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Health Management

Patients' Satisfaction with Quality Attributes of Primary Health Care

Services in Nigeria
Abolaji Joachim Abiodun
Journal of Health Management 2010 12: 39
DOI: 10.1177/097206340901200104

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 Quality Attributes of Primary Health Care Services in Nigeria 39

Patients’ Satisfaction with

Quality Attributes of Primary
Health Care Services in Nigeria
Abolaji Joachim Abiodun

Patients’ satisfaction with health care is an important health outcome which has implications
for capacity utilisation. And, in health systems that emphasise the cooperation and involvement
of the community, both in terms of resources contribution and management, satisfaction
with health care assumes an important dimension in terms of its implication for success
of public health programmes. This study, based on administered questionnaires, examines
patients/users’ satisfaction with quality attributes of health care services at the primary level
facilities in order to provide feedback to health personnel and management for change and
learning. The study employs correlation and multivariate regression analysis to determine the
quality attributes that determine overall satisfaction with care. Our findings suggest the need
to emphasis ‘empathy’ for care providers; and while a reasonable level of physical facilities
should be provided, care providers have the task to communicate their technical competence
to care seekers to ensure capacity utilisation at the primary level.

Introduction

Empirical evidences attest to the fact that most public health care facilities in
Nigeria operate more for their own convenience and not that of the patient,
their families or members of the public. Health workers’ incessant strikes
over remunerations (Khemani 2004); small and unkempt waiting rooms
in public clinics and hospitals; and unsympathetic care procedures bear
eloquent testimony to this fact. In the same vein, the private care providers
are only slightly better as ‘exploitative cost of Medical treatment, time wasting
in outpatient ward and widespread demand for payment before treatment
are common measures commonly adopted in the country by private care
providers’ (Oni and Salman 1997, cited in Adeoti, 2001: 71). These exposed

Journal of Health Management, 12, 1 (2010): 39–54

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DOI: 10.1177/097206340901200104

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40 Abolaji Joachim Abiodun

situations make the examination of community or patients’ satisfaction with

care in the Nigerian health system very important.
Patients’ satisfaction with the health care they receive is an important
health outcome (Maxwell 1984) which has implications for capacity util-
isation. However, while there are extensive literatures on patients’ or clients’
satisfaction with medical services in developed nations (Carr-Hill 1992;
William 1994), there are, to our knowledge, few studies examining the
question of satisfaction with health care and community health centres in
the developing world settings of Africa (Gilson et al. 1994; Newman et al.
1998). This could be the logical result of the fact that most people in develop-
ing nations are more concerned about basic economic survival than about
health services.
And, in countries like Nigeria where primary health care (PHC) forms
the cornerstone of health development, satisfaction with care assumes im-
portant dimension in terms of implications for the success of primary health
programmes. Rural dwellers, who form the bulk of the population, have con-
siderable uncertainty regarding a guaranteed income. Therefore, they may
be primarily concerned with the basic needs of life rather than improving
the quality of their health life.
In its basic form, PHC emphasises the cooperation and involvement of
the community, both in terms of management and resources contribution.
This strategy towards health care provision and management is reasonably
justified, especially in resource-poor countries, where the goal of poverty
reduction provides a powerful case for health investments. Interestingly, in
most rural communities in Nigeria, PHC is not only the first point of con-
tact for most patients, it is the only available health practice setting for most
people in the rural areas.
In terms of institutions, the components of the PHC are: the public health
centres and clinics, dispensaries, private clinics and maternity centres. Thus,
we have decided to focus attention on one of the primary care level insti-
tutions, the health centres, since they are the most numerous of the PHC
institutions in Nigeria. In addition, we hoped that the study will provide an
opportunity for users of the health centres to express their opinions about the
health services received in these health centres and therefore, open a dialogue
between the local government health department and the population it
serves. In addition, quantified data regarding patient satisfaction can enable
providers and health care planners and evaluators to maintain or improve
standard of care.

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 Quality Attributes of Primary Health Care Services in Nigeria 41

Therefore, the overall purpose of this article is to gain insight into users’
satisfaction with quality attributes of care provided at the primary level in
Nigeria. We seek to determine the level of users’ satisfaction with health
services and which service quality characteristics influence overall satisfaction
with care and thereby, provide feedback to workers and management for
learning and change.

Literature Review

Satisfaction with quality of health care provision can be conceptualised as

the degree of congruency between a patient’s expectation of services and care
and his perception of the services and care received. Satisfaction is based on
an individual’s reaction to the perceived difference between performance ap-
praisal and expectations. Disconfirmed expectation leads an individual to
a state of dissatisfaction, while the confirmation of expectation yields satis-
faction. The fact that the patients are not able to evaluate the quality of
care clinically makes the assessment of satisfaction all the more important
(Chaska et al. 1980; Dawn and Thomas 2004; Oswald et al. 1998). Research
efforts have established that satisfaction assessments and service quality per-
ceptions are closely connected (Fowler et al. 1991; Oswald et al. 1998).
Satisfaction, like quality, is a multidimensional construct. Thus, satisfaction
with a service organisation is premised on satisfaction with multiple aspects
of the organisation (Crosby and Stephens 1987; Oliver and Swan 1989;
Suprenant and Solomon 1987). Put differently, overall service satisfaction is
a construct with multiple indicators at the attribute level (Oliva et al. 1992).
For a health care service to be evaluated positively on quality terms, it must
perform well on most care service quality dimensions, whereas to be judged
adversely, poor performance on one or just a few dimensions is sufficient
(Ofir and Simonson 2001).
During a health care encounter, users or health care consumers are ex-
posed to service attributes that are cognitively processed and help to affect
an individual’s perception of quality service delivery, hence satisfaction
(Anderson and Mittal 2000; Scotti and Dolinsky 1997). These attributes
comprise the structure of service and include modern equipment, layout of
facilities, convenient location, etc. Indeed, research efforts have documented
the importance of tangible elements of health care service (Reidenbach and
Sandifer-Smallwood 1990).

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42 Abolaji Joachim Abiodun

Further, customers’ satisfaction derived from their perception of quality

of service may be derived from their assessment of the intangible elements
associated with the interaction between the customers and the health
personnel during care. These intangible elements include such aspects as
responsiveness, courtesy, competence, and access and availability of phys-
icians and other hospital staff (Dawn and Thomas 2004, Zeithaml et al. in
Bergman and Klefsjo 1994). Other process characteristics, as identified by
Reidenbach and Sandifer-Smallwood (1990), included care givers’ expressions
of empathy. However, communication and interpersonal aspects of health
caring have been found to rank most in importance to health care customers
(Cohen 1996; Hall and Dornan 1988; Williams and Calnan 1991).

Study Area

The study area for the present study is Moba Local Area of Ekiti State,
Nigeria. It is located between latitude 6° and 8° North of the equator and
longitude 4° and 6° East of the Greenwich meridian. The local government
lies within a transitional zone between the forest and savanna vegetation in
the plains of south-western Nigeria, and with a length of about 33 km and
breath 22 km, the local government sits on a landmass of about 1,056 square
km. This local government, like many others, is characterised by poor road
network, absence of industrial establishments, predominance of farming as
the main occupation of the inhabitants and a fairly large population with
low income. In some communities in the local government, the health post
is the only available health practice setting, while in two or so locations, we
have a comprehensive health centre.

Materials and Methods

The universe for this study consisted of users of PHC centres and clinics in
Moba Local Government of Ekiti State, Nigeria. The users included both
current and past ones that could be identified with the assistance of health
workers in these clinics. Therefore, the research instrument (questionnaire)
was administered to both active and recall patients over a four-week period.
Respondents were selected using a purposeful sampling, which excluded
teenagers of 17 years and below. The reason was to exclude respondents who
might not comprehend the demand of the research instrument and, hence,

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 Quality Attributes of Primary Health Care Services in Nigeria 43

trivialise their responses. In addition, purposive sampling permits realistic

pursuit of information and reflects the explorative nature of this research, in
line with the methodological suggestions of Miles and Huberman (1994).
Samples were drawn from each facility, bearing in mind the size and usage
of the health facility in focus, to bring the sample size to 200 respondents.
However, deliberate efforts were made to obtain responses across socio-
demographic characteristics of gender, age and education in order to enrich
the data set. To secure the cooperation of respondents, particularly, the il-
literate segment, the nature and purpose of the study was explained to the
respondents, in addition to making the questionnaire respondent-friendly
with respect to design and wording. Notwithstanding, research assistants
were used to interpret the questions to the illiterate.
The questionnaire was developed for use as an exit survey at the health
centres. Thus, the questionnaires were administered largely on departing
patients or parents identified and approached. Some of the exiting patients,
in particular the illiterate, were approached at a distance from the health
facilities. This was to ensure a ready and honest evaluation of the services
received or the facilities at the health centres. Besides, and giving the need to
interpret the questions to some respondents, we reckoned it was reasonable
to keep the heath workers away from the respondents’ evaluations of their
performances.
The research instrument (questionnaire) was broadly divided into two
major sections. Section one was focused on demographic information of the
respondents. Section two provided information on the nature of interaction
with the health care provider and the facilities at the health centres. These
questions were designed to enable respondents, on the strength of their
experiences in these clinics, to directly evaluate the care received. The logic
for the study’s research methodology is to accept the evaluative impression
of respondents as valid expression of satisfaction with attributes specified in
respect of health care services in these health centres. Therefore, subject to the
usual limitations of the survey research methodology used in this research,
the data set generated may be taken to represent a rich data set.
The design of the questionnaire benefited from literatures dealing with
quality in health care, specifically from the works of Greene (1976), Nelsin
(1981), Reidenbach and Sandifer-Smallwood (1990) and Zifko-Baliga
and Krampf (1997). The questions were centred on such health service
quality related variables as ‘effectiveness’ or ‘outcome of care’ received to
altering health for better or reduction of pains, access to care, skills and

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44 Abolaji Joachim Abiodun

knowledge deployed by the health personnel in service delivery (that is,

providers competence), physical facilities employed in care delivery, provider’s
courtesy and responsiveness to patients. Respondent’s satisfaction with
these attributes was evaluated on a seven-point scale from very poor to very
good. All responses represent users’ reports, and were not corroborated with
observational evidence.

Results and Discussion

Respondents’ Profile

Table 1 shows the distribution of respondents’ age, sex and education. The
following subsections provide the discussions of the respondents’ profile.

Gender The evaluative impression of both males and females were con-
sidered important to enrich this study. However, the gender distribution
of respondents was skewed towards the female in each location. Overall,
Table 1
Background of the Respondents

Frequency
Village/Hamlet Males Females Total Percentage
A 12 23 35 19.1
B 27 43 70 38.3
C 34 44 78 42.6

Age composition (Years) Frequency Percentage

<29 35 19.2
30–39 74 40.4
40–49 54 29.5
50 and above 20 10.9

Education Frequency Percentage

Illiterate 37 20.2
Primary education 63 34.4
Secondary 54 29.5
Post-secondary 29 15.9

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 Quality Attributes of Primary Health Care Services in Nigeria 45

60.1 per cent of the respondents were females and 39.9 per cent were male.
This seems understandable because our empirical observations suggest that
females utilise these facilities more, on their own account and for the care
of their children.

Age Common wisdom asserts that experience is the best teacher. Thus,
experiences built over the years on account of age or ‘times’ may influence
our perceptions or evaluations of similar or new development around us. In
term of age, majority of the respondents were in the age ranging from 30 to
39 and 40 to 49 years. The mobility of these groups, reproductive activities
or accessibility may have occasioned their usage of these facilities. Parents’
perception of care quality was assumed to influence the decisions of the
<29 years group.

Education Majority of the respondents have at least primary education.

And, being a rural environment without tertiary institution, the percentages
of respondents with education above secondary level is 15.9 per cent. These
respondents have higher likelihood of interaction with advance health facilities
normally associated with tertiary institutions. Expectedly, therefore, they
are most likely to possess a more sophisticated view of quality of care, one
that encompasses structure, process and outcome of care. Overall, we expect
respondents’ educational level to influence their assessment, though such
expectation was not explicitly investigated in this present work.

Patient Satisfaction Indices in the Three Locations

Table 2 presents the mean score values and standard deviation (SD) of the
satisfaction indices for the quality attributes of health care for each of the
facilities. The table demonstrates that the majority of persons utilising
these health centres/clinics are moderately satisfied with their health care
services, except for the facilities in location ‘I’, which is rated below average
with their men folk (2.92). This opinion may have been occasioned by
the responsiveness and willingness of the health personnel which is, to the
men, considered below their acceptable level. Interestingly, the responses of
females are quite different with respect to their overall satisfaction with the
care offered in this facility, ‘I’, and responsiveness of the health workers.
Those who considered the services in these facilities as qualitative might
seek help from these facilities sooner and use more of the centres/clinics

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 Table 2
Mean Score and Standard Deviation (SD) of Health Care Quality Satisfaction for the Health Centres/Clinics

Health centre I Health centre T Health centre G

Mean SD Mean SD Mean SD
Factor M F M F M F M F M F M F
Overall general satisfaction with care 2.92 5.00 1.71 2.00 4.70 4.72 2.02 1.66 4.18 4.61 1.82 1.45
N= 12 23 27 43 34 44
Service effectiveness or Outcome 3.45 4.74 1.76 1.56 4.19 4.30 1.51 1.55 4.12 3.95 2.02 2.19
N= 12 23
Responsiveness to patients 2.94 4.89 2.23 1.91 4.27 4.79 1.51 1.72 5.00 4.96 1.46 1.33
N= 17 18 26 44 34 44
Perceived competence of health workers 4.08 4.83 1.28 1.15 4.22 3.79 1.95 1.75 4.59 3.93 1.47 1.59
N= 12 23
Health personnel empathy 4.25 4.61 1.96 1.95 4.00 4.21 1.73 1.60 4.82 4.57 1.83 1.38
N= 12 23
Access to health care service 4.58 4.57 1.79 2.07 4.67 4.23 1.71 1.32 4.06 4.83 1.53 1.74
N= 12 23
Health personnel courtesy 5.06 4.20 2.36 2.27 4.56 4.12 1.87 1.81 4.82 4.57 1.64 1.66
15 20 27 43 34 44
Physical Facilities employed in care 4.30 4.43 1.85 1.97 4.81 4.49 1.52 1.74 3.68 4.52 2.33 2.04
N= 12 23 27 43 36 42

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Note: 1 = low satisfaction; 7 = high satisfaction.
 Quality Attributes of Primary Health Care Services in Nigeria 47

services than those who are dissatisfied. These dissatisfied individuals, given
the environment, may choose to use traditional healers or forgo medical
attention.
Possession of adequate knowledge, experience shows, does not ensure
its application to the care of patients. It is needful that care providers com-
municate with their patients some understanding of the diagnosis and
treatment in order to enlist their cooperation and minimise their distress.
Respondents’ perception and satisfaction with the knowledge and ability of
the health personnel in locations, T and G, appeared slightly below average
with the female respondents; in any case, these females showed greater uti-
lisation of these facilities on account of their health and their children’s health
needs. Respondents, from Table 2, demonstrated sensitivity to the quality
attribute of the services providers, especially factors relating to the providers’
technology which is usually low at the PHC facilities in the country, making
the assessment of the human-related factors all the more important.

Correlations Results of Satisfaction with Care Service Attributes

Respondents overall general satisfaction with health care was correlated with
service quality attributes for each of the facility evaluated. The result is as
shown in Tables 3 and 4.
In each of the facilities, a fair relationship exists between respondents’
satisfaction with care and the outcome experienced from service encounter.
The association was as high as 0.585 (facility G); 0.467 (facility T); and
0.417 (facility I). In addition to service effectiveness, the responsiveness
of personnel in these health care centres seem to show a similar pattern of
association with satisfaction in all the centres; the physical facility employed
in care and access to these centres and health care personnel showed a rather
low but positive association with satisfaction. Generally, service effectiveness
(that is improved health status of individuals), which has a capacity of bringing
about confidence in the health centres services to altering health for better;
facilities (equipment, physical facilities and appearance of health personnel);
responsiveness (promptness of health staff to serve and attend to patients); and
access, that is, ease of contact with required health personnel for services,
have associations, though low in some cases, with the satisfaction of the
respondents. A plausible explanation for the low but positive association is
that rural dwellers are primarily concerned with quick restoration of their
health and have lower expectations about the sophistication of care facilities

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 Table 3
‘Composite Data’ and Location G

Variables Overall satisfaction Outcome Responsiveness Competence Empathy Courtesy Access Facility Sex
Overall satisfaction 1
Efficiency 0.509 1
(0.585)
Responsiveness 0.242 0.473 1
(0.339) (0.445)
Competence 0.78 0.227 0.413 1
(0.144) (0.195) (0.243)
Empathy 0.166 0.221 0.351 0.420 1
(0.388) (0.328) (0.399) (0.478)
Courtesy 0.015 0.071 0.215 0.210 0.334 1
(0.112) (0.209) (0.206) (0.249) (0.367)
Access 0.215 0.126 0.140 0.268 0.285 0.267 1
(0.316) (0.165) (0.140) (0.427) (0.284) (0.252)
Facility 0.237 0.263 0.226 0.235 0.245 0.233 0.428 1
(0.396) (0.374) (0.242) (0.167) (0.171) (0.173) (0.36)
Sex 0.082 0.007 0.041 –0.126 –0.021 –0.097 0.036 0.109 1
(0.159) (–0.047) (0.053) (–0.171) (0.128) (–0.067) (0.13) (0.211)

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Notes: (a) Correlations with location G (r) scores in bracket.
(b) Most of the correlation is significant at the 0.01 level and 0.05 level (2-tail).
 Table 4
Location T and I Correlation Matrix

Variables Overall satisfaction Outcome Responsiveness Competence Empathy Courtesy Access Facility Sex
Overall satisfaction 1
Outcome 0.47 1
(0.42)
Responsiveness 0.08 0.39 1
(0.36) (0.76)
Competence –0.02 0.18 –0.42 1
(0.15) (0.45) (0.70)
Empathy 0.10 0.09 0.25 0.28 1
(–0.13) (0.19) (0.46) (0.59)
Courtesy –0.07 –0.12 0.04 0.02 0.29 1
(–0.02) (0.11) (0.44) (0.47) (0.37)
Access 0.13 –0.12 –0.00 0.24 0.27 0.27 1
(0.16) (0.38) (0.38) (0.05) (0.30) (0.28)
Facility –0.04 –0.03 0.06 0.31 0.34 0.34 0.43 1
(0.16) (0.38) (0.47) (0.29) (0.49) (0.23) (0.59)
Sex 0.00 0.05 0.09 –0.12 0.08 –0.18 0.18 0.17 1
(0.049) (0.01) (0.12) (–0.02) (0.20) (0.20) (0.00) (0.20)

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Notes: (a) Location I scores are in brackets.
(b) Correlation is significant at the 0.01 and 0.05 level (2-tail).
50 Abolaji Joachim Abiodun

employed. In addition, little knowledge of and infrequent contact with the

health professionals may make them overlook disagreeable responsiveness
of the health care personnel. Again, other considerations in health care may
have been taken as secondary to what they could immediately link with their
economic well-being.

Regression Result of Satisfaction with Care Services Attributes

The results of multivariate regression on care satisfaction are as shown in

Table 5. The results show that service effectiveness, providers’ empathy and
access to health care services were significant determinant of satisfaction with
the health care in location G.
In location T, only service effectiveness and access to care appeared to
be a significant determinant of satisfaction with care in the health centre
located in that community. However, for community housing facility, I—the
smallest in terms of population and facilities—providers’ empathy ranks as
the singlemost significant determinant of care satisfaction; even then, it seems
to negatively affect satisfaction. The failures of personnel in this facility on
empathy rather negatively influence respondents’ satisfaction with care.
The low association of provider’s competence, that is, the skills, knowledge
and ability of the providers to perform required services, r = 0.152 (facility I),
–0.02 (facility T) and 0.144 (facility G), and the insignificance of its regression
score is indicative of defective technical skills on the part of providers or the
providers’ inability to communicate their understanding of the diagnosis and
treatment in order to enlist the cooperation and minimise the distress of the
respondents. ‘The result has been lack of faith’ in the numerous lower level
facilities and overcrowding of the secondary facilities due to the fact that
some patients who should not ideally go there are there.
Generally, most human resource-related variables of quality of service
(courtesy on the part of health care providers, health personnel’s empathy
and responsiveness to patients) were found out to be either insignificant or
to impinge negatively on satisfaction with care. A cause for worry exists at
the lower level facilities, with the emphasis on community involvement in
management and resource contribution. In addition, effective caring and
diagnosis depend significantly on providers’ interpersonal skills, especially in
‘history-taking’ process of diagnosis and securing patients’ compliance. The
poor perception of the technical competence of the health personnel may
have been occasioned by their failures on these quality attributes.

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 Table 5
Regression Results of the Variables by Health Centres

Estimated Standard error Significance

Variables T G I T G I T G I
Intercept 2.421 1.668 2.396 1.16 0.636 1.694 00 0.01 0.00
Efficiency 0.549 0.496 0.177 0.122 0.075 0.354 00 0.0 0.622
Responsiveness –0.0768 0.013 0.373 0.133 0.090 0.429 0.565 0.882 0.393
Competence –0.154 –0.012 0.193 0.122 0.082 0.387 0.212 0.214 0.622
Empathy 0.0801 0.059 –0.454 0.127 0.079 0.262 0.523 0.459 0.095
Courtesy –0.0901 –0.070 –0.108 0.117 0.069 0.182 0.444 0.311 0.556
Access 0.223 0.168 0.0839 0.131 0.079 0.242 0.080 0.036 0.732
Physical facilities 0.0188 0.055 0.0844 0.123 0.068 0.239 0.883 0.429 0.727
Sex –0.104 0.173 0.269 0.396 0.246 0.762 0.794 0.487 0.727

Note: I: R-square = 0.278; T: R-square = 0.291; G: R-square = 0.301.

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52 Abolaji Joachim Abiodun

Recommendations and Conclusion

Providers’ characteristics were linked with consumers’ satisfaction with care

in order to see which characteristics can be accorded recognition in the care
value system at the primary level. In doing so, providers may be encouraged
to modify their behaviour in the path of those characteristics that make for
consumers’ satisfaction. The results of this study show that a reasonable
association exists between care satisfaction and outcome of care. An indication
of a prevailing concern to maintain or regain health, this concern appears
reasonable given the uncertainty regarding a guaranteed income in the rural
communities which usually demand immediate return to work. From this
study, it seems rational to encourage empathy among the health personnel,
and possibly, when choosing new entrants into primary care training pro-
gramme and/or when the need for promotion to higher cadre arises, a measure
of empathy should be used as a criterion for selection.
Medical training, professional examinations for licensure or board certi-
fication should ordinarily be counted sufficient for equipping health workers
with the required skills, knowledge and ability to perform required health care
services. That is sufficient to equip them with the required skills, knowledge
and ability to perform required health care services. But, it would appear
that there are some implications for public policy decisions from this study,
especially in the area of health personnel attitude change and training. A
battery of training modules (included as part of college training) focused
on inculcating or stirring politeness, considerations, kindness, interest in
patients’ general well-being, readiness to help and direction of such attitude
to care is required, especially at the primary care level facilities. A policy of
attitudinal change on the part of health personnel is necessary in order to
improve perceptions of care in the health centres.
Planning efforts need to devote careful attention to facilities employed for
health care delivery at the primary level, while health care personnel need to
communicate their technical skills in application. Again, the management
of personnel and physical facilities should be with a conscious focus on pro-
jecting the key attributes sought by users as evidence of quality of care. This
is required if capacity utilisation at the primary care level has to be increased
and the secondary level facilities decongested for the good of the Nigerian
health delivery systems.

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 Quality Attributes of Primary Health Care Services in Nigeria 53

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Abolaji Joachim Abiodun is at Department of Business Studies, Covenant University, P.M.B

1023, Ota, OgunState, Nigeria. E-mail: abijoac@yahoo.com

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