School-going learners are more likely to access HIV and contraceptive care at locations with friendly providers, Wi-Fi and other value-added services: Findings from a discrete choice experiment among learners in Gauteng, South Africa

Abstract

Background: Many Adolescents in Sub-Saharan Africa do not access HIV and reproductive health services optimally. To improve uptake of these services, it is important to understand the students preferences for how services are delivered so that implementation strategies can reflect this. Methods: A discrete choice experiment (DCE) was used to elicit preferences. The DCE was conducted in 10 high schools situated in neighbourhoods of varying socioe-conomic status (SES) in Gauteng (South Africa). Students aged ≥15 years (Grades 9-12) were consented and enrolled in the DCE. Conditional logistic regression was used to determine preferred attributes for HIV and contraceptive service delivery. Results were stratified by gender and neighbourhood SES quintile. (1≡Lowest SES; 5≡Highest SES). Results: The DCE was completed between 07/2018-09/2019; 805 students were enrolled (67% female; 66% 15-17 years; 51% in grades 9-10). 54% of students in quintile 1 schools had no monthly income; 38% in quintile 5 schools had access to USD7 per month. Preferences were similar for male and female students. Students strongly preferred services provided by friendly, non-judgmental staff (Odds ratio 1.63; 95% Confidence Interval: 1.55-1.72) where confidentiality was ensured (1.33; 1.26-1.40). They preferred services offered after school (1.14; 1.04-1.25) with value-added services like free WiFi (1.19; 1.07-1.32), food (1.23; 1.11-1.37) and youth-only waiting areas (1.18; 1.07-1.32). Students did not have a specific location preference, but preferred not to receive services within the community (0.82; 0.74-0.91) or school (0.88; 0.80-0.96). Students attending schools in high SES neighbourhoods expressed a preference for private care (1.15; 0.98-1.35). Costs to access services were a deterrent for most students irrespective of school neighbourhood; female students were deterred by costs ≥USD3 (0.79; 0.70-0.91); males by costs ≥USD7 (0.86; 0.74-1.00) Conclusions: Preferences that encourage utilisation of services do not significantly differ by gender or school neighbourhood SES. Staff attitude and confidentiality are key issues affecting students decisions to access HIV and contraceptive services. Addressing how healthcare providers respond to young people seeking sexual

A modeling framework for translating discrete choice experiment results into cost-effectiveness estimates: an application to designing tailored and scalable HIV and contraceptive services for adolescents in South Africa

“…This work builds on a discrete choice experiment (DCE) that was conducted to estimate preferences of school going adolescents for accessing HIV and contraceptive services(15). The DCE was conducted in 10 high schools situated in neighbourhoods of varying socio-economic status (SES) in Gauteng South Africa between 07/2018-09/2019 ( Figure 1 ).…”

“…From the above study, six factors were found to be facilitators for uptake of HIV and contraceptive services (15). These were the six attributes and levels that showed significant change in probability of a choice being selected.…”

“…We used coefficients from the DCE (15) to estimate the expected increase in uptake of HIV and contraceptive services as the outcome measure for a cost-effectiveness analysis. We defined the baseline to be the set of attributes that most closely reflects current practice (Location: clinic, time: morning, staff attitude: unfriendly, confidentiality: none, incentives: none and provision of all health services).…”

“…The results from a DCE can help policy makers understand the impact of making certain changes to current services on service acceptability or uptake. Recent research has been conducted to determine the preferences of school going youth for HIV and contraceptive services through the use of a DCE(15). Key service characteristics including staff attitude, confidentiality and value-added services like availability of Wi-Fi, food and youth-only waiting areas were found to be key attributes affecting the decision to access care.…”

“…In order to guide future trials or implementation, we used the results of the DCE with school going youth (15) to model the expected costs and impact (in terms of increase in the proportion of youth accessing health services) of attributes of health services. We used coefficients of expected uptake of HIV and contraceptive services from a recently conducted DCE (20), as an estimated outcome measure as part of a cost-effectiveness analysis.…”