Effects of Health System Approach Intervention on Adherence to Appointments in Antenatal and Postnatal Clinics in Public Hospitals in Selected Counties in Kenya

Abstract

African medical setting has about 42% missed appointment rate. With about 44% missed appointment rate in antenatal and postnatal clinics, Kenya wastes up to 22% of health resources caused by both facility and patient factors. According to UNICEF 2017 report, 502,860 children were not immunized in 2017, and 1.7 million children born between 2013 and 2017 did not receive all prescribed vaccines. Homabay and Kisumu Counties recorded 42% and 35% missed appointment rates in antenatal and postnatal clinics respectively in 2019 as per 2019 Hospital “Did Not Attend Reports”. This study assessed the effect of health system approach intervention on adherence to appointments in antenatal clinics in public hospitals in Kenya. Specifically, the study assessed: the influence of organization of maternal and child health services; contribution of health workers; influence of access; influence of patient characteristics; and effect of system-wide communication on adherence to appointments in antenatal clinics in public hospitals. The study adopted a case control with a quasi-experimental research design in which two hospitals were purposively sampled for inclusion (Homabay and Kisumu County Hospitals) because of the high under-five mortality, poverty rates, and high HIV prevalence rates. These facilities are also ranked on the same level by the Ministry of Health. The study targeted 4 hospital managers and 200 registered antenatal clients in their first trimester of pregnancy. Stratified sampling and proportionate sampling were used to sample clients, and purposive sampling for hospital managers. Yamane Formula was used to determine sample size. The study sample comprised of 133 antenatal clients (Homabay County Hospital 70, Kisumu County Hospital 63) and 2 hospital managers per hospital. A self-administered structured questionnaire and a key informant interview guide were used to collect data. Findings revealed that, in Homabay and Kisumu County hospitals, 55 (78.6%) and 33 (55%) of antenatal clients had missed their appointments because of the long waiting time; 50 (71.4%) and 37 (61.7%) due to poor consultation process; 50 (71.4%) and 27 (45%) due to inadequate responsiveness towards their needs; 50 (71.4%) and 34 (56.7%) due to poor staff attitude; 55 (78.6%) and 30 (50%) due to high opportunity cost of seeking services; and 55 (78.6%) and 25 (41.7%) due to the long distance to the facility. An intervention in form of system wide communication on the above factors in Homabay County reduced missed appointments to 6 (9.1%) due to short waiting time; 10(15%) due to enhanced consultation process; 9 (13.6%) due to better staff responsiveness; and 14 (21.2%) due to improved staff attitude. Single, separated and young antenatal clients miss more appointments than the married, cohabiting, and older clients. The Pearson chi-square test also showed p value of 0.000 revealing a strong association between the variables. The logistic regression models depicted high odds ratio (at 95% confidence interval) of appointment adherence with positive increase in independent variables. Also, the independent variables have a p<0.05 depicting high significance to dependent variable. Conclusively, there is a high missed appointment rate in ANC clinics in Homabay and Kisumu County hospitals because of long waiting time and poor consultation process; poor staff attitude and inadequate staff responsiveness; and high opportunity cost and facility location. The study recommends that the two counties reorganizes MCH services by increasing consultation points; train staff on public relations; devolve crucial ANC services to remote areas; adopt this study’s system approach intervention; and community health workers to educate mothers on the significance of ANC services to improve adherence to appointments in ANC clinics.