“If You Have No Money, You Might Die”: A Qualitative Study of Sociocultural and Health System Barriers to Care for Decedent Febrile Inpatients in Northern Tanzania

Abstract

Infectious diseases are a leading cause of mortality in low-and middle-income countries (LMICs) despite effective treatments. To study the sociocultural and health system barriers to care, we conducted a qualitative social autopsy study of patients who died from febrile illness in northern Tanzania. From December 2016 through July 2017, we conducted in-depth interviews in Arusha and Kilimanjaro regions with a purposive sample of 20 family members of patients who had died at two regional referral hospitals. Of the deceased patients included in this study, 14 (70%) were adults and 10 (50%) were female. Patients identified their religion as Catholic (12, 60%), Lutheran (six, 30%), and Muslim (two, 10%), and their ethnicity as Chagga (14, 70%) and Sambaa (two, 10%), among others. Family members reported both barriers to and facilitators of receiving health care. Barriers included a perceived lack of capacity of local health facilities, transportation barriers, and a lack of formal referrals to higher levels of care. Family members also reported the cost of health care as a barrier. However, one facilitator of care was access to financial resources via families' social networks-a phenomenon we refer to as social capital. Another facilitator of care was families' proactive engagement with the health system. Our results suggest that further investment in lower level health facilities may improve care-seeking and referral patterns and that future research into the role of social capital is needed to fully understand the effect of socioeconomic factors on healthcare utilization in LMICs.

Complications and mortality of typhoid fever: A global systematic review and meta-analysis

“…In some settings, poor transportation infrastructure, cost of healthcare, and difficulty in obtaining referrals can result in the sickest patients not reaching care. 5 , 6 , 7 Alternatively, community-based studies alter the outcome towards the null by enhancing typhoid diagnosis and management, allowing early treatment before progression to severe and complicated disease. 137 We attempted to limit other selection biases in non-surgical studies by stratifying by setting type, region and sub-region, and age, and by including only those that used culture of normally sterile sites to confirm typhoid fever.…”

“…4 Additionally, delays in diagnosis and treatment occur as a result of barriers to care, such as difficulty accessing tertiary facilities because of delayed referral, distance, and the cost of healthcare. [5][6][7] Timely and accurate diagnosis and treatment of typhoid fever in the community is needed to avert complications requiring hospitalization and death. 2 Such complications include typhoid intestinal perforation (TIP), gastrointestinal hemorrhage, hepatitis, cholecystitis, myocarditis, shock, encephalopathy, pneumonia, and anemia.…”

“… 4 Additionally, delays in diagnosis and treatment occur as a result of barriers to care, such as difficulty accessing tertiary facilities because of delayed referral, distance, and the cost of healthcare. 5 , 6 , 7 …”

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“…While people living with NCDs may enrol in social health protection in order to cope with the direct financial cost of accessing healthcare, patients must still deal with the indirect costs of accessing care and with reduced abilities to work or perform activities of daily living ( 19 , 20 ). When patients face a substantial burden of opportunity costs or when formal social health protection schemes fail to adequately protect against catastrophic OOPs, many turn to their social network for support ( 21 , 22 ).…”

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“…In developing countries, the public health goal of preventing and controlling typhoid disease through sanitation and adequate medical care is challenging. Besides that, delays in diagnosis and treatment occur due to barriers to medical care, such as difficulty accessing medical facilities caused by delayed referral, the distance to hospital, and the cost of getting healthcare [5][6][7].…”