ABSTRACT: It is widely accepted that healthcare-seeking behaviour is neither limited to nor terminated by access to one single healthcare provider. Yet the sequential conceptualisation of healthcare-seeking processes has not diffused into quantitative research, which continues to analyse healthcare access as a "one-off" event. The ensuing lack of understanding healthcare behaviour is problematic in light of the immense burden of premature death especially in low- and middle-income countries. This paper presents an alternative approach. Based on a novel survey instrument, we analyse original survey data from rural India and China that contain 119 unique healthcare pathways among 637 respondents. We offer three applications of how such sequential data can be analysed to enhance our understanding of people's health behaviour. First, descriptive analysis of sequential data enables more a comprehensive representation of people's health behaviours, for example the time spent in various healthcare activities, common healthcare pathways across different groups, or shifts in healthcare provider access during a typical illness. Second, by analysing the effect of mobile technology on healthcare-seeking process characteristics, we demonstrate that conventional, sequence-insensitive indicators are potentially inconsistent and misleading approximations when compared to a more precise, sequence-sensitive measure. Third, we describe how sequential data enable transparent and flexible evaluations of people's healthcare behaviour. The example of a sequence-insensitive evaluation suggests that household wealth has no statistical link to an illustrative "ideal" form of public healthcare utilisation. In contrast, sequence-sensitive evaluations demonstrate that household wealth is associated with an increased likelihood of bypassing referral processes and approaching unregulated and costly informal and private practitioners before accessing a public clinic. Sequential data therefore do not only reveal otherwise neglected locational idiosyncrasies, but they also yield deeper insights into the drivers of people's health behaviours compared to a conventional approach to "access to healthcare."
Project description:Antimicrobial resistance (AMR) is a global health priority. Leading UK and global strategy papers to fight AMR recognise its social and behavioural dimensions, but current policy responses to improve the popular use of antimicrobials (eg, antibiotics) are limited to education and awareness-raising campaigns. In response to conceptual, methodological and empirical weaknesses of this approach, we study people's antibiotic-related health behaviour through three research questions.RQ1: What are the manifestations and determinants of problematic antibiotic use in patients' healthcare-seeking pathways?RQ2: Will people's exposure to antibiotic awareness activities entail changed behaviours that diffuse or dissipate within a network of competing healthcare practices?RQ3: Which proxy indicators facilitate the detection of problematic antibiotic behaviours across and within communities?We apply an interdisciplinary analytical framework that draws on the public health, medical anthropology, sociology and development economics literature. Our research involves social surveys of treatment-seeking behaviour among rural dwellers in northern Thailand (Chiang Rai) and southern Lao PDR (Salavan). We sample approximately 4800 adults to produce district-level representative and social network data. Additional 60 cognitive interviews facilitate survey instrument development and data interpretation. Our survey data analysis techniques include event sequence analysis (RQ1), multilevel regression (RQ1-3), social network analysis (RQ2) and latent class analysis (RQ3).Social research in AMR is nascent, but our unprecedentedly detailed data on microlevel treatment-seeking behaviour can contribute an understanding of behaviour beyond awareness and free choice, highlighting, for example, decision-making constraints, problems of marginalisation and lacking access to healthcare and competing ideas about desirable behaviour.NCT03241316; Pre-results.
Project description:In recent years, supported by non-governmental organizations (NGOs), a number of community-based health insurance (CBHI) schemes have been operating in rural India. Such schemes design their benefit packages according to local priorities. This paper examines healthcare seeking behaviour among self-help group households with a view to understanding the implications for the benefit packages offered by such schemes.We use cross-sectional data collected from two of India's poorest states and estimate an alternative-specific conditional logit model to examine healthcare seeking behaviour.We find that the majority of respondents do access some form of care and that there is overwhelming use of private providers. Non-degree allopathic providers (NDAP) also called rural medical practitioners are the most popular providers. In the case of acute illnesses, proximity plays an important role in determining provider choice. For chronic illnesses, cost of care influences provider choice.Given the importance of proximity in determining provider choice, benefit packages offered by CBHI schemes should consider coverage of transportation costs and reimbursement of foregone earnings.
Project description:BACKGROUND: WHO recommends prompt diagnosis and quinine plus clindamycin for treatment of uncomplicated malaria in the first trimester and artemisinin-based combination therapies in subsequent trimesters. We undertook a systematic review of women's access to and healthcare provider adherence to WHO case management policy for malaria in pregnant women. METHODS AND FINDINGS: We searched the Malaria in Pregnancy Library, the Global Health Database, and the International Network for the Rational Use of Drugs Bibliography from 1 January 2006 to 3 April 2014, without language restriction. Data were appraised for quality and content. Frequencies of women's and healthcare providers' practices were explored using narrative synthesis and random effect meta-analysis. Barriers to women's access and providers' adherence to policy were explored by content analysis using NVivo. Determinants of women's access and providers' case management practices were extracted and compared across studies. We did not perform a meta-ethnography. Thirty-seven studies were included, conducted in Africa (30), Asia (4), Yemen (1), and Brazil (2). One- to three-quarters of women reported malaria episodes during pregnancy, of whom treatment was sought by >85%. Barriers to access among women included poor knowledge of drug safety, prohibitive costs, and self-treatment practices, used by 5%-40% of women. Determinants of women's treatment-seeking behaviour were education and previous experience of miscarriage and antenatal care. Healthcare provider reliance on clinical diagnosis and poor adherence to treatment policy, especially in first versus other trimesters (28%, 95% CI 14%-47%, versus 72%, 95% CI 39%-91%, p = 0.02), was consistently reported. Prescribing practices were driven by concerns over side effects and drug safety, patient preference, drug availability, and cost. Determinants of provider practices were access to training and facility type (public versus private). Findings were limited by the availability, quality, scope, and methodological inconsistencies of the included studies. CONCLUSIONS: A systematic assessment of the extent of substandard case management practices of malaria in pregnancy is required, as well as quality improvement interventions that reach all providers administering antimalarial drugs in the community. Pregnant women need access to information on which anti-malarial drugs are safe to use at different stages of pregnancy. Please see later in the article for the Editors' Summary.
Project description:This paper examines the experiences of seeking healthcare for rural Chinese older people, a population who experiences the multiple threats of socio-economic deprivation, marginalization, and lack of access to medical care, yet have been relatively overlooked within the existing scholarly literature. Based on ethnographical data collected from six-month fieldwork conducted in a rural primary hospital in Southern China, this paper identifies a widespread discouraging, dispiriting attitude regarding healthcare-seeking for rural older members despite the ongoing efforts of institutional reforms with a particular focus on addressing access to health services amongst rural populations. Such an attitude was expressed by older people's families as well as the public in their narratives by devaluing older members' health care demands as "unworthy of care and treatment" ("buzhide zhi" in Chinese). It was also internalized by older people, based on which they deployed a family-oriented health-seeking model and strategically downgraded their expectation on receiving medical care. Moreover, underpinning this discouragement and devaluation, as well as making them culturally legitimate, is the social expectation of rural older people to be enduring and restrained with health-seeking. Simultaneously, this paper highlights the sourc2e of institutional and structural impediments, as they intersect with unfavorable socio-cultural values that normalize discouragement and devaluation.
Project description:Background:Saudi Arabia's healthcare sector is growing at a hasty stride; nevertheless, the quality of healthcare consumption remains challenged by the growing caseload in free public health facilities. Insurance could ease this pressure by moving some healthcare demand to private facilities conditional on its ability to enact health-seeking behaviour. These potential effects remain under-investigated. Therefore, the aim of this study was to investigate whether health insurance nudges health-seeking behaviour using data from Saudi Arabia. Materials and Methods:The study used nationally representative secondary data, obtained from the Family Health Survey, conducted in 2018, in Saudi Arabia. Health-seeking behaviour was measured by individual attendance of medical check-up. To account for endogeneity due to non-random selection of individuals into insurance, the analysis employed the inverse propensity weighting and the instrumental variables methods. Results:The results revealed that health insurance leads to increased chances of going for medical check-up. The effects are higher amongst non-Saudi nationals relative to citizens. Furthermore, people who purchase personal health insurance schemes are more likely to go for checks-ups, followed by individuals provided by the private sector and government sector. Finally, the study found that insurance positively nudges hypertension, diabetes, and cholesterol specific medical check-ups. Conclusion:The findings indicated the need for health policy to increase access to health insurance in Saudi Arabia. A notable policy response is the introduction of national health insurance coverage, which has already proven in other countries as an effective measure to attain universal access to improved health. Nevertheless, results from this study highlighted variations in demand for health seeking based on type of insurance with highest returns in personal insurance. Policy should leverage on this behaviour response by introducing insurance packages that share premiums with citizens to incentivise utilisation. The results can also be used to design policy responses to demand for insurance, in the entire Arabian Gulf region, since these countries have similar health financing mechanism with Saudi Arabia.
Project description:BACKGROUND:Primary healthcare services must respond to the healthcare-seeking needs of persons with a wide range of personal and social characteristics. In this study, examined whether socially vulnerable persons exhibit lower abilities to access healthcare. First, we examined how personal and social characteristics are associated with the abilities to access healthcare described in the patient-centered accessibility framework and with the likelihood of reporting problematic access. We then examined whether higher abilities to access healthcare are protective against problematic access. Finally, we explored whether social vulnerabilities predict problematic access after accounting for abilities to access healthcare. METHODS:This is an exploratory analysis of pooled data collected in the Innovative Models Promoting Access-To-Care Transformation (IMPACT) study, a Canadian-Australian research program that aimed to improve access to primary healthcare for vulnerable populations. This specific analysis is based on 284 participants in four study regions who completed a baseline access survey. Hierarchical linear regression models were used to explore the effects of personal or social characteristics on the abilities to access care; logistic regression models, to determine the increased or decreased likelihood of problematic access. RESULTS:The likelihood of problematic access varies by personal and social characteristics. Those reporting at least two social vulnerabilities are more likely to experience all indicators of problematic access except hospitalizations. Perceived financial status and accumulated vulnerabilities were also associated with lower abilities to access care. Higher scores on abilities to access healthcare are protective against most indicators of problematic access except hospitalizations. Logistic regression models showed that ability to access is more predictive of problematic access than social vulnerability. CONCLUSIONS:We showed that those at higher risk of social vulnerability are more likely to report problematic access and also have low scores on ability to seek, reach, pay, and engage with healthcare. Equity-oriented healthcare interventions should pay particular attention to enhancing people's abilities to access care in addition to modifying organizational processes and structures that reinforce social systems of discrimination or exclusion.
Project description:OBJECTIVES:To examine the associations of parental social and economic position with health-seeking behaviour for diarrhoea and acute respiratory infection (ARI) among under-5 children in Myanmar and explore potential underlying mechanisms. DESIGN:A cross-sectional study. SETTING:A secondary dataset from the nationwide 2015-2016 Myanmar Demographic and Health Survey (MDHS). PARTICIPANTS:All under-5 children in the sampled households with reported symptoms of diarrhoea and ARI during the 2-week period preceding the MDHS survey interview. PRIMARY AND SECONDARY OUTCOME MEASURES:Four parental health-seeking behaviours: 'seeking treatment', 'formal health provider', 'public provider' and 'private provider' were considered. Social and economic positions were determined by confirmatory factor analysis. Multilevel logistic regressions were employed to examine the associations of social and economic positions with health-seeking behaviours for diarrhoea and ARI. Mediation analyses were conducted to explore potential underlying mechanisms in these associations. RESULTS:Of the 4099 under-5 children from the sampled households in MDHS, 427 (10.4%) with diarrhoea and 131 (3.2%) with ARI were considered for the analyses. For diarrhoea, social position was positively associated with seeking treatment and private provider use (adjusted OR: 1.60 (95% CIs: 1.07 to 2.38) and 1.83 (1.00 to 3.34), respectively). Economic position was positively associated with private provider use for diarrhoea (1.57 (1.07 to 2.30)). Negative associations were observed between social and economic positions with public provider use for diarrhoea (0.55 (0.30 to 0.99) and 0.64 (0.43 to 0.94), respectively). Social position had more influence than economic position on parental health-seeking behaviour for children with diarrhoea. No evidence for a significant association of social and economic position with health-seeking for ARI was observed. CONCLUSIONS:Social and economic positions were possible determinants of health-seeking behaviour for diarrhoea among children; and social position had more influence than economic position. The results of this study may contribute to improve relevant interventions for diarrhoea and ARI among children in Myanmar.
Project description:BACKGROUND:Studies report that vulnerable groups like people with disabilities have less access to healthcare. This study compares health service access between women with and without disabilities in general and explores the challenges encountered by women with disabilities in accessing maternal healthcare services during pregnancy. METHODS:A mixed method study was conducted in Rupandehi district of Nepal implementing a cross-sectional survey among 354 women including 79 women with disabilities, supplemented by 43 in-depth interviews. Descriptive and bivariate statistical analysis of quantitative data using Pearson's Chi-square test for association was carried out, while qualitative data were analysed following the theme content analysis using a framework approach. RESULTS:The vast majority of women from both groups, women with and without disabilities (71% vs 74%) reported that the nearest health facility from their location was more than 30 minutes walking distance (P>0.05). Half of the women with disabilities walked to health facilities for ANC check-ups. Over one-third of women without disabilities and a slightly lesser proportion of women with disabilities (29%) used a low-cost means of transport (rikshaw, bi/tri-cycles) (P>0.05). Distribution of health facilities found uneven and poorly linked with road transport facilities. None of the health facilities accommodated the needs of women with disabilities with accessible buildings and convenient opening time. The travel cost and the extra cost of services, staff shortage, often delayed and inadequate drug supplies were common problems for both women with and without disabilities. Unavailability of beds during delivery, insensitive providers with negative attitudes and abusive behaviour, inadequate knowledge and experience in providing services to the people with disabilities as well as unwelcoming health facility environment made services particularly inaccessible to women with disabilities. CONCLUSION:Maternal healthcare services are not easily and equitably accessible to women with disabilities. To increase access to healthcare for this vulnerable group, improvements are needed in distribution and management of resources from transportation through service delivery, as well as improved provider knowledge and awareness of a human rights approach to disability and health.
Project description:Creating better access to good quality healthcare for the poor is a major challenge to development. In this study, we examined inter-linkages between poverty and disease, referred to as poverty-related diseases (PRDs), by investigating how Cameroon Development Corporation (CDC) camp dwellers respond to diseases that adversely affect their health and wellbeing. Living in plantation camps is associated with poverty, overcrowding, poor sanitation and the rapid spread of diseases. In a survey of 237 CDC camp dwellers in Cameroon, we used the health belief model to understand the drivers (perceived threats, benefits and cues for treatment seeking) of reported responses. Using logistic regression analysis, we looked for trends in people's response to malaria. We calculated the odds ratio of factors shown to have an influence on people's health, such as food, water, sanitation challenges and seeking formal healthcare for malaria. Malaria (40.3%), cholera (20.8%) and diarrhoea (17.7%) were the major PRDs perceived by camp dwellers. We found a strong link between what respondents perceived as PRDS and hygiene conditions. Poverty for our respondents was more about living in poor hygiene conditions than lack of money. Respondents perceived health challenges as stemming from their immediate living environment. Moreover, people employed self-medication and other informal health practices to seek healthcare. Interestingly, even though respondents reported using formal healthcare services as a general response to illness (84%), almost 90% stated that, in the case of malaria, they would use informal healthcare services. Our study recommends that efforts to curb the devastating effects of PRDs should have a strong focus on perceptions (i.e. include diseases that people living in conditions of poverty perceive as PRDs) and on hygiene practices, emphasising how they can be improved. By providing insights into the inter-linkages between poverty and disease, our study offers relevant guidance for potentially successful health promotion interventions.
Project description:BACKGROUND:A key component of universal health coverage is the ability to access quality healthcare without financial hardship. Poorer individuals are less likely to receive care than wealthier individuals, leading to important differences in health outcomes, and a needed focus on equity. To improve access to healthcare while minimizing financial hardships or inequitable service delivery we need to understand where individuals of different wealth seek care. To ensure progress toward SDG 3, we need to specifically understand where individuals seek reproductive, maternal, and child health services. METHODS:We analyzed Demographic and Health Survey data from Bangladesh, Cambodia, DRC, Dominican Republic, Ghana, Haiti, Kenya, Liberia, Mali, Nigeria, Senegal and Zambia. We conducted weighted descriptive analyses on current users of modern FP and the youngest household child under age 5 to understand and compare country-specific care seeking patterns in use of public or private facilities based on urban/rural residence and wealth quintile. RESULTS:Modern contraceptive prevalence rate ranged from 8.1% to 52.6% across countries, generally rising with increasing wealth within countries. For relatively wealthy women in all countries except Ghana, Liberia, Mali, Senegal and Zambia, the private sector was the dominant source. Source of FP and type of method sought across facilities types differed widely across countries. Across all countries women were more likely to use the public sector for permanent and long-acting reversible contraceptive methods. Wealthier women demonstrated greater use of the private sector for FP services than poorer women. Overall prevalence rates for diarrhea and fever/ARI were similar, and generally not associated with wealth. The majority of sick children in Haiti did not seek treatment for either diarrhea or fever/ARI, while over 40% of children with cough or fever did not seek treatment in DRC, Haiti, Mali, and Senegal. Of all children who sought care for diarrhea, more than half visited the public sector and just over 30% visited the private sector; differences are more pronounced in the lower wealth quintiles. CONCLUSIONS:Use of the private sector varies widely by reason for visit, country and wealth status. Given these differences, country-specific examination of the role of the private sector furthers our understanding of its utility in expanding access to services across wealth quintiles and providing equitable care.