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 understanding.”
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 prevention.
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 appointments.
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 respect.
Being involved in decisions about care.
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 possible ratings.
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 belief.
Participants who gave the highest ratings to their care providers in terms of being treated with dignity and respect (p = 0.015), always 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 attendance.
“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.”
Flickinger TE et al. Higher quality communication and relationships are associated with improved patient engagement in HIV care. J Acquir Immune Defic Syndr, online edition, DOI: 10.1097/QAI0b013e318295b86a, 2013.