# Annex 3. WASH, quality of care, and patient satisfaction

A systematic review on patient satisfaction by Bouzid et al (2018) identified 21 papers that had a WASH component. Nine of the 21 studies were found from the focus countries (3 from Uganda, 2 from each of Ethiopia and Tanzania, and 1 from each of Kenya and Madagascar) and are presented in Table 11.

**Table 11. Review of literature**

|**Country**|**Title**|**Findings **|**Comment**|**Source**|
|---|---|---|---|---|
|Ethiopia|Perceived<br>patient<br>satisfaction<br>with<br>inpatient services at<br>one<br>Specialized<br>Hospital|Toilet<br>cleanliness:<br>18.5%<br>(35/189) were satisfied while<br>81.5%<br>(154/189)<br>were<br>dissatisfied. 76.6% (145/189)<br>were satisfied with cleanliness<br>of the ward.|Research clearly identified a link<br>between patient outcomes and<br>patient satisfaction scores.|Woldeyohanes<br>et al (2015)|
|Ethiopia|Assessment<br>of<br>antiretroviral<br>treatment (ART) care<br>service<br>provision<br>in<br>Tigray Region health<br>centers, North Ethiopia|High scores of satisfaction<br>were reported for courtesy<br>and respect 95.80% (684/714)<br>and<br>privacy<br>93.28%<br>(666/714).<br>Access<br>and<br>cleanliness to latrines were<br>not always assessed. Toilet<br>cleanliness was unsatisfact-<br>ory for 35.32% (243/688).|Adjusted OR for satisfaction was<br>2.22 (95% CI 1.62 to 6.32) for toilet<br>cleanliness.<br>Measures<br>such<br>as<br>increasing access to ART service,<br>availing clean toilet and ART drugs<br>may<br>further<br>increase<br>client<br>satisfaction.<br>Clean<br>toilets<br>are<br>required especially for HIV/AIDS<br>patients to prevent coinfections.|Tessema and<br>Adnae (2015)|
|Kenya|Quality of care and<br>contraceptive use in<br>urban Kenya|78.5% of facilities (204/260)<br>have running water.|Facility infrastructure and most<br>aspects of client satisfaction—<br>including privacy issues, amount of<br>information given, waiting time and<br>overall<br>satisfaction—were<br>unrelated to contraceptive use.|Tumlinson et<br>al (2015)|
|Madag-<br>ascar|Evidence<br>on<br>the<br>reliability<br>of<br>client<br>satisfaction surveys –<br>data<br>from<br>matched<br>facility and household<br>data in Madagascar|An appearance index (mean<br>of<br>binary<br>indicators<br>for<br>dirtiness, humidity damage,<br>decay of walls, floors and<br>ceilings, evidence of insects<br>and<br>condition<br>of<br>toilet<br>facilities) was calculated. The<br>appearance index was 0.84 in<br>household surveys and 0.91 in<br>exit surveys for the same<br>facilities.|The findings suggest that reported<br>satisfaction in exit surveys is biased<br>strongly upward for subjective<br>questions regarding treatment by<br>staff and consultation quality, but<br>not<br>for<br>relatively<br>objective<br>questions about facility condition<br>and supplies.|Glick (2009)|
|Tanzania|Patients’<br>level<br>of<br>satisfaction on quality<br>of<br>health<br>care<br>at<br>Mwananyamala<br>hospital<br>in<br>Dar<br>es<br>Salaam, Tanzania|422 patients were enrolled.<br>Mean gap score indicated<br>overall dissatisfaction with<br>the<br>quality<br>of<br>care.<br>Respondents were dissatis-<br>fied with general cleanliness<br>(p<0.001), and insufficient<br>and toilets (p<0.001).|The<br>questionnaire<br>has<br>five<br>dimensions (tangibles, reliability,<br>responsiveness,<br>assurance<br>and<br>empathy) to determine patients’<br>level of satisfaction. The gap score is<br>the<br>difference<br>between<br>mean<br>perception and mean expectation<br>scores.|Khamis<br>and<br>Njau (2014)|
|Uganda|Quality<br>of<br>neonatal<br>healthcare<br>in<br>Kilimanjaro<br>region,<br>northeast<br>Tanzania:<br>learning from mothers’<br>experiences|80 mothers were interviewed<br>from 13 peripheral facilities<br>and 32 from referral hospital.<br>Only 2% discussed issues of<br>hygiene. The state of toilets at<br>referral hospital were as<br>expected for 59% while, in<br>peripheral hospitals 28% were<br>as expected. Toilets were|The most common reasons for<br>primary delays: quality of treatment<br>at the facility 55.1% (27/49) and<br>cost of medical care 32.6% (16/49).<br>Parameters for secondary delays<br>were distance from home (11.1%)<br>and<br>combined<br>distance<br>and<br>transport (7.4%).|Mbwele et al<br>(2013)|

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