Most Outpatients at a Zanzibar District Hospital Report Dissatisfaction, Survey Finds

Nearly six out of every ten adults seeking care at a busy district hospital in Zanzibar walked away from their outpatient visit dissatisfied, according to a new facility-based study that offers one of the most detailed portraits yet of how patients experience frontline healthcare in the semi-autonomous Tanzanian archipelago. The research, published in BMC Health Services Research, surveyed 309 adult outpatients at Jitimai District Hospital and found that 182 of them — 58.9 percent, with a 95 percent confidence interval of 53.3 to 64.3 percent — reported dissatisfaction with the care they received. In a health system where the outpatient department is often the first and only point of contact between citizens and formal medicine, that figure is more than a statistic. It is a signal that the interface where trust in healthcare is built or broken may be failing a majority of the people it serves.

The study team, led by Chukwuma J. Okafor of the State University of Zanzibar together with colleagues Islam H. Mwita, Rodolfo Isidro Bosch Bayard, and Aziza Japhary, designed their investigation as a cross-sectional survey, a snapshot approach that captures patient attitudes at a single point in time. They adapted the Patient Satisfaction Questionnaire, a widely used instrument in health services research, into a structured 28-item tool spanning nine distinct domains: the physical environment, courtesy and interpersonal manner, communication, accessibility, time spent with the doctor, convenience, technical quality, expenses, and general satisfaction. This multidimensional framing matters because patient satisfaction is not a single feeling but a composite judgment, assembled from everything from the cleanliness of the waiting area to whether a clinician explained a diagnosis in words the patient could understand.

The granularity of the questionnaire allowed the researchers to see precisely where the service was succeeding and where it was collapsing. Administrative interactions fared comparatively well: 83.2 percent of respondents expressed satisfaction with registration staff, suggesting that the clerical backbone of the outpatient department functions acceptably. But the picture deteriorated sharply when the researchers turned to the human and environmental dimensions of care. Communication and patient-centred care items registered very low satisfaction, and a striking 92.9 percent of respondents reported dissatisfaction with cleanliness. Long waiting times emerged as another prominent source of frustration, compounding the sense that patients were spending hours in an unhygienic environment only to receive hurried, impersonal consultations.

Methodologically, the study makes several choices that reflect a growing sophistication in how health services researchers handle common outcomes and imperfect data. Because dissatisfaction affected well over 10 percent of the sample, the authors used modified Poisson regression with robust variance rather than ordinary logistic regression. The technical rationale is important: when an outcome is common, odds ratios derived from logistic models systematically overstate the underlying prevalence ratios, inflating the apparent strength of associations. Poisson regression with robust standard errors directly estimates prevalence ratios, giving a more honest picture of how much more likely one group is to be dissatisfied than another. Reporting adjusted prevalence ratios with 95 percent confidence intervals, the team identified lower satisfaction linked to perceived affordability, accessibility, and perceived socioeconomic barriers.

Equally notable is what the authors chose to disclose about the limits of their own statistics. Two adjusted prevalence ratios — one for perceived socioeconomic influence and one for female sex — came out with magnitudes exceeding 20, values so extreme that no prevalence ratio can plausibly represent them as true effects. Rather than presenting these numbers as headline findings, the researchers flagged them as almost certainly reflecting instability in the underlying data, reporting them for completeness but explicitly declining to interpret them as precise or generalisable effect sizes. They also reported that a logistic-regression specification of the same model failed to converge, a phenomenon known as quasi-complete separation, and chose to state this openly rather than dress up unstable odds-ratio estimates as reliable results. In a field where inflated effect estimates are too often laundered into policy claims, this kind of transparency is rare and welcome.

The reliability of the survey instrument itself received similarly candid treatment. The overall 28-item scale achieved a Cronbach’s alpha of 0.685, a figure the authors describe as acceptable-to-borderline, sitting just below the conventional 0.70 threshold that many researchers treat as the floor for internal consistency. Domain-level reliability varied widely, ranging from 0.42 to 0.82 for domains containing three or more items, and several domains did not reach conventional reliability thresholds at all. Instead of burying this variation behind a single summary statistic, the team reported it domain by domain, acknowledging that some subscales of the adapted questionnaire measured their intended constructs less consistently than others. For readers, this means the domain-level satisfaction percentages should be read as descriptive indicators of where problems lie rather than as precision instruments.

The authors are equally careful about the study’s sampling design. The 309 participants were recruited through a non-probability approach that combined purposive selection of the study hospital with convenience sampling of outpatients during the data-collection period. Convenience sampling, while practical in a busy clinical setting, cannot guarantee that the surveyed patients represent the full population of outpatients, and the researchers accordingly frame their multivariable associations as hypothesis-generating for this particular facility rather than as confirmed, generalisable predictors of patient satisfaction. This is a methodologically honest posture, and it does not diminish the study’s practical value; it simply locates its conclusions at the level of Jitimai District Hospital, where they are most actionable.

Ethical oversight for the research was provided by the Zanzibar Health Research Ethics Committee, which granted approval under number ZAHRE/02/ST/FEB/2025/51, with additional administrative permission from the State University of Zanzibar and the hospital administration. The study was conducted in accordance with the Declaration of Helsinki, and every participant provided written informed consent after being told the study’s purpose, their right to decline or withdraw at any stage without any effect on their care, and the confidentiality protections in place. Only adults aged 18 and above were eligible, so no parental or guardian consent procedures were required. The authors received no external funding for the work and declare no competing interests, and the article is published open access under a Creative Commons licence.

What elevates the study beyond a single hospital’s report card is its identification of modifiable targets. The domains that performed worst — communication, interpersonal care, cleanliness, and waiting time — are precisely the ones that facility-level quality improvement programmes can address without waiting for new buildings, new equipment, or new budgets of the magnitude required for tertiary care upgrades. Training clinicians in patient-centred communication, reforming provider attitudes, tightening cleaning protocols, and reorganising patient flow to cut waiting times are all interventions with documented track records in low- and middle-income country settings. The authors conclude that interventions targeting patient-centred communication, provider attitudes, and financial and access barriers are essential to improve outpatient service quality, and their data give hospital managers a concrete priority list.

The broader significance lies in what the findings suggest about health systems across similar settings. Outpatient departments in low-resource contexts are the primary interface between patients and healthcare systems, and service quality at that interface critically shapes whether people seek care early, adhere to treatment, or trust public medicine at all. Evidence from Zanzibar has historically been limited, making this study a useful data point for regional health planners. If nearly 59 percent dissatisfaction can be documented at one district hospital with transparent methods and honest uncertainty, the question becomes how many neighbouring facilities would produce similar numbers under the same scrutiny — and whether the modest, well-defined fixes this study points toward, from cleaner corridors to kinder consultations, might be among the highest-yield investments available to health systems operating on thin margins.

Subject of Research: Patient satisfaction and its associated factors among outpatients at a district hospital in Zanzibar

Article Title: Patient satisfaction and associated factors among outpatients at a district hospital in Zanzibar: a facility-based cross-sectional study

Article References: Okafor, C. J., Mwita, I. H., Bosch Bayard, R. I., & Japhary, A. (2026). Patient satisfaction and associated factors among outpatients at a district hospital in Zanzibar: a facility-based cross-sectional study. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15685-7

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15685-7

Keywords: patient satisfaction, outpatient care, Zanzibar, district hospital, health services research, PSQ-18, modified Poisson regression, low- and middle-income countries, healthcare quality, communication, waiting times, cleanliness