Patient perceptions of and satisfaction with care have become important indicators of the quality of services and the relationship of services to treatment outcomes. However, assessment of these indicators continues to be plagued by measurement problems, particularly the lack of variance in satisfaction data. In this article, we present a new approach to better capture patient perceptions of experiences in care, the Dynamics of Care (DoC) assessment. It is an in-depth approach to defining and assessing patients' perspectives at different junctures in care, including their decisions about whether and where to seek care, the barriers encountered, and the treatments and services received.The purpose of this article is to describe, validate, and discuss the benefits and limitations of the DoC, which was administered as part of a longitudinal study to evaluate the New York State HIV Special Needs Plan (SNP), a Medicaid managed care model for people living with HIV/AIDS. Data are from 426 study respondents across two time points.The results demonstrate the validity and value of the DoC. Help seeking decisions and satisfaction with care appear to be situation-specific, rather than person-specific. However, barriers to care appear to be more cross-situational for respondents, and may be associated with clients' living situations or care arrangements. Inventories in this assessment that were designed to identify potential deterrents to help seeking and difficulties encountered in care demonstrated clear principal component structures, and helped to explain satisfaction with care. The problem resolution index was found to be independent from satisfaction with care and the data were more normally distributed. DoC data were also associated with subsequent utilization and change in quality of life.The DoC was designed to be a flexible, integrated measure to determine individuals' salient service needs, help seeking and experiences in care. One of the many strengths of the assessment is its focus on specific problems in context, thus providing a more sensitive and informative way to understand processes in care from the patient's perspective. This approach can be used to direct new programs and resources to the patients and situations that require them. There is mounting evidence that variations in perceived quality of health care among people with HIV/AIDS affect patient behavior, especially adherence to medication regimens and other physician recommendations, as well as health outcomes -9. As a Funding agencies have also placed an emphasis on clients' perceptions of care. The Health Resources and Services Administration (HRSA), in providing guidance to its Ryan White CARE Act grantees, has recommended that service planners and providers pay close attention to client satisfaction as they develop and implement their service delivery systems . The empDespite widespread consensus that perceived quality of care, and patient satisfaction in particular, is important to measure, and despite much investment in instrument development, the assessment of patient satisfaction has been and continues to be plagued by critical measurement issues . There iSeveral studies suggest that health status per se, rather than degree of improvement in health status due to medical care, also influences satisfaction ratings; there is some evidence that healthier patients tend to report greater satisfaction with health care ,14,17. SGiven the pitfalls of satisfaction measurement and its debatable value for quality improvement, there has been a call for new approaches to the assessment of patient perceptions of care. A number of researchers have emphasized the need for increased attention to narrative, specifically patients' detailed accounts of what went well and what did not, as well as reports about what did or did not happen when patients received care, what they experienced in light of what they value, and whether needs have been met ,8,14,19.These concerns led us to develop a novel approach to the assessment of health service use and quality, which we refer to as the "Dynamics of Care" assessment. The purpose of this article is to describe, validate, and discuss the benefits and limitations of the Dynamics of Care assessment, which was developed for a longitudinal evaluation study called "Choices in Care." The study was designed to evaluate New York State's Special Needs Plan – a comprehensive care model created for people with HIV and their children that was developed as an alternative to both Medicaid fee-for-service (FFS) and to Medicaid managed care . The larIndividuals were eligible to participate in the Choices in Care study if they enrolled in one of the Special Needs Plans (SNPs) in the prior three months, or if they received care through the traditional Medicaid FFS system. Enrollment in a SNP is voluntary, and the majority of people with Medicaid in New York City who are HIV+ are still receiving care through the FFS model. Thus, we oversampled SNPs enrollees to facilitate comparison with FFS. New SNP enrollees and FFS recipients were eligible for the study if they were 18 years of age or older, spoke either English or Spanish, resided in New York City, had the cognitive capacity to complete the informed consent and a 1 hour interview, and were not incarcerated at the time of the recruitment call.The Special Needs Plan model began in 2003. To date, the three active plans have an enrollment of over 2000 individuals. Study recruitment began in September, 2003, following approval from the Institutional Review Boards at Memorial Sloan-Kettering Cancer Center and the New York State AIDS Institute; recruitment concluded in January, 2007. We recruited new SNP enrollees within 45–90 days of their enrollment into one of the three plans, in order to get baseline information about their health status upon entering the plan, before they had an opportunity to make use of SNP services. New SNP Enrollees were identified from a roster of names provided monthly by the New York State Department of Health (NYSDOH) AIDS Institute. It is important to note that upon enrolling in a SNP, individuals were informed that they would be contacted for plan evaluation purposes. While all individuals had the opportunity to take part in the study, only a percentage were reached by phone and agreed to participate during the eligible timeframe (up to 90 days post enrollment). The comparison group of fee-for-service recipients was recruited concurrently as a convenience sample; they self-selected for the study by responding to flyers posted at Designated AIDS Centers, at community based organizations, and Adult Day Health Care programs. The majority of these recruitment sites provide care to HIV+ individuals under the fee-for-service model and to people enrolled in one of the Special Needs Plans. For privacy reasons, it was not feasible to obtain a list of all HIV+ fee-for-service recipients from which to recruit.The purpose of the Choices in Care evaluation is to examine access to care, perceived quality of life, member satisfaction and patient reported outcomes among HIV+ adult medicaid recipients. Since the study's inception, 306 SNP enrollees and 322 FFS recipients have been recruited, for a total of 628 subjects. The study refusal rate among known eligible SNP enrollees was 12%. The majority of analyses reported here are based on data from 426 respondents who have completed the first and second (of five) study interviews.Study participants were interviewed five times, at three month intervals, in order to compare patient needs, access to care, quality of care, and patient outcomes across the SNP and FFS samples, and within the SNP sample across the three plans. The present validation study draws on data from the baseline and three-month interviews. The informed consent process occurred at the time of the baseline interview. Each interview took 30–45 minutes to complete and was conducted either in person at the study offices in New York City or on the phone, whichever was more desirable for the participant. Interviews were conducted in English or Spanish, depending on the participant's preference. In addition to transportation reimbursement, participants received $25 for the first interview, $30 for the second, $35 for the third, $40 for the fourth and $45 for completing the fifth.Information about personal characteristics, including self-identified gender, age, race/ethnicity, whether the respondent's primary language is English or not, and education level (high school graduate or not), was obtained in the baseline interview. The Choices in Care study was designed to examine impact of care on patient reported outcomes. Thus, outcome measures were collected at baseline and again at six months, including health status, treatment adherence, risk behaviors, and quality of life. The main Dynamics of Care assessment occurred at the intervening three month interview, with brief follow-up questions occurring during the six month interview, including questions about the current status and resolution of events in care identified at the three month time point (see discussion of measure below).The Dynamics of Care assessment was designed to capture patients' experiences of care in detail, for the purpose of evaluation and quality improvement. It is an in-depth approach to defining and assessing patients' perspectives at different junctures during an episode of care, including their decision whether and where to seek care, the barriers they encountered, and the treatments and services they received. The Dynamics of Care is an interviewer administered assessment that begins by asking respondents whether they experienced problems in the last three months in nine specific areas ("trigger events") that the Special Needs Plan was designed to address. These areas include: 1) Adherence to Medical Instructions; 2) Medical Problems; 3) Specialty & Inpatient Hospital Care; 4) Preventive Health Care & Screening; 5) Sexual Risk Behavior; 6) Family Planning; 7) Psychological Symptoms; 8) Substance Use; and 9) Life Circumstances & Demands. This first part of the measure, the Events in Care Screening Questionnaire (ECSQ) contains 54 yes/no items and serves to identify the areas of recent concern to each patient . RespondThe main part of the Dynamics of Care interview explores respondent experiences, with respect to three selected events in care. The interview is structured with skip patterns to probe relevant questions depending upon how far individuals have progressed in regard to seeking and obtaining care. For each of the three trigger events, respondents are asked to provide a brief narrative description of the concern. They then delineate whether or not they sought care and what factors influenced that decision, including provider recommendations. Among those who were or are actively seeking care, we ask about any barriers and delays that they have encountered. For those who have already started receiving services it is determined which providers they have seen; respondents are then asked about experiences in care including the outcome of referrals, coordination of care, and communication with providers. Respondents are also asked to rate satisfaction with help received from the main provider involved with their care pertaining to each event. In addition, overall experience of problem resolution is explored including whether or not they are seeking or receiving care, or trying to handle a problem on their own.highest in terms of satisfaction with care available, and the area the patient rated lowest in terms of satisfaction with care available. If more than one area receives an equally high or an equally low satisfaction rating, interviewers were instructed to select area(s) that tended to be identified as concerns less frequently, in our initial piloting of the ECSQ measure . This procedure effectively oversampled infrequent concerns, which made it possible to conduct analyses related to less frequent areas of concern. In sum, the Dynamics of Care assessment guides respondents to identify key events related to their care, and to describe what has transpired regarding that event up to that point. By tracing specific episodes in this way, it is possible to understand discrete circumstances and cause-effect associations based upon each individual's immediate experiences. In essence, this approach trades the breadth and lack of specificity inherent in global satisfaction ratings for a high degree of precision in the assessment of narrowly framed but highly salient experiences. As we shall detail in description of analyses below, the Dynamics of Care measure may be examined with respect to specific areas of care or summarized across areas to create a variety of different summary variables.If a participant mentions problems in more than three of the nine areas, three events are selected for further probing based on the area of greatest concern to the patient, the area that the patient rated Number of health care providers and composition of health care team: Respondents were asked to identify all of the health care providers that were part of their current health care team or whom they had seen in the six months preceding the baseline interview for care.• Plan enrollment status: Respondents were classified as a member of one of the NYSDOH Special Needs Plans, or as a Medicaid fee-for-service (FFS) recipient.• Years since HIV diagnosis: Respondents were asked the month and year when they first tested positive for HIV.• CD4 Count: Measured as less than or equal to 200, or greater than 200, based on respondent report.• Undetectable viral load: Determined by a response of "undetectable" to the question "Do you know or remember the results of your last viral load count?"• HIV-related diagnoses:• Total number is based on respondents' indication of whether they had ever been diagnosed with any of 11 different opportunistic infections, disorders and malignancies .∘ Number of conditions for which the respondent was not receiving treatment was determined by asking respondents to indicate whether the condition had been completely treated, whether they were being treated at that time, or were never treated.∘ Number of symptoms: Respondents were asked if they had any of 11 different psychological and physical symptoms in the past four weeks. Examples of symptoms include trouble with thinking, concentrating, or memory; fever, chills, sweats.• Physical and psychological quality of life composites from the MOS-SF36: This widely used 36-item measure of health related quality of life and functional status yields physical and psychological quality of life composites, each scored from 0–100 with higher scores indicating greater well-being [• ll-being .The respondents were asked their history and current activity (within the last 3 months) in a variety of risk behaviors including:History of and current hard drug  use• Sexual history- having a sexual partner who is an injection drug user; having a sexual partner who is HIV seronegative; whether or not the respondent was ever a sex worker; and unprotected sex behavior• Criminal justice involvement• Tobacco use• Excessive alcohol use• Variables include: self-identified gender; age; race/ethnicity; whether the respondent's primary language is English or not; education level (high school graduate or not); number of sources of income (0–9); monthly gross income from all sources; housing stability (whether or not the respondent lives in a place of his/her own); whether the respondent self-identified as gay or bisexual; whether the respondent had a spouse or partner; whether the respondent was living with a partner; number of other adults and minor children in the household; and whether the respondent was living with another seropositive person.Analyses were based on data from 426 respondents who completed the first two study interviews. All data were analyzed using SPSS V12.0 for Windows. In the results section that follows, we first present the characteristics of the sample, including demographic information, health status, health care utilization, and risk behavior. We next describe our identification and sampling of Events in Care for further assessment in the Dynamics of Care. Finally, we present a series of analyses of the psychometric and response properties of each section in the Dynamics of Care, including stage of help-seeking, barriers and delays encountered while seeking help, and perceived quality of interaction with main providers. For each section of the measure, we give the item response rates and intraclass correlations across respondents' specific areas of care. We also provide data on inter-item reliability and the principal component structure of summary scores. Lastly, we determine whether Dynamics of Care measures were related to demographic and health-related measures through a series of multiple regression analyses.Detailed demographic characteristics are outlined in Table With respect to risk behaviors, 75% of the sample has a history of crack, heroin, or other injection drug use; 23% had used one or more of these drugs in the past three months. Fifty-nine percent had sex with someone who injects drugs, and 18% have traded sex for money, drugs, or other needs. Nineteen percent of respondents reported having unprotected sex in the past three months, and 7% had unprotected sex with someone who is seronegative. Twenty-one percent had smoked one or more packs of cigarettes a day in the past three months, and 10% reported that they had too much alcohol in the past three months.The first part of the Dynamics of Care assessment entails identifying and prioritizing events of interest to the respondent. As noted above, we developed the ECSQ, a face-valid measure including 54 items that probe needs in nine areas of concern. In each area, we asked whether people living with HIV/AIDS (PWHAs), had specific problems or concerns in the past three months, whether they needed additional information, and whether their providers had raised concerns. Detailed results of the validation of the ECSQ are presented in a separate paper . ResponsDue to practical limitations of time, we decided to ask respondents the Dynamics of Care questions in only three of their identified areas of concern. As mentioned above, in order to select a representative sample of clients' concerns for further discussion in the Dynamics of Care assessment, we first asked respondents to rate their satisfaction with services available to them in each area, in order to select areas in which they were most and least satisfied. Then, we asked them to indicate which area represented their "biggest concern or need." These ratings allowed us to follow-up on clients' most salient concerns, as well as additional areas of concern that varied in terms of level of satisfaction with services. When several different areas received a respondent's highest or lowest rating, interviewers were instructed to select one of the areas that were mentioned less frequently in our pilot data, specifically, Family Planning, Sexual Risk Behavior or Substance Use. In other words, we designed the process to over-sample areas that tended to be mentioned less frequently. Table Life Circumstances & Demands (20%), Medical Problems (21%), and Psychological Symptoms (16%) were identified most often as respondents' biggest areas of concern, in contrast with Substance Use (5%), Sexual Risk Behavior (4%), and Family Planning 3%) , Sexual Risk Behavior (51%), Preventive Health Care & Screening (48%) and Specialty and Inpatient Hospital Care (46%) , Specialty and Inpatient Hospital Care (32%), and Psychological Symptoms (30%). Areas least likely to receive lowest ratings included Family Planning (11%) and Substance Use (15%) . It is also possible to combine like items across areas of assessment, to derive idiographic  measures of processes in care that are comparable across individuals, despite differences in events in care. For example, it is reasonable to examine individuals' average satisfaction across providers. Similarly, we can indicate whether clients ever encountered a particular barrier in seeking care, irrespective of the specific events in care under consideration.For the present paper, we have focused analysis on summary ratings derived from the dynamics measurements. This provided an opportunity to consider how baseline individual differences in health care, health status, and personal characteristics related to experiences in care. In order to present analyses in a cogent fashion, we will focus on each section of the interview in sequence: Stage of Help-Seeking, Barriers and Delays Encountered while Seeking Help, Perceived Quality of Interaction with Main Providers and Problem Resolution. This is necessary because sample size changes from section to section . This sequential approach also conveys how the assessment can highlight and focus on different junctures in care.For each section of the measure, we present information on item response rates, as well as item homogeneity (intraclass correlations) across respondents' sampled areas of care. We also provide information on data reduction procedures, including inter-item reliability  and principal component structure of various summary scores. These results are presented in the narrative or in separate tables, below. Finally, we describe results of a series of multiple regression analyses to determine whether Dynamics of Care measures were related to demographic and health-related measures in a coherent fashion. In order to filter the large number of predictor measures and focus in on the strongest and most reliable associations with each dynamics variable within the different sections, we conducted separate regression analyses to identify the strongest predictors from each set of measures, and then considered only those predictors in a final, overall analysis. Results of all regression analyses are presented in similar format, summarized in Tables 467The first section of the Dynamics of Care interview assesses whether and when individuals started to seek help for each sampled event in care. To be selected, these events had to have been a concern at some point during the three months prior to the interview; however, the onset of these concerns could have occurred earlier. Thus, of the 969 events sampled for probing, 16% had emerged as problems in the last month and an additional 28% occurred in the past three months. Of the remaining events, 13% emerged within the past six months, 14% within the past year, and 29% had been problems for a year or more. Respondents had already started to receive help for 52% of the sampled events, were actively seeking help for 16%, and were considering seeking help for 21%. For the remaining 11% of events, respondents said that they would not consider seeking professional help. Across 387 individuals (of a possible 428) who identified at least one event in care, 80% were already receiving help for at least one of their sampled concerns, 34% were seeking help for at least one concern, 41% were contemplating help seeking in some area, and 23% mentioned at least one area in which they would not consider seeking professional help. Among 262 individuals for whom three events were sampled, intraclass correlations (ICC) in help seeking status indicators were relatively low across areas of care, ranging from .02 to .09. . The timing of the onset of individuals' different concerns also had a moderate ICC = .23. These results suggest that the interview succeeded in eliciting discussion of individual problems and concerns that were distinct from one another.In order to study differences in help seeking, we created composite scores reflecting the proportion of events for which an individual was receiving, seeking, contemplating or avoiding help. Correlates of these composites are presented in Table Help seeking was also associated with presence of providers. As expected, receipt of help was generally associated with provider recognition of problems and presence of different types of providers. However, people seeking help tended to report greater involvement with case managers, especially compared to people who were already connected to services. Help seeking was also associated with individual health status. People who reported poorer physical quality of life at baseline were more likely to be seeking care, while those with fewer symptoms were more likely to say that they would not consider professional help. Alternatively, recent sexual risk behavior and alcohol use were associated with seeking and contemplating care, respectively. Help seeking was also related to indicators of socioeconomic status, with employed individuals more engaged in care, in contrast with those who were recently involved in the criminal justice system or who had not completed high school. Ethnic differences also emerged. Spanish-speaking Hispanics were more likely to have been receiving help, but respondents who identified as Hispanic reported being less likely to not consider seeking help. Active help seeking was also associated with living with other adults and particularly other HIV+ individuals. Younger respondents were also more likely to be considering help.In order to better understand help seeking, the Dynamics of Care assessment includes a series of nine items that ask about beliefs and preferences that might deter help seeking. These items and their orthogonal varimax principal component structure are presented in Table Correlation analyses indicated that these components explained differences in help seeking. In particular, the decision to not consider professional help was significantly associated with lack of desire for additional information to get things on track , the belief that it was not necessary to learn to live with the problem at hand , and the feeling that the problem was unimportant . Alternately, the desire to obtain information to get things back on track was positively associated with both considering help  and seeking help . As might be expected, people already in care were less likely to feel that their concerns were not important enough to warrant formal help .Results of regression analyses shown in Table despite fewer years since diagnosis. These individuals also tended to have fewer sources of income. Again, people who were willing to enroll in a Special Needs Plan were less likely to report that they felt uncomfortable seeking help.The second pattern, feelings of being embarrassed and judged when seeking help were associated with mental health and family planning concerns, both potentially stigmatizing issues in this population. Findings suggest that this feeling may be predominant among people diagnosed at a later stage of disease: correlates included having a higher number of providers, more symptoms, and more lifetime diagnoses, The third pattern, people involved in riskier behavior were more inclined to avoid professional care. Deterrents to help seeking were associated with two of the least prevalent areas of concern, sexual risk and substance use. The beliefs that nothing would help, that the concern was not important enough to seek help, and that it was preferable to address problems independently may account for the lower reporting of concerns in these areas. Respondents who reported higher sexual risk behavior and substance use at baseline were also more inclined to dismiss professional help and to want to handle things on their own. Again, having an undetectable viral load contributed to the feeling that concerns did not warrant professional help.Finally, deterrents to help seeking reflected several social and cultural differences evident in our sample. Spanish-speaking respondents were likely to have a fatalistic view of help-seeking as futile. Gay or bisexual respondents also expressed this feeling of futility. Hispanics in general were more likely to want more information in order to resolve concerns on their own. Clients with fewer sources of income were more likely to feel stigmatized, and to try to address problems on their own. Individuals with minor children in the household were likely to see their own needs as unimportant. These findings highlight the ability of the Dynamics of Care assessment to identify help-seeking issues and concerns specific to particular individuals and particular needs.Of the 387 clients who reported at least one event in care during the preceding three months, 92% (355) were either seeking or receiving services for at least one of the concerns that they had identified. For these respondents, we were able to ask about barriers to care that they had encountered while seeking care, and whether these barriers contributed to delays in care and actually obtaining care. We included questions about the following barriers: difficulty getting an appointment (encountered by 14% of respondents); problems with transportation or distance (13%); inconvenient hours (12%); accessibility problems due to stairs, curbs, lack of ramps and the like (8%); language difficulties (5%); cost of care or lack of coverage (4%); and provider refusal to provide care (1%). Overall, 72% of clients reported none of these barriers, 13% had encountered one barrier, 8% reported two barriers, 4% three barriers, and 4% four or more. Intraclass correlation coefficients were quite high for most of these barriers, including transportation (.69), inaccessibility (.58), language problems (.43), costs (.39) and hours (.35), indicating that people were generally dealing with the same barriers across several domains of care. However, this finding did not hold for appointment difficulties (.18) and provider refusal (.00), which were apparently more provider-specific.As is evident in Table The barriers to care reported here were only weakly associated with actually receiving versus seeking care. The only significant barrier that kept clients from connecting to care was transportation . However, many barriers contributed significantly to delays in care that made the problem worse. Such delays were reported by 23% of respondents, and were associated with inconvenient hours , provider refusal , difficulty getting appointments , inaccessibility , transportation , and costs of care or insurance coverage . Combined, these barriers explained 10% of the variance in delays in care (p < .001). Additional correlates of delay are presented on Table Of the 355 respondents who had sought help for at least one of their concerns, 87% (308) connected with care and were able to discuss services that they had received over the past three months. In general, satisfaction with care was quite high. Of the 52% of sampled events (500 out of 969) where contact with a main provider occurred, clients were "very satisfied" with the help they received 88% of the time, "somewhat satisfied" 8% of the time, "somewhat dissatisfied" 2% and "very dissatisfied" 2%. In order to obtain a satisfaction variable with a better distribution, we determined the lowest level of satisfaction reported by clients for any of their sampled areas of care. The majority of clients, 82%, were very satisfied with the care they received across all sampled areas. Of the remainder, 11% rated themselves as somewhat satisfied with at least one episode of care, 4% were somewhat dissatisfied with at least one area, and 3% were very dissatisfied with the help they received for at least one sampled event. Intraclass correlation of satisfaction ratings was .17, indicating only a modest association. In other words, if a patient was dissatisfied with help received for one area, they were slightly more likely to report dissatisfaction in other areas. Note that clients' lowest rating of satisfaction with help received was correlated with the more global rating of satisfaction with available services used to select events for probing , although this correlation was necessarily attenuated by the skewed distribution of this measure. Consistent with the literature on satisfaction assessment, regression analysis presented on Table In addition to satisfaction ratings, we also asked clients to rate whether they encountered specific difficulties in their care. These 14 items and their orthogonal varimax principal component structure after promax rotation are presented in Table Difficulties in care were associated with different areas of concern and baseline health status, as presented on Table More serious problems in relationships with providers, captured on the second component, were associated with medication adherence and specialty care. Clients receiving physical or occupational therapy were more likely to mention these difficulties, as were people who had more lifetime diagnoses, had greater physical quality of life problems, were gay or bisexual, or were involved in the criminal justice system. Several correlations suggest that people currently involved in riskier behavior  were less likely to attribute disrespect or blame to their providers. Recipients of specialty care as well as those with more lifetime diagnoses, poorer psychological quality of life and higher sexual risk behavior were more likely to report that they had difficulty with instructions and that the help they were offered was impractical. It is also noteworthy that clients who were employed were more likely to report that help was impractical. Family disagreements about care and interference of care with other responsibilities were most strongly associated with concerns about psychiatric symptoms and life circumstances, but were also related to substance use, sexual risk and specialty care concerns. Disagreements were associated with a greater number of medical referrals, as well as poorer physical health, greater risk behavior and lower monthly income. Again people who used tobacco or who engaged in sex work were less likely report these disagreements.Greater difficulties in care were negatively correlated with satisfaction with help received, including unclear instructions , provider not responding to questions , perceived disrespect , and family disagreements with care . Overall, difficulties accounted for 42% of the variance in satisfaction (p < .001).Given its focus on specific events in care, it is natural to ask about problem resolution as part of the Dynamics of Care interview. This question was pertinent to all events, even if respondents had not started to seek or receive care. Of the 969 events in care sampled, 17% were rated as "all settled," 16% as "mostly settled," 28% as "partly settled," and 39% as "not at all settled." Problem resolution had a moderate ICC of .21 across different areas of concern, indicating that these ratings were largely event-specific. Across participants, only 7% of respondents stated that all of the events and concerns identified through screening were fully resolved at the time of the Dynamics in Care interview, and 66% said that none of the sampled concerns were fully resolved. Given the wide range of variation across different areas of concern, we created a problem resolution index that yielded a weighted average score across areas sampled: individuals received 1 point for each concern that was fully resolved, 1/2 point for concerns that were mostly resolved, -1/2 point for concerns that were partly resolved and -1 point for concerns that were not at all resolved. This weighted index made it possible to examine factors that influenced overall problem resolution. These results are presented on Table Problem resolution was lower among individuals whose concerns involved psychiatric symptoms, wellness and prevention, and specialty or inpatient hospital care. Individuals who sought care from several providers for particular concerns had a lower problem resolution index. However, individuals who enrolled in a Special Needs Plan were likely to report better problem resolution, perhaps reflecting their proactive choice in care. Better problem resolution was associated with fewer years living with HIV and better psychological quality of life at baseline. Individuals who had a history of sex work or unstable housing reported worse problem resolution. Problem resolution was also higher among women compared to men in our sample.We also examined the impact of the Dynamics of Care on problem resolution. We conducted a series of analyses to examine how each section of the Dynamics of Care interview was related to the problem resolution index, including significant correlates and overall variance explained by each section. In terms of help seeking status, receiving help was associated with problem resolution , in contrast to seeking help , and contemplating help . People who were deterred from help seeking because they felt embarrassed also reported lower problem resolution . However, higher problem resolution was associated with not considering help , and with the belief that a problem was not important enough to seek help . Overall, help seeking accounted for 14% of the variance in problem resolution .Problem resolution was less directly related to the barriers that people encountered while seeking help. Inconvenient hours of service  and transportation problems  were both associated with diminished problem resolution, as were the experience of delays that made the problem worse . Overall, barriers and delays accounted for 5% of the variance in the problem resolution index . Satisfaction and difficulties encountered in care also explained further variance in problem resolution. The correlation between satisfaction and problem resolution was . Difficulties encountered in care were each negatively correlated with problem resolution, including family disagreements and conflicting responsibilities that are affected by care , lack of response to questions , perceived disrespect and lack of confidence in care  and unclear instructions . All together, satisfaction and difficulties explained 4% of the variance in problem resolution . This is consistent with the observation in the literature that satisfaction alone does not adequately capture the degree of resolution of problems in care.In order to determine whether measures derived from the Dynamics of Care interview were useful in understanding health delivery outcomes, we conducted a series of regression analyses to predict different service use measures and quality of life at our six month follow-up, three months after the dynamics interviews were completed (N = 291). Follow-up variables included several aspects of service use in the month preceding the six month interview: number of provider office visits , number of home visits , telephone contacts , and overnight stays in the hospital . We also examined how Dynamics in Care related to changes in quality of life over six months, from the baseline interview. About 30% of the sample declined and 46% of the sampled improved by 5 or more points  in physical quality of life, while 33% declined and 44% improved by 5 or more points in psychological quality of life. In order to conduct a stringent test of the value of the dynamics of care measure, we controlled baseline quality of life scores prior to entering dynamic measures. Since we used absolute measures of follow-up service utilization rather than change scores, we controlled for baseline measures of years since diagnosis, symptoms, opportunistic infections and malignancies, CD4 count over 200, undetectable viral load, number of conditions for which treatment has not been obtained, and quality of life. We also controlled for the occurrence of events in care identified at three months, to distinguish emergent needs from processes in care. Partial correlation coefficients of dynamics of care predicting six month utilization and QOL are presented in Table As Table The Dynamics of Care assessment was designed to be a flexible, integrated approach to determine individuals' salient service needs, help seeking, and experiences in care. Procedures for screening events in care were successful in capturing current concerns of Medicaid clients. It is noteworthy that nearly half of these events had not yet been brought to the attention of care providers. One significant advantage of patient-oriented assessment is the ability to gain perspectives on care that are not available from any other source. This assessment procedure sheds light on concerns that may not make it into care because of patients' sense of futility, embarrassment, or independence.The Dynamics of Care approach also permits contrasts between different concerns in care. Although the extent of cross-situational consistency represented by ICCs differed from variable to variable, this variation appeared to make sense in terms of the construct under consideration. As our analyses show, help seeking decisions and satisfaction with care each appear to be situation-specific, rather than person-specific. In other words, individuals may choose to seek help for one problem but avoid assistance for another. Alternatively, barriers to care appear to be more cross-situational for respondents in this sample, and may be associated with clients' living situation or care arrangements. However, this seemed to depend upon the nature of the barrier.Two inventories embedded in this assessment, to assess potential deterrents to help seeking and difficulties encountered in care, demonstrated very clear principal component structure, and were helpful in understanding aspects of help seeking and satisfaction with care. The problem resolution index also proved to be independent from satisfaction with care and had better distributional properties than satisfaction. The Dynamics of Care measure has clear potential to distinguish situations in which one outcome is achieved in lieu of the other.after controlling for this baseline measure.The Dynamics of Care assessment was associated with subsequent utilization and change in quality of life. Although these effects were small after covariates were taken into account, the nature of the relationships made sense. For example, people with more questions and unclear instructions at three months said that they spent more time on the phone with providers at six months. Home care was less likely when clients reported family disagreements about care. Although certain dynamics variables were correlated with baseline psychological quality of life, they were still associated with changes in service use and physical quality of life Despite these strengths, the Dynamics of Care procedure has several limitations that must be highlighted. The Dynamics of Care data are somewhat complicated to work with, including a different number of concerns sampled per respondent and different skip patterns dependent upon help-seeking status. The number of events sampled was also limited by available time. Additional information might be gained from probing more events, and it is necessary to establish that the client's "biggest concern" really is the most important one to discuss.It is also important to distinguish the algorithm used to assess service use from the particular instrument discussed here. The particular events sampled were very much driven by the questions and concerns we had regarding Medicaid-supported HIV/AIDS care and the Special Needs Plan. Other ways of identifying and sampling events in care could be developed. It would be possible to focus in more depth on one aspect of care . It would also be possible to use different strategies to sample events, including standard symptom-related screeners, discharge planning assessments, and even provider-nominated categories. Assessment of help seeking decisions could include more items about positive reasons to obtain care as well as deterrents, and difficult items could be balanced with benefits of care. Nonetheless, all of these modifications would fit readily into a Dynamics of Care framework that emphasizes the analysis of a specific concern, problem, or need. We view this as a general framework that must be tuned to the specific assessment situation, much like social network analysis.In this report, we provided a psychometric overview of the Dynamics of Care assessment and we constructed global summary variables for this purpose. However, we have used or plan to use Dynamics of Care data in a number of different ways:• To structure and amplify case reports on individual clients• To highlight and monitor specific quality improvement projects• To determine whether primary care providers respond differently to different needs• To examine interaction effects among areas of concern and patient vulnerability measures – to see whether patients' known behavioral health risks play out as problems in care.• In addition, we have also developed a follow-up reassessment of the Dynamics of Care measure to track the trajectory of specific problems over time. For example, how long do individuals strive to overcome barriers and at what point do they say that help seeking is futile?This focus on specific problems in context is intended to provide more sensitive and informative ways to understand processes in care from the patient's perspective. This approach leads to a more grounded and systematic description of health care that can be used to direct new programs and resources to the patients and situations that require them.DoC stands for Dynamics of Care. SNP stands for Special Needs Plan. The study was designed to evaluate New York State's Special Needs Plan – a comprehensive care model created for people with HIV and their children that was developed as an alternative to both Medicaid fee-for-service (FFS) and to Medicaid managed care. MCO stands for Managed Care Organization. HRSA stands for Health Resources and Services Administration. ARS stands for Acquiescent Response Set. NYSDOH stands for New York State Department of Health. DAC stands for Designated AIDS centers. ECSQ stands for Events in Care Screening Questionnaire. QOL stands for Quality of Life. GED stands for General Equivalency Diploma. PWHA stands for People living with HIV/AIDS. ICC stands for Interclass correlationsThe author(s) declare that they have no competing interests.Bruce Rapkin (BR) is the Principal Investigator of the project; he performed the statistical analysis and wrote the analysis and discussion sections. Elisa Weiss (EW) is the Project Director and took the lead in writing the background and methods sections. Rosy Chhabra (RC) is the former Project Director and contributed to the development of the measures and study design. Laura Ryniker (LR) is the Project Coordinator and helped to write the manuscript. Shilpa Patel (SP) participated in the data collection of the study and helped to write the manuscript. Jason Carness (JC) participated in the data collection of the study and helped to draft the background section. Roberto Adsuar (RA) participated in the data collection of the study and helped to draft the manuscript. Wendy Kahalas (WK) participated in the statistical analyses for the paper and reviewed many versions of the analysis section. Carol DeLaMarter (CD) participated in the design of the study and measures; she also reviewed and provided feedback on earlier versions of the manuscript. Ira Feldman (IF) participated in the design of the study and measures; he also reviewed and provided feedback on earlier versions of the manuscript. Judy DeLorenzo (JD) participated in the design of the study and measures; she also reviewed and provided feedback on earlier versions of the manuscript. Ellen Tanner (ET) participated in the design of the study and measures; she also reviewed and provided feedback on earlier versions of the manuscript.All authors read and approved the final manuscript.


Many countries in middle- and low-income countries today suffer from severe staff shortages and/or maldistribution of health personnel which has been aggravated more recently by the disintegration of health systems in low-income countries and by the global policy environment. One of the most damaging effects of severely weakened and under-resourced health systems is the difficulty they face in producing, recruiting, and retaining health professionals, particularly in remote areas. Low wages, poor working conditions, lack of supervision, lack of equipment and infrastructure as well as HIV and AIDS, all contribute to the flight of health care personnel from remote areas. In this global context of accelerating inequities health service policy makers and managers are searching for ways to improve the attraction and retention of staff in remote areas. But the development of appropriate strategies first requires an understanding of the factors which influence decisions to accept and/or stay in a remote post, particularly in the context of mid and low income countries (MLICS), and which strategies to improve attraction and retention are therefore likely to be successful. It is the aim of this review article to explore the links between attraction and retention factors and strategies, with a particular focus on the organisational diversity and location of decision-making.This is a narrative literature review which took an iterative approach to finding relevant literature. It focused on English-language material published between 1997 and 2007. The authors conducted Pubmed searches using a range of different search terms relating to attraction and retention of staff in remote areas. Furthermore, a number of relevant journals as well as unpublished literature were systematically searched. While the initial search included articles from high- middle- and low-income countries, the review focuses on middle- and low-income countries. About 600 papers were initially assessed and 55 eventually included in the review.The authors argue that, although factors are multi-facetted and complex, strategies are usually not comprehensive and often limited to addressing a single or limited number of factors. They suggest that because of the complex interaction of factors impacting on attraction and retention, there is a strong argument to be made for bundles of interventions which include attention to living environments, working conditions and environments and development opportunities. They further explore the organisational location of decision-making related to retention issues and suggest that because promising strategies often lie beyond the scope of human resource directorates or ministries of health, planning and decision-making to improve retention requires multi-sectoral collaboration within and beyond government. The paper provides a simple framework for bringing the key decision-makers together to identify factors and develop multi-facetted comprehensive strategies.There are no set answers to the problem of attraction and retention. It is only through learning about what works in terms of fit between problem analysis and strategy and effective navigation through the politics of implementation that any headway will be made against the almost universal challenge of staffing health service in remote rural areas. In recent years major initiatives have been launched to tackle health and inequalities in access to health. These include the Millennium Development Goals initiative and programmes to combat the major priority diseases . However for these relatively well-financed initiatives to bear fruit, they require effective, efficient and equitably provided health services. The health workforce has been identified as the key to effective health services ,2. At thJoint Learning Initiative in recent years [The work conducted by the nt years  has confThe maldistribution of personnel has its roots in long-standing global inequalities. It has been aggravated more recently by the disintegration of health systems in low-income countries and by the global policy environment ,5,6. OneThe inequitable distribution of health professionals found between countries is mirrored within countries. Most countries display serious disparities between levels of care and between urban and rural areas. In Bangladesh, for example, four metropolitan districts have 35% of all doctors but only 14.5% of the country's population , and which strategies to improve attraction and retention are therefore likely to be successful. It is the aim of this review article to explore the links between attraction and retention factors and strategies, with a particular focus on the organisational diversity and location of decision-making.The discussion of attraction and retention factors and strategies falls within the broad scope Human Resource Management (HRM) as a strategic and coherent approach to managing staff of an organisation . HRM covThis review article focuses on the lower end of the hierarchy of wealth described by Padarath and colleagues and picks up on Buchan's suggestions of complex interactions between factors impacting on attraction and retention of health workers in remote rural areas in within mid and low income countries and a consequent need for bundles of HRM strategies to improve the latter. We take this one step further by exploring the organisational location of the key decision-makers with particular reference to the public sector. Taking stock of the current knowledge in this area will hopefully contribute to the on-going learning process in this somewhat neglected area and support further research on how the remote rural areas can be better staffed with health workers in the future.To find out what is already known about attraction and retention a review of the current literature was conducted.The majority of the literature on the factors behind geographical distribution of staffing originates from industrialised countries. We therefore had to draw substantially on that literature, but where possible we have used experiences from MLICs. We recognise that the MLIC literature also covers a wide range of situations related to income levels, geographic locations, indigenous labour markets and balance of type of employer, making it more challenging to draw conclusions of universal relevance.Because of our desire to capture as much literature as possible focussing on MLIC, and to provide a textured and rich review of factors and strategies, we opted for a narrative rather than systematic review method, using an iterative approach to finding new literature.staff retention, retention in rural areas, retention in low-income countries, turnover, medically underserved area, job satisfaction. These terms were searched by themselves and in conjunction with professional classifications: health workers, nurses, doctors, mid-level workers. In addition, we conducted a systematic search of pertinent journals, including the Australian Journal of Rural Health, Health Services Research, Human Resources for Health, the Journal of Rural Health, and Rural Remote Health, and included unpublished literature (using authors' knowledge of the field). Lastly, we used a snow-balling approach to identifying further literature from the reference lists in relevant journal articles. Our search initially included articles focussing on high- and low-income countries, but was then honed down to focus on low-income countries. About 600 papers were initially assessed and 55 eventually included in the review.Document searches were conducted in a number of ways. We conducted Pubmed searches using the following search terms: The extent to which health workers can be attracted to and retained in remote areas depends on two interrelated aspects: the factors which contribute to health workers' decisions to accept and the stay in a remote post; and the strategies employed by governments to respond to such factors.There are many different theories and models coming from different disciplines which attempt to categorise and explain the factors impacting on workforce mobility. Some of these, such as the Neoclassic Wage Theory, suggest that the choice is driven largely by financial motives  and by tBoth push and pull factors impact on the individual who makes a decision about moving to, leaving or staying in a job in many different ways. Any decision by an individual will be the result of a complex interplay between these factors. For the purposes of analysis and strategy development it is helpful for policy-makers and managers to have some way of organising the different factors. We have done this by grouping the different types of environment surrounding the individual  who are easier to attract and retain.3. Change the nature of service delivery or, if necessary, stop providing it.4. Develop alternative service delivery systems .In this paper we limit ourselves to consideration of option 1, linked to the preceding analysis of factors affecting attraction and retention. The type of strategies for improving attraction to and retention in remote rural areas fall into four broad categories:1. Recruitment and training for rural practice.2. The use of incentives and compulsory services.3. Improving working conditions.4. Improving living conditions.Documented strategies within these broad categories have been either employed individually or in bundles.Targeted recruitment and selection, the location and content of training programmes, as well as opportunities for continuing education are commonly used strategies.The Government of Thailand, for example, has had considerable success in improving equitable access to healthcare throughout the country over the last four decades, and rural recruitment, in combination with rural location of training, has played an important role. Locally recruited and trained health workers are better equipped for their and prepared for living in remote areas. Nurses, midwives, junior sanitarians and other paramedics are recruited and trained locally, assigned to placements in their home towns and licensed to serve in the public sector alone ,45.Education for Health and the Journal of Rural and Remote Health supports this finding. While an extensive literature exists which concerns itself with strategies to making health professions education more appropriate, very few studies report on the impact of educational changes on long-term professional choices and behaviours.In African countries a number of governments have taken steps to open new medical schools which introduce problem-solving, student focussed and community-based approaches to medical education. Examples can be found in Ethiopia, Ghana and Kenya . HoweverCountries have employed a number of different forms of incentives and compulsory service, either on their own or in combination to attract or compel health workers to work in rural areas.Indonesia, for example, employed a combination of compulsory service, preferential access to training and financial incentives for working in remote areas. Doctors working in remote areas are able to earn double the salary of doctors working in urban areas, a difference, however, which is virtually eliminated by better additional earning opportunities in urban areas. They also increased their chances for being recruited into the prestigious civil service which provides state-subsidised specialist training. Preparedness to serve in remote areas increased with the introduction of this incentive, more substantially among graduates from schools from remoter areas, and less so among women with children .In Thailand, students recruited by the Ministry of Public Health receive heavily subsidised tuition and free clothing, room and board, and learning materials during their studies in return for carrying out compulsory public health service – usually in remote areas – after graduation ,45.In South Africa the Ministry of Health introduced compulsory service as well as financial incentives to address inequities in the distribution of health personnel, the rural and scarce skills allowances. While the financial incentives appear to have influenced some health workers to change their short-term career plans, staffing of the most rural hospitals remains a problem, and hospitals in remote rural areas remain without doctors .Zambia has recently introduced a package of measures to attract doctors to and retain them in remote rural areas . The pacMany Latin American countries have made use of compulsory rural service, particularly for medical doctors, for many years. Mexico set up the first such programme in 1936. Cavender and Alban revisited the Ecuadorian programme, established in 1970, in the late 1990s . They foOther writers argue that bonding and compulsory service arrangements are fraught with problems, as they are difficult to enforce, easy to undermine and most countries lack the administrative capacity and the political will to enforce such a system ,49. TheyThere is very limited evidence of strategies aimed at improving working conditions and job satisfaction, although a number of studies discuss the benefits of introducing participatory management and flexibility in US institutions ,50-52.One exception is the introduction of supportive supervision, which has led to improved motivation in a number of countries, thus potentially impacting on decisions to stay. Case studies in a number of countries, including Papua New Guinea and the Phillippines found that supervision improved not only work satisfaction but also performance and quality of care in remote settings ,54. ThesWhile the literature in many cases shows a correlation between quality of living conditions and willingness to move to or stay in a particular area, there is much less evidence in the literature that this knowledge has led to systematic and wide-spread efforts to improve living conditions in areas that struggle to attract or retain staff. An exception is Thailand which invested heavily in general rural infrastructure as part of its extensive district development programme: staff housing at rural district hospitals became a priority, as did basic infrastructure such as roads, phones, water supplies and radio communication. Nitayarumphong et al. acknowledge, however that despite these efforts, "living conditions in most of the rural districts are still very different from those of the central districts in terms of education, communication and transportation. This is still the limitation of health manpower distribution to rural areas ."The Zambian Health Worker Retention Scheme – piloted initially for doctors – has included refurbishment of government housing and school fees to allow staff to send their children away for better education in the retention package . HoweverIf the staffing of rural and remote areas is to be improved, strategies employed by government structures have to address the factors which impact on attraction and retention in a given context. We have not been able to find evidence in the literature that, having identified the factors impacting on attraction and retention, government employers developed appropriate HRM strategies in direct response to such findings. From the literature review, it is evident that certain strategies, such as targeted recruitment and training as well as incentives and compulsion are frequently reported. However, strategies which address immediate living environments are less commonly described in the literature, even though such strategies would be investments not only for the health sector but for the entire population. Interestingly, the literature also reports little evidence of strategies which address management and working conditions at the work place, although the importance of the immediate working environment on attraction and retention has been identified in numerous studies.What can explain this mismatch? There are likely to be a number of reasons, amongst them the fact that in many countries health planning does not have a good track record of being evidence based. Furthermore, human resource managers often lack the knowledge and skills and sometimes the authority to improve local working conditions in an environment where the political will to address retention issues remains weak. Another possible explanation may lie in the fact that the factors identified fall within the decision-making powers of a number of different government ministries. If mapped onto Figure The empirical evidence suggests that, with a few exceptions, strategies are not comprehensive and often limited to a single or limited number of factors. If however, as the evidence suggests, "no single intervention is likely to provide a sustainable solution to all workforce challenges facing an organisation ," there Firstly, because of the complexity of attraction and retention, there is a strong argument to be made for bundles of interventions. At present there is little documented evidence of such 'bundles' in middle and low income countries. Those exceptions that do exist, such as Thailand and Indonesia, seem to indicate that the introduction of bundles of compulsion and incentives appear to mostly have found favour in periods of political transformation, with the assistance of substantial political backing. More recently Zambia has seen bundles of interventions in their health worker retention scheme which includes financial incentives and career development opportunities in addition to those mentioned earlier.Secondly, the elements of the bundles needed are diverse , as are the decision-makers in charge of influencing such elements . GivThe staffing of public sector health facilities in remote rural areas is a serious challenge for many ministries of health. There are HRM strategies for addressing difficulties in attraction and retention, though their effectiveness will depend on a number of steps. First, the analysis of the factors determining attraction and retention. The knowledge about these factors in MLICS is quite well developed. Second, the identification of HRM strategies – usually a bundle of strategies – to respond appropriately to the problems. Much less is known about what individual strategies work in MLICS – and this is further complicated by lack of knowledge about what is the best mix in a bundle. Those are what could be considered the 'technical' steps. The political steps – usually by far the hardest to address – involve bringing the key decision-makers together to form a coherent strategy. An important precursor is to identify who all the key actors are. This paper has provided a simple framework to start that process. What is now needed is more research and further evidence on processes of identification and implementation of HRM strategies to improve attraction and retention, long-term sustainability of such strategies, and the impacts on staffing in remote areas. There are no set answers to the problem of attraction and retention. It is only through learning about what works in terms of fit between problem analysis and strategy and effective navigation through the politics of implementation that any headway will be made against the almost universal challenge of staffing health service in remote rural areas.The author(s) declare that they have no competing interests.UL and TM conceived of the article and had primary responsibility for the initial draft of the manuscript. UL, TM and MD all contributed substantially to the methods, intellectual content of the review, and writing and finalisation of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here: