Background
Non-communicable diseases (NCDs) are a global threat to human health and the development and economy in low-income countries. The 2010 global status report of the World Health Organization (WHO) on NCDs, shows that NCDs, particularly cardiovascular diseases, cancers, diabetes, and lung diseases, have emerged as leading causes of mortality in the world [
1,
2]. NCD prevalence is steadily increasing, including among working age populations [
3]. Recent studies indicate that COPD and hypertension (HT) are among the most common causes of mortality [
4,
5].
COPD is a progressively disabling disease of the lower respiratory tract. In addition to the risk of dying, a major concern is the occurrence of comorbidities. Abot 50% of COPD patients have at least one other chronic disease and among them hypertension is the most frequent [
6,
7]. HT is the leading risk factors and contributes to chronic cardiovascular disease occurrence, ischemic heart diseases and stroke. COPD severity is reported as associated with increased risk of hypertension [
6].
In a review of 23 developing countries Bangladesh shows the 9th highest rate of age-standardized mortality due to NCDs, primarily including cardiovascular diseases (CVDs) and diabetes [
7]. A recent hospital study across Bangladesh shows that about one-third of admissions of patients aged over 30 years are due to the major NCDs [
7].
As a leading cause of mortality and morbidity among those over 40 years of age, COPD shows one of the most alarming NCDs increases in Bangladesh. COPD prevalence is 13% among men and women aged 40 years and above [
6]. The two most important causes of COPD are smoking and indoor air pollution [
8‐
10]. COPD accounted for 559/100,000 disability-adjusted life-years, ranking Bangladesh in top five countries with the highest prevalence [
11]. The Bangladesh Demographic and Health Survey 2011 reports that HT prevalence is 32% among adults aged ≥35 years [
12]. A more recent study reports that HT prevalence is 12.4% in rural areas and 16.1% in urban areas [
13]. The National NCD Risk Factor Survey of 2010 shows that about 11% of women and 8% of men were aware of these conditions but did not seek any treatment [
14]. About 79% of HT patients does not take regular treatment for their sickness [
15].
It is clear that COPD and HT are important public-health problems in Bangladesh. The demographic transition and changes in lifestyle, along with increased rates of urbanization, are major factors in the rise of these conditios. As the disease burden shifts towards higher ages, the health systems of the country face growing demands of both rich and poor people [
16]. The present national essential services package does not include prevention or the treatment of chronic diseases. The annual ‘Reality Check’ study of the ultra poor observes an increasing demand of care for both condition and highlights the need for information on the societal consequences of COPD and HT, healthcare-seeking behaviour, and services availability and their community responsiveness [
17].
This article describes the consequences of HT and COPD on daily functioning of patients, healthcare-seeking behaviour, and provider responses.
Methods
This cross-sectional study was conducted during 2012–2013. The study used a mixed method approach i.e. both quantitative and qualitative techniques were applied. The qualitative data were collected after completion of a patient survey for complementing survey data. Qualitative research among the sampled households explored key topics raised after initial analyses of the survey data. The survey questionnaire examined the consequences of COPD and HT. Descriptive qualitative techniques examined the consequences of COPD and HT, healthcare seeking behaviours, and the responses of the health systems. The qualitative data lead to a more indepth understanding of the process and mechanisms in the use of health care and bring in the topic raised by those health care providers who are consulted most often.
Definitions
Hypertension was defined as systolic blood pressure of ≥140 mm hg or diastolic blood pressure of ≥90 mm hg or being on antihypertensive medication without showing systolic and diastolic measures of above normal [Alam S 2010, an unpublished research protocol on HT].
COPD is a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible [Alam S 2010, an unpublished research protocol on COPD].
ADL scores are describing the level of those activities of daily living that indicate the functional status of a person, referring to daily care activities within the place of residence, in the outdoor environments, or both.
Financial crisis: a situation in which the income of a family experiences suddenly reduces as a consequence of an acute or chonic disease.
Health service provision in study sites
In the study sites, the distribution of public healthcare services and facilities follows the same pattern of administrative tiers ranging from national (mostly capital-based in Dhaka), regional (in divisions), district, sub-district, to community level provisions. Secondary and tertiary care in both urban and rural sites is the sole responsibility of the Minsitry of Health and Family Welfare (MoHFW).
At the rural sites, the Upazila (sub-district) Health Complex (UHC) is a fixed service-delivery point designed to provide first-level referral services to the people. The UHC is meant for curative, preventive, promotive and rehabilative health services using the hospital facility and by field-level workers. In each UHC, there are posts for nine doctors, including one Upazila Health and Family Planning Officer (UHFPO). UHFPO, the Chief Health Officer of the upazila, is also the head of the UHC. Other doctors in the UHC include junior consultants-4, residential medical officer-1, assistant surgeon-2, and dental surgeon-1. The UHC provides outpatient, inpatient, and emergency services, limited diagnostic and imarging services, emergency obstetric care, maternal healthcare, and dental care.
Below Upazila level there are three types of static health facilities at the union level (8–10 unions in each upazila). These are Union Subcentres, Union Health and Family Welfare Centres (UHFWCs) and Community Clinics (CCs). Service providers at the union-level facilities include Medical Officers/Assistant Surgeons, Medical Assistant (MA), Pharmacist, and member of lower service staff (MLSS).
The main health workforce at community level is the domiciliary staff called Health Assistants (HAs). They are placed in community level. They make home-visits to provide primary health care (PHC) services and collect routine health data. The HAs routinely organize outreach centres for PHC services.
In urban sites, the Ministry of Local Government, Rural Development and Cooperative (MoLGRDC) is responsible for health matters, which are executed by the city corporation/municipality authorities. City corporation/municipal authorities are supported by various government and non-government organizations and private-sector agencies that also provide services in urban sites. The government sector, including municipal health department, and NGOs concentrate on preventive and promotive healthcare while the private sector concentrates mainly on curative healthcare.
The traditional medicine systems practiced in Bangladesh include the Unani and Ayurvedic which have a joint governing board, although each has its own network of teaching colleges. The expansive informal sector includes traditional birth attendants, drug vendors, and village doctors.
Study sites and subjects
The study was conducted in one rural (Matlab) and one urban (Kamalapur) surveillance sites of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) and included (a) patients with hypertension, (b) patients with COPD, or (c) patients with both conditions living in the study sites, and (d) healthcare providers working within the study areas.
Sampling
The sampled households (N = 989) were identified and sampled from an existing list of households identified earlier as having at least one patient with COPD or hypertension, living in Matlab (n = 483) or in Kamalapur (n = 506). The list was the result from previously conducted epidemiological studies [Alam S 2010, unpublished research protocols on HT and COPD]. The present study included all patients identified through the screening process of the studies [Alam S 2010, unpublished research protocols on HT and COPD]. The earlier studies were population-based on the prevalence and determinants of hypertension and COPD [Alam S 2010, an unpublished research protocol on HT] and a follow-up study to assess of rate of decline in pulmonary function in the diagnosed COPD cases [Alam S 2010, an unpublished research protocol on COPD].
In total, 3758 people were interviewed in each study site to measure the prevalence of hypertension. Here, age-stratified lists of all the subjects were obtained from the database of the Health and Demographic Surveilance system of icddr,b. For each age stratum, the required number of individuals was randomly selected. The availability of subjects was verified through a door-to-door visit. The study team contacted each selected individual to explain the study objectives, invited them for participation in the study and detected patients following standered procedure.
Study inclusion criteria
The study included all adult males and non-pregnant females, aged ≥20 years, who did not suffer from any heart attack or stroke, who had no history of heart or kidney failure, not suffering from any acute illness during recruitment, and who were able to provide valid consent for participation, and were willing to participate in the study.
For COPD, the individuals were randomly selected by Alam’s study [Alam S 2010, an unpublished research protocol on COPD] for examination with spirometry for dictation. In total, 3758 individuals were randomly tested through spirometry in each site to identify COPD patients. Here, the included age group were the ≥40-year-old individuals.
Data collection
All the patients of hypertension, COPD, and comorbidity clinically diagnosed during the epidemiological study [Alam S 2010, unpublished research protocols on HT and COPD] were interviewed using a structured questionnaire to assess the consequences of the diseases on household livelihoods, healthcare-seeking behaviours, and coping strategies. A questionnaire was designed to gather information on the consequences of the diseases on the affected individuals and their households, healthcare-seeking behaviors, overall implications for household livelihoods, and coping strategies adopted. Questions were included to assess if the patient unable to do work during the illness. If yes, the interviewee was asked how long she or he was unable to do work during the illness. If the patient faced financial problems due to not being able to work, questions were asked to assess the ADL score and to quantify the financial problems. The questionnaire was pretested before administration. Experienced interviewers administrated the questionaires. They received both classroom and field training on collection of data from hypertension and COPD patients.
Qualitative techniques
In-depth interviews
In-depth interviews to ask about the financial household conquences were conducted among 24 hypertension and 24 COPD patients, stratiefied by gender, income status and age. They were from both study sites. Experienced qualitative researchers were involved in data-collection. Intensive training was imparted to them on data-collection through the techniques mentioned above. They used formal guidelines. The interviewers explained the objectives of study, why the participant was selected, what type of question would be asked during interview with the patients and took consent before starting of interviews. The key area of interest included: assessment of financial assets of households at the time when the illness started and how these changed as the illness progressed, with increased expenditure on healthcare and/or decreased income generation; and an exploration of treatment-seeking patterns, how these changed over time, and what variables affected these.
Using information from the sample survey, a purposive sample of most commonly-used providers was drawn to undertake key-informant interviews of their characteristics and advice, treatment, and referral practices in relation to COPD and hypertension. In total, 15 providers of various categories, selected from the community, sub-district, district and tertiary-level facilities from each site, were interviewed. The commonly involved providers were selected based on analysis of survey data. During survey, the patients were asked the name and address of service providers to whom they mostly visit for their treatment. The service providers whose names mostly mentioned by the patients were selected for key informant interviews. It involved a detailed assessment of providers, focusing on their capacity to provide advice, treatment, and referral services in relation to COPD and hypertension. Data on socioeconomic and demographic characteristics of service providers were also collected. They were asked about their training and career history. A semi-structured questionnaire allowed exploration of experience and confidence in treating hypertension or COPD conditions. Referral linkages to the public health system were particularly examined. Information was also collected on the formal service-delivery system and the extent to which the system treats hypertension and COPD conditions.
Data analyses
Data were entered using the customized visual BASICS/FoxPro software 9.0 and were analyzed using the SPSS software (version 19). The precision of estimates from the quantitative surveys were based on 95% confidence interval (CI). Bivariate and multivariate analyses were carried out, with statistical significance based on 95% CL. Logistic regression analysis was conducted to identify factors that were significantly associated with consequences of the diseases and care-seeking behaviors.
Qualitative information collected through in-depth interviews and key-informant interviews were transcribed, translated into English, and analyzed using contents analysis. Analysis of qualitative data was begun with the first field activities and led to refinements as the study proceeded. From the beginning, we conducted thematic analysis to understand care seeking behaviours and health systems response. The data collector prepared transcript after completion of each interview. The data processing included reading, coding, displaying, reducing, and interpreting. The reading and coding were initiated while data were collected. The primary themes and sub-themes were identified through initial coding. After reading, re-reading, and coding the text, the primary themes and sub-themes were merged with the main themes. When the main themes were formalized, we performed matrix analysis for displaying the data. However, the data-display and reduction process was conducted once all data were collected.
Ethical clearance
All the respondents gave written consent before participating in the study. The Research Review Committee and the Ethical Review Committee of icddr,b approved the study. The interviews conducted interviews in isolated places and discussed between interviewer and interviewee. Confidentiality of data was strictly maintained.
Statement of compliance to the RATS guideline for qualitative component
We follow the RATS guideline for qualitative component of the manuscript (please see the RATS checklist provided as an Additional file
1).
Discussion
Our study reports the important health and social consequences of HT and COPD, the health care seeking behaviour of patients and responses of health providers in Bangladesh.
We found lower ADL scores among patients of COPD than among those with hypertension and their combined effects. Results of logistic regression showed significantly higher OR of low ADL scores in case of comorbidities as compared to those with hypertension.
Qualitative information shows more ADL impairment among the patients than the quantitative ADL scores. This might be due to more probing during qualitative data collection. Two-thirds of the COPD patients reported their inability to perform daily activities in various forms, such as bathing, taking food by own hand, getting dress, and praying. Many reported that COPD restricted their movements. Due to this physical condition, most of them could not carry out their daily household activities, such as cooking, cleaning, gardening, and cattle rearing.
There were high out-of-pocket expenditure and loss of income. Self-treatment of conditions during the initial stage was common in all the groups. Our study showed that the chronic conditions warranted high out-of-pocket expenditure and loss of wage or income more in the urban site than the rural site. The most common option households adopted to cope was borrowing money from relatives or friends, followed by reducing expenditure on food and reducing savings.
Around half of both rural and urban cases did not seek any medical treatment for COPD and HT. Many did not realize that they had the condition, mistakenly believing that breathlessness is just a factor of getting older, and the disease does not affect people aged less than 40 years. Many believed they were merely suffering from ‘smoker’s cough’, which is not important enough to bother their doctors. These findings are also consistent with findings of a study by the World Health Organization [
18]. The most common reason for not seeking any treatment was lack of felt-need for seeking care, followed by lack of money. A large majority sought treatment from pharmacies and from untrained village doctors. Seeking services from public-sector doctors was rare in rural Matlab and very few in urban Dhaka. Lack of awareness, information, education, and motivation might have played a role for not seeking treatment. The primary resorts for communities were typically pharmacies/drugstores and a range of informal providers from traditional healers to semi- or untrained village doctors or’quacks’. We observed a limited access of qualified biomedical providers by the poor. The key factors that affect health-seeking behaviors include knowledge about conditions and available services in the locality, cost of treatment and availability of finance, cultural preferences, and socioeconomic and gender relationships. Rigorous awareness raising programmes involving community health workers both in rural and urban areas may contribute in prevention and control HT and COPD.
Seeking care from formally-trained providers was higher in an urban setting and was higher for hypertension. The referral mechanism for COPD and hypertension patients was inadequate, and many were not referred until the severity of diseases increased. The qualitative data showed that unidentified COPD placed a substantial burden on patients, resulting in decreased lung function and associated symptoms, and led to physical impairment.
Our findings are consistent with findings of a study by Ahsan Karar in Bangladesh [
16]. It is clear from above findings that COPD and HT have impacts on ADL and financial situation of patients, make the patients vulnerable in terms of physically and economically. Therefore, policy level should take immediate steps to develop programmes on prevention and control of COPD and HT.
The limitation of the study was that the sample of qualitative component were selected purposively and there may be a risk of selection bias. However, for minimizing the selection bias, sampling was done considering geographical areas (rural and urban), age (young adult and old) and gender (males and females).
The important factors relating to responses of providers included background and (both formal and non-formal) training, position in the local’market’ for services, relationships with members of the local community and relevant authorities, degree of specialization, and links to formal service provision. Except the specialized hospitals, the healthcare facilities are not well-equipped; the providers had no adequate training on the diagnosis and management of hypertension and COPD patients; and there was no referral and follow-up system for patients. These need special attention of the MoHFW of the Government of Bangladesh. The MoHFW should ensure treatment for HT and COPD from trained providers. Further, healthcare facilities at PHC level needs to equipt to responed the needs of patients with COPD and HT.
Conclusions and implications
Few studies have explored the health consequences of HT and COPD, care seeking behaviour of patients, and the health system responses in Bangladesh, not in other low-income settings. In Bangladesh, no standard and evidence-based program is available for providing services to patients with hypertension and COPD, except in some very limited specialized hospitals at the tertiary levels. The findings of our study revealed that at PHC level, the health systems of Bangladesh are not yet ready to respond to the needs of patients with hypertension and COPD. On the other hand, although MoHFW has recently taken some initiatives, there is no strategic approach to include these diseases in the primary healthcare structure. However, PHC facilities should be equped to address the needs of HT and COPD patients and to reduce household level poverty. Active involvement of community health workers in prevention and control of HT and COPD may be a good strategy. Research to assess the effectiveness of such strategies is essential before proceeding to their large-scale implementation.
Acknowledgements
The research was funded by the National Heart, Lung and Blood Institute (NHLBI), National Institutes of Health (NIH), USA. icddr,b acknowledges with gratitude the commitment of NHLBI, NIH, USA to its research efforts. The authors are grateful to the hypertension and COPD patients for providing information for this research. The authors also acknowledge with gratitude the contributions of the research staff, such as Mr. Ali Imam, Dr. Ali Tanweer Siddique, Mr. Shahabuddin Bhuiyan, Mr. Wazed Ali, Ms Roksana Karim, and Ms Ishrat Jaben who were involved in the collection, processing and analysis of data.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
JU, LN, NA, and DSA were involved in developing the concept and implementation of the study, analysis of data, and writing of the manuscript. HS was involved in analysis of qualitative data and writing of the manuscript. JU and AHC were also involved in the collection and processing of data. All the authors read and approved the final manuscript.