Choice of Healthcare Providers: Assessing Perception of Healthcare Consumers

Protocol (Description of the Project)

1. Title of the project: Choice of Healthcare Providers: Assessing Perception of Healthcare Consumers.

2. Type of Study:

Prospective study- cross sectional study

3. Aims & objectives (hypotheses if applicable): Aim: - The study aims to explore and analyze the factors influencing the choice of healthcare providers among healthcare consumers.

Objectives**-**

i.          To understand the factors that affect the choice of healthcare provider

ii.          To identify the most effective factors that affect the choice of healthcare provider.

Hypothesis**-**

H01-There is no significant effect of cost of services in consumers selecting the hospitals for availing care.

Ha1-There is a significant effect of cost of services in consumers selecting the hospitals for availing care.

H02-There is no significant effect of prior experience in the choice of hospitals.

Ha2-There is a significant effect of prior experience in the choice of hospitals.

H03-There is no significant effect of waiting time on the selection of hospitals for availing healthcare services.

Ha3-There is a significant effect of waiting time on the selection of hospitals for availing healthcare services.

H04-There is no significant effect of quality of treatment on choice of hospital.

Ha4-There is a significant effect of quality of treatment on choice of hospitals.

 4. Justification for study (whether of national significance with rationale):  Healthcare consumers in the past relied heavily on their doctors, consultants, families, and friends when making decisions about hospitals, services, and treatment choices due to a lack of knowledge and awareness. The perspectives of both consumers and marketers, however, have changed over time. The healthcare consumers have begun to demand high-quality information, treatment services, and personalization as a result of increased literacy rates, rising incomes, and growing awareness brought on by a deeper media penetration. Healthcare consumers now choose medical services with greater attention than in the past. Hence this study intends to understand the factors that affect their choice of hospitals so the outcomes of the study will be beneficial for the hospital administrators such that the factors that are important to the patients need to be emphasised to promote the healthcare services of the hospitals.5. Departments involved: The In-Patients and Out-Patients of General medicine department.

6. Study period: The time required for the study is from September 2023 to May 2024.

Sample size: The formula for a finite population that is used is-

n =Z2 p(1-p)N / e2 (N-1) +Z2 p(1-p)                      (Kothari,2008) Where,

N=Population Size

Z=Level of confidence

p=Expected proportion

e=Marginal error

n = (1.96) 2 (0.50) (1−0.50) (415660) (0.05) 2(415660−1) +(1.96) 2(0.50) (1−0.50)

Substituting the value for out-patient sample,

N=415660

Z=1.96

p=0.50

e=0.05

The value of n=383.81, which is rounded off to 384.

Substituting the value for in-patient samples,

N=8248

i.e.,            n = (1.96) 2 (0.50) (1−0.50) (8248) (0.05) 2(8248−1) +(1.96) 2(0.50) (1−0.50)

The value of n=367.07, which is rounded off to 367.

The sample size obtained is 751.

8. Materials and methods:

a) Inclusion and exclusion criteria: Inclusion criteria-  study includes all in-patients and out-patients above the age of 18 years.Exclusion criteria: Paediatric and psychiatric patients are excluded from the study.

b) Biological materials required (type - blood, tissue etc and quantity): Yes ☐    No   ☒

i) Biological material: nil. ii) Biosafety Measures: not applicable

c) Statistical methods: Descriptive statistics and advanced statistical tests like correlations, regression, and T-tests for independent samples will be performed.

d) Tools used: Structured questionnaire for collecting and Jamovi statistical software for analyzing data.

9. Detailed description of procedure/processes: This quantitative cross-sectional study will be conducted in a multi-specialty tertiary care hospital in coastal Karnataka after obtaining approval from the institutional ethics committee. The researcher will be individually administering the questionnaire to the patients who are willing to participate and give consent to participating the study. The patients will be selected at randomly and will answer the questions in around 10-15 minutes. The study will use a structured questionnaire with two components that will be given to a sample of 751 patients, including in-patients and out-patients. The first component includes the respondents’ demographic information, while the second section includes numerous constructs based on an adapted Anderson’s behavioural model. The model included need, enabling, and predisposing factors. Primary characteristics of the patient, such as demographic segmentation, are predisposing variables. Enabling factors refer to a patient’s ability to access services, such as education, treatment waiting times and quality, and cost-related concerns for the chosen treatment alternatives. The nature and severity of the illness are the main need-related variables and particulars using constructs comprising 3,8,6,6 and 2 statements that assess cost concern, quality of treatment, prior experience, waiting time, and need factor respectively1. A 5-point Likert scale will be used to measure the responses and the data analysis will be done by conducting regression and t-tests for independent samples.

10. Outcome measures: The factors that influence the choice of hospital from the healthcare consumer’s perspective.

11. Potential risks and benefits: Risks-There is minimal risk to the study respondents. However, the researcher assures that the confidentiality of the personal information will not be disclosed.

Benefits –

i.          More patient-centered care is provided as a result of improved patient care, and patients feel appreciated and included in their treatment choices.

ii.          Policymakers and healthcare organizations can utilize this data to create efforts that will ultimately result in more equitable healthcare for everyone by addressing differences in patient experiences, access, and quality of care.

12. **Ethical considerations and methods to address issues:**The researcher seeks approval from the Institutional Ethics Committee and Obtained permission from the medical superintendent of KH Manipal to conduct the study.

13. Budget (give details) and proposed funding source: not applicable

14. Review of literature (within 1000 words): The researcher reviewed studies on the choice of healthcare provider and healthcare consumer perceptions using databases such as Google Scholar, Scopus, Web of Science, and PubMed to identify the study by using the keywords expanding "Patients’ choice", "Healthcare provider", "Quality of health care", "Patients’ satisfaction", and "Indian healthcare system". Only studies published in English literature are taken into consideration. By reviewing the abstracts and relevance of studies conducted in many countries that highlighted the concept of hospital selection from the perspective of the healthcare consumer, the researcher succeeded in coming across 10-11 relevant papers published between the year 2012-2022, concerning the research topic and the majority of the studies were conducted outside of India, in countries like German, The Netherlands, China, South Africa, and Saudi Arabia.  In many of the studies, the researchers conducted a quantitative, cross-sectional study, using data obtained through a questionnaire. The responses of the respondents were assessed on a 5-point Likert scale. However, in several research, data was collected through interviews or observations in addition to questionnaires. In many research, the data was analyzed using t-tests for independent samples, correlations, regression, and variance analysis.

Patients’ choice was originally developed as an approach to cut down on waiting times2. The concept of patients’ choice is crucial to comprehend in a developing nation like India, which struggles to provide its citizens with publicly funded healthcare services3. Questions belong to whether patients actively choose their providers, whether they make use of the available information, and whether a country’s health insurance system gives them enough opportunity and freedom to choose4. Patients in South Africa were expected to visit a clinic near their residences5but in Nigeria, high standards of treatment and competent staff are important, whereas in the UK and the US, financial factors play a major role6. Comprehensive testing and examination, medical expertise, and consumer service attitude affected hospital decisions, and low service costs were an essential component of a choice of healthcare Centre in China. Singh et al. explain that 23,778 governmental hospitals and 43,486 private hospitals, a total of 11.8L &7.14L beds in private & government hospitals respectively in the year 2022 in India2.60% of patients in Western studies opted for a hospital close to their residence. Patients choose to have surgery after they receive a second referral from a facility that is more distant and has a shorter waiting list7. In India, patients frequently prioritize cost and proximity in that proportion. When a patient’s health is poor in rural India, distance has less of an impact on their provider choice. In serious situations, quality takes priority over cost and distance. In circumstances where a referral is necessary, individuals are not given the option to choose which healthcare facility they will see but are instead encouraged to travel to a facility that will best fulfill their needs8. Severe health conditions also call for professional appropriate judgment & timely referrals. India has a poor level of health literacy and awareness, and the research on the factors influencing patients’ choices is insufficient2. About 20% of the population is covered by national and state government health insurance programs, and 10% by private insurance. In 2014–2015, it was found that out-of-pocket expenditures accounted for 62.6% of all health spending3. The existing literature identified multiple gaps in their analysis, including the fact that respondents with greater financial status and educational backgrounds were prone to select private hospitals since public hospitals failed to meet their higher expectations(9). The ability to cure was given less importance by respondents who lived close to hospitals, whereas subjective feelings like easy access to doctors and affordable care were given a higher priority regardless of the respondents’ health situations10. Consumers of healthcare view information based on patient experiences as at least as valuable as hospital-based information on the provision of service11. People who live outside the catchment area suffer significant out-of-pocket costs or settle for local services due to distance and pockets of poverty as access hurdles to healthcare providers. Lack of information, inadequate referrals, insufficiently trained staff, and time and transport constraints are the barriers to exercising healthcare consumer choice3.

The researcher found attributes that can be measured using an adapted Anderson’s behavioural model, which was used in the cited studies conducted in Bangladesh and China11,10. The researcher applied the same framework model to the following research frameworks, such as "cost-concern", "quality of treatment", "prior experience", "waiting time", and "chronic illness" to address the observed gap. Based on this literature review the proposed study will be using the below given conceptual framework for its research.

 Fig.1: Conceptual Framework.

15. References:

1.Andersen RM. Revisiting the behavioral model and access to medical care: does it matter?. Journal of health and social behavior. 1995 Mar 1:1-0.

2.Singh S, Lakshmi V, Somu G, Kamath R. Determinants of Hospital Choice among Patients and Perceptions of the Same among Hospital Employees in a Tertiary Care Corporate Hospital in Mumbai, India. The Open Public Health Journal. 2022 Dec 20;15(1).

3.Chauhan V, Sharma A, Sagar M. Exploring patient choice in India: a study on hospital selection. International Journal of Healthcare Management. 2021 Apr 3;14(2):610-20.

4.Victoor A, Delnoij DM, Friele RD, Rademakers JJ. Determinants of patient choice of healthcare providers: a scoping review. BMC health services research. 2012 Dec;12:1-6.

5.Hlongwa ZC, Mahomed S. Factors influencing patients’ choice of clinic at Inanda, KwaZulu-Natal. African Journal of Primary Health Care & Family Medicine. 2021 Sep 22;13(1):2968.

6.Kozikowski A, Morton-Rias D, Mauldin S, Jeffery C, Kavanaugh K, Barnhill G. Choosing a Provider: What Factors Matter Most to Consumers and Patients?. Journal of Patient Experience. 2022 Jan;9:23743735221074175.

7.Bojanapu S, Mathur M, Jacob J, Sharma A, Nundy S. Patient preference for a particular hospital: A prospective questionnaire-based investigation from India. Current Medicine Research and Practice. 2020 Nov 1;10(6):260.

8.Monfared IG, Garcia J, Vollmer S. Predictors of patients’ choice of hospitals under universal health coverage: a case study of the Nicaraguan capital. BMC Health Services Research. 2021 Dec;21:1-9.

9.Yu M, Zhao G, Tang D. The relationship between internal and external factors about the outpatients’ choice of hospital: A cross‐sectional study from Jiaxing City, China. Health Science Reports. 2022 Sep;5(5):e821.

10.Schuldt J, Doktor A, Lichters M, Vogt B, Robra BP. Insurees’ preferences in hospital choice—A population-based study. Health Policy. 2017 Oct 1;121(10):1040-6.

11.Imtiaz A, Khan NM, Hasan E, Johnson S, Nessa HT. Patients’ choice of healthcare providers and predictors of modern healthcare utilization in Bangladesh: Household Income and Expenditure Survey (HIES) 2016–2017 (BBS). BMJ open. 2021 Dec 1;11(12):e051434.