1. Introduction. Dr. Rahul Krishnan Kutty 1, Hailay Gebremichael 2, Kidane Tadesse 3, Kiflom Negash 4, Birhane Teame 5, Mueez Abraha 6

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1 (An Indexed, Referred and Impact Factor Journal) ISSN: Evaluation of Patient s Satisfaction level and Associated factors of Physiotherapy Services in Mekelle Ortho-Physiotherapy Centre, North Ethiopia: A Cross Sectional Study Dr. Rahul Krishnan Kutty 1, Hailay Gebremichael 2, Kidane Tadesse 3, Kiflom Negash 4, Birhane Teame 5, Mueez Abraha 6 1,2,4 Lecturer in Physiotherapy, Department of Physiotherapy, School of Medicine, College of Health Sciences, Mekelle University, Mekelle, Ethiopia 3 Biostatistics and Health Informatics, Department of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia 5 Physiotherapist, Mekelle-Ortho Physiotherapy Centre, Mekelle, Ethiopia 6 Lecturer in Anatomy, Department of Anatomy, College of Medicine and Health Sciences, Gondar University, Gondar, Ethiopia Abstract Background: Patient satisfaction can be one indicator of quality of care. Patient satisfaction continues to receive attention as a measure of the outcome of physical therapy intervention. Quality of care continues to be a major concern for health care providers and a major focus for health services research. Equally important is the satisfaction of patients because they expect value for their money, time and effort to attend for treatment. In addition, patients also expect to benefit from the physiotherapy service to improve their quality of life. The main aim of the study was to investigate whether patients were satisfied with the physiotherapy service they received for their illness in Mekelle Ortho-Physiotherapy Centre. Method: Institution based cross sectional study was carried out at Mekelle Ortho-Physiotherapy Centre, Tigray region, Northern Ethiopia from August to December A structured format questionnaire was prepared which is inclusive of questions related to assess the patient s satisfaction level were listed. The collected data were entered and cleaned and analyzed in SPSS version 20 statistical soft ware. Frequencies and percentages were done for categorical variables. Variables which have association in Bivariate analysis at p-value of 0.05 was selected for multivariate analysis. Finally, statistical significance was ensured at 95% CI and p-value of < Result: The analysis revealed that those who were married are 21 times satisfied with the centre, than those who were single CI(2-56), and those respondents who responded there is enough refreshment/ lounges are 13 times satisfied with the service provided in the center CI( ). Those who agreed with the Scheduling the treatment time according to the holiday /weekend are 12 1 times more likely satisfied than their counter parts CI( ). Those who prefer to refer someone to the Mekelle Ortho-Physiotherapy Center for Physical Therapy are 16 times more satisfied that those who didn t prefer to refer someone to the center CI( ). Another result which show significant is as the number of duration of treatment increases by one the level of satisfaction of an individual decreases by 35% 0.65 CI ( ). Conclusion: The study suggests that the satisfactory patients are more when compared to dissatisfactory patients. Factors which affect patient s physiotherapy satisfactions are identified. Being a married one, saying there enough refreshment in the center and those respondents who prefer to refer someone to Orthophysiotherapy center were found to increase the patient satisfaction rate. Keywords: Physiotherapy, Patient satisfaction, Physiotherapy practice, Mekelle, Ethiopia. 1. Introduction Patient satisfaction can be one indicator of quality of care. Patient satisfaction continues to receive attention as a measure of the outcome of physical therapy intervention. Quality of care continues to be a major concern for health care providers and a major focus for health services research 1. Although many operational definitions of quality of care focus on the personal knowledge, skills, and expertise of the clinician rather than on other aspects of the treatment

2 (An Indexed, Referred and Impact Factor Journal) ISSN: experience, patient satisfaction, in our opinion, constitutes a dimension of care outside of the physical therapist's immediate control. Yet, technical quality and patient satisfaction are synergistically linked to influence the outcomes of care, for example, that dissatisfied patients are less likely to use professional advice, thus undermining both primary and secondary prevention 2. Therefore, in light of the hypothesized relationships among the technical expertise of the care provider, the experience of the person receiving the care and how that person values care, and measures of outcomes of the care provided, any comprehensive formulation of an operational definition of quality in health care should state that patient satisfaction is a necessary construct 3,4. Patient satisfaction remains an important concept for health care providers. We are not alone in believing that health care providers can no longer rely on sources of information that omit the patient's perspective in the definition of quality of care 5. Based on the large number of instruments developed for practices, physical therapists appear to have recognized the value of feedback from patients 6. Physiotherapy Center is a center that provides specialized health care services to community intended to develop, maintain, and restore maximum movement and functional ability. Intervention includes; assessment, functional diagnosis, planning of treatment, and implementation of intervention and evaluation of outcome of client s condition. Health services, whether public or private, should be managed along sound business practices. Customers are concerned with the quality of services or products and their costs 7. According to a research product supplying companies should provide an environment with a mutually satisfying exchange relationship between them and the customers. In this case, both parties increase value for each other and this would result into sustainable partnerships. Author further concluded that customers get satisfaction when they receive services or products equal to the value of their money 8. Delivery of high-quality, cost-effective healthcare services have increasingly become a focus of policy-makers, clinicians, insurance carriers and patient advocacy groups 9. In order to deliver such care, assessment of patient satisfaction with health care services should be an ongoing process. Both formal and informal methods of the data collection can be used aiming at identifying the needs of the client or customer 10. The feedback received from the clients could be used to further improve and develop the services by taking action where specific comments have been made 11. When such action has been taken it improves patient satisfaction which has been seen to influence other outcomes of the health care 12. When clients are dissatisfied with the service or product, they spread negative information and complain to others. This influences them to change to the services or products of competitors resulting in a heavy loss to the organization. On the other hand, satisfied clients tend to recommend the services or products of those organizations to other people who finally become new clients of those firms 10. Today, intellectually, physically, or emotionally disabled individuals comprise a significant portion of the world population 13. Disability is also more common among children in the low- and middle-income countries. Moderate disability rates are similar for males and females in high-income countries, but females have somewhat higher rates of severe disability. In low- and middle income countries, male and female disability rates are similar; although females aged years tend to have higher levels of moderate disability in Africa, the Eastern Mediterranean and the Western Pacific 14. Some five to eight million women and men in Ethiopia, or 7 to 10 per cent of the population, have a disability 15. To eradicate this issue physiotherapy is one of the answers, where by the physiotherapeutic measures are helping to solve this challenge. Presently Ethiopia fighting with the infectious diseases, but on other hand non communicable diseases and disability is a very huge sign of concern. For a huge population a few physiotherapy centers in whole country shares the responsibility to fight against disability. One of the fully equipped and effective Physiotherapy centre is Mekelle Ortho-Physiotherapy Centre in Mekelle city. Doctors usually refer patients with Disorders for treatment by physiotherapists who use a variety of interventions. The selection of interventions seems to depend on the knowledge, skills and personal preferences of the physiotherapist. In the physiotherapy departments Mekelle Ortho- Physiotherapy Centre, patients suffering from variety of diseased state are treated by well trained physiotherapists. Physiotherapists are increasingly 2

3 (An Indexed, Referred and Impact Factor Journal) ISSN: challenged by the service consumers to provide evidence for best practice considering the cost of treatment to the individual, tax payer and health insurance funder. Equally important is the satisfaction of patients because they expect value for their money, time and effort to attend for treatment. In addition, patients also expect to benefit from the physiotherapy service to improve their quality of life. It is within this context that the following research questions and hypothesis were formulated. The main aim of the study was to investigate whether patients were satisfied with the physiotherapy service they received for their illness in Mekelle Ortho- Physiotherapy Centre and its associated factors, which may form a link of understanding between the Mekelle Ortho-Physiotherapy Centre management and the service consumers based on the latter s experience and perceptions of physiotherapy for patients. Hence, its outcome may serve as a basis for management to ensuring cost effective, efficient and quality physiotherapy services. 2. Methodology All subjects included in study have undergone treatment in Mekelle Ortho-Physiotherapy Centre, during the study duration and willing to participate in research were included. Institution based cross sectional study was carried out at Mekelle Ortho- Physiotherapy Centre, Tigray region, Northern Ethiopia. Subjects with expression difficulty unable to read and write, head injury patients were excluded from the study. A structured format questionnaire were prepared which is inclusive of demographical profile of the participants (Age, Sex, Education, and Occupation) and questions related to assess the patient s satisfaction level were listed. The questionnaire were translated to the national language of Ethiopia (Amharic) and local language of Tigary (Tigrigna) with the help of professional language translator, One week prior the actual data collection, the questionnaires were pre-test on 12 people with all possible age group. The finding of the pre-test were used to revise arrangement of the questionnaire, i.e. order of questions, and skip patterns, the time needed to complete interview and the number of data collectors in need were estimated. To insure the quality of the data, training on how to administer and collect the data were given for supervisor and data collectors for 2 days. In addition data collectors training manual were prepared. Regular supervision and follow-up were made by supervisor and the principal investigator to check up data collection process, accuracy and completeness of data. The questionnaires were distributed by the researcher to patient who had under gone physiotherapy treatment and a consent forms were obtained from each participant. Proceeding participants were asked to answer the question and questionnaires were collected back. 2.1 Data Analysis The collected data were entered and cleaned in SPSS version 20 statistical soft ware. Again the data was analyzed using SPSS version 20. Frequencies and percentages were done for categorical variables. Normality for the population distribution was checked with histogram for continuous variables, for normally distributed population the measures of central tendency (mean) and dispersion (standard deviation), while for non-normally distributed population the measure of central tendency (median) and measure of dispersion (Interquartile range) was reported. Binary logistic regression was carried out to determine the association between a set of independent variables and the dependent variable (Patient satisfaction) and to see which variables is significantly affect the Patient satisfaction. Variables which have association in bivariate analysis at p- value of 0.05 were selected for multivariate analysis. Finally, statistical significance was ensured at 95% CI and p-value of < Results 3.1 Characteristics of study participants A total number of 187 participants were included in this study. 62% of the participants were male and 38% of females. 61% of the participants were from Tigray in native and 28.9% from Amhara and rest 10% from other region from the country and 64% of the participants are employed. In terms of educational status of the participants 42.2% of them were having a primary education. In terms of participants marital status 59.9% of them were unmarried (single). 3

4 (An Indexed, Referred and Impact Factor Journal) ISSN: (Table-1) Table 1: Socio-demographic characteristics of study participates at Mekelle Ortho-physiotherapy center, Ethiopia, 2014 Characteristics Number Percent Sex Male Female Native Amhara Tigray Afar Other Occupation Unemployed Employed Education Primary High School Diploma Degree Masters Marital Status Single Married Income < >

5 (An Indexed, Referred and Impact Factor Journal) ISSN: According to the collected data from the questionnaire, out of 187 participants,147(78%) of them have never taken physiotherapy treatment previously. 175(93.6%) participants responded the responsible physiotherapist had a introduction session before treatment and 175(93.6%) participants responded that the initial treatment was in their desired time frame. 108(57.8%) of respondents were not treated according to scheduled time during holidays and weekends % 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% satisified Not Satisified 10.00% 0.00% First Aid Kit Drinking Water Restroom Lounge Fire Extingusher Figure-1 Level of satisfaction of subjects regarding the basic amenities in Mekelle Ortho-physiotherapy Center, Ethiopia, % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% Satisified Not Satisified 30.00% 20.00% 10.00% 0.00% PT introduction Intial Evalution Sceduling time Recommdation Figure-2 Level of satisfaction of subjects regarding the basic treatment protocol in Mekelle Orthophysiotherapy Center, Ethiopia,

6 (An Indexed, Referred and Impact Factor Journal) ISSN: Satisfaction related questions Total numbers of 187 respondents, out of that 148(79.1%) of the respondents were satisfied with the courtesy of the office personal in the centre, 118(63.1%) of the respondents were satisfied with the courtesy of Physiotherapists in the centre.62 (33.3%) of the respondents were very satisfied with the phone facilities in the centre. 78(41.7%) of the respondents were satisfied with the physiotherapist because of the treatment procedure and other formalities were clearly explained to the subjects. 87(46.5%) of the subjects were satisfied that initial evaluations and treatment techniques were explained to them and 52(27.8%) were neutral. 87(46.5%) were satisfied with the way there queries regarding the treatment were answered responsibly. 88(47.1%) of the subjects were satisfied by the appointment of the way treatment was started promptly. 95(50.8%) of the subjects were satisfied from the individual attention given to them by the physiotherapist. 123(65.8%) of the subjects were satisfied with the improvement of their disorders after taking treatment in the centre. regarding the cleanliness 106(56.9%) of the subjects were satisfied and 39(20.9%) gave a neutral responds. For the atmosphere of the centre majority 124(66.3%) were satisfied. 83(44.4%) of the subjects were satisfied with the physiotherapeutic equipments available in the centre. 102(54.5%) of the subjects were satisfied with parking facilities in the centre. Regarding the billing and paperwork, 151(80.7%) & 117(62.6%) of the subjects respectively were satisfied. 100(53.5%) and 55(29.4%) of the subjects were satisfied and had neutral response respectively for the overall impression on the centre. Regarding the privacy during the treatment 130(61.7%) of the subjects were satisfied, and about the waiting area in the centre 129(69%) of the subjects were satisfied and 26(13.9%) had neutral response regarding the same. Out of 187 respondents, 102(54.4%) were satisfied with the service of the center. The results for overall satisfaction level in centre, which promptly suggests that the patients taking physiotherapy treatment are satisfied with the services provided. 3.3 Factors associated with level of patient satisfaction The data was analyzed by Bivariate and multivariate regression; the variables which were significant in multivariate logistic regression are interpreted in the table. The analysis revealed that those who were married are 21 times satisfied with the centre, than those who were single CI(2-56). Moving on to the other results, those who said there is enough refreshment/ lounges are 13 times satisfied with the service provided in the center CI( ). Those who agreed with the Scheduling the treatment time according to the holiday /weekend are 12 times more likely satisfied than their counter parts CI( ). Those who prefer to refer someone to the Mekelle Ortho-Physiotherapy Center for Physical Therapy are 16 times more satisfied that those who didn t prefer to refer someone to the center CI( ). Another result which shows significant is as the number of duration of treatment increases by one the level of satisfaction of an individual decreases by 35% 0.65 CI ( ).(Table-2) 6

7 (An Indexed, Referred and Impact Factor Journal) ISSN: Table- 2 Factors associated with level of patient s satisfaction at Mekelle Ortho-physiotherapy Center, Ethiopia, Variable COR P-value 95%CI AOR P-value 95%CI Sex Male 1 Female Occupation Unemployed 1 Employed Education Primay 1 High School Diploma Degree Master Marital status Single 1 Married * Income 1000 or less or less or less Others IntroPT Yes Firstaidkit Yes Restroom Yes Lounge Yes * Treatmenttime Yes * Reference Yes * DurationofRx * * Statistically significant at P-value <

8 (An Indexed, Referred and Impact Factor Journal) ISSN: Discussion The dimensions of patient satisfaction identified in this study include patient-physiotherapist interaction, professionalism of service, the clinical environment and patient compliance with treatment. Other dimensions focus on the impact of physiotherapy overall opinion of service. Factors associated with patient satisfaction are discussed under the above dimensions. 4.1 Demographic status The study results shows that subjects who were taking treatment in the centre with a marital status married are 21 times satisfied than those who are single. This may be due to the fact married person have more stressed factors when considered with single, where married person feels more stress relieved by the physiotherapeutic treatment in terms of physical and psychological context, which is directly associated with satisfaction of service in the centre. 4.2 Aspects associated with the atmosphere of the centre The findings of the study demonstrated that the majority of the patients (79%) agreed that the centre areas were clean. The atmospheres of the centre (90%) of the patients are satisfied. Those who said there is enough refreshment/ lounges are 13 times satisfied with the service provided in the center. To contrast, in another study found that cleanliness of the treatment areas had a significant association with patient satisfaction were found also to add patient satisfaction in physiotherapy outpatient clinics has been found to be influenced by non-clinical issues like cleanliness 16. Another article that comes in line with this study states that patients need to be treated in a clean, comfortable and safe environment 17. patient always increases. In line with is study another article explains that Specific attributes considered important by patients included professionalism, competence, friendliness, and caring The ability to communicate effectively was another highly rated therapist characteristic, particularly in explaining the patient s condition and educating the patient about self-management strategies More over the majority of the patients are very satisfied with the quality and efficiency of how care is organized appear to be contributory dimensions of patient satisfaction Patients were more satisfied with good access to services, particularly convenient clinic hours, location, and parking as well as available and approachable support staff 18. Patients were less satisfied if the standard of the premises regarding cleanliness and professional appearance was poor, there was a lack of privacy, the cost of treatment was high, or there were long waiting times 21, Care providers In this study which submerses that those who prefer to refer someone to the Mekelle Ortho-Physiotherapy Center for Physical Therapy are 16 times more satisfied than those who didn t prefer to refer someone to the center. This can be justified by the fact that if the patients are satisfied with the service in the centre they tend to pass this information across the society and community, this in turn as a publicity hype for the centre. As the number of duration of treatment increases by one the level of satisfaction of an individual decreases by 35%. There are multiple factors which revolve around this statement, which is if the cases presented to the centre is chronic one which naturally takes more time to recover and the level of satisfaction is influenced. Proven evidence,in another study done on patient satisfaction which draws a point that patients were more satisfied when treated by the same practitioner over the course of treatment and when the treatment duration was adequate Aspects of treatment associated with satisfaction In this study those who agreed with the Scheduling the treatment time according to the holiday /weekend are 12 times more likely satisfied than their counter parts. This will be validated by the fact that attitude of physiotherapist and the treatment given to the patients. When the treatment or scheduled in time comfortable for the patient and the treatment plan and the procedure is explained well the satisfaction of 8 5. Conclusion The study was focused on the patient s satisfaction level in the Mekelle ortho-physiotherapy centre for the service provided by them. The study suggests that the satisfactory patients are more when compared to dissatisfactory patients. Factors which affect patient satisfaction with service were identified under the following dimensions of patients satisfaction, namely interaction between physiotherapists and the patient, professionalism of service and the treatment

9 (An Indexed, Referred and Impact Factor Journal) ISSN: environment. Other factors associated with patient satisfaction were the patients compliance with treatment and duration of the treatment. These factors were significantly associated with patient satisfaction. The results further showed that majority of the patients stated that they improved after physiotherapy interventions. Patient improvement was also significantly associated with their satisfaction with the service. This study has helped to understand many positive and negative points about the service and environment in the centre. This studies final conclusion shows that patients taking physiotherapy treatment are overall satisfied with centre. Acknowledgement We are grateful to Mekelle Orthophysiotherapy staffs for their kind cooperation, all respondents who participated in this study. We also remain thankful for the data collectors and supervising. Competing Interests The authors declare that they have no competing interests. Authors Contributions RK, HG, KN, KT, BT, MA designed the study, analyzed the data, drafted the manuscript and critically reviewed the article. References [1] Brook RH, McGlynn EA. Maintaining quality of care. In: Ginzberg E, ed.health Services Research. Cambridge, Mass: Harvard University Press;1991: [2] Ellwood PM Jr, Paul BA. But what about quality? Health Aff (Millwood).1986;5: [3] Donabedian A. The quality of care: how can it be assessed? JAMA.1988;260: [4] Elliot KM, Hall MC, Stile GW. Service quality in the health care industry: how are hospitals evaluated by the general public? Journal of Hospital Marketing.1992 ;7: [5] Nelson CW. Patient satisfaction surveys: an opportunity for total quality improvement. Hospital and Health Services Administration.1990 ;35: [6] Patient Satisfaction Instruments: A Compendium. Alexandria, Va: American Physical Therapy Association;1995. [7] Naumann, E & Giel, K. (1995).Customer satisfaction measurement and management. Cincinnati, Ohio: Thomson executive Publisher. [8] Gummesson, E. (2002). Total relationship marketing second edition: Marketing management, relationship strategy and CRM approaches for the network economy. Oxford, Boston: Butterworth Heinemann. [9] Thomas, R. J., Witt, B. J., Lopez-Jimenez, F., King, M. L. & Squires, R. W. (2005). Quality indicators in cardiovascular care. Journal of Cardiopulmonary Rehabilitation, 25 (5):249. [10] Lamb, Jr. C. W., Hair, Jr. J. F., MacDaniel, C., Boshoff, C.&Terblanche, N. S. (2004). Marketing. Second South African edition, Cape Town: Oxford University Press Southern Africa. [11] MacLeod, M., Bruce, F. & Bell, H. (1999). Patient views of outcome in a multidisciplinary treatment centre, British Journal of Therapy and Rehabilitation, 6 (2): [12] May, S. J. (2001). Part 1: Patients satisfaction with management of back pain. Physiotherapy, 87 (1):4-9. [13] Sen & Yurtsever 2007, 238 Patient views of outcome in a multidisciplinary treatment centre. [14] (WHO 2004, ), Annual Report, online. [15] (UNICEF April 2009),(ILO, 2004: Ethiopia.). annual report [16] Roush, S. E. & Sonstroem, R. J. (1999). Development of the physical therapy outpatient satisfaction survey (PTOPS). Physical Therapy, 79 (2): [17] Carle Foundation Hospital (2005). Patient rights and responsibilities. [Online]. Available ml) [18] Casserley-Feeney SN, Phelan M, Duffy F, et al. Patient satisfaction with private physiotherapy for musculoskeletal pain,bmc Musculoskelet Disord. 2008;9:50. [19] MacDonald CA, Cox PD, Bartlett DJ. Productivity and client satisfaction: a comparison between physical therapists and student-therapist pairs. Physiother Can. 2002;54: [20] Cooper KS, Blair, H. Hancock, E. Patient centredness in physiotherapy from the perspective of the low back pain patient. Physiotherapy. 2008;94: [21] May SJ. Patient satisfaction with management of back pain. Physiotherapy. 2001; 87:4 20. [22] Hills R, Kitchen S. Satisfaction with outpatient physiotherapy: focus groups to explore the views

10 (An Indexed, Referred and Impact Factor Journal) ISSN: of patients with acute and chronic musculoskeletal conditions. Physiother Theory Pract. 2007;2:1 20. [23] Stephens B, Gross DP. The influence of a continuum of care model on the rehabilitation of compensation claimants with soft tissue disorders. Spine. 2007;32: ) 10