Health care utilisation in Cox's Bazar district, Bangladesh, during the first year of the COVID-19 pandemic: A mixed-methods study among host communities

To respond to the COVID-19 pandemic, countries introduced public health and social measures that had indirect societal, economic consequences. Concerns during epidemics include continuity of routine health services. We investigate how healthcare utilisation and healthcare seeking behaviour changed during the first year of the COVID-19 pandemic among host communities in Cox's Bazar, Bangladesh. This mixed-methods study combines quantitative analyses of routine health data and population-based findings about healthcare seeking behaviours. Trends in consultations changed according to facility level (higher-level facilities included Upazila Health Complexes and District Hospitals; lower-level facilities included Community Clinics and Union Health and Family Welfare Centers). At the pandemic's beginning, drops were seen at higher-level health facilities for outpatient department (OPD) consultations, respiratory infections, and antenatal care. Minor reductions or increases were seen at lower-level facilities for the same services. Half of the subdistricts reported a cumulative increase in OPD and respiratory tract infection consultations. Most subdistricts reported a cumulative decrease in antenatal care. Child vaccinations dropped in all subdistricts, half of which did not catch-up, resulting in a cumulative decrease of delivered doses. Fear of contracting COVID-19 and financial constraints were the main reasons for decreased access. Drivers of healthcare seeking behaviours should be better understood to guide preparedness and service delivery modalities at primary and secondary levels.

Health care barriers and perceived mental health among adults in Canada during the COVID-19 pandemic: a population-based cross-sectional study

INTRODUCTION

The perceived mental health of individuals in Canada who faced health care barriers during the COVID-19 pandemic is underexplored.

METHODS

We analyzed data collected March to June 2021 from adults who reported needing health care services within the past 12 months in the Survey on Access to Health Care and Pharmaceuticals during the Pandemic. Unadjusted and adjusted logistic regression analyses examined the associations between health care barriers (appointment scheduling problems, delaying contacting health care) and high self-rated mental health and perceived worsening mental health compared to before the pandemic, overall and stratified by gender, age group, number of chronic health conditions and household income tertile.

RESULTS

Individuals who experienced pandemic-related appointment changes or had appointments not yet scheduled were less likely to have high self-rated mental health (aOR = 0.81 and 0.64, respectively) and more likely to have perceived worsening mental health (aOR = 1.50 and 1.94, respectively) than those with no scheduling problems. Adults who delayed contacting health care for pandemic-related reasons (e.g. fear of infection) or other reasons were less likely to have high self-rated mental health (aOR = 0.52 and 0.45, respectively) and more likely to have perceived worsening mental health (aOR = 2.31 and 2.43, respectively) than those who did not delay. Delaying contacting health care for pandemic-related reasons was associated with less favourable perceived mental health in all subgroups, while the association between perceived mental health and pandemic-related appointment changes was significant in some groups.

CONCLUSION

Health care barriers during the pandemic were associated with less favourable perceived mental health. These findings could inform health care resource allocation and public health messaging.

Health care utilization of individuals with Rome IV irritable bowel syndrome in the general population

BACKGROUND

Irritable bowel syndrome (IBS) is highly prevalent worldwide but mechanisms for healthcare seeking behaviours in this patient group are poorly understood.

OBJECTIVE

To describe healthcare utilization and identify factors associated with seeking healthcare amongst IBS subjects in the general population.

METHODS

An internet survey was completed by 6,300 individuals equally distributed between United States, United Kingdom and Canada. The Rome IV diagnostic questionnaire was used to identify subjects with IBS. Data on demographics, medical history, gastrointestinal (GI) and non-GI symptoms, quality of life and health care consumption was collected.

RESULTS

A total of 5,931 subjects were included; 274 (4.6%) IBS subjects and 5657 (95.3%) non-IBS controls. IBS subjects reported more doctor consultations for both GI and other health problems as well as increased use of medication and rate of abdominal surgery (appendectomy excluded). Having healthcare insurance or access to free public healthcare (adjusted odds ratio (AOR) 4.49, 95% confidence interval (CI) 1.31-15.44), followed by high frequency of bloating (AOR 2.65, 95% CI 1.42-4.93) and increasing age (AOR 1.02, 95% CI 1.01-1.05) were found to be independently associated with being an IBS consulter while doctor-diagnosed IBS subjects were more likely to be female and to report abdominal pain as their most bothersome GI symptom than other consulters with IBS.

CONCLUSION

IBS subjects have higher healthcare utilization than non-IBS controls, medication use and abdominal surgery included. Furthermore, consulters with and without an IBS diagnosis differ in sex distribution and symptom profiles. Hence, awareness of the possibility of unnecessary medical and surgical treatment in IBS subjects and a sex-related diagnostic bias by doctors is warranted.

Self-reported health problems, health care seeking behaviour and cost coping mechanism of older people: Implication for primary health care delivery in rural Bangladesh

BACKGROUND

Optimum utilization of primary health care system by older people is a challenge for every low and middle income country. Little is known about self reported health problems, health care seeking behaviour and cost coping mechanism of older people in developing countries.

OBJECTIVES

This study aimed to measure self-reported health problems, health care seeking behaviour and expenditure coping mechanism of older people, and to describe its implication for primary health care delivery in rural Bangladesh.

METHODOLOGY

It was a cross sectional study. In total, 362 older people were enrolled who sought health care preceding the last month of the interview. Descriptive and bivariate data analysis along with proportion test (z test) was carried out.

RESULTS

The most frequent self-reported health problems were fever (43.8%) followed by physical pain (15.2%). More than half of the respondents (57.5%) had a second health problem. Only one third (33.8%) visited qualified health providers having minimum western health or medical training from government approved authority. More than half (54%) of the older people spent for health care out of pocket from their own. Only 2% older people sold their assets or took loans to meet their health care. 36% older people thought that they could afford to pay for health care in future.

CONCLUSIONS

The findings of this study will help in developing primary health care policy for older people in rural Bangladesh and similar settings in South Asia.

How do users adopt health information from social media? The narrative paradigm perspective

INTRODUCTION

A recent trend in health information seeking and sharing is the use of social media. Although there are several benefits to the use of social media for health communication, the quality of health information exchanged on social media is troubling due to its informal, unregulated mechanisms for information collection, sharing and promotion. Therefore, it is important to understand how users adopt health information from social media.

METHOD

Considering the user-generated and storytelling nature of social media messages, this research employed the narrative paradigm perspective to explain the social media health information adoption phenomenon. Specifically, narrative coherence (NC) and narrative fidelity (NF) were hypothesised to have positive effects on the intention to adopt (IA). Additionally, socio-economic status (SES) was viewed as a proxy variable to cognitive capability and was hypothesised to moderate the effects of NC and NF. A scenario-based survey was conducted to test the proposed research model.

RESULTS

We obtained a total of 257 valid questionnaires. The results indicated that NF (p < 0.001) had a positive effect on the IA social media health information. The NC (p < 0.01) had no impact on the low SES users but a positive impact on the high SES users. Further, the effect of NF (p < 0.01) on the IA was higher for high SES users than low SES users.

CONCLUSIONS

NC and NF are two major driving forces in social media health information adoption, and the effect of both narrative paradigm variables depends on the SES users.

IMPLICATIONS

Results of this study show how the narrative paradigm, with a focus on the storytelling method of communication rather than logical scientific argument, can not only explain the uptake of health messages from social media, but also provide guidance as to how to create health messages on social media that more effectively target end users.

How people-centred health systems can reach the grassroots: experiences implementing community-level quality improvement in rural Tanzania and Uganda

Background

Quality improvement (QI) methods engage stakeholders in identifying problems, creating strategies called change ideas to address those problems, testing those change ideas and scaling them up where successful. These methods have rarely been used at the community level in low-income country settings. Here we share experiences from rural Tanzania and Uganda, where QI was applied as part of the Expanded Quality Management Using Information Power (EQUIP) intervention with the aim of improving maternal and newborn health. Village volunteers were taught how to generate change ideas to improve health-seeking behaviours and home-based maternal and newborn care practices. Interaction was encouraged between communities and health staff.

Aim

To describe experiences implementing EQUIP's QI approach at the community level.

Methods

A mixed methods process evaluation of community-level QI was conducted in Tanzania and a feasibility study in Uganda. We outlined how village volunteers were trained in and applied QI techniques and examined the interaction between village volunteers and health facilities, and in Tanzania, the interaction with the wider community also.

Results

Village volunteers had the capacity to learn and apply QI techniques to address local maternal and neonatal health problems. Data collection and presentation was a persistent challenge for village volunteers, overcome through intensive continuous mentoring and coaching. Village volunteers complemented health facility staff, particularly to reinforce behaviour change on health facility delivery and birth preparedness. There was some evidence of changing social norms around maternal and newborn health, which EQUIP helped to reinforce.

Conclusions

Community-level QI is a participatory research approach that engaged volunteers in Tanzania and Uganda, putting them in a central position within local health systems to increase health-seeking behaviours and improve preventative maternal and newborn health practices.

A Q-methodology study of flare help-seeking behaviours and different experiences of daily life in rheumatoid arthritis

BACKGROUND

Previous studies have not addressed rheumatoid arthritis (RA) patients' help-seeking behaviours for RA flares, and only one small qualitative study has addressed how patients experience daily life on current treatment regimes. Thus, this study aims to identify clusters of opinion related to RA patients' experiences of daily life on current treatments, and their help-seeking behaviours for RA flares.

METHODS

Using Q-methodology (a methodology using qualitative and quantitative methods to sort people according to subjective experience), two separate studies were conducted with the same sample of RA patients (mean age 55, 73% female). Thirty participants sorted 39 statements about daily life (Q-study 1) and 29 participants separately sorted 23 statements about flare help-seeking (Q-study 2). Data were examined using Q-factor analysis.

RESULTS

Daily life with RA (Q-study 1): Three factors relating to the experience of living with RA were extracted and explained. Patients belonging to Factor A (mean age 62, 86% female) use effective self-management techniques to control the daily impact of RA. Those in Factor B (mean age 55, 75% male) struggle to self-manage and cope. Whilst patients in Factor C (mean age 42, 100% female) prioritise life responsibilities over their RA, reporting less impact.Flare help-seeking (Q-study 2): Two factors explaining the experience of flare help-seeking (unrelated to the factors from Q-study 1) were extracted and explained. Factor X (68.8% on biologics) reported seeking help quickly, believing the medical team is there to help. Factor Y (0% on biologics) delay help-seeking, concerned about wasting the rheumatologist's time, believing they should manage alone. All participants agreed they sought help due to intense pain and persistent, unmanageable symptoms.

CONCLUSIONS

Patients with different characteristics appear to manage RA life in different ways and men may struggle more than women. Whilst all patients are prompted to seek help by persistent, unmanageable symptoms, some delay help-seeking. Further research is needed to quantify the severity of daily symptoms, the level of symptoms needed for patients to define themselves as in flare and to understand the support needs of RA men.

Using verbal and social autopsies to explore health-seeking behaviour among HIV-positive women in Kenya: a retrospective study

BACKGROUND

There is limited understanding of the factors that influence decisions to seek HIV care and treatment services in community settings. The aim of this study was to explore the socio-cultural and health system factors affecting health-seeking behaviour among deceased women in Kenya who were living with HIV at the time of death.

METHODS

Out of a total of 796 deaths for which a caregiver was available to provide information, retrospective data were drawn from verbal and social autopsies administered to caregivers of 218 women who had died of AIDS-related illnesses aged 15 to 49 years. Information was collected on essential elements of the care-seeking process from the onset of severe illness episodes and analysed using qualitative and quantitative techniques.

RESULTS

Results from the quantitative data showed that poor women were less likely to access formal health services (OR = 0.2; p < 0.001) compared to non-poor women. The qualitative data showed that socioeconomic status, poor knowledge and understanding of AIDS-related illness, distance to facility and transportation costs, medical pluralism, stigma, low HIV risk perception, lack of family support and health care system barriers contributed to delays/constraints in seeking care.

CONCLUSIONS

The findings highlight important issues that have implications for addressing challenges faced by women living with HIV, including non-adherence to treatment regimen and late diagnosis of HIV. Provision of transportation subsidies as part of the national social safety-net strategy can help in addressing financial constraints associated with transportation costs among poor women living with HIV.

Applying behavioural economics to health systems of low- and middle-income countries: what are policymakers' and practitioners' views?

Interest in behavioural economics has soared in recent years, particularly because of its application to several areas of public policy, now including international development, education, and health. Yet, little is known about how the policy and political implications of behavioural economics are perceived among stakeholders. Using an innovative vignette-based online survey, we assessed the opinions of 520 policymakers and practitioners around the world about health policy recommendations emanating from behavioural economics principles that are relevant to low- and middle-income country settings. We also determined the sources of disagreement among the respondents. The results suggest that there is strong support for health policies based on the concepts of framing choices to overcome present bias, providing periodic information to form habits, and messaging to promote social norms. There is less support for policies which use cash rewards as extrinsic motivators either to change individual behaviour related to the management of chronic conditions or to mitigate risky sexual behaviour. The sources of disagreement for these policy prescriptions derive mainly from normative concerns and perceived lack of effectiveness of such interventions. Addressing these disagreements may require developing a broader research agenda to explore the policy and political implications of these prescriptions.

Why older women do or do not seek help from the GP after a fall: a qualitative study

BACKGROUND

It is recommended that older people report their falls to their general practitioner (GP), to identify falls risk factors. However, many older people do not report falling to their GP. Little is known about the reasons why older people do and do not seek help about falling.

OBJECTIVE

To explore why older women do or do not seek GP help after a fall.

METHODS

A qualitative study, using semi-structured interviews with 11 community-dwelling women aged ≥ 65 years, living in Adelaide, Australia, who had fallen in the last 12 months. Interviews focused on women's experience of falling and seeking GP help. Interviews were analysed using constant comparison.

RESULTS

Four women sought GP help when they believed their fall-related injury was serious enough. Family and a bystander persuaded three women to attend for a fall-related injury. The four women who did not seek help believed their fall or fall-related injury was not serious enough to seek help and justified this by using internal rationales (they monitored and managed the outcome of falling, they wanted to be associated with a positive image and attitude, and they recognized and interpreted the cause and control of falling) and external rationales (they did not want to waste GPs' time for trivial reasons and they believed they did not have timely access to their GP).

CONCLUSIONS

Given the reasons why some older women do not seek help for falling, GPs should routinely ask older women for their 12-month fall history.

Sex differences in health care-seeking behavior for acute coronary syndrome in a low income country, Peru

OBJECTIVE

: Recognizing reasons for prehospital delay after symptoms of acute coronary syndrome (ACS) is established in developed countries yet evidence from Latin America is limited. We aimed to assess ACS symptom recognition, health care-seeking behavior, and confidence in local health care facilities to take care of ACS by gender in a sample of Peruvians.

METHODS

: A community-based interview survey in a peri-urban area in Lima, Peru. The 24-item study instrument included vignettes and questions assessing identification of urgent and emergent ACS symptoms, anticipated help-seeking behaviors, and confidence in local health care facilities.

RESULTS

: In the study population (90 people; 45.6% men; mean age, 43.5 years), women were 4 times less likely to correctly attribute symptoms of chest pain to the heart (OR = 0.23; 95% CI: 0.063-0.87; P = 0.03). Women were much more likely to respond that a man would "Seek help" (OR = 4.54; 95% CI: 1.21-16.90; P = 0.024) and that "Yes," a woman would be less likely to seek help for chest pain symptoms (OR = 3.26; 95% CI: 1.13-9.41 P = 0.029) after adjusting for age, education level, age at migration, and history of chest pain. Women were less likely than men to think that their local Health Care Post would help them if they had a heart attack (2.1% vs. 14.6%; P = 0.04), and only 18.7% of women believed that their local emergency room would help them.

CONCLUSIONS

: Our findings suggest women are less likely to seek help for chest pain and women and men in a peri-urban area in Peru are not confident in their local health care facility to treat urgent or emergent ACS symptoms.

A comparison of irritable bowel syndrome patients managed in primary and secondary care: the Episode IBS study

BACKGROUND

It is thought that people with irritable bowel syndrome (IBS) who consult secondary care have more severe symptomatology than those treated mainly in primary care.

AIMS

To describe the physical and psychological symptoms of IBS, and the health-related quality of life of patients managed in primary and secondary care.

DESIGN OF STUDY

Cross-sectional observational survey.

SETTING

The general population of the United Kingdom (UK).

METHODS

A cohort of people with IBS symptoms was recruited via a UK-wide newspaper advertisement. Frequency, duration and severity of symptoms, and health-related quality of life data were collected by semi-structured telephone interviews. Descriptive analysis allowed the comparison of those managed in primary care with those consulting secondary care. Logistic regression was used to identify factors associated with patients consulting secondary care.

RESULTS

Data on 486 participants with confirmed IBS (Rome II criteria) were examined. Similar patterns in symptom severity were found in primary and secondary care groups. Factors associated with IBS patients consulting secondary care were: male sex, a longer length of time since diagnosis, having frequent bowel motions, not having dyspepsia in the past 3 months, and having used medication and alternative therapies. Although patients managed in secondary care have greater impairment to their usual activities, both groups had similar health-related quality-of-life profiles.

CONCLUSION

High levels of physical and psychological morbidity were present in population-based volunteers managed in both primary and secondary care. This study suggests that patients with IBS managed solely in primary care are affected as much as those attending secondary care.