Determinants of Hepatitis-Related Service Quality by Patients in Ghana: Implications for Quality Improvement

Abstract

Hepatitis B infection remains a public health concern in Ghana with about 8.4% of the adult population chronically infected. A number of these patients access care in health facilities, yet the extent to which they perceive the care quality is not documented. We used exploratory descriptive qualitative study to understand the factors that shape 16 patients’ perceptions of hepatitis-related service quality in a tertiary hospital in Ghana. We adopted the service quality model by Brady and Cronin to guide the study. Participants were recruited purposively, and data analysis followed the procedure of Braun and Clarke. We found distinct patient concerns encompassing various aspects of care, including privacy, waiting times, clinic accessibility, and staff attitudes and expertise. Nurse-front desk interactions and education provided on hepatitis treatment emerged as areas requiring improvement. The physical environment, including cleanliness and ambient conditions, influenced patient satisfaction; however, systemic challenges such as long waiting time and insufficient clinic operational days were identified as major sources of discontent. There is the need for a patient-centered approach in healthcare delivery, integrated services, enhanced privacy measures, and a comfortable and welcoming healthcare environment.

Introduction

Viral hepatitis, particularly hepatitis B and C, poses a significant public health threat around the world resulting in chronic infections and disproportionately impacting many regions. ¹ Current estimates show that over 350 million people globally are living with viral hepatitis. ² Twenty-one countries within the WHO Western Pacific region, Eastern Mediterranean regions, Southeast Asia regions, European regions, Americas, and African regions have contributed to over 80% to the global burden of hepatitis B. ³ Ghana is one of the countries in Africa with national prevalence estimate of 8.36% for chronic hepatitis B and 3.0% for hepatitis C.^4–6 Regional variations are documented, with the central region of Ghana reporting a 11.5% prevalence of hepatitis B.^4–6 For example, 12.4% of patients who received hemodialysis at the Central Region Teaching hospital had hepatitis B infection, ⁷ whiles 24.4% of newly diagnosed patients with HIV infection who were undergoing care evaluation at the same hospital were also found to have hepatitis B and C. ⁸ Despite the preventability of hepatitis B and the curability of hepatitis C, nearly 90% of those infected in Africa lack critical care. ² Additionally, there are reported cases of service dissatisfaction expressed by patients with hepatitis. ⁹

Healthcare service quality is critical in fostering a long-lasting bond between patients and healthcare service providers. Patient feedback and sentiments serve as essential metrics for measuring service quality, and strict adherence to healthcare principles positively correlates with perceived quality.^10,11 In effect, high-quality healthcare services can benefit individuals with hepatitis by ensuring access to accurate diagnosis, timely treatment initiation, regular clinical monitoring, and proper management of co-infections. ¹² Furthermore, severe complication including liver damage, cirrhosis, liver cancer, and even death can be averted when patients with hepatitis have access to quality care. ¹²

However, variations in access to advanced diagnostic tools and antiviral medication for hepatitis treatment exist. ¹³ For example, unlike high-come countries that have better access to advanced diagnostic tools and effective antiviral medication,^13,14 low resource countries, including Ghana face several individual and structural level barriers that impede care quality. ¹⁵ As Ghana strives toward achieving the United Nations’ (UN) SDGs 3.3, and 2030 hepatitis elimination targets, we cannot ignore the important contribution that quality improvement could add. ¹⁶ This study sought to highlight the perspectives of patients with hepatitis who access care from a liver clinic regarding quality of services in order to profess solutions that could potentially address the gaps that characterize their experience.

Methods

Design

An exploratory descriptive qualitative design was used to understand broadly how patients with hepatitis B perceived service quality. We considered this design appropriate because little is known about the phenomenon in Ghana.

Research Setting

The study was conducted at the Cape Coast Teaching Hospital (CCTH), which serves as the main referral center for the central region. We selected CCTH because it provides hepatitis related services with a specific day for specialist liver clinic. It is a 400-bed capacity hospital where medical students receive training as well. The hospital has about 1915 staff, out of which 1049 are staff of the nursing directorate and 448 are staff of the medical directorate. ¹⁷ Overall, about 2,859,821 Ghanaians reside in the region. ¹⁸

Theoretical Perspective

The theoretical model adopted for this study is the service quality model by Brady and Cronin (2001). ¹⁹ According to the model, interaction quality, physical environment quality, and outcome quality were the three key aspects that explain service quality. Each of these dimensions consists of three corresponding subdimensions such as attitude, behavior, and experience (interaction quality); ambient conditions, design, and social factors (physical environment quality); waiting time, tangibles, and valence (outcome quality).

Participants

We included patients diagnosed with hepatitis B, C and D who were seeking medical care at the time of the study. Once patient was eighteen years and above and provided written consent, we included them. However, those who were acutely ill and could not engage in an interview were excluded.

Sampling Technique and Data Collection Procedure

The study employed a purposeful sampling technique ²⁰ to recruit participants on clinic days (ie, Tuesday) with the assistance of unit nurses. We provided comprehensive information in a language they understood, outlining study objectives, privacy policies, and the right to withdraw. Confidentiality was maintained and informed consent was obtained, with interviews conducted in private rooms. Data collection continued until saturation was reached at the 16th participants. The interviews lasted between 45 min and 1hour.

Face-to-face interviews were conducted with the aid of a semi-structured interview guide. The interview guide was developed based on the study objectives, incorporating the constructs of hierarchical model of perceived service quality. ²¹ The interview guide was pretested on two patients to ensure its ability to elicit accurate responses. During each interview, we kept a field notebook to record other relevant observations and participant reactions that emerged during the interview process.

Data Analysis

The data was processed using NVivo version 12.2 software. We followed Braun and Clarke's (2006) framework ²² for thematic analysis to analyse the data. The audio record interviews were transcribed verbatim. All the transcripts were coded by EDA, CAA and JMK, followed by discussions of the codes and generation of major themes by the authors. The constructs of the service quality model proposed by Brady and Cronin (2001) ¹⁹ guided the analysis procedure. Discussion continued until consensus was reached. We shared the transcripts with two participants to establish whether the content reflected their views.

Participants’ Demographics

This study recruited 16 people with hepatitis B, ranging from 19 to 56 years old. All participants were Ghanaian citizens residing in the Greater Accra, Central, Western, or Western North regions. The duration of their hepatitis B infection ranged from 1 year to 18 years. Most participants (14) accessed care from the liver clinic at CCTH for regular monitoring and treatment. Overall, three themes and five subthemes emerged from the data. The themes are (1) Quality of interaction between patients and providers, (2) perceived quality of the physical environment, and (3) perceived outcome quality. Table 1 presents the themes and subthemes.

Table 1.

Themes and subthemes.

Themes	Subthemes
Interaction between patients and providers	Attitudes of healthcare personnels
	Perceived healthcare personnel's skills and expertise
Perceived quality of the physical environment	Ambient condition
perceived outcome quality	Waiting time
	Working hours

Interaction between Patients and Health Care Providers

Two subthemes emerged from this theme: (1) attitudes of healthcare personnels and (2) perceived healthcare personnel's skills and expertise.

Attitudes of Healthcare Personnels

Most of the participants mentioned that the health care providers were pleasant, welcoming and friendly. That, they received them with smiles which made them relaxed and further reduced their stress. However, the participants were concerned with the limited time that the doctors spent with them in the consulting room. That some physicians failed to explain the disease condition as well as answer their questions to their satisfaction.

They are professionals and for their interaction, I like it, they are good. They talk to you professionally and politely and receive you with cheerful faces. (PLWHB 2)

My problem is with the doctors. They want to do things quickly, and there is little conversation between us. (PLWHB 1)

However, there were some participants who said they had an unpleasant experience with the front desk staff at the liver clinic.

I had an encounter with the front desk nurses and their behavior were not up to standard. (PLWHB 12)

Perceived Healthcare Personnel's Skills and Expertise

According to the participant, receiving education and information about the HBV, the pros and cons of treatment, and the side effects of drugs, nutrition, life lifestyle management, and coping skills were very important to them. Some participants described the physicians and nurses as very knowledgeable and added that they act professionally when it comes to diagnosis and treatment as compared to other facilities some participants have previously attended. All participants stated that the healthcare workers do inform them about their follow-up visits and write them on their cards.

… they know their work, because I did not know some of the things that were happening to me but when I came here, they taught me. I was educated on the importance of the medications as well as the side effect to expect. (PLWHB 8)

Sometime before I come here, I will do one or two checks on the internet. When I come, the care provided is the same as the one I read. (PLWHB 1)

The newly diagnosed participant expressed concerns about the number of laboratory investigations often requested by the junior physicians. They further added that there was a clear difference between the expertise of the junior and senior physicians because they felt that some of the laboratory investigations requested by the junior physicians were unnecessary which increased their follow up visit period.

You know the experienced ones are specific with their education, they go straight to the point but those who I think are now learning have to go round and round before you will understand them. (PLWHB 6)

Perceived Quality of the Physical Environment

One subtheme emerged from this theme: ambient condition.

Ambient Condition

The outwards and internal environment of the facility in general was described by the participants to be neat and serene. All the participants said there was no unusual smell at the clinic. The room temperature was described by some participants as normal while others described the waiting area as being very warm sometimes, especially during the day. The noise at the facility was said to be minimal and some said the noise is always from the patients that visit the clinic and not from the health staff.

There is no noise apart from the few when the nurse calls names to check their vitals. The noise is from us the patient and it also depends on the number of patients at the clinic at a time. If there are many people here, there will be a lot of noise. (PLWHB 13)

Some participants expressed their dissatisfaction with the space in the waiting area. They stated that the waiting area serves four different clinics which are run on the same day. That sometimes the place gets congested by patients visiting another clinic, most especially those accessing Ear, Nose and Throat (ENT) services and therefore they should separate the ENT clinic from the hepatitis clinic.

Sometimes you come and there is no space for everyone so you must go back and stand and at times when they call you at the back you will not hear them. The people coming to ENT are many, so they cause the place to be congested sometimes. (PLWHB 12)

Some participants expressed displeasure with the number of staff working at the registration center at the hepatitis clinic. Participants said only two nurses register and check the vital signs of all the patients accessing the four different clinics on Tuesdays of which the hepatitis clinic is part. Due to the high number of patients attending the clinic in a day, one has to wait a long time before it gets to their turn thereby delaying care.

It's okay just that the population is huge, if they could increase the number of nurses who do registration and check vitals, it will help. All the people pass through these two people which takes a lot of time. (PLWHB 12)

Perceived Outcome Quality

Two subthemes emerged from this theme: (1) waiting time and (2) working hours.

Waiting Time

Participants measured the waiting time with the following: waiting time for a turn, time spent in the consulting room, time spent for the test to be performed, time waiting for test results, and waiting time at the pharmacy. All the participants interviewed expressed dissatisfaction with the waiting time at the liver clinic. Participants stated that they had to wait longer hours for the doctors to return from ward rounds. One participant indicated that she reported to the facility at 7:00am but the physician came to the consulting room around 11:00am. Some participants expressed their worry about losing employment due to the delays at the clinic which affect their work attendance.

Most of the time, they normally keep long before coming, Today I came here around 7: 00 am and it is 11:00 am, and it is now that they are in. It means we have to spend the whole day here. You cannot go anywhere again not even work. (PLWHB 6)

Most participants said ever since they started the clinic, they have not met one physician twice, and they believe this is a contributing factor to the delay or increase in the time spent at the consulting room. That the new physician had to review their folder to have an appreciation of their condition before intervening. This according to the participants leads to an increase in the number of times one has to visit the facility in a month and repeated laboratory tests that are requested.

My problem is that whenever you come, personally l doesn’t remember meeting the same doctor twice. (PLWHB 2)

Most of the participants said they waited for about an hour before they were called in for their laboratory test to be done and waited for some time before they received their lab results. Participants describe the turnaround time to be shorter when they go for the laboratory tests outside the hospital.

Sometimes when I come here it quite a queue. (PLWHB 1)

Working Hours

Most of the participants expressed satisfaction with the working hours with which service is rendered at the hepatitis clinic. However, some participants were not too satisfied with the duration of the appointment schedule. Though the clinic operations start from 8:00am, the nurses often ask them to go back and return the following week when they report at 10:00am. Reason being that they have reached their target for the day.

We come early in the morning and wait for hours before the doctors will come. Apart from that, when you come late too, they will tell you they have closed or reached their target for the day. (PLWHB 14)

Yes, we have been told we have to get here before 10:00 so when you come after that time you will be asked to go back and come next week. (PLWHB 13)

Other participants interviewed expressed displeasure with the number of days the clinic runs in a week. Participants recommended that the liver clinic be organized throughout the week other than the once-a-week.

Discussion

The findings unveiled themes that reflect the perceived quality of interaction between patients living with hepatitis and healthcare providers. The themes highlighted both positive and negative aspects of their experiences. The perceived quality of healthcare provider attitudes played a crucial role in shaping the overall satisfaction of PLWH. Positive aspects of healthcare interactions included healthcare professionals friendliness and eagerness to assist. Participants, particularly praised doctors for their effective communication and detailed explanations, emphasizing the significance of these attributes in delivering quality care. This positive sentiment aligns with existing literature that underscores the role of effective doctor-patient communication in enhancing patient satisfaction and health outcomes ²³ However, dissatisfaction emerged regarding the attitudes of nurses at the front desk in the hepatitis clinic. This contrasted with the principles of patient-centered care, which emphasize empathy and understanding. ²⁴ Topics such as treatment options, drug side effects, nutrition, lifestyle management, and coping skills were deemed crucial for empowering patients to effectively manage their condition. This emphasizes on knowledge which aligns with previous studies that have underscored the importance of patient education in improving health outcomes. ²⁵

The study also explored the role of ambient conditions in shaping patient experience within the liver clinic. Participants consistently expressed positive sentiments about the overall physical environment, emphasizing factors such as minimal noise levels, neatness, and a serene setting. These findings resonate with studies that highlights the importance of a well-maintained and organized facility in promoting a sense of order and enhancing the patient experience. ²⁶ Moreover, the study highlighted the role of nonvisual factors like temperature, smell, and noise influencing patient satisfaction and overall outcome quality of healthcare. ¹⁰ While overall positive sentiments were expressed about the clinic's cleanliness, participants expressed dissatisfaction with the sharing of the waiting area with ENT clients which led to congestion, indicating potential challenges in facility design and layout planning. The practice of using a single room for simultaneous consultations with two different patients by some doctors raised concerns about patients’ privacy and confidentiality. Participants expressed a desire for individual offices for each doctor, emphasizing the importance of privacy in healthcare settings. ²⁷

Participants also expressed dissatisfaction with the frequency of the hepatitis clinic, which operates only once a week. This poses challenges for patients, especially those traveling from distant locations. Some participants suggested expanding the clinic's operating days from Monday to Friday to accommodate patients from faraway regions, emphasizing the need for accessible healthcare services. Prolonged waiting times before consulting with healthcare providers, was a significant concern impacting daily life. Patient education on expected waiting times can contribute to a more positive perception and experience.^28,29 The experience of accessing healthcare at the facility appeared to hinge significantly on whether it was the individual's first visit or a subsequent one. The absence of directional cues complicated the navigation process for first-time visitors, emphasizing the importance of directional signage and clear wayfinding strategies in healthcare facilities. ³⁰ The study also revealed concerns about rigid adherence to daily targets for patient arrivals after 10:00 am, potentially leading to individuals being turned away and instructed to return the following week. Thus, flexibility in appointment scheduling would enhance patient satisfaction and adherence to medical appointments. ³¹ While participants were generally satisfied with the type of service they received, concerns were expressed about the frequent change of doctors attending to PLWH. Participants emphasized the importance of having staff well-versed in hepatitis care to ensure continuity and minimize the need for repeated tests which come with extra cost.

The study's findings should be viewed with some strengths and limitations. This is one of the few studies that have broadly explored how PLWH perceived the quality of service using service quality model by Brady and Cronin (2001). ¹⁹ However, due to the small sample size, generalization is not possible. There is also a likelihood of recall bias given that the participants have to retrospectively share their experience regarding the service. These were minimized by asking clear and unambiguous questions and probing for accurate information. Also, the interview guide was pilot tested, and field notes were used to document interviewers’ observations, thoughts and reflections during the period of data collection and analysis.

Conclusion

The study provided valuable insights into the perceptions of PLWH regarding their interactions with healthcare providers and the overall healthcare environment. Addressing issues related to healthcare provider attitudes, facility conditions, scheduling flexibility, and continuity of care could significantly contribute to an enhanced patient experience within the hepatitis clinic. The findings underscore the importance of patient-centered care principles and effective communication in ensuring the well-being and satisfaction of individuals living with hepatitis.