Aabstract

Background

Tuberculosis (TB) is a second major global public health problem and the leading infectious cause of death in Ethiopia. Patients under directly observed treatment short-courses (DOTs) have a higher treatment success rate and reduced drug resistance. A successful treatment outcome and adherence to the treatment are related to patient satisfaction with the DOT strategy. Client satisfaction is one of the indicators of the quality of care. In this perspective, there were limited studies in Ethiopia related to patient satisfaction with the DOTs strategy in the prevention and control of TB to achieve the 鈥樷�橢ND TB Strategy.鈥欌�� Therefore, this study was aimed at identifying the TB patients鈥� satisfaction with the DOTs strategy and associated factors in Gamo Zone, Southern Ethiopia.

Methods

An institutional-based cross-sectional study design for quantitative data and a phenomenological approach were employed for qualitative data. The calculated sample size was 374. A systematic random sampling method was used to select study participants. A pre-tested structured interviewer-administered questionnaire for quantitative data and focus group discussions (FGDs) for qualitative data were used for data collection. Bivariable and multivariable analyses were used. The determinants with a p-value鈥�<鈥�0.05 were declared to have a significant association with the outcome variable, and an adjusted odd ratio with a 95% confidence interval (CI) was used.

Results

A total of 358 patients participated in the study, with a response rate of 95.72%. The majority of study participants鈥� ages ranged between 25 and 34 years. The tuberculosis DOT satisfaction rate was 61.17% [56.10-66.25%, 95%CI]. The TB patients who took treatment for 20 weeks or more were 3.97 times [AOR鈥�=鈥�3.97; 95% CI (1.55鈥�10.16)] more likely to be satisfied with the DOTs service provided. However, the participants who perceived transport costs as high were 79% [AOR鈥�=鈥�0.21; 95% CI (0.06鈥�0.71)] less likely to be satisfied with DOTs. Qualitatively, the participants reported that there was a major problem with laboratory services, which resulted in delays and long appointments to get the results in addition to lack of clean toilets and safe water to swallow medications.

Conclusion

The satisfaction rate for tuberculosis DOTs observed in this study appears to be relatively lower in comparison to other studies. Availing DOTs service nearby patients to enhance the accessibility of the service is crucial to improving patients鈥� satisfaction with DOTs service. Reducing laboratory result delays by improving laboratory service is essential to enhancing patients鈥� satisfaction with DOTs. Moreover, improving toilet services, and availing safe water to swallow medications is recommended to enhancing patients鈥� satisfaction with DOTs service.

Introduction

Worldwide, Tuberculosis (TB), curable and preventable disease, is the second leading infectious killer after COVID-19 (above HIV and AIDS) [1].

According to the World Health Organization鈥檚 (WHO) global TB report, an estimated 10听million people were ill with TB, with an estimated 1.2听million and 251,000 deaths among HIV-negative and HIV-positive people, respectively [1].

It is estimated that 2.5听million people fell ill with TB in the African and continues to be a significant public health problem which accounts for 23% of new case and 31% of TB-related deaths [2].

Ethiopia is among the countries with the highest TB burden [3]. Even though TB deaths have dropped significantly, it is still continued to be the leading infectious killer in Ethiopia [4, 5].

The Directly Observed Treatment Short-course (DOTs) strategy is a global and effective TB control approach that was declared in 1994 [6], has been believed to be a cornerstone, and remains a central pillar in improving treatment success, enhancing treatment adherence, controlling drug resistance, strengthening the health system, and engaging health care providers [7, 8]. The DOTS strategy has five-component package: political commitment, diagnosis using sputum smear microscopy, regular supply of TB drugs and laboratory, short-course chemotherapy, and standard system for recording and reporting the number of cases and treatment outcome [9].

According to the studies that were conducted in India, the level of satisfaction of the study participants towards TB services ranged from 76 to 87% [10,11,12]. Other studies in Uganda showed that 91% of the study participants were satisfied with the TB services provided to them [13]. Besides, studies in Ethiopia pointed out that the satisfaction level of DOTs ranged from 67 to 91% [14,15,16].

Health facility structure-related, process-related (facility service delivery system)-related, and outcome-related factors can affect satisfaction with DOTs service [17]. Accordingly, previous studies revealed that structure-related factors such as access to TB services nearby [12, 15, 18]. treatment room privacy, safety of the facility, and easy access to refill drugs [13, 15] were associated with the DOTs satisfaction. In addition, process-related factors such as a friendly and caring attitude of health care providers [19], waiting time, explanation and response to the questions, and skills of the health care providers have been associated with patient satisfaction with the DOTs strategy, according to reports from Ethiopia [15], Uganda [13], and Nigeria [12]. Symptom reduction after taking the treatment was also related to satisfaction with DOTs [15]. On the other hand, treatment interruption, poor adherence to the treatment, and deviance from the treatment were related to dissatisfaction with the DOTs strategy [13, 14].

Measuring a patient鈥檚 satisfaction with a health care service is a major concern for a treatment that requires long follow-up [10]. However, there was limited evidence with regards to TB patients鈥� satisfaction with the DOTs strategy in Ethiopia, particularly in southern Ethiopia. Thus, this study was aimed at identifying the level of TB patients鈥� satisfaction with the DOTs strategy and associated factors in public health facilities in Gamo Zone, Southern Ethiopia.

Methods and materials

Study area

The study was conducted in public health facilities in Gamo Zone, South Ethiopia Regional state. According to the 2007 census conducted by the Central Statistical Agency of Ethiopia, the zone has a total population of 1,123,388 with 558,297 (49.7%) of men, 565,091 (50.3%) women [20]. The Zone is composed of 14 districts with administrative town of Arba Minch, which is located 495听km (km) from Addis Ababa. There were one general hospital, four primary hospitals, and fifty-six health centers in the Gamo zone.

Study design and period

A facility-based cross-sectional study design for quantitative data and a phenomenology study approach for qualitative data were used from January 1 to June 30, 2021.

Source population

All TB patients under DOTs service in public health facilities in the Gamo zone.

Study population

All TB patients who had been registered for DOTs service in public health facilities in the Gamo zone and fulfilled inclusion criteria were study population.

Eligibility criteria

All TB patients aged 15 years and older and those under directly observed treatment for at least two weeks were included. And seriously ill patients were excluded from the study.

Sample size determination for quantitative data

The sample size was determined by a single population formula with the following assumptions: 5% margin of error, 95% confidence level, and satisfaction level from the previous study in Addis Ababa [15]. Based on these assumptions, the calculated sample size was 374 after considering a 10% non-response rate.

$$\:n = \frac{{{{\left( {Z{\alpha _{/2}}} \right)}^2}.\:\:pq}}{{{d^2}}}$$

Where:

n鈥�=鈥塪esired sample size.

p鈥�=鈥塧ssumed proportion of satisfaction level from the previous study.

q鈥�=鈥�1- p.

伪 (level of significance or committing type one error鈥�=鈥�5%).

Z (The standard normal curve at 95% CI and 5% level of significance鈥�=鈥壜扁��1.96 (two sided).

W (Margin of error or the deference in population and sample estimates鈥�=鈥�5%).

n= (1.96)² * 0.67 * 0.33)/ (0.05)².

n鈥�=鈥�340.

Expecting a 10% non-response rate, the final sample size calculated was 374.

Sampling procedure for quantitative data

Gamo Zone has four town administrations and 14 districts. In this zone, there was one general hospital, four primary hospitals, and 56 health centers providing DOTs service. About 40% of the facilities were selected randomly from each level. The proportional allocation of the sample was made in selected health facilities. For a proportional allocation of the sample for each health facility, the facility鈥檚 annual patient load was obtained from the preceding year. Accordingly, a monthly patient flow was estimated. The study respondents were selected using a systematic random sampling method as follows in (Fig.听1).

Fig. 1

Sampling procedure for selecting study participants in public health facilities Gamo zone, Ethiopia 2021

Study design for qualitative data

A qualitative study method was employed to gain a comprehensive understanding of DOTs strategies by gathering insights from multiple viewpoints within a group setting to complement the quantitative study.

Sample size determination for qualitative data

A total of 48 participants were involved in eight FGDs, each group containing six participants.

Operational definitions and measurements

Directly observed treatment (DOT)

is watching the patient taking every recommended or scheduled dose in the right combinations, on the correct schedule for the appropriate duration though help of TB treatment supporters [15, 21].

Patient satisfaction

the feeling of the TB patient and his or her perception of TB care services with the DOTS strategy [15].

Donabedian model

The modern model for improving health care quality is used to measure health care quality by categorizing it into three categories [17].

Health facility structure:

an environment in which health care is provided.

A health facility service delivery system (process)

is a method of providing health care services.

Outcome

a result of health care.

Satisfaction measurement

It was measured by a Likert scale which contains 23 items. Each item contains a score of a five-point scale ranging from 1 (very dissatisfied) to 5 (very satisfied) i.e. (1鈥�=鈥塻trongly dissatisfied, 2鈥�=鈥塪issatisfied, 3鈥�=鈥塶eutral, 4鈥�=鈥塻atisfied, 5鈥�=鈥塻trongly satisfied). The respondents with a score of less than the mean were classified as dissatisfied, and those with a score of mean value and above were considered satisfied [15, 22].

Seriously ill patients

Included TB patients with; life-threatening disease鈥�=鈥塧cute disseminated miliary TB, TB meningitis or TB peritonitis; Risk of severe disability鈥�=鈥塻pinal TB, TB pericarditis, bilateral TB pleural effusion, renal TB; Extensive X-ray lesions without cavitation in immune-compromised patients, e.g., diabetics, HIV-positives, or patients with other concomitant disease.

Data collection methods and tools

For quantitative data

A pre-tested, structured interviewer-administered questionnaire adopted from the previous study [15] was used for data collection. Amharic version of the questionnaire was used for data collection. The data were collected by BSc nurses and BSc public health care personnel, and experienced MSc public health personnel supervised the data collection. Two days of training were given to data collectors and supervisors on the purpose of the study and how to interview study participants. The data collection instrument contains 23 items with a 5-point Likert鈥檚 scale, where the level of satisfaction ranges from strongly dissatisfied to strongly satisfied, 1 to 5. The items were categorized into three based on the Donabedian quality healthcare model [17]. Accordingly, 10 items focus on the structure, 10 items on the process, and 3 items on the outcome.

For qualitative data

The data were collected through focused group discussions (FGDs). The FGDs were conducted by the investigators. FGDs were recorded both on audiotape and in handwriting. The audiotape was then transcribed.

Data processing and management

For quantitative data

The data were collected using the Kobo Toolbox and analyzed by Stata 14. The descriptive statistics were performed. Frequency and percent were used to present categorical predictors. Binary logistic regression analysis was performed to see the combined effect of predictors on patients鈥� satisfaction and to select potential candidates for the final model; variables with a P-value of 鈮も��0.25 in the bivariable analysis were passed to the multivariable logistic regression analysis. A multivariable logistic regression analysis was performed to identify the independent effects of predictors on outcome variables. The factors with P鈥�<鈥�0.05 were considered to have a significant association with satisfaction with the DOTS strategy, and adjusted odd ratios with a 95% confidence interval (CI) were used to measure the degree of association.

For qualitative data

The field notes and audio that were collected in Amharic were translated and transcribed verbatim to English by the investigators and other TB experts. The collected data were transcribed, and emerging ideas were listed without strict sequences. The codes and subthemes/categories for the listed ideas were created. Themes were generated from those categories. Thematic analysis was done.

Data quality assurance

A pre-test was conducted by taking 5% of the sample size outside of the study area before the actual study. Based on the pre-test results, the questionnaire was adjusted contextually and terminologically and administered to the study population. Collected data were checked for completeness, and consistency; daily close supervision was maintained.

Results

Socio-demographic characteristics

A total of 358 patients participated in the study, with a response rate of 95.72%. Of the total study participants, 233 (65.1%) and 125 (34.9%) were males and females, respectively. The majority of study participants鈥� ages ranged between 25 and 34 years. Two hundred ten (58.66%) of the study participants were rural residents, and 99 (27.65%) of the participants had no formal education, whereas nearly one-third of participants had secondary education (Table听1).

Table 1 Socio-demographic characteristics of the tuberculosis patients with directly observed treatment short-course strategy in Gamo Zone public health facilities (N鈥�=鈥�358), 2021

Health and treatment-related characteristics

Nearly two-thirds of the study participants, 233 (65.08%) traveled鈥夆墹鈥�30听min to get service from a nearby health facility. Among study participants, 41.06% and 41.62% were on TB treatment for 2鈥�8 weeks and 9鈥�19 weeks, respectively. Three hundred and fifteen patients (87.99%) had treatment supporters. Of those, 173 (54.92%) chose a family member as their treatment supporter (Table听2).

Table 2 Health-related characteristics of the tuberculosis patients with directly observed treatment, short-course strategy in Gamo Zone public health facilities (N鈥�=鈥�358), 2021

Factors related to TB treatment service satisfaction

Among the three service categories (structure, process, and outcome) used to assess the overall satisfaction of the DOT strategy, the majority of the patients were satisfied with the services provided to them and the health care providers鈥� interactions, facility-related information, and treatment outcomes they gained after starting TB treatment.

Health facility structure-related factors

More than two-thirds of the participants were satisfied with the availability of the necessary equipment, drugs, and laboratory reagents to treat TB. The highest level of patient satisfaction was recorded regarding the treatment room鈥檚 privacy. However, a relatively lower level of satisfaction was noted for the availability of signage and directions on where to go in the health facility (Table听3).

Table 3 Structure-related measuring item of tuberculosis patients with directly observed treatment, short - course strategy in Gamo Zone public health facilities, 2021

Health facility service delivery system (process) related factors

The findings revealed that the lowest level of satisfaction was documented on 鈥樷�檋ealth care providers (HCPs) used medical terms without explaining what they meant.鈥樷�� However, the highest level of participant satisfaction was recorded in the explanation and response of HCPs to patient questions and HCPs鈥� ability to diagnose, treat, and care for TB (Table听4).

Table 4 Process-related measuring item of tuberculosis patients with directly observed treatment, short - course strategy in Gamo Zone public health facilities, 2021

Outcome related factors

A nearly comparable proportion of the study participants were satisfied with the TB symptoms reduction rate and physical and psychological well-being gained due to TB treatment (Fig.听2).

Fig. 2

Outcome measuring item of tuberculosis patients with DOTs strategy in selected health facilities, 2021

Factors associated with TB patient鈥檚 satisfaction with the DOTS strategy

In binary logistic analysis, age, occupation, time to travel to the health facility, duration of the treatment, perceived transport cost, TB treatment supporter, type of TB, and perceived time spent with a health care provider were associated with the outcome variable at a p-value of 鈮も��0.25. However, only the duration of treatment and perceived transport cost were significantly associated with the outcome variable at p鈥�<鈥�0.05 in the multivariable logistic regression model.

The TB patients who took treatment for 20 weeks or more were 3.97 times [AOR鈥�=鈥�3.97; 95% CI (1.55鈥�10.16)] more likely to be satisfied with the DOTs service provided in public health facilities compared to their counterparts. On the other hand, the patients who spent high transportation costs to get service to the health facilities were 79% [AOR鈥�=鈥�0.21; 95% CI (0.06鈥�0.71)] less likely to be satisfied with DOTs as compared with those who spent low and medium costs to travel (Table听5).

Table 5 Multivariable logistic regression for the factors associated with TB treatment satisfaction with DOTs strategy in Gamo Zone public health facilities, 2021

Qualitative study findings

Characteristics of focus group participants in qualitative study

A phenomenological approach was employed to generate qualitative data, where eight focus group discussions (FGD) were conducted, with each group consisting of six members. The mean age of the FGD was 35 years. Each group was composed of males and females. A total of 20 female participants were involved in the FGDs. The participants were selected from the intensive and continuation phases of the treatment. The interview guide questions, or probing questions, were 鈥淲hat do you explain about your comfortableness with the registration room, laboratory, and treatment room? How do you explain the TB care you received at this health facility? What do you tell us about health care workers welcoming and respecting you when you receive care? How do you feel now after taking anti-TB medicine? And what do you suggest for TB treatment service improvement?鈥� These provoking or leading questions, initially developed in English from different literatures [14, 15, 17] were translated and transcribed verbatim by the researcher and other TB experts into Amharic versions before conducting the interview. Since the qualitative interview in the current study was aimed at providing supplementary information, the researchers mainly relied on quantitative work to discuss the current study findings.

DOT satisfaction

Five themes were identified by the focus group participants. Theme I: deals with registration and laboratory service. Theme II: reviews facilities stand in the selected healthcare institutions (toilets and safe water). Theme III: discusses TB clinic care and service. Theme IV: emphasizes improvement after starting to take anti-TB medication. Theme V: explores suggestions for service improvement to enhance TB DOT satisfaction.

Theme I: Registration and laboratory service

From Five themes of FGD identified to assess patients鈥� satisfaction with DOTs Strategy, major problems were reported regarding registration rooms and laboratory service. The Patients generally indicated there were long waiting times at the registration areas, long appointment systems, and result delays were the frequent problems.

One participant explained: 鈥淭here is a problem in the laboratory. The lab result was not given on time. I stayed for 12 days to get the result and suffered a lot for a single result.鈥�

The other respondent added, 鈥淚 agree with what he said鈥� I came here on the first day of December, and until the 12th of the month, they gave me an appointment for the laboratory result, but they didn鈥檛 solve my problem.鈥�

Theme II: Facilities stand in the selected healthcare institutions (toilets and safe water)

The focus study participants explained that the main problem related with facilities was getting clean toilets and the availability of safe water to swallow medications. A few participants argued that they did not know where the toilet was and where the water avails for swallowing the medications. The respondent explained the inconvenience as: 鈥淭he toilet condition is not good. I prefer not to use the toilet because, post-toilet, most of the time even it causes me abdominal discomfort.

The focus study participants explained lack of clean toilets and safe water to swallow medications. The respondents explained that though there were improvements in symptom reduction after onset of TB treatment but there is no water to take the drugs and clean toilet, which enables us to use near to the treatment room. The respondent explained the premise inconvenience as: 鈥淔or truth, nobody can use the toilet because of its unpleasant smell and uncleanness. I can assure it is not good for patients even for those healthy personnel. I should have to go to Cafeteria or hotel to empty my colon since there was no convenient toilet.鈥�

The respondent also added 鈥淭he other problem is lack of water to clean hands, and to take medicine.鈥�

Another respondent explained the water problem as follows: 鈥淭hey add water into the tanker where many people put their hands on it. There is no clean water to take medicine, and to clean hands after rest room.鈥�

Theme III: TB clinic care and service

The discussants stated that the healthcare providers in TB clinics were welcoming and friendly.

Most patients reported having friendly relationships with health care service providers at the TB clinics. Participants further said they benefited from the information they obtained from professionals on duration and side effects of treatment, risks of non-adherence as well as dietary practices to follow and habits to avoid. Many of the participants declared that 鈥渢he care we get here is wonderful, and the providers gave us the advice we wanted in a way we understood.鈥� A few discussants stated that 鈥渆ven if the clinics get closed during regular appointments after the phone call, they will come soon after they call to provide the service and counseling they require.鈥�

Theme IV: Improvement after starting anti-TB medication

The study focus group participants stated, 鈥淲e get symptom relief; the symptoms reduced from day to day, our weight increased, our appetite improved, and we are psychologically well soon after starting the medications.鈥樷�� Besides, many of the participants reported that they did not experience major problems associated with taking medications.

Theme V: Suggestion for service improvement

The discussants suggested the services at registration and the laboratory should be improved to enhance TB-DOT client satisfaction. They forwarded the idea that priority should be given to TB patients, or if possible a separate TB laboratory service room established or considered. The suggestions were explained by the respondent: 鈥淚鈥檓 still going to request the lab service improvement and water availability. Another discussant added, 鈥淚 am satisfied from the side of HCPs because I don鈥檛 stay for more than 15 minutes. I took my medicine and advice they give within 10 minutes鈥�. 鈥淢y main comment would be regarding Laboratory service delivering system I kindly request concerning bodies to improve and give priority to the lab.鈥�

Discussion

This study was aimed at assessing tuberculosis patients鈥� satisfaction with directly observed treatment short-course strategy, and associated factors in southern Ethiopia, with a total of 358 participants included. The study findings showed that the proportion of the patient satisfaction rate was 61.17% [56.10-66.25%, 95%CI], and the TB patients who took treatment for 20 weeks or more were satisfied with DOT service. However, those who perceived high transport costs were less likely to be satisfied with the service.

The finding of this revealed that the satisfaction rate of DOTS service was 61.17% [56.10-66.25%, 95% CI]. This finding was lower when compared to other study findings in Ethiopia, [13, 14], Uganda [13], and India [9, 10, 15]. The discrepancy may be due to study health facility variations, where the current study included peripheral health centers that were sited in different geographic locations in the zone. Besides, the variation may be due to health care workers鈥� capacity and motivation level [19].

Similar to the previous study finding [22], waiting areas, safety of seats, and easy access of the HCPs to refill patients鈥� medication were identified as structure-related factors that lead to patient satisfaction.

However, the lack of signage and direction guidance on where to go in the health facility, 66 (18.44%), and the lack of cleanliness and poor working order of latrines, 46 (12.85%), were attributes of patient dissatisfaction. In contrast to the study conducted in Kampala, Uganda [13], the current study showed the highest patient satisfaction regarding treatment room privacy (66.76%).

Different study findings [11, 12, 14] revealed that the friendly and caring attitude of health care workers, short waiting times, explanations, and responses to the questions and skills of HCPs were stated as factors for the highest patient satisfaction. However, in this study, the appointment system to follow up and the allotted time of HCPs to check clinical conditions were found to be attributes of patient satisfaction, whereas using medical terms without explaining their meanings and spending an extensive amount of time with registration were stated as process-related causes of dissatisfaction in this study.

Like other studies [14, 18], in this study, the duration of treatment for 20 weeks and above and perceived transport cost were significantly associated with patients鈥� satisfaction with directly observed treatment short course strategy.

The TB patients who took treatment for 20 weeks or more [AOR鈥�=鈥�3.97; 95% CI (1.55鈥�10.16)] were 3.97 times more likely to be satisfied with the DOTS service compared to their counterparts. This study finding is supported by previous study findings [13, 15, 23] where patients with increased treatment duration and those with improvement in symptom reduction are more likely to be satisfied with DOTS services.

The patients who spent high transportation costs to get service to the health facilities were 79% [AOR鈥�=鈥�0.21; 95% CI (0.06鈥�0.71)] less likely to be satisfied with DOTS as compared with those who spent low and medium costs. The possible explanation for this is the fact that since the study area included hospitals and health centers with different geographical locations and less road accessibility, the patients might be exposed to high transport costs, which may lead to patients鈥� dissatisfaction with the DOT strategy. This finding is also supported by study conducted in Addis Ababa Ethiopia where participants dissatisfied due to making a daily visit to health facilities for DOT service due to the distance of the facilities from their residences, lack of or high transportation cost [21].

Another possible reason could be, although TB services are supposed to be provided free of charge, TB affected families spend different types of costs in the process of seeking care, which might include health and non-health related costs which might lead them to dissatisfaction [24].

The quantitative approaches highlighted, similar to the study conducted in Ethiopia [14, 15], the study shows that satisfaction level of patients with TB are influenced by on time availability and good reception of HCP, provision of information and respect to the patients and waiting time.

However, current study shows delay in laboratory result, lack of clean toilets and safe water to swallow medications as major factors of tuberculosis DOTs strategy dissatisfaction.

Conclusion

The tuberculosis DOTs satisfaction rate in this study was lower than in other studies. The TB patients who took treatment for 20 weeks or more were more likely to be satisfied with DOTs. However, the participants who reported a perceived high transport cost were less likely to be satisfied with DOTs. In the qualitative report, the participants indicated that there was a major problem with laboratory services, which resulted in delays and long appointments to get the results besides lack of clean toilets and safe water to swallow medications. Enhance the accessibility of the DOTs service to the community level and minimizing laboratory result delays is crucial to improve patients鈥� satisfaction with DOTs strategy. Moreover, improving toilet sanitation, and availing safe water in health facilities to swallow medications is recommended to enhancing patients鈥� satisfaction with DOTs service.

Data availability

All relevant data in the current study is available in the submitted manuscript.