Level of Clients’ Satisfaction and Associated Factors with the Service of Out-Patient Department in Dilla University Referral Hospital, Southern Ethiopia, 2021

Background. Client satisfaction with seeking healthcare is generally regarded as one of the core outcomes of the health system. Various eorts are underway to provide hospitals with the necessary manpower, medical equipment, and other services to suit the demands of their patients. e goal of this study was to determine the level of client satisfaction with outpatient department services and the factors that inuence it at Dilla Referral Hospital in Ethiopia. Methodology. A cross-sectional investigation was undertaken in a hospital setting. An interviewer-administered quantitative data were collected on socio demographic characteristics of respondents and their satisfaction level with the dierent components of the outpatient services. SPSS version 20 was used to conduct the analysis.e connection between independent and dependent variables was evaluated using bivariate analysis (p< 0.25). To discover the determinants of client satisfaction and control cofounding, multivariate logistic regression was performed (p≤ 0.05). Result. e study enrolled a total of 419 individuals, with a response rate of 98.3%. Overall, 52.2 percent of clients were satised with the health services provided by the hospitals’ outpatient departments. Client satisfaction was signicantly predicted by the cleanliness of the consultation room (AOR 2.05, 95% CI: 1.06–3.95), payment status (AOD 1.68, 95% CI: 1.08–2.63), and telling clients about the etiology of sickness (AOR 0.55, 95% CI: 0.34–0.87). Conclusion. e general satisfaction of outpatients with Dilla referral hospital’s OPD clinics healthcare services was low.e cleanliness of the consultation room, payment status, and readiness to suggest the service to others were all linked to a positive outcome.


Introduction
e level of client satisfaction is one of the most important factors in determining the quality of healthcare services [1].
Client satisfaction is a multifaceted healthcare issue that is in uenced by what clients expect from a service and the service provider's experience. Client expectations about the quality of care are also linked to the perceptions of care, and when patients have favorable impressions, their clinical experience and outcomes are more likely to be positive [2].
Understanding how consumers feel about the healthcare and treatment they have received is crucial to improving the service's quality [3]. In general, the outpatient department accounts for the majority of healthcare delivery sites because it is the point of rst contact between the hospital and the community, as well as the hospital's shop window. As a result, the clients in outpatient department clinics face a variety of issues, such as overcrowding, consultation delays, a lack of proper guidance, and so on, leading to client dissatisfaction [4].
According to a survey conducted in various countries' public tertiary hospitals, the levels of client satisfaction with health care varied. Client satisfaction with services provided from Nigeria [5], Bangladesh [6], and rural India [7] was reported to be 78.5%, 68.9%, and 89.1%, respectively, in a study. A similar study was carried out on the outpatient performance of teaching hospitals in Ethiopia, including the University of Gondar teaching hospital [8], Jimma university referral hospital, [9] and Wolaita Sodo university teaching hospital [10], which revealed satisfaction rates of 22.0%, 57.1%, and 54.2%, respectively.
e Ethiopian government has implemented various methods to improve the quality of health care service delivery, such as the health system improvement program. Yet, client dissatisfaction remains high, ranging from 22% to 80.1% [3,11]. It is because of the fact that Ethiopia's and most developing countries' healthcare systems are severely lacking in terms of financing, efficiency, equity, and quality, and they are ill-prepared to face these issues [12]. Client perceptions of healthcare systems appear to have been largely ignored by healthcare managers in developing countries, and clinicians lack awareness and adequate training to address patients' expectations [13]. As a result, the purpose of this study was to assess the level of client satisfaction with outpatient health services and factors associated with it at Dilla University Teaching Hospital. As a result, this research can help to provide stakeholders with evidence-based information that can be used to improve hospital quality.

Study Area.
e study was conducted in Dilla university referral hospital, which is found in Dilla town Gedeo zone, South Nations Nationalities, and Peoples Region (SNNPR), Ethiopia. It is located about 360 km South of Addis Ababa and 95 km from Hawassa (the administration center of SNNPR). Dilla university referral hospital (DURH) is established in 1977 E.C/1985 G.C as a zonal hospital in Gedeo zone with the former name of Dilla Hospital until June 11/2001 E.C, which was changed to DURH. e hospital gives healthcare service for around 5 million peoples in Gedeo zone and neighboring Oromia region districts. It is a referral center for surrounding primary hospitals and health centers and is also open 24 hours for emergency services. e hospital has six main departments (medical, surgical, orthopedic, pediatrics, gynecology/obstetric, and psychiatry wards), three special care units (medical intensive care unit, neonatal intensive care unit and surgical recovery room), and four clinics (eye, antiretroviral treatment, dental, and dermatology).

Study Design and Period.
Institutional-based crosssectional study was conducted from June 7/2021-July 7/ 2021. e source population will include all clients who visited the hospitals for outpatient health services between June 7, 2021, and July 7, 2021, including guardians for minors who are unable to provide information independently.
Clients who visited the outpatient departments of Dilla university referral hospital in Southern Ethiopia during the study period were the study population, which was chosen using a systematic random sampling technique (using clients medical record ID numbers from the registration (log) book as the sampling frame).

Inclusion Criteria
(i). All clients of all ages (for children with their attendants) who were presented to OPDs to get health services were included in the study.

Exclusion Criteria
(i). Very seriously ill clients who did not have somebody to accompany them. (ii). Clients came for the second time during the study period.

Sample
Size. e sample size was estimated using the single population proportion calculation with the following assumptions: 54.2 percent [10], (Z/2 � 1.96), 5% margin of error at 95 percent confidence level, and 10% nonresponse rate. A total of 419 people were included in the study.

Sampling Technique.
e average number of client flow in the total OPD in the same month of the previous year (2020) and the month prior to the actual data collection period (2021), which was taken from the log book at each OPD as the baseline for estimating OPDs client flow, was used to determine proportionate allocation. en, to choose respondents, a systematic random selection procedure using clients' medical record ID numbers was used. e sampling interval (k value) was calculated by dividing the source population (which will be derived from the average number of client flows in the total OPD in the same month of the previous year (2020) and the month prior to the actual data collection period (2021) by the total sample size (419), and it was found to be seven. is period was used to choose study subjects in every OPD. e first client was chosen at random from the OPD service users (by lottery method).

Data Collection.
e exit interviews of clients were conducted in confidential rooms using a structured and pretested questionnaire. e questionnaire was developed for the purpose of data collection after reviewing relevant literature.
e questionnaire was modified from related literature [3,9,10] with minor changes to fit the study's objectives. e questionnaire in the beginning was prepared in English and then translated into Amharic and back to English to ensure consistency, however, it was finally administered in Amharic, the common language. It was an interviewer-administered structured questionnaire. e questionnaire was designed to obtain information on socio demographic characteristics of respondents (9 items) and their satisfaction level with the different components of the outpatient services. Client satisfaction is a collective outcome of different kinds of services provided in the hospital. In this study, it was measured using 17-item questions, which is composed of three dimensions. Service utilization, patient and healthcare provider interaction, and facility-related information were the three different dimensions assessed.
Overall patient satisfaction is measured using five items in the questionnaire. Each item has a 5-point Likert scale, ranging from 1 (very dissatisfied) to 5 (very satisfied).

Variables
Level of client's satisfaction.

Independent Variables
(i). Patient satisfaction is influenced by sociodemographic parameters, such as age, educational status, income, payment, marital status, occupation, and residence/address. (ii). Patient and healthcare provider interaction (provision of information, interview by their own language, clarity of instruction for investigations and prescriptions, courtesy of healthcare providers, and maintenance of privacy and confidentiality) (iii). Institutional aspects and pattern of visit (waiting and exam room cleanliness, registration process, waiting and walking time, and service availability) (ordered laboratory, X-ray, drugs, and supplies in the hospital).

Operational
Definition. e level of patient satisfaction: all five measuring items in the scale to measure satisfaction together yield a maximum score of 25 and a minimum score of 5. Satisfaction level was measured by the responses for every five items summed and transformed to give an individual level satisfaction score from 0 to 100 percentage for each item used as percentage mean score.
Overall satisfaction level: 75% and above response rate of the five satisfaction measuring items was categorized as "satisfied," and those who were satisfied in less than 75% of the five satisfaction measuring items were categorized as "dissatisfied" [14].
is cut point was taken because the satisfaction measuring questions were expected to be answered by majority of respondents.

Quality Assurance Techniques.
en, for ease of communication during the interview, English questionnaires were translated into Amharic (common language). e questionnaire was pretested in 5% (21 participants) of the total sample size, and it was not included in the study. Based on the results, suitable changes were made, such as unclear items being adjusted to be simple and clear. At the end of each data collecting day, the lead investigator evaluated all of the obtained data for completeness, accuracy, clarity, and consistency of the questionnaire. Any errors discovered during data entry were addressed after the original questionnaire was revised.

Data Management and Analysis. SPSS version 20
statistical package was used to check for mistakes, recode, enter, and analyze the acquired data. To summarize the data, descriptive statistics, such as frequencies, and cross-tabulation, such as percentages, were utilized first. Bivariate logistic regression analysis was done, variables with p-value less than 0.25 were included in multivariable logistic regressions analysis, and p value less than or equal 0.05 was used as a measure of statistical significance. Finally, the findings were presented in the form of text, tables, and graphs.

Ethical Considerations.
e school of medical and public health provided ethical approval. Before the actual data collection, a copy of the letter was sent to the hospital's responsible organizations, and authorization was gained. After the goal of the study was presented to the clients, verbal informed consent was taken from them. ey would also be advised that the information they provided would not be shared with any third parties. e study did not use anyone's name or any other identifying information.

Sociodemographic Characteristics of Respondents.
e study enrolled 419 participants, with a response rate of 98.3%. e age of 31.8% of clients was in the range of 28 to 37 years, of which, 237 (57.5%) were men. Regarding their educational status, 108 (26.2%) were unable to read and write. From the total number of participants, 118 (28.6%) worked as farmers. More than half of the respondents (56.5%) were from urban area (Table 1).

Institutional
Aspects and Pattern of Visit. 141 (34.1%) of the total respondents had only visited the facility once. When asked why they came, 298 (72.3%) said it was because they were sick. Nearly one third of the clients, 149 (33.7 percent), did not pay for the services and received them for free.
399 clients (96.4%) received a prescription paper for drugs and supplies out of the total responses. Some of the prescribed drugs were obtained from the hospital's pharmacy by 257 (62.4 percent) of those with a prescription. Concerning the cleanliness of the waiting area and consultation room, 49.3% and 88.6% of respondents said they were clean, respectively ( Table 2).

3.3.
Interaction with the Healthcare Provider. More than two-thirds of the respondents (68.7%) said the provider told them the name and cause of their sickness and more than half (51%) said they were given information on how to prevent the condition from recurring (Table 3).

Levels of Client Satisfaction with Different Components of Health Service Provision.
Of the total number of participants, 286 (69.4%) said that they were satisfied with the time it took to see a health worker. On other hand, 285 (69.2) were Advances in Public Health satisfied with provider-related characteristics (courtesy and respect of healthcare providers). Most of (69.7%) the clients gave the clarity of the service provider's instructions on investigations/prescriptions a higher satisfaction rating (Table 4).
In this study, the overall client's satisfaction in outpatient service of DURH was 52.2% as shown below (Figure 1).

Factors Associated with Clients' Satisfaction.
In binary logistic regression, eight variables were identified at p-value less than 0.25 to be fitted for multivariable logistics regression. ese variables were educational status, address, payment status, travel time, information on name and cause of illness, drug and supplement order, cleanliness of the consultation room, and recommendation of the service. In multivariable logistic regression, cleanliness of the consultation room, willingness to recommend the service to others, information on the name and cause of illness, and payment status were the statistically significant predictors of client satisfaction.
As a result, clients who thought the consultation room was clean were 2.05 times (95% CI: 1.06-3.95) more satisfied than those who thought the consultation room was dirty. Clients who are ready to recommend the service to others are 2.03 times (95% CI: 1.32-3.11) more satisfied than those who do not recommend the service to others. Clients who did not pay for health services were 1.68 times (95% CI: 1.08-2.63) satisfied than those who paid. Clients who were informed of the name and cause of their sickness were 2.01 times (95% CI: 1.45-2.05) more satisfied than those who were not informed of the name and cause of their illness (Table 5).

Discussion
Our study finding shows that the overall patient satisfaction rate is 52.2%. is level of satisfaction is low when compared to the results of studies conducted in Hawassa University Other * motorcycle deriver, other * * Waqefeta and no religion, other * * * Wolayita, Hadiya.    [10,11,15,16]. e difference could be because of the fact that specialized teaching hospitals are better equipped and have a greater diversity of health professionals, better diagnostic facilities, health service infrastructures, and service providers of various levels who are expected to demonstrate the standard way of patient examination, resulting in a higher overall satisfaction level.
It is low when compared to a survey conducted in a Nigerian public tertiary hospital, which found that 78.5% of patients were satisfied with hospital services [5]. It could be because of the differences in setup and the client's perception of the service, as well as societal and cultural issues. e other finding of the study shows that 91.6% of respondents said the consultation room was clean. is level of satisfaction with the cleanliness of the facilities is comparable to the 90% satisfaction found in research done at Wolaita Sodo University Teaching Hospital [10]. It is low when    [14]. Payment status is another predictor of clients' satisfaction in this study, as nonpaying (free) for health care service respondents are more satisfied than paying respondents. It may be related to the fact that their expectation of the services may rise when they incur certain costs to the services.
is finding is in agreement with the studies conducted that when people acquire health insurance, their expectations for services rise. is conclusion is supported by research conducted at Wolaita Sodo University teaching hospital [10].
Another aspect of client satisfaction is the likelihood of recommending the service to others. According to the findings of this study, 70.7 5% of respondents are satisfied with their desire to suggest the service to others, compared to those who do not. It is low when compared to that in the research conducted in a Nigerian public tertiary hospital, which found that 91.7% of respondents would suggest the hospital to a friend [5]. e disparity could be attributable to the type of service provided or the difference in hospital and setting facilities.
In this study, providing information about the name and cause of their sickness had a detrimental impact on patient satisfaction. According to the findings of this study, 69% of patients were told about their illness's name and causes. It is higher than that in research done in basic healthcare clinics in central Ethiopia, which found that 62.6% of patients were unaware of the source of their sickness [16]. is disparity could be related to the differences in setup and resources between referral hospitals and health centers.

Limitations of the Study.
Because the respondents were questioned in the hospital compound, the results of this study may be prone to social desirability bias. Furthermore, patients may experience a brief period of satisfaction following their consultation, which is followed by a period of dissatisfaction.

Conclusion
Outpatients' overall satisfaction with DURH's OPD clinics' healthcare services was low. Patient satisfaction was positively associated with cleanliness of the consultation room and payment status, desire to suggest the service to others, as well as information supplied on the name and etiology of their ailment.

Data Availability
Data used are available upon reasonable request to the corresponding author.

Ethical Approval
e Dilla University Ethical Review Board provided ethical clearance and a permission letter.

Consent
Participants were given written informed consent. e confidentiality of the information provided by respondents was ensured.

Conflicts of Interest
e authors declare that they have no conflicts of interest.