Skip to main content
Download PDF

Optimizing primary healthcare experience: assessing client satisfaction in Kaduna State, Northwest Nigeria

BMC Primary Care volume 25, Article number: 231 (2024) Cite this article

Abstract

Background

Client satisfaction is a multidimensional construct focusing on clients’ perceptions and evaluations of the treatment and care received. It is one of the factors affecting the outcomes of healthcare and the use of health services. Therefore, we aimed to assess clients’ satisfaction with PHC services in Kaduna State, Northwest Nigeria.

Methodology

A cross–sectional descriptive study was conducted in Kaduna State, Northwest, Nigeria which evaluate the satisfaction of clients and caregivers accessing healthcare in PHC centres. A sample size of 217 was determined using Fisher’s formula, with a multi-stage sampling technique used to randomly select eligible respondents, who have accessed at least a PHC service in any of the PHCs in the State were included in the study, A semi-structured, interviewer-administered questionnaire was administered, and the data collected was analyzed using SPSS version 23.0. Appropriate statistical tests were used to examine the association between dependent and independent variables, while predictor variables that showed significant association with the outcome variables were further subjected to logistic regression analysis, to determine factors that affect clients’ satisfaction with PHC services. Statistical significance was determined at an alpha level set at 0.05 at a 95% confidence interval.

Results

Thirty-one percent of the respondents were satisfied with PHC services in Kaduna State with a mean composite satisfaction score of 3.78 ± 0.67. Age, ethnicity, level of education, and occupational status were factors affecting clients’ satisfaction with PHC services among the respondents. On multivariate analysis, age, ethnicity, educational status, and occupational status were significant factors affecting clients' satisfaction with PHC services. Clients of Hausa/Fulani extraction are one and a half times less likely to be satisfied with PHC services when compared to clients from other tribes [aOR = 1.5, 95% CI (1.21–4.67); p = 0.003]. In terms of educational status, clients with formal education are one and a one-third times more likely to be satisfied [aOR = 1.3, 95% CI (0.17–0.94)] with PHC service when compared with their counterparts with informal education (p = 0.034).

Conclusion

Clients’ satisfaction with PHC services in Kaduna State, Northwest Nigeria was sub-optimal. Healthcare providers were recommended to improve their attitude bearing in mind clients’ peculiarities.

Peer Review reports

Background

Primary Healthcare (PHC) services consist of healthcare services and activities that interface between the community and the healthcare system [1]. It includes all the basic healthcare services to be provided to the community, including immunization, integrated management of childhood diseases, skill birth attendance, maternal care, prevention of mother-to-child transmission, amongst others. It is essential for attaining an acceptable level of health for the public and is also an integral and critical component of the healthcare system of any country. Countries with strong PHC services have healthier populations [2]. This is because the effective provision of efficient PHC services ensures the promotion, protection, and restoration of the health of the community [1]. However, PHC facilities should be accessible to all irrespective of their socio-economic status. Healthcare service utilization is an important determinant of health [3]. The decision to use available health services partly depends on clients’ satisfaction and their perception of the service providers. PHC service utilization has remained limited across the globe, especially in many parts of developing countries [4]. This presents a daunting challenge to Universal Health Coverage (UHC) and in return the attainment of the Sustainable Development Goals (SDG). Studies have attributed many factors to the poor PHC service utilization in sub-Saharan Africa generally, and in Nigeria specifically [5]. These factors include financial means to pay for such services; means to reach and use the services; confidence in the quality of the care provided and ability to receive care without compromising privacy; confidence in the ability to communicate with healthcare service providers, and overall clients’ satisfaction with services provided in PHC facilities [1]. Client satisfaction is defined as judgments made by the recipients of healthcare as to whether their expectations have been met [6]. It is a multidimensional construct that focuses on clients’ perceptions and evaluation of the treatment and care received [7, 8]. A relationship exists between clients’ satisfaction and healthcare utilization, and clients’ satisfaction determines future access to health services. Clients’ satisfaction has long been considered an important component when measuring health outcomes and quality of care [6]. It is one of the factors affecting the outcomes of healthcare and the use of health services. Hence, the level of clients’ satisfaction is one of the mechanisms used in measuring the level of quality of healthcare service delivery [9] and addressing clients’ expectations was found to be associated with high client satisfaction and better health outcomes [10]. Clients are by far the best judges since they accurately assess and provide inputs which can help in the overall improvement of quality healthcare provision through the rectification of the system weaknesses by the concerned authorities [11]. However, clients' perceptions about healthcare service delivery as well as health systems have been largely ignored by government and healthcare managers in developing countries [12], and healthcare providers lack the awareness and adequate training to address clients’ expectations [6]. To improve the quality of provision and outcome of care, predictors of dissatisfaction must be identified and eliminated.

A report by the WHO African region puts the level of PHC utilization on the continent at 5–7% [13]. This translates to about 93–95% underutilization of the services despite the monumental budgetary expenditure on PHCs.Clients frequently bypass PHC facilities in favour of higher-level hospitals despite the substantial additional time and financial costs. This results in over-burdened and overstretched facilities with a consequent reduction in the quality of services, and of course clients’ dissatisfaction with healthcare service delivery at higher levels of care [14]. In Kenya, Namibia and Sri Lanka, more than 50% of the population bypasses PHC facilities for antenatal care (ANC), immunization services, and treatment of childhood illnesses [15]. In Nigeria where PHC is the bedrock of its health system; and almost half a decade after the Alma-Ata declaration, the health indices are still poor, with a large body of evidence suggesting widespread under-utilization of PHC services. The extent of poor utilization of PHC services in the nation generally, and the northern states in particular was appalling [5]. In Nigeria, particularly in Kaduna State where the present study was carried out, studies have shown on the level of utilization of PHC services and the factors that have affected the utilization [16], with majorly dissatisfied with the services being offered. This is due to the non-availability of trained personnel, attitudes of staffs, waiting time and non-availbility of diagnostic tools. Studies conducted in other part of Nigeria, relating to clients’ satisfaction revealed that overall client satisfaction ranges between 62.6%—90% [17, 18] with some of the clients being dissatisfied with PHC services. However, the respondents showed an average level of dissatisfaction with the general cleanliness of the facility and a relatively higher level (64%) of dissatisfaction with waiting areas [19, 20]. Studies also revealed that respondents were dissatisfied with distance of the facility with their dwellings, working hours of facilities, language barriers, attitude of healthcare workers, client–provider interpersonal interaction and relationship, hospital facilities, missing records, quality access to care, and cost of treatment [21,22,23]. Clients often make more payments for repeated or replacement of the investigations or procedures without convincing explanation or apology from the healthcare providers. This has over time caused untold hardship, disappointment, and often embarrassment to the clients and, or their relatives, with resultant postponement, suspension, or outright termination of medical care. Treatments are often not fully explained to the clients or at best without courtesy and human dignity [24]. This has resulted in deaths, disabilities, complications, treatment failures, or loss of financial resources that could have been prevented only if there had been good communication between healthcare workers and clients [22]. Additionally, lack of confidentiality and poor interpersonal communication between clients and the healthcare providers have worsened the problems of clients with the resultant absence of, decreased, or lower levels of reported satisfaction among the majority of such clients [25]. These realities have resulted in poor utilization of PHC facilities and services by the intended or prospective client. The conduct of this study is therefore justified againts the background, because there exists a relationship between clients’ satisfaction and healthcare utilization. In the same vein, clients’ satisfaction determines future access to health services [26]. Similarly, understanding the determinants of clients’ satisfaction helps healthcare systems to address clients’ needs and adjust their expectations to realistic and achievable targets or expectations in line with the vision outlined in the current Nigerian National Health Act [27] and National Policy Framework [28]. Furthermore, many of the well-known frameworks to structure health system thinking, such as WHO’s building block and the “control knobs” framework include a measure of clients’ subjective evaluation of health services, such as satisfaction or responsiveness as major components of the main health systems outcomes [29]. Furthermore, in developed countries and a few developing ones, clients’ satisfaction is a widely recognized factor used to assess the quality of PHC service delivery [26]. This, however, has not been fully studied in our climes [30]. The low clients’ satisfaction with PHC services is to a certain extent associated with poor PHC service utilization in Nigeria generally and in Kaduna state specifically. However, the association of poor clients’ satisfaction with PHC services has not been documented in this environment. It is therefore hoped that the findings from this study will not only stimulate further research but will also form the basis for a series of interventions to bridge the gap in the existing body of knowledge concerning clients’ satisfaction. The information to be obtained through assessing clients’ satisfaction will determine the level of care to be delivered by healthcare providers and as a result, would be used to hold health providers accountable for their services. The information generated from this study will not only be used as a tool for decision-making but will also be used as a reference point to make further recommendations on improving the experience of clients being seen at PHC facilities in Kaduna state specifically, and Nigeria generally. This study, therefore, aims to assess clients’ satisfaction with PHC services in Kaduna State, Northwest Nigeria.

Methodology

Study design and area

The study was a cross-sectional descriptive study conducted in Kaduna State, Northwest Nigeria. Kaduna State is located in the geographic ‘heart’ of Nigeria where it shares borders with five other States—Kano, Katsina, Niger, Plateau, Nasarawa, in addition to Nigeria’s federal Capital Territory – Abuja. Kaduna occupies an area of approximately 48,473.2 square kilometers and has a projected 2023 population of about 10 million (projected from the 2006 census), with an annual growth rate of 2.5%. The state is mostly populated by Hausa, Fulani, Gwari, Katab, Bajju, Kataf, Kagoro, Moro’a Jaba, Gbagyi, Kanninkon, Ninzam, Chawai, Atyap, and Ham Kurama ethnic communities, with up to 36 other indigenous ethnic groups found in different parts of the State. The state also has a considerable population of other Nigerians who settled in when its capital city of Kaduna served as the capital of the defunct Northern Region. Hausa and English are the most common languages of communication. Politically, the state is divided into three (3) senatorial zones—Northern, Central and Southern zones. There are 23 Local Government Areas (LGAs) in the state with 255 political wards and the healthcare delivery system in Kaduna State is broad-based, comprising public, private-for-profit, and private-not-for-profit mainly faith-based health facilities. The Federal Ministry of Health provides Tertiary Healthcare services in the State through the five (5) federal health facilities in the State comprising Ahmadu Bello University Teaching Hospital (ABUTH), National Eye Care Center, National Ear Care Center, Federal Neuropsychiatric Hospital, and the 44 Military Reference Hospital. The Kaduna State Ministry of Health, on the other hand, provides secondary healthcare services through the 30 General and Specialist Hospitals, while the Local Governments provide primary healthcare through the 1,068 functional PHC facilities in the State. In addition, there are 656 private health facilities, and over 2,500 registered patent medicine vendors and Traditional Birth Attendants (TBAs) within the State [31]. The State has eight (8) academic institutions and four (4) post-basic training programs for human resources training and development.

Sampling and data collection

The minimum sample size for the study was estimated using Fisher’s formula with a Proportion (p) of 0.83 from a previous study [18], a reliability coefficient of 1.96 at 95% Confident Interval, and a degree of freedom of 0.05. We use Fisher’s formula for this study because it provides us with the best option to do a simple random sampling in order to estimate the value of the population’s satisfaction to PHC services. Hence an estimated minimum sample size of 217 was obtained for the study. The study population comprised clients and caregivers accessing healthcare in PHC centres owned by the Kaduna State Primary Health Care Development Board (PHCDB). Clients and caregivers accessing care in public PHC facilities in Kaduna State who have accessed at least a PHC service in any of the PHC centres within the State in the last year were included in the study, while those with mental health problems, emergency conditions, and those with hearing or speech difficulty that may limit or hinder their ability to hear or respond to the data collection process were excluded from the study. A multi-stage sampling technique comprising five stages (selection of political ward, selection of LGAand selection of clients to respond to exit questionnaire) was used for the study. The number of clients to whom the clients' exit questionnaire was administered was proportionately determined based on the average clients’ turnover per PHC centres. A pre-tested, semi-structured, interviewer-administered questionnaire adapted from the Long-Form Patient Satisfaction Questionnaire (PSQ-III) [32], Short-Form Patient Satisfaction Questionnaire (PSQ-18) [33], and Patient Satisfaction Questionnaire (PSQ) [34] and modified based on the specific objectives of the study was electronically administered with handheld Android devices using Open Data Kit (ODK) software to the randomly sampled respondents by a team of ten (10) research assistants comprising of two (2) resident doctors and eight (8) Community Health Officers (CHOs) from the Department of Community Medicine, Ahmadu Bello University Teaching Hospital Zaria. The psychometric properties of the questionnaire were evaluated with face and content validity, with the face validity assessed by five staff of the Department of Community Health, Ahmadu Bello Zaria (2), Ministry of Health (1) and National Primary Health Care Development Agency (2). They commented on the relevance, reading level and ambiguity using a five-point Linkert scale. The content validity was assessed by sharing the draft questionnaire with four professors of community health to provide feedback on the level of clarity, relevance, and importance using a Linkert scale of 1–5. It was then tested quantitatively using Scale-content validity index (only item with < 0.90 were retained) and Item-content validity index (only items with value < 0.79 were retained). The reliability of the questionnaire was evaluated using internal consistency (Cronbach’s alpha coefficient with a value of 0.7 were considered good) and stability methods (intraclass correlation coefficient of 0.7 was considered good). The research assistants were the recruited based on their previous experience in data collection in studies similar to this study and trained on the objectives of the study, questionnaire administration, ethical issues in research, ODK, clients’ satisfaction, and the study protocol before the data collection. The researchers supervised the data collection process and ensured that the research protocol was strictly adhered to. Daily review meeting of research assistants and researchers was held during the data collection to ensure consistency and completeness of questionnaires as well as identify and address challenges encountered during the data collection to re-strategize for the subsequent days.

Data management and analysis

All electronic questionnaires retrieved were assessed and found to be correctly completed. Data analysis was done under the supervision of an experienced statistician, using the computer software, IBM Statistical Package for Social Sciences (SPSS) version 23.0 into which the data was exported. Data analysis was started by computing the frequencies and percentages of respondents’ socio-demographic characteristics. Clients’ satisfaction with PHC was assessed using a set of 27 questions across four (4) major domains based on a 5-point Likert Scale. An average combined composite score of 1 to 5 was expected for each question based on the responses obtained. Using the average respondents combined composite score, clients’ satisfaction with PHC services was assessed. Respondents with an average combined composite score of ≥ 3 were considered to be satisfied with PHC services, while those with a combined composite score of < 3 were considered to be dissatisfied with PHC services provided. For univariate analysis, descriptive statistics was conducted using mean and standard deviation (for normally distributed continuous data). Simple frequencies and percentages were reported for categorical data. Data was presented in the form of tables and charts using Microsoft Office Excel 2016. Bivariate analysis was used to examine the association between dependent and independent variables. A chi-square test of association was done to determine the significant (p ≤ 0.05) associations between independent and dependent variables. Predictor variables that showed significant association with the outcome variables were further subjected to logistic regression analysis, to determine factors that affect clients’ satisfaction with PHC services. Statistical significance was determined at an alpha level set at 0.05 at a 95% confidence interval. The findings were summarized using appropriate tables and relationships between variables were determined using appropriate test statistics. Results were considered statistically significant if the p-value was ≤ 0.05.

Results

A total of 217 questionnaires were administered, out of which 198 were retrieved. This gives response rates of 91.24% for the study.

Clients’ socio-demographic factors

Table 1 shows that the sociodemographic data of the respondents with a predominantly young population, majorly aged between 30–39 (43.4%)with their mean age ± Standard Deviation, SD as 40.07 ± 7.69 years. Most 172 (86.8%) of the clients were females and are majorly Hausa by tribes (143 (72.4%). Similarly, Muslims were predominant among the respondents (176 (88.7%). Also, most respondents (166 (84.0%) were ever married. In terms of educational status, 78 (39.5%) of the respondents had secondary school as their highest level of education. A high proportion of the clients (52 (26.4%) were petty traders. However, 146 (73.7%) of the clients had an average monthly income below ₦50,000.00 with a median of ₦10,000.00 (interquartile range ₦16,000.00).

Table 1 Socio-demographic characteristics of respondents
Full size table

Clients’ satisfaction with PHC services

Table 2 showed that clients had a satisfaction score of 4.13 ± 0.95 with the extent to which they felt that they could have refused any proposed test, treatment, or procedure if they wanted to.

Table 2 Clients’ composite satisfaction score with PHC services
Full size table

Clients’ Satisfaction with PHC Services

Figure 1 revealed the client’s satisfaction with PHC services. It shows that only 31.1% of the clients were satisfied with PHC services who visited a facility for their healthcare needs.

Fig. 1
figure 1

Clients general satisfaction with PHC services

Full size image

Factors affecting clients’ satisfaction with PHC services

At bivariate level, Table 3 showed that clients’ satisfaction with PHC services was significantly affected by age (0.026), ethnicity (0.003), religion (0.030), occupation (0.002), highest level of education (0.020), and average monthly income (0.001).

Table 3 Socio-demographic factors affecting clients’ satisfaction with PHC services
Full size table

Multivariate (Logistic Regression Analysis) of socio-demographic factors that affect clients’ satisfaction with PHC services

On multivariate analysis, Table 4 showed that age, ethnicity, educational status, and occupational status were significant factors affecting clients' satisfaction with PHC services. Table 4 showed that clients of 30 years and above had almost a three-fold likelihood of being satisfied with PHC services compared to those below 30 years of age. Clients of Hausa/Fulani extraction are one and a half times less likely to be satisfied with PHC services when compared to clients from other tribes. In the same vein, clients not gainfully employed had twice as much likelihood of being satisfied with PHC services as compared to their gainfully employed counterparts. In terms of educational status, clients with formal education are one and a one-third times more likely to be satisfied [aOR = 1.3, 95% CI (0.17–0.94)] with PHC service when compared with their counterparts with informal education (p = 0.034).

Table 4 Determinants of clients’ satisfaction with PHC services
Full size table

Discussion

Clients’ level of satisfaction with PHC was generally found to be 31.1%. However, this study also reported a higher average mean score above 3.6 in all the four dimensions being assessed. The findings of this study are quite low in comparison with reported studies which reported 78.5%, 83% and 83% of clients with overall satisfaction with services received, respectively [18, 35, 36]. These findings are equally lower than findings from a survey conducted in Thailand with 86.7% of clients satisfied with services [37]. This is also lower than findings reported which ranges from 63–95% in Haryana (79.3%); in Lucknow, (81.6%); in Kashmir (72%); in India (88%) and (95%); and in Andra Pradesh (63%) [38,39,40,41,42,43]. In contrast to this, however, a study conducted at Indira Gandhi Memorial Hospital, reported lower levels of clients’ satisfaction (10.4%) in comparison with the findings of this study [44]. It is important to note, however, that expressed opinions may not reflect the true feelings of clients about their satisfaction with healthcare services received. Furthermore, confusion may arise even when opinions are expressed honestly; for instance, long waiting times may induce patients to regard health providers as discourteous or lacking in skill thereby grading them low on satisfaction scores. Indeed, waiting time was used in some studies as a means of judging health providers' skills and knowledge. Apart from variations in the way services are delivered, differences in the study population and hence patient expectations could affect satisfaction levels. The latter could also be affected by sociocultural differences and variations in levels of literacy. The cultural milieu and relatively lower level of literacy of our catchment population could have affected their level of satisfaction. In addition, variations in methodology and timing of the study could explain some of the differences. For example, in many studies, age were found to be the strongest predictor of patient satisfaction across most dimensions [43,44,45,46]. These variation in satisfaction across the four dimension and the predictors might be associated with differences in healthcare systems, cultural contexts or methodologies, as these calls for caution in comparing our findings with previous studies. In Northern Nigeria where our study was conducted, there is a wide disparity between PHC services, which could have contributed in the high difference in general satisfaction and expectation among patients who participated in our study. These factors might include out-of-pocket cost they might not expect, but satisfactory with the four domains. This is similar to a study which reported patient satisfaction in a tertiary public hospital in Nepal [41] and India [40, 42]. It could probably be concluded that the reason why most satisfaction studies in developing countries have high reports of low levels of satisfaction among clients could be due to inadequate, inappropriate, incompetent, poorly mixed, and poorly remunerated health workforce. Overall satisfaction score and mean score for different domains of clients’ satisfaction were also found to be similar. The study revealed that “Clients’ satisfaction with the extent to which they felt that they could have asked for a second opinion about their proposed test(s), treatment or procedure(s) if they wanted to”, “Clients’ satisfaction with health workers’ respect for their rights to have an opinion” and “Clients’ satisfaction with the cleanliness of the hospital surrounding” had the highest mean satisfaction scores among the constituents of “Clients’ satisfaction with PHC facility processes”, “Clients’ satisfaction with PHC care and treatment management” and “Clients’ satisfaction with the physical aspect of PHC facility” respectively. This finding is like that of a study on patient satisfaction in primary healthcare services in Egypt [45], which indicated that the majority of clients had high satisfaction scores for PHC facility process, care, and treatment management as well as aspect of PHC facility. The study further revealed higher satisfaction scores with components of clients’ satisfaction with PHC facility processes in comparison with components of other constituents of clients’ satisfaction with PHC services. These findings could be explained by the fact that most of the clients find consultations with the healthcare providers fulfilling their desire to come to the facility. This is where they interact one-on-one in private, and establish relationships with the providers, which is vital for the success of primary healthcare. The utmost communication and information sharing with the providers thereby gives them renewed confidence about whatever ailment they came in with. According to a study [46], non-understanding of clients’ information needs will affect any meaningful service improvement made. These characteristics are of immense importance in contributing to clients’ satisfaction with, and ratings of services received. In another study [47] on patient experiences about participants and healthcare service delivery characteristics, it was reported that for any meaningful success to be recorded, primary healthcare providers must establish relationships with their clients [47]. From the study findings, the clients were most pleased with the provision of information. This concurs with the findings of a study on advice to clients in Swedish primary healthcare, which found that provision of information is ranked higher by clients in terms of factors contributing to their satisfaction [48]. Another study also showed that clients value information highly, as satisfaction in this regard correlated strongly with the amount of information clients received from their Health providers [49]. Another finding of this study indicated that the majority of the clients have high satisfaction scores with components of clients’ satisfaction with the PHC facility process associated with the communicative behaviours of PHC health providers. These findings highlight two points. Firstly, the satisfaction rate of clients is not too bad. The reason may be that being satisfied is a subjective variable and many factors could influence clients’ satisfaction. Thus, the high satisfaction score of clients is not necessarily indicative of the optimum or high quality of healthcare. On the other hand, high clients’ satisfaction may be due to the low expectations of clients, or it could even be influenced by some kind of interviewers’ manner. Therefore, it is argued that one cannot assume the higher quality of healthcare services leading to higher satisfaction levels and/or low scores of satisfactions should not be considered as lower quality of health services, especially in climes where the general population is not well-informed about healthcare quality standards. A study has supported these findings [50]. The second point is that the clients’ satisfaction level could be improved through better training on IPCs. This is because client/provider IPCS training could improve knowledge and skills of IPC among PHC providers and enable them to communicate with their clients more effectively. Other studies have shown that IPCS training could improve clients' satisfaction [51]. In similar research, contrary results were obtained, and this study observed on bivariate analysis that age, ethnicity, religion, occupation, highest level of education, and average monthly income significantly affect clients’ satisfaction with PHC services [50]. However, the results of studies examining the influence of socio-demographic characteristics on patients' satisfaction are varied. A meta-analysis has also reported that patients' demographics are a minor factor in their satisfaction, while another two-level analysis [52, 53] and concluded that clients’ socio-demographic profiles represent 90—95% of the variance in rates of satisfaction. The findings of this study are similar to a study [54] that revealed that educational and occupational status appeared to be statistically associated with satisfaction factor score. This is also in agreement with findings that reported from their study that age significantly affect clients’ satisfaction with PHC services, with clients sixty-year-olds or older being more satisfied (75% vs. 58%) than those below the age of 60 years [51]. Findings of this study was in accordance with the results of studies [52, 53] that revealed a statistically significant relationship between patients’ educational level and the overall score of their satisfaction with services. On the contrary, findings of this study vary with those that show that none of the socio-demographic characteristics significantly relate to patients' satisfaction [55]. This might suggest the universality of man's expectations and demands on health facilities which are independent of these socio-demographic factors. Clients 30 years and above were found to be more likely to be satisfied with PHC services than their counterparts who were less than 30 years of age. In the same vein, clients of Hausa/Fulani extraction are one and a half times less likely to be satisfied with PHC services in comparison with clients of other ethnicities. The study further revealed that clients with informal education are one and a one-third times less likely to be satisfied with PHC services compared to those with formal education. Similarly, those unemployed are twice as likely to be satisfied with PHC services than those employed. Similar to the findings of this study; studies conducted have observed that the clients’ satisfaction scores improve with increasing age [55,56,57,58]. In this study, it was found that those with informal education were less satisfied with healthcare facilities when compared to those with any formal education. This finding may be due to the fact that the less literates are more suspicious of the healthcare facilities and thus are less satisfied with healthcare services provided by the facilities. Similar to our findings, some studies have also observed that those unemployed tend to be more satisfied, as compared to those employed. However, some of the limitations of this study include recall bias because of the retrospective nature of some of the questions asked, willful misstatements, and reluctance by some respondents to admit dissatisfaction with services received in PHC facilities because of fear of being victimized or denied access at the point of care by healthcare providers. Our study may also not be generalized in the at sub-national levels as the State seems to have differences in availability of human resources, healthcare service quality and diagnostics. However, our study can be applicable towards improving healthcare services in Nigeria as they provide similar types of services. Also, there could be a number of patients satisfaction dimensions we didn’t include in our questionnaire, especially looking at the supply side that may influence service delivery. Even though we didn’t collect any data related to the supply side factors, our study provides a baseline for future study on healthcare workers’ attitude toward their work, incentives and remuneration that eventually affect patient satisfaction. We also couldn’t assure that the correlates of the patient satisfaction in our study are indeed causal, due to the cross-sectional nature of the study. A more robust study which follows the client/patient for a number of visit and have several controlled variables can give a more causal relationship including the supply-side dynamic of the PHC service. In our study, we use client rather than patient—which in some setting is termed as “derogatory language”. We also use client satisfaction as adapted from studies, but the section is more related to the experiences and evaluations of patients. Therefore, we recommend that readers take a more look at the finding of each item instead of those based on the mean score of the four dimensions. Despite limitations relating to this study, association or predictors can be used to initiate some policy dialogue and influence the quality of healthcare delivery at PHC level in Nigeria. It will also be a good resource to formulate plans and programs to improve client satisfaction in PHC levels.

Conclusion and recommendation

This study has established that about one-third (31%) of the respondents were satisfied with PHC services in Kaduna State, Northwest Nigeria, with a mean average composite satisfaction score of 3.78 ± 0.67. The study further revealed that clients were more satisfied with the physical aspect of PHC facilities than with PHC facility processes; PHC care and treatment management; and general PHC service delivery. The study also found that socio-demographic factors like age, ethnicity, level of education, and occupation affect clients’ satisfaction with PHC services in Kaduna State, Northwest Nigeria. Consequently, it was recommended that there is a need to encourage PHC providers to improve their attitude towards clients and devise holistic (structure, process, and health outcome) approaches to client care bearing in mind political, economic, socio-cultural, as well epidemiological peculiarities of clients. Similarly, the healthcare providers should be motivated to provide services, bearing in mind different demands, attitudes, and perceptions of clients with different socio-demographic profiles. Future research designs that incorporate the supply-side dynamics and address a wide range of our limitation will be important to advance plans and programs to improve client satisfaction at PHC levels.

Availability of data and materials

Data or supplementary information files are provided upon request from the corresponding author.

References

  1. World Health Organisation. Rio Political Declaration on Social Determinants of Health. Geneva: WHO. 2011. Retrieved from http://www.who.int/sdhconference/declaration/en/. Accessed 23 Nov 2023.

  2. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Wamala SP, Merlo J, Boström G, Hogstedt C. Perceived discrimination, socioeconomic disadvantage and refraining from seeking medical treatment in Sweden. J Epidemiol Community Health. 2006;61(5):409–15. https://doi.org/10.1136/jech.2006.049999.

    Article  Google Scholar 

  4. Say L, Raine R. A systematic review of inequalities in the use of maternal health care in developing countries: examining the scale of the problem and the importance of context. Bull World Health Organ. 2007;85:812–9.

    Article  PubMed  PubMed Central  Google Scholar 

  5. National Population Commisiion (Nigeria), & ICF International. Nigeria Demographic and Health Survey. Abuja, Nigeria and Rockville, Maryland, USA: NPC and ICF International. 2013. Retrieved from https://dhsprogram.com/pubs/pdf/FR293/FR293.pdf. Accessed 27 Sept 2023.

  6. Okoye M, Ukwe C, Okoye T, Adibe M, Ekwunife O. Satisfaction of HIV patients with pharmaceutical services in South Eastern Nigerian hospitals. Int J Clin Pharm. 2014;36(5):914–21.

    Article  PubMed  Google Scholar 

  7. Sanchez-Piedra CA, Prado-Galbarro FJ, Garcia-Perez S, et al. Factors associated with patient satisfaction with primary care in Europe: Results from the EUprimecare project. Qual Prim Care. 2014;22:147–55.

    PubMed  Google Scholar 

  8. Batbaatar E, Dorjdagva J, Luvsannyam A, Savino MM, Amenta P. Determinants of patient satisfaction: a systematic review. Perspect Public Health. 2017;137(2):89–101. https://doi.org/10.1177/1757913916634136.9.

  9. Ruiz RM, Torres LA, Jaramillo MI. The effect of patients' met expectations on consultation outcomes. A study with family medicine residents. J Gen Internal Med. 2007;22(1), 86-91.

  10. Donabedian A. Evaluating the quality of medical care. Milbank Q. 2005;83(4):691–729. https://doi.org/10.1111/j.1468-0009.2005.00397.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Ganguly E, Sharma PK. Client satisfaction with quality of healthcare in a rural area in southern India. J Public Health Epidemiol. 2014;6(7):239–45. https://doi.org/10.5897/JPHE2013.0536.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Rozenblum R, Lisby M, Hockey PM, Levtzion-Korach O, Salzberg CA, Lipsitz SR, &, et al. Uncovering the blind spot of patient satisfaction: An international survey. BMJ Qual Saf. 2011;20(11):959–65. https://doi.org/10.1136/bmjqs-2011-000173.

    Article  PubMed  Google Scholar 

  13. World Health Organization. Community-directed interventions for major health problems in Africa: A multi-country study. Geneva, Switzerland: WHO. 2008. Retrieved from http://www.who.int/iris/handle/10665/43826. Accessed 23 Nov 2023.

  14. Kurfi AM, Kalu NU, Sambo MN, Idris HS. Understanding the barriers to the utilization of primary health care in a low-income setting: implications for health policy and planning. J Public Health Africa. 2013;4(3):64–7.

    Google Scholar 

  15. Audo MO, Ferguson A, Njoroge PK. Quality of healthcare and its effects in the utilization of maternal and child health services in Kenya. East Afr Med J. 2006;82(11):547–53.

    Article  Google Scholar 

  16. Otovwe A, Elizabeth S. Utilization of Primary Health Care Services in Jaba Local Government Area of Kaduna State Nigeria. Ethiop J Health Sci. 2017;27(4):339–50. https://doi.org/10.4314/ejhs.v27i4.5.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Babalola TK, Okafor IP. Client satisfaction with maternal and child healthcare services at a public specialist hospital in a Nigerian province. Turkish J Public Health. 2016;14(2):117–27. https://doi.org/10.20518/tjph.30550.

    Article  Google Scholar 

  18. Iliyasu Z, Abubakar IS, Abubakar S, Lawan UM, Gajida AU. Patients’ satisfaction with services obtained from Aminu Kano Teaching Hospital, Kano, Northern Nigeria. Niger J Clin Pract. 2010;13(4):371–8.

    CAS  PubMed  Google Scholar 

  19. Ige K, Nwachukwu C. Areas of dissatisfaction with primary health care services in government-owned health facilities in a semi-urban community in Nigeria. J Rural Trop Public Health. 2010;9(2):19–23.

    Google Scholar 

  20. Mittal A, Kaushal G, Sabherwal N, Pandey N, Kaustav P. A Study of Patient-Physician Communication and Barriers in Communication. Int J Res Foundation in Hospital Healthcare Admin. 2015;3(2):71–8.

    Google Scholar 

  21. Eze C, Okaro A. Survey of patient satisfaction and obstetric ultrasound scan services at University of Nigeria Teaching Hospital, Enugu, Nigeria. Niger J Health Biomed Sci. 2006;5(1):93–7.

    Google Scholar 

  22. Hicks J. Side-effects of ineffective communication. 2021. Retrieved from http://medicaloffice.about.com/od/leadershipresources/tp/5-Side-Effects-OfIneffective-Communication.html. Accessed 1 July 2023.

  23. Smith PC, Araya-Guerra R, Bublitz C, Parnes B, Dickinson LM, Van Vorst R, Westfall JM, Pace WD. Missing clinical information during primary care visits. JAMA. 2005;293(5):565–71. https://doi.org/10.1001/jama.293.5.565.

    Article  CAS  PubMed  Google Scholar 

  24. National Patient Safety Agency. National Reporting and Learning System (NRLS): Data Summary Issue 8. 2007. Retrieved from http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-datasummaries/?entryid45=598420745. Accessed 27 Sept 2023.

  25. World Health Organization. The World Health Report: Make every mother and child count. Geneva, Switzerland: WHO. 2005. Retrieved from https://www.afro.who.int/sites/default/files/2017-07/whr2005_en.pdf. Accessed November 2024.

  26. Nwankwo IU, Udeobasi OC, Osakwe CS, Okafor GO. Public Perception and Assessment of Primary Healthcare Service in Mbaukwu Community of Awka South Local Government Area, Anambra State, Southeast Nigeria. Int J Perceptions Public Health. 2017;1:121–126.

  27. National Assembly. National Health Act, 2014: Explanatory memorandum. 2014. Retrieved from http://www.nassnig.org/document/download/7990. Accessed 20 Aug 2023.

  28. Federal Ministry of Health. National Health Policy 2016: Promoting the health of Nigerians to accelerate socio-economic development. Abuja, Nigeria: Author. 2016. Retrieved from https://naca.gov.ng/wp-content/uploads/2019/10/National-Health-Policy-Final-copy.pdf. Accessed 20 Aug 2023.

  29. Umeano-Enemuoh JC, Onwujekwe OE, Uzochukwu BSC, Ezeoke OP. Patients’ satisfaction and quality of care in a tertiary institution in Southeast Nigeria. Int Res J Basic Clin Stud. 2014;2(2):14–9.

    Google Scholar 

  30. Kjeken I, Dagfinrud H, Mowinckel P, Uhlig T, Kvien TK, Finset A. Rheumatology care: Involvement in medical decisions, received information, satisfaction with care, and unmet health care needs in patients with rheumatoid arthritis and ankylosing spondylitis. Arthritis Rheum. 2006;55:394–401.

    Article  PubMed  Google Scholar 

  31. Kaduna State Ministry of Health. The Kaduna state integrated maternal, newborn and child health strategic plan 2012–2015. Kaduna: Kaduna State Ministry of Health, 10–1. 2011. Retrieved from https://ngfrepository.org.ng:8443/bitstream/123456789/3218/1/Kaduna%20State%20Strategic%20Health%20Development%20Plan%202010-2015.doc.pdf. Accessed Nov 2024.

  32. Marshall AA. The structure of patient satisfaction with outpatient medical care. Psychol Assess. 1993;5(4):477–83.

    Article  Google Scholar 

  33. Ware JE. Measuring the quality of care: The patient satisfaction component. Paper presented at the National Conference on Quality Assurance in Ambulatory Health Care, Chicago. 1987.

  34. Ware JE, Davies AR, Stewart AL. The measurement and meaning of patient satisfaction. Health Med Care Serv Rev. 1978;1(1):1–15.

    PubMed  Google Scholar 

  35. Adekanye AO, Adefemi S, Okuku AG, Onawola KA. Patients’ satisfaction with the healthcare services at a north central Nigerian tertiary hospital. Niger J Med. 2013;22(3):218–24.

    CAS  PubMed  Google Scholar 

  36. Ofovwe CE, Ofili AN. Indices of patient satisfaction in an African population. Soc Sci Med. 2005;61(2):582–6. https://doi.org/10.1016/j.socscimed.2004.11.052.

    Article  Google Scholar 

  37. Khan AM. Patient satisfaction towards medicine outpatient department services in Bunphaeo Autonomous Hospital, Samut Sakhon Province, Thailand (Master's thesis). Mahidol University, Nakhon Pathom. 2007. Retrieved from https://repository.ju.edu.et/bitstream/handle/123456789/214/Ebsa%27s%20Final%20Thesis%20includung%20comment%20of%20external%20examination%20%282%29.pdf?sequence=1&isAllowed=y . Accessed 20 July 2023.

  38. Qadri SS, Pathak R, Singh M, Ahluwalia SK, Saini S, Garg PK. An assessment of patient satisfaction with services obtained from a tertiary care hospital in rural Haryana. International Journal of Collaborative Research on Internal Medicine & Public Health. 2012;4(8):1524–37.

    Google Scholar 

  39. Kumari R, Idris MZ, Bhushan V, Khanna A, Agarwal M, Singh SK. Study on patient satisfaction in the government allopathic health facilities of Lucknow district, India. Indian J Commun Med. 2009;34(1):35–42.

    Article  Google Scholar 

  40. Qureshi W, Naikoo GM, Baba AA, Jan F, Wani NA, Hassan G et al. Patient satisfaction at tertiary care hospitals in Kashmir: A study from the Lala Ded Hospital Kashmir, India. Int J Health. 2009;8;2.

  41. Adhikari M, Paudel NR, Mishra SR, Shrestha A, Upadhyaya DP. Patient satisfaction and its socio-demographic correlates in a tertiary public hospital in Nepal: a cross-sectional study. BMC Health Serv Res. 2021;21(1):135. https://doi.org/10.1186/s12913-021-06155-3.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Jawahar SK. A study on out-patient satisfaction at a super specialty hospital in India. J Med Update. 2007;2(2):10–4. https://doi.org/10.4314/ijmu.v2i2.39849.

    Article  Google Scholar 

  43. Mahapatra P, Srilatha S, Sridhar P. A patient satisfaction survey in public hospitals. J Acad Hospital Administra. 2001;13:11–5.

    Google Scholar 

  44. Ibrahim A, Chompikul J, Isaranurug S. Patient Satisfaction with Health Services at the Outpatient Department Of Indira Gandhi Memorial Hospital, Male' Maldives 2008.

  45. Mona ES, Meky FA, Abou El Enein NY, Mahdy MY. The effect of a training program in communication skills on primary health care physicians knowledge, attitudes and self-efficacy. J Egypt Public Health Assoc. 2009;84(3/4):261–83.

    Google Scholar 

  46. Al-Qatari G, Haran D. Determinants of users’ satisfaction with primary health care settings and services in Saudi Arabia. Int J Qual Health Care. 1999;11:523–31.

    Article  CAS  PubMed  Google Scholar 

  47. Abdel-Tawab N, Roter D. The relevance of client-centered communication to family planning settings in developing countries. Soc Sci Med. 2002;54:1357–68.

    Article  PubMed  Google Scholar 

  48. Johansson K, Bendtsen P, Akerlind I. Advice to patients in Swedish primary care regarding alcohol and other lifestyle habits: How patients report the actions of GPs in relation to their own expectations and satisfaction with the consultation. Eur J Pub Health. 2005;15:615–20.

    Article  Google Scholar 

  49. Diperte BL, Denegri B, Hernandez O. An evaluation of the impact of training Honduran healthcare providers in interpersonal communication. Int J Qual Healthcare. 1999;12:459–501.

    Google Scholar 

  50. Brown JB, Boles M, Mullooly JP. The effect of clinician communication skills training on patient satisfaction. Ann Intern Med. 1999;131(11):822–9.

    Article  CAS  PubMed  Google Scholar 

  51. Raivio R. Assessing patient satisfaction in primary health care – Reliable information and benchmarking. The World Book of Family Medicine – European Edition, 2015. 1–3. 

  52. Narenjiha M, Haghighat S, Bahaddor H, Shajari J, Jameie SB. The importance of physicians’ communication skills and patients’ satisfaction. Thrita J Med Sci. 2012;1(2):57–61.

    Article  Google Scholar 

  53. Ferranti DEMG, Forth VE, Rauworth J, Lee J, Williams MV. Assessing patient perceptions of hospitalist communication skills using the communication assessment tool (CAT). J Hosp Med. 2010;5(9):522–7.

    Article  PubMed  Google Scholar 

  54. Birhanu Z, Assefa T, Woldie M, Moranka S. Determinants of satisfaction with health care provider interactions at health centers in central Ethiopia: A cross-sectional study. BMC Health Serv Res. 2010;10:78.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Atkinson A. Answering the eternal question: What does the customer want? Cornell Hotel Restaur Adm Q. 1988;29(2):12–4.

    Article  Google Scholar 

  56. Jackson JL, Chamberlin J, Kroenke K. Predictors of patient satisfaction. Soc Sci Med. 2001;52:609–20.

    Article  CAS  PubMed  Google Scholar 

  57. Sixma HJ, Spreeuwenberg PM, van der Pasch MA. Patient satisfaction with the general practitioner: A two-level analysis. Med Care. 1998;36(2):212–29.

    Article  CAS  PubMed  Google Scholar 

  58. Oredola AS, Odusanya OO. A survey of the perception of the quality of and preference of healthcare services amongst residents of Abeokuta South Local Government, Ogun State, Nigeria. Niger J Clin Pract. 2017;20(8):1088–97. https://doi.org/10.4103/njcp.njcp_292_16.

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

None.

Author information

Authors and Affiliations

  1. National Health Insurance Authority, Abuja, Nigeria

    Muhammad Bashar Jibril, Mohammed Nasir Sambo, Hadiza Sulaiman & Hassan Shuaibu Musa

  2. Abubakar Tafawa University, Bauchi, Nigeria

    Abubakar Musa

  3. Ahmadu Bello University, Zaria, Nigeria

    Zaharaddeen Babandi Shuaibu & Lawal Aminu

  4. Society for Family Health, Abuja, Nigeria

    Yusuf Hassan Wada

  5. University of Cambridge, London, UK

    Aliko Ahmed

Authors
  1. Muhammad Bashar Jibril
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Mohammed Nasir Sambo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hadiza Sulaiman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Hassan Shuaibu Musa
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Abubakar Musa
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Zaharaddeen Babandi Shuaibu
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Lawal Aminu
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yusuf Hassan Wada
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Aliko Ahmed
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MBJ and YHW wrote the main manuscript; MBJ, YHW, MNS, HS, HSM, AM, ZBS, LA, OI and AA reviewed the draft copy of the manuscript and all reviewed the final version of the manuscript.

Corresponding author

Correspondence to Yusuf Hassan Wada.

Ethics declarations

Ethics approval and consent to participate

Ethical clearance was sought for and obtained from the Health Research Ethics Committee of Ahmadu Bello University Teaching Hospital, Zaria (ABUTHZ/HREC/G25/2019) before the commencement of the study. A letter of introduction was obtained from the University to the Chairmen of the local government areas where the study was carried out. Also, Permission to carry out the study was obtained from the Kaduna State Ministry of Health through the State Primary Health Care Development Board (SPHCDB). Permission to carry out the study was sought from the LGA PHC department and an informed consent to participate was sought from participants (informed consent for all illiterate participants was obtained from their parents and/or their legal guardians). Permission was also obtained from the local government council and the village heads/community gatekeepers, as well as the facility in charge where the study was conducted. The nature and objectives of the study were explained to each participant and assurance of confidentiality and anonymity was given, to obtain evidence-based, informed, written consent for participation in the study by way of signing or thumb-printing the consent form. Participants were made to understand that participation in the study was completely voluntary ab initio, and individuals who did not consent to participate in the study were exempted. The respondents’ right to voluntary participation and right to withdraw at any stage of the study, or absolute refusal to participate in the study was equally emphasized and duly respected and was not made to affect the care or treatment they received in the health facility in any way. Finally, respondents were made to understand that participation in this study would not cause any physical harm to them. In the same vein, participants were made to understand that as part of the benefit of participating in the study, findings from the study would be used by policymakers to formulate and implement policies and practice frameworks that would enhance clients’ satisfaction with service delivery in PHC facilities in the State. By participating in the research, participants were willing to contribute towards achieving these set objectives towards building a healthier and more productive population. The research was also conducted in accordance with Helsinki Ethical Principles for Medical Research involving human participants and the local guidelines as outlined in the ethical approval guidelines.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Jibril, M.B., Sambo, M.N., Sulaiman, H. et al. Optimizing primary healthcare experience: assessing client satisfaction in Kaduna State, Northwest Nigeria. BMC Prim. Care 25, 231 (2024). https://doi.org/10.1186/s12875-024-02481-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12875-024-02481-7

Keywords

BMC Primary Care

ISSN: 2731-4553

Contact us