Cross-border mobility and social networks: Laotians seeking medical treatment along the Thai border

Community engagement for stakeholder and community trust in healthcare: Short-term evaluation findings from a nationwide initiative in Lao PDR

BACKGROUND

Trust remains a critical concept in healthcare provision, but little is known about the ability of health policy and interventions to stimulate more trusting relationships between communities and the health system. The CONNECT (Community Network Engagement for Essential Healthcare and COVID-19 Responses Through Trust) Initiative in Lao PDR provided an opportunity to assess the community-level impact of a trust-building community engagement approach.

METHODS

A mixed-method process evaluation was implemented from 10/2022-12/2023 among 14 diverse case study communities in four provinces across Lao PDR. Data collection involved two rounds of census surveys (3161 observations incl. panel data from 618 individuals) including an 8-item trust scale, 50 semi-structured interviews with villagers, and 50 contextualizing key informant interviews. The two data collection rounds were implemented before and three months after village-based CONNECT activities and helped discern impacts among activity participants, indirectly exposed villagers, and unexposed villagers in a difference-in-difference analysis.

RESULTS

Stakeholders attested strong support for the CONNECT Initiative although community-level retention of trust-related themes from the activities was limited. Quantitative data nevertheless showed that, at endline, the 8-item trust index (from [-8 to +8]) increased by 0.95 points from 4.44 to 5.39 and all trust indicators were universally higher. Difference-in-difference analysis showed that villagers exposed to the CONNECT activities had a 1.02-index-point higher trust index compared to unexposed villagers. Trust impacts improved gradually over time and were relatively more pronounced among men and ethnic minority groups.

CONCLUSIONS

The CONNECT Initiative had considerable direct and systemic effects on community members' trust in their local health centers in the short term, which arose from strong stakeholder mobilization and gradual institutional learning. Relational community engagement approaches have the potential to create important synergies in health policy and broader cross-sectorial strategies, but also require contextual grounding to identify locally relevant dimensions of trust.

Trust in healthcare: methodological and conceptual insights from mixed-method research in Lao People's Democratic Republic

BACKGROUND

Global health foregrounds trust as a key requirement for the achievement of international health initiatives, but it remains an elusive concept that is often mobilised without consideration of its dimensions, drivers and downstream behavioural consequences. This paper aims to contribute to the conceptual development and measurement of 'patient trust in primary healthcare' from the lower middle-income country perspective of rural Lao PDR.

METHODS

A two-phase mixed-method research design was implemented between January 2021 and April 2023. Phase 1 involved exploratory qualitative research to understand the local expressions and dimensions of patient trust in primary healthcare, with 25 semistructured interviews and 17 focus group discussions (120 participants) in eight villages in Bokeo Province. Phase 2 involved explanatory research to assess patterns of trust systematically at scale in 14 villages across four provinces, wherein 26 cognitive interviews, 17 expert interviews and non-participant community observations informed a community census survey with 1838 participants. We analysed qualitative data through content-oriented thematic analysis and developed an 8-item trust scale on that basis. Quantitative data analysis used descriptive statistical and regression analysis.

RESULTS

We found that trust in primary healthcare is readily understood and intrinsically valuable in rural Lao PDR. Key dimensions included communication, respectful care, relationship, fairness, integrity, reputation, assurance of treatment and competence. The survey highlighted that reputation, competence, integrity and respectful care had the lowest trust scores. Health centre operations predicted the local expressions of trust. The behavioural consequences of trust were limited to a positive statistical association with antenatal care uptake among pregnant women but outweighed by alternative measures that also captured the availability of healthcare facilities.

CONCLUSIONS

Overall, the development of our quantitative trust scale offers a process model for future researchers. We conclude that interpersonal, institutional and service-related trust require more explicit recognition in health system development and integration into health policy.

Smoothness as a quality of care: An STS approach to transnational healthcare mediation

Medical travel and transnational healthcare involve various difficulties such as the distance and disconnect between patients and healthcare providers, language barriers or logistical challenges of moving ill bodies across space. Medical travel facilitation steps in with some sort of brokerage service that contributes to overcoming or managing these difficulties and, as this paper suggests, acts to create a quality of 'smoothness'. By unpacking three salient facilitation practices, namely connecting, communicating, and coordinating, this paper conceptualises the empirically derived category of 'smoothness'. This as a disposition, outcome, and spatio-temporal manoeuvre of medical travel facilitation. Based on the way in which such practices of mediation act to create smoothness, namely in an attentive, persistent, and collective tinkering manner, this paper suggests that some practices of medical travel facilitation are productively thought not just about setting up the possibility of care transnationally, but that they are key forms of care in itself. Based on these findings, smoothness is considered to be a central but also contested quality of medical travel facilitation and brokerage in a broader sense, but as proposed here, also for care. This conclusion potentially has implications not just for the study of transnational healthcare and mediation activities, but also that of care and transnational mobilities more generally.

Of odysseys and miracles: A narrative approach on therapeutic mobilities for ayurveda treatment

In the past two decades, health care has become a global market and transnational practice. An emerging body of literature examines the astounding variety of drivers, conditions, and experiences. However, the question of how traveling abroad for treatment emerges as an option and takes shape in people's illness trajectories has gained little attention thus far. This article attends to this gap by following the stories of people with chronic conditions who travel to India for Ayurveda treatment out of dissatisfaction with local biomedical health care. This study expands the focus of current research on transnational therapeutic mobilities in three ways: (1) by shifting the attention from being a foreign patient or medical traveler to becoming one, (2) by integrating quests for other-than-biomedical therapies, and (3) by applying a narrative approach to the field. Results show that apart from social, human, and financial resources, it takes certain patient-subjectivities to mobilize patients across borders and healing systems.

Lived experience of State-sponsored intra-national overseas therapeutic mobility for stem cell transplantation

This article focuses on the lived experience of patients with haematological cancer who were transferred from La Réunion (a French overseas Department) to mainland France to undergo allogeneic haematopoietic stem cell transplantation (allo-HSCT). Based on a qualitative study conducted between February 2020 and January 2021 with allo-HSCT recipients, their family caregivers and healthcare professionals, we examined the social, economic and cultural factors shaping the patients' complex experience. We have called this kind of State-sponsored intra-national medical transfer "overseas therapeutic mobility". The patients' experience of this therapeutic journey beyond their geographical and cultural frontiers has some similarities with transnational therapeutic mobility. Overseas therapeutic mobility to undergo highly technical treatment requires considerable logistic efforts and mobility skills. The remoteness of their families and their affective and cultural environment give mobile patients a feeling of disorientation and causes them much social suffering. The two-fold condition of being a sick person with a possibly lethal disease and being treated overseas can be regarded as a double ordeal. In addition, the unfunded costs place a heavy burden on the patients and those whose families have limited resources. This study points to the cleavages which occur between post-colonial overseas regions and mainland France, and the territorial inequalities existing in patients' access to specialized treatment due to French policies of healthcare centralization.

Diagnostic testing: therapeutic mobilities, social fields, and medical encounters in the transnational healthcare practices of Polish migrants in the UK

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Diagnostic testing is seldom explored in studies of migrants’ healthcare practices.

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Tests’ availability and doctors’ willingness to discuss results are crucial for migrants’ evaluation of the care received.

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Test results are moved between private and public sectors and national borders.

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Movements of patients and tests establishes relationships with doctors and have therapeutic effects.

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Future studies should consider testing as a fundamental component of migrants’ health.

While diagnostic tests are a fundamental component of contemporary medical practice they are seldom considered in studies of transnational healthcare. This article investigates the little-studied role played by diagnostic testing in the healthcare-seeking practices of migrants. It is concerned with the experiences of Polish migrants living in the UK and who access a variety of health services in their host and origin countries across the public and private sectors. We analyse data from semi-structured phone interviews conducted in 2020 with 32 adult Poles living in the UK who identified as having themselves, or non-professionally caring for someone with, a long-term health condition. The article contributes to the literature on migrants’ transnational healthcare practices by showing the centrality of diagnostic technology in their health management and sense-making through the creation, modification, and maintenance of ‘transnational social fields’ (Levitt and Schiller 2004). By emphasizing the role of tests in the patient-doctor relationship the article exposes the therapeutic outcomes of the mobilities of patients and tests as they intersect with physicians in multiple medical encounters.

Health-seeking behaviours in a malaria endemic district in Lao People's Democratic Republic: a mixed methods study

OBJECTIVES

This mixed methods study was conducted to explore the barriers and facilitators for health-seeking behaviours in a malaria endemic district in Lao PDR.

DESIGN

A convergent mixed methods design.

SETTING

Two malaria endemic villages in Thapangthong district, Savannakhet Province, Lao PDR.

PARTICIPANTS

Villagers and healthcare workers in the two villages in Thapangthong district.

METHODS

In the quantitative part, a pretested questionnaire was used to identify the health-seeking behaviours of the villagers. In the qualitative part, focus group discussions were employed to explore health-seeking behaviours of the villagers and in-depth interviews were used to explore the perceptions of the healthcare workers. Descriptive statistics were computed and multiple logistic regressions were used to identify the factors associated with perceived severity and perceived susceptibility. Thematic analysis was used to analyse the qualitative data. Quantitative and qualitative results were integrated in joint displays.

RESULTS

In the quantitative part, data were collected from 313 villagers from both villages. For malaria, 96.0% and 98.2% of villagers from villages A and B, respectively, would first seek treatment at public health facilities. Villagers who have not experienced malaria before were more likely to perceive that the consequences of malaria were serious compared with those who have experienced malaria before (adjusted OR=1.69, 95% CI: 1.03 to 2.75). However, qualitative data showed that villagers faced problems such as lack of medicines and medical equipment. Healthcare workers also mentioned the lack of manpower and equipment in the in-depth interviews. Nevertheless, villagers still preferred to seek treatment at the health center as the National Health Insurance was introduced.

CONCLUSIONS

Public health facility usage was high but barriers existed. Effective policy and enabling environment such as the introduction of the National Health Insurance could help accelerate the progress towards the malaria elimination goal. Moreover, the benefits could go beyond the context of malaria.

Estimating the national burden of hospitalizations for influenza-associated severe acute respiratory infection in the Lao People's Democratic Republic, 2016

Objective

Estimates of the burden of influenza are needed to inform prevention and control activities for seasonal influenza, including to support the development of appropriate vaccination policies. We used sentinel surveillance data on severe acute respiratory infection (SARI) to estimate the burden of influenza-associated hospitalizations in the Lao People's Democratic Republic.

Methods

Using methods developed by the World Health Organization, we combined data from hospital logbook reviews with epidemiological and virological data from influenza surveillance from 1 January to 31 December 2016 in defined catchment areas for two sentinel sites (Champasack and Luang Prabang provincial hospitals) to derive population-based estimates of influenza-associated SARI hospitalization rates. Hospitalization rates by age group were then applied to national age-specific population estimates using 2015 census data.

Results

We estimated the overall influenza-associated SARI hospitalization rate to be 48/100 000 population (95% confidence interval [CI]: 44–51) or 3097 admissions (95% CI: 2881–3313). SARI hospitalization rates were estimated to be as low as 40/100 000 population (95% CI: 37–43) and as high as 92/100 000 population (95% CI: 87–98) after accounting for SARI patient underascertainment in hospital logbooks. Influenza-associated SARI hospitalization rates were highest in children aged < 5 years (219; 95% CI: 198–241) and persons aged ³ 65 years (106; 95% CI: 91–121).

Discussion

Our findings have identified age groups at higher risk for influenza-associated SARI hospitalization, which will support policy decisions for influenza prevention and control strategies, including for vaccination. Further work is needed to estimate the burdens of outpatient influenza and influenza in specific high-risk subpopulations.

Cross-border medical travels from Cambodia: pathways to care, associated costs and equity implications

In low- and middle-income countries, patients may travel abroad to seek better health services or treatments that are not available at home, especially in regions where great disparities exist between the standard of care in neighbouring countries. While awareness of South-South medical travels has increased, only a few studies investigated this phenomenon in depth from the perspective of sending countries. This article aims to contribute to these studies by reporting findings from a qualitative study of medical travels from Cambodia and associated costs. Data collection primarily involved interviews with Cambodian patients returning from Thailand and Vietnam, conducted in 2017 in the capital Phnom Penh and two provinces, and interviews with key informants in the local health sector. The research findings show that medical travels from Cambodia are driven and shaped by an interplay of socio-economic, cultural and health system factors at different levels, from the effects of regional trade liberalization to perceptions about the quality of care and the pressure of relatives and other advisers in local communities. Furthermore, there is a diversity of medical travels from Cambodia, ranging from first class travels to international hospitals in Bangkok and cross-border 'medical tourism' to perilous overland journeys of poor patients, who regularly resort to borrowing or liquidating assets to cover costs. The implications of the research findings for health sector development and equitable access to care for Cambodians deserve particular attention. To some extent, the increase in medical travels can stimulate improvements in the quality of local health services. However, concerns remain that these developments will mainly affect high-cost private services, widening disparities in access to care between population groups.

Factors associated with patient payments exceeding National Health Insurance fees and out-of-pocket payments in Lao PDR

BACKGROUND

Attaining universal health coverage is a target in the Sustainable Development Goals. In Lao PDR, to achieve universal health coverage, the government is implementing a national insurance scheme, initially targeting the informal sector.

OBJECTIVE

The purpose was to assess: i) the percentage of NHI patients who paid above the scheduled amount, based on individual billing payment; and ii) the factors related to overpayment.

METHODS

Descriptive cross-sectional study based on a structured questionnaire administered at health facilities in face-to-face interviews with 1,850 patients in six provinces.

RESULTS

All 1,850 participants worked in the informal sector. Of these, 78.8% of respondents (77.9% of in-patients; 79.5% of out-patients) made co-payments or were exempted from. Factors associated with in-patients paying above the scheduled fee were living in the province and district (OR = 2.8; 95%CI 1.2 to 6.3); not having documents with them (OR = 21.2; 95%CI 5.6 to 80.3); or not having documents (OR: 7.8; 95% CI 2.1 to 28.6). Significant factors associated with additional costs for out-patients were level of facility used at the provincial hospital (OR:1.4; 95% CI 1.1 to 1.9); older age (OR = 2.2; 95%CI 1.5 to 3.1); living in the province and district (OR = 2.3; 95%CI 1.5 to 3.7); living more than 5 km from the facility (OR = 1.4; 95%CI 1.1 to 1.9); buying medicine or supplies outside of the health facility (OR: 5.6; 95% CI 3.1 to 10.2); not bringing documents (OR:9.1; 95% CI 6.1 to 13.5), not having the right documents (OR: 8.9; 95% CI 5.4 to 14.8).

CONCLUSIONS

A number of patients paid above scheduled fee rates, which may deter people from utilising services when needing them. There is a need for increased understanding of the benefits of the national insurance scheme among patients and healthcare staff.

Forest Fevers: traditional treatment of malaria in the southern lowlands of Laos

ETHNOPHARMACOLOGICAL RELEVANCE

Malaria is still a highly challenging public health issue in southern Lao PDR, with increasing cases of artemisinin resistance and Plasmodium vivax infections which are more complicated to treat. Traditional medicine has a long history of use in Laos, and is primarily practised by traditional village healers, who possess unique bodies of transmitted knowledge focused on herbal prescriptions, including those for the treatment of malaria. Villagers also use plants for healthcare in the home. The aim of the study is to document local fever concepts and use of herbal remedies, and examine whether they may have potential as complementary treatments against malaria.

MATERIALS AND METHODS

The study took place in Champasak province in the far south of Laos, in primarily lowland areas. First, 35 traditional healers across the 10 districts of the province were interviewed to elicit details about knowledge and treatment of fevers. Second, a household survey was conducted in a village in a malaria-endemic area; 97 households were interviewed on fever incidence, differentiation, treatment-seeking behaviour and knowledge of plant-based remedies for fevers. Plants indicated by both healers and villagers were collected and voucher specimens deposited in the herbarium of the National University of Laos for identification.

RESULTS

Malaria is a well-known pathology among the healers and villagers of lowland Champasak province; biomedical treatments are preferentially used, but traditional medicine is a popular complementary method, especially in chronic cases with additional symptoms. 30 different fever types were recorded, which were usually named symptomatically, and grouped into 12 categories. Some were described as forms of malaria, which was conceived as a dynamic, changing pathology affecting many body systems. Healers formulate treatments based on symptoms and the person's constitution, and with the intention of creating specific pharmacological actions associated with temperature or flavours. 11 of the healers gave prescriptions for malaria (27 in total), including 47 identified plant species. The most-used plants (4 or more use-reports) were also the most cited in the literature for use against malaria, demonstrating a correspondence between Lao healers and other traditional medical systems. Furthermore, some of these species show promising results for future research, especially Amorphophallus paeniifolius (Dennst.) Nicolson and Alocasia macrorrhizos (L.) G. Don.

CONCLUSION

Traditional healers are important actors in the treatment of malaria in southern Laos, and herbal remedies should be evaluated further by the use of reverse treatment outcome trials, especially those which may be of use as complementary remedies in treating P. vivax. Initiatives on knowledge transmission, medicinal plant conservation and healthcare integration are also urgently needed.

The patient-doctor relationship in the transnational healthcare context

Moving away from paternalism to more equal forms of interaction in the patient-doctor relationship has been seen in positive light by policymakers, patients' rights advocates and scholars alike. Nonetheless, against the background of commercialisation and consumerism, empirical research showcases how reduced asymmetries bring in tensions and friction between patients and doctors (Greenfield et al. 2012). This paper contributes to the discussion through the examination of the patient-doctor relationship in the niche setting of private transnational healthcare markets which involve patients travelling overseas for care and where commodification, consumerism and care go hand-in-hand. It is geographically focused on two large cities in South-Eastern Europe as settings where health care is provided to foreign patients - Athens and Istanbul - and empirically draws on qualitative interviews with doctors who run small/medium practices. The findings highlight that, despite excessive consumerism, power asymmetries are not mitigated but patient vulnerability shapes the patient-doctor relationship. In the transnational context, the patient faces an additional source of vulnerability: a condition of foreignness. As such, the findings stress that one relationship model (the consumerist) does not, per se, replace an older one (e.g. the Parsonian). Instead, the consumer-provider dimension co-exists with the client-expert, patient-doctor and, finally, host-guest relation.

Herbal medicine for epilepsy seizures in Asia, Africa and Latin America: A systematic review

RELEVANCE

More than 70 million people suffer epilepsy worldwide. Low availability of anti-epileptic drugs, side-effects and drug-resistant epilepsy affect the quality of life of persons with epilepsy in countries with a poorly developed health system. Herbal medicine is frequently used for this neurological condition.

OBJECTIVES

The main objective was to provide a detailed analysis of Herbal Medicine used for neurological conditions related with epilepsy in Asia, Africa and Latin America. More broadly, this study aims to highlight species with assessed efficacy (cross-cultural use, pharmacological effects on models of epileptic seizures) and safety (toxicological data in laboratory) information, in order to point out species of interest for further studies. A critical assessment of models used in pharmacological evaluations was done.

MATERIALS AND METHODS

The systematic search for Herbal Medicine treatments for epilepsy was performed considering all the articles published until February 2017 through three scientific databases. It was made with MeSH terms and free text defining the epilepsy seizures and plant species. We included studies carried out in Asia, Africa and Latin America. All articles reporting the use of Herbal Medicine to treat epilepsy seizures and/or their pharmacological evaluation were retained for further analysis.

RESULTS

The search yielded 1886 articles, from 30 countries. Hundred and six articles published between 1982 and 2017 were included, corresponding to a total of 497 use reports for 351 plant species belonging to 106 families. Three hundred and seventy seven use reports corresponding to 264 species in ethnopharmacological surveys and 120 evaluation reports corresponding to 107 species were noted. Twenty-nine reports, for 29 species, combined both ethnopharmacological and pharmacological evaluation. Fifty eight studies originated from Africa, 35 studies from Asia and 18 from Latin America. Highest use report was noted for rhizomes of Acorus calamus L. (12 use report in 1 country) and leaves of Bacopa monnieri (L.) Wettst. (8 use report in 2 countries). Therefore these species display the highest use convergence. Regarding pharmacological evaluation most studied species were: Leonotis leonurus (L.) R.Br. (4 evaluation reports in 1 country), Uncaria rhynchophylla (Miq.) Miq. ex Havil. (3 evaluation reports in 2 countries) and Calotropis gigantea (L.) Dryand. (3 evaluation reports in 1 country). In vivo models of chronic epilepsy were more relevant than in vitro models or chemical models inducing acute seizures for pharmacological assessment.

CONCLUSION

Species with the highest use report were not those with pharmacological evaluation. It will be pertinent to assess the pharmacological effects and safety of medicinal plants used mostly by traditional healers on predictive models of seizures.

Explanatory factors of adherence to community-based management of epilepsy in Lao PDR

RELEVANCE

A low level of knowledge about epilepsy among health workers, a context of stigmatizing sociocultural beliefs, and a low availability of antiepileptic drugs in Lao People's Democratic Republic (PDR) are major gaps in the medical management of people with epilepsy in this country.

OBJECTIVES

The principal objective of the study was to identify the associated factors of adherence to community healthcare structures in Lao PDR. Specific objectives were to evaluate patients' adherence status, practices and knowledge about epilepsy and its care, and factors influencing decision-making on therapeutic interventions.

MATERIALS AND METHODS

The study was an observational cross-sectional survey about knowledge, attitudes, and practices, handled from February to May 2016. Eighty-seven people with epilepsy were identified in two areas in the periphery of Vientiane Capital through an active screening in villages and homes. Semidirective questionnaires were conducted to collect quantitative and qualitative data. Quantitative analysis included a comparison of adherent vs. nonadherent people with epilepsy, using Chi-square or Fisher's test. Advanced qualitative lexical analysis was carried out on the open-ended questions.

RESULTS

Sixty-two people with epilepsy were included and the adherence rate to community care was 67.7%. The only sociodemographic variable that differed significantly between adherent and nonadherent members was the income level (p = 0.015): the wealthiest class of people with epilepsy did not adhere to community healthcare. Eleven percent of people with epilepsy thought that epilepsy was contagious, 80.6% that medication may reduce epilepsy seizure rates, and 33.9% that it was possible to cure epilepsy permanently. Physicians informed about the disease in 69.0% of adherent people with epilepsy and in 40.0% of nonadherent ones (p = 0.029), whereas villagers were involved in 29.0% and 50.0% of cases, respectively. There was a significant difference between the two groups for the prescribed antiepileptic drugs (p = 0.012): phenobarbital covered 73.8% of adherent people with epilepsy but only 40% of nonadherent ones. Half of nonadherent people with epilepsy went regularly to a central hospital in the Vientiane Capital, 15.0% went to Thailand, and 10.0% practiced self-medication in occasional mobilities.

CONCLUSION

A wider range of antiepileptic drugs at a reduced cost and the promotion of adherence to community healthcare would allow a better management of people with epilepsy in Lao PDR.

Cross-border spatial accessibility of health care in the North-East Department of Haiti

BACKGROUND

The geographical accessibility of health services is an important issue especially in developing countries and even more for those sharing a border as for Haiti and the Dominican Republic. During the last 2 decades, numerous studies have explored the potential spatial access to health services within a whole country or metropolitan area. However, the impacts of the border on the access to health resources between two countries have been less explored. The aim of this paper is to measure the impact of the border on the accessibility to health services for Haitian people living close to the Haitian-Dominican border.

METHODS

To do this, the widely employed enhanced two-step floating catchment area (E2SFCA) method is applied. Four scenarios simulate different levels of openness of the border. Statistical analysis are conducted to assess the differences and variation in the E2SFCA results. A linear regression model is also used to predict the accessibility to health care services according to the mentioned scenarios.

RESULTS

The results show that the health professional-to-population accessibility ratio is higher for the Haitian side when the border is open than when it is closed, suggesting an important border impact on Haitians' access to health care resources. On the other hand, when the border is closed, the potential accessibility for health services is higher for the Dominicans.

CONCLUSION

The openness of the border has a great impact on the spatial accessibility to health care for the population living next to the border and those living nearby a road network in good conditions. Those findings therefore point to the need for effective and efficient trans-border cooperation between health authorities and health facilities. Future research is necessary to explore the determinants of cross-border health care and offers an insight on the spatial revealed access which could lead to a better understanding of the patients' behavior.

Understanding medical travel from a source country perspective: a cross sectional study of the experiences of medical travelers from the Maldives

BACKGROUND

The resolution adopted in 2006 by the World Health Organization on international trade and health urges Member States to understand the implications of international trade and trade agreements for health and to address any challenges arising through policies and regulations. The government of Maldives is an importer of health services (with outgoing medical travelers), through offering a comprehensive universal health care package for its people that includes subsidized treatment abroad for services unavailable in the country. By the end of the first year of the scheme approximately US$11.6 m had been spent by the government of Maldives to treat patients abroad. In this study, affordability, continuity and quality of this care were assessed from the perspective of the medical traveler to provide recommendations for safer and more cost effective medical travel policy.

RESULTS

Despite universal health care, a substantial proportion of Maldivian travelers have not accessed the government subsidy, and a third reported not having sufficient funds for the treatment episode abroad. Among the five most visited hospitals in this study, none were JCI accredited at the time of the study period and only three from India had undergone the National Accreditation Board for Hospitals (NABH) in India. Satisfaction with treatment received was high amongst travelers but concern for the continuity of care was very high, and more than a third of the patients had experienced complications arising from the treatment overseas.

CONCLUSION

Source countries can use their bargaining power in the trade of health services to offer a more comprehensive package for medical travelers. Source countries with largely public funded health systems need to ensure that medical travel is truly affordable and universal, with measures for quality control such as the use of accredited foreign hospitals to make it safer and to impose measures that ensure the continuity of care for travelers.

A realist synthesis of cross-border patient movement from low and middle income countries to similar or higher income countries

Patient travel across borders to access healthcare is becoming increasingly common and widespread. Patients moving from high income to middle income countries for healthcare is well documented, with patients seeking treatments that are cheaper or more readily available than at home. Less well understood is when patients move from one low income country to another or from a low income country to a higher income country. In this paper, a realist review was undertaken to explore why, in what contexts and how patients from lower income countries travel to countries with the same, or more advanced, economies for planned healthcare. Based on an initial scoping of the literature and discussions with key informants, we generated an initial theory and set of propositions about why, how, who and in what contexts people cross international borders for planned healthcare. We then systematically located and synthesized (1) peer-reviewed studies from the Scopus, Embase, Web of Science and Econlit databases; (2) non-indexed reports using key informants and Google; and (3) papers from the reference lists of included documents, to glean supportive or contradictory evidence for our initial propositions. As we reviewed the literature and extracted our data, we drew on the work of Pierre Bourdieu to understand the interplay between material and non-material capital and cognitive processes in decisions to cross borders for healthcare. Patient travel was largely undertaken due to a lack of services in the home country and/or unacceptability of local services, with decisions on when, and where, to travel, usually made within the patient's social networks. They were able to travel via use of multiple resources, including social networks, economic and cultural capital, and habitus. Those patients with greater volumes of the aforementioned factors had greater healthcare options; however, even those with limited resources engaged in patient travel. Patient movement challenges traditional ways of thinking about public health and the notion of health systems contained within the nation state. Further research is needed to better understand the effects of patient travel, and how to harness the benefits of patient travel without exacerbating existing health inequalities.

"Ensure that you are well aware of the risks you are taking…": actions and activities medical tourists' informal caregivers can undertake to protect their health and safety

Background

When seeking care at international hospitals and clinics, medical tourists are often accompanied by family members, friends, or other caregivers. Such caregiver-companions assume a variety of roles and responsibilities and typically offer physical assistance, provide emotional support, and aid in decision-making and record keeping as medical tourists navigate unfamiliar environments. While traveling abroad, medical tourists’ caregiver-companions can find themselves confronted with challenging communication barriers, financial pressures, emotional strain, and unsafe environments.

Methods

To better understand what actions and activities medical tourists’ informal caregivers can undertake to protect their health and safety, 20 interviews were conducted with Canadians who had experienced accompanying a medical tourist to an international health care facility for surgery. Interview transcripts were subsequently used to identify inductive and deductive themes central to the advice research participants offered to prospective caregiver-companions.

Results

Advice offered to future caregiver-companions spanned the following actions and activities to protect health and safety: become an informed health care consumer; assess and avoid exposure to identifiable risks; anticipate the care needs of medical tourists and thereby attempt to guard against caregiver burden; become familiar with important logistics related to travel and anticipated recovery timelines; and take practical measures to protect one’s own health.

Conclusion

Given that a key feature of public health is to use research findings to develop interventions and policies intended to promote health and reduce risks to individuals and populations, the paper draws upon major points of advice offered by study participants to take the first steps toward the development of an informational intervention designed specifically for the health and safety needs of medical tourists’ caregiver companions. While additional research is required to finalize the content and form of such an intervention, this study provides insight into what practical advice former caregiver-companions state should be shared with individuals considering assuming these roles and responsibilities in the future. In addition, this research draws attention to the importance of ensuring that such an intervention is web-based and readily accessible by prospective caregiver-companions.

Factors influencing decisions of Laotian patients to use health care services in Thailand

Background: Thailand has been facing a gradual increase in use of cross-border health care. Nevertheless, no evidence regarding factors influencing cross-border use of health care by Laotian patients in public Thai hospitals among this group has been established.

Objectives: To assess the use of cross-border health care by Laotian patients, and factors that may influence health services in public Thai hospitals along the border.

Methods: This study consisted of two parts. (1) Site-visits to 53 Thai public hospitals along the Thai-Laos border during May to July 2011 and collection of data regarding the use of health care services by Laotian patients. (2) A structured questionnaire survey was conducted via face interviews by trained researchers. Findings were analyzed using descriptive statistics and multiple logistic regression.

Results: The most common conditions for which treatment was sought were common diseases and basic operative procedures. All hospitals had been facing substantial financial burden, particularly for inpatient care. The analysis of use indicated that a perception of differences in the quality of health services, ability to pay for treatment anywhere, and distance to health services were three major factors affecting the decision of Laotian patients to cross the border to obtain health care in Thailand. Interviews with hospital directors and staff revealed that more financial support and a clear policy for care of Laotian patients was needed.

Conclusions: The perception of better quality of health care in Thailand by Laotian patients was the major factor affecting cross-border use of health care services. Assistance to improve healthcare in Laos and financial support for subsidizing care for the indigent Laotian patients is needed.

Informal workers and access to healthcare: a qualitative study of facilitators and barriers to accessing healthcare for beer promoters in the Lao People's Democratic Republic

Background

Informal workers often face considerable risks and vulnerabilities as a consequence of their work and employment conditions. The purpose of this study was to examine the interplay between the experience of informal work and access to health, using as an example, female beer promoters employed in the informal economy, in the Lao People’s Democratic Republic.

Methods

In-depth interviews were undertaken with 24 female beer promoters working in beer shops, restaurants and entertainment venues in Vientiane City. The recruitment strategy of snowball sampling was used. Interviews explored the beer promoter’s experience of the organization of work, perceived healthcare needs, access to healthcare and insurance, and health seeking practices. The data was analysed thematically and subsequently using Bourdieu’s concepts of habitus, capital and field.

Results

Most of the beer promoters included in the study were 18 years of age, single, had worked as beer promoters for more than one year and just over half were working to support their higher education. The beer promoters demonstrated a holistic view of health, also viewing good health as contributing to being beautiful – an important attribute in their work. Many reported that their work conditions, including the noisy environment, exposure to second-hand tobacco smoke, long hours on their feet and sexual harassment negatively affected their physical and mental health. Only four participants had any form of health insurance with access to healthcare constrained by individual characteristics, health system factors and the conditions of their informal employment.

Conclusions

Drawing on the work of Bourdieu, the study shows how both employment and illness are linked to habitus embodied in everyday practices, access to capital and the position the female beer promoters hold in the social hierarchy in the field of employment.