In this dissertation, I address three issues related to patient-perceived quality of care: the impact of switching to the new World Health Organization (WHO) HIV treatment guidelines on patient perception of quality of care, the impact of rolling-out a quality improvement (QI) training intervention on mothers’ perception of the quality of postnatal care, and the association between patient perceptions of quality and their decisions to bypass healthcare facilities for care. Chapter one presents an overview as well as key insights form all three papers.
In chapter two, I investigated the impact of early access to antiretroviral therapy (ART) versus national standard of care on patient satisfaction using data from a stepped-wedge cluster randomized controlled trial in Swaziland. The outcomes of interest included, patient ratings of perceptions of overall quality of care, wait time, consultation time, level of involvement in treatment decision-making, and respect received from the health worker. The results show no evidence of a causal impact of early initiation of ART on patient perception of overall quality of care, or perception of quality of care in the other domains measured. The results also showed a time trend of increasing negative perception of quality as the study progressed.
In chapter three, I investigated the impact of a quality improvement training intervention on women’s perception of the quality of postnatal care using data from a stepped-wedge cluster randomized controlled trial in primary health care (PHC) clinics in rural South Africa. Results show no evidence of a causal impact of the QI training on patient perception of quality of postnatal care in any of the domains assessed. The results also showed time trends with increasing positive perception of quality over time in three out of the five domains assessed: patient-provider communication, consultation-time, and level of involvement in treatment decision making.
In chapter four, I explored the associations between perceptions of quality of antenatal care and sick-child care on patients’ decisions to bypass healthcare facilities in nine low- and middle-income countries. The results showed that measures of structural quality were more consistent predictors of patients’ bypassing behavior compared to measures of technical quality
