United Kingdom Department for International Development, Dar Es Salaam office, Dar Es Salaam, Tanzania.
Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
PLoS Med. 2018 Aug 13;15(8):e1002636. doi: 10.1371/journal.pmed.1002636. eCollection 2018 Aug.
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.
在非洲的公共卫生艾滋病毒治疗项目中，长期保留仍然是一个挑战。存在许多改进策略（例如，将服务更接近家庭，减少就诊频率，延长诊所营业时间，改善服务人员态度），但由于资源有限，无法实施所有措施，实施者缺乏数据来确定优先事项。我们使用离散选择实验（DCE）来量化对提高保留率的一些潜在诊所改进的偏好。
我们从赞比亚卢萨卡省的治疗机构中寻找失去随访的艾滋病毒患者（定义为最后一次预约超过 90 天）的随机样本。在联系到的患者中，我们要求他们在 2 家假设的诊所之间进行选择，这些诊所的设施具有以下 5 种属性：在诊所等待的时间（1、3 或 5 小时），距离居住地到诊所的距离（5、10 或 20 公里），每次补充时提供的抗逆转录病毒药物（1、3 或 5 个月），营业时间（仅上午，上午和下午，或上午和星期六）以及工作人员态度（“粗鲁”或“友善”）。我们使用混合效应逻辑回归来估计每个属性水平的相对效用（即偏好）。我们计算了患者愿意接受多少额外的等待时间或旅行距离，以获得其他所需的护理特征。2015 年 12 月 9 日至 2016 年 5 月 31 日，我们向 385 名患者提供了调查，其中 280 名参与了调查（平均年龄 35 岁；60%为女性）。患者表现出对友善而非粗鲁提供者的强烈偏好（相对效用为 2.66；95%CI 1.9-3.42；p <0.001）。在标准的等待意愿或旅行意愿分析中，患者愿意多等待 19 小时或多旅行 45 公里，以获得友善而非粗鲁的提供者。在替代分析中，对患者在实验中实际面临的权衡进行了限制，表明患者愿意接受离家 10 公里（而不是 5 公里）的设施，每次就诊需要等待 5 小时（而不是 1 小时），并且可以获得 3 个月的药物治疗（而不是 5 个月），以获得友善（而不是粗鲁）的提供者。本研究受到实验中包含的属性可能无法捕获偏好的其他重要决定因素的限制。
在这项研究中，患者愿意花费大量的时间和精力，并且愿意接受很大的不便，以获得态度友善的提供者。除了服务提供方式的重新设计（例如，差异化服务提供模式）之外，当前的改进策略还应优先考虑改善服务提供者的态度和促进以患者为中心-这是一个政策关注有限的领域。
