Quality of primary care from the patient perspective in South West Malawi : Development and application of the Malawian Primary Care Assessment Tool (Pcat-Mw)

Abstract

Background Primary care is considered as a vehicle for accelerating progress towards universal health coverage and for building efficient, effective, and integrated healthcare systems. Measuring patients’ experience and satisfaction with healthcare services is among Malawi’s health sector strategic goals to complement evaluation of clinical health outcomes. However, Malawi does not have validated tools for assessing primary care performance from patients’ experience. The purpose of the study was therefore to develop a validated tool for the assessment primary care performance based on patients’ experience of care in public health facilities in Malawi. Study objectives: 1. To develop and validate a Malawian version of a primary care assessment tool (PCAT-Mw) 2. To assess the quality of primary care based on patients’ experience in a rural district health system in Malawi. 3. To assess the association between quality of primary care and types of public health facilities in the South West health zone in Malawi. Methods: The South African version of the primary care assessment tool was assessed for face and content validity and then translated into Chichewa, a widely spoken local language. The tool was then used in a cross-sectional survey in Neno district, Malawi in August and September 2016. Data on patients’ primary care experience and their sociodemographic, healthcare and health characteristics was collected. Exploratory and confirmatory factor analysis was performed to evaluate internal consistency, reliability and construct validity of items and scales. Likert scale assumption testing and descriptive statistics were done on the final factor structure of the questionnaire. These results were reported in Paper I. In Paper II, mean scores were derived for the following dimensions: first contact access, continuity of care, comprehensiveness, community orientation and total primary care. Linear regression models were used to assess association between primary care dimension scores and patients’ characteristics. A second survey was conducted in 12 public primary care facilities in Neno, Blantyre and Thyolo districts in July 2018. ANOVA at 0.05 significance level was performed to compare primary care dimension means and total primary care scores. Linear regression models at 95% CI were used to assess associations between primary care dimension scores, patients’ characteristics and healthcare setting. Results: The validation process used responses of 631 patients representing 97.8% response rate. A tool was constructed comprising seven multi-item scales, representing five primary care dimensions (first contact, continuity, comprehensiveness, coordination and community orientation). All the seven scales achieved good internal consistency, item-total correlations and construct validity. Cronbach’s alpha coefficients ranged from 0.66 to 0.91. A satisfactory goodness of fit model was achieved (GFI = 0.90, CFI = 0.91, RMSEA = 0.05, PCLOSE= 0.65). In Neno, participants reported poor performance in first contact access, relational continuity and comprehensiveness of services available. Acceptable performance was reported in communication continuity, comprehensiveness of services provided and community orientation. Sex, geographical location, self-rated health status, duration of contact with facility and facility affiliation were associated with patients’ experience with primary care A total of 962 respondents represented 96.1% response rate in the second survey. Patients in Neno health centers scored higher than those in Thyolo and Blantyre health centers respectively in total primary care performance. Primary care performance in health centers and in hospital clinics was similar in Neno (20.9 vs 19.0, p= 0.608) while in Thyolo, it was higher at the hospital than at the health centers (19.9 vs 15.2, p<0.001). Urban and rural facilities showed a similar pattern of performance. Conclusion: The PCAT-Mw is a reliable and valid tool to assess core concepts of primary care as seen from patients’ perspective in Malawi. PCAT-Mw has dimensions that reflect the attributes of the conventional definition of primary care. This study reports poor quality of first contact access, comprehensiveness of the services available and relational continuity of care. Communication continuity of care was reported by patients to be acceptable across different settings of primary care. Several factors were associated with patients’ experience of primary care and they included sex, duration of affiliation with facility, reason for seeking care (acute or chronic) increasing self-rated health and the type of primary care facility. These results showed considerable variation in experiences among primary care users in the public health facilities in Malawi. Factors such as funding, policy and clinic level interventions influence patients’ reports of primary care performance. These factors should be further examined in longitudinal and experimental settings.