Dimensions, social and healthcare setting determinants of client satisfaction for HIV/AIDS services: a systematic review
1School of Public Health, The University of Queensland, Brisbane, Australia
2College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
3School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
*Corresponding author; email: yaklilu12@gmail.comAbstract
Introduction
Quality HIV/AIDS care affects clients’ health-seeking behaviour and adherence to services, which can be evaluated through the patient’s satisfaction with the services. There was an information gap on the status and contributors to HIV/AIDS clients satisfaction, which supports comprehending universal health coverage. This review presented dimensions and comprehensive determinants of HIV/AIDS clients satisfaction.
Methods
We conducted a systematic review based on articles from Web of Science, EMBASE, PubMed, Google Scholar, and grey literature sources. Studies that have reported satisfaction of people living with HIV or at least one determinant and are written in English with full-text available were included. Findings from each study were described in a narrative description.
Results
There was a heterogeneous level of HIV/AIDS clients’ satisfaction in different settings and countries. Accessibility of services, confidentiality, waiting time to receive care, technical competency, knowledge, and attitude of health care workers were frequently reported determinants. Educational and employment status were common modifiable social factors.
Conclusions
Public health programmes should follow a multi-pronged approach to fulfil people living with HIV clients’ healthcare needs. It is vital to improve HIV care integration with primary healthcare, improve financing of HIV care, digitalise healthcare settings, invest in pre-service education and in-service training, provide culturally sensitive services, strengthen social works and behavioural change communication services.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
No
Introduction
HIV/AIDS has remained an epidemic disease, causing many countries in the world to face health, economic, and societal challenges due to the large number of people living with HIV (1). Different strategies, such as “90-90-90” and “goals of ending the HIV epidemic”, are endorsed to halt HIV transmission (2). These strategies need to be implemented while maintaining a minimum of acceptable healthcare standards, ‘leaving no one behind’ quality of care (3, 4).
Therefore, quality of care has been given due attention (5), which can be evaluated by using patient satisfaction (6). Satisfied people who live with HIV are more likely to have good antiretroviral therapy adherence and not lose their regular healthcare schedule (7). Measuring clients’ satisfaction discloses the effectiveness of healthcare provision and the performance of healthcare workers (8, 9). It also ensures whether healthcare strategies are implemented effectively with the standard of care and have an impact on ending the HIV epidemic (10) which should be evaluated continuously.
Patient satisfaction involves collating feedback using different tools and domains (11, 12). Domains include client-patient interaction, service accessibility, therapeutic communication, timely care, culturally sensitive care, confidentiality, and privacy (13, 14). These domains reflect how patient-centred care should be. The World Health Organisation cherishes the significance of patient satisfaction in improving healthcare services everywhere in the world. These domains can be assessed using medical record reviews, direct patient feedback mechanisms, technology assisted devices (online platforms), and interviews (15–17). However, there was no comprehensive evidence about the clients’ satisfaction with HIV/AIDS services despite original studies in different countries (18–23).
Accordingly, the purpose of this review was to synthesis HIV/AIDS clients satisfaction and identify determinants of the healthcare services they received. The findings from the review will allow HIV programme planners and clinicians to make evidence-based and informed decisions to improve the quality of HIV care services.
Methods
Protocol registration and reporting
The ‘Preferred Reporting Items for Systematic Reviews and Meta-analysis’ guideline was used to conduct and report the review findings (24). The topic was registered in ‘the International Prospective Register of Systematic Reviews’ with registration number CRD42020207215.
Information sources and search
PubMed, EMBASE, and Web of Science core electronic databases were searched. We also manually searched Google Scholar and cross-references. The last search was on 12 June 2021.
The search included any combination of the following search terms: ‘human immunodeficiency virus’, ‘acquired immunodeficiency syndrome’, “tuberculosis”, “TB”, “HIV”, “AIDS”, “patient”, “satisfaction”, “determinants”, “predictors”, “risk factors”, “associated factors”, and “factors”. The Boolean operators “AND”/“OR” conjunctions were used to combine terms. An example search strategy fitted for PubMed was (((((“HIV” [MeSH Terms] OR HIV OR “Acquired immunodeficiency syndrome” OR AIDS OR “Human immunodeficiency virus/Acquired immunodeficiency syndrome” OR HIV/AIDS) OR ((Tuberculosis [MeSH Terms] OR TB OR tuberculosis))) OR (((((“Tuberculosis“[Mesh]) AND (“HIV“[Mesh])) OR ((“Tuberculosis“[Mesh]) AND (“Coinfection“[Mesh]))) OR ((“HIV“[Mesh]) AND (“Coinfection“[Mesh]))) OR (((((HIV[tiab]) OR (“human immunodeficiency virus“[tiab])) AND ((co-infection[tiab]) OR (coinfection[tiab]))) OR (((TB[tiab]) OR (tuberculosis[tiab])) AND ((co-infection[tiab]) OR (coinfection[tiab])))) OR (((TB[tiab]) OR (tuberculosis[tiab])) AND ((HIV[tiab]) OR (“human immunodeficieny virus“[tiab])))))) AND ((“Patient satisfaction” [MeSH Terms]) OR “patient experience” OR “patient priorities” OR “client satisfaction” OR “user satisfaction“)) AND (determinants OR predictors OR “factors affecting” OR measurement OR dimensions OR aspects OR attributes OR “associated factors” OR “risk factors“)) NOT ((“Review” [Publication Type]) OR (“Clinical Conference” [Publication Type])).
Eligibility criteria, study selection and data extraction
Inclusion criteria were those studies report the satisfaction or at least one determinant for people living with HIV/AIDS services conducted amongst all age groups and published in English with full-text available. These services include HIV services (ART and opportunistic infections treatments, clinical consultation and preventive, rehabilitative, and palliative care services), pharmaceutical services and ART laboratory services.
We did not restrict the date of publication and country. When we found two or more studies with the same contents, studies published first if have complete data were included. We excluded studies conducted other than the English, qualitative studies, conference presentation, and citation and abstract only.
All citations were exported to the EndNote X7 reference library to remove duplicates (25). Screening was made according to the inclusion and exclusion criteria. First, title screening was performed. Second, articles were evaluated for abstract. Then, their full texts were evaluated to be included in the review.
Articles eligible for full-text review were extracted using a data extraction form using Microsoft Excel 2010. Data were collected about characteristics of the articles include data collection period, country, study population, study design, satisfaction measurement tool, data collection method, sample size, and main findings. In extracting the main findings, the satisfaction level was dependent variable, while individual, health worker and healthcare setting were independent variables.
Risk of bias assessment
The “Newcastle-Ottawa Scale” was applied to evaluate the quality of each study (26). The study considered as low risk for bias when it scores ≥50% and above the value of assessment criteria, and high risk for bias when the score of each assessment criteria became below the 50% of criteria (Supplementary file 2).
Data analysis
Studies that have appeared with reported satisfaction levels using proportion, mean value or specific dimensions or its associated factors were systematically described. Determinants were grouped in the personal, health worker, and healthcare settings levels. Results were presented by figures and tables. The pooled percentage and trend over time of satisfied HIV clients was not performed because of heterogeneity of measurement tool in the included articles. Additionally, sensitivity analysis, regression analysis and publication bias did not be performed.
Results
Search results
The search process accessed 4,848 articles. Of these, 58 were from EMBASE, 164 were from Google Scholar, 1,497 were from PubMed and 3,129 were from Web of Science. A total of 4,720 articles remained after duplicates removed. Then, 4,565 articles were excluded because of unrelated titles and citations only. Of the articles that got the full-text screening phase, 33 were excluded. To end with, 66 articles included in the final review (Figure 1); 32 were available in Web of Sciences and PubMed, 11 in PubMed, 17 in Google Scholar, 3 in all PubMed, Web of Sciences and EMBASE, 1 in both PubMed and EMBASE, and 2 grey literatures from Google.
Characteristics of articles
The final review has included a total of 66 studies. Authors collected data between 1988 (27) and 2019 (28), and published it between 1993 and 2021. According to the WHO region, 42 articles were published in Africa (19, 22, 23, 28–66), 9 studies in the South-East Asia (18, 67–74), 9 studies in the America (7, 27, 75–81), 4 in the Western Pacific (20, 82–84) and 2 in the European (21, 85) region. Specific to country, 17 were from Ethiopia, 12 from Nigeria, 7 from India, 6 each from South Africa and the United States of America, 3 from Tanzania, 2 each from Brazil, Vietnam and Zambia, and 1 each from United Kingdom and Kenya, Australia, Cameroon, Canada, China, France, Kenya, Russia, and Thailand. Regarding the study population, two among paediatrics and caregivers (28, 49) and one among all age groups (37), two did not report the age category (27, 81) and the remaining 61 were conducted among the adult age group. One study was conducted among males (80) and two of the studies were among women (76, 78) while others were among both sexes (Table 1).
Dimensions in the satisfaction tool
Thirty-one dimensions were used in the satisfaction measurement tool. Fifteen were used at once which are assurance, empathy, managing therapy, healthcare provider understood clients’ needs, management of staff, clients’ decisions in treatment, benefited more than expected, discrimination and grievance redressal, support, organisation of the services, perceived improved health, perception and knowledge of clients on ARV drugs, always obtained medication and prompt attention. Figure two depicts the dimensions shared by two or more articles (Figure 2).
Satisfaction
Forty-two papers have appeared with percentage of satisfaction, while the percentage of dis-satisfied patients was published in two studies. In Ethiopia, fourteen studies found percentages of satisfaction ranging from 46.2% to 92.6%. In Nigeria, nine studies were published with reported percentages of satisfied HIV clients ranging from 56.5% to 99.6%: South Africa (between 65 and 98.0%), India (61.3% and 88.0% overall percentage), Brazil (80.0%), Tanzania (70.0 and 92.3%), Vietnam (42.4%), Cameroon (91.2%), France (16.0% and 15.9% for dimension), USA (85.5%), Canada (88.0%), Russia (86.0%), and Zambia (74.1%) (Table 1).
Determinants of satisfaction of People living with HIV
Thirty-four articles have reported on determinants of satisfaction. There were healthcare settings (health service and health worker-related) and patient-related determinants.
Health service factors
Accessibility, authority/health facility level, healthcare cost and HIV care integration to primary healthcare are health service-related factors.
Perceived convenience of the location of health centre (75), perceived convenience and cleanliness (47, 61, 72), perceived availability of the services (50), higher health system responsiveness score (19), better perceptions of resources and services (37), perceiving the high number of nurses working at the treatment centre (64), presence of drinking water in the health facility (72), availability of ordered laboratory tests (56), visiting the health centre less frequently (20), HIV clients who travel distance that took short time (18, 57, 63), those disagreed with the access of toilets than strongly disagree (46) had a positive association with satisfaction of people living with HIV. The absence of signs and directions to ART clinics reduced client satisfaction (63)
Public-owned healthcare facility users (45) were less satisfied than the private-owned facility. In contrast, those caregivers whose HIV-infected children have received care in private facilities (49) and HIV clients attending rural facilities (37) were less satisfied. Patients who got services in the decentralised than centralised health facility (75), tertiary healthcare facility than secondary health facility (41), health centre (19), dispensary level than a hospital (31), club than clinic (35), and did not possess health care cards (20) were more satisfied. HIV clients who attended provincial and district clinics than central clinics (83, 84) and costs over 120 birrs (54) were less satisfied. HIV service integration with primary healthcare increases satisfaction (29).
Health worker factors
Health worker determinants were technical competency, waiting time to receive care, time to advise or consult clients, information provision, interpersonal relationship, knowledge and attitude of healthcare provider, and confidentiality and privacy. Technical competency encompasses healthcare service adherence to the standard of care, or competency, ability and performance of healthcare workers by following the professional code of ethics. Information provision is offering information and health education about drug-drug and drug-food interactions and guidance towards treatment. Interpersonal relationship refers to therapeutic communication in the way of sharing information, active listening, participation of patients, reflecting of acceptable behaviour and patient-centre interactions. Confidentiality in healthcare incorporates keeping or not disclose information and medical records of patients to a third person.
Those who perceived receiving a high quality of care (19, 47, 78), received services from nurses and health officers than doctors (54), waited a long time to receive care (20, 29, 33, 43, 56, 61, 72, 75), have got advice long time (51, 53), received information or health education (29, 43, 46), good interpersonal relationship (46, 50), perceived received care from knowledgeable and good attitudes/behaviour healthcare providers (20, 37, 45, 72, 82), perceived confidentiality is maintained (20, 45, 50, 72), perceived privacy during receiving services (46, 50), perceived low-level than high-level stigma and discrimination (51, 57), and perceived respected by nurses (75) were more likely to be satisfied.
One study revealed HIV clients were dissatisfied with the information provided during specimen collection (47).
Patient (sociodemographic and health condition) determinants
Age, gender, residency, marital status, religion, educational status, employment status, monthly income, patient support, health status, being on HAART, adherence to care, treatment duration, HIV disclosure status and being a drugs user were identified as unique modifiable and non-modifiable personal determinants.
Older age groups (18, 21, 44, 46, 57, 63) and female HIV clients (28, 29, 44, 61, 64) were more likely to be satisfied. In another two studies, females were less satisfied (45, 82). Two studies found that urban residency was more likely to be satisfied with HIV care services (44, 45). Conversely, another study revealed those who were living in rural areas were more likely to be satisfied (65). Those who married (44, 46) and divorced (46) than single, and those living with spouses or partners were more satisfied (84). Five studies determined the more educated were positively associated with satisfaction (28, 44, 50, 53, 57). On the other hand, four articles revealed the reverse in which less-educated HIV patients were more satisfied (18, 65, 82, 83). Those employed were more satisfied based on three studies (20, 44, 64). Other studies explained that unemployed patients (31), merchants (60), daily laborers (46), farmers (46) and students (60) were more satisfied than a government employee. In contrast, another study revealed that daily laborers were less satisfied than a merchant (51).
Those who had no monthly income were less satisfied (46), where as another study identified that the richest HIV clients were less satisfied (84).
Patients who perceived have support from friends and one’s family and comfortable housing conditions were more satisfied (21, 51, 81).
Patients who were perceived to have impaired mental health (19, 78), those on WHO stage II, III and IV (83), and patients having problems of pain or discomfort (83) had lower satisfaction level. Those who had hepatitis C co-infection (21), cluster of differentiation 4 (CD4) count >500 (53), being on HAART (78), taking treatment for 2 years and above (53), had fewer HAART side effects (21), having good adherence to HIV care (18, 65), those disclosed their seropositivity (50) and rated their disclosure status as very good (51) had more level of satisfaction. Another study revealed those who had higher CD4 counts (84) and drug users (84) were less satisfied.
Discussion
The overall HIV/AIDS client satisfaction level has appeared inconclusive due to different settings and health systems, and differences in measurement tools. Based on this review, the majority of articles included accessibility and availability dimensions in the measurement tool of satisfaction. It is difficult to conclude that overall satisfaction is higher or lower even in countries with ineffective treatment outcomes (86), unfair distribution of HIV and general healthcare resources (87), ineffective financial risk protection (88), low adherence to clinical practice guidelines, poor service delivery indicators, suboptimal clinical practice (89–93), the application of emerging medical technologies to care (94, 95), an increasing discriminatory attitude (96), and a low progress record in ending the AIDS pandemic (97, 98).
With these challenges, findings in specific WHO regions were apparent. In the Americas region, a large percentage of people living with HIV are satisfied with healthcare services. In line with this, the majority of patients other than those with HIV in the USA were highly satisfied with the services received at outpatient medical services (99). In Canada, the majority of clients come to healthcare for needs other than HIV-related services grade the hospital services as very good (100). In contrast to the American region, people living with HIV make up less than half of study participants satisfaction with healthcare services in Vietnam. In contrast, clients who received care other than HIV-related services reported a higher satisfaction level in the same country (101). In the European region, two extremes were reported: the lowest in France and the highest in Russia. Another study in Russia showed that clients who received other healthcare services claimed a lower rate of satisfaction with the quality of care (102). In the southeast Asia region, the percentage of satisfied people living with HIV were almost comparable with TB (103) and type-2 diabetes mellitus patients (104).
This review identified the satisfaction of people living with HIV associated with healthcare settings, health workers, and patient-related issues. A global review of literature about patient satisfaction other than HIV clients revealed similar findings to this review (105). Another review from developing countries about maternal care revealed that healthcare setting, health service factors, socio-economic status, and health status affect the satisfaction level of clients (106). Evidence from a study in Pakistan also identified personal and health worker-related variables associated with the satisfaction of diabetes mellitus patients (107).
To see individual determinants, accessibility, authority/health facility level, healthcare cost, and HIV care integration into primary healthcare were health service-related factors. Accessibility due to unavailability of services, locations and distances of health facilities, financial problems, individual acceptability of the service, and waiting much time to receive healthcare (108–110) create unmet healthcare needs. HIV integration services with primary healthcare increase patient satisfaction by minimising waiting time and enhancing coordination of care (111). Integrated HIV services at the primary healthcare level default to reaching most of the community without going a long distance, and an issue of equity, accessibility, and availability may be resolved as a result.
Health worker-related determinants were technical competency, waiting time to receive care, time to advise or consult clients, information provision, interpersonal relationships, knowledge and attitude of healthcare providers, stigma and discrimination, confidentiality, and privacy. Technical competence is part of general competence and the main focus of patient perception, mainly about the skill of providers (112). Patients’ perception of the positive attitude and behaviour of care providers could arise from the caring, respectful, and friendly approach of healthcare providers which affect satisfaction (113). Consultation time was directly associated with HIV patients’ satisfaction. Due to the chronic nature of lifelong treatment or non-curable disease, HIV patients might be stressed, anxious, and have an impaired quality of life (114–116). Those who received advice and counselling, had good communication with care giver, felt privacy and confidentially kept could be more satisfied.
Clients’ demographic conditions influenced the way they feel to the services they received. Except age and gender, which need age and gender-sensitive services, others were modifiable determinants. This implies due to the unique features of HIV and longevity, provision of HIV/AIDS services should consider comprehensive parameters. Therefore, culture and context specific services should also be implemented that should cover both social determinants of health and social determinants process.
Limitation
Articles other than English were excluded. The pooled global estimation, pooled estimated variation across the regions, and trend over time of satisfaction were not explored because of the variety of measurement tools used across studies.
Conclusions
Implementing multi-pronged interventions in healthcare settings and patient-related factors could foster client satisfaction with health services. It is vital to improve HIV care integration at the primary healthcare level, establish or strengthen the financing of HIV care, digitalise healthcare settings, invest in pre-service education and in-service training, provide culturally sensitive services, establish or strengthen and coordinate social work with the health system, strengthen behavioural change communication and rehabilitative services, and enhance political commitment and institutional capacity. These can serve as the building blocks of a framework for action to improve the determinants of HIV client’s satisfaction.
Data Availability
All relevant data are within the manuscript and its Supporting Information files.
Acknowledgement
We acknowledge Mr. Scott Macintyre, Librarian at The University of Queensland, Australia for assisting search of MeSH terms and building search strings and The University of Queensland, Australia for allowed to use databases which are not publicly available.
Conflict of interest
The authors declared no conflict of interest.
Fund
Authors have not received any fund to conduct this research.
Supplementary files
Supplementary file 1: Search strategies
Supplementary file 2: Quality status of included articles