Using discrete choice experiments to elicit preferences for maternal health care in Ghana Presenting author: David Newlands University of Aberdeen, Scotland, 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 ( international.org), a multi-country, multi-disciplinary research project on maternal ill health, funded principally by the Gates Foundationwww.immpact- international.org

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 AHospital B Care by skilled attendants Trained MidwifeNurse Staff attitudeUnfriendlyFriendly Time taken to get to hospital 90 minutes120 minutes Availability of vital equipment SomeAll Cost of care¢120,000¢240,000 Which scenario would you choose? (tick one box only) Prefer APrefer 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 ownership C.Expenditure D.Maternal health questions E.DCE with visual aids F.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*** ***-0.725*** Attitude-.474***-0.507***-0.448*** Time-.002***-0.004*** Equipment-.813***-0.887***-0.748*** Cost-.0015***-0.002*** *** Constant.115***0.177***0.055 N Prob(Chi 2 ) Psuedo R

AttributeVariable nameLevels and coding of variables Care by skilled attendantSkilled attendentMidwife = 0 Nurse = 1 Staff attitudeattitudeFriendly = 0 Unfriendly = 1 Time taken to get to hospitalTime30 minutes = minutes = minutes = minutes = 120 Availability of vital equipmentEquipmentAll = 0 Some = 1 Cost of careCost¢0 = 0 ¢60,000 =60 ¢120,000 =120 ¢240,000 =240

Rationality/consistency checks % of respondents passing: Rationality check 194 Rationality check 295 Consistency check88

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