The study used a definition of quality of health care based on the framework by Donabedian 20, 21. Structural inputs, process and outcomes were assessed in this study using a triangulation of instruments. This was to ensure that wide ranges of quality issues were captured and a fully rounded analysis of quality of antenatal care services is achieved. The research instruments were observation checklists and semi structured questionnaires.
Health worker interview questionnaire (Appendix 1): This was a self administered questionnaire that consists of 15 questions and in two parts; the first part explored the socio- demographic data such as the age, sex, cadre and the duration of work experience of the health care workers, while the second part dealt with supervision questions such as if they had schedules for visits and last supervisory visit. Also questions on recent training and their perceptions on the difficulties faced in carrying out their duties were asked. The questions were a combination of open ended and closed ended where they were expected to tick their response.
Client exit interview (Appendix 2): This was a four part interviewer administered questionnaire that was a modification of MEASURE service provision assessment exit interview for antenatal care client67. The questionnaire explored the socio- demographic characteristics such as the age, marital status, religion; ethnicity, occupation and income of the clients. Also the obstetric history such as parity, family planning awareness and practice were explored. The clients’ experiences and perceptions of services received were also explored and a fourth section on their level of satisfaction with the various aspects of the services received. Responses to questions were varied; a few questions were open ended, some responses were “yes or no and don’t know, undecided or can’t remember,” while in some questions their responses were to be circled from a list of options.
The observation checklists were an adaptation of checklists as described by national standards of personnel and essential equipment for PHC centres ANC/interview room and performance standards for the assessment of process attribute of care 65, 66. The checklists were used to audit the facility equipment (appendix 3) and physical infrastructure, drugs and supplies and to observe provider-client interaction (appendix 4); personnel (appendix5).
The observation checklist of essential equipment had a total of 15 items that were listed and the minimum quantity required per facility as well as columns to indicate items that were present or absent. The last column remark was to indicate if item was functional or not.
Appendix 4 is a checklist for assessment of general infrastructure, process attributes of antenatal care and drugs/ supplies. The checklist had four columns. The first column indicates attribute of quality being assessed, second column for description / item for observation, third column for maximum score that was attainable per item observed and the fourth column for score that was awarded to the facility being assessed.
The checklist of process of care was made up largely of lists of tasks that providers were expected to carry out in their interaction with client (history and physical examination), treatment and health information provided to client during consultation.
Appendix 5 is a checklist of proposed health manpower for PHC facility and comprised of six cadres of manpower for PHC facility65. Each cadre had a minimum number of staff that was required for each PHC facility stated against it.
3.7 Data collection
Data was collected between May and October 2009. Data was first collected at the urban health facilities from the first week of May to the second week of June and data collection days were on antenatal clinic days which were Tuesdays and Thursdays. At the rural health facilities data was collected from the third week of June to the last week of October and
data collection days were Thursdays when clients presented for antenatal clinic follow up visits. Data collection in the urban facilities lasted for about seven weeks due to larger client load than the rural health facilities. On each interview day, the research team were introduced to clients by the head of the facility at the patient waiting area where prayers and health talks are held. After the introduction, the principal investigator explained the purpose of the research and the eligibility criteria to the clients and answered questions that arose. Eligible and consenting clients were recruited after they had been seen by health care providers (i.e. at the end of consultation). Exit interviews were done in a quiet place away from the consulting area to provide privacy and enable clients express themselves freely.
Informed consent was obtained verbally and data was collected using interviewer administered questionnaire by four research assistants. The research assistants were one national youth corps, an undergraduate of a tertiary institution and two secondary school certificate holders. They had undergone two day training on how to collect accurate data using the instrument. The research assistants were assessed for consistency and method of validation of responses and where defects were observed necessary corrections were made.
The questionnaire was designed in English; however, clients who did not understand English had the questions translated to them in their native language. Each questionnaire took about 15 minutes to complete. In order to avoid double entry of clients who had been previously interviewed during earlier antenatal visits, the index numbers on the antenatal cards of the clients were recorded on clients’ questionnaires and cross checked at the end of each day with previously completed questionnaires. Where the same index numbers were found, only one was used for analysis in the study. However, when a client requested to be interviewed more than once, she was obliged by the interviewer but the questionnaire was not included in the data for analysis.
A total sample of all consenting health care providers present on each antenatal clinic day during the study period was done using a time cluster sampling technique i.e. self administered questionnaires were distributed by the principal investigator only to those present/ on duty during the ANC clinic hours. A total of 25 urban and 22 rural health care workers were available for the interview of a total of 68 urban and 45 rural health care workers on the nominal roll provided by the heads of facilities. However, explanations provided by heads of facilities for the discrepancies in the number of those who were available for interview and the total health workers in the nominal roll were that some were working in other shifts (evening and night shifts), a few were on leave/ off duty and some who were JCHEWS were working in the community, hence could not participate during the antenatal clinic hours. Those providing antenatal services at the urban health facilities were nurse midwives, public health nurses and CHOs while at the rural health facilities, services were provided by community health officers and community health extension workers. There was only one public health nurse in the rural health facilities and did not participate actively in providing clinical care to clients during the study period.
Observations of client- provider interactions were done by the author in the sampled health facilities. At each facility, observation of the first ten client-provider interactions (similar procedure was carried out in other studies75, 80,) was done using a modification of checklist for process attribute66 (appendix 4). The health workers were not told the purpose of the observation so as not to bias the findings. The author sat in the consulting room to observe as well as listen during the consultation by the health worker. The observer however appeared to be doing something else such as checking records i.e. not making it obvious to the providers that they were being observed.
In each health facility, equipment, personnel, infrastructure, drugs and supplies checklist was also completed by the investigator who interviewed the head of the facility. The responses were confirmed by physical inspection of all available equipment and supplies.