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seeking behaviour in rural Ethiopia
5School of Foreign Service, Georgetown University, Doha, QatarCorrespondence toResults We find almost universal preference for modern care. Foregone care ranges from 0.6% for diarrhoea to 2.5% for tetanus. There is a systematic relationship between socioeconomic status and choice of providers mainly for adult related conditions with households in higher consumption quintiles more likely to seek care in health centres, private/Non Government Organization (NGO) clinics as opposed to health posts. Delays in care seeking behaviour are apparent mainly for adult related conditions and among poorer households.
Health EconomicsPrimary CareStrengths and limitations of this study
This paper identifies factors that drive healthcare seeking behaviour in rural Ethiopia using context specific clinical vignettes which avoid reporting bias in a self perceived need.
It examines healthcare seeking behaviour for child related and adult related conditions separately and investigates differences in the level and timing of care sought.
While the use of clinical vignettes allows us to establish patterns of healthcare seeking behaviour across population groups that are not driven by differences in health status, there is the risk that the reported hypothetical healthcare seeking behaviour does not match the actual healthcare seeking behaviour.
Because the symptoms described in the vignettes are quite specific and severe, they might not pick up foregone care in relation to diseases that are more difficult to recognise or more chronic in nature. These changes have been accompanied by a rapid expansion of healthcare infrastructure at all levels.1 3 There has been an 18 fold increase in the number of health posts in 2011 and a 7 fold increase in replica van cleef bangle the number of health centres over the same period.4 6 Consequently, it is estimated that primary healthcare coverage, defined as a village level access to a health post, has increased from 51% in 2000 to 92% in 2011.1 ,3
Despite these increases in the supply of healthcare and increases in the utilisation of some specific services, overall outpatient healthcare utilisation rates remain low and have increased only marginally from 0.27 visits in 2000 to 0.3 visits in 2011.1 ,3 ,7 Institutional deliveries have gone up from 5% to 11% in the same period, but remain extremely low compared with other sub Saharan African countries (eg, 28.3% in Eritrea, 43% in Kenya, 73% in Senegal and 75% in Malawi).8 Therefore, the main aim of this paper is to examine the extent of foregone care and to gain an understanding of the factors that are responsible for driving a wedge between availability and utilisation.
Available attempts at measuring foregone care for developed countries typically rely on explicitly asking survey respondents whether they did not use care when needed.9 ,10 For low income and middle income countries the evidence is mainly limited to the use and inequity in use of maternity and child (preventive) care.11 Self reported information on foregone care is likely to be biased, in particular in low income settings where knowledge about medical conditions and the need for care may be limited.12 This is illustrated by comparing data from the Ethiopian World Health Survey, which reveals that only 13% of respondents in the poorest quintile reported an unmet need for medical care,13 to data from the 2011 Ethiopian Demographic Health Survey in which 74.4% of women in the poorest quintile reported not having received any antenatal care during their last pregnancy.14 The current study therefore uses a series of context specific child related and adult related clinical vignettes to explore the healthcare seeking behaviour of rural Ethiopian households. Survey respondents are presented with well defined medical cases and asked about treatment needed. By fixing the medical condition, variation in responses to the vignettes may be attributed only to individual differences in perceptions of the care needed and not due to varying severity in the ill health condition.15 19 Studies that have used clinical vignettes in high income countries reveal that in these countries lower socioeconomic (ethnic or education level) groups are more likely to consult a doctor for a given set of symptoms. Therefore, they conclude that inequalities in actual healthcare utilisation may be attributed to barriers in healthcare provision and differences in case management due to ethnic origins and not due to difficulties in understanding the symptoms of the disease or due to a lower perception of the need for care.15 18 Despite the potential advantages of using healthcare vignettes as an alternative technique to analyse van cleef jewelry replica healthcare seeking behaviour, this approach has not been widely used in the context of low income and middle income countries where presumably variations in the perceived need for healthcare are much greater than in high income countries.11 A recent exception is a study in Peru. Based on a vignette designed to capture acute coronary syndrome (ACS), this study reports that women are less likely to recognise symptoms of ACS and also less likely to seek healthcare for chest pain as compared with men.19
The analysis deals with three issues. First, do households seek modern care? Second, conditional on seeking modern care, where do they seek care? And finally, what is the timing of their care seeking behaviour?This study is a part of a larger project which aims to evaluate a pilot community based health insurance scheme (CBHI) which was rolled out in four main regions (Tigray, Amhara, Oromiya and Southern Nations, Nationalities and People's Region (SNNPR)) of the country in June 2011 (see figure 1). In each of the pilot regions, which together account for about 86% of the country's population,20 the government chose three rural districts as CBHI pilot districts. Districts were selected if they had undertaken healthcare financing reforms designed to increase cost recovery and retention of locally raised revenues and if they had geographically accessible (located close to a main road) health centres. Our household survey covered all 12 CBHI pilot districts and four control districts (1 from each region) which were selected on the same basis as the pilot CBHI districts. It is important to point out that districts were not selected on the basis of healthcare seeking behaviour or awareness of health issues. From each of the sampled districts, six villages (kebeles) were randomly selected, and from each village 17 households were randomly chosen (based on household lists obtained from the village administrative office), yielding a total of 1632 households comprising 9455 individuals. Respondents were typically the head of the household (87%) or the spouse of the household head (13%). The survey was canvassed between March and April 2011 and contains extensive information on a variety of individual and household socioeconomic attributes including information on health status, healthcare utilisation and healthcare seeking behaviour.
Location of the survey regions.
Open in new tabFigure1 Location of the survey regions.
The household survey instrument contains five short clinical vignettes which were developed with input from researchers at Addis Ababa University's School of Public Health. The vignettes are based on illnesses that are widely prevalent in the study region and may be related to acute respiratory infection/pneumonia among babies, diarrhoea affecting female infants, an adult male replica Van Cleef & Arpels yellow gold bracelet experiencing malaria, an adult male experiencing tetanus and an adult female affected by tuberculosis. According to information from the WHO's Global Health Observatory, in terms of burden of disease (BOD), diarrhoea, respiratory infections, malaria and unintentional injuries are the four most prominent contributors to the country's BOD.21 The vignettes were primarily designed to enable an exploration of heterogeneity in healthcare seeking behaviour for conditions affecting children and adults. For each case, respondents were asked what they would do, that is, whether and where they would seek care and when they would seek care in case they or someone in their household were to experience the symptoms described in the vignettes. Respondents were offered a set of 11 choices for a healthcare provider including an option for foregone care (do nothing). Based on the government's service guidelines, diagnosis and treatment for diarrhoea and malaria are expected to be available at health posts. Health centres and hospitals are expected to be able to cater to all the illnesses described in the vignettes. The vignettes were designed with the view that medically the immediate care seeking option may be considered the appropriate course of action (for details, see appendix 1).
In addition to the vignettes, information on a range of other variables was collected in order to enable an exploration of the associations between healthcare seeking behaviour and other attributes of interest. These include information on household demographic composition, education of the household head, household health status, economic status as captured by per capita household consumption, attitudes towards modern healthcare and a range of variables to control for access to public (health) infrastructure and finally a set of indicators to control for regional differences. Descriptive statistics for the sample as a whole as well as region specific descriptive statistics are provided in appendix 2.
5School of Foreign Service, Georgetown University, Doha, QatarCorrespondence toResults We find almost universal preference for modern care. Foregone care ranges from 0.6% for diarrhoea to 2.5% for tetanus. There is a systematic relationship between socioeconomic status and choice of providers mainly for adult related conditions with households in higher consumption quintiles more likely to seek care in health centres, private/Non Government Organization (NGO) clinics as opposed to health posts. Delays in care seeking behaviour are apparent mainly for adult related conditions and among poorer households.
Health EconomicsPrimary CareStrengths and limitations of this study
This paper identifies factors that drive healthcare seeking behaviour in rural Ethiopia using context specific clinical vignettes which avoid reporting bias in a self perceived need.
It examines healthcare seeking behaviour for child related and adult related conditions separately and investigates differences in the level and timing of care sought.
While the use of clinical vignettes allows us to establish patterns of healthcare seeking behaviour across population groups that are not driven by differences in health status, there is the risk that the reported hypothetical healthcare seeking behaviour does not match the actual healthcare seeking behaviour.
Because the symptoms described in the vignettes are quite specific and severe, they might not pick up foregone care in relation to diseases that are more difficult to recognise or more chronic in nature. These changes have been accompanied by a rapid expansion of healthcare infrastructure at all levels.1 3 There has been an 18 fold increase in the number of health posts in 2011 and a 7 fold increase in replica van cleef bangle the number of health centres over the same period.4 6 Consequently, it is estimated that primary healthcare coverage, defined as a village level access to a health post, has increased from 51% in 2000 to 92% in 2011.1 ,3
Despite these increases in the supply of healthcare and increases in the utilisation of some specific services, overall outpatient healthcare utilisation rates remain low and have increased only marginally from 0.27 visits in 2000 to 0.3 visits in 2011.1 ,3 ,7 Institutional deliveries have gone up from 5% to 11% in the same period, but remain extremely low compared with other sub Saharan African countries (eg, 28.3% in Eritrea, 43% in Kenya, 73% in Senegal and 75% in Malawi).8 Therefore, the main aim of this paper is to examine the extent of foregone care and to gain an understanding of the factors that are responsible for driving a wedge between availability and utilisation.
Available attempts at measuring foregone care for developed countries typically rely on explicitly asking survey respondents whether they did not use care when needed.9 ,10 For low income and middle income countries the evidence is mainly limited to the use and inequity in use of maternity and child (preventive) care.11 Self reported information on foregone care is likely to be biased, in particular in low income settings where knowledge about medical conditions and the need for care may be limited.12 This is illustrated by comparing data from the Ethiopian World Health Survey, which reveals that only 13% of respondents in the poorest quintile reported an unmet need for medical care,13 to data from the 2011 Ethiopian Demographic Health Survey in which 74.4% of women in the poorest quintile reported not having received any antenatal care during their last pregnancy.14 The current study therefore uses a series of context specific child related and adult related clinical vignettes to explore the healthcare seeking behaviour of rural Ethiopian households. Survey respondents are presented with well defined medical cases and asked about treatment needed. By fixing the medical condition, variation in responses to the vignettes may be attributed only to individual differences in perceptions of the care needed and not due to varying severity in the ill health condition.15 19 Studies that have used clinical vignettes in high income countries reveal that in these countries lower socioeconomic (ethnic or education level) groups are more likely to consult a doctor for a given set of symptoms. Therefore, they conclude that inequalities in actual healthcare utilisation may be attributed to barriers in healthcare provision and differences in case management due to ethnic origins and not due to difficulties in understanding the symptoms of the disease or due to a lower perception of the need for care.15 18 Despite the potential advantages of using healthcare vignettes as an alternative technique to analyse van cleef jewelry replica healthcare seeking behaviour, this approach has not been widely used in the context of low income and middle income countries where presumably variations in the perceived need for healthcare are much greater than in high income countries.11 A recent exception is a study in Peru. Based on a vignette designed to capture acute coronary syndrome (ACS), this study reports that women are less likely to recognise symptoms of ACS and also less likely to seek healthcare for chest pain as compared with men.19
The analysis deals with three issues. First, do households seek modern care? Second, conditional on seeking modern care, where do they seek care? And finally, what is the timing of their care seeking behaviour?This study is a part of a larger project which aims to evaluate a pilot community based health insurance scheme (CBHI) which was rolled out in four main regions (Tigray, Amhara, Oromiya and Southern Nations, Nationalities and People's Region (SNNPR)) of the country in June 2011 (see figure 1). In each of the pilot regions, which together account for about 86% of the country's population,20 the government chose three rural districts as CBHI pilot districts. Districts were selected if they had undertaken healthcare financing reforms designed to increase cost recovery and retention of locally raised revenues and if they had geographically accessible (located close to a main road) health centres. Our household survey covered all 12 CBHI pilot districts and four control districts (1 from each region) which were selected on the same basis as the pilot CBHI districts. It is important to point out that districts were not selected on the basis of healthcare seeking behaviour or awareness of health issues. From each of the sampled districts, six villages (kebeles) were randomly selected, and from each village 17 households were randomly chosen (based on household lists obtained from the village administrative office), yielding a total of 1632 households comprising 9455 individuals. Respondents were typically the head of the household (87%) or the spouse of the household head (13%). The survey was canvassed between March and April 2011 and contains extensive information on a variety of individual and household socioeconomic attributes including information on health status, healthcare utilisation and healthcare seeking behaviour.
Location of the survey regions.
Open in new tabFigure1 Location of the survey regions.
The household survey instrument contains five short clinical vignettes which were developed with input from researchers at Addis Ababa University's School of Public Health. The vignettes are based on illnesses that are widely prevalent in the study region and may be related to acute respiratory infection/pneumonia among babies, diarrhoea affecting female infants, an adult male replica Van Cleef & Arpels yellow gold bracelet experiencing malaria, an adult male experiencing tetanus and an adult female affected by tuberculosis. According to information from the WHO's Global Health Observatory, in terms of burden of disease (BOD), diarrhoea, respiratory infections, malaria and unintentional injuries are the four most prominent contributors to the country's BOD.21 The vignettes were primarily designed to enable an exploration of heterogeneity in healthcare seeking behaviour for conditions affecting children and adults. For each case, respondents were asked what they would do, that is, whether and where they would seek care and when they would seek care in case they or someone in their household were to experience the symptoms described in the vignettes. Respondents were offered a set of 11 choices for a healthcare provider including an option for foregone care (do nothing). Based on the government's service guidelines, diagnosis and treatment for diarrhoea and malaria are expected to be available at health posts. Health centres and hospitals are expected to be able to cater to all the illnesses described in the vignettes. The vignettes were designed with the view that medically the immediate care seeking option may be considered the appropriate course of action (for details, see appendix 1).
In addition to the vignettes, information on a range of other variables was collected in order to enable an exploration of the associations between healthcare seeking behaviour and other attributes of interest. These include information on household demographic composition, education of the household head, household health status, economic status as captured by per capita household consumption, attitudes towards modern healthcare and a range of variables to control for access to public (health) infrastructure and finally a set of indicators to control for regional differences. Descriptive statistics for the sample as a whole as well as region specific descriptive statistics are provided in appendix 2.
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