Our study assessed patient satisfaction across several dimensions in a tertiary care public hospital in Nepal. About 92 % of patients were satisfied with the interpersonal manner of doctors; however, only 39 % of patients were satisfied in the dimension of general satisfaction. Several socio-demographic factors were associated with seven dimensions of patient satisfaction. Age was found to be the strongest predictor of patient satisfaction across most of the dimensions.
There was a wide variation in patient satisfaction across the seven dimensions in our study. A recent study conducted in the Bir Hospital, the largest public tertiary hospital in Nepal, did not show such a wide variation across the seven dimensions of patient satisfaction. Such difference between that study and our study might be due to difference in service availability. Bir Hospital provides a wide range of services whereas our study hospital provides comparably a limited range of outpatient, inpatient, diagnostic and emergency services. Further, a study in Australia used a similar patient satisfaction questionnaire to that implemented in our study, but did not find such a wide variation across seven dimensions ; the percentage of satisfaction in the financial aspect was the highest (87.4%) while the dimension of accessibility and convenience had the lowest level of satisfaction (72.9%) in their study . Such a wide discrepancy between various dimensions between our study and the Australian study may be due to differences in health care settings, financing mechanisms, and the priority given to patient satisfaction by concerned agencies.
In our study, the general satisfaction of the patients was relatively low (39%). Our low general satisfaction rate was mainly driven by item 17 of PSQ-18, “I am dissatisfied by some things about the medical care I receive.” This dissatisfaction may be due to the absence of some facilities or amenities other than medical services such as availability of drinking water, provision of sanitary toilets etc. A shortage or scarcity of such non-medical amenities may have reduced general satisfaction. Contrast to our study, a recent study by Poudel et. al. in a tertiary hospital in Nepal showed a general satisfaction rate of 73%. The hospital where they conducted their study is the largest public hospital in Nepal that has some super-specialized services as well; the patients’ disease status and their severity may be totally different in that hospital compared to our study. Further, a study by Holikatti et al in India observed a general satisfaction rate of 57 %, which is higher than that presented in our study . Similarly, a study conducted in North London reported 71 % satisfaction on the general satisfaction scale . Various assessments conducted in the Netherlands demonstrated from 79 to 88 % general satisfaction [21, 22] along with the upward shifting of patient satisfaction in Dutch university medical centers . These findings contrast with our study’s finding of general satisfaction which was much lower (39%). Such a high difference in general satisfaction could result from a large gap between expectations and reality among patients who participated in our study. At the same time, the disease status, unavailability of desired amenities or facilities in our study site might have reduced the general satisfaction rate.
Further, in the specific domains of interpersonal manner and communication aspects, patient satisfaction was significantly higher in our study. A study by Holikatti et al found that the satisfaction rate in the interpersonal aspects among patients receiving psychiatric services was 71.4% ; their finding was much lower compared to our finding of 90% satisfaction in this domain. The higher level of satisfaction in interpersonal aspects in our study was mainly driven by a friendly and courteous manner of doctors. Such differential satisfaction rates in interpersonal manner may be due to difference in the nature and severity of diseases among studies. The patient satisfaction in these two domains also depend upon the communication skills of the doctors as evidenced by previous studies.[24–26]
A study conducted in a private hospital in India demonstrated that approximately 91% of the patients were satisfied with the time spent to the doctor , while the proportion of satisfaction of patients in this dimension in our study was 59%. This could be due to doctors spending less time with patients and no much effort put into making a doctor-patient relationship in public hospitals—our study hospital is overstretched with nearly 30 visitation per day per doctor . Regarding affordability, a study by Rizal in the eye services at Nepal Medical College showed that 76.8% of the patients were satisfied , while our study showed 66% satisfaction with financial aspects. Eye care services are relatively inexpensive in Nepal compared to general OPD services . Although Nepal’s government implemented a health insurance program in Bhaktapur hospital for more than two years with the aim of providing easy access to health care, our study showed only 45% of patients were satisfied in the domain of accessibility and convenience. This low level of satisfaction was largely driven by the unavailability of needed medical specialists, and the problems in obtaining appointments for medical care right away.
In our study, the main predictors for the general satisfaction of the patient were age, gender, ethnic groups, education, and occupation. A systematic review of the determinants of patient satisfaction around the world revealed that age was the most important and consistent predictor of patient satisfaction . Similarly, we found a strong association of age and satisfaction across six dimensions of patient satisfaction with a positive association between satisfaction and age. This association could be explained from different perspectives. First, this could be due to differences in perception of treatment; the older people are more experienced with the care process and the potential weaknesses of health care system . Second, the older people are usually more comfortable with paternalistic type of care rather than patient centered care. Similarly, the elderly people may have a lower than that of younger people .Our study showed that the religion of the patient was an important predictor across four dimensions of patient satisfaction. A secondary analysis of data from a health and retirement study conducted in the United States demonstrated that the patients who believed that religion was a very important part of their life exhibited higher levels of patient satisfaction . Consequently, differences in patient satisfaction among religions, such as between followers of Hinduism and non-followers, would constitute an important area for future exploration.
In our study, female patients were more likely to be satisfied in terms of general satisfaction and time spent with doctor. Contrast to our finding, studies in Malaysia  and Nigeria  showed male patients were more satisfied compared to their counterparts. In our study, we believe this could be due to a greater number of female service providers in Bhaktapur Hospital. Previous studies showed that female patients were more satisfied with female health care providers  and patients of female physicians were more satisfied than those of male physicians .
In our study, Janajati ethnic group were more likely to be satisfied than other groups. This may be due to the reason that most of the doctors at our study hospital belonged to same ethnic group.
In our study, overall, the educated patients were more likely to be satisfied. The patient who had higher level of education may have better understanding about the limitation of public health system. Getting expected or higher level of care might have raised their satisfaction level compared to the patient who had lower level of education. Similar to our finding, a study in psychiatric patient in Qatar showed a higher satisfaction among educated patient. However, a study in Iran  revealed the educated patient were less satisfied; this might be due to higher level of expectation in educated people.
Although our study contributed new perspectives in the area of patient satisfaction in Nepal, there are some limitations. First, our findings may not be generalized in the hospitals at the district level or below because of differences in the availability of human resources, diagnostics, and health care services. However, our results could be applicable to the secondary and tertiary level hospitals in Nepal as these hospitals provide similar types of services as rendered in our study hospital. Usually, in Nepal, the patient visit to secondary or tertiary hospitals when their illnesses are not properly addressed at primary or district level hospitals. Similar studies at or below the district level could provide more specific findings for primary level hospitals. Second, there could be a number of correlates of patient satisfaction which we didn’t include in our questionnaire due to resource constraints. For example, severity of the patient’s disease status affects their satisfaction. Due to technical complexities to measure severity of illness, we did not assess patient disease status and severity. Apart from some patient characteristics, we did not collect the supply-side factors such as doctors’ attitude towards their work, their remuneration and incentives, and the opportunity for career growth; these may influence service delivery, eventually affecting patient satisfaction. Even though we did not collect data from the perspectives of health workers, our findings from the patient perspectives also provide some signals about doctors’ availability and their behavior towards patients. Third, due to the cross-sectional nature of the study, we can’t assure that the correlates of the patient satisfaction in our study are indeed causal. However, these associations can be used to initiate some interventions to enhance patient satisfaction. A more robust study design that follows the same patients for a number of visits and controls several explanatory variables can give causal associations. Fourth, the translation of PSQ-18 in Nepalese context may affect the finding of the study; however, during pre-testing we evaluated the internal reliability and consistency, which was above the acceptance level. Despite such limitations, the findings of this study constitute a useful resource for the Nepalese government to formulate plans and programs to improve patient satisfaction, especially in tertiary care hospitals.