Evaluation of patients with schizophrenia satisfaction with out-patient care: a comparison of two diverse psychiatric settings in Nigeria

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JOURNAL OF BEHAVIORAL HEALTH, 2019
VOL 8, NO. 2, PAGE 48–56
10.5455/jbh.20190121103746
ORIGINAL RESEARCH Open Access
Evaluaon of paents with schizophrenia sasfacon with out-paent care:
a comparison of two diverse psychiatric sengs in Nigeria
Adetunji Obadeji1, Victoria Ire Elegbede2, Lateef Olutoyin Oluwole1
1Department of Psychiatry, Eki State University Teaching Hospital, Ado-Eki, Nigeria
2Psychiatric Unit, Ace Medicare Clinics, Ota, Nigeria
Contact Adetunji Obadeji doctunjioba@yahoo.com Department of Psychiatry, Eki State University Teaching Hospital,
Ado-Eki, Nigeria.
© 2019 The Authors. This is an open access arcle under the terms of the Creave Commons Aribuon NonCommercial ShareAlike 4.0
(hps://creavecommons.org/licenses/by-nc-sa/4.0/).
ABSTRACT
Background: Paent’s sasfacon with care is an important construct in determining
the quality of care and adherence to treatment. This study was aimed at comparing
the sasfacon level of paents with schizophrenia regarding the outpaent care in
community mental health seng with that of typical psychiatric hospital and idenes
factors accounng for any dierence.
Methods: This is a comparave cross-seconal survey of paents with the diagnosis
of schizophrenia aending the outpaent clinic of the Neuropsychiatric Hospital (NPH)
and the State Community Psychiatric Services Centre (OSCPSC), Oke Ilewo, both in
Abeokuta, Ogun State, Nigeria. Paents’ sasfacon was assessed using the Charleston
Psychiatric Outpaent Sasfacon Scale (CPOSS). Frequency distribuon, mean scores
with standard deviaons, independent t-test, and analysis of variance were calculated
as deemed appropriate. The level of signicance was set at p < 0.05.
Results: Out of the 260 paents sampled, 22 opted out, thus giving a response rate of
91.5%; 121 from NPH and 117 from OSCPSC. With the excepon of employment status,
the two centers did not dier signicantly on other socio-demographic variables. The
overall mean CPOSS scores for the respondents at NPH and OSCPSC were comparable
(p = 0.287). Meanwhile, parcipants at OSCPSC were signicantly sased more with
record ocers’ help, clinic hours, waing me, and cost of treatment (p < 0.05), while
parcipants at NPH were signicantly sased more with treatment center’s appearance
(p = 0.001). Similarly, paents with lower level of educaon and females parcularly those
from OSCPSC are likely to be sased more with their care than do other categories.
Conclusion: Although, paents’ overall sasfacon with out-paent care was found
to be similar in both sengs, paents aending OSCPSC enjoy easier access to care
and relavely lower cost compared with their counterpart at NPH, who were relavely
sased more with the appearance of the treatment center.
ARTICLE HISTORY
Received January 21, 2019
Accepted March 27, 2019
Published April 06, 2019
KEYWORDS
Paents’ sasfacon;
schizophrenia; community
care; out-paent;
psychiatric hospital; quality
of care
Introducon
Patient’s satisfaction with care is an important
factor in determining the quality of care and patient
adherence to treatment [1]. It is a key to evaluating
mental health system and the extent to which
outcomes are achieved [2,3]. Generally, there are
     
with health care delivery; hospital infrastructure,
waiting time before consultation, quality of
clinical services rendered, physical comfort, drug
availability, attitude of doctors and other health
care workers, emotional support, and respect for
patients’ preferences among others [4,5].
Among patients with mental illness, several
      
patients’ satisfaction. Of these, greater patient’s
      -
ated with patients’ demographics such as older age,
lower education, being married, and having higher
social status [6,7]. Nonetheless, one other study had

www.jbehavioralhealth.com 49
Evaluaon of paents’ sasfacon with out-paent care
reported no association with most demographic
variables [8]. Apart from patients’ demographic,
the diagnosis [9,10], treatment program [11,12],
the duration of the illness [13], patients’ expecta-
tion [14], and institutional characteristics such as
the hospital size are other important factors [15].
Patient’s satisfaction with care is also an important
factor in predicting default clinic attendance [16].
Varying global levels of patients’ satisfaction
to psychiatric services have been reported in the
literature [7,17–22], and these ranged from 39.3%
to 91.9% with the least reported in London and
the highest in South Africa. According to Yimer et
al. [22], in Ethiopia, the global satisfaction with
the psychiatric outpatient clinic was about 61%,
with the patients who were widowed, male, urban
dwellers, and those with poor social functioning
or with a diagnosis of schizophrenia likely to be
       
hand, no association was found between levels of
education, distance from the health service facility,
wealth index, and satisfaction with outpatient
psychiatric service in their study.
In a study looking at the determinant of patients’
satisfaction with their mental health care and
quality of life of adults of working age who were
receiving input from a community mental health
team in North Yorkshire [23], patients’ age and
their satisfaction in other areas of their lives such
as housing, money, and relationships predict
satisfaction with psychiatric service while gender
and duration of disorder were unrelated to service
satisfaction.
In Nigeria, most studies have reported high levels
of satisfaction with psychiatric services [8,20,21].
In a recent study among patients with schizophre-
nia, high level of satisfaction was reported in the
area helpfulness of the records clerk, helpfulness
of services received, and the overall quality of care
[8]. Nevertheless, low areas of satisfaction were
recorded on items relating to assessing the cost of
billing and waiting time. Waiting times and cost of
services have been reported as the major constraint
to quality service delivery in Nigeria and sub-Sa-
hara Africa [21,24].
In recent time, there has been move to de-insti-
tutionalized psychiatric care with an emphasis on
community care. Despite this move, psychiatric
service still takes place largely in major psychiatric
hospital in most developing nations. Nonetheless,
patient’s satisfaction with out-patient care has been
shown to predict the quality of life [8], hence the
outcome of care. A comparison of patients’ satis-
faction with outpatient care in a typical psychiatric
hospital and community care setting will provide an
insight into the quality of care in these two settings.
The objective of the present study was to deter-
        
level of satisfaction of patients with schizophrenia
attending an outpatient care at community psychi-
atric setting compared with those attending typical
psychiatric hospital, and those factors accounting
for any difference. It was hypothesized that patients
managed at a specialized center would display
higher satisfaction rates as a result of more inten-

Methods
Research design and seng
The study was a comparative cross-sectional survey
of patients who met the criteria for the diagnosis of
schizophrenia attending the outpatient clinic both
at the Neuro-psychiatric Hospital (NPH), Aro, and
the Ogun State Community Psychiatric Services
Centre (OSCPSC), Oke-Ilewo, both in Abeokuta,
Ogun State, Nigeria.
Study populaon
The outpatients of NPH, Aro, and the OSCPSC,
Oke-Ilewo were chosen for the study. The patients
were selected based on the following criteria: (i)
Diagnosed with schizophrenia by a Consultant
Psychiatrist and met ICD-10 criteria for schizophre-
nia based on the Diagnostic Criteria for Research
for ICD-10, (ii) had been attending the clinic for at
least 6 months (to ensure acquaintance with most
aspects of the clinic), (iii) absence of co-morbid
medical condition(s) that could disturb the patient’s
ability to comprehend or respond appropriately to
the questionnaire, and (iv) were clinically stable to
engage in the interview session, and (v) be in the
age range of 18–70 years.
The sample size was calculated using the statis-
tical formula for studying proportions with a popu-
lation <10,000 [25]. Based on this, a sample size of
260 was estimated, including an extra 10% and this
was shared equally between the two centers, that is,
130 subjects from each center.
Data collecon
A pro forma was developed to assess the socio-de-
mographic and clinical variables such as age, sex,
employment status, marital status, education,

50 J Behav Health • 2019 • Vol 8 • Issue 2
Adetunji Obadeji, Victoria Ire Elegbede, Lateef Olutoyin Oluwole
duration of attendance, and frequency of admis-
sion. Perception of patients’ satisfaction with the
outpatient clinic was assessed using the Charleston
Psychiatric Outpatient Satisfaction Scale (CPOSS).
        
point likert scale, with an E5 response format: 5,
excellent; 4, very good; 3, good; 2, fair; 1, poor; and
a “does not apply” option for all except the last item.
The last item is rated on a four-point scale (1 = Yes,

4 = No, Probably). It was developed at the Medical
University of South Carolina, Charleston, in the
United States of America [24]. The items on the
Charleston Psychiatric Outpatient Satisfaction Scale
(CPOSS) cover administrative, clinical/treatment,
and environmental areas. For purpose of clarity,
some of the items on the scale were reworded in
line with the nature of the service provided in the
Hospital. For example, helpfulness of the secretary
was readjusted to read Helpfulness of the Records
        
        
and services. The overall satisfaction was calcu-
lated from the sum of the 13 items excluding the
two anchor items. The reliability and validity of
the CPOSS have been reported in Nigeria [20]; the
    -
vergent validity ranged between 0.30 and 0.68.
Ethical consideraon
After explaining the purpose of the study to each
patient, a written informed consent was sought
and obtained from every participant. Likewise, eth-
ical approval was also obtained from the Research
Ethics Committee of the Neuropsychiatric Hospital,
Aro. Similarly, an approval to carry out the study
was also obtained from the Permanent Secretary
of the Ogun State Hospitals Management Board for
permission to carry out the study at the OSCPSC,
Oke Ilewo, and approval communicated through the
managing Psychiatrist.
Data analysis
Data were analyzed using Statistical Package for
Social Science version 17 (SPSS Inc.). Frequency
distribution was computed for socio-demographic
variables and mean scores and standard devia-
tions for CPOSS scores as deemed appropriate.
Patients’ socio-demographic and clinical variables
in the two centers were compared using chi-square.
Independent t-test was used to explore the rela-
tionship between the mean total CPOSS scores and
individual item of CPOSS score of patients from the
two centers while the mean CPOSS score of various
categories under socio-demographic and clinical
variables of the respondents from the two centers
were compared using analysis of variance (ANOVA).
p < 0.05.
Results
General measures

criteria were approached at both centers. A total of
238 responded and completed the interview trans-
lating to 91.5% response rate. The 238 respondents
who completed the interview were made up of 121
from Neuropsychiatric Hospital, Aro (NPH), and
117 from OSCPSC. The overall mean age for all the
238 respondents was 37.78 (SD = 11.50) years.
Socio-demographic characteriscs
As shown in Table 1, the majority of the partic-
ipants at both centers were between 25 and 34
years. The mean age was 37.94 ± 10.20 years and
37.62 ± 12.70 years for the respondents at NPH
and OSCPSC, respectively. There was no statistically
       -
dents at the two centers (t = 0.20, p = 0.84). Among
the 238 respondents, 97 (40.8%) were males and
141 (59.2%) were females. Fifty-two (43.0%) of
the NPH group were males and 69 (57.0%) were
females, while at OSCPSC, 38.5% were males and
61.5% were female. There was no statistical signif-
icant difference in the gender distributions across
2 = 0.33, p = 0.564). With
the exception of employment status (p = 0.013), the
        
other socio-demographic variables such as marital
status, educational status, and religion (p > 0.05).
Comparison of the NPH and OSCPSC respondents’
scores on the CPOSS
The overall mean CPOSS score for the respondents
at NPH was 63.22 ± 9.93, while at OSCPSC it was
64.48 ± 8.16. (tp = 0.287).
On the whole, most items on CPOSS were scored
higher by participants at OSCPSC relative to those
at NPH; waiting time, cost of treatment, clinic hours,
 
higher (p < 0.05). On the other hand, respondents
       
treatment center appearance (p = 0.001). Other
comparisons were as shown in Table 2.

www.jbehavioralhealth.com 51
Evaluaon of paents’ sasfacon with out-paent care
Relaonship between mean total CPOSS score and
socio-demographic variables
As shown in Table 3, the relationships between the
mean total CPOSS scores of various categories of
socio-demographic variables of the respondents
from the two centers were explored using ANOVA.
The difference in the mean CPOSS score of each
category of gender (male and female) from both
p < 0.001). Similarly, there
 
scores of different levels of education of participants
from the two centers were compared (p = 0.043). On
post-hoc test, the different in the mean scores was

a higher mean CPOSS score than other categories of
gender (p = 0.028); however, none of the categories
of level of education from the two centers was able
to explain the difference observed.
Relaonship between mean total CPOSS score and
clinical variables
Comparison of the NPH and OSCPSC respondents’
mean total CPOSS scores and clinical variables
(such as the age of onset of illness, number of ill-
ness episodes, and duration of illness and presence
of side effects of medications) from the two center

with care (p > 0.05). Details of the comparison of the
NPH and OSCPSC respondents mean total CPOSS
scores and their clinical variables are provided in
Table 4.
Table 1. Comparison of socio-demographic characteriscs of the NPH and OSCPSC respondents.
Socio-demographic variables NPH
N = 121
N (%)
OSCPSC
N = 117
N (%)
χ2 df p
Age (years)
18–24 10 (8.3) 11 (9.4)
25–34 51 (42.1) 60 (51.3) 9.42 4 0.051
35–44 31 (25.6) 14 (12.0)
45–54 19 (15.7) 15 (12.8)
≥55 10 (8.3) 17 (14.5)
*Mean age (years) 37.94 (10.2) 37.62 (12.7)
Gender
Male 52 (43.0) 45 (38.5) 0.33 10.564
Female 69 (57.0) 72 (61.5)
Marital status
Married 46 (38.1) 39 (33.3) 0.57 20.753
Single 51 (42.1) 53 (45.3)
Others 24 (19.8) 25 (21.4)
Educaonal level
None 10 (8.3) 14 (12.0)
Primary 39 (32.2) 50 (42.7) 5.05 3 0.168
Secondary 45 (37.2) 31 (26.5)
Terary 27 (22.3) 22 (18.8)
Employment status
Schooling/Apprenceship 12 (9.9) 11 (9.4)
Employed 91 (75.2) 70 (59.8) 8.71 20.013
Unemployed 18 (14.9) 36 (30.8)
Religion
Chrisanity 81 (66.9) 81 (69.2) 0.057 10.811
Others 40 (33.1) 36 (30.8)
*t = 0.20, p = 0.84.

52 J Behav Health • 2019 • Vol 8 • Issue 2
Adetunji Obadeji, Victoria Ire Elegbede, Lateef Olutoyin Oluwole
Discussion
Patient’s satisfaction with care is one of the indices
to measure the outcome of mental health care
service as well as a key parameter for the evaluation
of a mental health care system [2,26]. It is not just
a means of assessment of care but also provides an
opportunity for improvement of the quality of care,
including adherence to treatment and continuity of
outpatient care [27]. In this study, we compared the
level of satisfaction of patients with schizophrenia
attending a typical psychiatric hospital out-patient
care with those from community-based care.
Globally, the levels of patients’ satisfaction with out-
patient care were essentially similar, though with
slightly higher score recorded in community care
setting. However, when compared with a similar
study [8] among a similar population of patients
in a typical psychiatric hospital in the major city in
Nigeria like Lagos, participants in our study rated
their satisfaction with the out-patient care higher.
The difference may have resulted from patient-
overload in the center where the previous study
was conducted or possibly some reforms aimed
at making the centers in this study more patient-
friendly, particularly the main psychiatric hospital
in this study.
Studies have shown that some hospital variables
such as hospital infrastructure, waiting time before
consultation, quality of clinical services rendered,
physical comfort, drug availability, the attitude
of doctors and other healthcare staff, emotional
support and respect for patients’ preferences
     
delivery [4,5]. Some of these variables may have
explained the differences noted in these studies.
On consideration of individual items on CPOSS,
patients with schizophrenia at the OSCPSC were
   the cost of treatment,
      
compared with patients attending an out-patient
clinic at the NPH. Similarly, in a typical psychiatric
like NPH, low areas of satisfaction were recorded
on items relating to the cost of treatment and
waiting time [8]. In Nigeria and other sub-Sahara
Africa, waiting times and cost of services have been
reported as major challenges affecting quality of
     
the complexity of services at major psychiatric
hospitals, more importantly in our environment
compared with community service where patients
have relatively easy access to most of the services
provided. On the other hand, patients attending

     
relatively higher scores on items such as the
appearance of the treatment center, amenities
for conveniences, waiting areas’ appearance, and
desire to recommend the center to other. Patients’
perception of the hospital environment including
interpersonal, technical components of patients’
care as well as the structural component such as the
Table 2. Comparison of the NPH and OSCPSC respondents’ scores on the CPOSS.
Item of sasfacon Mean (SD) score on CPOSS Stascs
NPH OSCPSC tdf p-value
Record ocer’s help 4.28 (0.90) 4.56 (0.73) −2.603 228.846 0.010
Explanaon on Payment 4.11 (1.13) 4.21 (1.12) −0.670 236 0.504
Waing me 3.80 (1.17) 4.15 ( 1.03) −2.650 234.125 0.009
Informaon about Problem 4.17 (1.05) 4.37 (0.952) −1.494 236 0.136
Respect for opinion about treatment 4.32 (0.87) 4.47 (0.79) −1.369 236 0.172
Match of treatment plan to needs 4.31 (0.95) 4.40 (0.86) −0.745 236 0.457
Service helpfulness 4.48 (0.78) 4.55 (0.73) −0.695 236 0.488
Overall quality of care 4.46 (0.74) 4.56 (0.69) −1.092 236 0.275
Waing area Appearance 4.36 (0.83) 4.11 (1.09) 1.945 216.164 0.053
Treatment Center Appearance 4.55 (0.77) 4.17 (0.99) 3.307 219.215 0.001
Clinic hours 4.15 (1.01) 4.39 (0.86) −2.012 236 0.045
Out-paent service locaon 4.25 (0.95) 4.34 (0.81) −0.819 236 0.414
Amenies for Convenience 4.15 (1.08) 4.03 (1.08) 0.818 236 0.414
Cost of treatment 3.91 (1.18) 4.26 (0.98) −2.465 230.866 0.014
Recommendaon of treatment center 3.92 (0.33) 3.88 (0.42) 0.758 236 0.449

www.jbehavioralhealth.com 53
Evaluaon of paents’ sasfacon with out-paent care
location, attractiveness, cleanliness, and convenient
  
[28–30].
Although necessary, most of these “cosmetic”
may have been part of those things that account for
an increase in the cost of treatment at this center.
Nonetheless, an improvement in the appearance
of community care setting alongside the provision
of basic facilities for comfort will likely improve
patients’ satisfaction with such out-patient care.
As noted literature [28,31], the level of satisfaction
    


patients.
In this study, with the exception of employment
       
in term of any socio-demographic variables.
This difference noted here may have been due to
“selection process”; the NPH is a referral center,
with relatively expensive services. The relatively
high cost of treatment in this hospital may have
attracted the people who are working and can
afford the higher cost of treatment. However,
patients’ satisfaction with care as measured by the
     
socio-demographic variables such as gender and
      
observed when the mean total CPOSS scores of
different categories of gender from the two centers
were compared, with female patients from the two
centers expressing more satisfaction with care than
their male counterparts, more importantly those
from OSCPS. This may be due to the fact that male
patients with mental illness have higher expectation
from their care-givers [32] and are more likely
to have higher level of education than female
counterparts [33,34]. Similarly, patients with either

more with their care than the more educated ones
       
of patients with schizophrenia satisfaction with
out-patient care [8,18], besides marital status,
none of the socio-demographic variables was
Table 3. Relaonship between mean total CPOSS scores and socio-demo-
graphic variables: NPH and OSCPSC compared.
Sociodemographic
variables
Mean score (SD) on CPOSS ANOVA
NPH OSCPSC F p
Age (years)
18–30 65.0 (9.83) 64.8 (8.55) 1.194 0.313
>30 62.5 (9.93) 64.4 (7.99)
Gender
Female 65.5 (8.99) 66.3 (6.79) 6.429 p < 0.001
Male 60.3 (10.43) 61.5 (9.30)
Marital status
Married 65.1 (10.26) 66.9 (6.37) 2.649 0.050
Not married 62.1 (9.62) 63.27 (8.70)
Level of educaon
<Secondary school 67.8 (7.67) 65.3 (7.44) 2.764 0.043
Secondary school and
above
60.1 (10.15) 63.5 (8.92)
Employment status
Employed 62.7 (10.23) 65.8 (7.63) 2.057 0.107
Unemployed 64.9 (8.92) 62.5 (8.60)
Locaon of abode
Abeokuta 60.6 (10.47) 64.9 (6.80) 1.349 0.259
Outside Abeokuta 64.0 (9.69) 63.7 (10.42)
Religion
Chrisanity 62.9 (9.72) 63.8 (8.41) 0.339 0.797
Other religion 63.9 (10.45) 66.0 (7.46)

54 J Behav Health • 2019 • Vol 8 • Issue 2
Adetunji Obadeji, Victoria Ire Elegbede, Lateef Olutoyin Oluwole
associated with satisfaction with out-patient care.
This observation may be due to the methodological
approach adopted in those studies.
Generally, studies [6,7,23] had shown association
between greater psychiatric patients’ satisfaction
with care and patients’ demographics such as older
age, less education, higher social status, poor social
functioning, while another study [22] reported that
psychiatric patients who are widowed, male, urban
dwellers, those with poor social functioning, and
those with a diagnosis of schizophrenia were likely
.
In the same vein, none of the clinical variables
such as the age of onset, duration of illness, num-
ber of antipsychotic drugs, route of administration
of antipsychotic, and numbers of appointment kept
did predict patients’ satisfaction. Similarly, a study
had also reported no association between clinical
variables and patients’ satisfaction with psychiatric
care [35]. Conversely, other studies had reported
an association between patients’ satisfaction and
clinical variables such as duration of illness and
    

less with care compared with other major psychiat-
ric diagnoses such as major depression or bipolar
affective disorders [7,22].
Conclusion
Patients’ satisfaction with out-patient care was
found to be similar in both settings, though with
a relatively higher score among patients attending
community care setting. The two centers do not differ
 
out-patient care. Comparatively, patients attending

hours, waiting time, cost of treatment, and Record
       

Table 4. Relaonship between mean total CPOSS score and clinical
variables: NPH and OSCPSC compared.
Clinical variables Mean Score (SD) on CPOSS ANOVA
NPH OSCPSC F p
Age of onset (years)
<35 63.41 (9.91) 64.22 (8.24) 0.65 0.58
≥35 62.06 (10.31) 65.89 (7.77)
Duraon of illness in years
<5 61.63 (11.32) 64.47 (9.52) 0.99 0.40
>5 64.01 (9.14) 64.48 (9.54)
Duraon of remission in years
<2 62.14 (10.75) 64.67 (8.52) 1.06 0.37
≥2 64.48 (8.82) 64.30 (7.87)
Number of anpsychoc drugs
1 64.56 (8.90) 65.74 (7.27) 1.23 0.33
2 or more 62.74 (10.28) 63.57 (8.68)
Number of episodes
1–2 62.86 (10.26) 66.23 (7.36) 1.17 0.32
>2 63.62 (9.64) 63.84 (9.11)
Route of anpsychoc drug
Oral or depot 63.85 (8.56) 65.90 (7.18) 1.21 0.31
Oral and depot 62.93 (10.56) 63.38 (8.74)
Any side eect
Yes 62.46 (9.98) 62.52 (7.31) 1.69 0.17
No 63.59 (9.94) 65.75 (8.47)
Appointments kept
<4 64.93 (8.90) 63.07 (8.40) 2.01 0.11
4 and above 62.35 (10.37) 65.82 (7.75)

www.jbehavioralhealth.com 55
Evaluaon of paents’ sasfacon with out-paent care
of the treatment center. Similarly, satisfaction with
     
to the level of education and gender, with females
from both centers expressing greater satisfaction
with outpatient care than their male counterparts.
The satisfaction of psychiatric outpatients could
be improved by improving infrastructures and
provision of basic facilities that will enhance the
comfort of patient, particularly at community care
centers, while at the NPH, reducing waiting time,
clinic hours, cost of treatment, and improving
support are important steps to improving
patients’ satisfaction. Generally, community-based
psychiatric may provide a comparably better care
than those obtained in major psychiatric hospital.
Acknowledgments
The authors would like to thank the study partici-
pants for their precious time and their cooperation
and members of staff of NPH and OSCPS for their
support and cooperation during data collection.
Funding
Nil.
Conict of Interest
None declared.
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