Quality of primary care from the patient perspective in South West Malawi Development and application of the Malawian Primary Care Assessment Tool (Pcat-Mw) Luckson Wandani Dullie Thesis for the degree of Philosophiae Doctor (PhD) University of Bergen, Norway 2020 Quality of primary care from the patient perspective in South West Malawi Development and application of the Malawian Primary Care Assessment Tool (Pcat-Mw) Luckson Wandani Dullie ThesisAvhandling for the for degree graden of philosophiaePhilosophiae doctorDoctor (ph.d (PhD). ) atved the Universitetet University of i BergenBergen Date of defense:2017 06.02.2020 Dato for disputas: 1111 © Copyright Luckson Wandani Dullie The material in this publication is covered by the provisions of the Copyright Act. Year: 2020 Title: Quality of primary care from the patient perspective in South West Malawi Name: Luckson Wandani Dullie Print: Skipnes Kommunikasjon / University of Bergen 2 SCIENTIFIC ENVIRONMENT Quality of primary care from the patient perspective in South West Malawi: Development and application of the Malawian Primary Care Assessment Tool (Pcat-Mw) Luckson Wandani Dullie During the course of this thesis project, the candidate was enrolled in the doctoral education program at the Center for International Health of the Faculty of Medicine and Dentistry, University of Bergen, Norway. The scientific environment was the Health Services Research Group and the Research Group for General Practice at the Department of Global Public Health and Primary Care at the University of Bergen. 3 TABLE OF CONTENTS SCIENTIFIC ENVIRONMENT ............................................................................................................. 2 ACKNOWLEDGEMENTS .................................................................................................................... 5 ABBREVIATIONS ................................................................................................................................ 7 ABSTRACT ............................................................................................................................................ 8 LIST OF PUBLICATIONS .................................................................................................................. 11 1. INTRODUCTION ........................................................................................................................ 12 1.1 Context ........................................................................................................................................ 12 1.2 Organization of health services in Malawi ................................................................................. 13 1.3 Providers of healthcare in Malawi .............................................................................................. 13 1.4 The role of primary care in health systems ................................................................................. 14 1.5 The state of primary healthcare in Malawi ................................................................................. 15 1.6 Current efforts to improve primary care in Malawi .................................................................... 17 1.7 Progress on health indicators ...................................................................................................... 18 1.8 Persisting challenges for the Malawi health system ................................................................... 19 1.9 Study framework ......................................................................................................................... 19 1.10 Defining quality in healthcare ................................................................................................... 23 1.11 Measures of primary care quality .............................................................................................. 23 1.11.1 Structure measures of primary care quality ....................................................................... 23 1.11.2 Process measures of primary care quality .......................................................................... 24 1.11.3 Outcome measures of primary care quality ....................................................................... 25 1.12 Conceptual and operational definitions ..................................................................................... 25 2. STUDY AIM AND OBJECTIVES .................................................................................................. 28 2.1 Study rationale ............................................................................................................................ 28 2.2 Study aim .................................................................................................................................... 28 2.3 Study objectives .......................................................................................................................... 28 3. METHODS ................................................................................................................................... 30 3.1 Study instrument: The Primary Care Assessment Tool ........................................................ 30 3.2 Cross cultural adaptation of the ZA-PCAT ........................................................................... 32 3.2.1 Face and Content validity ............................................................................................. 32 3.2.2 Translation and cultural adaptation ............................................................................... 35 3.2.3 Feasibility and understanding of the questionnaire- pilot testing ................................. 35 3.3 Study setting and facilities .................................................................................................... 35 3.4 Study population, participants and Sample size .................................................................... 36 4 3.5 Data collection ...................................................................................................................... 37 3.6 Study variables ...................................................................................................................... 38 3.7 Data management and Statistical analyses ............................................................................ 39 3.8 Ethical approvals, consent and permissions .......................................................................... 41 4 SUMMARY OF RESULTS.......................................................................................................... 42 4.1 Paper I ................................................................................................................................... 42 4.2 Paper II .................................................................................................................................. 44 4.3 Paper III ................................................................................................................................ 46 5. DISCUSSION ............................................................................................................................... 51 5. 1 Methodological considerations .................................................................................................. 51 5.1.1 Study design ......................................................................................................................... 51 5.1.2 Use of Delphi and nominal group techniques in study I ...................................................... 51 5.1.3 Precision ............................................................................................................................... 52 5.1.4 Validity ................................................................................................................................ 52 5.1.5 Structural validity of the questionnaire ................................................................................ 53 5.1.6 Confounding ........................................................................................................................ 53 5.1.7 Selection bias ....................................................................................................................... 53 5.1.8 Data collection ..................................................................................................................... 54 5.1.9 Information bias ................................................................................................................... 54 5.1.10 Recall bias .......................................................................................................................... 55 5.1.11 Social desirability bias ....................................................................................................... 55 5.1.12 Generalizability .................................................................................................................. 55 5.1.13 Some analytical aspects ..................................................................................................... 56 5.2. DISCUSSION OF RESULTS .................................................................................................... 57 5.2.1 Filling a gap in patient experience measurement tools ........................................................ 57 5.2.2 Primary care performance in south west zone in Malawi .................................................... 59 5.2.3 Factors