Development, validation & pilot testing of a questionnaire to assess healthcare seeking behaviour, healthcare service utilization & out-of-pocket expenditure of Particularly Vulnerable Tribal Groups of Odisha, India

Background & objectives: Assessing healthcare seeking behaviour (HSB), healthcare utilization and related out-of-pocket expenditures of Particularly Vulnerable Tribal Groups (PVTGs) of India through a prism of the health system may help to achieve equitable health outcomes. Therefore, this comprehensive study was envisaged to examine these issues among PVTGs of Odisha, India. However, there exists no validated questionnaire to measure these variables among PVTGs. Therefore, a study questionnaire was developed for this purpose and validated. Methods: Questionnaire was constructed in four phases: questionnaire development, validity assessment, pilot testing and reliability assessment. Nine domain experts face validated questionnaire in two rounds, followed by a single round of quantitative content validity. Next, the questionnaire was pretested in three rounds using cognitive interviews and pilot-tested among 335 and 100 eligible individuals for the two sections healthcare seeking behaviour (HSB-Q) and maternal and child healthcare service utilization (MCHSU-Q). Internal consistency reliability was assessed for de novo HSB-Q. Results: On two rounds of expert-driven face validity, 55 items were eliminated from 200 items. Questionnaire showed moderate to high content validity (item-level content validity index range: 0.78 to 1, scale-level content validity index/universal agreement: 0.73; scale-level content validity index/average: 0.96 and multirater kappa statistics range: 0.6 to 1). During the pre-test, items were altered until saturation was achieved. Pilot testing helped to refine interview modalities. The Cronbach alpha and McDonald’s omega assessing internal consistency of HSB-Q were 0.8 and 0.85, respectively. Interpretation & conclusions: The questionnaire was found to be valid and reliable to explore healthcare seeking behaviour, maternal and child healthcare utilization and related out-of-pocket expenditure incurred by PVTGs of Odisha, India.

COVID-19: Parents’ Healthcare-Seeking Behaviour for their Sick Children in Nigeria - An Online Survey

Introduction: The current COVID-19 pandemic has greatly affected the wellbeing of children,either directly or through the effects of the response. Measures are in place to curb the spread of the virus in Nigeria, but little is known of the effect these stringent measures have on the healthcare-seeking behaviour of parents for their sick children.Aim:This survey sought to describe parents’ healthcare-seeking behaviour for their sick children during the COVID-19 lockdown in Nigeria.Study Design: Descriptive cross-sectional.Methods:A cross-sectional survey was conducted among Nigerian parentswith children less than 18 years of age, via an online Google doc questionnaire administered through WhatsApp instant messaging. Using snowball sampling technique, 260 respondents from affected Nigerian states were recruited over one month. Chi-square tested differences between variables in assessing if healthcare-seeking behaviour was affected; statistical significance level was set at p-value <0.05.Results:The median age was 38 years (IQR:9); 155 (59.7%) were females, 167 (64.2%) had tertiary education, while 83 (31.9%) had low income. Half (50%) of the respondents cited that the lockdown had affected their healthcare-seeking behaviour for their sick children; this did not significantly differ by geopolitical zone of residence (χ2=3.90, p-value=0.42), and other variables. Thirty-seven 37 (14.3%) agreed their children couldn’t get routine immunizations as scheduled.Conclusion:The COVID-19 pandemic lockdown considerably affected parents’ healthcare-seeking behaviour for their sick children in Nigeria. Contextual strategies aimed at health system strengthening and improved accessibility are needed to mitigate the effect of COVID-19 on parental access and utilization of healthcare facilities

Financial Incentives and Maternal Health: Where Do We Go from Here.

Health financing strategies that incorporate financial incentives are being applied in many low- and middle-income countries, and improving maternal and neonatal health is often a central goal. As yet, there have been few reviews of such programmes and their impact on maternal health. The US Government Evidence Summit on Enhancing Provision and use of Maternal Health Services through Financial Incentives was convened on 24-25 April 2012 to address this gap. This article, the final in a series assessing the effects of financial incentives—performance-based incentives (PBIs), insurance, user fee exemption programmes, conditional cash transfers, and vouchers—summarizes the evidence and discusses issues of context, programme design and implementation, cost-effectiveness, and sustainability. We suggest key areas to consider when designing and implementing financial incentive programmes for enhancing maternal health and highlight gaps in evidence that could benefit from additional research. Although the methodological rigor of studies varies, the evidence, overall, suggests that financial incentives can enhance demand for and improve the supply of maternal health services. Definitive evidence demonstrating a link between incentives and improved health outcomes is lacking; however, the evidence suggests that financial incentives can increase the quantity and quality of maternal health services and address health systems and financial barriers that prevent women from accessing and providers from delivering quality, lifesaving maternal healthcare.

Healthcare-seeking Behaviour among the Tribal People of Bangladesh: Can the Current Health System Really Meet Their Needs.

Despite the wealth of studies on health and healthcare-seeking behaviour among the Bengali population in Bangladesh, relatively few studies have focused specifically on the tribal groups in the country. This study aimed at exploring the context, reasons, and choices in patterns of healthcare-seeking behaviour of the hill tribal population of Bangladesh to present the obstacles and challenges faced in accessing healthcare provision in the tribal areas. Participatory tools and techniques, including focus-group discussions, in-depth interviews, and participant-observations, were used involving 218 men, women, adolescent boys, and girls belonging to nine different tribal communities in six districts. Data were transcribed and analyzed using the narrative analysis approach. The following four main findings emerged from the study, suggesting that the tribal communities may differ from the predominant Bengali population in their health needs and priorities: (a) Traditional healers are still very popular among the tribal population in Bangladesh; (b) Perceptions of the quality and manner of treatment and communication can override costs when it comes to provider-preference; (c) Gender and age play a role in making decisions in households in relation to health matters and treatment-seeking; and (d) Distinct differences exist among the tribal people concerning their knowledge on health, awareness, and treatment-seeking behaviour. The findings challenge the present service-delivery system that has largely been based on the needs and priorities of the plainland population. The present system needs to be reviewed carefully to include a broader approach that takes the sociocultural factors into account, if meaningful improvements are to be made in the health of the tribal people of Bangladesh.

Influences on Healthcare-seeking during Final Illnesses of Infants in Under-resourced South African Settings.

To examine how health caregivers in under-resourced South African settings select from among the healthcare alternatives available to them during the final illness of their infants, qualitative interviews were conducted with 39 caregivers of deceased infants in a rural community and an urban township. Nineteen local health providers and community leaders were also interviewed to ascertain opinions about local healthcare and other factors impacting healthcare-seeking choices. The framework analysis method guided qualitative analysis of data. Limited autonomy of caregivers in decision-making, lack of awareness of infant danger-signs, and identification of an externalizing cause of illness were important influences on healthcare- seeking during illnesses of infants in these settings. Health system factors relating to the performance of health workers and the accessibility and availability of services also influenced healthcare-seeking decisions. Although South African public-health services are free, the findings showed that poor families faced other financial constraints that impacted their access to healthcare. Often there was not one factor but a combination of factors occurring either concurrently or sequentially that determined whether, when, and from where outside healthcare was sought during final illnesses of infants. In addition to reducing health system barriers to healthcare, initiatives to improve timely and appropriate healthcare-seeking for sick infants must take into consideration ways to mitigate contextual problems, such as limited autonomy of caregivers in decision-making, and reconcile local explanatory models of childhood illnesses that may not encourage healthcare-seeking at allopathic services.

Healthcare-seeking Behaviour for Common Infectious Disease-related Illnesses in Rural Kenya: A Community-based House-to-house Survey.

Community surveys of healthcare-use determine the proportion of illness episodes not captured by health facility-based surveillance, the methodology used most commonly to estimate the burden of disease in Africa. A cross-sectional survey of households with children aged less than five years was conducted in 35 of 686 census enumeration areas in rural Bondo district, western Kenya. Healthcare sought for acute episodes of diarrhoea or fever in the past two weeks or pneumonia in the past year was evaluated. Factors associated with healthcare-seeking were analyzed by logistic regression accounting for sample design. In total, 6,223 residents of 981 households were interviewed. Of 1,679 children aged less than five years, 233 (14%) had diarrhoea, and 736 (44%) had fever during the past two weeks; care at health facilities was sought for one-third of these episodes. Pneumonia in the past year was reported for 64 (4%) children aged less than five years; 88% sought healthcare at any health facility and 48% at hospitals. Seeking healthcare at health facilities was more likely for children from households with higher socioeconomic status and with more symptoms of severe illness. Health facility and hospital-based surveillance would underestimate the burden of disease substantially in rural western Kenya. Seeking healthcare at health facilities and hospitals varied by syndrome, severity of illness, and characteristics of the patient.

Overlapping Medication Associated with Healthcare Switching among Korean Elderly Diabetic Patients

This study was performed to describe the patterns of healthcare switching with overlapping use of anti-diabetic medication in the elderly using the Korea Health Insurance Review and Assessment Service's claims data. The study subjects were ambulatory elderly diabetic patients (ICD-10, E10-14) receiving at least one oral anti-diabetic drug or insulin, and visiting healthcare facilities more than two times between January and December 2005. A total of 457,975 elderly diabetic ambulatory care patients were identified. The mean of visiting frequencies was 9.0 ( +/- 3.6) and switching frequencies was 1.5 ( +/- 0.8) during 2005. Switching group consisted of 33% of total study subject. Healthcare switching was common in female patients who were older, and had treated polytherapy more in rural areas. The movement among primary care medical services was very common among the patients in the switching group (52.6%). A statistically significant correlation was observed between the healthcare switching and concomitant drug use (rho = 0.96), and overlapping days (rho = 0.57). The use of overlapping anti-diabetic medication increased with the extent of healthcare switching. Further, frequent switching of healthcare between primary clinics was observed. Efforts should be made to establish continuity for the elderly diabetic patients with the identification of frequent switching with overlapping medication.

Causes of Death of Adults and Elderly and Healthcareseeking before Death in Rural Bangladesh.

The health system of a country needs to be adjusted to patterns of morbidity and mortality to mitigate the income-erosion consequences of prolonged ill-health and premature death of adults. Population-based data on mortality by cause are a key to modifying the health system. However, these data are scarce, particularly for rural populations in developing countries. The objectives of this study were to determine the burdens of health due to major causes of death obtained from verbal autopsy of adults and the elderly and their healthcare-seeking patterns before death in a welldefined rural population. There were 2,397 deaths—613 were among adults aged 15-59 years and 1,784 among the elderly aged 60+ years—during 2003-2004 in the health and demographic surveillance area in Matlab, a rural area of Bangladesh. Trained interviewers interviewed close relatives of the deceased using a structured verbal-autopsy questionnaire to record signs and symptoms of diseases/ conditions that led to death and medical consultations before death. Two physicians independently assigned the underlying causes of deaths with disagreements resolved by a third physician. The physicians were able to assign a specific cause in 91% of the cases. Rates and proportions were used for estimating the burden of diseases by cause. Of all deaths of adults and the elderly, communicable diseases accounted for 18% and non-communicable diseases for 66%, with the proportion of non-communicable diseases increasing with age. Leading non-communicable diseases were diseases of the circulatory system (35%), neoplasms (11%), diseases of the respiratory system (10%), diseases of the digestive system (6%), and endocrine and metabolic disorders (6%), all of which accounted for 68% of deaths. Injury and other external causes accounted for another 5% of the deaths. During terminal illness, 31% of the adults and 25% of the elderly sought treatment from medical doctors, and 14% of the adults and 4% of the elderly died in healthcare facilities. The findings suggest that the health managers and policy-makers of Bangladesh should recognize the importance of prevention and management of chronic diseases and place it on the health agenda for rural people.

Perceptions of Quality of Care for Serious Illness at Different Levels of Facilities in a Rural Area of Bangladesh.

This study was conducted to explore care-seeking for perceived serious morbidities and users’ perceptions about quality of care at different facilities in Matlab, Bangladesh. This is a secondary analysis of baseline community survey data of the Matlab Essential Obstetric Care Project conducted in 2001. Principal component and factor analysis methods were used for computing summary quality and socioeconomic indicators. During perceived serious morbidity of any household member within the last one year, 88.1% (776/881) used health resource outside home. Of them, 25.6% visited informal care providers, 17.8% peripheral public facilities, 7.9% tertiary hospitals, 7.3% facilities of non-governmental organizations, and 41.4% private facilities as the highest healthcare resources. Socioeconomic status and type of morbidity were significant predictors for choice of the highest level of care. Most (86.1%) of those who sought care outside the home were satisfied with the quality of services provided for their last serious morbidities. Users of organized private-sector and tertiary facilities perceived the quality of services better than users of informal care providers and peripheral public facilities. Behaviour and attitude of the service providers and availability of medicines were significant predictors for perceived quality of care. Peripheral public-health facilities were of poor quality and grossly under-used. Further research should explore the technical aspect of quality of care in different facilities, along with perceptions of service providers to design client-focused interventions to impact the use of healthcare services. There is no reason to overlook informal care providers, they should rather be trained and monitored.