Patients' Perception of the Quality of Gynecological Services in a Tertiary Public Health Facility in Lagos, Nigeria.

To facilitate improvements in health service delivery, patients' satisfaction with gynecological services was assessed at a tertiary hospital. Five hundred gynecological care-seekers who presented for outpatient consultation, inpatient care, or theatre procedures had face-to-face interviews using close-ended questionnaires. The assessment encompassed hospital ambience, healthcare providers' attitude, waiting time, duration of consultation among others. Univariate and bivariate analyses were performed with SPSS 22.0 software. Mean age was 37.8 ± 10.9 years; 319(63.8%) had tertiary education; 81(16.2%) and 82(16.4%) had inpatient and theatre care, respectively; 233(46.6%) were managed for infertility. One in five respondents reported delayed retrieval of medical records (20.8%), dissatisfaction with hospital meals (22.2%) and 31.6% were displeased with waiting time. Overall, 92.7%, 74.2%, and 66.7% of participants reported high levels of satisfaction with theatre, outpatient, and inpatient care, respectively. Age and education were significantly associated with outpatient satisfaction level (P = .015; P < .001 respectively). Though the majority expressed satisfaction with the quality of care, outpatients' waiting time was considered lengthy. We recommend a detailed appraisal of outpatient routines and periodic evaluation of gynecological services.

Introduction

The provision of high-quality health care that guarantees patient satisfaction is a challenge that health institutions and administrators face in most developing countries. Poor-quality health care is most prevalent in low- and middle-income countries (1) where it constitutes a major driver of excess mortality across different disease conditions (2).

Quality in health care delivery connotes the provision of effective, safe, and timely care that is centered on patients’ needs (3). It also implies excellence and attainment of recommended standards in satisfying the needs of clients and health care providers (4). Quality of service is a measure of the difference between a client's expectations before service utilization and perception after the service is received; this has a significant effect on patient satisfaction (5).

Assessment of quality of care can be difficult because it is multidimensional (1); encompassing complex processes of evaluating, diagnosing and treating patients; and appraising treatment outcomes. Quality assessment in health care has become very important (6) since poor quality can cause interruptions or discontinuation of care, which may adversely impact health outcomes (7–9).

In 2016, 5 million excess deaths in low and middle-income countries were estimated to arise from poor-quality care and 3·6 million from non-utilization of health care (2).

Quality assessment may be from the perceptive of clients, healthcare providers, or hospital management (10). Since gaps often exist between management and client perception of service quality (11), patient-based assessments are essential performance metrics of health care institutions. They provide unbiased feedback, emphasize institutional strengths and weaknesses, and guide strategies to meet patients’ expectations. Surveys from various parts of the world have shown diverse degrees of clients’ overall satisfaction with health services (12–15).

Assessment of gynecological services is particularly important because women constitute a vulnerable group that requires satisfactory services for the continued patronage of health care facilities. Factors such as gender of service provider and privacy among others have been reported to affect patients’ level of satisfaction with gynecological services (16).

In Nigeria, patients often complain of prolonged waiting times, overcrowding at clinics, poor staff attitude, inadequate communication and lack of drugs, among others (7,8,15). In addition, clients’ satisfaction with services in public health facilities has been rated lower than in private facilities (17,18). Assessment of clients’ perception of care provides baseline data for comparison, identifies areas for improvement, and assists in the evaluation of interventions (19).

To our knowledge, no previous study has addressed the quality of care in the gynecological department of Lagos State University Teaching Hospital (LASUTH). Hence, there is a need to document clients’ perception of care quality. Information obtained may be useful in designing interventions for improving the overall quality of gynecological services in LASUTH.

Methods

Study Setting

This cross-sectional study describes patients’ perception of the quality of gynecological inpatient, outpatient, and theatre services at LASUTH, Ikeja, Nigeria.

Nigeria is classified as a lower-middle-income country with an estimated total population of 206,139,589 (20). The health care system is organized into primary, secondary, and tertiary levels, which is complemented by private and other non-governmental health care facilities. Lagos is the smallest state in Nigeria with a landmass of 3.557 km2 yet her population is estimated as 21 million. It is located in the South-West geopolitical zone and the people are of different ethnic origins and at various levels of socio-economic strata.

LASUTH is a government-owned tertiary level facility that has a mission to provide high-quality health care services in a friendly environment where patients’ satisfaction is the ultimate.

The consultant-led gynecology outpatient clinics run every weekday. The clinic had commenced a staggered appointment system at the time of the study but patients were yet to fully embrace it. Some patients were seen on a first-come-first-serve basis.

The gynecology outpatient unit had a waiting area, medical record office, nurses’ station, consulting rooms, and examination rooms. The gynecology wards had a total bed capacity of 20. Meals are provided thrice daily by the hospital catering department.

The nurses run two shifts in 24 hours. The main hospital theatre serviced the gynecology unit. It had a designated suite for gynecological surgeries. There is a minor theatre for day cases, a 4-bedded recovery room, changing rooms, a reception, relatives’ waiting area, nurses’ station, and anesthetists’ room.

This study was conducted at the gynecology unit described above, which was a temporary facility used for about seven years while the definitive unit, “Ayinke House” was being renovated. The department has recently moved to the definitive unit which is bigger and better equipped with 170-bed capacity, contemporary equipment that includes 30 incubators, five operating theatres, oxygen plants, an intensive care unit and a very high-dependency unit among others.

Study Population

The participants were women seeking gynecological outpatient or inpatient care, some of which eventually had gynecological surgical procedures in LASUTH theatre.

Inclusion and Exclusion Criteria

All women who presented for gynecological outpatient consultation or inpatient care during the study period were offered enrolment if they had a minimum of three gynecological outpatient clinic attendance within six months of the interview. Women with less than three outpatient clinic attendance and those who did not consent were excluded.

Additional inclusion criteria were admission into the gynecological ward for a minimum of 72 hours for completion of inpatient services assessment, and having undergone a gynecological surgical procedure within the study period for completion of theatre service assessment. All respondents were interviewed at the gynecological outpatient clinic or gynecological ward.

Ethical Approval

The study was approved by the Health Research and Ethics Committee of Lagos State University Teaching Hospital (LREC) Reference Number: LREC. 06/10/1027. Participation was voluntary and all participants gave informed consent before participation.

Sampling and Sample Size Determination

The sample size was calculated on an assumption of 95% confidence interval (CI); 50% prevalence of high level of satisfaction; and an error margin of 0.5%. Twenty percent of the calculated sample size was added for attrition and a minimum sample size of 461 was required. Using a convenience sampling technique, 500 consecutive participants who met the inclusion criteria were interviewed.

Data Collection and Analysis

The survey utilized a face-to-face interview with pretested close-ended questionnaires adapted from previous studies and administered by House Officers over three months. The interviewers were fluent in Yoruba, the local language, and they doubled as interpreters.

The questionnaire addressed socio-demographic data and respondents’ level of satisfaction with gynecological services. A Likert- pattern scale with five possible responses assessed satisfaction. Scores of 1, 2, 3, 4, and 5 were assigned to very dissatisfied, dissatisfied, neutral, satisfied, and very satisfied, respectively.

Twenty-three questions assessed patients’ level of satisfaction with outpatient services and the maximum obtainable score was 115. An overall satisfaction score for outpatient services was calculated as a composite of the 23 questions for each respondent. A total score of 40 and below were classified as low level of satisfaction, 41 to 80 as moderate, and higher than 80 as a high level of satisfaction.

Nine questions assessed satisfaction with inpatient care; the total obtainable score was 45. Scores of 1 to 15 were regarded as low level of satisfaction, 16 to 30 as moderate and more than 30 as high. Eight questions assessed respondents’ level of satisfaction with theatre services. The maximum obtainable score was 40; scores of 1 to 14 were regarded as low; 15 to 27 as moderate; and above 27 as a high level of satisfaction.

Descriptive analysis was done by simple frequencies and proportions. Bivariate analysis was used to assess factors associated with patient satisfaction and P values less than .05 were considered significant.

Statistical Product and Service Solutions (SPSS version 22) was used for data entry and analysis.

Results

Data were complete in all 500 questionnaires administered giving a response rate of 100%. All 500 participants experienced outpatient care; of these, 81(16.2%) had inpatient care in addition, while 82(16.4%) had gynecological surgical procedures.

The mean age of participants was 37.8 ± 10.9 (SD). A majority (81.2%) were below 45 years. Most were Yoruba (63.0%) and of Christian faith (79.4%). Three in 4 (76.4%) were married. About two-thirds (63.8%) had tertiary education; while 12.0% had only primary or no formal education. About half of respondents (52.6%) were nulliparous and 46.6% attended for infertility and endocrine problems. Another 40.8% presented with fibroids. About 42.0% had commenced treatment which was non-surgical in 62.4% of those on treatment.

Respondents were satisfied with most aspects of outpatient care (Table 1). Some expressed displeasure with waiting time and the physician's duration of the consultation. Patients’ overall outpatient experience was rated higher at subsequent visits when compared to initial visits. A good proportion of outpatients (74.2%) reported a high overall level of satisfaction with gynecological outpatient services.

Table 1.

Respondents’ Level of Satisfaction With Gynecological Outpatient Services.

n = 500	VD	D	N	S	VS
Cleanliness of the waiting area	8(1.6)	34(6.8)	55(11.0)	151(30.2)	252(50.4)
Quietness of the waiting area	10(2.0)	31(6.2)	74(14.8)	141(28.2)	244(48.8)
Comfort and amenities in waiting area	16(3.2)	45(9.0)	85(17.0)	138(26.7)	216(43.2)
Duration of retrieving folder	28(5.6)	76(15.2)	78(15.6)	139(27.8)	179(35.8)
Duration of waiting before seeing doctor	53(10.6)	105(21.0)	81(16.2)	93(18.6)	168(33.6)
Overall experience at first visit	31(6.2)	74(14.8)	81(16.2)	111(22.2	203(40.6)
Overall experience at subsequent visit	14(2.8)	51(10.2)	82(16.4)	133(26.6)	220(44.0)
Privacy in consulting room	19(3.8)	46(9.2)	61(12.2)	126(25.2)	248(49.6)
Understanding of physician's terminologies	12(2.4)	36(7.2)	66(13.2)	109(21.8)	276(55.2)
Physician's listening skills	7(1.4)	31(6.2)	57(11.4)	127(25.4)	278(55.6)
Physician's attitude, behavior and manners	5(1.0)	30(6.0)	66(13.2)	117(23.4)	282(56.4)
Physician's respect for client's preference	5(1.0)	18(3.6)	68(13.6)	124(24.8)	285(57.0)
Physician's technical skills and competence	5(1.0)	27(5.4)	60(12.0)	121(24.2)	287(57.4)
Physician's explanation of diagnosis, procedure or treatment regimen	7(1.4)	34(6.8)	64(12.8)	120(24.0)	275(55.0)
Record staff personal manners, courtesy, respect, sensitivity and friendliness	12(2.4)	24(4.8)	78(15.6)	111(22.2)	275(55.0)
Nursing staff personal manners, courtesy, respect, sensitivity and friendliness	11(2.2)	25(5.0)	64(12.8)	112(22.4)	288(57.6)
Adequacy of time spent with physician	5(1.0)	20(4.0)	65(13.0)	124(24.8)	286(57.2)
Physician's involvement of respondent in decision making	7(1.4)	18(3.6)	62(12.4)	130(26.0)	283(56.6)
Emotional support given by physician	8(1.6)	12(2.4)	62(12.4)	135(27.0)	283(56.6)
Caregivers added value to client's health	8(1.6)	13(2.6)	59(11.8)	126(25.2)	294(58.8)
Information received was useful to client	5(1.0)	13(2.6)	60(12.0)	128(25.6)	294(58.8)
Respondent's understanding of care plan	8(1.6)	11(2.2)	55(11.0)	132(26.4)	294(58.8)

VS, very satisfied; S, satisfied; N, neutral; D, dissatisfied; VD, very dissatisfied.

Respondents were least satisfied with feeding and privacy on the ward while other aspects of inpatient services were rated positively (Table 2).

Table 2.

Respondents’ Satisfaction With Gynecological Inpatient and Theatre Services.

Inpatients (n = 81)	VD	D	N	S	VS
Location of the ward	5(6.2)	5(6.2)	6(7.4)	27(33.3)	38(46.9)
Cleanliness of the ward and rest room	1(1.2)	9(11.1)	8(9.9)	23(28.4)	40(49.4)
Comfort and amenities in the ward	1(1.2)	7(8.6)	9(11.1)	25(30.9)	39(48.2)
Feeding pattern on the ward	8(9.9)	10(12.3)	18(22.2)	18(22.2)	27(33.3)
Overall experience on the ward	2(2.5)	4(4.9)	20(24.7)	20(24.7)	35(43.2)
Privacy on the ward	5(6.2)	10(12.3)	15(18.5)	16(19.8)	35(43.2)
Promptness of care	0(0.0)	6(7.4)	17(21.0)	23(28.4)	35(43.2)
Manners of other staff; courtesy, respect, competence and friendliness	0(0.0)	10(12.3)	16(19.8)	13(16.0)	42(51.9)
Manners of nursing Staff; courtesy, respect, competence, friendliness	0(0.0)	14(17.3)	10(12.3)	22(27.2)	35(43.2)
Theatre users (n = 82)	VD	D	N	S	VS
Location of the theater	1(1.2)	3(3.7)	8(9.8)	27(32.9)	43(52.4)
Cleanliness of the theater	1(1.2)	3(3.7)	7(8.5)	24(29.3)	47(57.3)
Comfort in the theater	1(1.2)	2(2.4)	8(9.8)	24(29.3)	47(57.3)
Theater reception	1(1.2)	4(4.9)	18(22.0)	16(19.5)	43(52.4)
Attitude of account personnel; courtesy, respect, competence and friendliness	2(2.4)	3(3.7)	17(20.7)	15(18.3)	45(54.9)
Attitude of perioperative nurse; respect, courtesy, competence friendliness	0(0.0)	6(7.3)	7(8.5)	23(28.1)	46(56.1)
Competence of anesthetists	1(1.2)	4(4.9)	9(11.1)	19(23.2)	49(59.8)
Experience with anesthesia	2(2.4)	2(2.4)	8(9.8)	18(22.0)	52(63.4)

VS, very satisfied; S, satisfied; N, neutral; D, dissatisfied; VD, very dissatisfied.

Overall satisfaction level with gynecological inpatient services is shown in Figure 1; with 1 in 3 clients reporting a low or moderate level of satisfaction.

Figure 1.

Respondents’ level of satisfaction with gynecological inpatient services.

The majority of the respondents were very satisfied with most aspects of theatre services as shown in Table 2. Up to 92.7% of the respondents had a high overall level of satisfaction with theatre services.

There were statistically significant associations between respondents’ age and level of education and satisfaction with outpatient care (P = .015 and P < .001, respectively) as shown in Table 3. Respondents with a higher level of education had a positive perception of outpatient services when compared with patients with lower educational levels.

Table 3.

Association Between Respondents’ Socio-Demographic Characteristics and Level of Satisfaction With Outpatient Services.

Characteristics	Low/Moderate(n = 129)	High(n = 371)	Statistics
Age group (years)
<36	72(30.4)	165(69.6)	P = .015*
36 to 45	43(25.4)	126(74.6)
>45	14(14.9)	80(85.1)
Ethnic group
Yoruba	74(23.5)	241(76.5)	P = .191
Igbo	31(30.4)	71(69.6)
Others	24(30.8)	54(69.2)
Hausa	0(0.0)	5(100.0)
Religion			P = .078
Christianity	111(28.0)	286(72.0)
Islam	17(17.0)	83(83.0)
Others	1(33.3)	2(66.7)
Marital status
Married	98(25.7)	284(74.3)	P = .970
Single	27(26.0)	77(74.0)
Others	4(28.6)	10(71.4)
Highest level of education
None/Primary	111(34.1)	214(65.9)	P < .001*
Secondary	16(13.2)	105(86.8)
Tertiary	2(3.7)	52(96.3)

‘*’ means significant.

There were no significant associations between respondents’ socio-demographic characteristics and level of satisfaction with inpatient and theatre services.

Discussion

This study revealed that the majority (92.7%, 74.2%, and 66.7%) of clients seeking gynecological care at the LASUTH, Ikeja, Nigeria reported high levels of satisfaction with theatre, outpatient, and inpatient services, respectively. Respondents’ mean age was 37.8 ± 10.9 which is comparable to 40 ± 15.2 and 31.9 ± 12.0 reported in 2 public outpatient clinics of Lagos and Kano, respectively (7,15). The modal age group of ‘below 36 years’ compares well with that of another study from South-West Nigeria that specifically evaluated gynecological patients’ perception of care (16).

In keeping with the predominant ethnic group of South Western Nigeria, about two-thirds of our respondents (63.0%) were Yoruba; this is despite the heterogeneous population of Lagos. This pattern was also displayed in the Kano study where 73% of respondents were Hausas, Kano being a predominantly Hausa community (7).

The religious distribution of respondents was skewed with 79.4% practicing Christianity and 20.0%, Islam; notwithstanding an almost equal distribution of Christians and Muslims in Lagos State. Other researchers have documented similar ratios of Christian to Muslim participants in Lagos (15,18). Muslim women seeking reproductive health services may prefer non-public facilities for religious reasons. Privacy and confidentiality are important elements that influence a woman's utilization of healthcare, especially when dealing with gynecological services.

Most respondents (76.4%) were married and more than half (52.6%) were nulliparous. This pattern is reflective of our study population that targeted users of gynecological services rather than general outpatients or community-based participants. The majority attends for infertility and tend to be married. Omotayo et al reported a similar pattern (16). Almost two-thirds (63.8%) had tertiary education. However, a community-based study that assessed recent users of health facilities in Lagos reported that merely 19% of participants had tertiary education (18).

Respondents’ level of satisfaction with gynecological outpatient services of 74.2% is high and comparable to 77%, 80.8%, and 83% previously reported (7,12,15).

A higher proportion of gynecological patients (95.7%) were satisfied with morning clinic sessions in Akure, Nigeria (16) while 94% of Lagos community members reported satisfaction with services received (18). Another study reported that 96.5% of pregnant women who received care at private and public health facilities within the 3 healthcare levels were satisfied with the care received (21).

Notably, 31.6% of our respondents were dissatisfied with the duration of time spent awaiting doctors’ reviews. A similar proportion (30%) of patients were dissatisfied with waiting time in Northern Nigeria (7). Though, a staggered gynecological appointment is already operational in LASUTH, it is yet to bring the desired reduction in patients’ waiting time. Patients prefer to arrive earlier than scheduled to evade the traffic situation in Lagos. Factors such as the late arrival of patients and the inadequate number of attending doctors have been identified to affect waiting time in other settings. At times, doctors spend longer than usual consultation time with some patients, causing delays in attending to others. Clients must be informed when delays are envisaged as this positively influences clients’ perception of care.

Respondents’ level of satisfaction with gynecological inpatient care was the lowest as only two-thirds (66.7%) had a high level of satisfaction. This is not unexpected since about 1 in 5 were dissatisfied with hospital meals, privacy on the ward and attitude of the ward nurses. Our findings differ from that of Iliyasu et al who reported a high level of satisfaction in 88% of respondents who had inpatient care (7).

Differences in satisfaction level may be a reflection of differences in study design, variations in data collection tools, and health care features are considered by the client as most germane. Quality of care may also differ in different settings and regions of the world.

Quality-related experiences reported by patients sometimes draw the attention of hospital managers to services that may have been overlooked. Such problems may have been addressed without achieving a complete resolution. Alternative solutions proffered by patients may help resolve such problems.

Clients’ level of satisfaction with theatre services was most remarkable with 92.7% reporting a high level of satisfaction. In Gondar, Northwest of Ethiopia, the overall level of patient satisfaction with perioperative surgical services was 98.1% (22). An overall satisfaction level with a perioperative care score of 92.1% was also reported in the Netherlands using the Leiden Perioperative care Patient Satisfaction questionnaire (23).

Respondents’ age and level of education were significantly associated with the level of satisfaction with gynecological outpatient care (P = .015; P < .001, respectively). This suggests that the older the patient, the higher the level of satisfaction with gynecological outpatient services. Younger clients tend to have higher expectations. Older age was among the predictors of high ratings of satisfaction in a study in Port Harcourt, Nigeria (24). Older people may pay less attention to certain aspects of functional service quality and are more easily satisfied with the services provided (25).

Our study revealed that clients with higher educational levels reported a higher level of satisfaction. This is at variance with some studies (26,27) but similar to findings reported among private hospitals users in South-South Nigeria (28). It may be that most well-educated clients have written off our public health care facilities; their expectations are probably much lower than the quality eventually encountered and this leads to positive levels of satisfaction. Well educated clients are also more likely to comprehend instructions than those with lower educational levels (28).

We reported no significant associations between respondents’ ethnic group, religion, marital status, and level of satisfaction with outpatient care (P = .079), (P = .263), (P = .199), and (P = .656), respectively. Akinyinka et al reported no statistically significant associations between socio-demographic characteristics of community members and satisfaction level with recently used health care facilities in Lagos State (18).

No significant associations were found between respondents’ socio-demographic characteristics and level of satisfaction with gynecological inpatient or theatre services.

Respondents’ rating of care providers’ (physicians, nurses, medical records, and theatre personnel) attitude was high with more than 90% reporting satisfactory levels. The hospital management must ensure that medical staff are reinvigorated to interact nicely with patients since patients’ satisfaction can be enhanced by an excellent patient-staff relationship (29).

The overall experiences of outpatient respondents at first and subsequent clinic visits were compared; the mean scores for first and subsequent visits were 3.76 and 3.99, respectively. Respondents reported better experiences during subsequent visits. Reasons for this may include more familiarity with the clinic routine.

Overall, respondents’ perception of the quality of care was satisfactory, with moderate to high levels of satisfaction reported in most spheres evaluated. Our findings will impact initiatives that will improve the quality of care in our gynecological unit specifically, and the hospital, generally. Such improvement will require efforts from other units of the hospital especially the referenced departments such as catering, records, and accounts department; and not just health care providers in the gynecology department. The “new Ayinke” has a dedicated catering unit that is determined to improve the quality, quantity, and variety of patients’ meals. Patients are also continuously reminded of the need to embrace staggered appointment to reduce waiting time.

Strength and Limitation

This is a speciality specific assessment of the quality of hospital services that evaluated sub-units independently. Our findings cannot be generalized to represent patients’ perception of gynecological service in Nigerian tertiary hospitals because the standard of practice varies nationwide. Participants’ response bias cannot be completely eliminated since a researcher-administered questionnaire was employed. Qualitative studies will be desirable to complement quantitative findings in future researches.

Conclusion

In conclusion, patients perceived the gynecological services of LASUTH positively, especially the theatre and outpatient services. When gynecological services are satisfactory, clients’ utilization improves and this translates to improved health and better reproductive health indices. We recommend service improvement plans that will address clients’ waiting time, privacy, duration of consultation, quality of patients’ meals, as well as enhance patients’ care through a more friendly staff attitude. A periodic patient satisfaction survey should be institutionalized to provide feedback for continuous quality improvement.