Study design

Qualitative exploratory descriptive design was used in conducting this study. Qualitative exploratory descriptive design was found to be useful in exploring experiences of older people in healthcare [30]. The design enabled researchers in this study to have in-depth understanding into challenges and expectations of healthcare by elderly persons in Ghana. The study was reported using the COREQ criteria for reporting qualitative research [31].

Study setting

Ghana is a country in West-Africa with a current projected population of 30.3 million people [32]. Ghana is divided into 16 regions. These 16 regions are divided into northern, middle and southern zones. The Northern zone consist of Upper West, Upper East, Northern, Northern East, and Savannah Regions [33]. The middle zone consist of Brong Ahafo, Bono East, Ahafo and Ashanti Regions [33]. The southern zone is made up of Western, Western North, Central, Greater Accra, Volta, Oti, and Eastern Regions [33]. This study was undertaken in three purposely selected regions in Ghana: one region from the southern zone, one from the middle zone and the other from the northern zone. Volta Region was selected from the Southern Zone, Ashanti from the middle zone and the Upper West from the Northern Zone. There are 17 district hospitals in the Volta Region, 25 district hospitals in the Ashanti Region, and 3 district hospitals in the upper west Region [33]. The bed capacities of public health hospitals in the Ashanti, Upper West and Volta are 1230, 225, and 1400 respectively [33]. Data was collected from these three regions because researchers wanted to have an in-depth understanding into challenges and expectation of elderly persons in many areas of Ghana.

Population and sampling

A purposive sampling technique was used in selecting one region from each of the three zones in Ghana. A purposive sampling technique was utilised in selecting regions because the researchers wanted to include a region from each of the three regional zones (northern zone, middle zone and southern zone) in Ghana. The Ashanti, Volta and Upper West Regions were selected from each zone. Participants in these regions were also selected through a purposive sampling technique. The targeted population for this research were persons who were 60 years and above, who had visited district hospitals in selected regions. These persons were selected in line with the United Nations (UN) definition an elderly person. The UN defines the elderly as a persons who is 60 years or above [1]. All participants were within the ages of 60 and 89 years. Only elderly persons who had visited the hospital during the year were involved in study. Participants were recruited through district focal persons of the Ministry of Gender and Social protection. Letters were sent to older persons requesting their participation in study. Only older persons who indicated their willingness to participate and met inclusion criteria were contacted for data collection. Only persons who could speak English were included in study. Older people who had intellectual disabilities or had mental illnesses were excluded from study.

Data collection

Data were collected with a semi-structured interview guide which was formulated by the research team (S1 Appendix). The semi-structured interviews were conducted in English since all participants could speak English. The interview guide was pretested on ten older people in other regions to identify ambiguous questions. Questions asked during interviews included the following: 1. Can you describe any challenges from healthcare workers that you faced when you visited a district hospital here for treatment? 2. Describe your perception of healthcare in Ghanaian district hospitals. 3. Describe how you see the current care of the elderly in Ghanaian hospitals. 4. Describe ways you think health workers can improve their care for you in the hospital. Probes were used to elicit further descriptions of challenges and expectations. Data were collected within a three-month period from December 2018 to February 2019. Each interview lasted between one and two hours. Five participants were initially interviewed in each region. Additional five persons were interviewed in each region as saturation was not determined with the initial interviews. Saturation was determined after interviewing the 30^th participant. The number of participants selected for qualitative interviews depends on the purpose of the study [34]. Qualitative studies work with small numbers that are feasible to study in depth [34]. Transcribed data was shown to some participants for their comments. Transcribed data were securely stored on a flash drive which was password protected.

Data analysis

Data analysis was conducted with qualitative content analysis. Data was analysed manually by research team which was headed by a professor of nursing. Data was analysed in line with COREQ criteria for analysing qualitative research data [31]. The COREQ criterion for analysing qualitative data uses the following pattern: coding; derivation of categories from codes; formation of themes; participants checking of codes; presentation of quotations. The research team sat together and read through the content of field data. Data was cleaned by removing all identifiable information. Codes were found during readings of transcripts. Codes were discussed within the research team. Similar codes were used by the team to create families and similar families grouped together as themes. The themes were discussed among all members of the research team for agreement. The themes were also discussed with some participants to find out if themes represented their views.

Rigour

A pretest of semi-structured interview guide was carried out in the Central Region. Pretest ensured that ambiguous questions were modified to make them clearer for participants. The researchers had prolonged interactions with elderly persons to ensure in-depth understanding of findings that emerged. Member checking was carried out to validate data from the participants. Data transcriptions and coding were done by the research team to ensure that the right challenges and expectations were reported. Researchers went back to elderly persons to find out if themes formulated represented their opinions. The background of the authors as qualitative researchers further helped in providing qualitative research rigour in the study.

Ethical consideration

Ethical approval for this study was granted by the Committee on Human Research Publication and Ethics (CHRPE) at the Kwame Nkrumah university of Science and Technology (KNUST), Ghana with reference number CHRPE/AP/634/18. Permissions were also sought from district assemblies where data were collected. Anonymity and confidentiality were explained to participants. Participants were assured that withdrawal from study will not in any way attract sanctions. Informed consent forms were filled and signed by participants. Participants were identified with codes to ensure anonymity. Questions that could cause any form of psychological trauma on participants were avoided.

Demographic data of respondents

As shown in Table 1, the majority of participants were women. All participants were within the ages of 60 and 89. The majority of elderly persons were Christians and as many as 40% were widows/widowers. The highest level of formal education for most participants was primary school level (see Table 1). About 67% were retired from their formal jobs.

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Table 1. Demographic characteristics of participants.

https://doi.org/10.1371/journal.pone.0245451.t001

Inadequate information from health workers regarding care of the older person

Majority of participants pointed out that inadequate information from health workers in the out-patient department and other departments in Ghanaian district hospitals was a challenge for them. Elderly persons did not have detailed explanations of nursing activities when they visited district hospitals for care. Elderly persons indicated they did not receive specific education from nurses and medical officers regarding maintenance of good health in old age. Some participants attributed the lack of information from nurses and medical officers to inadequate time and workload:

…Nurses and doctors did not explain issues into details when taking care of me. Maybe it is because they don’t have much time. Not much explanation is given on the needs and how important that task will affect my health. We also need more information on how to prevent diseases from getting to us in our old age

[AP3].

Some participants shared their thoughts on the need for receptions in district hospitals similar to what can be found in several other organisations in Ghana. Others said they wished they could be given necessary information at these proposed receptions without having to ask for such information from nurses and medical officers:

… I think nurses and doctors could give us enough information without asking. If they can have receptions to give us information in the hospital, it will be good

[AP5].

……Some nurses should be at receptions to explain things to us to understand well. Information is necessary to know what to do.….we don’t have to ask for information all the time before we are offered important information about our health…

[AP7]

Need for routine check-up visits

Participants were of the view that problems they faced could be reduced to the barest minimum through regular check-up visits from healthcare workers. Participants indicated that these check-up visits could take place in their communities or homes. Check-up visits in their homes or communities will help reduce the cost of transportation to hospitals for healthcare:

….For me, there should be regular check-up programs for us in our homes. These check-up visits could be free so that many of our challenges can be prevented. It will prevent our travels and monies spent on travelling all the way to the hospitals

[AP24].

…….I think sometimes these check-up visits can be done in our communities. Sometimes nurses and other health workers can come and see how we are doing in our homes. It will be good for us, so we do not take cars and spend our little monies going to the hospital

[AP26].

Some participants also recommended that in the absence of the regular visits by health workers, health workers can alternatively call them on the phone on regular basis to check up on them:

…Even if health workers can’t come to us regularly, they should call us on the phone on some regular basis to find out how we are doing. We have phones now, so we are ready for health workers to call us and check up on us

[AP7].

…Check-up visits can even be done through calls to us by health workers, so we know whether we really need to come to the hospital. I am reluctant to take a car all the way to the hospitals for check-up………

[AP28].

Participants shared their thoughts on the importance of regular check-up visits from nurses as pertains to monthly antenatal programs for pregnant women in Ghanaian hospitals.

……Just like what is done for pregnant women, we can also have dedicated days to come for our check-up or reviews. Nurses have done it for pregnant women so why can’t they do it for us too?

[AP18].

A call for dedicated units and consulting rooms

Participants suggested that Ghanaian district hospitals should be designed to prevent queuing for elderly persons. Creation of elderly wards and consulting rooms with aged care experts were suggested by participants. Participants expected health workers to dedicate a consulting room to them to reduce their waiting time at the out-patient department:

…….I mean there should be departments and special health workers for elderly persons. The health workers can find a separate room or unit for us where they will see only elderly persons.…

[AP11].

For us not to queue for longer periods, health workers who have knowledge in old people care should be employed to care for elderly persons. In that case, we will just go straight to see our health workers when we go to the hospital…

[AP9].

Participants were of the view that hospital mangers and health workers could help in setting up these special units and consulting rooms for the elderly client:

…. Managers and health workers of the district hospitals in this country should come together and develop a plan that will make sure that there are units with experts for the elderly in every hospital just for the elderly……

[AP3].

…Our hospitals should create units and consulting rooms just for us to come and see specialist health workers…….

[AP24].

Inadequate information from health workers regarding care of the older person

Participants indicated that healthcare workers did not provide them with enough information on how to prevent diseases in their old age. This may be due to inadequate education of health workers in gerontological care in Ghana [11, 29]. Clinical staff such as nurses and medical officers are not examined in gerontological care during their licensing examinations [11, 35]. A policy on inclusion of gerontology content in the training of healthcare workers in Ghana may contribute to addressing issues of inadequate information from health professionals regarding aged care. Healthcare workers in Ghana should be provided knowledge on the current national aging policy of Ghana [36] in order to understand their roles regarding the care of the older Ghanaian. Training could be conducted through workshops to improve knowledge of healthcare workers. These ideas are supported by previous studies from other parts of the world [37–40]. These studies [37–40] recommend curriculum modifications and training in gerontology as necessary steps for meeting expectations of elderly persons and achieving positive health outcomes for the elderly.

Financial burden of the older Ghanaian regarding healthcare

Participants in this study indicated that meeting the current healthcare cost in hospitals is a challenge to them. Currently the National Health Insurance Scheme (NHIS) only covers elderly persons above 70 years [21] whilst life expectancy of the Ghanaian elderly person is 63 years and compulsory retirement is 60 years [14]. The national health insurance scheme could be extended to elderly persons between 60 years and 69 years since many of them may not live to 70 years to benefit from the current elderly health insurance package. Today’s generation owe it as a duty to honour and guarantee better living conditions for our elderly persons [21] as they have contributed their quota to the development of the nation [36]. Ageing could also be defined in terms of functionality rather than a stage in a life time because some elderly persons could function at the age of 60 and beyond [41, 42].

The fact that 33% of elderly participants in this study were still actively engaged in various forms of employment (Table 1) shows that some older people could work after age 60. Rehiring older people is in line with the United Nation’s (UN) recommendation on rehiring retired persons to enhance knowledge transfer to the younger generation of workers [43]. Retiring every elderly person at the age of 60 may be disadvantageous to institutions which could benefit from their experiences. The UN recommends development of regulations for the utilisation of the experiences of elderly persons who are over 60 years [43]. Older people who are active and still working after age 60 may find it easier to pay for their healthcare cost and avoid unorthodox methods of treatments which complicates their conditions. Being active at an old age has also been shown to improve physical and psychological well-being of older people [44–46].

Dedicated units and consulting rooms for the care of older Ghanaians

In this study, older Ghanaians indicated that they expected hospitals to implement dedicated services towards older people’s care. Participants indicated the need for dedicated units and consulting rooms with gerontology experts where they could be provided services. Evidence available shows such dedicated services can reduce complications and admission rates in older people and cost effective for both older people and health facilities [47, 48]. Older persons could have their check-up visits in these dedicated units to avoid queuing with other aged groups. Staff from these dedicated aged care units could provide regular community care to older Ghanaians. Specialist training could be provided to health workers in order to provide such dedicated services to older people. Academic and clinical gerontology experts could help establish advanced specialist courses for health workers in Ghana to be able to manage these dedicated units. Implementing these suggested dedicated units for older people will prevent the frustration of constant queuing, which was a major concern of participants in the study.

Aged care home services could also be introduced by the Ghana Health Service (GHS) as pertains in other countries [49, 50]. The introduction of aged care home services by the GHS should be accompanied by appropriate regulatory and monitoring mechanisms that will protect and improve health of older Ghanaians. This is because increasing commercialisation, lack of regulation and inadequate monitoring can result in poor quality care for elderly persons in aged care homes [50]. The regulatory mechanism could include the use of professionally trained persons and adequate remuneration for these professionals. Elderly care models that are implemented in Ghana should integrate client choices, community/primary health care services, residential and non-residential elderly care services, as these have been found to be effective in other countries [51].