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Abstract
Objectives The nature of patient–provider interactions and communication is widely documented to significantly impact on patient experiences, treatment adherence and health outcomes. Yet little is known about the broader contextual factors and dynamics that shape patient–provider interactions in high HIV prevalence and limited-resource settings. Drawing on qualitative research from five sub-Saharan African countries, we seek to unpack local dynamics that serve to hinder or facilitate productive patient–provider interactions.
Methods This qualitative study, conducted in Kisumu (Kenya), Kisesa (Tanzania), Manicaland (Zimbabwe), Karonga (Malawi) and uMkhanyakude (South Africa), draws upon 278 in-depth interviews with purposively sampled people living with HIV with different diagnosis and treatment histories, 29 family members of people who died due to HIV and 38 HIV healthcare workers. Data were collected using topic guides that explored patient testing and antiretroviral therapy treatment journeys. Thematic analysis was conducted, aided by NVivo V.8.0 software.
Results Our analysis revealed an array of inter-related contextual factors and power dynamics shaping patient–provider interactions. These included (1) participants’ perceptions of roles and identities of ‘self’ and ‘other’; (2) conformity or resistance to the ‘rules of HIV service engagement’ and a ‘patient-persona’; (3) the influence of significant others’ views on service provision; and (4) resources in health services. We observed that these four factors/dynamics were located in the wider context of conceptualisations of power, autonomy and structure.
Conclusion Patient–provider interaction is complex, multidimensional and deeply embedded in wider social dynamics. Multiple contextual domains shape patient–provider interactions in the context of HIV in sub-Saharan Africa. Interventions to improve patient experiences and treatment adherence through enhanced interactions need to go beyond the existing focus on patient–provider communication strategies.
- AFRICA
- ANTERETROVIRAL THERAPY
- HIV CLINICAL CARE
- QUALITATIVE RESEARCH
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Footnotes
Handling editor Jackie A Cassell
Contributor All authors contributed to the development of The Bottlenecks Study protocol (PI: AW). JR, CN, MM, OB, KO supervised the data collection by trained research assistants and prepared detailed site reports. KO, conducted the analysis and prepared the first draft of this manuscript. MM, MS, JR, AW, made significant contributions to the manuscript and revised it for intellectual content. All authors have read and commented on the manuscript. All authors have approved the final manuscript and act as guarantors of the paper.
Funding The Bottlenecks study was funded by the Bill & Melinda Gates Foundation (OPP1082114). In addition, the Kisesa HDSS component was funded by NIH through IeDEA project. AW is funded by a Population Health Scientist award, jointly funded by the UK Medical Research Council (MRC) and the UK Department for International Development (DFID) under the MRC/DFID Concordat agreement, and is also part of the EDCTP2 programme supported by the European Union. Research (undertaken in Kisesa) reported in this publication was supported by the National Institute of Allergy and Infectious Diseases (NIAID), Eunice Kennedy Shriver National Institute Of Child Health & Human Development (NICHD), National Institute on Drug Abuse (NIDA), National Cancer Institute (NCI), and the National Institute of Mental Health (NIMH), in accordance with the regulatory requirements of the National Institutes of Health under Award Number U01AI069911 East Africa IeDEA Consortium. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Competing interests None declared.
Ethics approval Ethical approval was obtained from LSHTM (Ref: 10389). Malawi National Health Sciences Research Committee #15/5/1427 (Karonga); Medical Research Coordination Committee is MR/53/100/370 (Kisesa); Kenya Medical Research Institute (KEMRI) Scientific and Ethics Review Unit (SERU) KEMRI/SERU/CGHR/018/3115 (Kisumu); Medical Research Council of Zimbabwe MRCZ/A/1990; University of KwaZulu-Natal, South Africa, UKZN/BE338/15.
Provenance and peer review Commissioned; externally peer reviewed.
Data sharing statement This paper uses data from a multicountry qualitative study to explore the dynamics that shape patient–provider interactions and in turn influence patient engagement in HIV programmes.