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1. Introduction
1.1 Statement of the problem
Mental disorders are commonly occurring and often seriously harming in whole countries throughout the world(1). Mental illness is accountable around 14% of the world widely burden of disease whereas majority of the countries not more than 1% of their total health expenditure to mental health care service (2).Integration of mental health service into general medical services at all level is the foremost recommendation of the World Health Organization (WHO) mental health Gap Action Program(3). In the recent yearsin Ethiopia have shown a great changes in the pattern of mental health care services have transformed from isolation and rejection to integration and active involvement in general medical care(4).
over the last few decade, the concern of’ clients satisfaction with Psychiatricpatients has widely accepted and gained more attention across the global in mental health care service(5)(6). Satisfaction can be described as a patient’s response to several aspects of their service experience and thus evaluate the mental health-care services as well as the providers from their own subjective point of view(7,8).Patient satisfaction on the other hand is defined to be a result of each patient’s view of the care designed for that patient to reduce his/her problems(9).Satisfaction with mental health services has been proposedto be an integral part of determining the outcomes and performance of mental health clinical service provision(10).Patientsatisfaction with care is recognized as an important concept to assess in evaluating the quality of mental health care. In addition, it provides a feed-back for the evaluation and determination of the quality of service. Thus, assessing patient satisfaction with mental illness is advantageous and necessary(11).Assessment of patientsatisfaction with mental health care is measured as a major component of quality management and reflects mental healthcare professionals’ ability to meet their patients’ needs and expectations(12).Patient satisfaction is one of the most important areas of identifying and determining performance in any mental health system, although it is a complex to measure the satisfaction and apparentresponsiveness of health systems as not only the clinical but also the several non-clinical outcomes of care do affect the patient satisfaction(13).In mental health care good patients’ satisfaction is also strongly associated with high significant outcome in the assessment and improvement of qualityof mentalhealth care service, including adherence to treatment, intent to return for care and continuity of outpatient care and complete treatment regimens which have better health outcomes(14,15).Poor patient satisfaction with mental health care has causes of poor compliance to treatment, discontinuation of care and follow up which ultimately leads to poor health outcomes(16,17).
Different studies indicated that global level of patient satisfaction, scores ranged from 33.5% to 98.5%in US(18), 77.3% in India(19), 75% in Pakistan(20), 42.7 % in Libya(21), and 67.1 % in Ethiopia(22).
There have been a several studies conducted on level of patients’ satisfaction with mental health care service in the developed countries however, on this area few studies were conducted in Ethiopia(23). Understanding of level of patient satisfaction will useful in promoting metal health facility and service providers to support programs aimed at helping mental health professionals to deal with the problem and to improve quality of care(24).
Aim of this study is to identify the gap on level of patients’ satisfaction with psychiatric patient is the primary rationale for conducting this study. Additionally factors associated with level of patient satisfaction will be investigated.

1.2 Literature review
1.2.1 Magnitude
Longitudinal study conducted in the U.S,for two years based on Patient Satisfaction and to Change Care Provider, indicates that about 66 % of those who expressed the least satisfaction changed providers during the next year, as compared with about 42% of the most satisfied patients. Thus, the one third of patients who were leastsatisfied was about 57% more likely to change provider. Individuals scoring in the middle satisfaction distribution were about 27% more likely to change physicians than the most satisfied group and were about 24% less likely to change than the least satisfied group(25).
A survey conducted inGeneva, Switzerlandin differenttwelve public outpatients’ psychiatric clinics of adults’ treatment settings, using CSQ-8 Client Satisfaction Questionnaire measuring global satisfaction, among707 study participants, the result ofglobal satisfaction rate was showed that high (38.5% satisfied and 54.6% very satisfied). (26).
comparative cross-sectional study done in Germany based on secondary data in different selected hospitals using WeisseListe/White List” for patient satisfaction,in the four quality dimensions showed that the mean rating of patient satisfaction was approximately 81.5%, (medical care 82.85%, nursing care 81.76%, organization and service 79.34% and in general 82.43%). In general, all hospitals included in study were succeeded a high level of patient satisfaction with patient care.Conversely, a standard deviation of up to ±6.5% and a range of up to 41% revealed clear differences in patient satisfaction between hospitals(27).
A Survey carried out in University of California, Los Angeles among 1004 outpatients with anxiety disorders frompatients to received appropriate anti-anxiety medication in the previous 6 months,667 study participants(66.6%) reported being satisfied or very satisfied with their overall health care service. But 432 subjects (44.8%) of patients reported being satisfied or very satisfied with their mental health care(28)
A Study done in Austria, in four community mental health centers and in two psychiatric hospital wards among 420 study subject found 60 % had a positive overall satisfaction score with service; 99 (24 %) had an overall score of 0, showing a neutral evaluation; and 67 (16 %) had a negative overall score(29).
Prospective study done in France for 6-month follow up by using randomized and controlled open-label study with Patients of schizophrenia, randomly assigned 124 members’ into four groups of standard psychiatric assessment; QoL assessment with standard psychiatric assessment; and QoL feedback with standard psychiatric assessment. Global satisfaction was significantly higher in the QoL feedback group (72.5% of patients had a high level of satisfaction) compared with the standard psychiatric assessment (67.5%) and QoL assessment groups (45.2%)(30).
Cross-sectional survey conducted in China on Patient satisfaction in public and private hospitals using Picker Patient Experience Questionnaire (PPE-15). Majorityof (77.9%) graded the global satisfaction with the hospital as score 7 or above, where 10 is the highest satisfaction score. The mean global satisfaction scores for public and private sectors were 7.3 and 7.8, respectively(31).
Cross-sectional study done in Indiafrom patients of age 18-60 years receiving medication for at least six months from outpatient treatment center of Mental Health Institution using interview method of Patient Satisfaction Questionnaire (PSQ-18) showed that general satisfaction level was 57%. But the remaining was not satisfied with the service. (32).
Cross-sectional facility-based study done on patients’ satisfaction in Saudi Arabia which the data collected through a pre-coded and interviewer-administered questionnaire, the respondents result indicated that 81.7%were satisfied and the 18.3%wereunsatisfied. The reasons behind satisfaction of the respondents were asked close ended questions to choose the most important single reason for satisfaction(33).
A cross-sectional study conducted in Iran, the study’s sample that consisted of 969 patients who were recruited from eight private general hospitals.Using patient Satisfaction questionnaires (PSQ-21 items). The study result displayed that about 45% of the discrepancy in overall satisfaction was explained by four dimensions of perceived service quality. The cost of services, the quality of the process and the quality of interaction had the greatest effects on the overall satisfaction of patients, but not found a significant effect on the quality of the physical environment on patient satisfaction(34).
Quantitative descriptive cross-sectional study done in Uganda, with medical consultations of 384 respondents were interviewed by using a structured questionnaire adapted from the Medical Interview Satisfaction Scale (MISS-21), from the study sample 53.9% were satisfied with the medical consultation(35).
Institutional based cross sectional study done in Ethiopiaon psychiatric patients using Charleston Psychiatric Outpatient Satisfaction Scale, a 15-item Likert scale ranging.The global satisfaction of patient showed that 61.2% almost half of the participants revealed high satisfaction with the psychiatric care services. The three items for which most patients showed higher satisfaction with monthly service bill (93.4%), appearance of the office (85.5%), and distance from transportation (84.4%). The three items for which most patients showed lower satisfaction were amount of waiting time (49.4%), location of the outpatient service (46%), and appearance of the waiting area (67.3%)(36)
1.2.2 Factors associated with health care service satisfaction
Different studies showed that other than the quality of Patient satisfaction is affected by many factors such as the quality of service delivery, patients’ diagnosis, age, gender, living conditions and previous service experiences, monthly income, waiting time for service, Communication With Doctors, responsiveness of hospital staff, information given about treatment, Cleanliness of the hospital, and respect for patient preferences. Mismatch between patient expectation and the service received is related to decreased satisfaction. Assessing patient perspectives gives them a voice, which can make mental health services more responsive to people’s needs and expectations (37 -39).
A survey conducted in Switzerland, in different treatment settings of psychiatric outpatient department, using CSQ-8 Client Satisfaction Questionnaire measuring global satisfaction, Reasons for greater satisfaction were therapeutic interventions, relationship with staff and confidentiality, while a lower satisfaction were related to information on treatment and medication, clinic organization and environment. A significantly larger proportion of male, single, pensioned, chronically-ill patients with minimum education were followed at the general psychiatric consultation centers, where diagnosis of schizophrenia was the most frequent less satisfied(26).
A Study done in Austria, in four community mental health centers and in two psychiatric hospital wards, Patients were mostly satisfied with staff and least satisfied with other patients. Inpatient or outpatient setting was not related to satisfaction. The interactions between status and setting were also not significant. The chi square test showed that long-term patients had a significantly more positive impression of care than did first-time patients and that first-time patient’s evaluated care significantly more neutrally than did long-term patients(29).
Cross-sectional study done in India, from patients of receiving treatment for at least six months from outpatient department of Mental Health Institute, using interview method of Patient Satisfaction Questionnaire (PSQ-18),anxiety disorder (36.6%), major depressive disorder (30.0%), bipolar disorder (16.6%), and schizophrenia (16.6%). Greatest level of satisfaction was noted in interpersonal aspects (71.4%) and time spent with doctors (62.4%). Diagnostic categories were statistically significant; patients with depression had the highest score followed by those with anxiety disorder, bipolar, and the least was with schizophrenia patients(32).
While another cross sectional study carried out in India, in public health facilities more teenagers (82.7%) were satisfied with the dimensions of service provision at the health care facilities as compared to middle aged; in dispensaries health care facility management practices and literacy of the patient are significantly correlated. In polyclinic, the physical environment of the health facility was significantly related to satisfaction. At Community health center, physical environment of the health facility and literacy of the patients are significant factors affecting patient satisfaction. At district hospital, the physician care along with literacy of the patient determines patient satisfaction(19).
Cross-sectional facility-based study done on patient’s satisfaction in Saudi Arabia which the reasons behind satisfaction of the respondents were based on the literature the reason given cleanliness of the hospital , technical competencies of staff, respect of client, good handling and good services. The first reason behind satisfaction was the cleanliness of the facility (33.1%). Other reasons were good staff 73 (24.2%), respect and good handling 70 (23.2%), good services 25 (8.3%). Other reasons behind satisfaction constituted 11%(33).
Cross-sectional study done in sir Lanka on level of patient satisfaction about being financially Cost of services for medical expenses most patient were not satisfied (76.5%), 23.51% was satisfied with the price of pocket spent on medical service. The overall score is very satisfying with 41.8% of patients, 58.2% suggesting low value of environmental satisfaction. According to the patient education, the secondary school group were highly (14.7%) satisfied with care services. The least percent found in no education groups and 3.5% with high satisfaction. In most of the surveys higher educated patients incline to be less satisfied with the services and low educated patients would be more satisfied with services(40).
A prospective cross sectional study conducted in Qatar based on the psychiatry hospital male patients (55.5%) were more satisfied with the treatment of psychiatrists than females (44.5%). 91.6% literate patients with 25% university graduates and 36.3% having secondary level of education. Significant associations were observed between male and female patients in their satisfaction level in terms of marital status, educational level, occupation, and monthly income. The satisfaction level significantly increased with higher education in both the groups(41).
Cross sectional study completed in Egypt on Patient satisfaction strongly and positively correlated with doctors’ hearing patient complaints, duration of waiting time, site of medical service, system of hospital follow-up, waiting areas and negatively correlated with disease relapses. While other clinical and demographic factors did not correlate with client satisfaction. However, in regression analyses, the duration of waiting in the center and the number of disease relapses, were the most important determinants of service satisfaction(42)
Quantitative descriptive cross-sectional study done in Uganda with medical consultations using a structured questionnaire adapted from the Medical Interview Satisfaction Scale (MISS-21), Patients’ average scores showed lowest satisfaction for information provision compared with communication skills, patient confidence in the clinicians and consultation time. Being older, employed, living further away from the health center and frequently visiting the center were positively associated with patient satisfaction(35).
A cross sectional study done in Ethiopia, 63.1% of the participants responded as satisfied by provider related characteristics, 62% of patients were satisfied with the way health providers concerned about their privacy. Most of the patients rated higher satisfaction level to service characteristic and services variables than provider related characteristics. Only 64.3% patients were satisfied to the cleanliness of waiting area and nearly 40% of patients were not satisfied to the availability of drugs in the facility. Overall only 57.2% of patients are satisfied their visit of medical outpatient services in the facility(43)
Another Cross sectional study carried out in Ethiopia, from the total of 414 respondents, 239 (57.7%) patients were satisfied by the overall service rendered in the hospital. Majority of the patients 350(84.5%), 253(61.1%) 368(88.9%), 288(69.6%) were satisfied with the availability of professionals for consultation, privacy during examination, quality of medical equipment’s, clean and tidy environment respectively. Age, educational status, payment status, waiting time, availability of drug and supply were found to be significantly associated with patient. Furthermore, respondents who had higher education and spent more than two hours in the hospital before getting service were 61% and 84% less likely satisfied than those who were illiterate(44).

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