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Understanding preferences for HIV care and treatment in Zambia: Evidence from a discrete choice experiment among patients who have been lost to follow-up

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      Abstract

      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.

      Abstract

      In a discrete choice experiment carried out in Zambia, Elvin Geng and colleagues study the preferences for treatment provision of HIV patients lost to care.

      Author summary

      Why was this study done?
      • To achieve optimal impact, public health should tailor services to meet, whenever possible, the preferences of populations that could benefit from services.

      • Although a global effort to provide treatment for HIV has saved millions of lives, many patients are still inconsistently engaged in care and fail to achieve full health benefits of ART.

      • Choice experiments—still a relatively novel tool in public health—can be used to identify preferred features of a health service as well as the relative strength of those preferences in comparison with each other.

      • In such an experiment, researchers ask patients to consider a series of comparisons between 2 hypothetical services (e.g., 2 clinics) in which features of that service (e.g., time spent at the facility during a visit) differ. The choices made by a population reveal which features of the services are most desired, as well as how much of another characteristic would they trade for what they desire.

      What did the researchers do and find?
      • We used such a choice experiment in patients who were lost to follow-up from HIV care. First, we intensively traced patients who were lost to follow-up in the community. Then, we administered a choice survey to those contacted in person who consented.

      • In the choice experiment, patients were asked to select between 2 hypothetical facilities that varied in the following 5 attributes: distance from facility to residence (1, 5, or 20 km), time spent waiting at the facility (1, 3, or 5 hours), opening hours (8:00 am–12:00 noon, 8:00 am–3:00 pm, or 8:00 am–12:00 noon plus Saturdays), the quantity of HIV medications dispensed at each visit (1, 3, or 5 months), and the attitude of providers (“rude” or “nice”).

      • Overall, 280 patients were surveyed. Patients expressed a strong preference for nice, as opposed to rude, providers, as well as strong preferences for longer versus shorter medication refill duration. As expected, shorter distance, less waiting time, and longer opening hours were also desired.

      • A standard willingness to wait analysis suggested that patients would trade up to 19 hours of waiting time to access a facility with nice as opposed to rude providers. A willingness to travel analysis suggested that patients were willing to travel an extra 45 km to see a nice as opposed to a rude provider.

      • An alternative approach to quantifying trade-offs avoiding values that fall outside of the range specifically asked in the choice experiment (i.e., the standard willingness to wait suggested a value of 19 hours, exceeding the 5-hour maximum offered in the experiment) suggested that patients were willing to give up 5 months of medications to receive 3 months only, travel 10 km (rather than 5), and spend 3 hours waiting (rather than 1) at a visit, all in order to access a facility with nice providers.

      What do these findings mean?
      • In addition to current improvement efforts to increase drug dispensation, move services closer to home, and extend hours (in differentiated service delivery models), a concomitant effort to improve healthcare worker attitude has not been undertaken but may represent a high priority.

      • International donor agencies as well as national governments responding to the HIV epidemic should consider incorporating training on patient-centered perspectives and communications into investments to build human resources for health.

      • Healthcare worker morale and job satisfaction should be systematically assessed and improved.

      Related collections

      Most cited references 30

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      Effective physician-patient communication and health outcomes: a review.

      To ascertain whether the quality of physician-patient communication makes a significant difference to patient health outcomes. The MEDLINE database was searched for articles published from 1983 to 1993 using "physician-patient relations" as the primary medical subject heading. Several bibliographies and conference proceedings were also reviewed. Randomized controlled trials (RCTs) and analytic studies of physician-patient communication in which patient health was an outcome variable. The following information was recorded about each study: sample size, patient characteristics, clinical setting, elements of communication assessed, patient outcomes measured, and direction and significance of any association found between aspects of communication and patient outcomes. Of the 21 studies that met the final criteria for review, 16 reported positive results, 4 reported negative (i.e., nonsignificant) results, and 1 was inconclusive. The quality of communication both in the history-taking segment of the visit and during discussion of the management plan was found to influence patient health outcomes. The outcomes affected were, in descending order of frequency, emotional health, symptom resolution, function, physiologic measures (i.e., blood pressure and blood sugar level) and pain control. Most of the studies reviewed demonstrated a correlation between effective physician-patient communication and improved patient health outcomes. The components of effective communication identified by these studies can be used as the basis both for curriculum development in medical education and for patient education programs. Future research should focus on evaluating such educational programs.
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        Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders.

        There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya. A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up. Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h. In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P = 0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03). These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings.
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          Conjoint analysis applications in health--a checklist: a report of the ISPOR Good Research Practices for Conjoint Analysis Task Force.

          The application of conjoint analysis (including discrete-choice experiments and other multiattribute stated-preference methods) in health has increased rapidly over the past decade. A wider acceptance of these methods is limited by an absence of consensus-based methodological standards. The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) Good Research Practices for Conjoint Analysis Task Force was established to identify good research practices for conjoint-analysis applications in health. The task force met regularly to identify the important steps in a conjoint analysis, to discuss good research practices for conjoint analysis, and to develop and refine the key criteria for identifying good research practices. ISPOR members contributed to this process through an extensive consultation process. A final consensus meeting was held to revise the article using these comments, and those of a number of international reviewers. Task force findings are presented as a 10-item checklist covering: 1) research question; 2) attributes and levels; 3) construction of tasks; 4) experimental design; 5) preference elicitation; 6) instrument design; 7) data-collection plan; 8) statistical analyses; 9) results and conclusions; and 10) study presentation. A primary question relating to each of the 10 items is posed, and three sub-questions examine finer issues within items. Although the checklist should not be interpreted as endorsing any specific methodological approach to conjoint analysis, it can facilitate future training activities and discussions of good research practices for the application of conjoint-analysis methods in health care studies. Copyright © 2011 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.
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            Author and article information

            Affiliations
            [1 ] United Kingdom Department for International Development, Dar Es Salaam office, Dar Es Salaam, Tanzania
            [2 ] Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
            [3 ] University of California, San Francisco, San Francisco, California, United States of America
            [4 ] University of Alabama at Birmingham, Birmingham, Alabama, United States of America
            [5 ] James Cook University, Townsville, Australia
            [6 ] Johns Hopkins University, Baltimore, Maryland, United States of America
            [7 ] University of California, Berkeley, Berkeley, California, United States of America
            [8 ] Georgetown University, Washington D.C., United States of America
            Massachusetts General Hospital, UNITED STATES
            Author notes

            I have read the journal’s policy, and the authors of this manuscript have the following competing interests: EHG is a member of the Editorial Board of PLOS Medicine. The remaining authors have declared that no competing interests exist.

            Contributors
            ORCID: http://orcid.org/0000-0001-7983-5649, Role: Conceptualization, Role: Data curation, Role: Formal analysis, Role: Funding acquisition, Role: Investigation, Role: Methodology, Role: Project administration, Role: Software, Role: Validation, Role: Visualization, Role: Writing – original draft, Role: Writing – review & editing
            Role: Conceptualization, Role: Funding acquisition, Role: Investigation, Role: Project administration, Role: Resources, Role: Supervision, Role: Writing – original draft, Role: Writing – review & editing
            Role: Conceptualization, Role: Funding acquisition, Role: Investigation, Role: Project administration, Role: Resources, Role: Supervision, Role: Writing – original draft, Role: Writing – review & editing
            Role: Data curation, Role: Formal analysis, Role: Methodology, Role: Software, Role: Validation, Role: Visualization, Role: Writing – review & editing
            Role: Data curation, Role: Software, Role: Writing – original draft, Role: Writing – review & editing
            ORCID: http://orcid.org/0000-0001-9103-7746, Role: Conceptualization, Role: Funding acquisition, Role: Investigation, Role: Project administration, Role: Resources, Role: Supervision, Role: Writing – original draft, Role: Writing – review & editing
            ORCID: http://orcid.org/0000-0002-3448-7983, Role: Conceptualization, Role: Funding acquisition, Role: Project administration, Role: Writing – original draft, Role: Writing – review & editing
            Role: Conceptualization, Role: Data curation, Role: Investigation, Role: Methodology, Role: Project administration, Role: Supervision, Role: Writing – original draft, Role: Writing – review & editing
            ORCID: http://orcid.org/0000-0002-4731-7828, Role: Conceptualization, Role: Funding acquisition, Role: Methodology, Role: Project administration, Role: Resources, Role: Writing – original draft, Role: Writing – review & editing
            ORCID: http://orcid.org/0000-0002-7626-6273, Role: Data curation, Role: Software, Role: Validation, Role: Visualization, Role: Writing – review & editing
            Role: Conceptualization, Role: Funding acquisition, Role: Investigation, Role: Supervision, Role: Writing – original draft, Role: Writing – review & editing
            ORCID: http://orcid.org/0000-0002-7924-6761, Role: Conceptualization, Role: Funding acquisition, Role: Investigation, Role: Project administration, Role: Resources, Role: Supervision, Role: Validation, Role: Writing – original draft, Role: Writing – review & editing
            ORCID: http://orcid.org/0000-0002-0825-1424, Role: Conceptualization, Role: Data curation, Role: Formal analysis, Role: Funding acquisition, Role: Investigation, Role: Methodology, Role: Project administration, Role: Software, Role: Supervision, Role: Validation, Role: Visualization, Role: Writing – original draft, Role: Writing – review & editing
            Role: Academic Editor
            Journal
            PLoS Med
            PLoS Med
            plos
            plosmed
            PLoS Medicine
            Public Library of Science (San Francisco, CA USA )
            1549-1277
            1549-1676
            13 August 2018
            August 2018
            : 15
            : 8
            30102693
            6089406
            10.1371/journal.pmed.1002636
            PMEDICINE-D-18-00211
            (Academic Editor)
            © 2018 Zanolini et al

            This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

            Counts
            Figures: 3, Tables: 2, Pages: 15
            Product
            Funding
            Funded by: funder-id http://dx.doi.org/10.13039/100000865, Bill and Melinda Gates Foundation;
            Award ID: OPP1105071
            Award Recipient : ORCID: http://orcid.org/0000-0002-0825-1424
            Funded by: funder-id http://dx.doi.org/10.13039/100000060, National Institute of Allergy and Infectious Diseases;
            Award ID: K24 AI134413
            Award Recipient : ORCID: http://orcid.org/0000-0002-0825-1424
            Funded by: funder-id http://dx.doi.org/10.13039/100000060, National Institute of Allergy and Infectious Diseases;
            Award ID: P30 AI027763
            Award Recipient : ORCID: http://orcid.org/0000-0002-0825-1424
            Funding for this study was provided by the Bill and Melinda Gates Foundation (OPP1105071) https://www.gatesfoundation.org/. Funding was also provided by the National Institute of Allergy and Infectious Diseases (K24 AI134413 and P30 AI027763) https://www.niaid.nih.gov/. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
            Categories
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