Sociodemographic Determinants of Patients’ Satisfaction with the Quality of Care in the General Hospitals in Ebonyi State, Nigeria

Introduction: The purpose of the study was to assess sociodemographic determinants of patients’ satisfaction with the quality of care in the General Hospitals in Ebonyi State. Four hypotheses were formulated for the study. Demographic characteristics of age, level of education, marital status, and income level on patients’ satisfaction were ascertained. Methods: A cross-sectional survey research design was used for the study. The population of the study comprised 1, 363, 633 (18 years and above) who attended general out-patient clinics in the General Hospitals using a sample of 400. Data were analyzed using mean (x ), t-test, and analysis of variance (ANOVA) were used to answer the hypothesis at 0.05 level of significance. The SPSS version 20 was employed for the analysis. Results: Findings showed that patients who were 40–60 years (x = 2.96), had tertiary education (x = 2.97), earned income of N40, 000 – N59, 000 (x = 2.96) and were married (x = 3.09) were most satisfied. Besides, age, marital status, and income were not significantly associated (p>0.05) with patients’ satisfaction while the level of education was significant (p<0.05). Conclusion: The study revealed that older age, more educated, middle-class income earners, being married were more satisfied with the quality of care received. Efforts should be made by Health workers to ensure that all patients are satisfied irrespective of their demographic characteristics.


Introduction
The health sector in any economy forms the bedrock of its growth and development. An effective and efficient health sector not only meet the health needs of the citizenry but also boost the nation's Gross Domestic Product (GDP) by generating enormous revenue to the government and a healthy citizenry. Thus the provision of quality health services is indispensable, yet the health care delivery system in Nigeria is characterized by problems of quality of care and accessibility to care (Anyika, 2014;Shagaya, 2015). Patient satisfaction has emerged as an essential index to determine the excellence of care (Surur, Teni, Girmay, Moges, Tesfa, & Abraha, 2015). Hospital routine can be best assessed by measuring the level of patient satisfaction with communication between health workers and patients which has been reported as very poor, these have made them to be at the mercy of the health care workers in those hospitals (Alrubaiee, & Alkaa'ida, 2011;Zhang, Wang, Yu, & Zhao, 2018;Chandra, Ward, & Mohammadnezhad, 2019) For most countries, research on patients' satisfaction and patients' experience with hospitals are done most often and the feedback gotten are made available to the public together with other indicators of health care quality. The hospitals in the developed countries are aware of the consequence of delivering patient approval as a tactical variable and a vital determinant of long-term feasibility and success (Amole, Oyetoye, & Kuye, 2015). Unfortunately, patients' satisfaction with the quality of health services provided in the nation's hospitals seemed to have been for the most part overlooked by health care managers, hospital administrators, politicians, and other decision-makers in the sector. Thus, patients choose health care based on the satisfaction they received from various health facilities. Consequently, this resulted in an astronomical increase of medical tourism by Nigerians abroad for even cases that can be managed successfully by our health sector with a depletion of the nation's foreign reserves. For instance, about 78 billion naira (over 8,500 million US dollars) is spent by Nigerians yearly to seek health care services abroad mainly from seeming shortcoming in the home health care delivery organization (Megbelayin, Babalola, Kurawa, Opubiri, & Okonkwo, 2015).
Furthermore, any strategy to promote self-reliance and encourage the usage of the existing hospitals must utilize patients' voices as a guide in the design of the health sector. To reverse this ugly trend, several survey studies have been conducted to assess patients' satisfaction in Nigerian hospitals, though they are insufficient for policymaking. Even though Ebonyi state government runs 13 general hospitals that are sited in the 13 LGAs and 424 primary health care centers, there is low patronage as there is a surge of patients in tertiary and private health facilities even for ailments that can be treated at their facilities. It is to this end that this research was set to explore the Sociodemographic determinants of patients' satisfaction in state-owned General Hospitals in all the Local Government Area of Ebonyi State, Nigeria using demographic variables such as age, gender, and educational level. Four hypotheses guided this study and were tested at p< 0.05 level of significance.

Hypotheses
1) There is no significant difference in patients' satisfaction based on age.
2) There is no significant difference in patients' satisfaction based on the Educational level.
3) There is no significant difference in patients' satisfaction based on marital status. 4) There is no significant difference in patients' satisfaction based on income.

Research Design
The study adopted the descriptive survey research design. This design was considered appropriate and adequate for this study because it has been used in previous studies by Karaca and Durna, (2019). The researcher recruited a sample size from the larger populace to explore and interpret the status of outpatients' satisfaction with the quality of care in the hospitals in Ebonyi State.

Area of the Study
The study was carried out in Ebonyi state, which occupies a land area of 5,954 square kilometers and is situated between longitude 70 and 80 301 E and latitude 50 401 and 60 541 north of the equator. The state is part of the southeast geopolitical zone and bounded in the north by Benue state, in the west by Enugu state, in the east by Cross River State and in the south by Abia state. The population of Ebonyi state for 2016 is 2, 64,776 (projected from 2006 census of 2,173,501 with a projected growth rate of 2.8%). The population of male and female are 1,416,334 (48.62%) and 1,481,067 (51.38%) respectively, children under 5 years were 579,480 (20%), pregnant women were 144,870 (5%) and women of childbearing age is 637,428 (22%). Nearly 75% of the State population is engaged in subsistent agrarian economic activities. The economy is majorly driven by the public sector and 56% of the population lives below U$1 per day (GDP) with high levels of unemployment and underemployment and with very few industries with low output. The state runs a three-tier health care system which are primary, secondary, and tertiary levels. The Federal government is responsible for tertiary healthcare which is the apex of the healthcare delivery and provides specialized services through the Federal Teaching Hospital Abakaliki (FETHA), Vesico-Vaginal Fistula (VVF) center. The state provides care through the 13 General Hospitals and 6 Rural Mission Hospital while the Local Government Council takes care for Primary Health Care Services. There

Sample and Sampling Techniques
A multi-stage sampling procedure was used to select a sample of 400 out-patients that attended the State-owned General Hospitals in the thirteen LGAs. The first stage involved clustering and random sampling of the zones namely: Abakaliki, Afikpo, and Onueke education zones; the second stage involved the determination of sample size for each zone identified in the first stage: Abakaliki education (131), Onueke education (119), and Afikpo (150), to ensure equal representation of all the zones in the State. In the third stage, two General hospitals were selected per zone giving rise to a total of 6 hospitals. Lastly, the participants were selected using a simple random technique of balloting without replacement.

Ethical approval
Ethical approval was obtained from the Review Board of the Department of Human Kinetics and Health Education, gjhs.ccsenet.org Global Journal of Health Science Vol. 12, No. 11; Faculty of Education, Ebonyi State University (EBSU/FOE/KHE/018). Informed consent was also obtained from all the respondents for the study.

Instrument for Data Collection
The instrument for data collection was a self-administered questionnaire titled: Patient Satisfaction with quality of Care. The questionnaire has 10-item consisting of 2 sections: Sections 1 has 4 items on the socio-demographic characteristics of the respondents based on age, educational level, marital status, household income, and clinics attended while; 2 is made up of 6 items meant to elicit information on waiting time, communication, empathy, competency, cost, and access. The items were measured on a four-point Likert scale through 1 to 4 which indicated: 1-very dissatisfied; 2-dissatisfied; 3-satisfied; and 4-very satisfied. The reliability of the instrument was established using data collected from 30 patients in a general hospital within the study setting not included in the sample. The internal consistency of the instrument was computed using Cronbach alpha. The process yielded an overall reliability of the coefficient of 0.795 which was deemed good enough for this study. This was utilized by Otani, Waterman, Faulkner, Boslaugh, & Dunagan, (2010).

Method of Data Analysis
The returned copies of the questionnaires were cross-checked for completeness of responses. Of 400 copies distributed, 396 were retrieved representing a 99% return rate, thereafter, data were analyzed using mean (x) score, standard deviation, t-test and Analysis of Variance (ANOVA).
A criterion mean (x) of 2.50 was set for the study which was derived by adding up the scale values and dividing the sum by the number of scale options. Thus: 4+3+2+1 = 10/4 + 2.50. A criterion means of 2.50 and above was adjudged to be highly satisfied while below 2.50 was considered 'lowly satisfied'. Also, a t-test and ANOVA were used to test hypotheses at p< 0.05 level of significance (Uzoagulu, 2011).   Table 3 showed the analysis of variance (ANOVA) among respondents of different ages in their satisfaction with the quality of care in the state. There was no significant difference in patients' satisfaction with waiting time, empathy, competency, cost of service, and access among the respondents of different ages (p > 0.05); while on communication, there is a significant difference in patients' satisfaction (p < 0.05) with health providers. Thus, based on age, the null hypothesis that there is no significant difference in patients' satisfaction with waiting time, empathy, competency, cost of service and access were accepted while the null hypothesis that there is no significant difference in patients' satisfaction with communication with health workers was rejected. Based on educational qualifications, there is a significant difference in patients' satisfaction with waiting time, communication, empathy of health workers among respondents of different level of educational qualification (p < 0.05), but there is no significant difference in their satisfaction with competency access, and cost of the service (p > 0.05). Thus based on educational qualifications, the null hypothesis that there is no significant difference in patients' satisfaction with competency access and cost of service is accepted and the null hypothesis that there is no significant difference in patient satisfaction with waiting time, communication, empathy, and access is rejected.

Analysis of Variance (ANOVA) on Patients' Satisfaction Based on Socio-demographics
The analysis indicates that there is no significant difference among respondents of different marital statuses in their satisfaction with waiting time, communication, empathy, and access to facilities (p > 0.05). On competency, and cost of services, there is a significant difference among respondents based on marital status (p < 0.05). Thus the null hypothesis that there is no significant difference among respondents of different marital statuses on satisfaction with waiting time, communication, empath, and access will be accepted and the null hypothesis that there is no significant difference in patient satisfaction with competency, and cost of service will be rejected.
The analysis indicates that there is no significant difference among different levels of income on their satisfaction with waiting time, communication, competency, cost of service, access to facilities, and empathy (p < 0.05). Therefore, the null hypothesis that there is no significant difference in patients' satisfaction with waiting time, communication competency, cost of service, access to facilities, and empathy, based on income levels of the respondents was accepted.
Regarding income, this study showed a higher satisfaction among those with higher income levels (N40,000 -N59,000 and >80,000) which is not statistically significant ( x  = 2.97, p> 0.05) ( Table 2, 3). This is in line with the findings of Saeed, Mohammed, Magzous, et al., (2001) and Liu and Fang (2019) who reported that higher-income respondents have high more satisfaction while Devi, Laishram, Singh, and Devi (2020) found no significant difference between the level of satisfaction with income. In contrast, Ashrafun and Uddin (2011);and Afzal, et al., (2014) reported that respondents with a higher level of income had a lower level of satisfaction. Chen, Li, and Zhang (2016) stated there was no significant association between patients' satisfaction and family income. Contrastingly, Myburgh, Solanki, Smith, and Lalloo, (2005) stated that socioeconomic status were significant predictors of levels of satisfaction with the services of health care providers. Supported by Cosma, et al (2020) who found a statistically significant relationship between patients' satisfaction and income. Other reports revealed that lower-income respondents were more satisfied and was significantly associated with level of satisfaction (Afzal et al., 2011;Vidhya & Rajakumar, 2014;Okeke et al., 2019;Jovanovic, et al., 2020)

Conclusions
Conclusively the study revealed that patients of older age, more educated, middle-class income earners, married, were more satisfied with the quality of care. However, only the level of education was significant in this study. Efforts should be made by Health workers to ensure that all patients are satisfied irrespective of their demographic characteristics.