Using discrete choice experiments to elicit preferences for maternal health care in Ghana

Presenting author:David NewlandsUniversity of Aberdeen, Scotland, UKd.newlands@abdn.ac.uk

Co-authors:Aba Daniels, University of Ghana Laura Ternent, University of Aberdeen

Discrete choice experiments (DCEs)

• DCEs are a type of stated preference technique for establishing the importance of the different attributes of a good or service

• Now well established in the analysis of health care in developed countries

• Much less commonly used in developing countries – partly because respondents’ self administration of questionnaires requires a literate population

• It is necessary in such settings to provide respondents with additional support, such as visual aids

DCE of maternal care in Ghana

We conducted a DCE to elicit individual preferences for hospital based maternal health care in Ghana, with one sample using the traditional method of self administration and with another sample using visual aids

Study was conducted as part of Immpact (www.immpact-international.org), a multi-country, multi-disciplinary research project on maternal ill health, funded principally by the Gates Foundation

Methods

• Five attributes and appropriate levels were selected to represent aspects of hospital based maternal health care, by consulting expert opinion and from a focus group discussion

Five attributes were:• Care by skilled attendant• Staff attitude• Time taken to get to hospital• Availability of vital equipment• Cost of care

• Attributes and levels were combined into 17 discrete choice sets

Example of a choice set

Choice 1 Hospital A Hospital B

Care by skilled attendants

Trained Midwife Nurse

Staff attitude Unfriendly Friendly

Time taken to get to hospital

90 minutes 120 minutes

Availability of vital equipment

Some All

Cost of care ¢120,000 ¢240,000

Which scenario would you choose? (tick one box only) Prefer A Prefer B

Choice sets

• The choice sets included two tests of rationality and a test of consistency

• The visual aids used to represent the attributes and levels were designed by artists at the University of Ghana

Visual aid illustrating staff attitude

Visual aid illustrating cost of care

Questionnaire

Questionnaire comprised six sections:

A. Household roster: age, sex, occupation, education, marital status

B. Housing and asset ownershipC. ExpenditureD. Maternal health questionsE. DCE with visual aidsF. Comprehension questions

• Trained enumerators administered the survey (sections A-D, F) and used visual aids to record respondents’ choices (section E)

Sample

• Individuals were selected from three communities in the Cape Coast region of Ghana

• Enumerators entered the village, chose the first house in each village to be interviewed randomly, and chose every other house thereafter until a quota had been reached

• Interviewed either a male or female adult respondent

Respondents’ characteristics

104 men, 102 women

Mean age 33

Marital status: 76% married/cohabiting, 17% never married

Occupation: 24% trading, 22% fishing, 16% skilled self employed, 14% unskilled self employed, 10% skilled employed

Education: 42% no formal education, 15% primary, 31% middle, 8% secondary, 3% post secondary

Results

Logit model (all respondents)

Logit model (men only)

Logit model (women only)

Skilled attendant

-.720***

-0.724*** -0.725***

Attitude -.474*** -0.507*** -0.448***

Time -.002*** -0.004*** -0.0004

Equipment -.813*** -0.887*** -0.748***

Cost -.0015*** -0.002*** -0.0015***

Constant .115*** 0.177*** 0.055

N 3288 1664 1624

Prob(Chi2) 0.0000 0.000 0.000

Psuedo R2 0.1813 0.192 .01743

Attribute Variable name Levels and coding of variables

Care by skilled attendant Skilled attendent Midwife = 0

Nurse = 1

Staff attitude attitude Friendly = 0

Unfriendly = 1

Time taken to get to hospital Time 30 minutes = 30

60 minutes = 60

90 minutes = 90

120 minutes = 120

Availability of vital equipment Equipment All = 0

Some = 1

Cost of care Cost ¢0 = 0

¢60,000 =60

¢120,000 =120

¢240,000 =240

Rationality/consistency checks

% of respondents passing:

Rationality check 1 94

Rationality check 2 95

Consistency check 88

Conclusions

• Main results were as hypothesised

• Large proportion of respondents passed rationality and consistency tests

• With visual aids, DCEs can be used widely in developing countries, not just among the educational elite