Caregivers ’ perception of the quality of child health care services in a General Hospital in Lagos State Nwosu

Nigeria shoulders about 10% of global childhood mortality rates. This poor statistics is related to the poor quality of child healthcare services in the country. This recent study assessed the quality of the different aspects of child healthcare services in an urban General Hospital in Lagos state, Nigeria. Descriptive cross-sectional study was undertaken. Participants were caregivers attending the Child welfare Clinic in a General Hospital in Lagos State. A calculated minimum sample size of 214 caregivers were recruited, and data collected using a pre-tested, interviewer questionnaire at exit point. The mean age of the respondents was 32.3 standard deviation (SD) ± 6.9 years. The mean waiting time was 112.76 min SD ± 63.70 min. Majority of the respondents 176 (82.3%) were satisfied with overall quality of services received. Majority of the clients suggested an improvement in staff attitude (29.1%) and reduction in waiting time (28.6%) as ways to improve satisfaction.


INTRODUCTION
Quality of care is one of the major public health concerns in this 21st century.Countries have developed various models of quality assurance.These serve to ensure client satisfaction and overall improvement of their health care delivery services (Adogu et al., 2012).Often, caregivers have little opportunity to express their opinions or to define what they think about the quality of services.Clients' interview accords the opportunity of knowing how well or how badly clients perceived the services offered them through the use of client interview forms (Ajenifuja, 2011).The importance of involving and using consumer perceptions of services is widely recognized in maternal and child health services in developed nations; and of the best measures of quality of care comes from the patients' perspective.However, this concept has not been fully recognized or accepted in developing countries such as Nigeria (Audo et al., 2005).Nigeria's under-five mortality rates (U5MR) is one of the highest in Africa (157 per 1000 live births) (Ogunnowo et al., 2005).Malaria, low immunization coverage, diarrhea, acute respiratory infections (ARI) and vaccine preventable diseases(VPD) in addition to malnutrition still account for almost ninety percent of these deaths (Bankole and Taiwo, 2013).This alarming rate is not unrelated to the poor quality of child healthcare services in Africa (Campbell, 2007;Ehiri et al., 2005).
Assessment of the quality of child health services by caregivers has shown some causes for concern.Major areas of concern include: inadequacy of staff, materials and equipment, poor attitude and conduct of health workers, long waiting time, technical incompetence, high cost of services, etc (Emmanuel et al., 2013;Juma and Manongi, 2009;Kebashin and Haroon, 2010).
The aim of this study was to assess the caregivers' perception of the quality of the different aspects of child health services provided in a General Hospital in Lagos state.

METHODOLOGY
The Child Welfare Clinic of an urban General Hospital in Lagos State has staff strength of a doctor and 5 nurses.Immunization, health education, treatment of minor ailments and other services are offered to an average of 37 and 150 clients daily and monthly, respectively.This descriptive cross sectional study conducted between 10th to 18th June, 2013, recruited 214 eligible consenting caregivers attending the Child Welfare Clinic based on the calculated minimum sample size, using the Cochran's formula.The 28 question, four sectioned, closed and open-ended intervieweradministered questionnaire sought to answer question on sociodemographic information; perception of caregivers on the adequacy of staff and materials; staff attitude and conduct; perception of waiting time and the overall satisfaction with quality of child health services.Ethical clearance was obtained from the Research and Ethics Committee of the Lagos University Teaching Hospital.All ethical research protocols were strictly adhered to.Three research assistants were trained for one hour for two days and the study instrument pretested in a similar general hospital among 20 care givers.Data was entered and analyzed using statistical package for social sciences (SPSS) 18. Categorical variables were presented in tables.
In assessing adequacy of staff and materials, the five-point Likert scale method was used and scores were assigned thus: 1 = very inadequate, 2 = inadequate, 3 = neutral, 4 = adequate, 5 = very adequate.Due to the low number of people in the categories, the five point scale was merged into three level scales, very inadequate and inadequate becoming "inadequate" neutral remaining as it is and adequate and very adequate becoming "adequate" (Ross, 2003).The same modality was also employed in the assessment of the staff attitude and conduct, with the five point scale merged into poor, neutral and good.Assessing the level of caregivers' satisfaction in this study was subjective using the following parameters; very unsatisfied, unsatisfied, neutral, satisfied and very unsatisfied.And this may be a possible limitation to the study.

Ethical approval
Ethical approval was sought and gotten from the Research and Ethics Committee of Lagos University Teaching Hospital (LUTH).

Waiting time and overall satisfaction
The  4).Over 176 (82.3%) of respondents were satisfied with the overall quality of child health care services (Table 5).

Socio-demographic characteristics
The gender distribution revealed a majority of female caregivers with 185 (80%) of them being mothers.This is similar to findings in Nnewi, Nigeria where about 82% of the female caregivers were mothers of the children (Campbell, 2007).Other similar studies had also revealed  Mean satisfaction: 3.97 SD ± 0.9.
that children are more likely to be brought to the clinic by their mothers (Emmanuel et al., 2013;Ross, 2003).Majority of the respondents were Christians and similar to another study done in Lagos State where nearly 7 out of ten (69%) of the respondents were Christians (Juma and Manongi, 2009).About 87 (40%) of the respondent had secondary education in line with study where 36% of the respondents also had a secondary school education (Campbell, 2007).

Perceived adequacy
In this study 137 (67.7%) of the respondents perceived the staff strength in the health facility to be adequate in tangent with the Tanzanian study where 80% of the respondents gave a favourable response to staff adequacy (Ross, 2003).Up to 84.4% of the respondents felt drugs in the facility were adequate, however, 13 (11.5%)felt that availability of drugs was inadequate, and in consonance with Kenyan study with 17% of the respondents citing unavailability of drugs at the health facilities as a reason for under-utilization of these facilities (Udonwa et al., 2010).

Staff attitude and conduct
The attitude and conduct of the nurses was the most poorly rated.Over 56 (25%) of the respondents rated the nurses' attitude in treating clients with respect and dignity as poor.Above 165 (81.3%) of the respondents felt that the doctors were good at initial reception.This finding however contrasts the findings of some studies where most of the respondents felt that the care providers were unable to introduce themselves at reception or greet the caregiver (Kebashin and Haroon, 2010;UNICEF/World Health Organization, 2003).

Waiting time and overall satisfaction
The mean waiting time of 112.76 SD ± 63.70 min found in this study was similar to a study in Lagos, LUTH where the waiting time was found to be 92.4 min.Around 156 (73.2%) of the respondents perceived the waiting time to see the health care provider as either long or very long.This is a major inhibiting factor to satisfaction as over 58 (28.6%) of the caregivers suggested that a reduction in waiting time will lead to improvement in the facility.This finding conforms to the findings of some notable studies done in Nigeria (Juma and Manongi, 2009;Uzochukwu et al., 2004).The mean consultation time was 9.2 SD ± 5.6 min.This is similar to a study carried out in South Africa which revealed that the mean duration of a consultation was 8.2 SD ± 4.7 min (UNICEF/World Health Organization, 2003).The commonest problem areas that needed improvement as suggested by the respondents include; staff attitude, waiting time, staff strength etc.However, over 176 (82.3%) of the respondents were satisfied.This level of satisfaction is similar to that of many previous studies (Campbell, 2007;Emmanuel et al., 2013;Juma and Manongi, 2009;Kebashin and Haroon, 2010).The socio-demographic characteristics of the respondents however were not significantly associated with overall level of satisfaction with services received.

Conclusion
Majority of the respondents was satisfied with the services at the facility.However, there is a need to improve the attitude of the staff especially that of the nurses and record staff.Also, the waiting time should be reduced as this is a factor that leads to under-utilization of health care facilities.There is also a need to increase the staff strength, as a limited number of health workers are likely to lead to an increase in waiting time.

Table 2 .
Respondents views on different aspects of adequacy in the facility.

Table 4 .
Perceived Waiting Time at the Clinic (N=204).

Table 5 .
Respondents views on the level of satisfaction with overall quality of care.