A critical assessment of the WHO responsiveness tool: lessons from voluntary HIV testing and counselling services in Kenya

Health System Responsiveness for Persons with HIV and Disability in South Western Uganda

Background

Inequitable access to Human Immunodeficiency Virus/Acquired Immune Syndrome (HIV/AIDS) Treatment and Care Services (HATCS) for People With Disabilities (PWD) is a hurdle to ending the pandemic by 2030. The aim of this study was to evaluate the Health System's Responsiveness (HSR) and associated factors for PWD attending HATCS at health facilities in South Western Uganda.

Methods

Between February and April 2022, we enrolled a total of 106 people with disabilities for a quantitative study and 14 key informants from selected primary care HIV clinics. The World Health Organization Multi-country study's disability assessment schedules 2.0 and Health system responsiveness (HSR) questionnaire were adopted to measure the level of disabilities and responsiveness, respectively. The level of HSR was evaluated using descriptive analysis. The association between socio-demographics, level of disabilities and HSR was evaluated through binary and multivariable logistic regression. The qualitative data were collected from 14 key informants using interview guide and analyzed according to thematic areas (deductive approaches).

Results

Overall, Health system responsiveness (HSR) was at 47.62% being acceptable to people living with HIV and Disabilities in south western Uganda. Across different domains, the best performance was reported in social consideration (68.57%) and autonomy (67.62%). The least performance was registered in dignity (2.83%), confidentiality (2.91%), prompt Attention (17.35%) and Choices (30.48%). Whereas performance in communications (53.92%) and quality of basic amenities (42.27%) were average. There were no socio-demographics or disability variables that were predictive of HATCS responsiveness. PWDs experienced lack of social support, poor communication, stigma and discrimination during the HATCs services. On the other hand, the health-care providers felt frustrated by their inability to communicate effectively with PWDs and meet their need for social support.

Conclusion

HSR was comparatively low, with dignity, confidentiality, prompt attention, and choice ranking worst. To address the universal and legitimate requirements of PWDs in accessing care, urgent initiatives are required to create awareness among all stakeholders.

The patient journey of newly arrived asylum seekers and responsiveness of care: A qualitative study in Germany

Background

Research on health and healthcare for asylum seekers and refugees (ASR) has focused strongly on accessibility and legal entitlements, with quality of care receiving little attention. This study aimed to assess responsiveness, as non-medical quality of care, in the narratives of ASR patients recently arrived in Germany.

Methods

31 ASR with existing medical conditions were recruited in six refugee reception centres and three psychosocial centres. Semi-structured, qualitative interviews were conducted which reconstructed their patient journey after arrival in Germany. Interviews were recorded, transcribed verbatim and evaluated using thematic analysis.

Results

The experiences of participants throughout the patient journey provided a rich and varied description of the responsiveness of health services. Some dimensions of responsiveness, including respectful treatment, clear communication and trust, resurfaced throughout the narratives. These factors were prominent reasons for positive evaluations of the health system, and negative experiences were reported in their absence. Other dimensions, including cleanliness of facilities, autonomy of decision-making and choice of provider were raised seldomly. Positive experiences in Germany were often set in contrast to negative experiences in the participants’ countries of origin or during transit. Furthermore, many participants evaluated their experience with healthcare services in terms of the perceived technical quality of medical care rather than with reference to responsiveness.

Conclusion

This qualitative study among ASR analysed patient experiences to better understand responsiveness of care for this population. While our results show high overall satisfaction with health services in Germany, using the lens of responsiveness allowed us to identify particular policy areas where care can be strengthened further. These include in particular the expansion of high-quality interpreting services, provision of professional training to increase the competency of healthcare staff in caring for a diverse patient population, as well as an alignment between healthcare and asylum processes to promote continuity of care.

Health system responsiveness in maternity care at Hadiya zone public hospitals in Southern Ethiopia: Users' perspectives

Background

Health system responsiveness refers to non-financial, non-clinical qualities of care that reflect respect for human dignity and interpersonal aspects of the care process. The non-clinical aspects of the health system are therefore essential to the provision of services to patients. Therefore, the main purpose of this study was to assess the responsiveness in maternity care, domain performance and factors associated with responsiveness in maternity care in the Hadiya Zone public Hospitals in Southern Ethiopia.

Methods

A hospital-based cross-sectional study was employed on 413 participants using a systematic sampling technique from 1 July to 1 August 2020. An exit interviewer–administered questionnaire was used to collect data. EpiData (version 3.1) and SPSS (version 24) software were used for data entry and analysis, respectively. Bivariate and multivariable logistic regression were computed to identify the associated factors of health system responsiveness in maternity care at 95% CI.

Results

The findings indicated that 53.0% of users gave high ratings for responsiveness in delivery care. In the multivariable logistic regression analysis, mothers aged ≥ 35 (AOR = 0.4; 95% CI = 0.1–0.9), urban resident (AOR = 2.5; 95% CI = 1.5–4.8), obstetrics complications during the current pregnancy (AOR = 2.1; 95% CI = 1.1–3.0), and caesarean delivery (AOR = 0.4; 95% CI = 0.2–0.7) were factors associated with poor ratings for responsiveness in maternity care.

Conclusion

In the hospitals under investigation, responsiveness in maternity care was found to be good. The findings of this study suggest that the ministry of health and regional health bureau needs to pay attention to health system responsiveness as an indicator of the quality of maternity care.

Health system responsiveness: a systematic evidence mapping review of the global literature

BACKGROUND

The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems' functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness.

METHODS

A mixed method systemized evidence mapping review was conducted. We searched PubMed, EbscoHost, and Google Scholar. Published and grey literature; conceptual and empirical publications; published between 2000 and 2020 and English language texts were included. We screened titles and abstracts of 1119 publications and 870 full texts.

RESULTS

Six hundred twenty-one publications were included in the review. Evidence mapping shows substantially more publications between 2011 and 2020 (n = 462/621) than earlier periods. Most of the publications were from Europe (n = 139), with more publications relating to High Income Countries (n = 241) than Low-to-Middle Income Countries (n = 217). Most were empirical studies (n = 424/621) utilized quantitative methodologies (n = 232), while qualitative (n = 127) and mixed methods (n = 63) were more rare. Thematic analysis revealed eight primary conceptualizations of 'health system responsiveness', which can be fitted into three dominant categorizations: 1) unidirectional user-service interface; 2) responsiveness as feedback loops between users and the health system; and 3) responsiveness as accountability between public and the system.

CONCLUSIONS

This evidence map shows a substantial body of available literature on health system responsiveness, but also reveals evidential gaps requiring further development, including: a clear definition and body of theory of responsiveness; the implementation and effectiveness of feedback loops; the systems responses to this feedback; context-specific mechanism-implementation experiences, particularly, of LMIC and fragile-and conflict affected states; and responsiveness as it relates to health equity, minority and vulnerable populations. Theoretical development is required, we suggest separating ideas of services and systems responsiveness, applying a stronger systems lens in future work. Further agenda-setting and resourcing of bridging work on health system responsiveness is suggested.

[Evaluation of health center's primary care responsiveness by patients with chronic illnesses]

OBJECTIVE

To evaluate the health systems' response capacity according to the perception of chronic patients, and the factors related to that perception.

METHOD

Source of data: patients diagnosed with at least one chronic disease who visited primary care centers during June and July 2015 in a basic health area of La Rioja.

DESIGN

cross-sectional descriptive study based on interviews to over 18s who visited primary care centers. The dependent variable was the health systems' response capacity and independent variables were sociodemographic and health related. In order to collect data, trained interviewers conducted a short questionnaire in Spanish from the World Health Organization Multi-country Survey Study with 403 subjects. Descriptive statistics, bivariate and multivariate logistic regression were performed.

RESULTS

The overall health systems' response capacity was considered good by 87.10%. The domains that scored highest were: confidentiality (99.3%), dignity (98.3%) and communication (97.3%). Those evaluated worst were: rapid service (38,6%) and quality of basic services (31.8%). Low social class was the most important factor associated with the responsiveness, mainly with autonomy and rapid service. Sex, educational level, and occupation were related to communication domain, and patients with worse perceived health rated the general response worse. The domains considered most important were dignity (33.5%) and rapid service (30.5%).

CONCLUSIONS

The domains best evaluated were those related to respect for people. Rapid service has a low health systems' response capacity, but a high importance, and therefore requires priority action.

Perception of the primary health care response capacity by patients with and without mental health problems, and health professionals: qualitative study

BACKGROUND

The objective of this study is to deepen our understanding of perceptions towards Primary Health Care Response Capacity by specifically using patients with and without mental disorders, as well as family doctors and a manager, in order to compare and endorse perspectives. For it, a qualitative study was performed. In-depth interviews were conducted with 28 patients with and without mental health disorders and focus groups were held with 21 professionals and a manager. An inductive thematic content analysis was performed in order to explore, develop and define the emergent categories of analysis.

RESULTS

The fundamental domains for patients are dignity, communication, and rapid service. People with mental health problems also highlight the domain of confidentiality as relevant, while patients who do not have a mental health problem prioritize the domain of autonomy. Patients with mental health disorders report a greater number of negative experiences in relation to the domain of dignity. Patients do not consider their negative experiences to be a structural problem of the system. These findings are also endorsed by health care professionals.

CONCLUSIONS

It is necessary to take these results into account as responsive systems can improve service uptake, ensure adherence to treatment, and ultimately enhance patient welfare.

Realist evaluation to improve health systems responsiveness to neglected health needs of vulnerable groups in Ghana and Vietnam: Study protocol

BACKGROUND

Socio-economic growth in many low and middle-income countries has resulted in more available, though not equitably accessible, healthcare. Such growth has also increased demands from citizens for their health systems to be more responsive to their needs. This paper shares a protocol for the RESPONSE study which aims to understand, co-produce, implement and evaluate context-sensitive interventions to improve health systems responsiveness to health needs of vulnerable groups in Ghana and Vietnam.

METHODS

We will use a realist mixed-methods theory-driven case study design, combining quantitative (household survey, secondary analysis of facility data) and qualitative (in-depth interviews, focus groups, observations and document and literature review) methods. Data will be analysed retroductively. The study will comprise three Phases. In Phase 1, we will understand actors' expectations of responsive health systems, identify key priorities for interventions, and using evidence from a realist synthesis we will develop an initial theory and generate a baseline data. In Phase 2, we will co-produce jointly with key actors, the context-sensitive interventions to improve health systems responsiveness. The interventions will seek to improve internal (i.e. intra-system) and external (i.e. people-systems) interactions through participatory workshops. In Phase 3, we will implement and evaluate the interventions by testing and refining our initial theory through comparing the intended design to the interventions' actual performance.

DISCUSSION

The study's key outcomes will be: (1) improved health systems responsiveness, contributing to improved health services and ultimately health outcomes in Ghana and Vietnam and (2) an empirically-grounded and theoretically-informed model of complex contexts-mechanisms-outcomes relations, together with transferable best practices for scalability and generalisability. Decision-makers across different levels will be engaged throughout. Capacity strengthening will be underpinned by in-depth understanding of capacity needs and assets of each partner team, and will aim to strengthen individual, organisational and system level capacities.

Who are more responsive? Mixed-methods comparison of public and private sector physicians in rural Bangladesh

Responsiveness of physicians (ROPs) reflects the social actions by physicians to meet the legitimate expectations of health care users. Responsiveness is important since it improves understanding and care seeking by users, as well as fostering trust in health systems rather than replicating discrimination and entrenching inequality. Given widespread public and private sector health care provision in Bangladesh, we undertook a mixed-methods study comparing responsiveness of public and private physicians in rural Bangladesh. The study included in-depth interviews with physicians (n = 12, seven public, five private) and patients (n = 7, three male, four female); focus group discussions with users (four sessions, two male and two female); and observations in consultation rooms of public and private sector physicians (1 week in each setting). This was followed by structured observation of patient consultations with 195 public and 198 private physicians using the ROPs Scale, consisting of five domains (Friendliness; Respecting; Informing and guiding; Gaining trust; and Financial sensitivity). Qualitative data were analysed by framework analysis and quantitative data were analyzed using two-sample t-test, multiple linear regression, multivariate analysis of variance, and descriptive discriminant analyses. The mean responsiveness score of public sector physicians was statistically different from private sector physicians: -0.29 vs 0.29, i.e. a difference of - 0.58 (P-value < 0.01; 95% CI - 0.77, -0.39) on a normalized scale. Despite relatively higher level of responsiveness of private sector, according to qualitative findings, neither of the sectors performed optimally. Private physicians scored higher in Friendliness, Respecting and Informing and guiding; while public sector physicians scored higher in other domains. 'Respecting' domain was found as the most important. Unlike findings from other studies in Bangladesh, instead of seeing one sector as better than the other, this study identified areas of responsiveness where each sector needs improvements.

What constitutes responsiveness of physicians: A qualitative study in rural Bangladesh

Responsiveness entails the social actions by health providers to meet the legitimate expectations of patients. It plays a critical role in ensuring continuity and effectiveness of care within people centered health systems. Given the lack of contextualized research on responsiveness, we qualitatively explored the perceptions of outpatient users and providers regarding what constitute responsiveness in rural Bangladesh. An exploratory study was undertaken in Chuadanga, a southwestern Bangladeshi District, involving in-depth interviews of physicians (n = 17) and users (n = 7), focus group discussions with users (n = 4), and observations of patient provider interactions (three weeks). Analysis was guided by a conceptual framework of responsiveness, which includes friendliness, respecting, informing and guiding, gaining trust and optimizing benefits. In terms of friendliness, patients expected physicians to greet them before starting consultations; even though physicians considered this unusual. Patients also expected physicians to hold social talks during consultations, which was uncommon. With regards to respect patients expected physicians to refrain from disrespecting them in various ways; but also by showing respect explicitly. Patients also had expectations related to informing and guiding: they desired explanation on at least the diagnosis, seriousness of illness, treatment and preventive steps. In gaining trust, patients expected that physicians would refrain from illegal or unethical activities related to patients, e.g., demanding money against free services, bringing patients in own private clinics by brokers (dalals), colluding with diagnostic centers, accepting gifts from pharmaceutical representatives. In terms of optimizing benefits: patients expected that physicians should be financially sensitive and consider individual need of patients. There were multiple dimensions of responsiveness- for some, stakeholders had a consensus; context was an important factor to understand them. This being an exploratory study, further research is recommended to validate the nuances of the findings. It can be a guideline for responsiveness practices, and a tipping point for future research.

Development and validation of a structured observation scale to measure responsiveness of physicians in rural Bangladesh

BACKGROUND

Responsiveness of physicians is the social actions that physicians do to meet the legitimate expectations of service seekers. Since there is no such scale, this study aimed at developing one for measuring responsiveness of physicians in rural Bangladesh, by structured observation method.

METHODS

Data were collected from Khulna division of Bangladesh, through structured observation of 393 patient-consultations with physicians. The structured observation tool consisted of 64 items, with four Likert type response categories, each anchored with a defined scenario. Inter-rater reliability was assessed by same three raters observing 30 consultations. Data were analyzed by exploratory factor analysis (EFA), followed by assessment of internal consistency by ordinal alpha coefficient, inter-rater reliability by intra-class correlation coefficient (ICC), concurrent validity by correlating responsiveness score with waiting time, and known group validity by comparing public and private sector physicians.

RESULTS

After removing items with more than 50% missing values, 45 items were considered for EFA. Parallel analysis suggested a 5-factor model. Nine items were removed from the list owing to < 0.50 communality, <0.32 loading in un-rotated matrix, and <0.30 on any factor in rotated matrix. Since 34 items (i.e., the number of remaining items after removing nine items by EFA) were loaded neatly under five factors, explained 61.38% of common variance, and demonstrated high internal consistency with coefficient of 0.91, this was adopted as the Responsiveness of Physicians Scale (ROP-Scale). The five factors were named as 1) Friendliness, 2) Respecting, 3) Informing and guiding, 4) Gaining trust, and 5) Financial sensitivity. Inter-rater reliability was high, with an ICC of 0.64 for individual rater's reliability and 0.84 for average reliability scores. Positive correlation with waiting time (0.51), and higher score of private sector by 0.18 point denote concurrent, and known group validity, respectively.

CONCLUSIONS

The ROP-Scale consists of 34 items grouped under five factors. One can apply this with confidence in comparable settings, as this scale demonstrated high internal consistency and inter-rater reliability. More research is needed to test this scale in other settings and with other types of providers.

What is health systems responsiveness? Review of existing knowledge and proposed conceptual framework

Responsiveness is a key objective of national health systems. Responsive health systems anticipate and adapt to existing and future health needs, thus contributing to better health outcomes. Of all the health systems objectives, responsiveness is the least studied, which perhaps reflects lack of comprehensive frameworks that go beyond the normative characteristics of responsive services. This paper contributes to a growing, yet limited, knowledge on this topic. Herewith, we review the current frameworks for understanding health systems responsiveness and drawing on these, as well as key frameworks from the wider public services literature, propose a comprehensive conceptual framework for health systems responsiveness. This paper should be of interest to different stakeholders who are engaged in analysing and improving health systems responsiveness. Our review shows that existing knowledge on health systems responsiveness can be extended along the three areas. First, responsiveness entails an actual experience of people’s interaction with their health system, which confirms or disconfirms their initial expectations of the system. Second, the experience of interaction is shaped by both the people and the health systems sides of this interaction. Third, different influences shape people’s interaction with their health system, ultimately affecting their resultant experiences. Therefore, recognition of both people and health systems sides of interaction and their key determinants would enhance the conceptualisations of responsiveness. Our proposed framework builds on, and advances, the core frameworks in the health systems literature. It positions the experience of interaction between people and health system as the centrepiece and recognises the determinants of responsiveness experience both from the health systems (eg, actors, processes) and the people (eg, initial expectations) sides. While we hope to trigger further thinking on the conceptualisation of health system responsiveness, the proposed framework can guide assessments of, and interventions to strengthen, health systems responsiveness.

The examination of quality of pregnancy care based on the World Health Organization's "Responsiveness" model of selected pregnant women in Tehran

INTRODUCTION

The World Health Organization (WHO) Responsiveness model showing the ability of health systems in fulfilling people's expectations in connection with nonclinical aspects is an appropriate pattern to assess healthcare. The purpose of this study was to determine the status of pregnancy care provisions based on the responsiveness model.

METHODS

This was a cross-sectional study conducted by randomly sampling 130 women visiting selected hospitals in Tehran in 2015. A researcher-made questionnaire based on the responsiveness model of WHO was used to collect data. We determined the face validity and content validity of the questionnaire, and its reliability was confirmed by Cronbach's alpha coefficient (0.94) and test-retest analysis (0.96). The obtained data were analyzed by SPSS version 20 descriptive statistics, t-test, one-way ANOVA, Pearson product-moment correlation coefficient, and Spearman correlation.

RESULTS

Total responsiveness from the perspective of service recipients was 69.46±14.65 from 100. The obtained scores showed that, in the range of 0 to 100, 73.02 were about basic amenities (the most score), 72.93 about dignity, 70.91 about communication, 70.76 about confidentiality, 66.30 about provision social needs, 65.96 about choice of provider, 65.92 about autonomy, and 52.65 about prompt attention (the lowest score), which are representing the average level of service quality. There were significant relationships between participating in preparation class of labor and dignity (p<0.001), autonomy (p=0.01), provision social needs (p=0.01), and overall responsiveness (p=0.03). It was obtained that there is a significant linear relationship between scores given to hospitals and dimensions of responsiveness (p=0.05). Findings indicated a significant relationship between insurance type and dimensions of choice of provider (p=0.03) and communication (p=0.03).

CONCLUSION

The mean score of service quality in the present investigation illustrated that nonclinical dimensions have been disregarded and it has potential to be better. So some grand plans are needed.

Task shifting or shifting care practices? The impact of task shifting on patients' experiences and health care arrangements in Swaziland

BACKGROUND

In the quest to achieve early HIV treatment goals, national HIV treatment programmes dependent on international funding have been dramatically redesigned over the last 5 years. Bottlenecks in treatment provision are conceived of as health system problems to be addressed via structural and logistical fixes (routine HIV testing, point-of-care equipment, nurse-led antiretroviral treatment initiation, and patient tracking). Patient perspectives are rarely taken into account when such fixes are being considered. Patients' therapeutic experiences often remain at the periphery during the planning stage and are only considered within the context of monitoring and evaluation audits once programmes are up and running.

METHODS

Ethnographic research was conducted in five clinics in Swaziland between 2012 and 2014. Participatory approaches were used to collect data; the first author trained as an HIV counsellor in order to collect observational data on the continuum of care, and conducted in-depth interviews with interlocutors involved at the different phases.

RESULTS

Although recently adopted global HIV strategies have proven effective in scaling up treatment in Swaziland, our research demonstrates that the effort to expand services rapidly and to meet donor targets has also undermined patients' therapeutic experiences and overtaxed health workers, both of which are counterproductive to the ultimate goal of treatment scale-up. This article provides a perspective beyond the structural elements that impede universal treatment, and explores patient views and experiences of the strategies adopted to support further treatment expansion, with a particular focus on the shifting of key care and logistical tasks to expert clients.

CONCLUSION

We argue that in the quest to achieve universal early access to treatment, both donors and states must go beyond strengthening health systems and strive to enhance the quality of patient experiences and take seriously health worker limitations.

The views and experiences of nurses and midwives in the provision and management of provider-initiated HIV testing and counseling: a systematic review of qualitative evidence

BACKGROUND

Global progress towards HIV prevention and care is contingent upon increasing the number of those aware of their status through HIV testing. Provider-initiated HIV testing and counseling is recommended globally as a strategy to enhance uptake of HIV testing and is primarily conducted by nurses and midwives. Research shows that provider-initiated HIV testing and counseling implementation is sub-optimal. The reasons for this are unclear.

OBJECTIVES

The review aimed to explore nurses' and midwives' views and experiences of the provision and management of provider-initiated HIV testing and counseling.

INCLUSION CRITERIA

TYPES OF PARTICIPANTS

All cadres of nurses and midwives were considered, including those who undertake routine HIV testing as part of a diverse role and those who are specifically trained as HIV counselors. Types of phenomenon of interest: The review sought to understand the views and experiences of the provision and management of provider-initiated HIV testing and counseling (including perceptions, opinions, beliefs, practices and strategies related to HIV testing and its implementation in practice).

CONTEXT

The review included only provider-initiated HIV testing and counseling. It excluded all other models of HIV testing. The review included all countries and all healthcare settings. Types of studies: This review considered all forms of qualitative study design and methodology. Qualitative elements of a mixed method study were included if they were presented separately within the publication.

SEARCH STRATEGY

A three-step search strategy was utilized. Eight databases were searched for papers published from 1996 to October 2014, followed by hand searching of reference lists. Only studies published in the English language were considered.

METHODOLOGICAL QUALITY

Methodological quality was assessed using the Qualitative Assessment and Review Instrument developed by the Joanna Briggs Institute.

DATA EXTRACTION

Qualitative findings were extracted using the Joanna Briggs Institute Qualitative Assessment and Review Instrument.

DATA SYNTHESIS

Qualitative research findings were pooled using a pragmatic meta-aggregative approach and the Joanna Briggs Institute Qualitative Assessment and Review Instrument software.

RESULTS

This review included 21 publications from 18 research studies, representing a wide range of countries and healthcare settings. There were 245 findings which were aggregated into 12 categories and five synthesized findings. 1. Nurses/midwives are supportive of provider-initiated HIV testing and counseling if it is perceived to enhance patient care and to align with perceived professional roles. 2. Nurses'/midwives' ability to perform provider-initiated HIV testing and counseling well requires an appropriate infrastructure and adequate human and material resources. 3. At the organizational level, nurses'/midwives' engagement with provider-initiated HIV testing and counseling is facilitated by an inclusive management structure, alongside the provision of ongoing training and clinical supervision. Provider-initiated HIV testing and counseling is hindered by difficulties in fitting it into existing workloads and routines. 4. Nurses/midwives perceive that good quality care in provider-initiated HIV testing and counseling involves finding a balance between public health needs and individual patient needs. Good care requires time and the ability to apply a patient centred approach. 5. The emotional work involved in provider-initiated HIV testing and counseling can be stressful. Nurses/Midwives may require support to deal with complex moral and ethical issues.

CONCLUSIONS

This review shows that provider-initiated HIV testing and counseling is supported by nurses/midwives who strive to implement it according to principles of good care and a patient centered approach. Nurses/midwives face multiple operational, infra-structural, resource and ethical challenges in the implementation of provider-initiated HIV testing and counseling.

IMPLICATIONS FOR PRACTICE

The implementation process for provider-initiated HIV testing and counseling would benefit from using a quality improvement framework. Nurses/midwives undertaking provider-initiated HIV testing and counseling require management support, ongoing training and adequate infrastructure/resources. Additional guidance is required on legal/ethical issues in testing of children and in third party disclosure.

IMPLICATIONS FOR RESEARCH

Operational research is required to determine an optimal skill mix and optimal methods of integrating provider-initiated HIV testing and counseling into existing work routines.

Determinants of patient-reported experience of cancer services responsiveness

Background

In coming years, patient-reported data are expected to play a more prominent role in ensuring early and efficient detection of healthcare system dysfunctions, developing interventions and evaluating their effects on health outcomes, and monitoring quality of care from the patient’s perspective. The concept of responsiveness relates to patient-reported experience measures that focus on the system’s response to service users’ legitimate expectations. We explored this concept in an effort to address unresolved issues related to measuring and interpreting patient experience. Our objectives in this study were to report on patients’ perceptions of cancer services responsiveness and to identify patient characteristics and organizational attributes that are potential determinants of a positive patient-reported experience.

Methods

A cross-sectional survey was conducted of 1379 cancer patients in nine participating ambulatory cancer clinics in hospitals across the province of Quebec, Canada. They were invited to complete the Cancer Services Responsiveness tool, a 19-item questionnaire evaluating patients’ perceptions of the responsiveness of cancer services. Sociodemographic data and self-reported clinical and organizational data were collected. Descriptive statistical analysis, univariate and multivariate logistic regressions were performed.

Results

The patients surveyed generally perceived cancer services as highly responsive. The individual determinants of overall responsiveness found to be significant were self-assessed health status, age, and education level; organizational determinants were academic affiliation and geographic location of the clinic.

Discussion

Responsiveness refers to distinctive indicators of healthcare quality focused on patient-provider interactions and presents a complementary picture to other patient-reported experience measures. The identified determinants of patients’ positive experience with cancer services provide valuable information to guide care providers in targeting quality improvements.

Conclusions

Finally, our results suggest these determinants should be further studied to eliminate confounders and produce usable results.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-1104-9) contains supplementary material, which is available to authorized users.

Boundaries of confidentiality in nursing care for mother and child in HIV programmes

BACKGROUND

Confidentiality lies at the core of medical ethics and is the cornerstone for developing and keeping a trusting relationship between nurses and patients. In the wake of the HIV epidemic, there has been a heightened focus on confidentiality in healthcare contexts. Nurses' follow-up of HIV-positive women and their susceptible HIV-exposed children has proved to be challenging in this regard, but the ethical dilemmas concerning confidentiality that emerge in the process of ensuring HIV-free survival of the third party - the child - have attracted limited attention.

OBJECTIVE

The study explores challenges of confidentiality linked to a third party in nurse-patient relationships in a rural Tanzanian HIV/AIDS context.

STUDY CONTEXT

The study was carried out in rural and semi-urban settings of Tanzania where the population is largely agro-pastoral, the formal educational level is low and poverty is rife. The HIV prevalence of 1.5% is low compared to the national prevalence of 5.1%.

METHODS

Data were collected during 9 months of ethnographic fieldwork and consisted of participant observation in clinical settings and during home visits combined with in-depth interviews. The main categories of informants were nurses employed in prevention of mother-to-child transmission of HIV programmes and HIV-positive women enrolled in these programmes.

ETHICAL CONSIDERATIONS

Based on information about the study aims, all informants consented to participate. Ethical approval was granted by ethics review boards in Tanzania and Norway.

FINDINGS AND DISCUSSION

The material indicates a delicate balance between the nurses' attempt to secure the HIV-free survival of the babies and the mothers' desire to preserve confidentiality. Profound confidentiality-related dilemmas emerged in actual practice, and indications of a lack of thorough consideration of the implication of a patient's restricted disclosure came to light during follow-up of the HIV-positive women and the third party - the child who is at risk of HIV infection through mother's milk. World Health Organization's substantial focus on infant survival (Millennium Development Goal-4) and the strong calls for disclosure among the HIV-positive are reflected on in the discussion.

'Born before arrival': user and provider perspectives on health facility childbirths in Kapiri Mposhi district, Zambia

Background

Maternal mortality remains high in sub-Saharan Africa. Health facility intra-partum strategies with skilled birth attendance have been shown to be most effective to address maternal mortality. In Zambia, the health policy for pregnant women is to have facility childbirth, but less than half of the women utilize the facilities for delivery. ‘Born before arrival’ (BBA) describes childbirth that occurs outside health facility. With the aim to increase our understanding of trust in facility birth care we explored how users and providers perceived the low utilization of health facilities during childbirth.

Methods

A qualitative study was conducted in Kapiri Mposhi, Zambia. Focus group discussions with antenatal clinic and outpatient department attendees were conducted in 2008 as part of the Response to Accountable priority setting and Trust in health systems project, (REACT). In-depth interviews conducted with women who delivered at home, their husbands, community leaders, traditional birth attendants, and midwives were added in 2011. Information was collected on perceptions and experiences of home and health facility childbirth, and reasons for not utilizing a facility at delivery. Data were analysed by inductive content analysis.

Results

Perspectives of users and providers were grouped under themes that included experiences related to promotion of facility childbirth, responsiveness of health care providers, and giving birth at home. Trust and quality of care were important when individuals seek facility childbirth. Safety, privacy and confidentiality encouraged facility childbirth. Poor attitudes of health providers, long distances and lack of transport to facilities, costs to buy delivery kits, and cultural ideals that local herbs speed up labour and women should exhibit endurance at childbirth discouraged facility childbirth.

Conclusion

Trust and perceived quality of care were important and influenced health care seeking at childbirth. Interventions that include both the demand and supply sides of services with prioritizing needs of the community could substantially improve trust and utilization of facilities at childbirth, and accelerate efforts to achieve MDG5.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2393-14-323) contains supplementary material, which is available to authorized users.

Barriers to access to antiretroviral treatment for HIV-positive tuberculosis patients in Windhoek, Namibia

SETTING

Namibia faces a high burden of tuberculosis (TB) and HIV-infection. In 2011, 50% of the TB patients were co-infected with HIV. While all patients co-infected with TB and HIV are eligible for antiretroviral treatment (ART), only 54% were reported to have received ART according to national data.

OBJECTIVE

To explore the perspective of healthcare professionals on barriers to access to ART for HIV-positive TB patients.

DESIGN

Nine semi-structured qualitative interviews were conducted with healthcare professionals from TB and HIV services in Windhoek in 2012 to investigate access barriers to ART for HIV-positive TB patients in Namibia.

RESULTS

Many barriers known from other African countries were also present in Namibia. The barriers rated as most important were: staff shortage (health system level); limited training (healthcare worker level); and fear of stigma and discrimination (patient/community level). Direct treatment costs and limited availability of antiretroviral medication were not observed as barriers. Interference with TB treatment and ART by some Pentecostal churches was revealed as an important barrier that has not yet received sufficient attention.

CONCLUSION

The study identified access barriers to ART for HIV-positive TB patients and their relevance in Namibia. The findings provide evidence for tailored interventions to increase ART-uptake among HIV-positive TB patients.

Factors associated with health facility childbirth in districts of Kenya, Tanzania and Zambia: a population based survey

Background

Maternal mortality continues to be a heavy burden in low and middle income countries where half of all deliveries take place in homes without skilled attendance. The study aimed to investigate the underlying and proximate determinants of health facility childbirth in rural and urban areas of three districts in Kenya, Tanzania and Zambia.

Methods

A population-based survey was conducted in 2007 as part of the ‘REsponse to ACcountable priority setting for Trust in health systems’ (REACT) project. Stratified random cluster sampling was used and the data included information on place of delivery and factors that might influence health care seeking behaviour. A total of 1800 women who had childbirth in the previous five years were analysed. The distal and proximate conceptual framework for analysing determinants of maternal mortality was modified for studying factors associated with place of delivery. Socioeconomic position was measured by employing a construct of educational attainment and wealth index. All analyses were stratified by district and urban–rural residence.

Results

There were substantial inter-district differences in proportion of health facility childbirth. Facility childbirth was 15, 70 and 37% in the rural areas of Malindi, Mbarali and Kapiri Mposhi respectively, and 57, 75 and 77% in the urban areas of the districts respectively. However, striking socio-economic inequities were revealed regardless of district. Furthermore, there were indications that repeated exposure to ANC services and HIV related counselling and testing were positively associated with health facility deliveries. Perceived distance was negatively associated with facility childbirth in rural areas of Malindi and urban areas of Kapiri Mposhi.

Conclusion

Strong socio-economic inequities in the likelihood of facility childbirths were revealed in all the districts added to geographic inequities in two of the three districts. This strongly suggests an urgent need to strengthen services targeting disadvantaged and remote populations. The finding of a positive association between HIV counselling/testing and odds in favor of giving birth at a health facility suggests potential positive effects can be achieved by strengthening integrated approaches in maternal health service delivery.

A framework of a health system responsiveness assessment information system for iran

BACKGROUND

Responsiveness assessment of health system with the quality information is the key in effective evidence-based management of the health system.

OBJECTIVES

This qualitative study defines the necessary components required for the health system responsiveness assessment information system (HS-RAIS).

MATERIALS AND METHODS

This study was conducted based on mixed-methods approach and by using Delphi technique (29 participants in first round and 25 participants in second round) and semi-structured interviews in Iran 2013. The participant selection strikes a balance between being able to provide valid data, and increasing representative's leverage. The final framework for HS-RAIS was extracted from in-depth interviews with ten key informants.

RESULTS

We followed these recommendations and developed a framework in 10 components including: minimum datasets, data sources, data gathering, data analysis, feedback and dissemination, legislative needs, objectives of health system responsiveness assessment, repetition period, executive committee and stewardship.

CONCLUSIONS

This framework provides useful information for decision-making at all levels about assessment of health system.

Heterogeneous HIV testing preferences in an urban setting in Tanzania: results from a discrete choice experiment

BACKGROUND

Efforts to reduce Human Immunodeficiency Virus (HIV) transmission through treatment rely on HIV testing programs that are acceptable to broad populations. Yet, testing preferences among diverse at-risk populations in Sub-Saharan Africa are poorly understood. We fielded a population-based discrete choice experiment (DCE) to evaluate factors that influence HIV-testing preferences in a low-resource setting.

METHODS

Using formative work, a pilot study, and pretesting, we developed a DCE survey with five attributes: distance to testing, confidentiality, testing days (weekday vs. weekend), method for obtaining the sample for testing (blood from finger or arm, oral swab), and availability of HIV medications at the testing site. Cluster-randomization and Expanded Programme on Immunization (EPI) sampling methodology were used to enroll 486 community members, ages 18-49, in an urban setting in Northern Tanzania. Interviewer-assisted DCEs, presented to participants on iPads, were administered between September 2012 and February 2013.

RESULTS

Nearly three of five males (58%) and 85% of females had previously tested for HIV; 20% of males and 37% of females had tested within the past year. In gender-specific mixed logit analyses, distance to testing was the most important attribute to respondents, followed by confidentiality and the method for obtaining the sample for the HIV test. Both unconditional assessments of preferences for each attribute and mixed logit analyses of DCE choice patterns suggest significant preference heterogeneity among participants. Preferences differed between males and females, between those who had previously tested for HIV and those who had never tested, and between those who tested in the past year and those who tested more than a year ago.

CONCLUSION

The findings suggest potentially significant benefits from tailoring HIV testing interventions to match the preferences of specific populations, including males and females and those who have never tested for HIV.

The emergence and evolution of HIV counselling in Zambia: a 25-year history

HIV-related counselling practices have evolved since emerging in Zambia in 1987. Whereas, initially, the goal of HIV counselling was to provide psychological support to the dying and their families, as knowledge about HIV grew, counselling objectives expanded to include behavioural change, encouraging safer sexual practices, encouraging disclosure, convincing people to test, treatment adherence and shaping HIV-positive people's sexual and reproductive choices. This paper highlights a number of key shifts in counselling practices in Zambia over the last 25 years, demonstrating the relationship between those shifts, changes in medical technology, (inter)national political will and the epidemiological maturity of the disease.

Evaluation of responsiveness of community health services in urban China: a quantitative study in Wuhan City

Background

With the objective of the national health services systems reform to move care to the community, community health services (CHS) are becoming the gateways of the health system in China. This study aims to evaluate the levels and distributions of the responsiveness of CHS in urban China and identify the relevant features to provide the government with policy advice on the improvement of CHS responsiveness.

Methods

A total of 872 face-to-face interviews were conducted in community health centers (CHCs) from 2007 to 2009. Indicators of responsiveness that were recommended by the World Health Organization were adopted, and non-conditional logistic regression analysis was performed to explore the factors associated with the levels and distributions of the responsiveness of CHS.

Results

The responsiveness scored at a fairly ‘good’ level of 7.45, 7.45, and 7.46 for CHS in years 2007, 2008, and 2009, respectively. The representative responsiveness inequality indexes were 0.097, 0.101, and 0.109, respectively, indicating the moderately balanced distributions of responsiveness in these three years. During this period, the scores of responsiveness elements were highest at 7.44 to 8.34 in “dignity”, “communication”, and “social support”, while lowest at 6.76 to 7.54 in “autonomy”, “confidentiality”, and “basic amenities”. The results of the logistic regression analysis suggested that five elements (OR value), namely, “dignity” (1.414–3.345), “communication” (1.218–3.655), “basic amenities” (1.251–2.362), “prompt attention” (1.098–1.590), and “autonomy” (1.416–2.173), had significant associations with CHS responsiveness.

Conclusions

The responsiveness of CHS in Wuhan City was fairly good but still requires further improvement, particularly on the working conditions of CHCs and communication skills trainings among CHS workers.

The experiences of HIV-positive women living in an African village: perceptions of voluntary counseling and testing programs

Kenya has approximately 1.4 million adults infected with HIV/AIDS, with a national prevalence rate of approximately 7.4%. The majority of the Kenyan people have not participated in a Voluntary Counseling and Testing (VCT) program and do not know their HIV status. This increases the likelihood of infecting others and spreading the disease. The

PURPOSE

Living in fear, making the decision to be tested, the journey toward acceptance, changing behavior, planning for the future, and encouraging others to be tested. VCT programs are crucial in attaining goals related to the prevention and management of AIDS. By exploring these women's experiences and perceptions, issues concerning AIDS and the acceptance and use of VCT may be better understood.

Practicing provider-initiated HIV testing in high prevalence settings: consent concerns and missed preventive opportunities

BACKGROUND

Counselling is considered a prerequisite for the proper handling of testing and for ensuring effective HIV preventive efforts. HIV testing services have recently been scaled up substantially with a particular focus on provider-initiated models. Increasing HIV test rates have been attributed to the rapid scale-up of the provider-initiated testing model, but there is limited documentation of experiences with this new service model. The aim of this study was to determine the use of different types of HIV testing services and to investigate perceptions and experiences of these services with a particular emphasis on the provider initiated testing in three selected districts in Kenya, Tanzania, and, Zambia.

METHODS

A concurrent triangulation mixed methods design was applied using quantitative and qualitative approaches. A population-based survey was conducted among adults in the three study districts, and qualitative data were obtained from 34 focus group discussions and 18 in-depth interviews. The data originates from the ongoing EU funded research project "REsponse to ACountable Priority Setting for Trust in Health Systems" (REACT) implemented in the three countries which has a research component linked to HIV and testing, and from an additional study focusing on HIV testing, counselling perceptions and experiences in Kenya.

RESULTS

Proportions of the population formerly tested for HIV differed sharply between the study districts and particularly among women (54% Malindi, 34% Kapiri Mposhi and 27% Mbarali) (p < 0.001). Women were much more likely to be tested than men in the districts that had scaled-up programmes for preventing mother to child transmission of HIV (PMTCT). Only minor gender differences appeared for voluntary counselling and testing. In places where, the provider-initiated model in PMTCT programmes had been rolled out extensively testing was accompanied by very limited pre- and post-test counselling and by a related neglect of preventative measures. Informants expressed frustration related to their experienced inability to 'opt-out' or decline from the provider-initiated HIV testing services.

CONCLUSION

Counselling emerged as a highly valued process during HIV testing. However, counselling efforts were limited in the implementation of the provider-initiated opt-out HIV testing model. The approach was moreover not perceived as voluntary. This raises serious ethical concerns and implies missed preventive opportunities inherent in the counselling concept. Moreover, implementation of the new testing approach seem to add a burden to pregnant women as disproportionate numbers of women get to know their HIV status, reveal their HIV status to their spouse and recruit their spouses to go for a test. We argue that there is an urgent need to reconsider the manner in which the provider initiated HIV testing model is implemented in order to protect the client's autonomy and to maximise access to HIV prevention.