Assessment of Patient Satisfaction with TB Care Services in Southern Afghanistan

Introduction

Tuberculosis (TB) remains one of the leading causes of morbidity and mortality from infectious diseases worldwide, disproportionately affecting low-and middle-income countries (LMICs), with fragile health systems.^1,2 Weak health infrastructure, shortages of trained health workers, limited financial resources, and disruptions in service delivery continue to undermine the effectiveness of TB control programs in many settings.^1,3 Beyond biomedical challenges, patient-centered dimensions of care such as accessibility, affordability communication, and perceived quality play a crucial role in shaping treatment adherence and outcomes.⁴

Globally, there were 10.8 million new TB cases in 2023. In the same period, an estimated 1.8 million people died from TB.⁵ Despite the scale-up of TB care programs over the past two decades, Afghanistan, a low-income country in South Asia, faces persistent challenges in TB prevention and care.⁶ As such, there were 52,407 new TB cases in 2022.⁷ In Afghanistan, most TB care services are coordinated and managed by the public sector under the National Tuberculosis Control Program (NTP).⁶ Decades of conflict, political instability, and socioeconomic hardship have severely constrained the capacity of the health system, particularly in the South and other underserved areas.⁶ Previous studies in Afghanistan have documented substantial barriers to effective TB care, including diagnostic delays, limited access to services, high levels of TB-related stigma, mental health comorbidities, and treatment non-adherence.^8–10 Additionally, several studies have noted poor counseling services for TB across the country.^8–10 Socioeconomic inequalities, low levels of health literacy, and insufficient healthcare infrastructure further intensify these issues.^6,11 Moreover, the recent funding restrictions are anticipated to further deteriorate TB care programs in countries like Afghanistan.¹² Together, these factors underscore the urgent need to evaluate not only clinical outcomes but also patients’ experiences with TB care services.

Patient satisfaction is widely recognized as a key indicator of healthcare quality and system responsiveness.^13–15 In the context of TB care, higher patient satisfaction has been associated with improved healthcare-seeking behavior, better adherence to anti-TB treatment, reduced loss to follow-up, and more favorable clinical outcomes.^16,17 Conversely, dissatisfaction with care may contribute to poor treatment engagement and suboptimal program performance.¹⁶ Studies from LMICs have reported substantial variability in patient satisfaction with TB services, with reported levels ranging from approximately 53% to over 90% depending on setting, measurement tools, and health system characteristics.^18–20

Existing evidence suggests that patient satisfaction with TB care is influenced by a complex interplay of sociodemographic, clinical, and health system–related factors. Systematic reviews have identified associations with age, sex, place of residence, marital status, education, income, and perceived health status, as well as service-related factors such as waiting time, provider attitude, communication quality, and distance to healthcare facilities.^18,20 Additional studies have highlighted the role of TB-related stigma, mental health status, out-of-pocket costs, and social support in shaping patients’ perceptions of care.^16,19,21 Importantly, the relative importance of these factors varies across contexts, underscoring the need for setting-specific evidence.^18,20

Despite the high burden of TB and well-documented challenges in healthcare delivery, no study to date has systematically assessed patient satisfaction with TB care services in Afghanistan. This represents a critical evidence gap, particularly given the country’s fragile health system and pronounced regional disparities in access to care. Southern Afghanistan is characterized by limited healthcare infrastructure, a high proportion of rural populations, and significant socioeconomic challenges, all of which may influence patients’ access to and experiences with TB care services.^22,23 Understanding patients’ experiences and perceptions of TB services is essential for informing patient-centered interventions, improving service quality, and strengthening TB control efforts in the Afghan context. Therefore, this study aimed to assess the level of patient dissatisfaction with TB care services and to identify associated sociodemographic, clinical, and health system factors among TB patients in Southern Afghanistan. The findings are intended to inform policymakers, program managers, and healthcare providers in designing targeted strategies to improve the quality, equity, and effectiveness of TB care services.

Methods

Study Setting and Design

A facility-based cross-sectional study was conducted among adult TB patients attending selected TB care facilities in Southern Afghanistan. The study was carried out between October and December 2025 in the out-patient departments (OPDs) of six high-volume TB treatment centers, including the Kandahar Provincial TB center, Mirwais Regional Hospital (MRH), and Spin Boldak District Hospital (DH) in Kandahar province, as well as the provincial TB centers in Helmand, Uruzgan, and Zabul provinces. These facilities were purposively selected based on administrative data from provincial public health directorates, indicating that they manage the highest number of TB patients in the region.

Study Population and Eligibility Criteria

The target population comprised adult (≥ 18 years old) TB patients residing in Southern Afghanistan. The study population included TB patients who were receiving follow-up care at the selected facilities during the study period. Patients were eligible for inclusion if they were aged 18 years or older, had a confirmed diagnosis of TB (irrespective of case type), and were receiving TB treatment at one of the selected facilities at the time of data collection.

Sample Size and Sampling Procedures

We calculated the sample size using the single-proportion formula [n = Z²P (1−P)/(d)²] for cross-sectional studies, assuming a 50% (maximum estimate) level of patient dissatisfaction with TB care, a Z score of 1.96, and a 5% margin of error.²⁴ After adding 10% to account for non-response, a sample size of 422 was obtained. The total sample size was allocated proportionally to the six TB care facilities based on patient load. Consequently, 90 patients were assigned to the MRH, 85 to the Spin Boldak DH, 60 to Kandahar Provincial TB center, and 70, 62, and 55 to the provincial TB centers in Helmand, Zabul, and Uruzgan Provinces, respectively. TB registers at each facility were then reviewed, and all patients meeting the inclusion criteria were listed. From this sampling frame, participants were selected using simple random sampling. Among the 422 TB patients, 3 (0.7%) had very severe illness, and 6 (1.4%) refused to participate in the study. The final analysis includes 413 TB patients with complete data sets.

Study Variables

Outcome Variable

The outcome variable was patients’ satisfaction level with TB care services, measured using the Patient Satisfaction Questionnaire (PSQ-18).^25,26 This universal 18-item scale assesses satisfaction across seven domains: (i) general satisfaction, (ii) technical quality, (iii) interpersonal manner, (iv) communication, (v) financial aspects, (vi) time spent with the doctor, and (vii) accessibility and convenience. Each item was rated on a five-point Likert scale ranging from 1 (strongly agree) to 5 (strongly disagree), with items 1, 2, 3, 5, 6, 8, 11, 15, and 18 reverse-coded. Higher scores indicated greater satisfaction with TB care services. Domain-specific scores were calculated by averaging the responses within each domain, generating a mean score for each domain. A dichotomous variable (satisfied vs dissatisfied) for the PSQ-18 scale was created using the sample means as cut-off values, consistent with approaches used in previous studies.^25,27,28 Accordingly, patients who scored less than the mean value were considered dissatisfied, and those who scored the mean or greater than the mean value were considered satisfied. A forward-backward method of translation was used to obtain the Pashtu version of the PSQ-18. The translation was done by two expert translators, and re-checked by the local public health expert and the first author to ensure the accuracy of the translation process. Prior to the actual study, we also pilot-tested the scale among 30 TB patients receiving care at a non-participating healthcare facility (Bost University Teaching Hospital) to assess face validity and clarity. Feedback from the pilot testing was used to refine and finalize the questionnaire. In the current study, Cronbach’s α for the Pashtu version of PSQ-18 was 0.91.

Independent Variables

The independent variables were demographic characteristics (age, sex, marital status, education level, employment status, residential area, distance to healthcare facility, out-of-pocket expenditures during treatment, and household monthly income), and clinical and other related characteristics (TB type, TB case type, self-perceived severity, treatment phase, medical comorbidity, counselling during treatment, adverse reactions, and smoking status). Although counseling availability during TB care and counseling quality (Q1, Q11, and Q15) are related constructs, collinearity diagnostics indicated no problematic multicollinearity. Therefore, this variable was retained to better capture the functionality of TB counseling services at the study sites.

Data Collection

Data on sociodemographic characteristics, clinical variables, and PSQ-18 were collected via a structured questionnaire administered during face-to-face interviews. Data were collected by 12 trained nurses (6 females and 6 males) who received training on interviewing techniques, data documentation, and research ethics. All participants provided informed consent prior to participating. Patients were recruited upon leaving the healthcare facility and interviewed in a private room within the facility. Each interview took approximately 15–20 minutes. Moreover, data collection procedures were regularly monitored and supervised by the principal investigators.

Statistical Analysis

All statistical analyses were performed using Stata Version 18 (StataCorp, College Station, TX).²⁹ Descriptive statistics were used to summarize patients’ sociodemographic characteristics, clinical factors, and responses to PSQ-18 items and main domains. A binary logistic regression model was fitted to assess the association between the independent variables and satisfaction status. Prior to model fitting, variables were tested for multicollinearity. No individual variance inflation factor (VIF) was greater than 5, indicating acceptable multicollinearity. Covariates with a bivariate association at p < 0.25 were considered for multivariable modeling. We reported odds ratios (ORs) and 95% confidence intervals (CIs) for each independent variable. Statistical significance was set at the 0.05 level, and all p-values are two-sided.

Results

As shown in Figure 1, 44.5% of participants (95% CI: 39.6%–49.4%) were classified as dissatisfied with TB care services in Southern Afghanistan (Figure 1).

Figure 1 Patient satisfaction status with TB care services in Southern Afghanistan.

Descriptive Characteristics

Table 1 summarizes the sociodemographic characteristics of the study participants. The mean age of patients was 39.4 ± 16.9 years. Most participants were aged > 35 years (49.6%), male (58.6%), currently married (71.4%), from rural areas (60.0%), and had no formal education (51.8%). About one-third (28.8%) of the participants were employed, 43.6% reported that the distance to the healthcare facility was a barrier to accessing care. Nearly two-thirds (62.2%) had a monthly household income between 5000 and 10,000 Afghanis, and 39.2% reported incurring out-of-pocket expenses during TB treatment.

Table 1 Sociodemographic Characteristics of the Participants (n=413)

Clinical and Other Related Characteristics

Clinical and treatment-related characteristics are presented in Table 2. Most participants were new TB cases (82.6%) and had pulmonary TB (66.8%). Nearly half (48.6%) perceived their disease as severe. Regarding treatment status, 36.8% of participants were in the initial phase of treatment, while the remainder were in the continuation phase. The majority (78.9%) reported receiving counselling during TB treatment. A small proportion (7.3%) experienced medication side effects, and 35.6% reported at least one comorbid medical condition. Additionally, 19.6% of participants were current smokers.

Table 2 Clinical and Other Related Characteristics of the Participants (n=413)

Patient Satisfaction Across PSQ-18 Items

Descriptive statistics for individual PSQ-18 items are shown in Table 3. Mean item scores ranged from 2.42 to 4.10, indicating substantial variability in patients’ perceptions of care quality. The lowest mean score was observed for the item related to the financial burden of TB care, while higher scores were observed for items assessing interpersonal manner, accessibility, convenience, and explanations provided by healthcare workers. The detailed descriptive statistics for the items of PSQ-18 are presented in the supplementary file (See Supplementary Table 1).

Table 3 Descriptive Statistics for the 18 Items of the Patient Satisfaction Questionnaire (PSQ-18)

Patient Satisfaction Across PSQ-18 Domains

Mean satisfaction scores across PSQ-18 domains are presented in Table 4. The highest levels of satisfaction were observed in the interpersonal relationship domain (mean = 4.02; 80.4%), followed by technical quality (mean = 3.82; 76.4%) and communication (mean = 3.81; 76.2%). In contrast, satisfaction was lowest for the financial aspects domain (mean = 2.94; 58.8%), followed by time spent with the doctor (mean = 3.39; 67.8%). These domains accounted for the greatest proportion of reported dissatisfaction.

Table 4 Satisfaction Level for the Domains of Patient Satisfaction Questionnaire-18 (PSQ-18)

Factors Associated with Patient Dissatisfaction

Multivariable analysis identified several factors associated with patient dissatisfaction (Table 5). The likelihood of dissatisfaction was greater in patients living in rural areas (AOR = 1.72; 95% CI: 1.07–2.77), in patients with monthly household income of 5000–10,000 Afghanis (AOR = 1.73; 95% CI: 1.07–2.79), and those who incurred out-of-pocket money during treatment (AOR = 1.68; 95% CI: 1.06–2.67). Moreover, patients who were in the continuation phase of treatment (AOR = 1.83; 95% CI: 1.12–2.98), those who did not receive counselling during treatment (AOR = 7.25; 95% CI: 3.86–13.61), and those who were currently smoking (AOR = 2.05; 95% CI: 1.16–3.60) were more likely to dissatisfy with TB care.

Table 5 Likelihood of Patients’ Dissatisfaction with TB Care Services in Southern Afghanistan

Discussion

This study assessed the satisfaction levels among TB patients in Southern Afghanistan and identified key sociodemographic, economic, and treatment-related factors associated with dissatisfaction. Nearly half (44.5%) of the patients were not satisfied with TB care services in the study area, indicating substantial gaps in patient-perceived quality of care. Several factors, including place of residence, monthly household income, expenses during treatment, counselling, treatment phase, and smoking status, were found to be associated with patients’ dissatisfaction with TB care services. To our knowledge, this is the first study to systematically assess patient satisfaction with TB services in Afghanistan, thereby addressing an important evidence gap in a fragile and conflict-affected setting.

Our analysis showed that the magnitude of patient dissatisfaction with TB care services in Southern Afghanistan (44.5%) is considerably higher than levels reported in other LMICs, such as 14% in India,¹⁹ and 38.9% in Ethiopia.²¹ This relatively high burden of dissatisfaction may reflect longstanding structural challenges in Afghanistan’s health system, including limited resources, workforce shortages, geographic barriers, and ongoing socioeconomic instability.^6,7,9,30 Importantly, dissatisfaction was particularly pronounced in the financial aspects and time spent with healthcare providers, suggesting that both economic barriers and perceived service quality play a central role in shaping patients’ experiences with TB care.^18–21 Collectively, these findings underscore the critical role of patient satisfaction in treatment outcomes and highlight the need for policymakers to prioritize patient-centered approaches in strengthening TB care programs in Afghanistan.

A key finding of this study was the presence of marked urban–rural disparities in patient dissatisfaction. Patients residing in rural areas had greater odds of dissatisfaction with TB care services than those living in urban areas. This finding is consistent with earlier studies conducted in LMICs,^16,18,20 and likely reflects inequities in healthcare infrastructure, transportation difficulties, longer travel times, and reduced access to trained health professionals in rural settings.^7,30,31 In Afghanistan, where rural populations constitute a large proportion of TB patients, these disparities highlight the need for decentralised and community-based TB services that are better aligned with patients’ geographic and socioeconomic realities.^7–9,30

Economic vulnerability emerged as another important determinant of dissatisfaction. Patients with lower household income and those who incurred out-of-pocket expenditures during treatment were more likely to be dissatisfied with TB care services. This finding is consistent with studies conducted in other LMICs.^32,33 Under the Afghanistan NTP, TB diagnosis, treatment, and anti-TB drugs are fully free for all irrespective of age, gender, geography, ethnicity, religious or political origin. However, indirect costs mostly affect the poor and contribute to dissatisfaction.³⁴ These findings underscore the importance of addressing catastrophic and hidden costs associated with TB care through social protection mechanisms, transport support, and targeted financial assistance, particularly for low-income households.¹²

Treatment-related factors also played a significant role. Patients in the continuation phase of treatment were more likely to report dissatisfaction than those in the initial phase. This finding aligns with previous studies conducted in Ethiopia and Pakistan.^16,21 This may be attributable to reduced clinical attention, fewer counselling interactions, and cumulative treatment fatigue over time, all of which contribute to lower patient satisfaction.^16,19,35 Similar patterns have been observed in other settings, where reduced follow-up and counselling during later treatment stages contribute to lower satisfaction and increased risk of non-adherence.^10,18 These findings suggest that sustained patient engagement and supportive care throughout the entire course of TB treatment are essential through Direct Observational Therapy (DOT).

Not receiving counselling during TB treatment was the strongest predictor of dissatisfaction in this study. Patients who did not receive counselling had markedly higher odds of dissatisfaction. This highlights the central role of communication, education, and psychosocial support in patient-centered TB care.^18,30,36 Additionally, counselling during TB treatment has been shown to reduce TB-related stigma and mental health symptoms and may influence patient satisfaction through both direct and indirect pathways; directly by enhancing patients’ understanding of their condition, trust in healthcare providers, and sense of reassurance, and indirectly by strengthening perceptions of provider competence and overall quality of care.^37–39 In Afghanistan, TB care programs entail the provision of TB testing, counselling, and treatment for TB patients during their visit to TB centers. However, previous studies have documented substantial gaps and suboptimal quality in counselling services for TB patients.^6,9,10,40 While the magnitude of this association should be interpreted cautiously due to the cross-sectional design and potential residual confounding, the finding reinforces the importance of integrating high-quality counselling as a core component of TB services. Moreover, engaging family members as the primary source of emotional and practical support, dissatisfaction with treatment can be alleviated, thereby strengthening adherence to anti-TB treatment.

The association between current smoking and dissatisfaction with TB care is also noteworthy. Smoking may be linked to dissatisfaction through multiple pathways, including poorer health status, increased symptom burden, or unmet expectations regarding care.^41,42 For smokers, the dual burden of cigarette expenses and reduced income from health issues may amplify dissatisfaction with TB care.⁴³ In addition, smokers may experience stigma or less supportive interactions within healthcare settings.^44,45 Given the well-established adverse effects of smoking on TB treatment outcomes, integrating smoking cessation counselling into routine TB care could improve both patient satisfaction and clinical outcomes.

Finally, several factors were not significantly associated with dissatisfaction in the adjusted analysis, including sex, education level, TB type, and perceived disease severity. This suggests that dissatisfaction with TB care in this setting may be driven more by structural and service-related factors than by individual clinical characteristics, reinforcing the need for health-system–level interventions.

Limitations

This study has several limitations that should be considered when interpreting the findings. First, this is the first reported use of the Pashtu version of PSQ-18; several psychometric properties require further validation. Second, the data collected in this study were self-reported and, therefore, could be subject to information and social desirability biases. Third, additional predictors, such as staff attitude, waiting time to receive TB care, mental health status, service quality, and the availability of financial support, which were not collected in the current study, could influence patients’ satisfaction with TB care services. Therefore, future studies should consider these variables in their analyses. Fourth, the facility-based sampling approach may limit generalizability. Additionally, the study was conducted in selected facilities across four provinces in Southern Afghanistan, and the findings may not be representative of TB patients in other regions of the country. Fifth, the cross-sectional study design precludes causal inference. Observed associations should be interpreted as correlational, and the temporal direction of some relationships, such as those between counselling, smoking status, and patient dissatisfaction, cannot be definitively established. Finally, dichotomizing patient satisfaction using the sample mean as a cut-off may have reduced variability and affected comparability with studies using alternative scoring approaches. However, this method has been used in prior research,^16,25,28 and allowed for pragmatic identification of factors associated with dissatisfaction in this context.

Despite these limitations, our study has the potential to inform health policy and programs aimed at improving TB care in the country, particularly in Southern Afghanistan.

Conclusion

This study found that nearly half of TB patients receiving care in Southern Afghanistan were dissatisfied with TB care services, reflecting important gaps in patient-centered care within a fragile health system. Dissatisfaction was driven by socioeconomic vulnerability, rural residence, out-of-pocket costs, treatment phase, smoking, and particularly lack of counselling. Strengthening TB care should build on existing National Tuberculosis Control Program activities by improving the quality and consistency of counselling services across all treatment phases, expanding community-based and decentralized care, and reducing financial barriers for vulnerable populations. Given the strong social structure in Afghanistan, engaging and empowering family members in counselling and treatment support may provide a culturally appropriate and feasible strategy to enhance patient satisfaction, adherence, and overall treatment outcomes.