Thesis submitted for the degree: Doctor of Philosophy, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg
June 2017. / The epidemics of tuberculosis (TB) and Human Immunodeficiency Virus (HIV) in sub-Saharan Africa
are closely related and particularly persistent, proving a considerable burden for healthcare provision,
and complicating utilization of care. Concern has been expressed about patients’ experience at
healthcare facilities as this may impact on drug adherence, treatment success and willingness to return
for regular monitoring and drug pick-up. This is particularly relevant for HIV programmes, with HIV
now a chronic disease, with daily treatment necessary for life; TB treatment is limited in duration, to six
months although can be as long as two years in case of multiple drug resistant TB.
Utilization of healthcare services is an important determinant of health outcomes generally, with public
health relevance, particularly for HIV and TB services in areas of high prevalence. The main aim of
universal health coverage is to make healthcare accessible without barriers based on affordability,
availability or acceptability of services. Various factors have been shown to hinder or enable patient
utilization of healthcare services, such as organization of services, costs of transport to and from clinics,
time loss at clinics receiving care, staff attitudes, waiting times and cleanliness of facilities.
Objectives
This study aimed to determine and quantify factors associated with healthcare utilization in patients
utilizing HIV care (including those not yet initiated on antiretroviral treatment (ART) - pre-ART) or TB
treatments in a rural sub-district of Hlabisa in KwaZulu-Natal and to understand healthcare providers’
perspectives regarding patient care and provision of quality care. The study used data from patient exit
interviews, and additionally findings from interviews with healthcare providers in the local HIV treatment
and care programme, structured around the responses from the patient-exit interviews.
The study had three specific objectives: 1) to establish and quantify factors associated with healthcare
utilization, with utilization decomposed to availability, affordability and acceptability of healthcare
services, for patients in HIV or TB treatment and care; 2) to quantify ability-to-pay for healthcare and
identify associated factors for patients in pre-ART care, or on ART or TB treatment; 3) to understand the
healthcare providers’ perspectives regarding patient care and provision of quality HIV care.
Methods
In 2009 patient-exit interviews were conducted in six primary healthcare (phc) clinics in rural South
Africa with 300 patients receiving ART and 300 patients receiving TB treatment; patients were
randomly selected using a two-stage cluster random sampling approach with primary sampling units
(phc) selected with probability-proportional-to-size. In 2010 an additional 200 HIV-infected patients in
pre-ART care from the same clinics were interviewed. Patient-exit interviews were conducted in a
private room outside the facility and all data were analysed using STATA 11. In 2012, a qualitative
study was carried out with healthcare providers in eight (of 17) randomly selected phc clinics; 25 ART
healthcare providers were engaged in discussion structured around patient-exit interviews feedback to
assess possible challenges/facilitators ART healthcare providers face when providing care. Discussions
took place in the consultation rooms when no clinical sessions were ongoing and these were recorded
and transcribed; and data were managed using Nvivo 10. Thematic content analysis was conducted using
both inductive and deductive approaches and clinic or healthcare provider identifiers were removed and
replaced with pseudonyms.
Summary statistics describe patient characteristics by patient group and key availability, acceptability
and affordability factors associated with utilization of healthcare services; separate univariate and
multivariable regression models were run to assess associations between patient characteristics and these
key availability, acceptability and affordability factors. Patient socio-demographic characteristics (sex,
age, education, employment and marital status) were controlled for and adjusted for clustering at
facility-level. Factor analysis was performed to investigate underlying patient satisfaction factors.
Results
Socio-demographic characteristics of the patients
More women than men were seen in the primary care clinic, especially among pre-ART patients (79%),
followed by 62% HIV and 53% utilized TB care, with an age-sex profile comparable to previous studies
in the area. Pre-ART patients were significantly younger than ART and TB patients, with a median age of
32 years for pre-ART patients, 39 years for ART patients and 37 years for TB patients. Unemployment at
household level was high, up to 86% of ART patients’ head of households were unemployed and only 9%
of TB patients were employed. / MT2017
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/23178 |
| Date | January 2017 |
| Creators | Chimbindi, Natsayi Zanile |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | Online resource (143 leaves + appendices), application/pdf |
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