“Provider discretionary power practices to support implementation of patient-centered HIV care in Lusaka, Zambia”

Abstract

IntroductionTraditional patient-provider relationships privilege the providers, as they possess the formal authority and clinical knowledge applied to address illness, but providers also have discretion over how they exercise their power to influence patients' services, benefits, and sanctions. In this study, we assessed providers' exercise of discretionary power in implementing patient-centered care (PCC) practices in Lusaka, Zambia.MethodsHIV clinical encounters between patients on antiretroviral therapy (ART) and providers across 24 public health facilities in Lusaka Province were audio recorded and transcribed verbatim. Using qualitative content analysis, we identified practices of discretionary power (DP) employed in the implementation of PCC and instances of withholding DP. A codebook of DP practices was inductively and iteratively developed. We compared outcomes across provider cadres and within sites over time.ResultsWe captured 194 patient-provider interactions at 24 study sites involving 11 Medical Officers, 58 Clinical Officers and 10 Nurses between August 2019 to May 2021. Median interaction length was 7.5 min. In a hierarchy where providers dominate patients and interactions are rapid, some providers invited patients to ask questions and responded at length with information that could increase patient understanding and agency. Others used inclusive language, welcomed patients, conducted introductions, and apologized for delayed services, narrowing the hierarchical distance between patient and provider, and facilitating recognition of the patient as a partner in care. Although less common, providers shared their decision-making powers, allowing patients to choose appointment dates and influence regimens. They also facilitated resource access, including access to services and providers outside of scheduled appointment times. Application of DP was not universal and missed opportunities were identified.ConclusionSupporting providers to recognize their power and intentionally share it is both inherent to the practice of PCC (e.g., making a patient a partner), and a way to implement improved patient support. More research is needed to understand the application of DP practices in improving the patient-centeredness of care in non-ART settings.

Patterns of person‐centred communications in public HIV clinics: a latent class analysis using the Roter interaction analysis system

“…rude behaviour and scolding) have been identified as a key determinant of the client experience and retention in care in these settings [1–13]. Our assessment extends and complements this existing evidence by characterizing the frequencies and typologies of these known gaps between client−provider communication and what clients desire [1, 7, 10, 21, 23, 25, 32]. We note that a majority of interactions focus primarily on medical topics, although a small but noticeable percentage of interactions give significant attention to psychosocial topics.…”

“…differentiated service delivery) have primarily focused on changing the care infrastructure [16][17][18], but relatively less emphasis has been placed on targeting the underlying nature of client−provider interactions and integration of person-centred communication (PCC) behaviours (e.g. shared decision-making, attention to empathy, open-ended questions and using discretionary power to accommodate client needs) [15,[19][20][21][22][23][24][25].…”

“…differentiated service delivery) have primarily focused on changing the care infrastructure [ 16 , 17 , 18 ], but relatively less emphasis has been placed on targeting the underlying nature of client−provider interactions and integration of person‐centred communication (PCC) behaviours (e.g. shared decision‐making, attention to empathy, open‐ended questions and using discretionary power to accommodate client needs) [ 15 , 19 , 20 , 21 , 22 , 23 , 24 , 25 ]. A deeper understanding of these interactions and patterns, frequencies and typologies of client−provider communication behaviours can help inform strategies to improve the person‐centredness and quality of care delivery, and, ultimately, long‐term outcomes in public health HIV facilities [ 7 , 10 , 15 , 19 , 26 , 27 , 28 , 29 , 30 ].…”

“…Furthermore, communication can often be hierarchical, directive and dominated by the provider with limited efforts to elicit input from clients regarding preferences or anticipated challenges with care/treatment, which can further exacerbate other ongoing barriers (e.g. competing obligations and stigma) [ 13 , 21 , 22 , 23 , 29 , 31 , 32 , 33 , 34 , 35 , 36 ]. Due to different roles and responsibilities in overburdened health systems, these behaviours and interaction dynamics may also manifest differently across healthcare worker (HCW) cadres [ 21 , 22 , 31 , 37 , 38 , 39 ].…”

“…competing obligations and stigma) [ 13 , 21 , 22 , 23 , 29 , 31 , 32 , 33 , 34 , 35 , 36 ]. Due to different roles and responsibilities in overburdened health systems, these behaviours and interaction dynamics may also manifest differently across healthcare worker (HCW) cadres [ 21 , 22 , 31 , 37 , 38 , 39 ]. Systematically characterizing the different patterns of client−provider communication can thus reveal valuable insights about its current state in public health HIV clinics and help to build a better understanding of the road forward for delivering truly person‐centred care.…”