Effect of pecuniary costs and time costs on choice of healthcare providers among caregivers of febrile children in rural Papua New Guinea.

BACKGROUND: User fees, transportation costs, and time costs impair access to healthcare by rural communities in low and middle income countries. However, effects of time costs on demand for healthcare are less understood than effects of user fees for health providers. In addition, prospective patients might not know about all health services available. This study aims to investigate how the family caregivers of febrile children respond to the pecuniary costs and time costs in their choice of health providers in rural Papua New Guinea. METHODS: Using an original questionnaire, we surveyed households in the catchment area surrounding Dagua Health Center in East Sepik Province, Papua New Guinea, during February-March 2015. We estimated the probability of choosing one among four categories of providers (i.e., the health center, aid posts, village health volunteers [VHVs], or home-treatment) via a mixed logit model in which we restrict alternatives to those for which family caregivers knew cost information. RESULTS: Of 1173 family caregivers, 96% sought treatment for febrile children from four categories of providers. Almost all knew the location of the health center and a health volunteer, but only 50% knew the location of aid posts. Analysis by discrete choice model showed that pecuniary costs and time costs were inversely associated with the probability of choosing any type of provider. We then changed pecuniary costs and time costs counterfactually to calculate and compare the probability of choosing each provider. Time costs affected the choice more than pecuniary costs, and individual heterogeneity appeared among caregivers with respect to pecuniary costs. When pecuniary or time costs of VHVs are altered, substitution between VHVs and home-treatment appeared. CONCLUSIONS: Our findings suggest that policies to increase awareness of aid posts and reduce time costs in addition to treatment fees for each category of healthcare provider could help developing economies to improve access to essential healthcare services.

Comparison of Health Service Utilization for Febrile Children Before and After Introduction of Malaria Rapid Diagnostic Tests and Artemisinin-Based Combination Therapy in Rural Papua New Guinea.

BACKGROUND: In Papua New Guinea (PNG), a malaria treatment policy using rapid diagnostic tests (RDTs) plus artemisinin-based combination therapy (ACT) was widely introduced to rural communities in 2012. The objectives of the study were to evaluate the effect of this RDT/ACT introduction to a rural PNG population on health service utilization and to compare factors associated with health service utilization before and after the RDT/ACT introduction. METHODS: Household surveys with structured questionnaires were conducted before and after the introduction of RDT/ACT in a catchment area of a health center in East Sepik Province, PNG. We interviewed caregivers with children less than 15 years of age and collected data on fever episodes in the preceding 2 weeks. Using propensity score matching, febrile children before the introduction of RDT/ACT were matched to febrile children after the introduction. Then, the adjusted difference in the proportion of health service utilization [i.e., the average treatment effect (ATE) of the introduction of RDT/ACT on health service utilization] was estimated. We also employed a multilevel Poisson regression model to investigate factors influencing the use of health services. RESULTS: Of 4,690 children, 911 (19%) were reported to have a fever episode. The unadjusted proportion of health service utilization was 51.7 and 57.2% before and after the RDT/ACT introduction, respectively. After matching, no significant difference in the health service utilization was observed before and after the introduction of RDT/ACT (ATE: 0.063, 95% confidence interval -0.024 to 0.150). Multilevel regression analysis showed that the consistent factors associated with a higher utilization of health services were severe illness and being female. CONCLUSION: The utilization of health services was not significantly different before and after the introduction of RDT/ACT. Villagers may have neither sufficient informations on the new protocol nor high acceptance of RDT/ACT. The observed gender bias in health service utilization could be due to female caregivers' preferences toward girls.

Frequency of the functionally relevant aryl hydrocarbon receptor repressor (AhRR) Pro185Ala SNP in Papua New Guinea.

The diverse cultural and social habits of the Papua New Guinea (PNG) population include betel quid chewing and more recently smoking. The formation of DNA adducts from betel quid is mediated by the cytochrome P450 (CYP) enzymes, including CYP1A2. The tobacco smoke compounds can induce CYP1A2. The transcription factor AhR (aryl hydrocarbon receptor) is involved in the regulation of CYP1A2 expression. AhR activity is itself regulated by other transcription factors, including the aryl hydrocarbon receptor repressor (AhRR). The AhRR Pro185Ala (rs2292596; 565C>G) minor allele was recently associated with a lower AhR repressor activity, leading to a higher CYP1A2 inducibility. We investigated AhRR Pro185Ala SNP in the East Sepik populations in PNG and found a high frequency of 53.4% of the minor allele, significantly different from other Asian populations. We can hypothesize that a high frequency of the AhRR SNP can be a risk factor in the incidence of oral cancer and other neoplasias in PNG due to higher inducibility of CYP1A2. The potential role of AhRR pharmacogenetics in the risk of developing cancers associated with betel quid chewing and smoking should be addressed and clarified in future epidemiological studies in PNG.

Austronesian origin of the 27-bp deletion of the erythrocyte band 3 gene in East Sepik, Papua New Guinea inferred from mtDNA analysis.

The 27-bp deletion in the erythrocyte band 3 gene (B3Delta27) constitutes a genetic basis for Southeast Asian and Melanesian ovalocytosis. The distribution of B3Delta27 has been interpreted to reflect malaria selection or dispersal of the recent expansion of Austronesian-speaking populations. To explore these two hypotheses, we examined eight malarious populations of the East Sepik Province of Papua New Guinea (PNG) that speak both the Austronesian and Papuan languages. The B3Delta27 allele frequencies within populations were not positively correlated with malaria endemicities. In contrast, statistically significant geographical variations in the B3Delta27 allele distribution were observed. B3Delta27 was high (0.06-0.07) in the islands, intermediate (0.02-0.03) in coastal regions, but was absent or rare (0.00-0.01) in inland populations. Furthermore, the prevalence of the mitochondrial DNA region V 9-bp deletion, associated with the Austronesian expansion, was significantly correlated with that of B3Delta27. These results suggest that B3Delta27 was introduced by Austronesian-speaking people within the past 3,500 years and subsequently expanded to populations along the coasts and islands of PNG. This study highlights the contribution of population origins, patterns of gene flow, disease selection and genetic drift in determining the genetic compositions of present populations.