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Factors contributing to patients’ satisfaction with public health services in

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African Journal for Physical Activity and Health Sciences (AJPHES) Volume
23(1:1), March 2017, pp. 59-68.

Factors contributing to patients’ satisfaction with public health

services in the Eastern Cape, South Africa

N. PHASWANA-MAFUYA1,2, K. PELTZER1,3,4 , E. HOOSAIN1,2 AND B. MASEKO1

1
Human Sciences Research Council, South Africa;
E-mail: nphaswanamafuya@hsrc.ac.za
2
Nelson Mandela Metropolitan University, South Africa
3
University of Limpopo, Polokwane, South Africa
4
ASEAN Institute for Health Development, Mahidol University, Salaya, Thailand

(24 September 2015; Revision Accepted: 6 February 2017)

Abstract

A cross-sectional study was carried out among patients to assess the factor structure of their
satisfaction with Primary Health Care (PHC) services. Using a structured questionnaire, we
conducted exit interviews with a sample of 19 136 patients aged 18+ years in 266 PHC facilities,
Eastern Cape, South Africa. To determine factor structure, principal component analysis with
varimax rotation was done. Subsequently, there were five components that explained 52.8% of
the total variance. Factor 1 (eigenvalue: 7.6) had items on dignity (talked respectfully) and
communication (clear explanations) and explained 25.5% of the variance. Factor 2 (eigenvalue:
2.8) had items on the quality of basic amenities (cleanliness) and explained 9.2% of the variance.
Factor 3 (eigenvalue: 2.5) had management-related items (complaints) and explained 8.5% of the
variance. Factor 4 (eigenvalue: 1.7) related to Information, Education and Communication
materials which explain 5.5% of the variance. Factor (eigenvalue: 1.2) had items on prompt
attention (waiting time) and explained 4.0% of the variance. Dignity, communication and basic
amenities were identified as major factors determining patient satisfaction.

Keywords: Patient satisfaction, factor structure, primary health care, South Africa.
How to cite this article:
Phaswana-Mafuya, N., Peltzer, K., Hoosain, E. & Maseko, B. (2017). Factors contributing to
patients’ satisfaction with public health services in the Eastern Cape, South Africa. African
Journal for Physical Activity and Health Sciences, 23(1:1), 59-68.

Introduction

Patient satisfaction surveys are critical in demonstrating the degree of success in

any form of service delivery (Sitzia & Wood, 1997; Andaleeb, 2001; Ajayi,
Olumide & Oyediran, 2005; National Department of Health, 2011; Australian
Institute of Health and Welfare, 2014). Patients' views on levels of satisfaction
with primary health care (PHC) services are being given more priority in
programme implementation and policy-making as they measure the quality of
care, service standards, performance standards and contribute to an increase in
service utilization (Campbell, Ramsay & Green, 2001; Muhondwa, Leshabari,
Mwangu, Mbembati & Ezekiel, 2008; Peltzer, 2009; Doyle, Lennox & Bell,
60 Phaswana-Mafuya, Peltzer, Hoosain and Maseko

2013; Beattie, Lauder, Atherton & Murphy, 2014; Price et al., 2014). The
success of health systems in resource-poor countries appear to be dependent on
patients' opinions and their satisfaction with services (Newman, Gloyd,
Nyangezi, Machabo & Muiser, 1998; Luxford & Sutton, 2014). The
consequence of patient dissatisfaction in such settings can include patients
defaulting on treatment regimens and follow-up care, as well as dissuading
others from accessing the health-care system (Andaleeb, Siddiqui & Khandakar,
2007; Jacobsen & Hasumi, 2014). It is important to examine which factors
contribute to patient satisfaction because the South African government has
increased its commitment to improve the quality of PHC services and the fact
that PHC is largely utilized by the disadvantaged majority (Department of
Health, 2007). South Africans generally rely on public health services, with less
than 20% of the population on private medical insurance coverage (Shisana,
Rehle, Louw, Zungu-Dirwayi, Dana & Rispel, 2006). In the Eastern Cape
Province, 10.9% of the population benefits from private medical aid while the
province has below 9% of all private and independent hospitals in South Africa
(HASA, 2011). There are 808 PHC facilities (clinics) and 72 public hospitals in
the Eastern Cape (National Health Facility Baseline Audit, 2012); the current
study was conducted in 266 PHC facilities. Knowledge of the factors influencing
patient satisfaction is of great advantage to health programme managers who
want to arrest falling utilization rates of public sector health facilities (Bernhart,
Wiadnyana, Wihardjo & Pohan, 1999). Therefore, this study sought to assess the
psychometric properties of the Health Systems Trust (2004) patient satisfaction
survey tool. This will contribute towards the development of a valid patient
satisfaction questionnaire for future studies in South Africa.

Methodology

Design and setting

A cross-sectional survey was done among patients exiting 266 PHC facilities in
2008, Eastern Cape, South Africa.

Sample
A total of 266 PHC facilities were selected by the provincial Department of
Health. A total of 19 136 out of 19 401 (99% response rate) patients aged 18+
years that visited the facilities during data collection period participated in the
study.

Ethical considerations
Provincial and institutional ethics approvals were obtained from the relevant
bodies. The respondents were each verbally informed of the study and then
provided with an information sheet. Only respondents who provided informed
consent to be interviewed were included in the study. Each patient who provided
 Patients’ satisfaction with public health services 61

informed consent was interviewed in their preferred language by a trained

interviewer.

Procedure
One fieldwork coordinator and four fieldworkers were trained and allocated to
each clinic to conduct patient interviews. The interviews were completed within
five consecutive days at each clinic. The fieldwork process in the clinic was
supervised and coordinated by the clinic nurse.

Measures
The Patient Satisfaction survey tool adapted from the Health Systems Trust
(2004) was used. The adaptation process was done in consultation with the
provincial Department of Health. Questions on socio-demographics, health state,
reason for visiting the PHC facility and utilization of health care services were
added. Following this, translations were conducted from English into the other
two predominant languages, namely: Afrikaans and Xhosa. These were back-
translated and piloted for quality assurance purposes. The questionnaire had the
following measures: socio-demographics, waiting time, t physical state of the
facilities, travel costs, travel time, interaction between health care worker and
patient, availability of information and education material and existence of a
complaints’ management system. The response options (except demographics)
were assessed on a Likert-type scale (Strongly Agree=5; Strongly Disagree=1).

Data analyses
Data analysis was conducted through IBM-SPSS for Windows, version 23
(Chicago, USA). Descriptive statistics were used to compute the frequency of the
study variables of the study population. Principal component analysis (varimax
rotation) was conducted to determine the factor structure of the patient
satisfaction questionnaire. Factors with an eigenvalue of more than one were
kept for varimax rotation as per the Kaiser-Guttman criterion. Questionnaire
items with factor loading of .40 and higher were included in the discussion.
Sampling adequacy was determined using the Kaiser-Meyer-Olkin measure
using .6 as the recommended value. The level of significance was determined
using the Bartlett’s test of sphericity. The internal consistency of the sub-scales
was examined through Cronbach’s alpha.

Results

Almost all participants were Black African (97.9%) and were without a job
(92.7%) and unable to meet their needs (90%). Approximately 75% were female
and more than two-thirds (69.4%) were aged 50 years or less. Only one in five
had no formal education. Over half of the participants (54%) mentioned that their
health was not good and that consequently they had been in the PHC facility in
the last year for about 6 times (Table 1).
62 Phaswana-Mafuya, Peltzer, Hoosain and Maseko

Table 1: Socio-demographics of the study sample

Sample characteristics Frequency Percentage
Sex
Men 4453 24.0
Women 14130 76.0
Age
≤34 8298 44.8
35-50 4567 24.6
≥51 5663 30.6

Education
None 3957 21.7
Grade 7 6958 38.1
Grade 10 4108 22.5
Grade 12 or more 3241 17.7
Currently working 1248 7.1
Enough money
Not enough 8294 53.3
A little bit 5450 35.0
Moderately 1317 8.5
Mostly 278 1.8
Completely 222 1.4

Factor structure of patient satisfaction with PHC services

Table 2 presents patient satisfaction factors identified through principal
component analysis with varimax rotationwhich resulted in five components that
explained 52.8% of the total variance. Sampling adequacy was .92, which was
greater than .6 and the Bartlett’s test of sphericity showed strong evidence of
association (p < 0.001). The principal component analysis with varimax rotation
identified five components that explained 52.8% of the total variance.

Factor 1 (eigenvalue: 7.6) had items on dignity (talked respectfully) and

communication (clear explanations) and explained 25.5% of the variance. Factor 2
(eigenvalue: 2.8) had items on the quality of basic amenities (cleanliness) and
explained 9.2% of the variance. Factor 3 (eigenvalue: 2.5) had management-related
items (complaints) and explained 8.5% of the variance. Factor 4 (eigenvalue: 1.7)
related to Information, Education and Communication materials which explain 5.5%
of the variance. Factor (eigenvalue: 1.2) had items on prompt attention (waiting
time) and explained 4.0% of the variance. Dignity, communication and basic
amenities were identified as major factors determining patient satisfaction. Nine
items were removed because (1) they did not contribute the factor structure; (2) they
had a factor loading less than .40 (minimum criterion). All items loaded more than
.50 in their respective factor except two items, namely questions 11 and 27 (see
Table 2). The Cronbach’s alphas were high, i.e. factor 1 with 11 items (.84), factor 2
with 6 items (.85), factor 3 with 5 items (.80), factor 4 with 4 items (.80) and factor 5
with 4 items had the least (.70).
 Patients’ satisfaction with public health services 63

Table 2: Principal component analysis with varimax rotation of patient satisfaction

Factors
1 2 3 4 5

Dignity/Communic

Prompt attention
Basic amenities

Management
Complaint

IEC
ation
Items
1) “The nurse spoke in language understood by patient” .51
2) “The facility is usable by disabled people” .52
3) “The health care worker who consulted with me responded to all .59
questions relating to my illness”
4) “I offered permission to be assessed and treated” .60
5) “All staff respected my privacy” .55
6) “The health worker that consulted consulted with me was courteous” .70
7) “The health care workers in this facility show interest in their patients” .69
8) “In future, I will come back to this facility when I am ill” .73
9) “I was satisfied with the manner in which I was attended to at this .68
facility”
10) “I will tell my family/friend to come to this facility when they are sick” .68
11) “I always get medication when I come to this facility” .45
12) “The facility building is in a good state” .70
13) “The facility and its surrounds are tidy” .75
14) “The facility has toilets” .71
15) “The toilets are in a good state” .85
16) “The toilets are tidy” .82
17) “The facility has sufficient rooms for consultation” .65
18) “I know where and to whom to report complaints” .77
19) “I write and put my complaints in the suggestion box provided” .72
20) “I received feedback whenever I complained” .78
21) “Raising complaints and suggestions contribute towards improved .62
delivery of services”
22) “I know the chairperson/member of the clinic committee of this .68
facility”
23) “I saw a Patients’ Rights Charter written on the walls of the facility in .78
a language I understand”
24) “I saw Batho Pele Principles written in a language I understand on the .76
walls of the facility”
25) “During waiting period, I sometimes learn very useful things from the .70
posters and other Information, Education and Communication (IEC)
materials”
26) “The posters and other IEC material are in a language I understand” .79
27) “The registration procedures in this clinic are satisfactory” .46
28) “The time I had to wait before I was examined was reasonable” .69
29) “If I received medicines or pills I did not have to wait long for them” .73
30) “There are fast queues in this clinic” .69
Eigenvalues 7.6 2.8 2.5 1.7 1.2
Variance (%) 25.5 9.2 8.5 5.5 4.0
64 Phaswana-Mafuya, Peltzer, Hoosain and Maseko

The Cronbach’s alpha coefficients were high, i.e. factor 1 with 11 items (.84),
factor 2 with 6 items (.85), factor 3 with 5 items (.80), factor 4 with 4 items (.80)
and factor 5 with 4 items had the least (.70). For each factor, composite scores
were generated using the average of the items loaded on each factor. Higher
scores implied better patient satisfaction. Dignity and communication were
highly rated in terms of patient satisfaction; however the distribution was
negatively-skewed. Descriptive statistics of the five patient satisfaction scale
factors are presented in Table 3. A normal distribution was assumed as the
skewness and kurtosis were within an acceptable range and the histograms
showed that the distributions was approximately normal (not shown here).
Although a varimax rotation was used, moderate to high correlations between
each of the composite scores existed .32 between Factor 1 and factor 2, .25
between Factor 1 and 3, .34 between Factor 1 and 4 and .53 between Factor 1
and five.

Table 3: Descriptives of the five Patient Satisfaction Scale factors (N = 16,786)

Factor name Items M (SD) Skewness Kurtosis Alpha
Dignity/Communication 11 4.21 (.51) -.98 3.25 .84
Basic amenities 6 3.78 (.72) -.80 .21 .85
Complaint Management 5 4.25 (.88) -.29 -.54 .80
IEC 4 3.94 (.81) -.97 1.12 .80
Prompt attention 4 3.93 (.73) -.88 1.08 .70

Discussion

This study explored the factors contributing to patient satisfaction with PHC.
The factors that significantly contributed to satisfaction with PHC services were
in descending order: dignity/communication, basic amenities, management of
complaints, IEC and prompt attention. These factors have also been
acknowledged in literature. The patient and provider relationship has long been
reported to be important in determining client satisfaction with services (Sira,
1982; Dale & Marsh, 1993; Phillips Brooks, 1998; Peltzer & Phaswana-Mafuya,
2012).

Shisana et al. (2013) found that being treated with respect by health practitioners
(85.9%) was viewed as a positive health care experience. In this regard, private
sector patients reported having much better experiences (46.8%) than their public
health care user (17.7%) counterparts. Peltzer (2009) found that the main factors
that contributed to patient satisfaction among South Africans were having access
to health care services, effective communication, being treated with dignity,
confidentiality and availability of essential amenities of good quality (Peltzer,
2009). De Jager and Du Plooy (2007) also found that communication in a
language understood by patients; clear information signage, personal safety and
cleanliness, contributed to satisfaction with services. Andaleeb (2001) also
identified communication as one of the factors contributing to patient satisfaction
 Patients’ satisfaction with public health services 65

with PHC services. Jacobsen and Hasumi (2014) reported in a national survey of
South Africans that about two in five (43.8%) participants had experienced at
least one problem and about one in five (19.1%) participants had experienced
multiple problems during their health facility visit with regard to “a long waiting
time (34.8%), impolite staff (10.1%). The Demographic Health Survey
(Department of Health, 2007) revealed that a long waiting period was one of the
main reasons for feeling unsatisfied with health care services in public hospitals
(41.5%) and community health centres (CHC) (38.1%). Other factors were
negative attitudes of health care personnel in public hospitals (22.8%) and CHC
(25.9%) and not having medication that has been prescribed in public hospitals
(15.8%) and CHC (17.7%). Similarly, the main reasons for being dissatisfied
with health care services in the private health sector were negative attitude from
staff and unaffordable cost (Shisana et al, 2013). The patient satisfaction survey
help to gauge the levels of satisfaction with public PHC services in the Eastern
Cape and may have similar value in other parts of South Africa. Through the use
of factor analysis and multiple linear regression the factors that contribute to
patient satisfaction with PHC services can also be extracted from the data sets
generated. This has implications for cost and efficiency.

Limitations of the study

The usual limitations for studies of this nature apply, most notably a recall bias
on items not related to the current visit to the health facility. As a result, some
items had comparatively lower response rates than others. In some instances,
respondents declined to participate further as a result of pressing practical
matters such as having to get to work or catch a mode of public transport. The
study was limited to only those persons who visited the health facilities during
the survey period. The results can therefore be generalised to only the
participating population and not to the entire catchment population of each
facility.

Acknowledgements

The authors wish to thank the Eastern Cape Department of Health for funding
the patient satisfaction survey. The cooperation of facility managers and the
many patients who participated in the study is hereby acknowledged.

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