Association between Provider-patient relationship, communication, accessibility convenience, and perceived quality of care from patients living with HIV before and during SARS-CoV-2 pandemic

Abstract

Objective
This study aimed to investigate the perspective of people living with HIV (PLWH) with respect to their relationship with their provider, provider communication, accessibility, and perceived quality of care before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

Design
Primary data were collected from an infectious disease clinic outpatient setting using the PSQ-18 short form. The data were collected between February and March 2021. The study population included (a) non-institutionalized individuals, (b) individuals aged 18 years and older, (c) individuals living with HIV/AIDS, and (d) individuals who had had a provider visit in the past 12 months at an infectious disease clinic.

Methods
Multiple regression was used to assess the relationship between the dependent and independent variables using a cross-sectional quantitative analysis.

Results
The study revealed a statistically significant relationship between PPR and perceived quality of care from the perspective of patients living with HIV before and during the SARS-CoV-2 pandemic.

Conclusion
The study results indicated that overall provider-patient relationship (PPR), communication, accessibility, and convenience were related to perceived quality of care. The study findings also revealed that PPRs can uniquely impact perceived quality of care. Provider accessibility was also found to uniquely impact a patient’s perceived quality of care. Finally, the study results demonstrated that HIV patients who have a good relationship with healthcare providers and a high level of satisfaction tend to perceive high-quality healthcare.

Literature review
All databases known to the author were searched

Full text

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Association between Provider-patient relationship,
communication, accessibility convenience, and
perceived quality of care from patients living with
HIV before and during SARS-CoV-2 pandemic
Elisha CALDWELL (  elishacaldwell1986@gmail.com )
Franklin University
Research Article
Keywords:
Posted Date: November 26th, 2022
DOI: https://doi.org/10.21203/rs.3.rs-2306933/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License. 
Read Full License

Page 2/13
Abstract
Objective
This study aimed to investigate the perspective of people living with HIV (PLWH) with respect to their
relationship with their provider, provider communication, accessibility, and perceived quality of care
before and during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.
Design:
Primary data were collected from an infectious disease clinic outpatient setting using the PSQ-18 short
form. The data were collected between February and March 2021. The study population included (a) non-
institutionalized individuals, (b) individuals aged 18 years and older, (c) individuals living with HIV/AIDS,
and (d) individuals who had had a provider visit in the past 12 months at an infectious disease clinic.
Methods
Multiple regression was used to assess the relationship between the dependent and independent
variables using a cross-sectional quantitative analysis.
Results
The study revealed a statistically signicant relationship between PPR and perceived quality of care from
the perspective of patients living with HIV before and during the SARS-CoV-2 pandemic.
Conclusion
The study results indicated that overall provider-patient relationship (PPR), communication, accessibility,
and convenience were related to perceived quality of care. The study ndings also revealed that PPRs can
uniquely impact perceived quality of care. Provider accessibility was also found to uniquely impact a
patient’s perceived quality of care. Finally, the study results demonstrated that HIV patients who have a
good relationship with healthcare providers and a high level of satisfaction tend to perceive high-quality
healthcare.
Literature review:
All databases known to the author were searched
Introduction

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The relationships between patients living with HIV and their care providers have long been studied in the
medical literature; however, this association and its impact on health outcomes are unclear. Some
researchers have found a positive association between patient-provider relationships (PPR), whereas
others have been inconclusive [1–3]. Similarly, communication and accessibility to care as measures of
patient satisfaction have gained attention in the last two decades as a metric to evaluate healthcare
facilities’ performance. Perceived quality of care, on the other hand, builds on the foundation of how
patients conceive and relate to their healthcare providers. The perception of the quality of care is a health
system factor that inuences patients’ decision-making regarding their health status. Patients’ perception
of their health status determines how they examine their care providers and the services they receive. In
this study, the provider–patient relationship is a measure of the constructs of provider interpersonal
manner, and the two terms are used interchangeably. By contrast, perceived quality of care is measured
by the construct of technical quality, and both terms are used interchangeably.
The imbalance between patients as consumers who need help and doctors as skilled professionals who
provide critical care, medical goods, and services has gained much attention over the last two decades.
Patients’ perceived quality of care is as important as the providers’ medical diagnoses. The paternalistic
view that portrays the doctor as having the power to take control of the patient’s treatment has shifted to
mutual relationships [4–6]; thus, the demand to investigate how patients perceive care, their relationships
with providers, and provider communication through multiple encounters has become increasingly
inevitable. Integrating feedback from patients—specically feedback from patients living with HIV/AIDS
[7]—into the decision-making process [8] is associated with better health outcomes [9] and promotes
patients’ access to quality health care.
The transformation of HIV from a highly life-threatening disease to a manageable chronic disease [10–
12] has confronted patients with HIV/AIDS and their care providers with social and cultural realities [11,
13]. HIV care researchers have emphasized randomized controlled trials, clinical-based research, and
evaluation of biomedical and behavioral interventions and treatment in pursuit of care, whereas
sociological researchers have advocated approaches that inuence cultural factors and individual
behavioral outcomes [13]. A dearth of systematic research has examined provider communication and
accessibility to care and satisfaction with the healthcare system and services from the perspective of
HIV- positive patients despite the 37.8million [7, 14–16] people who live with the disease worldwide. The
WHO reported that 27% of the world’s population does not know their HIV status (as cited in [7]). Research
has cited stigma as one of the underlying causes preventing individuals from being tested, disclosing
their HIV status, or taking antiretroviral drugs [7]. Stigmatization can cause a person living with HIV to
become disengaged from healthcare services at any level, and those who perceive a high level of stigma
are over four times more likely to report poor access to care [7]. Listening to patients and incorporating
their feedback into medical decisions is crucial for improving patients’ access to healthcare.
Purpose of the Study

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The researcher conducted a cross-sectional quantitative study to ascertain whether there was an
association between PPR, communication, accessibility, convenience (the independent variables), and
perceived quality of care (the dependent variable) from the perspective of patients living with HIV before
and during the SARS-CoV-2 pandemic. Three research hypotheses were used to examine whether PPR,
communication, and accessibility, held constant for other variables, could signicantly predict
participants’ perceptions of quality of care.
Research Questions
RQ1: What is the relationship between PPR and perceived quality of care, controlling for communication
and provider accessibility, from the perspective of patients living with HIV before and during the SARS-
CoV-2 pandemic?
RQ2: What is the relationship between patient communication and perceived quality of care, controlling
for PPR and accessibility, from the perspective of patients living with HIV before and during the SARS-
CoV-2 pandemic?
RQ3: What is the relationship between accessibility and perceived quality of care from the perspective of
patients living with HIV before and during the SARS-CoV-2 pandemic?
Study Population
The researcher obtained quantitative data from 58 respondents and analyzed the data to determine the
signicance of the research questions. The minimum sample size determined for the study was 128, but
due to the SARS-CoV-2 pandemic that did not allow face-to-face data collection and the diculties in
recruiting HIV patients in the study due to stigma, only a 46% response rate was achieved. Although
research has indicated that the mean response rate for patient satisfaction surveys in research is 72.1%,
nearly 20% of published studies featured a response rate below 50%; therefore, the response rate in this
study is similar to that of prior studies [17–18]. Additionally, other researchers have found that the patient
satisfaction survey rates can range from 16–80% [19]. The study participants who met the recruitment
criteria were (a) non-institutionalized, (b) aged 18 years or older, (c) living with HIV/AIDS, and (d) had a
provider visit in the past 12 months at an infectious disease outpatient clinic. The infectious disease
clinics were in Richmond, Virginia, and these clinics provide medical services to people living with HIV
(PLWH). The demographic composition of the study participants was mixed, suggesting that the HIV
clinic is client-centered and provides services to a wider segment of the population.
Descriptive Statistics
First, descriptive statistics were collected from a sample of 58 respondents (Table1). Seven respondents
chose not to provide any demographic information in the survey; thus, the demographic data for only 51
individuals were presented. Most study participants were between the ages of 55 and 64 (27.5%),
followed by those aged 35–44 (21.6%), 25–34 (17.6%), 65–74 (15.7%), and 45–54 (13.7%). Of the
respondents, 72.5% identied as male and 27.5% identied as female. Most participants had completed
at least a 2-year degree or some college (72.4%), and the remaining had completed a high school

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diploma/GED or less. Ninety-eight percent were identied as non-Hispanics. Across races, 34.5% of
participants were White, 31% were Black or African American, and the remaining were a combination of
multiracial, Native Hawaiian or other Pacic Islander, or other.
PSQ-18 Instrument
In the composite of the patients’ satisfaction questionnaire (PSQ-18), the global rating for PPR falls
within the category of interpersonal manner (Items 10 and 11), a measure of (a) “Doctors acted too
business-like and impersonal,” and (b) “My doctors treat me in a very friendly and courteous manner.”
Similarly, the global rating for communication on the PSQ-18 (Items 1 and 13) measures (a) “Doctors are
good about explaining the reason for medical tests” and (b) “Doctors sometimes ignore what I tell them
while the global rating for accessibility and convenience.” Items 8, 9, 16, and 18 measure (a) “I had easy
access to the medical specialists,” (b) “Where I get medical care, people have to wait too long for
emergency treatment,” (c) “I found it hard to get an appointment for medical care right away,” and (d) “I
was able to get medical care whenever I needed it.” On the other hand, the construct for perceived quality
of care or technical quality has global ratings found in Items 2, 4, 6, and 14, which measure (a) “My
doctor’s oce has everything needed to provide complete medical care,” (b) “Sometimes doctors Make
me wonder if their diagnosis is correct,” and (c) “I have some doubts about the ability of the doctors who
treat me.”
Individual items in the PSQ-18 were averaged (Table2). The constructs with the highest mean scores
were accessibility (1.89), followed by interpersonal manner (1.40), which suggests that HIV patients’
accessibility to care is signicant for improving their care. Factors that prevent PLWH from accessing
providers, such as logistics, including transportation and location to HIV services, must be improved.
Communication had the lowest mean score, indicating that communication in HIV services could be
driven by providers’ authority with less patient participation.
Data Cleaning and Screening
The researcher tested this nal model to ensure that it met all ordinary least-squares linear regression
assumptions. First, to ensure that no nonlinear associations were detected, scatterplots depicting the
relationships between each predictor variable and dependent variable were examined. The absence of
nonlinear associations was conrmed by a non-signicant Ramsey RESET test, which also tests for
nonlinear combinations of independent variables to determine whether these variables would create a
better tting model. Thus, the model was correctly specied. Second, all residuals were found to be
normal and conrmed via a non-signicant Shapiro–Wilk test:
W
(56) = .955,
p
= .11. The researcher tested
for heteroskedasticity using the Breusch-Pagan test and found a non-signicant result,
X
(21) = 24.985,
p
= .25, indicating no issues of heteroskedasticity. This researcher found no major issues of independence
of observations in the data, and the model was specied correctly (e.g., a non-signicant Ramsay RESET
test). Finally, the researcher found no multicollinearity issues among the variables (e.g., all VIF values
below 10.0), and an outlier analysis determined that no observations had an inuential or unusual impact

Page 6/13
on the regression model coecients (e.g., no standardized residuals greater than + 3.0 or less than −
3.0).Results of the Linear Regression Model
After all constructs were created, the researcher used a multiple linear regression model to examine the
relationship between PPR, communication and accessibility, and perceived quality of care, controlling for
other variables (see Table3). Although the respective research questions were stated to appear as stand-
alone, the researcher’s intention was to use all predictors in a single model. When regressing the perceived
quality of care on PPR, patient communication, and provider accessibility, the R-squared for the overall
model was .544, indicating that these three variables explained 54.4% of the variation in perceived quality
of care in the model summary. The overall model was also statistically signicant (
F
[3, 54] = 21.467,
p
< .001).
In the rst research question, the results of the hypotheses included a
p
-value of (< .05), indicating a
statistically signicant relationship between the PPR and perceived quality of care from the perspective
of patients living with HIV before and during the SARS-CoV-2 pandemic. When controlling for patient
communication and provider accessibility, PPR signicantly predicted perceived quality of care (
p
< .05).
Specically, every unit increase in PPR was associated with a .403 unit (Likert score) increase in
perceived quality of care (
p
< .001). This nding suggests that PPRs inuence patients’ satisfaction with
their level of access to health care. In addition, the mean score for interpersonal PPR was high (1.4),
which demonstrated that spending time with PLWH and treating patients in a friendly and courteous
manner could improve the level of care among PLWH.
For the second research question, the results were not statistically signicant. Findings from the
regression model showed a
p
-value (.451) greater than .05; thus, no signicant relationship was found
between patient communication and perceived quality of care, holding constant for PPR and provider
accessibility from the perspective of patients living with HIV before and during the SARS-CoV-2
pandemic.
In the third research question, provider accessibility signicantly predicted perceived quality of care (
p
< .05). There is a signicant relationship between provider accessibility and perceived quality of care,
holding constant for PPR and patient communication from the perspective of patients living with HIV
before and during the SARS-CoV-2 pandemic. Each unit increase in provider accessibility was associated
with a .259 unit (Likert score) increase in perceived quality of care (
p
< .05). Provider accessibility had the
highest mean score, demonstrating that accessibility, such as convenience and access to medical
specialty, waiting time, and appointment for medical care, among others, were factors that PLWH
considered when choosing their care providers.
Discussion
Advances in HIV treatment and prevention should help every PLWH overcome the challenges of structural
barriers in PPRs, provider communication, accessibility, and quality of care. Structural barriers in the
health care system that undermine access to care, patient satisfaction, and quality of care, such as health

Page 7/13
literacy decits, stigma, and challenges navigating the complex health system, can hamper any effort in
the HIV epidemic response [20]. As reported by the CDC, of those living with diagnosed or undiagnosed
HIV in 2018, nearly 56% received some form of HIV care, 50% were retained in care, and 56% were virally
suppressed or lived with undetected HIV [21]. Research has revealed that white people are six times more
likely to be prescribed PrEP than black people and that healthcare providers are less likely to discuss PrEP
with black clients [22]. Thus, advances in HIV treatment and prevention tend to have a lesser benet on
people from ethnic, racial, and sexual minority groups [20].
This study revealed a signicant relationship between PPR, provider accessibility, and high-quality care.
Healthcare providers in HIV care, treatment, and prevention should incorporate PCCMs that engage
patients living with HIV; doing so may require more than just medical intervention. For example, the
national strategy of ending the HIV epidemic initiative by 2030 [20] would require overcoming social and
structural barriers in HIV care by allowing patients to participate in the care process. As this study shows,
incorporating patients’ viewpoints into care must include a strategy-based biomedical intervention from
social and psychological perspectives. A signicant amount of effort has been put into HIV prevention
and treatment in the United States, which has resulted in a 69% reduction in mortality and a 48%
reduction in new diagnoses since the mid-1990s [20]; however, these efforts have been made solely
through biomedical strategies. Shifting the focus to incorporating health education and promotion into
an HIV prevention strategy framework that engages healthcare providers and patients would be more
effective in eliminating structural barriers for PLWH. For example, research has found that only 55% of
white physicians agree that patients with HIV from minority groups received less quality care than white
patients [23].
The demographic characteristics of the study participants showed that the majority (24.1%) were aged
between 55 and 64 years, followed by participants aged 35–44 years (19.1%) and participants aged 25–
34 years (15.5%). Providers should make efforts to remove systematic barriers to education and care
among these populations. To improve the health outcomes of patients living with HIV, providers should
deliver healthcare services across these age categories to increase the likelihood of retention in care and
the viral suppression rate. The study results revealed that 27.6% of participants had attended some
college or obtained 2-year degree, 22.4% reported having a 4-year degree, and 22.4% indicated having
more than a 4-year college degree. Although communication was not signicantly related to perceived
quality of care, providers involved in HIV care, treatment, and services should be aware of the various
educational backgrounds of patients living with HIV. This information could help develop a
communication network that engages patients in active communication, thus minimizing the likelihood
of patients being lost to care.
Study Implications
Data from the CDC (n.d.) indicated that as of the end of 2018, an estimated 1.2million Americans had
been diagnosed with HIV; however, diagnoses in the United States have decreased by 7% among adults
and adolescents between 2014 and 2018. In 2018, 37,968 people were diagnosed with HIV in the United

Page 8/13
States; 67% of the diagnoses were among gay and bisexual men, 24% were among heterosexuals, and
7% were among people who inject drugs [15]. Of the new HIV-reported diagnoses in the United States in
2018, 42% were Black or African American, a racial group that represents only 13% of the U.S. population
[22]. Fifty-six percent of the new infections reported in U.S. men in 2017 were in Black and Hispanic MSM,
a group representing less than 1% of the U.S population [20].
Despite being a highly contagious disease, the clinical implications of SARS-CoV-2 outcomes in PLWH
and AIDS patients have been derived from biomedical interventions. Prior research has highlighted the
paucity of published studies on the clinical outcomes of PLWH who are coinfected with SARS-CoV-2
despite 37.9million PLWH worldwide [24]. Gervasoni et al. observed that many published studies
reporting clinical outcomes in patients with HIV infected with SARS-CoV-2 were either case reports or
small case series. Gervasoni et al. suggested that the results from these studies indicate that patients
with controlled HIV may not be at an increased risk of SARS-CoV-2, unless the patient has a comorbidity
that improves their overall risk.
The current study is important because it highlights that patients with HIV are more likely to have equal
and better access to medical and non-medical services when structural barriers in healthcare are
removed. The study results provide healthcare providers with the tools needed to establish proper care for
patients living with HIV. The results of this study show that healthcare providers should be inclusive and
provide integrated care for patients living with HIV based on PCCM. The PCCM suggests that patients
should be the center of care, and providers should incorporate patient feedback into their care
management.
Implications for Future Research
Future researchers could examine the impact of communication and provider accessibility on perceived
quality of care in HIV research during SARS-CoV-2 in other parts of Virginia that offer HIV services. Future
studies could also broaden the focus of this research to include more than two infectious disease clinics.
Although studies have shown that patients living with HIV who are actively on ART with moderate clinical
symptoms of SAR-CoV-2 respond to COVID-19 treatment faster than the general population [25], the
impact of HIV disproportionately affects people in racial and ethnic minority groups and gay and bisexual
men [21]. These structural barriers could complicate the concept of patient-centered care (PCCM), which
could undermine the general level of satisfaction with healthcare services among HIV-infected patients
living with HIV.
Study Limitations
This study has several limitations. First, it was challenging to recruit 126 participants to enroll in the
study because of (a) the SARS-CoV-2 pandemic, (b) the IRB not allowing face-to-face data collection, (c)
the researcher being an external investigator unaliated with the study site, and (d) PLWH being hard to
recruit in HIV research. Although the results from this study can be used as a benchmark in HIV research,
they cannot be generalized to the general population because of the small sample size. Data were
collected from two infectious disease clinics in Richmond, Virginia, Brazil.

Page 9/13
Conclusion
This study aimed to determine the relationships between PPR, communication, accessibility, and
perceived quality of care from the perspective of patients living with HIV before and during the SARS-CoV-
2 pandemic. The results indicated that overall, PPR, communication, accessibility, and convenience were
related to perceived quality of care. The study ndings also revealed that PPRs can uniquely impact
perceived quality of care. Provider accessibility was also found to uniquely impact a patient’s perceived
quality of care. Finally, the study results demonstrated that HIV patients who have a good relationship
with healthcare providers and a high level of satisfaction tend to perceive high-quality healthcare.

Page 10/13
Table 1
Demographic Characteristics of Participants
Category N %
Age
 
18 to 24 1 1.70%
25 to 34 9 15.50%
35 to 44 11 19.00%
45 to 54 7 12.10%
55 to 64 14 24.10%
65 to 74 8 13.80%
75 or older 1 1.70%
Gender
 
Female 14 24.10%
Male 37 63.80%
Race
 
Black or African American 18 31.00%
Multiracial 4 6.90%
Native Hawaiian or other Pacic Islander 1 1.70%
Not indicated 7 12.10%
Other 8 13.80%
White 20 34.50%
Hispanic Origin
 
No, not Hispanic or Latino 50 86.20%
Yes, Hispanic or Latino 1 1.70%
Education
 
Eighth grade or less 1 1.70%
High school graduate or GED 8 13.80%
Some college or 2-year degree 16 27.60%
Four-year college graduate 13 22.40%
More than 4-year college degree 13 22.40%

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Table 2
Descriptive Statistics
N Mean SD
Technical quality 58 1.49 0.83
Interpersonal manner 58 1.41 0.83
Communication 58 1.26 0.92
Accessibility 58 1.89 0.98
Table 3
Regression Analysis Summary for Predicting Technical Quality
(Coecients)
B SE
B t p
Interpersonal manner 0.403 0.155 0.403 2.608 0.012
Communication 0.099 0.13 0.109 0.759 0.451
Accessibility 0.259 0.112 0.303 2.308 0.025
Declarations
Declarations
Ethical Approval
The research was carried out in accordance with Franklin University Institutional Review Board (IRB)
following general guidelines as adapted from the Code of Federal Regulations (CFR Title 45, part 46,
2009) minimum risks to subject. All participants provided written informed consent prior to enrolment in
the study.
Competing interests
There is no known competing nancial interests or personal relationships that could have appeared to
inuence the work reported in this paperAuthors' contributionsNo ApplicableFundingThis research
received no specic grant from any funding agency in the public, commercial, or not-for-prot
sectors.Availability of data and materialsThe datasets generated during and/or analyzed during the
current study are available from the corresponding author on reasonable request.
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Unsectioned Paragraphs
1918 Ryconda Rd
Fayetteville, NC 28304
Word Count: 4,327
Number of References: 25
Number of Tables: 3
Number of Fig.0
Access
HIV
SARS-CoV-2
Quality of care