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Abstract Background Pregnant women can misinform or withhold their reproductive and medical information from providers when they interact with them during care decision-making interactions, although, the information clients reveal or withhold while seeking care plays a critical role in the quality of care provided. This study explored ‘how’ and ‘why’ pregnant women in Ghana control their past obstetric and reproductive information as they interact with providers at their first antenatal visit, and how this influences providers’ decision-making at the time and in subsequent care encounters. Methods This research was a case-study of two public hospitals in southern Ghana, using participant observation, conversations, interviews and focus group discussions with antenatal, delivery, and post-natal clients and providers over a 22-month period. The Ghana Health Service Ethical Review Committee gave ethical approval for the study (Ethical approval number: GHS-ERC: 03/01/12). Data analysis was conducted according to grounded theory. Results Many of the women in this study selectively controlled the reproductive, obstetric and social history information they shared with their provider at their first visit. They believed that telling a complete history might cause providers to verbally abuse them and they would be regarded in a negative light. Examples of the information controlled included concealing the actual number of children or self-induced abortions. The women adopted this behaviour as a resistance strategy to mitigate providers’ disrespectful treatment through verbal abuses and questioning women’s practices that contradicted providers’ biomedical ideologies. Secondly, they utilised this strategy to evade public humiliation because of inadequate privacy in the hospitals. The withheld information affected quality of care decision-making and care provision processes and outcomes, since misinformed providers were unaware of particular women’s risk profile. Conclusion Many mothers in this study withhold or misinform providers about their obstetric, reproductive and social information as a way to avoid receiving disrespectful maternal care and protect their privacy. Improving provider client relationship skills, empowering clients and providing adequate infrastructure to ensure privacy and confidentiality in hospitals, are critical to the provision of respectful maternal care.

Introduction: Patient centred care is often at odds with disease-focused evidence-based clinical practice, particularly for patients with multiple chronic conditions (CCs). To assess the extent to which care for patients with multimorbidity was not guideline-concordant and the reasons why not, examining reasons stratified by disease. Methods: Retrospective cohort study conducted within the context of a nurse-primary care physician team-based care management program, the Comprehensive Care for Multimorbid Adults Project (CC-MAP) across 12 primary care clinics in Israel. This study included CC-MAP patients aged 45+ years who had at least two of eight common CCs. Forty-four guideline-based care processes for these eight CCs and dyslipidemia (‘focus conditions’) were evaluated over one year prior to data collection, through EHR review, including: lifestyle modifications, diagnostic and follow-up tests, medications, non-medication treatments, and specialist referrals. When care was not guideline-concordant, reasons why not were examined by: biomedical, personal and care burden, and system related factors. Proportions of non-guideline-concordant care and related reasons were assessed overall and stratified by focus condition. Reasons were also stratified: provider-driven if the clinician didn’t refer care, and patient-driven if care was referred but not followed by the patient. Results: 4515 care processes were evaluated among 204 multimorbid patients, on average aged 72.3 years (SD 9.7) and with 3.8 (SD 1.1) CCs. Overall, 20.8% of care was not guideline-concordant, and when examining disease-specific care for the focus conditions, ranged from 14.7% (for IHD) to 48.9% (for depression). Of 1071 reasons why care deviated from guidelines, 59.8% were provider-driven and 40.2% patient-driven. Thirty-five percent of all reasons given were biomedical-related, 28.5% personal and care burden-related, 13.3% system-related, 11.9% other and 11.9% unknown. A higher proportion of reasons were provider-driven than patient-driven for atrial fibrillation, congestive heart failure, diabetes, and hypertension specific care; whereas, a higher proportion of reasons were patient-driven than provider-driven for chronic kidney disease, chronic obstructive pulmonary disease, depression, and dyslipidemia. For ischemic heart disease, the provider- and patient-driven reasons were fairly evenly divided. Discussion: Patients with multimorbidity do not receive about a fifth of guideline recommended care overall, but this proportion varies substantially across diseases. More than a third of non-guideline-concordant care is driven by biomedical reasons, and about a third attributed to patient-related reasons. Conclusions: Understanding the drivers to deviations from guidelines can inform improvements to guidelines and care delivery for patients with multimorbidity. Lessons learned: These findings show that many clinical, personal patient, and system-related reasons exist for deviation from guidelines. Quantifying these types of reasons may provide a basis for tailoring assessments of the appropriateness and compatibility in combining disease-specific guidelines for multimorbid patients. Limitations: An evaluation in a control group or in a usual care setting was not possible for this study and while the extent of guideline-concordance was measured, this was not linked to outcomes. Suggestions for future research: Future research could examine these patterns of care in a usual care practice setting, as well as aim to evaluate the relationship of guideline-concordant care with clinical outcomes among multimorbid patients.

Introduction: Patient centred care is often at odds with disease-focused evidence-based clinical practice, particularly for patients with multiple chronic conditions (CCs). To assess the extent to which care for patients with multimorbidity was not guideline-concordant and the reasons why not, examining reasons stratified by disease. Methods: Retrospective cohort study conducted within the context of a nurse-primary care physician team-based care management program, the Comprehensive Care for Multimorbid Adults Project (CC-MAP) across 12 primary care clinics in Israel. This study included CC-MAP patients aged 45+ years who had at least two of eight common CCs. Forty-four guideline-based care processes for these eight CCs and dyslipidemia ('focus conditions') were evaluated over one year prior to data collection, through EHR review, including: lifestyle modifications, diagnostic and follow-up tests, medications, non-medication treatments, and specialist referrals. When care was not guideline-concordant, reasons why not were examined by: biomedical, personal and care burden, and system related factors. Proportions of non-guideline-concordant care and related reasons were assessed overall and stratified by focus condition. Reasons were also stratified: provider-driven if the clinician didn't refer care, and patient-driven if care was referred but not followed by the patient. Results: 4515 care processes were evaluated among 204 multimorbid patients, on average aged 72.3 years (SD 9.7) and with 3.8 (SD 1.1) CCs. Overall, 20.8% of care was not guideline-concordant, and when examining disease-specific care for the focus conditions, ranged from 14.7% (for IHD) to 48.9% (for depression). Of 1071 reasons why care deviated from guidelines, 59.8% were provider-driven and 40.2% patientdriven. Thirty-five percent of all reasons given were biomedical-related, 28.5% personal and care burden-related, 13.3% system-related, 11.9% other and 11.9% unknown. A higher proportion of reasons were provider-driven than patient-driven for atrial fibrillation, congestive heart failure, diabetes, and hypertension specific care; whereas, a higher proportion of reasons were patientdriven than provider-driven for chronic kidney disease, chronic obstructive pulmonary disease, depression, and dyslipidemia. For ischemic heart disease, the provider- and patient-driven reasons were fairly evenly divided. Discussion: Patients with multimorbidity do not receive about a fifth of guideline recommended care overall, but this proportion varies substantially across diseases. More than a third of nonguideline- concordant care is driven by biomedical reasons, and about a third attributed to patientrelated reasons. Conclusions: Understanding the drivers to deviations from guidelines can inform improvements to guidelines and care delivery for patients with multimorbidity. Lessons learned: These findings show that many clinical, personal patient, and system-related reasons exist for deviation from guidelines. Quantifying these types of reasons may provide a basis for tailoring assessments of the appropriateness and compatibility in combining disease-specific guidelines for multimorbid patients. Limitations: An evaluation in a control group or in a usual care setting was not possible for this study and while the extent of guideline-concordance was measured, this was not linked to outcomes. Suggestions for future research: Future research could examine these patterns of care in a usual care practice setting, as well as aim to evaluate the relationship of guideline-concordant care with clinical outcomes among multimorbid patients. [ABSTRACT FROM AUTHOR]