Stakeholder perceptions on patient-centered care at primary health care level in rural eastern Uganda: A qualitative inquiry

Expectations of clients, insurers, and providers: a qualitative responsiveness assessment among private health insurance sector in Kampala-Uganda

BACKGROUND

There is less attention to assessing how health services meet the expectations of private health insurance (PHI) actors, clients, insurers, and providers in developing countries. Interdependently, the expectations of each actor are stipulated during contract negotiations (duties, obligations, and privileges) in a PHI arrangement. Complementary service roles performed by each actor significantly contribute to achieving their expectations. This study assessed the role of PHI in meeting the expectations of clients, insurers, and providers in Kampala. Lessons from this study may inform possible reviews and improvements in Uganda's proposed National Health Insurance Scheme (NHIS) to ensure NHIS service responsiveness.

METHODS

This study employed a qualitative case-study design. Eight (8) focus group discussions (FGDs) with insured clients and nine (9) key informant interviews (KIIs) with insurer and provider liaison officers between October 2020 and February 2021 were conducted. Participants were purposively selected from eligible institutions. Thematic analysis was employed, and findings were presented using themes with corresponding anonymized narratives and quotes.

RESULTS

Client-Provider, Client-Insurer, and Provider-Insurer expectations were generally not met. Client-provider expectations: Although most facilities were clean with a conducive care environment, clients experienced low service care responsiveness characterized by long waiting times. Both clients and providers received inadequate feedback about services they received and delivered respectively, in addition to prompt care being received by a few clients. For client-insurer expectations, under unclear service packages, clients received low-quality medicines. Lastly, for provider-insurer expectations, delayed payments, selective periodic assessments, and inadequate orientation of clients on insurance plans were most reported. Weak coordination between the client-provider and insurer did not support delivery processes for responsive service.

CONCLUSION

Health care service responsiveness was generally low. There is a need to commit resources to support the setting up of clearer service package orientation programs, and efficient monitoring and feedback platforms. Uganda's proposed National Health Insurance Act may use these findings to: Inform its design initiatives focusing on operating under realistic expectations, investment in quality improvement systems and coordination, and efficient and accountable client care relationships.

Is a bio-psychosocial approach model possible at the first level of health services in the Democratic Republic of Congo? An organizational analysis of six health centers in South Kivu

BACKGROUND

The health system, in the Democratic Republic of Congo, is expected to move towards a more people-centered form of healthcare provision by implementing a biopsychosocial (BPS) approach. It's then important to examine how change is possible in providing healthcare at the first line of care. This study aims to analyze the organizational capacity of health centers to implement a BPS approach in the first line of care.

METHODS

A mixed descriptive and analytical study was conducted from November 2017 to February 2018. Six health centers from four Health Zones (South Kivu, Democratic Republic of Congo) were selected for this study. An organizational analysis of six health centers based on 15 organizational capacities using the Context and Capabilities for Integrating Care (CCIC) as a theoretical framework was conducted. Data were collected through observation, document review, and individual interviews with key stakeholders. The annual utilization rate of curative services was analyzed using trends for the six health centers. The organizational analysis presented three categories (Basic Structures, People and values, and Key Processes).

RESULT

This research describes three components in the organization of health services on a biopsychosocial model (Basic Structures, People and values, and Key processes). The current functioning of health centers in South Kivu shows strengths in the Basic Structures component. The health centers have physical characteristics and resources (financial, human) capable of operating health services. Weaknesses were noted in organizational governance through sharing of patient experience, valuing patient needs in Organizational/Network Culture, and Focus on Patient Centeredness & Engagement as well as partnering with other patient care channels.

CONCLUSION

This study highlighted the predisposition of health centers to implement a BPS approach to their organizational capacities. The study highlights how national policies could regulate the organization of health services on the front line by relying more on the culture of teamwork in the care structures and focusing on the needs of the patients. Paying particular attention to the values of the agents and specific key processes could enable the implementation of the BPS approach at the health center level.

People-centred primary health care: a scoping review

BACKGROUND

Integrated people-centred health services (IPCHS) are vital for ensuring comprehensive care towards achieving universal health coverage (UHC). The World Health Organisation (WHO) envisions IPCHS in delivery and access to health services. This scoping review aimed to synthesize available evidence on people-centred primary health care (PHC) and primary care.

METHODS

We conducted a scoping review of published literature on people-centred PHC. We searched eight databases (PubMed, Scopus, Embase, CINAHL, Cochrane, PsycINFO, Web of Science, and Google Scholar) using search terms related to people-centred and integrated PHC/primary care services. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist to select studies. We analyzed data and generated themes using Gale's framework thematic analysis method. Themes were explained under five components of the WHO IPCHS framework.

RESULTS

A total of fifty-two studies were included in the review; most were from high-income countries (HICs), primarily focusing on patient-centred primary care. Themes under each component of the framework included: engaging and empowering people and communities (engagement of community, empowerment and empathy); strengthening governance and accountability (organizational leadership, and mutual accountability); reorienting the model of care (residential care, care for multimorbidity, participatory care); coordinating services within and across sectors (partnership with stakeholders and sectors, and coordination of care); creating an enabling environment and funding support (flexible management for change; and enabling environment).

CONCLUSIONS

Several people-centred PHC and primary care approaches are implemented in HICs but have little priority in low-income countries. Potential strategies for people-centred PHC could be engaging end users in delivering integrated care, ensuring accountability, and implementing a residential model of care in coordination with communities. Flexible management options could create an enabling environment for strengthening health systems to deliver people-centred PHC services.

Impacts of disrespectful care and abusive care practices in maternity units and potential interventions to improve the quality of care in low- and middle-income countries: A narrative review

This review article explored the impacts of disrespectful care and abusive care practices and the potential interventions to eliminate those practices. Respectful maternity care is a fundamental right for all women. It ensures that women are able to exercise their rights in maternity care. However, research studies have shown the recent prevalence of poor-quality care for women in maternity units in low- and middle-income countries. The literature on this topic was searched on PubMed, Medline, Google Scholar, Cochrane, Science Direct/ Elsevier, and SCOPUS. A total of 24 qualitative and quantitative research articles were included. Thematic analysis was conducted by using the six steps. Impacts are coded on topics including psychological impacts due to disrespectful and abusive care practices, impact on the care process, normalization of the absence of care, suppression of knowledge regarding the labor process, and poor obstetric outcomes. Interventions are coded on topics including programs for health professionals to improve care, education and empowerment programs targeting the women and community, enacting policies and guidelines regarding disrespectful and abusive care practices and improving the facilities in the healthcare system. The majority of the evidenced-based interventions were multi-component and tailored to the needs of a particular setting. More research evidence is needed to inform the healthcare authorities and policymakers to transform these potential interventions into practice. Future research should clearly document the effectiveness of various combinations of interventions, feasibility, cost-effectiveness, and outcomes.

Provider perspectives on patient-centredness: participatory formative research and rapid analysis methods to inform the design and implementation of a facility-based HIV care improvement intervention in Zambia

INTRODUCTION

Implementation of patient-centred care (PCC) practices in HIV treatment depends on healthcare workers' (HCWs) perceptions of the acceptability, appropriateness and feasibility of such practices (e.g. use of intentional, metric-driven activities to improve patient experiences).

METHODS

We applied rapid, rigorous formative research methods to refine a PCC intervention for future trial. In 2018, we conducted focus group discussions (FGDs) with 46 HCWs purposefully selected from two pilot sites. We elicited HCW perceptions of HIV service delivery, HCW motivation and perceived value of patient experience measures intended to improve PCC. FGDs utilized participatory methods to understand HCW responses to patient-reported care engagement challenges and Scholl's PCC Framework principles (e.g. seeing a patient as a unique person), enablers (e.g. care coordination) and activities (e.g. patient involvement). Our rapid analysis used analytic memos, thematic analysis, research team debriefs and HCW feedback to inform time-sensitive trial implementation.

RESULTS

While HCWs nearly universally identified with and supported principles of PCC in both facilities, they raised practical barriers given the practice environment. HCWs described motivation to help patients, attached value to seeing positive health outcomes and the importance of teamwork. However, HCWs reported challenges with enablers needed to deliver PCC. HCWs cited a work culture characterized by differential power dynamics between cadres and departments restricting HCW autonomy and resource access. Barriers included inflexibility in accommodating individual patient needs due to high patient volumes, limited human resources, laboratory capacity, infrastructure and skills translating patient perspectives into practice. HCW motivation was negatively influenced by encounters with "difficult patients," and feeling "unappreciated" by management, resulting in cognitive dissonance between HCW beliefs and behaviours. However, the enactment of PCC values also occurred. Results suggested that PCC interventions should reduce practice barriers, highlighting the value of mentors who could help HCWs dynamically engage with health system constraints, to facilitate PCC.

CONCLUSIONS

While HCWs perceived PCC principles as acceptable, they did not think it universally appropriate or feasible given the practice environment. Participatory and rapid methods provided timely insight that PCC interventions must provide clear and effective systems enabling PCC activities by measuring and mitigating relational and organizational constraints amenable to change such as inter-cadre coordination.

Kusankha Pamodzi: Health Care Decision-Making Preferences Among Patients with Cancer in Malawi

Background

Oncology teams are encouraged to include patient preferences and goals of care in determining appropriate treatment courses. There are no existing data from Malawi exploring decision-making preferences among cancer patients.

Methods

In the oncology clinic in Lilongwe, Malawi, 50 patients were surveyed for decision making.

Results

Most participants (70%, n = 35) preferred to engage in shared decision making regarding cancer treatment. About half (52%, n = 24) did not feel that their medical team involved them in decision making and 64% (n = 32) felt that they were never or only sometimes listened to by the medical team. Nearly all (94%, n = 47) preferred to have their medical team inform them how likely treatments are to lead to cure.

Conclusions

Shared decision making was the preferred mode of treatment decision making by the majority of the surveyed cancer patients in Malawi. Cancer patients in Malawi may have similar preferences to cancer patients in other low-resource settings regarding decision making and communication.

Clients satisfaction at primary healthcare facilities and its association with implementation of client service charter in Tanzania

Background

Client service charter (CSC) provides information about what people can expect in a facility’s services; what is expected of clients and service providers. Tanzania implemented Star Rating Assessment (SRA) of primary health care (PHC) facilities in 2015/16 and 2017/18 using SRA tools with 12 service areas. This paper assesses the status of service area 7, namely client focus that checked if client was satisfied with services provided and implementation of CSC through three indicators–if: CSC was displayed; CSC was monitored; client feedback mechanism and complaints handling was in place.

Methods

We extracted and performed a cross-sectional secondary data analysis of data related to clients’ focus that are found in national SRA database of 2017/2018 using STATA version 15. Client satisfaction was regarded as dependent variable while facility characteristics plus three indicators of CSC as independent variables. Multivariate logistic regression with p-value of 5% and 95% confidence interval (CI) were applied.

Results

A total of 4,523 facilities met our inclusion criteria; 3,987 (88.2%) were dispensaries, 408 (9.0%) health centres and 128 (2.8%) hospitals. CSC was displayed in 69.1% facilities, monitored in 32.4% facilities, and 32.5% of the facilities had mechanisms for clients’ feedback and handling complaints. The overall prevalence of clients’ satisfaction was 72.8%. Clients’ satisfaction was strongly associated with all implementation indicators of CSC. Clients from urban-based facilities had 21% increased satisfaction compared rural-based facilities (AOR 1.21; 95%CI: 1.00–1.46); and clients from hospitals had 39% increased satisfaction compared to dispensaries (AOR 1.39; 95%CI: 1.10–1.77).

Conclusion

The implementation of CSC is low among Tanzanian PHC facilities. Clients are more satisfied if received healthcare services from facilities that display the charter, monitor its implementation, have mechanisms to obtain clients feedback and handle complaints. Clients’ satisfaction at PHC could be improved through adoption and implementation of CSC.

Current practices and future preferences of type 2 diabetes care in Ethiopia: A qualitative study on the perspectives of patients, health professionals, and policymakers

BACKGROUND AND AIMS

This study aimed to examine perspectives of patients, health professionals, and policymakers on current practices and their future preferences for type 2 diabetes care in a tertiary hospital in Ethiopia.

METHODS

An exploratory qualitative study was undertaken through interviews and focus groups with patients, health professionals, and policymakers. The participants were purposively sampled. Thematic analysis was undertaken.

RESULTS

Fifty-nine participants were involved in the study. Participants' perspectives on current practices and future preferences comprised three themes: organisation of type 2 diabetes care delivery and infrastructure; continuity of care; and structured diabetes education. The current organisation comprised physicians, such as endocrinologists and endocrinology fellows, and nurses. Some nurses received training on diabetes foot and diabetic eye, which enabled patients to receive diabetes foot and diabetic eye care, respectively. The hospital lacked essential resources, such as medications, laboratory and diagnostic services, and diabetes educators, which hindered patient-centred care. Patients complained that the physical set-up at the hospital was not conducive to their privacy during consultations. Participants reported infrequent patient follow-up and monitoring, which contributed to uncontrolled diabetes. Future preferences involved access to essential resources and comprehensive diabetes care, such as structured diabetes education for improved patient outcomes. Participants sought out the development of tailored and context-specific diabetes management approaches that could meet specific patient needs and preferences.

CONCLUSIONS

The findings have implications for designing patient-centred diabetes care tailored to the hospital's context and key stakeholders' preferences. This tailoring requires strong leadership to ensure availability of essential resources.

Social Context, Self-Efficacy, and Patient-Centered Service Behavior of Medical Professionals: The Moderating Role of Achievement Motivation

Patient-centered services are high-value, high-quality medical services that can improve patient satisfaction and safety. However, little is known about their driving mechanisms. This study examined whether external (social context) and internal (self-efficacy) motivation affects medical professionals' patient-centered service behavior, and explored the moderating role of medical professionals' achievement motivation. A cross-sectional survey was conducted with medical professionals at public hospitals in Hangzhou. Descriptive statistics, hierarchical linear regression analysis, and structural equation modeling were used to analyze the data. The final analysis included 1,612 medical professionals. Results indicated that perceived social context and self-efficacy had direct and positive effects (β = 0.578, β = 0.269) on medical professionals' patient-centered service behavior. Social context also indirectly influenced medical professionals' patient-centered service behavior mediated by self-efficacy (β = 0.149). Additionally, achievement motivation played a moderating role (β = -0.037) between the social context and self-efficacy. From the results it can be deduced that an excellent social environment and strong self-efficacy can promote the patient-centered service motivation of medical professionals. This promoting effect is even more significant under the moderating effect of high achievement motivation. Governments, health administrative departments, and hospital management should use internal and external motivation factors to promote medical professionals' patient-centered service behavior. Along with formulating relevant laws and regulations, efforts should also be made to guide medical professionals to improve their self-efficacy and achievement motivation, thereby encouraging patient-centered medical service behavior.

Intra-household Variation in Pathways to Care for Epilepsy and Mental Disorders in Eastern Uganda

Integrating mental, neurological, and substance use (MNS) health care into the public health system has become a global priority, with mental health, and well-being now being part of the Sustainable Development Goals. In the aim to provide good quality care for MNS disorders, understanding patients' pathways to care is key. This qualitative study explores the pathways to care of patients attending an outpatient mental health clinic of a district hospital in eastern rural Uganda, from the perspectives of their caregivers. Twenty seven in-depth interviews were conducted with caregivers of MNS patients visiting the clinic, with a focus on four case-presentations. Data analysis consisted of thematic and emergent content analyses using NVivo 11. Results across all interviews highlight that chosen help-seeking itineraries were largely pluralistic, combining and alternating between traditional healing practices, and biomedical care, regardless of the specific MNS disorder. Intra-household differences in care seeking pathways—e.g., where one patient received traditional help or no care at all, while the other received biomedical care—depended on caregivers' perceived contextual illness narrative for each patient, in combination with a variety of other factors. If interpreted as a form of bewitchment, traditional medicine and healing was often the first form of care sought, while the mental health clinic was seen as a recourse to “free” care. Patients, especially younger children, who showed visible improvements once stabilized on psychotropic medication was a source of motivation for caregivers to continue with biomedical care at the mental health clinic. However, stock-outs of the free psychotropic medication at the clinic led to dissatisfaction with services due to out-of-pocket expenses and precipitated returning to alternative therapy choices. This article showcases the importance of understanding the complex and varied combinations of individual, cultural, socioeconomic and structural factors that may affect caregivers' choices of pathways to care for patients with MNS disorders in eastern rural Uganda. These cumulative complex processes and context-specific help-seeking behaviors, which ultimately impact patient treatment and MNS health outcomes, need to be first acknowledged, understood and taken into account if we are to promote more inclusive, effective and integrated public mental health systems globally.

EVANGELICALISM IN UGANDA: IMPLICATIONS FOR PUBLIC HEALTH AND BIOETHICS

Considered attention is needed to the interplay between evangelical and charismatic religions and legislation in Uganda and their implications for public health, bioethics, and medical education. This manuscript examines the growth of the evangelical and charismatic movements in Uganda during the past several decades, concurrent trends in the formulation and implementation of law and public policy, and implications for the prevention and treatment of sexually transmitted infections, family violence, physician-patient communication, and medical and health education. The article concludes with suggested strategies to address the adverse consequences stemming from the interjection of religious perspectives into the domains of public health, clinical care, and health education.

Community participation in the collaborative governance of primary health care facilities, Uasin Gishu County, Kenya

INTRODUCTION

Community participation in the governance of health services is an important component in engaging stakeholders (patients, public and partners) in decision-making and related activities in health care. Community participation is assumed to contribute to quality improvement and goal attainment but remains elusive. We examined the implementation of community participation, through collaborative governance in primary health care facilities in Uasin Gishu County, Western Kenya, under the policy of devolved governance of 2013.

METHODS

Utilizing a multiple case study methodology, five primary health care facilities were purposively selected. Study participants were individuals involved in the collaborative governance of primary health care facilities (from health service providers and community members), including in decision-making, management, oversight, service provision and problem solving. Data were collected through document review, key informant interviews and observations undertaken from 2017 to 2018. Audio recording, notetaking and a reflective journal aided data collection. Data were transcribed, cleaned, coded and analysed iteratively into emerging themes using a governance attributes framework.

FINDINGS

A total of 60 participants representing individual service providers and community members participated in interviews and observations. The minutes of all meetings of five primary health care facilities were reviewed for three years (2014-2016) and eight health facility committee meetings were observed. Findings indicate that in some cases, structures for collaborative community engagement exist but functioning is ineffective for a number of reasons. Health facility committee meetings were most frequent when there were project funds, with discussions focusing mainly on construction projects as opposed to the day-to-day functioning of the facility. Committee members with the strongest influence and power had political connections or were retired government workers. There were no formal mechanisms for stakeholder forums and how these worked were unclear. Drug stock outs, funding delays and unclear operational guidelines affected collaborative governance performance.

CONCLUSION

Implementing collaborative governance effectively requires that the scope of focus for collaboration include both specific projects and the routine functioning of the primary health care facility by the health facility committee. In the study area, structures are required to manage effective stakeholder engagement.

Shared decision-making between health care providers and patients at a tertiary hospital diabetic Clinic in Tanzania

Background

Patients’ participation in decision making regarding their treatment is defined in ethical, legal and human rights standards in the provision of care that concerns health providers and the entire community. This study was conducted to document experiences of patients and health care providers on shared decision making.

Methods

This study employed a phenomenological study design using in-depth interview technique. Study participants were diabetic patients visiting the clinic and healthcare providers working at Muhimbili National Hospital. Data was collected using the semi-structured interview guide with open-ended questions using an audio digital recorder. Content analysis method was used during analysis whereby categories were reached through the process of coding assisted by Nvivo 12 software.

Results

Participants in this study expressed the role of shared decision-making in the care of patients with diabetes, with report of engagement of patients by health care providers in making treatment decisions. Participants reported no use of decision-making aids; however, health education tools were reported by participants to be used for educating patients. Limited time, patient beliefs and literacy were documented as barriers of effective engagement of patients in decision making by their healthcare providers.

Conclusion

Engagement of patients in decision-making was noted in this study as experienced by participants of this study. Time, patient beliefs and patient literacy were documented as barriers for patients engagement, therefore diabetic clinic at Muhimbili National Hospital need to devise mechanisms for ensuring patients involvement in treatment decisions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06041-4.

Patients' Involvement in Decision-Making During Healthcare in a Developing Country: A Cross-Sectional Study

PURPOSE

Patient autonomy and participation have a significant impact on patient satisfaction and compliance with treatment. We aimed to establish and describe the level of shared decision-making (SDM) among the patients in a developing country. Uganda is a low resource country with a 2019 GDP of 35.17 billion US dollars. In some regions, over 60% of Ugandans live below the national poverty line and most of them depend on the underfunded health care system.

METHODS

A cross-sectional, quantitative study was carried out among the outpatients attending Kisenyi Health center IV, Kampala, Uganda. An interviewer-administered questionnaire with a 5-point Likert scale was used to assess patients' SDM. All statistical analysis was performed using STATA 15 software.

RESULTS

A total of 326 patients participated in this study. Majority of the participants were females (n=241, 73.9%) and aged 18-35 years (n=218, 66.9%). Only 22 (7%) of the participants knew the name of their consulting doctor. Most of the participants, 84% were given enough time to narrate their symptoms. Overall, only 11.3% (n=37) of the participants had adequately participated in SDM. The overall mean score of participation in SDM was 2.7 (SD:0.8). Participants who knew the name of their consulting doctor were approximately 11 times more likely to participate in SDM (OR: 10.7, 95% CI: 4.2-27.0, P<0.0001).

CONCLUSION

The majority of patients attending Kisenyi Health Center IV did not adequately participate in SDM. Continued medical education should be organized for healthcare professionals to promote SDM.

Patient perspectives on interpersonal aspects of healthcare and patient-centeredness at primary health facilities: A mixed methods study in rural Eastern Uganda

INTRODUCTION

Patient-centered care (PCC) is an approach to involve patients in health care delivery, to contribute to quality of care, and to strengthen health systems responsiveness. This article aims to highlight patient perspectives by showcasing their perceptions of their experience of PCC at primary health facilities in two districts in Uganda.

METHODS

A mixed methods cross-sectional study was conducted in three public and two private primary health care facilities in rural eastern Uganda. In total, 300 patient exit survey questionnaires, 31 semi-structured Interviews (SSIs), 5 Focus Group Discussions (FGDs) and 5 feedback meetings were conducted. Data analysis was guided by a conceptual framework focusing on (1) understanding patients' health needs, preferences and expectations, (2) describing patients perceptions of their care experience according to five distinct PCC dimensions, and (3) reporting patient reported outcomes and their recommendations on how to improve quality of care.

RESULTS

Patient expectations were shaped by their access to the facility, costs incurred and perceived quality of care. Patients using public facilities reported doing so because of their proximity (78.3% in public PHCs versus 23.3% in private PHCs) and because of the free services availed. On the other hand, patients attending private facilities did so because of their perception of better quality of care (84.2% in private PHCs versus 21.7% in public PHCs). Patients expectations of quality care were expressed as the availability of medication, shorter waiting times, flexible facility opening hours and courteous health workers. Analysis of the 300 responses from patients interviewed on their perception of the care they received, pointed to higher normalized scores for two out of the five PCC dimensions considered: namely, exploration of the patient's health and illness experience, and the quality of the relationship between patient and health worker (range 62.1-78.4 out of 100). The qualitative analysis indicated that patients felt that communication with health workers was enhanced where there was trust and in case of positive past experiences. Patients however felt uncomfortable discussing psychological or family matters with health workers and found it difficult to make decisions when they did not fully understand the care provided. In terms of outcomes, our findings suggest that patient enablement was more sensitive than patient satisfaction in measuring the effect of interpersonal patient experience on patient reported outcomes.

DISCUSSION AND CONCLUSION

Our findings show that Ugandan patients have some understanding of PCC related concepts and express a demand for it. The results offer a starting point for small scale PCC interventions. However, we need to be cognizant of the challenges PCC implementation faces in resource constrained settings. Patients' expectations in terms of quality health care are still largely driven by biomedical and technical aspects. In addition, patients are largely unaware of their right to participate in the evaluation of health care. To mitigate these challenges, targeted health education focusing on patients' responsibilities and patient's rights are essential. Last but not least, all stakeholders must be involved in developing and validating methods to measure PCC.