Patient-centered care and associated factors among outpatient attendees in primary hospitals in South Gondar Zone, Northwest Ethiopia: a mixed methods study

Abstract

Background

According to the Picker Institute model, patient-centred care (PCC) includes respect for patients’ values, preferences, and expressed needs; information, communication, and education; access to care; emotional support; involvement of family and friends; continuity and transition; physical comfort; and coordination and integration of care. It is one of the six aims for quality improvement guiding today’s health care systems. However, PCC remains underutilized by both patients and professionals, and significant challenges persist in its implementation worldwide. Additionally, few studies have examined the level of and factors associated with PCC practices in Ethiopia.

Objective

To assess PCC practices and their associated factors among outpatient attendants at primary hospitals in the South Gondar Zone, Northwest Ethiopia, in 2024.

Methods

A facility-based explanatory sequential mixed-methods study was conducted from March 18 to May 10, 2024. A total of 567 participants were selected using systematic random sampling. Binary logistic regression with adjusted odds ratios (AORs), 95% CIs, and p-values was used for quantitative data analysis. For the qualitative part, nine participants were selected for in-depth interviews. Thematic analysis was performed using Open Code 4.3, and the qualitative findings were used to explain the quantitative results.

Results

The proportion of PCC was 50.5% (95% CI: 46.3%-54.7%). In the qualitative analysis, PCC was categorized into two sub-themes: satisfactory PCC and not satisfactory PCC. The multivariable analysis showed that age above 34 years (AOR = 1.85; 95% CI: 1.186–2.89), consultation and empathy (AOR = 2.26; 95% CI: 1.39–3.7), shared decision-making (SDM) (AOR = 3.70; 95% CI: 2.36–5.75), perceived quality of services (AOR = 3.26; 95% CI: 2.014–5.26), medical care (AOR = 1.87; 95% CI: 1.16-3.00) and perceived workload on providers (AOR = 1.72; 95% CI: 1.033–2.847) were significantly associated with PCC. The qualitative findings indicated that informational factors, provider intimacy, shared-decision making, social support, availability of medicines, and medical care were factors affecting PCC.

Conclusion

Half of the outpatients received good PCC at primary hospitals in the South Gondar Zone. Age, perceived quality of services, consultation and empathy, SDM, and perceived workload on providers were among the variables associated with PCC. This suggests that increased attention needed including awareness creation for patients, attendants, and providers, as well as close supervision of healthcare professionals’ interactions with patients, to enhance the implementation of PCC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-026-14117-w.

Background

PCC is a concept that gained significant importance in healthcare research in the late 1990s [1]. Today, it is widely recognized as a core value in medical practice and represents an open approach to healthcare. The American Institute of Medicine (IOM) defines PCC as care that is respectful of and responsive to patients’ individual preferences, needs, and values. It emphasizes aligning clinical decisions with patients’ values and actively involving patients in their own care. Improving PCC is recommended to ensure high-quality healthcare [2, 3]. According to the Picker Institute model, PCC has eight dimensions: respect for patients’ values, preferences, and expressed needs; information provision and education; access to care; emotional support; involvement of family and friends; continuity and transition; physical comfort; and care coordination and integration [4].

Although international studies have examined patient-entered care from the perspective of staff and health workers’ to identify key factors associated with its provision, data from both the patient’s and health professionals’ perspectives can optimize health care delivery [5].

To our knowledge, there is limited information on PCC and its associated factors. In assessing hospital services, outpatient services have been neglected. There is limited research on PCC in hospital outpatient settings in Ethiopia. The findings from this study will provide information on overall PCC implementation and its related factors. A qualitative study in the Amhara region revealed that some patients did not participate in the care they received. They were not invited to ask questions because health care providers were not in a position to answer questions. Patients also did not understand some of the medical terminology that health care providers used when communicating with them [6].

Patients have the fundamental right to appropriate and prompt care, the correct medication, knowledge of their condition, and involvement in their care so they can make informed decisions and be informed about their health [7]. Although patients’ rights are recognized when visiting healthcare facilities, many countries around the world fail to provide the right care at the right time that delivers clinical benefit, is safe and meets patients’ needs and preferences. In practice these rights are often not fulfilled. Every day, patients are affected by healthcare processes and systems without a significant reduction in the severity and frequency of these impacts [7, 8].

Despite the proven benefits of PCC, it remains underutilized by both patients and professionals, and significant problems with its implementation persist worldwide [9]. A lack of quality healthcare is a major cause of suffering and death. The IOM estimates that nearly 98,000 patient deaths result from preventable human error [10].

In developed countries such as the United Kingdom, the USA, Australia, Germany, and others, PCC has been implemented in policy but is rarely applied in medical practice. In a state hospital in Saudi Arabia, a study found that care was resource- and staff-centred rather than patient- or person-centred. A total of 63.4% of participants did not know they had the right to be fully informed about their diagnosis and treatment plan [11].

A study of low- and middle-income countries found that approximately 5 million deaths occur among people who have access to the healthcare system but receive poor quality care [12]. Poor quality healthcare is one of the main causes of excess mortality from communicable and non- communicable diseases, injuries, and neonatal illnesses. Therefore, the introduction of PCC could address many healthcare problems, such as poor health outcomes, high service costs, and the spread of communicable and non-communicable diseases [13].

In low- and middle-income countries (LMICs), PCC is limited. In several resource-poor countries, healthcare providers and staff lack PCC skills. Although it is increasingly recognized as a key aspect of quality healthcare in Africa, it remains poorly implemented in practice [14–16]. A qualitative study in Zambia reported disrespectful or unfriendly care that undermined patients’ trust in the values and professionalism of healthcare staff [17]. Another qualitative study on patient-centred care and nurses’ perceptions in primary healthcare facilities in Nigeria found that providers did not pay sufficient attention to individual or contextual factors and sometimes treated patients with such disrespect that patients described the care as abusive and inhumane. Patient preferences appear to be largely ignored and patients are given little information about their condition or treatment [18].

Studies in Ethiopia have suggested that a lack of PCC limits access to health care, reduces health knowledge, and prevents patients from expressing their concerns. This leads to decreased compliance with treatment plans, increased patient dissatisfaction, increased patient distress, longer hospital stays, higher costs, and poorer overall health outcomes. Additionally, health professionals often fail to provide detailed information about diagnoses and treatments, leaving patients uncertain about the quality of care they receive [19]. Awareness of PCC, staff motivation, heavy workload, professional competencies, effective communication, absence of ethical guidelines, lack of a clear organisational culture, and absence of specific policies and guidelines on PCC were identified as barriers and challenges to PCC implementation [20–25]. Studies in Addis Ababa and Bahir Dar revealed that the overall perceived patient-centred health care practices (PCHCPs) of admitted patients in public hospitals were poor [19, 26]. In Ethiopia, the health status of the population is poor compared with that of some low-income countries in sub-Saharan Africa. Currently, the government of Ethiopia is committed to delivering quality health care, as reflected in health policy and the strategic health plan. Thus, measuring PCC and identifying its predictors will be helpful [27].

Measuring PCC from patients’ perspectives is critical for identifying areas needing improvement in healthcare delivery and serves as a key performance indicator for healthcare facilities. This enhances transparency about services and fosters trust between healthcare providers and patients [28]. Despite many global, continental and national efforts to improve community health, the fundamental aspects of PCC quality care delivery and patient involvement remain under strain, even with significant resources and advancements in healthcare [29]. For most sub-Saharan African countries, including Ethiopia, rigorous evidence on PCC remains scarce. Existing peer-reviewed studies are mostly descriptive and largely focused on specific health problems [18]. Thus, this study addresses the following research questions: (1) What is the level of PCC for outpatients attending public hospitals (2)? What factors are associated with PCC?

Materials and methods

Study setting and period

The study was conducted at primary hospitals in the South Gondar Zone, Northwest Ethiopia, in 2024. The South Gondar Zone is located in the Amhara region, approximately 670 km northwest of Addis Ababa, the capital of Ethiopia, and 100 km from the regional city of Bahir Dar [30]. There are nine public primary hospitals, one comprehensive specialized hospital, 96 health centers, and 405 health posts in this zone. Of the nine public primary hospitals, three were randomly selected: Nefas-Mewcha, Mekane-Eyesus, and Tach-Gayint hospitals, with an average yearly patient flow of 142,653, of which 137,165 were outpatients. The study was conducted from March 18, 2024, to May 10, 2024.

Study design

A facility-based explanatory sequential mixed method study was used.

Source population

All outpatients in primary hospitals in South Gondar Zone, Northwest Ethiopia, 2024.

Study population

All patients who attended the outpatient department (OPD) of the randomly selected primary hospitals were included.

Inclusion criteria

Outpatient visitors aged greater than or equal to 18 years were included.

Exclusion criteria

Outpatient visitors who were awkward or seriously ill and had difficulty communicating were excluded from the study.

Sample size determination

Sample size determination for the quantitative study

The sample size for the quantitative part was estimated using a single population proportion formula, considering a population proportion (p) of patient-cantered care of 33.7% from a study conducted at hospitals in Bahir Dar city [19], with a 95% confidence interval, 5% margin of error, 10% nonresponse rate, and a design effect of 1.5, resulting in a final sample size of 567 [26, 31].

Sample size determination for qualitative study

For the qualitative study, nine participants were purposively selected for in-depth interviews after analysing of the quantitative data, and data collection continued until relative information saturation was reached.

Sampling technique and procedure

Sampling technique and procedure for the quantitative study

A multistage sampling technique was employed to select the study participants. Of the nine primary hospitals in South Gondar Zone, three (30%) [26], public hospitals were randomly selected for this study using simple random sampling (lottery method). Study participants were then recruited from the selected hospitals using a systematic random sampling technique based on patient data from the previous month. The sampling interval (k) was determined as k = N/n = 5103/570 = 9. Since data were collected over half a month, the total number of patients who visited the three hospitals in 15 days (N = 5103) was used. The first participant was selected by the lottery method, and the remaining samples were included according to the pattern k = 9, or x, x + ik, where x is the first selected participant and i starts from 1, 2, 3, .x + nk. For proportional allocation, the final sample sizes were116 for Tach-Gayint, 201 for Mekane-Eyesus, and 250 for Nefas-Mewcha hospitals (Fig. 1).

Fig. 1.

Sampling procedure for PCC and associated factors in South Gondar Zone, Northwest Ethiopia, 2024

Sampling technique and procedure for the qualitative study

For the qualitative study, participants for in-depth interviews were purposively selected until relative saturation of ideas was reached. Nine participants took part in the study from the three primary hospitals mentioned above including senior healthcare providers, patients visiting the facilities, and managers.

Study variables

Dependent variable

Level of patient-centred care (good/poor).

Independent variables

Sociodemographic variables: sex, age, residence, occupation, marital status, income, educational level and religion.

Patient-related factors: type of illness, frequency of visits, intimacy with providers, community-based health insurance, distance from the hospital, and perceived severity of disease and social support.

Provider-related factors: consultation and empathy, information on medication, clinical decision-making involvement, perceived workload and medical care.

Health system factors: perceived quality of services, perceived waiting time, ease of access to services, privacy during care, availability of medication and perceived physical environment.

Operational definition

Patient-centred care: PCC was measured using eight dimensions with corresponding items: patient preference (5), education and communication (4), physical comfort (3), access to care (3), emotional support (3), continuity and transitional care (3), coordination and integrated care (3), and involvement of family or friends (3), for a total of 27 questions on a Likert scale (1 [strongly disagree] to 5 [strongly agree]). The sum of all items resulted a raw total score ranging from 27 to 135. The mean score was then calculated, and respondents scoring above the mean were classified as having ‘good PCC’, while those scoring at or below the mean were classified as having ‘poor PCC’ [4, 32].

Data collection methods and tools

Data collection methods and tools for quantitative study

A structured questionnaire was used to collect quantitative data. The instrument was based on standard data collection tools and adapted through a review of related studies [19, 26, 27, 32–34]. The study questionnaire includes five main sections and a number of questions to collect data on patients’ sociodemographic characteristics, the eight dimensions of PCC, provider-related variables, patient-related variables, and health system-related variables. Data were collected by five trained nurses, with one public health officer assigned as a supervisor to facilitate data collection. The standard tools used were as follows:

1. A validated 21-item “K-PCC” from South Korea and a 36-item patient-centred primary care instrument from the Netherlands were used to measure the level of the dependent variable, PCC in outpatients.

2. Consultation and empathy were measured using the Consultation and Relational Empathy (CARE) questionnaire, which contains eight items.

3. The 9-item Shared Decision-Making Questionnaire (SDM-Q-9) is used to assess the decision-making style of a physician during patient treatment.

4. The OSSS is a three-item scale with a range of 3–14 [33].

Data collection methods and tools for qualitative study

For qualitative data, the principal investigator prepared open-ended questions (interview guides) after analysing the quantitative data and reviewing different articles [18, 35] to explore information on the circumstances of PCC and its associated factors. In-depth interviews were conducted to maintain privacy, and a mobile recorder was used to record data during the interviews.

Data quality control

Data quality control for the quantitative study

The interviewer-administered structured questionnaire was initially prepared in English, translated into the local language Amharic, and then back translated into English to ensure consistency. One day of training was provided to the data collectors on the study objectives, data collection tools and procedures, and how to approach respondents politely. The reliability of the tool was assessed by investigators, with Cronbach’s α values of 0.894 for measuring patient-centred care, 0.808 for consultation and empathy (CARE) questions, and 0.817 for shared decision-making questions, indicating good reliability. A pretest was conducted on 5% [20] of outpatient visitors at Woreta Primary Hospital, and the final data collection tool was revised based on feedback. The collected data were carefully checked for completeness and consistency daily. For the qualitative data, the interview guide was first prepared in English, then translated into Amharic, and finally retranslated into English for analysis and presentation. The recorded audio was listened to repeatedly for familiarization, and the transcribed data were read extensively before identifying the thematic areas of the study for better exploration. Every point recorded in the notebook was cross-checked with the phone recordings for consistency.

Data entry, processing and analysis

Data entry, processing and analysis for the quantitative study

Each questionnaire was checked for completeness and consistency by data collectors and the investigator. The data were then entered into EPI Data Manager version 4.6 and exported to the Statistical Package for Social Sciences (SPSS) version 27 for analysis. Descriptive statistics summarised and presented the information as frequencies, means, percentages, tables, and graphs with 95% confidence intervals. Bivariate and multivariate logistic regression analyses assessed the associations between each independent variable and the dependent variable (PCC). Independent variables with P < 0.25 in the bivariate logistic regression analysis were retained for the multivariable logistic regression analysis. An adjusted odds ratio (AOR) with a 95% CI and a p value less than 0.05 was used to declare the strengths and factors significantly associated with the outcome variable. Model fit was checked using the Hosmer–Lemeshow goodness-of-fit test, and the overall model was considered a good fit with a P value > 0.05. The model was fitted with a P value of 0.663. Multicollinearity was checked using the variance inflation factor (VIF). A VIF < 10 and tolerance > 0.1 indicated the absence of multicollinearity. There was no multicollinearity among the predictor variables, as indicated by VIF values ranging from 1.107 to 1.537.

Data entry, processing and analysis for qualitative study

After data collection, the audio recordings were first transcribed and then translated into English for analysis. The transcripts were read repeatedly to gain a thorough understanding of the data, and the data were coded. The transcribed data codes were refined and organized into categories using Open Code 4.03 software. The identified themes were presented with important quotes from the respondents. Finally, the findings from the thematic analysis were reported.

Results

Quantitative results

Sociodemographic characteristics of the participants for quantitative findings

A total of 562 patients participated in this study, with a response rate of 99%. Regarding sociodemographic characteristics, 289 (51.4%) respondents were female, 284 (55.2%) were aged above 34 years, and 288 (51.2%) lived in urban areas, and 356 (63.3%) were married (Table 1).

Table 1.

Sociodemographic characteristics of respondents among outpatients at primary hospitals in South Gondar Zone, Northwest Ethiopia, 2024 (n = 562)

Variables	Category	Frequency	Percent (%)
Sex	Male	273	48.6
	Female	289	51.4
Age	18–34	252	44.8
	Above 34	310	55.2
Residence	Urban	288	51.2
	Rural	274	48.8
Religion	Orthodox	507	90.2
	Muslim	55	9.8
Marital status	Married	356	63.3
	Single	154	27.4
	Others*	52	9.3
Educational status	Cannot read and write	143	25.4
	Primary education	207	36.8
	Secondary education	86	15.3
	Diploma and above	126	22.4
Occupation	Farmer	185	33
	Private	71	12.6
	Gov’t employed	100	17.8
	Merchant	59	10.5
	Student	88	15.7
	Others**	59	10.5
Monthly income in ETB	< 5000	201	46.4
	5000–9999	197	45.5
	>=10,000	35	8

*Divorced, separated, Widowed, **Housewife, Jobless, ETB - Ethiopian Birr

Clinical service and health system related characteristics

Two hundred twenty-five (40%) of the participants were new to visiting hospitals within one year. Three hundred forty-two (63%) of the participants had an acute illness duration of less than one month. Approximately three fourths 430 (76.5%) of the respondents were aware of their disease or case, but only 221 (39.3%) and 248 (44%) of the respondents communicated their plan of care and treatment options with the provider, respectively. Regarding medication information, 397 (70.6%) of the respondents perceived they received appropriate medication information. More than half, 312 (55.6%) of the respondents reported good consultation and empathy. Approximately half, 266 (47.3%) of the study participants received high-quality services. Four out of five (79.5%) and two-thirds, 380 (67.6%), of the respondents had privacy during care and easy access to services, respectively. More than one-third, 219 (39%) of the participants received all prescribed medications from the facilities. Three hundred five (54%) of the participants perceived a good hospital environment and good social support (Table 2).

Table 2.

Clinical service and health system related characteristics among outpatients at primary hospitals in South Gondar Zone, North West, Ethiopia, 2024 (n = 562)

Variables	Category	Frequency	Percent (%)
Type of service	New	225	40
	Repeat	184	32.7
	Follow up	153	27.3
Duration of illness in days	Acute ( < = 30 days)	342	63
	Chronic (> 30 days)	199	37
CBHI	Yes	343	61
	No	219	39
Diseases awareness	Yes	430	76.5
	No	132	23.5
Plan of care	Yes	221	39.3
	No	341 248 314 397 165	60.7 44.1 55.9 70.6 29.4
Awareness on treatment option	Yes
	No
Medication information	Yes
	No
Perceived severity of disease	Very severe	65	11.5
	Severe	267	47.5
	Moderate	201	35.8
	Mild and others*	29	5.2
Intimacy	Yes	142	25.3
	No	420	74.7
Involved in decision making	Agree	272	48.4
	Disagree	290	51.6
Consultation and empathy	Poor	250	44.5
	Good	312	55.6
Workload	Yes	161	28.6
	No	401	71.4
Perceived quality of services	Low	296	52.7
	High	266	47.3
Perceived waiting time	Short	340	60.5
	Long	222	39.5
Easy access to services	Poor	182	32.4
	Good	380	67.6
Privacy during care	Poor	115	20.5
	Good	447	79.5
Availability of medication	All	219	39
	Some	309	55
	Others*	34	6
Hospital environment	Poor	257	45.7
	Good	305	54.3
Social support	Poor	258	46
	Good	304	54

CBHI − Community−based health insurance, *those without illness (e.g., family planning users) * None and advice

Level of patient-centred care

Overall, 50.5% (95% CI 46.3%-54.7%) of the participants received good PCC (Fig. 2).

Fig. 2.

Level of PCC among outpatients in South Gondar Zone, Northwest Ethiopia, 2024 (n = 562)

The qualitative results revealed that PCC was addressed using two sub-themes: satisfactory PCC and unsatisfactory PCC. In the satisfactory PCC sub-theme, one patient reported being informed about her general medical condition by the provider, while another patient actively participated in her care and treatment, which is part of PCC: “… My disease condition, lab test result, and medication information have been told to me” (P2-28-year-old female Patient) and “… I took my prescribed medicines appropriately. I listen to physicians’ advice well and I have improved” (P8-55-year-old female patient). In the unsatisfactory PCC sub-theme, most patients explained that the practice of PCC was limited and inconsistent. One participant (P6) described that the general condition of the patient was not well communicated to either the patient or their families. “…Health professionals did not tell much about the diseases. Patient choice is not expected, of course, it may be a characteristic of the profession, but I believe it should not always be so. There is a gap in communicating about the general condition of the patient. Patients and families who support them may become stressed or anxious unless providers inform them about the general condition of the patient” (P6 = A 45- year- old, male patient).

All responsible bodies for patient care in the hospital did not emphasize PCC, and they did not measure or evaluate it. The practice as an initiative also limited and it requires staff coordination but coordination lacking.

Patient’s preferences and choices were not considered; they didn’t give emphasis to patients during care. There was no efficiency, abuse with no solution even for minor problems. Even patients are cared by students, it was not satisfactory in applying PCC as explored by the respondents.

…We’re not practicing and evaluating PCC as a single initiative (P7-30 year’s old male provider).

Dimensions of patient-centred care

PCC is measured via eight dimensions with a total of 27 respective questions. With respect to information education and communication (IEC), approximately 310 (55%) of the respondents received information and education about their overall condition, 318 (56%) maintained their physical comfort, 352 (63%) had good access to care, and approximately 302 (54%) of the respondents’ care was coordinated with good continuity and transition (Table 3).

Table 3.

The eight dimensions of PCC among outpatients in South Gondar Zone, Northwest Ethiopia, 2024 (n = 562)

S.no	Variables	Category
		Poor n(%)	Good n(%)
1.	Patient preference	295(52.5)	267(47.5)
2.	Physical comfort	244(44)	318(56)
3.	Coordination of care	260(46)	302(54)
4.	Continuity and transition	256(46)	306(54)
5.	Emotional support	289(52)	273(48)
6.	Access to care	210(37)	352(63)
7.	IEC	252(45)	310(55)
8.	Family and friends	287(51)	275(49)
9.	Over all PCC	292(49.5)	270(50.5)

Factors associated with patient-centred care

The multivariable analysis revealed that age, perceived quality of care, SDM, consultation and empathy, medical care and perceived workload were significantly associated with PCC at a P value < 0.05. The odds of good PCC among outpatients aged above 34 years was 1.85 (AOR = 1.85; 95% CI: 1.186–2.89) times greater than that among outpatients aged 18–34 years. Additionally, the odds of good PCC among patients with good consultation and empathy was 2.26 (AOR = 2.26; 95% CI: 1.39–3.7) times greater than that among patients with poor consultation and empathy. Compared with their counterparts, patients who agreed with shared decision-making were 3.70 (AOR = 3.70; 95% CI: 2.37–5.76) likely to have a PCC. “…Medicine is self-treatment if so, we patients must be actively involved in the care given.” (P8-55 year’s Pt).

Furthermore, the odds of good PCC among patients who had high perceived quality of care was 3.26 (AOR = 3.26; 95% CI: 2.014–5.26) higher than that among patients who had low perceived quality of care. The odds of good PCC among patients who had good medical care was 1.87 (AOR = 1.87; 95% CI: 1.16-3.00) times greater than that among patients who had no medical care, “…patients and physician should communicate and agreed on the medical care” (P4- A 33 years old CCO). And patients who perceived that providers had no workload were 1.72 (72%) times greater odds of good PCC than patients who perceived that providers had a workload (AOR = 1.72; 95% CI: 1.033–2.847) (Table 4).

Table 4.

Bivariable and multivariable logistic regression results for the study of PCC and associated factors among outpatients in the South Gondar Zone, Ethiopia (n = 562)

Variables	Category	Patient-centered care		COR (95% CI)	AOR (95% CI)
		Good	Poor
Residence	Urban	170	138	1.00	1.00
	Rural	114	140	1.5(1.083,2.113)	1.14 (0.624,2.08)
Age	18–34	115	137	1.00	1.00
	Above 34	169	141	1.428 (1.023,1.994)	1.85 (1.186,2.89)**
Occupation	Government employed	68	32	1.00	1.00
	Private	63	67	0.442 (0.257,0.76)	0.504(0.25,1.01)
	Farmer	90	95	0.466(0.268,0.742)	0.474(0.244,0.923) * 0.028
	Others#	63	84	0.353(0.207,0.601)	0.599(0.30,1.189)
Distance	Near	164	135	1.00	1.00
	Medium	95	124	0.63(0.44,0.896)	1.05(0.576,1.924)
	Far	25	19	1.083(0.57,2.05)	1.25(0.49,3.17)
Waiting time	Short	191	149	1.00	1.00
	Long	93	129	0.562(0.399,0.79)	0.905 (0.554,1.48)
Service type	New	104	121	1.00	1.00
	Repeat	79	105	0.875(0.59,1.29)	0.84(0.496,1.424)
	Follow up	101	52	2.26(1.477,3.456)	1.277(0.713,2.29)
Prescribed drugs	All	133	86	1.00	1.00
	Some Others	135 16	174 18	0.51(0.360,0.727) 0.586(0.284,1.21)	0.67(0.24,1.899) 0.48(0.175,1.32)
PQOS	Low	82	214	1.00	1.00
	High	202	64	8.24(5.64,12.04)	3.26 (2.014,5.26) ***
Social support	Poor Moderate	70 141	83 156	1.00 1.072(0.725,1.585)	1.00 0.835 (0.496,1.40)
	Strong	73	39	2.22(1.343,3.668)	1.07(0.55,2.089)
SDM	Agree	78	212	8.48(5.8,12.4)	3.70(2.37,5.76) ***
	Disagree	206	66	1.00	1.00
Work load	Yes	114	47	3.296(2.224,4.884)	1.72(1.033,2.847) *
	No	170	231	1.00	1.00
Consultation and Empathy	Poor	78	208	1.00	1.00
	Good	206	70	7.85(5.39,11.43)	2.26(1.39,3.7)***
Duration	Acute Chronic	151 122	191 77	1.00 2.00(1.4,2.86)	1.00 0.78(0.384,1.59)
Recipient approach	Poor	65	133	1.00	1.00
	Good	219	145	3.09(2.15,4.44)	1.52(0.948,2.440)
Access to services	Poor	67	115	1.00	1.00
	Good	217	163	2.28(1.59,3.286)	0.85(0.61,1.61)
Hospital Environment	Poor	97	160	1.00	1.00
	Good	187	118	2.614(1.86,3.68)	0.993(0.578,1.532)
Medical care	No	117	217	1.00	1.00
	Yes	167	61	5.078(3.50,7.347)	1.87(1.16,3.00) **
Privacy during care	Poor	29	86	1.00	1.00
	Good	255	192	3.94(2.48,6.24)	1.48(0.815,2.70)

#student, housewife, and jobless; PQOS: perceived quality of services; SDM: shared decision-making; *, ** and *** indicate significantly associated variables at p values of < 0.05, < 01, and < 0.001, respectively

Qualitative finding

Sociodemographic characteristics

A total of nine participants were interviewed for qualitative data. Approximately 7 (77.7%) of the participants were male, married, had a diploma or above, and were urban residents. Among the participants, 5 (56%) were aged 18–34 years, and all were orthodox religious followers (Table 5).

Table 5.

In-depth interview participants profile in the study of PCC in South Gondar Zone, Northwest Ethiopia, 2024 (n = 9)

code	Age	Sex	Marital status	Religion	Residence	Occupation	Participant type
P1	50	M	Married	Orthodox	Rural	Farmer	Patient
P2	28	F	Married	Orthodox	Urban	Housewife	Patient
P3	28	M	Single	Orthodox	Urban	Gov’t employed	Provider
P4	33	M	Married	Orthodox	Urban	Gov’t employed	CCO
P5	31	M	Single	Orthodox	Urban	Gov’t employed	CCO
P6	45	M	Married	Orthodox	Urban	Merchant	Patient
P7	30	M	Married	Orthodox	Urban	Gov’t employed	Provider
P8	55	F	Married	Orthodox	Rural	Housewife	Patient
P9	29	F	Married	Orthodox	Urban	Gov’t employed	Provider

CCO= Chief Clinical Officer (medical director)

The participants were identified by code (P1………. P9) corresponding to exploration speech.

Three main themes and fourteen subthemes emerged. These themes were patient perspective of PCC (subthemes: satisfactory PCC and unsatisfactory PCC), factors influencing PCC (subthemes: informational factors, intimacy, medical care, social support, shared decision making, availability of drugs and privacy during care) and barriers to practicing PCC (subthemes: patient health literacy, HCP characteristics, organizational capacity, training and supervision and seasonal factors) (Table 6), (Fig. 3).

Table 6.

Thematic presentation of in-depth interviews the study of PCC and associated factors among outpatients in the South Gondar Zone, Northwest Ethiopia, 2024 (n = 9)

Main themes	Subthemes	Descriptions of subthemes
Regarding patient-centered care	Satisfactory Patient-centered care	“… My diseases condition, lab test result and medication information has been told to me” (P2-28 year’s old female Pt) and “…I took my prescribed medicines appropriately. I hear physicians’ advice well and I get improved” (P8-55 years old female Pt).
	Not satisfactory Patient-centered care	“…We’re not practicing and evaluating PCC as a single initiative” (P7-30 year’s old male provider).
		“…didn’t tell much about the diseases. Patient choice is not expected and they didn’t tell about the general condition of the patient” (P6-45 year’s old Pt).
Factors affecting PCC practice	Informational factors	“…health education is given on regular basis with but at the examination rooms, they didn’t explain about the nature of the disease” (P1-55 year’s old male patient).
	Intimacy of provider	“…we do not know what they are and we confused, and there’s no intimacy” (P6-45 years old male Pt).
	Shared decision making	“…Medicine is self-treatment if so, we patients must be actively involved in the care given.” (P8-55 year’s Pt).
	Social support	“…we have a social committee to support patients. (P4-33 year’s CCO). Sometimes If you go to health institutions frequently the community humiliates you (P8-55 year’s Pt).
	Availability of medicines	“…accessing all drugs at the hospital is not possible for most patients” (P1-55 years old male Pt).
	Medical care	“…patients and physician should communicate and agreed on the medical care” (P4- A 33 years old CCO).
Barriers of patient-centered care	Training/supervision	“…There is no Intensive M&E, training and feedback mechanism to evaluate PCC practice independently in this hospital” (P5-31 years CCO).
	Patients health literacy	“…Patients want to go home sooner thus we didn’t participate in our health condition” (55 years Pt).
	HP characteristics	“…Health professionals didn’t give attention to patients who served, they are not punctual”(P2-28 years Pt).
	Organizational capacity	“…there is no enough medical supply, bed, chairs, tables access to services and there is lack of specialty care” (P1 -55 years male Pt and 33 years CCO).
	Seasonal factors	“…Current politics affects our healthcare delivery system; health system and facilities should be an independent from politics” (P5-31 years old male CCO).

Fig. 3.

Thematic analysis framework on level of PCC among outpatients in South Gondar zone, North West, Ethiopia, 2024

Discussion

The findings of this study showed that half (50.5% (95% CI: 46.3%-54.7%)) of the patients received good PCC. This result is consistent with a cross-sectional study conducted in Tigray, where approximately 54.5% of respondents reported experiencing good PCC [36]. The findings also consistent with a report by the National Healthcare Quality Agency, which indicated that PCC was utilized in only 45–62% of patient interactions [37]. Additionally, this finding falls within the range reported in studies from African countries, where the level of PCC practice ranges from 27.8% to 83.2%. This wide range may be due to the inclusion of various PCC findings in African studies, including those from Ethiopia [26, 38]. The findings of this study were lower than those of a mixed-methods study conducted in South Wollo Zone public hospitals, where 60.9% of patients received PCC. This variation may be explained by differences in setting, study population, and the tools used in the studies [31]. The study setting in the South Wollo zone included all types of hospitals, where service delivery may differ by hospital level. Moreover, the population in the South Wollo Zone study focused on inpatients, and PCC was measured with 36 questions. In addition to the above implication, there was limited involvement of private health facilities in the South Gondar Zone, which led to a high patient load and resulted in heavy workloads and time constraints because most patients used public healthcare facilities.

This finding was lower than that of another cross-sectional study conducted at hospitals and health centers in Addis Ababa, where 60.8% of outpatient respondents had a good perception of PCC. The variation could be due to differences in study settings tools, and analysis between these studies; in the previous study, PCC was assessed using a 14-item instrument that did not include the dimensions for its measurement [39]. This finding was much lower than those of studies conducted in Saudi Arabia [40] and Norway [41], where 73% and 85% of patients, perceived good PCC, respectively. This discrepancy could be due to differences in socioeconomic status, study design, healthcare systems, and measuring tools, as the previous study used 17-scale questionnaires.

On the other hand, this finding was higher than those of cross-sectional comparative studies conducted in Bahir Dar city [19] and Addis Ababa city public hospitals [26], where 33.7% and 27.8% of respondents, respectively, rated PCC practice as good. This difference could be due to the use of a comparative cross-sectional design, a minimum sample size for public hospitals, and the inclusion of inpatient attendants in those studies.

Regarding the identified factors, age was one of the determinants of PCC among outpatients. Patients older than 34 years had 1.85 times higher odds of receiving PCC compared to those aged 18–34 years. This may be explained by the fact that patients aged 35–64 years are more likely to participate in their medical care, seek more information, communicate with their physicians, and follow medical advice. This finding was supported by the qualitative results of this study, which indicated that older patients are more likely to receive PCC. This may be related to the fact that as patients age, they often value maintaining independence and autonomy, and PCC empowers them to be involved in decision-making. Health professionals should tailor their approaches to the unique needs of patients across all age groups [42]. However, this finding, was inconsistent with the results of a study conducted in South Wollo and another study titled “Socioeconomic Differences in Patient Participation Behaviours in Doctor‒Patient Interactions,” in which younger patients participate more [31, 43]. The variation may be due to differences in the age distribution of respondents who participated in these studies.

In the in-depth interviews, most respondents identified informational factors, intimacy with providers, awareness of medical care, social support, SDM, availability of medications, perceived provider workload, and privacy during care as influential factors. In contrast, patients’ health literacy, health professionals’ characteristics, organizational capacity, seasonal factors, training, and supervision were described as barriers to the practice of PCC. These factors were also mentioned in the findings of a qualitative study on the WHO’s global strategy for integrated health services and a qualitative study conducted at hospitals in the BGR, Ethiopia [9, 44].

Consultation and empathy were additional factors influencing PCC. This study found that patients who received good consultation and empathy were 2.26 times more likely to experience PCC than those who had inadequate consultation and empathy. These results suggest that patients’ perceptions of care are significantly shaped by consultation and empathy. Since consultation and empathy impact treatment outcomes, the qualitative study supported this finding, showing that consultation and empathy affect treatment outcomes. An effective approach to patients, characterized by consultation and empathy, facilitates PCC practice because patients communicate freely with the medical team. As one participant stated, “…I look at patients with positive attitudes. I have my family and I treat patients as if they were my family. We should respect and understand patients’ problems; when they become sick, they come to us and communicate their problems. They want to recover from illness because they respect and trust us.” (P9), A US study revealed that higher levels of perceived empathy during consultation were associated with higher levels of PCC [45], and a cross-sectional study in central Ethiopia indicated that empathy is crucial to achieving patient centeredness in clinical consultations [27]. This may be because, as healthcare providers demonstrate empathy and consultation, it benefits the patient, maintains a more positive work environment, and fosters a culture of compassion [46]. By incorporating consultation and empathy into healthcare practice, professionals can create a more positive and supportive environment, leading to better patient outcomes and overall well-being.

Shared decision-making was the strongest predictor of PCC. This study also found that patients who agreed with shared decision-making were 3.70 times more likely to have good PCC than those who disagreed. The qualitative finding supported this result, as patients and providers agreed on a common goal for patient recovery; that is shared decision-making during treatment increases patient satisfaction. “…Patient-centred treatment is a medical service with patient involvement as a bilateral consensus; patients’ decisions coexist with physicians’ decisions, and patients are satisfied as they communicate and decide with providers” (P6). This may be because shared decision-making is a key measure and crucial aspect of PCC that enhances patient autonomy, improves treatment outcomes, and strengthens the patient–provider relationship [47].

The odds of having a good PCC among patients with a high perceived quality of services were 3.26 times greater than among those with a low perceived quality of services. This was also supported by a study conducted in South Wollo hospitals [31]. This could be due to patients who perceive the quality of services as high, are more satisfied with PCC, and may be actively involved in their own healthcare decisions [48].

Medical care was another factor in PCC practice. The odds of good PCC among patients who had communicated about their medical care were 1.87 times greater than among patients who had not communicated about their medical care. This finding was supported by qualitative result, as communication between patients and providers about the general medical condition, from disease awareness to medication information could increase the practice of PCC. “…Patients and providers should communicate about medical care, including plans of care for the patient, to reach a common consensus. My disease condition, lab test results, and medication information have been communicated to me” (P4, P2). This was consistent with other studies, which found that PCC practice was associated with awareness of diseases, treatment options, and communication about the plan of care and medications [26, 39, 49]. Another study reported that ambulatory patients had an increased need to share information and power with physicians, which was associated with better health outcomes [43, 50]. In addition, clinicians are responsible for ensuring that patients are well informed about their medical care [51]. This implies that, for adherence to treatment, the provision of comprehensive services is important and allows for enhanced PCC.

The odds of good PCC among patients who perceived that providers had no workload were 1.72 times greater than among those who perceived providers had a workload. Approximately 71.4% of participants believed there was no workload for providers, but the presence of workload affects the practice of PCC. This was supported by qualitative finding: “sometimes there is workload and the presence of workload affects the practice of PCC” (P3&P7). Other studies also revealed that provider workload was significantly associated with perceptions of PCC. Participants who perceived no workload for providers were more likely to perceive good PCC [15]. This may be related to high workload and staffing challenges, which can undermine healthcare providers ability to deliver true PCC, as they may be forced to prioritize efficiency over fully engaging with and responding to patient needs. Therefore, reducing workload through appropriate staffing and resource allocation could enable a more patient-centred approach [52].

Although it was not associated with quantitative assessment, intimacy with providers could affect PCC, as it serves as a gateway for initiating PCC practice. This was evidenced by in-depth interviews: “…Even though we have told our complaint we did not introduce ourselves to each other or know who was caring for us. There were so many professionals we knew before, but now we do not know who they are; there is no intimacy; even they read our names from our medical folder”(P1, P3&P8). This finding was supported by studies in Bahir Dar and Addis Ababa, which showed that patients with good intimacy with care providers have good PCC practices, potentially improving relationships. Patients are encouraged to disclose their issues without frustration. Patients who believed that intimacy with health care providers had a 60% greater chance of perceiving their encounter as good, implying that intimacy with health care providers is directly related to PCC [19, 26].

Social support was explored qualitatively as being related to good PCC. As the number of client, staff, and community relationships increases, support also grows: “We have a social committee to support patients. Our community is miserable, especially in cases of illness. However, sometimes if you go to health institutions frequently, the community humiliates you” (P4). This finding was also supported by studies conducted in the USA and Ethiopia, which found that strong perceived social support was associated with good physician–patient relationships [9, 44].

Another factor explored in in-depth interviews was the availability of prescribed drugs. Most patients receive only some of the prescribed drugs at the facility, leading to dissatisfaction with the overall service, which is associated with PCC practice. They expressed that “accessing all drugs at the hospital is not possible for most patients; we purchase medicines from private pharmacies, we have been given referrals, and for most referrals the cause is access to medical equipment and medicines” (P1&P9). In this study, approximately 39% of the respondents received all prescribed drugs, which is much lower than the findings of a study conducted among patients attending public hospitals and health centers in Addis Ababa, in which approximately 72.7% obtained the prescribed medication within the health facility [39]. This variation may be due to good access to medical supplies in Addis Ababa following different study settings.

The strength of this study was use of a mixed-method study design. On the contrary, the limitation included social desirability bias due to the patients’ self-report.

Conclusion

The study revealed that among outpatient attendants, only half of the patients received good PCC, and the strongest factors were. Age, perceived quality of care, consultation and empathy, shared decision making, awareness of medical care and perceived workload on providers. The respondents in the in-depth interviews indicated that the implementation of PCC was inconsistent and somewhat limited, and the factors explored by most respondents were informational factors; intimacy with providers; awareness of medical care; social support; SDM; availability of medications; privacy during care; patient health literacy; health professionals’ characteristics; organizational capacity; training/supervision; and seasonal factors, which hinder the practice of PCC. Even if, PCC is a current Ethiopia national healthcare quality and safety strategy, this study indicated that a lot activities needed to improve it.

As a short term, training for providers, health literacy campion for patients, reduce workload by effective implementation of triage system, and improving communication allows to improve PCC. As a long term, the Ethiopian Federal Ministry of Health with the federal ministry of education should emphasize PCC for health science trainees, including in the health care curriculum, and design appropriate policies to strengthen the implementation of PCC in health institutions. It is good to conduct quantitative and qualitative studies from both patients’ and health professionals’ perspectives, including concealed observations, to explore the real individual and organizational factors of patient-centred care.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

AOR

Adjusted odds ratio

CARE

Consultation and Relational Empathy

IOM

Institute of Medicine

OPD

Outpatient Department

OSSS

Oslo Social Support Scale

PCC

Patient-Centred Care

PCHCP

Patient-Centred Healthcare Practice

SDM

Shared decision-making

SPSS

Statistical Package for Social Science

Author contributions

FKN conceptualized, analysed, interpreted and wrote the draft manuscript. GAY interpreted and reviewed the draft manuscript. MM conceptualized, reviewed and edited the draft manuscript. AAM performed the analysis and editing of the draft manuscript. AWA performed the analysis and editing of the draft manuscript. GB interpreted, reviewed and edited the draft manuscript. ZW conceptualized, analysed, interpreted, drafted and reviewed the manuscript. All the authors have read and approved the final manuscript.

Funding

There is no funding.

Data availability

All the data generated or analysed during this study are included in this published article.

Declarations

Ethics approval and consent to participate

The study was performed following the Declaration of Helsinki. Ethical approval was obtained from the Debre Tabor University Institute of Research Ethics Review Committee with reference number DTU/Res/305/16. A permission letter was obtained from the zonal health department and administrators of the selected hospitals before patients were contacted. Verbal consent from participants who could not read and write and written informed consent was obtained from participants who could read and write. The confidentiality of the study was assured by the avoidance of possible identifiers.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.