QAI Journal for Healthcare Quality and Patient Safety

: 2019  |  Volume : 1  |  Issue : 2  |  Page : 26--31

Caregiver satisfaction with quality of care in the pediatric medical ward of a large hospital in Botswana

Mbaakanyi Masikara1, Alemayehu Mekonnen Gezmu1, Merrian Brooks2, Lesego Gabaitiri3, Tonya Arscott-Mills4,  
1 Department of Paediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
2 Centre for Global Health, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
3 Department of Statistics, Faculty of Social Sciences, University of Botswana, Gaborone, Botswana
4 Botswana and University of Pennsylvania Partnership, Gaborone, Botswana

Correspondence Address:
Dr. Alemayehu Mekonnen Gezmu
Department of Paediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, P.O. Box UB00713, Gaborone


Context: Few studies in developing settings seek to determine caregivers' level of satisfaction with medical services provided for their children. High-quality medical care is associated with improved health outcomes and higher health-care utilization. Aims: We sought to understand caregiver satisfaction in the pediatric ward of a large hospital in Botswana. Settings and Design: A cross-sectional, descriptive survey was conducted in the pediatrics medical ward at a referral hospital in Gaborone, Botswana, between September and October 2017. Subjects and Methods: A cross-sectional survey was conducted on caregivers admitted with their children in the pediatric ward of a large multispecialty hospital in Botswana. A total of 250 caregivers took a modified Service Quality Instrument from September to October 2017. The quality service instrument provides expectation and perception data in two subscales and assesses the difference between expectation and perception score, or gap score, for five dimensions of medical care. Statistical Analysis Used: All data were analyzed using Statistical Package for Social Science software. Results: The mean gap scores for the cohort were all negative, showing poor satisfaction and discrepancies between expectations and perceptions. The overall mean gap score was at − 0.315 (P < 0.001). The gap scores were as follows: for tangibles, –0.372; reliability, –0.1656; responsiveness, –0.210; assurance, −0.137; and empathy, −0.198. There was a statistically significant difference between the mean gap scores of caregivers in the oncology (−0.08) and medical cohort (−0.35) (P < 0.005). Conclusions: Caregivers in the hospital with their children were dissatisfied with the quality of care their children received in each quality domain measured. Hospital and government leaders of growing health systems have an opportunity to create environments and communication that are responsive to the needs of caregivers who are partners in the care of children.

How to cite this article:
Masikara M, Gezmu AM, Brooks M, Gabaitiri L, Arscott-Mills T. Caregiver satisfaction with quality of care in the pediatric medical ward of a large hospital in Botswana.QAI J Healthc Qual Patient Saf 2019;1:26-31

How to cite this URL:
Masikara M, Gezmu AM, Brooks M, Gabaitiri L, Arscott-Mills T. Caregiver satisfaction with quality of care in the pediatric medical ward of a large hospital in Botswana. QAI J Healthc Qual Patient Saf [serial online] 2019 [cited 2020 Aug 12 ];1:26-31
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Full Text


Quality of health care is defined as a degree of performance in relation to a defined standard of interventions known to be safe and has the capacity to improve health within the available resources.[1]

Over the past 20 years, patient satisfaction surveys have gained increasing attention as meaningful sources of information that can be used to develop an effective action plan for quality improvement in health-care organizations.[2] Historically, the establishment of quality standards was delegated to medical professionals who, not surprisingly, defined it in terms of technical delivery of care. Recent literature, however, supports the importance of patient perspective when designing plans for quality improvement.[3] In fact, patient satisfaction can lead to decreased morbidity and reduced death rate.[4],[5],[6],[7] One US study of patients with myocardial infarction showed that higher patient satisfaction was associated with reduced mortality.[8] Patient satisfaction is also linked to treatment adherence, increased continuity of care, better understanding and retention of medical information, decreased likelihood to change physicians, and decreased patient malpractice litigation.[8] Hospitals with high patient satisfaction provided more efficient care with shorter lengths of stay for surgical patients as well.[8]

In Botswana, the large hospital studied has previously used a generic questionnaire that is not tailored for the health sector or to assess the expectations and perception of health-care quality. Seitio-Kgokgwe et al., in 2014, assessed the overall performance of Botswana public hospitals with a focus on the organization and governance, service availability, service capacity, and service quality.[9] The study found that there was a lack of focus on quality. Specifically, there was a lack of evidence of clinical governance structures and strategies related to quality, failure to address quality issues in management meetings, and lack of procedures for conducting clinical audits or monitoring the effectiveness of care.[9] Kgokgwe's work did not address health-care quality from the client perspective at all. Bamidele et al. examined adults' satisfaction with care provided in a primary health service in Botswana. They found that the majority (63.9%) of patients were displeased with the time spent at the facility. The participants also felt that increases in workforce (36%) and improvements in staff training (15%) were key areas for improvement.[10] Our study is the first in Botswana, and, to our knowledge, the only study in a low-middle-income, English-speaking African country, to assess patient satisfaction of the caregivers of hospitalized pediatric patients in a referral hospital.

 Subjects and Methods


This cross-sectional, descriptive survey was conducted in the pediatrics medical ward at a referral hospital in Gaborone, Botswana, between September and October 2017. The hospital is in an urban area with a population of about 230,000. The pediatric ward admits between 150 and 200 patients a month, that is, approximately 1800–2400 pediatric admissions a year. The pediatric ward is open with cubicles housing eight or more beds each. In total, the ward has 34 pediatric beds, which are sometimes augmented by floor beds when there is an overflow of patients. There are general pediatric and oncology services led by two different teams to care for patients admitted for inpatient stays in the hospital. The medical staff in the ward include pediatricians, pediatric residents, medical officers, interns, nurses, and medical students. Caregivers are required to remain with their pediatric patients when they are inpatients in the hospital and are required to feed and bath and otherwise care for the child's needs.


All caregivers of children admitted to the pediatric medical ward for <24 h were recruited until the sample size was reached. We excluded patients with no caregivers staying with them in the hospital, caregivers with patients admitted <24 h, and caregivers who were interviewed on a previous admission.


We used the Service Quality Instrument (SERVQUAL) to assess patient-rated quality. The SERVQUAL model assesses patient level of satisfaction in two categories (1) expectations and (2) perceptions of actual care received, which is called the service quality gap.[11] The SERVQUAL contains 22 pairs of Likert-like scale questions designed to measure customers' expectation of a service and the customers' perception of a service provided by an organization. These 22 questions cover five dimensions including tangibles, reliability, responsiveness, assurance, and empathy. To assess a service quality, the gap for each question is calculated based on comparing the perception score with the expectation score. The positive gap score means that customers' expectations are met or exceeded, whereas the negative score means the opposite.[12] The SERVQUAL has been validated with Kaiser–Meyer–Oklin value of 0.871 and principal component analysis for expectation and perception showing five components with eigenvalues exceeding 1, consistent with the original SERVQUAL five-domain instrument validated in other settings.[13] Internal consistency reliability was assessed in our sample using the Cronbach's alpha for the overall scale (α = 0.7).

Ethical approval was obtained from the Institutional Review Boards at the Botswana Ministry of Health, Princess Marina Hospital, and the University of Botswana. Data collection forms were de-identified to ensure patient confidentiality.

Data analysis

All data were analyzed using Statistical Package for Social Science software Statistical Package for Social sciences (SPSS) Ver 20 software (Chicago, USA). The mean expectation and perception scores for all participants were averaged, and the gap score for all participants was calculated by subtracting the overall perception score from the expectation score. We used a one-sample t-test to analyze whether the difference between overall expectations and overall perceptions scores was statistically significant. If the perception equaled or was above the expectation, the service quality was considered satisfactory (positive gap score). However, if the expectation exceeded the perception, the service quality was considered unsatisfactory (negative gap score). We then calculated the mean gap score for each of the five subdomains of the SERQUAL including tangibles, reliability, empathy, assurance, and quality. As with the overall scores, we used the t-test to analyze the difference between expectation and perception scores. We also performed subgroup analysis comparing differences between caregivers whose children were being cared for by the oncology group and caregivers whose children were being cared for by the general pediatric group. We also performed a subgroup analysis comparing those admitted <7 days and those admitted for <7 days. All analyses were considered statistically significant at P < 0.05.



The mean age of the participants was 31.5 ± 7.76 years (range 18–66), with 246 (98.4%) females and 4 (1.6%) males as caregivers. Most of our caregivers had a secondary school level of education (144 [57.6%]) followed by tertiary (81 [32.4%]), and 10% had a primary school education. Patients were admitted to the hospital between 2 and 46 days, with most patients staying <7 days (85.2%). Of the 250 patients admitted, 14.8% had oncologic diagnosis and the rest were general pediatric patients. The three most common medical reasons for admission included pneumonia (28%), acute gastro enteritis (12.4%), and febrile seizure (7.2%) [Table 1].{Table 1}

Mean satisfaction gap scores

Of the 250 caregivers, 70.8% (n = 177) had a negative service satisfaction as indicated by a negative gap score and 29.2% (n = 73) had a positive service satisfaction as indicated by a positive gap score. The mean overall gap score for all SERVQUAL items is negative (−) (0.315 [P = 0.00]), indicating that caregiver expectations were generally not meet.

This dissatisfaction was maintained in each of the five domains for the study sample, with each of the gap scores for the five domains being negative. The gap scores for each domain are shown in [Figure 1]. The largest gap was –0.372 for tangibles, and the smallest was 0.137 for assurance.{Figure 1}

The tangible domain dissatisfaction was mostly due to their disagreement with the statement that “the ward was clean” with a mean gap of −0.64 (P < 0.001). The least amount of dissatisfaction was found in the assurance domain at −0.1370 (P < 0.008). Caregivers were most dissatisfied with the statement of “the medical staff is trustworthy,” with a mean gap score of −0.192 (P < 0.009), followed closely by “the staff had support to do their job well,” with a mean gap score of −0.180 (P < 0.005).

Although the overall scores and subdomain scores indicated dissatisfaction, a few individual items did result in mean gap scores that indicated that caregivers were satisfied. These included the empathy statements “The staff provided individual attention to each child” and “the medical staff gives personal attention to my child” with gap scores of −0.068 and −0.078, respectively, that had corresponding P > 0.05. The overall mean gap scores and expectation and perception scores of the SERVQUAL for the cohort are summarized in [Table 2].{Table 2}

Demographics also made a difference in the overall gap scores. The overall study population being less educated and older resulted in less of a gap between expectations and perceptions of quality of service and environment for their children. [Table 3] illustrates the major demographic differences.{Table 3}


This study conducted in the pediatric ward of a large referral hospital in the capital city of Botswana examined caregiver expectations and perceptions of care. Overall, the caregivers were dissatisfied by the quality of the environment and of the care their children received. More than 70% of the caregivers had an overall negative gap score. There was dissatisfaction in all the subdomains studied including tangibles, reliability, empathy, assurance, and responsiveness, with negative gap scores indicating low levels of satisfaction. These results indicate that there is an unmet need for caregivers to know that their children are receiving high quality care.

Other studies exploring different elements of health-care setting also showed negative results with adult patients, and even health-care providers were asked how satisfied they are with the facilities and provider motivations.[14],[15],[16] Similar to studies conducted in other low-to-middle-income countries (LMICs), our results show that caregivers were unhappy mostly about the tangibles followed by responsiveness items.

The caregivers did not think that “the ward equipment is up-to date” or that “the ward was clean,” with each of these survey items having the largest dissatisfaction as indicated by the mean gap score. According to the Donabedian model, there is a strong relationship between the three domains of structure, process, and outcome, which exist in the context of quality of care.[17] Tangibility in the SERVQUAL model would represent structure category in the Donabedian model. Donabedian suggests that if the structural aspects of care are not addressed, then the other categories will be affected. This is reflected in our results. Equipment includes the number of available functional beds, mattresses, monitoring machines, and just the general state of the building used to house the hospital where the present study was conducted. In Ghana, tangibility had a positive gap score indicating that clients were happy with the structural aspects of care, which are the physical facility, equipment, and human resources.[18] According to Donabedian, this is what one needs to work on first before one can expect improvements in other areas. Peprah et al. study in Ghana showed overall satifaction to be good, eventhough domains outside of tangibility areas were left for improvement which by itself support Donabedian's claims.[18] It is also possible that cultural factors such as a practice in Botswana called “Botsetsi,” a practice of isolation, and a clean environment done in order to protect the health of newborn infants, may explain our caregivers' high expectations for cleanliness or orderliness. However, there is still need for more detailed studies to look at the cultural influences and other factors on quality of care in Botswana.

Responsiveness could represent process in the Donabedian scale. Our caregivers found that prompt, clear, and responsive service and communication was not satisfactory. They also did not agree that “the medical team was available at all times,” or that “the staff was reassuring about condition of my child.” This couple be explained by availability or visibility of the medical team. It could also be due to poor communications skills of both doctors and nurses or due to medical staff who are not spending time to address caregiver concerns. Another possible factor could be poor nurse-to-patient ratio, given that the hospitals' average is 1:9–1:12 and even higher in times of high census.[19] We believe that this is a strong reason for the poor satisfaction for responsiveness as opposed to a perception of carelessness. Our caregivers agreed that “the medical staff cares” with an insignificant gap, indicating that expectations were met (P = 0.490), highlighting that though caregivers were dissatisfied with responsiveness, they thought that when they did interact with providers, caring was not a major factor.

We expected that the satisfaction between the oncology and medical cohort would favor the oncology team. The mean difference in satisfaction was statistically significant with P = 0.005, indicating less dissatisfaction in caregivers whose children had oncological problems. We suspect that this result is due to a number of factors such as the fact that the oncology census is lower, the oncology team usually has more interactions with their patients, clients spend more days per admission thus getting to know providers, and providers do more extensive counseling sessions due to the nature of the diseases. However, the oncology team had to deal with the same tangibility factors and the same difficulties with nurse-to-patient ratios. Thus, though there were differences in mean caregiver satisfaction between the general pediatric and pediatric oncology teams, the oncology team still has a small negative gap score, indicating that expectations were almost met.

A few interesting demographic factors correlated with differing levels of satisfaction. Caregivers' educational levels correlated with their gap scores. For primary school level, there was no statistical difference between the expectation and perception scores, which meant that expectations were met, while for the secondary and tertiary school level, the mean gap was significant. These findings are consistent with those of other studies, which have also found that caregivers with higher level of education had higher mean gaps.[20],[21] Their mean gap scores correlated with higher expectations from the beginning (4.02 expectation scores in primary educated caregivers versus 4.19 and 4.2 expectation scores in secondary and tertiary educated caregivers), which may be due to an increased awareness and education related to quality measures and standards.

We also noted that caregivers over 40 years of age had higher levels of satisfaction than those <40. Tokunaga and Imanaka in Japan also noted that the older the respondents, the higher the satisfaction with care.[22] We suspect that older clients might be more familiar with the health system and know what it can offer. Anecdotal experience also allows us to speculate that older clients expect a more paternalistic model of care, whereas younger clients, however, expect to be more involved in decision-making process. In India, researchers have found that these dynamics result in higher satisfaction among older patients.[23] It is unclear how this reflects on older caregivers of children, and this will be a further area of study.

The study had a few limitations. The study did not consider the condition in which patients were in when they were admitted or their experiences, which could influence their expectations and perceptions. It is possible that the high levels of illness seen among pediatric oncology patients would explain the differences between the general pediatric and oncology teams. In future studies, we will explore this important element when doing patient satisfaction surveys.[24],[25] The study was cross-sectional, hence only representing outcomes at a moment in time and in that particular time of the year. Satisfaction may also be influenced by how full the hospital was at the time of the study. The caregiver level of satisfaction was largely dependent on self-response by participants and did not assess how their views might. Third, the study only assessed caregivers in the pediatric medical ward, but those in the pediatric surgical ward, neonatal ward, and outpatient clinics were not included. This limits the applicability of the results, though it does apply to similar inpatient pediatric or pediatric oncology settings. Fourth, the subgroup analyses, including the comparison of general pediatrics versus oncology and longer versus shorter stays, were secondary outcomes and thus not powered adequately. Lastly, we had not considered inclusion of employee work satisfaction as satisfied employees reinforce customer satisfaction.[26]

There are several strengths to consider. The measures were solid with measured reliability and validity in this setting. The SERVQUAL questionnaire is a standardized tool to measure service quality applied in different environments, has been used in a variety of settings, and is seen as a quality assessment of satisfaction. This study provides further evidence to support the applicability of the Donabedian model in the settings of caregivers staying with children in a hospital in an LMIC. Although this study was conducted in one facility, there may be broader applicability in other inpatient pediatric units with similar contexts to the one studied.


This study provides everyone on the medical team, hospital administrators, and government sponsors with information to begin the work needed to improve patient satisfaction in settings similar to ours. Recommendations might include improving ward cleanliness, having up-to-date equipment, and communicating better with our clients. Structure, process, and outcome are interrelated, and in order to improve quality of care, all must function well to achieve the expected outcome. Future studies will provide greater context to both expectations and perceptions and explore tangible solutions to influence caregiver satisfaction in pediatric wards.


The authors would like to acknowledge the parents (or caretakers) and patients who took part in our study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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