Abstract
Background:
India accounts for the highest burden of tuberculosis cases in the world. Patient satisfaction is a key criterion for evaluating the quality of healthcare services as satisfaction has been found to be associated with superior compliance and better outcomes. Study was planned with the objectives to assess the patient’s satisfaction regarding treatment-related services under NTEP.
Materials and Methods:
Community-based cross-sectional study was carried out at Ahmedabad Municipal Corporation (AMC) Area. A total of 200 participants were included in the study from various zones of AMC. Probability-proportional-to-size sampling was done and patients seeking care at public (126; 63%) and private (74; 37%) healthcare facilities were included. Questionnaire contained questions related to general sociodemographic profile of participants and satisfaction to NTEP service for which, PSQ-18 Questionnaire was utilized.
Results:
Overall satisfaction to NTEP services was found to be 86%. Amongst public healthcare facilities satisfaction was found to be 86.5% whereas in private healthcare facility it was 85.1%. Compliance to TB treatment was found in 91.5% of participants. Domains such as general satisfaction, communication, time spent with doctors, and accessibility and convenience were found to be statistically significant at private facility compared with public healthcare facility.
Conclusion:
Statistically significant difference was found between patient satisfaction at public and private health facilities in domains of general satisfaction, communication, time spent with doctor, and accessibility and convenience. The same domains at public and private type of healthcare facilities were found to have statistically significant role in treatment compliance by study participants.
Keywords: Compliance, health system, national tuberculosis elimination programme, patient perspective, patient satisfaction questionnaire-18, satisfaction, tuberculosis, user experience
BACKGROUND
Tuberculosis (TB) is a global health concern; nearly one-third of the global population is infected with Mycobacterium tuberculosis.[1] India accounts for the highest burden of tuberculosis (TB) in the world, with 26% of all TB cases.[2] The recently published Lancet Global Health Commission on High-Quality Health Systems in the SDG Era has acknowledged the need to improve quality of care in low and middle-income countries and has recommended that health systems be measured according to elements of competent care and user experience.[3]
Patient satisfaction is a key criterion for evaluating the quality of healthcare services. It can be defined as the level of congruence between patients’ expectations and their perceptions concerning care received. It is a positive evaluation of the dimensions of healthcare and also a subjective perception that may be considered a reflection of reality.[4] Nonhealth industries recognize that positive customer satisfaction and reviews lead to economic benefits like company growth, recommendations, and customer loyalty.[2] Likewise, Patient satisfaction has been reported to influence one’s health status and is used to evaluate the process of care. Greater satisfaction may be associated with superior compliance, improved attendance at return visits, and better outcomes.[5]
The Government of India has committed to the elimination of TB through rapid declines in disease burden, mortality, and morbidity by 2025. Although there has been significant progress in coverage and scale-up of basic TB services, gaps in the quality of care still remain to exist. Quality of TB care has frequently been found to be substandard and highly variable across India’s public and private health systems.[2] Knowing patients’ satisfaction would enable TB programmers to understand the gaps in healthcare delivery and clinicians to understand the specific needs of individual patients so that strategies of improving healthcare delivery and quality of care are instituted.[5]
The percentage of satisfied tuberculosis patients ranged from 53.5% to 97.2% in the various countries of the world.[6] Further research on TB care is necessary. As a result, determining levels of satisfaction and its parameters remains a research priority. There is a paucity of data regarding patient satisfaction with NTEP services in Ahmedabad district, Gujarat. Hence this study was planned with the objectives to assess the patient’s satisfaction regarding treatment-related services under NTEP, to compare the satisfaction level amongst study participants seeking treatment at public and private healthcare facilities, and to find association between treatment compliance and patient satisfaction.
MATERIALS AND METHODS
A community-based cross-sectional study was carried out at Ahmedabad Municipal Corporation Area. The study was conducted amongst patients diagnosed with tuberculosis. Study was initiated after obtaining Institutional Ethics Committee Permission.
According to study of Zekariyas Sahile Nezenega et al.[1] prevalence of patient satisfaction was 90%. Hence, P = 90%, q = 100-P = 10%, L = 5% of P = 4.5%
Sample size = (1.96)2* P * q/L2= (1.96)2 * 90 *10/(4.5)2 = 3457.44/20.25 = 170.73
Addition of 20% nonresponse rate to calculated sample size, the final sample size was considered as 200.
After undertaking preliminary visit to District TB Centre, Ahmedabad the data on number of TB patients for the year 2020-21 was obtained. Based on the data of previous year, Probability-proportional-to-size sampling was performed and the total sample size was divided according to the patients seeking care at public (126; 63%) and private (74; 37%) healthcare facilities. Majority (188; 95%) were selected as drug-sensitive and remaining (12; 5%) were drug-resistant TB patients.
Data collection was performed through community-based personal interview. For all participants, before the interview, telephonic permission was obtained for the visit. Patients 18 years and above who had completed at least 2 months of anti-TB treatment and gave consent were included in the study. Those patients having physical or mental disability were excluded from the study.
Piloting for validation of questionnaire was done before the start of the study. Multi-stage simple random sampling technique was used for selection of study patient. The sample was drawn from all 6 zones of Ahmedabad Corporation area proportionately from public and private sector, based on data of registered TB patient at AMC area. From each zone, one public and one private health institute providing tuberculosis-related health services was selected through simple random sampling. From each public and private health institute, participants were selected through simple random sampling method. From public healthcare facility 21 (20 drug sensitive 1 drug-resistant) participants were selected and from private healthcare facility 12 (11 drug-sensitive and 1 drug-resistant) participant from four zones and 13 from two zones were selected.
Questionnaire contained two parts. First was related to general sociodemographic profile of patients. For second part related to satisfaction, patient satisfaction, PSQ-18 Questionnaire was used.[7] Socioeconomic classification was based on modified prasad classification which is calculated using latest available All India-Consumer Pricing Index (Industrial Worker)[8] of March 2023. Analysis was carried out by investigator (s) of the study using MS Excel and Statistical Package for Social Sciences version 26.
RESULTS
Sociodemographic details of study participants are given in Table 1. Male gender (64.5%) was more common than female. Majority of the patients were belonging to Hindu religion (87%). Married patients (63.5%) and employed (37.5%) were higher. Lower middle socioeconomic class was more common (37%) followed by upper middle (22.5%). Majority of the study participants (140; 70.0%) had pulmonary type of TB. Based on treatment received, 188 participants belonged to drug-sensitive and 12 belonged to drug-resistant TB treatment category.
Table 1.
Sociodemographic details of study participants (n=200)
| Sociodemographic variable | Categories | Frequency (%) |
|---|---|---|
| Age (in completed years) | 18-59 | 178 (89.0%) |
| >60 | 22 (11.0%) | |
| Gender | Male | 129 (64.5%) |
| Female | 71 (35.5%) | |
| Education (last completed) | Illiterate | 12 (6.0%) |
| Primary | 40 (20.0%) | |
| Secondary | 53 (26.5%) | |
| Higher Secondary | 60 (30.0%) | |
| Graduate | 28 (14.0%) | |
| Postgraduate | 07 (3.5%) | |
| Religion | Hindu | 174 (87.0%) |
| Muslim | 24 (12.0%) | |
| Christian | 02 (1.0%) | |
| Marital status | Married | 127 (63.5%) |
| Unmarried | 66 (33.0%) | |
| Widow/Widower | 07 (3.5%) | |
| Occupation (current) | Unemployed | 48 (24.0%) |
| Employed | 75 (37.5%) | |
| Retired | 10 (5.0%) | |
| Homemaker | 41 (20.5%) | |
| Student | 26 (13.0%) | |
| Occupation (past) | Unemployed | 15 (7.5%) |
| Employed | 111 (55.5%) | |
| Retired | 05 (2.5%) | |
| Homemaker | 40 (20.0%) | |
| Student | 29 (14.5%) | |
| Socioeconomic classification (Modified Prasad Classification*) | Class I | 23 (11.5%) |
| Class II | 45 (22.5%) | |
| Class III | 42 (21.0%) | |
| Class IV | 74 (37.0%) | |
| Class V | 16 (8.0%) |
As shown in Table 2, there was a statistically significant difference (P = 0.006) between patients attending public and private healthcare facilities in regards to duration between enrollment and treatment initiation.
Table 2.
Comparison between diagnosis, enrollment and treatment initiation amongst study participants (n=200)
| Mean±SD |
Independent t-test p value | ||
|---|---|---|---|
| Public healthcare facility (n=126) | Private healthcare facility (n=74) | ||
| Duration between diagnosis and enrollment | 2.22±3.2 | 3.01±5.0 | 0.174 |
| Duration between enrollment and treatment initiation | 2.18±6.4 | 0.11±0.8 | 0.006 |
| Duration between diagnosis and treatment initiation | 4.40±7.1 | 3.12±5.0 | 0.174 |
On inquiring about addiction, 100 (50.0%) participants informed of having history of addiction. Tobacco chewing was the most common form seen in 74 patients followed by beedi smoking (28), cigarette smoking (10), and alcohol consumption (18). Suffering from one or more co-morbidities was reported by 39 (19.5%) participants out of which 34 (87.2%) took regular treatment for their co-morbidity. Diabetes mellitus was most common seen in 27 (57.0%) participants, followed by hypertension among 15 (31.0%) participants.
Analysis of past history showed that 34 (17.0%) patients had similar complaints in past and amongst them, 18 (52.9%) had taken anti-TB treatment. In the remaining 16 (47.1%) participants who had no prior history of consuming anti-TB drugs, 09 (56.2%) participants got their complaint resolved with routine antibiotic therapy. Although inquiring about family history, it was found that family members of 50 (25.0%) participants were suffering or had suffered from TB in past.
One-fifth of participants (43; 21.5%) had history of contact with known case of TB in past 1 year before their diagnosis. Moreover, 11 (5.5%) patients also informed that one or more family member, close relative or colleagues were diagnosed with TB after their diagnosis. To prevent secondary cases, only 79 (39.5%) participants were using personal protective equipment such as mask.
Majority (187; 93.5%) participants had informed their family member, close relative, or colleagues about their disease, and amongst them 65 (34.8%) participants felt change in behavior of those who were informed about their disease. Among all participants, 38 (19.0%) felt that healthcare facility is far from their residence and 34 (17.0%) had difficulties/problem in traveling to the healthcare facility. On inquiring about the behavior of healthcare provider toward study participants, it was found that 184 (92.0%) participants felt behavior of staff (other than the doctors) was good and 190 (95.0%) participants felt behavior of doctor was good toward them. Feeling of compromising of privacy associated to disease by the healthcare staff was reported by 8 (4.0%) participants.
Majority (187; 93.5%) of the study participants were satisfied with timing of work at healthcare facilities. Working hours affected due to visit at healthcare facility was informed by 51 (25.5%) of participants. 25 (12.5%) participants felt that they had to wait for long in order to receive service at healthcare facility. Amongst all participants, 127 (63.5%) participants informed that they suffered from financial loss related to ongoing TB treatment. Loss of daily wages and/or loss of employment due to TB was reported by 38 (19.0%) participants. Improvement after starting TB treatment was reported by 192 (96.0%) participants. Compliance to TB treatment was found in 183 (91.5%) of the participants. Only 90 (45.0%) participants were receiving Direct Benefit Transfer, amongst them 35 (38.9%) participants faced trouble in getting the benefit. Amount received as DBT was considered to be inadequate by 56 (62.2%) participants.
Overall satisfaction was found in 172 (86.0%) participants. Comparison of satisfaction between participants taking treatment from public healthcare facility and private healthcare facility is given in Table 3. Statistically significant difference (P < 0.05) was found between patient satisfaction at public and private health facilities in domains of general satisfaction, communication, Time spent with doctor, and accessibility and convenience.
Table 3.
Comparison of patients’ satisfaction between public and private healthcare facility (n=200)
| Scale PSQ-18 | Public healthcare facility (n=126) |
Private healthcare facility (n=74) |
Z proportion test statistic (P) | ||
|---|---|---|---|---|---|
| Satisfied | Unsatisfied | Satisfied | Unsatisfied | ||
| General satisfaction | 63 (50.0%) | 63 (50.0%) | 55 (74.3%) | 19 (25.7%) | 3.37 (0.001) |
| Technical quality | 91 (72.2%) | 35 (27.8%) | 58 (78.4%) | 16 (21.6%) | 0.96 (0.329) |
| Interpersonal manner | 100 (79.4%) | 26 (20.6%) | 56 (75.7%) | 18 (24.3%) | 0.60 (0.543) |
| Communication | 76 (60.3%) | 50 (39.7%) | 61 (82.4%) | 13 (17.6%) | 3.25 (0.001) |
| Financial aspects | 87 (69.0%) | 39 (31.0%) | 48 (64.9%) | 26 (35.1%) | 0.61 (0.541) |
| Time spent with doctor | 54 (42.9%) | 72 (57.1%) | 58 (78.4%) | 16 (21.6%) | 4.88 (<0.0001) |
| Accessibility and convenience | 72 (57.1%) | 54 (42.9%) | 59 (79.7%) | 15 (20.3%) | 3.24 (0.001) |
| Overall satisfaction | 109 (86.5%) | 17 (13.5%) | 63 (85.1%) | 11 (14.9%) | 0.27 (0.787) |
Z proportion statistic was applied and statistical association was found between domains of general satisfaction, communication, time spent with doctor, and accessibility and convenience which is given in Table 4.
Table 4.
Association between satisfaction and compliance to treatment between patients seeking care at public and private healthcare facility (n=200)
| Scale PSQ-18 | Compliance of patients attending Public healthcare facility (n=126) |
Compliance of patients attending Private healthcare facility (n=74) |
Z proportion test statistic (P) | ||||
|---|---|---|---|---|---|---|---|
| Yes | No | Chi-square (P) | Yes | No | Chi-square (P) | ||
| General satisfaction | |||||||
| Satisfied | 57 | 6 | 1 | 53 | 2 | 0.157 | <0.0001 |
| Unsatisfied | 57 | 6 | 16 | 3 | |||
| Technical quality | |||||||
| Satisfied | 81 | 10 | 0.57 | 56 | 2 | 0.064 | 0.094 |
| Unsatisfied | 33 | 2 | 13 | 3 | |||
| Interpersonal manner | |||||||
| Satisfied | 90 | 10 | 1 | 53 | 3 | 0.59 | 0.977 |
| Unsatisfied | 24 | 2 | 16 | 2 | |||
| Communication | |||||||
| Satisfied | 66 | 10 | 0.161 | 58 | 3 | 0.210 | <0.0001 |
| Unsatisfied | 48 | 2 | 11 | 2 | |||
| Financial aspects | |||||||
| Satisfied | 78 | 9 | 0.88 | 48 | 0 | 0.004 | 0.675 |
| Unsatisfied | 36 | 3 | 21 | 5 | |||
| Time spent with doctor | |||||||
| Satisfied | 48 | 6 | 0.59 | 55 | 3 | 0.294 | <0.0001 |
| Unsatisfied | 66 | 6 | 14 | 2 | |||
| Accessibility and convenience | |||||||
| Satisfied | 62 | 10 | 0.054 | 56 | 3 | 0.265 | <0.0001 |
| Unsatisfied | 52 | 2 | 13 | 2 | |||
| Overall satisfaction | |||||||
| Satisfied | 97 | 12 | 0.32 | 60 | 3 | 0.157 | 0.492 |
| Unsatisfied | 17 | 0 | 9 | 2 | |||
DISCUSSION
A total of 200 participants were included amongst which unemployment rose from 7.5% to 24.0%. Majority participants belonged to economically productive age group (18-59 years). Lower middle to lower socioeconomic class was most affected. Duration between diagnosis and enrolment was less at public healthcare facility compared with private facility but duration between enrolment and treatment initiation was less at private healthcare facility which was statistically significant.
Overall satisfaction to NTEP services was found in 172 (86.0%) participants. The percentage of satisfied tuberculosis patients ranged from 53.5% to 97.0% in the African countries,[1,5,9] 71.5 to 97.2% in Southeast Asian countries,[10,11] 82.0% in Pakistan, East-Mediterranean,[12] and 92.9% in Armenia, the European region.[13] Comparison of overall satisfaction between public and private healthcare facility was 86.5% and 85.1% respectively which is almost equal. A study conducted in Brazil[14] among patients in the public sector observed that the highest rates of satisfaction (>89%) which was because of doctor availability during consultation and privacy during attendance which is similar to current study. However, a study conducted in South Africa[15] among patients visiting the public sector observed that 44% patients were dissatisfied with the provider which is quite less compared with the current study. A study in Sudan reported that 96% of patients found providers to be receptive.[16] However, a study in India reported 20 (9%) of DOTS patients felt that the staff was rude.[17] In current study only 8% reported staff of having bad attitude toward them.
Experience of change in behavior by family members, relatives of colleagues was experience by almost one-third of the study participants. Such experience of stigma related to TB may lead to lost-to-follow-up amongst such participants which has been found in various studies.[15,18]
Domains such as interpersonal manner, financial aspect, and overall satisfaction with NTEP service was high amongst participants attending public healthcare facility compared with private healthcare facility, whereas general satisfaction, technical quality, communication, time spent with doctor, and accessibility and convenience were found to be better amongst participants attending private healthcare facility
Various bottlenecks which may affect satisfaction related to NTEP services that were identified and their possible solutions are mentioned in Table 5.
Table 5.
Bottlenecks in patient satisfaction and their possible solutions
| Bottlenecks | Possible solutions |
|---|---|
|
DBT related issues | |
| Irregularity in receiving DBT which is perceived by some participants | •Timely distribution of DBT should be ensured by State TB cell through regular monitoring and addressing the reasons for delay. |
| DBT amount is not satisfactory as perceived by some participants | •Amount of DBT should be revised based on evaluation at regular intervals as per different settings (urban, ruraland tribal). |
|
Non-DBT related financial aspects | |
| Loss of daily wages or Loss of job due to TB reported by few participants | •Vocational rehabilitation should be made part of the programme based on the socioeconomic status of the individual. •To protect against loss of job or loss of wages due to TB disease, legislative measure similar to maternity leave can be implemented after multicentric study. •Counseling of employers regarding non-infectious nature of disease after intensive phase can be integrated in the programme to avoid loss of job. |
| High out of pocket expenditure because of preference of patients for private healthcare facility | •Through multicentric study reason for preference of private healthcare facility over publioc healthcare facility should be found out and those reasons should be addressed following which patients should be motivated to use the public healthcare facilities. •Programme ombudsman which is easily accessible to patients should be formed to deal with problems faced by patients at public healthcare facility. |
|
Communication and time spent with doctor related issues | |
| Long waiting time and inadequate time spent with the doctor at public healthcare facilities | •Dedicated staff of NTEP such as TB health visitor, treatment supervisor or pharmacist can give additional time for counseling and other services as per satisfaction of the patient. •Similar to National AIDS Control Program, peer educators can be involved and incentivized and activities such as focused group discussion can be carried out. |
CONCLUSION
As per PSQ-18, Overall satisfaction related to NTEP services was found to be satisfactory. Interpersonal manner, financial aspect, and overall satisfaction with NTEP service were high amongst participants attending public healthcare facility compared with private healthcare facility, whereas General satisfaction, technical quality, communication, time spent with doctor, and accessibility and convenience were found to be better amongst participants attending private healthcare facility.
Treatment compliance was found to be satisfactory amongst study participants. Statistically significant difference was found between patient satisfaction at public and private health facilities in domains of general satisfaction, communication, time spent with doctor and accessibility and convenience. The same domains at public and private type of healthcare facilities were found to have statistically significant role in treatment compliance by study participants. Factors identified which affected satisfaction to NTEP services were professional care, relational empathy, time spent with the doctor, waiting time to receive the service, technical competency accessibility and convenience and out-of-pocket expenditure and other financial aspects.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
The Investigators would like to acknowledge approval, financial support, and opportunity provided by State TB officer and Chairperson-State Task Force for NTEP for the Operational Research on TB services which is one of the fore-running programme of the nation. Heartfelt thanks to all study participants for giving their invaluable time and suggestions for the Research.
Funding Statement
Gujarat State Operational Research Committee (NTEP).
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