Profile and client satisfaction among clients of Integrated Counselling and Testing Centre for human immunodeficiency virus in Delhi

Background: Integrated Counseling and Testing Centre (ICTC) is a place where a person is counseled and tested for human immunodefi ciency virus (HIV) and also a key entry point to the prevention of HIV infection and treatment of HIV infected people. The ICTC services are cost-effective and noncoercive intervention in the prevention of HIV/AIDS. The satisfaction of the clients availing these services indicates the quality of the services provided. Objective: The objective was to study the profi le and satisfaction of clients attending counseling services of integrated counseling and testing centers in Delhi. Materials and Methods: The study was a descriptive, cross-sectional, health facility based study. The study was done in 20 ICTCs of Delhi. The ICTCs were chosen on the basis of population proportion to size. Consecutive sampling method was followed for recruiting the clients. After obtaining written consent, exit interview of 300 clients was undertaken. Results: Among 300 clients, 204 (68%) were males, and 96 (32%) were females. Majority, 267 (89%) of the clients were staying with family and 33 (11%) were staying with friends/roommates. The total number of referred clients was 270 (90%) and self-referred or direct walk-in client was 30 (10%). Among the direct walk-in/self-referred clients, 12 (40%) clients were recommended by their friends to come, 4 (13.3%) clients seek to avail ICTC services because of high risk behavior and 14 (46.7%) clients wanted to get tested for HIV as their spouse was HIV positive. About 96.3% of the clients who attended the counseling services were found to be satisfi ed. Conclusion: The proportion of self-referred/direct walk-in clients was very low, and low level of awareness about the HIV test and counseling services was found among the clients. This refl ects the need to enhance the efforts directed at increasing the awareness of HIV test and counseling services. The satisfaction of clients could be further improved by better counseling sessions.


INTRODUCTION
Human immunodefi ciency virus (HIV) is a global pandemic and has been a serious public health concern due to its soaring magnitude.In India, HIV continues as a notable health problem with an adult prevalence of 0.31%. [1]HIV counseling and testing services are key entry point in prevention of HIV infection, treatment and care of people who are infected with HIV.When availing counseling and testing services, people can access accurate information about HIV prevention and undergo HIV test in a supportive and confi dential environment. [2]In most of the developed countries, assessing patient satisfaction has been a part of evaluation of health care delivery system. [3]In India, studies have been done on patients satisfaction in directly observed treatment short course (DOTS) center and primary health care settings. [4]Patient satisfaction is an patient perspective that refl ects the quality of health services. [3]Measuring patient satisfaction would help in assessment of performance of health care service delivery. [5]The present study was undertaken to interview the clients who were availing the counseling services.The objective was to study the profi le and satisfaction of clients attending counseling services in integrated counseling and testing centers in Delhi.

Study population
The study was conducted in integrated Counseling and Testing Centers (ICTCs) of Delhi, India.There were 75 ICTCs in public health sector of Delhi at the time of the study (as of March 2011).This is excluding 16 Prevention of Parent to Child Transmissions, which were exclusively for antenatal clients and were having separate reporting system with the State AIDS Control Society.The clients attending the ICTCs were the study population.

Study design and sampling
The study was a descriptive, cross-sectional, facility based study.Twenty ICTCs out of 75 ICTCs were selected on the basis of probability proportion to size, that is on the basis of number of clients' catered by ICTCs in the year 2011.Sample size was calculated taking the prevalence of 90% client satisfaction found in previous study. [6]To reduce the homogeneity of responses of the clients from the selected 20 ICTCs, design effect was used allowing the cluster design structure of ICTCs.A nonresponse rate of 5% was expected (based on response obtained during pilot study) and was considered during the sample size calculation.The calculated sample size was 300.Hence, 20 clients per selected ICTCs were interviewed.

Data collection tool
The study instrument used in the study was tools for evaluating HIV voluntary counseling and testing by UNAIDS. [7]In the study tool, client satisfaction component was used for assessing client satisfaction.This tool was a generic tool, which had been standardized and validated.The tool for assessing client satisfaction was modifi ed with addition of Likert scale with eight statements.Relevant sociodemographic details of clients were also collected.The client satisfaction questionnaire was translated into local language (Hindi).This was back translated to English by another person.

Data collection procedure
Pretesting of the questionnaire was done in 45 clients in two ICTCs, which were not part of main study and corrections were made.Consecutive sampling method was done for selecting clients, as the interview of the clients was done in outpatient department.The clients who had attended the counseling, willing to participate in the study were included in the study.The data collection was done from January 2012 to December 2012.

Measures
For statements of client satisfaction, scoring was given on a fi ve point Likert scale (strongly disagree and disagree, neutral, agree and strongly agree).Reverse Likert scale was used for the statements that indicated dissatisfaction.The statements were given scores: 1. Disagree and strongly disagree, 2. Neutral, 3. Agree and strongly agree.
The total maximum score of eight statements were 24.The client satisfaction were graded as satisfi ed (score >16) and not satisfi ed (score <16).

Data entry and analysis
The data collected were analyzed with SPSS version 20.0 (SPSS, IBM).Questionnaires were checked for completeness and correctness before entering into the worksheet.Data validation checks were performed at a regular interval for data entered into the worksheet of Microsoft Excel (Microsoft Corporation).Signifi cance of difference in proportions (qualitative variables) was calculated using Chi-square test.Signifi cance of P value was taken if P < 0.05.

Ethical consideration
The interview was undertaken only after obtaining written consent from the clients.Confi dentiality of the clients was maintained at all points of study.There was no mention of name or complete address of the client anywhere in the interview schedule.The study was approved by Institutional Ethical Review Board of Safdarjung Hospital, New Delhi.Permission to conduct the study was obtained from project director, Delhi State AIDS Control Society, Delhi.

Sociodemographic profi le of the clients
A total of 300 clients were interviewed, among which 204 (68%) were males, and 96 (32%) were females with male:female of 2.1:1 [Table 1].There were no refusals from the clients.The age of the clients ranged from 12 years to 60 years with a mean (standard deviation)

Time spent in availing the services
The clients stated that mean time spent in locating the ICTC site was 11 min; however it ranged between 1 and 30 min.The mean time period spent in waiting to see the counselor was 17 min (5-60 min) and the mean time duration spent in the counseling session was 7 min (2-20 min).

Reason to attend integrated Counseling and Testing Centre
The total number of referred clients was 270 (90%) and selfreferred or direct walk-in clients were 30 (10%) [Figure 1].Among the direct walk-in/self-referred clients, 12 (40%) clients reported that their friends recommended them to come ICTC, 4 (13.3%)clients seek to avail ICTC services because of their high risk behavior and 14 (46.7%)clients wanted to get tested for HIV as their spouse was HIV positive.Among the facility referred clients, majority, 176 (65.2%) of the clients had been referred from tuberculosis clinic/DOTS center, followed by referral from other departments.Among the 94 (34.8%) clients referred from other departments, majority 49 (18.2%)clients were from Department of Surgery followed by Gynecology 29 (10.7%) and Medicine 16 (5.9%)Departments [Table 2].

Perspective of the clients about the counseling
Most of the clients, 291 (97%) said that they did not feel hesitant in expressing themselves to counselors, while 9 (3%) clients said that they felt hesitant or unable to express due to reasons-counselor was of opposite gender 5 (1.7) and diffi culty in understanding counselors, language 4 (1.3%).Among the clients who attended the posttest counseling, 24 (61.5%)clients said that they were able to meet the same counsellor before and after HIV testing.

Satisfaction of the clients
Two hundred and eighty nine (96.3%) clients who attended the counseling services scored >16 and were found to be satisfi ed [Table 3 and Figure 2].
The client satisfaction score was analyzed with the referral status of the clients (facility referred and self-referred) to fi nd the differences in the mean scores between the groups.However, the difference found was not statistically signifi cant (P = 0.447) [Table 4].

DISCUSSION
Among the 300 clients, only 10% (30) clients were self-referred and 90% (270) clients were facility referred/provider initiated.This fi gure is lesser than the national average [1] in which the client initiated/selfreferred were 31.4%.Similar results were found in a study done by Papanna et al. with 89% provider initiated clients. [8]The proportion of provider initiated clients in other studies varied between 11% and  50%. [9,10]Surprisingly, among the direct walk-in clients, only 13.3% visited the ICTC due to suspected high risk behavior.This compels the need of creating further awareness about HIV counseling and removing various barriers of clients in visiting ICTC.Due attention has to be paid to increase the direct walk-in clients, as the main purpose of establishment of ICTC could not be served.
The time duration spent in locating the site of ICTC ranged from 1 to 30 min with a mean time of 10 min.There is a necessity of placing guiding sign boards in ICTC location premises to guide the clients to ICTC thereby reducing any extra time spent in searching the ICTC within the health facility.The median time duration spent by clients in waiting to see the counselor was 15 min.Though this is much lesser when compared to other studies. [8,11]Recruiting additional counselor in the centers where the client load is high could be done liberally to reduce the waiting time.The duration of time spent by clients in the counseling sessions ranged from 2 to 20 min.The time spent during the counseling session could have been adequate for clients to get benefi ted fully without any unanswered doubts.This would help in reducing the high risk behaviors as well.
The client satisfaction found in the present study was 96.3%.Similar results of client satisfaction were found in some studies. [6,12]However, few studies reported low level of client satisfaction and reasons were due to untrained counselors, low education level of clients, lack of adequate spent time with the counselor, lack of trust in confi dentiality, and other barriers. [8,11,13]ough the overall client satisfaction was satisfactory (96.3%), certain issues need to be addressed including the waiting time to meet counselors and time spent during the counseling as these determine the quality of the services.Also, few clients reported that they felt hesitant in expressing themselves to the counselor of opposite sex.This suggests the mandatory requirement of both male and female counselors in all the ICTCs.

CONCLUSION
The proportion of self-referred/direct walk-in clients was very low and low level of awareness about the HIV test and counseling services was found among the clients.This refl ects the need to enhance the efforts directed at increasing the awareness of HIV test and counseling services.Though the satisfaction of clients with the counseling services was satisfactory, duration and content of the counseling session shall be improved so that all the clients receive suffi cient information during these session with the counselors.

Figure 1 :Figure 2 :
Figure 1: Distribution of clients according to the reasons for attending the counseling session at integrated Counseling and Testing Centre (n = 300) Figure 2: Distribution of statements of client satisfaction (n = 300)
ICTC = Integrated Counseling and Testing Center of 29 (

Table 2 : Reasons for attending ICTC services and their relation with sociodemographic profi le of clients
Chi-square test was applied, ICTC = Integrated Counseling and Testing Centre International Journal of Medicine and Public Health | Oct-Dec 2014 | Vol 4 | Issue 4

Table 4 : Client satisfaction scores of exit interview at ICTC
ICTC = Integrated Counseling and Testing Centre, HIV = Human immunodefi ciency virus

Table 3 : Satisfaction of the clients with counseling session at ICTC Client satisfaction statements (n = 300) Disagree Neutral Agree Frequency (%) Frequency (%) Frequency (%)
The counselor showed interest in explaining issues pertaining to HIV that I was not aware of 2 (0.7) 18 (6) 280 (93.3)During the session I was given the opportunity to ask questions and clarify my doubts ICTC = Integrated Counseling and Testing Centre, HIV = Human immunodefi ciency virus