International Journal of Academic Medicine

: 2021  |  Volume : 7  |  Issue : 4  |  Page : 233--239

Predictors of patient satisfaction with surgical care in a low-middle-income country

Kelechi E Okonta1, Daprim S Ogaji2,  
1 Department of Surgery, University of Port Harcourt, Choba, Port Harcourt, Nigeria
2 Department of Preventive and Social Medicine, University of Port Harcourt, Choba; Africa Centre of Excellence in Public Health and Toxicological Research (ACE-PUTOR), Port Harcourt, Nigeria

Correspondence Address:
Dr. Kelechi E Okonta
Department of Surgery, University of Port Harcourt, Choba


Introduction: Patient attending a surgical clinic may have some factors contributing to favorable satisfaction following consultations. This study is to determine the predictors of patient satisfaction with care in the surgical outpatient clinic (SOPC) of a University Teaching Hospital in a low-middle-income country. Materials and Methods: This is an analytical cross-sectional study which was conducted at the SOPC of a University Teaching Hospitals. A systematic sampling method with a sample interval of 1:2 was used to enroll respondents after consultation with a doctor using the short form of the Patient Satisfaction Questionnaire-18. The reliability test showed that the questionnaire section for overall satisfaction was acceptable (α =0.67 which was higher than the lowest acceptable threshold of 0.60 (obtained from substantial sample). Descriptive and inferential analyses were performed using the SPSS statistical software and P ≤ 0.05 was considered significant. Results: A total of 466 respondents provided complete information giving a response rate of 95.1%. About 52.8% were males and 47.2% were females. The mean age ± standard deviation was 43.2 ± 15.2. The overall level of satisfaction was 60.9%, 95% confidence interval was 59.7–62.0, and the predictors for overall patients' satisfaction were male gender, older age of patient, higher monthly income, higher self-rated health status, and beneficiaries of free health care. Conclusion: The level of patients' satisfaction with quality of surgical care was high and the identified predictors being male, free health care, and patients' self-rating of health status. The following core competencies are addressed in this article: Interpersonal and communication skills, Patient care, Practice-based learning and improvement, Systems-based practice.

How to cite this article:
Okonta KE, Ogaji DS. Predictors of patient satisfaction with surgical care in a low-middle-income country.Int J Acad Med 2021;7:233-239

How to cite this URL:
Okonta KE, Ogaji DS. Predictors of patient satisfaction with surgical care in a low-middle-income country. Int J Acad Med [serial online] 2021 [cited 2022 Oct 5 ];7:233-239
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Patients' satisfaction directly reflects the quality of surgical care as doing with other objective measures of quality of surgical care.[1],[2],[3] This means that patients should report higher level of satisfaction with the receipt of optimal quality of care.[4],[5] However, there are inconsistent reports of direct relationship between objective measure of quality of care and subjective measures such as level of patient satisfaction in the literature, with some studies, demonstrating no relationship or an inverse relationship.[6],[7]

Patient satisfaction can be conceptualized by theoretical models such as “value expectancy model,” “fulfillment model,” and the “discrepancy model.”[8] The periodic survey of the level of patient satisfaction with care is imperative because of its potential impact on patient-centric outcome and for policy formulation.[2],[3],[9],[10] Patient satisfaction has also been shown to be an important quality outcome indicator used to determine the success of the services delivery systems.[11] The identification of modifiable predictors of patient satisfaction could provide clearer focus for quality improvement interventions that would enhance patient uptake of available health care.[12] While this is desirable, these determinants of patient satisfaction with care may vary from one health-care setting to another.[10],[13]

The predictors of patient satisfaction can be classified into nonmodifiable factors such as age, sex, and race, while the modifiable factors are insurance status, time taken to travel, educational level, weight, and financial status.[14],[15] Other common methods used for classification of these factors are clinical or nonclinical factors and preoperative and postoperative factors.[16],[17]

There is no set of consistent predictors of patients' satisfaction with care as factors such as sociodemographic,[13] staff humaneness, satisfaction from environment and patient awareness,[18] and hospital performance[10] have been identified from previous studies. The aim of the study is to determine the level and predictors of patient's satisfaction with surgical care.


This was an analytical cross-sectional study conducted in the Surgical Out-patient Clinic (SOPC) in a tertiary health institution in a middle-income country. The study population included patients who were 18 years and older and who gave their consent to participate in the exit interview. The minimum sample size of 422 was calculated using the formula for cross-sectional survey and providing for a 10% nonresponse. The participants in this study were recruited through systematic sampling method with a sample interval of 1:2 of daily attendees at the Surgical Out-Patient Clinic (SOPC). All even-numbered patients from the clinic register were identified for administration of questionnaire at the end of their encounter with the clinic. The questionnaires were self-administered to the surgical patients at the point of exit for each eligible patient who gave his or her consent at the exit point, and about 15 min was given for the completion of the questionnaires. The short form of the Patient Satisfaction Questionnaire (PSQ-18) PSQ-18 questionnaire was validated in a recent study conducted in the teaching hospital was used.[19] The questionnaire has seven domains which include general satisfaction, communication, time spent with doctor, interpersonal manner, convenience, accessibility, and financial aspects. The face and content validation of the scale were conducted to improve understanding, clarity of the content, and reflect the context of patients' satisfaction with surgical care services.

Ethical approval was obtained from the University of Port Harcourt Research Ethics committee, permission to carry out the study in the department of surgery was obtained from the Head of Department of Surgery, and individual consent was obtained from each participant in this study


A total of 490 questionnaires were administered with complete responses received from 466 giving a response rate of 95.1%. The internal consistency reliability measured using the Cronbach's alpha coefficient was α = 0.67. From [Table 1], there were slightly more males (52.8%) recruited into the survey, and majority of the respondents were aged 40–60 years (42.7%), married (53.6%), Christian with postprimary level of schooling (87.1%). Most of these respondents reside within the state (92.3%), earn less than $420.0/month (81.8%), were repeat visitors to the SOPC (60.9%) and paid at the point of receiving services (83.3%).{Table 1}

From [Table 2], the overall level of patient satisfaction with care at the SOPC was 60.9%, confidence interval (CI): 59.7–62.0% and this level ranged from their satisfaction with the financial aspects of their care (52%, CI: 50.0–54.1%) to their satisfaction with the communication with the health workers (70.3%, CI: 68.4–71.9%).{Table 2}

[Table 3] which reported the mean and standard deviations of the level of satisfaction of categories of patients across the various domains of the PSQ-18 showed that patient satisfaction varies across patients' groups.{Table 3}

The predictors of patients' overall satisfaction and with the various domains of the PSQ-18 were presented in [Table 4]. The generated linear regression models which predicted between 3.1% and 7.6% of the variation of patient satisfaction across domains of the PSQ-18 explained by the independent variables included in the model were not significant in predicting patient satisfaction with time spent with the doctors (P = 0.337) and their satisfaction with access and convenience of the facility (P = 0.074).{Table 4}

The predictors of patients' satisfaction with communication with the doctors were increasing age and mode of payment for services. Patients aged 40–60 years reported a mean satisfaction score of at least 5% higher than those aged less than 40 years. This difference is statistically significant (t465 = 1.98, P = 0.048). Being female (P = 0.009), having beyond primary level of schooling (P = 0.021) and being under an insurance coverage or paying out of pocket compared to free treatment were significant predictors of patients' satisfaction with interpersonal manner. The predictors of satisfaction with technical care were being female (P = 0.032), higher earning, higher self-rated health status (P = 0.041), and mode of payment. Patients who were residing outside the state were significantly more satisfied with the financial aspects of their care as well as those who reported higher self-rated health status. The predictors of overall satisfaction were being female (P = 0.018), earning less than $420.0 monthly (P = 0.036), reporting higher self-rated health status (P = 0.002), and the mode of payment.


The overall level of satisfaction of these patients was moderate, and the level of satisfaction varied across domains of the PSQ-18. There were no consistent predictors of patient satisfaction across all domains of this scale. The response rate of the questionnaires administered in person during this survey was high. The options available for the administration of survey questionnaires include telephoned, directly by survey assistants, mailed only, e-mailed only, or Internet mediated only, or a combination of these modes. The selected mode of administration may affect the response rate, and nonresponse bias affects both the validity and reliability of a questionnaire survey.[20] Besides the person-to-person mode of administration and retrieval of completed questionnaire which could enhance the response rate, the high response rate reported in this study may also be reflective of the high level of interest and the ability of surgical patients to provide feedback on their experience with care at the clinic.[21]

It is, however, interesting to record such a high level of patients' satisfaction with surgical care given in the department and hospital, especially on the setting of lack of adequate facilities and equipment. For instance, in the US, a total of 2953 hospitals that were assessed for patients' satisfaction and quality of surgical care, it was observed that the level of patients' satisfaction was 69.5%.[10] Still, in another study in the US, the level of patient satisfaction score was 68.0%.[3] In Norway, the patient satisfaction score was 59%.[22] However, when developing countries were surveyed for their patient satisfaction for surgical care, it was observed that higher scores were recorded. For instance, a developing country such as Tanzania reported that a patient satisfaction score of 97% of patients was satisfied with the surgical care they received[23] while Ethiopia reported that the overall score of patient satisfaction with surgical services were 98.1%.[24] It seems comparatively, that developing countries recorded higher levels of patients being satisfied with the surgical care they received than developed countries.

The measurement of patient satisfaction like most human judgments can be affected by factors that inhibit negative feedback or promote positive feedback if rigorous measurement methodologies are not deployed.[25] It is not uncommon to find the level of satisfaction of patient with their relationship and communication with staff higher than most other domains of patient satisfaction in this setting.[26] The level of satisfaction with the communication with their doctors ranked top followed by interpersonal manner of the doctors in this survey. Communication between the doctor and his patients is an invaluable aspect of surgical care as it has been observed that much of the patients' dissatisfaction and many of their complaints are due to breakdown in the doctor-patient relationship.[27] Personal attributes of a surgeon had been identified as most predictive of high patient satisfaction was effective communication before surgery.[17] In fact, a direct correlation between the communication skills of doctors and the satisfaction of their patients was reported in an Iranian study.[28]

A direct concern from these findings is whether there exists a porous safety net in the current financial risk protection provided under the National Health Insurance Scheme. It is obvious that inadequate budgetary allocation to public health services made it imperative to introduce and maintain cost-recovery measures requiring health consumers to pay for what they receive to sustain services in health facilities. Out-of-pocket payment at the point of accessing health care has been shown to have negative consequences on households accessing adult and pediatric care in tertiary health facilities.[29]

Strengths and limitations of the study

This study derived its strength from the use of validated instrument in the measurement of patient satisfaction, the representative of the population included in the sample, and the high response rate following direct method of questionnaire administration.

Some limitations of these findings of this study include the use of cross-sectional design which limits causal interpretations from the findings and the finding that the independent variables included in the various regression models only explain an infinitesimally small proportion of the variation of patient satisfaction. It is also pertinent to note that results obtained from facility-based survey of patient satisfaction may be markedly higher from community-based survey.[21] Finally, while the study considered quality through the eyes of the patient, it is imperative to be aware of the need of the diverse stakeholders in institutional quest for quality.

Implications of the findings

This study revealed some predictors of patient satisfaction which can form the foci for quality improvement interventions that would lead to the evolution of a patient-centric care in this practice. The predictors of patients' satisfaction can be broadly divided into those that are modifiable and those that cannot be modified. This distinction is important when findings from predictor studies would form the foci for quality improvement. However, not all modifiable risk factors are under the remit of health-care delivery system making intersectoral collaboration an imperative.


This study reported moderate level of patient satisfaction with marked variability along the various domains used in conceptualizing patient satisfaction. Commonly identified predictors were sex, education, income level, mode of payment, and perceived health status. These are not entirely under the remit of the health-care delivery system. There is a need to integrate patient satisfaction survey into quality improvement interventions in surgical care and promote intersectoral collaboration in the improvement of patient satisfaction with surgical care.

Authors' contributions

KEO was involved in conceptualization, planning, and implementation of the study. Data collection team was headed by KEO. All authors contributed to the interpretation of the results and also read and approved the final manuscript.


We are grateful to the staff and patients of the Department of Surgery for their cooperation during the period of data collection in this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is [UPH/CEREMAD/REC/MM61/071].


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