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

Patient-reported satisfaction is a core indicator of health-system responsiveness in Universal Health Coverage (UHC) monitoring, yet its determinants in rural Sierra Leone were poorly characterized. This study, conducted in October 2024 across three rural border districts (Kailahun, Kambia, and Pujehun), used a two-stage cluster design to survey 750 household respondents, of whom 679 had used a formal health facility in the prior 12 months (analytic sample; 75.1% female; mean age 28.2 years). A validated 29-item instrument measured overall satisfaction and eight patient-experience domains, with high internal consistency (Cronbach α = 0.87).

Overall, 55.2% of users were satisfied or very satisfied, but rates ranged widely: 75.8% in Kambia, 49.1% in Kailahun, and 37.9% in Pujehun (p<0.001). Multivariable proportional-odds ordinal logistic regression, with cluster bootstrap confidence intervals, identified staff attitude as the strongest predictor of higher satisfaction (adjusted odds ratio [AOR] 2.74 per one-point increase, 95% CI 2.03–3.70), followed by waiting-time satisfaction (AOR 1.89, 95% CI 1.39–2.46) and medicine availability (AOR 1.43, 95% CI 1.16–2.10). Travel-time category, facility type, and sex were not independently associated.

Large district disparities persisted after adjustment: compared with Kambia, the AOR for higher satisfaction was 0.27 in Kailahun and 0.33 in Pujehun, with adjusted probabilities of high satisfaction at 0.72, 0.48, and 0.43, respectively. The authors conclude that respectful provider behavior, shorter waits, and reliable medicine supply—all amenable to district-level management—are the dominant actionable drivers, whereas geographic distance is not. Persistent gaps suggest tailored quality-improvement efforts are needed in Kailahun and Pujehun.