Patients’ Treatment Satisfaction: Experiences of HIV Patients in a Tertiary Hospital in Southwest Nigeria

: According to the World Health Organization, about 40 Million people are living with HIV/ AIDS, where two-third resides in the African region and about 2 Million of them are from Nigeria. Hence, this study assessed the satisfaction of patients with services provided in a tertiary hospital in southwest Nigeria. This is due to the fact that the satisfaction of patients is a measure used to evaluate the quality of health care delivery of a hospital and from health care services providers. It is a cross sectional study that employed purposive and convenience sampling methods using well-structured questionnaires to retrieve information from HIV/ AIDS patients. A total of 143 respondents participated fully and whose data were analyzed using Statistical Package for Social Science (SPSS version 20), where the level of patient’s satisfaction was measured. The patients’ satisfaction was based on Service Quality (SERVQUAL) framework. Result from the study revealed that the patients were currently satisfied with the services being offered them, at a grand mean of 4.46 and standard deviation of 0.52. Also, the respondents ranked responsiveness dimension of SERVQUAL framework first with an average mean of 4.53 and standard deviation of 0.47. They ranked Empathy dimension as the lowest dimension, with an average mean of 4.36 and standard deviation of 0.58. Thus, the study recommends that health workers should be trained by the government on how to convey affection while providing services to HIV/ AIDS patients.


Introduction
Healthcare service delivery is an essential mandate for the achieving health targets for sustainable development goals (SDGs) and the satisfaction of patients is a measure of evaluating the quality of healthcare delivery, especially epidemics like HIV/ AIDS [1].The sustainable development goal three (SDG 3) is a measure of improving life expectancy of citizens of different countries and thus necessitates reduction of life threatening disease such as HIV/ AIDS [2].As a result, improving the health status of people places a demand on countries to strengthen their healthcare system.This is necessary to tackle high mortality rate which caused by several factors which include the burden of HIV/ AIDs.According to World Health Organization [1], there are 1.9 Million people living with HIV/ AIDS in Nigeria, which is an improvement from 3.2 Million people as at 2016.However, according to the National Agency for the Control of AIDS [3] resources available to drive HIV/AIDS treatments for the people are limited, hence available resources must be strategically distributed.This strategic deployment of resources has led to about 52% Nigerians who are still unaware of their HIV status [4].Hence, the need to look at the efficiency of services rendered to people with HIV/ AIDS to avoid transmission to people without HIV/ AIDS.Also, Nigeria is the fourth country in the world with the highest number of people living with HIV/ AIDS (PLWHA) exceeding South Africa, Mozambique and India [5].Consequently, PLWHA in the country are confronted with different challenges such as access to health care services, shortage of manpower in the health service centers, congested health care facilities, knowledge gap among health care providers and sides effect of the drugs used for treatment, high cost of treatment and fluctuating funding of the different programs for PLWHA by the Federal government of Nigeria [3,6,7].Moreover, patients are confronted with other barriers, such as patients' low socioeconomic status, long waiting times, inadequate knowledge of HIV, user fees, stigma and discrimination, and interference with antiretroviral (ART) therapy [8,9].
To assess the quality of service delivery, patients' satisfaction constitutes a key measure through the feedback from the service utilizers.Today, patients are conscious of their rights in terms of healthcare services rendered by the service provider [10].Patients' satisfaction often determines the extent at which they adhere to medical advice, care and prescribed treatment schedule [11] Dissatisfaction with health services can have serious consequences which may result in patients not following treatment regimens, failing to go for follow-up care and spreading negative information to discourage others from using a healthcare service [12].Healthcare facilities are required to offer quality service to improve the health status of the patients and maintain a healthy population [10,13].
According to the National Agency for the Control of AIDS [3], effective performance of health care delivery have a tremendous effect on critical HIV intervention that impacts on HIV risk, transmission, morbidity and mortality.This will help in attaining the United Nations of 90 -90 -90 targets and the goal of ending AIDS epidemics by 2030.Therefore, this study investigated the satisfaction of PLWHA as regards the services rendered to them.This will evaluate current strategies of services being rendered to the patients and thus give insights into better ways of improving health care services to optimize PLWHA socio-economic contribution.Consequently, to minimize the spread of HIV/AIDs in Nigeria, there is need to assess the level of satisfaction of patients with service delivery in HIV/AID healthcare facilities.This will assist in minimizing mortality rate thereby contributing to the socio-economic development of the nation.

Patient Satisfaction
Patient satisfaction is a multidimensional concept, based on a relationship between experiences and expectations.The term patient satisfaction as used herein means the positive emotional reaction to the consultation and the positive experience of the treatment in its various aspects.It has also been described as the gap between what patients expect to receive as a service and what they actually get [14].Generally, it is how happy the patients are with their transaction and overall experience with the company.By and large, it is a very subjective concept that can be hard to measure, but which is of great importance in health care.This is because it gives direct feedback to service providers, as an important indicator of quality of services and shows the relationship between services and treatment outcomes [15].It can also be valuable competitive tools that helps to improve patient's quality of life and helps service providers determine customer's specific problems that require attention [12].
According to Beattie, Pinto, Nelson and Nelson, [16] patient's satisfaction relates to the results of the treatment they have received while their satisfaction with the care focuses on their satisfaction with the services they have received.In order to achieve the satisfaction, it is discovered that most of the patients' concerns revolve around the health care facilities which include access, cost of the treatment and treatment time [16].Moreover, Beattie, Turner, Dowda, Michener and Nelson [17] found that overall patient satisfaction was more related to the degree at which healthcare providers answered the patients' questions and the respect they give them during the care.The same researchers found that patients acknowledged the value of their interaction with the health care provider especially when they discussed relevant information related to their problems with them.
The Servqual framework A range of studies have described patient satisfaction differently and have used a variety of tools and dimensions to measure patients' satisfaction with health services [14,18,19,20,21,22].Many studies in both developed and developing countries have successfully used the SERVQUAL tool / framework.For example a study conducted by Parasuraman et al. [23], and another study that was done in Bangladesh which identified the determinants of patient satisfaction with public, private and foreign hospitals used a modified SERVQUAL framework Andaleeb et al affirms this [12].Variables that had the greatest impact on satisfaction were the doctor composite, tangibles, nurse composite and hospital procedures, but these varied between the types of hospitals.SERVQUAL has also been used to measure quality of dental health care in the United Kingdom, comparing private and public facilities [24].The results were judged to be significant for the managing partners in the dental surgeries as they demonstrated patient expectations and perceptions.
The SERVQUAL tool is used to measure service quality by assessing five dimensions of a service provided, that can influence clients' satisfaction.Although originally developed as a marketing tool, it has been adapted by many authors for use in assessing patient satisfaction with health care.Generally, a diversity of areas of health care have been studied using SERVQUAL, including general health services; eye treatment; comparing group and solo clinic practices; chronic kidney disease screening; public and private laboratory services for HIV related testing and HIV/AIDS clinical care in a government hospital [25,26].
An adaptation of the SERVQUAL framework, established by Parasuraman et al. was used [24].The main dependent variable was patient satisfaction with HIV/AIDS care.This was influenced by various predictors, that is, reliability of services, assurance of staff, tangibles within the health facility, staff responsiveness and empathy.These predictors influence the outcome as well as each other sometimes.For example, when a staff member makes proper prescriptions the first time (reliability) this may show that they are knowledgeable and skilled (assurance) while this knowledge is also needed before hand in order for them to make proper prescriptions.
Most of these studies identified SERVQUAL as being useful in measuring service quality and patient satisfaction and recommended its use.Other advantages of SERVQUAL include the fact that it was tested and found to have strong reliability (total scale reliability often close to 0.9) and validity (face, content and convergent validity).In addition, it can be adapted or supplemented to fit the situation when necessary.Below are brief explanations of the predictors of SERVQUAL; a) Tangibility According to McDougall & Snetsinger tangibility is defined as the degree to which a product or service can provide a clear concrete image" [27].They investigate in the definition further that tangibility has both a physical and a mental component.Early discussions were more concerned with the physical components because theorists were more interested in a customer's examination and evaluation before subscribing to a service.The mental component refers to customers' ability to grasp mentally what they will receive if they purchase the service.Tangibility features focus more on the ability to visualize the service [28].
b) Reliability It is the ability to perform the promised service dependably and accurately.Customers want to count on their providers; therefore health care service provider best efforts are better spent making service reliable [29] c) Responsiveness Responsiveness concerns the preparedness of health professional in proving service to patients.Timeliness of activities of health professionals, making sure clients go through successful review, providing immediate services to patients/clients/payment of suppliers [30,31].d) Assurance Assurance concerns with knowledge and courtesy of health professionals and their ability to convey trust and confidence.Service providers are expected to be experts of the service they are delivering.SERVQUAL research showed it's important to communicate that expertise to customers [29].In assurance, the skills and politeness of health professions needs to be impact believe and hope by clients.
e) Empathy Health professionals should have client's best interest at heart, and should therefore understands their specific needs.The hospital provides care and individualized attention to its clients.
Overall, SERVQUAL has been demonstrated as a valuable tool in assessing quality of health care services [32].It is a powerful tool, as it allows one not only to estimate the overall level of satisfaction but also to identify dimensions where experience transcends expectations and dimensions where experience falls short of the expectations [32].It was chosen for this study basing on the preceding reasons

Research Methodology
The study was conducted at the University of Medical Sciences Teaching Hospital (UNIMEDTH), Ondo state in Southwest Nigeria.The teaching hospital is a major health care facility in Ondo State, which comprises of the two major former State's government hospitals in the state precisely (Ondo town and Akure city) constitutes the two centers for the hospitals.. Hence, the patients are those that attend the two centers.The study population are patients living with HIV/ AIDS in Ondo state.The study is a cross sectional study using purposive and convenience sampling methods.A total of one hundred and fifty (150) HIV/ AIDS patients were selected from both Ondo town and Akure center of the UNIMEDTH constituted the sample size.The study used a well-structured questionnaire to collect data from the respondents.
However, not all the patients were selected based on the study inclusion and exclusion criteria.The inclusion criteria are HIV/ AIDS positive clients ≥ 18 years old, clients who voluntarily given written informed consent to participate, clients who are able to communicate in either English or Yoruba language and clients who enrolled for treatment at the teaching hospital.The Exclusion criteria are clients who visit the teaching hospital but did not give consent to get involved in the study, clients who could not communicate in English or Yoruba and clients who are seriously sick.
Hence, to achieve the objective of this research paper, one hundred and fifty (150) questionnaires were distributed to the HIV/ AIDs patients and one hundred and forty -three (143) was properly completed and returned, representing a percentage of 96%.Moreover, according to Moser and Kalton (2017), the result of a survey could be considered significant, if the response rate is not lower than 30 -40%, which validates the response rate for this paper.However, before proceeding with data analysis, preliminary test were carried out to identify missing data and to ascertain data normality, using SPSS and Microsoft excel software.Missing data were identified and replaced with their mean according to the research work of Hair, Black, Babin and Anderson (2010) in order to retain both their quantitative and qualitative attributes.

Ethical Clearance
The study and the collection of data were granted ethical approval by the Ministry of Health, Ondo State ethical clearance committee after a thorough scrutiny of the study's proposal and questionnaires.The researchers ensured that all participants in the study consented to the survey without coercion after clearly introducing the study objectives to them.Respondents could refuse to participate or not in the survey at any time and this does not affect their continuation of health care services.Also, confidentiality was ensured as there was no name requested from the respondents or any other personal information unrelated to the study objectives.

Measures and Instruments
The study research instrument was questionnaires, which were divided into two parts, where part 1 addressed the social demographic information of the respondents and part 2 sought questions on the satisfaction of patients using SERVQUAL framework consisting of five dimensions; Tangibles, Reliability, Responsiveness, Assurance, and Empathy.A five (5) point Likert scale was used to measure the response of the nineteen (19) indicators for the five (5) dimensions.The Likert scales ranges from 5 -strongly agree, 4 -Agree, 3 -Undecided, 2 -Disagree and 1 -Strongly Disagree.The data collected were analyzed using Statistical Package for social science (SPSS version 25.0), using research tools of frequency, percentage, and Mean Score rating.

Demographic Information of Respondents
Tale 1 revealed the demographic information of patients living with HIV and AIDs, whose level of satisfaction with HIV treatment services were assessed.The table 1 revealed that 26.6% of the respondents are male, while female make up the remaining 73.4% of the respondents.This shows that more than two -thirds of the respondents are female.The Table 1 further revealed that majority of the PLWHA are between the ages of 30 -39, constituting 53.15%, while below 20 years constitutes 1.39%, 20 -29 years constitutes 13.28 and 32.17% of the respondents are above 40 years.This further revealed that more than 80% of the respondents are above 30 years old, representing an adult population, who have the mental knowledge of what they are saying.Also, Table 1 revealed that 65% of the respondents are married, 13.3% are single, 8.4% are divorced and 13.3% are widowed.Also, 8.4% of the respondents did not attend any level of school, 21% stopped schooling at primary school, 54.5% stopped their education at secondary schools, 2.8% are still in tertiary institutions, 11.2% are graduates and 2.1% are post graduate students.Also, looking at the economic status of the respondents, 36.4% are skilled workers, 26.6% are semiskilled workers, 23.8% are unskilled workers and 13.3% are unemployed.This occupational statistics revealed that 63.7% of the respondents have staggering economic conditions.Furthermore, 86.7% of PLWHA are in the Asymptomatic stage of the disease and 13.3% are in the symptomatic stage, which shows that majority of the respondents don't have HIV symptoms again.Also, 97.9% of the respondents are on ART and 2.1% are not on ART (perhaps because they are freshly diagnosed).Moreover, the average years of the respondents that have been living with HIV is 5 years according to Table 1 and graphically represented in figure 1.

Level of Patients Satisfaction
Table 2 revealed the level of satisfaction the patients have with HIV treatment service rendered to them.The satisfaction was measured based on SERQUAL dimensions of Tangibles, Reliability, Responsiveness, Assurance and Empathy [13,33,34].
From Table 2, the Responsiveness dimension has an average mean of 4.53 and a standard deviation of 0.47 depicting the willingness and eagerness of the staff of the health facilities to render adequate service to the patients.However, the first indicator with a mean of 4.56 and standard deviation of 0.51, shows that 56.6% of the patients strongly agree about the availability and prompt administration of retroviral drugs while 42.7% disagrees.Also, the second indicator with a mean of 4.54 and a standard deviation of 0.54, have 97.9% of the respondents agreeing that equipment used during service delivery are available, functional and quickly put together those equipment for the well-being of the patients.Moreover, in the interpretation of Laboratory results during the process of treatment, 98.6% of the patients believes that health workers correctly interprets their results and explain to them in an understandable formats, constituting a mean of 4.50 and a standard deviation of 0.58.
The reliability dimension has an average mean of 4.51 with a standard deviation of 0.47, depicting that there is a high level of satisfaction with healthcare facilities and services.The dimension first indicator has a mean of 4.59 and standard deviation of 0.53, which further revealed that 97.9% of respondents agreed that proper description and dosage of drugs are given by healthcare workers in University of Medical sciences teaching hospital.Also, all the respondents (100%) agreed that there are regular supply of drugs for treatment at the healthcare facilities, which is the second indicator, having a mean of 4.57 and a standard deviation of 0.49.The last indicator for the reliability dimension has a mean of 4.37 and standard deviation of 0.65, revealed that 92.4% of the respondents agrees that health workers that provides services to them are also supervised to ensure they are given adequate and proper treatment and service.
The tangible dimension of Table 2, has an average mean value of 4.49 and standard deviation of 0.57 reflecting the physical appearance of the health facilities and the neatness of their staff.The dimension's first indicator has a mean of 4.49 and standard deviation of 0.65, revealing that 98.6% of the patients opined that the staff dresses well and neatly.The second indicator has a mean value of 4.49 and standard deviation of 0.82, where 96.5% agreed that the environment of health facilities is hygienic and always clean.The third indicator has a mean of 4.48 and standard deviation of 0.54, of which 99.3% of the respondents agreed that equipment for treatment are modern and available.
Moreover, the Assurance dimension in Table 2 has an average mean of 4.42 and standard deviation of 0.49, showing the ability of the health workers to convey trust and confidence in an acceptable manner to the respondents.The first indictor of the dimension has a mean of 4.52 and standard deviation of 0.54, where 99.3% of the respondents agreed that a health worker provides explanation to them in a confident manner.The last indicator of the dimension has a mean of 4.32 and standard deviation of 0.79, where 95.1% of the respondents are of the opinion that staff of the teaching hospital are fair, hence they can be trustworthy.Also, Table 2 revealed that the last dimension, Empathy has an average mean of 4.36 and standard deviation of 0.58, revealing that health workers of healthcare facilities shows compassion in rendering services.The first indicator of the dimension has a mean value of 4.41 and standard deviation of 0.71, where 97.3% agreed that health workers shows adequate care when attending to patients.The last indicator with a mean of 4.36 and standard deviation of 0.58, of which 94.4% of the respondents agreed that health workers provides personal care and mental support.
Furthermore, Table 3 revealed the ranking of the dimensions measuring the satisfaction of the patients according to their mean response rating and standard deviation.The Table 3 revealed that the first ranked dimension is Responsiveness with a mean of 4.53 and a standard deviation of 0.47.The second dimension is Reliability, with a mean value of 4.51 and standard deviation of 0.47.The third dimension is Tangible with a mean of 4.49 and standard deviation of 0.57.The fourth dimension is Assurance, with a mean value of 4.42 and standard deviation of 0.49.The fifth dimension is Empathy with a mean value of 4.36 and Standard deviation of 0.58.The ranking by the respondents revealed that, they are satisfied more with the enthusiasm of staff that gives them treatment, which is usually done in a pleasant manner and done without wasting time.It also revealed that the health worker sometimes does not show compassion to the patients in their attitudes and most especially their body language.
However, the respondents agreed that they have a high level of satisfaction with services delivered by the healthcare workers.The overall level of satisfaction is revealed in the Grand mean of Table 2 and Table 3, which is 4.46 and a standard deviation of 0.52.This revealed that majority of the respondents are satisfied with the level of the service rendered to them.This is in conformity with the research work of Ndayongeje and Kazaura in Tanzania, where they have high level of satisfaction with HIV treatment [35].

Conclusion and Recommendation
The study concludes that majority of the patients with HIV/ AIDS are satisfied with the level of treatment offered to them and the manner in which they are offered, through the prism of the five (5) SERVQUAL dimensions.Moreover, during the period of carrying out the survey, the patients emphasized that the health workers called them on their mobile phones whenever they miss there clinic days and also to check/ remind them about their drugs and when to take such drugs.
The study recommends that staff should be encourage and train to show more affection to the patients, health care facility should be expanded and spacious enough to accommodate more patients on clinic days to stop patients from standing and hanging around the clinic venue and staff involved in HIV/ AIDS treatment should be provided with incentives to boost their morale.

Osho
Patrick Olanrewaju et al.: Patients' Treatment Satisfaction: Experiences of HIV Patients in a Tertiary Hospital in Southwest Nigeria

Table 1 .
Demographic Information of Respondents.

Table 2 .
Level of Patients Satisfaction.

Table 3 .
Ranking of dimensions measuring patient satisfaction.