Patient satisfaction with community clinic care : facility and household based survey in a sub-district in Bangladesh

Bangladesh government has initiated a project with the title of "Revitalization of Community Health Care Initiatives in Bangladesh (RCHCIB)" to further develop the Community Clinics (CCs) and strengthen their operations in delivering primary health care. Measuring patient satisfaction with CC service users can play an important role in developing quality care. The objectives of this study were to measure patient satisfaction with CC through facility (CC) based survey and to measure overall patient satisfaction with CC through household based survey. The overall mean patient satisfaction score was 3.7 ± 1.0 and 2.4 ± 1.1 for facility based survey and household based survey, respectively. Policy and strategy should be done to increase quality of care resulting high level of patient satisfaction to service provided at CCs.


Introduction
Patient satisfaction has long been considered as an important component when measuring health outcome and quality of care. 1,2A satisfied patient is more likely to develop a deep and long lasting relationship with their medical provider, leading to improve compliance, continuity of care and ultimately better health outcome. 3,4ustomer satisfaction is an important measure of service quality in health care organizations.From a management perspective, patient satisfaction with health care is important for several reasons.Firstly, satisfied patients are more likely to maintain a consistent relationship with a specific Patient satisfaction with community clinic care: facility and household based survey in a sub-district in Bangladesh

Key words: Patient satisfaction, community clinic care, Bangladesh
Mst. Jannatul Ferdousi MSS, Lecturer, Department of Economics, Government PC College, Bagerhat Email: hn.ferdousi_pccollege@yahoo.com provider.Secondly, by identifying sources of patient dissatisfaction, an organization can address system weaknesses, thus improving its risk management. 5T h irdly, satisfied patients are more likely to follow specific medical regimens and treatment plans.Finally, patient satisfaction measurement adds important information on system performance, thus contributing to the organization's total quality management.
Health service quality has three dimensions: client quality, professional quality and management quality. 6In many developing countries, the public sector has attempted to expand its share of primary health care in rural areas, but still suffers from under

Mediscope
The Journal of GMC utilization. 7,8In developing countries such as Bangladesh, few studies have sought patient view on satisfaction with services, and there is little effort to involve them in measuring satisfaction or defining health service standards. 9 We recognize that quality as perceived by the health care recipient is vitally important.As a result of this new focus, measurement of customer satisfaction has become equally important.The aim of this study is to measure patient satisfaction with primary health care services provided from CCs in rural Raigonj, Bangladesh.The results of the study can be used to improve the performance of the primary health care delivery from CCs.

Primary health care in Bangladesh
Primary health care is delivered from three tiers at rural area in Bangladesh (Fig. 1).
The delivery of primary health care in Bangladesh has been taking a remarkably new shape through establishment of 13000 community clinics, one for every 6000 rural populations.The existing union and upazila level health facilities will also provide CC service.

Facility based survey
Twenty CCs were selected randomly from 28 functioning CCs.Patient satisfaction were measured for reception of the patient, convenient time of the patient, waiting time by the patient, transportation of the patient to clinic, environment of the CC, secrecy of the patient, understanding of problem by provider, behavior of the provider, repetition of using the service and overall satisfaction.
A preliminary questionnaire was first developed in English using Likert scale, then translated into Bengali and retranslated several times until it was user friendly and captured the desired constructs.The questionnaire was pre-tested and feedback was used to refine until it was ready for data collection.
A total number of 314 data were collected by a 10-member team of skilled data collectors.
Patients were selected following a systematic random sampling.If the data collectors missed any patients due to time management, he/she was instructed to allow any of the patients just after finishing each interview.The study was conducted out of the CCs or in an area out of all external influence coming from third person like health staff member or curious onlooker within thirty minutes of receiving care from the CCs.All patients aged 18 years and above and the children accompanied b y person aged 18 years and above, who visited the facility were included.All patients Fig. 1.Primary health care delivery system in rural Bangladesh developed as highly satisfied, satisfied, no opinion, dissatisfied and highly dissatisfied.
Mean and standard deviation were also calculated from the Likert scale.The highest to lowest level of satisfaction were scored 5 to 1.

Results
Table 1 shows the highest satisfaction score was 4.0±1.0 for transportation to CCs followed by 4.0±1.0 for repetition of receiving service from the CC.The lowest score was 3.3±1.1 for waiting time followed by 3.5±1.1 for reception of the patients.T h e facility based overall satisfactions mean score was 3.7 ±1.0.The survey revealed that the household based overall satisfaction mean score was 2.4±1.1.
Table 2 shows that overall patients satisfactions were leveled 19.7% and 43.0% for highly satisfied and satisfied, respectively.Only 3.8% patients were highly dissatisfied.
Of the total 2023 households visited, 210 patients received health care from any of the CCs.Table 3 shows that only 5.2% and 17.6% patients were highly satisfied and satisfied, respectively (Table 3).On the other hand 18.1% patients showed highly dissatisfaction (Table 3).
were interviewed after they had consulted the health care provider.Informed verbal consent was taken from all the participating patients before the start of the interview after describing about the objective of the study and the approximate time that will be needed for the completion of the interview.The prescribing health care provider was largely kept unaware of the procedure, except in unavoidable circumstances, to avoid the bias in their behavior with the patient.

Household based survey
Ten percent of the total households were selected randomly from 10 villages at the same areas where the study was conducted.A total 2023 households were surveyed to find out the CC users.Questionnaire developed for data collection from the users of CC.Five data collectors collected data.In this case the respondent was mother in the households.After ensuring that there is one who received health care from CCs during previous month of the interview was interviewed by the data collector.Only overall satisfaction data were collected during household based survey.

Data Analysis
Data were entered into a software SPSS 15.5 version after necessary coding and editing.Five point Likert scale was T h e study measured the level of satisfaction among the service users from the CCs.The highest satisfaction was rated for transportation to the clinics and the mean was 4.0.We found that there was no cost for seeking health services from the centre.No respondents hired any vehicle that incurred cost.All the patients reached the centre either on foot or by bicycle.Zero cost for reaching the facilities might play an important role for higher level of satisfaction.Similar findings were found in a study which found that travel time to the CC was 12.4 min and 88.0% percent patients visited the centre on foot. 11Ziaul et el also found in their study that 39.0% patients preferred health centre due to close proximity to their residence. 12The study revealed that patient satisfaction was lowest for the waiting time.Previous studies also identified that long waiting time and insufficient consultation time as factors contributing to patient dissatisfaction in Bangladesh. 13,14H e alth Assistants (HAs) and Family Welfare Assistants (FWAs) were deputed to serve the patients in the CCs until the recruitment of the Community Health Care Providers.The basic duties of HAs and FWAs are to visit door to door to cover Expanded Program on Immunization and to serve family planning methods for couples.Many patients claimed that the providers did not come to the centre timely and appropriate trained personals were not in place.This might be a reason for patients' dissatisfaction while receiving service at CCs.
Overall patient satisfaction mean score was 3.7±1.0and 2.4±1.1 from facility based survey and household based survey, respectively.Facility based survey result showed that more than 60.0% were satisfied and only 22.8% were satisfied in case of household based survey.This study indicated a variation of patient satisfaction for facility based survey and household based survey.There may be a lot of influential factors (elderly patients, chronic diseases, incapability of recall, seasonal variation, etc) that may lead to low level of patient satisfaction for household based survey.Other explanations are to be explored in future studies.
Limitations of the study were the following: a) the study was done only to measure patient satisfaction of facility based and household based survey, b) it was unable to show the socioeconomic status of the patients, and c) it was unable to show the whole scenario of patient satisfaction in the country.

Conclusion
Measuring patient satisfaction with CC service users can play an important role in developing quality care.The objectives of this study were to measure patient satisfaction with CC through facility based survey and to measure overall patient satisfaction with CC through household based survey.The overall mean patient satisfaction score was 3.7 ± 1.0 and 2.4 ± 1.1 for facility based survey and household based survey, respectively.Policy and strategy should be done to increase quality of care resulting high level of patient satisfaction to services provided at CCs.

JM Ferdousi ORIGINAL ARTICLE Abstract
Bangladesh government has initiated a project with the title of "Revitalization of Community Health Care Initiatives in Bangladesh (RCHCIB)" to further develop the Community Clinics (CCs) and strengthen their operations in delivering primary health care.Measuring patient satisfaction with CC service users can play an important role in developing quality care.The objectives of this study were to measure patient satisfaction with CC through facility (CC) based survey and to measure overall patient satisfaction with CC through household based survey.The overall mean patient satisfaction score was 3.7 ± 1.0 and 2.4 ± 1.1 for facility based survey and household based survey, respectively.Policy and strategy should be done to increase quality of care resulting high level of patient satisfaction to service provided at CCs.