In choosing care, HIV patients in Zambia prefer kindness over convenience

As a healthcare patient, what would you sacrifice for a provider with a nice—rather than rude—attitude? For HIV patients in Zambia, the answer may surprise you.

According to findings of a study published August 13, 2018, in PLOS Medicine, 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 UC San Francisco's Elvin Geng, MD, MPH, 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 programs 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 prioritize 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 favor 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 45 kilometers to see nice rather than rude providers. Patients also reported a preference for a facility located ten kilometers (about six miles) 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."