Family Practice, 2014, Vol. 31, No. 3, 303–310 doi:10.1093/fampra/cmu004 Advance Access publication 3 March 2014
Patients’ attitudes and experiences of relational continuity in semi-urban general practices in Oman Mohammed Al-Azria,*, Ruqaiya Al-Ramadhanib, Nada Al-Rawahib, Kawther Al-Shafeea, Mustafa Al-Hinaia and Abdullah Al-Maniric Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, bMinistry of Health and cThe Research Council, Muscat, Oman.
a
Received October 29 2013; revised January 8 2014; Accepted January 29 2014.
Abstract Background. Relational continuity is a cornerstone of primary care. In developing countries, however, little research has been conducted to determine the perception and experiences of patients in view of relational continuity in primary care. Objective. To study the role of relational continuity in primary care settings and its effect on patients’ perceptions and experiences. Methods. A questionnaire-based survey was conducted at eight primary care health centres (PCHCs) in Al-Seeb province, Muscat, the capital city of Oman. All Omani patients aged 18 years and above attending their PCHCs during the study period were invited to participate in the study. Results. From a total of 1300 patients invited, 958 Omani patients agreed to participate in the study (response rate = 74%). More than half of the patients (61%) expressed the preference of consulting the same primary care physician (PCP) to whom they were accustomed.This increased to 69% if the patients had psychosocial problems and to 71% if the patients had chronic medical conditions. A significant proportion of the respondents (72%) felt comfortable and relaxed when consulting the same PCP and 67% expressed an interest in maintaining continuity with the same PCP. The general perspective held by the majority of the studied patients (61%) indicated that relational continuity improved both the patients’ medical conditions (51%) and the quality of services (61%). In actuality, however, only 18% experienced relational continuity in their PCHCs. The preference for relational continuity was significantly increased among patients who identified a favourite PCP (P = 0.029) and among educated patients (P = 0.023). Conclusion. Although it is relatively difficult to consult with the same PCP, the majority of Omani patients have experienced several benefits from relational continuity within the context of patient–physician relationship. The preference for relational continuity was highly expressed by patients with chronic or psychosocial problems, patients who were educated and those who identified a named PCP. In view of these findings, the basis of relational continuity if progressed, a great effort is needed to develop and implement strategies to promote relational continuity in primary health care in Oman. Key words: Oman, patients’ attitudes, patients’ experiences, primary care, relation continuity, semi-urban.
© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
303
Downloaded from http://fampra.oxfordjournals.org/ at Univ. of Massachusetts/Amherst Library on July 9, 2015
*Correspondence to Mohammed Al-Azri, Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, PO Box 35, Muscat 123, Sultanate of Oman; E-mail: [email protected]
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Introduction every visit. This poses a great obstacle towards relational continuity, considering that patients might be seen by different PCPs at each visit leading to conflicting advice and less ‘personal care’, which could adversely affect the outcome and overall quality of care (3,9,10). A previous study conducted in 2009 on 319 Omani patients recruited from four PCHCs revealed that relational continuity for patients was crucial to obtain a more personalized care (14). To our knowledge, this is the largest study to be conducted in Middle Eastern countries examining patients’ perceptions and experiences of relational continuity in primary care settings.
Methods Designing the questionnaire The questionnaire used to assess continuity of care was developed based on the literature (14–18). Although relational continuity of a patient may occur with one or more PCP (2), the definition employed in this study corresponds to ‘the relationship of the patient with the same PCP’. The questionnaire covered three main aspects: socio-demographic characteristics of participants (nine items), perception of relational continuity (nine items) and experience/application of relational continuity (15 items). The statements for each item were formulated with three responses on a Likert scale (agree, disagree or neutral). The questionnaire was first translated into Arabic to ensure and preserve the meaning and was then back translated into English by another team. A pilot study of 50 patients was also conducted in a selected PCHC to test the suitability of the questionnaire. A few questions on the aspect of perception of relational continuity were modified after the pilot study.
Selection of the health centres This study was conducted in Al-Seeb suburban province, which is one of the largest and most populated towns in the Muscat Governorate (the capital city of Oman). The total population of Al-Seeb based on the 2010 census was 223 449, of which 47% were Omani (19). There was a total of eight PCHCs in Al-Seeb, providing primary care health services to Omanis and expatriates working in the government sector. The selection of all PCHCs was based on the convenience to collect data within the set timeframe. The characteristics of the selected PCHCs are outlined in Table 1.
Sample size We assumed that 50% prevalence of patients would favour relational continuity with 5% marginal error and 95%
Downloaded from http://fampra.oxfordjournals.org/ at Univ. of Massachusetts/Amherst Library on July 9, 2015
Continuity of care has traditionally been regarded as the cornerstone of primary care worldwide, as it is consistent with the quality of care and improving patient outcomes (1–3). Several types of continuity have been identified in the literature ranging from relational (interpersonal), longitudinal, team, management, cross-boundary to informational; however, the most important type of continuity among these is relational (interpersonal) continuity (4–6), which is defined as ‘care provided from one or more named health care professionals with whom the patient can develop a therapeutic and interpersonal relationship’ (2). Relational continuity promotes ‘personal care’ by enhancing the patient–physician relationship and acts as an important factor in achieving satisfaction for both patients and physicians alike (2,7). However, studies have shown that several factors could influence relational continuity, the patient–physician relationship being one of them (8). For example, it has been shown that patients who convey trust and confidence with their physicians were more likely to maintain relational continuity; while on the other hand, lack of trust or confidence will enhance movement of patients from one doctor to another (9). Patient satisfaction is also thought to help maintain relational continuity, which ultimately improves the quality of care (3). Likewise, it has been observed that patients who maintain relational continuity were more likely to be satisfied with consultations and with the provided services (3,10). Oman is one of the developing countries located on the southeastern tip of the Arabian Peninsula with a total population of 2.8 million, based on the 2010 census, of which 1.9 million were non-Omani (11). About 36% of Omanis were aged 65 years; the median age of Omanis was 21 years (11). Primary health care (funded by the government, through the Ministry of Health (MOH), for all Omanis and nonOmanis working in the government sector) is considered to be the first portal of entry to all levels of health care services in Oman. There are also several private hospitals and polyclinics located mainly in the major cities providing health care services. The Ministry of Health in Oman emphasized the importance of primary care as a key factor in attaining the highest quality of health services the for Oman’s population (12). The MOH also supports easy access and delivery of health care services in all regions of Oman through a network of primary care health centres (PCHCs). Primary care physicians (PCPs) are the first point of contact, who then refer patients needing specialist consultation to secondary and tertiary care hospitals (13). But although the MOH has placed great emphasis on the importance of continuity and comprehensiveness of care at the primary care level, patients nevertheless present as ‘walk-in’ and consult any PCP (13). Generally, the majority of patients who attend the PCHCs were neither booked nor encouraged to see the same PCP at
Relational continuity in semi-urban general practices
Table 1. Total number of registered and recruited patients and total number of PCP working in each PCHC Name
Total number of registered patients
Total number of working PCPs
Total number of recruited patients
PCHC1 PCHC2 PCHC3 PCHC4 PCHC5 PCHC6 PCHC7 PCHC8
73 280 39 921 76 858 65 650 70 318 53 445 68 559 58 280
13 11 12 11 13 12 11 12
171 127 117 107 121 106 108 101
Patient selection The study sample was comprised of Arabic-speaking patients aged 18 years and above, attending any of the eight PCHCs in Al-Seeb, during the month of June 2012. An explanation of the study was given to the patients by two trained research assistants. Literate patients who agreed to participate were asked to sign a consent form and were then asked to complete the questionnaire while waiting to see PCPs for consultation. For illiterate patients, the questionnaire was administered by the research assistants. Patients unable to speak Arabic, children, and emergency cases were excluded from the study. Confidentiality of the collected data was assured and patients were informed that their responses would not affect future management by their PCPs. Other patients not included in the study were asked to complete an anonymous demographic information form that included questions on age and sex. Data collection was conducted while the patients were waiting to consult with their PCPs. The study was approved by the Research and Ethics Committee of the College of Medicine and Health Sciences, Sultan Qaboos University.
Data analysis Data was analysed using the Statistical Package for the Social Sciences, version 20. Cronbach’s alpha test to assess the internal consistency and coefficients of 0.87 for perception of relational continuity and 0.94 for experience/application of relational continuity were obtained. The proportion, mean, median and other measures of distribution were estimated for variables included in the questionnaire. Chi-square test was used to test associations between the items related to continuity of care and demographic data. A P value
Patients’ attitudes and experiences of relational continuity in semi-urban general practices in Oman Mohammed Al-Azria,*, Ruqaiya Al-Ramadhanib, Nada Al-Rawahib, Kawther Al-Shafeea, Mustafa Al-Hinaia and Abdullah Al-Maniric Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, bMinistry of Health and cThe Research Council, Muscat, Oman.
a
Received October 29 2013; revised January 8 2014; Accepted January 29 2014.
Abstract Background. Relational continuity is a cornerstone of primary care. In developing countries, however, little research has been conducted to determine the perception and experiences of patients in view of relational continuity in primary care. Objective. To study the role of relational continuity in primary care settings and its effect on patients’ perceptions and experiences. Methods. A questionnaire-based survey was conducted at eight primary care health centres (PCHCs) in Al-Seeb province, Muscat, the capital city of Oman. All Omani patients aged 18 years and above attending their PCHCs during the study period were invited to participate in the study. Results. From a total of 1300 patients invited, 958 Omani patients agreed to participate in the study (response rate = 74%). More than half of the patients (61%) expressed the preference of consulting the same primary care physician (PCP) to whom they were accustomed.This increased to 69% if the patients had psychosocial problems and to 71% if the patients had chronic medical conditions. A significant proportion of the respondents (72%) felt comfortable and relaxed when consulting the same PCP and 67% expressed an interest in maintaining continuity with the same PCP. The general perspective held by the majority of the studied patients (61%) indicated that relational continuity improved both the patients’ medical conditions (51%) and the quality of services (61%). In actuality, however, only 18% experienced relational continuity in their PCHCs. The preference for relational continuity was significantly increased among patients who identified a favourite PCP (P = 0.029) and among educated patients (P = 0.023). Conclusion. Although it is relatively difficult to consult with the same PCP, the majority of Omani patients have experienced several benefits from relational continuity within the context of patient–physician relationship. The preference for relational continuity was highly expressed by patients with chronic or psychosocial problems, patients who were educated and those who identified a named PCP. In view of these findings, the basis of relational continuity if progressed, a great effort is needed to develop and implement strategies to promote relational continuity in primary health care in Oman. Key words: Oman, patients’ attitudes, patients’ experiences, primary care, relation continuity, semi-urban.
© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
303
Downloaded from http://fampra.oxfordjournals.org/ at Univ. of Massachusetts/Amherst Library on July 9, 2015
*Correspondence to Mohammed Al-Azri, Department of Family Medicine and Public Health, College of Medicine and Health Sciences, Sultan Qaboos University, PO Box 35, Muscat 123, Sultanate of Oman; E-mail: [email protected]
Family Practice, 2014, Vol. 31, No. 3
304
Introduction every visit. This poses a great obstacle towards relational continuity, considering that patients might be seen by different PCPs at each visit leading to conflicting advice and less ‘personal care’, which could adversely affect the outcome and overall quality of care (3,9,10). A previous study conducted in 2009 on 319 Omani patients recruited from four PCHCs revealed that relational continuity for patients was crucial to obtain a more personalized care (14). To our knowledge, this is the largest study to be conducted in Middle Eastern countries examining patients’ perceptions and experiences of relational continuity in primary care settings.
Methods Designing the questionnaire The questionnaire used to assess continuity of care was developed based on the literature (14–18). Although relational continuity of a patient may occur with one or more PCP (2), the definition employed in this study corresponds to ‘the relationship of the patient with the same PCP’. The questionnaire covered three main aspects: socio-demographic characteristics of participants (nine items), perception of relational continuity (nine items) and experience/application of relational continuity (15 items). The statements for each item were formulated with three responses on a Likert scale (agree, disagree or neutral). The questionnaire was first translated into Arabic to ensure and preserve the meaning and was then back translated into English by another team. A pilot study of 50 patients was also conducted in a selected PCHC to test the suitability of the questionnaire. A few questions on the aspect of perception of relational continuity were modified after the pilot study.
Selection of the health centres This study was conducted in Al-Seeb suburban province, which is one of the largest and most populated towns in the Muscat Governorate (the capital city of Oman). The total population of Al-Seeb based on the 2010 census was 223 449, of which 47% were Omani (19). There was a total of eight PCHCs in Al-Seeb, providing primary care health services to Omanis and expatriates working in the government sector. The selection of all PCHCs was based on the convenience to collect data within the set timeframe. The characteristics of the selected PCHCs are outlined in Table 1.
Sample size We assumed that 50% prevalence of patients would favour relational continuity with 5% marginal error and 95%
Downloaded from http://fampra.oxfordjournals.org/ at Univ. of Massachusetts/Amherst Library on July 9, 2015
Continuity of care has traditionally been regarded as the cornerstone of primary care worldwide, as it is consistent with the quality of care and improving patient outcomes (1–3). Several types of continuity have been identified in the literature ranging from relational (interpersonal), longitudinal, team, management, cross-boundary to informational; however, the most important type of continuity among these is relational (interpersonal) continuity (4–6), which is defined as ‘care provided from one or more named health care professionals with whom the patient can develop a therapeutic and interpersonal relationship’ (2). Relational continuity promotes ‘personal care’ by enhancing the patient–physician relationship and acts as an important factor in achieving satisfaction for both patients and physicians alike (2,7). However, studies have shown that several factors could influence relational continuity, the patient–physician relationship being one of them (8). For example, it has been shown that patients who convey trust and confidence with their physicians were more likely to maintain relational continuity; while on the other hand, lack of trust or confidence will enhance movement of patients from one doctor to another (9). Patient satisfaction is also thought to help maintain relational continuity, which ultimately improves the quality of care (3). Likewise, it has been observed that patients who maintain relational continuity were more likely to be satisfied with consultations and with the provided services (3,10). Oman is one of the developing countries located on the southeastern tip of the Arabian Peninsula with a total population of 2.8 million, based on the 2010 census, of which 1.9 million were non-Omani (11). About 36% of Omanis were aged 65 years; the median age of Omanis was 21 years (11). Primary health care (funded by the government, through the Ministry of Health (MOH), for all Omanis and nonOmanis working in the government sector) is considered to be the first portal of entry to all levels of health care services in Oman. There are also several private hospitals and polyclinics located mainly in the major cities providing health care services. The Ministry of Health in Oman emphasized the importance of primary care as a key factor in attaining the highest quality of health services the for Oman’s population (12). The MOH also supports easy access and delivery of health care services in all regions of Oman through a network of primary care health centres (PCHCs). Primary care physicians (PCPs) are the first point of contact, who then refer patients needing specialist consultation to secondary and tertiary care hospitals (13). But although the MOH has placed great emphasis on the importance of continuity and comprehensiveness of care at the primary care level, patients nevertheless present as ‘walk-in’ and consult any PCP (13). Generally, the majority of patients who attend the PCHCs were neither booked nor encouraged to see the same PCP at
Relational continuity in semi-urban general practices
Table 1. Total number of registered and recruited patients and total number of PCP working in each PCHC Name
Total number of registered patients
Total number of working PCPs
Total number of recruited patients
PCHC1 PCHC2 PCHC3 PCHC4 PCHC5 PCHC6 PCHC7 PCHC8
73 280 39 921 76 858 65 650 70 318 53 445 68 559 58 280
13 11 12 11 13 12 11 12
171 127 117 107 121 106 108 101
Patient selection The study sample was comprised of Arabic-speaking patients aged 18 years and above, attending any of the eight PCHCs in Al-Seeb, during the month of June 2012. An explanation of the study was given to the patients by two trained research assistants. Literate patients who agreed to participate were asked to sign a consent form and were then asked to complete the questionnaire while waiting to see PCPs for consultation. For illiterate patients, the questionnaire was administered by the research assistants. Patients unable to speak Arabic, children, and emergency cases were excluded from the study. Confidentiality of the collected data was assured and patients were informed that their responses would not affect future management by their PCPs. Other patients not included in the study were asked to complete an anonymous demographic information form that included questions on age and sex. Data collection was conducted while the patients were waiting to consult with their PCPs. The study was approved by the Research and Ethics Committee of the College of Medicine and Health Sciences, Sultan Qaboos University.
Data analysis Data was analysed using the Statistical Package for the Social Sciences, version 20. Cronbach’s alpha test to assess the internal consistency and coefficients of 0.87 for perception of relational continuity and 0.94 for experience/application of relational continuity were obtained. The proportion, mean, median and other measures of distribution were estimated for variables included in the questionnaire. Chi-square test was used to test associations between the items related to continuity of care and demographic data. A P value
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