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Perceived Patients’ Satisfaction, Barriers and Implications on Engagement in Antiretroviral Treatment Services in Cameroon within the HIV Test and Treat Context

Rogers Ajeh*, Halle Ekane, Egbe O. Thomas, Anastase Dzudie, Assob N. Jules

Faculty of Health Sciences, University of Buea, Buea, Cameroon

Abstract: Introduction: Patients’ satisfaction has been associated with improved adherence, retention and antiretroviral treatment (ART) outcomes. Sustained engagement in ART is a prerequisite for attaining universal ART coverage. This study describes perceived patients’ satisfaction, barriers and implications on engagement in ART services within the context of the HIV Test &Treat (HIV T&T) strategy. Materials and methods: Between August and September 2018, HIV positive clients who initiated ART and key HIV care providers (HCPs) in three HIV clinics in Cameroon were interviewed. Ethical and administrative clearances for the study were obtained from the appropriate quarters. A thematic approach was used to analyze the data. Results: A total of 45 HIV positive clients and 21 HCPs were interviewed. Patients’ satisfaction varied with HIV service. Patient-reported barriers included: long waiting time, poor reception, delay between time of HIV diagnosis and ART initiation, poor coordination between HIV testing and ART services, poor flexibility in ART delivery system, large tablet size of ARVs/indefinite treatment duration, side effects. Inadequate counselling, overcrowding in the HIV clinics, patients’ non-appreciation of ART benefits were reported by patients and HCPs. Some barriers were linked to the HIV T&T strategy and many of them limited patients’ engagement in ART. Conclusion: Patient satisfaction varied with HIV service. Some of the barriers to patients’ satisfaction were linked with the implementation of the HIV T&T strategy and negatively impacted patients’ engagement in ART services. These views should be considered in evaluating and improving the quality of HIV care.

Keywords: patients’ satisfaction, barriers, antiretroviral treatment, HIV test and treat strategy

Received March 02, 2019; Revised April 17, 2019; Accepted May 23, 2019

Citation: Rogers Ajeh, Halle Ekane, Egbe O. Thomas, Anastase Dzudie, Assob N. Jules, Perceived Patients’ Satisfaction, Barriers and Implications on Engagement in Antiretroviral Treatment Services in Cameroon within the HIV Test and Treat Context. American Journal of Public Health Research, 7 (2). 73-80. January 2019. doi:10.12691/ajphr-7-2-5

1. Introduction

Sustained engagement in antiretroviral treatment programs (ART) is indispensable for the attainment of the World Health Organization’s recommended HIV T&T 90-90-90 targets [1,2,3,4]. Today, most HIV infected individuals receiving combination antiretroviral therapy can achieve an undetectable plasma HIV-RNA level [5,6]. Nevertheless, deficits in the spectrum of engagement in HIV care including suboptimal adherence to therapy and retention in care pose significant barriers to achieving optimal treatment outcomes [7,8].

With the increasing access to ART globally, health care systems, including health care workers face significant challenges in continuing the provision of ART to rapidly growing numbers of patients [9]. A systematic review in 2007 indicated that in sub-Saharan Africa (SSA) only 60% of patients remained on ART up to 2 years after starting treatment, with loss to follow-up and death as the leading causes of patient attrition [10].

The World Health Organization (WHO) recommended two strategies to avert the high attrition rates, including: task shifting of HIV treatment, the decentralization of ART to primary health care (PHC) clinics and community ART adherence groups [11]. This when implemented could avert high attrition rate. Decentralization and task shifting have provided essential relief and assistance for health care providers and assisted in increasing access to ART for patients. However, high rates of patient attrition remain [12].

Several other system-related factors associated with low patient satisfaction have also been associated with lower adherence to care, including, length and quality of the interaction with a physician and/or nurse, and shortages in HCP and medical supplies [13,14,15,16]. Health system responsiveness (HSR) measures quality of care based on patients' experiences within the health system. Significant associations have been found between adherence to antiretroviral therapy (ART) and follow-up among patients with HIV and the HSR domains of communication, dignity, promptness, and access to HIV care [13,17,18].

Taking into consideration patient views is thus increasingly considered to be a useful complement, and a necessary component of the evaluation of the quality of care [19,20]. Patient satisfaction is a construct related to several HSR domains, is a subjective measure of a patient's perceived needs and expectations for health system interactions, and how these relate to their actual experiences and perceptions of care received [18,21]. Satisfied patients are likely to be an indication of a successful HIV program with larger numbers of adherent patients [14].

General and specific objectives: This study aimed at describing perceived patients’ satisfaction, barriers and implications on sustained engagement in ART services in three regional hospitals in Cameroon within the context of the HIV test & treat strategy. Specifically, the study aimed to: i) describe patients’ satisfaction with HIV services, ii) identify barriers to patients’ satisfaction, and iii) assess the implication of the barriers to patients’ satisfaction on patients’ engagement in ART services.

2. Materials and Methods

2.1. Study Design and Procedure

HIV positive clients on ART and clients lost to follow up (LTF) who initiated ART in three regional hospital’s HIV clinics in Cameroon, following the implementation of the HIV T&T strategy in May 2016, were interviewed. Clients LTF were defined as not showing up at the clinic for drug refill for more than three consecutive months, and not showing up during the time of data collection.

The pre-tested interview guide was developed following formal and informal discussions with three patients on ART, three patients LTF, three HCPs and a thorough review of literature. Themes identified included: perceived patients’ satisfaction with HIV care services, perceived patients’ dissatisfaction with HIV services, perceived barriers to patients’ satisfaction, and implications of these barriers on patients’ engagement in care. Probes were included for each theme. In-depth interviews were conducted by six trained research assistants (two per site) through August to September 2018. Written informed consent was obtained from each participant and the interviews were audio recorded after obtaining their permission.

To understand HCP’s perspective of patients satisfaction, and if some of the perceived barriers could be linked to the implementation of the HIV T&T strategy, we also interviewed HCPs in the three clinics who provided care to HIV positive clients before and after the implementation of the HIV T&T strategy. We prioritized physical interviews but many of the patients LTF and few HCPs who could not be reached physically were interviewed through phone calls and verbal consent was obtained. The ethical clearance for this study was obtained from the University of Buea Institutional Review Board [22], while administrative clearances were obtained from the study hospitals.

2.2. Study Area

The Bamenda Regional Hospital (BRH) in the North West Region, the Limbe Regional Hospital (LRH) in the South West Region, and the Yaoundé Jamot Hospital (YJH) in the Centre Region were included in the study. All the sites have a specialized HIV treatment center and provide care to about 12,500 HIV positive clients; BRH (5000), LRH (4000) and YJH (3500). Each of these hospitals has a medical doctor in charge of the treatment center and other staff including nurses, pharmacy attendants, counselors and psychosocial workers.

2.3. Study Population and Sampling Method

A total of 66 participants (36 females and 30 males), constituting 45 HIV positive clients and 21 HCP were purposively selected for in-depth interview. For each site, we selected 10 ART active and 5 LTF HIV positive patients for interview. Of the 10 ART active patients, 5 were patients seen at their first or second visit and the other 5 were those who had been much longer in care. Including patients LTF allowed us to uncover information regarding barriers to retention in ART. Interviewing patients at first visit allowed to uncover any potential barriers for subsequent visits.

Seven (7) HCP were selected per clinic in the respective HIV care services and by virtue of their strategic role in HIV care delivery. We included; the clinic coordinator (medical doctor), the nurse in charge of the treatment center, two nurse counselors (including the head), two psychosocial workers, one pharmacy attendant. The age ranged between 24 – 55 years for the HIV positive participants and 30- 50 for the HCP.

2.4. Data Management and Analysis

The digitally recorded interviews were transcribed in verbatim. Field notes were converted into data documents. The transcripts were then read and re-read, during which notes and early impressions were made. The coding of data was guided by organizing the data under predefined themes. A deductive–inductive approach was used to assign data to predefined themes and to assign new themes. Using QDA Miner Lite, a thematic analysis was done to extract the pre-defined themes from the data documents and the in-depth interviews.

3. Results

The results of the study were classified under the following themes: patients’ satisfaction with HIV care services and reasons; barriers to patients’ satisfaction with HIV care services; impact of the HIV T&T strategy on patients’ satisfaction, impact of barriers to patients’ satisfaction on effective engagement in care.

3.1. Satisfaction with HIV Care Services and Reasons

More than half of the patients expressed satisfaction with the general care provided at enrollment, and the extent of expressed satisfaction varied from site to site, with specific sites reporting relatively more satisfaction. Patients generally reported more satisfaction during their initial visits compared to subsequent ones. The drivers to patients’ satisfaction are presented on Table 1 below.

Table 1. Reasons for patient satisfaction with HIV care services

Table 2. Health system barriers to patients’ satisfaction with HIV care services

Table 3. Patient (individual) level barriers to patients’ satisfaction with HIV care services

3.2. Barriers to Patients’ Satisfaction with HIV Services

Slightly less than half of the participants reported varied degree of discontentment with the HIV care provided. The main barriers, classified under health system and individual level, to satisfaction are presented in Table 2 and Table 3.

3.3. Barriers to Patients’ Satisfaction Reported to Have Adversely Impacted Patients’ Engagement in HIV Care

Some of the barriers to patients satisfaction in Table 2 & Table 3 above were reported to have adversely impacted patients’ ability to be retained in HIV care at the site, notably: Long patient waiting time, poor attitude of some HCP, poor coordination between HIV testing and ART treatment services, and non-flexibility or responsiveness of the drug delivery system to patients’ specific needs, stigma and non-appreciation of the benefits of ART amongst asymptomatic patients, ARV drugs side effects and inadequate patient counselling (See representative quotes for these barriers in Table 2 & Table 3).

4. Discussions

Low patient satisfaction have been associated with poor adherence and retention in HIV care [14,17,23], posing a threat to the attainment of universal ART coverage. In Cameroon, there is a paucity in literature on patients’ satisfaction and its barriers following the implementation of the HIV T&T strategy. This study described perceived patients’ satisfaction, barriers and implications on engagement in ART care from patients’ and HCP’s perspective. Barriers included: long patient waiting time, poor quality of reception and inconsistency in HCP attitude, poor flexibility in the ART delivery system, stigma, large size of the ARV drugs/indefinite duration of therapy, ARV side effects, poor coordination between HIV testing and ART services, delay between time of HIV diagnosis and ART initiation, patients’ perceived feeling of wellness coupled with adverse side effects of ARVs amongst asymptomatic patients, and overcrowding at the HIV clinics. An understanding of these factors is essential to guide health system responsiveness to patients’ needs and consequently improved retention and ART outcomes.

4.1. Patients’ Satisfaction with ART Services and Reasons

This study revealed fluctuations in patients’ satisfaction, ranging from expression of high to low. We also noted that patients were relatively more satisfied with the care provided at enrollment compared to subsequent care. It is expected that health care providers, generally, would show more empathy and give more time in counselling at the time of HIV diagnosis and ART initiation. The lower satisfaction reported over time suggests that patients may still be in need of psychosocial support even after several months or years following ART initiation, underscoring the need for HCP to develop and continue to provide a standardized and contextualized package of care to patients across the care continuum. A study conducted in the BRH in 2014 reported a 92.1% satisfaction amongst patients on ART [24]. Another study in Ethiopia in 2012 reported 89.6% satisfaction [25] and another in India reported 61.3% overall satisfaction in 2016 [26]. However, lower levels (42,4%) of patients’ satisfaction with HIV care services has been reported in other countries [27]. The major reasons reported for patients’ satisfaction included: good quality of counselling and patient reception especially at enrollment, peer influence and stigma reduction, improvement in patients’ health status following ART initiation, availability of free ARVs and care, and multiple-month ARVs delivery. It is worth noting that peer influence, stigma reduction, free ARVs and HIV care, multiple month drug delivery system was reported by patients and HCPs. Most of these reasons have been reported by other studies [14,15,25]. In this study, the relationship between peer influence and patient satisfaction was linked to the patients feeling more comfortable and encouraged, after meeting their peers who were looking very healthy at the HIV clinic. In a similar way, some participants reported they felt less stigmatized after meeting many peers and other people at the treatment center, looking strong and healthy, giving them the feeling that they were just part of a larger group. Although the HIV T&T strategy has not shown sufficient evidence in stigma reduction [28], it has however been associated with much higher retention and viral suppression rate [29]. Regarding improvement of the patients’ health status, several studies have elucidated an overall increase in patients’ satisfaction with improvement in their health status [30,31]. The perceived relationship between lower cost or free HIV care and increased patients’ satisfaction reported in this study has been reported [32]. This suggests that the free ARV and HIV care in Cameroon contribute to overall patients’ satisfaction in our HIV clinics. Finally, the multiple-month drug delivery system, adopted by some HIV clinics in this study, was not only reported to have reduced patients’ fare, it also served time as some patients had to come to the clinic for drug refill only twice in a year. It is however necessary to assess the impact of this approach on patients’ clinical follow up and long term treatment outcomes.

4.2. Barriers to Patient Satisfaction

The identified reasons for low patients’ satisfaction included: long patient waiting time, poor quality of patient reception and inconsistency in HCPs’ attitude, poor flexibility in the ART delivery system, stigma, large tablet size of ARVs/indefinite duration of therapy, ARVs side effects, poor coordination between HIV testing and ART services, delay between time of HIV diagnosis and ART initiation, patients’ perceived feeling of wellness coupled with adverse side effects of ARVs amongst asymptomatic patients (non-appreciation of ART), and overcrowding and inadequate counselling at the HIV clinics. Most of the these reasons have been reported by other studies [13,14,15,16,25,33]. Barriers reported by patients and HCPs included overcrowding, inadequate counselling, and ARV drugs side effects. Long patient waiting time was the most commonly patient reported reason for dissatisfaction with HIV care, and it seems to be a growing concern following the implementation of the HIV T&T strategy in Cameroon, characterized by a rapid increase in the patient volume, overcrowding in HIV treatment centers and overwhelming of the health man power.

However, some of these barriers seemed not to have been extensively described by other studies. These include; long gap between time of HIV diagnosis and ART initiation, poor coordination between HIV testing and ART services, poor flexibility in ART drug delivery system, large tablet size of ARVs and indefinite treatment duration, inconsistent HCP attitude, and perceived feeling of wellness amongst asymptomatic patients. Delay in ART initiation following HIV diagnosis was interestingly identified as one of the reasons for patients’ dissatisfaction. It was interpreted as some sort of mal intention on the part of the HCP. It is worth noting that this was limited to patients enrolled in care during the pre-HIV T&T era, who did not start ART for ineligibility reason, and came back and initiated ART during the test and treat period. A participant compared her experience with those enrolled during the test and treat period, and asked why she was not also placed immediately on ART after her HIV diagnosis. Poor coordination between HIV testing and ART services also emerged as one of reasons for low patient satisfaction. Provider initiated HIV testing and counselling (PITC) amongst other strategies enforced to accelerate HIV testing could have led to the people diagnosed of HIV in transit or out of their communities of residence without adequate orientation on how to continue accessing ARVs. Poor coordination between healthcare actors has been reported as a health system barrier to HIV care access [34]. Systems to ensure sustainable linkage of people diagnosed HIV positive to appropriate HIV treatment services seem to be inadequate within the test and treat context. Mechanisms to ensure effective referral and counter referral to ART services for patients diagnosed out of their communities of residence need to be put in place and reinforced. Perceived feeling of not being sick pointed out by HCP as a reason for lower satisfaction was not very surprising as some studies have shown perceived lack of need for medical services as a cause of ART attrition amongst asymptomatic patients and lower satisfaction amongst high CD4 count patients [27,35]. These patients were generally not sick at the time of diagnosis and may not really appreciate the benefits of being on ART and dealing with ARV side effects and associated stigma. Such patients require more counselling and education on the benefits of early ART initiation. Non flexibility or poor responsiveness of the ART drug delivery system to specific client needs was also noted as a reason for patient dissatisfaction. Some participants, with occupations that require them to frequently work out station for several weeks or months, expressed difficulties getting drugs from the HIV clinic to cover the period of time they will be out. Some reported that the HIV clinic requires them to present a mission order prior to getting drugs, which was often not available. This unfortunately constituted one of the health system barriers to ART access [33,34]. It may be necessary to investigate and implement strategies to increase the responsiveness of clinic level drug delivery systems to patients’ needs. Large size of the ARVs used was also reported to have rendered the drugs difficult to swallow. To some, it was discouraging having to take the drug every day for the rest of their lives, and indicated they would be more satisfied if the ARVs were taken once or twice a week. These could constitute some important considerations during patient counselling and guide research oriented towards improving ARVs friendliness. There is need to investigate these factors further in order to better improve overall patients’ satisfaction and HIV treatment outcomes.

4.3. Barriers to Patient Satisfaction Linked to the Implementation of the HIV T&T Strategy

Barriers to optimal patients’ satisfaction including; low quality of interaction between the patients and the HCP, patients’ perceived feeling of wellness coupled with adverse side effects of ARVs amongst asymptomatic patients, rapid increase in patients’ volume and overcrowding in HIV clinics, were reported by some HCPs to be attributable to the implementation of the HIV T&T strategy. This seems likely given that the HIV T&T strategy is characterized by a rapid increase in the volume of patients on ART, and increased number of asymptomatic patients initiating ART, a subgroup that has been associated with higher ART attrition [35,36,37,38]. As discussed above, avoiding rushing ART initiation when patients are not adequately prepared, providing more counselling and therapeutic education especially to asymptomatic patients and balancing HCP to patient ratio may optimize patients’ satisfaction in the era of the universal test and treat strategy.

4.4. Barriers to Patient Satisfaction Perceived to have Adversely Impacted Patients’ Ability to Effectively Engage in Care

Finally, the barriers to optimal patients’ satisfaction, perceived to have negatively impacted the patients’ ability to effectively engage in care included: Long patient waiting time, poor reception and attitude of some HCP, poor coordination between HIV testing and ART treatment services, non-flexibility or poor responsiveness of the drug delivery system to patients’ specific needs, non-appreciation of the benefits of ART by asymptomatic patients, inadequate counselling and rushing patients to initiate ART due to initial misunderstanding of the HIV T&T principle. As reported by some HCPs, the last three factors were responsible for the very high attrition rate experienced in their clinics during the first year of the implementation of the HIV T&T strategy. Most of these factors, which have been discussed above, constitute health system barriers to effective delivery of HIV care services to patients [34]. Thus, a high consideration should be given to health system barriers when designing strategies to improve patients’ satisfaction and engagement in HIV care and services.

5. Conclusion

Perceived patients’ satisfaction varied with HIV care services provided. Relative to long term HIV care, patients were generally more satisfied with initial care. The reasons for patients’ satisfaction or dissatisfaction were both patient and health system related, though health system barriers were most implicated. The barriers reported to have adversely influenced patients’ ability to effectively engage in ART services, some of which were linked with the HIV T&T strategy included: Long patient waiting time, poor attitude of some HCPs, poor coordination between HIV testing and ART treatment services, non-flexible ARV delivery system, non-appreciation of the benefits of ART by asymptomatic patients, inadequate counselling and rushing patients to initiate ART. Taking into account these barriers may be useful in evaluating and improving the quality of HIV care. Quantitative studies to investigate the association and impact of the aforementioned factors on patient satisfaction are needed.

6. Public Health Implications of the Study

The universal HIV T&T strategy, which is the global approach to eliminate HIV/AIDS by 2030, is still relatively new in many SSA countries. Its successful implementation depends on early evaluation of its effectiveness in different settings and communities, and learning from the experiences to further improve its implementation. This study described the health system and individual barriers to patients’ satisfaction, a major determinant of ART retention and treatment outcome. Knowledge of these barriers is needed to improve the patients’ satisfaction, and thus, advancing towards attaining the USAIDS 90-90-90 target.

7. Limitations of the Study

This study was a qualitative, thus, the findings are subjective and not generalizable. However, the study was conducted in three hospitals in three different regions in Cameroon, and it assessed both patients’ and HCP’s perspectives. Moreover, the study revealed an in-depth understanding of patients’ satisfaction and its barriers, which could not have been unveiled by a quantitative design. Finally, the findings of this study serve as an important basis for generating hypothesis that can be verified by quantitative studies.

Acknowledgements

This paper is part of a PhD thesis by Rogers Ajeh Awoh, under the supervision of Prof. Assob Nguedia Jules, Prof. Egbe O. Thomas and Prof. Halle Ekane. Our profound gratitude to Prof. Kathryn Anastos of the Albert Einstein College of Medicine for financially supporting the PhD program. Gratitude to my family, the entire staff of the Department of Public Health of the University of Buea, the staff of CRENC, the Administration of the study hospitals and most especially the HCP and people living with HIV/AIDS for their contributions.

Statement of Competing Interests

The authors have no competing interests.

List of Abbreviations

HIV Human immunodeficiency virus

HIV T&T HIV test and treat

HCP HIV care provider

ART Antiretroviral treatment

ARV Antiretroviral

WHO World Health Organization

RNA Ribonucleic Acid

SSA Sub Saharan Africa

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