pp1 While relevant the two original dimensions of

While relevant, the two original dimensions of patient-centeredness did not completely capture the range of PPC types participants discussed. Both qualitative and quantitative data supported the importance of the third dimension: guiding patient behaviors (“showing the path”). Participants were highly vocal in expressing opinions regarding “showing the path” in IDIs, FGDs and survey free-response items, and survey participants placed a higher relative value on their vignette preference for this dimension compared to the other two. Aspects of previous literature from sub-Saharan Africa validate the relevance of this dimension, as the “sharp talk” variation reflects the “scolding” often cited as a barrier to HIV patient retention (Dahab et al., 2008; Layer, Brahmbhatt, et al., 2014; McMahon et al., 2016). While some participants did discuss their own interruption in care and treatment as explanations for their choices, these factors were not quantitatively associated with the likelihood of choosing any particular vignette. As our data were limited to measures of preference, we cannot tell whether patients’ experiences with PPC were concordant or discordant with their stated preferences. As we found that different patients preferred different styles of guiding patient behavior, it may be that concordance with a patient’s preferred pp1 is a more important factor in retention in care than preferred style. Evidence from our qualitative work supports the notion that a more individualized approach to PPC may help patients overcome barriers to continued retention and adherence (Hurley et al., 2017). We found few significant associations between demographic characteristics and vignette preference, though education level stood out as one potentially important predictive variable. Like some studies in high-income settings, participants with higher education were more likely to indicate preference for shared power (Say et al., 2006). Yet contrary to the association reported among patients Sierra Leone (Lau et al., 2013), we found that higher education increased odds of choosing a biomedical (not high psychosocial regard) style. From a patient-centered perspective, our findings among highly educated participants are somewhat paradoxical, as shared power is characteristic of patient-centeredness, but a biomedical style contrasts with it. However, it may be that the social talk that characterizes adamadenya may help a lower educated patient feel on equal ground with the provider, but those with a higher education may already feel equal to the provider and expect a more academic style to demonstrate quality or technical competence. Further, participants who felt the PPC at their treatment center needed improvement were more likely to choose shared power and reject “sharp talk” style, suggesting that increases in shared power and decreases in “sharp talk” may improve satisfaction with PPC among these patients. Beyond these factors, no other demographic characteristics were associated with preference for any vignette. Other researchers have questioned the utility of predicting PPC preferences with demographic variables. Garfield and colleagues modeled preferences for shared decision-making with a number of demographic variables among patients in the UK and found that their model could only account for 14% of the variance in preference (Garfield, Smith, Francis, & Chalmers, 2007). These and our present findings suggest that providers should be wary of making assumptions about PPC preferences based on a demographic profile. The “no preference” responses and their significant association with lower education deserve reflection. It possible that participants who offered “no preference” responses did not fully understand the task. Some free responses suggest that many did not feel empowered to express a choice. Some seemed to consider the provider authority unquestionable, and thought it was strange that we were asking their opinion on provider behavior. If lack of empowerment is a viable explanation, these “no preference” responses hold significance beyond survey validity. In the environment of a health facility, participant reluctance to offer opinions signals a need for patient empowerment in addition to improvements in provider communication skills, especially considering the positive relationship between active patient involvement and ART adherence (Chen et al., 2014; Ironson, Lucette, & McIntosh, 2015). One model intervention in Namibia reported increased question-asking and decreased fear among ART patients who underwent a communication empowerment training (Maclachlan, Potter, et al., 2016; Maclachlan, Shepard-Perry, et al., 2016).