Measuring Organizational Culture in Ethiopia's Primary Care System: Validation of a Practical Survey Tool for Managers

Background: Organizational culture has been widely recognized as predictive of health system performance and improved outcomes across various healthcare settings. Research on organizational culture in healthcare has been largely conducted in high-income settings, and validated scales to measure this concept in primary healthcare systems in low-and middle income country (LMIC) settings are lacking. Our study aimed to validate a tool to measure organizational culture in the context of the Ethiopian Primary Healthcare Transformation Initiative, a collaborative of the Federal Ministry of Health and the Yale Global Health Leadership Initiative to strengthen primary healthcare system performance in Ethiopia. Methods: Following established survey development and adaptation guidelines, we adapted a 31-item U.S.-based organizational culture scale using (1) cognitive interviewing, (2) testing with 1176 district and zonal health officials from four regions in Ethiopia, and (3) exploratory factor analysis. Results: Based on the results of cognitive interviewing, an adapted 30-item survey was piloted. The factor analyses of 1,034 complete surveys (88% complete responses) identified five constructs of the scale which demonstrated strong validity and internal consistency: learning and problem solving, psychological safety, resistance to change, time for improvement, and commitment to the organization. Of the 30 a priori items, 26 items loaded well on the five constructs (loading values 0.40-0.86), and 4 items failed to load. Cronbach alpha coefficients were 0.86 for the scale as a whole and ranged from 0.65 to 0.90 for the subscales. The five-factor solution accounted for 62% of total variance in culture scores across respondents. Conclusion: Through validation and factor analyses, we generated a 26-item scale for measuring organizational culture in public primary healthcare systems in low-and middle-income country settings. This validated tool can be useful for managers, implementers, policymakers, and researchers to assess and improve organizational culture in support of improved primary healthcare system performance. Keywords: Organizational Culture; Primary Care; Survey Validation; Ethiopia; Sub-Saharan Africa; Healthcare Quality