Menu
Menu
Menu
Menu
We examined the views of providers and users of the surgical system in Freetown, Sierra Leone on processes of care, job and service satisfaction and barriers to achieving quality and accessible care, focusing particularly on the main public tertiary hospital in Freetown and two secondary and six primary sites from which patients are referred to it. We conducted interviews with health care providers (N = 66), service users (n = 24) and people with a surgical condition who had chosen not to use the public surgical system (N = 13), plus two focus groups with health providers in primary care (N = 10 and N = 10). The overall purpose of the study was to understand perceptions on processes of and barriers to care from a variety of perspectives, to recommend interventions to improve access and quality of care as part of a larger study. Our research suggests that providers perceive their relationships with patients to be positive, while the majority of patients see the opposite: that many health workers are unapproachable and uncaring, particularly towards poorer patients who are unable or unwilling to pay staff extra in the form of informal payments for their care. Many health care providers note the importance of lack of recognition shown to them by their superiors and the health system in general. We suggest that this lack of recognition underlies poor morale, leading to poor care. Any intervention to improve the system should therefore consider staff-patient relations as a key element in its design and implementation, and ideally be led and supported by frontline healthcare workers.
We conducted qualitative research in one tertiary referral hospital, two secondary hospitals and six primary care sites (Peripheral Health Units, PHUs) in the Western Area of Sierra Leone, which encompasses Freetown and its environs. This paper draws on interviews (N = 66) carried out with health care providers in these facilities and interviews (N = 37) with patients or those with treatable surgical conditions, which were conducted between May 2018 and August 2019. The patient group was split into two smaller sub-groups: those who used the public system and completed care (N = 18) and those who began care in the public system but did not complete care (N = 6). We further interviewed a group of people who were suffering from a condition that was amenable to surgical care, but who had chosen not to use the public system (N = 13). Finally, we conducted two focus group discussions (FGDs), one each with heads of PHUs in the urban (N = 10) and rural (N = 10) districts of the Western Area, respectively. The data were collected by two of the authors of the paper and three research assistants, under the supervision of the lead author. See Table 1 for information on the category and location of interviewees. Health workers interviewed, by category, location and gender The tertiary centre was chosen because it is the main public hospital providing adult surgical services in Freetown and receives patients from across the country. The two secondary sites were included because they are two Freetown-based hospitals that refer surgical and other cases to the tertiary centre. The six PHUs were purposively chosen through a combination of geographical area and size of facility. PHUs in Sierra Leone are divided into three groups, in ascending order of size: Maternal and Child Health Posts (MCHPs),2 Community Health Posts (CHPs)3 and Community Health Centres (CHCs).4 We chose one CHC, one CHP and one MCHP each from Western Area Urban and Western Area Rural, the two districts of the Western Area. Sampling for the study was purposive. We interviewed health workers who had experience of treating surgical patients, on both the wards and in theatre, and those who worked in facilities delivering little or no surgical care but who had experience of referring surgical patients to larger facilities. Most patients were recruited from among those who were admitted to the surgical wards at the tertiary hospital. They were approached while in the hospital and the study was introduced. These patients were contacted one month after they left the hospital and the study was explained in more detail, followed by the formal consent process. Informed consent was gathered from every participant through the use of participant information and consent forms, which participants had 24 h to examine before agreeing to participate. No patients declined to participate. Those who had not sought care were identified by PHU staff. PHUs are firmly embedded in communities, so staff at these facilities could be expected to know people who were suffering from surgical conditions even if they had not formally sought care. FGDs and interviews with health workers took place at their workplaces or at the tertiary centre. Interviews with patients and those with untreated surgical conditions took place in their homes. In the case of those who had accessed surgical services, the interviews took place at least 30 days after they had left the hospital. The only exclusion criterion for both providers and users was people under the age of 18. There was no maximum age. We chose the three different user groups because we wanted to understand experiences of and views on the surgical system from a variety of perspectives. We were aware that poorer patients frequently do not complete care, so were keen to ensure that we interviewed this group of people, to reduce the chances of introducing socio-economic bias into recruitment. We interviewed those who had not sought care in the public system because they could provide a unique perspective on perceived barriers to care, having felt unable to access the public system despite suffering from a condition that was amenable to surgical care. The interviews with health workers covered a variety of issues, including their job satisfaction, perceived barriers to care-seeking in the community, their relationships with both colleagues and patients, and perceptions of how well or badly their work was recognized by patients and by their superiors. Interviews with patients covered their experiences of seeking care and their choice of facility, experiences once inside the system, relationships with care providers and perceptions on how the surgical system could improve. Interviews with those who had not sought surgical care in the public system covered their reasons for choosing not to seek this type of care and their experiences of using informal providers or self-care. They also addressed issues around perceptions of how the public system could be made more accessible to them. Interviews and FGDs took place in both Krio and English, depending on the participants. The majority was in Krio. The interviews and focus groups were audio recorded. English interviews were transcribed verbatim and Krio interviews underwent a simultaneous translation and transcription. They were then inputted into NVivo version 12, where they were analysed using a thematic analysis approach. Ethical approval was obtained from the ethics committees of the authors’ institutes.
N/A
