Towards Enhanced Healthcare: A Mixed Methods Exploration of Responsiveness in Gamo Gofa Zone Hospitals, Southern Ethiopia

Study design

This study employs a mixed-methods approach that incorporates both a cross-sectional survey and focus group discussions. The data collection period spanned from March 2011 to June 2013.

Study setting and participants

This study was conducted in three public hospitals situated within the Gamo Gofa Zone of the Southern Nations, Nationalities, and People’s Region (SNNPR) of Ethiopia. The zone, encompassing 29 districts with a total population of 1,597,767, features key healthcare facilities such as one zonal hospital (Arba Minch), two district hospitals (Chencha and Sawula), 21 health centers, 46 rural health centers and stations, and 463 health posts. Notably, the zone has witnessed a growth in the number of healthcare institutions (Gamo Gofa Zone Health Department Annual Report, 2010).

The sample size for the cross-sectional survey was calculated using the single population proportion formula, considering a population prevalence of 0.5, a 95% confidence level, and an alpha value of 0.05 for the margin of error. The total sample size was 422, with a non-response rate of 10%. A proportional-to-size allocation was employed to distribute participants to each hospital. This allocation was based on the proportion of patients who visited outpatient and inpatient departments in the month preceding the study period. Subsequently, respondents from the respective hospitals were selected using a systematic sampling procedure. All patients who were not in a critical condition, as well as parents or caregivers of children or critically ill patients, were eligible to be interviewed.

Focus group discussions were conducted in all three hospitals, with each group consisting of 10 to 12 members. Participants were purposefully selected from among residents who had used healthcare services from hospitals within the past year and did not participate in the interview. Focus group discussions were concluded after eight sessions, as information saturation was reached, with a total of 72 participants.

Data collection instruments and procedures

The data for this study were collected using a structured questionnaire and discussion guide adapted from prior studies and translated into Amharic to ensure relevance to the study setting (Ustun et al., 2003; WHO, 2001). Trained interviewers conducted patient exit interviews in a private room within the hospital compound to ensure privacy and confidentiality. The interview took place after the respondents had received all necessary services and utilized a structured questionnaire to assess various aspects of health service responsiveness.

The focus group discussions, each lasting 90 min, commenced with a concise introduction of the topic by the principal investigator. The discussion topics encompassed 1) positive experiences of engaging with healthcare providers, 2) negative experiences of engaging with healthcare providers, and 3) perceived characteristics of responsive healthcare systems. The tape-recording of the discussions was conducted with the explicit consent of all participants, thereby ensuring comprehensive collection of qualitative data.

Data analysis

The quantitative data were entered into SPSS version 26 and subjected to a comprehensive process that included cleaning, editing, and coding. Descriptive statistics were employed to calculate frequencies, while mean scores were computed for Likert Scale instruments using a range of 1 to 5 (1 = very bad to 5 = very good) to assess the level of responsiveness. Principal component analysis was performed to reveal the majority of variances by employing a reduced number of factors, enabling the treatment of variables as continuous in subsequent regression analyses. This analysis employed the principal component extraction method with an eigenvalue of one or higher and utilized varimax rotation methods. Satisfaction scores were obtained using factor analysis. Wealth quantiles were established, and bivariate and multiple linear regressions were employed to identify factors influencing responsiveness in the outpatient department (OPD). A statistical significance level of 0.05 was applied in all analyses.

For the qualitative data, audiotapes from each session were transcribed verbatim, translated into English, and imported into a qualitative data management software (QSR NVivo 9) for analysis. A thematic analysis approach was employed to organize emerging themes from the data, and the results were presented in a narrative form. The findings derived from the qualitative data were then triangulated with the quantitative data to ensure a comprehensive and nuanced interpretation of the study results.

Ethical consideration

The study adhered to ethical standards in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Arba Minch University Ethical Review Committee on November 30/2011 (reference number: RCS/014/03). Official permission to conduct the study was granted by the administrators of the participating hospitals.

Consent to participate

Prior to participation, all participants received detailed information about the study, including its purpose, potential benefits and risks, and assurances of privacy and confidentiality. Informed consent was obtained verbally, either directly from the participants or from their caregivers for those unable to provide consent themselves. The decision to use verbal consent was approved by the ethics committee and was chosen to accommodate participants who might face literacy challenges or felt hesitant about signing documents. This approach ensured inclusivity and comfort during the consent process. The verbal consent procedure was documented and adhered to the ethical standards set by the approving ethics committee.

Characteristics of the survey respondents

In total, 419 participants participated in the survey, resulting in a response rate of 99.28%. The median age of the participants was 28 years (range: 12–85 years). Among all the respondents, 87.8% were users of outpatient services ( Table 1).

Health service utilization pattern

Among the outpatient service users, the primary reasons for hospital visits were illness (93.5%) and checkups (6.5%), with 51.6% being first-time visitors. Among the inpatient service users, 68.6% were new visitors. Of the 16 repeat inpatient service users, 31.3% were admitted at least once in the last month and another 31.3% were admitted at least once in the last year. During their present visit, 49% of the inpatient service users stayed in the hospitals for 3-5 days, whereas 39.2% stayed for 1-2 days.

The median travel time for outpatient service users was 30 minutes, with the range falling between 5 minutes and 3 and half hours. In comparison, the median travel time for inpatient service users was approximately 45 minutes, with a range extending from 1 minute to 10 hours.

Level of responsiveness

The mean scores showed that confidentiality received the highest rating among outpatient respondents, whereas dignity received the highest rating among inpatient respondents. Conversely, prompt attention and quality of basic amenities received the lowest mean scores among outpatient and inpatient respondents, respectively. Social support was ranked as the second-lowest score component in inpatient health services ( Table 2).

In the present study, only 10.3% of the total outpatient respondents reported having the necessary information to choose their healthcare provider. Most respondents (35.3%) received treatment from nurses, followed by health officers (25.8%). Similarly, 20.1% and 15.8% of the respondents were treated by medical doctors (general practitioners and specialists) and midwives, respectively. Notably, 75% of the care providers were male.

Principal components of responsiveness with outpatient health services

In the principal component analysis (PCA), three components emerged, each with eigenvalues greater than one, collectively accounting for 58.1% of the variance in outpatient health service responsiveness. Patient-centered communication (Component 1), comprising eight items, explained 31.0% of the total variance, as depicted in Figure 1. Moreover, the patient-centered care environment (Component 2), consisting of five items, explained 18.2% of the variance, while prompt attention (Component 3), featuring one item related to prompt attention, accounted for 8.9% of the total variance.

Figure 1. Principal components of health service responsiveness in hospitals, Gamo Gofa zone, 2013.

Predictors of responsiveness with outpatient health services

In a bivariate regression analysis, various factors including occupation, educational status, marital status, wealth score, sex, age, ethnicity, religion, means of transportation, self-judged health status, expectation of services, perceived possibility of an appointment, possession of information to choose care providers, consultation duration, and satisfaction score, were analyzed as predictors of the components identified through PCA. Table 3 presents the statistically significant variables in Model 1. These variables were then included in the multiple linear regression analysis and their values are shown in Model 2 of Table 3. According to the results of the bivariate model, public employees had 0.37 units higher (p≤0.001) score in the patient-centered care environment than students. The means of transportation also demonstrated a significant impact on all components, with patients who arrived on foot scoring 0.35 units higher (p≤0.001) in patient-centered communication than those using public transportation.

In the multiple linear regression model, patients who self-judged their health status as “very well” had a 0.6 units higher score (p≤0.001) for prompt attention compared to those with a “good” self-judged status. Respondents who were uncertain about the possibility of appointments when needed scored 0.57 units lower (p≤0.001) in patient-centered communication. Similarly, patients lacking information to choose their healthcare provider had a 1.34 units lower score (p≤0.001) in the patient-centered care environment than those with information.

Qualitative part

The findings obtained from the focus group discussions offer valuable insights into various aspects of responsiveness to healthcare. The results revealed distinct themes and subthemes that were systematically categorized within the six pre-classified components of responsiveness, and one newly emerged theme. These findings contribute to a refined understanding of the healthcare experiences and perceptions of the participants.

1. Autonomy:

Under the theme of autonomy, the emergent subtheme of lack of shared decision making was identified as a concern among participants. They expressed frustration with the discharge of patients without improvement and perception of excessive referrals. Participants highlighted instances in which care providers made decisions without adequate patient assessment, thereby limiting their involvement in the decision-making process. A participant from Arba Minch shared his father’s experiences with Arba Minch Hospital. He stated that his father was discharged from the hospital, despite not showing any improvement after completing his medication.

2. Prompt attention:

Four subthemes were identified: carelessness, insensitivity to time, transportation difficulties, and enhanced reception services. Participants reported instances of carelessness and insensitivity to time on the part of providers, which led to negative consequences, such as missed work and denial of treatment. One participant described a significant incident that occurred while caring for his sister at a hospital. The situation involved a young woman who required intravenous (IV) infusion but had exhausted the available glucose supply in the cannula, resulting in distress. Another participant from Sawula Hospital expressed his concerns, stating, “If they do not know you personally, they will tell their assistant to give you a bed and then they leave… When you come back after buying the prescribed medications, they are already gone; who can help you then?" On the other hand, transportation challenges were identified, particularly the difficulties of carrying patients over long distances using a traditional stretcher locally known as Kareza. However, there were improvements in hospital reception services following the implementation of business process reengineering (BPR).

3. Quality of basic amenities

The subtheme of Unsafe Night arose from concerns regarding basic amenities, specifically in relation to noise and light-related issues. Participants shared their experiences of how noise from adjacent rooms and overcrowded single rooms affected their inpatient experience. Furthermore, light-related problems were identified as causing delays in care and restricting caregivers’ movement. A discussant from Chencha recounted his experience, stating, “I came with my wife, but there was no power. We had to wait a long time. The darkness is more disturbing than our pain at night, as caregivers fall in the rooms due to the absence of light." Although progress has been made in improving the physical structure, decentralized payment centers, and hospital cleanliness, much work remains to be done to address these concerns.

4. Provider choice:

The subthemes that emerged in relation to provider choice were perceived provider competence, limited choices, and weak supervision. These were explored through codes such as professional ethics, concerns about diagnosis and drug prescriptions, and low trust in the quality of healthcare providers’ training. In addition, the challenges faced when choosing providers are discussed, including issues such as shortages, turnover, and doctor fatigue. However, a positive anecdote from Chencha Hospital highlighted recent acts of doctors, with one participant commenting, " … A doctor donated his blood to her and saved her life. This was a humane and worthwhile deed in God’s and our eyes."

5. Dignity:

The subthemes of discrimination, mistreatment, and insecurity were identified within the dignity component. Participants acknowledged a decrease in discrimination following the implementation of business process reengineering (BPR), with instances cited from previous experiences of healthcare providers prioritizing individuals they knew personally. Experiences of mistreatment and insecurity were also disclosed, underscoring the need for further improvement. One participant highlighted the significance of the provider approach, declaring, "The best thing for a human being is giving hope…and if you have a good approach, the patient who is dying may recover. But if you insult him… he would rather like to die."

6. Social support:

The subthemes identified regarding social support were a lack of empathy and short visiting periods. Respondents conveyed that hospital personnel appeared to be less attentive and allowed insufficient visiting time despite a substantial demand for visits. Additionally, instances of inadequate cooperation with family caregivers have been acknowledged. One such instance was recounted by a participant from Arba Minch Hospital, where a university student attempted to return to her friend’s hospital room but was denied entry by the guard because she forgot her caregiver’s badge at the hospital when she left for an exam at her university. This incident was presented as an indication of low empathy among hospital staff. Furthermore, despite a significant number of family members and relatives visiting the hospitals, their visiting times were brief. One participant expressed the challenges they faced: “When my relatives visited me on weekends, it was overcrowded at the entrance door, and the allowed visiting time was from 2:00 PM to 3:00 PM” (Discussant from Arba Minch Hospital).

7. Desired service development

The discussion on desired service development revealed two key sub themes: accessibility and coordination of services and improvements to basic amenities. Participants emphasized the importance of healthcare resource availability, prompt and coordinated care, and well-organized services. Additionally, there was strong desire for improved basic amenities, including cafeterias, food shops, and a clean, well-structured hospital. These improvements were highlighted as essential for enhancing the overall healthcare experience.