Satisfaction with care in a Brazilian psychiatric inpatient unit : differences in perceptions among patients according to type of health insurance

INTRODUCTION
User satisfaction assessment in mental health services is an important indicator of treatment quality. The objective of this study was to evaluate treatment satisfaction in a sample of inpatients with mental disorders and the associations between levels of satisfaction and clinical/sociodemographic variables.


METHODS
This exploratory study investigated 227 psychiatric inpatients who answered the Patient Satisfaction with Mental Health Services Scale (SATIS-BR) and the Perception of Change Scale (EMP). SATIS scores were analyzed according to associations with clinical and sociodemographic data. Pearson correlations were used to correlate SATIS scores with other variables.


RESULTS
We found a high degree of satisfaction with care at the psychiatric inpatient unit assessed. In general, patients rated maximum satisfaction for most items. The highest satisfaction scores were associated with patients receiving treatment through the Brazilian Unified Health System (SUS) and with less education. SATIS showed a moderate positive correlation with EMP. The worst evaluated dimension was physical facilities and comfort of the ward.


CONCLUSION
Patients treated via SUS may be more satisfied than patients with private health insurance when treated in the same facility. The evaluation of treatment satisfaction can be used to reorganize services at psychiatric inpatient units.


Introduction
The World Health Organization (WHO) suggests evaluation of mental health services to guarantee the quality of service provided. 1In recent decades, patient opinions have gained the interest of clinicians, administrators and service accreditation agencies. 2,3tients may perceive their health status, symptoms, and improvement differently from the clinical and assistant staff, [4][5][6][7] adding an important perspective to the evaluation of outcomes.Patient satisfaction indexes are important indicators of quality of care. 8e evaluation of results from the outlook of the patient is a new perspective in mental health and is particularly important in psychiatric wards.Historically, the psychiatric hospital has stigmas and prejudgments arising from the old asylum model of care that was frequently related to abandonment and exclusion, abuses (maltreatment and punishment) and the lack of a medical perspective. 9,10Despite many important changes, the transition from asylums to general hospitals has not yet been sufficiently followed with quality result assessments, particularly in Brazil.2][13][14][15] To the authors' knowledge, only one study has evaluated the outcome based on the patient's outlook. 5tisfaction with treatment is an important factor in the quality of treatment and is related to greater adherence, greater frequency of service use and reduction of treatment abandonment rates. 16Satisfaction assessment can predict treatment results and can also be considered a result in itself. 17Studies involving psychiatric inpatients have shown that factors such as older age, 3,18,19 male gender, 3,18,19 better health status, 19 general hospital admission (relative to psychiatric hospital), pleasant atmosphere, shorter hospitalization time, 19 treatments received, staff availability 17 and perception of improvement 5 are factors associated with greater satisfaction with treatment.However, the Brazilian perspective poses even greater challenges to the theme, since the national health system has mixed financing.While the Brazilian Unified Health System (Sistema Único de Saúde [SUS]), which is public, universal and free, is the one with the greatest coverage, it is often seen as of poor quality and low efficiency.
Conversely, private health insurance plans have a high cost, and are therefore inaccessible to many people, but are seen as presenting higher quality, suggesting that their users may be more satisfied.Despite these perceptions, there are no studies evaluating satisfaction with care in psychiatric inpatient units considering the type of health insurance as an independent variable.Thus, beyond the exploratory investigation, we hypothesize that type of health insurance could play a role in the variation of patient satisfaction.For this purpose, all analyses were planned in a sample of inpatient users receiving treatment through both public and private health insurances.They received the same mental health care at the same psychiatric unit during a defined period of study (avoiding seasonal interferences or medical and nurse staff disparities).They had equal bed quality and were assisted by the same medical and nursing staff.
This study aims to evaluate satisfaction with treatment and care in a sample of inpatients with mental disorders treated at a general hospital and to evaluate the associations between level of patient satisfaction with clinical treatment and sociodemographic variables, particularly type of health insurance (public vs. private).

Sample, setting and design
This was an exploratory cross-sectional study.All patients admitted to the psychiatric hospitalization unit of Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (HSL/PUCRS), from April 2014 to July 2016 were invited to participate.The unit has 21 psychiatric beds, of which 11 are designated to patients with private health insurance and 10 to patients who use the public health system (SUS), without physical distinction in relation to type of insurance, i.e., both private and SUS patients may stay in the same room and will receive the same care).The beds are divided into seven rooms with three beds each (male and female rooms), circulation areas and a common area (TV room, reading room and dining room), which is also a visiting area.The physical structure of the unit is similar to that of treatment areas from other medical specialties in the same hospital.There is no access to external open environment in the ward; the space is small and is not adapted for complementary activities (occupational therapy, physical education and group therapies).
Inclusion criteria were broad, and all patients hospitalized during the study period who accepted to answer the research instruments were invited to participate.Individuals who refused to participate in the study or those who could not read or understand the instruments were excluded.A total of 321 individuals were invited.Of these, 49 patients did not complete the Patient Satisfaction with Mental Health Services Scale (SATIS-BR), did not agree to participate or were clinically unable to answer the instrument.In addition, we excluded 15 records of patients who had been hospitalized for less than 7 days (8 records), records without sufficient data identification (5 records), and cases showing typing errors in SATIS-BR (2 records).
Therefore, the final sample consisted of 257 patients (80% of the initial sample) who completed the SATIS-BR and agreed to participate in the study by signing a free and informed consent form.

Procedures
Routine application of the instruments has been described previously. 5 This same worker also applied the family versions of the instruments EMP and CGI (EMP-F and CGI-F).
Therefore, the attending physician was blinded both to the patient's and the patient family's responses.This minimized any potential biasing of the physician's assessment of improvement.All participants were informed about the research objectives, the security of the data, that the interview would not interfere with their treatment and that there were no right or wrong answers to the questions.

Instruments
The clinical and sociodemographic questionnaire used in this study was a standard clinical instrument containing sociodemographic questions (such as gender, age, marital status, educational level and type of health insurance) and questions addressing clinical aspects (e.g., number of previous hospitalizations, previous psychiatric treatment and initial psychiatric diagnosis).
In addition, the following CGI assessment scales were used: severity (CGI-S), improvement (CGI-I), improvement assessment by the patient (CGI-P) and improvement assessment by the family (CGI-F).The GAF was used to evaluate the level of functioning of the individuals.These instruments were routinely applied to all patients hospitalized at the psychiatric unit.
The SATIS-BR tool was originally developed by the WHO to assess satisfaction with mental health care in three groups: patients, families and professionals.
The instrument consists of 13 questions with answers arranged as 5-point Likert scales.Higher scores mean a higher degree of satisfaction.In addition, the final part of the SATIS-BR presents open questions regarding the user's reviews on the service.The

SATIS-BR was translated to and validated in Brazilian
Portuguese for use with psychiatric outpatients with adequate psychometric properties of construct validity, convergent validity and reliability. 20In the validation study, item 6 was eliminated for having a coefficient of saturation below the minimum criterion established.
Thus, the final instrument in Brazilian Portuguese consists of 12 items with possible scores ranging from 12 to 60 points.We also used the factorial solution and showed suitable psychometric performance in relation to its construct validity, convergent validity, internal consistency and temporal stability. 21It was also evaluated for psychiatric inpatients.There was a slightly different factor structure in relation to the original scale. 5In our sample, we used the total scores of the instrument and its factors in the analyses, with an internal consistency result of α=0.847.

Statistical analysis
Sociodemographic and clinical data were described as means and standard deviations for continuous variables and as absolute numbers and percentages for categorical variables.To evaluate the correlations among SATIS and other continuous variables, Pearson correlations were calculated with the following parameters: very weak (0.00 to 0.19), weak (0.20 to 0.39), moderate (0.40 to 0.59), strong (0.60 to 0.79) and very strong (0.80 to 1.00). 22We used the Student's t-test for independent samples to calculate the association between categorical and continuous variables.Categorical variables were analyzed with the Pearson chi-square tests; post-hoc analyses of the adjusted residuals were also performed to reveal differences among the categories of each variable.Oneway analysis of variance (ANOVA) followed by the Tukey post-hoc test was used to compare parametric variables among three or more groups.
The significance level for all tests was 0.05, and all analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 21.0.

Ethical considerations
All participants signed an informed consent form.
This study was approved by the research ethics committee of PUCRS (protocol 1.035.483).

Results
The final sample consisted of 257 patients who filled out the SATIS-BR.Of these, 59.5% were women with at least 9 years of schooling (65%), single or divorced (55.2%).Most of the patients had private health insurance (52.2%), but about half of the sample was hospitalized through SUS (45.5%).The main reason for psychiatric hospitalization was suicide risk (ideation or attempt) (40.9%).The most prevalent psychiatric diagnoses were bipolar disorder (25.9%) followed by unipolar depression (22.4%) and personality disorders (18%).The mean time of hospital stay was 31 days.Table 1 summarizes the main clinical and sociodemographic findings of the sample.

Variable n (%) or mean (SD)
Age (years) (n=257), mean (SD) 43.28 (17.9)  (aspect of the unit).SUS patients scored significantly higher than private health insurance patients for both total score and all three SATIS-BR factors.Patients with less schooling were more satisfied than those with more schooling considering the total score of the instrument.In Factor 3, differences in schooling were significant among the three grades.Patients admitted for suicide risk were more satisfied than patients admitted for other reasons, for both the total score and Factor 1.
There was a small but significant difference between the group that had never been hospitalized before and the one with three or more hospitalizations in relation to Factor 1 (competence and understanding of the team).
The first group was more satisfied.No differences were found in severity ratings between the private and public health insurance groups.

Discussion
This article evaluated treatment satisfaction in patients hospitalized in a general hospital psychiatric unit.We found a high degree of general satisfaction in the sample.The highest satisfaction scores were found mainly in patients admitted through the public health system (SUS), in those with lower educational level and in patients admitted for suicide risk.The worst dimension was comfort and structure of the unit.SATIS showed a moderate correlation with patient perception of improvement and adequate internal consistency.This is the first study in Brazil to evaluate psychiatric inpatient satisfaction.
The patients were quite satisfied, which is consistent with the literature. 3,18,23However, some factors associated with satisfaction showed heterogeneous findings.While gender, 3,18,24,25 psychiatric diagnosis, [25][26][27] age 2,3,18,24 and types of symptoms 17 are related to treatment satisfaction in many studies, our findings did not show this.The main variables associated with higher satisfaction were socioeconomic status (lower schooling and receiving treatment through SUS) and being hospitalized for suicide risk.While socioeconomic aspects will be discussed further, we believe that the Occupational status 254 0.901 0.595 0.759 0.886 Employed or active 93 53.greater satisfaction observed in patients hospitalized for suicide risk may be related to better outcomes in these patients in relation to patients with other chief complaints, according to a previous study in the same environment. 14Since in most cases suicidal ideation is transient, and patients can relate their improvement to the care environment of hospitalization, they can feel greater satisfaction than those admitted for other complaints in which improvement takes longer.
The highest impact variable on treatment satisfaction was type of health insurance.This -along with schooling level -reflects socioeconomic level.Patients in the public health system (SUS) were more satisfied, showing not only higher total SATIS scores, but also in the three domains.These differences, although not explored in the current study, may be related to some peculiarities of our institution.Unlike most health services, where public and private wards are located and handled separately, our unit does not make room distinctions based on the patient's type of health insurance.A study on user satisfaction in southern Brazil found that patients with private health insurances expect treatment privileges and feel dissatisfied when treated in the same environment as SUS users. 28In addition, SUS is not considered a benefit in Brazil, but rather "the last resort," i.e., when there is no financial condition to pay for private health insurance.Thus, SUS users can feel privileged when they have access to the same services as private health insurance users.The high degree of satisfaction with treatment assessed by SATIS was also seen in other studies involving SUS users. 29,30In addition, social inequality (a condition highly related to discrepancies in relation to the type of health insurance) may be a more important factor for the perception of health states (and care) than other variables commonly related to individual differences, making this variable key in the evaluation of results, especially in highly unequal countries such as Brazil. 31ke other papers in the literature, we found an important association between treatment satisfaction and perception of improvement by the patient. 5,25,30,32positive correlation was found between SATIS scores and changes perceived by the patients (as evaluated by EMP) and impression of improvement (as assessed by CGI-P).This did not occur when SATIS scores were correlated with the physician's perception, neither with CGI-I (no correlation) nor with GAF (very weak correlation).These disparities between the perceptions of physicians vs. those of patients are widely recognized 7,4 and increase the need to include the perceptions of patients themselves in the evaluation of results.
The worst satisfaction dimension was in relation to the comfort and structure of the unit -especially among patients with private health insurance.This result was expected because indeed the psychiatric ward is poorly adapted to the mental health care environment (small living space, lack of privacy, absence of external area).
This indicates the need for adaptations in design and structure.For example, adding single rooms could increase the sense of privacy and cleanliness. 33The literature is unclear regarding the effects of design, comfort, environment, and structure of psychiatric units on clinical outcomes.Some studies have shown an improvement in the perception of the environment, 34,35 changes in social behavior 36 and treatment satisfaction and quality of life 35 in wards that redesigned their facilities.However, this remains inconclusive. 37While there are arguments for psychiatric wards to maintain shared rooms, paradoxically, individual rooms have already been associated with improved social behavior. 38his is because patients can opt for a private space, and yet they can also often leave the room, unlike patients staying in rooms with other patients who may isolate themselves searching for privacy. 39Other structural and design changes also influence the patients and the team, including the well-being of the users -an important outcome in health. 33,37is study has several limitations.First, our sample is of convenience and was selected in only one institution  40 which measure a number of complementary dimensions of the construct not contemplated by SATIS.However, we opted for an instrument already translated and validated for our environment, 20 and here we offer further evidence of its validity in psychiatric inpatients.Fourth, there are many confusing factors related to the construct satisfaction and assessment of psychiatric inpatient settings.These are related to patient characteristics and the peculiarities of institutions and professionals and have implications in study results. 37Our study was exploratory and did not aim to control these factors.The present results should be confirmed in future controlled studies.Furthermore, the SATIS-BR was only validated for outpatient settings.
However, the instrument does not present specific items that limit the application environment, and our results add some reliability indicators (such as high internal consistency for the instrument in general and for Factors 1 and 3), very similar to another study conducted with outpatients. 20The validity of the SATIS-BR in the inpatient environment, however, needs to be tested, since the condition of instability at a time of acute recovery may affect patient responsiveness.Finally, because this was a cross-sectional study, our findings cannot be interpreted in terms of causal relationships.Even so, this is the first Brazilian study of this type, and it paves the way for future research with more robust designs.
In summary, the patients were satisfied with the treatment received at the psychiatric inpatient unit.
Briefly, at the time of patient discharge, the attending physician answered the Clinical Global Impression Scale -Improvement (CGI-I).To avoid measurement bias (patient embarrassment in answering the questionnaire to their physician), a researcher not directly involved in patient care applied the SATIS-BR, the Perception of Change Scale -Patient Version (Escala de Mudança Percebida [EMP]), the Global Assessment of Functioning (GAF), and the Clinical Global Impression -Patient Version (CGI-P).
of three factors proposed by Bandeira & Silva in the Brazilian Portuguese validation, namely: SATIS Factor 1, competence and understanding of the team; SATIS Factor 2, Help and reception of the team; and SATIS Factor 3, Physical conditions of the unit.In this work, we performed the association analyses using the total scores of the instrument and its factors (rather than means).The internal consistency (Cronbach's alpha) of SATIS-BR, SATIS Factors 1, 2 and 3 in our sample were 0.836, 0.807, 0.635 and 0.735, respectively -similar to the results reported by Bandeira & Silva.Finally, the EMP consists of 19 items that assess the patient's perception about changes in life as a result of receiving treatment, with response options arranged as 3-point Likert scales: 1 indicates worse than before; 2 no change; and 3 better than before.Of the 19 items on the scale, a global item assesses how the patient perceives, in general, the results of the treatment received.The remaining items assess perceived changes in various dimensions of the patient's life (e.g., physical, psychological and social life).The EMP was translated to and validated in Brazilian Portuguese in southern Brazil.Due to the particularities mentioned above, our findings should be viewed with caution regarding their external validity.Second, we only used quantitative SATIS data.While open-ended questions can offer important data about treatment satisfaction, their analysis ran counter to the quantitative goal of the work.Third, we used only one instrument for satisfaction assessment.There are at least 15 psychiatric inpatient satisfaction assessment instruments available, Satisfaction was mainly related to the perception of improvement and was greater among patients in the public health system group.The evaluation of treatment satisfaction is an important outcome in health and should be incorporated into the reorientation of changes in the processes of organization, team training, and physical design improvements.The theme needs to be better analyzed, with controlled studies for the various confounding factors related to the characteristics of the patients and the peculiarities of each institution.

Table 1 -
Sociodemographic and clinical characteristics of the total sample CGI = Clinical Global Impression; SATIS-BR = Patient Satisfaction with Mental Health Services Scale -Brazilian Version; SD = standard deviation; SUS = Brazilian Unified Health System.

Table 2
shows the correlations of the total SATIS-BR scores with its three factors and with the clinical evaluation scales.The total SATIS-BR scores showed significant positive and strong correlations with all its The complete tabulated data consisting of the means, standard deviations and medians obtained for each item of the instrument are available from the authors upon request.Table3presents association analyses of the SATIS-BR total score and its three factors with clinical and sociodemographic variables.No significant associations were found for gender, psychiatric diagnosis, occupational status, marital status or length of stay for either the total score of the instrument or its factors.There was only a weak correlation of age (r=0.145) with Factor 3

Table 2 -
Correlations among SATIS-BR, SATIS factors and clinical scales CGI-F = Clinical Global Impression -Family; CGI-I = Clinical Global Impression -Improvement; CGI-P = Clinical Global Impression -Patient; GAF = Global Assessment of Functioning; EMP = Perception of Change Scale -Patient Version; SATIS = Patient Satisfaction with Mental Health Services Scale.* p<0.01; † p<0.05.

Table 3 -
Associations of SATIS-BR and its factors with clinical and sociodemographic variables