Nowadays, the quality of care provided to patients by health establishments represents one of the essential objectives of health systems in the world and in Tunisia specifically. In fact, the evaluation of the quality of the services offered is a validated indicator of the efficiency of a health system. ¹

Several elements reflect the quality of the healthcare, including patient satisfaction. ^{2 – 4}

In Tunisia, a North-African developing country, intra-hospital activity in third line hospitals represents a very important part of the activity of the healthcare system, whether for hospitalizations, surgical procedures or outpatient consultations.

Sahloul University Hospital in Sousse is one of the largest 3rd line hospitals in the Tunisian center. It also drains several regions of east, center, north and south of Tunisia.

In physical medicine and rehabilitation (PM&R), the services differ from other medical or surgical department by the multidisciplinary management involving several healthcare providers (physiotherapists, nurses, occupational therapists, speech therapists, etc).

Several studies focusing on the measurement of patient satisfaction in the PM&R departments have been carried out internationally. ^{5 – 7} However, there are only a few publications on this subject in Tunisia.

The aim of our work is to study the satisfaction of inpatients and outpatients in the PM&R department of Sahloul hospital in 2020 and to specify the factors associated with satisfaction in order to improve the quality of the care provided during and after the Covid-19 era.

The total number of patients included in this study was 240. Among these patients, there were 58.3% inpatients and 41.7% outpatients. Participants answered the questionnaire themselves in 84.6% of cases and 15.4% of the answers were provided by a family member who accompanied the patient during his physical therapy. ¹³

The average age of the patients was 42±19.56 years with a minimum of 06 months and a maximum of 77 years (median: 45 [Q1=29, Q3=57] years). The majority of our study’s participants had primary education level (38.2%) and 22.3% of patients were illiterate. The distribution of participants according to socio-demographic characteristics is described in Table 1.

The most frequent conditions were the pathologies of the central nervous system (52.5%) with a predominance of post-traumatic paraplegia (10.4%), cerebral palsy (9.2%) and stroke sequelae (8.8%). Cauda equina syndrome represents the most common condition for the pathologies of the peripheral nervous system (2.9%). Polyarthralgia was the most common osteoarticular condition (11.7%).

Among the hospitalized patients included in our sample, 15% developed complications. Urinary tract infection was the most common complication (7.1%), followed by pressure ulcer (2.9%) and pulmonary embolism (1.4%) ( Table 1).

Currently in Tunisia, there are only two hospitalization departments in physical medicine: in Tunis at the Kassab Institute of Orthopedics and at the Tunisian center at the Sahloul university hospital in Sousse. The PM&R department of Sahloul Hospital drains all patients from the center and sometimes from southern Tunisia where there is not yet a PM&R hospitalization unit. However, no work has been conducted in this department with the aim of evaluating the quality of the health care and describing the shortcomings of the services provided.

We decided to conduct a descriptive cross-sectional study to measure the satisfaction of inpatients and outpatients of the PM&R department of Sahloul university hospital during the year 2020, including patients from all age groups, which has not been achieved until now in a physical medicine department in Tunisia.

Our study showed an overall satisfaction with administrative procedures (D1) of 76.3% with a statistically higher rate for hospitalizations versus outpatient consultations (87.9% vs 60.0%, p<0.001). Delanian et al. ¹⁴ in 2008, using a self-administered questionnaire, studied the satisfaction of patients treated in a PM&R day hospital created at the Timone hospital in Marseille and the satisfaction with the reception at the admission office was 94%.

The difference in satisfaction of dimension D1 of our questionnaire that we found between hospitalization and outpatient consultation could be explained by the fact that at Sahloul university hospital, the hospitalization department and the admissions’ office for hospitalizations are located in the same main hospital building. Besides, registering for the outpatient consultation is done in a second building where the waiting time in front of the counters is longer, which is a major inconvenience for patients with a functional limitation.

Our results showed a satisfaction rate for the treatment received in our service (D2) of 58.8%. The highest satisfaction rate was for the feeling of security during treatment (88.3%) and the lowest rate for the quality of information received at the end of treatment (57.9%). This is similar to the study conducted by Devreux et al. ⁸ in Jeddah including the questionnaire on which we based to conduct our study, they found a satisfaction with the treatment of 79.9%, the feeling of security of 81.6% with the lowest rate for information received at the end of treatment: 69.2%. ⁸

Joublin ¹⁵ studied the satisfaction of patients treated in “Le Belloy” functional and professional rehabilitation center, located in Oise-France. She found a high rate of satisfaction reaching 100% for the feeling about the competence of the physiotherapist and the quality of care, while the lowest satisfaction rate was 90% for the continuity of care. ¹⁵ In Tunisia, Ghidaoui et al. ¹⁶ found that 86% of parents believed that doctors were understanding with their children. Listening, availability and general benevolence of doctors towards the child were appreciated with 95% of parents satisfied. ¹⁶ For satisfaction with the logistics (D3), our results showed a rate of 70.8%. This is far from the results of Joublin ¹⁵ who found a satisfaction rate of 99% for the logistics of the functional and professional rehabilitation center Le Belloy, while Delanian et al. ¹⁴ found 81% satisfaction with the logistics of the PM&R day hospital at the Timone hospital center in Marseille.

The global assessment of physical therapy (D4) in our department showed a satisfaction rate of 82.1%. This is similar to data from Devreux et al., ⁸ where the global satisfaction rate for rehabilitation care is 80.6%. Delanian et al. ¹⁴ found global satisfaction estimated at 98% for patients treated in the PM&R day hospital in Marseille. ¹⁴

Concerning the factors associated with satisfaction studied in our work, our results showed for the socio-demographic factors a statistically significant difference in satisfaction between the age groups for the D1 admission procedures (p=0.017) and for the treatment received D2 (p=0.036). Our results join the data of the literature. In the study of factors associated with global patient satisfaction in rehabilitation facilities in New Jersey, USA, Oh-Park et al. ¹⁷ found that the dissatisfied patients were older (mean age 68.9 versus 67.7). ¹⁷

In our study, there was no statistically significant relationship between patient satisfaction and patients’gender for all the dimensions studied. For Afzal et al. ¹⁸ also, gender did not show a significant effect on the satisfaction score. Besides, Thi et al. ¹⁹ noted a higher frequency of complaints for women (60.4%) when measuring satisfaction.

Regarding the education level, our results showed that patients who were illiterate or had a basic level of education were more satisfied than those with a secondary or university education level for logistics (D3) (p=0.036). Worldwide, Afzal et al. ¹⁸ showed that illiterate or less educated patients were significantly more satisfied (p=0.003) with the care provided by the health establishment considered. Thi et al. ¹⁹ reported a higher level of dissatisfaction in patients with a post-secondary level of education (72%) towards the quality of care. ¹⁹ In Tunisia, in a rehabilitation department, Ghidaoui ¹⁶ found similar results: the high level of education of mothers negatively influences satisfaction with the proper functioning of the department as well as therapeutic interventions. ¹⁶

Regarding the period of physical therapy, patients were more satisfied before the Covid-19 period for all the dimensions of the questionnaire in our study. In the literature, we found several studies of satisfaction during the Covid period before and after the implementation of new measures to protect patients. ^{20 , 21}

Regarding the difference in satisfaction between the before and during Covid-19 period found in our study, this could be the consequence of the long waiting time in the queues at the check-in counters in the outpatient unit and its association with a greater risk of contamination by Covid-19 because of the non-respect of distancing and the wearing of masks by certain patients. During the waves of the pandemic, paramedical staff with chronic illnesses and the visually impaired have benefited from long-term leaves. This resulted in a lack of staff of physiotherapists working in the Sahloul PM&R department with deployment and solicitation of the remaining staff. These measures would have caused an exhaustion of the staff working in the Covid period, having as a probable consequence a drop in the performance and quality of the care provided, thus responsible for patient dissatisfaction. In Tunisia, telemedicine should be developed: prepare the legislative framework (virtual medical visits and remote drug prescriptions recognized by social security) and provide the necessary means (computers, internet connection available in doctors' offices) in order to overcome the shortcomings in healthcare, especially in times of crisis.

For the satisfaction of patients hospitalized in the Sahloul PM&R department, we did not find a relationship with the pathologies treated (neurological or osteoarticular/musculotendinous) in the different dimensions of satisfaction studied. In the literature, Oh-Park ¹⁷ reported that patients dissatisfied with rehabilitation had more neurological diagnoses (44.0% versus 31.3%). ¹⁷

Ghidaoui ¹⁶ in her study including children with cerebral palsy found a significant positive correlation (p=0.05) between the satisfaction of the patient-caregiver relationship and the GMFCS classification (The Gross Motor Function Classification System is a 5-level clinical classification that describes the gross motor function of people with cerebral palsy and therefore reflects the severity of the motor disability). There was also a significant positive correlation between satisfaction with the care provided and the level of impairment according to the GMFCS classification (p=0.01). The heavier the pathology, the less satisfied the mothers were. ¹⁶

In our study, for the occurrence of complications in hospitalized patients, we found that patients who had no complications were more satisfied than those who had one or more complications for all the dimensions studied without statistically significant difference. In the literature, authors found that patients were significantly less satisfied when they develop complications. ^{22 – 24}

Our descriptive cross-sectional study of the patients’ satisfaction treated in the Sahloul-Sousse PM&R department during the year 2020 has strengths and limitations.

Considering the international studies of satisfaction in rehabilitation settings, the numbers of patients included vary considerably from one publication to another. The size of our sample was calculated and represents a strength of this study compared to previous work conducted in our country. ¹⁶ The questionnaire used is a validated tool in Arabic, easy to administrate with limited number of questions. In addition, this scale was validated for inpatients and outpatients, which enabled us to recruit patients from both units of the PM&R Sahloul department. Another positive point of our work tool is the use of four dimensions of satisfaction which are: administrative procedures, functional treatment received, logistics as well as the global assessment of the physical therapy, which enabled us to have a general idea of satisfaction in the rehabilitation setting. ⁸ The presence of a validated version in Arabic encouraged the use of this questionnaire in our study since it goes with the socio-cultural context of the Tunisian population. ¹⁰ The limitation of this tool may be the absence of open questions allowing patients to express themselves regarding their satisfactions and dissatisfactions without being limited in their answers by pre-established proposals. Another limitation of our study is that satisfaction is a subjective concept and may vary over time, hence the utility of using validated scales. In addition, the data collection conditions were more appropriate for hospitalized patients (ward rooms, calm atmosphere, more time to ask questions and explain them properly to patients) than for consultants at the outpatient unit. To avoid variability in data collection we standardized data collection: for each participant, the interviewer should introduce himself, explain the objective of the study and ask for the patient's approval for participation, then his answers should be collected without intimidating or influencing him. Data collection was performed also by the same trained interviewer.

Finally, based on the results of our study, we suggest the following recommendations in order to improve patients’ satisfaction and to ensure the proper functioning of PM&R departments: •

Digitization of admission procedures in order to limit patients’ movements and the duration of registration.

Patient satisfaction with the healthcare services provided is a major criterion for evaluating the health system and the continuous improvement of the services offered. For this, several teams around the world have opted for the study of satisfaction and its associated factors in order to improve the quality of their services. Our study showed globally good levels of satisfaction in the Sahloul PM&R department. Nevertheless, other studies need to be conducted in order to study the other factors that can influence satisfaction and to propose action plan to improve health services in developing countries.

The research idea was conceived by Sonia Jemni and Rihab Moncer. Data acquisition, draft preparation and writing was carried out by Leila Hamadou, Rihab Moncer and Rym Ghammam. The rest of the authors reviewed the article, revised the discussion critically and checked the references.

All authors have revised and approved the final version of the manuscript.