In South Africa, patients are meant to attend the clinic close to their place of residence. However, patients often choose which clinic to attend, which results in overcrowding.
This study aimed to investigate the structural and process factors influencing patients’ choice to attend a community health centre (CHC) in KwaZulu-Natal, South Africa.
The study was conducted at the Inanda C Community Health Centre (CHC).
Systematic random sampling was used to select study participants. A structured questionnaire was used to collect socio-demographic data and assess the factors influencing patients’ choice to attend this CHC.
There were 400 patients who participated. The commonest structural indicator that patients agreed on as the reason they attend Inanda C CHC was because it has enough medication (126, 73.3%). There was a significant difference in the proportion of patients who agreed that seeing a doctor instead of nurse was a reason for attending this clinic with 118 (68.6%) patients from within the catchment area and 170 (74.6%) from outside the catchment area. The commonest process indicators that patients from within and outside the catchment area agreed on as reasons for attending Inanda C CHC were ‘the doctor or nurse explains my sickness and treatment to me’ and ‘I get good quality of care’.
The structural and process indicators that influence patients’ choice of clinic may need to be improved at other clinics in this area in order to decrease the overcrowding at this clinic.
The responsibility of government is to ensure access to affordable healthcare to all citizens. Access to healthcare comes with the responsibility on the healthcare provider to meet the needs of the patients. The choice of healthcare provider is influenced by both patient factors and healthcare provider characteristics. Healthcare provider characteristics are quality indicators that may be categorised as structural, process or outcome.
In South Africa, a major challenge within the health sector is the inequality in the distribution of infrastructure, financial and human resources between private and public healthcare facilities. The private health sector serves less than 20% of the population and the public health sector serves the majority of South Africans.
Studies have shown that whilst distance to the clinic is an important determinant in clinical usage, there is an interplay between demographic, social and other quality factors.
In South Africa, in the province of KwaZulu-Natal there are 11 health districts. The allocation of resources to healthcare facilities is managed at the district level. In Ethekwini Health District, there are issues with overcrowding at Inanda C Community Health Centre (CHC) with reported underused CHC approximately 10 km away.
The aim of this study was to determine the proportion of patients who attend Inanda C CHC from outside the catchment area and investigate the factors influencing patients’ choice to attend this clinic.
This was an analytic, cross-sectional study.
The study was conducted at Inanda C CHC, which serves a catchment population of approximately 95 000 people living in the areas of Newtown C, Ezimangweni, Bhambayi, Nhlungwane and Mzomusha. Services at the clinic include maternal and child health, mental health service, human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), tuberculosis and general outpatient services and emergency care, pharmacy and X-ray services.
The study population were adult patients (≥ 18 years) attending the General Outpatient Department at Inanda C CHC during the month of February 2019.
Systematic random sampling was used. The first study participant was selected randomly from the queue and thereafter every third person was selected. Patients who were referred to the clinic from another healthcare facility were excluded. Based on a conservative estimate that 30% of patients attending this clinic were from outside the catchment area, a sample size of 384 was estimated to achieve a statistical power of 80% to detect a small-medium effect size of 0.16 with significance level (alpha) of 0.05.
A structured questionnaire was used to collect socio-demographic data (age, gender, employment status, area of residence) and assess healthcare provider factors influencing patients’ choice to attend this clinic. Additional data collected related to time taken to travel to the clinic, mode of transport and the reason for attending the clinic. A subset of questions on patients’ reasons for not attending a clinic closer to their home was administered to those patients who reported to reside outside the Inanda C CHC catchment area. The questionnaire was developed in English and translated to IsiZulu and then translated back to English to ensure that meaning of the questions remained the same. The questionnaire was piloted amongst 50 participants to ensure that the questions were sufficient to meet the study objectives. Statements relating to structural and process indicators were provided and a four-point Likert scale was used to assess the participant’s response. The participant had to select between the options ‘strongly agree’, ‘agree’, ‘disagree’ or ‘strongly disagree’ for each of the statements. The questionnaire was administered by the investigator who marked the participants’ responses on the questionnaire.
The responses ‘agree’ and ‘strongly agree’ were combined and categorised as agree and the same process was followed for the responses ‘disagree’ and ‘strongly disagree’. The area of residence of a patient was classified as either from the Inanda C CHC catchment area or outside the catchment area. Continuous variables were expressed as a mean and compared using the student’s
The ethical approval for this study was received from University of KwaZulu-Natal Biomedical Research Ethics Committee (BE680/18). Gatekeeper permission was obtained from the KwaZulu-Natal Provincial Health Research and Ethics Committee (KZ_201812_020). All participants signed an informed consent form before participating in the study.
A total of 400 participants were included in the study. The majority of participants were female (242, 60.5%). The mean age for males was 47.8 years (standard deviation [s.d.] = 19.1) and the mean age for females was 44.7 years (s.d. = 18.0),
Socio-demographic profile of patients and reasons for attending Inanda C Community Health Centre, 2019.
Variable | Lives within catchment area |
Lives outside of catchment area |
|||
---|---|---|---|---|---|
% | % | ||||
18–39 | 82 | 47.7 | 100 | 43.9 | 0.492 |
40–59 | 35 | 20.3 | 42 | 18.4 | - |
60+ | 55 | 32.0 | 86 | 37.7 | - |
Male | 69 | 40.1 | 89 | 39.0 | 0.45 |
Female | 103 | 59.9 | 139 | 61.0 | - |
Employed | 23 | 13.4 | 26 | 11.4 | 0.218 |
Unemployed | 57 | 33.1 | 85 | 37.3 | - |
Self-employed | 6 | 3.5 | 2 | 0.9 | - |
Pensioner | 54 | 31.4 | 82 | 36.0 | - |
Student | 32 | 18.6 | 33 | 14.5 | - |
Yes | 111 | 64.5 | 157 | 68.9 | 0.211 |
No | 61 | 35.5 | 71 | 31.1 | - |
Illness | 151 | 89.9 | 184 | 79.7 | < 0.004 |
Accident | 17 | 10.1 | 46 | 20.3 | - |
More than half the sample (
The lack of doctors, insufficient number of doctors and long waiting time to see a doctor were the commonest reasons (
Reasons patients from outside the Inanda C Community Health Centre catchment area choose not to attend clinics closer to their area of residence (
Variable | Agree |
|
---|---|---|
% | ||
There are not enough nurses | 222 | 97.4 |
There are not enough doctors | 226 | 99.1 |
It takes too long to see a doctor | 226 | 99.1 |
I do not get to see a doctor | 226 | 99.1 |
Nurses are not good at their job | 216 | 94.7 |
Doctors are not good at their job | 209 | 91.7 |
The staff is unfriendly | 215 | 94.3 |
They do not have enough medication | 225 | 98.7 |
They have long queues | 225 | 98.7 |
Nurses or doctor do not explain my sickness or treatment to me | 212 | 93.0 |
The commonest structural indicator that patients agreed on as the reason they attend Inanda C CHC was because it has enough medication (126, 73.3%) (
Comparison of structural indicators influencing patients’ choice to attend Inanda C Community Health Centre, 2019.
I choose to attend Inanda C Community Health Centre because: | Lives within catchment area |
Lives outside catchment areas |
|||
---|---|---|---|---|---|
% | % | ||||
Agree | 119 | 69.2 | 160 | 70.2 | - |
Disagree | 53 | 30.8 | 68 | 29.3 | - |
Agree | 122 | 70.9 | 173 | 75.9 | - |
Disagree | 50 | 29.1 | 55 | 24.1 | - |
Agree | 118 | 68.6 | 170 | 74.6 | - |
Disagree | 54 | 31.4 | 58 | 25.4 | - |
Agree | 93 | 54.1 | 151 | 66.2 | - |
Disagree | 79 | 44.9 | 77 | 33.8 | - |
Agree | 122 | 70.9 | 171 | 75.0 | - |
Disagree | 50 | 29.1 | 57 | 25.0 | - |
Agree | 122 | 70.9 | 174 | 76.3 | - |
Disagree | 50 | 29.1 | 54 | 23.7 | - |
Agree | 126 | 73.3 | 179 | 78.5 | - |
Disagree | 46 | 26.7 | 49 | 21.5 | - |
The most common process indicators that patients from within the catchment area and patients from outside the catchment area agreed on as reasons for attending Inanda C CHC was ‘the doctor or nurse explains my sickness and treatment to me’ (163, 94.8% and 221, 96.9%, respectively) followed by ‘I get good quality of care’ (160, 93.0% and 218, 95.6%, respectively) (
Comparison of process indicators influencing patients’ choice to attend Inanda C Community Health Centre, 2019.
I choose to attend Inanda C Community Health Centre because: | Lives within catchment area |
Lives outside catchment areas |
|||
---|---|---|---|---|---|
% | % | ||||
Agree | 160 | 93.0 | 218 | 95.6 | - |
Disagree | 12 | 7.0 | 10 | 4.4 | - |
Agree | 110 | 64.0 | 169 | 74.1 | - |
Disagree | 62 | 36.0 | 59 | 25.9 | - |
Agree | 150 | 87.2 | 211 | 92.5 | - |
Disagree | 22 | 12.8 | 17 | 7.5 | - |
Agree | 148 | 86.0 | 211 | 92.5 | - |
Disagree | 24 | 14.0 | 17 | 7.5 | - |
Agree | 163 | 94.8 | 221 | 96.9 | - |
Disagree | 9 | 5.2 | 7 | 3.1 | - |
Agree | 113 | 65.7 | 170 | 74.6 | - |
Disagree | 59 | 34.3 | 58 | 25.4 | - |
There was no association between gender and the structural or process indicators. Younger patients (18–39 years) were less likely to agree with the structural indicators and with the process indicator on the doctor or nurse explaining the condition to the patient. There was no association between employment status and the indicators linked to waiting time and short queues (results not shown).
This is the first reported study that assessed patients’ reasons for attending a CHC in the public health sector in KwaZulu-Natal. The high proportion of females (60.5%) is in contrast to the general population of Inanda township where 52.0% are female. Whilst it has been shown that females tend to seek healthcare more frequently than males, it must also be observed that more than half of the females attending Inanda C CHC were from outside the clinic catchment area.
More than half of the patients in this study lived outside the clinic catchment area. This is in contrast to findings from a study carried out in Pretoria where 80% of participants reported to attend healthcare facilities closest to them.
The structural indicators that were found to be contributory factors for patients to attend Inanda C CHC (availability of enough medication, doctors and nurses being good at their job and enough medical and nursing staff) may also be because this clinic being a CHC as opposed to a primary healthcare clinic. In South Africa, primary healthcare clinics are staffed with clinical nurse practitioners and medical doctors who visit the clinic once a week, whereas at CHCs, medical doctors are available every day, with a wider range of services and medication available. Moreover, the rehabilitation team consists of a physiotherapist, occupational therapist and speech therapist who visit the CHC at least once a week. In addition, the CHC offers a 24-h emergency service and has X-ray facilities, both of which are not offered at a primary healthcare clinics.
The most common process indicators that contributed to patients choosing to attend Inanda C CHC were related to the staff (attitude and explaining the condition to the patient) and quality of care including short waiting times. In Europe similar observations were made where explaining medical condition and medication to the patient had a positive influence on their choice of health facility.
When comparing the structural and process indicators amongst patients from within and outside Inanda C CHC catchment area, patients from outside the catchment area were more likely to cite short queues, waiting time, staff friendliness and attitude as reasons for attending this clinic. This is in contrast to studies in the United States and United Kingdom that have shown that patients are influenced by financial reasons.
Interestingly, we did not find an association between employment and selecting short queues and waiting time as reasons for attending the clinic. It is possible that these patients had taken a day off work and were therefore not in a hurry to return to work. We also found no association between gender and any of the structural or process indicators. This in contrast to findings from Nigeria and Tanzania where women preferred skilled professional and reliable access to drugs and equipment and respectful staff who are attentive over other healthcare facility features.
One of the limitations of this study is that it was a quantitative study, so we were unable to explore further on patients’ reasons for choosing to attend Inanda C CHC. Factors such as social stigma, particularly for diseases such as HIV have been reported as influencing patients to attend clinics away from home.
A large proportion of patients attending Inanda C CHC are not from the clinic catchment area. Staff attitude and quality of care are important factors that patients consider when selecting which clinic to attend. Further research at clinics in the surrounding areas is warranted to assess the structural and process indicators that may need to be improved in order to decrease the overcrowding at this clinic.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Z.C.H. conceptualised the research, collected and analysed the data with the assistance of a biostatistician and wrote all versions of the manuscript. S.M. supervised all aspects of the research and reviewed all versions of the manuscript.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
The data that support the findings of this study are available from the corresponding author, Z.C.H., upon reasonable request.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the author.