Perspective of Healthcare Providers on Assessing The Quality And Accessibility of Health Services for Chronic Diseases in Jordan During Covid-19: A Mixed Method Study

doi:10.21203/rs.3.rs-2468736/v1

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Research Article

Perspective of Healthcare Providers on Assessing The Quality And Accessibility of Health Services for Chronic Diseases in Jordan During Covid-19: A Mixed Method Study

https://doi.org/10.21203/rs.3.rs-2468736/v1

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published 23 Aug, 2023

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Background: Hospital services in all parts of the world were severely affected by the crisis caused by the Coronavirus pandemic. This was particularly concerning for patients who suffer from chronic diseases. Aim: This study aims to assess the quality and accessibility of chronic disease services, it examines the association of socio-demographic factors with the quality and accessibility of chronic disease services, and it explores the barriers and facilitators of quality and accessibility to chronic disease health services during the COVID -19 pandemic, from the perspectives of healthcare providers.

Method: Design: A mixed method design was used in this study. In the quantitative part of the study, a questionnaire was used. The qualitative part of the study was conducted by using a focus group discussion approach. Sample: Data were collected from healthcare providers. Setting: The institutions involved were Public ,private and teaching hospitals .Analysis: The collected data were analyzed using SPSS Statistics Version 25. The interview responses were analyzed using the thematic analysis approach.

Results: This study found that the quality and accessibility of chronic disease services in northern Jordan were affected during COVID-19. Quantitative: Most of the participants reported barriers to access and a moderate level of quality during COVID-19. Qualitative: Four main themes were identified in relation to the barriers and facilitators of both quality and accessibility of chronic disease health services during COVID-19.

Conclusion: The quality and accessibility of chronic disease services were affected during COVID -19. In addition, sociodemographic factors helped to predict the quality and accessibility of chronic disease services during COVID-19, from healthcare providers perspectives. The findings of this study provide healthcare policymakers with information and evidence that is crucial in guiding them to make informed decisions and develop more appropriate interventions to help patients recover from the long-term impact of COVID-19.

COVID-19

Accessibility

Quality

Chronic Diseases

Sociodemographic Variables

Chronic diseases, which are noncommunicable, and caused by modifiable and non-modifiable factors¹. Patients with chronic diseases rely on routine health services to maintain their health status, they should have continuous and timely care to prevent problems and reduce the mortality rate^2,3. Patients who encounter a barrier to accessing healthcare services have an increased risk of mortality due to delayed diagnosis and treatment ⁴.These problems became more pronounced during the COVID-19 era.

COVID-19, which emerged in China in late 2019⁵, caused world governments to impose a range of mitigating policies, such as social distancing, lockdowns, and curfews, to overcome its impacts. Healthcare facilities made a substantial shift of financial, technical, and healthcare forces to tackle the high numbers of cases of highly infectious and critically ill patients with COVID-19.This inevitably caused a major disruption to non-COVID-19 services, including chronic disease services⁶

Disruptions of chronic disease services were examined during a rapid assessment conducted by WHO in January 2021, which revealed a disruption of one or more essential chronic disease services among the surveyed countries⁶.The policies put in place to mitigate the spread of the virus resulted in high barriers to accessing healthcare services and a discontinuation of some health services⁷.In addition to accessibility problems, COVID 19 disrupted the primary care system which negatively impacted the quality of healthcare services for patients with chronic diseases ⁸.

The objectives of this study are to assess the quality and accessibility of chronic disease services. To examine the impact of socio-demographic factors on the quality and accessibility of chronic disease services. Lastly, to explore the barriers and facilitators of quality and accessibility to chronic disease health services during the COVID − 19 pandemic, from the perspectives of healthcare providers.

The mixed method research design was applied in this study, quantitative design was used to assess the quality and accessibility of chronic disease services during COVID-19 and to predict the factors affecting quality and accessibility. To gain more insight and get a rich detailed understanding about the barriers and facilitators affecting both quality and accessibility of chronic disease a qualitative design was used . The core principle behind this type of research is that combining qualitative and quantitative data reveals new information that cannot be revealed by either type of data alone ⁹.

Design

Quantitative. A descriptive, correlational, cross-sectional design was used. Descriptive correlational designs are used to gather information from a representative sample of the population to describe/explore a phenomenon or examine relationships among phenomena ¹⁰.This design was deemed appropriate for this study where the study variables were described and the relationships between the dependent variables (Quality and accessibility of chronic disease services) and the independent variables (Socio-demographic variables) were examined.

Qualitative. An exploratory design was used.

Setting

Quantitative. The study was multisite as it was conducted at five hospitals in northern Jordan. The inclusion criteria for selecting these facilities were: representing different health sectors (including public, teaching, and private sectors), providing different chronic disease services, and being main and large facilities. These facilities belong to different health sectors: Public (Al-Ramtha Hospital and Al-Mafraq Governmental Hospitals), Private (Irbid Specialty Hospital and Irbid Islamic Hospital), and teaching university hospital (King Abdullah University Hospital).

Qualitative. The study was conducted at Irbid Specialty Hospital.

Sample

The participants were selected as follows: Healthcare providers were working in direct contact with chronic diseases patients as physicians, nurses, and pharmacists in Jordan. All held an academic qualification such as diploma, bachelor’s degree, or Master’s.

Quantitative. A total of 412 healthcare providers were recruited using the convenience sampling method, due to COVID-19 restrictions which made random sampling impossible. The sample size was determined based on the sample-to-variable ratio. For hierarchical or multiple regression analysis, as recommended by Tabachnick and Fidell (1989) and cited in ¹¹, five participants were selected for each predictor variable as a "reasonable minimum requirement". In our analysis, we had a ratio of 37 participants:1 predictor.

Qualitative. Twelve healthcare providers were recruited using the purposive sampling method, to acquire in-depth information according to their experiences¹².The sample size was determined based on saturation of data.

Instruments

Quantitative. Self-reporting instrument in the Arabic language was used to collect quantitative data in this study. The instrument contained the following sections:

Demographic Variables. Each of the following variables was assessed: age, gender, marital status, job title, educational level, place of working, place of residence, region, work experience, attending training and development courses, ways of commuting to the workplace.

Accessibility. The measure of access (Access-31) was developed using a literature review and the qualitative method ¹³ was used to assess the accessibility of chronic disease services . The Access-31 comprises 22 items. Items are rated on a binary scale of problem/no problem. The original instrument had some modifications, i.e., deleting the affordability dimension, which is not applicable as we measured the barriers of chronic disease patients’ accessibility, not healthcare providers, so a pilot study of 30 participants was carried out, then reliability was tested using Kuder Richardson. The resulting scores of KR20 =.77 and KR20 >0.7 were considered acceptable.

Quality. The quality of health care services was assessed using a questionnaire developed by ¹⁴. The questionnaire comprises 34 items. Items are rated on a 5-point Likert -type scale, ranging from 1 (Strongly disagree) to 5 (Strongly agree. Questionnaire was tested to ensure it was valid and reliable by the original author, Cronbach alpha was .92 ¹⁴.

Qualitative

Semi-structured questions were designed to conduct focus group discussion. Focus group discussions were used due to the major role of group participants, rather than the major role of the group moderator in the individual interview, to collect data ¹⁵. The interviews were conducted in Arabic. A total of two groups from healthcare providers from the assigned hospital, with each interview session lasting between 45 and 60 minutes. The interviews were face-to-face. All discussions were recorded through a recorder application and later only themes and chosen verbatim were translated into English.

Data Collection

Before data collection began, the study objectives, ethical considerations, inclusion, and exclusion criteria, the possibility of withdrawing at any point during the research phase were explained to all prospective participants . Those individuals who agreed to participate were asked to provide permission for the researcher to use findings for scientific research and to sign the consent form.

Quantitative. For the quantitative part, the data collection took place in 2021 (September - November). Data collection occurred using the instruments described above. Participants received the study instrument packet to be filled out in a private room at the hospital.

Qualitative. For the qualitative part, the data collection took place in 2022 (June - July) at Irbid specialty hospital in northern Jordan. Data collection was carried out using semi-structured predetermined questions. The study interview sessions were then scheduled based on the participants’ availability.

Data Management and Analysis

Quantitative. Data was securely stored, and only the researcher had access to them. All completed questionnaires were coded in Microsoft Excel, reviewed for accuracy, and imported into IBM© SPSS© statistics version 25. The analysis plan began by assessing the data for missing values and outliers. Before running the statistical analysis tests, a standard data check was conducted to make sure that the data were free of missing, outliers, and undefined values. Some missing values were found in certain items and not replaced due to the large sample, and to make sure that missing data did not bias the results. Little's Missing Completely at Random (MCAR test) was insignificant (p=0.981), implying that the values are missing completely at random, reflecting no systematic bias in the data. The normality test was satisfied based on Skewness values for scale variables (accessibility and quality of healthcare services) and was found to fall within the acceptable range (-0.5 to 0.5), which indicates that both variables are normally distributed. The box plot shows no significant outliers or extreme values in the data set. Descriptive statistics were used to describe the sample. The sample and variables were described by measures of central tendency and dispersion appropriate to the level of measurement. The frequencies and percentages are used to represent categorical data such as marital status. Multiple linear regression was used to predict the quality and accessibility of healthcare services. Before conducting multiple regression, Spearman rho, point biserial, and point multi-serial correlation were used as a preliminary step to assess the potential correlation between the independent variables and the outcome. The findings of correlational analysis could provide some idea of what to expect as far as the strength of the prediction model that will be generated using multiple regression.

Qualitative. For the qualitative part, permission to record the meetings was obtained from all participants. Data was securely stored, and only the researcher had access to them. All completed interviews were coded in and checked for accuracy. Data analysis began by identifying key concepts. Coded data were then categorized into themes and subthemes and analyzed using thematic analysis using Microsoft Word and highlighting and identifying patterns of themes in the interview data. Thematic analysis was used to collect patterns across the verbatim ¹⁶.

Sample characteristics. A total of 412 healthcare providers were enrolled in this study with the majority of the sample being female (249 - 60.4%), nurses (329 - 79.9%), working in governmental hospitals (232 - 56.3%), married (264 - 64.1%), hold a bachelor’s degree (290 - 70.4%), living in governorate (262 - 63.6%), and the vast majority were from the north region of Jordan (388 - 94.2%). The healthcare providers’ work experience was equally distributed between less than 5 years (162 - 39.3%) and 6-15 years group (164 - 39.8%). 275 (66.7%) of them were in the age group (20-35 years). With regard to attending training and development courses in the healthcare field and ways of reaching the workplace, the results revealed that more than half of the study sample had attended training and development healthcare courses (261 - 63.3%) and used their cars to reach the workplace (246 - 59.7%).

Accessibility of chronic diseases services. The descriptive statistics for the accessibility questionnaire total score revealed that the mean score was 4.77(SD 2.80), indicating that the chronic disease patients in the study have a moderate barrier level toward accessing healthcare services according to healthcare providers' perspective. Additionally, 163 (39.5%) healthcare providers perceive a moderate level of barriers toward chronic disease patient services, and only 19 (4.6%) have no barriers toward accessibility to healthcare services. Furthermore, (24.8%) and (31.1%) perceive a high and low barrier, respectively.

Association of healthcare providers’ socio-demographic variables with accessibility of chronic disease services. The result of multiple linear regression in Table (1) demonstrated that the model explained around 6.0% of the variance in the dependent variable and that model was statistically significant. F (5,411) =6.034, p≤0.001, revealing that there is at least one predictor that has a prediction power to predict the score of the dependent variable. Moreover, the place of residence was a significant positive predictor for accessibility to healthcare services (B=0.838, t=2.994, p=0.003), revealing that living in a village corresponds with increased barriers toward accessibility to healthcare services by 0.838 units compared to living in the governorate. Similarly, attending healthcare courses was a significant positive predictor for accessibility to healthcare services (B=0.763, t=2.723, p=0.007), demonstrating that not attending training and development healthcare courses corresponded with increased barriers toward accessibility to healthcare services by 0.763 units for those who attended. Work experience and age were not statistically significant predictors for accessibility to healthcare services (P>0.05).

Table 1:Multiple linear regression of predicting accessibility barriers to healthcare services

Dependent Variable	Coefficient
Dependent Variable	Predictor	B	SEM	T Value	Sig	VIF	Tolerance
Accessibility barriers to healthcare services	Place of residence	0.838	0.28	2.994	0.003	1.0	0.99
	Attendance of training and development courses	0.763	0.28	2.723	0.007	1.0	0.99
	Age	-0.135	0.41	-0.329	0.742	2.1	0.48
	Experience 1-5 years	0.418	0.33	1.278	0.202	1.4	0.71
	Experience More than 15 years	-0.256	0.15	-1.721	0.086	1.8	0.55

F value =6.034,R^2adj= 0.058, p≤0.001 Durbin Watson 1.637

Quality of chronic diseases services. The descriptive statistics for the quality questionnaire revealed that the mean score was 3.36 (SD 0.77), indicating that the healthcare providers in the study have a moderate level of quality of healthcare services. Additionally, half of the sample (220 - 53.4%) have a moderate level of quality of healthcare services and only 42 (10.2%) have a low-quality level. Furthermore, (36.4%) have a high-quality level.

Association of healthcare providers’ socio-demographic variables with quality of chronic disease services. The results of multiple linear regression in Table (2) demonstrate that the model explained around 4.0% of the variance in the dependent variable and that model was statistically significant. F (7,411) =3.455, p≤0.001, revealing that there is at least one predictor that has a prediction power to predict the score of the dependent variable. Moreover, the place of residence was a significant inverse predictor for the quality of healthcare services (B=-0.159, t=2.580, p=0.040) revealing that living in a village corresponds with a decrease in the quality of healthcare services by -0. 159 unit, compared to those who live in the governorate. Similarly, not attending training and development healthcare courses was a significant inverse predictor for quality of healthcare services (B=-0.189, t=2.437, p=0.015), demonstrating that not attending training and development healthcare courses corresponded with a decrease in the quality of healthcare services score by -0.189 unit compared to those who attended. Finally, having a higher degree significantly inversely predicted the quality of healthcare services (B=-0.222, t=-2.139, p=0.033), revealing that the providers who have higher educational degrees correspond with a decrease in the quality of healthcare services score by -0.222 units than those who have a bachelor's degree, while work experience, diploma degree and age were not significant predictors of quality of healthcare services (p>0.05).

Table 2: Multiple linear regression of predicting the quality of healthcare services

Dependent Variable	Coefficient
Quality of Healthcare Services	Predictor	B	SEM	T Value	Sig	VIF	Tolerance
	Place of residence	-0.159	0.077	-2.580	0.040	1.0	0.992
	Attendance of training and development courses	-0.189	0.077	-2.437	0.015	1.0	0.984
	High degrees	-0.222	0.104	-2.139	0.033	1.0	0.962
	Experience 1-5 years	-0.062	0.091	-0.677	0.499	1.4	0.691
	Experience Above 15 years	-0.005	0.041	-0.123	0.903	1.8	0.550
	Diploma degree	0.107	0.111	0.960	0.338	1.1	0.931
	Age	0.188	0.114	1.656	0.099	2.1	0.479

F value =3.455, R^2adj= 0.040, p≤0.001. Durbin Watson 1.85

Results/ Qualitative. Twelve healthcare providers were enrolled in this study, with the majority of the sample being female (80%) and living in urban areas (70%). Marital status was distributed equally between married (50%), and single (50%). The data analysis revealed 4 major themes and 6 subthemes, as shown in Table 3, which capture healthcare providers experiences related to accessibility and quality of chronic disease health services during COVID-19.

Table 3: Themes and subthemes

Theme	Subthemes
1. Accessibility barriers to chronic disease health services during COVID-19, from healthcare providers’ perspectives.	Transportation Fear of infection
2. Accessibility facilitators to chronic disease health services during COVID-19, from healthcare providers’ perspectives.	Availability of Personal Protective Equipment (PPE ) COVID-19 vaccination
3. Quality barriers to chronic disease health services during COVID-19, from healthcare providers’ perspectives.	Healthcare staff shortages
4. Quality facilitators to chronic disease health services during COVID-19, from healthcare providers’ perspectives.	Safety protocols

Statement of principal findings

Our study findings indicate that almost 95.4% of providers perceive barriers to their patient's accessibility to chronic disease health services, whereas only 4.6% reveal no barriers to accessibility during COVID-19. Which is consistent with ¹⁷.

Our findings indicate that the level of the quality of chronic diseases services was moderate. The level of quality of chronic diseases services was severely impacted by COVID -19, as revealed by the fact that almost 10.2% of providers perceive a low quality of their patient's services, whereas 53.4% reveal moderate quality services during COVID-19. This is in line with a study from Belgium ¹⁸.

Interpretation within the context of the wider literature

Quantitative

Place of residence: The study demonstrates a significant prediction effect of place of residence on the accessibility of chronic disease health services. This shows that living in a village corresponds with increased barriers toward accessibility to healthcare services by 0.838 units, compared to those living in the governorate. Which is consistent with ¹⁹.

Course attendance: The study demonstrates a significant prediction effect of attending training and development courses and accessibility of chronic disease health services. The attendance of courses by healthcare providers corresponds with decreased barriers toward accessibility to healthcare services by 0.763.Previous research reveals that training courses during COVID-19 for health providers improve the knowledge of consequences and prevention methods of COVID-19 pandemic that may reflect on their competency to enhance patients’ outcomes ²⁰. However, this does not have an impact on accessibility. The discrepancy could be attributed to the limited or absence of literature regarding the impact of healthcare training on patient accessibility.

Place of residence: The study demonstrates a significant prediction effect of place of residence on the quality of health services. Our results reveal that living in a village corresponds with a decrease in the quality of healthcare services compared to those who live in the governorate. The decreased quality could be attributed to the fear of being infected by COVID-19 which prevents them from utilizing health services outside their region ²¹.

Course attendance: The study demonstrates a significant prediction effect of attending training and development courses on the quality of health services. Our results reveal that not attending training and development healthcare corresponded with a decrease in the quality of healthcare services compared with those who attended such courses. The current findings remained consistent with previous research ¹⁴.

Qualitative

Barriers to accessing chronic disease services were perceived during COVID-19 among healthcare providers. The first barrier was transportation services that were disrupted during COVID-19, preventing chronic disease patients from accessing healthcare services. This is consistent with¹⁷.The second barrier was fear of infection, which prevented many people from accessing chronic disease services. This is consistent with ¹⁸.

Facilitators to accessing chronic disease health services were highly noticed among healthcare providers during COVID-19. The first facilitator was the availability of Personal Protective Equipment(PPE). A study from Jordan among healthcare providers revealed that Jordanian Ministry Of Health provided healthcare providers with PPE,The availability of PPE was accompanied by a lower COVID-19 infection rate ²². The second facilitator was the COVID-19 vaccination. In our study, the participating healthcare providers revealed that their patients who got vaccinated showed a lower degree of fear toward accessing healthcare services due to the vaccination of both patients and healthcare providers. Healthcare providers in Jordan had a higher intention to get vaccinated ²³.

Barriers to quality chronic disease healthcare services were highly noticed among healthcare providers during COVID-19. In our study, the participating healthcare providers discussed healthcare staff shortages as a barrier to quality services during COVID-19. Healthcare providers overwhelmed by workload reported tiredness as affecting the quality of care they delivered to patients. The study results remained consistent with previous literature²⁴.

Facilitators to quality chronic disease healthcare services were highly noticed among healthcare providers during COVID-19. In our study, the participating healthcare providers discussed safety protocols, i.e., pre-admission PCR test for patients, as a significant facilitator to prevent disease transmission and deliver quality chronic disease services during COVID-19.This is consistent with ²².

Strengths and limitations

This study used a convenience sampling approach, which may mean that the study sample is not representative of all chronic disease patients in Jordan as it is limited only to those who were willing to participate. The researcher was not able to take proportional sampling due to COVID-19 restrictions in the country. Additionally, this study was conducted at a time when the disease was relatively new, and people were afraid and lacked information. As such, the intended sample size of healthcare providers in the interviews was 16 participants. However, two participants from the first group were withdrawn at the beginning of the discussion, and thus dropped out from the analysis. Two participants also dropped out from the analysis because, despite being experienced in healthcare quality services, they were not delivering any health services for patients at the time of the data collection.

Despite these limitations, to the best of the researcher’s knowledge, this is the first study to assess the level of both quality and accessibility, explore barriers and facilitators perceived by healthcare providers, and examine the prediction effect of sociodemographic on quality and accessibility in Jordan . Most existing studies focus on the disruption of services caused by the spread of COVID-19.

The provision of clinical services to patients who do not have COVID-19 has been impacted by the restructuring of healthcare systems to address the COVID-19 pandemic. The results of this study are consistent with the literature on the changes in the quality and accessibility of chronic disease services because of the pandemic. This study makes a valuable contribution to the field of research on the assessment of accessibility and quality of chronic disease services during COVID-19. The findings of this study provide healthcare policymakers with information and evidence that is crucial in guiding them to make informed decisions and develop more appropriate interventions to help patients recover from the long-term impact of COVID-19.

Ethical Approval and Consent to Participate

The study was approved by IRB committees of the study setting (Al-Mafraq and Al-Ramtha Governmental Hospitals, King Abdullah University Hospital, Irbid Specialty Hospital, and Irbid Islamic Hospital) and Jordan University of Science and Technology, and followed Declaration of Helsinki Ethical Principles for Medical Research Involving Human Subjects.

Prior to data collection, the study objectives; ethical considerations; and inclusion and exclusion criteria were explained to all participants. Participants who agreed to participate were asked to sign a written consent form and provide a permission for the primary investigator (PI) to use findings for scientific research. They then received the study instrument packet to be filled out in a private room at the hospital.

In regard to sampling method and data collection, three ethical principles were applied including respect for persons, justice, and confidentiality. For protecting the principle of respect for persons, the participants were informed about the nature and objectives of the study and written informed consent was obtained. For maintaining justice, no one of the healthcare providers working at the mentioned hospitals was excluded based on his/her race or religion. Confidentiality was achieved by collecting study’s data anonymously, coded IDs were created to use for data collection and analysis. The study’ data was securely stored in password-secured computer files. Only the right people, including the authors had access to the data.

Consent to Publication

Not applicable

Data Availability Statement

The Data will be available upon a reasonable request from corresponding author Raya T. Albataineh by email ([email protected]).

Conflict of Interests

There is no any conflict of interest.

Funding

This study was funded by Jordan University of Science and Technology [ 20210343].

Acknowledgments

The authors would like to thank all healthcare providers who participated in this study. We are also thankful to the administration of included hospitals and faculty of medicine in Jordan University of Science and Technology. Special thanks to Jordan University of Science and Technology for funding this study and supporting authors.

Author’s Contributions

R.A designed the work and planned the statistical analysis.

M.A designed the work and planned the qualitative analysis.

W.A collected the data and performed the statistical analysis.

All authors assisted with drafting the manuscript. All authors read and approved the final manuscript

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No competing interests reported.

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Perspective of Healthcare Providers on Assessing The Quality And Accessibility of Health Services for Chronic Diseases in Jordan During Covid-19: A Mixed Method Study

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