https://doi.org/10.15218/ejnm.2019.04 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article Patients' Satisfaction about Health Services in Out-patients Clinics of Teaching Hospitals in Erbil city ABSTRACT INTRODUCTION Clients satisfaction refers to the levels of satisfaction that the clients experience hav- ing used a medical service in all levels and all domains. Satisfaction is the reflects the gap between the target or desired services and experiences of services provided by health care professionals, from the clients' view *1,2+. Out-Patients Department (OPD) is a department that provides the main linkage of the hospital with the public, its primary objective to provide medical ser- vices for the clients in minimal costs, and its scope of services are different from Background and objectives: Outpatients' satisfaction is important aspect to evaluation lev- els of quality and quantity services provided in outpatients departments. The study aimed to assess patients' satisfaction toward health care provided in out-patients clinics of Rizgary and Hawler Teaching Hospitals and find out the factors that are associated with levels of satisfaction. Methods: A cross–sectional study was conducted in Hawler and Rizgary Teaching Hospitals in Erbil city. The study started from April 1st, 2017 to July 1st, 2017. A convenience meth- od of sampling was used to recruit 500 participants who attended in Out-patients Clinics 238 (47.6%) from Rizgary Hospital, and 262 (52.4%) from Hawler Hospital. The question- naire format was designed by researches for data collection. The questionnaire consisted of two parts: part one socio-demographic and hospitalization data and part two included 59 questions about health care services. Five points Likert scale was used to assess pa- tients' satisfaction. The Statistical Package for the Social Sciences, version 22 was used da- ta enter and analysis. A chi-square test of association was used to compare proportion. Results: The study found 27.8% of patients were satisfied, with respect to all health ser- vices (including physicians, nurses, pharmacies, and laboratories) and in health aspects (including communication, maintain for privacy of patients and respect them, counseling and advising roles, and time spend with patients) . There was an association between pa- tients' satisfaction and age categories, levels of income, and the number of visits to outpa- tient departments. Conclusions: The majorities of outpatients have no idea regarding satisfaction or not satis- fied with health services in outpatients departments of major hospitals in Erbil city. There were significant association between the level of satisfaction with age, level of income and hospital. Keywords: Patients' satisfaction, Outpatients departments. Ako Ramadan Satar; Daub Health Centre, Kirkuk Directorate of Health, Ministry of Health, Kirkuk, Iraq. Ibrahim Hassan Mustafa; Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: ako.ramadan@yahoo.com ) 26 Erbil Journal of Nursing & Midwifery Received: 23/9/2018 Accepted: 15/1/2019 Published: 30/5/2019 mailto:Ako.ramadan@yahoo.com. https://doi.org/10.15218/ejnm.2019.04 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article area to area, mostly OPD's the services are curative (including diagnosis and treat- ment), follow up of chronic diseases and referring, in addition rehabilitation, and some time immunizing *3+. Many studies indicated that increased level of quality of health services has relationship with in- creased level of clients' satisfaction *4+. Studies aimed to find methods to increase clients' satisfaction the results indicated that the hospitals' administrations should create new methods to decrease waiting time in clinics, improve good dialogues skills between healthcare professionals and patients, and maintain privacy of patients. In addition, tudies recommended it's nec- essary to do training courses for physicians and other health care professionals to im- prove their abilities and skills to counseling and guiding the patients *5,6+. A study by Nabbuye-Sekandl and his collogues carried in Mulago Hospital, Uganda in year 2011. Results indicated that health services pro- vided in hospital should devise innovative ways to reach high satisfaction scores for outpatients clinic care. Adequate facilities should provide for patients and services should be more patients-centered in out- patients clinics to achieve all clients' needs *7+. For the purpose of assessing levels of clients' satisfaction, hospitals' administra- tors periodically need to gather and analy- sis related data to identify quality of healthcare services in actually and using the results for improving the quality of healthcare service for better levels *8-10+. Health services are different from country to country but in well-functioning health systems the health services should have number of characteristics including com- prehensive, accessibility, caregiver, conti- nuity, quality, person-centeredness, coor- dination and accountable and efficiency *11+ . Few studies concerned on outpa- tient’s satisfaction toward health services provided in public hospital in Erbil city. This study aimed to assess patients' satis- faction with health care services provided in out-patients clinics of Rizgary and Hawler Teaching Hospitals and find out the factors that are associated with levels of satisfaction . A cross–sectional study was conducted in Out-patients Departments of Hawler and Rizgary Teaching Hospitals in Erbil city. During April 1st, 2017 to July 1st, 2017. A convenience method of sampling was used to recruit 500 participants who attended in out-patients clinics 238 (47.6%) from Rizgary Hospital, and 262 (52.4%) from Hawler Hospital. The sample size was determined by Yamance statistical formula (n=N/1+N(e)2) *12+, after esti- mating the rate of patients visited in the both OPDs in the month from the medical record. (The small n letter in formula indi- cated to sample size, the Capital N letter indicated to population size, and e small letter indicated to level of precision of sampling error which equals to 0.05). By process of entering the known data in for- mula and as (3858)/1+ (3858)*(0.05)2=362 sample size, researchers selected 500 pa- tients as a study sample to reach more representative sample size and for purpose strengthening study. Patients' age ≥18 years, both genders, have ≥ 2 times visiting during one year were included. Patients with mental or psychological problems were excluded. Data was gathered by the self-report method by using the question- naire format that was designed by re- searchers. The validity of the questionnaire was assessed by fifteen experts from different medical and nursing fields. The questionnaire consists of two parts; part one related to socio-demographic charac- teristics of patients and hospitalization da- ta (such as age, gender, marital status, lev- els of family income in the month, the METHODS 27 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2019.04 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article The mean of patients' satisfaction score (M±SD) was 180.7 ±29.4 (Table 1). The pro- portion of male and female were rough to equal. The highest percentage of the sam- ple was 42.8% among age category 19 to 29 years, followed by 38.6% was age cate- gory 30 to 40 years. results show that more than half (51.2%) of the study sam- ple has enough income for daily life, fol- lowed by 46.2% of the sample mentioned there income level is not enough for daily life. results show that 58% of the sample has 2-3 times visiting outpatients' clinics during one year (Table 2). Results showed that the highest scores more than half in majority in all out-patients departments were recorded in neutral (among them the highest score 63.4%was recorded in facili- ties services, and lowest score 46.8was recorded in laboratory services), only 16.0% of the sample was high satisfied to- ward nursing services, and 31.6% of the sample was dissatisfied toward laboratory services (Table 3). Results showed the satisfaction of out-patients toward health care aspects were scored in majorly neu- tral for all aspects more than half of the sample 54.6% and 53.8% respectively were scored neutral satisfaction for the time which spends with patients and maintains patient privacy and respects respectively. Regarding communication highest score 45.4% was scored in neutral satisfied the rest was rough to equal distribute between satisfied and dissatisfied. Regarding health professionals' advice and counseling more than one third (38%) of the patients were neutral, and more than a quarter of them (25.8%) were dissatisfied (Table 4). Results show more than half 257 (51.4%) of the sample was neutral satisfied about health services, and 139 (27.8%) was satis- fied, the rest 104 (20.8%) was dissatisfied. Results also show that there was no number of visiting outpatients' clinics, and hospitals). Part two includes a number of questions about health care services. A five-point Likert scale was used to assess patients' satisfaction, were score five indi- cated the highest level of satisfaction and score one indicated the lowest level of satisfaction. Patients were asked 59 ques- tions to assess their satisfaction with health care services. The equation accrued by subtracting lower score (59) from upper score (295) then the result divided by three. Dissatisfied (59-137) Neutral (138- 216) and Satisfied (217-295). To identify out-patients satisfaction about health pro- fessionals including physicians, nurses, pharmacies, laboratories and facilities (included number and type of seats, ade- quately car parking, cleanness status, direc- tional follow inside clinics, heating, cooling, lighting and ventilation system) and to identify patients satisfaction for the as- pects of the healthcare services that pro- vided by the healthcare professionals (including communication skills, respects and maintain the privacy of patients, advis- es and counseling role for patients, and amount of time spent with patients) each one of these items in separates scores. The researchers calculated all scores relat- ed to each one of them, then presented it into three levels: dissatisfied (for the low score), neutral (for the medium score) and satisfied (for the high score). The research was approved by the Ethical Committee of the College of Nursing, Hawler Medical University and permission from General Directorate of Health in Erbil city. The Sta- tistical Package for the Social Sciences (SPSS, version 22) was used data enter and analysis. The descriptive statistical analysis which involved frequency, percentage, mean and standard division were used. Chi -square test of association was used to compare proportion. A P- the value of ≤ 0.05 was considered as statically signifi- cant. 28 Erbil Journal of Nursing & Midwifery RESULTS https://doi.org/10.15218/ejnm.2019.04 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article differences between male and female re- garding levels of satisfaction (dissatisfied, neutral, and satisfied) (P. value=0.144). Re- sults show more than half (54.8%) of dis- satisfied were patients in the age group 20- 29, and 38.1% of the satisfied were pa- tients in the age group 40 and more. Highly significant statistically differences (P. value <0.001). Results also show that only 13 (2.6%) of the whole sample has exceeded enough income for daily life among them 0.0% were recorded in dissatisfied, the others were distributed between neutral and satisfied respectively. Patients who have enough income for daily life harvest- ed 70.5% in the satisfied group. Highly sig- nificant statistically differences (p. value <0.001). Regarding differences of levels of satisfaction between the clients of both hospitals (Rizgary and Hawler) results show 75.5% of satisfied patients were clients of Hawler Hospital, against only 24.5% of them were clients of Rizgary Hospital High- ly significant statistically differences (p. val- ue <0.001) (Table 5). 29 Erbil Journal of Nursing & Midwifery Table2: Socio-demographic characteristics of the study sample % No. Variables 49.8 50.2 249 251 Sex Male Female 42.8 38.6 18.6 214 193 93 Age 19-29 30-40 41-51 46.2 51.2 2.6 231 256 13 Levels of income Not enough for daily life Enough for daily life Exceeds enough for daily life 58.0 42.0 290 210 Number of visiting outpatients clinic 2-3 visits 4-5 visits 100 500 Total Stander Deviation Range Maximum Minimum Mean 29.4 128.0 240.0 112.0 180.7 Table1: Describe satisfaction status of study sample Table 3: Patients' satisfaction toward health services Total (%) Satisfaction levels Health care aspects Satisfied No. (%) Neutral No. (%) Dissatisfied No. (%) 500(100) 102 (20.4) 263 (52.6) 135 (27.0) Physicians 500(100) 80 (16.0) 284 (56.8) 136 (27.2) Nursing 500(100) 181 (36.2) 278 (55.6) 41 (8.2) Pharmacy 500(100) 108 (21.6) 234 (46.8) 158 (31.6) Laboratory 500(100) 97 (19.4) 317 (63.4) 86 (17.2) Facilities https://doi.org/10.15218/ejnm.2019.04 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article The results of this study showed that the average of patients' satisfaction has stayed in 180.7 which is in the second the highest half of the total score (Table 1). Present study show the highest scores in all type of health services were harvested in the neu- tral, very limited percentage of sample was dissatisfied toward pharmacy services and less than twenty percentage of sample was satisfied toward nursing care (Table 3). Results of a study carried in Malaysia by Abd Munaf indicated that the overall health satisfaction was high in outpatients of public and private hospitals. The study also finds there was a relationship be- tween satisfaction of patients and waiting time in the outpatient's clinic *16+. Study of Amini and Amiri indicated the most of the patients scored satisfaction with health services; the highest score was recorded for physicians, while the lowest score went 30 Erbil Journal of Nursing & Midwifery Table 4: Satisfaction level of sample according to outpatients' services Satisfaction levels Health care aspects Satisfied No. (%) Neutral No. (%) Dissatisfied No. (%) 137(27.4) 227(45.4) 136(27.2) Health professionals' communication 84(16.8) 269(53.8) 147(29.4) Patients' privacy maintain and respect 181(36.2) 190(38.0) 129(25.8) Health professional advice and counseling 147(29.4) 273(54.6) 80(16.0) Time spends with patients Table 5: Association between levels of satisfaction and socio-demographic variables Levels of satisfaction P value Variables Dissatisfied 104(20.8) No.(%) Neutral 257(51.4) No.(%) Satisfied 139(27.8) No.(%) Sex Male Female 57 (54.8) 47 (45.2) 117 (45.5) 140 (54.5) 75 (54.0) 64 (46.0) 0.144 Age categories 20-29 30-39 40+ 57 (54.8) 44 (42.3) 3 (2.9) 110 (42.8) 110 (42.8) 37 (14.4) 47 (33.8) 39 (28.1) 53 (38.1) ≤0.001 Levels of income Not enough for daily life Enough for daily life Exceeds enough for daily life 46 (44.2) 58 (55.8) 0 (0.0) 150 (58.4) 100 (38.9) 7 (2.7) 35 (25.2) 98 (70.5) 6 (4.3) ≤0.001 Hospitals Rizgary 63 (60.6) 141 (54.9) 34 (24.5) Hawler 41 (39.4) 116 (45.1) 105 (75.5) ≤0.001 *The satisfied level consisted27.8% of whole sample DISCUSSION https://doi.org/10.15218/ejnm.2019.04 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article to time waiting. The inconsistencies among studies maybe related to differences be- tween facilities, and services of hospitals *6+.Table 4 in the present study also shows that the highest scores of health profes- sionals about services aspects were distrib- uted majority (more than half and some- times near to half) for neutral in most be- havioral activities which involved times dedicated with patients, maintains privacy of patients and respect them, and commu- nication skills of health professionals with the patients. The results of Table 4 verify the results of table 3in the present study about most of the scores were went to neutral. These results are predictable be- cause the services are available in out- patients clinics but it's not enough in qual- ity and quantity, and our patients have courtesies in there speaking when they evaluate services. In addition patients in Erbil want the service in out-patients what- ever type with regardless of its quality. Therefore the results gone to neutral level Studies indicated that training health pro- fessional principles of communication skills and counseling is necessary to increase pa- tients' satisfaction *17- 19+. This study shows that 27.8% of the whole study sam- ple was satisfied toward health services which provided in outpatients clinics of both Rizgary and Hawler Hospitals (Table 5). In a study carried by Asefa and his col- leagues in Hawassa University Teaching Hospital, in the year 2014 results indicated that 80.1% of patients were satisfied tow- ered health services provided in outpa- tients clinics of the hospital and association between patients' satisfaction and good communication with patients, length of staying in outpatients' clinics to take the healthcare, and available main health ser- vices *5+.The inconsistencies between the results of the two studies maybe related to differences between qualities of health ser- vices in hospitals. The present study shows that there were no differences between male and female regarding satisfaction lev- els. The Study carried of Nabbuye-Sekandl and his colleagues indicated that there were no significant differences between males and females regarding satisfaction *7+. Regarding age the present study showed satisfaction of outpatients in- creased in patients age 40 and more the association between age groups and levels of satisfaction were significant. Nabbuye- Sekandl et al indicates that there were no significant differences between age groups and levels of satisfaction *7+. The present study also shows that there was an associ- ation between levels of income and satis- faction of patients towered health services in out-patient clinics. Highest scores of satisfied were recorded with those who have enough income for daily life. The re- sults of a study carried by Net in year 2007 indicated that there was no association between levels of income and levels of out -patients satisfaction *13+. While Pascoe (1983), found that increases income among patients is a factor for decrease satisfaction toward nursing *14+. Al-Tawil et al in the year 2015 indicated that in- come is subjective and participants could be erroneously classified into different lev- els of income groups *15+. The association between socio-demographic characteris- tics of clients and their levels of satisfac- tion were divers from study to other *4+. Present study found that the satisfaction of outpatients in Hawler Hospital is better than the satisfaction of the outpatients clinic at Rizgary Hospital. Present study concluded that only 27.8% of the whole sample was satisfied with health services, the majority of scores were recorded neutral satisfaction in all health services. There was a significant as- sociation between patients' satisfaction 31 Erbil Journal of Nursing & Midwifery CONCLUSIONS https://doi.org/10.15218/ejnm.2019.04 Erbil j. nurs. midwifery, Vol. 2, No. (1), May, 2019 Original Article *8+ Aldebasi YH, Ahmed MI. Patients’ Satisfac- tion with Medical Services in the Qassim Area. Journal of Clinical and Diagnosis Re- search. 2011; Res. 5(4):813-817. *9+ Donabedian A. The quality of care: how can it be assessed? Journal of the American Med- ical Association 1988;260(12):1743–8. Avail- able from Doi: jama.1988.03410120089033.https:// jamanetwork.com/journals/jama/article- abstract/374139. *10+ Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality care.Journal of Medi- cal care Organization. 1988;25:25–36. Avail- able pubmed/2966123. *Access in May 20, 2018+. *11+ WHO. Health service delivery. 2010. Availa- ble from:www.who.int/healthinfo/systems/ WHO_MBHSS_2010_section1_web.pdf *Access in March 12, 2018+. *12+ Ajays SS., Micah BM. Sampling techniques and determination of sample size in applied statistics research: an overview. Internation- al Journal of Economics Commerce and Man- agement, UK; 2014; 2(11)1-22. *13+ Net N. Patients' satisfaction towards health services at the out-patient department clinic of Wangnumyen Community Hospital Sa- kaeo Province, Sakaeo Province: Mahidol University Thailand. *Thesis+. 2007. *14+ Pascoe GC. Patient satisfaction in primary health care: a literature review and analysis: EvalProg Plan 1983; 6(3-4):185-210. Availa- ble from: https://www.ncbi.nlm.nih.gov/ pubmed/10299618. *Access in March 17, 2018+. *15+ Al-TawilNG., Mustafa IH., Ismahil ZA. Inpa- tients satisfaction toward nursing services in medical and surgical wards of Rizgary Teach- ing Hospital, Erbil, Iraq.Zanco Journal of Medical Science; 2016;20(2):1349-55. *16+ AbdManaf NH, Nooi PS. Patients' satisfaction of services quality in Malaysian Public Hospi- tal. The Asian Journal of Quality. 2016; 10(1): 77-87. Available from: https:// doi.org/10.1108/15982688200700028 *17+ Azizam N A, Shamsuddin K. Health care pro- vider- patient communication: a satisfaction study in the outpatients clinic at Hospital Kuala Lumpur. Malays Journal of Medical Science. 2015; 22(3)56-64. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4681722/. *Access in Apr 10, 2018+. and age categories, levels of income, and number of visits to outpatients' clinics, and there was a difference between patients of Rizgary Hospital and Hawler Hospital re- garding outpatients' satisfaction. The authors report no conflict of interests. *1+ Prakash B. Patients satisfaction. Journal of Cutaneous and Aesthetic Surgery Sep. 2010; 3(3):151-5. Available from: Doi: 10.4103/0974-2077.74491/.https:// www.researchgate.net/ *2+ Aragon SJ, Gesell SB. 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