Abstract
Introduction: Despite having access to several clinics and health centres in their local communities, numerous patients opt to go directly to hospitals for non-emergencies and minor ailments. Reasons for this include their perceptions of the quality of primary health care services, the attitudes and perceptions of health workers, opening hours of clinics, community involvement and participation, and drug and equipment availability as well as the quality of infrastructure. Perceptions of size, a lack of specialty care and limited services were most frequently mentioned as reasons why patients bypassed their local primary health care facilities.
Aim: This study aimed to identify the reasons given by patients presenting with minor ailments, for bypassing their local primary health care facilities in the Greater Tzaneen municipal area to Letaba Hospital.
Methods: A cross-sectional descriptive study was performed at Letaba Hospital over a three-month period, from 23 June 2008 to 15 August 2008, in which non-referred patients presenting with minor ailments were randomised and entered into the study on a voluntary basis. A preset questionnaire was utilised for data-collection purposes. A total of 293 participants were included in the study. The questionnaire aimed to determine the demographic profile of patients who present with minor ailments at hospital, to explore the reasons why these patients bypass their local clinics and to evaluate their knowledge, perceptions and attitudes regarding their local clinics.
Results: Most patients indicated that they came to the hospital because they wanted to be seen by a doctor, followed by the request to see a dentist. The study identified that patients expressed both positive and negative opinions concerning their local clinics.
Conclusion: Numerous factors influence the service-seeking behaviour of rural patients. Patients bypass their local clinics due to perceptions regarding the quality of health care services at the hospital. Improving the quality aspects of clinics and enhancing the services rendered will not only increase the utilisation of clinic services, but also reduce hospital overcrowding.
Introduction
The Greater Tzaneen municipal area has a well-established health care system, which includes Letaba Hospital (a regional hospital), two district hospitals, two community health centres and 34 primary health care facilities. Despite having access to several clinics and health centres in their local communities, some patients go directly to hospitals for non-emergencies and minor ailments without first consulting their local primary health care facilities.
Deciding where to consult is determined by community perceptions of the quality of primary health care services, including attitudes and perceptions of health workers, opening hours of clinics, community involvement and participation, availability of drugs and equipment as well as the quality of infrastructure. Perceptions of size, a lack of speciality care and limited services were most frequently mentioned in the literature as reasons why patients bypassed their local primary health care facilities.Citation1–3
Addressing the problems that influence the satisfaction of patients is essential in ensuring that widely available and efficacious primary-level health care becomes effective in practice and that these facilities are utilised optimally. Understanding the community’s perceptions of quality of care is therefore invaluable in developing measures to increase the utilisation of primary care facilities.
The aim of this study was to investigate the reasons given by patients who present with minor ailments at Letaba Hospital for bypassing their local primary health care facilities.
Methodology
A cross-sectional descriptive study was done, utilising a questionnaire as data-collection tool. The sample was systematically selected (every third subject who met the criteria) from self-referred patients who presented at Letaba Hospital with minor ailments and informed, written consent was obtained from each research subject.
The sample size was calculated using the following formula: n0 = Z² p q/e². A sample of 276 respondents was required for a 5% margin of error and a total of 293 questionnaires were subsequently collected over a three-month period, from 23 June 2008 to 15 August 2008. All emergencies (referred or non-referred) and individuals who were unwilling or unable to provide informed consent were excluded from this study.
A pre-tested, closed-ended structured questionnaire was developed, with the assistance of a statistician, based on information extracted from Khumalo et al.,Citation1 as no standardised questionnaires were available in the literature. The questionnaire included demographic information and the reasons for the patient coming directly to the hospital, as well as the patient’s perceptions, attitudes towards and knowledge about his or her local clinic. The questionnaire comprised a total of 25 questions and was translated into all the locally spoken languages including, Xitshonga, Sesotho and English. The translations were done by a professional translator and verified by another independent translator. Finally, a pilot study was conducted during the first week of June 2008 to test the questionnaire (pilot participants were not included in the main study).
A formally trained research assistant, fluent in the local languages, administered all the questionnaires and data obtained from the completed questionnaires were analysed by a statistician using computer-based software (Epi-Info™ version 6 [CDC, Atlanta, GA, USA] and STATA version 9.0 [Stata Corp, College Station, TX, USA]). The chi-square test and Fisher’s exact t-test were used to test for statistical significance and a p-value of less than 0.05 was considered statistically significant. In addition, Kendall’s tau-b analysis was performed to test the strength of association when both variables were measured at the ordinal level.
Ethical considerations
All research participants gave informed consent in writing in their home language before being interviewed and consent was obtained from the legal guardians or immediate family members of minors and patients who could not provide consent due to intellectual impairment. Approval for the research was obtained from the Medunsa Campus of the University of Limpopo (now Sefako Makgatho Health Sciences University) Research and Ethics Committee. Permission to carry out the research was obtained from the Department of Health in Limpopo Province and Letaba Hospital.
Results
Demographic information
The demographic information is presented in Table . Highlights were that the majority of the participants, 201 (68.6%) were female and of these 51 (25.4%) were pregnant; 173 (59.05%) of the participants were between the ages of 20 and 40 years (mean age: 29.39 years; 27.63–31.15, 95% CI); most of them, 186 (63.48%) had secondary or tertiary education and more than half were unemployed 164 (55.97%). About half (144, 49.15%) came from a radius of 10 km or less from the hospital.
Table 1. Demographic information
Specific reasons for coming to hospital
The three most common reasons indicated by participants for bypassing their local clinics were: (1) to see a doctor (31.1%); (2) to see a dentist (24.2%); and (3) for a termination of pregnancy (10.9%). Table presents the specific reasons for patients attending unreferred at Letaba Hospital.
Table 2. Reasons for coming to the hospital
Opinions regarding local clinics
Half of the participants, 151 (51.5%) indicated that they had never attended for consultation at the hospital previously and 155 (52.9%), reported that they had done so at least once previously at a clinic.
A clinic was located near to the homes of 261 (89.1%) of the participants, while 29 (9.9%) indicated that there is no clinic near their homes. The clinic was within walking distance for 159 (54.3%) of the participants and 71 (24.2%) stated that they have to take a taxi, bus or a car to travel to their local clinic.
The majority of participants (221,75.4%), indicated that their local clinic was open every day of the week. In response to the opening hours of the local clinic, most (138, 47.1%), indicated that the clinic is open day and night.
No association was found between the knowledge of a visiting doctor at the clinic and the reason for consultation at hospital being the request to be seen by a doctor (p = 0.408). On the question as to whether nurses at the clinic are well trained, a statistically significant relationship was found in that females were more likely to believe that clinic nurses are well trained, compared with males (p = 0.022). Educated subjects were more inclined to respond that clinic staff members do not treat patients kindly, compared with uneducated subjects, who had a more positive response (p = 0.013).
More opinions are cited in Table .
Table 3. Opinions about local clinics
Discussion
Demographic characteristics of patients bypassing their closest clinic
Several authors found patients bypassing clinics to be predominantly female, younger, better educated and with higher incomes.Citation4,5 Similarly, in our study, the majority of the participants were female (68.6%) and their mean age was 29.39 years. More than half (52.22%) had an education up to secondary level (grades 8 to 12). Contrary to the authors referred to above, most of the participants in our study (55.97%) reported that they were unemployed. Our findings did not establish a link between employment and bypassing clinics, which is echoed by Akin and HutchinsonCitation.6
Reasons for choosing the hospital
According to Paul and Rumsey patterns of bypassing clinics showed that patients have a relatively sophisticated understanding of the facilities they are visiting and are not visiting, as well as of their own illness conditionsCitation.4 Patients seek facilities that are staffed by more knowledgeable physicians, who observe prescription practices and are polite, while patients generally avoid clinics that do not meet these standards. They seek the care of higher quality providers, even at a greater cost.Citation4,5 This sentiment is echoed by our findings: Participants in our study bypassed their clinics when specific services were not rendered or perceived not to be rendered at clinic level, to see a doctor, a dentist or to terminate a pregnancy. It can be argued that pregnant patients generally have confidence in primary care facilities in the Greater Tzaneen area for basic antenatal care, but seek help at the hospital when the pregnancy is unwanted. At the time of the study termination of pregnancy was done only at hospital level.
Opinions of patients concerning their local clinics
Several authors have noted that patients bypass primary health care (PHC) clinics because of the lack of equipment, combined with a shortage of drugs and health workers, impolite behaviour by health workers, lack of urgency and medication shortages, which were common experiences impacting on the perceived quality of services offered at PHC facilities.Citation3,7–9 Similarly, our study suggests that knowledge and perceptions of clinics have a direct impact on the utilisation patterns of patients who bypass their nearest health care facility, as patients seek help at the facility that they perceive will render the best quality of care. We found that only 28.33% of patients were of the opinion that clinics could assist with basic health problems; 43% of the subjects thought that clinic nurses are well trained; only 40.27% knew that their local clinic has a visiting doctor; 41.30% of the subjects indicated that their clinic did not always have medicine available; 40.61% responded that there is sufficient equipment and furniture at the local clinic and only 32.08% thought that the community is involved in making decisions about clinics. Somewhat of a contradiction is that only 5.12% reported that they came to the hospital because there was no medication at the clinic.
Contrary to findings of the authors already mentioned, most of our participants (55.9%) were of the opinion that they were treated kindly by the clinic staff. Interestingly, those respondents with higher than secondary-level education were more inclined to respond that clinic staff members do not treat patients kindly (p = 0.013), which is again in line with the literature.Citation4,5 A majority of respondents (79.18%) thought that their local clinic was clean and 75.43% knew that clinics in the Greater Tzaneen municipal area are open seven days a week.
Conclusions
Letaba Hospital Outpatient Department encounters some patients who present with minor ailments. This is despite the fact that the Greater Tzaneen Municipal area has a well-established primary health care infrastructure. The majority of subjects indicated that their main reasons for coming to the hospital were their desire to be treated by a doctor, followed by the need to be seen by a dentist. We recommend that the primary health care services are marketed to the communities they serve, patient satisfaction surveys should be conducted and acted upon regularly, the doctors’ visits to the clinics should be improved, and also that dental and termination of pregnancy services be expanded to primary care level.
References
- Khumalo I, Mangongo B, Schneider H. Community perceptions of the quality of health care service. HST Update. 1999;40:12–3.
- Rieber GM, Benzie D, McMahon S. Why patients bypass rural health care centers. Minn Med. 1996;79(6):46–50.
- Baltussen RMPM, Yé Y, Haddad S, et al. Perceived quality of care of primary health care services in Burkina Faso. Health Policy Plan. 2002;17(1):42–8.10.1093/heapol/17.1.42
- Paul BK, Rumsey DJ. Primary care providers bypassing in rural Kansas. Trans Kans Acad Sci. 2002;105(1–2):79–90.10.1660/0022-8443(2002)105[0079:PCPBIR]2.0.CO;2
- Liu J, Bellamy G, Barnet B, et al. Bypass of local primary care in rural counties: Effect of patient and community characteristics. Ann Fam Med. 2008; 6(2):124–30, 6.10.1370/afm.794
- Akin J, Hutchinson P. Health-care facility choice and the phenomenon of bypassing. Health Policy Plan. 1999;14(2):135–51.10.1093/heapol/14.2.135
- Leonard KL, Mliga GR, Mariam DH. Bypassing health centers in Tanzania: Revealed preferences for observable and unobservable. Columbia University discussion paper. 2001;0001–02:1–43.
- Masango-Makgobela A, Govender I, Ndimande J. Reasons patients leave their nearest healthcare service to attend Karen Park Clinic, Pretoria North. Afr J Prim Health Care Fam Med. 2013 Oct 5 [cited 2015 June 16]. Available from: http://www.phcfm.org/index.php/phcfm/article/view/559.
- Kahabuka C, Moland KM, Kvåle G, et al. BMC Health Services Research. 2012;12:158. Available from: http://www.biomedcentral.com/1472-6963/12/158.