https://doi.org/10.15218/ejnm.2020.14 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article Patient’s Satisfaction with Health Care Services in Erbil City/Iraq ABSTRACT INTRODUCTION Patient satisfaction with health care pro- viders is of great significance. Thus, it is important to identify weaknesses in the health system, through the patient’s eyes, to improve the quality of provided care[1]. Awareness has grown of how patients per- ceive the quality of their care. Patient satisfaction has become a tool to gain attention and value among the pa- tients as well as providers. Hospitals and other health care centres are increasingly using this information while making im- portant decisions regarding the operation- al and treatment plans [2]. The patient satisfaction data is the key indicator of the quality of care and treatment delivered Background and objective: Patient satisfaction is one of the most important factors to de- termine the success of a health care facility. It is a relative phenomenon, which evaluates the patients’ perceived needs, their expectations from a health system, and the experi- ence of health care. Patient satisfaction is the main goal today for most health care organi- zations, from hospitals to physician practices and other health care agencies. This study aimed to compare patient satisfaction with the health care services provided by public and private hospitals in Erbil City. Methods: A cross-sectional study was conducted using a non-probability purposive sample of 450 patients (225 from public and 225 from private hospitals) who were seeking health care in hospitals in Erbil City. The data were collected between the 7th of January and 15th of November 2016 by direct interviews and filling of the standardized questionnaires (Patient Satisfaction Questionnaire-18). Results and Discussion: Most of the patients in public hospitals expressed a neutral level of satisfaction with received health services (80.9%) while 10.7% were dissatisfied and only 8.4% were satisfied with the provided health care. On the contrary, most of the patients in private hospitals (80%) were satisfied with their care, with only 20% expressing a neutral level of satisfaction with private health care services. These findings show that there is a very high statistical difference between patient satisfaction in the governmental and pri- vate hospitals in Erbil City (Mean ± Standard Deviation 45.35 ± 3.520), (56.42 ± 5.696) (p- value= <0.001). Conclusion: Most of the patients were satisfied with private health care services but not with public hospitals health services in selected hospitals in Erbil City in Iraq. Keywords: Patient satisfaction; Health care services; Governmental; Public and Private hospitals. Dlzar Omer Qadir; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Saleem Saaed Qader; Department of Kurdistan Board of Medical Specialties, Erbil, Iraq. Dara Abdulla Al-Banna; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. Ahmed Ali Rasool; College of Dentistry, Hawler Medical University, Erbil, Iraq. Jamal Kareem Shakor; Nursing Department, Sulaimani Polytechnic University, Sulaymaniyah, Iraq )Correspondence: jamal.shakor@spu.edu.iq) 119 Erbil Journal of Nursing & Midwifery Received: 13/4/2020 Accepted:19/7/2020 Published: 30/11/2020 mailto:jamal.shakor@spu.edu.iq https://doi.org/10.15218/ejnm.2020.14 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article by the physicians, other health staff and the hospital as a whole. The health centres can use survey results to design and track quality improvement over time, as well as compare themselves to other health cen- tres [3]. By conducting their own surveys, the health care organizations can recognize and resolve potential patient satisfaction problems and thus improve their future strategies. Having satisfaction surveys also helps to identify the specific needs of the patients for the health care providers [4]. Hospitals that are committed to providing excellent health care services, including patient satisfaction, establish multiple pro- grams and initiatives to achieve these goals. Measuring performance is essential to assessing the effects of continuous efforts to improve the quality of care and ensuring the pursuit of excellence in hospi- tals [5]. Increasingly, patient satisfaction is acknowledged as a key organizational per- formance measure. In addition to providing a unique perspective on the performance of a hospital, patient satisfaction is consid- ered as a predictor of a patient’s willing- ness to follow treatment, to return, or to recommend a service to others e.g. friends or relatives [6]. Patient satisfaction has emerged as a critical outcome of medical care due to increasing emphasis on pa- tients as consumers of services in the med- ical marketplace [7]. Improved patient care has become a priority for all health care service providers with the optimum objec- tive of achieving a high degree of patient satisfaction [8] Patients’ socioeconomic background influences their perception of health care services to various degree. A study in Korea has shown that low-income people were more satisfied with the uni- versity health service than the hospitals [10]. Similarly, high education is mostly as- sociated with patient satisfaction [11]. This study aims to compare patient satis- faction with the health care services provided by public and private hospitals in Erbil City. The study was conducted in some public and private hospitals in Erbil City, Kurdi- stan Region, Iraq. Governmental hospitals were Rizgary, Maternity and Hawler Teach- ing Hospitals, and private hospitals includ- ing the Paky Hospital, Zheen International Hospital, and CMC Hospital. The hospitals were randomly selected according to their recognition and those with a high number of patients. A non-probability, convenience (purposive) sampling was used to obtain the representative sample according to inclusion criteria. In this study, 450 pa- tients (225 from public and 225 from pri- vate hospitals) were recruited to the study. The study included patients of both gen- ders, aged 18 years and over who had been admitted for more than 24 hours and agreed to participate in the study. The pa- tients at the end stage of their life were excluded from the study. This study was approved by the Scientific and Ethics Com- mittee of the College of Nursing, Hawler Medical University, Erbil, Iraq. Institutional approval for conducting the study in public hospitals was also obtained from the Gen- eral Directorate of Health in Erbil. Formal permission to undertake the study in pri- vate facilities was attained directly from the hospital administrations. The study was explained to the patients in their na- tive Kurdish language and the patients were told that they have the rights to with- draw from the study at any stage. The in- formation about the patients was kept confidential throughout the study and afterwards. Each form for each patient was coded with a number. The patients were informed that in case of any interest achieved from the study in the future, they would have a right of free access to the health care provided by these 120 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2020.14 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 52.4%), from the urban residential area (79.6% and 73.8%) as demonstrated in Ta- ble 1. Table 2 shows the overall level of patient satisfaction with health care services in both governmental and private hospitals. Most of the patients answered neutrally regarding the health care services in the governmental hospitals (80.9%), while 10.7% of participants were dissatisfied and only 8.4% satisfied with health care ser- vices. Most of the patients in private hospi- tals were satisfied with the health care ser- vices they received (80%), with only 20% of the patients being dissatisfied. Table 3, shows a very high statistical differ- ence between the mean of patient satis- faction in governmental and private hospi- tals (p-value= <0.001) with 11.067 mean difference (M ± SD of governmental hospi- tals 45.35 ± 3.520 and 56.42 ± 5.696 of pri- vate hospitals), which means that most patients were more satisfied with the pri- vate health services than with governmen- tal health care. hospitals for a certain period of time. Data were collected using a standardized ques- tionnaire (short-form patient satisfaction questionnaire PSQ-18), which was devel- oped by RAND Health Research Organiza- tion for medical outcomes study. The PSQ- 18 is a short-term version that retains many characteristics of its full-length coun- terpart. The PSQ sub-scales show accepta- ble internal consistency reliability. The questionnaire contains 18 items tapping each of the seven domains of satisfaction which includes: general satisfaction, tech- nical quality, interpersonal manner, com- munication, financial aspects, time spent with doctors, and accessibility and conven- ience with some modifications. The re- sponses contain both positively worded and negatively worded items, ranging from strongly agree to strongly disagree [7]. The method of data collection was through di- rect interview with each patient by re- searchers. The questionnaire was translat- ed into the Kurdish language by the linguis- tic expert and fully explained to the pa- tients. Statistical analysis The data were analysed using the Statistical Package for Social Sciences (SPSS, Version 23) applica- tion for statistical data analysis. Independ- ent t-test was used to know the statistical difference in the mean of patient satisfac- tion in private and public hospitals. 450 patients (225 from public and 225 from private hospitals) who were seeking health care in Erbil City were re- cruited to this study. Concerning the socio- demographic characteristics, the highest percentage of the patients in both govern- mental and private hospitals were in the age group 19-32 years (41.8% and 57.8%), female in gender (68.9% and 65.3%), grad- uated from secondary school (24.4% and 30.2%), currently married (87.1% and 83.6%), keeping house/homemaker (54.7% 121 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2020.14 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 122 Erbil Journal of Nursing & Midwifery Table 1: Sociodemographic characteristics of the study sample Sociodemographic characteristics Hospital setting Total Governmental Private No. (%) No. (%) No. (%) Age groups/years 19-32 94 (41.8) 130 (57.8) 224 (50) 33-46 87 (38.7) 59 (26.2) 146 (32) 47-60 29 (12.9) 21 (9.3) 50 (11) 61-74 15 (6.7) 15 (6.7) 30 (7) Total 225 (50) 225 (50) 450 (100) Gender Male 70 (31.1) 78 (34.7) 148 (30) Female 155 (68.9) 147 (65.3) 352 (70) Total 225 (50) 225 (50) 450 (100) Level of Education Illiterate 32 (14.2) 21 (9.3) 53 (12) Can read and write 38 (16.9) 16 (7.1) 54 (12) Primary school 51 (22.7) 56 (24.9) 107 (24) Secondary school 55 (24.4) 68 (30.2) 123 (27) Institution or college 49 (21.8) 64 (28.4) 113 (25) Total 225 (50) 225 (50) 450 (100) Marital status Never married 20 (8.9) 34 (15.1) 54 (12) Currently married 196 (87.1) 188 (83.6) 384 (85) Divorced 1 (0.4) 2 (0.9) 3 (0) Widowed 8 (3.6) 1 (0.4) 9 (2) Total 225 (50) 225 (50) 450 (100) Occupational status Paid work 5 (2.2) 4 (1.8) 9 (2) Self-employed 38 (16.9) 47 (20.9) 85 (19) (volunteer or charity) 10 (4.4) 11 (4.9) 21 (5) Student 16 (7.1) 18 (8.0) 34 (8) Housewife 123 (54.7) 118 (52.4) 241 (57) Retired 4 (1.8) 6 (2.7) 10 (2) Unemployed (health reason) 20 (8.9) 8 (3.6) 28 (6) Unemployed (other reason) 9 (4) 13 (5.8) 22 (6) Total 225 (50) 225 (50) 450 (100) Residential area Urban 179 (79.6) 166 (73.8) 345 (77) Rural 46 (20.4) 59 (26.2) 105 (23) Total 225 (50) 225 (50) 450 (100) Times of visit 1-4 187 (83.1) 217 (96.4) 404 (90) 5-8 38 (16.9) 8 (3.6) 46 (10) Total 225 (50) 225 (50) 450 (100) https://doi.org/10.15218/ejnm.2020.14 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 123 Erbil Journal of Nursing & Midwifery Patient satisfaction with health care pro- vided by doctors and other health staff is of great importance. Thus, it is important to identify the weaknesses of the health system from the patients’ perspective to improve and promote health care in the region [9]. This cross-sectional study was based upon direct interviews of 450 pa- tients who received health care in public and private hospitals in Erbil City. Most of the patients were young in their 2nd and 3rd decade (19-32 years) of their life (41.8% in public versus 57.8% in private hospitals) and 33-46 years (38.7% in public versus 26.2% in private hospitals). The rest of the patients were above 47 years of age (19.6% in public versus 16% in private hos- pitals). So, in the current study, young peo- ple attended private hospitals more than public hospitals while aged people were admitted to public hospitals more. In this study, there were 68.9% females, 14.2% were illiterate, while 85.8% graduated ei- ther from university (21.8%) or secondary school, so most of the patient are aware of health services offered by the hospitals whether in private or public. 8.9% of the patients were single, 3.6% were widow, 38% were self-employed, 79.96% were living in the City of Erbil and 83.1% had 1- 4 visits to the hospital. According to the current study, more educated people uti- lized private hospitals rather than govern- mental hospitals. High satisfaction in the private hospital might be related to socio- demographic factors such as age and edu- cation. There is another study that con- firmed that the level of education is a pre- dictor for patient satisfaction [11]. Table 2: Overall level of satisfaction among patients visiting governmental and private hospitals Overall level of satisfaction Hospital setting Total Governmental Private No. (%) No. (%) No. (%) Highly satisfied 0 (0) 0 (0) 0 (0) Satisfied 19 (8.4) 180 (80) 199 (44) Neutral 182 (80.9) 45 (20) 227 (50) Dissatisfied 24 (10.7) 0 (0) 24 (5) Strongly dissatisfied 0 (0) 0 (0) 0 (0) Total 225 (50) 225 (50) 450 (100) Table 3: Comparison between governmental and private hospitals regarding the patient’s satisfaction Hospital setting N Mean Std. Devi- ation Std. Error Mean t-value Mean Difference P-value Government 225 45.35 3.520 0.235 24.79 11.067 < 0.001 Private 225 56.42 5.696 0.380 DISCUSSION https://doi.org/10.15218/ejnm.2020.14 Erbil j. nurs. midwifery, Vol. 3, No. (2), Nov, 2020 Original Article 124 Erbil Journal of Nursing & Midwifery The level of satisfaction of the patients in the public facilities during their visit to the hospital was neutral in 80.9%, 10.7% of patients were dissatisfied and only 8.4% were satisfied with provided health ser- vices. In private hospitals, 80% of patients were satisfied and 20% gave a neutral re- sponse. Thus, this study has shown that health care in Erbil City differs between public and private hospitals. This finding is consistent with another study, which has shown the difference in the level of satis- faction seen in Korea where people mostly more prefer the university health system rather than hospitals [10]. Private hospi- tals have high levels of patient satisfaction and aim to continuously optimize health service provision. They always compete among themselves to attract patients lo- cally and nationally. In some countries, medical tourism plays an important role in the economy of the country e.g. Jordan, Turkey, and India. Research studies have shown that patient satisfaction plays a ma- jor role in medical tourism, and patient satisfaction is unique to influence interna- tional medical tourists [12, 13]. Currently, the private hospitals in Kurdistan play an important role in health care services and they help the public hospitals to decrease the burden on the government and pro- vide many benefits for the patients and the society. Patients can get senior doctors and health care immediately at any time in private hospitals unlike in the public health sector [14]. A major barrier to private hos- pitals attendance is out-of-pocket costs as there is no health insurance system in the region for the people to use private hospi- tals and outpatient or consultant clinics services. Outpatient and hospital costs at the national level are not clear, but it is clear that they are high for the patients and their families e.g. in Australia out-of- pocket consultation costs to patients vary nationally ($110–$480) [15]. In Erbil City, the patients are more satis- fied with the health care in private hos- pitals than in public hospitals. The gov- ernment should improve the care pro- vided in the public sector and strengthen the weaknesses in the health system. Research and education about decision- making regarding the choice between public and private hospital attendance should be encouraged, and information about diseases and the way of manage- ment is critical in extending and improv- ing the lives of people and decreasing the complications of diseases. The gov- ernment should improve the health ser- vices to assimilate all the society’s need and to encourage both public and pri- vate health insurance. Encouragement of private health insurance in the region is very important to decrease the out-of- pocket expenses for the patients. Patient satisfaction is an important tool to as- sess the quality of health care and to en- courage medical tourism from the rest of Iraq in the near future and from the neighboring countries in the long term. The author declares no conflicts of inter- est. The authors’ involvement in the study is reflected in the order of their names. [1] Thayaparan AJ, Mahdi E. The Patient Satisfaction Questionnaire Short Form (PSQ-18) as an adaptable, reliable, and validated tool for use in various settings. Medical Education Online. 2013, 18:21747. [2] Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L, et al. 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