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Patient satisfaction and perceived quality of care
Favourable perceptions of health personnel conduct were associated with higher odds of overall satisfaction for non HIV (OR=3.53, 95% CI 2.34 to 5.33) and HIV (OR=11.00, 95% CI 3.97 to 30.51) visits. Better perceptions of resources and services were also associated with higher odds of satisfaction for both non HIV (OR=1.66, 95% CI 1.08 to 2.55) and HIV (OR=4.68, 95% CI 1.81 to 12.10) visits. Two additional dimensions of perceived quality of care healthcare delivery and accessibility of care were positively associated with higher satisfaction for non HIV patients. The odds of overall satisfaction were lower in rural facilities for non HIV patients (OR 0.69; 95% CI 0.48 to 0.99) and HIV patients (OR=0.26, 95% CI 0.16 to 0.41). For non HIV patients, the odds of satisfaction were greater in hospitals compared with health centres/posts (OR 1.78; 95% CI 1.27 to 2.48) and lower at publicly managed facilities (OR=0.41, 95% CI=0.27 to 0.64).
Conclusions Perceived quality of care is an important driver of patient satisfaction with health service delivery in Zambia.
Patient satisfactionPerceived quality of careExit interviewHIVZambiaStrengths and limitations of this studyTo the best of our knowledge, this study is the first to examine the association between perceived quality of care and patient satisfaction through exit interviews across Zambia.
Adequacy of medical resources and provider conduct and practices were significant predictors of overall patient satisfaction.
Facility characteristics such as management type, location and level of facility were important determinants of patient satisfaction.
Methodological concerns associated with over representation of users and lack of causality are acknowledged.
BackgroundFor nearly 25years, the World Health Organization (WHO) has identified meeting individuals' universally legitimate expectations as a key health system objective.1 Patient satisfaction and ratings have been given increasing importance for measuring the quality of health services and are routinely used in developed countries for continuous quality improvement and value based incentive payments.2 ,3 In addition to the intrinsic importance of meeting reasonable expectations, patient satisfaction and perceptions are associated with healthcare utilisation and choice of provider.4 6 Studies have also linked satisfaction to treatment adherence for HIV patients, which has important implications for individual patient outcomes and preventing resistance to antiretroviral drugs (ARVs).7 ,8
This study focuses on patient satisfaction and perceptions in Zambia, a sub Saharan African country with 16.2 million citizens.9 Approximately 80% of Zambian health facilities are publicly managed, and the government has worked to decentralise decision making to the district level since 1991.10 While service utilisation has improved in recent years, it continues to be a major concern; in the 2013 2014 Demographic and Health Survey (DHS), 64% of deliveries were performed by a skilled provider and 66% of children received medical attention for diarrhoea.11
HIV is a priority issue in Zambia, where adult prevalence was estimated at 13.3% in the 2013 2014 DHS.11 In 2012, Zambia dispensed ARVs to over 500000 patients at 564 facilities, most of which were stand alone vertical facilities associated with a general clinic.12 ,13 Currently, the National Aids Strategic Framework emphasises moving towards a model that integrates HIV prevention, diagnosis and treatment with other primary health services.14 While integration is still underway, a scaled up pilot at 12 primary care clinics in Lusaka found that integration offered management and organisational advantages, but not human resource or infrastructure gains.15 17
Despite evidence that satisfaction can drive the utilisation of antiretroviral therapy (ART) and other priority services, Zambia lacks a systematic means of monitoring and responding handbag Hermes replica to patient opinions. Zambian patient perceptions have only been measured in a handful of small studies in limited populations. A study of maternity care in Lusaka found that while 89% of women rated care as 'good' or 'very good', 21% were shouted at, scolded or otherwise treated badly during delivery.18 In another survey, the majority of patients were not satisfied with the quality of care for sexually transmitted diseases at an urban health centre.19 A third study was conducted across three districts and found average district level adult satisfaction scores ranging from 70% to copy handbag Hermes 76%.20 Adults gave lower satisfaction ratings in periurban areas in this study, suggesting that satisfaction varies by facility type and location.20 No prior national studies have described the extent of this variation or examined factors that explain it.
Research in other developing settings have identified a variety of factors that may drive satisfaction, including provider attitudes and respectfulness, technical provider ability, wait time, drug availability, facility appearance, and patient expectations.21 25 The findings have varied depending on the country and setting, leaving a gap in knowledge as to what drives satisfaction in the Zambian context.
In this study, we report findings from exit surveys of patients receiving HIV and non HIV services at a diverse sample of facilities across Zambia. We describe levels and variations in patients' overall satisfaction, as well as their perceptions of specific interpersonal and technical aspects of care. bag Hermes copy Additionally, we examine how individual characteristics, facility level factors, and perceptions of specific aspects of care relate to overall satisfaction, to highlight areas for potential interventions to improve patient satisfaction in Zambia.
MethodsSample and data collectionThe exit interviews were conducted between Hermes bag fake December 2011 and May 2012 across 16 Zambian districts as part of the Access, Bottlenecks, Costs, and Equity (ABCE) project. The details of this project are documented elsewhere and available online.26
A two step stratified random sampling process was used to select health facilities. First, Zambia's districts (72 at the time, currently 103) were stratified on the basis of average household wealth, population density and skilled birth attendance (SBA) coverage. One district was randomly selected from each wealth population SBA category, in addition to the capital, Lusaka. In each selected district, we selected all hospitals, two urban health centres, three rural health centres, and a quota of associated health posts. The exit interviews were conducted at a subset of the facilities selected for the overall ABCE project. Our study reports on interviews conducted at 104 facilities. Compared with all facilities in Zambia, we oversampled hospitals and urban health centres and undersampled rural health centres and health posts to allow for platform specific analyses (see online supplementary appendix table 1). Our sample is representative of the Zambian population and health delivery system, except that we oversampled hospitals to allow for separate analyses of hospital data. The sample of patients who sought care was also skewed towards females, which is expected due to several factors including women seeking maternal health services and a higher HIV prevalence among women (15.1%) than men (11.3%).11
At each facility participating in the exit survey, 30 patients were systematically sampled as they exited. Sampling intervals varied from every patient to every four patients, depending on the patient volume reported by the facility manager. The sample size of 30 patients at each facility was estimated using the Kish method with the following assumptions: patient satisfaction rate of 10%, precision of 5%, of 1%, design effect of two, and non response rate of 20%. The estimated sample from the Kish method was further adjusted to allow for robust subgroup analyses (eg, HIV vs non HIV; hospital vs health clinic; rural vs urban). Interviews were conducted over at least two days at each facility. Patients were required to be 15years or older and in an appropriate physical and mental state to be eligible to complete the survey. If a patient was too young or otherwise ineligible, an eligible attendant was asked to answer on their behalf when possible. Verbal consent was obtained from all respondents, and surveys were conducted in a location where the facility staff and other patients were not present.
Trained research assistants recorded exit interview responses electronically using the DatStat data collection software. On a daily basis, data were uploaded to a database accessible from Seattle, where they were continually verified for quality during the collection process. The median interview time was nine minutes.
Favourable perceptions of health personnel conduct were associated with higher odds of overall satisfaction for non HIV (OR=3.53, 95% CI 2.34 to 5.33) and HIV (OR=11.00, 95% CI 3.97 to 30.51) visits. Better perceptions of resources and services were also associated with higher odds of satisfaction for both non HIV (OR=1.66, 95% CI 1.08 to 2.55) and HIV (OR=4.68, 95% CI 1.81 to 12.10) visits. Two additional dimensions of perceived quality of care healthcare delivery and accessibility of care were positively associated with higher satisfaction for non HIV patients. The odds of overall satisfaction were lower in rural facilities for non HIV patients (OR 0.69; 95% CI 0.48 to 0.99) and HIV patients (OR=0.26, 95% CI 0.16 to 0.41). For non HIV patients, the odds of satisfaction were greater in hospitals compared with health centres/posts (OR 1.78; 95% CI 1.27 to 2.48) and lower at publicly managed facilities (OR=0.41, 95% CI=0.27 to 0.64).
Conclusions Perceived quality of care is an important driver of patient satisfaction with health service delivery in Zambia.
Patient satisfactionPerceived quality of careExit interviewHIVZambiaStrengths and limitations of this studyTo the best of our knowledge, this study is the first to examine the association between perceived quality of care and patient satisfaction through exit interviews across Zambia.
Adequacy of medical resources and provider conduct and practices were significant predictors of overall patient satisfaction.
Facility characteristics such as management type, location and level of facility were important determinants of patient satisfaction.
Methodological concerns associated with over representation of users and lack of causality are acknowledged.
BackgroundFor nearly 25years, the World Health Organization (WHO) has identified meeting individuals' universally legitimate expectations as a key health system objective.1 Patient satisfaction and ratings have been given increasing importance for measuring the quality of health services and are routinely used in developed countries for continuous quality improvement and value based incentive payments.2 ,3 In addition to the intrinsic importance of meeting reasonable expectations, patient satisfaction and perceptions are associated with healthcare utilisation and choice of provider.4 6 Studies have also linked satisfaction to treatment adherence for HIV patients, which has important implications for individual patient outcomes and preventing resistance to antiretroviral drugs (ARVs).7 ,8
This study focuses on patient satisfaction and perceptions in Zambia, a sub Saharan African country with 16.2 million citizens.9 Approximately 80% of Zambian health facilities are publicly managed, and the government has worked to decentralise decision making to the district level since 1991.10 While service utilisation has improved in recent years, it continues to be a major concern; in the 2013 2014 Demographic and Health Survey (DHS), 64% of deliveries were performed by a skilled provider and 66% of children received medical attention for diarrhoea.11
HIV is a priority issue in Zambia, where adult prevalence was estimated at 13.3% in the 2013 2014 DHS.11 In 2012, Zambia dispensed ARVs to over 500000 patients at 564 facilities, most of which were stand alone vertical facilities associated with a general clinic.12 ,13 Currently, the National Aids Strategic Framework emphasises moving towards a model that integrates HIV prevention, diagnosis and treatment with other primary health services.14 While integration is still underway, a scaled up pilot at 12 primary care clinics in Lusaka found that integration offered management and organisational advantages, but not human resource or infrastructure gains.15 17
Despite evidence that satisfaction can drive the utilisation of antiretroviral therapy (ART) and other priority services, Zambia lacks a systematic means of monitoring and responding handbag Hermes replica to patient opinions. Zambian patient perceptions have only been measured in a handful of small studies in limited populations. A study of maternity care in Lusaka found that while 89% of women rated care as 'good' or 'very good', 21% were shouted at, scolded or otherwise treated badly during delivery.18 In another survey, the majority of patients were not satisfied with the quality of care for sexually transmitted diseases at an urban health centre.19 A third study was conducted across three districts and found average district level adult satisfaction scores ranging from 70% to copy handbag Hermes 76%.20 Adults gave lower satisfaction ratings in periurban areas in this study, suggesting that satisfaction varies by facility type and location.20 No prior national studies have described the extent of this variation or examined factors that explain it.
Research in other developing settings have identified a variety of factors that may drive satisfaction, including provider attitudes and respectfulness, technical provider ability, wait time, drug availability, facility appearance, and patient expectations.21 25 The findings have varied depending on the country and setting, leaving a gap in knowledge as to what drives satisfaction in the Zambian context.
In this study, we report findings from exit surveys of patients receiving HIV and non HIV services at a diverse sample of facilities across Zambia. We describe levels and variations in patients' overall satisfaction, as well as their perceptions of specific interpersonal and technical aspects of care. bag Hermes copy Additionally, we examine how individual characteristics, facility level factors, and perceptions of specific aspects of care relate to overall satisfaction, to highlight areas for potential interventions to improve patient satisfaction in Zambia.
MethodsSample and data collectionThe exit interviews were conducted between Hermes bag fake December 2011 and May 2012 across 16 Zambian districts as part of the Access, Bottlenecks, Costs, and Equity (ABCE) project. The details of this project are documented elsewhere and available online.26
A two step stratified random sampling process was used to select health facilities. First, Zambia's districts (72 at the time, currently 103) were stratified on the basis of average household wealth, population density and skilled birth attendance (SBA) coverage. One district was randomly selected from each wealth population SBA category, in addition to the capital, Lusaka. In each selected district, we selected all hospitals, two urban health centres, three rural health centres, and a quota of associated health posts. The exit interviews were conducted at a subset of the facilities selected for the overall ABCE project. Our study reports on interviews conducted at 104 facilities. Compared with all facilities in Zambia, we oversampled hospitals and urban health centres and undersampled rural health centres and health posts to allow for platform specific analyses (see online supplementary appendix table 1). Our sample is representative of the Zambian population and health delivery system, except that we oversampled hospitals to allow for separate analyses of hospital data. The sample of patients who sought care was also skewed towards females, which is expected due to several factors including women seeking maternal health services and a higher HIV prevalence among women (15.1%) than men (11.3%).11
At each facility participating in the exit survey, 30 patients were systematically sampled as they exited. Sampling intervals varied from every patient to every four patients, depending on the patient volume reported by the facility manager. The sample size of 30 patients at each facility was estimated using the Kish method with the following assumptions: patient satisfaction rate of 10%, precision of 5%, of 1%, design effect of two, and non response rate of 20%. The estimated sample from the Kish method was further adjusted to allow for robust subgroup analyses (eg, HIV vs non HIV; hospital vs health clinic; rural vs urban). Interviews were conducted over at least two days at each facility. Patients were required to be 15years or older and in an appropriate physical and mental state to be eligible to complete the survey. If a patient was too young or otherwise ineligible, an eligible attendant was asked to answer on their behalf when possible. Verbal consent was obtained from all respondents, and surveys were conducted in a location where the facility staff and other patients were not present.
Trained research assistants recorded exit interview responses electronically using the DatStat data collection software. On a daily basis, data were uploaded to a database accessible from Seattle, where they were continually verified for quality during the collection process. The median interview time was nine minutes.
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