Philosophiae Doctor - PhD / Introduction: The overall aim of this study was to develop a programme to facilitate quality client-centred care in Primary Health Care clinics of the rural West Coast District. Research design and -method: Both quantitative and qualitative methods were applied for this study . Phase 1, a situational analysis collected and analysed quantitative data from the perspective of clients and clinical nurse practitioners via structured questionnaires. The population included all clients 18 years and older (N=137 991) of the fixed clinics (N=25) in the five subdistricts of the West Coast District. According to the Cochran formula a sample of (n=383) should be adequate to represent the population. Non-proportional sampling was applied to estimate the number of participants per clinic. An all-inclusive sample of (n=64) clinical nurse practitioners participated in the study. Phase 2, the qualitative part of the situational analysis, applied five focus group discussions to explore and describe the managers and allied health professionals’ perceptions about quality client-centred care. A semi-structured interview schedule was compiled to guide the focus group discussions. An all-inclusive sample was utilised to include all the managers and allied health professionals of the five subdistricts (N=43). Phase 3 included the development of the programme based on the study findings and literature. Quantitative results: The analysis revealed the following quality client-centred care challenges, namely: Patient Rights (Domain 1) were not always respected and adhered to as these were characterised by: language (statistical p<0.001 and practical significant with a large effect size d=0.74); Satisfaction and Safety (statistical p<0.001 and practical significant with a medium effect size d=0.55); Referral Procedures (statistical significant p<0.001); Waiting Times (statistical p<0.001 and practical significant with a medium effect size d=0.47) and Confidentiality difficulties (statistical p<0.001 and practical significant with a medium effect size d=0.68). The Domain 2, Clinical Governance, Care and Safety showed shortcomings as highlighted by the Client and his/her Family (statistical p<0.001 and practical significant with a large effect size d=0.77). Clinical Support Services, Domain 3, revealed inadequacies regarding the continuous availability of medication (statistical significant p<0.008) and the reporting of side-effects (statistical significant p<0.001). Furthermore, Public Health Domain 4, showed that clients identified community health promotion and disease prevention events (statistical p<0.01 and practical significant with a large effect size d=0.79), and home visits by the community healthcare workers (statistical p<0.001 and practical significant with a large effect size d=1.09) as both a “problem” and a “gap”. Leadership and Corporate Governance, Domain 5 was characterised by the lack of: visible organograms (clients mean 2.40), community communication (clients mean 2.12 & clinical nurse practitioners mean 2.36), visibility of goals, values and future plans of the Western Cape Department of Health (statistical p<0.001 and practical significant with a medium effect size d=0.59) and role and function of the clinic committees (statistical significant p<0.008). Moreover, Domain 6, Operational Management was challenged by inadequate staffing levels (statistical significant p<0.003). Lastly, Domain 7: Infrastructure was characterised by the lack of drinking water in the waiting areas (clients mean 2.08 & clinical nurse practitioners mean 2.02), inadequate clinic space (clients mean 2.10 & clinical nurse practitioners 2.23); maintenance not up-to-date (statistical significant p<0.002); physical appearance of the clinic (statistically significant p<0.001) did not have a positive effect on staff morale and evacuation plans (statistical p<0.001 and practical significant with a medium effect size d=0.54) were not visible. In addition, correlations between the domains showed that the domains are not in silos, but are interdependent on another. Qualitative results The qualitative, thematic data analysis revealed various inadequacies regarding quality client-centred care. Theme One about the Patient Rights revealed that patients were not always treated with the necessary respect and dignity. Theme Two concerning Patient Care, revealed that focus group participants were well-informed on what the concept client-centred care entailed. However, patients and or clients did not always experience their care as client-centred. Theme Three about the Clinical Support Services, indicated shortages of medication and medical equipment; long waiting time for specialists and rehabilitation referral appointments. Theme Four, referring to the Public Health confirmed that health promotion and prevention activities are limited, due to various organizational factors and community healthcare workers’ activities which are limited to home-based care activities. Theme Five, Corporate Governance and Leadership matters were characterised by too many processes or “red tape” resulting in inefficient procurement processes, inadequate staffing and inactive health committees. Theme Six, Operational Management highlighted the severe pressure under which the operational managers have to work, resulting from their twofold role of being the clinic manager and at the same time operate as a clinical nurse practitioner. Theme Seven refers to Infrastructure and Facilities and is characterised by inadequate maintenance and lack of space according to the number of clients and package of care. To summarise: The situational analysis revealed 81 problems. These problems form the evidence base for the development of the programme to facilitate quality client-centred care in primary helth care clinics of the rural West Coast District.

This study was carried out as part of efforts to better understand the factors that impinge on childbirth service delivery and to develop guidelines to help improve the quality and safety of childbirth services in Ghana. The objectives were to: assess the factors that influence client-centredness; explore women’s and health professional’s views of and experiences with client-centred childbirth services; and develop guidelines to assist improve client-centred childbirth services in hospitals. The fixed mixed methods design comprising both quantitative and qualitative methods was employed. Structured questionnaire and exit interviews were used to gather data from 754 women who delivered in the hospitals. Furthermore, in-depth interviews were used to examine the experiences of women, doctors and midwives. STATA MP Version 13 was used to analyse the data by generating frequencies, chi-square and binary logistic regression results. Qualitative data analysis was analysed through data reduction, data display and generation of themes and categories. The process of developing the guidelines comprised: drafting based on the findings of the study and additional literature review, and a number of reviews by senior health professionls to build consesnsus on the content. With a response rate of 97.8%, the results indicated average performance. A number of the items examined under demographic characteristics, ante-natal, labour and postnatal care were significantly associated with the experience of excellent client-centred care. These included: number of weeks pregnant before delivery; health professional who assisted with delivery; mode of delivery; labour pain management; and length of stay after delivery. On the whole, the findings of the quantitative study were support by that of the structured interviews. Most of the themes from in-depth interviews with women were had to do with the relationship between health care provider and clients. Issues of support during childbirth; decision-making and informed choice; and continuity were raised. Themes deduced from the doctors’ and midwives’ interviews demonstrated a fair understanding of principles of client-centred care and delineated relational as well as client, health care worker and organisational factors that facilitate or limit effective implementation of client-centred care. The findings of the studies were used to develop guidelines to help improve services. It is recommended that the Ministry of Health, Ghana adopt the guidelines and provide the enabling environment for its effective implementation. / Health Studies / D. Litt. et Phil. (Health Studies)

This study was carried out as part of efforts to better understand the factors that impinge on childbirth service delivery and to develop guidelines to help improve the quality and safety of childbirth services in Ghana. The objectives were to: assess the factors that influence client-centredness; explore women’s and health professional’s views of and experiences with client-centred childbirth services; and develop guidelines to assist improve client-centred childbirth services in hospitals. The fixed mixed methods design comprising both quantitative and qualitative methods was employed. Structured questionnaire and exit interviews were used to gather data from 754 women who delivered in the hospitals. Furthermore, in-depth interviews were used to examine the experiences of women, doctors and midwives. STATA MP Version 13 was used to analyse the data by generating frequencies, chi-square and binary logistic regression results. Qualitative data analysis was analysed through data reduction, data display and generation of themes and categories. The process of developing the guidelines comprised: drafting based on the findings of the study and additional literature review, and a number of reviews by senior health professionls to build consesnsus on the content. With a response rate of 97.8%, the results indicated average performance. A number of the items examined under demographic characteristics, ante-natal, labour and postnatal care were significantly associated with the experience of excellent client-centred care. These included: number of weeks pregnant before delivery; health professional who assisted with delivery; mode of delivery; labour pain management; and length of stay after delivery. On the whole, the findings of the quantitative study were support by that of the structured interviews. Most of the themes from in-depth interviews with women were had to do with the relationship between health care provider and clients. Issues of support during childbirth; decision-making and informed choice; and continuity were raised. Themes deduced from the doctors’ and midwives’ interviews demonstrated a fair understanding of principles of client-centred care and delineated relational as well as client, health care worker and organisational factors that facilitate or limit effective implementation of client-centred care. The findings of the studies were used to develop guidelines to help improve services. It is recommended that the Ministry of Health, Ghana adopt the guidelines and provide the enabling environment for its effective implementation. / Health Studies / D. Litt. et Phil. (Health Studies)