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 Table of Contents  
Year : 2017  |  Volume : 20  |  Issue : 2  |  Page : 139-148

Impact of structural and interpersonal components of health care on user satisfaction with services of an outpatient clinic of a Nigerian tertiary hospital

1 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Family Medicine, Mayo Clinic, Rochester, 55905 MN, USA

Date of Web Publication14-Nov-2017

Correspondence Address:
Godpower Chinedu Michael
Department of Family Medicine, Aminu Kano Teaching Hospital, PMB 3452, Kano
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DOI: 10.4103/tjmr.tjmr_22_17

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Background: Patient satisfaction plays a key role in health-care reforms and service delivery. It is determined by patient's perception of the structural, interpersonal, and technical components of care. With current efforts toward universal coverage, government-owned National Health Insurance Scheme (NHIS)-accredited health facilities may need to improve the structural and interpersonal aspects of patients' care to survive in the emerging competitive health-care industry in Nigeria. Materials and Methods: A cross-sectional study of 220 NHIS enrollees randomly selected from patients attending the Staff Clinic of Aminu Kano Teaching Hospital Kano assessed patients' satisfaction with the structural (service-window-locations, cleanliness, adequacy of seats and toilets, and staff sufficiency) and interpersonal (staff friendliness, communication, respectfulness, response-to-requests, and efficiency) components of care as well as overall clinic satisfaction using a modified general practice assessment questionnaire. Results: Most of the respondents (65.9%) were satisfied with the clinic services. Respondents' satisfaction with the clinic's cleanliness, ease in locating medical records' unit and retrieving laboratory results, adequacy of doctors, friendly/respectful and responsive cashiers and clinical assistants (CAs), receiving satisfactory explanation on how to use prescribed drugs and unavailable drugs were all associated with the overall clinic satisfaction. However, cashiers' efficiency (odds ratio [OR] = 6.5, P = 0.006) and CAs' responsiveness (OR = 5.0, P = 0.03) were the predictors of overall satisfaction. Conclusion: Improvements in patients' overall satisfaction with the clinic services may require increasing the proportion of patients satisfied with the cashiers' efficiency and CAs' responsiveness (or those with similar roles) in service delivery.

Keywords: Cashier efficiency, clinical assistant's responsiveness, health insurance, outpatients, patient satisfaction

How to cite this article:
Michael GC, Aliyu I, Grema BA, Thacher TD. Impact of structural and interpersonal components of health care on user satisfaction with services of an outpatient clinic of a Nigerian tertiary hospital. Trop J Med Res 2017;20:139-48

How to cite this URL:
Michael GC, Aliyu I, Grema BA, Thacher TD. Impact of structural and interpersonal components of health care on user satisfaction with services of an outpatient clinic of a Nigerian tertiary hospital. Trop J Med Res [serial online] 2017 [cited 2020 Sep 23];20:139-48. Available from: http://www.tjmrjournal.org/text.asp?2017/20/2/139/218209

  Introduction Top

Continuous improvements in the quality of care provided by health-care facilities (private or government owned) are required for their survival in the present-day competitive health-care market. Patient satisfaction (PS), though a subjective assessment, aids health-care managers in improving the quality of services rendered by their facilities.[1],[2] PS is known to be associated with better understanding of their disease, treatment adherence, improved outcome, and reduced legal suits against health workers.[3] It is determined by patients' perception of the structural, interpersonal, and technical components of patients' care. The structural component includes convenient location, access to care, physical setting, or atmospherics[4] (i.e., its attractiveness, cleanliness, and convenient facilities), cost of care, and availability of workforce and facilities.[5] The interpersonal component includes the interpersonal skills of health workers (their friendliness, respectfulness, communication, empathy, and response to patient's requests).[5] The technical aspect, though often poorly assessed by patients, includes knowledge and competence of health-care workers, quality of care, interventions, and outcomes.[5]

Several patients' satisfaction studies in Nigeria have shown variations in outcome, reflecting differences in patient characteristics and service experience. These studies reveal that satisfaction can be influenced by patients' sociodemographics (such as age), clinic waiting times,[6] general health insurance knowledge, and awareness of contribution by beneficiaries of the National Health Insurance Scheme (NHIS) (among health-insured populations).[7] Others studies have also revealed that varying proportions of patients are satisfied with services rendered by health facilities in Nigeria, ranging from 42% to 83%.[6],[7],[8],[9]

As Nigeria expands its NHIS toward universal health coverage, it is likely that the structural elements of care and the interpersonal skills of health-care workers in accredited facilities may continue to play an important role in determining enrollees' choices of these facilities. However, despite the plethora of PS studies in northern part of Nigeria,[6],[7],[9] none of the studies to our knowledge, assessed the extent to which satisfaction with each component of healthcare impacted overall satisfaction with services offered by NHIS-accredited healthcare facilities. This study, therefore, assessed the effect of structural and interpersonal components of health care on health-care consumer's overall satisfaction with the services rendered by the Staff Clinic of Aminu Kano Teaching Hospital (AKTH) Kano, Northwest Nigeria. The study outcome is expected to identify the structural and interpersonal components of patient care that impacted overall patients' satisfaction; this may be helpful to the clinic managers in improving services and patronage.

  Materials and Methods Top

We conducted a descriptive cross-sectional study between December 1, 2015 and January 5, 2016 at the staff clinic of AKTH, where over 2700 hospital staff and their dependents obtain primary care outpatient services. Over 87% of clinic users have health insurance (NHIS).[10] From clinic records, an average of 250 patients is seen weekly. The clinic has an exclusive account unit, but shares the pharmacy, medical records, and nursing and laboratory units with over 30,000 NHIS enrollees of the hospital (staff and their dependents inclusive). The study population was hospital staff (and their dependents) seeking care at the clinic during the 5-week study period.

Using 83% (the proportion of satisfied respondents reported by Iliyasu et al. in Kano)[9] and the Leslie Fisher formula for estimating sample size for descriptive studies,[11] a total of 216 patients were enrolled. An additional 10% was added for possible incomplete data and nonrespondents, hence 240 participants were recruited. Patients aged 18 years and above and who had received care from the clinic for at least the preceding 1 year were included. Patients below 18 years of age or critically ill were excluded from the study. A systematic random sampling technique was used in participant selection. A sampling interval of 5 was derived from dividing the sampling frame of 1250 patients (250/week × 5 weeks) by the estimated sample size of 240. Hence, every 5th patient who attended the clinic and met eligibility criteria during the study period was selected until the sample size was reached. The first patient was selected by balloting.

Participants while seated in the waiting area were given a pretested, self-administered modified general practice assessment questionnaire for completion in English or Hausa (local language) by three trained research assistants. The questionnaire, which was initially in English, was translated to Hausa and back translated into English by two physicians and a Hausa linguistic professional to check for consistency and semantic validity. To prevent double sampling, the NHIS enrollment card of participants was noted and each participant was advised against completing the questionnaire more than once. The questionnaire assessed the participants' sociodemographic characteristics, level of satisfaction with location of and access to services, cleanliness and ventilation, seats and toilets' adequacy, orderliness of service, staff friendliness and respectfulness, responsiveness (response to patient's requests), availability of staff in sufficient number, ease of retrieving patient files during registration at the medical records unit (MRU), ease of retrieving laboratory results at collection center, cashier efficiency (effective use of time and energy), and explanation on how to use prescribed drugs and unavailable drugs. The frequency of delays at the accounts' unit was classified into low (for responses of “never” or “sometimes”) and high (for “usually” and “always”) before making payments. Regular supervision of the research assistants and reviewing of the completed questionnaire were carried out daily by the principal investigator. The overall clinic satisfaction was also assessed. The Likert scale response was used to assess respondents' level of satisfaction. The satisfaction items were scored as follows: 1 = very dissatisfied, 2 = dissatisfied, 3 = fairly satisfied, 4 = satisfied, and 5 = very satisfied. Ratings of 1 or 2 were considered dissatisfied while ratings of 3, 4, or 5 were considered satisfied. Responses of “satisfied” and “dissatisfied” were used to assess the overall clinic satisfaction.

Data were entered and analyzed using Epi Info Version (2012) (CDC, Atlanta GA, USA). They were summarized using frequency tables, means, and standard deviations. Chi-square test was used to compare the effect of satisfaction with multiple variables (structural and interpersonal components of care) on overall satisfaction. Logistic regression was used to examine the independent effects of variables on overall satisfaction to find the predictors of overall satisfaction. P < 0.05 was considered statistically significant. Ethical approval was obtained from the AKTH Research Ethics Committee. Written informed consent was obtained from each participant before administration of questionnaires; confidentiality of the collected data was maintained.

  Results Top

Sociodemographic characteristics of respondents

Of the 240 patients selected, 20 provided minimal data or did not return questionnaire; therefore, data for the remaining 220 respondents (representing a 91.7% response rate) were used for analysis. There was slightly higher proportion of females, i.e., 111 (50.5%) with a near-equal sex ratio [Table 1]. Their ages ranged from 18 to 59 years, with a mean of 35.8 ± 8.2 years. The 36–44 years' age group had the highest frequency, i.e., 82 (37.3%). Respondents were predominantly civil servants 168 (77.1%), Muslims 214 (97.3%), of the Hausa tribe 175 (79.5%), and had tertiary education 163 (75.8%). All respondents had health insurance.
Table 1: Respondents' sociodemographic characteristics

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Overall clinic satisfaction and relationship with sociodemographic characteristics

One hundred and forty-five (65.9%) respondents were satisfied with the overall clinic services while 75 (34.1%) were dissatisfied. There was an insignificant statistical association between the age, sex, religion, occupation, level of education, and overall satisfaction [Table 2].
Table 2: Respondents' sociodemographic characteristics and relationship with overall satisfaction

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Respondents' perception of the clinic's structural environment

A majority of respondents were satisfied with the clinic's cleanliness, ventilation, seat, and toilet adequacy, and the “ first come first serve” order of services [Table 3]. Most respondents (81.8%) located the MRU with ease. Satisfaction with clinic's cleanliness was significantly associated with increased odds of overall satisfaction (odds ratio [OR] = 2.8, 95% confidence interval [CI] = 1.0–7.9, P = 0.04). Similarly, respondents' perception of difficulty in locating the MRU was associated with decreased odds of overall satisfaction (OR = 0.4, 95% CI = 0.2–0.9, P = 0.02). Satisfaction with the clinic ventilation, adequacy of seats, adequacy of toilets, and service orderliness had insignificant association with the overall satisfaction.
Table 3: Respondents' perception of clinic structural environment and overall satisfaction

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Respondents' perception of the staff friendliness/respectfulness and responsiveness

[Table 4] shows that the majority of respondents were satisfied with the health workers' friendliness and respectfulness. Respondents' satisfaction with cashiers' (OR = 2.1, 95% CI = 1.0–4.5, P = 0.04) and CAs' (OR = 2.2, 95% CI = 1.1–4.6, P = 0.03) friendliness/respectfulness was significantly associated with increased odds of overall satisfaction. No significant associations were observed between respondents' satisfaction with friendly/respectful attendants, records' staff, laboratory staff, pharmacy, nurses and doctors, and overall satisfaction. Similarly, the majority of respondents were satisfied with all the health workers' responsiveness. Respondents' satisfaction with the cashiers' (OR = 2.6, 95% CI = 1.2–5.6, P = 0.01) and CAs' (OR = 3.3, 95%CI = 1.5–7.1, P = 0.002) responsiveness was significantly associated with increased odds of overall satisfaction. There were no significant associations between satisfaction with doctors-, nurses-, pharmacy staff-, laboratory staff-, record staff friendliness/respectfulness, doctors-, nurses-, pharmacy staff-, laboratory staff-, record staff-, attendants' responsiveness and overall satisfaction.
Table 4: Respondents' perception of staff friendliness/respect and responsiveness and overall satisfaction

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Respondents' perception of the staffs' availability

Most respondents were satisfied with the available number of health workers at the clinic [Table 5]. Satisfaction with the available number of doctors was significantly associated with increased odds of overall satisfaction (OR = 1.9, 95% CI = 1.1–3.6, P = 0.03). However, there was an insignificant association between satisfaction with sufficiency of other staff and overall satisfaction.
Table 5: Relationship between respondents' perception of staff availability and overall satisfaction

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Respondents' perception of other service windows

[Table 6] shows that, at registration, 163 (74.1%) respondents had their files retrieved with ease. Fifty-seven experienced difficulty, with 75% of those attributing it to missing case files. No significant association between perception of ease in file retrieval and overall satisfaction was observed (OR = 0.57, CI = 0.30–1.05, P = 0.07). Fifty-six (25.6%) respondents had difficulty in retrieving their laboratory results, mainly (55.6%) attributable to missing results. Respondents' perception of difficulty in retrieving results was significantly associated with decreased odds of overall satisfaction (OR = 0.4, 95% CI = 0.2–0.8, P = 0.008). At the pharmacy unit, most respondents, i.e., 134 (60.9%) did not obtain all prescribed drugs predominantly because some drugs were unlisted, i.e., 8 (65.7%). Incomplete dispensing was reported to occur sometimes in 114 (53.3%), never in 64 (29.9%), always in 22 (10.3%), and usually in 14 (6.5%) patients. All but one respondent with incomplete drugs purchased it out-of-pocket while one returned later to obtain drug. Similarly, most respondents (60%) were dissatisfied with the explanation for drugs' unavailability. Satisfactory explanation for unavailable drugs was significantly associated with increased odds of overall satisfaction (OR = 2.4, 95% CI = 1.3–4.5, P = 0.004). Ninety percent of respondents received satisfactory explanation on how to use drugs, and a significant association between the satisfactory explanation on drug use and increased odds of overall satisfaction was observed (OR = 2.6, 95% CI = 1.1–6.3, P = 0.03). At the accounts' unit, 79.8% of respondents experienced reduced delays. No significant association was observed between frequency of delays and overall satisfaction (OR = 0.63, CI = 0.32–1.25, P = 0.18). However, 89.9% of respondents were satisfied with the efficiency of cashiers, and satisfaction with cashier efficiency was significantly associated with increased odds of overall satisfaction (OR = 6.3, 95% CI = 2.3–17.0, P = 0.00007).
Table 6: Respondents' perception of other service windows

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Predictors of overall patient satisfaction

After excluding the minimally significant variables associated with overall satisfaction such as satisfaction with cleanliness and cashiers' friendliness (with P = 0.04), logistic regression of the remaining variables showed that satisfaction with cashiers' efficiency (OR = 5.16, 95% CI = 1.5–17.5, P = 0.009) and CAs' responsiveness (OR = 5.0, 95% CI = 1.2–21.5, P = 0.03) were the strong predictors of overall satisfaction in our study [Table 7].
Table 7: Predictors' variables for overall clinic satisfaction

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  Discussion Top

The 65.9% overall patients' satisfaction found in our study was higher than those obtained by Adamu and Oche in Sokoto (50%), Northwest Nigeria,[6] and Osungbade et al. (56%) in Ibadan, Southwest Nigeria.[12] However, it was lower than the value obtained by Iliyasu et al. (83%) in Kano,[9] and those obtained in Turkey and India.[13] Direct comparisons among these study findings were difficult because of the use of different scales of measurement and study populations. The Sokoto study population was without health insurance while the Ibadan study used mean composite domain scores to categorize respondents though among insured population. In Kano, Iliyasu et al. studied in- and out-patients' satisfaction with services in 2009 and had an overall satisfaction rate of 83%.[9] Eighty-eight percentage, 88%, 87%, and 84% of patients were satisfied with patient–provider relationship, in-patient services, hospital facilities, and access to care, respectively.[9] However, they did not state how satisfaction with each segment of care impacted the overall satisfaction. The Kano,[9] Turkey, and Indian[13] studies did not state if health-insured patients were among the respondents. Health insurance is known to reduce patients' satisfaction because insured patients tend to demand for better services and see it as their right.[7] Sociodemographic variables such as education also reduce PS for similar reason,[5] but we found no association between sociodemographic variables and overall satisfaction. This could be due to the differences in the measuring scales, the study population, or the masking effects of other variables such as the interpersonal skills of the staff shown in this study. There is, therefore, a need for future replication studies using consistent measurement scales and study populations.

Furthermore, the structural component of care which was termed “atmospherics” by Kotler (in a study by Farias et al.)[4] to describe how the physical and controllable environment affects a buyer's purchasing propensity which did not impact overall satisfaction in this study. However, other older reports have demonstrated that use of atmospherics results in better customer satisfaction, patronage, and advertising via word of mouth; attributing this effect to its cognitive, emotional, and physiological influences on customers.[14],[15],[16],[17] Other studies have also shown that patients patronize health facilities because of their location, equipment, and available facilities.[18],[19] Though this study did not assess satisfaction with the clinic's equipment, the findings of satisfactory clean clinic environment, ease in locating services such as the MRU, and adequacy of doctors were not predictors of overall satisfaction. These were surprising outcomes because insufficient number of health-care personnel such as doctors has been reported as reasons for prolonged waiting time in developing countries like Nigeria and prolonged clinic wait time has been cited as a predictor of overall satisfaction in Nigeria.[6] Similarly, in many public hospital laboratories, experience has shown that many patients have difficult times given samples to or retrieving results from the laboratory; the satisfaction with the ease in retrieving laboratory results was not a predictor of overall satisfaction. These outcomes could also be explained by the differing study populations and measuring scales.

Similarly, the interpersonal components of patients' care such as the friendliness, respectfulness, and responsiveness of the clinic's cashiers and CAs, and satisfactory effort of the pharmacy put in explaining to patients that drugs prescribed were unavailable or on how to use them were associated with overall satisfaction but were not determinants of overall satisfaction.

However, the strong predictors of overall satisfaction in our study were the efficiency of the cashiers and the CAs' responsiveness. Studies have shown that the health worker's interpersonal skill improves service delivery in Nigeria.[20] Our findings were also similar to those reported by Ahmad et al., where PS was determined by staff attitude, their communication skills, technical skill, and responsiveness.[21] However, our findings contrasted with views that PS was influenced by age and total clinic waiting time,[6] treatment outcome and nurses' kindness,[22] and constructs of convenience (consisting of convenient check-in and check-out processes, reservation systems for treatment/procedures, and acceptable waiting time).[19],[23] Unfortunately, waiting time was not measured, and our study population was different; our study was on outpatients where measurements of check-in and check-out processes were unnecessary and we did not assess satisfaction with treatment outcome (a technical component of care). Additionally, our study respondents were NHIS enrollees and the NHIS required a copayment of 10% of the cost of all prescribed drugs.[24] Large numbers of patients commonly queue up to make this payment, resulting in delays and frustrations at the pay points, especially with the dismal health worker-patient ratio cited as the cause of prolonged clinic waiting time in many developing countries.[25] Most respondents were satisfied with the effective use of time and energy by the cashiers. This result was also similar to an earlier report by Iliyasu et al.[9] Our study finding supports the view that an efficient billing and payment system is required in the administration of outpatient health services as the satisfactory payment services greatly impacted overall PS. Clinic managers should see improvements in the work attitude of their cashiers through regular training as a priority to improve patients' satisfaction with their facility.

The CAs' response to patient requests was the second predictor of overall satisfaction observed. This view was also expressed by Ahmad et al. where staff responsiveness influenced PS.[21] Prior to consultation in most clinics in Nigeria, different categories of health workers are used to organize patient flow in the clinic. In our study site, CAs (trained female community health extension workers)[26] were used for this purpose. They receive patients' folders from the MRU and interact with the patients in the waiting area, usher in patients into the consulting rooms, and are helpful as chaperons, interpreters, fill clinic registers in the consulting rooms, and give direction to new patients after consultation. A majority of respondents were satisfied with their response to their requests; this is similar to a study in India where politeness and helpfulness of paramedical staff impacted overall satisfaction.[13] This suggests that patient's opinion of a health facility's services could be formed even before he/she sees the doctor. It is not uncommon to find public hospital patients seeking for help from health workers and receive poor or no attention. With the expansion of the NHIS in Nigeria, patients are looking for health-care facilities among the legion of accredited primary care facilities (private and public)[24] that will treat them like “kings.” Furthermore, the use of atmospherics and proper health worker selection at recruitment seem well entrenched in private hospitals. Common experience is an attractive reception/waiting area with well-mannered beautiful/handsome receptionist on arrival. The patients are appropriately treated as customers. The private hospital managers know that these components of patient care are important and that patients' loyalty is required for the hospital's survival. This is often lacking in government-owned facilities in Nigeria. Hence, the remarkable display of interpersonal skills by the CAs and cashiers in this study was commendable.

Policy implication

Though our study site was a segment of the hospitals' service units, it served as a performance audit of the hospital's services from the patient's perspective. The 65.9% overall satisfaction suggests a need to increase the proportion of satisfied patients if consumer loyalty is desired. This is necessary because the NHIS regulation permits enrollees to switch provider if dissatisfied with services after 6 months of enrollment.[24] Strategies to increase overall satisfaction may require increasing the proportion of patients satisfied with the clinics' cashier efficiency and CAs' responsiveness. This may require training and retraining of health workers, especially on interpersonal skills to engender best practices, employment of electronic payment, appointment, and health records' systems along with effective monitoring and supervision at all levels.

Limitations of our study

Among the limitations of our study was the use of staff as respondents. This may have affected some responses since it was their colleagues who were being assessed. They may fear that their responses will affect the health workers' attitude toward them. The use of 1-year clinic experience as inclusion criteria precludes the comparison of different durations of clinic usage with overall satisfaction. This may be a subject for future research. Similarly, this study did not include inpatients and those in the emergency room, hence generalization will be limited to similar outpatient settings.

  Conclusion Top

Some structural and interpersonal components of health care were associated with respondents' overall satisfaction. However, the interpersonal skills of public health workers such as CAs' responsiveness or those who play similar role and the efficiency of cashiers are important predictors of overall satisfaction. Measures aim at improving overall satisfaction may require increasing the proportion of patients satisfied with the cashiers, CAs, or those who play similar roles.


The authors are grateful to the research assistants Saminu Shehu, Zubaida Kalleel, Firdausi Sani, and staff of the Family Medicine department of AKTH.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]

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