Browsing by Author "Rice B"

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    Comparison of patient exit interviews with unannounced standardised patients for assessing HIV service delivery in Zambia: a study nested within a cluster randomised trial.
    (2023-Jul-05) Sikombe K; Pry JM; Mody A; Rice B; Bukankala C; Eshun-Wilson I; Mutale J; Simbeza S; Beres LK; Mukamba N; Mukumbwa-Mwenechanya M; Mwamba D; Sharma A; Wringe A; Hargreaves J; Bolton-Moore C; Holmes C; Sikazwe IT; Geng E; Center for Innovation in Global Health, Georgetown University Medical Center, Washington, District of Columbia, USA.; Department of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama, USA.; Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia kombatende.sikombe@cidrz.org.; Implementation Science Unit, Center for Infectious Disease Research in Zambia, Lusaka, Zambia.; Social and Behavioural Science Research Group, Center for Infectious Disease Research in Zambia, Lusaka, Zambia.; Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.; Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.; Internal Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA.; Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine Faculty of Public Health and Policy, London, UK.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
    OBJECTIVES: To compare unannounced standardised patient approach (eg, mystery clients) with typical exit interviews for assessing patient experiences in HIV care (eg, unfriendly providers, long waiting times). We hypothesise standardised patients would report more negative experiences than typical exit interviews affected by social desirability bias. SETTING: Cross-sectional surveys in 16 government-operated HIV primary care clinics in Lusaka, Zambia providing antiretroviral therapy (ART). PARTICIPANTS: 3526 participants aged ≥18 years receiving ART participated in the exit surveys between August 2019 and November 2021. INTERVENTION: Systematic sample (every n OUTCOME MEASURES: We compared patient experience among patients who received brief training prior to their care visit (explaining each patient experience construct in the exit survey, being anonymous, without manipulating behaviour) with those who did not undergo training on the survey prior to their visit. RESULTS: Among 3526 participants who participated in exit surveys, 2415 were untrained (56% female, median age 40 (IQR: 32-47)) and 1111 were trained (50% female, median age 37 (IQR: 31-45)). Compared with untrained, trained patients were more likely to report a negative care experience overall (adjusted prevalence ratio (aPR) for aggregate sum score: 1.64 (95% CI: 1.39 to 1.94)), with a greater proportion reporting feeling unwelcome by providers (aPR: 1.71 (95% CI: 1.20 to 2.44)) and witnessing providers behaving rude (aPR: 2.28 (95% CI: 1.63 to 3.19)). CONCLUSION: Trained patients were more likely to identify suboptimal care. They may have understood the items solicited better or felt empowered to be more critical. We trained existing patients, unlike studies that use 'standardised patients' drawn from outside the patient population. This low-cost strategy could improve patient-centred service delivery elsewhere. TRIAL REGISTRATION NUMBER: Assessment was nested within a parent study; www.pactr.org registered the parent study (PACTR202101847907585).
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    Effect of a multicomponent, person-centred care intervention on client experience and HIV treatment outcomes in Zambia: a stepped-wedge, cluster-randomised trial.
    (2025-Jan) Sikombe K; Mody A; Goss CW; Simbeza S; Beres LK; Pry JM; Eshun-Wilson I; Sharma A; Mukamba N; Mulenga LB; Rice B; Mutale J; Zulu Dube A; Mulabe M; Hargreaves J; Bolton Moore C; Holmes CB; Sikazwe I; Geng EH; Johnson & Johnson, Cape Town, South Africa.; Department of Medicine, Georgetown University, Washington, DC, USA.; Implementation Science Unit, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Public Health Sciences, School of Medicine, University of California, Davis, CA, USA.; Zambian Ministry of Health, Lusaka, Zambia.; Implementation Science Unit, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK. Electronic address: kombatende.sikombe@cidrz.org.; Division of Infectious Diseases, Washington University School of Medicine, St Louis, MO, USA.; Implementation Science Unit, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia; Division of Infectious Diseases, University of Alabama, Birmingham, AL, USA.; Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK; Sheffield Centre for Health and Related Research (SCHARR), School of Medicine and Population Health, University of Sheffield, Sheffield, UK.; Department of Public Health Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK.; Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA.; Implementation Science Unit, Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
    BACKGROUND: Recipients of health services value not only convenience but also respectful, kind, and helpful providers. To date, research to improve person-centred HIV treatment has focused on making services easier to access (eg, differentiated service delivery) rather than the interpersonal experience of care. We developed and evaluated a person-centred care (PCC) intervention targeting practices of health-care workers. METHODS: Using a stepped-wedge, cluster-randomised design, we randomly allocated 24 HIV clinics stratified by size in Zambia into four groups and introduced a PCC intervention that targeted caring aspects of the behaviour of health-care workers in one group every 6 months. The intervention entailed training and coaching for health-care workers on PCC practices (to capacitate), client experience assessment with feedback to facilities (to create opportunities), and small performance-based incentives (to motivate). In a probability sample of clients who were pre-trained on a client experience exit survey and masked to facility intervention status, we evaluated effects on client experience by use of mean score change and also proportion with poor encounters (ie, score of ≤8 on a 12-point survey instrument). We examined effects on missed visits (ie, >30 days late for next scheduled encounter) in all groups and retention in care at 15 months in group 1 and group 4 by use of electronic health records. We assessed effects on treatment success at 15 months (ie, HIV RNA concentration <400 copies per mL or adjudicated care status) in a prospectively enrolled subset of clients from group 1 and group 4. We estimated treatment effects with mixed-effects logistic regression, adjusting for sex, age, and baseline care status. This trial is registered at the Pan-African Clinical Trials Registry (202101847907585), and is completed. FINDINGS: Between Aug 12, 2019, and Nov 30, 2021, 177 543 unique clients living with HIV made at least one visit to one of the 24 study clinics. The PCC intervention reduced the proportion of poor visits based on exit surveys from 147 (23·3%) of 632 during control periods to 33 (13·3%) of 249 during the first 6 months of intervention, and then to eight (3·5%) of 230 at 6 months or later (adjusted risk difference [aRD] for control vs ≥6 months intervention -16·9 percentage points, 95% CI -24·8 to -8·9). Among all adult scheduled appointments, the PCC intervention reduced the proportion of missed visits from 90 593 (25·3%) of 358 741 during control periods to 40 380 (22·6%) of 178 523 in the first 6 months, and then 52 288 (21·5%) of 243 350 at 6 months or later (aRD for control vs the intervention -4·2 percentage points, 95% CI -4·8 to -3·7). 15-month retention improved from 33 668 (80·2%) of 41 998 in control to 35 959 (83·6%) of 43 005 during intervention (aRD 5·9 percentage points, 95% CI 0·6 to 11·2), with larger effects in clients newly starting treatment (aRD 12·7 percentage points, 1·4 to 23·9). We found no effect on treatment success (based on viral load) in a nested subcohort (379 [83·7%] of 453 in the control phase vs 402 [83·8%] of 480 in the intervention phase; aRD 0·9 percentage points, -5·4 to 7·2). INTERPRETATION: Improving the caring aspects of health-care worker behaviour is feasible in public health settings, enhances client experience, reduces missed appointments, and increases retention. FUNDING: The Bill & Melinda Gates Foundation.