Arianna Zanolini 1 , Kombatende Sikombe 2 , Izukanji Sikazwe 2 , Ingrid Eshun-Wilson 3 , Paul Somwe 2 , Carolyn Bolton Moore 2 , 4 , Stephanie M. Topp 5 , Nancy Czaicki 3 , Laura K. Beres 6 , Chanda P. Mwamba 2 , Nancy Padian 7 , Charles B. Holmes 2 , 6 , 8 , Elvin H. Geng 3 , *
13 August 2018
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.
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.
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.
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.
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.
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.
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.