1Bouzid M, et al. BMJ Glob Health 2018;3:e000648. doi:10.1136/bmjgh-2017-000648

What is the impact of water sanitation and hygiene in healthcare facilities on care seeking behaviour and patient satisfaction? A systematic review of the evidence from low-income and middle-income countries

Maha Bouzid,1 Oliver Cumming,2 Paul R Hunter1

Research

To cite: Bouzid M, Cumming O, Hunter PR. What is the impact of water sanitation and hygiene in healthcare facilities on care seeking behaviour and patient satisfaction? A systematic review of the evidence from low-income and middle-income countries. BMJ Glob Health 2018;3:e000648. doi:10.1136/bmjgh-2017-000648

Handling editor Soumitra Bhuyan

► Additional material is published online only. To view please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjgh- 2017- 000648).

Received 15 November 2017Revised 22 February 2018Accepted 15 March 2018

1Norwich School of Medicine, University of East Anglia, Norwich, UK2Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK

Correspondence toDr Maha Bouzid; M. Bouzid@ uea. ac. uk

AbsTrACTPatient satisfaction with healthcare has clear implications on service use and health outcomes. Barriers to care seeking are complex and multiple and delays in seeking care are associated with significant morbidity and mortality. We sought to assess the relationship between water, sanitation and hygiene (WASH) provision in healthcare facilities (HCF) and patient satisfaction/care seeking behaviour in low-income and middle-income countries. Pubmed and Medline Ovid were searched using a combination of search terms. 984 papers were retrieved and only 21 had a WASH component warranting inclusion. WASH was not identified as a driver of patient satisfaction but poor WASH provision was associated with significant patient dissatisfaction with infrastructure and quality of care. However, this dissatisfaction was not sufficient to stop patients from seeking care in these poorly served facilities. With specific regard to maternal health services, poor WASH provision was the reason for women choosing home delivery, although providers’ attitudes and interpersonal behaviours were the main drivers of patient dissatisfaction with maternal health services. Patient satisfaction was mainly assessed via questionnaires and studies reported a high risk of courtesy bias, potentially leading to an overestimation of patient satisfaction. Patient satisfaction was also found to be significantly affected by expectation, which was strongly influenced by patients’ socioeconomic status and education. This systematic review also highlighted a paucity of research to describe and evaluate interventions to improve WASH conditions in HCF in low-income setting with a high burden of healthcare-associated infections. Our review suggests that improving WASH conditions will decrease patience dissatisfaction, which may increase care seeking behaviour and improve health outcomes but that more rigorous research is needed.

InTroduCTIonThe water, sanitation and hygiene (WASH) attributable burden of disease is large and concentrated within low-income and middle-income countries (LMIC). A total of 842 000 diarrhoeal disease deaths (of which,

361 000 occurred in children under 5 years old) were attributed to inadequate WASH in 145 countries.1 Despite considerable progress in improving access to WASH services under the Millennium Development Goals (MDGs), a significant proportion of the world’s poor still lack access to safe WASH.2 However, reporting for the MDGs focused on WASH access in the community. By contrast, there has been little exploration of the impact of inadequate WASH provision in healthcare facilities (HCF) in LMIC. In 2015, WHO and

Key questions

What is already known? ► A WHO/Unicef report (2015) highlighted the lack of adequate water, sanitation and hygiene (WASH) provision in many healthcare facilities (HCF) in low-income and middle-income countries (LMIC).

► Patient satisfaction and care seeking behaviour have been extensively used to monitor and improve the quality of care.

► The evidence on the contribution of poor WASH to patient dissatisfaction and care seeking behaviour is unclear.

What are the new findings? ► This systematic review sought to assess the relationship between WASH in HCF and patient satisfaction/care seeking behaviour in LMIC.

► Our findings showed that WASH status was not the main driver of patient satisfaction as other factors were more significant to users.

► Nevertheless, poor WASH provision was associated with significant patient dissatisfaction and stopped women from seeking care at maternity services.

► This is the first systematic review to be published on this topic.

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Unicef assessed WASH status in 66 101 HCF in 54 LMIC.3 This assessment showed that 38% of facilities lacked access to water, 19% had no improved sanitation and 35% had no soap and water facilities. The issue of lack of WASH in HCF is of paramount importance because vulnerable populations are over-represented in these settings and the risk of infection and death is heightened. There is a growing awareness about this issue at a national and inter-national level and an intergovernmental commitment to address this inequity. Indeed, progress on WASH provi-sion in healthcare settings is currently being monitored as part of the Sustainable Development Goals (SDGs).4–6

Healthcare-associated infections (HCAI) are a major challenge in LMIC, where it has been estimated that the risk is 2–20 times higher than in developed countries.7 The highest rates of HCAI have been reported from the Eastern Mediterranean and South East Asia regions (11.8% and 10%, respectively) but this is an under-estimation due to poor recording and lack of patient follow-up.7 As most HCAI are transmitted via the hands of healthcare workers through direct contact or environ-mental contamination, hand washing remains the single most important preventive strategy.7 8 The importance of WASH in healthcare settings was established long ago by the work of Alexander Gordon9 and Ignaz Semmelweis10 with regard to puerperal fever in the 18th and 19th centu-ries and more recently with regard to HCAI outbreaks where unsafe water or hygiene have been implicated.11–14 In contrast to high-income countries, there is relatively little evidence on the burden of HCAI in LMIC. A recent systematic review estimated that HCAI prevalence in LMIC was 15.5 per 100 patients, compared with 7.1 and 4.5 per 100 patients, in Europe and USA, respectively.15 It is plausible that much of this excess is due to inadequate WASH. However, the disease burden associated with inadequate WASH provision is likely greater than the HCAI burden alone. Indeed, inadequate WASH could have large impacts on health outcomes through its influ-ence on patient satisfaction, care seeking behaviour and staff morale.

The barriers to care seeking are characterised using the three delays model developed by Thaddeus and Maine16

comprising: delays in deciding to seek care (primary delay), delays in reaching the health facility (secondary delay) and delays in receiving quality care once at the health facility (tertiary delay).17 Delays in receiving care have been estimated to be responsible for 30% newborn deaths in Uganda,17 45% of child deaths from diarrhoea and acute respiratory infections in Mexico18 and an increased odds of intrauterine fetal death of 6.6 (95% CI 1.6 to 26.3) for over an hour delays among Women in Afghanistan.19

Care seeking barriers are multiple and include care-takers’ failure to identify early danger signs that should trigger appropriate care seeking behaviour, cost (espe-cially for medication), distance to the facility, imped-iments related to weather or social unrest, lack of supervision for other children at home, lack of trans-port and, particularly relevant to this review, dissatisfac-tion with the quality of care.20 Afsana and colleagues21 consider that barriers to using hospital care are mainly related to care quality, especially for maternity services (often inadequate, unaffordable, insufficiently staffed and lacking medically trained professionals). Patient satisfaction is a commonly used indicator of health-care quality and was shown to affect service use, clinical outcomes and patient retention.22 It is considered a reli-able measure to understand patients’ needs and to make strategic decisions to improve care quality.23 However, no standardised system exists and a wide range of patient satisfaction indicators have been used as highlighted in a recent systematic review.23 The aim of this systematic review was to assess the impact of poor WASH provision in HCF in LMIC on two relevant indicators of healthcare quality: patient satisfaction and care seeking behaviour.

MeTHodsThe review methods are reported in accordance with the ‘Preferred Reporting Items for Systematic Reviews and Meta-Analyses’ (PRISMA)24 (checklist: online supple-mentary file 1).

search strategy and inclusion criteriaPubmed and Medline Ovid were searched in March 2016 for articles published in English after the year 2000 using the search terms outlined in table 1. A combination of specific and broad search terms was used in order to retrieve all relevant papers. ‘Developing countries’ was included as a search term in two out of five searches so as not to exclude relevant studies. LMIC were classified based on income level as defined by the World Bank data. No restrictions on study design and duration were applied. Reference lists were manually scanned for addi-tional relevant papers, which were included if eligible. Papers that had no WASH component were excluded.

data extraction and analysisRelevant data were extracted from all included papers using a standardised form. These data were: geographic

Key questions

What do the new findings imply? ► Inadequate WASH provision in HCF in LMIC may increase the risk of healthcare-associated infections (HCAI).

► Beyond the HCAI burden, poor WASH provision may increase patient dissatisfaction and limit care seeking behaviour, leading to adverse health outcomes.

► Improving WASH provision in HCF should be prioritised as a means of addressing HCAI but also to address patient satisfaction and encourage timely care seeking.

► Global best practice guidelines combined with concerted action at the national policy level would support progress in ensuring adequate WASH provision in HCF in LMIC.

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BMJ Global Health

location, type of study, type of healthcare facility, inter-vention (if any) and main findings. All quantitative and qualitative findings were recorded. Data were summa-rised narratively and no meta-analysis was conducted because of the heterogeneity between studies and use of different indicators of patient satisfaction.

resulTsThis systematic review assessed the effect of WASH in HCF on two quality of care outcomes: patient satisfaction and care seeking behaviour. Although WASH was rarely the primary focus of the included studies, all included some assessment of WASH conditions in HCF and their impact on patient satisfaction and/or care seeking behav-iour.

The search strategy retrieved 984 articles (table 1). After removal of duplicates and screening of abstracts, 54 papers were considered eligible (figure 1). Following full

Table 1 Combined search strategy and number of papers retrieved

Search strategyNumber of papers retrieved

(WASH OR Water OR Sanitation OR Hygiene) AND health care (MeSH: delivery of Health care) AND developing countries (Mesh) AND (satisfaction OR acceptance)

32

(water OR hygiene OR sanitation) AND care seeking AND developing countries

37

‘Patient Acceptance of Health Care’ AND (water OR sanitation OR hygiene)

461

Toilet AND (patient acceptance OR satisfaction)

87

Patient satisfaction AND developing countries

367

Total 984

Figure 1 PRISMA flow diagram for peer-reviewed literature search and included studies. From Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009;6:e1000097. For more information, visit www.prisma-statement.org.

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text scanning, only 21 papers were found to have a WASH component and were therefore included. The details of the papers and extracted data are presented in table 2. Included papers covered various countries, settings and healthcare delivery systems. There were studies from India (n=4), Uganda (3), Ethiopia (2), Nigeria (2), Tanzania (2), Kenya (1), South Africa (1), Malawi (1), Burkina Faso (1), Madagascar (1) and Zambia (1). All but three studies were cross-sectional (18/21), with one case control study, two review studies and one systematic review.

The level of satisfaction with WASH provision was reported in most studies. However, some studies reported on composite indicators of patient satisfaction and these were also noted. The papers were categorised according to the type of healthcare system, in particular, find-ings for maternity services were presented separately. Additionally, three papers investigated improvement interventions.

WAsH in HCF other than maternity servicesSeveral papers reported patient dissatisfaction rates with WASH in non-maternal health service. Woldeyohanes and colleagues assessed patient satisfaction with in-patient services in Ethiopia and reported 81.5% were dissatisfied with toilet cleanliness (table 2).25 A study in antiretroviral treatment clinic in Ethiopia showed a lower, but signifi-cant, dissatisfaction with toilet cleanliness (35.3%).26 The authors highlighted the importance of maintaining good hygiene levels, especially for patients with HIV/AIDS. Ezegwui and colleagues investigated patients’ satisfaction with eye care hospital in Nigeria and found that 71.7% of patients were dissatisfied with toilet facilities (only one toilet for patients and no running tap water).27 A study of rural healthcare system in India highlighted the link between poor WASH provision and patient dissatisfac-tion, with 50% respondents reporting that in surveyed government hospitals toilets are either ‘not at all usable’ or ‘dirty needed cleaning’.28 In addition, 3% of health facilities did not have toilets and drinking water was avail-able in only 55% of hospitals. The authors concluded that provision of clean toilets with privacy and safe drinking water would improve client satisfaction.28 While all these studies reported low patient satisfaction with WASH provision, a study in an eye care hospital in India reported high patient satisfaction with toilets (83.2%), water facilities (99.4%) and cleanliness (99.4%).29 Indeed, no respondent judged these as poor. However, 16.9% did not answer the toilet question. It is unclear if WASH provision was adequate in the HCF investigated as the paper was not focused on WASH, thus this informa-tion was not provided.

Khamis and colleagues investigated patient satisfac-tion with quality of care in an outpatient department in Tanzania using perception and expectation questions and calculating mean gap score between the two compo-nents.30 The study reported high overall dissatisfaction with quality of care, with a mean gap score of −2.88.30 The

mean gap score was −0.5 and −0.67 for general cleanliness and sufficient chairs and toilets, respectively (table 2), showing a moderate level of dissatisfaction.30

Mohammed and colleagues assessed the responsiveness of healthcare services for insured patients in Nigeria.31 One of the responsiveness domains was quality of facilities, which included provision of clean toilets in the hospital. Only 42.8% of users were satisfied with the quality of facilities and low-income users reported better quality of services than high-income users.31 Westaway and colleagues investigated interpersonal and organisational dimensions of patient satis-faction in a diabetic clinic for black patients in South Africa and found that the most important items for satisfaction were availability of a seat and a toilet in the waiting area and cleanliness.32

In a study investigating quality of care and contraceptive use in Kenya, 78.5% of facilities had running water; however, facility infrastructure and patient satisfaction indicators were not associated with contraceptive use.33 The cost of service and toilet facilities were the main areas of dissatisfaction.

Glick investigated the reliability of exit surveys frequently used to assess patient satisfaction.34 The respondents’ opin-ions were collected and answers were compared between exit and household surveys. Courtesy bias was found to influence respondents’ answers resulting in overestimates of patient satisfaction from exit surveys. This bias was stronger for subjective questions such as treatment by staff and consultation quality compared with objective questions such as facility conditions.34

WAsH in maternity servicesNine out of 21 studies focused on WASH conditions specif-ically around maternal health services, covering antenatal, delivery and postnatal care. Srivastava and colleagues conducted a systematic review investigating determinants of women’s satisfaction with maternal healthcare in devel-oping countries and covered all three dimensions: struc-ture, process and outcome.35 A good physical environment was found to be associated with a positive assessment of the health facility. In Bangladesh, when availability of services (a composite of waiting area and time, drinking water and clean toilet) was rated good, mothers were more satisfied with care quality.35 Cleanliness and maintenance of hygiene were also significant determinants of satisfaction in Bang-ladesh, Gambia, Thailand, India and Iran. Interpersonal behaviour, specifically provider courtesy and non-abuse, were the most widely reported determinants of women satisfaction.35 However, other factors influenced perceived maternal satisfaction including access, cost, socioeconomic status and reproductive history.35

Steinmann and colleagues assessed women’s satisfac-tion with latrines and hand washing stations in rural India and their impact on care seeking behaviour.36 They reported significant discrepancies between public and private health facilities. The average number of latrines per HCF was 2.4 (1.3 in public and 3.5 in private facil-ities). One healthcare centre had no latrine and dedi-cated latrines for woman were rarely available.36 The

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Tab

le 2

Im

pac

t of

WA

SH

in h

ealth

care

faci

litie

s on

pat

ient

sat

isfa

ctio

n an

d c

are

seek

ing

beh

avio

ur

Ref

eren

ceT

itle

Loca

tio

nTy

pe

of

stud

yC

ont

ext

Inte

rven

tio

nFi

ndin

gs

Furt

her

com

men

ts

Wat

er a

nd s

anit

atio

n

W

old

eyoh

anes

 et 

al25

Per

ceiv

ed p

atie

nt

satis

fact

ion

with

in-

pat

ient

ser

vice

s at

Jim

ma

Uni

vers

ity S

pec

ializ

ed

Hos

pita

l, S

outh

wes

t E

thio

pia

Eth

iop

iaC

ross

-sec

tiona

lTh

is s

tud

y ai

ms

to

mea

sure

and

des

crib

e th

e le

vel o

f pat

ient

sa

tisfa

ctio

n w

ithin

in

-pat

ient

hea

lthca

re

serv

ices

Toile

t cl

eanl

ines

s: 1

8.5%

(3

5/18

9) w

ere

sati

sfied

w

hile

81.

5% (1

54/1

89)

wer

e d

issa

tisfi

ed. 7

6.6%

(1

45/1

89) w

ere

satis

fied

with

cl

eanl

ines

s of

the

war

d.

Res

earc

h cl

early

iden

tified

a li

nk

bet

wee

n p

atie

nt o

utco

mes

and

p

atie

nt s

atis

fact

ion

scor

es.

Te

ssem

a an

d A

dna

e26A

sses

smen

t of

an

tiret

rovi

ral t

reat

men

t (A

RT)

car

e se

rvic

e p

rovi

sion

in T

igra

y R

egio

n he

alth

cen

ters

, Nor

th

Eth

iop

ia

Eth

iop

iaC

ross

-sec

tiona

lP

erce

ived

leve

ls o

f clie

nts’

sa

tisfa

ctio

n w

ith h

ealth

se

rvic

es a

t A

RT

clin

ic le

vel

in h

ealth

cen

tres

Hig

h sc

ores

of s

atis

fact

ion

wer

e re

por

ted

for

cour

tesy

an

d r

esp

ect

95.8

0%

(684

/714

) and

priv

acy

93.2

8%

(666

/714

).A

cces

s an

d c

lean

lines

s to

la

trin

es w

ere

not

alw

ays

asse

ssed

. To

ilet

clea

nlin

ess

was

uns

atis

fact

ory

fo

r 35

.32%

(243

/688

).

Ad

just

ed O

R fo

r sa

tisfa

ctio

n w

as

2.22

(95%

CI 1

.62 

to 6

.32)

fo

r to

ilet

clea

nlin

ess.

Mea

sure

s su

ch a

s in

crea

sing

acc

ess

to A

RT

serv

ice,

av

ailin

g cl

ean

toile

t an

d A

RT

dru

gs m

ay fu

rthe

r in

crea

se c

lient

sa

tisfa

ctio

n.C

lean

to

ilets

are

req

uire

d

esp

ecia

lly f

or

HIV

/AID

S p

atie

nts

to p

reve

nt o

pp

ort

unis

tic

and

no

n-o

pp

ort

unis

tic

coin

fect

ions

.

Tu

mlin

son 

et a

l33Q

ualit

y of

car

e an

d

cont

race

ptiv

e us

e in

ur

ban

Ken

ya

Ken

yaC

ross

-sec

tiona

lTh

e st

udy

hyp

othe

sis

is t

hat

poo

r q

ualit

y of

fa

mily

pla

nnin

g se

rvic

e p

rovi

sion

is a

bar

rier

to

cont

race

ptiv

e us

e

78.5

% o

f fa

cilit

ies

(204

/260

) ha

ve r

unni

ng w

ater

.Fa

cilit

y in

fras

truc

ture

and

mos

t as

pec

ts o

f clie

nt s

atis

fact

ion—

incl

udin

g p

rivac

y is

sues

, am

ount

of

info

rmat

ion

give

n, w

aitin

g tim

e an

d

over

all s

atis

fact

ion—

wer

e un

rela

ted

to

con

trac

eptiv

e us

e.

G

aluk

and

e et

 al43

Dev

elop

ing

hosp

ital

accr

edita

tion

stan

dar

ds

in

Uga

nda

Uga

nda

Cro

ss-s

ectio

nal

Acc

red

itatio

n is

not

wel

l es

tab

lishe

d in

mos

t d

evel

opin

g co

untr

ies

for

seve

ral r

easo

ns, i

nclu

din

g in

suffi

cien

t in

cent

ives

, in

suffi

cien

t tr

aini

ng a

nd a

sh

orta

ge o

f hum

an a

nd

mat

eria

l res

ourc

es

Sel

f-as

sess

men

t ho

spita

l acc

red

itatio

n to

ol d

evel

oped

for

a re

sour

ce-l

imite

d c

onte

xt.

Am

ong

accr

edita

tion

item

s (1

) phy

sica

l inf

rast

ruct

ure

and

(2) i

nfec

tion

cont

rol

and

was

te m

anag

emen

t ar

e re

leva

nt t

o W

AS

H. 2

7.5%

(1

1/40

) hos

pita

ls w

ere

not

trac

king

infe

ctio

n ra

tes

and

32

.5%

(13/

40) h

ad fu

nctio

nal

ster

ilisa

tion

equi

pm

ent.

Goo

d p

erfo

rman

ce w

as m

easu

red

in

ava

ilab

ility

of e

qui

pm

ent

and

ru

nnin

g w

ater

, 24

hour

s st

aff

calls

sys

tem

s, c

linic

al g

uid

elin

es

and

was

te s

egre

gatio

n. P

oor

per

form

ance

was

mea

sure

d in

ca

re fo

r th

e vu

lner

able

, sta

ff liv

ing

qua

rter

s, p

hysi

cian

per

form

ance

re

view

s, p

atie

nt s

atis

fact

ion

surv

eys

and

ste

rilis

ing

equi

pm

ent.

O

kwar

o et

 al44

Cha

lleng

ing

logi

cs o

f co

mp

lex

inte

rven

tion

tria

ls: c

omm

unity

p

ersp

ectiv

es o

f a

heal

th c

are

imp

rove

men

t in

terv

entio

n in

rur

al

Uga

nda

Uga

nda

Cro

ss-s

ectio

nal

Att

ract

pat

ient

s to

hea

lth

cent

res

thro

ugh

imp

rove

d

serv

ices

and

att

itud

es

of s

taff

and

bet

ter

man

agem

ent

of fe

vers

The

inte

rven

tion

aim

s to

enh

ance

qua

lity

of

care

at

pub

lic h

ealth

ce

ntre

s an

d b

y ex

tens

ion

imp

rove

mal

aria

-rel

ated

he

alth

ind

icat

ors

in

com

mun

ity c

hild

ren

Man

y he

alth

cen

tres

la

cked

run

ning

wat

er a

nd

elec

tric

ity.

Imp

rove

men

ts in

an

timal

aria

l dru

g av

aila

bili

ty

wer

e no

ted

but

com

mun

ity

mem

ber

s w

ere

dis

app

oint

ed

with

the

qua

lity

of c

are

rece

ived

.P

atie

nts

cont

inue

d t

o se

ek

care

at

heal

th c

entr

es t

hey

cons

ider

ed in

adeq

uate

.

The

inte

rven

tion

targ

eted

mal

aria

co

ntro

l to

the

excl

usio

n of

oth

er

dis

ease

s or

bas

ic in

fras

truc

ture

su

ch a

s in

-pat

ient

fac

iliti

es o

r cl

ean

wat

er.

Req

uest

s b

y p

atie

nts

to in

crea

se t

he

num

ber

of h

ealth

wor

kers

, exp

and

b

uild

ings

and

sp

ace

with

in fa

cilit

ies,

p

rovi

de

clea

n w

ater

and

ele

ctric

ity,

in-p

atie

nt s

ervi

ces,

and

cle

an

toile

ts w

ere

rep

orte

d.

E

zegw

ui e

t al

27P

atie

nts’

sat

isfa

ctio

n w

ith

eye

care

ser

vice

s in

a

Nig

eria

n te

achi

ng h

osp

ital

Nig

eria

Cro

ss–s

ectio

nal

Eva

luat

e p

atie

nts’

sa

tisfa

ctio

n w

ith t

he c

are

rece

ived

71.7

% (2

20/3

07) w

ere

not

sati

sfied

wit

h to

ilet

faci

litie

s. T

here

is o

nly

one

to

ilet

for

pat

ient

s an

d t

here

is

no

run

ning

tap

.

The

mai

n ar

eas

of d

issa

tisfa

ctio

n w

ere

the

cost

of s

ervi

ce a

nd t

oile

t fa

cilit

ies.

Con

tinue

d

on June 1, 2020 by guest. Protected by copyright.

http://gh.bmj.com

/B

MJ G

lob Health: first published as 10.1136/bm

jgh-2017-000648 on 9 May 2018. D

ownloaded from

6 Bouzid M, et al. BMJ Glob Health 2018;3:e000648. doi:10.1136/bmjgh-2017-000648

BMJ Global Health

Ref

eren

ceT

itle

Loca

tio

nTy

pe

of

stud

yC

ont

ext

Inte

rven

tio

nFi

ndin

gs

Furt

her

com

men

ts

K

ham

is a

nd N

jau30

Pat

ient

s’ le

vel o

f sa

tisfa

ctio

n on

qua

lity

of h

ealth

 car

e at

M

wan

anya

mal

a ho

spita

l in

Dar

es

Sal

aam

, Ta

nzan

ia

Tanz

ania

Cro

ss-s

ectio

nal

Det

erm

ine

pat

ient

s’

leve

l of s

atis

fact

ion

on

the

qua

lity

of h

ealth

care

d

eliv

ered

at

the

out-

pat

ient

dep

artm

ent

422

pat

ient

s w

ere

enro

lled

. M

ean

gap

sco

re w

as

(−2.

88±

3.1)

ind

icat

ing

over

all

dis

satis

fact

ion

with

the

q

ualit

y of

car

e.R

esp

ond

ents

wer

e d

issa

tisfie

d w

ith g

ener

al

clea

nlin

ess

(−0.

50; p

<0.

001)

, an

d s

uffi

cien

t ch

airs

and

to

ilets

(−0.

67; p

<0.

001)

.

The

que

stio

nnai

re is

div

ided

into

fiv

e d

imen

sion

s (ta

ngib

les,

rel

iab

ility

, re

spon

sive

ness

, ass

uran

ce a

nd

emp

athy

) to

det

erm

ine

pat

ient

s’

leve

l of s

atis

fact

ion.

The

mea

n ga

p

scor

e is

cal

cula

ted

as

the

diff

eren

ce

bet

wee

n m

ean

per

cep

tion

scor

e an

d m

ean

exp

ecta

tion

scor

e.

M

oham

med

 et 

al31

Ass

essi

ng r

esp

onsi

vene

ss

of h

ealth

 car

e se

rvic

es

with

in a

hea

lth in

sura

nce

sche

me

in N

iger

ia: u

sers

’ p

ersp

ectiv

es

Nig

eria

Ret

rosp

ectiv

e, c

ross

-se

ctio

nal s

urve

yIn

sure

d u

sers

’ p

ersp

ectiv

es o

f the

ir he

alth

care

ser

vice

s’

resp

onsi

vene

ss

42.8

% (3

41/7

96) o

f use

rs

wer

e sa

tisfie

d w

ith t

he q

ualit

y of

faci

litie

s.Th

is in

clud

ed h

avin

g en

ough

sp

ace,

sea

ting

pla

ces

and

fr

esh

air

in r

oom

s an

d w

ard

s as

wel

l as

a cl

ean

faci

lity

and

cl

ean

toile

ts in

the

ho

spit

al.

Low

-inc

ome

insu

red

use

rs

rep

orte

d b

ette

r q

ualit

y of

fa

cilit

ies

than

hig

h-in

com

e us

ers

(p<

0.00

1).

Res

pon

sive

ness

is in

clud

ed in

p

atie

nt s

atis

fact

ion

and

qua

lity

of

care

lite

ratu

re, a

nd r

efer

s to

the

w

ay in

div

idua

ls a

re t

reat

ed a

nd

the

envi

ronm

ent

in w

hich

the

y ar

e tr

eate

d.

‘Qua

lity

of b

asic

faci

litie

s’

(cle

an w

aiti

ng r

oo

ms,

to

ilet

faci

litie

s, e

xam

inat

ion

room

s an

d s

urro

und

ings

) is

imp

orta

nt

to p

atie

nts

in t

heir

exp

erie

nce

of

resp

onsi

vene

ss.

R

ay e

t al

28A

n as

sess

men

t of

rur

al

heal

th c

are

del

iver

y sy

stem

in s

ome

area

s of

W

est

Ben

gal-

an o

verv

iew

Ind

iaC

ross

-sec

tiona

l ob

serv

atio

nal s

tud

yId

entif

y ex

tent

of

utili

satio

n of

hea

lthca

re

faci

litie

s an

d u

nder

stan

d

heal

thca

re s

eeki

ng

beh

avio

ur in

the

co

mm

unity

13.9

7% (6

3/45

1) w

ere

dis

sati

sfied

wit

h ca

re

qua

lity.

27%

and

23%

cl

ient

s re

po

rted

tha

t to

ilets

w

ere

‘no

t at

all

usab

le’ a

nd

‘dir

ty n

eed

ing

cle

anin

g’,

resp

ectiv

ely

(n=

174)

. S

afe

dri

nkin

g w

ater

was

av

aila

ble

in 5

5% o

f th

e fa

cilit

ies

(n=

18).

Res

tro

om

s w

ere

eith

er o

f p

oo

r q

ualit

y o

r th

e cl

ient

s d

id n

ot

use

them

, whi

le t

hey

wer

e no

t av

aila

ble

in 3

% o

f he

alth

fa

cilit

ies.

Cle

anlin

ess

of t

he p

rem

ises

, fac

e-lif

t (o

f pub

lic h

ealth

cen

tres

), an

d c

lean

to

ilet

with

priv

acy

and

ava

ilab

ility

o

f sa

fe d

rink

ing

wat

er c

ould

im

pro

ve c

lient

sat

isfa

ctio

n in

rur

al

heal

thca

re d

eliv

ery

syst

ems.

S

udha

n et

 al29

Pat

ient

sat

isfa

ctio

n re

gard

ing

eye

care

se

rvic

es a

t te

rtia

ry

hosp

ital o

f cen

tral

Ind

ia

Ind

iaD

escr

iptiv

e st

udy

To e

valu

ate

pat

ient

s'

satis

fact

ion

rega

rdin

g ey

e ca

re s

ervi

ces

The

maj

ori

ty o

f re

spo

nden

ts

wer

e hi

ghl

y sa

tisfi

ed w

ith

toile

t 83

.2%

(133

/160

), w

ater

fac

iliti

es 9

9.4%

(1

59/1

60) a

nd c

lean

lines

s (1

59/1

60).

16.9

% (2

7/16

0)

did

no

t an

swer

the

to

ilet

que

stio

n an

d o

ne e

ach

for

wat

er a

nd c

lean

lines

s q

uest

ion.

Tab

le 2

C

ontin

ued

Con

tinue

d

on June 1, 2020 by guest. Protected by copyright.

http://gh.bmj.com

/B

MJ G

lob Health: first published as 10.1136/bm

jgh-2017-000648 on 9 May 2018. D

ownloaded from

Bouzid M, et al. BMJ Glob Health 2018;3:e000648. doi:10.1136/bmjgh-2017-000648 7

BMJ Global Health

Ref

eren

ceT

itle

Loca

tio

nTy

pe

of

stud

yC

ont

ext

Inte

rven

tio

nFi

ndin

gs

Furt

her

com

men

ts

W

esta

way

et 

al32

Inte

rper

sona

l and

or

gani

zatio

nal d

imen

sion

s of

pat

ient

sat

isfa

ctio

n:

the

mod

erat

ing

effe

cts

of

heal

th s

tatu

s

Sou

th A

fric

aA

cro

ss-s

ectio

nal

anal

ytic

al s

tud

y d

esig

nTo

iden

tify

the

und

erly

ing

dim

ensi

ons

of p

atie

nt

satis

fact

ion

in d

iab

etic

cl

inic

for

bla

ck p

atie

nts

263

pat

ient

s w

ere

surv

eyed

. Th

e m

ost

imp

orta

nt it

ems

for

satis

fact

ion

wer

e av

aila

bili

ty

of a

sea

t in

the

wai

ting

area

(0

.73)

, ava

ilab

ility

of

a to

ilet

in t

he w

aiti

ng a

rea

(0.7

0)

and

cle

anlin

ess

(0.7

0).

Am

eniti

es a

nd a

ttrib

utes

of c

are

wer

e ce

ntra

l to

the

orga

nisa

tiona

l d

imen

sion

of p

atie

nt s

atis

fact

ion.

G

iven

leng

thy

wai

ting

tim

es

in S

out

h A

fric

a’s

pub

lic h

ealt

h fa

cilit

ies,

it is

no

t su

rpri

sing

tha

t th

e av

aila

bili

ty o

f a

seat

and

to

ilet

in t

he w

aiti

ng a

rea

feat

ured

so

pro

min

entl

y. C

lean

lines

s w

as

also

per

ceiv

ed a

s an

imp

orta

nt

satis

fact

ion

area

.

G

lick34

How

rel

iab

le a

re s

urve

ys

of c

lient

sat

isfa

ctio

n w

ith

heal

thca

re s

ervi

ces?

E

vid

ence

from

mat

ched

fa

cilit

y an

d h

ouse

hold

d

ata

in M

adag

asca

r

Mad

agas

car

Cro

ss-s

ectio

nal

Inve

stig

atio

n of

the

re

liab

ility

of e

xit

surv

eys

by

com

par

ing

pat

ient

sa

tisfa

ctio

n ou

tcom

es

to p

opul

atio

n-b

ased

ho

useh

old

sur

veys

An

app

eara

nce

ind

ex (m

ean

of b

inar

y in

dic

ator

s fo

r d

irtin

ess,

hum

idity

dam

age,

d

ecay

of w

alls

, floo

rs a

nd

ceili

ngs,

evi

den

ce o

f ins

ects

an

d c

ond

itio

n o

f to

ilet

faci

litie

s (p

rese

nce

and

cl

eanl

ines

s)) w

as c

alcu

late

d.

The

app

eara

nce

ind

ex w

as

0.84

in h

ouse

hold

sur

veys

an

d 0

.91

in e

xit

surv

eys

for

the

sam

e fa

cilit

ies.

The

nu

mb

er o

f res

pon

den

ts w

ere

262

and

770

, res

pec

tivel

y.

The

find

ings

sug

gest

tha

t re

por

ted

sa

tisfa

ctio

n in

exi

t su

rvey

s is

bia

sed

st

rong

ly u

pw

ard

for

sub

ject

ive

que

stio

ns r

egar

din

g tr

eatm

ent

by

staf

f and

con

sulta

tion

qua

lity,

b

ut n

ot

for

rela

tive

ly o

bje

ctiv

e q

uest

ions

ab

out

fac

ility

co

ndit

ion

and

sup

plie

s.

Wat

er, s

anit

atio

n an

d h

ygie

ne in

mat

erni

ty s

ervi

ces

S

rivas

tava

et 

al35

Det

erm

inan

ts o

f wom

en’s

sa

tisfa

ctio

n w

ith m

ater

nal

heal

th c

are:

a r

evie

w o

f lit

erat

ure

from

dev

elop

ing

coun

trie

s

Dev

elop

ing

coun

trie

sS

yste

mat

ic r

evie

wId

entif

y d

eter

min

ants

of

wom

en’s

sat

isfa

ctio

n w

ith m

ater

nity

car

e in

d

evel

opin

g co

untr

ies

Goo

d p

hysi

cal e

nviro

nmen

t w

as s

igni

fican

t in

wom

en’s

p

ositi

ve a

sses

smen

t of

the

he

alth

faci

lity

and

mat

erna

l ca

re s

ervi

ces.

In B

angl

ades

h,

mot

hers

who

rat

ed t

he

avai

lab

ility

of s

ervi

ces

at

the

faci

lity

(a c

omp

osite

of

wai

ting

area

, dri

nkin

g w

ater

, cl

ean

toile

t an

d w

aitin

g tim

e)

as ‘g

ood

’ wer

e si

gnifi

cant

ly

mor

e sa

tisfie

d w

ith c

are

than

th

ose

who

rat

ed t

he s

ervi

ces

as ‘p

oor’

.C

lean

lines

s, g

ood

ho

usek

eep

ing

serv

ices

an

d m

aint

enan

ce o

f hy

gie

ne w

ere

rep

orte

d a

s d

eter

min

ants

of s

atis

fact

ion

in B

angl

ades

h, G

amb

ia,

Thai

land

, Ind

ia a

nd Ir

an.

Det

erm

inan

ts o

f mat

erna

l sa

tisfa

ctio

n co

vere

d a

ll th

ree

dim

ensi

ons

of c

are:

str

uctu

re,

pro

cess

and

out

com

e. S

truc

tura

l el

emen

ts in

clud

ed g

ood

phy

sica

l en

viro

nmen

t, c

lean

lines

s, a

nd

avai

lab

ility

of a

deq

uate

hum

an

reso

urce

s, m

edic

ines

and

sup

plie

s.

Acc

ess,

cos

t, s

ocio

econ

omic

st

atus

and

rep

rod

uctiv

e hi

stor

y al

so in

fluen

ced

per

ceiv

ed m

ater

nal

satis

fact

ion.

Pro

cess

of c

are

dom

inat

ed

the

det

erm

inan

ts o

f mat

erna

l sa

tisfa

ctio

n. In

terp

erso

nal b

ehav

iour

w

as t

he m

ost

wid

ely

rep

orte

d

det

erm

inan

t, p

artic

ular

ly a

roun

d

pro

vid

er b

ehav

iour

in t

erm

s of

co

urte

sy a

nd n

on-a

bus

e.

Tab

le 2

C

ontin

ued

Con

tinue

d

on June 1, 2020 by guest. Protected by copyright.

http://gh.bmj.com

/B

MJ G

lob Health: first published as 10.1136/bm

jgh-2017-000648 on 9 May 2018. D

ownloaded from

8 Bouzid M, et al. BMJ Glob Health 2018;3:e000648. doi:10.1136/bmjgh-2017-000648

BMJ Global Health

Ref

eren

ceT

itle

Loca

tio

nTy

pe

of

stud

yC

ont

ext

Inte

rven

tio

nFi

ndin

gs

Furt

her

com

men

ts

S

tein

man

n et

 al36

Ava

ilab

ility

and

sa

tisfa

ctor

ines

s of

latr

ines

an

d h

and

was

hing

st

atio

ns in

hea

lth fa

cilit

ies,

an

d r

ole

in h

ealth

see

king

b

ehav

ior

of w

omen

: ev

iden

ce fr

om r

ural

Pun

e d

istr

ict,

Ind

ia

Ind

iaC

ross

-sec

tiona

l/q

uest

ionn

aire

-bas

edIn

vest

igat

ion

of t

he

WA

SH

infr

astr

uctu

re in

sm

all h

ealth

faci

litie

s an

d

surv

ey o

f exp

ecta

tions

an

d s

atis

fact

ion

amon

g w

omen

12 h

ealt

h fa

cilit

ies

wer

e as

sess

ed (6

pri

vate

and

6

pub

lic).

The

mea

n nu

mb

er

of

latr

ines

per

hea

lthc

are

faci

lity

was

2.4

(ran

ge

0–8)

, b

ut w

as lo

wer

in p

ublic

(m

ean

1.3;

ran

ge

0–2)

tha

n in

pri

vate

fac

iliti

es (m

ean

3.5;

ran

ge

1–8)

. One

fac

ility

ha

d n

o la

trin

e an

d o

ne h

ad

an u

nim

pro

ved

latr

ine.

Gen

eral

ly, o

ne h

and

w

ashi

ng s

tati

on

(tap

) was

av

aila

ble

per

latr

ine

but

tw

o p

ublic

fac

iliti

es d

id n

ot

have

any

han

d w

ashi

ng

stat

ions

. The

mea

n nu

mb

er

of

hand

was

hing

sta

tio

ns

was

0.8

(ran

ge

0–2)

in p

ublic

fa

cilit

ies

and

3.7

(ran

ge:

1–

8) in

pri

vate

fac

iliti

es.

So

ap w

as o

ften

mis

sing

fr

om

han

d w

ashi

ng s

tati

ons

(6

/12)

. Ded

icat

ed la

trin

es

for

wo

men

wer

e ra

re.

WA

SH

inst

alla

tio

ns in

hea

lth

faci

litie

s ar

e g

ener

ally

acc

epta

ble

in

pri

vate

fac

iliti

esw

hile

im

pro

vem

ents

are

nee

ded

in

som

e g

ove

rnm

ent

faci

litie

s.W

om

en e

xpec

t W

AS

H p

rovi

sio

n in

hea

lth

faci

litie

s, a

nd v

iew

the

ir

qua

lity

in a

bro

ader

fra

mew

ork

of

‘cle

anlin

ess’

, whi

ch t

hey

cons

ider

w

hen

cho

osi

ng f

acili

ties

.K

ey W

AS

H f

eatu

res

imp

ort

ant

to

wo

men

are

: num

ber

of

latr

ines

, th

eir

clea

nlin

ess

and

ava

ilab

ility

o

f w

ater

and

acc

esso

ries

(suc

h as

d

ustb

ins)

.O

ther

fact

ors,

suc

h as

a g

ood

re

put

atio

n, w

ell-

resp

ecte

d a

nd

com

pet

ent

doc

tors

wer

e co

nsid

ered

m

ore

imp

orta

nt t

han

WA

SH

sta

tus.

For

amb

ulat

ory

vis

its,

incl

udin

g

child

bir

th, W

AS

H s

tatu

s w

as s

een

as le

ss c

riti

cal t

han

for

pro

long

ed

hosp

ital

isat

ion.

P

hilib

ert

et a

l42N

o ef

fect

of u

ser

fee

exem

ptio

n on

per

ceiv

ed

qua

lity

of d

eliv

ery

care

in

Bur

kina

Fas

o: a

cas

e-co

ntro

l stu

dy

Bur

kina

Fas

oA

qua

si-e

xper

imen

tal

des

ign

with

bot

h in

terv

entio

n an

d

cont

rol g

roup

s

Ass

essi

ng w

heth

er

wom

en’s

sat

isfa

ctio

n w

ith

del

iver

y ca

re is

influ

ence

d

by

a to

tal f

ee e

xem

ptio

n

In t

he in

terv

entio

n gr

oup

, d

eliv

ery

care

is fr

ee o

f ch

arge

at

heal

th c

entr

es

870

wom

en w

ere

inte

rvie

wed

. 60

0 in

inte

rven

tion

grou

p a

nd

270

in c

ontr

ol g

roup

. 90%

w

ere

satis

fied

with

del

iver

y ca

re in

bot

h in

terv

entio

n an

d

cont

rol g

roup

s.Th

e p

oore

st w

omen

wer

e m

ore

high

ly s

atis

fied

with

d

eliv

ery

envi

ronm

ent

than

the

w

ealth

iest

one

s, e

spec

ially

co

ncer

ning

hyg

iene

and

co

mfo

rt.

Qua

lity

of c

are

was

ass

esse

d u

sing

th

ree

com

pon

ents

: car

e p

rovi

der

-p

atie

nt in

tera

ctio

n, n

ursi

ng c

are

and

d

eliv

ery

envi

ronm

ent.

Pat

ient

s ar

e of

ten

incl

ined

by

cour

tesy

to

resp

ond

pos

itive

ly t

o q

uest

ions

on

satis

fact

ion

with

car

e q

ualit

y. T

his

leve

l of c

ourt

esy

is

high

er fo

r in

terp

erso

nal r

elat

ions

hip

s b

etw

een

care

pro

vid

ers

and

p

atie

nts.

Oth

er b

iase

s: in

timid

atio

n b

y m

ale

inte

rvie

wer

and

non

-sam

plin

g of

re

mot

e ho

useh

old

s.

Tab

le 2

C

ontin

ued

Con

tinue

d

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BMJ Global Health

Ref

eren

ceT

itle

Loca

tio

nTy

pe

of

stud

yC

ont

ext

Inte

rven

tio

nFi

ndin

gs

Furt

her

com

men

ts

M

bw

ele

et a

l37Q

ualit

y of

neo

nata

l he

alth

care

in K

ilim

anja

ro

regi

on, n

orth

east

Ta

nzan

ia: l

earn

ing

from

m

othe

rs’ e

xper

ienc

es

Tanz

ania

Cro

ss-s

ectio

nal s

tud

y us

ing

qua

litat

ive

and

qua

ntita

tive

app

roac

hes

Ass

ess

mot

hers

’ ex

per

ienc

es, p

erce

ptio

n an

d s

atis

fact

ion

with

ne

onat

al c

are

in t

he

hosp

itals

80 m

othe

rs w

ere

inte

rvie

wed

fr

om 1

3 p

erip

hera

l fac

ilitie

s an

d 3

2 fr

om a

ref

erra

l ho

spita

l. O

nly

2% d

iscu

ssed

is

sues

of

hyg

iene

. One

m

othe

r m

entio

ned

tha

t th

e fa

cilit

y sh

ould

‘inc

reas

e th

e le

vel o

f hy

gie

ne’.

The

sta

te o

f to

ilets

at

refe

rral

ho

spit

al w

ere

as e

xpec

ted

fo

r 59

%

resp

ond

ents

whi

le, i

n p

erip

hera

l ho

spit

als

28%

w

ere

as e

xpec

ted

. To

ilets

w

ere

wo

rse

than

exp

ecte

d

for

7% a

nd 2

6% in

ref

erra

l an

d p

erip

hera

l ho

spit

als,

re

spec

tive

ly.

The

mos

t co

mm

on r

easo

ns fo

r p

rimar

y d

elay

s: q

ualit

y of

tre

atm

ent

at t

he fa

cilit

y 55

.1%

(27/

49) a

nd

cost

of m

edic

al c

are

32.6

% (1

6/49

). P

aram

eter

s fo

r se

cond

ary

del

ays

wer

e d

ista

nce

from

hom

e (1

1.1%

) an

d c

omb

ined

dis

tanc

e an

d

tran

spor

t (7

.4%

).

Te

tui e

t al

38Q

ualit

y of

Ant

enat

al

care

ser

vice

s in

eas

tern

U

gand

a: im

plic

atio

ns fo

r in

terv

entio

ns

Uga

nda

Cro

ss-s

ectio

nal

Ass

essm

ent

of q

ualit

y of

AN

C (A

nten

atal

car

e)

serv

ices

in e

aste

rn

Uga

nda

with

a g

oal o

f b

ench

mar

king

74.6

% (2

17/2

91) r

esp

ond

ents

ra

ted

the

AN

C s

ervi

ce a

s sa

tisfa

ctor

y. In

fect

ion

cont

rol

was

ava

ilab

le in

73.

4%

(11/

15) f

acili

ties.

Cle

anlin

ess

was

d

issa

tisfa

ctor

y fo

r 4.

1%

(12/

291)

, fai

rly s

atis

fact

ory

for

25.8

% (7

5/29

1) a

nd

satis

fact

ory

in 7

0.1%

(2

04/2

91).

Dat

a co

llect

ed t

o ga

uge

infe

ctio

n co

ntro

l: ex

iste

nce

of

pip

ed r

unni

ng

wat

er, w

ater

buc

kets

or

bas

ins,

ha

nd w

ashi

ng s

oap

, dis

pos

able

ha

nd d

ryin

g to

wel

s, w

aste

bin

s,

shar

ps

cont

aine

rs, d

isp

osab

le la

tex

glov

es a

nd d

isin

fect

ion

solu

tion.

The

varia

ble

s as

soci

ated

with

hi

gh s

atis

fact

ion

wer

e p

rovi

der

’s

attit

ude

(87.

6%) a

nd e

xam

inat

ion

room

priv

acy

(83.

5%).

How

ever

, av

aila

bili

ty o

f med

icin

es (3

2.3%

) and

w

aitin

g tim

e (2

5.1%

) had

the

hig

hest

d

issa

tisfa

ctio

n ra

tes.

G

abry

sch

and

 Cam

pb

ell40

Stil

l too

far

to w

alk:

lit

erat

ure

revi

ew o

f the

d

eter

min

ants

of d

eliv

ery

serv

ice

use

Low

or

mid

dle

in

com

e co

untr

ies

Lite

ratu

re r

evie

w (o

f re

view

art

icle

s)Id

entifi

catio

n of

var

ious

fa

ctor

s re

late

d t

o d

eliv

ery

serv

ice

use

Sho

rtco

min

gs in

med

ical

ca

re a

re o

ften

cou

ple

d w

ith

shor

tcom

ings

in h

ygie

ne.

Wo

men

cri

tici

se d

irty

to

ilet

faci

litie

s, la

ck o

f w

ater

and

as

epti

c p

ract

ices

as

wel

l as

lack

of d

rugs

or

too

early

ca

esar

ean

sect

ions

.

Per

ceiv

ed q

ualit

y of

car

e ha

s an

im

por

tant

influ

ence

on

care

 see

king

b

ehav

iour

. Poo

r p

erso

nal a

nd

med

ical

qua

lity

of c

are,

cla

sh w

ith

cultu

re a

nd fe

ar o

f pro

ced

ures

may

d

ecre

ase

use.

K

ongn

yuy

et a

l45C

riter

ia-b

ased

aud

it to

im

pro

ve w

omen

-frie

ndly

ca

re in

mat

erni

ty u

nits

in

Mal

awi

Mal

awi

Cro

ss-s

ectio

nal/

inte

rvie

ws

To a

sses

s an

d im

pro

ve

wom

en-f

riend

ly c

are

in

mat

erni

ty u

nits

in M

alaw

i

280

wom

en w

ere

inte

rvie

wed

ab

out

care

q

ualit

y. T

he a

udit

resu

lts

wer

e p

rese

nted

, and

re

com

men

dat

ions

mad

e.

A r

e-au

dit

(367

wom

en)

was

con

duc

ted

3 m

onth

s la

ter

and

per

form

ance

co

mp

ared

.

Sig

nific

ant

imp

rove

men

t w

as

reco

rded

for

clea

nlin

ess

of

mat

erni

ty w

ard

s (8

9.6

vs

97.0

%; p

<0.

001)

. How

ever

, th

ere

wer

e no

sig

nifi

cant

ch

ang

es in

pro

visi

on

of

clea

n b

athr

oo

m a

nd t

oile

t (8

3.6

vs 8

0.4%

; p=

0.28

2).

Eac

h he

alth

fac

ility

sho

uld

ass

ess

the

avai

lab

ility

and

fun

ctio

ning

o

f to

ilets

and

bat

hro

om

s.

Whe

re a

vaila

ble

, the

y sh

oul

d

be

func

tio

nal a

nd k

ept

clea

n. If

la

ckin

g, t

hey

sho

uld

be

req

uest

ed.

One

hea

lth

cent

re r

eque

sted

and

ha

d a

new

to

ilet

but

no

rep

ort

on

the

imp

act

of

this

imp

rove

men

t w

as p

rese

nted

.

Tab

le 2

C

ontin

ued

Con

tinue

d

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BMJ Global Health

Ref

eren

ceT

itle

Loca

tio

nTy

pe

of

stud

yC

ont

ext

Inte

rven

tio

nFi

ndin

gs

Furt

her

com

men

ts

M

acK

eith

et 

al39

Zam

bia

n w

omen

’s

exp

erie

nces

of u

rban

m

ater

nity

car

e: r

esul

ts

from

a c

omm

unity

sur

vey

in L

usak

a

Zam

bia

Cro

ss-s

ectio

nal/

com

mun

ity s

urve

y q

uest

ionn

aire

s

Exa

min

e ac

cess

, co

vera

ge a

nd q

ualit

y of

car

e in

mid

wiv

es r

un

mat

erni

ty s

ervi

ce

845

wer

e in

terv

iew

ed.

74%

wou

ld li

ke t

o se

e im

pro

vem

ents

ove

rall

and

18

.23%

wo

uld

like

to

see

b

ette

r hy

gie

ne in

to

ilets

an

d b

athr

oo

ms

at h

ealt

h fa

cilit

ies.

G

riffit

hs

and

 Ste

phe

nson

41U

nder

stan

din

g us

ers’

p

ersp

ectiv

es o

f bar

riers

to

mat

erna

l hea

lth c

are

use

in M

ahar

asht

ra, I

ndia

Ind

iaC

ross

-sec

tiona

l/in

terv

iew

sId

entifi

catio

n of

key

so

cial

, eco

nom

ic a

nd

cultu

ral f

acto

rs in

fluen

cing

w

omen

’s d

ecis

ions

to

use

mat

erna

l hea

lthca

re

45 w

omen

wer

e in

terv

iew

ed.

Res

pon

den

ts id

entifi

ed p

oor-

qua

lity

of s

ervi

ces

offe

red

at

gov

ernm

ent

inst

itutio

ns

to b

e a

mot

ivat

ing

fact

or fo

r d

eliv

erin

g at

hom

e: ‘I

t w

as

safe

in t

he h

ouse

and

the

nu

rse

was

pre

sent

to

do

the

del

iver

y. In

gov

ernm

ent

hosp

ital,

del

iver

y ro

om is

no

t th

ere.

To

ilet

and

wat

er

faci

litie

s ar

e no

t th

ere.

So

I fe

lt s

afe

to g

ive

bir

th in

the

ho

use’

.

Soc

ioec

onom

ic s

tatu

s w

as n

ot

foun

d t

o b

e a

bar

rier

to s

ervi

ce u

se

whe

n w

omen

per

ceiv

ed t

he b

enefi

ts

of t

he s

ervi

ce t

o ou

twei

gh t

he c

ost,

an

d w

hen

the

serv

ice

was

with

in

reas

onab

le d

ista

nce.

The

tab

le s

umm

aris

es t

he c

hara

cter

istic

s of

incl

uded

stu

die

s an

d t

heir

mai

n fin

din

gs.

WA

SH

com

pon

ents

are

pre

sent

ed in

bol

d.

WA

SH

, wat

er, s

anita

tion

and

hyg

iene

.

Tab

le 2

C

ontin

ued

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mean number of hand washing stations was 2.3 (0.8 for public and 3.7 for private facilities), with two public centres lacking any hand washing facilities. WASH provi-sion is generally acceptable in private healthcare centres but needs improvement in government facilities.36 Good reputation, competent and respected doctors and ability to deal with complications were the main factors influencing the choice of HCF. For ambulatory care, including child birth, WASH provision was considered less important compared with prolonged hospitalisation settings.36

Mbwele and colleagues investigated the quality of neonatal healthcare in Tanzania.37 Two per cent of mothers commented on hygiene issues and one mother suggested that improvements in hygiene were needed. Most respondents reported that the condition of toilets was as expected, while a few found them worse than expected (table 2).37 The main reason for primary delay was quality of treatment followed by cost of medical care, while secondary delay was due to distance from home, transport and complaints about unfriendliness of care workers. Tetui and colleagues investigated the quality of antenatal care in Uganda and reported that 74.6% of respondents were satisfied with care quality, while 70% were satisfied with cleanliness.38 Although data on piped water and hand washing were collected as part of the assessment, no report on WASH and patient satisfac-tion was provided. Infection control was a major focus and 73.4% HCF were deemed to have good infection control measures.38 MacKeith and colleagues assessed women’s experience of urban maternity care in Zambia and reported that 74% would like to see general improve-ments; however, only 18.23% clearly expressed the need for better hygiene in toilets and bathrooms.39

Gabrysch and colleagues reported that women criticise dirty toilets, lack of water and aseptic practices, high-lighting combined shortcomings in personal interaction, medical care and hygiene.40 They concluded that the perceived quality of care had a major influence on care seeking behaviour.40 Griffiths and colleagues investigated users’ perspectives of barriers to maternal healthcare use in India through identification of key social, economic and cultural factors influencing women’s decision to seek maternal care.41 Quality of care and safety issues as well as lack of WASH provision were motivating women to give birth at home. A respondent stated, ‘It was safe in the house and the nurse was present to do the delivery. In the government hospital, the delivery room is not there. Toilet and water facilities are not there. So I felt safer to give birth in the house’.41 Socioeconomic status was not a barrier to service use when women considered the benefit to outweigh the cost, providing it was within reasonable distance.41 Philibert and colleagues reported that, in Burkina Faso, socioeconomic status influences patients’ expectation and satisfaction, with the poorest women more satisfied with delivery environment than the wealth-iest ones.42 Courtesy bias leads women to respond more positively to care quality questions, which does not reflect

their true opinion.42 Courtesy bias was more pronounced for interpersonal relationships between patients and care providers,42 which is in accordance with the findings of Glick (in a non-maternity setting).34

Improvement interventions and accreditation in HCFDeveloping accreditation standards in Ugandan hospitals was investigated by Galukande and colleagues.43 Accred-itation items included physical infrastructure, infection control and waste management. While the majority of hospitals reported having infection control protocol in place, only half were recording needle stick injuries and vermin control.43 Perhaps more surprisingly, 27.5% hospi-tals were not tracking infection rates even for caesarean sections. In addition, the authors reported inadequate capacity to sterilise equipment in all hospitals, which would contribute to HCAI.43 The study reported good provision of running water but no mention of sanitation. Okwaro and colleagues investigated community percep-tion of healthcare improvement intervention in rural Uganda.44 The formative research showed that many HCF (in this case malaria treatment centres) lacked running water. Following the intervention, antimalarial drug availability has improved; however, other require-ments including more health workers, provision of clean water and clean toilets have not been addressed. There-fore, this intervention was not sufficient to elicit major changes or influence patients’ decision about healthcare use.44 Indeed, several patients continued to seek care at inadequate heath centres. The authors reported that the main limitation of such an intervention is the focus on a particular disease and therefore failing to address multiple inadequacies observed in HCF in LMIC.

One paper investigated a criteria-based audit to improve a maternity unit in Malawi, where an initial audit resulted in the formulation of recommendations and a second audit 3 months later would report on any observed improvements.45 Significant improvements in cleanliness were achieved post audit; however, no significant changes in provision of clean toilets and bathrooms were noted.45 The authors reported that one health facility requested and obtained a new toilet, which should contribute to address the issue of inadequate WASH provision in healthcare setting.45

dIsCussIonPatient satisfaction is a good indicator of quality of care provided and impacts on care seeking behaviour. In the reviewed studies, inadequate WASH in HCF was associ-ated with increased patient dissatisfaction and was even a barrier to service use in some settings (most notably maternity services). This systematic review of current evidence has informed a conceptual model of patient dissatisfaction, detailing relevant factors and repercus-sions of low patient satisfaction (figure 2). In this model, patient dissatisfaction results in delayed care seeking, poor health outcomes and reduced staff morale. Good

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BMJ Global Health

infrastructure including adequate WASH provision is an integral part to high quality of healthcare. Inadequate WASH provision is one of the elements influencing patient dissatisfaction, though it was not found to be a major driver. Other factors relevant in resource-poor settings were significantly influencing patient satisfaction and care seeking behaviours in LMIC. The relative impor-tance of WASH on patient satisfaction is context-specific and depends on the type of healthcare service and the length of stay. Indeed, the lack of safe WASH facilities in delivery rooms was frequently cited as the reason for women to prefer home delivery. Women expect HCF to have adequate WASH, and rightly so, as this is pivotal for their human right, dignity and infection prevention. Achieving this, however, remains a distant prospect in many healthcare settings in LMIC.

The limitations of this study include a relatively small publication window (2000–2016), which was chosen to exclude historic (or outdated) WASH provision and a search strategy that could have been further opti-mised to retrieve all relevant papers. Potential further limitations are the difficulty of retrieving eligible LMIC research, likely to be published in national journals not indexed in the databases searched and studies are not necessarily indexed properly (particularly regarding LMIC status/country affiliation). Finally, the studies included were mostly cross-sectional with potentially biased outcome measures and perhaps more importantly no study designed to specifically assess the causal effect of WASH provision on patient satisfaction and/or care seeking behaviour was found. The limitations of some of the included studies are related to study design, such

as small sample size, lack of randomisation and patient recruitment procedures, as well as outcome measures such as heterogeneous indicators of patient satisfaction and potentially biased findings.

This review focused on WASH and patient satisfac-tion/care seeking because of the large disease burden associated with delayed care seeking. The link between perceived quality of care and attendance at HCF (patients who received quality care tend to return and recommend the facility to relatives) was supported by several studies and the WHO recommends the evaluation of patients’ satisfaction for the improvement of HCF.46 However, perceived quality of care is highly subjective. It includes satisfaction with the outcome, the interventions and the service received (staff friendliness, availability of supplies and waiting times) as well as objective measures of care quality such as facility infrastructure, equipment and staffing.40 However, even these measures are subjective because they depend on the discrepancy between expec-tation and reality, strongly influenced by socioeconomic traits and subpopulation groups. Indeed, it was reported that wealthier women and patients with higher education were consistently less satisfied with delivery environment and quality of care, respectively.31 42 It was noted, however, that factors other than WASH actually drive the selection and use of health facility.36 Therefore, it is perhaps not surprising that patients continue to use HCF with inade-quate WASH provision (table 2).44

The evaluation of patient satisfaction is usually performed using patient questionnaires, administered at either the HCF or households. It has been shown that exit questionnaires tend to overestimate patient

Figure 2 Conceptual model of implications of patient dissatisfaction with care quality. The model details the interactions between patient dissatisfaction, inadequate WASH provision, care seeking behaviour and health outcomes. WASH, water, sanitation and hygiene.

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satisfaction level due to courtesy bias (although this was mainly for treatment by staff and consultation quality and not facility condition).34 Intimidation bias was also reported when female interviewees felt intimidated by a male interviewer.42 Therefore, household surveys may provide more reliable estimates of patient satisfaction.34 However, household surveys could also yield biased results as they are associated with substantial under-reporting of healthcare use, especially when the recall period was over 1 month.47

The availability of skilled birth attendants is crucial to provide emergency obstetric care and reduce maternal and newborn mortality.48 This is part of the official guid-ance and improving WASH provision should increase use of maternal health services in LMICs. Concernedly, a study reported higher mortality rates after obstetric care.49 The reasons were: seeking help very late and in crit-ical condition and lack of timely and adequate care once at the health facility. Birth attendants may not provide socioculturally appropriate and respectful care leading to poor uptake.48 Previous delivery by a male provider made women choose home delivery during the subsequent pregnancy (OR 3.90; 95% CI 2.30 to 6.65).46 It was stated that ‘efforts aimed at improving maternal and child health in developing countries should take cognisance of the sociodemographic and cultural underpinnings of maternal health seeking behaviour’.50 Complaints of abuse, neglect and poor treatment are common in mater-nity services.51 Therefore, in addition to improving facil-ities’ infrastructure, care quality and cost-effectiveness, improvements in maternity services should also address providers’ attitudes and interpersonal behaviours.48 This highlights the scale and complexity of the issues investi-gated and the high number of shortcomings that need to be addressed.

The importance of WASH in HCF extends beyond patient satisfaction and care seeking behaviour because inadequate WASH may also be associated with a signif-icant burden of HCAI. Poor sanitary conditions and hand hygiene in hospital settings would result in several gastrointestinal and opportunistic infections. Unfortu-nately, poor hand washing practices around birth are still prevalent and continue to pose risks to mother and baby. In an observational study, the proportion of birth attendants who washed their hands prior to assisting with delivery was 24% in India, 69% in Bangladesh and 32% in Nepal.52 Hand washing of birth attendants was asso-ciated with 49% reduction in maternal mortality (OR 0.51, 95% CI 0.28 to 0.93)52 and 19% (range 1%–34%) reduction in all cause neonatal mortality.53 Effective hand washing in HCF has benefits for a wide range of other HCAI,54 although adherence to good hand hygiene practices is a persistent challenge. Addressing this issue requires changes in both behaviour and infrastructure; hand hygiene practices will only improve if healthcare workers are motivated to change their behaviour and when adequate facilities (taps with running water and soap) are available.

ConClusIonThe provision of adequate WASH in HCF is important to protect vulnerable populations and reduce HCAI. However, WASH provision is still inadequate in many HCF in LMIC. This systematic review assessed the impact of WASH provision on care seeking behaviour and patient satisfaction. Our review suggests that improving WASH conditions will decrease patience dissatisfaction, which may increase care seeking behaviour and improve health outcomes but that more rigorous research is needed.

Contributors PRH conceptualised the study. MB did literature search, paper screening, data collection and manuscript writing. OC assisted with topic selection and discussion. All authors contributed to the manuscript.

Funding MB was partially supported by the Water, Sanitation, Hygiene and Health programme at the WHO. PRH is supported by the National Institute for Health Research (NIHR) Health Protection Research Units in Gastrointestinal Infections and Emergency Preparedness and Response in partnership with Public Health England (PHE).

disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, the Department of Health or PHE. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Competing interests None declared.

Patient consent Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

data sharing statement No additional data are available.

open Access This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http:// creativecommons. org/ licenses/ by/ 4. 0/

© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

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