Background
Poor client-provider interactions lead to reinforcing cycles of treatment interruptions (TIs) and fear of return, undermining sustained retention. We previously demonstrated a multicomponent person-centered care intervention (PCCi) targeting healthcare worker (HCW) behavior improved client experience and retention in care. To understand mechanisms of improved retention, we evaluated the effect of PCCi on return after TIs and sustained retention after return, hypothesizing that friendlier HCW attitudes enable successful reengagement into care.
Methods
We implemented PCCi at 24 clinics in Zambia in a stepped-wedge, cluster-randomized trial. PCCi targeted caring aspects of HCW behavior using 1) training and coaching on PCC practices, 2) measurement and feedback of client experience (via exit interviews), and 3) small facility-level incentives. We examined individuals who became >30 days late to a scheduled visit (i.e., TI) during the study, categorizing exposure to intervention vs. control based on the last visit prior to the TI (only first TI during study included). We used electronic health records to assess the effect of PCCi on 1) return to care after a TI, and 2) repeat TIs among those who returned. We used multistate analytic methods with bootstrapped confidence intervals to estimate incidence of return and prevalence of sustained reengagement after return. Individuals were censored at intervention crossover or database closure.
Results
From Aug 2019 to Nov 2021, 128,901 clients (n=69670 control, n=59231 intervention) became >30 days late (64.3% female, median age 38y [IQR 31, 45], median years in care 3y [IQR 1, 7]). PCCi led to an increased incidence of return after TI at 6-months (64.7% intervention vs. 61.7% control, risk difference [RD] +3.0 [CI 2.6–3.3%]) and 12-months (72.3% vs. 67.7%, RD +4.6% [CI 4.2–5.0%]). Among returners, PCCi decreased incidence of repeat TIs (44.3% vs. 55.6%, RD -11.4% [CI -12.2– -10.8%]) and increased the proportion in care (with or without repeat TIs) (82.7% vs. 73.4%, RD +9.3 [CI 8.7–10.0%]) at 12-months after return. Overall, PCCi increased the proportion of individuals in care 12-months after a TI from 51.5% to 60.1% (RD +8.7% [CI 8.2–9.1%]).
Conclusions
PCCi improved rates of return to care after TIs, sustained reengagement after return, and overall retention among individuals with TIs. Strategies targeting caring aspects of HCW behavior and client experience may help lower barriers to and address persistent challenges with reengagement in care.