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Original research
Factors associated with positive user experience with primary healthcare providers in Mexico: a multilevel modelling approach using national cross-sectional data
  1. Kelsey Holt1,
  2. Svetlana V Doubova2,
  3. Dennis Lee3,
  4. Ricardo Perez-Cuevas4,
  5. Hannah H Leslie5
  1. 1Department of Family and Community Medicine, University of California, San Francisco, California, USA
  2. 2Epidemiology and Health Services Research Unit, CMN Siglo XXI, Mexican Institute of Social Security, Mexico City, Mexico
  3. 3Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
  4. 4Division of Social Protection and Health, Interamerican Development Bank, Kingston, Jamaica
  5. 5Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
  1. Correspondence to Dr Kelsey Holt; kelsey.holt{at}


Objective This study aimed to investigate factors associated with patient experience with primary care in a large public health system in Mexico and determine the amount of variability in experience attributable to facility-level and state-level factors.

Methods We analysed cross-sectional 2016 national satisfaction survey data from the Mexican Social Security Institute (IMSS). Patient-level data were merged with facility-level data and information on poverty by state. We assessed general contextual effects and examined the relationship of patient, facility and state factors with four patient experience measures using random effects logistic regression.

Results 25 745 patients’ responses from 319 facilities were analysed. The majority experienced good communication (78%), the opportunity to share health concerns (91%) and resolution of doubts (85%). 29% of visits were rated as excellent. Differences between facilities and states accounted for up to 12% and 6% of the variation in patient experience, respectively. Inclusion of facility-level contextual effects improved model predictions by 8%–12%; models with facility random effects and individual covariates correctly predicted 64%–71% of individual outcomes. In adjusted models, larger patient population was correlated with worse reported communication, less opportunity to share concerns and less resolution of doubts. Men reported more positive communication; older individuals reported more positive communication and experiences overall, but less opportunity to share concerns; and more educated individuals were less likely to report positive communication but more likely to report resolution of doubts and overall positive experiences. Preventive care visits were rated higher than curative visits for resolution of doubts, but lower for opportunity to share concerns, and specific conditions were associated with better or worse reported experiences in some cases.

Conclusion Quality improvement efforts at IMSS facilities might bolster individual experiences with primary care, given that up to 12% of the variation in experience was attributable to facility-level differences. The relationship between individual characteristics and experience ratings reinforces the importance of patients’ expectations of care and the potential for differential treatment by providers to impact experience.

  • primary care
  • patient centered care
  • Mexico

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See:

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  • Contributors KH, SVD and HHL conceived of the study; KH, HHL and DL conducted the analysis; KH drafted the manuscript; SVD, HHL, DL and RPC provided substantive feedback on the manuscript.

  • Funding HHL and DL received support from the Bill and Melinda Gates Foundation (Award OPP1161450, Kruk).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This secondary analysis of deidentified data was approved by IMSS Research and Ethics Committee (No. R 2018-785-037).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Patient-level and state-level data are available in public, open access repositories. Patient-level outcomes: State-level poverty data: Facility-level data may be obtained from a third party and are not publicly available. Data on Mexican Institute of Social Security (IMSS) facility characteristics are available from IMSS on request after approval for analyses from the IMSS Health Research Ethics Committee (contact:

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