DOI: 10.5061/dryad.ncjsxksw5
title: Perceived quality of care among households ever enrolled in a community-based health insurance scheme in two districts of northeast Ethiopia: A community-based, cross-sectional study

description: Objectives: The purpose of this study was to examine how clients perceived
 the quality of health care they received and to identify
 associated factors both at the individual and facility levels.
 Design: A community-based, cross-sectional study.  Setting: Two
 rural districts of northeast Ethiopia, Tehulederie and Kallu.
 Participants: 1081 rural households who had ever been enrolled in
 community-based health insurance and visited a health center at least once
 in the previous 12 months.  Furthermore, 194 health care
 providers participated in the study to provide cluster-level data. Outcome
 measures: The outcome variable of interest was the perceived quality of
 care, which was measured using a 17-item scale. Respondents were asked to
 rate the degree to which they agreed on 5-point response items relating to
 their experiences with health care in the outpatient departments of nearby
 health centers. A multilevel linear regression analysis was used to
 identify predictors of perceived quality of care. Results: The mean
 perceived quality of care was 70.28 (SD=8.39). Five dimensions of
 perceived quality of care were extracted from the factor analysis, with
 the patient-provider communication dimension having the highest mean score
 (M=77.84, SD=10.12), and information provision having the lowest (M=64.67,
 SD=13.87). Wealth status, current insurance status, perceived health
 status, presence of chronic illness, and time to a recent health center
 visit were individual level variables that showed a significant
 association with the perceived quality of care. At the cluster level, the
 work experience of health care providers, patient volume, and an
 interaction term between patient volume and staff job satisfaction also
 showed a significant association.   Conclusions: Much work
 remains to improve the quality of care, especially on information
 provision and access to care quality dimensions. A range of individual and
 cluster-level characteristics influence the perceived quality of care. For
 a better quality of care, it is vital to optimize the patient-provider
 ratio and enhance staff job satisfaction.
description: Individual-level data were collected through face-to-face
 interviews with household heads at their homes or workplace using a
 structured questionnaire via an electronic data collection platform. The
 data collectors submit the completed forms to a data aggregating server
 daily, which allowed us to review the submissions and streamline the
 supervision process. The Perceived Quality of Care (PQoC), which is the
 outcome variable of interest, was measured using a 17-item scale designed
 after a thorough review of validated tools. Respondents were asked to rate
 the extent to which they agreed on a set of items relating to their
 experiences with the health care they received in the outpatient
 departments of nearby health centers. Each item was designed on a 5-point
 response format with 1 - strongly disagree, 2 - disagree, 3 - neutral, 4 -
 agree and 5 - strongly agree. The summary scores for the PQoC and its
 dimensions were calculated for individual respondents by adding the scores
 of each item. This gives a scale ranging from 17 (1×17) to 85 (5×17) for
 the overall PQoC score. For quality dimensions consisting of three and
 four items, the scale ranges from 3 to 15 and 4 to 20, respectively. When
 reporting the results, the scores were arithmetically transformed to a
 scale of 20 to 100. This allows the comparison of mean scores of PQoC, its
 dimensions, and each measurement item on a common scale. Cluster-level
 data were collected from 12 health centers that provide health care for
 the population in the sampled Kebeles. Patient volume data were obtained
 by reviewing the monthly service delivery reports of health centers, while
 data related to work experience, affective commitment, and job
 satisfaction were collected through a self-administered questionnaire
 among health care providers who worked more than one year in the current
 facility.   The data which was stored in the online
 data aggregator (Kobo server) was downloaded, organized, cleaned, and
 edited using MS Excel spreadsheet. Then, it was exported to Stata version
 17 for statistical analysis. Exploratory factor analysis was performed to
 assess the validity of the quality measurement scale. To compare mean
 scores of PQoC and its dimensions among subgroups, an independent t-test
 and a one-way analysis of variance (ANOVA) with Tukey's post-hoc test
 were used. Because the outcome variable was considered a continuous
 variable, a multilevel linear regression model was fitted to identify its
 predictors. The PQoC was assumed to be influenced by the characteristics
 of households (individual-level variables) as well as the characteristics
 of health centers (cluster-level variables). Cluster-level data were
 linked to individual-level data based on the usual source of health care
 for each study participant. Considering the hierarchical structure of the
 data, where patients are nested within health centers, a two-level linear
 regression model was applied. In this study, there were 12 health centers,
 hence the Restricted Maximum Likelihood estimation approach was employed
 because it is appropriate for smaller cluster sizes. 
description: Data was analyzed using Stata 17 (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC.).  Please refer to README file for more instruction