Doctoral Degrees (Family Medicine and Primary Care)

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Browsing Doctoral Degrees (Family Medicine and Primary Care) by Author "Mohamoud, Gulnaz"

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    An evaluation of the quality of service delivery in private primary care facilities in Nairobi, Kenya
    (Stellenbosch : Stellenbosch University, 2021-12) Mohamoud, Gulnaz; Mash, Robert; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Family and Emergency Medicine. Family Medicine and Primary Care.
    ENGLISH SUMMARY : Introduction: The World Health Organization (WHO) states that well-functioning primary health care (PHC) should be the foundation of effective health systems. Primary care (PC) is a subset of PHC, and is a “key process in the health system that supports first-contact, accessible, continued, comprehensive and coordinated patient-focused care.” In sub-Saharan Africa (SSA), health systems still face many challenges and PC remains poorly functioning in many countries. Measuring the quality of PC service delivery and identifying the strengths and weaknesses will help policy makers and implementers improve PC and achieve better health outcomes. Kenya’s Health Policy 2012-2030 aims to promote higher quality and better access to services, however, “quality” remains a major challenge. The private health care system provides 52% of all health care services and may have a bigger role to play in the future. In Kenya, most of the PC in the private sector is provided by general practitioners (GPs), the majority of whom do not have specialist postgraduate training. Due to diversity and fragmentation of the private PC system, there is little data on the strengths and weaknesses of key elements of PC service delivery. Hence, the new knowledge from our study is aimed at kick-starting future evaluations leading to a long term improvement in quality in service delivery in line with the existing and new health needs that are anticipated over the next few decades. The main aim of this study was to evaluate the quality of service delivery in PC facilities by GPs in the private sector in Nairobi, Kenya. Five studies were performed to measure the key elements of quality PC: first-contact access, coordination, continuity, comprehensiveness and person-centredness. The abstracts for the five articles are provided below. Article 1: Perceptions regarding the scope of practice of family doctors amongst patients in primary care settings in Nairobi. Background: Primary care is the foundation of the Kenyan health care system, providing comprehensive care, health promotion and managing all illnesses across the lifecycle. In the private sector in Nairobi, PC is principally offered by general practitioners. Little is known about how patients perceive their capability. The aim was to assess patients’ perceptions of the scope of practice of GPs working in private sector PC clinics in Nairobi and their awareness of the new discipline of family medicine. Methods: A descriptive survey using a structured, self-administered questionnaire in eight private sector PC clinics in Nairobi. Simple random sampling was used to recruit 162 patient participants. Results: Of the participants, only 30% knew the difference between FPs and GPs. There was a high to moderate confidence (>60%) that GPs could treat common illnesses, provide lifestyle advice, offer family planning and childhood immunisations. In adolescents and adults, low confidence (<60%) was expressed in their ability to manage tuberculosis, human immunodeficiency virus and cancer. In the elderly, there was low confidence in their ability to manage depression, anxiety, urinary incontinence and diabetes. There was low confidence in their ability to provide antenatal care and pap smears. Conclusion: Patients did not perceive that GPs could offer fully comprehensive PC services. These perceptions may be addressed by defining the expected package of care, designing a system that encourages the utilisation of PC and employing family physicians. Article 2: Evaluation of the quality of service delivery in private sector, primary care clinics in Kenya. Background: The quality of PC service delivery is an important determinant of clinical outcomes. The patients’ perspective is one significant predictor of this quality. Little is known of the quality of such service delivery in the private sector in Kenya. The aim of the study was to evaluate the quality of service delivery from the patient’s perspective in private sector, PC clinics in Nairobi, Kenya. Methods: The study employed a descriptive cross-sectional survey by using the General Practice Assessment Questionnaire in 378 randomly selected patients from 13 PC clinics. Data were analysed using the Statistical Package for Social Sciences. Results: Overall, 76% were below 45 years, 74% employed and 73% without chronic diseases. Majority (97%) were happy to see the general practitioner (GP) again, 99% were satisfied with their consultation and 83% likely to recommend the GP to others. Participants found the receptionist helpful (97%) and the majority were happy with the opening hours (73%) and waiting times (85%). Although 84% thought appointments were important, only 48% felt this was easy to make, and only 44% were able to access a particular GP on the same day. Overall satisfaction was higher in employed (98%) versus those unemployed (95%), studying (93%) or retired (94%) (p < 0.001). Conclusion: Patients reported high satisfaction with the quality of service delivery. Utilisation was skewed towards younger, employed adults, without chronic conditions, suggesting that PC was not fully comprehensive. Services were easily accessible, although with little expectation of relational continuity. Further studies should continue to evaluate the quality of service delivery from other perspectives and tools. Article 3: Evaluation of the quality of communication in consultations by general practitioners in primary care settings, Nairobi, Kenya. Background: Primary care is the starting point for patients seeking health care. High quality PC requires effective communication to support person-centredness, continuity and coordination of care, and better health outcomes. In Kenya, there is very scanty knowledge about the quality of communication in consultations by GPs in the private sector. Hence, the aim was to evaluate the quality of communication in consultations by GPs. Methods: Descriptive, observational cross-sectional study of 23 GPs consultations in 13 primary care facilities in Nairobi. One consenting adult patient was randomly selected from the GP’s list for an audio recording of their consultation. Audio recordings were assessed using the Stellenbosch University Observation Tool. The overall score for each consultation was obtained out of a maximum of 32. Data was analysed using the Statistical Package for Social Sciences version 25. Results: The median age of the GPs was 30.0 years (IQR: 29-32) with a median of 3-years’ experience after graduation (IQR=3-6). Median consultation time was 7.0 minutes (IQR=3-9). Median score of the consultations was 64.3% (IQR: 48.4-75.7). The GPs fully performed skills in gathering information, making a diagnosis and in its explanation and management. The GPs did not make an appropriate introduction, nor explore the family and social context or patient’s perspective. Patients were not fully involved in the shared decision making process. Safety netting and closure was not fully addressed. There was a significant positive correlation between the consultation scores and duration of the consultations (r=0.680, p=0.001). Conclusion: Consultations were brief, with low-to-moderate complexity and had a biomedical approach. Training in communication skills with the goal of providing person-centred care will result in higher quality consultations and PC. Article 4: The quality of primary care performance in private sector facilities in Nairobi, Kenya. Background: Integrated health services with an emphasis on PC are needed for effective primary health care and achievement of universal health coverage. The key elements of high quality PC are first-contact access, continuity, comprehensiveness, coordination, and person-centredness. In Kenya, there is little information on these key elements and such information is needed to improve service delivery. This study aimed to evaluate the quality of PC performance in a group of private sector clinics in Nairobi, Kenya. Methods: A cross-sectional descriptive study adapted the Primary Care Assessment Tool (PCAT) for the Kenyan context and surveyed 412 systematically sampled PC users, from 13 PC clinics. Data was analysed to measure 11 domains of PC performance and two aggregated PC scores using the Statistical Package for Social Sciences. Results: Mean primary care score was 2.64 (SD=0.23) and the mean expanded primary care score was 2.68 (SD=0.19), implying poor overall performance. The domains of first contact-utilisation, coordination (information system), family-centredness and cultural competence had mean scores of >3.0 (acceptable to good performance). The domains of first contact (access), coordination, comprehensiveness (provided and available), ongoing care and community-orientation had mean scores of < 3.0 (poor performance). Older respondents (p=0.05) and those with higher affiliation to the clinics (p=0.01) were more likely to rate PC as acceptable to good. Conclusion: These private sector clinics in Nairobi had a poor overall performance. Performance could be improved by deploying family physicians, increasing the scope of practice to become more comprehensive, improving access after-hours and marketing the use of the clinics to the practice population. Article 5: General practitioners’ training and experience in the clinical skills required for comprehensive primary care, Nairobi, Kenya. Background: Quality service delivery in primary care requires availability of motivated and competent health professionals. There is a paucity of evidence on the ability of PC providers to deliver comprehensive care and no such evidence is available for GPs practising in the private sector in Kenya. Therefore, the aim was to evaluate the GPs’ training and experience in the clinical skills required for comprehensive primary care. Methods: This was a cross-sectional descriptive survey using an adapted questionnaire, originally designed for a national survey of PC doctors in South Africa. The study evaluated self-reported clinical skills performance of all 25 GPs at the 13 PC clinics in Nairobi. Results: GPs were mostly under 40 years with less than 10 years of experience with an almost equal gender distribution. Categories with moderate performance included adult health, emergencies, communication and consultation, child health and clinical administration skills. Whilst, weak performance included surgery, ear-nose-and-throat, eyes, women’s health and orthopaedics. The GPs lacked training in specific skills related to proctoscopy, contraceptive devices, skin procedures, intra-articular injections, red reflex test and use of a genogram. Conclusion: Majority of the GPs were young with few years of clinical experience after graduation. GPs lacked training and performed poorly in some of the essential and basic skills required in PC. The gaps highlighted the need for training and broadening the model of care to offer a more comprehensive package. Training in family medicine can also be offered, which aims to deliver an expert generalist and attention should be given to health systems design and the necessary inputs required to support more comprehensive care. Final conclusions: The patients visiting these private clinics consisted mostly of young to middle-aged adults, who were well-educated and employed. Most of the patients did not have any chronic conditions and reported their health status as good to excellent. Overall ratings showed high satisfaction in relation to first-contact utilisation, services by the receptionists, the regular opening hours of the clinics and short waiting times. Even though patients expressed the desire to book appointments via the phone, access to this service was limited. Access to a particular GP by phone or for emergency consultations was also limited. Utilisation and long-term affiliation with the practice was reported as good, suggesting reasonable longitudinal continuity. Patients expressed high satisfaction with care enablement and had confidence in the GPs’ honesty and trustworthiness. Informational continuity was also strong, although relational continuity less so, as patients did not express a commitment to any particular GP. Patients had limited expectations of the comprehensiveness of services offered by the GPs. Patients also reported low confidence in the GPs’ ability to manage and provide care for many core aspects of PC. The clinics were not comprehensive in the range of services available and provided. The gaps were evident in areas such as chronic conditions, antenatal care, advice for lifestyle modifications, women’s and men’s health screening. The facilities did not offer a complete primary health care team such as access to a social worker, physiotherapist, counsellor or dietician. There was poor performance by the GPs in some of the essential and basic skills required to offer a more comprehensive package of care in areas such as women’s health, ear, nose and throat, ophthalmology and orthopaedics. The information system supported care coordination and was excellent due to an integrated electronic health record system and contributed to patient satisfaction. GPs conducted brief consultations of low-moderate complexity and showed a substantial commitment to parallel coordination of care within the clinic. However, the quality of sequential coordination was reported as borderline and patients were rarely referred to the hospital. Patients felt confident in and satisfied with brief bio-medical consultations. GPs were able to obtain sufficient biomedical information, make an appropriate diagnosis, as well as formulate and explain an appropriate management plan. However, there were gaps in the provision of whole-person medicine related to the patient’s perspectives and context, exploration of patient’s psychosocial and occupational history, shared decision making process, provision of safety netting and closure. Patients, however, felt that GPs were sufficiently family-centred and culturally competent. The combined observations of all these studies confirm that this private health care system is not offering fully accessible, continuous, coordinated, comprehensive and person-centred primary care. A number of recommendations are made to improve the quality of PC.