Experiences of Primary Health Care Clients in Jordan: Qualitative Study

1.1. Background

Service users of PHC express a variety of experiences and expectations when assessing it in different countries [1, 10, 12-15]. Take the access to health services as a measure of those experiences and expectations. e.g., in countries such as Nigeria, cost and income were the main determinants of access to primary care [2, 15]. A study from the United Kingdom (UK) showed that access to primary care was affected by non-practice-related factors such as age and ethnic group. These two factors alone were significant measures of a client’s satisfaction. The same study also highlighted the ability to make a quick appointment with a particular general practitioner (GP) was another important measure of access to primary care [13].

A recent systematic review of access to primary care included 20 qualitative studies with a total of 689 clients from 10 countries [16]. This review identified four main domains affecting access to primary care: i.e., communication; coordination; relationships; and personal value [16].

Studies from the Middle East on access to primary care are scarce and clients’ experiences are not the focus. A cross-sectional quantitative study was conducted in the city of Irbid, located north of Jordan, in 2014. It investigated patterns and factors associated with the utilisation of PHC among 190 elderly people. The PHC services were used by 68.4 per cent of the sample in the preceding six months, and by 73.8 per cent in the previous 12 months. The presence of chronic illnesses was the strongest predictor for PHC utilisation [17]. Although the participants did not give their experiences, the study was limited to one city and the elderly population.

Another study identified the main problems facing the Iraqi PHC and then prioritize the needed changes [18]. It was based on a qualitative survey of 46 primary care managers, public health professionals and academics in Erbil, north of Iraq. The study provided recommendations for improving the PHC system. e.g., reorganisation action of the services and leadership, regulation of public-private practice, improving prevention and health education, and provision of continuing professional training and development [18]. While this study resulted in the identification of structural improvements to the PHC delivery system, most improvements would probably not have been recognised by the clients.

In Jordan, there are a variety of potentially negative impacts on the delivery of PHC [19, 20]: a) non-aligned health care providers in PHC provision toward a common goal; b) new graduates work as general practitioners upon completion of one year of internship without receiving post-graduate training in family medicine or general practice. c) secondary healthcare services receive unnecessary referrals from primary care; d) significant delay in diagnosis of breast and colorectal cancer amongst symptomatic clients which leads to diagnoses at more advanced disease stages.

Office of Disease Prevention and Health Promotion [21] reported that PHC services are the foundation of healthcare, the first to deal with disease exposure and treatment, dealing with chronic diseases, and offering preventive care. However, the client’s access to PHC varies due to the cost of service, distance and travel to the service provider, the language of the service provider and managing time off work to receive the service. These measures probably do not give a clear picture of many Jordanian clients who seek PHC services in the hospitals. Hospital services compared to PHC centres are considered expensive, crowded and geographically far from the residents’ local area. The question that we seek to answer, is why some clients use PHC services and why others go to hospitals to receive this service or part of it?

Research is needed to inform health systems and policymakers about the gaps in health, the quality of the service and the performance of health services. Evidence from research is required to gain insights into these gaps and how to translate the evidence into policies and decisions. One of the key issues in PHC is the assessment of its quality and performance by asking the service users and exploring their experiences. Therefore, we ask here: what are the experiences of the clients (users) of PHC service in Jordan?

2.1. The Study Design And Methods

This study adopted a qualitative research design to investigate the experiences of PHC service users [22]. Focus groups were useful because they combined interviewing and group interaction especially when the researcher wanted to investigate clients’ opinions [23, 24]. During conduction, we found the interaction between participants produced data and ideas that could not be revealed in an individual interview.

2.2. Setting

The study took place in three Jordanian cities, Amman, Irbid, and Al-Karak. Recruitment was done from primary care attendants and purposeful selection of clients who refer to secondary care as PHC service providers from both the Ministry of Health (MoH) clinics and the private sector.

2.3. Study Population

The target clients selected to participate in focus groups were selected purposefully because the intention is not to make inferences about a larger population, but to understand how clients in the focus groups think and talk about their use of primary health services. Therefore, we set up focus groups to explore diversity and determine the range of views, instead of ascertaining representativeness. The focus group (FG) participants were similar because all were users of primary health services; this maximised the comfortable feeling to express their opinions. the interaction between participants during FG motivated explaining, scrutinising, and rationalising of their views.

The recommended size for FGs is six to eight participants to avoid limiting the extent and range of experience that can be drawn upon or silencing group members from revealing their views [24]. In total, 22 clients attended three FG interviews: The first FG was attended by seven participants from (Amman) in the central region; the second FG was attended by seven from the southern region, and the third FG was attended by eight from the northern region.

2.4. Data Collection

The FG interviews were moderated by one of the authors’ AN with two assistants trained in recording notes and observing participants. The interview started with a broad open question then all FG interviews with clients were conducted following specific instructions described in an interview guide. Probing questions were used when necessary to guide the discussion and focus the group members on understanding the phenomena involved. FG interviews were conducted in health centres’ meeting rooms and took an average of 60 minutes. All interviews were recorded digitally, and participants were informed about recording during the instructions and before signing the consent form.

At the beginning of each FG, the moderator AN sets ground rules for the participants that will be heard during the discussion and should be kept confidential. This was to confirm the protection of confidentiality which was not controlled by the researcher during the discussion. Pseudonyms were used for the quotations from the participant’s FGs to confirm confidentiality.

2.5. Trustworthiness

Three FGs conducted as those achieved segmentation and saturation of data particularly when the length of the interview was not restricted. Three categories were selected one from each region as a segment. However, after conducting the first FG the moderator AN noticed the repetition of data yielded during the second FG. There were no new insights gained during the third FG; this confirmed saturation. Scientific rigour for the qualitative data was achieved through procedures to ensure the trustworthiness of data, such as dependability audit, three researchers debriefing (credibility), dense description of the sample and peer review to assure transferability and confirmability [23].

2.6. Data Analysis

The qualitative data analysis was conducted by thematic analysis using NVivo 9.0 (QSR International). Overall, one researcher AN was the primary analyst of the collected data and started the analysis immediately after the first FG. Thematic analysis of the respondents’ statements provided information that was used for the development of free codes. In a series of meetings, the project team discussed those codes, categorised them, and then agreed on final themes based on the data from FG interviews. Analysis was conducted by listening to the recordings of the FGs several times and then coding the voice-file sections that contained the subthemes. After collecting all codes for all FGs, two of the researchers categorised the codes independently. Afterwards, they agreed on a universal set of codes. This was followed by deriving final themes from the categories (Fig. 1).

The interview was recorded and coded by the AN. Double-checking for accuracy of the free codes performed by MA and GK both have qualitative research experience. Data analysis is conducted initially on the Arabic voice recordings of the interviews. The codes, categories and themes were extracted in English. During the writing of the findings section, all final identified free voice quotations were translated into English. Quotations were transcribed from the translated emerging themes into English. Confirmation of the translation is checked by giving the final English themes to a professional bilingual translator to do a back translation into Arabic. Complete congruence between the Arabic and English versions of the themes was obtained.

2.7. Ethical Consideration

The study was approved ethically by Mutah University Ethics Committee (Ref. No. 20162). The reported methodology and data conform with the ethical standards of the committee responsible for human experimentation at Mutah University, and with the Helsinki Declaration of 1975, as revised in 2013 (http://ethics.iit.edu/ecodes/node/3931). The Higher Council of Health Council also informed the Directors of Health and Directors of involved health centres and hospitals in Amman, Karak, and Irbid to facilitate the conduction of this study (Ref. No. HHC/General Study/317). All participants were volunteers and consented in writing for taking part in this project. Clients who participated in this study volunteered to take part in the FG discussions when invited by their physicians and after reading the information sheet and consenting to take part. The focus group discussion was voice recorded digitally. Their personal information was removed and given pseudo names during data analysis. Apart from the invitations introduced by the physicians and the support letters by health directors, no contribution from the public and the clients in the study design or conduct of the study, analysis, or interpretation of the data or preparation of this manuscript.

3.1. Clients’ Experiences with GPs

One of the identified key positive factors about access to PHC in Jordan was the short waiting time and availability of same-day care on most occasions. The PHC centres provide a wide range of services to the community and are easily accessible to people in all regions and locations. Participants reported that the main advantage of PHC in Jordan was the quick access and comprehensive coverage. Reported services were treatment of acute conditions, the possibility of early detection of chronic diseases, mother-and-child care, and immunisation. Another advantage was providing services close to where the clients live, especially for residents in peripheral areas. Moreover, the clients reported the friendly relationship between PHC physicians and their clients and the trust they have built with their clients. One of the participants remarked on efficient dealing with clients, knowledge of their social and economic status, saving their time and resources, and finally emphasised the cooperation of physicians in the follow-up process.

“Some health professionals work with consciousness. I refer to one doctor who followed up on my son’s case and I prefer not to change this doctor. This is preferable because the doctor knew the treatment of my son.” (Male, Middle region)

Another client reported an interesting positive experience with a health centre in the southern region, she said:

“I have experience with primary health centre doctor who is always ready for his clients. He always prepares their prescriptions in advance, once the client visits him the prescription is ready in a bag [of medications] to pick up. He was in this health centre for 20 years and knew everyone well. If you ask him about any client, he will tell you the entire story and tell you the story of the client’s family members. …It is easy to deal with this doctor.” (Female, southern region)

3.2. Primary Healthcare Doctor’s Capability and Professionalism

Participants reported that there are major contributions for GPs at primary health services. They know the case in advance, deal efficiently with clients, know the social and economic background of their clients, communicate friendly with clients, save clients’ time and money, and provide appropriate follow-up for clients.

“In this health centre, the doctors deal friendly and respect clients, while in the hospital’s doctors have a load of duties and after midday get bored of providing service.” (Female, Northern region)

The GPs in the PHCs are in contact with their clients and know them usually personally. This leads to understanding their client’s behaviours and accepting their frustration professionally. A female participant recognised the compassion attribute for those GPs and stated:

“When clients visit the doctor, they are usually frustrated, tired, and nervous; doctors receive them calmly, in open heart and mind, and absorb their nervousness.” (Female, southern region)

Although there are positive attributes for the GPs in the PHCs, many clients choose not to refer to these primary health centres and go elsewhere. In the following theme, the study reports why clients seek health care in the secondary health system or the private sector.

3.3. Causes of not Seeking Advice at the Primary Health Level

Participants identified some potential barriers to access to PHC in Jordan. They reported some weaknesses and limitations are either related to the system, staff, or the service itself. The system-related factors included poor compliance with working hours, insurance causes, moonlighting (doctors have dual jobs; for example, work in health centres and have a private clinic at the same time), service provided only if a mediator is available, and limited available services.

Barriers related to staff included: inappropriate reception from staff, some doctors not complying with working hours, lack of speciality or well-trained doctors to manage their cases, and they have not assured the competency of some doctors who provide health care to them. A male participant stated:

“I visited a doctor in a health centre at 11:30, the nurse said we finished duty today, the doctor is not available now, then she asked me what is your complaint? Then she picked a medication from the pharmacy, and she gave it to me. That is all.” (Male, Southern region)

Participants also mentioned points related to service weakness including limited preventive medicine services, frequent equipment failure or being out of order, limited trust in the effectiveness of available medications, and delay in referrals. Some clients reported worries of deterioration in their case because of delays in referral to hospitals.

“I referred to an X health centre, my daughter was complaining of her ear, the doctor asked me; what shall I do for her. I said I do not know. She replied, shall I examine her? My daughter kept crying. Then the doctor said: as she would not stop crying no need to examine the baby.” (Female, southern region)

The clients emphasised “understaffing” as a key barrier to PHC improvement in Jordan. They hypothesised that understaffing at PHC is leading to inappropriate behaviour and limited communication skills, unprofessional reception for the client, ineffective treatment of the client’s case, and delayed or inappropriate referral.

Another major identified limitation of PHC services in Jordan was the lack of control over access to secondary care. Some clients visit different service points and receive similar treatment for the same complaints. The system fails in detecting those clients who get the same service several times for the same health problem.

3.4. How to Improve PHC Service in Jordan

Participants were also approached to get their opinion on methods of improving access and services at PHC in Jordan. Most indicated the need to focus on staffing issues and provide more training for PHC staff, mainly for GPs.

“There is a need to provide health centres with experienced doctors not the newly graduated, and to give them enough training.” (Male, southern region)

The three themes will be discussed in the following section in light of the previous literature.

4.1. System-related Issues

Providing primary health services in secondary health service centres is expensive for the government and the clients altogether. It is a core responsibility of the government to ensure the availability and accessibility of quality primary health services on an equitable basis. Health-care leadership, innovations, family practice, inter-sectoral collaboration, effectiveness and accountability are key steps toward achieving this goal [26].

In Jordan, PHC services are mainly delivered by general physicians who are not properly trained to deliver people-centred healthcare services. There is a persistent shortage of Family Doctors. To compensate for this, it is recommended that GPs undergo specific training to bridge the gap in family practice knowledge and skills and to actively participate in Continuous Professional Development (CPD) programmes.

Accountability mechanisms and a rigorous supervision system in place could motivate healthcare providers to commit to their work in terms of working hours, quality and quantity of healthcare services, provider-client encounters and continuity of care [26-29].

With the relatively high public health expenditure in Jordan, achieving universal health coverage (UHC) is not far. According to the 2015 census, 55% of the population was covered by any type of health insurance scheme [30]. However, given the fragmented health sector and the complex governance layout in Jordan, reforms are needed in healthcare financing mechanisms to achieve UHC. In addition, effectively allocating funds and applying health economics principles in healthcare financing, using different models of public-private partnership, and applying information technologies may as well support reaching this goal.

4.2. Limitations

The number of focus groups was limited because of budget, however, the researchers found it enough as no new data was generated after the 2nd one and number of participants in each group was suitable and one health system governing the service. Therefore, if the same study is applied elsewhere, consideration for the health system and social differences should be counted.

Although this study reports important information about the quality and experiences of patients regarding primary health care utilization, we indicate that the setting was public sector only because primary health care is mainly provided by it in Jordan. However, few participants from the private sector have already taken part, but it seems they utilise the public service at the same time. Therefore, it is recommended to consider conducting a study in a private sector setting and another one for welfare and not-for-profit organisations which provide services for a considerable proportion of refugees.

This study like all qualitative studies was difficult to obtain strict conclusions and generalise the findings in comparison to those following the quantitative paradigm. Although the sample was selected purposefully, the researchers did not interfere directly in selecting them, but the gatekeepers were informed of inviting participants who are informants and willing to give details as much as possible. The moderator AN was able to give every participant enough room to give his or her views freely and the researchers conducted a thorough check of the rigour. One point noticed during this check when revising the notes for the FG conduction in Irbid; the facilitator discovered after the session ended that one of the participants was an employee in the same health centre who was a client on the day of invitation to FG. The coding and analysis of the interview assure the other participants did not recognize her and she had no influence on the opinions of others during the discussion. We presume, that if they knew her previously, may affect the opinions of the participants during the discussion. Therefore, this should be considered in any future study locally or internationally.