times when you bring someone here, he/she would request to be taken somewhere else. Do you get me? Their conduct and attitude here have soiled their reputation. So even if you bring someone here, he/she wants to go somewhere else.” Yaa, age 37 years “Yes, I would want that; in some way. I would want that, but sometimes too I come, and then I even get fed up. I tell myself today would be the last time coming here because of the delays. Sometimes, you come very early in the morning, and you leave in the evening because of the lateness of some of the doctors.” Abena, age 27 years It seemed these two participants had the desire to recommend the facility to others for health care. However, they were not sure their referees would be satisfied with the services provided at the facility. They were to some extent dissatisfied with the services. Two of the participants said their recommendations would be to those who stay closer to the facility but not because of the way they provide care to patients. “O yeah, of course. Once you live around, you have the opportunity to come around. Because I am not staying at Mamprobi and then go to Adabraka. No, I will not do that. I have to be where I am; the area where I am. So, I would suggest that everybody should be around.” Kwadwo, age 48 years 84 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services “Seriously, it depends on the location of the person. If the person is that close to me and may be the person needs that urgent care, I would recommend this place. However, if not too, I would recommend a different place, probably a private hospital or something.” Akua, age 28 years To Akua, her recommendation would be based on how urgent the referee needs medical attention. It appeared she was not going to recommend to others if their conditions did not warrant an urgent attention. Another participant said, she will recommend to others when they need treatment for minor conditions: “I think it is okay for them coming here. However, just petty things; not something bothering them that will lead them to death. Just something normal; something like a headache, stomach pains and the rest. But not something that will lead them to death, because they do not have enough facilities.” Adwoa, age 22 years It was only a few participants whose recommendation to others was based on their satisfaction with the health care provided at the facility. One of them shared that: “Yes I do tell people that they should come here I know someone, and she is a neighbour she is pregnant and I I told her she should come here she is gonna have a good health care here. She should come to the antenatal here.” Akosua, age 27 years. 4.6.2 Intentions to use the clinic in the future Participants shared their views on their intentions to use the facility in the future. Most of the participants had intentions to use the facility in the future. Some of their reasons were based on the extent to which they were satisfied with the health care. Other reasons included proximity of their place of stay to the health facility. Some participants shared that their subsequent use of the facility is based on their satisfaction with the health care provided. 85 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services “But when they attend to you, to be frank, they are great. So I always love coming back. Apart from the delays, I always love coming back.” Abena, age 27 years Yaw shared his intentions to use the polyclinic in the future: “To me, I think, as I said, that is why I always come to Mamprobi. Apart from the delays… then some attitude of some few nurses, apart from that, everything being done here is nice. Apart from these two, I like virtually everything.” Yaw, age 27 years Adwoa added: “I will be back…they are doing well. It is difficult caring for human beings. We thank God they have not started collecting bribes. So I will come here again.” Adwoa, age 22 years “As for me, I am happy with everything they do here…I will come here again anything I am not feeling well unless they transfer me to another place.” Afia, age 37 years From the quotes above, participants gave the impression that they would utilise the services in the future although they had some issues with the quality of health care at the polyclinic. A few of them also said they would use the facility again because they are staying closer to the facility and the cost involved in picking a car to a different place for health care. Two of them shared: “I will only come here because I am staying closer… more times I wish to come here instead of going to a farther place.” Akua, age 28 years “Sometimes picking a car and paying that fare to another place is expensive…because of that I will be here like that. Even if they do not receive me well, they will give me my medications.” Yaa, age 37 years However, a few of them were not that willing to use the facility again because they were dissatisfied with the health care services provided at the facility. 86 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services “Hmmm…I do not even know what to say…but, in fact, I am not that willing to be here again. Maybe, situations beyond my control will bring me here otherwise…hmm…I will not.” Yaw, age 27 years “Sometimes you do not have a choice…however, this place…the time wasting is too much. I may not come here again.” Kwaku, age 22 years This section has pointed out that participants’ further use of services was not only depended on their satisfaction and dissatisfaction but also other factors such as the proximity of the facility to their place of residence. 4.7 Needs/Suggestions of patients To answer the fifth research question “what are the needs of the patients?”, The theme that emerged was needs/suggestions of patients. This theme was not in line with the SERVQUAL model but emerged as a theme during the data analysis. From the data, the patients had needs for health care and also gave suggestions which they believed will help improve the quality of services provided at the polyclinic. Two sub-themes emerged under this theme namely: needs of patients and suggestions of patients. 4.7.1 Needs of Patients These were what participants required to be satisfied with the health care services at the polyclinic. It was found that participants required some services which they believed will make them keep utilising the services. Patients’ needs identified in the study included the need for good medical care, excellent hospitality and courteous behaviour from the staffs. They also needed good information and communication from the hospital staffs. 87 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Most of the participants had the need for good medical care. They wanted the staffs to listen to and take action on their concerns and give them the information they need in a way they (patients) can understand. A few of the participants also shared their concerns about discrimination and had the need for indiscriminate services. The quotes below show the needs of the participants: “When we come here, we want them to pay attention to what we say. Although they have the knowledge, we are sick, and we know how we are feeling…we need staffs who will pay attention to our details. Sometimes before you finish narrating your problems, they have already finished writing the medications, and that is not good.” Adwoa, age 22 years “They should use a language we understand when they are talking to us. Sometimes when they look at you, and they find out that you cannot speak English, your treatment is different. So we need indiscriminate healthcare services. We all deserve it no matter where you are coming from.” Ama, age 51 years A few of the participants also wanted staffs to promote and protect their health and maintain confidentiality and privacy as they care for them. Two of them shared their views: “We need confidential services…they do not have to discuss our issues outside or among themselves. They have to know that we all have problems and anybody at all can fall sick at any time including themselves.” Kofi, age 30 years “We need to be educated on our conditions for us to know how to care for ourselves at home and not only at the hospitals. They have to take time and explain everything to us. They also have to keep on maintaining privacy while they care for us.” Akua, age 28 years Most of the participants expected workers at the hospital to have excellent hospitality and courteous behaviour towards them (patients). It was found that participants wanted the 88 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services staff to give them a good reception and talk to them nicely as they believed it could help improve their treatment outcomes. “What I would like about this place is for the staff to welcome and treat us well. When you come here with your ailment, they should speak calmly with you and advise you if the need be. If they do that, it can help alleviate one’s condition even when he/she has not yet taken medication. It is not good to yell at people when they come here.” Yaa, age 37 years “And then welcoming patients too. The patients come; sometimes you do not even have to wait for the patient to come to you to ask questions. Sometimes, you see the patient walking around or something, you rather approach the person (the patient) and ask “Please what do you want? Are you looking for someone?” The approach; I think they should improve on it. Sometimes, they will not ask you; but you the patient asking the nurse too, it will be a problem. So I think they should improve.” Abena, age 27 years Another participant emphasised: “I think they should be talked to. When they are coming to work, at least we all have our problems. However, once you are at work, you should know that the patients are the reason why you are here. So at least, you should be very nice and have a smiling face for the patient to be able to approach you.” Yaw, age 27 years A significant number of them said they needed that the facility will have adequate logistics so that they will not have to be referred to other hospitals for continuity of treatment. Akua and Adwoa shared their needs this way: “We need good services…there should be items available like drugs and more machines at the laboratory. I do not like it when I have to be referred elsewhere.” Akua, age 28 years “They should bring specialist to this hospital…there are some times that we have to travel to another hospital for certain things. Meanwhile, this place too is a hospital, so they have to widen their scope of services.” Kwadwo, age 48 years 89 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Participants’ comments gave the impression that they want the facility to offer all services and have adequate logistics so that referrals will be minimised as sometimes they get stressed up moving to another facility to complete their treatment. 4.7.2 Suggestions of patients This was about the proposals put forward by participants for consideration. The patients gave many suggestions which should be implemented by the management of the facility to improve the health care. Most of the participants suggested that more staffs should be recruited especially nurses to avoid the number of hours they have to spend before they are attended to. The quotes below present some of their suggestions: “So, there are some places they need to get more of the nurses or may be the workers so that we reduce the patients being delayed.” Abena, age 27 years Adwoa added to what Abena said: “Ok, to me for the records unit, they have to get more people that will help assist them in looking for the folders. “Errm”, the laboratory too, they have to be more serious with work. They should not waste our time for…3 hours/2 hours waiting….it is very very bad.” Adwoa, age 22 years Kwaku also had this to share: “They need more staffs…that will improve the way they serve us. Sometimes the patients are many, but the nurses especially are few so they should bring more.” Kwaku, age 22 years These three participants suggested that the hospital should improve on their staffing as they believed will reduce the workload on the staff which will speed up the way the work and 90 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services influence the waiting time positively. They appeared to be concerned about the staffing of the polyclinic. A few of the participants suggested that their folders should be given to them to take care of it instead of filing it at the records department. This they believed will reduce the time they have to spend at the records department to get their folders before seeing a physician. One participant had this to say: “I do not know if they can do something about the records unit, because “erm” I think it will be more helpful if like the folders are being given out to the patients to take it home when you are coming then you bring it, with that you not going to spend so much time and it will be stress free for them and us please.” Akosua, age 27 years Others suggested that the pharmacy should be stocked with drugs to ease the burden of taking prescriptions outside the facility to buy. “With the pharmacy especially, they have to restock most of the drugs (especially at night). Moreover, then they should also check on some of their machines at the lab.” Akua, age 28 years 4.8 Summary of findings The findings indicated the satisfaction of patients with healthcare services, the influence of the hospital environment on patients’ satisfaction and facilitators/barriers to patients’ satisfaction. These were in line with the constructs of the SERVQUAL model which underpinned the study. Other findings which were identified through content analysis which was not related to the model included the effect of patients’ satisfaction on health seeking behaviour and the needs and suggestions of patients. 91 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services The study revealed that most of the participants were not satisfied with the health care services at the polyclinic. Their reasons for dissatisfaction included but not limited to the waiting time, negative attitudes of staffs, the hospital environment, assurance and reliability. The hospital environment largely influenced patients’ satisfaction with health care services. Most of them were satisfied with the appearance of the staffs, the cleanliness of the environment. However, they were dissatisfied with the unavailability of drugs and other logistics which they needed at the facility. Facilitators/barriers were found out as participants shared their experiences with the use of the facility. The majority of the participants commented on the negative attitudes of the staffs as a deterrent to their satisfaction with health care services. Other deterrents identified from content analysis included waiting time, lateness in responding to patients’ complaints, perceived low standards of care and lack of committed staffs. However, most of the participants were satisfied with the courtesy of the staffs and their ability to convey trust and confidence. It was also identified that participants’ health seeking behaviour or future use of the facility was influenced by their satisfaction with the health care services. They had various needs such as the need for good medical care, the need for information and the need for indiscriminate services. They also gave suggestions such as staffing, expanding the range of services and others to help improve the quality of healthcare services which in turn will give patients’ satisfaction. 92 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services CHAPTER FIVE DISCUSSION OF FINDINGS 5.0 Introduction This chapter is about the results of the study about the literature reviewed. The purpose of the research was to explore the patients’ satisfaction with health care service at the Mamprobi Polyclinic. The research sought to: • determine patients’ satisfaction with the quality of health care • explore how the hospital environment influences patients’ satisfaction with health care • identify the facilitators/barriers to patients’ satisfaction with the quality of health care • find out the effect of patients’ satisfaction with health care on health seeking behaviour • identify the needs of patients to improve patients’ satisfaction with health care system. Five major themes emerged from a thorough analysis of the data. In addition to themes, corresponding sub-themes were identified. The themes and sub-themes have been discussed in the ensuing sections. 5.1 Patients’ satisfaction with health care The study found that patients sought for health care with expectations and their satisfaction were based on the outcome of their expectations. Participants expected that they would be healed as they take their medications ordered by the doctors. They had confidence in the medical treatment and so expected that as the staffs have been trained in their respective areas, they will be able to care for them as such. However, a considerable number of them shared that their expectations were not met. 93 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services The finding of the current study that patients had expectations and their satisfaction was based on how their expectations were met is similar to the findings of Bowling, Rowe and McKee (2012). They found that patients had expectations for treatment and the ability of the health care to meet the expectations of patients with regards to the treatment outcomes matters most to patients (Bowling, Rowe and McKee, 2012). This implies that patients expectation can determine or maybe a significant determinant of patients’ satisfaction. However, when the expectations are high, meeting them becomes difficult and dissatisfaction results. The finding that patients had expectations for skilled health care providers corroborates with the findings of Creanga, Gullo, Kuhlmann, Msiska, and Galavotti (2017). They found that women who utilised prenatal care services had expectations for skilled providers which was a major determinant of their satisfaction with health care services (Creanga, Gullo, Kuhlmann, Msiska, and Galavotti, 2017). On satisfaction, the majority of patients in the current study were dissatisfied with the health care quality at the Polyclinic. They were dissatisfied because of the negative attitude of some staffs such as making calls or texting messages while attending to the patients, unavailability of some medications and non-functioning of some equipment. The patients stated that they were highly dissatisfied with the health care because of the time they waste at the facility. The current study concurred with the study of Khamis and Njau 2014 who found that patients’ were highly dissatisfied with the quality of health care at the Mwananyamala hospital in Tanzania. This could be as a result of staff related factors or the physical environment of the health facility (Khamis and Njau 2014). 94 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services This finding was contrary to that of Turkson (2009) who found that the majority of patients were satisfied with the quality of health care. Although this study was also conducted in Ghana, the differences in findings could be as a result of the demographic characteristics of participants used as well as the health care facility. Another study which was contrary to the current findings was the study by Tsai, Orav, & Jha, (2015) which found that the level of patients’ satisfaction with health care was high although there were large variations of satisfaction among the hospitals in United States(U.S). However, it was noted in their study that hospitals with high patient satisfaction provided much efficient care with shorter duration of stay. The difference could be as a result of the settings and the availability of machines in the high-income countries such as U.S. This could also be related to the positive perception they probably had about the health care services provided at the polyclinic. However, this is contrary to a study done at Muhimbili National Hospital in Dares Salaam, whereby a high proportion of patients were satisfied with the quality of care (Leshabari, Muhondwa, Mwangu, & Mbembati, 2008). Having shared the satisfaction of the patients on the health care at the polyclinic, the next section focuses on the influence of the health environment on patient’s satisfaction with health care at the polyclinic. 95 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 5.2 Hospital Environment (Tangibility) The appearance of the personnel was important to the patients. Most of them were happy with the way the staffs appear in general and how they dress. However, a few of them shared their displeasure in how some of the staffs especially the nurses dressed and appeared. They said that the appearance of some of the nurses makes them (nurses) not easily approachable. Most of the participants responded that the environment is very clean and does not look frightening. However, a few of the participants were not that pleased with the cleanliness of the environment. Similarly to findings of the current study, a study in Ghana by Turkson (2009) was found that the majority of patients rated the cleanliness of the various facilities used for the study as clean. This shows that the facilities in Ghana put cleanliness as a priority in health care delivery. The current finding also concurred with Al-Hawary (2012). He found that the cleanliness of the physical environment has a larger influence on patients’ satisfaction with the quality of health care. Other studies elsewhere have also found similar results of how patients’ value cleanliness in measuring the quality of health care (Çelik & Sehribanoglu, 2012). Patients in the current study said that there were some times that they had to take drugs from the pharmacy but that drug was not available there and so had to buy it from outside which was an extra cost they had to bear. This finding is similar to what Ahmed et al. (2015) found in their study. They found that most of the patients did not believe that all the prescribed drugs were available at the health facility. When patients have to go outside the hospital to buy medicine at an extra cost, they become dissatisfied with the health care, and this was observed in the current study. This implies that hospitals must ensure that the medicines they will need 96 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services to care for patients optimally are available at the facility so that patients can access such medicines at ease. According to the patients in the current study, there were some times that they got to the laboratory for investigations to be carried out on them but some machines were not functioning. A few of the participants also shared that there were some times that the beds were not enough for patients. This made them uncomfortable and dissatisfied to some extent with the health care services at the polyclinic. This concurred with the assertions of Ayimbillah, Atinga, Abekah-Nkrumah and Domfeh (2011) that the availability of functioning hospital amenities in a calm and neat environment make patients feel more comfortable and enjoy the provided services which in turn leads to satisfaction. This implies that such tangibles are needed at health care facilities to provide quality healthcare to patients. When patients are satisfied, it adds to their health and initiates a good behaviour towards health care services. Similarly, Senarath et al. (2014) also opined that regarding the physical environment of the health facility, equipment and amenities have a larger effect on patients’ satisfaction with quality health care. It was also found in the current study that there were not enough chairs at the facility for patients to sit on while waiting for their turn. This finding is contrary to what Ahmed et al. (2015) found in their study. In their study, almost half of the patients accepted that the chairs in the waiting room were enough for patients waiting for their turn of health care. Patients’ views are diverse and what satisfies the other may dissatisfy the other. Having discussed how the hospital environment influence patients’ satisfaction of health care, another 97 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services theme that emerged which was facilitators/barriers to patients’ satisfaction has been discussed in the ensuing section. 5.3 Facilitators/barriers to patients’ satisfaction It was found in the current study that, patients saw the standards of care as poor with regard to the poor records keeping, poor documentation, negligence and referring patients to specific places to do their laboratory investigations. This is in line with the findings of Peprah (2014) in his study at the Sunyani regional hospital in Ghana which used the SERVQAUL model to assess the determinants of patients’ satisfaction. He found that poor standards of care led to patients’ dissatisfaction with the health care services. He found these same factors of negligence where nurses were not even willing to answer the questions of patients (Peprah, 2014). Most of the participants in the current study shared that sometimes the staffs do not perform their services as expected of them. According to the participants in this study, some of the staffs neglect their duties and rather make the relatives of the patients render the care they are supposed to render. This led to the dissatisfaction of patients as patients in the study emphatically stated. Ramez (2012) observed that staff performance and attitudes of the consumer are the key indicators of service quality. This was not different from the observations of Ladhari (2010) who found the same indicators for service quality. Similarly, Al-Hawary et al. (2012) found that hospitals in Jordan which has been rated by patients as having high service quality are based on the performance of the staff in the 98 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services health facilities. This seems to imply that staff performance is key in determining the quality of health care. Therefore all health services have to ensure that staffs are held responsible for their various roles in the facilities. This may lead to patients’ satisfaction when ensured in the health facilities. Most of the participants spoke about the negative attitudes of some of the staffs towards them when they sought for health care services. It was noted that the negative attitudes some staffs gives to patients intensify their (patients) health condition. They complained of the staffs screaming at them which even scared them. Some were scared because of the negative attitudes of some of the nurses. They also said some of the staffs at the polyclinic are rude and they think such negative attitudes only happen at the public facilities. The current findings corroborate with the study findings by Gyapong et al. (2007) that patients complained of poor attitudes of staff which led to patients’ dissatisfaction and low utilisation of health care services. Turkson (2009) also found a similar result that poor attitudes of staff, thus showing no empathy may lead to low utilisation of health care services. This seems to suggest that despite the investment and policies aimed at improving utilisation of health services among Ghanaians, staff attitudes can deter patients from utilising the facilities. The findings that staffs were rude to patients in the current study agrees with the findings of Peprah (2014), who found that some of the staffs especially some laboratory assistants and nurses were rude to their patients and did not give them the needed attention when the patients needed it (Peprah., 2014). The current study also found that most of the patients were not comfortable with the long hours they had spent at the hospital before they got the needed attention. They 99 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services complained of the time they have to wait before they got the attention of the staffs especially the Physicians. Others also commented on the time they spend at the records unit before they are given their folders to go for a consultation. In all, patients were highly dissatisfied with the long waiting hours at the facility. This concurred with the assertion by Yousapronpaiboon and Johnson (2013) that the length of time patients spend before getting an appointment can lead to patients’ dissatisfaction with healthcare. Similarly, a study in Ghana by Aggrey and Appiah (2014) in Kumasi metropolis in Ghana found that patients wasted time at the facilities before they were attended to. They explained that the delays in the health facilities might be due to a conversation among staffs, insufficient staffs such as nurses and doctors which created increased workload (Aggrey &Appiah., 2014). These same factors were found in the current study as patients shared their experiences. However, the long waiting time was related to the number of patients staffs have to attend to on a particular day. For instance, there are some times that many patients come to the hospital which creates long queues at the out-patient department. Contrary to the current findings, Turkson (2009) found that the majority of patients found the waiting time at the facility to be reasonable. This may be due to the number of patients who utilise the facility as well as the number of staffs who reports for a shift as well as their performance. The current finding is also contrary to that of Ahmed et al. (2015) who found that more than more than half of the patients agreed that they did not spend much time at the pharmacy before they got their medicines. Nevertheless, this study was specific and focused on the 100 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services pharmacy department of the health care facility, but the current study explored the whole facility which may account for the differences in findings. The current study found that most of the participants were not nicely attended to and did not receive prompt attention from the staffs when they complained or when the staffs observed their (patients) conditions. They stated that some of the staffs do not bother when they lodge complaints or when the staffs observe that they need something. This also led to the dissatisfaction of patients with health care services. This finding corroborates with the findings of Nwankwo et al. (2010). They found that doctors’ late response to the complaints of patients and length of getting an appointment had the probability of negatively influencing patients’ satisfaction with health care services (Nwankwo et al., 2010). This can lead to patients making their arrangements and bribing some staffs to have attention than others who may refuse to give such. This surfaced in the current study. This seems to imply that patients needed prompt attention when they complained which all health workers must take note of to improve the quality of health care they provide at the various facilities. The findings of the study revealed that participants were not afraid of sharing their health histories with the staffs that have to know. They were assured of privacy and confidentiality. According to the participants, the staffs do well with regards to privacy and confidentiality issues. Almost all the participants said they trust the staffs for that and that they have not heard of any discussion of what they share with them outside. 101 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services This corroborates with the assertion by Aggrey and Appiah (2014) that the feelings of being secure and having trust in the provision of care accounts for patients’ satisfaction. However, contrary to the current study, he found that patients felt insecure with healthcare. In all the patients’ shared experiences on facilitators/barriers or factors likely to promote or hinder patients’ satisfaction has been discussed. The next section discusses the effects of patients’ satisfaction on their health seeking behaviour which was another theme that emerged when data was analysed. 5.4 Effects of patients’ satisfaction on their health seeking behaviour It was found that most of the participants said they would recommend the facility to others base on some conditions but not really because they were satisfied with the health care at the facility. Recommending the facility to others was based on the proximity of the facility to referee’s residence, treatment of minor conditions and satisfaction with health care. The current study found that most of the participants intended to use the facility in the future. However, it was not much based on their satisfaction but other factors such proximity of their residence to the health facility. However, a few of them were not that willing to use the facility again because they were dissatisfied with the health care services provided at the facility. Contrary to the current study, Mahmood, Ali, Faisal and Kumar (2014) in India found that patients’ health seeking behaviour was significantly associated with satisfaction with health care services. This implies that those who were satisfied with their previous use of the services had the intentions of seeking health care for their problems in the future. 102 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Moreover, other studies elsewhere have found that satisfied patients had intentions to use the services in the future base on the services provided to them (Akbaba, 2006 and Spencer et al., 2014). The differences in the findings could be as a result of the difference in settings. In my interaction with patients as a nurse in Ghana for seven years, I have come to observe that people in Ghana consider cost in seeking health care services over other quality of care factors. 5.5 Meeting Needs/Suggestions of patients to improve service quality Patients’ needs identified in the study included the need for good medical care, excellent hospitality and courteous behaviour from the staffs. They also needed good information and communication from the hospital staffs. The patients had the need for good medical care. They wanted the staffs to listen to and take action on their concerns and give them the information they need in a way they (patients) can understand. Participants also shared their concerns about discrimination and had the need for indiscriminate services and also wanted staffs to promote and protect their health and maintain confidentiality and privacy as they care for them. The need for good information and communication from hospital staffs which were identified in this study buttresses the findings of Yousapronpaiboon and Johnson (2013) that quality of health care services can be improved by improving patient-staff communications. Similarly, Kumari et al., (2009) and Sharma et al., (2010), found that doctor-patient communication is a significant predictor. This suggest that if it is ensured in health care facilities, it may improve on health care quality and possibly lead to patients’ satisfaction. 103 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services In the current study, most of the participants expected workers at the hospital to have excellent hospitality and courteous behaviour towards them (patients). It was found that participants wanted the staff to give them a good reception and talk to them nicely as they believed it can help improve on their treatment outcomes. Yildi and Demirors (2012) noted that the service which is customer oriented is provided based on the interest of the customer. In the current study, the patients gave suggestions of what should be done to improve the quality of healthcare in the polyclinic. The patients suggested that they needed that the facility will have adequate logistics; recruitment more staffs especially nurses and doctors to avoid time wasting. They also suggested that their folders should be given to them to take care of it instead of filing it at the records department as well as stocking the pharmacy with medicines. The current study confirms the assertion by Alrubaiee et al., (2011) and Ramez (2012) that patients’ suggestions to improve service quality has a strong contribution on quality health care which can result in patients’ satisfaction with the delivery of health care. 5.6 Usefulness of the SERVQUAL model in the study The SERVQUAL model which was used to underpin the study has been used by other researchers to study the quality of health care and patients’ satisfaction. The constructs were used in this study to formulate the objectives of the study and guided the literature review. It also helped to organise the themes that were generated from content analysis of the data that was gathered from the twelve participants. A review of the studies the model was applied in have been presented in chapter two. 104 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services The model focuses on only the service related factors that lead to patients’ satisfaction. Patient related factors that lead to the improvement of service quality is a limitation to the model. However, the patient factors that lead to satisfaction such as patients’ expectation, needs and suggestion to improve the quality of health care emerged. Nevertheless, the SERVQUAL model was effective in helping the researcher meet the objectives of the study. 105 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services CHAPTER SIX SUMMARY, IMPLICATIONS FOR NURSING, LIMITATIONS, CONCLUSION AND RECOMMENDATIONS 6.0 Introduction This chapter is on the summary of the study, implications of the findings for nursing research, education and practice. The limitations of the study and conclusions drawn from the study have also been presented here. The chapter also highlights the critical lessons drawn from the study and makes some cogent recommendations for Ministry of health/Ghana Health Service, Health care providers and Mamprobi Polyclinic. 6.1 Summary of the Study Healthcare delivery in Ghana relays strongly on patients’ satisfaction with healthcare services received in various the various health facilities. The Ministry of health and Ghana health service have therefore made the availability of patient’s charter accessible to patients and everyone interested. Technology has made access to information easy for all including patients who access our health care. Amongst the objectives of Ghana Health Services is to increase access to good quality health services (Ghana Health Services). Staffs who attend to the needs of patient try their best to ensure quality services are provided for all. Therefore the study explored patients’ satisfaction with the quality of healthcare at the Mamprobi polyclinic. 106 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 6.2 Implications The findings of the study points to nursing implications, focusing particularly on nursing education, research and practice. For Nursing Education Nursing education is very vital because the life of the patient depends of the educational knowledge of the health care provider. The findings showed a great deal of how nurses related to patients which was not encouraging. Education for nurses on their communication skills should be reiterated in their schools. Courses such as perspective of nursing should be a hallmark in the early stages of every study since it educates on what nursing is all about. Nursing education of student during clinical should be assessed again, weekly meeting with their educators should be arranged to address issues that come up. Lecturers and clinical tutors in the various nursing institutions should teach on the quality of health care and the importance of satisfying the patient who is the recipient of care. For Nursing Research First, this study appears to be one of the first studies to have used a qualitative approach to assess patients’ satisfaction with health care services at the Mamprobi polyclinic. It will therefore add to the existing literature on patients’ satisfaction with health care services. This study provides other researchers the opportunity to study service quality and use the qualitative approach to gain an in-depth knowledge about their study of choice. A further study looking at the patient factors combined with the health service related factors that influence satisfaction with quality healthcare should be conducted. 107 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services For Nursing Practice From the study it was revealed that nurses had bad attitudes and communicated wrongly with patients on issues. This implies that the right of the patient is being jeopardized when he/she should be treated with utmost respect at all times most especially at a time patients is sick and needs the services of staffs. The satisfaction of a patient depends greatly on how he/she is been received. Staffs of the polyclinic should be approachable to enable patients rely and approach them freely without any fear of being treated unfairly. Nursing practice should focus on meeting the needs of the patients spiritually, emotionally and physically. 6.3 Limitations The study had the following limitations. The identified limitation will help in further studies research on patients’ satisfaction with health care services at the Mamprobi Polyclinic. Only patients who assessed health care services at the Mamprobi Polyclinic were interviewed. Future studies should concentrate on other polyclinics. Moreover, patients who assessed care at the laboratory and radiotherapy department without passing through the OPD were not captured in the study. Result attained cannot be generalised since it does not give a wide view of other patients in Ghana. A further research can therefore be conducted using patients who assess those areas to assess their satisfaction in that area. 108 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 6.4 Conclusion Patient satisfaction with healthcare services is a means of assessing patient satisfaction with nursing care. This is important in evaluating whether patients’ needs are fulfilled and subsequently facilitating in the planning as well as implementing appropriate nursing interventions for patients. The findings of the study reveal that patients were not satisfied with the healthcare at the Mamprobi Polyclinic. The findings further stress on the need for improvement in the staff strength, physical environment of the polyclinic as well as making medicines available at the pharmacy to ensure patient satisfaction with health care service delivery. Since much of the patient related factors in quality health care was not explored in the study, other research can therefore focus on that. 6.5 Recommendations Based on the findings of the study, recommendations have been made to Ministry of health/Ghana Health Service, Health care providers and Mamprobi Polyclinic The Ministry of Health/ Ghana Health Service The Ministry of Health and Ghana Health Service should organise and sponsor workshops for staffs to improve upon their knowledge and also learn new things unknown to them. Training and supervisory interventions that encourage acquisition of interpersonal skills are recommended. Quality improvement systems in polyclinics and other facilities should be monitored closely so ensure that patients satisfaction. 109 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services The Ministry of Health should ensure quality of care initiatives that are responsive to patients’ needs can improve patient satisfaction; in turn, satisfied patients may have better treatment adherence and outcomes. The Ministry of Health should ensure adequate staffing to ease the workload on the few staffs at the health facilities in Ghana. Moreover, staffs who neglect their duties should be punished by the Ministry of Health. Health care providers Healthcare providers must take cognizance of the fact that, the patient is the reason for their work, hence, any care given must connect with the best interest and specific needs of the patient. Nurses therefore need to improve upon their human relation with patients. Nurses should make the effort of attending in-service trainings for skills development to improve on their performance. Health care providers should improve upon their knowledge by continuously upgrading themselves on new health conditions, ways of managing, side effect and the appropriate action to take to save the life of a patient. Mamprobi Polyclinic Management of the polyclinic should ensure that there is a reserve of all essential and commonly prescribed medicines in their store in order to avoid inconveniences faced due to shortage of medicines. 110 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Unit heads of the records department and the general OPD should make concerted efforts to device means of reducing client waiting to the barest minimum in order to promote quick delivery of health care services at the clinic. Management should establish or, if already existing, revamp the clinics quality assurance committee to ensure that staffs at all units are up to the task and provide prompt and effective services to clients. Management of the clinic in collaboration with the in-service training unit should organize regular customer service sensitization workshops for their staff in order to improve upon their reception and general attitude towards clients. Management of the clinic should look in to the unavailability of some drugs at the pharmacy and inability of patients to assess drugs using their NHIS. To the patients getting drugs to take forms a major aspect of the care they receive. Staffing of records unit with more staff will help ease the undue pressure which causes patients to wait for long before they are served. The modern computerised filing system should be considered instead of the traditional filing system. Considering the impact of environment on patients’ satisfaction, cleanliness should be guaranteed to make it safe and environmental friendly for patient. Since payment is done before utilisation of the open washroom, clients should see the value for their money in the aspect of cleanliness. Management of Mamprobi Polyclinic should periodically measure their performance in order to improve upon the quality of care. 111 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services REFERENCE Abor, P. A., Abekah-Nkrumah, G., & Abor, J. (2007). An examination of hospital governance in Ghana. : http://197.255.68.203/handle/123456789/6538 Abekah-Nkrumah, G., Dinklo, T., & Abor, J. (2009). Financing the health sector in Ghana:a review of the budgetary process. European Journal of Economics, Finance and Administrative Sciences, 17(2009), 45-59. 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ISBN 0029357012, 9780029357019 Zolnierek, K.B. & Dimatteo, M.R. (2009), Physician communication and patient adherence to treatment: a meta-analysis. Medical Care, 47 (8), 826-834. doi:10.1097/MLR.0b013e31819a5acc Zineldin, M. (2006). The quality of healthcare and patient satisfaction: an exploratory investigation of the 5Qs model at some Egyptian and Jordanian medical clinics, International Journal of Healthcare Quality Assurance, 19(1), 60-92. https://doi.org/10.1108/09526860610642609 127 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services APPENDICES Appendix A : Ethical Clearance 128 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Appendix B: Interview Guide 129 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 130 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 131 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 132 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Appendix C: Consent form 133 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 134 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 135 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services 136 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Appendix D: Introductory letter 137 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Appendix E: Summary of Demographic characteristics of Participants DEMOGRAPHIC CHARACTERISTICS OF PARTICIPANTS Participants Sex Ages Level Of Language ETHINI Marital Occupation Years Of In Educations Spoken CITY Status Assessing Years Mamprobi Polyclinic P1 M 48 TERTIARY ENGLISH EWE NOT TEACHER 6 MARRIED P2 F 22 TERTIARY ENGLISH AKAN NOT STUDENT 10 MARRIED P3 F 27 TERTIARY ENGLISH GA COHABITING SECRETARY 4 P4 F 28 TERTIARY ENGLISH GA NOT FASHION 5 MARRIED DESIGNER P5 F 37 JHS TWI AKAN COHABITING TRADER 5 P6 F 37 TERTIARY ENGLISH GA MARRIED VODAFONE 2 SUPERVISOR P7 F 51 TERTIARY GA GA DIVORCED SEAMSTRES 30 S P8 F 27 SHS ENGLISH AKAN NOT BUSINESS 10 MARRIED WOMAN P9 M 54 TERTIARY ENGLISH AKAN DIVORCED LECTURER 22 P10 M 22 TERTIARY ENGLISH GA NOT STUDENT 4 MARRIED P11 M 27 TERTIARY ENGLISH GA NOT ACCOUNTS 15 MARRIED OFFICER P12 M 30 TERTIARY ENGLISH AKAN NOT BUSINESS 0NE MARRIED MAN MONTH 138 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Appendix F: Thematic Code Frame THEMES CODE DESCRIPTION PATIENTS’ SATISFACTION PSWH This was the extent to which WITH HEALTHCARE patients were pleased with the quality of health care 1. Patients’ expectations services PTE This was the patients’ anticipation of healthcare services which included the care rendered and the people who render the care as well as the environment in which the care is rendered. 2. Satisfaction with health care This sub-theme was the SWHC extent to which participants were content or happy with the healthcare services rendered to them at the facility 3. Dissatisfaction with health care This was the extent to which DWHC participants were discontent not pleased with the quality healthcare at the Polyclinic. This covers the appearance HOSPITAL ENVIRONMENT HOET of the physical facilities, (TANGIBILITY) equipment, appearance of personnel and communication materials at the polyclinic 1. Appearance of the hospital personnel AOTHP This was about how participants viewed the hospital personnel and how they expected them to look or dress. 2. Cleanliness of the This sub-theme is about the environment COTE degree to which the hospital environment is kept clean. 3. Availability of drugs and AODAOL This is about how drugs and 139 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services other logistics other logistics were easily accessible by participants. FACILITATORS/BARRIERS FBTPS This was the participant’s TO PATIENTS’ perceptions of the health SATISFACTION service related factors that facilitates or impedes their satisfaction with the healthcare services provided at the polyclinic. 1. Reliability RBT Therefore, reliability was the participants’ perceptions of how the staffs at the polyclinic performed the guaranteed services consistently and correctly. 2. Standard of care SOC This was the accepted level of excellence of health care services 3. Empathy and EAR Responsiveness This was about how responsible and loyal staffs were to their patients This was about the provision of individualised attention to patients, the willingness to help patients and the provision of prompt service. 4. Assurance ASC This was about the knowledge and courtesy of staffs and their ability to convey trust and confidence. EFFECT OF PATIENTS’ EPSHB This was the influence of SATISFACTION ON THEIR patients’ satisfaction on HEALTH SEEKING their future use of the BEHAVIOUR facility. 1. Willingness to This was the desire of 140 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services encourage others to WEOF participants to recommend use the facility others to use the facility. 2. Intentions to use the clinic in the future This was the willingness of participants to use the use IUCTF the services in the future NEEDS/SUGGESTIONS OF NSOP This was the influence of PARTICIPANTS patients’ satisfaction on their future use of the facility. 1. Needs of participants NOP This was the desire of participants to recommend others to use the facility. 2. Suggestions of patients This was the willingness of SOP participants to use the use the services in the future 141 University of Ghana http://ugspace.ug.edu.gh Patients’ satisfaction with the quality of health care services Appendix G: Approval Letter 142