Modifiable service-delivery factors, not geography, drive patient satisfaction in rural Sierra Leone: a district-comparative cross-sectional household survey of 679 facility users

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Abstract Background Patient-reported satisfaction is a core tracer of health-system responsiveness in Universal Health Coverage (UHC) monitoring, yet its determinants in rural Sierra Leone are poorly characterised. We quantified overall and domain-specific satisfaction and identified modifiable predictors across three rural border districts. Methods We conducted a cross-sectional, population-based household survey in October 2024 in Kailahun, Kambia and Pujehun districts, using a two-stage cluster design (chiefdoms sampled with probability proportional to size; households sampled at random). A validated 29-item instrument measured overall satisfaction and eight patient-experience domains on five-point Likert scales. The primary outcome was the five-level single-item overall satisfaction rating. We fitted a multivariable proportional-odds ordinal logistic regression, with 95% confidence intervals (CIs) obtained by a cluster bootstrap resampling the 20 chiefdom clusters. Robustness was assessed with binary and composite-outcome sensitivity models. Results Of 750 respondents, 679 (90.5%) had used a formal health facility in the previous 12 months and formed the analytic sample (510 [75.1%] female; mean age 28.2 years [SD 13.8]). The instrument showed high internal consistency (Cronbach α = 0.87 for the five core domains). Overall, 375/679 (55.2%) were satisfied or very satisfied, ranging from 185/244 (75.8%) in Kambia to 110/224 (49.1%) in Kailahun and 80/211 (37.9%) in Pujehun (χ² = 70.8; p<0.001). In the adjusted model, staff attitude was the strongest predictor of higher satisfaction (adjusted odds ratio [AOR] 2.74, 95% CI 2.03–3.70; p<0.001 per one-point increase), followed by waiting-time satisfaction (AOR 1.89, 1.39–2.46) and medicine availability (AOR 1.43, 1.16–2.10). Travel-time category, facility type and sex were not independently associated. Large district disparities persisted after adjustment: relative to Kambia, the AOR for higher satisfaction was 0.27 (0.15– 0.50) in Kailahun and 0.33 (0.20–0.66) in Pujehun. Adjusted probabilities of high satisfaction were 0.72, 0.48 and 0.43, respectively. Conclusions Respectful provider behaviour, shorter waits and reliable medicine supply, all amenable to district-level management, were the dominant and actionable drivers of patient satisfaction, whereas geographic distance was not. Persistent between-district gaps call for tailored quality-improvement in Kailahun and Pujehun. Institutionalising routine patient-experience measurement would strengthen accountability for people-centred care and support equitable progress towards UHC. Author summary Whether people are satisfied with the care they receive shapes whether they return, follow advice and trust the health system, and it is a recognised marker of quality within Universal Health Coverage. Evidence on what drives satisfaction outside Sierra Leone’s capital has been thin, which limits the design of practical improvements in the rural districts where needs are greatest. We surveyed 679 recent health-facility users across three rural border districts and analysed which factors were most strongly associated with higher satisfaction, accounting for the clustered survey design. We found that how patients were treated by staff, how long they waited, and whether medicines were available mattered most, and that all three are within the control of facility and district managers. In contrast, how far patients travelled to reach care did not independently affect satisfaction once they arrived. Satisfaction differed sharply between districts even after adjustment, with Kailahun and Pujehun lagging well behind Kambia, pointing to differences in service delivery rather than in the people served. These findings identify concrete, low-cost priorities, staff communication, queue management and supply reliability, and make the case for routine measurement of patient experience to hold services accountable for people-centred care.

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