Patient Satisfaction with Health Care Services Provided at Hiv Clinics at Amana and Muhimbili Hospitals in Dar Es Salaam

Background: Since the establishment of free HIV/AIDS care and treatment services in Tanzania a lot of research has been done to assess how health care providers discharge their duties in these clinics. Little research however has been done regarding satisfaction of HIV patients with free health care services provided. Objectives: To determine satisfaction of HIV patients with health care services provided at the HIV clinics and specifically, to determine patients' satisfaction with the general physical environment of the clinic and with services offered by doctors, nurses, laboratory, and pharmacy. Methods: A cross-sectional study was conducted at Muhimbili National Hospital (MNH) and Amana hospital. A total of 375 patients attending outpatient HIV clinics were selected randomly and interviewed using a questionnaire, after obtaining a verbal consent. Data collected was analyzed using Epi-info program version 6. Results: Patients at Amana Hospital clinic were either very satisfied (44.3%) or satisfied (55.7%) and none were unsatisfied, while at MNH clinic 1.1% patients were very satisfied while (94.7%) were satisfied and (4.2%) were unsatisfied with health care services provided. Lack of privacy when consulting with doctors and the dispenser contributed to patients' unsatisfaction with the services. Conclusion: Most of the participants were satisfied with the services provided at the two clinics. However at MNH, a few patients were unsatisfied due to lack of privacy during consultation with doctors and with the pharmacy services.


Introduction
The government of Tanzania in 2004 established HIV clinics that provide free health care and treatment to HIV patients.Providing antiretroviral (ARV) therapy requires skilled personnel to handle the HIV patient as well as antiretroviral medicines.Training of health workers was therefore conducted and is still going on.Since then several studies have been carried out to evaluate providers' ability in these HIV care and treatment clinics. 1,2However, only a few studies have assessed if HIV-patients are satisfied with the health care services provided at these clinics. 3,4atient satisfaction has been defined as the patient's "Personal evaluation of providers' ability of health care services''.It reflects provider's ability to successfully deliver care that meets patients' expectations and needs. 5,6A number of factors have been shown to influence patients' satisfaction with health care services including patients' sociodemographic characters, physical health status, patients' personal understanding and expectations from various health care services i.e. doctors, nurses, laboratory and pharmacy services. 7,8,9The general physical appearance of the clinic as well as the general environment of the premises also influences the overall satisfaction of the patient. 10Length of waiting time before seeing the doctor has also been shown to influence patient satisfaction. 11he objective of this study was therefore to assess if HIV-patients are satisfied with health care services provided by doctors, nurses, laboratory technicians, and pharmaceutical personnel at HIV care and treatment clinics situated at Amana hospital and Muhimbili National Hospital.In addition the study assessed patients' satisfaction with the physical environment and cleanliness of the clinics.

Methods
This was a cross-sectional study conducted at MNH and Amana Hospital HIV clinics.The study involved 375 adult HIV patients attending the clinics and who were already on ARV therapy.Patients were selected randomly, with 190 patients from MNH clinic and 185 patients from Amana clinic.Children, inpatients, and those patients attending the clinics but not yet on ARV therapy, were excluded from the study.Patient's satisfaction with doctor's services, pharmacy services, nurses and laboratory services was assessed.Satisfaction with the general physical environment of the premises of the HIV clinic was also assessed.Ethical clearance was obtained from MUHAS Ethical Review Committee.Letters requesting permission to conduct the study at the clinics were sent to the respective hospitals.After obtaining permission, the researcher visited the clinics and collected data by interviewing patients.Patients were given a short introduction to the study and told the purpose of the study.They were assured that the information given would be kept confidential.They were then asked verbally whether they were willing to participate or not.Those who agreed were then interviewed.

Data collection and analysis
Data was collected using a pretested questionnaire by interviewing patients who consented.The questionnaire was made up of open ended and closed ended questions aiming at assessing the services offered.The questionnaire was pretested among 30 patients and then modified accordingly.Data was analyzed using Epi-info version 6 program; Frequencies and percentages scoring from 0 to 100% were calculated with high scores indicating higher levels of patients' satisfaction.

Results
Table 1 shows demographic features of 375 participants interviewed.Most people were between 31 to 35 yeals (34.4%).About two thirds were women (63.8%).All participants had been attending the clinics for more than a year.At Amana 93.5% of patients said they were counseled on the ARV side effects and all participants had privacy during dispensing of ARV medicines.At MNH 56.7% of patients were not counseled on ARV side effects (Fig 2 .)and the majority of participants (90.5%) had no privacy with the dispensers.

Figure 2: ARV side effect and interaction counseling
In both clinics the majority of respondents said the number of nurses providing services was adequate.Nurses' attitude while providing services and the overall patient's satisfaction with the nurses' services are indicated in table 4.Only (5.8%) of patients at MNH were unsatisfied with the laboratory services provided at the clinics, the rest of the results are indicated in table 4. Patients were satisfied with the physical environments of the clinic i.e. cleanliness of the toilets and premises in general.Waiting benches/chairs were available but patients reported that there are days when the clinics were crowded and the benches were not sufficient to carter for all patients.At both clinics however, the majority of the participant complained of spending about six hours or more at the clinics for the services as indicated in table 5.

Discussion
Results of this study show that most of the respondents said the doctors were available at the clinics but they complained of long times spent waiting for consultation.Patient waiting time in outpatient clinics has been the major complaint.It has been shown that if patients wait less than 30 minutes usually they are satisfied. 12One of the reasons why patients had to wait for a long time is that there is a large number of HIV patients attending the clinics while few doctors are employed to provide the services.Lack of human resources has been shown to be an important obstacle affecting health care service provision 11,13 .
The consultation time estimated by the majority of participants was about 10 to 15 minutes.This is similar to a study by Quintana et al 10 where the average consultation time observed was 11 minutes and that of Anderson et al 14 where patients who spent 10 minutes or more with the doctor were satisfied.Results on privacy during consultation with the doctor and the dispenser indicate that Amana clinic is doing well as nearly all patients reported privacy while at MNH clinic majority of the respondents had no privacy.When providing services to the patient privavcy is necessary, since it makes the patient feel comfortable, ask questions, and understand easily the information given by the doctors, dispensers, and counselors.Lack of privacy contributed to patients being unsatisfied with the services..15One of the predictors of satisfaction is the attitude of health workers.In our study the attitude of doctors, nurses, dispensers and laboratory technician was rated as being friendly and satisfying to the patient.However, at MNH clinic some of the participants said some health workers were unfriendly especially the dispensers (21.1%).Our results are similar to those of Muhondwa 16 who reported that at MNH patient were unsatisfied with negative attitudes of staff towards them.Regarding pharmacy services, drugs were available and the majority of patients were comfortable with the time spent waiting for the services (less than 30 minutes).However counseling of ARV side effects at MNH was not done properly.Similar results of patients being unsatisfied with the dispensing process have been reported by Marquez-Peiro et al 17 .Usually patients want patient care staff to explain about medications.Communicating with patients about medications especially on use and side effects has positive effects on their perceptions of pain and responsiveness, which is why it is correlated to overall patient satisfaction 8 .Regarding nurse and laboratory services, majority of the patients were satisfied, with only a few patients at MNH who were unsatisfied.The results of this study are similar to a study by Quintana 8 which showed that the majority of the patients were satisfied with nurse and laboratory services.The time of stay at the clinic was long most patients indicated spending more than five hours at the clinics, but this did not affect their satisfaction with the overall services at the clinics.

Conclusion
Most of the participants were satisfied with the services provided at the two clinics; however at MNH a few patients were unsatisfied.The study provides valuable information about the services delivered at the two clinics.Identified gaps in the delivery system of health care services, like lack of privacy during consultation with the doctor and dispensing of medicines at MNH, and lack of proper medication counseling contributed to patients not being satisfied.Working to eliminate the identified gaps can improve service and fully satisfy patients.

Figure 1 :
Figure 1: Privacy during consultation with the doctor

Table 2 : Patients' satisfaction with doctors' services
Availability of the Doctors at the clinic.