https://doi.org/10.15218/ejnm.2023.11 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Knowledge and Satisfaction for Patients Undergoing Coronary Angiography at Surgical Specialty Hospital Cardiac Center in Erbil City ABSTRACT Background and objectives: Patients' satisfaction is a vital indicator of the quality of health care. Nevertheless, current data on determinants of satisfaction in invasive proce- dures for the cardiac patients are deficient. Accordingly, this study aims to assess the knowledge and satisfaction level of patients who undergoing coronary angiography. Methods: A descriptive/cross-sectional study design was carried out among 350 coronary heart disease patients who performed coronary angiography at the surgical specialty hos- pital cardiac center in Erbil City. The study begins from of January 2023 to the 7th of Au- gust 2023. The data was collected via using a questionnaire which included patients' char- acteristic data, knowledge about coronary angiography and patient satisfaction question- naire. The collected data were analyzed via the frequency and percentages, mean and standard deviation, also the researcher used the Chi-square, independent t-test and one- way analysis of variance (ANOVA) also binary logistic regression analyses were performed. Results: Presented higher service satisfaction scores were found in younger patients, male, more educated, and with high monthly income respectively, The overall degree of satisfaction with coronary angiography care was 57.4 % while 42.6 % of the patients were dissatisfied with coronary angiography care, The factors affecting patient dissatisfaction were lack of patient trust (P-value =0.027, OR=0.499), not ensuring privacy during the pro- cedure (P-value 0.003, OR=0.447), unacceptable waiting time for admission (P-value <0.001, OR=5.857) and high costs procedure (P-value <0.001, OR=4.052). Conclusion: More than half of patients are satisfied with coronary angiography care de- spite most of them having inadequate knowledge. Keywords: Knowledge; Satisfaction; Coronary angiography. Chnar Salahaddin Qadir: Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Kurdistan Region, Iraq (Correspondence: chnar.qadir@hmu.edu.krd) 94 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Received: 16/08/2023 Accepted: 19/11/2023 Published: 30/11/2023 mailto:chnar.qadir@hmu.edu.krd?subject=chnar.qadir@hmu.edu.krd https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Henceforth coronary heart disease (CHD) is one most common causes of mortality worldwide, annually, is estimated 17.9 mil- lion lives. More than four out of five CHD deaths are due to heart attacks and stroke, and one-third of these deaths occur prem- aturely in people under 70 years of age [1]. In Iraq, the number of CHD is increased and considered as a health problem according to data provided the Iraqi Ministry of Health in the hospitals morbidity it was shown that 65% increase in hospital admis- sion due to coronary heart disease [2]. Thus, the Coronary angiography (CAG) is considered as a gold standard diagnostic procedure to identify the function of the heart, structural disorders, and main blood vessels. The coronary angiography is an imaging method that requires the insertion or introduce of the contrast media into the catheter into arterial or selected blood ves- sels. Also, it used to detect the coronary artery structure and assess the intensity or grade of lesions from atherosclerosis [3]. Therefore nowadays, it has become evi- dent that the care of hospitalized patient’s with the heart disease doesn’t regarded as merely as a preventing from the complica- tion of the disease and inadequate to the management of the illness but too includes evaluate of needs for the establishment of a higher level in quality care [4]. The health care services, patients' satisfaction have become the most important and chal- lenging competitive elements. Health care providers are presumed to offer both high quality of care and exceed clients' expec- tancy while being price conscious and effective [5].Cardiovascular diseases trajec- tory affects not only the patient but their family members, community and relation- ships with others too [6]. Patients who attend cardiac clinics need to have infor- mation, from those who experience and suffer from psycho-social needs, moreo- ver, they regularly need significant man- agement concerning medication [7]. Real- izing the experience of patient gives the healthcare provider the chance to improve a higher level of patient satisfaction. The most important and the key indicator of the improvement in quality of care and delivery, health system consistency, relia- bility and well-being is patients’ satisfac- tions [8]. The level of patient satisfaction in Iraq is expected to be worse [9], probably for the reason that the health care systems undeveloped have an inadequate capacity in offering appropriate and more effective health care also insufficient support to the health institutions. Noticeably, there is an inadequate number of healthcare profes- sionals to increase the number of patients. Moreover, the insufficient availability of drugs and laboratory investigations lead to more burden. in the end, the patient's trust, keeping privacy, waiting time, pa- tients teaching markedly affected patients’ satisfaction. Thus, and due to the men- tioned facts the study aimed to determine patients’ satisfaction and knowledge level toward coronary angiography care and fac- tors associated with dissatisfaction. The present study was a cross-sectional design which was carried out on patients with coronary heart disease (CHD) who performing coronary angiography at Cardiac Center in Erbil City. The current study started at the beginning of January 2023 to 7th August 2023. An ethical approval from the ethical committee was taken from Hawler Medical University at the College of Nursing. In the study areas, the investigator carefully chosen the participants and asked them to contribute to the study. The sample was present and aware of the study’s purposes, and the voluntary character of their involvement, 95 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article distributed into two categories based on the knowledge score: inadequate knowledge 50% and adequate knowledge >50% [11]. The final section of the ques- tionnaire is about patients' satisfaction, which was measured by PSQ- 18 scale, is a standard patient satisfaction questionnaire [12]. Seven different categories for evalua- tion include various domains of satisfac- tion (2 items) of general satisfaction, (4 items) of technical quality, (2 items) of in- terpersonal aspect, (2 items) of communi- cation, (2 items) of financial aspect, (2 items) of time spending, and (4 items) of accessibility and convenience. Answers for each item were based on 5 choices, The Likert scale 5-point rating for measuring level of satisfaction was used on a range from (strongly disagree to strongly agree). A scale from 1 to 5 was used to calculate the mean of the scores. The overall satis- faction scale score was divided into two main categories: satisfaction (equal to or above the mean) and dissatisfaction (below the mean). The total scores for items involved in each domain were dis- played and calculated as the mean. Through using this formula like [mean∗100/5], it was transferred into a percentage level of satisfaction. To analyze the data from SPSS software version 27 was used. A significant level that is less than or equal to 0.05 is considered. To de- scribe the variables of frequency and per- centages and to analyze the quantitative data, the mean and standard deviation were used. Also, one-way analysis of vari- ance, the chi-square and independent t- test, and additionally, binary logistic re- gression were performed (dependent vari- ables). The level or grade of patient satis- faction as measured through using the stander tools (PSQ-18 Scale) score (the de- pendent/outcome variable) and the inde- pendent factors (patient’s trust, fear of the procedure, privacy during the procedure, and the researcher informed all patients was taken confidentiality and privacy in their responses. They were told that they might reject or end up participating at any time without no experiencing any conse- quences. The total sample was (n=350) coronary heart disease patients and was carefully chosen with a purposive sam- pling method according to the inclusion criteria of the study. The participants of this study were patients who were ready and want to participate in the study, adult patients diagnosed with coronary heart disease, who need coronary angiography for the first time, and being conscious. While the exclusion criteria were patients who had unstable conditions, receiving any other invasive procedure and unable to give consent. The simple formula was used to calculate the suitable sample size in the prevalence study at Duhok Heart Center, Kurdistan-Iraq, who examined clin- ically diagnosed CAD patients who under- went coronary angiography (CAG); n=Z2P (1−P)/d2. Where n is the sample size, Z is the statistic corresponding to the level of confidence, P is the expected prevalence or proportion, and d is corresponding to the effect size, sample size 3.841*0.31*0.69/0.0025= 328 [10]. The questionnaire contains three parts. The first part which consisted of the general information (demographical data) which includes (age, gender, educational level, occupational status, monthly income, resi- dency and cigarette smoking). The second part was to determine the knowledge of patients about coronary angiography, which included (21 items), pre-coronary angiography (8 items), intra-coronary an- giography (4 items) and post-coronary an- giography (9 items). The patient responds to each item with the right answer (one score) and for the wrong answer (zero scores), the total maximum score is 21. The overall level of knowledge has been 96 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article waiting time for admission, high costs pro- cedure, procedure explanation, discomfort and irritability) the adjusted odd s’ ratio was used to comparing, the influence of factors on the outcome/consequence dis- satisfaction. Table 1. Description of demographic infor- mation of coronary heart disease patients. A total of 350 coronary heart disease pa- tients visited Surgical Specialty Hospital- Cardiac Center to perform coronary angi- ography. The minimum age of participants in the study is 31 years and maximum was more than 60 years old and the mean age with a standard deviation of the sample was 58.97±8.99, The highest percentage of studied coronary heart disease patients were male, (54%) were uneducated, (24.9%) was governmentally employed, 56% their insufficient monthly income, (68.6%) coming from urban, 54.3% was non -smoker, concerning patient’s knowledge about coronary angiography (61.9%) had inadequate knowledge while (39.1%) of them had adequate knowledge. In regard, the severity of the number of coronary ar- tery stenosis, a higher proportion of (48%) had moderate (50 % to 69 %) of the coro- nary artery was obstructed. Regarding the result of coronary angiography, a higher percentage of (57.7%) were diagnosed as percutaneous coronary intervention and (18.3%) of the coronary artery bypass graft. 97 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULTS Table 1. Demographical data of coronary heart disease patients Variables N (%) Age group (Years) 31-45 72(20.6) 46-60 84(24.6) >60 194(54.4) Gender Male 214(61.1) Female 136(38.9) Level of education Uneducated 189(54) Educated 161(46) Occupa- tion Governmental employed 87(24.9) Self-employed 80(22.9) Unemployed 29(8.3) Retired 34(9.7) Housewife 120(34.3) Monthly income Insufficient 196(56) Sufficient 154(44) Residency Urban 240(68.6) Rural 110(31.4) Cigarette smoking Non-smoker 190(54.3) Current smoker 52(14.9) Ex-smoker 108(30.9) Patients’ knowledge about coro- nary angi- ography Adequate knowledge 137(39.1) Inadequate knowledge 213(61.9) Coronary artery se- verity of stenosis Mild (<50%) 105(30) Moderate (50%–69%) 168(48) Severe (≥70%) 77(22) Therapeu- tical op- tions PCI 202(57.7) CABG 64(18.3) OMT 84(24) PCI (Percutaneous Coronary Intervention); CABG (Coronary artery bypass graft), OMT (Optimal Medical Therapy) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 98 were dissatisfied with technical quality (52.6%), interpersonal aspect (56%), com- munication (56.3%), and financial aspect (53.1%) respectively. While (50.9%) of them were satisfied with accessibility and convenience domain in general, the high- est percentage of satisfaction was (57.4%) of patients satisfied with coronary angi- ography care whereas (42.6%) of them wquality (P-value=0.037) interpersonal aspect (P-value=0.013), communication (P -value<0.001) and in accessibility and con- venience (P-value=0.023), whereas there was no statistically significance found in the domain of financial aspect (P-value =0. 217), time spent with doctor (P-value =0.880).ere dissatisfied. Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. The rating and scoring of study partici- pants on each domain of the level of pa- tient satisfaction were shown in [Table 2]. The high proportion (63.7%) was taken in the general satisfaction domain, com- pared to the domain that measures the amount of time spent with the physician, with health care personnel, which had a lower percentage (41.1%). Moreover, more than half a percentage of those Table 3. Display compares patient’s knowledge regarding coronary angi- ography and satisfaction, patients who had adequate knowledge significantly had more satisfaction than those who had in- adequate knowledge in the general satis- faction domain (P-value <0.001), technical Table 2. Description of patient satisfaction in different domains Domains of satisfaction Dissatisfied N(%) Satisfied N(%) General satisfaction 127(36.3) 223(63.7) Technical quality 184(52.6) 166(47.4) Interpersonal aspect 196(56.0) 154(44.0) Communication 197(56.3) 153(43.7) Financial aspect 186(53.1) 164(46.9) Time spending 206(58.9) 144(41.1) Accessibility and convenience 172 (49.1) 178(50.9) Overall satisfaction 149(42.6) 201(57.4) Table 3. Comparison patient’s knowledge of coronary angiography and satisfaction Domains of satisfaction Inadequate knowledge Adequate knowledge Mean difference P-value General satisfaction 2.16±1.38 2.82±1.66 -0.66 <0.001 Technical quality 2.44±1.35 2.77±1.51 -0.33 0.037 Interpersonal aspect 2.24±1.25 2.64±1.55 -0.40 0.013 Communication 2.01±1.24 2.59±1.54 -0.58 <0.001 Financial aspect 2.86±1.09 3.04±1.49 -0.18 0.217 Time spending 2.45±1.57 2.75±1.68 -0.30 0.880 Accessibility and convenience 2.57±1.43 2.95±1.57 -0.38 0.023 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 99 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4. Distribution the level of satisfac- tion of coronary heart disease patient with demographic information, the result indi- cates that younger patients (53.90±17.99) are more satisfied than older patients (41.78±20.82). In regard gender male pa- tients, (54.25±20.63) significantly had higher level of satisfaction than female (43.80±20.09).The study found that partici- pants who were educated (53.32±20.75) revealed highest levels of patient satisfac- tion with coronary angiography care when compared to uneducated persons (41.45±19.26). Participants who had in- sufficient monthly income (43.82±19.78) expressed lower satisfaction than patients with sufficient salary (51.04±21.26). In re- gard [Table 5] the findings show that fac- tors associated with patient dissatisfaction in coronary angiography care, it has been found that there was a significant associa- tion between dissatisfaction with coronary angiography care, partial inpatient trust (61.4%, P-value <0.001), inadequate priva- cy during the procedure (64.5%, P-value <0.001), disagreeing waiting time for ad- mission (52.5%, P-value <0.001), high costs of procedure (49.6%, P-value <0.001), inad- equate explanation about the procedure (55.1%, P-value <0.001).Table 6. Summariz- es the logistic regression of factors affecting ratings on the lower satisfaction were constructed to evaluate the associa- tion among selected variables and dissatis- faction with coronary angiography care. The variables chosen in the model were based on the bivariate analysis. The factors were put into the model discomfort and irritability, patient trust, fear of the proce- dure, inadequate privacy, waiting time for admission, high costs procedure and not explaining the procedure were put into the model. Model fit was measured by the like- lihood ratio statistic (χ2= 7.66, p=0.006) and the Hosmer and Leme show test (χ2= 16.57, p=0.35), the variability observed in the target variable is explained by the re- gression mode was R2 = 35.2%. Patients who lacked of trust half times more chance of being dissatisfied with coronary angiography care than full patient trust, patients with poor keeping privacy during the procedure were nearly half time more likely to report dissatisfaction than those with only keeping privacy during the pro- cedure. Compared to those who were disagreement with waiting time for ad- mission status, nearly 6 times more likely is associated with dissatisfaction. Addi- tionally, the person who reported high costs of procedures had 4 times more likelihood of being dissatisfied with health care service than those who agree with cost of angiography procedures. Finally, patients who had an inadequate explana- tion about the procedure had a 1.61 times further probability of have dissatis- fied with health care services than those who received an adequate explanation. https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 100 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4. Comparison of demographical data and patients’ satisfaction Demographic data N Satisfaction Mean ±SD P-value Age group (years) 31-45 72 53.90±17.99 <0.001 46-60 84 48.25±19.54 >60 194 41.78±20.82 Gender Male 214 54.25±20.63 <0.001 Female 136 43.80±20.09 Level of education Uneducated 189 41.45±19.26 <0.001 Educated 161 53.32±20.75 Occupation Governmental employed 87 50.24±19.11 0.105 Self-employed 80 49.21±22.28 Unemployed 29 38.38±20.33 Retired 34 49.00±23.93 Housewife 120 47.21±20.10 Monthly income Insufficient 196 43.82±19.78 <0.001 Sufficient 154 51.04±21.26 Residency Urban 240 49.24±20.74 0.068 Rural 110 44.85±21.04 Table 5. Factors influencing of patients’ dissatisfaction in coronary angiography care Factors Total Dissatis- fied N(%) Satisfied N(%) P- value Discomfort and irritability Yes 156 (44.6) 70(44.9) 86(55.1) 0.435 No 194(55.4) 79(40.7) 115(59.3) Patient’s trust Lack 83(23.7) 51(61.4) 32(38.6) <0.001 Full 267(76.3) 98(36.7) 169(63.3) Fear from procedure No 65(18.6) 23(35.4) 42(64.6) 0.194 Yes 285(81.4) 126 (44.2) 159(55.8) Privacy during procedure Inadequate 141(40.3) 91(64.5) 50(35.5) <0.001 Adequate 209(59.7) 58(27.8) 151(72.2) Waiting time for admission Unacceptable 263(75.1) 138(52.5) 125(47.5) <0.001 Acceptable 87(24.9) 11(12.6) 76(87.4) High costs of procedure Yes 270(77.1) 134(49.6) 136(50.4) <0.001 No 80(22.9) 15(18.8) 65(81.3) Procedure explanation Yes 178(50.9) 98(55.1) 80(44.9) <0.001 No 172(49.1) 51(29.7) 121(70.3) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article DISCUSSION 101 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Nowadays, diagnostic and therapeutic methods for coronary heart disease has been changed quickly. In our country, the health care staff number per patient is low and that causes a reduction in the time of examination, marking numerous difficul- ties. In these situations, it is not easy to perform and work more professionally and efficiently as health staff. The majority of heart disease patients have no information on coronary angiography, and inadequate knowledge about cardiovascular diseases. The present finding shows more than half the percentage of the study sample was satisfied with healthcare facilities in the domain of general satisfaction, while less than half the percentage of patients were satisfied in the domain of time spent with healthcare personnel, technical quality, interpersonal aspects and communication and financial aspect. It is comparable with a study done in in Jeddah Saudi Arabia show that more than three-quarter of pa- tients satisfied with health care services [13]. Likewise, the present study comes along with a descriptive study carried out on 340 heart disease patients at Tengku Ampuan Rahimah Hospital, in Malaysia, the study revealed that who revealed that most of the patient satisfaction were regarded the health service factors, par- ticularly general satisfaction, convenience and accessibility," while dissatisfaction regarding the orientation of doctors, par- ticularly the "time spent with the doctor," "interpersonal behaviors" and "communication" during counselling [14]. The present study shows that most of the patients had inadequate knowledge re- garding coronary angiography care. It was aligned with the present study findings of studies [15, 16] which were conducted in Cologne, Germany and Peshawar, Paki- stan respectively. It was indicated that the participants did not have sufficient knowledge about the coronary angi- ography. It might be due to lack of pa- tient education before performing coro- nary angiography. Also, the present study demonstrated that patients’ who had ad- equate knowledge significantly had more satisfaction than those who had inade- quate the knowledge, and this was sup- ported by study results that aimed of evaluating the conveying methods of in- formation concerning the coronary Table 6. Determinants of patient dissatisfaction in coronary angiography care Factors P-value OR 95% C.I. for OR Discomfort and irritability Yes 0.324 0.771 0.461 1.292 No Ref Patient’s trust Lack 0.027 0.499 0.27 0.923 Full Ref Fear from procedure Yes 0.492 1.274 0.638 2.545 No Ref Privacy during procedure Inadequate 0.003 0.447 0.261 0.766 Adequate Ref Waiting time for admission Unacceptable <0.001 5.857 2.706 12.675 Acceptable Ref High costs procedure Yes <0.001 4.052 2.026 8.106 No Ref Procedure explanation Yes 0.077 1.613 0.95 2.739 No Ref R2 = 35.2%, χ2= 7.66, P-valve=0.006 Hosmer and Leme show test χ2= 16.57, p=0.35 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article 102 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. to have higher levels of satisfaction with coronary angiography care as in compari- son to uneducated patients. The study results in parallel with a prior study done [23] which is identified that people with higher levels of educational background were more satisfied with their medical performance in the clinical setting. This may be because the participants with higher education levels are more familiar with what the hospital offers than partici- pants with lower levels of education. The results, here, are corroborate with [24], who found that patient education level was associated with satisfaction with care. The higher education contributes to greater responsiveness to health system care and services, ultimately leading to greater satisfaction. In addition, to what mentioned above, another study, found that educated people were statistically significant, and gained a higher score of satisfaction in healthcare facilities, also, displayed that higher satisfaction rate in PSQ-18 with hospital services and with the staff’s behavior [13].The participants who had insufficient monthly income ex- pressed lower satisfaction than partici- pants with sufficient income, high scores of satisfaction were noted and reported in people who had sufficient salary for daily needs. The result come along with another study conducted in 2015 which its result displays that there was a signifi- cant difference between satisfaction rates in patients towards health system and services and their monthly income [25]. Also, the findings come along with a study that indicated that insufficient sala- ries, dissatisfaction with lower health per- ception, and people were significant pre- dictions of satisfaction rates with the health care system and service [26].In this study, the factor affecting patients’ dis- satisfaction among all participants, was unacceptable due to the time for angiography and it was showed that most of the heart disease patients weren’t well alert angiography procedures [17]. Anoth- er by study showed that deficiency in pa- tients’ aware of in what manner the coro- nary angiography was performed and es- sential cares earlier and directly after that leads the patients’ to dissatisfy, and the patients can’t tolerate adherence to essen- tial care as needed and it may causes an rise in vascular access complications which are related to the procedure [18]. The find- ings of the current study revealed that the patient satisfaction with demographic data indicates that younger patients are more satisfied than older ones, this result is aligned with the findings of previous stud- ies in Malaysia [14] China [19], and Rawal- pindi in Pakistan [20] which are respond- ents of the mentioned studies who were aged fifty years, and more are about two times and a half less satisfied with outpa- tient clinics services than younger age groups. This the result of study demonstra- tions that the male patients significantly had higher satisfaction than the females, here the findings are in line with an earlier report [21] which revealed that the female patients who were more likely to have poorer coronary heart disease experience, dissatisfaction and low perception of their health care services compared with male patients. These findings are important to the public health hence they implications and require more research to understand- ed the sex‐definite differentiations of qual- ity in health care, providing, and eventually health consequences. Also, it was agreed with other previous findings of studies done in Malaysia [14] and Nigeria [22] ex- hibited male patients were more satisfied while in comparison to their counterparts, it also, revealed that male patients were more satisfied in general satisfaction and time spent with the physician. The study found that the educated patients showed https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.11 Erbil j. nurs. midwifery, Vol. 6, No. (2), Nov 2023 Original Article Conclusion REFERENCES 103 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. admission, this results was supported by another studies done by [13,27] was acknowledged that there were no enough times and method to communicate with the clinicians and physicians as a significant aspect in their lesser of satisfaction rating with health care facilities. Also, in their study [28] showed that the patients’ satis- faction rating and scores were undesirably correlated to the ready and waiting time. Likewise, this result is consistent with a study which was done in the United States, the study revealed that shorter time in waiting for care was associated with en- hancing and improved satisfaction rates [29].The present study reported that the patients’ trust in doctors who had chances to be fully satisfied with health care sys- tem. This finding is similar to an earlier study done by [30] displayed that patient empathy and trust was a positive correla- tion with patient satisfaction. Also, the re- sult of the study in line with the study done by [31] who reports that patients completely influenced their satisfaction in coronary angiography care by experience and confidence among the health care pro- viders. Furthermore, it has come along re- ported that, making sure privacy and confi- dentiality for essential services which is provided by the hospital had statistical be significance for patient satisfaction. More- over, healthcare providers should offer the highest level of privacy there to improve the level of satisfaction for patients with heart diseases [32]. The current study concluded that younger age, female, educated and sufficient monthly income exhibited higher service satisfaction scores in comparison to pa- tients who aged more than sixty years, male, uneducated and insufficient monthly income, respectively. In coronary heart dis- ease, a higher level of satisfaction rating and scoring in the domain of general satis- faction in comparison to the domain had a lower rating in measures of the amount of time spent with health care personnel. Moreover, more than half a percentage of those were dissatisfied with the technical quality, interpersonal aspect, communica- tion, and financial aspect, respectively. Whereas patients were satisfied with the domain accessibility and convenience. In general, most of the patients were satis- fied with coronary angiography. To sum up, patients who had adequate knowledge significantly had more satisfac- tion than those who had inadequate knowledge about coronary angiography. 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