Barriers to healthcare services' utilization in the health seeking process
Service acceptability depended on the health worker attitudes and practices. An example of poor attitudes and practices is illustrated by the following quote:
'The health workers treat us badly like we are not human beings, they may not even be bothered if someone dies compared with the traditional birth attendants who treat people humanely. In hospital they slap you and say "to avoid disturbances let's do the caesarian operation". This brings fear and skepticism in using the service. If you have grown up in poverty you may look older than you actually are and they will abuse you and say that "look that old woman who has come to give birth"' (FGD Medium wealth category, Nawangisa).
Another practice that was noted to be unacceptable was perceived gender discrimination.
'A customer is king (but) in the hospital women are mistreated because they may not have money. The men always have 'something" (FGD, Least Poor, Nawangisa).
Local illness and treatment perceptions as well as fear and stigma were also identified as barriers in the health seeking process. For instance, it was recognized that illness could be acute and serious requiring attention depending on the perceived urgency. Conditions that were identified as needing conventional care include 'vomiting in children, convulsions, "pressure" (hypertension), "ulcers" (chronic epigastric pain), dental problems, cough and chest pain, epilepsy, diabetes, malaria, and measles'. And yet, the perception that traditional care or faith healing was the norm for some conditions might deter conventional healthcare utilization for all wealth categories. This is illustrated in the quotes below:
' Artificial medicine for "nawawa" [condition where child presents with chills and cold spells], "eyabwe" [convulsions], "syphilis" and sexually transmitted diseases is inferior to local medicines.' (FGD Least poor, Kakongoka).
'Some types of balokole (born-again Christians) just pray for conditions like fever, snake bite, diarrhea, serious fall from a tree' (FGD Poorest, Nawangisa).
Related to the local illness perceptions was the lack of trust in the usefulness of certain interventions. This in some cases could deter the adoption of preventive actions:
'It's not easy to prevent malaria because even if you say you want to buy a mosquito net, you won't put it on when you are outside of the home conversing' (FGD Poorest, Namundudi).
Fear and stigma as barriers to use of some health services are illustrated in the quote below:
'There are illnesses that we don't take to health units where we have someone known to us. Like HIV/AIDS, here we just go to witch doctors. In fact, we don't even want to know that it's AIDS. We prefer to be told that it is witchcraft. People fear to give advice when they see signs of AIDS. They are afraid because that would be offending the sick, people shall ask you how you know ... how you come to imagine that it's HIV. When you mention testing to them, they will shun you and never want to talk to you again' (FGD Medium wealth category, Namundudi).
Steps in health seeking behavior could create delay in accessing appropriate treatment as illustrated in the quote below:
'For us when you feel ill, you go to the drug shop and explain your pains to the attendant, who chooses the drugs. When things do not work out, you go to the private clinic. The clinic nurse is more technical than the drug shop attendant who when defeated may refer you to a health centre and in case the condition is worse you are taken to Nakavule Iganga Hospital' (FGD Least Poor, Kakongoka).
Once illness was recognized and a decision made to seek care, not knowing where a service was provided led to choices of alternative or 'no-care'.
'For us once you have AIDS, you just go to witch doctors otherwise we don't have places to go for treatment. Once you have HIV, you just wait to die' (FGD Medium wealth category, Kakongoka).
Health service factors as determinants of utilization
Determinants of utilization in this approach were related to whether services were available, adequate, acceptable or affordable.
Availability of services
Availability of services was a perception translated to mean that services were within reasonable physical reach. The poorest wealth category identified the availability of free public care as enabling to the use of both preventive and curative services:
'If there isn't any money in the home we go to the health centre since we can sometimes get free treatment' (FGD Poorest, Kakongoka).
The proximity of local private clinics was also considered essential as first aid points:
'Our local health care options are near – some illnesses need first aid. For example acute illness such as convulsions, if a child has convulsions, we go to drug shops and private clinics because they are the nearest and also because we may not have transport to get to another facility' (FGD Medium wealth category, Nawangisa).
The presence of community medicine distributors was also reported as facilitating use of conventional health care but these were considered unreliable:
Community medicine distributors make it easy for us to access care but these are unreliable (FGD Poorest, Namundudi).
Adequacy of services
The adequacy of services was judged in light of perceived quality, the way services were organized, and the availability of commodities. The inadequacy of health services was noted for preventive and curative care as well as at the different levels. For instance, the distribution of free commodities enabled use of preventive actions such as condom use but this was inadequate to cater for existing demand:
'There is no way to get free condoms, maybe when there is an immunization outreach but we buy most of the time' (FGD Poorest, Namundudi).
At the public health centre II, participants decried the approach of health care providers, the lack of supplies and equipment. There was also a sense of inconvenience in the process of obtaining care.
'The health centre works only for twelve hours, there are always stock-outs, and health personnel are very rude and tough. No ambulance, poor referral system. Sometimes they delay to refer you to the hospital and may hold you only to tell you after a long time for example 6.00 pm when you can't do much. There is only one bed for maternity, few staff, they always insist to go by the book, may require of you unnecessary details and credentials etc.' (FGD Least poor, Kakongoka).
There was also a lack of trust in the health worker qualifications particularly in the local private clinics and hence the efficacy of the treatment given.
In our (private) clinics, we do not know the qualifications of our health workers. You can't ask them where they obtained their qualifications from, so long as they give you some treatment. For some conditions like severe anemia – these local health services cannot be useful yet you cannot afford referral. When you have fever you go and pay 200/- shillings worth of medication whatever it is. It could be chloroquine mixed with Aspirin
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we are never sure, whether it helps or not is another matter. You can't be sure that what you are getting is effective but we have no other option' (FGD Poorest, Nawangisa). At the government hospital the lack of supplies compromised perceived adequacy of services even for the least poor as they found it unrealistic to purchase medicines from without late at night.
Government hospitals have no supplies. There is a lack of medicines in government hospitals. You are sent to buy supplies at 2.00 am. Where do you buy supplies at 2.00 am ... so why bother to rush to a big hospital?' (Least Poor, Nawangisa).
Affordability
High cost was identified as a barrier to the adoption of certain preventive actions such as use of mosquito nets and condoms. High cost was also a barrier to treatment of both acute and chronic conditions. An example of high cost as a barrier to use is demonstrated in the following quote:
'Treatment of chronic diseases like AIDS, "ulcers" and "pressure" is expensive in terms of treatment and transport. It's not easy in fact someone can even die' (FGD Medium wealth category, Namundudi).
In addition, although public services are supposed to be free of charge, demand for unofficial fees presents a barrier to use particularly for the poor:
"There is someone who was taken by family members to the (public) hospital but even then he was brought back because they could not pay bribes to the medics" (FGD, Least Poor, Namundudi).
Livelihood assets as a determinant of use
Ownership of material, human and social resources that were reported as determinants of health care service use.
Material resources
Material resources that were related to use of services include financial, physical and natural capital. Financial capital in terms of cash and/or credit was identified as an important factor for use of services. Physical capital in terms of ownership of means of transport also facilitated use of services. Natural capital in terms of ownership of livestock and land was not mentioned as an important factor during the focus group discussions but was identified with being wealthier during the community meetings and was implicitly linked to having more money. The least poor identified that bad (feeder) roads during bad weather as well as the lack of ambulances hinder access to health services but they had the means to overcome these. In particular, proximity to the main tarmac road was reported as a facilitating factor to use of services. The least poor reported that they were able to take advantage of this situation even late into the night because of the good security situation.
'If one has transport we can go to bigger hospitals because there is security in the area and one can even travel at 2 am in the morning. Proximity to the main road is a facilitating factor as well as security even late into the night if the health care is available' (Least Poor, Nawangisa).
However even the least poor occasionally found it problematic to access health services when cash was unavailable.
'What makes it easy for us to use health services is that we have some money. However, during the dry season we have no money and that makes it hard to access services' (FGD Least Poor, Kakongoka).
The medium wealth category and poorest categories reported a lack of financial resources to meet health care costs as an outstanding barrier as one group member remarked.
'Money is everything and yet we don't have it. If you don't have money it means no services. Don't waste your time. Just go home and die' (FGD Medium wealth category, Kakongoka).
Human resources/Health literacy
The level of education and/or health literacy did not directly limit use but reportedly influenced the potential benefit from use of health care services.
'Uneducated people can't read instructions, prescriptions or have a better understanding of health related issues. Those who are more educated are more confident, they also follow prescriptions and know why and what to do. Those of us who never went to school sometimes fail to explain our illness to the doctors because we do not know English' (FGD Poorest, Namundudi).
Social resources
Social resources from friends and family were identified as useful in overcoming some of the existing barriers to utilization of health services. These resources included financial support from friends and/or family to overcome high cost of the health services; transport to attend comprehensive health services; information on where certain health services were found; and relationships with health workers that helped to make services more receptive. Social standing was assessed in terms of how one is regarded in the community. It was a probing question related to discrimination and whether access to social resources helped one to overcome this potential barrier to health care utilization. Social standing or what people think of you was not identified as a hindrance to utilizing health care services as noted below:
'Social standing in society or what people think of you is not a hindrance to accessing health care; the biggest hindrance is money' (FGD Poorest, Nawangisa).
The FGDs of the medium wealth category and poorest reported that social resources to use health services could be accessed through friends, relatives and employers but these were limited in terms of the potential to overcome barriers to use of services.
'Us we do not have friends who can help us access health services when we don't have money. We don't have such people more especially we have spent the money on taking our children to school. We don't have people with big jobs in government. Friends only give advice but not money. Friends may give advice on which doctor or traditional healer to visit but no money. Friends or relatives may get you an herb or even direct you on how to prepare a treatment concoction but not give you actual money' (Poorest, Namundudi).
The least poor on the other hand reported networks that are more useful:
'If friends and relatives hear of your calamity they come and fetch you and take you to hospital' (Least Poor, Kakongoka).
Knowing someone at a public health facility could be useful in terms of accessing health care services. Such a scenario is demonstrated in the following quote:
'We had a sick child (anaemic), I needed blood urgently but was failing then all of a sudden I run into someone I know who works there so I explained and in an instant, I got all the services I needed' (Poorest, Namundudi).
The poorest wealth category identified potential networks that could be useful in mobilizing resources to enable them use health care services. In addition they identified potential reasons for why these networks were not accessed by people in their category. For one it was perceived that helpfulness in the community was limited and was related to the ability to give something back in return.
'No we do not have friends who help us to access health care. Maybe our MPs could have helped but they are not useful in this matter. People know that if they help you, you may not pay back' (Poorest Category, Nawangisa).
Furthermore, it was felt that community helpfulness had also declined.
'In those days Moslems used to help each other, it doesn't happen these days, not even during Ramadan – you can sit next to each other, one drinking porridge and the other with nothing to take. It doesn't mean anything anymore' (Poorest, Nawangisa).