Developing attributes and attribute-levels for a discrete choice experiment on preference for primary healthcare providers among urban slum dwellers in Bangladesh

Abstract Background Due to rapid urbanization, in many low- and middle-income countries (LMICs), urban primary healthcare (PHC) systems are not compatible with meeting the growing need for healthcare services. However, limited research exists on what patients consider important when seeking PHC services from various types of providers in LMICs like Bangladesh. This study aimed to identify and prioritise attributes to develop a discrete choice experiment (DCE) intended to elicit PHC preferences among people living in the slums of Dhaka, Bangladesh. Methods To identify and prioritise key attributes for developing choice sets for DCE in a local context, we followed a two-phase process. In the first phase, attributes were identified through: (a) a systematic review of relevant literature, (b) four focus group discussions with community members who had and had not utilised PHC services in the past year, and (c) eight key informant interviews with supply-side stakeholders. In the second phase, the attributes were reduced and refined through (d) a ranking exercise with 15 community participants, (e) one-to-one consultations with four urban health experts, and (f) pretesting the draft DCE instrument. Results The systematic review, FGDs, and KIIs together yielded a long list of 25 attributes, which was reduced to 12 for the community ranking exercise. Six attributes were finally selected for the DCE: travel time to reach a healthcare centre, waiting time, type of healthcare provider, recommendation from neighbours/relatives, consultation fee, and medicine expenditure. Attribute levels reflected the range of experiences identified in the qualitative data analysis and were refined through expert consultation and pretesting. During pretesting, comprehension of attributes and levels was found to be difficult for people with low literacy and these difficulties were addressed through revising the wording and introducing graphical Q-cards. Conclusions This study contributes to the existing literature on the development of attributes and levels for a DCE. By documenting a transparent, replicable process, this study offers researchers a practical worked example of developing DCE attributes in understudied low-income urban settings.