Background
Methods and materials
Study design
Study time and settings
Study participants and sampling strategy
Data collection procedure
Data analysis and theoretical framework
Results
Characteristics of the participants
Variables | Study sites | Combined | |||
---|---|---|---|---|---|
Cumilla | Jhenaidah | Rajshahi | Sylhet | ||
Age in years (mean ± SD) | 55 (± 12) | 54 (± 10) | 49 (± 5) | 43 (± 11) | 51 (± 8) |
Gender (n) | |||||
Male (n) | 9 | 10 | 12 | 10 | 41 |
Female (n) | 11 | 15 | 14 | 11 | 51 |
Education (n) | |||||
No formal education (n) | 10 | 9 | 7 | 7 | 33 |
Primary school (I–V grade) (n) | 4 | 8 | 9 | 11 | 32 |
Secondary school (VI–X grade) (n) | 4 | 8 | 5 | 3 | 20 |
Higher (> X grade) (n) | 2 | - | 5 | - | 7 |
Marital status (n) | |||||
Married (n) | 16 | 16 | 14 | 15 | 61 |
Unmarried (n) | 3 | 4 | 5 | 2 | 14 |
Widowed (n) | 1 | 5 | 7 | 4 | 17 |
Family type (n) | |||||
Nuclear (n) | 5 | 10 | 2 | 6 | 23 |
Joint (n) | 15 | 15 | 24 | 15 | 69 |
Occupations (n) | |||||
Formal (n) | 4 | 3 | 2 | 4 | 13 |
Informal (n) | 16 | 22 | 24 | 17 | 79 |
Religious identity (n) | |||||
Muslim (n) | 16 | 25 | 17 | 16 | 74 |
Hinduism (n) | 4 | - | 6 | 4 | 14 |
Others (n) | - | - | 3 | - | 3 |
Income (n) | |||||
< 5000 tk (n) | - | 4 | 5 | - | 9 |
5,000–10,000 tk (n) | 4 | 11 | 15 | 5 | 35 |
> 10,000 tk (n) | 16 | 10 | 6 | 16 | 48 |
NCD status (n) | |||||
Developed at least 1 NCD (n) | 6 | 14 | 11 | 9 | 40 |
Multiple NCDs (n) | 14 | 11 | 15 | 12 | 52 |
Length of suffering from NCDs (n) | |||||
< 3 years (n) | 3 | 3 | 2 | 2 | 10 |
3–5 years (n) | 9 | 3 | 3 | 7 | 22 |
> 5 years (n) | 8 | 19 | 21 | 12 | 60 |
Characteristics | Values |
---|---|
Age in years (mean ± SD) | 42 (±9) |
Gender (n) | |
Male (n) | 9 |
Female (n) | 5 |
Type of provider (n) | |
Healthcare professional (n) | 8 |
Healthcare manager (n) | 2 |
Policy planner/independent consultant (n) | 2 |
Civil society/NGO workers (n) | 2 |
Length of service/experience (n) | |
< 5 years (n) | 3 |
6–10 years (n) | 4 |
> 10 years (n) | 7 |
Thematic analysis
Individual factors
Female and/or elderly people are more likely to come to nearby healthcare facilities. The CCs and FWCs are the nearest healthcare facilities located in the village or ward levels. They are comfortable visiting facilities that are located a short distance away.
I had a feeling of extreme fatigue, shortness of breath, and dizziness. I had upper body discomfort and chest pain. I thought these were happening due to gastritis and took medicine to reduce it from a local drug outlet. But my pain and discomfort come and go. Once I visited a doctor at UHC and learned I had high blood pressure and high cholesterol. It had developed for a long time, but I did not recognize it.
I developed high blood pressure over the last few years, but it might not make me ill and affect my normal life. I do not pay much attention to it as it is normal.
In many cases, NCD patients are asymptomatic. They don’t understand that they have high pressure. They may come to the health facilities for other diseases and are diagnosed with diabetes, high blood pressure, cholesterol, and heart diseases. The lack of realizing the symptoms and risk factors of diseases may lower the preference and willingness to receive healthcare services from the primary level facilities around them.
Community people hardly realize the importance of preventive services. Prevention is the key to better managing NCDs. Early detection, awareness building for lifestyle modification, and timely referral are important parts of preventive services. But people usually visit the healthcare center to seek these services due to the misperception that healthcare services are curative services.
Primary healthcare facilities are for managing common colds, fever, coughing, and headaches. They will give you a few iron tablets or gastric tablets. That’s it.
Most delivery patients and females, specifically married females, are more willing to go to primary healthcare facilities. Except for these, if NCD patients go there, they don’t give any importance as it is a female-focused healthcare service. (A male participant from the FGD in Cumilla)
It’s believed young people aged below 60 are unlikely to develop NCDs like diabetes, heart diseases, and respiratory diseases. Thus, young people have little or no chance of seeking NCD services from nearby healthcare facilities. (A female participant from the FGD in Rajshahi)
There is a lot of misconception regarding NCDs. Many people believe young people under the age of 50 have less chance of developing NCDs, which is not true in many cases. In many cases, young people have symptoms of diabetes, asthma, or heart disease, but they are reluctant to visit nearby primary healthcare facilities. Thus, the condition gets worse, and when they visit upper-level healthcare facilities they need modern and specialized care. (A KII participant from Jhenaidah)
Self-management or home remedy for NCDs, including respiratory illness, diabetes, and heart disease, are long-standing practices in our country that limits the willingness to visit nearby healthcare facilities on many occasions.
Interpersonal or family factors
I have diabetes. I eat plant leaves, kalojira (black cumin), and methi (dried fenugreek leaves) as my mother advised. I think these are good for managing diabetes, as senior family members had experienced this for a long time.
Our parents and grandparents are used to following traditional methods for treating a wide range of illnesses. I think these methods are good and useful for our generation too.
Wealthy family members are more likely to prefer secondary or tertiary-level healthcare facilities as their first contact because they like to attain high-quality care. They may have little or no trust in primary healthcare facilities
Wealthy families prefer to get care from private hospitals or clinics. Healthcare services at private healthcare facilities involve a relatively higher cost, but they may consider the quality of care.
When people get sick, they seek advice or information from their peers or close friends regarding healthcare facilities and options that influence their health-seeking.
Community and social factors
Drugs outlets are the most available physical structure around us. Drugs salespersons are well-known. They are welcoming and knowledgeable about many diseases or complications. They are available at any time and charge no fees for advising about medicines. We prefer to visit them as a point of contact.
Drugs salespersons are well-known and charge no fees for recommending medicines that may attract people from the community.
We go to the village doctors. If they say, “I can’t treat it, go to the city,” then we go there.
Village doctors are the most common and influential health service providers in our context. They provide service through generations. People often trust, rely on, and accept their services to a great extent.
Traditionally, informal providers have greater acceptance in our society. Many people believe that they can provide good care and manage complicated cases like cancer or other chronic conditions. People prefer to seek care from them instead of qualified doctors due to their beliefs.
Many families trust kabiraj, ojha, and faith healers to manage NCDs. They may offer care at minimal cost with confidence. They are usually overconfident about their service and assure the patients at the highest level, which may attract many of us.
They were popular in the past. But, nowadays, people avoid them.
Organizational and health system factors
If I go to the union level facilities at Union Sub-Center, they will give me only paracetamol and napa tablets. But I have to spend 50 BDT (1 BDT ≅ 87 USD) on the travel fare. I can buy a few packets of tablets with this travel fare.
I have diabetes and need to do some diagnostic tests, but the primary-level facilities do not have that capacity. I prefer to go to private facilities as they have modern instruments. (A male participant from a FGD in Jhenaidah)
Some patients prefer to seek care from private facilities but come to the government facilities to get medicine as it is free. I acknowledge that the supply of medicine is still insufficient, but they have increased significantly in the past few years. Over 20 types of medicine are provided in primary-level care facilities. It should be appreciated.
It takes almost two hours to get to the hospital which involves higher travel costs. Sometimes, it is better to visit a traditional provider in the community to save time and money.
The procedure is very slow in Upazila Health Complex. I have to take a ticket first, wait for a long time; it kills time. Say, I have taken the ticket at 10 a.m., and the doctor will see me at 1 p.m. after completing the round of indoor visits. Therefore, I have to sit until 1 p.m. I don’t have much time. Therefore, I went to private medical.
Actually, neither in Durgapur nor in Rajshahi will you get better treatment. Better treatment is available in a private clinic.
It is a trend to claim that government facilities do not provide quality care. People like to visit a good doctor, but who are the good doctors? People think good doctors are those who sit in private clinics with more patients. People have little or no trust in government facilities because they do not give irrational prescriptions. Suppose the patient needs paracetamol but expects azithromycin. Those who give are good doctors and provide good quality treatment. They have this mentality. The doctor has given me normal medicine; my problem will surely not be cured with it.
The treatment quality in the Upazila healthcare facilities is very bad. We go directly to Rajshahi (secondary and tertiary-level facilities).