Moving Toward Patient-Centered Care in Africa: A Discrete Choice Experiment of Preferences for Delivery Care among 3,003 Tanzanian Women

Objective

In order to develop patient-centered care we need to know what patients want and how changing socio-demographic factors shape their preferences.

Methods

We fielded a structured questionnaire that included a discrete choice experiment to investigate women’s preferences for place of delivery care in four rural districts of Pwani Region, Tanzania. The discrete choice experiment consisted of six attributes: kind treatment by the health worker, health worker medical knowledge, modern equipment and medicines, facility privacy, facility cleanliness, and cost of visit. Each woman received eight choice questions. The influence of potential supply- and demand- side factors on patient preferences was evaluated using mixed logit models.

Results

3,003 women participated in the discrete choice experiment (93% response rate) completing 23,947 choice tasks. The greatest predictor of health facility preference was kind treatment by doctor (β = 1.13, p<0.001), followed by having a doctor with excellent medical knowledge (β = 0.89 p<0.001) and modern medical equipment and drugs (β = 0.66 p<0.001). Preferences for all attributes except kindness and cost were changed with changes to education, primiparity, media exposure and distance to nearest hospital.

Conclusions

Care quality, both technical and interpersonal, was more important than clinic inputs such as equipment and cleanliness. These results suggest that while basic clinic infrastructure is necessary, it is not sufficient for provision of high quality, patient-centered care. There is an urgent need to build an adequate, competent, and kind health workforce to raise facility delivery and promote patient-centered care.     

Acceptance of Vaccinations in Pandemic Outbreaks: A Discrete Choice Experiment

Background

Preventive measures are essential to limit the spread of new viruses; their uptake is key to their success. However, the vaccination uptake in pandemic outbreaks is often low. We aim to elicit how disease and vaccination characteristics determine preferences of the general public for new pandemic vaccinations.

Methods

In an internet-based discrete choice experiment (DCE) a representative sample of 536 participants (49% participation rate) from the Dutch population was asked for their preference for vaccination programs in hypothetical communicable disease outbreaks. We used scenarios based on two disease characteristics (susceptibility to and severity of the disease) and five vaccination program characteristics (effectiveness, safety, advice regarding vaccination, media attention, and out-of-pocket costs). The DCE design was based on a literature review, expert interviews and focus group discussions. A panel latent class logit model was used to estimate which trade-offs individuals were willing to make.

Results

All above mentioned characteristics proved to influence respondents’ preferences for vaccination. Preference heterogeneity was substantial. Females who stated that they were never in favor of vaccination made different trade-offs than males who stated that they were (possibly) willing to get vaccinated. As expected, respondents preferred and were willing to pay more for more effective vaccines, especially if the outbreak was more serious (€6–€39 for a 10% more effective vaccine). Changes in effectiveness, out-of-pocket costs and in the body that advises the vaccine all substantially influenced the predicted uptake.

Conclusions

We conclude that various disease and vaccination program characteristics influence respondents’ preferences for pandemic vaccination programs. Agencies responsible for preventive measures during pandemics can use the knowledge that out-of-pocket costs and the way advice is given affect vaccination uptake to improve their plans for future pandemic outbreaks. The preference heterogeneity shows that information regarding vaccination needs to be targeted differently depending on gender and willingness to get vaccinated.     

Experiment in Progressive Patient Care

A successful experiment is described in providing total progressive patient care in a small hospital. This was based on dividing ward services into nursing and “hotel” services, the latter being provided by a housekeeping team. Patients were divided into three categories according to the amount of nursing care needed, and two wards were converted, one into an intensive care unit, the other into a homeward bound unit, with high and low nurse/patient ratios respectively.     

Patient Preferences for Treatment of Psoriasis with Biologicals: A Discrete Choice Experiment

Treatment dissatisfaction and non-adherence are common among patients with psoriasis, partly due to discordance between individual preferences and recommended treatments. However, patients are more satisfied with biologicals than with other treatments. The aim of our study was to assess patient preferences for treatment of psoriasis with biologicals by using computer-based conjoint analysis. Biologicals approved for psoriasis in Germany were decomposed into outcome (probability of 50% and 90% improvement, time until response, sustainability of success, probability of mild and severe adverse events (AE), probability of American College of Rheumatology (ACR) 20 response) and process attributes (treatment location, frequency, duration and delivery method). Impact of sociodemographic and socioeconomic characteristics and disease severity on Relative Importance Scores (RIS) of each attribute was assessed with analyses of variance, post hoc tests, and multivariate regression. Averaged across the cohort of 200 participants with moderate-to-severe psoriasis, preferences were highest for avoiding severe AE (RIS = 17.3), followed by 90% improvement (RIS = 14.0) and avoiding mild AE (RIS = 10.5). Process attributes reached intermediate RIS (8.2–8.8). Men were more concerned about efficacy than women (50% improvement: RIS = 6.9 vs. 9.5, p = 0.008; β = -0.191, p = 0.011 in multivariate models; 90% improvement: RIS = 12.1 vs. 15.4, p = 0.002; β = -0.197, p = 0.009). Older participants judged the probability of 50% and 90% improvement less relevant than younger ones (50% improvement: Pearson’s Correlation (PC) = -0.161, p = 0.022; β = -0.219, p = 0.017; 90% improvement: PC = -0.155, p = 0.028; β = -0.264, p = 0.004) but worried more about severe AE (PC = 0.175, p = 0.013; β = 0.166, p = 0.082). In summary, participants with moderate-to-severe psoriasis were most interested in safety of biologicals, followed by efficacy, but preferences varied with sociodemographic characteristics and working status. Based on this knowledge, physicians should identify preferences of each individual patient during shared decision-making in order to optimize treatment satisfaction, adherence and outcome.     

Embodied Choice: How Action Influences Perceptual Decision Making

Embodied Choice considers action performance as a proper part of the decision making process rather than merely as a means to report the decision. The central statement of embodied choice is the existence of bidirectional influences between action and decisions. This implies that for a decision expressed by an action, the action dynamics and its constraints (e.g. current trajectory and kinematics) influence the decision making process. Here we use a perceptual decision making task to compare three types of model: a serial decision-then-action model, a parallel decision-and-action model, and an embodied choice model where the action feeds back into the decision making. The embodied model incorporates two key mechanisms that together are lacking in the other models: action preparation and commitment. First, action preparation strategies alleviate delays in enacting a choice but also modify decision termination. Second, action dynamics change the prospects and create a commitment effect to the initially preferred choice. Our results show that these two mechanisms make embodied choice models better suited to combine decision and action appropriately to achieve suitably fast and accurate responses, as usually required in ecologically valid situations. Moreover, embodied choice models with these mechanisms give a better account of trajectory tracking experiments during decision making. In conclusion, the embodied choice framework offers a combined theory of decision and action that gives a clear case that embodied phenomena such as the dynamics of actions can have a causal influence on central cognition.     

Sensorimotor Learning Biases Choice Behavior: A Learning Neural Field Model for Decision Making

According to a prominent view of sensorimotor processing in primates, selection and specification of possible actions are not sequential operations. Rather, a decision for an action emerges from competition between different movement plans, which are specified and selected in parallel. For action choices which are based on ambiguous sensory input, the frontoparietal sensorimotor areas are considered part of the common underlying neural substrate for selection and specification of action. These areas have been shown capable of encoding alternative spatial motor goals in parallel during movement planning, and show signatures of competitive value-based selection among these goals. Since the same network is also involved in learning sensorimotor associations, competitive action selection (decision making) should not only be driven by the sensory evidence and expected reward in favor of either action, but also by the subject''s learning history of different sensorimotor associations. Previous computational models of competitive neural decision making used predefined associations between sensory input and corresponding motor output. Such hard-wiring does not allow modeling of how decisions are influenced by sensorimotor learning or by changing reward contingencies. We present a dynamic neural field model which learns arbitrary sensorimotor associations with a reward-driven Hebbian learning algorithm. We show that the model accurately simulates the dynamics of action selection with different reward contingencies, as observed in monkey cortical recordings, and that it correctly predicted the pattern of choice errors in a control experiment. With our adaptive model we demonstrate how network plasticity, which is required for association learning and adaptation to new reward contingencies, can influence choice behavior. The field model provides an integrated and dynamic account for the operations of sensorimotor integration, working memory and action selection required for decision making in ambiguous choice situations.     

Birth by Design: Pregnancy, Maternity Care, and Midwifery in North America and Europe

Birth by Design: Pregnancy, Maternity Care, and Midwifery in North America and Europe. Raymond DeVries. Cecilia Benoit. Edwin R. Van Teijlingen. and Sirpa Wrede. eds. New York: Routledge, 2001. xviii. 301 pp.     

Paediatric Care in General Practice: an Experiment in Collaboration

A project of joint consultation between a paediatrician and several general practitioners serving a group practice of 15,000 patients has shown that outpatient clinics held at a group-practice centre (when 36 children were seen at 78 consultations over 18 months) reduced the overall work-load, eliminated dual care, and directly benefited the doctors, the children, and their families.     

Informed Choice in Direct-to-Consumer Genetic Testing for Alzheimer and Other Diseases: Lessons from Two Cases

Health-related direct-to-consumer (DTC) genetic testing has been a controversial practice. Especially problematic is predictive testing for Alzheimer disease (AD), since the disease is incurable, prevention is inconclusive, and testing does not definitively predict an individual's future disease status. In this paper, I examine two contrasting cases of subjects who learn through genetic testing that they have an elevated risk of developing AD later in life. In these cases, the subject's emotional response to the result is related to how well prepared she was for the real-life personal implications of possible test results. Analysis leads to the conclusion that when groups of health-related genetic tests are offered as packages by DTC companies, informed consumer choice is rendered impossible. Moreover, I argue, this marketing approach contravenes U.S. Federal Trade Commission policies for non-deceptive commercial communications. I conclude by suggesting ways to improve the prospects for informed consumer choice in DTC testing.     

Rural Clinician Scarcity and Job Preferences of Doctors and Nurses in India: A Discrete Choice Experiment

The scarcity of rural doctors has undermined the ability of health systems in low and middle-income countries like India to provide quality services to rural populations. This study examines job preferences of doctors and nurses to inform what works in terms of rural recruitment strategies. Job acceptance of different strategies was compared to identify policy options for increasing the availability of clinical providers in rural areas. In 2010 a Discrete Choice Experiment was conducted in India. The study sample included final year medical and nursing students, and in-service doctors and nurses serving at Primary Health Centers. Eight job attributes were identified and a D-efficient fractional factorial design was used to construct pairs of job choices. Respondent acceptance of job choices was analyzed using multi-level logistic regression. Location mattered; jobs in areas offering urban amenities had a high likelihood of being accepted. Higher salary had small effect on doctor, but large effect on nurse, acceptance of rural jobs. At five times current salary levels, 13% (31%) of medical students (doctors) were willing to accept rural jobs. At half this level, 61% (52%) of nursing students (nurses) accepted a rural job. The strategy of reserving seats for specialist training in exchange for rural service had a large effect on job acceptance among doctors, nurses and nursing students. For doctors and nurses, properly staffed and equipped health facilities, and housing had small effects on job acceptance. Rural upbringing was not associated with rural job acceptance. Incentivizing doctors for rural service is expensive. A broader strategy of substantial salary increases with improved living, working environment, and education incentives is necessary. For both doctors and nurses, the usual strategies of moderate salary increases, good facility infrastructure, and housing will not be effective. Non-physician clinicians like nurse-practitioners offer an affordable alternative for delivering rural health care.