Abstract:
Background: Patient satisfaction has become an indicator and a standard part of evaluation of the health care system, despite its complex nature and multiple determinants of patient satisfaction. Health care now a day is a major service area for the people, thus it should satisfy its customers. There have been different mechanisms to enhance patient satisfaction. Adhere to services on patients’ preferences, meeting expectations and health care practice based on patients’ rights were among others. Making health care service more congruent with patients’ preferences, expectations and patients’ rights practice can be achieved through measurement and feedback of patients’ satisfaction and interventions that address patient concerns. Even countries have guaranteed patients' rights to process for resolving dissatisfactions with health care providers. The implementation of patients’ rights can increase patient satisfaction, as well as achieve equal distribution of responsibility between the patients, and health service providers. Thus research is needed to move forward with the structural changes regarding patients’ value judgments in the health care service. Studies on patients’ preference to use health care, patient expectation and patient rights practice as an important factor for patient satisfaction care rendered at health care facilities in the developing country context like Ethiopia are often neglected in health service researches and rarely subjected to scientific inquiry. Objectives: The study aimed to examine patients’ preference, expectations, and the lived experience of patients on patient rights practice as a factor of patient satisfaction at public hospitals in Amhara Region, northern Ethiopia. Methods: The study was carried out in nine public hospitals of Amhara Region of Ethiopia. It was designed as a mixed method study in which both quantitative and qualitative data collection and analyses were employed. About 1005 participants in the out and in patient departments of general, medical and surgical departments were involved in the preference study which used Discrete Choice Experiment method. A stated-preference discrete choice experiment survey was performed among patients who visited the hospitals. Six attributes namely waiting time, physician communication, nursing communication, drug availability, continuity of care, and diagnostic facilities were selected based on a literature review of the most important characteristics of hospital health care service. These attributes were reviewed and validated with vii inputs from patients and researchers in the field. Data were entered in SPSS Version 17 and analyzed using STATA version 12. A random-effects probit model was used to perform the analysis. Regarding the quantitative Pre-and-Post consultation study of patient expectation, 776 participants were involved in the study. Data were collected on two occasions; about the expectations before consultation, and how their expectations were met and their satisfaction after the consultation. Data were entered and analyzed using SPSS Version 17. Means were computed for the overall and the sub categories of expectation items. Paired t-test and logistic regression analysis techniques were also employed. For the qualitative study, data were collected using semi-structured interview from 22 patients who have had experience of health care service utilization in the hospital setting. The participants were selected purposively using maximum variation sampling technique based on criteria like age 18 and above years, both sexes, considering residence, educational status, and experience in the outpatient and inpatient departments. The interview (data) were tape-recorded, transcribed, translated, reviewed, and analyzed using an iterative content approach of phenomenographic researches. Open code software version 4.02 was used for data management. Main categories and sub categories were described. The outcome space was constructed based on main categories of patients’ conceptions and ways of understanding the phenomenon of patient rights practice. Results: The attributes included in the preference study; waiting time, physician communication, nursing communication, drug availability in the hospital pharmacy, continuity of care and diagnostic facilities had significant impact on participants’ decisions in the choice of hospitals. The waiting time coefficient showed a negative value in the main effects model (β=-0.773, P=0.026) indicated a higher probability of choosing a hospital with less waiting time for a consultation. Patients were willing to wait up to 3.3 (MRS, 3.263 95%, CI: 1.387-5.139) hours and 2.7 (MRS, 2.66 95%, CI: 1.769-3.556) hours to get full drugs in the hospital and good nursing communication, respectively. Preferences differ with sex occupation and type of hospitals. Farmers preferred a hospital with good nursing communication (=0.089, P<0.05), and partial drug availability (=0.101, P<0.05). viii Participants with no jobs preferred a hospital with partial drug availability (=0.150, P<0.05) and those patients who were from referral hospitals preferred a hospital that has continuity of care (=0.081, P<0.05). Patients expressed preferences in a decreasing order of all the significant attribute levels: a lot of diagnostic facilities, full drug availability, presence of continuity of care, good nursing communication, partial drug availability, good physician communication, and shorter waiting time for the consultation. A hospital with lots of diagnostic facilities was ranked at the top, which accounted for 65.9% of the log-likelihood. This was followed by full drug availability in the hospital, continuity of care, and good nursing communication collectively accounting for 23.5%. According to Degner Scale to measure the preference in making decisions about medical care, 412(53.1% of participants expressed a desire for sharing responsibility for which treatment is best for them. This indicates patients prefer collaboration on medical decision. Of the 776 patients included in the study, 594 (76.5%) were satisfied with the global measure of patient satisfaction. Significant mean difference was reported in overall expectation between preconsultation and post-consultation ( x 1 =39.62±10.27) to ( x 2= 47.34±14.45) with (t = -12.95, P<0.001). The Multivariable logistic regression analysis showed that the probability of patient satisfaction is contingent on post consultation expectation score level. Higher score of post consultation met expectation scores, less likely satisfied. Participants with excellent to good self-perceived health status groups were 3.5 times (OR, 3.53, 95% CI; 2.27-5.49) more likely satisfied than fair to very poor self-perceived health status groups. Similarly, the odds of satisfaction were higher among participants who had a lot of perceived control on health compared with their counter parts. The odds of satisfaction were significantly lower among patients who were disappointed with the consultation (OR, 0.32, 95% CI; 0.22-0.47) compared to patients who were not disappointed. Similarly, the odds of satisfaction were lower among participants who had previous experience in health care service compared with their counter parts. Compared with patients that felt a lot of influence on the consultation, the odds of satisfaction was significantly lower (OR, 0.58, 95% CI; 0.37-0.91) to patients who do not felt a lot of influence on the consultation. The association with pre consultation expectation scores and age were not significant in the multivariable regression analysis. ix The qualitative findings indicated patients described four qualitatively different main categories of patient rights practice. The main categories of description include: patient centered practice, being secured, respecting dignity and getting referral. Patient rights practice was understood from comprehensive to the lowest level hierarchically in the following order: patient centered practice, getting referral, respect dignity, and being secured. Conclusion: Patient satisfaction can be understood from the perspective of patient preference, expectations and patient rights of practice. Changes to the diagnostic facilities of a hospital are likely to have the greatest impact on patients’ preferences for hospital health care. Patient satisfaction had no relationship with pre-consultation expectations. But, it had relationship with post consultation met expectations. Based on the qualitative study, patient centered practice was a comprehensive way of illustrating patient rights practice in the hospital setting. Recommendations: Health service providers and managers should focus on patient experience and work on their preferences to enhance patient satisfaction. Providers should also acknowledge patient rights practice in the health care continuum. Policy makers should draft a frame work which incorporates patients have the right to choose to consult a health service, and which one to consult. The health care should incorporate patient centered care in health care based on the values and standards established by the patient and the health profession. Health care ethics training both in the pre-service and in-service as well as ethical reasons in daily activities should get due attention. Furthermore, health care providers should also take part to identify situations that violates patients’ rights and focused on to practice with their best effort. Future research on the preferences for health care in a specific hospital’s department/ward may be important to elicit disease-specific preferences for hospital health care. Other studies which incorporate health service providers should be conducted to address the complete picture of patient satisfaction and the match in expectation and patient rights practice between patients and health service providers. Key words: Patient preference, expectations, patient rights practice, hospital health care, patient satisfaction, Discrete Choice Experiment, Phenomenography.