Front. Public Health Frontiers in Public Health Front. Public Health 2296-2565 Frontiers Media S.A. 10.3389/fpubh.2025.1471297 Public Health Original Research Mental health service satisfaction among adults with mental illness attending a psychiatric outpatient clinic: a cross-sectional study Alemu Wondale Getinet 1 2 * Mwanri Lillian 3 Due Clemence 4 Azale Telake 5 Ziersch Anna 1 1Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University Adelaide, Adelaide, SA, Australia 2Department of Psychiatry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia 3Research Centre for Public Health, Equity, and Human Flourishing, Torrens University Australia, Adelaide, SA, Australia 4School of Psychology, The University of Adelaide, Adelaide, SA, Australia 5Institute of Public Health, College of Medicine, and Health Sciences, University of Gondar, Gondar, Ethiopia

Edited by: Carolyn Dewa, University of California, Davis, United States

Reviewed by: Snehil Gupta, All India Institute of Medical Sciences, India

Tesfaye Engidawu Segon, Mettu University, Ethiopia

 *Correspondence: Wondale Getinet Alemu, geti0001@flinders.edu.au 23 01 2025 2025 13 1471297 27 07 2024 08 01 2025 Copyright © 2025 Alemu, Mwanri, Due, Azale and Ziersch. 2025 Alemu, Mwanri, Due, Azale and Ziersch

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

 Background

Patient satisfaction with services is both a direct and indirect indicator of healthcare quality. It influences healthcare outcomes, patient retention, and the likelihood of medical malpractice claims. However, there is limited evidence on patient satisfaction with mental health services in Africa. Therefore, we aimed to assess mental health service satisfaction and its determinants in adult patients with mental illness in an outpatient clinic in Northwest Ethiopia.

 Methods

A hospital-based cross-sectional study was conducted from October to March 2023. Participants were selected using systematic random sampling with a sample interval of three, resulting in a total sample size of 638 invited to participate. Service satisfaction was measured using the interviewer-administered Client Satisfaction Questionnaire-8 (CSQ-8). Data entry, coding, and analysis were performed using SPSS-28. To examine the association of sociodemographic, clinical, social support, and substance use factors, bivariate and multivariate logistic regression analyses were applied. Statistical significance was declared at a p-value of <0.05 and 95% CI.

 Results

The rate of low mental health service satisfaction among people with mental illness in this study was 24.7%. According to our multivariate logistic regression analysis, people with urban residence 1.77 (1.15, 2.72), poor self-reported health 3.62(1.97, 6.67), having episodic illness ≥2/yr. 0.48 (0.32, 0.74), having relapse 1.75 (1.12, 2.73), and poor drug adherence 2.28 (1.20, 4.35) were more likely to have low mental health service satisfaction than their counterparts.

 Conclusions and recommendation

One-quarter of patients with mental illness in the outpatient clinic reported low satisfaction with mental health services. Factors associated with lower satisfaction included urban residency, episodic illness, relapse, poor self-reported health, and poor drug adherence. To enhance patient satisfaction, the clinic should prioritize targeted support for patients facing these challenges.

 service satisfaction mental health service satisfaction factors outpatient Ethiopia section-at-acceptance Public Mental Health Introduction

One of the goals of providing mental health services is patient satisfaction, which is also a key indicator of how well the mental health care system performs (1–4). Patient satisfaction is the degree to which patients feel that their overall medical and healthcare demands are being met (5). Satisfaction is affected by expectations and previous consumer perceptions of the consumption experience (6) and is determined by patient experiences (7). In mental health care, service satisfaction is frequently viewed as a vital process and quality indicator of service (8–11). Overall, evidence suggests that satisfied service consumers adhere to their therapy more rigorously, enabling them to gain more from their care service (12, 13). Conversely, dissatisfied people experience worse treatment outcomes, including nonadherence to therapy (14–16).

Rates of service satisfaction differ between nations. For example, in Europe, a survey conducted in Geneva showed that 93% of patients were satisfied with their outpatient psychiatric care (17). In the Netherlands, patients with psychosis reported low (19.4%), intermediate (48.9%), and high (31.7%) (18) service satisfaction; however, in Denmark, non-Western migrants attending specialized outpatient mental health clinics reported an overall satisfaction of 49% (19). In India, 87% of patients were satisfied with services (20), and in Kuwait, the satisfaction score was 27% in patients with schizophrenia (21). In Israel, 17% of psychotic patients reported being dissatisfied, barely satisfied (46%), moderately satisfied (26%) or delighted (12%) (22) with mental health services. In the African context, satisfaction scores range from 55 to 83% (23), with Ethiopia having satisfaction scores ranging from 57 to 99% (24–26).

Patient satisfaction studies are valuable and crucial means to identify gaps and create practical solutions for improving healthcare services (13). As patient satisfaction increases, trust between the patient and the medical staff also grows (27, 28). Quality of life has also been linked to patient satisfaction. For example, a study conducted in Norway showed that an unmet need for therapeutic relationships and quality of life had a negative association (29), and a review of analyses on quality of life and service satisfaction among psychotic patients indicated that there was a strong association (30) between these two indicators. Another study in Nigeria also showed that service satisfaction was correlated with quality of life (31). Satisfaction also affects treatment adherence, contributing to treatment failure and relapse (32, 33).

Available research on sociodemographic and clinical factors associated with patient service satisfaction comes from North American, European, and Pacific countries (12, 34, 35). There is inconsistent information about the influence of demographic factors, with age (13, 36), sex (13, 37), and education level (13, 37) being associated with satisfaction scores. Other studies have shown no association between these factors and satisfaction with age (19, 31) or sex (19, 31). Waiting time has been associated with satisfaction in some studies (13, 37, 38) but not in others (20). Clinical factors, including severe symptoms (39), a diagnosis of psychosis (37) and a diagnosis of schizophrenia (40), were found to be negatively associated with service satisfaction. Service satisfaction in patients with co-occurrence of mental illness and substance use has been studied in different countries. In the U.S., for example, the satisfaction score for adult patients diagnosed with comorbid mental health problems and alcohol and drug disorders was 29% (41). In Ethiopia, the satisfaction scores of mental illness patients with alcohol use disorder and nicotine dependence were 14.3 and 23.3%, (42) respectively. In a Tanzanian study, patient service satisfaction among patients with mental illness was 32.7% for those also with substance use, 21.7% for those with alcohol use, and 19.8% for those with tobacco and cannabis use disorders (12.9%) (43). These studies indicate that substance use affects service satisfaction for patients with mental illness (44).

Although quantitative research studies have shown that patients have high levels of service dissatisfaction, qualitative studies have shown further insight into patient satisfaction. For example, in Sweden, one study found high levels of service dissatisfaction among mental health service users (45), with evidence demonstrating increased satisfaction among service users who feel supported by staff (46). A study from Europe (Netherlands, Denmark, London, Spain and Italy) showed that service satisfaction was lower for individuals who had less support from family members (47). These studies suggest that it is important to look at a broader range of factors that might influence service satisfaction.

Previous studies on patient satisfaction with mental health services in Ethiopia including the study area differ from our study in several key areas. Notably, prior research did not examine the type of mental illness and its relationship to service satisfaction, history of previous admissions, the impact of episodic illness on satisfaction, or the role of family participation in healthcare on patient satisfaction in study area. Additionally, factors such as age of illness onset, duration of illness, and both subjective and objective illness severity in relation to service satisfaction were not addressed from previous study at study facility. These gaps highlight the need for the current study. This study sought to address a gap in evidence from Ethiopia in relation to associated with service satisfaction, as there has been limited research on this topic and only a narrow range of factors. Therefore, this study aimed to measure the magnitude of mental health service satisfaction among patients attending a psychiatry outpatient clinic in university of Gondar hospital Northwest Ethiopia and to examine the clinical, social support, psychoactive substance uses and sociodemographic predictor factors of satisfaction.

 Methods Study design and setting

This cross-sectional study was conducted in Ethiopia among people with mental illness at an outpatient clinic in the Amhara National Regional State at the University of Gondar Comprehensive Specialized Hospital Northwest Ethiopia from October 2022 to March 2023, a public sector institution.

 Source and population

All patients who visited the outpatient clinic of the University of Gondar Hospital were considered the source population, and all patients who visited the outpatient clinic of the hospital during the study period were considered the study population. A total of 638 patients with mental illness who were followed up in outpatient clinics were recruited. Those who had received outpatient care for their mental disorders for at least three months were included, a time period after which patients are more likely to be stable with their condition. Patients with acute mental illness who could not communicate because of severe physical or mental illness were excluded. The data were collected by psychiatry Nurses. The university of Gondar comprehensive specialized hospital serves for the catchment area for more than ten million people and service as referral for district region for more than 15 million people in Northwest Ethiopia.

 Sampling procedure

This paper reports on an examination of service satisfaction within a broader study of quality of life. The sample size was calculated using a single population proportion formula considering the following assumptions. We used a 41% prevalence of poor quality of life from a broader study conducted in Ethiopia, a 95% confidence level, and a 4% margin of error (48).

The following formula was used: n = (Zα/2)2 * P (1-P)/d2, where n is the minimum sample size needed, Z is a standard normal distribution (Z = 1.96) with a confidence interval of 95% and α = 0.05, d is the absolute precision or tolerable margin of error (4%), and P = estimated proportion is assumed to be 41% (0.41). Then, n = (1.96)2 *(0.41) *(0.59)/(0.04)2 = 580 and 10% nonresponse rates (580 *10/100) =58, with a 10 % nonresponse rate of 580 + 58 = 638. We used a systematic random sampling technique to obtain a total sample size of 638 patients who were followed up for the treatment of their mental illness from a group of 2,400 patients who were followed up at the University of Gondar Comprehensive Specialized Hospital, with a sample interval of three. Finally, 636 patients who had been followed up for at least three months and were 18 years old and older were included in the study, and two patients did not complete the study after commencement. Patients who had a clinical diagnosis of schizophrenia, depression, bipolar disorder, anxiety, other psychotic disorders, stress and trauma-related disorders, or somatization disorders were eligible for inclusion.

 Data collection

The data were collected using a standardized questionnaire during a face-to-face interview at the outpatient psychiatry clinic. The questionnaires were prepared in English and translated into the local language, Amharic. Five psychiatry nurses and two MSc psychiatry supervisors participated in the data collection. The data collectors and supervisors received two days of training, and a pre-test of two weeks was conducted but these results were not included in the final analysis. Based on the findings from the pre-test, the questionnaires were revised and finalized. The interview was estimated to take 45 min. As part of the consent process, data collectors sought permission to access the person’s health records, which could assist in providing background information of the patient’s specific diagnosis, medications, and previous history of hospital admission. The data collectors were supervised daily by assigned supervisors, and the filled questionnaires were checked daily by the supervisors and principal investigator. Questionnaires were reviewed daily for completeness by data collectors, supervisors, and then by the researcher throughout data collection. Two incomplete surveys were discarded from the final analysis.

 Variables

Mental health service satisfaction was the dependent variable of this study. The independent variables were sociodemographic characteristics (age, sex, marital status, educational status, living condition, job of participant, residence), clinical factors (type of mental illness, age of onset illness, duration of illness, number of episodes of illness per year, history of admission, comorbid illness, type of drug, drug side effects, counseling, duration of treatment, relapse, objective severity of illness, subjective severity of illness, suicidal ideation, family history of mental illness, waiting time in clinic sand self-reported health), social support-related factors (family not participating in patient care, relationship with family) and substance use factors (alcohol use, tobacco use, family history of substance use). Additional variables, such as self-esteem, drug adherence and legal issues, were also included.

 Measures Service satisfaction

The Client Satisfaction Questionnaire-8 (CSQ-8) comprises an eight-item questionnaire for assessing patients’ global satisfaction with services and has good psychometric properties (49). The CSQ-8 measures general satisfaction on eight scale items ranging from 1 (poor) to 4 (excellent), resulting in a total score ranging from 8 to 32. The level of satisfaction is classified as low (8–20), intermediate (21–25), or high (26–32). Psychometric evaluation of the CSQ-8 in the current sample showed high-scale reliability (Cronbach’s alpha = 0.84). The CSQ-8 has been validated in African Egypt and has internal consistency (Cronbach’s α = 0.88) (50).

Self-esteem

Self-esteem was measured with the single-item self-esteem scale. The single-item self-esteem scale is a measure of overall self-esteem. Participants rate the single item on a 5-point Likert scale ranging from 1 (not very true of me) to 5 (very true of me). Although shorter than the Rosenberg Self-Esteem Scale, the scale exhibits good convergent and comparable predictive validity (51). This item has not been validated in Ethiopia.

 Medication adherence

The Medication Adherence Scale (MARS-5) assesses patients’ standard treatment adherence through five questions and five response formats (1 = always, 2 = often, 3 = occasionally, 4 = rarely, and 5 = never). Responses are added for a total score ranging from 5 to 25, with higher scores indicating greater adherence. As advised by the developer, we used a cutoff point greater than or equal to 20 (52, 53) to indicate adherence. This scale has been validated in Africa and Nigeria (54).

 Substance use

Clients who used substances (for nonmedical purposes) such as alcohol, khat, cigarettes or cannabis in the last year before data collection were considered current substance users (55).

 Severity of illness

The Clinical Global Impression (CGI) scale of subjective and objective measurement was used to assess the severity of the illness. Responses 1–3 indicate mild, responses 4 indicate moderate, and responses 5–7 indicate severe according to the CGI scale (56). This scale has not been validated in Ethiopia/Africa.

 Data processing and analysis

After verifying accuracy and consistency, all the data were checked, cleaned, coded, and entered into SPSS-28, which was subsequently used to analyses the data. The dependent variable was mental health service satisfaction. First, bivariate logistic regression was used to independently evaluate the relationship between each independent variable and service satisfaction. To control for potential confounding effects, variables with p values less than or equal to 0.2 were fitted to a multivariable logistic regression model (57). After adjusting for odds ratios with 95% CIs, bivariate analysis was applied to identify relationships between dependent and independent variables and measure the associations of strength. A p value of <0.05 and a 95% CI were used to indicate statistical significance.

 Ethical clearance

Ethical approval was obtained from the Flinders University Human Research Ethics Committee and the Institutional Review Board of the University of Gondar. Written informed consent was obtained from the people who participated in the study. Respondents were briefed and made aware of the study goal and told of their unrestricted freedom to withdraw from the study at any time. Additionally, code numbers rather than personal identification were used to ensure confidentiality.

 Results Sociodemographic, clinical, substance use, and social support related characteristics of patients with mental illness in an outpatient clinic in Ethiopia, 2023

The study included 636 participants, yielding a 99.7% response rate. The average age was 35.5 years (±11.7). About half of the participants were female (324, 51%), and most (431, 67.8%) were urban residents. Schizophrenia was the most common diagnosis (274, 43%), followed by depression (192, 30.2%), bipolar disorder (50, 7.9%), anxiety disorder (39, 6.1%), other psychotic disorders (68, 10.7%), somatization disorder (7, 1.1%), and stress/trauma-related disorders (6, 0.9%). Antipsychotic medication was used by 301 participants (47.3%), and 135 (21.2%) were taking both antipsychotics and antidepressants. Of the total patients, 199 (31.3%) had been followed for over five years, nearly 589 (92.6%) reported good self-rated health, 412 (64.8%) experienced relapsing illness, 338 (53.1%) had two or more episodes per year, 316 (49.7%) reported low self-esteem, and 87 (13.7%) had poor drug adherence (Table 1).

Sociodemographic, clinical, substance use, and social support related factors of people with mental illness in an outpatient clinic in Ethiopia, 2023 (n = 636).

Variables Categories Frequency (n = 636) Percent (%)
Sociodemographic factors
Age Mean ± Sd 35.5 ± 11.7
Sex
Male 317 49.8
Female 319 50.2
Marital status
Married 253 39.8
Not married. 383 60.2
Educational status
Literate 451 70.9
Illiterate 185 29.1
Living condition
Living with family 541 85.1
Living alone 95 14.9
Job of participant
Employed 89 14
Not employed 547 86
Residence
Rural 205 32.2
Urban 431 67.8
Clinical factors
Type of mental illness
Schizophrenia 274 43.1
192 30.2
Depressive disorder 50 7.9
39 6.1
Bipolar disorder 68 10.7
6 0.9
Anxiety disorder 7 1.1
Other psychotic disorders
Stress/trauma-related disorder.
Somatization disorder
Age of onset illness
≤ 25 yrs. 287 45.1
>25 yrs. 349 54.9
Duration of illness ≤5 yrs. 235 36.9
>5 yrs 401 63.1
Number of episode/yr.
No episode 298 46.9
≥2 Episode/yr. 338 53.1
History of hospital admission
No admission 428 67.3
Admission 208 32.7
Comorbid illness
Yes 77 12.1
No 559 87.9
Type of drug
Antipsychotic 301 47.3
Antidepressant 123 19.3
Mood stabilizer 16 2.5
Anxiolytics 28 4.4
Antipsychotic and Antidepressant 135 21.2
Antipsychotic and mood stabilizers 33 5.2
Drug side effect
Yes 163 25.6
No 473 74.4
Counseling
Yes 128 20.1
No 508 79.9
Duration of Rx.
≤5 yrs. 437 68.7
>5 yrs., 199 31.3
Yes 412 64.8
No 224 35.2
Objective severity
Mild 493 77.5
Moderate 94 14.8
Severe 49 7.7
Subjective severity
Mild 424 66.7
Moderate 159 25
Severe 53 8.3
Yes 250 39.3
No 386 60.7
Yes 115 18.1
No 521 81.9
30 min-1 h. 534 84
2 h.-3 h. 102 16
Self-reported health
Good 589 92.6
Poor 47 7.4
Social support-related factors
Excellent 49 7.7
Very Good 147 23.1
Good 299 47
Fair 100 15.7
Poor 41 6.4
Yes 536 84.3
No 100 15.7
Substance use factors
Yes 43 6.8
No 593 93.2
Yes 141 22.2
No 495 77.8
Yes 78 12.3
No 558 87.7
Family Hx. Subs.
Yes 115 18.1
No 521 81.9
Additional variables
Self-esteem
Low self-esteem 316 49.7
High self-esteem 320 50.3
Drug adherence
Poor adherence 87 13.7
Good adherence 549 86.3
Yes 27 4.2
No 609 95.8
Service satisfaction among people with mental illness in an outpatient clinic

The mean and standard deviation of the CSQ-8 score were 23.6 (±4.1), demonstrating intermediate satisfaction. A total of 636 participants [157 (24.7%) reported overall low satisfaction, and 479 (75.3%) reported high satisfaction]. Almost half of the participants (52.8%) said that they received good-quality services; over half (52.5%) reported that they received the kind of service they wanted; some participants (42.6%) reported that the program met their needs; 49.5% of participants would recommend the program to a friend who needed similar help; 50.2% of participants were satisfied with the amount of support they had received; 44.3% patients believed the services they received helped them to deal more effectively with their problems; 38.8% had good satisfaction in a general sense with the service they received; and 49.4% had good responses and would come back if they sought help (Table 2).

Distribution of items of tools to measure service satisfaction in people living with mental illness in Ethiopia, 2023 (n = 636).

Client Satisfaction Questionnaire (CSQ-8) (Range 8–32) Poor1 Fair2 Good3 Excellent4
1 How would you rate the Quality of service received? 2.4% 31.4% 52.8% 13.4%
2 Did you get the kind of service that you wanted? 3% 26.4% 52.5% 18.1%
3 To what extent has our program met your needs? 2% 35.1% 42.6% 20.1%
4 If a friend needed similar help, would you recommend our program to them? 2.4% 18.7% 49.5% 29.4%
5 How satisfied are you with the amount of help you have received? 1.7% 26.6% 50.2% 21.5%
6 Have the services you received helped you to deal more effectively with your problems? 4.1% 25.9% 44.3% 25.6%
7 In an overall, general sense, how satisfied are you with the service you have received? 0.5 26.6% 38.8% 34.1%
8 If you were to seek help again, would you come back to our program? 0.6% 12.9% 49.4% 37.1%
Factors associated with low mental health service satisfaction

We used binary and multivariate logistic regression to identify factors associated with mental health service satisfaction. As planned, variables with p values ≤0.2 in the bivariate analysis were fitted into a multivariate logistic regression model to manage the impacts of confounding effects. A total of twenty-three variables had a p value ≤0.2. The sociodemographic factors (marital status, education, job, residence), clinical factors (number of episodes/yr., number of admissions, comorbid illness, duration of treatment, relapse, suicidal ideation, family history of mental illness, waiting time in clinics, self-reported health, objective severity of illness, subjective severity of illness, self-esteem, drug adherence), substance use factors (family history of substance use, tobacco use, khat use), and social support-related factors (relationship with family, family participates in treatment) were identified through analysis.

Multivariate logistic regression revealed that living in urban regions; having poor self-reported health; having a relapse, having episodic illness; and poor drug adherence were significantly associated with low mental health service satisfaction (Table 3).

Bivariate and multivariate logistic regression analysis of factors associated with low mental health service satisfaction among people with mental illness in Ethiopia, 2023 (n = 636).

Variables Categories Satisfaction Crude odd ratio (COR 95%CI) Adjusted odd ratio (AOR 95%CI) P - value
High Low
Marital status Marriednot married 199280 54103 11.35 (0.93, 1.97) 11.29 (0.86, 1.92) 0.112
Living condition Living with familyLiving alone 41366 12829 11.41 (0.87, 2.29) 11.01 (0.55, 1.88) 0.152
Education LiterateIlliterate 337142 11443 10.89 (0.59, 1.33) 11.14 (0.67, 1.93) 0.589
Job EmployedNot employed 61418 28129 10.67 (0.41, 1.09) 10.74 (0.43, 1.29) 0.110
Residence UrbanRural 317162 11443 1.35 (0.90, 2.01)1 1.77 (1.15, 2.72) *1 0.009
Number of episode/yr. No episode≥2 Episode/yr 215264 8374 10.72 (0.50, 1.04) 10.48 (0.32, 0.74) * 0.001
Hospital admission No admissionAdmission 320159 10849 10.91 (0.62, 1.34) 10.77 (0.50, 1.19) 0.646
Comorbid illness Noyes 43049 12928 11.90 (1.15, 3.15) 11.50 (0.85, 2.64) 0.111
Duration of Rx. ≤5 yrs.>5 yrs. 332147 10552 11.11 (0.76, 1.64) 10.80 (0.50, 1.27) 0.568
Relapse NoYes 182297 42115 11.67 (1.12, 2.50) 11.75 (1.12, 2.73) * 0.013
Suicidal ideation NoYes 301178 8572 11.43 (0.99, 2.06) 11.13 (0.74, 1.71) 0.053
Family Hx. MI NoYes 376103 11641 11.29 (0.85, 1.95) 11.04 (0.63, 1.72) 0.231
Family Hx. Subs. NoYes 39881 12334 11.35 (0.86, 2.12) 11.10 (0.63, 1.91) 0.180
waiting time in clinics 30 min-1 h.2 h.-3 h. 39683 13819 10.65 (0.38, 1.12) 10.70 (0.38, 1.27) 0.121
Rate your health GoodPoor 52430 6517 13.93 (2.14, 7.20) 13.62 (1.97, 6.67) * 0.001
R/ship with family ExcellentVery GoodGoodFairPoor 431232207023 0624793018 11.39 (0.53, 3.65)2.57 (1.05, 6.27)3.07 (1.18, 7.98)5.60 (1.95, 16.08) 10.97 (0.34, 2.75)1.21 (0.44, 3.32)1.37 (0.46, 4.06)2.16 (0.65, 7.19) 0.3010.8260.6180.142
Family participates patient care YesNo 41069 12631 11.46 (0.91, 2.33) 10.99 (0.54, 1.82) 0.984
Objective severity MildModerate & Severe 379100 11443 11.43 (0.94, 2.16) 10.96 (0.56, 1.64) 0.896
Subjective severity MildModerate & Severe 331148 9364 11.53 (1.06, 2.23) 11.23 (0.79, 1.90) 0.326
Tobacco use NoYes 45425 13918 12.35 (1.24, 4.43) 11.86 (0.94, 3.66) 0.320
Khat use NoYes 375104 12037 11.52 (0.91, 2.54) 10.77 (0.37, 1.58) 0.419
Self-esteem High self-esteemLow self-esteem 249230 7186 11.31 (0.91, 1.88) 11.09 (0.71, 1.65) 0.689
Drug adherence Good adherencePoor adherence 40673 14314 11.83 (1.00, 3.35) 12.28 (1.20, 4.35) * 0.012

* Variable which have significant association with dependent variable.

Participants from urban regions were 1.77 times more likely (AOR = 1.77, 95% CI: 1.15–2.72) to report lower satisfaction with services compared to those from rural regions.

Patients who self-reported poor health were 3.62 times more likely (AOR = 3.62, 95% CI: 1.97–6.67) to report low service satisfaction compared to those who reported good health.

The odds of low mental health service satisfaction were 1.75 times higher (AOR = 1.75, 95% CI: 1.12–2.73) among participants with relapsed illness compared to those without relapsing illness.

Patients with non-episodic illness were 48% less likely (AOR = 0.48, 95% CI: 0.32–0.74) to experience low mental health service satisfaction compared to those with episodic illness.

Participants with poor drug adherence had 2.28 times higher odds of low mental health service satisfaction (AOR = 2.28, 95% CI: 1.20–4.35) compared to those with good drug adherence.

 Discussion

Since service satisfaction is one of the factors that can affect service user quality of life and health outcomes, measuring outpatients’ satisfaction with mental health services in psychiatric clinics is essential. Furthermore, by measuring patient satisfaction, institutions may recognize areas were service delivery needs improvement. The current study was designed to determine mental health service satisfaction and associated factors among patients attending a psychiatry outpatient clinic.

The overall magnitude of high mental health service satisfaction was 75.3% (72–79.1%), while the remaining 24.7% reported low service satisfaction. This magnitude is similar to that of a previous study conducted University of Gondar Hospital in 2017, in which approximately 77.6% of the study participants were satisfied with outpatient care (58). These findings were also consistent with those of another study conducted in an outpatient clinic receiving mental health services at public hospitals in Mekelle town, Ethiopia, which reported a satisfaction rate of 72% (37). This similarity may be because of both studies likely shared similar factors influencing patient satisfaction, such as the quality of care, the approach of patients and healthcare providers, and access to medications and service availability. Additionally, the facilities in both studies were specialized hospitals with similar characteristics, which may have influenced patient satisfaction levels. The similarity of results suggests that common factors, such as improvements in service delivery and the availability of patient support, are key contributors to satisfaction in outpatient mental health services.

The satisfaction score was higher in our study than in other psychiatric outpatient hospital settings in Ethiopia, for example, at St. Poul Hospital in Ethiopia (50.3%) (59), university of Gondar Hospital (65.46%), at Dilla Hospital (55.4%) (38) and at Dessie Hospital (61.2%) (60). The discrepancy in satisfaction scores might be attributable to factors such as the use of different measurement tools, differences in mental health literacy among patients and mental health services, and differences in actual service quality of health care facilities. In general, mental health service satisfaction varies across Ethiopia due to significant differences in health infrastructure, the availability of mental health professionals, and access to essential medications. Urban areas have better facilities and more specialized services compared to rural regions. Additionally, cultural beliefs about mental illness differ across communities, influencing how people perceive and utilize mental health services. In some areas, higher levels of stigma toward mental illness cause to lower satisfaction, as people may face reduced social support and understanding (61, 62). The higher satisfaction score in our study, compared to other psychiatric outpatient settings in Ethiopia, could be attributed to several factors. Our study site has seen recent improvements in service delivery, including better patient-staff communication. As referral hospital, it benefits from senior professionals providing accessible care like psychiatrist, mental health professionals, clinical psychologist and social workers and psychiatry Nurses. additionally, the availability of medications and other resources, such as support services, plays a key role in patient satisfaction. Difference in similar setting may be related to time difference in the study, prior studies done before five years ago due to that there is quality of care difference in the service provided that cause difference in mental health service satisfactions.

When asked about their satisfaction specifically with the quality of care that was provided, almost half of the survey participants (52.8%) reported receiving good quality services in mental health care in the study setting. This observation was similar to the findings of a hospital-based study in Ethiopia, where almost 50% of patients were satisfied with the quality of service received in a psychiatry outpatient clinic, and better than the findings of another study conducted in Ethiopia on the perceived quality of a general medical outpatient service, where only 35% of participants reported receiving good quality service (63). These differences could have been a result of a variation of care in different settings, i.e., between services provided in specialized psychiatry outpatient clinics and those provided by general medical outpatient services, with specialized clinics receiving higher satisfaction scores compared to general medical services where electroconvulsive therapy and senior specialists were present.

According to international comparisons, the service satisfaction score in our study was greater than that reported in studies conducted among patients with mental illness in outpatient clinics in other African countries, including 50% in Egypt and 52.4% in Nigeria (64). Differences in service satisfaction scores across these studies may come from variations in data collection methods and study designs. For instance, while other studies included all patients attending psychiatric outpatient clinics, the Nigerian study focused exclusively on patients with schizophrenia. This narrower cohort of participants may have influenced the satisfaction scores.

Other studies across different continents have reported varying satisfaction scores; for example, in a study conducted in Pakistan, 72% of participants were satisfied with mental health services and in a study conducted in Geneva, 85% of patients reported satisfaction with their mental health outpatient treatment (17). Furthermore, equivocal findings have been demonstrated in different studies that aimed to measure mental health service satisfaction in more developed settings globally; for example, 45% of anxiety outpatients in Los Angeles, 53% of patients with mental health in Mexico and 52% of patients with mental illness in Ireland (65). These differences might be attributable to factors such as the study setting, cultural context and patient expectations of the facilities (36); differences in the data collection methods and study design; and variation in the satisfaction measurement tools used.

In terms of the factors associated with service satisfaction, the satisfaction level of participants in this study was significantly related to area of residence. Participants who were from urban areas were 1.77 times more likely to report low mental health service satisfaction than were those who came from rural areas. Previous studies have reported similar findings in mental health care services in Ethiopia; urban residence was found to be a factor associated with low satisfaction with mental health services provided in an outpatient psychiatry service of Dilla University referral hospital in southern Ethiopia (38), and in Dessie, those living in urban areas were less likely to be satisfied (60). This may be related to urban residents often have higher expectations for service quality due to the greater availability of resources and better infrastructure. Although urban areas offer a wide range of mental health services, in my opinion rural areas may benefit from stronger social networks and family or community-centered support systems. In addition, in my opinion informal support systems in rural areas are common and it can supplement formal care service, leading to higher patient satisfaction and future research should focus to study between service satisfaction and residency status.

This study found that patients with relapsed illness were 1.75 times more likely to report low satisfaction with mental health services compared to those without a relapsing illness. To our knowledge, no previous quantitative studies have directly compared these outcomes with our findings. It may be that patients who experience relapse may feel that the treatments and support provided are not effectively meeting their needs, leading to frustration and disappointment with mental health services. In addition, the increased time and financial demands associated with relapse can add stress, further affecting their overall satisfaction. Additionally, relapse may intensify feelings of stigma, which can lower their satisfaction with the care received (66, 67).

In this study, patients with poor self-rated health were 3.62 times more likely to report low satisfaction with mental health services compared to those with good self-rated health. This could be attributed to individuals with mental illness and poor self-rated health often experiencing life dissatisfaction, low mood or depression, memory and concentration difficulties, and challenges in maintaining positive social relationships with family, friends, and neighbors (68). These findings align with a national survey conducted in Australia, which explored poor self-rated health and its association with somatization disorder (69).

The results obtained from this study showed that patients who had poor drug adherence were more than twice as likely to have low mental health service satisfaction than participants with good drug adherence. Previous studies have reported similar findings showing that drug nonadherence is associated with service dissatisfaction, an indication that patients with mental illnesses may be more prone to not taking their medications as prescribed and may consequently develop low service satisfaction (70).

Studies considering factors associated with mental health service satisfaction have previously shown a statistical correlation between the short waiting time for services in the hospital (71–75). In this study, approximately 157 patients (25%) had low satisfaction with the wait time at the outpatient clinic; however, waiting time was not significantly associated with patient satisfaction in the final analysis. In contrast, another study in Ethiopia that was conducted in a medical outpatient clinic showed that having a waiting time of less than one hour was a predictor of perceived good quality care by patients with mental illness (63).

Notably, in the present study, unlike in other studies, age, marital status, education, job, type of diagnosis, suicidal ideation, and family history of mental illness were not significantly correlated with low service satisfaction among participants. Previous Ethiopian studies have shown the following variables to be associated with service satisfaction: being male, being widowed, having been diagnosed with schizophrenia, having poor social functioning, living a long distance from the hospital, waiting for the service for a long time, having a low monthly income (38), not being hospitalized, receiving medications from the hospital and having strong social support (76). The cause may be attributed to variations in the diagnosis of patients receiving care at facilities, and potential methodological variations in the study method should also be considered.

Strengths and limitations of the study

This study has several strengths and limitations. One of the strengths of this study is that this is the first study to show overall mental health service satisfaction among patients with mental illness in an outpatient clinic of a comprehensive specialized hospital in Ethiopia, including patients with different clinical diagnoses, such as schizophrenia, depression, bipolar disorder and other psychosis disorders. This is the first study to comprehensively examine the impact of sociodemographic, clinical, substance use, and social support-related factors on patients’ satisfaction with mental health services in Ethiopia. Additionally, factors such as relapse, episodic illness, and self-rated health have shown an association with low mental health service satisfaction. These are new factors that had not been previously assessed as predictors of low mental health service satisfaction among patients with mental illness.

This study has several limitations that should be considered, including (i) social desirability bias that could affect the questionnaire responses and data collectors are clinical stuffs working in the study area (ii) its cross-sectional nature and ability to determine the temporal relationship between patient satisfaction and related parameters, and (iii) the ability of the clinic to recruit patients who were more likely to be satisfied, the effect of which could have increased the satisfaction score for the study and lastly the study excluded severely ill patient who did not communicate that makes the result biased. It is also possible that those patients who were not satisfied with the service provision may have not attended the follow-up in the outpatient clinic and were therefore missing among the study participants.

 Conclusion and recommendations

The findings of this study showed that almost 25% of patients in outpatient clinics had low mental health service satisfaction, which requires improvement. Those from urban residences with episodic illness; with a relapse illness; with self-reported health, poor and good health; and poor drug adherence were found to have lower mental health service satisfaction. Therefore, hospital administrations, lawmakers, and accountable authorities should work on activities that increase patient satisfaction, considering these factors. Future research should focus on to study the relationship between service satisfaction and some variables like residence being urban and rural, and informal and formal support.

 Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

 Ethics statement

The studies involving human participants were reviewed and approved by Flinders University Human Research Ethics and Biosafety Committee as well as the University of Gondar. Written informed consent to participate in this study was provided by the patient.

 Author contributions

WA: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. LM: Methodology, Supervision, Validation, Writing – original draft, Writing – review & editing. CD: Methodology, Supervision, Writing – original draft. TA: Investigation, Methodology, Supervision, Writing – review & editing. AZ: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

 Funding

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

We want to thank all the study participants, data collectors, and supervisors who contributed their time and effort to complete the research. In addition, Wondale Getinet Alemu thanks Flinders University and the Australian Government Research Training Programme (RTP) for funding his PhD scholarship. This research was supported by the Australian Government Research Training Program (RTP) and Flinders University.

 Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

 Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

 Abbreviations

AOR, Adjusted odds ratio; CI, Confidence interval; COR, Crude odds ratio; CSQ, Client satisfaction questionnaire; MARS-5, Medication Adherence Rate Scale; CGI, Clinical Global Impression Scale; OR, Odds ratio; SD, Standard deviation; SPSS-28, Statistical Package for Social Science.

 References Blenkiron P Hammill C. What determines patients’ satisfaction with their mental health care and quality of life? Postgrad Med J. (2003) 79:337–40. doi: 10.1136/pmj.79.932.337, PMID: 12840123 Bramesfeld A Wedegärtner F Elgeti H Bisson S. How does mental health care perform in respect to service users' expectations? Evaluating inpatient and outpatient care in Germany with the WHO responsivenessconcept. BMC Health Serv Res. (2007) 7:1–12. doi: 10.1186/1472-6963-7-99, PMID: 17605786 Leonard KL. Is patient satisfaction sensitive to changes in the quality of care? An exploitation of the Hawthorne effect. J Health Econ. (2008) 27:444–59. doi: 10.1016/j.jhealeco.2007.07.004, PMID: 18192043 Al-Abri R Al-Balushi A. Patient satisfaction survey as a tool towards quality improvement. Oman Med J. (2014) 29:3–7. doi: 10.5001/omj.2014.02, PMID: 24501659 McMillan SS Kendall E Sav A King MA Whitty JA Kelly F . Patient-centered approaches to health care: a systematic review of randomized controlled trials. Med Care Res Rev. (2013) 70:567–96. doi: 10.1177/1077558713496318, PMID: 23894060 Gill L White L. A critical review of patient satisfaction. Leadersh Health Serv. (2009) 22:8–19. doi: 10.1108/17511870910927994 Bjertnaes OA Sjetne IS Iversen HH. Overall patient satisfaction with hospitals: effects of patient-reported experiences and fulfilment of expectations. BMJ Quality Safety. (2012) 21:39–46. doi: 10.1136/bmjqs-2011-000137, PMID: 21873465 Priebe S Miglietta E. Assessment and determinants of patient satisfaction with mental health care. World Psychiatry. (2019) 18:30–1. doi: 10.1002/wps.20586, PMID: 30600613 Shipley K Hilborn B Hansell A Tyrer J Tyrer P. Patient satisfaction: a valid index of quality of care in a psychiatric service. Acta Psychiatr Scand. (2000) 101:330–3. doi: 10.1034/j.1600-0447.2000.101004330.x, PMID: 10782555 Ruggeri M. Patients' and relatives' satisfaction with psychiatric services: the state of the art of its measurement. Soc Psychiatry Psychiatr Epidemiol. (1994) 29:212–27. doi: 10.1007/BF00796380, PMID: 7992145 Stamboglis N Jacobs R. Factors associated with patient satisfaction of community mental health services: a multilevel approach. Community Ment Health J. (2020) 56:50–64. doi: 10.1007/s10597-019-00449-x, PMID: 31522349 Fortin M Bamvita J-M Fleury M-J. Patient satisfaction with mental health services based on Andersen’s behavioral model. Can J Psychiatry. (2018) 63:103–14. doi: 10.1177/0706743717737030, PMID: 29056085 Chandra S Ward P Mohammadnezhad M. Factors associated with patient satisfaction in outpatient department of Suva sub-divisional Health Center, Fiji, 2018: a mixed method study. Front Public Health. (2019) 7:183. doi: 10.3389/fpubh.2019.00183, PMID: 31312630 Smith D Roche E O’Loughlin K Brennan D Madigan K Lyne J . Satisfaction with services following voluntary and involuntary admission. J Ment Health. (2014) 23:38–45. doi: 10.3109/09638237.2013.841864, PMID: 24484191 Chaka B. Adult patient satisfaction with nursing care. Gray literature: MPH thesis, department of community health, Addis Ababa University (2005). Shahbaz S Hans RK Mudassar S. Service quality, word of mouth and trust: drivers to achieve patient satisfaction. Sci Res Essays. (2010) 5:2457–62. Davy B Keizer I Croquette P Bertschy G Ferrero F Gex-Fabry M . Patient satisfaction with psychiatric outpatient care in Geneva: a survey in different treatment settings. Schweizer Archiv Fuer Neurologie Und Psychiatrie. (2009) 160:240–5. doi: 10.4414/sanp.2009.02087, PMID: 31760237 Vermeulen J Schirmbeck N van Tricht M de Haan L. Satisfaction of psychotic patients with care and its value to predict outcomes. Eur Psychiatry. (2018) 47:60–6. doi: 10.1016/j.eurpsy.2017.10.003, PMID: 29102660 Lindberg LG Mundy SS Kristiansen M Johansen KS Carlsson J. Satisfaction with mental health treatment among patients with a non-Western migrant background: a survey in a Danish specialized outpatient mental health clinic. Eur J Pub Health. (2019) 29:700–5. doi: 10.1093/eurpub/ckz090, PMID: 31155672 Jena S Gupta M. A survey of patient satisfaction of patients attending a psychiatry outpatient clinic at a tertiary care Centre. Int J Commun Med Public Health. (2018) 5:2026. doi: 10.18203/2394-6040.ijcmph20181717 Zahid MA Ohaeri JU Al-Zayed AA. Factors associated with hospital service satisfaction in a sample of Arab subjects with schizophrenia. BMC Health Serv Res. (2010) 10:1–11. doi: 10.1186/1472-6963-10-294, PMID: 20979599 Ratner Y Zendjidjian XY Mendyk N Timinsky I Ritsner MS. Patients' satisfaction with hospital health care: identifying indicators for people with severe mental disorder. Psychiatry Res. (2018) 270:503–9. doi: 10.1016/j.psychres.2018.10.027, PMID: 30347377 Iliyasu Z Abubakar I Abubakar S Lawan U Gajida A. Patients' satisfaction with services obtained from Aminu Kano teaching hospital, Kano, northern Nigeria. Niger J Clin Pract. (2010) 13:371–8. PMID: 21220848 Dagnew M Zakus D. Community perception on OPD performance of a teaching hospital in Gondar town. Ethiop Med J. (1997) 35:153–60. PMID: 9558753 Afework S Mariam DH Demeke B. Assessment of quality of services in private clinics in Addis Ababa. Ethiopia Ethiopian Medical J. (2003) 41:267–78. PMID: 15227892 Oljira L Gebre-Selassie S. Satisfaction with outpatient health services at Jimma hospital, south West Ethiopia. Ethiop J Health Dev. (2001) 15:179–84. Riklikienė O Didenko O Ciutiene R Daunoriene A Ciarniene R. Balancing nurses’ workload: a case study with nurse anaesthetists and intensive care nurses. Econ Soc. (2020) 13:11–25. doi: 10.14254/2071-789X.2020/13-2/1 Jakubowska A Bilan S Werbiński J. Chronic diseases and labour resources:" old and new" European Union member states. J Int Stud. (2021) 14:129–38. doi: 10.14254/2071-8330.2021/14-1/9 Ådnanes M Kalseth J Ose SO Ruud T Rugkåsa J Puntis S. Quality of life and service satisfaction in outpatients with severe or non-severe mental illness diagnoses. Qual Life Res. (2019) 28:713–24. doi: 10.1007/s11136-018-2039-5, PMID: 30392098 Petkari E Pietschnig J. Associations of quality of life with service satisfaction in psychotic patients: a meta-analysis. PLoS One. (2015) 10:e0135267. doi: 10.1371/journal.pone.0135267, PMID: 26275139 Afe TOBello-Mojeed M Ogunsemi O. Perception of service satisfaction and quality of life of patients living with schizophrenia in Lagos, Nigeria. J Neurosci Rural Practice. (2016) 7:216–22. doi: 10.4103/0976-3147.178652, PMID: 27114651 Hudak PL Hogg-Johnson S Bombardier C McKeever PD Wright JG. Testing a new theory of patient satisfaction with treatment outcome. Med Care. (2004) 42:726–39. doi: 10.1097/01.mlr.0000132394.09032.81, PMID: 15258474 Leebov W Scott G. Service quality Improvemenk the customer satisfaction strategy for healthcare. J Healthcare Qual. (1996) 18:35. doi: 10.1097/01445442-199607000-00009 Clignet F Houtjes W van Straten A Cuijpers P van Meijel B. Unmet care needs, care provision and patient satisfaction in patients with a late life depression: a cross-sectional study. Aging Ment Health. (2019) 23:491–7. doi: 10.1080/13607863.2018.1426716, PMID: 29356572 Kelly PJ Kyngdon F Ingram I Deane FP Baker AL Osborne BA. The client satisfaction Questionnaire-8: psychometric properties in a cross-sectional survey of people attending residential substance abuse treatment. Drug Alcohol Rev. (2018) 37:79–86. doi: 10.1111/dar.12522, PMID: 28480521 Thi PLN Briancon S Empereur F Guillemin F. Factors determining inpatient satisfaction with care. Soc Sci Med. (2002) 54:493–504. doi: 10.1016/S0277-9536(01)00045-4, PMID: 11848270 Desta H Berhe T Hintsa S. Assessment of patients’ satisfaction and associated factors among outpatients received mental health services at public hospitals of Mekelle town, northern Ethiopia. Int J Ment Heal Syst. (2018) 12:1–7. doi: 10.1186/s13033-018-0217-z, PMID: 30008801 Kassaw C Eskeziya A Anbesaw T. Magnitude of patient satisfaction and its associated factors at the outpatient psychiatry service of Dilla university referral hospital, southern Ethiopia, Dilla, 2020. PLoS One. (2022) 17:e0272485. doi: 10.1371/journal.pone.0272485, PMID: 35921288 McGranahan R Hansson L Priebe S. Psychopathological symptoms and satisfaction with mental health in patients with schizophrenia. Psychopathology. (2018) 51:192–7. doi: 10.1159/000487399, PMID: 29566391 Alkaabi S Al-Balushi N Al-Alawi M Mirza H Al-Huseini S Al-Balushi M . Level and determinants of patient satisfaction with psychiatric out-patient services, Muscat. Oman Int J Mental Health. (2019) 48:80–94. doi: 10.1080/00207411.2019.1585226 Regier DA Farmer ME Rae DS Locke BZ Keith SJ Judd LL . Comorbidity of mental disorders with alcohol and other drug abuse: results from the epidemiologic catchment area (ECA) study. JAMA. (1990) 264:2511–8. doi: 10.1001/jama.1990.03450190043026 Dawud B Yeshigeta E Negash A Mamaru A Agenagnew L Tolosa D . Community-based cross-sectional study. Clin Med Insights. (2017) 2021:1179557321989699. Karino K Ambikile JS Iseselo MK. Prevalence and factors associated with self-reported substance use among patients with mental illness in Dar Es Salaam, Tanzania: a cross-sectional analytical study. Ment Illn. (2023) 2023:1–8. doi: 10.1155/2023/3923793, PMID: 38654912 Stallvik M Flemmen G Salthammer JA Nordfjærn T. Assessing health service satisfaction among users with substance use disorders within the municipalities in Norway. Subst Abuse Treat Prev Policy. (2019) 14:18. doi: 10.1186/s13011-019-0207-4, PMID: 31060571 Svensson B Hansson L. Satisfaction with mental health services. A user participation approach. Nord J Psychiatry. (2006) 60:365–71. doi: 10.1080/08039480600937090, PMID: 17050294 Skar-Fröding R Clausen HK Šaltytė Benth J Ruud T Slade M Sverdvik HK. Relationship between satisfaction with mental health services, personal recovery and quality of life among service users with psychosis: a cross-sectional study. BMC Health Serv Res. (2021) 21:1–8. doi: 10.1186/s12913-021-06409-0, PMID: 33964917 Ruggeri M Lasalvia A Bisoffi G Thornicroft G Vazquez-Barquero JL Becker T . Satisfaction with mental health services among people with schizophrenia in five European sites: results from the EPSILON study. Schizophr Bull. (2003) 29:229–45. doi: 10.1093/oxfordjournals.schbul.a007000, PMID: 14552499 Shumye S Amare T Derajew H Endris M Molla W Mengistu N. Perceived quality of life and associated factors among patients with severe mental illness in Ethiopia: a cross-sectional study. BMC Psychol. (2021) 9:1–8. doi: 10.1186/s40359-021-00664-w, PMID: 34602067 Attkisson CC Greenfield TK. The client satisfaction questionnaire (CSQ) scales and the service satisfaction scale-30 (SSS-30). Outcomes Assessment Clinical Practice. (1996) 120:120–7. Shorub EM Rasas HH Kalifa AG. Satisfaction with Ain shams outpatient mental health services. Middle East current. Psychiatry. (2015) 22:186–92. doi: 10.1097/01.XME.0000470974.85176.c7, PMID: 33079766 Robins RW Hendin HM Trzesniewski KH. Measuring global self-esteem: construct validation of a single-item measure and the Rosenberg self-esteem scale. Personal Soc Psychol Bull. (2001) 27:151–61. doi: 10.1177/0146167201272002 Stone JK Shafer LA Graff LA Lix L Witges K Targownik LE . Utility of the MARS-5 in assessing medication adherence in IBD. Inflamm Bowel Dis. (2021) 27:317–24. doi: 10.1093/ibd/izaa056, PMID: 32195533 Ediger JP Walker JR Graff L Lix L Clara I Rawsthorne P . Predictors of medication adherence in inflammatory bowel disease. LWW. (2007) 102:1417–26. doi: 10.1111/j.1572-0241.2007.01212.x, PMID: 17437505 Ubaka CM Ibe OG Amorha KC Isah A Okonta MJ. Medication adherence among Nigerian patients with rheumatoid arthritis: a two instruments survey. J Pharm Health Serv Res. (2021) 12:11–7. doi: 10.1093/jphsr/rmaa007 Humeniuk R Ali R Babor TF Farrell M Formigoni ML Jittiwutikarn J . Validation of the alcohol, smoking and substance involvement screening test (ASSIST). Addiction. (2008) 103:1039–47. doi: 10.1111/j.1360-0443.2007.02114.x, PMID: 18373724 Kadouri A Corruble E Falissard B. The improved clinical global impression scale (iCGI): development and validation in depression. BMC Psychiatry. (2007) 7:1–7. doi: 10.1186/1471-244X-7-7, PMID: 17284321 Nakagawa S Cuthill IC. Effect size, confidence interval and statistical significance: a practical guide for biologists. Biol Rev. (2007) 82:591–605. doi: 10.1111/j.1469-185X.2007.00027.x, PMID: 17944619 Woldekidan NA Gebresillassie BM Alem RH Gezu BF Abdela OA Asrie AB. Patient satisfaction with psychiatric outpatient Care at University of Gondar specialized hospital: a cross-sectional survey. Psychiatry J. (2019) 2019:1–7. doi: 10.1155/2019/5076750, PMID: 31058180 Goben KW Abegaz ES Abdi ST. Patient satisfaction and associated factors among psychiatry outpatients of St Paulo's hospital, Ethiopia. Gen Psychiatr. (2020) 33:e100120. doi: 10.1136/gpsych-2019-100120, PMID: 32090194 Yimer S Yohannis Z Getinet W Mekonen T Fekadu W Belete H . Satisfaction and associated factors of outpatient psychiatric service consumers in Ethiopia. Patient Prefer Adherence. (2016) 10:1847–52. doi: 10.2147/PPA.S115767, PMID: 27703333 Sibitz I Amering M Unger A Seyringer M Bachmann A Schrank B . The impact of the social network, stigma and empowerment on the quality of life in patients with schizophrenia. Eur Psychiatry. (2011) 26:28–33. doi: 10.1016/j.eurpsy.2010.08.010, PMID: 21036554 Wang D-F Zhou Y-N Liu Y-H Hao Y-Z Zhang J-H Liu T-Q . Social support and depressive symptoms: exploring stigma and self-efficacy in a moderated mediation model. BMC Psychiatry. (2022) 22:117. doi: 10.1186/s12888-022-03740-6, PMID: 35168584 Utino L Birhanu B Getachew N Ereso BM. Perceived quality of medical services at outpatient department of public hospitals in Dawro zone, southern Ethiopia. BMC Health Serv Res. (2023) 23:209. doi: 10.1186/s12913-023-09178-0, PMID: 36864413 Omoronyia FR Ndiok AE Enang KO Obande EI. Patients’ satisfaction with psychiatric nursing care in Benin, Nigeria. Int J Africa Nur Sci. (2021) 14:100282. doi: 10.1016/j.ijans.2021.100282 Lally J Byrne F McGuire E McDonald C. Patient satisfaction with psychiatric outpatient care in a university hospital setting. Ir J Psychol Med. (2013) 30:271–7. doi: 10.1017/ipm.2013.54, PMID: 30189479 Corrigan PW Watson AC. Understanding the impact of stigma on people with mental illness. World Psychiatry. (2002) 1:16–20. PMID: 16946807 Link BG Struening EL Neese-Todd S Asmussen S Phelan JC. Stigma as a barrier to recovery: the consequences of stigma for the self-esteem of people with mental illnesses. Psychiatr Serv. (2001) 52:1621–6. doi: 10.1176/appi.ps.52.12.1621, PMID: 11726753 Yang H Deng Q Geng Q Tang Y Ma J Ye W . Association of self-rated health with chronic disease, mental health symptom and social relationship in older people. Sci Rep. (2021) 11:14653. doi: 10.1038/s41598-021-94318-x, PMID: 34282246 Mewton L Andrews G. Poor self-rated health and its associations with somatisation in two Australian national surveys. BMJ Open. (2013) 3:e002965. doi: 10.1136/bmjopen-2013-002965, PMID: 23811174 Lacro JP Dunn LB Dolder CR Jeste DV. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. J Clin Psychiatry. (2002) 63:892–909. doi: 10.4088/JCP.v63n1007, PMID: 12416599 Abolfotouh MA Al-Assiri MH Alshahrani RT Almutairi ZM Hijazi RA Alaskar AS. Predictors of patient satisfaction in an emergency care Centre in Central Saudi Arabia: a prospective study. Emerg Med J. (2017) 34:27–33. doi: 10.1136/emermed-2015-204954, PMID: 27480456 Renzi C Picardi A Abeni D Agostini E Baliva G Pasquini P . Association of dissatisfaction with care and psychiatric morbidity with poor treatment compliance. Arch Dermatol. (2002) 138:337–42. doi: 10.1001/archderm.138.3.337, PMID: 11902984 Sran M Pyra T Chen L Holroyd B McCabe C. P116: a scoping review of factors affecting patient satisfaction with care in North American adult emergency departments. Canadian. J Emerg Med. (2017) 19:S117. doi: 10.1017/cem.2017.318, PMID: 39776994 Preyde M Crawford K Mullins L. Patients' satisfaction and wait times at Guelph general hospital emergency department before and after implementation of a process improvement project. Can J Emerg Med. (2012) 14:157–68. doi: 10.2310/8000.2012.110590, PMID: 22575296 Renzi C Abeni D Picardi A Agostini E Melchi C Pasquini P . Factors associated with patient satisfaction with care among dermatological outpatients. Br J Dermatol. (2001) 145:617–23. doi: 10.1046/j.1365-2133.2001.04445.x, PMID: 11703289 Melkam M Kassew T. Mental healthcare services satisfaction and its associated factors among patients with mental disorders on follow-up in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia. Front Psychiatry. (2023) 14:1081968. doi: 10.3389/fpsyt.2023.1081968, PMID: 37324812