Developing a discrete choice experiment in Malawi: eliciting preferences for breast cancer early detection services

Preferences for Physical Examination Service in Community Health Service Center in China: A Discrete Choice Experiment

Objective

Physical examination services play a crucial role in the early detection of diseases, improving the effectiveness of treatment. However, the current physical examination services provided by community health service centers are limited. The objective of this study was to investigate the aspects of physical examination services that are most valued by residents.

Methods

Identify and develop attributes and levels through literature research and expert group interviews. A discrete choice experiment was designed. The main effects design gives rise to 16 choice sets. The 16 choice sets were grouped into 2 blocks, and respondents were randomly assigned to one of the blocks. In each choice set, respondents were asked to choose from two alternatives with an opt-out option. In 2023, the discrete choice experiment was administered in several community health service centers within a China population sample. A mixed logit and a latent class analysis were conducted.

Results

Participants (n = 399) preferred to receive health advice service. The services provided by the basic team with clinical experts are preferred over those provided solely by the basic team. The results indicated a preference for a participant to be serviced by face-to-face or telephone compared with WeChat. Low cost is also preferred. As participants grow older, their preference for face-to-face or telephone-based services increased. As participants' service demand increase, participants more preferred to receive interpretation of physical examination report and follow-up of important abnormal results, participants more preferred to be serviced by basic team with clinical experts or basic team with health manager etc.

Conclusion

We should improve the construction of the service team, optimize the service mode, expand the scope of examination services, reduce the cost of examination services, and meet the needs of residents for physical examination services. More attention should be paid to the needs of elderly and rural residents.

Awareness of human papillomavirus and acceptability of the vaccine among women in Palestine: is it time for policy adjustment?

Background

Progress has been made in the reduction of morbidity and mortality of cervical cancer by the implementation of human papillomavirus (HPV) vaccination programs. This study aimed to assess the awareness of Palestinian women about HPV as well as their knowledge and acceptability of the HPV vaccine and to examine the factors associated with good awareness.

Methods

This was a national cross-sectional study. Adult women were recruited from hospitals, primary healthcare centers, and public spaces in 11 Palestinian governorates using convenience sampling. A structured questionnaire was used for data collection. For each correctly answered question, one point was given. The total score was calculated and categorized into poor (0–10) and good awareness (11–21).

Results

The questionnaire was completed by 7223 women out of 8086 who were approached (response rate = 89.3%). A total of 7058 questionnaires were included in the final analysis; 4403 from the West Bank and Jerusalem (WBJ) and 2655 from the Gaza Strip. Women recruited from the Gaza Strip were younger, getting lower monthly incomes, and with fewer chronic diseases than women recruited from the WBJ.

Only 33 women (0.5%) displayed good awareness of HPV and its vaccine with 0.7% of women from WBJ and only 0.2% of women from the Gaza Strip. Completing post-secondary education, being employed or a student, and having a higher monthly income were associated with an increase in the likelihood of having good awareness.

Among women who had heard of HPV (n = 571, 8.1%), only 46 women (8.1%) reported familiarity with its vaccine. Women from the WBJ were more likely than women from the Gaza Strip to have heard about the HPV vaccine (0.9% vs. 0.2%). Most women agreed to receive the HPV vaccine themselves or for their daughters if it was given without cost or with a co-payment. No differences were found in the likelihood of agreeing to receive the HPV vaccine among women in the WBJ versus the Gaza Strip.

Conclusion

The overall awareness of HPV and its vaccine was extremely low. Inclusion of the HPV vaccine in the national immunization program could change this, especially as the HPV vaccine appeared to be acceptable.

Health preference research: An overview for medical radiation sciences

Understanding preferences of key stakeholders including patients, clinicians and policymakers can inform clinical practice, workforce and policy. It also allows health services to evaluate existing clinical practices, policies and procedures. This commentary aims to introduce medical radiation professionals to health preference research by describing commonly used preference methodologies, with a particular focus on discrete choice experiments. Relevant examples of health preference research will be highlighted to demonstrate the application of health preference research in medical radiation sciences.

Patient Preferences for Anxiety and Depression Screening in Cancer Care: A Discrete Choice Experiment

OBJECTIVES

Screening for anxiety and depression in cancer care is recommended, as identification is the first step in managing anxiety and depression. Nevertheless, patient preferences for anxiety and depression screening in cancer care are unknown. The objective of this study was to investigate and identify the aspects of an anxiety and depression screening program cancer patients value most, to inform decision-makers about ways to improve patient uptake and ultimately, the provision of patient-centered care.

METHODS

A discrete choice experiment was designed and implemented within an Australian cancer population sample. Participants were presented with a series of hypothetical screening programs labeled as "screening program 1" and "screening program 2" and were asked to choose their preferred one. The discrete choice experiment was administered using an online survey platform. A mixed logit and a latent class analysis was conducted.

RESULTS

Participants (n = 294) preferred screening to be conducted by a cancer nurse, face-to-face, and at regular intervals (monthly or every 3 months). Participants also preferred follow-up care to be delivered by mental health professionals embedded within the cancer care team. Factors that influenced preferences were the low cost and short waiting times for access to care.

CONCLUSIONS

Cancer patients prefer cancer services with integrated mental healthcare services. To maximize patient uptake, anxiety and depression screening programs should be routinely offered, delivered by oncology healthcare staff in a face-to-face format, and, postscreening, to be care for by mental health professionals embedded within the cancer service.

Can healthcare choice be predicted using stated preference data?

Lack of evidence about the external validity of Discrete Choice Experiments (DCEs)-sourced preferences inhibits greater use of DCEs in healthcare decision-making. This study examines the external validity of such preferences, unravels its determinants, and provides evidence of whether healthcare choice is predictable. We focused on influenza vaccination and used a six-step approach: i) literature study, ii) expert interviews, iii) focus groups, iv) survey including a DCE, v) field data, and vi) in-depth interviews with respondents who showed discordance between stated choices and actual healthcare utilization. Respondents without missing values in the survey and the actual healthcare utilization (377/499 = 76%) were included in the analyses. Random-utility-maximization and random-regret-minimization models were used to analyze the DCE data, whereas the in-depth interviews combined five scientific theories to explain discordance. When models took into account both scale and preference heterogeneity, real-world choices to opt for influenza vaccination were correctly predicted by DCE at an aggregate level, and 91% of choices were correctly predicted at an individual level. There was 13% (49/377) discordance between stated choices and actual healthcare utilization. In-depth interviews showed that several dimensions played a role in clarifying this discordance: attitude, social support, action of planning, barriers, and intention. Evidence was found that our DCE yields accurate actual healthcare choice predictions if at least scale and preference heterogeneity are taken into account. Analysis of discordant subjects showed that we can even do better. The DCE measures an important part of preferences by focusing on attribute tradeoffs that people make in their decision to participate in a healthcare intervention. Inhibitors may be among these attributes, but it is more likely that inhibitors have to do with exogenous factors like goals, religion, and social norms. Con-ducting upfront work on constraints/inhibitors of the focal behavior, not just what promotes the behavior, might further improve predictive ability.

Are Healthcare Choices Predictable? The Impact of Discrete Choice Experiment Designs and Models

BACKGROUND

Lack of evidence about the external validity of discrete choice experiments (DCEs) is one of the barriers that inhibit greater use of DCEs in healthcare decision making.

OBJECTIVES

To determine whether the number of alternatives in a DCE choice task should reflect the actual decision context, and how complex the choice model needs to be to be able to predict real-world healthcare choices.

METHODS

Six DCEs were used, which varied in (1) medical condition (involving choices for influenza vaccination or colorectal cancer screening) and (2) the number of alternatives per choice task. For each medical condition, 1200 respondents were randomized to one of the DCE formats. The data were analyzed in a systematic way using random-utility-maximization choice processes.

RESULTS

Irrespective of the number of alternatives per choice task, the choice for influenza vaccination and colorectal cancer screening was correctly predicted by DCE at an aggregate level, if scale and preference heterogeneity were taken into account. At an individual level, 3 alternatives per choice task and the use of a heteroskedastic error component model plus observed preference heterogeneity seemed to be most promising (correctly predicting >93% of choices).

CONCLUSIONS

Our study shows that DCEs are able to predict choices-mimicking real-world decisions-if at least scale and preference heterogeneity are taken into account. Patient characteristics (eg, numeracy, decision-making style, and general attitude for and experience with the health intervention) seem to play a crucial role. Further research is needed to determine whether this result remains in other contexts.

Improving early detection of breast cancer in sub-Saharan Africa: why mammography may not be the way forward

Background and methods

The prevention and control of breast cancer in sub-Saharan Africa (SSA) is an increasingly critical public health issue. Breast cancer is the most frequent female cancer in SSA and mortality rates from this disease are the highest globally. Breast cancer has traditionally been considered a disease of high-income countries, and programs for early detection have been developed and implemented in these settings. However, screening programs for breast cancer in SSA have been less effective than in high-income countries. This article reviews the literature on breast cancer in SSA, focusing on early detection practices. It then examines the case for and against mammography and other early detection approaches for breast cancer in SSA.

Results

Women with breast cancer in SSA are younger compared with high-income countries. Most women present with advanced disease and because treatment options are limited, have poor prognoses. Delay between symptom onset and healthcare seeking is common. Engagement with early detection practices such as mammography and breast examination is low and contributes to late stage at diagnosis.

Discussion

While early detection of breast cancer through screening has contributed to important reductions in mortality in many high-income countries, most countries in SSA have not been able to implement and sustain screening programs due to financial, logistical and sociocultural constraints. Mammography is widely used in high-income countries but has several limitations in SSA and is likely to have a higher harm-to-benefit ratio. Breast self-examination and clinical breast examination are alternative early detection methods which are more widely used by women in SSA compared with mammography, and are less resource intensive. An alternative approach to breast cancer screening programs for SSA is clinical downstaging, where the focus is on detecting breast cancer earlier in symptomatic women. Evidence demonstrates effectiveness of clinical downstaging among women presenting with late stage disease.

Conclusions

Approaches for early detection of breast cancer in SSA need to be context-specific. While screening programs with mammography have been effective in high-income countries, evidence suggests that other strategies might be equally important in reducing mortality from breast cancer, particularly in low-resource settings. There is a strong argument for further research into the feasability and acceptability of clinical downstaging for the control of breast cancer in SSA.

Electronic supplementary material

The online version of this article (10.1186/s12992-018-0446-6) contains supplementary material, which is available to authorized users.

Novel application of discrete choice experiment methodology to understand how clinicians around the world triage palliative care needs: A research protocol

Objective

As referrals to specialist palliative care (PC) grow in volume and diversity, an evidence-based triage method is needed to enable services to manage waiting lists in a transparent, efficient, and equitable manner. Discrete choice experiments (DCEs) have not to date been used among PC clinicians, but may serve as a rigorous and efficient method to explore and inform the complex decision-making involved in PC triage. This article presents the protocol for a novel application of an international DCE as part of a mixed-method research program, ultimately aiming to develop a clinical decision-making tool for PC triage.

Method

Five stages of protocol development were undertaken: (1) identification of attributes of interest; (2) creation and (3) execution of a pilot DCE; and (4) refinement and (5) planned execution of the final DCE.

Result

Six attributes of interest to PC triage were identified and included in a DCE that was piloted with 10 palliative care practitioners. The pilot was found to be feasible, with an acceptable cognitive burden, but refinements were made, including the creation of an additional attribute to allow independent analysis of concepts involved. Strategies for recruitment, data collection, analysis, and modeling were confirmed for the final planned DCE.

Significance of results

This DCE protocol serves as an example of how the sophisticated DCE methodology can be applied to health services research in PC. Discussion of key elements that improved the utility, integrity, and feasibility of the DCE provide valuable insights.

Valuing Attributes of Home Palliative Care With Service Users: A Pilot Discrete Choice Experiment

CONTEXT

Discrete choice experiment (DCE) is a quantitative method that helps determine which service attributes are most valued by people and consequently improve their well-being.

OBJECTIVES

The objective of this study was to test a new DCE on home palliative care (HPC).

METHODS

Cross-sectional survey using the DCE method with adult patients and their family caregivers, users of three HPC services in Portugal. Service attributes were based on a Cochrane review, a meta-ethnography, and the few existing DCEs on HPC: 1) team's availability, 2) support for family caregivers, 3) homecare support, 4) information and planning, and 5) waiting time. The experimental design consisted in three blocks of eight choice sets where participants chose between two service alternatives that combined different levels of each attribute. We piloted the DCE using cognitive interviewing. Interviews were analyzed for difficulties using Tourangeau's model of information processing.

RESULTS

The DCE was conducted with 21 participants of 37 eligible (10 patients with median Palliative Performance Scale score = 45, 11 caregivers). Most participants found the DCE easy (median 2 from 1 to 5), although two patients did not finish the exercise. Key difficulties related to comprehension (e.g., waiting time sometimes understood as response time for visit instead of time from referral to care start) and judgment (e.g., indecision due to similar service alternatives).

CONCLUSION

The DCE method is feasible and acceptable but not all patients are able to participate. In the main study phase, we will give more attention to the explanation of the waiting time attribute.

Breast Cancer Knowledge, Behaviors, and Preferences in Malawi: Implications for Early Detection Interventions From a Discrete Choice Experiment

PURPOSE

Breast cancer is the most common female cancer in Africa and leading cause of death resulting from cancer; however, many countries lack early detection services. In Malawi, women are frequently diagnosed with large tumors after long symptomatic periods. Little is known about local cancer knowledge.

METHODS

We administered a cross-sectional survey with a discrete choice experiment to a random sample in urban and rural areas of Lilongwe district. Bivariable and multivariable analyses determined factors associated with knowledge. Preference utilities for early detection interventions were estimated using a hierarchical Bayesian model in Sawtooth software.

RESULTS

Of 213 women recruited, fewer than half were aware of breast cancer. In multivariable analysis, electricity at home and knowing someone with cancer increased the odds of awareness. Women were more knowledgeable about symptoms than treatment or risk factors; more than 60% erroneously believed local misconceptions. Seventeen percent were aware of breast self-examination, and 20% were aware of clinical breast examination (CBE); few reported either behavior. Common barriers included not knowing where to access CBE and transportation difficulties. Discrete choice experiment results indicated the detection strategy (breast health awareness, CBE, or both) was the most important attribute of an intervention, followed by the encounter setting and travel time.

CONCLUSION

Addressing misconceptions in health messages and engaging survivors to promote early detection may help improve breast cancer knowledge in Malawi. Program designs accounting for women's preferences should provide breast health education and CBEs in convenient settings to address transportation barriers, particularly for women with low socioeconomic position.

Applying stated-preference methods to improve health systems in sub-Saharan Africa: a systematic review

INTRODUCTION

Sub-Saharan African health systems must balance shifting disease burdens with desires for robust institutions. Stated-preference methods have been applied extensively to elicit health care workers' preferences and priorities for rural practice. This systematic review characterizes the range of their applications to African health systems problems. Areas covered: A PRISMA protocol was submitted to PROSPERO. Six databases were queried for peer-reviewed articles using quantitative stated-preference methods to evaluate a health systems-related trade-off. Quality was assessed using the PREFS checklist. Seventy-seven articles published between 1996 and 2017 met review criteria. Methods were primarily choice-based: discrete-choice experiments (n = 46), ranking/allocation techniques (n = 21), conjoint analyses (n = 7), and best-worst scaling (n = 3). Trade-offs fell into six 'building blocks': service features (n = 27), workforce incentives (n = 17), product features (n = 14), system priorities (n = 14), insurance features (n = 4), and research priorities (n = 1). Five countries dominated: South Africa (n = 11), Ghana (n = 9), Malawi (n = 9), Uganda (n = 9), and Tanzania (n = 8). Discrete-choice experiments were of highest quality (mean score: 3.36/5). Expert commentary: Stated-preference methods have been applied to many health systems contexts throughout sub-Saharan Africa. Studies examined established strategic areas, especially primary health care for women, prevention and treatment of infectious diseases, and workforce development. Studies have neglected the emerging areas of non-communicable diseases.

Experiences and perceptions regarding clinical breast exam screening by trained laywomen in Malawi

PURPOSE

Despite the increasing burden, breast cancer control in sub-Saharan Africa is insufficient. Late diagnosis and lack of early detection and screening services contribute to high mortality. Clinical breast exam (CBE) screening can be valuable in low-income countries, including use of community health workers and non-health professionals to conduct exams. We assessed experiences of women who underwent CBE screening by trained laywomen in Lilongwe, Malawi, as part of a pilot program.

METHODS

The pilot study invited women attending urban health clinics to a breast cancer educational talk followed by CBE screening by trained laywomen. We purposively sampled participants from the pilot study and interviewed them about the screening experience and future cancer education programs and services.

RESULTS

Overall participants had positive experiences and were willing to undergo CBE screening by trained laywomen. Participants were motivated by the educational talk, shared newly acquired cancer knowledge with their social networks, and encouraged others to seek screening. Screened women suggested strategies for future interventions including combining breast and cervical cancer screening, using female providers, partnering with community leaders to increase uptake, and expanding services into the community.

CONCLUSIONS

Asymptomatic Malawian women accepted CBE screening by trained laywomen and considered breast cancer an important health issue. Women appreciated combined education and screening services and proposed further linkage of breast and cervical cancer screening. Based on our results, training laywomen to educate the public on breast cancer and conduct CBE is a feasible breast cancer control strategy in sub-Saharan Africa.