In this survey of primary care patients in the south-western health zone of Malawi, one-third of patients had poor SRH. Poor SRH was associated with female sex, increasing age, decreasing education, frequent HC attendance, and reported disability. Patients content with the service provided and who reported high scores of relational continuity from their health care providers reported better SRH as compared with others.
Prevalence of poor SRH
To the best of our knowledge, this is the first study on self-rated health in the south-western health zone of Malawi. Although the prevalence of poor SRH is lower than some figures from Sub-Saharan Africa (SSA) and comparable to findings from high-income settings it ought to be considered as suboptimal and a cause for concern (12, 14, 24–26). The latter is due to Malawi’s resource constraints, growing double burden of communicable and non-communicable diseases, increasing life expectancy, and declining mortality from conditions that once carried high mortality (27, 28). Since SRH is a stable construct, increasing life expectancy and declining HIV-associated mortality also portend a higher burden of poor SRH (29, 30).
The prevalence of poor SRH also highlights the importance of looking beyond the provision of freely accessible care, as is the case in Malawi, but also good quality patient-centred care to improve clinical outcomes and patients’ confidence in the health system (31).
SRH & socio-demographic characteristics
The pattern of disparity in SRH outcomes across the study sites was consistent with findings from other studies, which report better SRH among urban residents and participants with a better socioeconomic context (24, 25, 32, 33). Contrary to our expectations, the odds of poor SRH were highest in Neno despite Neno having the highest per capita expenditure on health, the highest proportion of participants who considered the treatment they received to be of good quality and being anecdotally reported as a popular health tourism destination for residents from neighbouring districts. Neno also has integrated care programmes, which are unique to the district, and are credited to have resulted in increased case finding and uptake of various primary care services including chronic infectious & non-infectious diseases, with consequential improvements in survival rates (34–36).
This SRH pattern suggests that the aforementioned qualities of primary care in Neno, though necessary, might be insufficient in efforts to improve SRH trajectories of communities such as in Neno. The pattern is, however, consistent with the “paradox of health” observed by Barsky, where excellent health, in the presence of (I) advanced medical care, (II) heightened consciousness of health, (III) commercialization of health, and (IV) medicalization of daily life, is associated with poor subjective health (37). The relative importance of each of the elements in this complex web of factors in Malawi is not yet known, but these elements highlight the overall importance of patients’ social context in their overall health and SRH trajectories. However, Barsky points at a paradoxical relationship that may be universal: health care succeeding at combating disease and mortality will not necessarily improve the perceptions of health of patients and populations.
The finding of female sex as an independent factor associated with poor SRH, though consistent with literature from other settings, is counterintuitive because (I) Malawi provides free health care for all, and (II) men in Malawi have a greater burden of disease and lower life expectancy (32, 38, 39). On the other hand, SRH is often associated with social, contextual factors and subjective wellbeing (30). This disparity, which has also been demonstrated among adolescents in other studies, can be attributed, at least in part to the male-female health survival paradox that may result from community views on health and masculinity (40–43). These result in women having more contact with the health system, having more diagnoses of conditions that are often non-lethal, and potentially having more knowledge about their health (39, 43). Consequently, women may be more responsive to changes in their bodies and may, more often than men, factor these when asked to rate their health. Other studies have also attributed Sex disparities in SRH, at least in part, to differences in stress and social determinants of health (38, 40).
SRH & quality of primary care
Relational continuity is independently associated with a reduced cost of care, improvements in uptake of preventive care, adherence to treatment, patient satisfaction with care, and health outcomes (44). It is a surrogate marker of patients’ trust and satisfaction, and its importance is expected to increase as the burden of chronic diseases grows (44, 45). Relational continuity is not an innate aspect of Malawi’s approach to primary care. Based on the personal experience of the authors (SK and LD), relational continuity in Malawian public primary care facilities is often a consequence of patient preference, healthcare worker shortages, and the presence of chronic diseases (e.g. HIV and diabetes). The presence of statistically significant associations between relational continuity and better SRH, albeit without systemic efforts to institute the same, suggests that relational continuity is a crucial and cost-effective ingredient for improving the quality of primary care and SRH in the study communities.
Participants’ age, presence of disabilities, and highest attained education are markers of social determinants of health. Marginalised populations (e.g. the disabled and people of low socioeconomic status) and the elderly are likely to be the greatest victims of these factors since they tend to experience socio-economic exclusion, reduced access to care, and numerous unique healthcare needs. Thus, the pillars of universal health coverage seem indispensable in the quest to improve SRH. The highest attained education of a participant is a valid measure of socioeconomic status and is probably associated with health knowledge and perception of self-efficacy (46).
The absence of a statistically significant association between comprehensiveness of services and SRH was another unexpected finding, which is probably a consequence of the uniformity in the range of services provided as part of the essential health package in Malawian primary care facilities.
Limitations and strengths
Our study has several limitations. The most important is the cross-sectional design where we cannot establish causal relationships between any of the factors identified and SRH. Another limitation is in the exploration of patient’s subjective reports. However, procedural strategies, namely: (I) explaining the purpose of the study to participants, (II) use of unambiguous Likert scale labels, and (III) using a mixture of response approaches, were used to minimise recall and desirability tendencies on the part of participants. All questions were asked in the vernacular language with clear wording that is consistent with similar international tools.
Although the tool is validated for use in our setting, the use of the tool in a clinical setting may have made some of the PCAT domains, especially “first-contact access”, prone to selection bias. Data on the objective health status of the participants, except self-reported disability, was not collected. Thus, the effect of various pathological processes, especially mental health conditions, which may affect one's perception of the quality of care received, were not factored in the analysis.