Customer satisfaction with clinical laboratory services provided by the Ethiopian health facilities: a systematic review and meta-analysis

Abstract

The clinical laboratory is an integral component of the healthcare system [1].It helps health professionals with disease diagnosis, guiding treatment, determining drug resistance, disease prevention, and disease control, identifying diseases of public health signi cance, and contributed to the public health policy development [1][2][3].It has different customers (patients, health professionals, public health authorities, and others who would like to get and use laboratory data for the community health) whose opinions are vital components in providing laboratory managers with opportunities to identify areas of improvement [4].Satisfaction is the degree to which the customers feel their needs ful lled by the service provider [5,6].
Customer satisfaction as an essential determinant of success and long-term survival of the healthcare industry has caught the providers' attention in the present competitive conditions [7][8][9].Evaluating to what extent clinical laboratory customers are satis ed with laboratory services is a vital quality domain, as satis ed patients are more likely to comply and continue using medical care services and stay within a health provider [10].
On the other hand, clients who are not satis ed with the laboratory services are more likely to discontinue the health services and may have worse outcomes because they miss appointments and live against the advice or fail to follow treatment plans [11].In most cases, the mismatch between patient expectations and the services they received leads dissatisfaction.Clinical laboratory service satisfaction is in uenced by the level of quality service delivered, staff professionalism, provision of the adequate information system, availability of ordered tests, length of waiting time to obtain laboratory results, location of laboratory room, and availability and/or accessibility of good latrine [12].The problems are aggravated mainly due to the lack of adequately designed laboratory rooms, shortage of short term and long term training for laboratory staff, lack of water and electricity, shortage of equipment and supplies, the absence of adequate maintenance and spare parts and lack of follow-up and supervision [13].Monitoring laboratory customers' satisfaction is an essential and useful tool required for laboratory quality improvement as well as to get accreditation [14].Customer satisfaction with medical laboratory services is the most important quality indicators in laboratory medicine that re ects the service provider's ability to successfully meet the customers' expectations and needs [15].It also facilitates the identi cation of problem areas and generates ideas for resolving these problems [16].Customer satisfaction is a signi cant component of a quality management system (QMS) and a considerable focus of the International Standardization for Organization (ISO) standards [5], Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and the College of American Pathologists (CAPs) Laboratory Accreditation Programs.These organizations require clinical laboratories to measure the level of their customer satisfaction as part of their respective accreditation programs at least once every two years inspection cycle [7,17].Measurement of customer satisfaction brings necessary customer preferences into the quality assessment process through which mistaken assumptions can be corrected and enable to focus on customers value most elements [18].

Study design and protocol registration
The protocol of the current systematic review and meta-analysis was designed following the "Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols" (PRISMA-P 2015) guidelines [19] and prospectively registered in the PROSPERO database with the protocol registration number of CRD42020187022.

Study setting
This review was conducted in Ethiopia, which is a highly populated country in eastern Africa.Currently, the population is estimated to be more than a hundred million.Because of the rapid growth of the population, the number of healthcare facilities is signi cantly increasing [20,21].Currently, the healthcare facilities are grouped into three major categories, including primary, secondary, and tertiary levels.Earlier in 2011, a total of 22,792 health facilities were registered in the country to provide different health services for the population in their catchment area.From this, about 125, 2999, 15,668, and 4000 contributed by hospitals, health centers, health posts, and private clinics, respectively [22].The health centers and health posts provide primary healthcare services, and approximately 40000 and 3000-5000 population, respectively, is allocated for them.Likewise, primary hospitals were established to serve about 60000-10000 population.General and specialized hospitals cover a wide area, and they mainly provide specialized and referral services for 1 to 5 million population [23].Currently, with the rapid increment of health facilities, the ratio of the healthcare worker to the health facilities is still inadequate [24].

Article searching strategy
Before starting the actual work, the PROSPERO database was searched to check the presence of similar projects related to this topic.Literature searching strategy, selection of eligible articles, data extraction, data analysis, and result reporting has done according to the PRISMA guidelines [25].Articles searched from Science Direct, HINARI, Medline through PubMed, African Journals Online (AJOL), and TRIP database databases using a combination of keywords and Boolean functions the PubMed search string is attached as a supplementary le (Supplementary materials 1).All the mentioned databases searched in English without publication year restriction.The database-speci c search strings were developed according to the database requirements.Besides, to include as many articles as possible, manual hand searching on google and Google Scholar was done.Moreover, reference lists of both included and excluded studies were screened.The most recent database search was done on April 1, 2020.

Article selection, eligibility, and data extraction
The searched studies imported into EndNote X9 software and duplicate articles were removed.Both authors screened the articles independently by title, abstract, and full-text to identify eligible studies.Studies were considered as eligible if they were primary studies and accessed in full-text format, conducted in Ethiopian settings, and published in English from peer-reviewed journals.Besides, studies with prevalence data clearly stated or if missed the presence of adequate data to calculate the prevalence (known sample size and number of satis ed customers) considered.The data abstraction form prepared in the Microsoft Excel Spreadsheet which includes; rst author's name, year of study, publication year, region, type of health facility, study group, study design, sample size, sampling technique, and the number of study participants satis ed with the laboratory services.Both authors extracted the data independently, and any disagreement (inconsistency) was resolved by discussion.

Quality assessment
The quality assessment was done independently by authors using the Joanna Briggs Institute (JIB) quality assessment tool for prevalence studies [26].The tool has nine quality domains with yes, no, unclear, and not applicable response options including; 1) appropriate sampling frame, 2) proper sampling technique, 3) su cient sample size, 4) description of the study subject and setting, 5) appropriate data analysis, 6) use of valid methods, 7) use of valid measurement, 8) appropriate statistical analysis, and 9) adequate response rate [26].Operationally, 1 and 0 values provided for yes and (no and unclear) responses, respectively.Finally, the composite and mean scores are computed.Studies with quality scores below the mean value and "mean score and above" were categorized as having a high and minimal risk of bias, respectively.The quality of data abstraction (inter-rater agreement) assessed using Cohen's Kappa, and the inter-reliability coe cient was found to be 0.784 (p < 0.001) that indicates excellent agreement.

Data synthesis and analysis
Data were analyzed using the malaprop program of STATA software, and the Freeman Tukey double arcsine transformation (ft) was enabled to include proportions close to 0 and 1 [27]; otherwise, those studies with 1 and 0 proportions could be omitted and lead to a biased estimate.This program computes the weighted pooled estimate and then perform back-transformation on the pooled estimate.The time transformed prevalence is weighted very slightly towards 50%, which enables 0 prevalence studies included in the analysis [28].When there is evidence of across study heterogeneity, the random-effects model is recommended for analysis [29].In this case, the Dersimonian and Laird method is most used [30].The presence of heterogeneity among studies checked using  2 test statistics, which estimates the presence of observed differences between-studies due to heterogeneity.The  2 value can range from 0 to 100%, and 0% indicates the absence of heterogeneity; whereas, 100% is a de nitive indicator of signi cant heterogeneity.The 25%, 50%, and 75% values represent low, medium, and high heterogeneity between studies, respectively [31].In addition, a p-value of <0.05 is used to declare heterogeneity [32].In this meta-analysis, the I 2 value was high (97.77%),which an indication of signi cant heterogeneity.Due to this reason, the analysis conducted using a random-effects model at 95% CI as opposed to the xed effects model to adjust the observed variability among studies.The possible sources of heterogeneity are investigated through strati ed analysis, sensitivity analysis, and meta-regression.Visual inspection of funnel plots and results of Egger's weighted statistics were used to investigate the presence of publication bias and small-study effects.All data management and statistical analysis performed using STATA software version 16.0 (Stator LLC College Station TX 77845, USA for windows version).

Study selection
Initially, 455 studies were retrieved from databases and hand searching.From this, 98 studies were removed due to duplication.Then, 357 articles were screened by title/ abstract, and 333 studies were studies excluded because of being unrelated to the current review.The remaining 24 full-text articles were further re ned, and 6 of them excluded due to studies being conducted in other countries, outpatient departments, inpatient departments, and emergency departments.Finally, 18 full-text articles ful lled the inclusion criteria and included in the review [Figure 1].Characteristics of primary studies included in the review Eighteen full-text articles [11,16,17,[33][34][35][36][37][38][39][40][41][42][43][44][45][46][47] included in the systematic review and meta-analysis that included a total of 8495 study participants.The smallest and largest sample sizes of the studies were 105 and 2399, respectively [17,42].Similarly, the lowest and highest level of the laboratory customer satisfaction was 48.3% and 90.8%, respectively [45,46].All the studies conducted using a cross-sectional study design.The earliest and latest studies were conducted in 2011 and 2020, respectively [17,40].Information about clinical laboratory service satisfaction obtained from four regions and two selfadministrative cities.Among studies, about one third obtained from Addis Ababa city.No study was obtained from the Somali, Benishangul Gomez, Afar, and Gambelia regions.About two-thirds of the studies were conducted on primary service users (clients) [Table 1].
A meta-analysis of customer satisfaction rate with clinical laboratory services in Ethiopia After applying different selection criteria, eighteen studies were included in the qualitative synthesis and meta-analysis.Based on the random-effects model, the value of I 2 is found to be 97.97% with p ≤ 0.01, which is an indicator of considerable heterogony among studies.Due to this, the pooled estimate was conducted using the random-effects model.The level of laboratory service satisfaction ranged from 48% to 91%, with a pooled estimate of 66% (95% CI: 59-73) [Figure 2].So, when there is signi cant heterogeneity among the included studies should be analyzed using the random-effects model rather than the xed effects model, and the possible sources of variability should deal using subgroup analysis or meta-regression as appropriate.

Investigation of heterogeneity
The subgroup analysis was conducted on the year of publication, sample size, sampling technique, study participants, and study quality.The heterogeneity among the subgroups did not signi cantly change.The lowest level of I 2 (88.82%) was among studies conducted with a sample size of below 384.The highest level of satisfaction (82%) among the study participants was obtained from the studies conducted between 2011and 2014.While the year of publication increases the level of customer satisfaction with clinical laboratory services is signi cantly decline [Table 3].

Meta-regression and sensitivity analysis
A meta-regression analysis was conducted to investigate the possible sources of heterogeneity.It is a preferred technique for investigating heterogeneity compared to subgroup analysis and has the advantage of running multiple covariates at the same time [48].The sample size and year of publications of the included studies were considered as covariates.While increasing sample size, there is a slight increment of customer satisfaction with clinical laboratory services (coef =0.02, p = 0.34).On the other hand, disapprovingly, when the publication year increases, the level of laboratory service satisfaction signi cantly decreases (coef = -4.39,p ≤ 0.01) [Figure 3].Further, a sensitivity analysis was performed by removing a single study from the analysis to ensure the stability of the overall effect estimate.The result indicated that removing a single study from the analysis did not signi cantly in uence the pooled estimate.The pooled effect estimate of laboratory service satisfaction ranged from 63.3%, 95% CI: 31.87-94.78(if Belay M. et al. is excluded) [45] to 77.0% 95% CI: 44.13-109.83(if Alelign A. et al. is excluded from the analysis) [46].The analysis of the sample sizes showed no in uence was observed on the overall effect estimate while removing a single study at a time from the analysis [Figure 4].

Publication bias
The presence of publication bias was evaluated using the funnel plot and objectively by Egger's and Begg's statistical tests.Each point in the funnel plot stands for a single study, an asymmetrical distribution of the points is indicative of the presence of publication bias [49].Publication bias occurs when published studies do not represent all the studies conducted.The funnel plot showed minimal evidence of publication bias.However, after conducting statistical tests, results showed no statistically signi cant publication bias (Egger's p = 0.21 and Begg's test p = 0.08) [Figure 5].

Discussion
Customer satisfaction with clinical laboratory services is a valuable tool to evaluate the degree to which how much the laboratory organization meets it's user preferences.Dissatisfaction with services can result in early withdrawal and signi cantly affect the long-term survival of the healthcare industry in general.It is also an essential component of the laboratory accrediting organization requirements.The level of laboratory service satisfaction rate among the included studies in Ethiopia is highly variable, ranging from 48-91%, with an estimated pooled satisfaction level of 66% (95% CI: 59-73).
Customer satisfaction is one of the most indicators of successful laboratory service provision, and it serves as a vital quality improvement tool.Thus, identifying factors associated with the level of satisfaction can support health service managers to design and implement the proper intervention for improvement.With this regard, though there was an adequate level of satisfaction among some studies about security and con dentiality of laboratory test results, customers among most studies were less likely satis ed with the con dentiality of their information.In some cases, patients were highly satis ed with the courtesy given by the laboratory professionals; however, the lack of prompt delivery of test results, particularly noti cation of critical data identi ed for feature improvement.The laboratory customers were less likely satis ed due to the provision of inadequate information during the specimen collection process, unavailability of laboratory workers during the working hours, and the lack of secure area to put personal utilities.Besides, bad clinical practices such as many needlestick attempts during blood collection processes, missing test results, cost of the laboratory services, and the lack of provision of adequate information on how to follow when using the laboratory services found as a source of complaint by the customers.Also, the location of the laboratory building within the health facility and the lack of adequate sitting arrangements around the waiting areas were less likely suitable for the laboratory customers.Further, the accessibility, hygienic status, and comfort of latrines has been identi ed as a signi cant problem for most of the laboratory services in Ethiopia, which needs adequate attention given by the health facility administrators, particularly by the laboratory heads and section supervisors.
The subgroup analysis showed no signi cant decline in the level of heterogeneity among the included studies in the meta-analysis.However, the lowest and highest level of satisfaction was noted among lowquality studies and studies conducted from 2011-2013.Regarding the associated factors, when the sample size increases, the level of laboratory service satisfaction slightly increases though the p-value was marginal (p = 0.34).On the other hand, disappointingly, when the year of publication increases the laboratory service signi cantly decreases that needs an incredibly detailed analysis.However, with this limited data, it is impossible to provide tangible evidence to verify this relationship.Regarding publication bias, the funnel plot suggested the presence of minimal evidence of publication bias; however, after conducting the statistical tests, results declare the absence of statistically signi cant publication bias.
In general, in this review the level of clinical laboratory service satisfaction pooled estimate was unsatisfactory.The year of publication showed a statistically signi cant relationship with service satisfaction.The primary areas where the customers lacked satisfaction include inadequacy of sitting arrangements, the lack of a secure place to put personal utilities during sample collection, poor latrine hygiene, and extended waiting time to get test results.The health facility administrators particularly service provision supervisors should exert their effort to enhance and maintain their customer satisfaction through strengthening the scope of existing diagnostic services, conducting periodic customer satisfaction surveys, implementing immediate corrective actions for complaints, and having a mechanism of continuous monitoring of laboratory activities.
Tables Table 1: Characteristics of the included studies in the systematic review and meta-analysis for the laboratory customer satisfaction in Ethiopia, 2020.Patients Patients were satis ed with the reliability of test results, laboratory facilities, and staff performance; however, they were dissatis ed with the latrine sanitation used for sample collection and the lack of explanation on how to follow when using the laboratory services.
Mengesha MB, 2015 [39] HPs Better satisfaction was observed legibility of results, followed by the manner of the profession, critical value noti cation, and knowledge of laboratory professionals.However, less satisfaction was found on the blood bank services, followed by the availability of senior laboratory experts in the laboratory.
Mindaye T, 2012 [11] Patients Patients who received blood drawing services less than 30 minutes more satis ed compared to those who underwent for more than 30 minutes.They are dissatis ed with the accessibility and availability of latrines, con dentiality issues, the ability of the phlebotomists, and cleanliness of the blood drawing area.

Tadele G, 2014 [38]
Patients The high level of satisfaction was obtained on the language laboratory workers used for communication and the presence of a waiting place around the laboratory.In contrast, low levels of satisfaction were obtained on the cleanness of latrine and location of the laboratory building in the health facility.
Tefera Z, 2017 [37] Patients The highest rate of satisfaction was obtained from the location of the laboratory and measures taken to ensure con dentiality during the sample collection process.However, patients were dissatis ed with the adequacy of sitting arrangements at the waiting area, latrine cleanness, and timeline of test results.

Teklemariam Z, 2013 [36]
Mixed Most of the patients were satis ed with the laboratory services.The highest rate of satisfaction was observed on the delivery of prompt test results and the availability of laboratory staff during working hours, respectively.However, the lowest level of satisfaction was identi ed on critical value noti cation and cleanness of latrine used for sample collection.
Teresa M, 2016 [35] Patients Provision of adequate information to collect the specimen, when & how to receive laboratory test results, respect from laboratory personnel, less than 30 minutes, and between 1and 2-hours waiting time to receive results were the identi ed determinant factors to patients` satisfaction with laboratory services.
Tesfaye T, 2014 [34] Patients Patients were highly satis ed with courtesy by laboratory workers; however, they were highly dissatis ed with the unavailability of laboratory workers during working hours.Signi cant dissatisfaction determinants were long waiting time to give laboratory specimens, lack of a place to put personal utilities during sample collection in the blood collection area and the latrine, and unavailability of requested test items.
Yeshanew AG, 2017 [33] Mixed The highest level of satisfaction was noted on the courtesy given by laboratory professionals to patients followed by the language of laboratory professionals used to communicate patients and the cost of laboratory services.However, the least level of patient satisfaction rate was found on the location and size of the laboratory, waiting for the place, and the cleanness of the latrine used for sample collection.The proportion of customer satisfaction rate with clinical laboratory services in Ethiopia.Sensitivity analysis of level laboratory customer satisfaction with clinical laboratories in Ethiopia.

Figure 3 A
Figure 3

Table 2 :
Key ndings of satisfaction and dissatisfaction with clinical laboratory services in EthiopiaPatientsPatients were satis ed with the general hygiene of the laboratory (82%), privacy and con dentiality of patient data (83.2%), and the cost incurred for laboratory services (86.5%).However, 56%, 58.4%, and 63.8% of the patients were dissatis ed with the location laboratory, availability, and accessibility of latrine, and latrine cleanness and comfort, respectively.PatientsPatients were satis ed with the language laboratory staff used for communication, hygiene, and attractiveness of the laboratory room, con dentiality of patient results, and the location of the laboratory in the hospital; however, patients were dissatis ed with latrine cleanness, length of waiting time, and lack of adequate information.

Table 3 :
Subgroup analysis of predictor variables the satisfaction of clinical laboratory services in