As a healthcare patient, what would you sacrifice for a provider with a nice – rather than rude – attitude? Medical Xpress reports that for HIV patients in Zambia, the answer may surprise. According to findings of a study, HIV patients in Zambia were willing to increase wait time and travel distance – and accept significant reduction in medication- in order to access a healthcare provider with a nice attitude.
The study, led by University of California – San Francisco's Dr Elvin Geng, professor of medicine, reveals how much patients value a positive attitude in relation to other aspects of clinical care. "This was a great opportunity to deepen our understanding of what people want from health services in resource-limited settings," said Geng.
Public health programmes in Africa have saved millions of lives, yet engagement in HIV care remains a challenge. Many people have limited access to care or fall out of care. You might expect people in need of healthcare to seek it, but this is not necessarily the case. "You add clinics and you think everyone is going to come to get treatment," said Geng. "It's not that simple."
Beyond adding physical and medical resources, which are limited, Geng and team wondered how to reach people in need of care. Competing priorities, like work and family, can get in the way. Further, there is no absolute value of treatment; in other words, it carries a different value for different people. Thus, it's important to consider how to prioritise solutions.
When considering how to improve treatment engagement of HIV patients, Geng looked beyond public health – to economics and marketing – for inspiration. "We learned about methods that have not been used much in public health," said Geng. "One of them was choice experiment."
A choice experiment aims to understand what people want from a good or service – its utility, like happiness or satisfaction – and what they would trade for other characteristics. Choice experiments can be used to identify preferred features of a utility as well as the strength of preference. For instance, when buying a new car, you may value both cost and gas efficiency. However, you may favour a car with weaker gas mileage if the list price is cheaper, suggesting you value cost over fuel economy, relatively speaking.
To consider how disengaged patients value traits of clinical care in Zambia, Geng and team used a choice experiment. Researchers surveyed 280 HIV patients (average age, 35 years; 60% female) who were 90 days late for their last scheduled appointment. Patients were asked to choose between two hypothetical clinics in which five attributes of the facilities were varied, including wait time, distance from residence to clinic, medication supply given at refill, hours of operation and staff attitude.
The findings showed a strong patient preference for "nice" versus "rude" providers and a willingness to wait 19 hours or travel 45km to see nice rather than rude providers.
Patients also reported a preference for a facility located 10km from home (as opposed to five) that required five hours of waiting per visit (as opposed to one), and which dispensed three months of medications (instead of five) in order to access nice (as opposed to rude) providers.
The findings suggest current improvement strategies to HIV care – and perhaps public health more broadly – should value provider attitude and promote patient-centeredness to improve engagement in care.
"To me, the findings further the idea that everyone wants to be treated fairly and with respect," said Geng. "This applies to people seeking health care in the US as well as to people in Africa."
Background: In public health HIV treatment programs in Africa, long-term retention remains a challenge. A number of improvement strategies exist (e.g., bring services closer to home, reduce visit frequency, expand hours of clinic operation, improve provider attitude), but implementers lack data about which to prioritize when resource constraints preclude implementing all. We used a discrete choice experiment (DCE) to quantify preferences for a number of potential clinic improvements to enhance retention.
Methods and findings: We sought a random sample of HIV patients who were lost to follow-up (defined as >90 days late for their last scheduled appointment) from treatment facilities in Lusaka Province, Zambia. Among those contacted, we asked patients to choose between 2 hypothetical clinics in which the following 5 attributes of those facilities were varied: waiting time at the clinic (1, 3, or 5 hours), distance from residence to clinic (5, 10, or 20 km), ART supply given at each refill (1, 3, or 5 months), hours of operation (morning only, morning and afternoon, or morning and Saturday), and staff attitude (“rude” or “nice”). We used mixed-effects logistic regression to estimate relative utility (i.e., preference) for each attribute level. We calculated how much additional waiting time or travel distance patients were willing to accept in order to obtain other desired features of care. Between December 9, 2015 and May 31, 2016, we offered the survey to 385 patients, and 280 participated (average age 35; 60% female). Patients exhibited a strong preference for nice as opposed to rude providers (relative utility of 2.66; 95% CI 1.9–3.42; p < 0.001). In a standard willingness to wait or willingness to travel analysis, patients were willing to wait 19 hours more or travel 45 km farther to see nice rather than rude providers. An alternative analysis, in which trade-offs were constrained to values actually posed to patients in the experiment, suggested that patients were willing to accept a facility located 10 km from home (as opposed to 5) that required 5 hours of waiting per visit (as opposed to 1 hour) and that dispensed 3 months of medications (instead of 5) in order to access nice (as opposed to rude) providers. This study was limited by the fact that attributes included in the experiment may not have captured additional important determinants of preference.
Conclusions: In this study, patients were willing to expend considerable time and effort as well as accept substantial inconvenience in order to access providers with a nice attitude. In addition to service delivery redesign (e.g., differentiated service delivery models), current improvement strategies should also prioritize improving provider attitude and promoting patient centeredness—an area of limited policy attention to date.
Arianna Zanolini, Kombatende Sikombe, Izukanji Sikazwe, Ingrid Eshun-Wilson, Paul Somwe, Carolyn Bolton Moore, Stephanie M Topp, Nancy Czaicki, Laura K Beres, Chanda P Mwamba, Nancy Padian, Charles B Holmes, Elvin H Geng
[link url="https://medicalxpress.com/news/2018-08-hiv-patients-zambia-kindness-convenience.html"]Medical Xpress report[/link]
[link url="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002636"]PLOS Medicine abstract[/link]