Abstract
Background:
Client satisfaction is a good predictor of performance of health programs. Hence, clients’ perception and satisfaction studies provide insight to improve the program.
Purpose:
To assess clients’ perception and satisfaction with Integrated Counselling and Testing Centres (ICTCs) for HIV in an operational setting.
Methods:
A total of 191 client exit interviews from 12 ICTCs. The clients were stratified into general and antenatal clients. A systematic random sampling was done at high client load centers.
Results:
Cumulative client satisfaction was found to be 60% (±24%). Most of the clients (76%) agreed that counseling cleared doubts about HIV and found counseling beneficial (71%). Only 32% of the clients could recall issues discussed during the sessions. However, 92.5% were satisfied with ICTC facilities.
Conclusions:
Poor perception and low satisfaction with ICTCs needs to be addressed as this could have a direct bearing on the program.
Introduction
Counseling for HIV and AIDS has become a core element of a holistic model of health care; in this model, psychological issues are recognized as integral to patient management. 1 The Voluntary Counselling and Testing Centre (VCTC) now known as the Integrated Counselling and Testing Centre (ICTC) provides a key entry point for the “continuum of care in HIV/AIDS” for all segments of the population. The acceptance of such services, however, depends on the satisfaction among the clients with services provided. 2 Client satisfaction in turn is predictive of clients’ decisions regarding choices, compliance with regimens, and outcome of the management. 3 Hence, carrying out client satisfaction studies provides a chance to assess clients’ perceptions in an operational setting. A few client satisfaction studies in Asia and Africa have identified factors such as male sex, client education level, and lack of information about care following voluntary counseling and testing that significantly affect client satisfaction with HIV counseling services. 4,5
In India, client satisfaction studies have been done in relation to primary health care services and tuberculosis control programs. The factors such as waiting time and unavailability of the health care provider had led to client dissatisfaction. 6 In the case of the tuberculosis control program, although client satisfaction was found to be very good, poor facilities and equipment affected client satisfaction. 7 However, we could not find any Indian studies related to ICTCs addressing the issues of client satisfaction, which forms a crucial cog in the HIV prevention program. Hence, the objectives of this study were to provide an insight into clients’ perceptions and satisfaction with ICTCs and provide recommendations to improve the current program.
Methodology
This cross-sectional study was conducted in the costal district of Udupi, South India. The district has 3 taluks with a population of 1 177 908 (2011 census). 8 The HIV counseling and testing services are provided through 13 ICTCs setup at primary health centers, community health centers, district hospital, and a medical school. The study was carried out between December 2009 and April 2010. The interviews were carried out by the same researcher, thus preventing interrater bias. The study population was stratified into general and antenatal clients (ANCs). The general clients included all other male and female clients attending the ICTCs other than ANCs. The sample size was calculated assuming the lowest possible level of client satisfaction with ICTC as 50%, 10% precision with 95% confidence interval. The sample size was estimated to be 120 (20% nonresponse rate). As the chances of the HIV-positive clients being included in the study was perceived to be very low, the sample size was doubled giving a final sample of 240.
Centers with client load of more than 100 per month were considered high client load centers. Systematic random sampling was done at these centers. Clients were selected using the formula K = N/n, where K is the sampling interval, N is the total population expected to attend the center in a month, and n is the average number of clients attending the centers per day. One number r, was randomly selected from the sampling interval as the first client, the subsequent clients selected were (r + 1K), (r + 2K), respectively. In the other centers, all the clients attending the center on the survey days were included.
Client exit interviews were conducted immediately after pretest and posttest counseling. The client exit interviews were conducted using tool number 7 of the Joint United Nations Programme on HIV/AIDS (UNAIDS) tools developed to evaluate Voluntary Counselling and Testing (VCT). 9 Superficial modifications were made to make it more applicable to the study by converting some of the questions to statements and rating them on a 5-point Likert scale, without changing the contents. The statements were rated under the following 5 categories—1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. Reverse Likert scoring was done for the statements that indicated dissatisfaction. The data were entered and analyzed using SPSS 11.5. Data are presented using descriptive statistics and results are expressed as proportions. To find the significant difference in client satisfaction between the groups, nonparametric tests (Mann-Whitney test) were used. P < .05 was taken as statistically significant.
Results
A total of 191 client exit interviews were conducted out of which 58% were general and 42% were ANCs. One of the centers was not evaluated as 2 ICTCs were situated in the same institution. A dropout rate of 12% was found in the study. In all, 75% of general clients and 97.5% of antenatal mothers were between the age group of 18 and 35 years. Among the general clients, the sample was equally distributed among the genders. Most (74%) of the clients were educated up to high school and were employed (94%; Table 1).
Sociodemographic Profile of Clients Attending ICTCs (n = 191).
Abbreviation: ICTC, Integrated Counselling and Testing Centre; CSW, Commercial Sex Workers.
Provider-initiated clients consisted of 89% of the clients, 9% were voluntary clients and 2% were referred by NGOs. Among the provider-initiated clients, 54% were referred from O&G and surgical specialties, followed by 24% by medicine, 5.2% by private practitioners, and 5.8% of the clients were referred by fieldworkers. Clients spent a median duration of 10 minutes (interquartile range [IQR]: 0-30) to see the counselors, whereas only 5 minutes (IQR 5-10) were spent during the session with the counselors, but they had to wait for 120 minutes (IQR 45-180) for the test report.
In the case of clients who attended pretest counseling, 84.9% were aware that they were going for HIV testing, but 93.8% of the posttest clients were aware of the HIV test. Only about 38.7% of the clients attending pretest counseling knew the meaning of the HIV test report, but the majority (83.6%) of the posttest clients were aware of the meaning of the HIV test report. With respect to issues discussed during the counseling session, 52% of the clients could not recall what was discussed during the session. In all, 32% of the clients said that the 4 common modes of transmission of HIV were discussed and 7% said methods of personal risk reduction were discussed.
The median (50th percentile) was taken to assess the extent of client satisfaction with the ICTCs. Most of the clients (76%) agreed that the counselor explained things related to HIV which they did not know, 71% found counseling beneficial, and 92.5% were satisfied with the ICTC services such as infrastructure and testing. More than 40% of the clients felt that counseling neither changed their views on HIV nor did they feel that they would have benefited if they had come earlier for counseling. Only about 44.5% of the clients felt the need to ask questions during the session. The cumulative percentage of client satisfaction with ICTCs was 60% (±24%; Table 2). In all, 73% of the clients said that they would recommend the service to relatives and friends. On comparing the client satisfaction between general and ANCs, a significant difference in opinion was found for the statements “My counselor explained about the things related to HIV which were not clear to me” (P < .001), “I was given a chance to ask questions during the session”( P = 0.02), “I found counseling very beneficial” (P < .001), and “The counseling session has not changed my views on HIV/AIDS (P = .02; Table 3). A majority (95%) of the clients said that the counselors were good and gave information related to modes of transmission of HIV. None of the clients expressed any concerns about discussing issues related to HIV with the counselors of the opposite sex. In all, 3% of the clients were dissatisfied with services provided at ICTCs.
Client Satisfaction with ICTCs.
Abbreviation: ICTC, Integrated Counselling and Testing Centre.
a 1 = Strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree.
Comparison of Client Satisfaction between General and ANC Clients’ Attending ICTCs.a
Abbreviations: ICTC, Integrated Counselling and Testing Centre; ANC, antenatal clients; SD, standard deviation.
a 1 = Strongly disagree; 2 = disagree; 3 = neutral; 4 = agree; 5 = strongly agree.
b Significant at .05 level.
Discussion
Our study evaluated client satisfaction with ICTC services provided under the National AIDS Control Programme phase 3 (NACP III), and the authors believe that the findings of this study could contribute to improving counseling services. None of the clients exhibited any form of discomfort while participating in our study.
Most of the clients had poor recall about what was discussed during the session. This might be due to the short duration of the sessions (5 minutes). Whether this reflects an inability of the client to sustain his or her interest in the session or a lack of involvement of the counselor has to be assessed and needs further studies. Among the information recalled by the clients after the sessions, the information about modes of transmission was clearly elucidated. None of the clients expressed any concerns about discussing issues related to HIV with the counselors of the opposite sex which was similar to the findings of the study of South African mine workers. 10
The cumulative percentage of client satisfaction with ICTCs in our study was found to be only 60% (SD ±24.7%) compared with 75.2% in the African PMTCT study 3 and 94% (SD ±6.2%) in the Egyptian study. 4 The factors such as being referred to ICTC without any individual interest, lack of time spent with the counselor, lack of trust in confidentiality, and other barriers identified in the study could have influenced client satisfaction. The authors believe that detailed focus group discussion would help in identifying the reasons for such low levels of satisfaction which may be the focus of further study. Yet, most clients also felt that the counseling services were beneficial and the knowledge about HIV was clearly delivered. Most of the clients also said that they would recommend the services to others. This indeed is the positive aspect of the ICTC services which can further be improved. Additionally, the ANC clients were more satisfied with ICTCs than the general clients and this difference was found to be statistically significant. The reason for this disparity could be due to acceptance of HIV testing and counseling as part of the regular antenatal checkups and also concern of the mothers for the babies. The finding, however, needs further evaluation. Fear about HIV/AIDS, concerns about confidentiality, and lack of awareness were the major barriers identified, which are consistent with the findings of the South African mine workers’ study. 10
Having evaluated clients’ satisfaction, the authors feel program officers and policy makers could take several steps to improve the services. These include advising the counselors to spend more time with the clients to discuss the implications of the disease. Counselors should concentrate on issues that would change the way people look at HIV as a disease and make counseling sessions more thought provoking, so that clients could express their feelings and clarify their doubts. The authors feel that there are certain limitations that need to be accounted for while interpreting the findings, including lack of time on the clients’ side as well as the sensitive nature of some of the questions that may have influenced the findings. Correcting the gaps identified by the study and addressing the barriers identified by the clients need attention as these could hamper the performance of the program.
Footnotes
Authors’ Note
The study was approved by the Institutional Ethics Committee, Kasturba Hospital Manipal. Permissions were obtained from the District health officer, program officer, and on-site ICTC managers before starting the study. Written informed consent was obtained from the clients, and interviews were conducted in a separate room within the health centers.
Acknowledgments
The authors would like to thank Dr Vaman Kulkarni, assistant professor, Department of Community Medicine Mangalore; Dr Ashok, District AIDS control officer of Udupi District; and Mr M S Kothian, biostatistician, KMC, Mangalore, for their valuable inputs during the study and all the clients who participated in the study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.