Author's response to reviewers

Title:BHSR-D-16-01595: Patients' satisfaction towards radiological service and associated

factors in Hawassa University Teaching and Referral Hospital, Southern Ethiopia, 2016

Authors:
Teshome Mulisa1: tmulisa286@gmail.com

Fasil Tessema2: alazarfasil@yahoo.com

Hailu Merga2*: hailu.merga2014@gmail.com

Version: 1 Date: January 24, 2017

Author's response to reviews:
January 24, 2017
Mr. Jane West
BMC Health Services Research
Editorial Office, BioMed Central
Dear Mr. Jane West,
Thank you very much for sending us your and the reviewers’ comments on our manuscript
[BHSR-D-16-01595: Patients' satisfaction towards radiological service and associated
factors in Hawassa University Teaching and Referral Hospital, Southern Ethiopia, 2016]

We hope that the revised manuscript now addresses all of your and the reviewers’ comments.
Please find attached the point-by-point response to these comments as well as the revised
manuscript with highlighted changes. We have ensured that our revised manuscript conforms to
the Journal style and also we have improved the English language.

If you have any further queries, please do not hesitate to contact us via our address below
Looking forward to hearing from you soon.
With Best Wishes,
Hailu Merga, MPH
Corresponding author
Department of Epidemiology, Jimma University, P. O. Box 378
Response to reviewers comments

Reviewer 1: Referee report

Manuscript Title: Patients' satisfaction towards radiological service and associated factors in
Hawassa University Teaching and Referral Hospital, Southern Ethiopia.
Manuscript ID: MHSR-D-16-01595
Revision version: 1
General comments: the study entertained an area that requires attention and is valuable to
understand the patients' perspectives of the services in a bid to improving healthcare.
Grammatical and typo errors are very common in the document. For example the title itself
"Patients' satisfaction towards radiological service and associated factors in Hawassa university
teaching and referral hospital, southern Ethiopia, 2016" shall be stated as … "Patients'
satisfaction towards radiological service and associated factors in Hawassa University Teaching
and Referral Hospital, Southern Ethiopia"
Response
Thank you. Now we have corrected the title as “Patients' satisfaction towards radiological
service and associated factors in Hawassa University Teaching and Referral Hospital, Southern
Ethiopia

-Line #15 under INTRODUCTION says "……..they receives"……change to they receive.

Response
Thanks. We have changed it to receive in our revised manuscript.
Major compulsory revision
Abstract: In the conclusion section, it was stated that "…It is recommended to give great care
and attention to more educated and unemployed respondents during radiological examination
procedure and also suggested that the department should decrease time taken to enter into
examination room." It is important to show that there has been lack of attention to towards
educated and employed? The main possible reason given in the discussion was their sensitivity to
errors and delay but not lack of attention.
Response
Thank you.
Introduction:
The authors' presentation of the introduction section shall follow a chronological order. It started
with quality, patient satisfaction, radiological services and then comes back to radiological
services. The radiological services can be presented towards the end of that particular section
(see line #20-40 for example).
Response
Thank you.

Methods: Exclusion of patients with critical condition but are sent to radiological departments
are excluded. The whole essence of improving quality is to provide good care to patients
including those in need of emergency services. As options to reach these groups of patients
might be available than omitting them, authors need to clarify this in the document.
Response
Thank you.
-the relevance and measurement/classification of attitude shall be justified.
Response
Thank you.

-How was the overall satisfaction calculated from the components? It is good to include in the
analysis. Moreover, the weights shall be described as satisfaction is a composite variable here.
Response
Thank you.

Discussion:
-the explanation given to lower rate of patient satisfaction among this study as compared to other
Ethiopian studies was the variation in services delivered. Were there evidences to clarify the
difference in availability of services between the study facility and the one used in comparison?
Good to indicate that clearly in the discussion.
Response
Thank you.

-the second page of discussion (lines #56-58) can be revised to be meaningful.

Response
Thank you.

Minor essential revisions

Abstract: the presentation of findings related to associated factors needs to be specifically
interpreted to those with preventive and positive association than describing together as "….
were factors associated with patients satisfaction more likely to be satisfied compared to those
who had more than two hours waiting time."
Response
Thank you.

Methods:
- the source and study population are merged together. The authors could preferably show the
large population group to which findings will be inferred. Statement from line #25-32 under
'population' is not clearly stated as to whether this was an inclusion or exclusion criteria.
Response
Thank you.

-Data entry: while double entry remains to be essential step in maintaining quality, subsequent
statistical steps to ensure consistency were not stated.
Response
Thank you.
Results:
-The texts under patient satisfaction are too detailed. It is good to produce a table or graph to
present the details so that short text is produced. The cost and waiting time section is also too
much - can be shortened.
Response
Thank you.
-the subtitle … "Patient suggestion and comments towards radiological services" does not go
with the contents presented under that. It might be replaced by a topic like "patients experiences
of the service…".
Response
Thank you.

-the interpretation of the Odds ratio for unemployed (0.067) was considered as 93.3% times less
likely. While the direction is correct, it is 93.3% less likely (times shall be omitted). The same is
true of all similar values.
Response
Thank you.

Discretionary revisions
Data collection procedures: The statement "….Exit interviews of patients were conducted using a
structured and pretested questionnaire. Data was collected by three grade ten completed trained
data collectors from." Is incomplete and requires completion.
Response
Thank you.

Population: quality seems important for children too. Therefore, why were only those age 18
years and above studied? What was the reason for excluding patients below 18 years?
Response
Thank you.

Discussion: the FIRST and SECOND limitations of the study are not important and can be
omitted.
Response
Thank you.

Reviewer 2: Review responses

Reviewer: Mulusew A.
Journal: BMC Health Services Research
Title: Patients' satisfaction towards radiological service and associated factors in Hawassa
university teaching and referral hospital, southern Ethiopia, 2016

Comments

1. There is no page number to the manuscript, why?

Response
Thank you.

2. On the title: the title is somewhat relevant to be studied since radiology service is not
studied separately and will provide important fed back to that department to keep quality
services. The title to be rewrite as: Patient satisfaction and associated factors on radiological
services in Hawassa University teaching and Referral Hospital, Southern Ethiopia, 2016
Response
Thank you.

3. On title page, authors put ' * ' to indicate the corresponding authors, but the it is not
indicated with astrix who is a corresponding author
Response
Thank you.

4. Comment on the abstract section:

* Introduction section (line 10-16) "Even though a number of studies have been conducted
about patient satisfaction in different health service departments for different reasons studies in
radiology services are flimsy in Ethiopia" Should be rewritten in short and precise form like
avoiding unnecessary words or phrase (departments for different reasons) and adding comma at
the end of the first close.
Response
Thank you.

* Methods: on line 24, the word "--sample of-- " between among and 321 is not
relevant/does not add any additional meaning to the issue
Response
Thank you.

* Line 28-36; mechanism of measuring patient satisfaction is not still clear even if the tool
contents are mentioned there. How the authors measured their outcome variable/ satisfied or
dissatisfied? And how? It is not clear, because, in the result section it is reported as overall
satisfaction was 71.6%. How converted in to dichotomous outcome variable? And when we say a
patient is satisfied? And vice versa?
Response
Thank you.

* Line 36-41: the sentence "Data were collected by grade ten completed, trained data
collectors via face-to-face exit interviewer administered questionnaires." It is better if written
like this: Grade ten completed data collectors collected data through face to face exit interview
using interviewer administered questionnaire.
Response
Thank you.

* On line 41-43: it says "Logistic regressions were used to identify independent factors…",
which type of logistic regression analysis? Not clear. Is it bivariate or multivariate or both?
Please make it clear
Response
Thank you.
* Results: ok
Conclusion and recommendation: on line22-24, authors recommended as "It is recommended to
give great care and attention to more educated and unemployed respondents….." Is it
recommendation and expected from researchers? They are recommending giving different types
of services to their customers. This by itself creates partiality and it is not a response to increase
those dissatisfied respondents at all. So, your recommendation is a direct interpretation of the
association there, which is wrong; it seems if religion of respondents become association and
recommend changing their religion or give partial service to those religion and create conflict
with customers because of their religion. The right recommendation may be increasing service
quality, minimizing waiting time, increasing patient-provider interactions, good patient
management at radiology department, etc . Please see this section again
Response
Thank you.

NB. Your abstract is longer than the expected (at maximal >350 words) become two pages, why?
The language should also be revised to this section and rest of the work. You should revise your
abstract by taking these comments as starting points.
Response
Thank you.

Introduction

* Here, you used miss placement or omitting punctuations, which is common; example, on
line 40, you missed comma after the word "nowadays".
Response
Thank you.

* On line 49-52, you need to use citation.

Response
Thank you.

* In your introduction, you did not cite your evidences appropriately and you took long
paragraph from one source, which is not recommended—plagiarism. For example, On second
page of your introduction, line 4-26, you mentioned several concepts of different scholars and
almost a half-page, but you mentioned only one source (8), why? At least between line 4 and 9,
line 9 and 12, line12 and 17, etc needs independent citations since they are different concept of
different authors. The same is true for others. Please see it again, it is a major issue in relation to
plagiarism/taking others' work without acknowledging them
Response
Thank you.

* On the same page, line 14-17, "you said radiological patient satisfaction get little attention
in Ethiopia as well as in other countries", why you need to say in other countries here? Are you
going to study those countries? See it again.
Response
Thank you.
* On the same page, line 19-21, you used "their high through put…" what does it to mean? It
is not clear or right way of writing.
Response
Thank you.

* On te same page, line 43-48, you said "overall health service quality compromised in
Ethiopia due to infrastructure and scarcity of health professionals" are you sure all are
compromised such as maternal and child health, TB, malaria, etc since got certified from
CDC/WHO? and how much you trust your reference? Is there scarcity of health professionals
now? I think, NO. please see and match your reference and the reality again
Response
Thank you.

* You need critically see your evidence, proper citation, language, punctuation, etc and
become to the point by avoiding redundancy of idea in your introduction section
Response
Thank you.

Methods

* Here, you said methods and subjects, I preferred to say only methods since you will get
subjects under methods and even it is not only subjects which are found under method section.
Response
Thank you.

* Please put the method section in a new separate page, not with the introduction page.
Response
Thank you.

* On this page, you used SNNPR, TB-HIV, ART, VCT, ICU…..without introducing the full
ones first
Response
Thank you.

* On your population section, line 25-32, or last sentence immediate before sample size
determination is not completed, see it again.
Response
Thank you.

* At the measurement section, was 3.5 your computed mean or a standard number you used?
and why you used mean score to your measurement, why not mode? Or median? was your data
normally distributed? Have you checked it? Or why not as percentage as most such studies are
using that approach? please justify such questions why you choose the mean which is highly
sensitive to change
Response
Thank you.

* On the same section, line 41, you need to put comma next to the "on the other hand,…"
Response
Thank you.

* On data collection tool and procedures, on line55-57, the sentence "Data was collected by
three grade ten completed trained data collectors from" is not complete sentence. On the same
section, you said as you developed you questionnaire by referring more related works, but you
did not cite or indicate your literatures that you used to develop your tool here, so that please. In
addition, was your tool adopted or adapted?
Response
Thank you.

* You need to have a separated Data management and quality sub section instead of putting
it simply under the data collection and procedure section which is only about tool and the
procedure
Response
Thank you.

* Data analysis:
* Instead of saying frequencies, percentages, etc it is better if you used a scientific term,
which is descriptive analysis were computed on different variables.
Response
Thank you.

* On line 33-38, "In addition, cross tabulations were done to establish the level of
relationship on key variables to find out the factors that influenced outcome variables." Are you
sure cross tabulation will tell you the relationship or association? I do not think so, see it please.
Response
Thank you.

* On line 43, why you used P-value <0, 25 as cutting for multivariate analysis? Because in
most of the time, p-value <0.2 is common. Do you have a special reason or justification here
please? Even what is the need to have such precondition? Do you think it is recommended
today? Were your variables more? Relate it with this concept please
Response
Thank you.

* You used 95% CI and p-value <0.05 as significant indicator to your variables
simultaneously, do you think they are different? Why not only one; either 95% CI or p-value
<0.05?
Response
Thank you.

* As much as possible, try to improve your language throughout your work please
Response
Thank you.

Result section

* Focus on your language please, especially you tried to use too long sentences and you
frequently miss use punctuations such as missing comma after using conjunction words like even
though, after that, any close which needs a comma, hence, therefore, and before the word
respectively, etc, for example, online48, the word Respondents' is not appropriate, it is
respondents not a posset ion. In general, the serious issue here is your language and punctuation,
need great revision
Response
Thank you.

* On the forth page of your result, line14; you said "Patients satisfaction with physical
environment of radiological service patients were also assessed" is not a clear sentence and there
are such several similar sentences throughout your document, please see it and act accordingly.
Response
Thank you.

* In your factor assessment section, you said "The study revealed that unemployed patients
were about 93.3% times (AOR=0.067, 95% CI: 0.007-0.622) less likely satisfied as compared to
housewife and students". Here, you comparison group /classification is improper, because when
we see job in terms of employment, both students and housewife are unemployed, so you are
comparing unemployed with unemployed/self-comparison. So, please see it again, it is a serious
issue while selecting comparison group.
Response
Thank you.

* Discussion

* Your justification why percent satisfaction is lower than other study in Ethiopia "This
difference might be because of absence of many qualified health personnel, delivery of wide
services and lack of availability of better instruments and equipment in radiology departments."
(14) Why you need not tell us the name of that hospital and what was the percentage of
satisfaction there? I got it is Hawassa (14), why you need to conduct the study there if it was
done on the same hospital? If your answer is it is a study at OPD, why you need to compare it
with Radiology department which are different? They are noncom parable, I saw the article and
there was no any information about radiology, but you simply tried to compare with OPD
satisfaction, which is unfair in terms of accuracy, fairness, etc. Another issue here is your
justification: do you think there is difference in radiologist, materials/instruments, services etc
within the same hospital? I, as a researcher and
evaluator, strongly oppose your justification. Therefore, your attempt is cheating and very
unscientific approach due to unreal logic.
Response
Thank you.

* Your references (1, 2,3, 6,7, 10, 12, 14, 16, 19,21) are out of your topic, they are OPD and
general satisfaction, so you cannot use them to discuss your findings, but possible to your
concept and back ground, methods, etc sections. But, you used them as comparison evidence to
justify your idea.
Response
Thank you.

* My general comment to you here is just do your discussion again based on only important
and updated evidences and be careful while giving reasons why/ justification to your arguments,
they should be inline you're your objective and issue that you want to discuss. And also be
specific in selecting your idea for discussion based on your objective/ be focused on your
objective. Do not direct copy your results from result section to discussion, no need of
duplication, rather just taking the message and justify critically using evidences either from your
study or your literature.
Response
Thank you.

* Try to improve your language which makes barrier to your readers, which is a serious issue
in your work.
Response
Thank you.

* "This large difference also might be due to excess patients to the radiology department as it
is the only referral hospital used in Sidama zone, Gedeo zone and also from nearby Oromia
regional state." All are satisfaction among OPD patients, why you need to use as justification
here please? Because OPD and radiology services are by far different if seen in terms of
satisfaction.
Response
Thank you.

* Conclusion and Recommendation:

* "In current study, it was found that the majority of the respondents were satisfied with the
radiological services; however, considerable numbers of patients were also dissatisfied."
Contradicting idea, if you said majority were satisfied, that is enough, we know there are few or
less than half were dissatisfied. So, avoid the idea since however.
Response
Thank you.

* Your conclusion is larger and seems a result or discussion section/be specific to your
objectives
Response
Thank you.

* You said: "Greater attention needs to be given to the interplay between patients' socio-
demographic factors…" what type of attention to socio demographic variables please? It is not
specific and your major problem is just direct interpreting the associations, which is dangerous.
So, your conclusion and recommendation section is poor, needs revision.
Response
Thank you.

* References
* Reference 16 and 17 are very old
* All (1-21) has errors in writing, for example, missing the period (.) between the journal
name and year of publication is common to all
Response
Thank you.

NB. Over all decision: It needs more revision works at all sections, especially, the discussion,
conclusion and recommendation, and background sections (being specific to your topic). The
language error is major to this paper. You need do big revision on it.
Response
Thank you.

Decision: Accepted for publication with major revision on method, language, discussion, and
conclusion and background sections.

Reviewer 3: General comment: a useful study to identify gaps for improvement of radiologic
services in the country and elsewhere with similar setting. However, the manuscript has
limitations which need to be revised and submitted.
The recommendation that great care to those educated and unemployed needs careful
interpretation; is not ethically correct. …what can the hospital do to them? The argument that the
illiterate groups are less demanding and relatively better satisfied is logical
Response
Thank you.

Specific comments
Abstract: needs to be shortened (refer guideline for word count)
Introduction: use of cross references better avoided; replace with original articles (e.g Ref#1,
2….)
Response
Thank you.

Materials and methods: correct the heading

* Data collectors are those completing grade 10, who are young students who are not familiar
with the technical/medical terms used in the questionnaire (instrument safety, radiation
protection, etc), and possibly unable to answer questions that could be asked by patients; thus,
there is a possibility of compromising quality of data.
Response
Thank you.

* Incomplete sentences (Line 25-32, 56)

Response
Thank you.
* Redundant sentences: Line 9-14 and the subsequent lines
Response
Thank you.

Result:
* Overall, this section has to be abridged (e.g if % satisfied is presented, no need to show the
remaining % unsatisfied
Response
Thank you.

* Ethnicity and religion have no value to add to the manuscript…leave them

Response
Thank you.

* Line 26: when describing attitude, what do you mean by "Radiologist/Radiographer were
not acting business like while performing the examination?
Response
Thank you.

* >50% of staff accepts opinion; another 20.3% do not accept. What about the rest?
Response
Thank you.

* Patients satisfied with physical environment: sentence is incomplete

Response
Thank you.

* It is not clear in what basis the radiological service fees were categorized
Response
Thank you.

* P17 Line 9; 2/3 stayed >12 hours; the percent given is 59.7% which was supposed to be
66.7%.....better to indicate actual number (same comment for Line 29…states nearly 1/5th for
24.5%).
Response
Thank you.

* Line 12-14, states majority stayed >12 hours; it is also stated majority waited <1 hour to
enter examination room. In its present form, it is not clear where they stayed such long
Response
Thank you.
* Instead of merging services with different TATs, it would have been better if authors
evaluate service delayance vis a vis standard TATs for a particular service (e.g CTscan
examination time varies when performed with and without patient preparation/oral contrast)
Response
Thank you.

* Line 26-52 less relevant, can be shortened with one sentence

Response
Thank you.

* Shorten Table legends

Response
Thank you.

Discussion:
* This part has repetition of result section as well as comparison of data with unrelated
services (e.g out patient, in patient services) e.g Ref 14, 17, 19
Response
Thank you.

* The discussion based on speculations like in line 53-60 could have been supported with
evidence from the studied health facility
Response
Thank you.

* Page20 Line 36: what kind of method variation do you suggest for satisfaction differences,
related to Privacy, between the current and other studies 0.3% vs >50% ?
Response
Thank you.

* Conclusion should emanate from the current findings. For example satisfaction data
regarding Fee for service was not analyzed by service type; same for the other variables. But,
conclusion is service specific.
Response
Thank you.

References:
* Need revision based on journal style
* Last names should be used (e.g Ref 14 Anteneh A should read as Asefa A; Ref 19 Ahmed
R should read as Raheen AR, etc..please check and correct all)
Response
Thank you.