University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA TITLE: FACTORS INFLUENCING THE USE OF MEDICAL EQUIPMENT AMONG CLINICAL HEALTH WORKERS AT SHAI OSUDOKU DISTRICT HOSPITAL BY AMPONSAH-TUFFOUR SAMUEL (10803732) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE OCTOBER, 2020 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Samuel Amponsah-Tuffour, hereby declare that with the exception of references to the literature and works of other researchers which have been duly acknowledged, the work in this dissertation is the result of my own work put together and that I have never before submitted it to any other tertiary institution for a degree. …………………………… 29/03/2021 Samuel Amponsah-Tuffour Date (Student) …………………………….. 29/03/2021 Dr. Thelma Ohene-Agyei Date (Supervisor) ii University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this piece of work to the memory of my father, Mr Kwadwo Agyemang Tuffour. May his soul continue to rest in peace. iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT This work was a success due to the input, contributions, and participation of several individuals and organisations who should be acknowledged. My first and foremost thanks goes to the Almighty God for his protection and guidance throughout this period. I thank the faculty members and staff of the Department of Health Policy, Planning, and Management and the School of Public Health. My sincere thanks go to my supervisor Dr Thelma Ohene-Agyei from the School of Pharmacy for her continual support and guidance. I am indebted to the entire management and staff of Shai Osudoku district hospital particularly to the study participants and the clinical engineering department who took time out of their busy schedule to participate and assist in the study. I also wish to thank my family, especially my sister Margaret Nimo, for their immense support and contribution. iv University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ii DEDICATION iii ACKNOWLEDGEMENT iv LIST OF ABBREVIATIONS x LIST OF TABLES xi LIST OF FIGURES xii DEFINITION OF TERMS xiii ABSTRACT xiv CHAPTER ONE 1 INTRODUCTION 1 1.0. Background 1 1.1. Problem Statement 3 1.2. Justification 3 1.3. Objectives of the study 4 1.3.1. General Objective 4 1.3.2. Specific Objectives 4 1.3.3. Research Questions 4 1.4. Outline of the dissertation 5 CHAPTER TWO 7 LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK 7 2.0. Introduction 7 2.1. Medical equipment health care institutions 7 2.1.1. Types of medical equipment available in health care institutions 8 2.1.1.1. Diagnostic/Monitoring medical devices 8 v University of Ghana http://ugspace.ug.edu.gh 2.1.1.2 Therapeutic medical devices 9 2.1.1.3. Assistive devices 9 2.1.1.4. Life-Support medical devices 9 2.2 Factors influencing the use of medical equipment in health care institutions 9 2.2.1. Organisational factors 9 2.2.1.1 Availability of consumables/accessories/spare parts 10 2.2.1.2. Training of users 10 2.2.2. Perceptual factors 11 2.3. Conceptual framework 12 2.4. Theoretical analysis 13 2.5. Summary of the chapter 14 CHAPTER THREE 15 METHOD 15 3.1 Introduction 15 3.2 Philosophical assumption 15 3.2 Study design 15 3.3 Study site 15 3.4. Study population 17 3.4.1. Inclusion criteria 17 3.4.2. Exclusion criteria 18 3.5. Sampling strategies 18 3.5.1. Sample size determination 18 3.5.2. Sampling method 18 3.6. Study variable 19 3.6.1. Independent variables 19 vi University of Ghana http://ugspace.ug.edu.gh 3.6.2. Study outcome 21 3.7. Data collection tools 22 3.7.1. Inventory list/Checklist 22 3.7.2. Questionnaire 22 3.7.3 Data quality control 23 3.9 Data processing and analysis 23 3.10 Ethical considerations 24 3.9. Summary of chapter 24 CHAPTER FOUR 25 RESULTS 25 4.1. Socio-demographic characteristics 25 4.2. Types of Medical Equipment 26 4.3 Assessment of use of medical equipment by health workers 27 4.4. Organisational factors 30 4.4.1. Training of health personnel on medical equipment usage 30 4.4.2. Availability of accessories and consumables 32 4.4.3. Policies and guidelines for using medical equipment 32 4.4.4. Policies and guidelines for using medical equipment 33 4.5. Perceptual factors 34 4.6. Bivariate analysis: Association between Socio-demographic characteristics and use of medical equipment 35 4.7. Bivariate analysis: Organisational factors and use of medical equipment 36 4.8. Bivariate analysis: Association between perceptual factors and use of medical equipment 37 4.9. Multiple linear regression analysis: Factors influencing use of medical equipment among health workers 38 vii University of Ghana http://ugspace.ug.edu.gh 4.10. Summary of the chapter 39 CHAPTER FIVE 41 DISCUSSION OF FINDINGS 41 5.0. Introduction 41 5.1. Socio-demographic factors associated with use of medical equipment 41 5.2. Types of medical equipment 41 5.3. Organisational factors associated with use of medical equipment 42 5.4. Perceptual factors associated with use of medical equipment 43 5.6. Factors influencing use of medical equipment 43 CHAPTER SIX 45 CONCLUSION 45 6.0. Introduction 45 6.1. Summary of the study 45 6.2. Limitations to the study 45 6.3. Recommendations 46 6.3.1. Ministry of Health/Ghana Health Service 46 6.3.2. Management of Shai Osudoku District Hospital 46 6.3.3. Health workers 47 6.3.4. Future research 47 REFERENCES 48 APPENDICES 52 APPENDIX A: List of SDGs 3 and some medical devices/technologies that help in their accomplishments 52 APPENDIX B: Consent Form 54 Appendix C: Questionnaires for factors associated with the use of medical equipment among clinical health workers at Shai Osudoku District Hospital 56 viii University of Ghana http://ugspace.ug.edu.gh APPENDIX D: Inventory List 63 APPENDIX E: Ethical Approval 64 ix University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS DHRC: Dodowa Health Research Centre ECG: Electrocardiogram GHS: Ghana Health Service IPM: Inspection and Prevention Maintenance OPD: Out-patient Department SDG: Sustainable Development Goals SOP: Standard Operating Procedure TAM: Technology Acceptance Model WHO: World Health Organisation WIFA: Women in Fertility Age x University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 2: Top ten OPD cases for WIFA at Shai Osudoku district hospital (2019)….……….…..8 Table 3.1a: Analytical framework: Socio-demographic and economic factors …..………………15 Table 3.1b: Analytical framework: organisational factors……………….………………………15 Table 3.1c: Analytical framework Perceptual factors…………………………………………...16 Table 3.1d: Dependent variable...…………………………………….…………………………17 Table 4.1: Type of medical equipment at Shai Osudoku District Hospital……...………………...22 Table 4.2: Socio-demographic characteristics of respondents………...………………………….24 Table 4.3: Bivariate analysis: Association between socio-demographic factors and use of medical equipment………………………………………………………..……………………………….32 Table 4.4: Bivariate analysis: Association between organisational factors and use of medical equipment………………………………………..……………………………………..………...33 Table 4.5: Bivariate analysis: Association between perceptual factors and use of medical equipment….……………………………………………………………………………………..34 Table 4.6: Multiple linear regression of the factors affecting the use of medical equipment among health workers…………………………………………………………………………….……...35 xi University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 2.1: Components of a maintenance programme……...……..……………………...……..12 Figure 2.2. Conceptual framework……………………………….………………........................13 Figure 3.1: Maps of Shai Osudoku District………...……………………………………………..17 Figure 4.1a: Availability of medical equipment when needed…………………………..……… .28 Figure 4.1b: Ability to use medical equipment…………………….. ………………..……….…29 Figure 4.1c: Use of medical equipment……………………………….………………………….30 Figure 4.2a: Training on of medical equipment……………………………………………….....31 Figure 4.2b: Time of last training……..………………………………………………………….31 Figure 4.2c: Accessories and consumables………………………..……………………………...32 Figure 4.2d: Policies and guidelines………………...……….…………….……………………..33 Figure 4.2e: Average repair time for medical equipment.………………….…………………….34 Figure 4.3: Perceptual factors………………………………………………………………….....35 xii University of Ghana http://ugspace.ug.edu.gh DEFINITION OF TERMS First-line maintenance: Maintenance activity that can be performed by the user of the equipment and normally takes place at the point of equipment use. Corrective maintenance: is maintenance performed to identify and rectify a fault so that the failed equipment can be restored to an operational condition. Preventive maintenance: is maintenance that is aimed at catching and fixing problems before they happen. Refresher training: training taken by a person already qualified or previously assessed as competent in a field to update skills and/or knowledge. xiii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Background: Medical equipment plays a crucial role in the diagnosis and treatment of patients in health facilities. An estimated 40% of medical equipment in hospitals in the sub-region is not in use. Optimizing its use and identifying the challenges and barriers to using them would help improve health outcomes. Objective: To determine the factors influencing the use of medical equipment by health workers in the Shai Osudoku District Hospital Methods: This was an explanatory cross-sectional study where structured questionnaires were administered to 108 health workers who were purposively sampled, made up of physicians, nurses, and midwives from the maternal department and female ward at the Shai Osudoku district hospital to identify guidelines and factors that influence the use of medical equipment. An inventory list was used to identify the medical equipment in the maternal health department and female ward and the proportion not in use. The use of medical equipment was assessed by aggregating 5 points scores from the availability of medical equipment for use when needed and the ability to effectively use medical equipment. The level of use of medical equipment was measured as a continuous outcome, the higher the score the higher the level of use. The data obtained was analyzed using STATA 16. All statistical analysis were computed and reported at a 95% confidence interval and an accepted p-value of p<0.05. Results: The results showed that 20% of medical equipment in the maternal department and the female ward of Shai Osudoku district hospital were out of use. The final analysis revealed that three factors were significantly associated with the use of medical equipment. These were clinical xiv University of Ghana http://ugspace.ug.edu.gh health workers knowledge of first-line maintenance (coefficient = 8.925, 95% CI = 1.873–15.976), refresher training (coefficient -7.932, 95% CI = -15.750 – -0.114), inaccessibility of procedure (coefficient = -8.648, 95% CI = -16.089 - -1.279). These were the only variables that showed statistical significance after adjusting for confounders. Conclusion: The study concludes that the use of medical equipment increases with an increase in user’s knowledge of first-line maintenance, which involves, proper cleaning of medical equipment, visual checks and inspections to identify defects, and performing function checks. As such training of clinical health workers on the use of medical equipment should emphasize first-line maintenance. Also, a regular inventory audit is necessary to determine critical shortages immediately. xv University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.0. Background Over the past two decades, there has been some improvement in maternal health-care but this improvement has been slow and as such much effort is needed if Ghana is to achieve the various health-related development goals. Some of the challenges have been the availability and utilization of medical equipment, Ghana Health Service (GHS, 2017). Medical equipment are devices used in diagnosing, monitoring, prevention, treatment or rehabilitation of the body resulting from injuries or diseases. These do not include disposable, single-use and implantable devices but can be used in combination with an accessory, consumable or other devices World Health Organisation (WHO, 2014). World Health Organisation (WHO, 2016) report on “Interagency list of medical devices for essential interventions for reproductive, maternal, newborn and child health”, observed that despite the advances in healthcare, complications from childbirth and pregnancy results in the death of about 1000 women daily and the majority of these deaths happen in the African sub- region. Health-related development goals such as sustainable development goals (SDGs) rely on good planning, appropriate use and management of medical devices that are safe and compatible with the settings where they are being used, World Health Organisation (WHO, 2014). Therefore, it is important to ensure that medical equipment are available, accessible and being used effectively. To ensure that health systems are responsive, guaranteed access to safe and quality medical equipment are needed (Moyimane, Matlala, & Kekana, 2017). 1 University of Ghana http://ugspace.ug.edu.gh Medical equipment and health-care delivery go hand in hand, as such its use must be maximized to ensure that patients benefit and there are quality health outcomes [ref]. One of the World Health Organisation's strategic objectives is centred on improving access, quality and use of medical devices. Health services delivery is heavily dependent on the availability, appropriateness, and acceptability of medical equipment. Diaconu et al. (2017), in the absence of appropriate and functional medical equipment, emergency care is not the only service affected but management and interventions for both non-communicable and communicable diseases are also affected. Timely provision of primary and critical health care will be compromised in the absence of reliable medical products (Mkoka, Goicolea, Kiwara, Mwangu, & Hurtig, 2014). When used in the context of a robust health system, medical equipment improves health outcomes, World Health Organisation (WHO, 2011). This indicates the importance of equipping health professionals with the necessary skills to enable them to be conversant with the use of medical equipment. There are several barriers to the use of medical devices in health care; availability of accessories and consumables, the type of medical equipment, well-trained staff to operate the equipment and guidelines and policies for using medical equipment (Malkin, 2007). The study done by Chaudhury and Kaul (2015) showed that there are also individual perceptual factors that should be considered as they can affect the utilization of medical equipment in facilities, there include maintenance downtime, restricted availability, availability of spare parts and the use of old equipment, among others. When considerations are not given to the needs of various hospitals in terms of medical equipment, it leads to non-use of the equipment World Health Organisation (WHO, 2010b). 2 University of Ghana http://ugspace.ug.edu.gh 1.1. Problem Statement Perry and Malkin (2011) argue that on average, about 38.3% of medical devices in low and middle- income countries are in use. The World Health Organisation Guidelines for Healthcare Equipment Donations stated that up to 70% non-use of medical devices in the sub-region. This is alarming, health development agendas like sustainable development goals rely on good planning, appropriate use, and management of medical devices that are safe and compatible with the settings where they are being used. The absence of functional medical devices in healthcare would result in poor patient health outcomes (Diaconu et al., 2017). The outbreak of the Ebola virus disease in West Africa was evident of the absence of functioning medical devices for quick and accurate diagnosis, which resulted in delays in emergency responses and loss of lives (Lartey et al., 2015). Knowledge of the state of medical equipment in health facilities and the factors affecting their use will lead to optimal usage, which will be beneficial to patients and the health care system. 1.2. Justification Recently, the ‘no bed syndrome’ rocked the country’s health system (Quansah, 2018) though some progress has been made in addressing this challenge, it persists. The availability and functional status of medical equipment in various healthcare facilities are not given the needed attention. Attaining universal health coverage means an increase in accessibility to medical care and ultimately an increase in the utilization of health facilities by the community. Hence, the need to ensure that supplies particularly medical equipment are enough to ensure the responsiveness of the health system 3 University of Ghana http://ugspace.ug.edu.gh This study brings to light the types of medical equipment available for use in maternal health and the proportion not in use. The study also provides information on the factors and challenges that influence the use of medical equipment. 1.3. Objectives of the study 1.3.1. General Objective To determine the types of medical equipment and the factors influencing the use of medical equipment by health workers in Shai Osudoku District Hospital 1.3.2. Specific Objectives 1. To identify the types of medical equipment available at the Shai Osudoku District Hospital 2. To determine the level of use and non-use of medical equipment at the Shai Osudoku District Hospital 3. To examine the association between socio-demographic characteristics and use of medical equipment at the Shai Osudoku District Hospital. 4. To examine the association between organisational factors and use of medical equipment at the Shai Osudoku District Hospital 5. To assess the association between perceptual factors and use of medical equipment at the Shai Osudoku District Hospital 1.3.3. Research Questions This study sought to answer the following questions: 1. What is the association between socio-demographic characteristics and use of medical equipment at the SODH? 4 University of Ghana http://ugspace.ug.edu.gh 2. What is the association between organisational factors and use of medical equipment at the SODH? 3. What is the association between perceptual factors and use of medical equipment at the SODH? 4. What types of medical equipment are available at the SODH? 5. What is the level of use of medical equipment at the SODH? 1.4. Outline of the dissertation The study is made of six parts, below is a summary of each chapter. Introduction The study is about understanding the factors that affect the use of medical equipment in health care institutions and knowing the types of equipment available at the institution. The state of medical equipment are not known, this study brought to light the nature of the equipment and what influence utilisation. Literature and conceptual framework Guided by previous studies in this area, the study focuses on organizational and perceptual factors that are associated with the use of medical equipment. The theory underlying the study was the Technology Acceptance Model (TAM). Method This was a cross-sectional study and study participants were purposively sampled. An inventory list was used to determine equipment available at Shai Osudoku District Hospital. Bivariate analysis using ordinarily least square regression was used to determine factors associated with the use of medical equipment. 5 University of Ghana http://ugspace.ug.edu.gh Results This section showed the analysis of data collected from Shai Osudoku District Hospital. The data collected showed that 80% of medical equipment were being used. Also, organisational factors affecting the use of medical equipment were refresher training and first-line maintenance. The perceptual factor associated with the use of medical equipment was identified to be procedure accessibility. Discussion This chapter focused on comparing the results of the study to previous studies. The types of medical equipment available were compared with the World Health Organisation list of priority medical devices. Factors affecting utilisation was also compared to previous works done in this area. Conclusion The final chapter summarised the previous sections to provide recommendations to policymakers, health workers, and health care institutions. It also provided the limitations to the study. 6 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW AND CONCEPTUAL FRAMEWORK 2.0. Introduction Medical equipment could potentially prevent maternal morbidity and mortality especially those due to haemorrhage and hypertension (Thairu, 2012). This chapter presents an analysis of works from previous studies on the factors that contribute to the use of medical equipment in health- care and the conceptual framework for the study. It provides an insight into the type of medical equipment in health facilities and socio-demographic, perceptual and organisational factors that affects utilisation of medical equipment. 2.1. Medical equipment health care institutions There are several types of medical devices on the market. The definition of a medical device according to WHO encompasses instruments, apparatus, software, reagents for in-vitro use, appliances, machines, implants, materials or any related article used alone or in combination with others for medical purposes (WHO, 2014). Medical equipment is a subset of medical devices. Their use requires regular maintenance, calibrations, user-training, and they exclude single-use/disposable and implantable devices. Medical equipment use is indispensable in efforts to achieve the health-related SDGs (WHO, 2014). In a qualitative study in South Africa on the critical shortage of medical equipment, interviewees lamented on the absence of critical equipment and also the non-functioning of available ones (Moyimane et al., 2017). 7 University of Ghana http://ugspace.ug.edu.gh To ensure the efficiency of medical equipment, the settings in which the equipment would be used need to be carefully considered. It is also important that the purchasing and donation of medical equipment be done in collaboration with health care providers (Bauserman et al., 2015). The table below shows the top ten Out-Patient Department (OPD) cases for Women In Fertility Age (WIFA) at Shai Osudoku district hospital in 2019. Table 2.1: Top ten OPD cases for WIFA at Shai Osudoku district hospital (2019) Medical condition No. of cases Malaria 538 Acute Urinary Tract Infection 478 Upper Respiratory Tract Infections 445 Diarrhoea Diseases 362 Anaemia 295 Periodontal diseases 294 Other diseases of the Female reproductive system 202 Skin Diseases 160 Gynaecological conditions 109 Ulcer 99 Source: Health information department, Shai Osudoku district hospital 2.1.1. Types of medical equipment available in health care institutions Medical devices can be classified based on their primary function as follow. 2.1.1.1. Diagnostic/Monitoring medical devices These are devices used to examine or determine the cause of a particular phenomenon related to a medical condition and also to monitor the progress of such conditions (Agaronnik, Campbell, Ressalam, & Iezzoni, 2019). Examples of such devices are thermometers, blood pressure monitors, positron emission tomography and computed tomography scanners, and chemistry analyzers. 8 University of Ghana http://ugspace.ug.edu.gh 2.1.1.2 Therapeutic medical devices As the name implies, their role is of therapeutic nature. They help restore, heal, and provide support for biological functions or structures (Santos et al., 2016). Examples of such devices are syringe and infusion pumps, artificial cardiac pacemakers, and TENS machines. 2.1.1.3. Assistive devices Assistive medical devices are devices intended to help people overcome a handicap such as hearing loss, mobility challenges, and vision impairment (Magnier, Thomann, Villeneuve, & Zwolinski, 2010). According to this report, only 5% to 15% of individuals in developing countries who need assistive technologies can acquire them. This challenge is mainly due to the high cost of devices, limited production, which cannot satisfy the global needs, and the poor quality of some of these devices (WHO, 2005). 2.1.1.4. Life-Support medical devices These devices are used to provide support where vital organs in the body have failed totally or partially in their required function. They take over either completely or partially in replacing the duties of the damaged organ. Life-support devices include medical ventilators, dialysis machines, and heart-lung machines. 2.2 Factors influencing the use of medical equipment in health care institutions 2.2.1. Organisational factors Guidelines and policies are essential from the conception and design of equipment. To ensure that action plans and national strategies for medical equipment match public health priorities there is the need for an overall needs assessment. When conducting need assessment, the burden of disease data, epidemiology disease surveillance and patterns of hospital treatment practices would ensure 9 University of Ghana http://ugspace.ug.edu.gh the closest matching of public health needs to medical equipment World Health Organisation (WHO, 2011). 2.2.1.1 Availability of consumables/accessories/spare parts The unavailability of consumables for the operation of various medical equipment is not uncommon in developing countries (Malkin, 2007). Consumables could be in the form of a liquid or supplies but unlike accessories, they mostly are not reusable. The unavailability of consumables and accessories is a barrier to the purchase of medical equipment and it also renders existing equipment unusable (Malkin, 2007). Malkin (2007) revealed that in most cases, the needed consumable/accessory is not available in the country. The involvement of all stakeholders when it comes to the purchasing of consumables readily available on the market is sometimes not considered. Acquiring spare parts for medical equipment in the developing world is quite difficult. For medical equipment that is approaching the stage of decommissioning and disposal, spare parts needed for repairs may no longer be available on the market. Moreover, in-house technicians may not have the expertise and the required tools to install the parts. 2.2.1.2. Training of users The use of medical equipment requires expert skills and knowledge, which can be achieved through education, training, and experience (Malkin, 2007). Technical and end-user training is essential to ensure that medical equipment is used effectively for its intended purpose. They can be in the form of detailed training (end-user training) or recall training (refresher training). Training provided should focus on the safe and proper use of medical equipment, troubleshooting and how to perform basic preventive maintenance (Mullally, 2013). 10 University of Ghana http://ugspace.ug.edu.gh End-user errors are the most common reported fault on medical equipment. About 90% of deaths and injuries in anesthesiology are attributed to user errors World Health Organisation (WHO, 2010a). This shows that usually, training provided for users is inadequate to meet the competency level needed to operate the increasing complexity of medical equipment. There is always the need for subsequent refresher training to make users adept in the use of medical equipment. 2.2.2. Perceptual factors Aside from the institutional factors, there are perceptual factors that contribute to the use of medical equipment. Chandhury and Kaul (2015) identified three crucial perceptual factors that affect utilization of medical equipment; obsolete machinery, maintenance delays, and restricted availability. There is a need to identify the perceptual factors peculiar to each setting. A good maintenance programme is of high importance to any medical facility irrespective of the size. Proper maintenance would also increase the lifespan of equipment. However, studies have shown that maintenance is an issue and about 60% of low- and middle-income countries (LMIC) are understaffed in the area of clinical engineering (Meara et al., 2015). 11 University of Ghana http://ugspace.ug.edu.gh Maintenance IPM Corrective maintenance Inspection Preventive maintenance Figure 2.1: Components of a maintenance programme Source: Medical equipment maintenance programme overview (WHO, 2011) 2.3. Conceptual framework Several factors affect the use of medical equipment in our healthcare facilities, identifying these factors are essential in improving the quality of healthcare. There are organisational, individual and perceptual factors affecting the use of medical devices or acting as a barrier to using them. The institutional factors relate to the policies governing the use of medical devices in the healthcare facility, having the human resource with adequate training to operate and manage medical devices that are in the facility. The availability of consumables, accessories, spare parts also affect the use of medical devices. Individual factors play a role in the use of medical equipment. These are mainly the socio- demographic factors which include the level of education of the end-user. 12 University of Ghana http://ugspace.ug.edu.gh Organisational Factors Training of Users Availability of Consumables Mainten ance Awareness of policies and Guidelines Perceptual Factors Maintenance Downtime Socio Demographic Ol d Equip ment Factors Equipment Breakdown Use of Medical Age Equipment Sex Av ailability of consumables Profession and accessories Religion Tra ined Pe rsonne l Educational Background Pro cedure Inaccessibility Figure 2.2: Conceptual framework 2.4. Theoretical analysis The Model of PC utilization (MPCU) and Technology Adoption Model (TAM) conceptual model for the study is closely related to the conceptual framework of this study. The original model of 13 University of Ghana http://ugspace.ug.edu.gh TAM (Davis, 1989), the original version of this theory looked at the perceived usefulness and perceived ease of use as the determinants for accepting a technology. The determinants of the use of medical equipment are socio-demographic, organisational and perceptual factors. The final version of this model introduced external variables as influencing perceived ease of use and usefulness. This applies to this study as organizational factors tend to influence perceptual factors. 2.5. Summary of the chapter Though the literature on the utilisation of medical equipment is limited, this chapter has elaborated from the few studies conducted in this area, the organisational and perceptual factors associated with the use of medical equipment. The next chapter explored the data study area, study population, study design, and data management and analysis. 14 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHOD 3.1 Introduction This chapter describes and explains the methodology of the study. It includes the study design, study population, data collection procedure and analysis. 3.2 Philosophical assumption The knowledge paradigm used is relativism as the research seeks to understand a phenomenon. This study focuses on health workers and their understanding and experiences in the use of medical equipment. The study looked at organisational, individual and perceptual factors and how they relate to the use of equipment by health workers at the Shai Osudoku District Hospital. 3.2 Study design This study was an explanatory cross-sectional study. This aimed at increasing knowledge on the area of medical equipment utilisation in health care institutions at a specific point in time. The aim of the study was to bring to light the equipment available and what affected their use. It was in 2 main components: 1. Identifying the types of medical equipment used in maternal health and determining the non-use. 2. Interviewing eligible participants to determine factors influencing the use of medical equipment at the maternal health department and female ward. 3.3 Study site The study was conducted at the Shai Osudoku district hospital. The hospital is located in Dodowa which is the capital of the Shai Osudoku District. According to the 2010 Population and Housing 15 University of Ghana http://ugspace.ug.edu.gh Census (PHC), the district has a population of 51,913. 25,272 (48.7%) are males while the remaining 26,621 (51.3) are females. The majority of the population, 76.7% reside in rural communities. 93.3% of the economically active population is employed. The census also revealed about 46.4% of the economically active population are employed in the forestry agriculture, fishing industry. The district has a District Hospital, 5 Community-based Health Planning and Services (CHPS) Zones, 2 Health Centers, and a private maternity home. The new Shai Osudoku district hospital was commissioned to start full operation on 4th April 2016. The hospital has a bed capacity of 120. The maternal department is made up of the Maternity ward and Antenatal Care (ANC) unit. 16 University of Ghana http://ugspace.ug.edu.gh Figure 3.1: Map of Shai Osudoku District Source: Dodowa Health Research Centre (DHRC) 3.4. Study population The study population will comprise all health workers in the maternal department and female ward, and physicians, nurses/midwives at the two departments. 3.4.1. Inclusion criteria 1. All individuals who consent to participate in the study 2. Physicians in the maternal health department at Shai Osudoku district hospital 17 University of Ghana http://ugspace.ug.edu.gh 3. Nurses and midwives in the maternal health department at Shai Osudoku district hospital 3.4.2. Exclusion criteria 1. Individuals who do not consent to participate in the study. 2. Clinical health workers who are not in the maternal health and female ward. 3.5. Sampling strategies This section presents the sample size determination and sampling method applied to select participants for the study 3.5.1. Sample size determination The sample size for the study was determined using the formula provided by Yamane (1967). 𝑁 𝑛 = 1 + 𝑁(𝑒2) n= sample size N = sample population e = margin of error 127 𝑛 = 1 + 127(0.052) The study used a population of 127 health workers in the maternal health department and female ward, substituting this into Yamane’s formula and using a margin of error of 5% gave a sample size of 97. Adjusting for a 10% non-response gave a total sample size of 106. 3.5.2. Sampling method Purposive sampling was used to sample eligible participants. Purposive sampling was used because there was a limited number of primary data source that could contribute to the original study. This procedure allowed individuals who meet the inclusion criteria to be selected. 18 University of Ghana http://ugspace.ug.edu.gh 3.6. Study variable The variables measured in this study were categorized into dependent and independent. The dependent variable was the Use of medical equipment and independent variables proportion of use of medical equipment and types of medical equipment, Socio-demographic characteristics, Organisational factors, and Perceptual factors 3.6.1. Independent variables The variables that can affect the outcome are socio-demographic variables, organisational and perceptual factors. The operational definitions and scale of measurements for the independent variables are shown in table 3.1a, 3.1b, 3.1c and 3.1d below. Table 3.1a Analytical framework: Socio-demographic and economic factors Variable Operational definition Scale of measurement Source of data Age of Respondent at last Age birthday Continuous in years Questionnaire Sex of Respondent being Sex male or female Nominal Questionnaire Highest formal education Educational level obtained Ordinal Questionnaire Respondent’s marital Marital status status Nominal Questionnaire What is the respondent's religion? Christianity Islam Religion Other Nominal Questionnaire 19 University of Ghana http://ugspace.ug.edu.gh Respondent’s occupation Nurse Midwife Medical Officer Occupation Physician Assistant Nominal Questionnaire Table 3.1b: Analytical framework: Organisational factors Variable Operational definition Scale of measurement Source of data Type of Name of the equipment and medical device classification Nominal Inventory list Maintenance routine, the procedure for reporting faulty Operational definition equipment, users knowledge on Questionnaire Guidelines and the standard operating procedure Nominal policies of medical equipment and first- Source of data Variable line maintenance Scale of measurement Teaching end-user about how the safe and effective use of Training medical equipment Nominal Questionnaire Consumable/A Materials required for using an ccessories equipment Ordinal Questionnaire Table 3.1c: Analytical framework: Perceptual factors Variable Operational definition Scale of measurement Source of data 20 University of Ghana http://ugspace.ug.edu.gh Maintenance downtime The time taken for Nominal Questionnaire equipment to be repaired and returned to users Obsolete equipment The use of old/worn-out Nominal Questionnaire equipment Breakdown Equipment that is not Nominal Questionnaire functional and has not been reported to the clinical engineer. Availability of Materials that are required Nominal Questionnaire accessories/consumable for the successful and s effective operation of some medical equipment Having personnel with the skill and expertise to use Trained personnel medical equipment Nominal Questionnaire Procedure Medical equipment not been Nominal Questionnaire inaccessibility used because there is no medical condition at the hospital requiring its use 3.6.2. Study outcome The outcome of the study was the use of medical equipment. The use of medical equipment by health workers was determined by the availability of medical equipment for use in the department when needed and health workers ability to use the equipment effectively. The scores from availability and ability to use were aggregated to give a cumulative score from 2 (minimum score) to 10 (maximum score). 21 University of Ghana http://ugspace.ug.edu.gh Table 3.1d: Dependent variable Variables Operational definition Scale of Source of data measurement Equipment Availability Medical equipment Ordinal Questionnaire available for use when needed Ability to use Being able to use Ordinal Questionnaire medical equipment safely and effectively for its intended purpose 3.7. Data collection tools 3.7.1. Inventory list/Checklist An inventory list from the Shai Osudoku district hospital was used to identify all the medical equipment used in the maternal department and the female ward. The proportion of medical equipment not in use was determined from this. That is, a checklist was developed to take inventory of available and functioning equipment at the hospital (see appendix C for the checklist). 3.7.2. Questionnaire A modified version of questionnaires from Chandhury and Kaul (2015) on factors affecting utilization of medical diagnostic equipment was used to collect data from the participants. They were largely closed-ended questions. The questionnaires required that respondents chose from a pre-defined response such as less than 1 week/more 4 weeks, yes/no, and sometimes available/always available. 22 University of Ghana http://ugspace.ug.edu.gh The questionnaires were in 4 sections. Section asked questions related to socio-demographic characteristics. Section B asked questions that helped to measure organisational factors and Section C asked about perceptual factors. Section D asked questions that helped to measure the level of use. The questionnaires were interviewer-administered. 3.7.3 Data quality control Two research assistants were recruited to assist with the collection of data. To ensure the reliability and validity of data collected, research assistants were trained on the ethics of conducting interviews. Also, the research assistants were through the rationale of the study and how to correctly fill all the questions. The data collected was double-checked for correct data capturing before subsequent entries into excel spreadsheet before importing into STATA for analysis. 3.9 Data processing and analysis Univariate analysis was used for frequencies and percentages of socio-demographic characteristics, organisational factors, and perceptual factors. Bivariate analysis helped to determine factors influencing the use of medical equipment. The use of medical equipment was assessed by aggregating scores from 2 Likert-type items, the availability of medical equipment for use when needed and the ability to use medical equipment. A scored of 2 to 10 was generated from cumulating the scores of equipment availability and user’s ability to use medical equipment. A score of 0% to 100% was generated for each of the study participants. Therefore, converting the outcome from being categorical to quantitative continuous. Ordinarily least square regression was used to determine factors influencing the use of medical equipment and multiple linear regression to adjust for confounders. All analysis was done using STATA 16. 23 University of Ghana http://ugspace.ug.edu.gh 3.10 Ethical considerations Ethical clearance was obtained before the commencement of data collection and informed consent was sought from study participants. Clearance was obtained from the Ghana Health Service Ethical Review Committee (GHS-ERC032/12/19). Approval was sought from the management of the Shai Osudoku district hospital, by writing formerly to both the District Health Directorate and Medical Superintendent of the hospital. The study had minimal risk; the questionnaires completed by participants are not of a sensitive nature. There were no direct benefits, however, findings from this were aimed at shedding light on the factors that influence the use of medical equipment in health-care. No compensation was paid to participants. All information collected was kept strictly confidential and used purposely for this study. No individual will be identified by name in the dissemination of reports or publications resulting from the study. All filled questionnaires were kept under lock and key and no third party had access to the filled questionnaires. After analyzing the data, the filled questionnaires will be stored for up to a period of 2 years and they will be destroyed by burning. Participating in this study was entirely voluntary and withdrawal from the study at any stage was allowed. Consent forms were provided for eligible participants who were willing and agreed to be a part of the study to sign. I declare no conflict of interest in this study and it was self-funded. 3.9. Summary of chapter This chapter outlined the process of analyzing and describing the variables for the study. The next chapter looked at the results from the data collected at Shai Osudoku District Hospital. 24 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.0. Introduction This study was aimed at determining the factors influencing the use of medical equipment at Shai Osudoku District hospital. A total of 108 participants were recruited for the study. 4.1. Socio-demographic characteristics Out of the 108 respondents, 82 were females representing 75.9% and 26 were males which also represented 24.1%. The mean age for the participants was 32. Most of the respondents were Christians (90.7%), with 8.3% and 0.9% being Islamic and Traditional religion respectively. The dominant profession was nursing (63.9%) followed by midwifery (30.6%), and medical officers (5.5%). Most of the respondent's highest level of education was HND/Diploma (64.8%). About 44% indicated that they had been in the department for more than 12 months while those who had been there for less than 6 months were 14.8%. Table 4.1: Socio-demographic characteristics of respondents Variable Frequency (N) Percentage (%) Sex Female 83 76.8 Male 25 23.2 Age Less than 25 25 23.2 26-35 63 58.3 More than 35 17 18.5 Religion Christianity 98 90.7 Islam 9 8.3 Traditional 1 0.9 Occupatio n Nurse 69 63.9 Midwife 33 30.6 25 University of Ghana http://ugspace.ug.edu.gh Physician Assistant 5 4.6 Medical Officer 1 0.9 Education SSSS/SHS/Vocation/Technical 1 0.9 HND/Diploma 69 64.8 First Degree/Higher 38 34.3 Duration <3 months 8 7.4 3-6 months 8 7.4 6-12 months 44 40.7 > 12 months 48 44.4 4.2. Types of Medical Equipment The table below shows the list of all medical equipment in both the maternal department and female ward of Shai Osudoku district hospital. A total of 251 medical equipment were identified and 201 were in use. Collectively, about 20% of the equipment in the department is not in use. Table 4.2: Type of medical equipment at Shai Osudoku district hospital Number Percentage Type of Equipment Total in use in use (%) Adult Diagnostic Set 10 10 100 Delivery Bed 4 10 100 Baby Pod Transporter 2 2 100 Baby Scales 5 3 60 Blood Pressure Monitor (Aneroid) 8 8 100 Blood Pressure Monitor (Digital) 8 4 50 Desktop Autoclave 2 2 100 Infusion Pump 8 0 0 Interpretive ECG Machine 1 0 0 26 University of Ghana http://ugspace.ug.edu.gh Ultrasound Unit (combination 12 4 33 doppler) Secure Refrigeration (82 litre 4 3 75 pharmacy) Electric Bed 17 16 94 Mechanical Bed 62 62 100 Scales (basic) 5 4 80 Stretcher 4 4 100 Wheelchair 8 8 100 Transport Ventilator 3 0 0 Syringe Driver/ Digital Injection 4 2 50 Device Examination Light Wall Mounted 8 8 100 Infant Incubator 7 7 100 Examination/Treatment Couch 1 1 100 High Spec Patient Monitor 10 6 60 Gynaecology Chair 4 3 75 Thermometer 8 3 38 Flow Meter 16 15 94 Pulse Oximeter 9 7 78 Phototherapy Unit 4 3 75 Manual Sphygmomanometer 8 3 38 Glucometer 6 6 100 Medical Gas 1 1 100 4.3 Assessment of use of medical equipment by health workers The level of use of medical equipment by health workers was determined by the availability of medical equipment for use in the department when needed and users’ ability to use the equipment 27 University of Ghana http://ugspace.ug.edu.gh effectively. These were measured on a scale of 1 to 5 with 1 being “Never available” and 5 being “Always available” for availability and 1 being “Poor” and 5 being “Excellent” for the ability to use medical equipment. As shown in figure 4.1a respondents indicated medical equipment are often available when needed (28.7%), 28 indicated rarely available (25.9%), 25 indicated sometimes available (23.1%), 17 indicated always available (15.8%), and 1 indicated never available (6.5%). On the ability to use medical equipment, 35 respondents indicated excellent (32.4), 29 indicated average (26.9%), 25 indicated below average (23.1%), 11 indicated excellent (10.2%), and 8 indicated poor (7.4%). Availabilty of medical equipment when needed 35 30 25 20 15 10 5 0 Never Available Rarely Available Sometimes Often Available Always Available Available Figure 4.1a: Availability of medical equipment when needed 28 University of Ghana http://ugspace.ug.edu.gh Ability to use medical equipment 40 35 30 25 20 15 10 5 0 Poor Below Above Average Above Average Excellent Figure 4.1b: Ability to use medical equipment The scores from availability and ability to use were aggregated to give a cumulative score from 1(minimum score) to 10 (maximum score), the higher the score the higher the level of use. The mean score for the use of medical equipment for the study was 6.36 with a 95% confidence interval of 5.98 – 6.75, the level of use for medical equipment is medium. 29 University of Ghana http://ugspace.ug.edu.gh Use for medical equipment 25 20 15 10 5 0 2 3 4 5 6 7 8 9 10 Figure 4.1c: Use of medical equipment 4.4. Organisational factors 4.4.1. Training of health personnel on medical equipment usage Figure 8 below presents a summary of the number of respondents who had received training on the use of medical equipment and the time for the training. Out of the 108 respondents, 61 (56.5%) indicated that they had received an end-user training on the use of medical equipment. Also, 32 (29.6%) had received refresher training on the use of medical equipment. 30 No. of Particapnts University of Ghana http://ugspace.ug.edu.gh Training on medical equipment 80% 70% 60% 50% 40% 30% 20% 10% 0% End-user training Refresher Training Yes No Figure 4.2a: Training on medical equipment Majority of the respondents (46%) who had received either an end-user training, refresher training or both indicated that the training was more than 12 months ago. Time for last training 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% < 3 months 3-6 months 6-12 months > 12 months Figure 4.2b: Time for last training 31 Percent (%) Percent (%) University of Ghana http://ugspace.ug.edu.gh 4.4.2. Availability of accessories and consumables Figure 6 presents results on the response of participants on the availability of consumables and accessories to be used with medical equipment when needed on a scale of 1-5 with “5=Always available and 1=Never available”. As shown, the majority (43%) of them indicated that consumables and accessories were sometimes available. Accessories and Consumables 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Always Often Available Sometimes Rarely Available Never Available Available Available Figure 4.2c: Accessories and consumables 4.4.3. Policies and guidelines for using medical equipment Health workers’ awareness of guidelines and policies on the use of medical equipment were assessed on these aspects; knowledge and awareness of the procedure for reporting faulty equipment, knowledge of the Standard Operating Procedure (SOP) for medical equipment, 32 Percent (%) University of Ghana http://ugspace.ug.edu.gh knowledge of first-line maintenance, and the average time for faulty equipment to be returned to the unit. Out of 108 respondents, 97 (90%) indicated that they are aware of the procedure for reporting faulty equipment to the clinical engineering department. Fifty-five respondents (51%) indicated knowledge of the standard operating procedure for medical equipment in their respective unit while 52 (48%) had knowledge of first-line maintenance of medical equipment. Policies and Guidelines 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Procedure Knowledge Knowledge for Reporting on SOP on First Line Faulty Maintenance Equipment Yes No Figure 4.2d: Policies and guidelines 4.4.4. Policies and guidelines for using medical equipment Out of 108 respondents, 34 (31%) indicated that the average time for equipment to be serviced and returned to users was less than a week. Respondents who indicated that the average time for servicing medical equipment was 1-2 weeks were 32 (30%), 26 (24%) disclosed that the average time was 2-4 weeks, and 16 (15%) indicated that it took more than 4 weeks. 33 Percent % University of Ghana http://ugspace.ug.edu.gh Average repair time for Medical Equipment 35% 30% 25% 20% 15% 10% 5% 0% Less than 1 week 1-2 weeks 2-4 weeks More than 4 weeks Figure 4.2e: Average repair time for medical equipment 4.5. Perceptual factors Six perceptual factors considered, figure 10 below shows the responses from participants. About 100 (92.6%) respondents indicated that maintenance delays influence the level of use of medical equipment, 20 (18.5%) indicated that using obsolete equipment does not influence the level of use, respondents whom indicated that breakdown influence the level of use of medical equipment were 85 (78.7%). While 57 (52.8%) respondents indicated that the availability of consumables and accessories affect the level of use of medical equipment, only 34 (31.5%) responded divulged that trained personnel influence the level of use of medical equipment. Also, 52 respondents (48.1%) indicated that inaccessibility of procedure affects the level of use of medical equipment. 34 Percent (%) University of Ghana http://ugspace.ug.edu.gh Perceptual factors 120 100 80 60 40 20 0 Yes No Figure 4.3: Perceptual factors 4.6. Bivariate analysis: Association between Socio-demographic characteristics and use of medical equipment None of the socio-demographic characteristics of health workers in the maternal and female department of Shai Osudoku district hospital showed a significant association (p<0.05) with the use of medical equipment. 35 University of Ghana http://ugspace.ug.edu.gh Table 4.3: Bivariate analysis: Association between Socio-demographic characteristics and use of medical equipment Variable Use of Medical Equipment Coefficient 95% Confidence Interval p-value Age Group (Years) 2.414 -3.584 – 8.411 0.427 Sex 3.628 -5.527 – 12.785 0.434 Religion 9.283 -2.258 – 20.824 0.114 Occupation -1.954 -9.740 – 5.831 0.620 Educational Level 2.308 5.574 – 10.189 0.563 Years in the Department -1.114 -4.742 – 2.514 0.544 4.7. Bivariate analysis: Organisational factors and use of medical equipment Among the areas of policies and guidelines for using medical equipment, refresher training and respondent’s knowledge of first-line or user maintenance showed a statistical significance with the use of medical equipment with a p=0.030 and p=0.034 respectively. Even though there was no statistically significant association between knowledge of the procedure for reporting faulty equipment, knowledge of the SOP for medical equipment, and end-user training, important patterns were identified. For instance, 56.4% of clinical health workers with knowledge of the Standard Operating Procedure (SOP) of medical equipment had a level of use of 36 University of Ghana http://ugspace.ug.edu.gh medical equipment above the point estimate for the use of medical equipment as compared to 49.1 of those who had no end-user training. Table 4.4: Bivariate analysis: Association between organisational factors and use of medical equipment Variables Use of Medical Equipment Coefficient 95% Confidence Interval p-value End-user Training -0.250 -8.044 – 7.544 0.949 Refresher Training -9.127 -17.350 – -0.905 0.030* Knowledge of Standard Operating 0.422 -7.325 – 8.169 0.914 Procedure Awareness of the Procedure for 1.996 -10.804 – 14.796 0.758 Reporting Faulty Equipment Knowledge of First-line Maintenance 8.242 0.654 – 15.829 0.034* *significant at p<0.05. 4.8. Bivariate analysis: Association between perceptual factors and use of medical equipment Statistically significant factors were time taken for the maintenance of medical equipment (p=0.018), the availability of accessories and consumables for medical equipment (p=0.032), accessibility of procedures at the hospital (p=0.004), and obsolete equipment (p=0.010). 37 University of Ghana http://ugspace.ug.edu.gh Table 4.5: Bivariate analysis: Association between perceptual factors and use of medical equipment Variable Use of Medical Equipment Coefficient 95% Confidence Interval p-value Maintenance Downtime 17.40 2.995 – 31.840 0.018* Obsolete/Old Equipment 12.750 3.086 – 22.414 0.010* Equipment Breakdown 3.483 -5.953 – 12.920 0.466 Availability of consumables\accessories 8.328 0.737 – 15.919 0.032* Trained Personnel -4.412 -12.708 – 3.884 0.294 Procedure Inaccessibility -11.044 -18.498 – -3.590 0.004* *significant at p<0.05 4.9. Multiple linear regression analysis: Factors influencing use of medical equipment among health workers Multiple linear regression was performed to establish the relationship between the use of medical equipment and the statistically significant factors associated with the use, controlling for all confounders. The factors that remained significant in the model were time taken for maintenance, using obsolete/old medical equipment, availability of accessories/consumables, inaccessibility of procedure, refresher training, and clinical health worker’s knowledge of first-line maintenance. The results of the regression indicated that refresher training, the inaccessibility of procedures, and users’ knowledge of first-line maintenance had a statistically significant association with the use of medical equipment while controlling for maintenance downtime, obsolete equipment and 38 University of Ghana http://ugspace.ug.edu.gh availability of consumable or accessories. Holding all other factors constant, for a unit increase in knowledge of first-line maintenance the use of medical equipment by clinical health workers increases by 8.925 units. A unit increase in the inaccessibility of procedures decreases the use of medical by 8.648 units while a unit increase in refresher training also decreases the use of medical equipment by 7.932 units, holding all other factors constant. The results are shown in the table below. Table 4.6: Multiple linear regression of the factors affecting the use of medical equipment among health workers Variable Use of Medical Equipment p-value Coefficient 95% Confidence Interval Maintenance Downtime 11.519 -2.154 – 25.192 0.098 Obsolete/Old Equipment 7.047 -2.430 – 16.525 0.143 Procedure Inaccessibility -8.648 -16.089 – -1.279 0.022* Availability of Consumables/Accessories 2.823 -4.757 – 10.404 0.462 Refresher Training -7.932 -15.750 – -0.114 0.047* Knowledge of First-line Maintenance 8.925 1.873 – 15.976 0.014* *significant at p<0.05 4.10. Summary of the chapter The study showed that most medical equipment (80%) available at the Shai Osudoku District were being used. Organisational factors such as refresher training and knowledge of first-line 39 University of Ghana http://ugspace.ug.edu.gh maintenance were associated with the use of medical equipment. Also, availability of consumables and accessories was associated with the use of medical equipment. The next chapter looked at the significance of the findings of this study in relation to previous studies. 40 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION OF FINDINGS 5.0. Introduction Even with the few studies available on medical equipment in health facilities, no studies have been conducted in Ghana on the factors affecting their use and their functional status. Using the Yamane (1967) formula, 108 health workers were recruited for the study which was conducted at the Shai Osudoku district hospital to determine the types of medical equipment that are available and are in-use at the maternal and female wards and the factors affecting their use. 5.1. Socio-demographic factors associated with use of medical equipment The socio-demographic factors that were considered in this study were age, sex, religion, educational level, time spent in the department, and occupation/profession. At a 95% confidence level and p<0.05 as the significant level, none of the factors were statistically significant. 5.2. Types of medical equipment In high-income countries, admissions to medical wards are mainly as a result of non- communicable diseases. While in low- and middle-income countries it is mainly due to communicable diseases. The work of Ali and Woldie (2011) shows that this trend is changing in some low- and middle-income countries. As such the type of medical equipment available for use should be subjective, depending on the morbidity trends. A report by the WHO (2016) lists priority medical devices for interventions for maternal and reproductive health according to the level of health care delivery. The equipment listed in the report is essential to strengthening the health system and improving the quality of care provided. The type of medical equipment identified at the Shai Osudoku district hospital was consistent with the report. 41 University of Ghana http://ugspace.ug.edu.gh Malaria, anaemia, and diarrhoea were among the top ten cases that were reported at Shai Osudoku district hospital in 2019. Management of severe malaria and diarrhoea include intravenous infusion at a controlled rate and regular checks of vitals among others. The maternal and female wards have medical equipment such as thermometers, infusion pumps, and high spec patient monitors to assist with these procedures. Dopplers and fetal heart rate detectors for determining the real-time heart rate of the fetus were also available at the maternal department. From the inventoried medical equipment about 80% of the equipment in the maternal and female departments were in use. This non-use of medical equipment appeared in the form of lack of training, maintenance delays, and the lack of accessories and consumables needed to operate the medical equipment. Thirty different types of medical equipment were identified in both departments, 13 out of the 30 had 100% use. The study showed that some critical medical equipment such as infusion pumps were not in use, having a 100% non-use, the same was the case for therapeutic ECG machine, and transport ventilator. The result of this study is consistent with the work of Perry and Malkin (2011) which reported that on average 38.2%, ranging from 0.83% to 47% of medical equipment in developing countries are not in-use. However, it did not collaborate a report of WHO (2000) indicating that up to 70% of medical equipment in sub-Saharan Africa are not in use. 5.3. Organisational factors associated with use of medical equipment The areas of focus were knowledge and awareness of the procedure for reporting faulty medical equipment to the clinical engineering unit, the average time taken for medical equipment to be serviced, equipment causing injury, knowledge of first-line maintenance, and knowledge of standard operating procedures for medical equipment. Despite the lack of definitive literature on 42 University of Ghana http://ugspace.ug.edu.gh organisational factors influencing use of medical equipment, the study revealed that awareness of first-line maintenance and refresher training was associated with a high level of use of medical equipment with p=0.014 and p=0.47 respectively. However, less than half of the respondents indicated that they had knowledge of first-line maintenance (48%), the same was the case for refresher training (33%). Although end-user training was not associated with high use of medical equipment, training for health workers on first-line maintenance should be done regularly. 5.4. Perceptual factors associated with use of medical equipment Based on an earlier study, the perceptual factors that were taken into account were maintenance downtime, obsolete equipment, breakdown of equipment, the availability of accessories/consumables, trained personnel, and inaccessibility of procedure (Chandhury & Kaul, 2015). The study revealed a significant association between four of the perceptual factors and the use of medical equipment by clinical health workers at Shai Osudoku district hospital. The factors were maintenance downtime, the availability of consumables and accessories, and the accessibility of procedure, and obsolete equipment. 5.6. Factors influencing use of medical equipment The use of medical equipment measured on a continuous scale was from 2 to 10, the average use of medical equipment was 6.36. Based on the scale of measurement adopted for this study, 2 being minimum and 10 the maximum, the use of medical equipment is medium. To control for confounders, a multiple linear regression was done and the model contained all the statistically significant factors. These findings are not consistent with the study conducted by 43 University of Ghana http://ugspace.ug.edu.gh Chaudhary and Kaul (2015) which reported obsolete medical equipment, maintenance delays, and non-availability of consumables and accessories as the factors affecting utilization. These differences in findings could be as attributed to the methodology that was used. When there are no medical procedures requiring the use of medical equipment, its use will be low. Also, refresher training had a negative correlation with the use of medical equipment, this may be attributed to the fact that 69.4% of respondents had no refresher training. 5.7. Summary of the chapter The study showed that training of users with a focus on first-line maintenance improves the use of medical equipment. Based on the inventoried equipment at the hospital, about 80% of the medical equipment are functional and being used. The final chapter looked at the significance of the study, recommendations and limitations of the study. 44 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION 6.0. Introduction The study has successfully identified the types of medical equipment that are at the maternal and female wards of Shai Osudoku district hospital and also the proportion of the equipment that is in use. This chapter elaborates on the summary of the study, recommendations to the appropriate institutions, and limitations of the study. 6.1. Summary of the study Percentages indicating the indicating equipment in use and not in use were determined from an inventory list. Bivariate analysis was used to identify socio-demographic, organisational and perceptual factors influencing the use of medical equipment before performing a multiple regression to eliminate confounders. The study has shown that 20% of the medical equipment at Shai Osudoku District Hospital are not in use. The factors that have been identified to affect the use of medical equipment in the hospital are refresher training, the inaccessibility of medical procedure by clients, and knowledge of first-line maintenance. 6.2. Limitations to the study 1. The selection of study participants was done by purposive sampling, this being a judgemental task makes the selection procedure vulnerable to some biases. As such the findings from the study cannot be generalized to other population groups. 2. The study utilizes cross-sectional data, therefore responses from participants can be different when measured at a different time. 45 University of Ghana http://ugspace.ug.edu.gh 3. Due to the paucity of literature exploring the availability of medical equipment and the factors affecting the use in health facilities, there were few previous studies to relate the study to. 6.3. Recommendations The following recommendations are made based on the findings from the study for consideration by Shai Osudoku district hospital, policymakers and health workers working with medical equipment. 6.3.1. Ministry of Health/Ghana Health Service 1. The ministry should ensure that health facilities are equipped with the needed medical equipment, taking into consideration the location and context where the equipment will be used. 2. Develop and ensure the implementation of guidelines and policies for using medical equipment 6.3.2. Management of Shai Osudoku District Hospital 1. There should be a regular audit of medical equipment to determine the shortages and functional status. 2. Training provided for health workers should focus on first-line maintenance of medical equipment. First-line maintenance should also be in the Standard Operating Procedure (SOP) for medical equipment and be made available to users. 3. For effective use, procurement and donation of medical equipment should be based on the public health needs of the health facility. 46 University of Ghana http://ugspace.ug.edu.gh 6.3.3. Health workers 1. Clinical health workers should insist on refresher training on medical equipment and also training on first-line maintenance 6.3.4. Future research 1. Future research should examine the use of medical equipment by health workers in other health facilities to give a wider view of the factors facilitating its use. 2. 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Interagency list of medical devices for essential interventions for reproductive, maternal, newborn and child health. 51 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX A: List of SDGs 3 and some medical devices/technologies that help in their accomplishments Target Example of health technology/medical device 3.1 By 2030 reduce the global maternal Blood pressure meters, pregnancy tests, surgical mortality ratio to less than 70 per 100,000 live instruments, cord clamps births 3.2 By 2030 end preventable deaths of Neonatal resuscitation devices, warming newborns and under-five children devices/incubators, diagnostics 3.3 By 2030 end the epidemics of AIDS, In-vitro diagnostics to initiate the right tuberculosis, malaria, and neglected tropical treatment diseases and combat hepatitis, water-borne diseases, and other communicable diseases 3.4 By 2030 reduce by one-third premature Diagnostics: in vitro, blood glucose mortality from non-communicable diseases meters, pathology; x rays…imaging, (NCDs) through prevention and treatment and Treatment: surgical instruments, promote mental health and wellbeing implants, radiotherapy, inhalers chemotherapy, cardiac support 52 University of Ghana http://ugspace.ug.edu.gh 3.7 By 2030 ensure universal access to sexual From condoms to contraceptive devices and reproductive health care services, including family planning, information and education, and the integration of reproductive health into national strategies and programmes 53 University of Ghana http://ugspace.ug.edu.gh APPENDIX B: Consent Form Study Title: Factors Affecting Use Of Medical Equipment Among Health Workers In Shai Osudoku District Hospital Participants’ Statement I acknowledge that I have read or have had the purpose and contents of the Participants’ Information Sheet read and satisfactorily explained to me in a language I understand (………………………). I fully understand the contents and any potential implications as well as my right to change my mind (i.e. withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research. Name or Initials of Participant………………………….. ID Code …………………………….. Participants’ Signature ……………………...OR Thumb Print…………………………… Date:…………………………………. Interpreters’ Statement I interpreted the purpose and contents of the Participants’ Information Sheet to the aforenamed participant to the best of my ability in the ..…………...… language to his proper understanding. All questions, appropriate clarifications sort by the participant and answers were also duly interpreted to his/her satisfaction. Name of Interpreter…………………………… Signature of Interpreter……………………….. Date:……………………… Contact Details 54 University of Ghana http://ugspace.ug.edu.gh Statement Of Witness I was present when the purpose and contents of the Participant Information Sheet were read and explained satisfactorily to the participant in the language he/she understood (…………………) I confirm that he/she was given the opportunity to ask questions/seek clarifications and the same were duly answered to his/her satisfaction before voluntarily agreeing to be part of the research. Name: ……………………………… Signature…………………………... OR Thumb Print ………............................ Date:…………………………… Investigator Statement And Signature I certify that the participant has been given ample time to read and learn about the study. All questions and clarifications raised by the participant have been addressed. Researcher’s name………………………………………. Signature …………………………………………………. Date…………………………………………………………. 55 University of Ghana http://ugspace.ug.edu.gh Appendix C: Questionnaires for factors associated with the use of medical equipment among clinical health workers at Shai Osudoku District Hospital Dear Respondent, I am Samuel Amponsah-Tuffour, a Master of Public Health student from the University of Ghana, I am conducting a study on the factors affecting the use of medical equipment at the Shai Osudoku district hospital. Any information provided will be treated confidentially and be used solely for the study. Thank you very much for your participation and kind responses. Date of Interview……………………………………………… Interviewer…………………………………………….. Qn No. Questions Response Respondent ID: Section 1: Socio-demographic characteristics 1 What was your age on your last birthday? 2 Sex of respondent 1. Male 2. Female 3 What is your religion? 1. Christianity 2. Islam 3. Traditional 4. Other (specify)……………………………….. 56 University of Ghana http://ugspace.ug.edu.gh 4 What is your occupation? ………………………………………….. 5 What is your highest level of formal education? 1. No formal education 2. Primary 3. Middle/JSS/JHS 4. SSS/SHS/Vocation/Technical 5. HND/Diploma 6. Degree/Higher 6 How long have you been working in this unit? 1. Less than 3 months 2. 3-6 months 3. 6-12 months 4. More than 12 months Section 2: Organisational factors associated with the use of medical equipment 7 Have you received end-user training in the use and operation of medical equipment in your unit? 1. Yes 2. No 8 Have you received refresher training in the use and operation of medical equipment 1. Yes 2. No 9 If yes, when was either or both of these training? 1. Less than 3 months ago 2. Between 3-6 months ago 3. 6-12 months ago 57 University of Ghana http://ugspace.ug.edu.gh 4. More than 12 months ago Does the unit have written guidelines and policies on the use of medical equipment? 10 1. Yes 2. No 11 Is there a procedure for reporting faulty medical equipment? 1. Yes 2. No 12 Has there been an incident of any medical equipment causing harm to a patient or yourself? 1. Yes 2. No 13 If yes, was this incident reported and investigated? 1. Yes 2. No 14 Do you have knowledge of the Standard Operating Procedures for medical equipment in the unit? 1. Yes 2. No 15 If yes, are these Standard Operating Procedures in writing? 1. Yes 2. No 16 How long does it take for a reported faulty/non-functioning medical equipment to be repaired and returned to the unit? 1. Less than a week 2. 1-2 weeks 58 University of Ghana http://ugspace.ug.edu.gh 3. 2-4 weeks 4. More than 4-weeks 17 Do you have adequate knowledge of first-line maintenance of medical equipment? 1. Yes 2. No 18 If yes to Question 17, tick which of the listed first-line maintenance practice(s) you know of and can perform effectively. Tick all that are applicable. 1. Cleaning of medical equipment 2. Visual checks and inspections to identify any defects 3. Performing function checks 4. Troubleshooting user errors 5. Replacing/Restocking consumables/accessories 19 Are accessories and consumables for medical equipment available when needed? 1. Always available 2. Often available 3. Sometimes available 4. Rarely available 5. Never available Section 4: Perceptual factors that influence the use of medical equipment 20 Does the time taken for maintenance such as repairing, installing accessories, and calibration of medical equipment affect the use of medical equipment? 1. Yes 2. No 59 University of Ghana http://ugspace.ug.edu.gh 21 Does using obsolete/old equipment affect their utilization? 1. Yes 2. No 22 Does the availability/unavailability of accessories and consumables affect the use of medical equipment? 1. Yes 2. No 23 Is the use of medical equipment affected by having received training in using the medical equipment? 1. Yes 2. No 24 Does the accessibility of medical procedures by patients affect the use of medical equipment? 1. Yes 2. No 25 Does the breakdown of equipment affect its use? 1. Yes 2. No Section 5: Use of Medical Equipment 26 How will you describe the availability of medical equipment when needed for use? 1. Never available 2. Rarely available 3. Sometimes available 4. Often available 5. Always available 60 University of Ghana http://ugspace.ug.edu.gh 27 Rate your ability to use medical equipment safely and effectively? 1. Poor 2. Below average 3. Average 4. Above average 5. Excellent 61 University of Ghana http://ugspace.ug.edu.gh 62 University of Ghana http://ugspace.ug.edu.gh APPENDIX D: Inventory List Type of medical equipment Total Number in-use 63 University of Ghana http://ugspace.ug.edu.gh APPENDIX E: Ethical Approval 64