|Year : 2018 | Volume
| Issue : 3 | Page : 177-185
How does the public perceive healthcare workers in Lagos? A comparison of health workers in public and private health facilities
Olumuyiwa Omotola Odusanya1, Modupe Rebekah Akinyinka1, Esther Oluwakemi Oluwole2, Babatunde Adeniran Odugbemi3, Omowunmi Qubrat Bakare1, Adeyinka Adeniran1
1 Department of Community Health and Primary Health Care, Lagos State University College of Medicine, Lagos, Nigeria
2 Department of Community Health and Primary Care, College of Medicine, University of Lagos, Lagos, Nigeria
3 Department of Community Health and Primary Health Care, Lagos State University Teaching Hospital, Lagos, Nigeria
|Date of Web Publication||26-Sep-2018|
Modupe Rebekah Akinyinka
Department of Community Health and Primary Health Care, Lagos State University College of Medicine, 1-5, Oba Akinjobi Road, Ikeja, Lagos
Source of Support: None, Conflict of Interest: None
Background: The perception of healthcare workers (HCWs) by community members is dependent on the quality of services rendered by HCWs and contributes to utilisation. The objective of the study was to assess the perception of health workers in both public and private facilities by residents of Lagos State. Materials and Methods: A descriptive cross-sectional study was conducted using mixed-methods approach. Respondents (n = 2000) were selected using a multistaged sampling technique from four local government areas. An interviewer-administered, pre-tested questionnaire developed for the study was used for data collection and focus group discussions were held. Domains assessed included competence, work attitudes, interpersonal skills and unethical behaviour. A perception index was generated. Data were analysed using the Statistical Package for the Social Sciences version 22, with level of significance set at 0.05 for quantitative data and ATLAS.ti software (Scientific Software, Berlin; version 7) for qualitative data. Results: At least seven out of ten participants (>71%) perceived the HCWs highly in the areas of professional competence, attitude to work, responsiveness and interpersonal skills. Out of a maximum of 12, doctors had the highest mean perception index (10.6 ± 1.9), laboratory scientists had 10.1 ± 2.1, pharmacists had 10.0 ± 2.3 and nurses had 9.6 ± 2.7. A larger proportion of respondents had a significantly better perception of workers in private facilities more than those in government facilities. Conclusion: Perception of health workers was high and was better in privately owned facilities. Periodic retraining of health workers and regular assessments of health facilities are recommended.
Keywords: Community, healthcare workers, Lagos, perception
|How to cite this article:|
Odusanya OO, Akinyinka MR, Oluwole EO, Odugbemi BA, Bakare OQ, Adeniran A. How does the public perceive healthcare workers in Lagos? A comparison of health workers in public and private health facilities. Niger Postgrad Med J 2018;25:177-85
|How to cite this URL:|
Odusanya OO, Akinyinka MR, Oluwole EO, Odugbemi BA, Bakare OQ, Adeniran A. How does the public perceive healthcare workers in Lagos? A comparison of health workers in public and private health facilities. Niger Postgrad Med J [serial online] 2018 [cited 2019 Feb 20];25:177-85. Available from: http://www.npmj.org/text.asp?2018/25/3/177/242200
| Introduction|| |
The perception of healthcare workers (HCWs) by community members (the public) varies, and it is informed by real-life experiences and powerful second-hand accounts. The way people perceive the quality of services rendered by HCWs usually determines how much people make use of those services. Therefore, a positive perception by the public is expected to translate into good utilisation of available services, while a negative perception may result in the non-use of facilities even when they have the state-of-the-art infrastructure, equipment and expertise. A person's perception of a HCW may be based on the observer's assessment of the HCW's performance measured by appearance, good interpersonal skills, attitude to work and competence. Ensuring that services rendered by HCWs are patient centred is one of the six dimensions of quality care and will translate into improved client satisfaction.
People are more likely to develop a strong perception because of a negative experience than they are of developing a strong perception because of a positive experience. When clients go through experiences such as lack of care which occurs during industrial actions by HCWs, or poor work attitudes when receiving healthcare, they tend to lose confidence in HCWs and have a poor perception of them. It has been found that when HCWs demonstrate good patient care, patients experience the greatest satisfaction. Clients' perceptions of public healthcare providers are generally low, but when the services are rendered in a timely manner, patients' perception become positive.
The poor public perception of HCWs seems to be more prevalent in developing countries than in developed countries. A Canadian study reported that about 84% of respondents perceived their experience with their HCWs as good (they were satisfied with the attention received), while 8% perceived their experience as poor and 7% rated it as neither good nor poor. A study in Australia showed that the respondents reported fairly high trust in their specialists and general practitioners (GPs) though many deemed that their GPs were more trustworthy than specialists. They also had high levels of trust in private hospitals compared with public ones but greater trust in public health insurance systems than private ones.
In South Africa, a study that assessed the perception of HCWs during an industrial action revealed that the public was dissatisfied with the industrial action and had strong objections to the perceived neglect of critically ill patients. A Ghanaian study reported that although 90% of respondents were either satisfied or very satisfied with the care given (which is higher than in some developed countries); however, some HCWs were perceived as rude, unfriendly, unapproachable or impatient and practiced favouritism. A study from Southeast Nigeria revealed that HCWs' behaviours militated against the use of maternal and child health services, as up to 48% of respondents did not use health facilities due to poor staff attitudes.
People's perception of health workers in Nigeria is comparatively poor. In Southwest Nigeria, an assessment of the public's perception of traditional birth attendants (TBAs) revealed that 52% of the respondents felt that TBAs provided more compassionate care than orthodox health workers, whereas in Ogun State, only 36% of respondents opined that HCWs had good attitudes and 43% reported a dislike for lack of timeliness of the services. Another study that assessed the patient's perception of quality of care in the emergency unit of a teaching hospital in Nigeria reported that many of the patients were displeased with their interactions with HCWs, and only small proportions rated the HCWs highly in several dimensions. Only 8% and 3% of respondents rated the overall attitude of doctors and nurses as excellent, respectively, courtesy was adjudged excellent by 2%, empathy by 3% and responsiveness by 10%.
A community-based study in Somolu local government area (LGA) of Lagos State reported that although 88% of respondents perceived HCWs as being responsive, 43% saw them as being rude, while 59% perceived that the HCWs were punctual at work. Factors affecting how HCW are perceived by the public include the age and the gender of the individual. Older age unlike educational qualification was found to be significantly associated with stronger trust in doctors. Gender was also found to be an important factor in Afghanistan where females had a more positive perception when the HCW was also a female.
An assessment of the perception of HCWs by the public and the reasons for such perceptions are essential so that recommendations on remedial actions can be made. This study was therefore undertaken to assess and compare the perception of the residents in Lagos State of the major cadres of HCWs working in public and private health facilities and identify factors influencing their perception.
| Materials and Methods|| |
Background information to study area
Lagos State was created on May 27, 1967. It is in the Southwest geopolitical zone of Nigeria. It was the capital of Nigeria until 1991. Ikeja is the capital city of the State. Lagos remains the economic capital of Nigeria. The State has twenty LGAs. Sixteen of the LGAs are classified as urban and four are rural. Health facilities are provided through a mix of private and public facilities at primary, secondary and tertiary levels.
The study design was descriptive and cross sectional using both quantitative and qualitative methods to investigate the perception of HCWs (four cadres namely doctors, nurses, pharmacists and laboratory scientists) by community members. These groups of HCWs interact more frequently with the public and their roles are easy to identify. An interviewer-administered questionnaire was used to obtain information for the quantitative aspect of the study. Focus group discussions (FGDs) were held for the qualitative aspect in four LGAs.
Study population and eligibility criteria
The study population was drawn from adult residents aged 18 years and above which were living in the selected LGAs.
Consenting adults aged 18 years and above living in the selected LGAs.
The entire study period was about 1 year.
Sample size determination
The minimum sample size for quantitative data collection was determined using the appropriate formula for prevalence studies. The statistical assumptions for determining the minimum sample size were as follows: a type 1 error rate of 5%, a prevalence of 0.58 of positive perception of health workers by community members, a precision of ±2.5% points and a 20% non-response rate. Thus, the calculated minimum sample size was 1919, which was rounded up to 2000. The participants for the FGD were purposively selected. One FGD session was held in each LGA and the number of participants was averagely ten.
A multistage sampling method was used to select the participants for quantitative data collection in this study. In the first stage, out of the 20 LGAs in Lagos state, of which 16 are urban and 4 are rural, four LGAs (three urban and one rural) were selected using stratified random sampling by balloting. These were Ikeja, Mushin, Ojo (urban) and Badagry (rural) LGAs. In the second stage, at each of the selected LGA, two wards were selected by simple random sampling by balloting. In the third stage, using the sampling frame of all streets in the selected wards, a minimum of ten streets were selected by using a table of random numbers.
The fourth stage involved selecting consecutive houses on each street using the local government house numbering system starting from the first number. In the fifth stage, one household was selected by balloting and a consenting adult was approached for the study. Where there was more than one consenting adult, one was chosen by balloting. Twenty-five respondents were selected from each street, and an equal number (500) of respondents were selected per LGA to allow for equal representation from all the selected areas. For qualitative data collection, one FGD was held per LGA. FGDs were held for female participants in Mushin, Ojo and Badagry and for male participants in Ikeja. Ten participants were selected via purposive sampling based on willingness and availability to participate in each FGD session.
Two instruments were developed for the study. The first was an interviewer-administered, pre-tested questionnaire which was developed from a review of the literature on the subject. The instrument had two sections. The first dealt with sociodemographic characteristics of the respondents, while the second section instigated the perception of HCWs in four main areas namely competence, work attitudes, interpersonal skills and unethical behaviour. The competence domain covered core functions of the cadre. Work attitudes were measured through punctuality and responsiveness. Interpersonal skills covered courtesy and empathy. Unethical behaviour was adjured through demand for gratification.
Face validation of the instrument was done by all the investigators. It was pre-tested among residents of Alimosho LGA which was not amongst the four utilised for the study. The alpha Cronbach's reliability coefficient was 0.792. The instrument was modified and administered after pre-testing.
The second tool was a FGD guide which had ten items.
It sought for information on the utilisation of health facilities, competence of health workers and problems encountered by the respondents during visits to health facilities.
The quantitative data were collected by four trained research assistants (who had a minimum of secondary school education) between February and March 2017. Research assistants were trained for 2 days prior to data collection. Participants for the FGD were invited and reminded via text messages and calls. The selected participants were within the same age range for each FGD. All sessions were audio recorded after obtaining written informed consent from the participants.
Data were entered using the IBM SPSS Statistics for Windows, Version 22.0 (IBM Corp, Armonk, NY, USA) after coding and cleaning. Health facilities were categorised into two namely government hospitals (including primary healthcare centres) and private hospitals. Six items on the perception index were selected to compute a perception index of HCWs. These were competence, punctuality, courtesy, responsiveness to clients, empathy and never shouting at clients. These were scored as always = 2, sometimes = 1 and never/undecided = 0. The scoring for shouting at patients was scored in reverse. A maximum of 12 marks was obtainable which was graded as >75% (9–12) as good; 50%–74% (6–8) as fair and <50% (0–5) as poor. Univariate and bivariate analyses and analysis of variance were done to identify factors associated with the perceptions of HCWs. The level of significance was set at P < 0.05.
Qualitative data were analysed using Atlas More Details.ti software version 7 (GmbH, Berlin, Germany). The data analysis was conducted using constant comparison analyses and thematic reporting.
The participants were informed of the objectives of the study and its potential benefits for the health system and the state. There was no risk of harm to them as there was no invasive procedure. Written informed consent was obtained from each participant prior to enrolment in the study. Ethical clearance was obtained from the Lagos State University Teaching Hospital (LASUTH) Ethics Committee with reference Number: LREC/06/10/755 (08/11/16–08/08/17).
| Results|| |
Two thousand respondents were recruited. The mean age was 37.6 ± 10.21 years. Almost nine out of ten respondents (87%) were <50 years of age. Majority (76%) of the respondents were married, 66% had secondary school education and 76% were self-employed [Table 1]. Among the 43 FGD participants, 77% were females, 79% were married, 42% had at least a secondary school education, while 35% had tertiary education.
[Table 2] shows respondents' perception of doctors. Almost all respondents (94%) felt that doctors in both public and private facilities were able to make an accurate diagnosis, 88% felt that they were able to give effective treatment and 81% felt that they were attentive to their complaints. The proportion of respondents (81%) willing to recommend a doctor from a private facility was significantly higher (P < 0.001) than the 70% willing to recommend doctors in government facilities. A statistically significantly higher (P <0.001) proportion of respondents who utilised private facilities (79%) felt that their doctors were more punctual and more responsive than the 71% of respondents using government facilities. About 82% of respondents felt that their doctors were courteous, while a significantly larger proportion (P < 0.001) of respondents who patronised private facilities (74%) felt that their doctors showed empathy for their clients compared with 66% amongst those using government-owned facilities. A statistically significantly greater proportion (P <0.001) of respondents who patronised private facilities (69%) reported that their doctors would never demand bribes compared with 55% of respondents who utilised government facilities.
The major opinion of the FGD participants was that the staff in private hospitals were more competent than their counterparts in public hospitals. A participant further emphasised that health workers in government hospitals sometimes referred their patients to their own private hospitals. An excerpt from the participant is shown as follows:
'Yes, I had a fracture, I used to play for my school team then in Ogun state, so I had the fracture here (indicating his hand) this is still the mark… so I came to General Hospital Ikeja, because I stay not too far away from here……. When I got there, they took an X-ray, then did the first manipulation, when I went for the second X-ray, it wasn't well aligned; they tried to align the bone three times. The third time, I was not given any injection, I actually sat down, there were like three doctors trying to manipulate my hand (the bone). I remembered I was screaming, I mean this is bone we are talking about here. Then the doctor said something that day. He said, “daddy I will refer you to one hospital.” That hospital is also here in Ikeja, it's a storey building. We later found out that, that same doctor owned the hospital. My dad felt really bad. When he discussed with one or two people, that the same doctor here, that had been trying to fix my hand (the broken bone) still referred us to his own private hospital, from the general hospital…. So since then I've been using private hospitals' (Ikeja_male_tertiary_38 years old_single).
[Table 3] shows the perception of nurses. A statistically significantly greater (P < 0.001) proportion of respondents (84%) perceived nurses in private facilities as being more caring than the 70% patronising government-owned facilities. More respondents (89%) significantly (P < 0.001) perceived that nurses in private facilities were more punctual than those in government-owned facilities (as rated by 76% of respondents). A significantly greater proportion (P < 0.001) of respondents perceived that nurses in private facilities had better interpersonal skills compared with their public facility counterparts, as 78% felt that the nurses in the private facilities were courteous compared with 66% of respondents who patronised government-owned facilities.
Furthermore, across all four FGD sites, participants agreed that other staff in the hospital had better attitudes towards their clients than the nurses. A participant from the Badagry FGD described her experience with a nurse who according to her almost slapped her during a visit.
'last year, or let me say this year, one nurse wanted to slap me'.…… in the General Hospital, she asked me to sit down somewhere. On that day, I was very sick. I had already submitted my card, so they gave me a place to sit. I then approached the nurse and I said, 'nurse, it is my turn to be attended to'. The nurse said; 'if you don't get away from in front of me I will clear you. I looked at the nurse again, and I said if I am not old enough to be your mother, you will be my younger sister'……… I became angry and stayed outside. One man saw me. I think he's a d octor there, he asked me what was wrong and said, 'where is the nurse?' I took him to where the nurse was. He told the nurse that, 'you are not doing your job, you are doing a bad thing, how can you be insulting this woman? Look at the condition of the woman'.
A female participant in Badagry explained, 'if you want to give birth, and you are shouting, they (the nurses) will send you out, they will say you are disturbing them, yes, they will say haven't you given birth before? Or when you are doing it, who did you shout for, that's how they abuse them, they will say when you are doing it, did you shout? So, don't shout at our ears. That's true, they abuse them. I might not go to general, but I do take people there, and I know the way things are there'.
Respondents' assessment of pharmacists is summarized in [Table 4]. The perception was significantly in favour (P < 0.04) of pharmacists in private facilities as 95% of those who attended private facilities felt that their pharmacists dispensed drugs accurately more than the 92% in government-owned facilities. A significantly greater (P < 0.001) proportion of respondents (75%) felt that the pharmacists in private facilities were punctual compared with the 69% of respondents patronising government-owned facilities. More respondents (85%) felt that the pharmacists in private facilities showed courtesy compared with the 77% amongst those using government-owned facilities (P < 0.001).
There was no statistically significant difference in the respondents' perceptions of the competence and punctuality of laboratory scientists in public or private facilities [Table 5]. A significantly higher proportion (P = 0.011) of respondents were willing to recommend laboratory scientists in private facilities (85%) more than those in government facilities (80%). A significantly greater proportion (P < 0.001) of respondents (60%) felt that the scientists in private facilities showed empathy compared with 49% in public facilities.
The unfriendly attitude of health workers was another challenge FGD participants faced at the health facilities. Participants mentioned neglect of clients and lack of respect for clients as some challenges they faced with health workers at the health facilities. A female participant from Badagry noted:
'They don't care for anyone. When we go there, they look at you as if you are nothing, they do not strive to preserve patients' lives; whether this patient will die or he will live, they will not consider that. They just leave patients and start discussing other issues, or they ask you to go and bring money to buy card.…… …they neglect you, you understand?….… So that's why I said before one dies in this hospital, let me go to private, I know private is expensive, but God will provide to make us have long life. I know my dear sister will have gone there two months ago, but by the grace of God, we rushed her to a private facility…' (Badagry_female_primary_43 years old_married).
The mean perception index was generally high for all the cadres of HCWs but was highest for doctors (10.6 ± 1.9), with a larger proportion of respondents having a better perception of HCWs in private facilities than in government-owned facilities [Table 6]. The perception index was significantly different across the four groups of health workers (F test = 51.74, P < 0.001). Increasing age was found to be significantly associated with good perception of doctors and laboratory scientists. Gender did not have any significant association with the perception of any cadre of HCWs. Educational qualifications had a significant association with perception of all cadres of HCWs. Income was significantly associated only with the perception of nurses and laboratory scientists [Table 7].
|Table 7: Sociodemographic characteristics of respondents and good perception of healthcare workers|
Click here to view
| Discussion|| |
This study sought to assess the perceptions of clients about doctors, nurses, pharmacists and laboratory scientists. Four main domains were investigated namely competence, work attitudes, interpersonal skills and unethical behaviour. At least seven out of ten participants perceived the HCWs highly, being highest for doctors (86%), pharmacists and laboratory scientists (80%) and nurses (70%). A high proportion of them were willing to recommend the HCWs they met to other clients and this was highest for laboratory scientists followed by pharmacists.
The positive perception given to the HCWs in this study agrees with studies in both developed and developing countries.,, Respondents' rating of HCW attentiveness for doctors (80%) is slightly lower than the 84% reported from Canada. The high level of competence may reflect the good quality of basic training received by the HCWs and probably continuing professional development which is now required by the respective professional regulatory bodies of HCWs in Nigeria. The perception levels found in this study are much higher than that reported from an emergency unit in a teaching hospital in Ogun State, Nigeria. The differences may be that the patients in that study needed acute care and had much higher expectations than the caregivers could provide.
Nevertheless, responsiveness remains a key area as no group of HCWs was rated higher than 76% of respondents, nurses receiving the lowest (66%). This is higher than the 43% rate reported from Ogun State, but lower than the 89% reported from Southeast Nigeria and 88% reported from a community-based study in Lagos. Empathy was another area where the respondents did not rate the HCWs very highly and may reflect a perception of the HCWs not being caring enough as evidenced from the FGDs. These are areas of concern for quality of care given by HCWs.
Participants in the FGDs confirmed that nurses in government hospitals often shouted and were rude to women in labour. The lack of hospitality towards patients in public facilities has been confirmed by a systematic review of the performance of private and public healthcare systems in low- and middle-income countries. The proportion of respondents (71%) that rated nurses to show courtesy is similar to the proportion of patients (median value of 76%) in hospitals in 12 European countries and the United States of America who felt that their nurses treated them with respect and to the proportion of patients (70%) in Nigeria who felt that the nurses had good attitudes towards work.
Doctors had the highest perception index, while nurses had the lowest. This observation may be due to the central role doctors play in healthcare more than other cadres. A study from the United States of America found that patient perception of physicians was high when there was physician–patient trust and with physicians who recommended the use of screening tests (such as colonoscopy, mammograms and prostate-specific antigen). In Kenya, community health workers were perceived to be knowledgeable and good if they were effective at the management of chronic diseases, but some were found to receive bribes which, however, was found to be very infrequent in this study.
Increasing age was found to be significantly associated with perception of doctors in agreement with a study from Australia. Gender was not found to have any significant association with perception unlike what was found in Afghanistan. The educational status of respondents was the only factor associated with the perception of all cadres of HCWs and may be a reflection of increasingly enlightened clientele. We cannot account for the fact that apart from education, no other sociodemographic characteristics of respondents had a consistent significant association with perception of HCWs. The perception index was significantly higher for private health facilities than government and is due in part to the business model utilised by the proprietors of the private facilities. This model focuses more on client centeredness and fast delivery of services. Participants in the FGDs were of the opinion that staff in the private sector seemed to be more competent than those in government hospitals although this may be difficult to verify.
The positive perception of the HCWs should serve as a pull factor for high utilisation of health facilities and the provision of good quality services. The HCWs should be motivated to sustain it. One way of doing this is through continuous professional development. Client-centred care should be the focus of HCWs in order to increase utilisation.
The limitations of this study include recall bias, which is a known limitation of questionnaire-based surveys, and social desirability bias as respondents are known to speak positively to interviewers. Careful explanation of the objectives and the anonymity required helped to minimise the latter. In addition, the study did not assess the work conditions and environment of the HCWs which may in part affect several aspects of their perception by the public. The perceptions measured were limited to doctors, nurses, pharmacists and laboratory scientists and may therefore not be applicable to several other cadres of HCWs who contribute to patient care.
| Conclusion|| |
The better level of perception of healthcare providers in the private sector may be related to higher expectation by the owners and a higher level of service delivery. Periodic retraining of health workers, especially on interpersonal skills and regular surveys of patient feedback using health facilities, are recommended. It is also important to encourage community members to demand for more accountability from HCWs and mechanisms for feedback and grievance such as suggestion boxes, contact telephone numbers and social media platforms made available.
Financial support and sponsorship
Study was funded by the Tertiary Education Trust Fund.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Frawley T. Public Perception/Expectation of the Health and Social Care System in Northern Ireland. Available from: http://www.nmg-tom-frawley.pdf
. [Last accessed on 2012 Jun 21].
Uzochukwu BS, Onwujekwe OE, Akpala CO. Community satisfaction with the quality of maternal and child health services in Southeast Nigeria. East Afr Med J 2004;81:293-9.
Ariba AJ, Thanni LO, Adebayo EO. Patients' perception of quality of emergency care in a Nigerian teaching hospital: The influence of patient-provider interactions. Niger Postgrad Med J 2007;14:296-301.
Fleming NS, Herrin J, Roberts W, Couch C, Ballard DJ. Patient-centeredness and timeliness in a primary care network: Baseline analysis and power assessment for detection of the effects of an electronic health record. Proc (Bayl Univ Med Cent) 2006;19:314-9.
Nwabueze SA, Adogu PO, Ilika AL, Asuzu MC, Adinma ED. Perception of quality of care in HIV/AIDS programmes among patients in a tertiary health care facility in Anambra state. Niger J Med 2011;20:144-50.
Campbell PC, Olufunlayo TF, Onyenwenyi AO. An assessment of client satisfaction with services at a model primary health care centre in Ogun state, Nigeria. Nig Q J Hosp Med 2010;20:13-8.
Ekos Research Associates. Shifting Public Perceptions of Doctors and Health Care, Final Report. Feb 2011. Available from: http://www.ekos.com
. [Last accessed on 2012 Jun 21].
Hardie EA, Critchley CR. Public perceptions of Australia's doctors, hospitals and health care systems. Med J Aust 2008;189:210-4.
Dhai A, Etheredge HR, Vorster M, Veriava Y. The public's attitude toward strike action by Health care workers and health services in South Africa. South Afr J Bioeth Law 2011;4:58.
Turkson PK. Perceived quality of healthcare delivery in a rural district of Ghana. Ghana Med J 2009;43:65-70.
Ebuehi OM, Akintujoye IA. Perception and utilization of traditional birth attendants by pregnant women attending primary health care clinics in a rural local government area in Ogun state, Nigeria. Int J Womens Health 2012;4:25-34.
Odusanya OO, Bamgbala AO. A community-based assessment of a model primary health care center. Niger Qt J Hosp Med 1999;9:260-3.
Hansen PM, Peters DH, Viswanathan K, Rao KD, Mashkoor A, Burnham G, et al.
Client perceptions of the quality of primary care services in Afghanistan. Int J Qual Health Care 2008;20:384-91.
Lwanga SK, Lemeshow S. Sample Size Determination in Health Studies. Geneva: World Health Organization; 1991.
Shortell SM, O'Brien JL, Carman JM, Foster RW, Hughes EF, Boerstler H, et al.
Assessing the impact of continuous quality improvement/total quality management: Concept versus implementation. Health Serv Res 1995;30:377-401.
Wysong PR, Driver E. Patients' perceptions of nurses' skill. Crit Care Nurse 2009;29:24-37.
Muntlin A, Gunningberg L, Carlsson M. Patients' perceptions of quality of care at an emergency department and identification of areas for quality improvement. J Clin Nurs 2006;15:1045-56.
Ughasoro MD, Okanya OC, Uzochukwu B, Onwujekwe OE. An exploratory study of patients' perceptions of responsiveness of tertiary health-care services in southeast Nigeria: A hospital-based cross-sectional study. Niger J Clin Pract 2017;20:267-73.
] [Full text]
Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public healthcare systems in low-and middle-income countries: A systematic review. PLoS Med 2012;9:e1001244.
Aiken LH, Sermeus W, Van den K, Sloane DM, Busse R, McKee M. Patient safety, satisfaction and quality of hospital care: Cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ 2012;344:e1717.
Oyetunde MO, Kelechi OM, Oyediran MO. Perception of patients and other health care professionals about nurses at the University College Hospital, Ibadan, Oyo State, Nigeria. Open J Nurs 2014;4:947-55.
Hojat M, Louis DZ, Maxwell K, Markham F, Wender R, Gonnella JS. Patient perceptions of physician empathy, satisfaction with physician, interpersonal trust and compliance. Int J Med Educ 2010;1:83-7.
Rachlis B, Naanyu V, Wachira J, Genberg B, Koech B, Kamene R et al.
Community perceptions of community health workers (CHWs) and their roles in management for HIV, tuberculosis and hypertension in western Kenya. PLos ONE 2016; 11: e0149412..
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]