Pilot study

Piloting of the study was conducted by an independent research assistant on 10 patients each from rural (Thyolo) and urban (Blantyre) outpatient mental health clinics. General acceptability of the questionnaire (CPOSS) was revealed by patients. However, during the pilot study one disturbance was noted. Due to inadequate rooms in outpatients departments for the hospital, it was noted that the rooms that were allocated for data collection were also supposed to be used for other activities such as individual counselling for patients during piloting. This caused some delays in completion of the questionnaire. Special rooms for data collection were then identified to rectify this challenge. Some amendments were made to the

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original questionnaire to match patients’ social demographic details and clinics set up as follows:

 The pilot study showed that the questionnaire should be reduced from a 15-item to a 12-item questionnaire due to the irrelevance of some of the items in the Malawian context. The three items excluded from the questionnaire, as they were deemed not applicable to the Malawian context of this study were: Information provided about payment for services, Parking area, and Clear and correct monthly bill.

 The first item of the CPOSS is helpfulness of the secretary/admin clerk. This was changed to “Helpfulness of the secretary” in order to suit the clinic. The presence of an administration block within the hospitals and close to outpatient mental health clinics, with an administrative clerk who did not interact with patients upon consultation, resulted in the option of “admin clerk” confusing patients. Since there were mental health volunteers, patient attendants and nursing staff to welcome patients at outpatients mental health clinics “Helpfulness of the secretary” did not confuse patients hence it was adopted in the questionnaire.

 As study participants were more fluent in the local language “Chichewa” as opposed to “English”, a decision was reached to administer the questionnaire in Chichewa.

 It was decided that the the researcher and the research assistant should read out the questionnaire to the study participants. This mode of questionnaire administration was preferred as it minimised the chances of leaving some of the questions unattended by the participants. The model helped to achieve a good response rate as well as clarification if need be for study participants.

38 3.6 Sampling and data collection

Systematic sampling (Polit & Beck, 2010) was used in this research study. The population which received outpatient mental health care at Thyolo district hospital and QECH from January to December 2012 was 600 and 800 respectively (Queen Elizabeth Central Hospital, 2012; Thyolo District Hospital, 2012). To determine sampling procedure, the population (600 and 800) for each mental health facility was divided by the required sample size (216) to find the sampling interval (Polit & Beck, 2010). This led to the sampling interval of every 5^th and 7^th user in rural and urban clinics respectively (Polit & Beck, 2010).

Data collection was conducted from 5th October to 24th December 2015. Outpatient psychiatric clinics were conducted on Mondays and Thursdays for Thyolo district hospital, and Mondays and Wednesdays for QECH (Queen Elizabeth Central Hospital, 2012; Thyolo District Hospital, 2012). Data were collected on every clinic day for that particular health facility. The starting point was the first user consulting on a clinic day at the beginning of the data collection period (Polit & Beck, 2010).

3.7 Procedure

Potential participants were approached by either the researcher or the research assistant who described the study objectives in detail and obtained written informed consent from the users willing to participate in the study (see Appendix A). The study participants were informed that the approximate duration of the interview was 15-20 minutes; as well as the purpose of the study and how they may benefit from participating. When study participants clearly understood the purpose of the research study, a consent form was signed by the participant, guardian and the researcher. Illiterate participants were allowed to print on the consent form with their thumb and the research assistant or the researcher assisted in reading out the

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consent form. The researcher collecting data and an impartial witness also signed the consent form. The questionnaires were administered in Chichewa as the participants were more fluent in this local and vernacular language in the southern part of Malawi. Confidentiality was observed by giving participants a code number and keeping their names hidden.

3.8 Measures

The Charleston Psychiatric Outpatient Satisfaction Scale (CPOSS) was used. In addition to CPOSS, socio-demographic information (nature of illness, age, gender, educational level, years of work and area of work, diagnosis, duration of illness, medication, number of hospital admissions, distance to the clinic and mode of transport to the clinics) was used.

The CPOSS is a satisfaction data collecting tool designed to measure adult psychiatric outpatient satisfaction with mental health services among users visiting outpatient mental health clinics. It is a 15-item questionnaire with domains of satisfaction. “Responses are rated on a 5-point likert scale ranged from 1 (“very dissatisfied”) to 5 (“very satisfied”), with higher score indicating more satisfaction” (Pellegrin et al., 2001, p. 816-817). However, items that ask availability of parking and information about payment and monthly bills were removed as they are irrelevant in Malawi context (see section 3.5). The psychometric properties of the CPOSS have been investigated in Israel and it demonstrates excellent internal consistency and good convergent validity with Cronbach’s α to be 0.94 and 0.88 for the client’s and guardian versions respectively (Elisha et al., 2012). Similary, Pellegrin et al.

(2001) found the internal reliability of the instrument α to be 0.87. However, the validity and reliability has not been established in Malawi. This is due to a dearth of mental health research in LMICs such as Malawi.

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Translation of the instrument into vernacular language “Chichewa” was done prior to administration of the CPOSS. Translation and back translation of the CPOSS was done into English and Chichewa. The questionnaire was pretested on 10 users from each outpatient clinic to ensure that it was easily understood and clear to the participants.