People who believe their care providers
know them as a person are more likely to keep their HIV clinic appointments,
research conducted in the United States and published in the online edition of
the Journal of Acquired Immune Deficiency
Syndromes shows. Patients also kept more appointments if their care
providers treated them with dignity and respect, listened carefully to them and
gave explanations that could be understood.
“Feeling known as a person can be regarded
as a measure of respect from providers, who recognize the unconditional value
of patients as persons,” suggest the authors. “This respect for patients as
persons may be manifested by particular provider behaviors, such as honoring
patients’ autonomy, listening attentively to patients’ viewpoints, and
explaining things in ways that accurately match patients’ levels of
The investigators hope their findings will
enable HIV care providers to improve the retention of people in care. This is
a matter of special concern in the United States where only 59% of
HIV-positive people remain in specialist care. Dropping out of care is
associated with an increased risk of illness and death. There are also concerns
that poor patient retention will undermine the use of HIV treatment as
Doctors at Johns Hopkins University,
Baltimore, therefore wanted to see if the quality of people’s relationships
with their HIV care providers played a role in keeping routine care
They designed a study involving 1363
participants who attended their clinic between 2004 and 2009. Each participant
completed a computer-assisted questionnaire rating the quality of communication
and relationship with their care providers in five key areas:
Being treated with dignity and
Being involved in decisions
Feeling listened to.
Having information explained in
a way that could be understood.
Feeling known as a person.
The investigators hypothesised rating
doctors and healthcare providers highly would be associated with higher levels
of attendance for routine clinic appointments.
“We sought to identify potential targets
for future provider-focused interventions to improve their interactions with
patients, promote retention in care, and help patients achieve better clinical
outcomes in HIV care,” explain the authors.
Most of the participants (65%) were male,
non-white (85%) and their mean age was 46 years. Two-thirds of participants were
taking antiretroviral therapy and 49% had an undetectable viral load.
Overall, participants attended approximately
two-thirds of their clinic appointments. Demographic and clinical
characteristics associated with keeping appointments included male sex (p =
0.05), white race, not using drugs or alcohol, taking HIV therapy, and having an
undetectable viral load and a higher CD4 cell count (all p < 0.001).
Participants rated their care providers highly
in all five domains, with between 85 and 94% of people giving the highest
The investigators adjusted their findings
to take into account factors known to affect clinic attendance, such as age,
sex, race and use of drugs and alcohol. This adjusted model showed that
people who believed that their care providers really knew them as a person
kept 6% more appointments than those who did not share this level of
Participants who gave the highest ratings to
their care providers in terms of being treated with dignity and respect (p =
having things explained in an understandable way (p = 0.073), and careful listening (p = 0.008) were 7,
7 and 6% more likely to keep their appointments respectively than people who
gave less than optimal ratings in these domains.
A high rating for involvement in decision-making
was not associated with significantly higher levels of attendance for
appointments (4% difference with participants giving less than optimal rating).
This finding surprised the investigators,
who noted “Prior work on decision-making preferences indicates that, compared
to patients who share decisions, patients who prefer to make decisions alone
are less likely to receive ART or to have suppressed viral loads, and patients who
prefer that the provider make the decisions are less likely to adhere to ART.”
The investigators then included all
communication and relationship variables into a single model which was adjusted
for demographic factors and substance use. This showed that feeling known as a
person was the only factor associated with significantly higher rates of clinic
“Our study suggests that appointment
adherence could be enhanced by optimizing the quality of relationships, so that
patients feel known and respected as persons by their providers,” conclude the
investigators. “Specific provider communication behaviors, such as listening
and carefully explaining, could make a difference in retaining their patients
in care…ultimately, evidence-based interventions to improve providers’
communications could be tailored to target skills with known links to patient
behaviors and outcomes.”