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African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20
Socioeconomic status and barriers to the use of free antiretroviral treatment for HIV/AIDS in Enugu State, south-eastern Nigeria a
Chijioke I Okoli & Susan M Cleary
b
a
Health Policy Research Group, University of Nigeria, College of Medicine , Enugu Campus, PMB, 01129, Enugu, Nigeria b
University of Cape Town, Health Economics Unit , Observatory 7925, Cape Town, South Africa Published online: 22 Jun 2011.
To cite this article: Chijioke I Okoli & Susan M Cleary (2011) Socioeconomic status and barriers to the use of free antiretroviral treatment for HIV/AIDS in Enugu State, south-eastern Nigeria, African Journal of AIDS Research, 10:2, 149-155, DOI: 10.2989/16085906.2011.593377 To link to this article: http://dx.doi.org/10.2989/16085906.2011.593377
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Copyright © NISC (Pty) Ltd
African Journal of AIDS Research 2011, 10(2): 149–155 Printed in South Africa — All rights reserved
AJAR
ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2011.593377
Socioeconomic status and barriers to the use of free antiretroviral treatment for HIV/AIDS in Enugu State, south-eastern Nigeria Chijioke I Okoli1* and Susan M Cleary2 Health Policy Research Group, University of Nigeria, College of Medicine, Enugu Campus, PMB 01129, Enugu, Nigeria University of Cape Town, Health Economics Unit, Observatory 7925, Cape Town, South Africa *Corresponding author, e-mail: [email protected]
1
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2
With about 3 million people living with HIV, Nigeria has approximately 8% of the global burden of HIV cases. In 2009, only about 34% of those in need of antiretroviral treatment (ART) were able to access care, which means that Nigeria was far from achieving the United Nations target of ‘universal access’ by 2010. This study aimed to describe the barriers to accessibility and the coping strategies employed to overcome these barriers among users of free ART services overall and by socioeconomic status (SES). Data were collected from 240 people receiving ART at one urban and one peri-urban health facility in Enugu State, south-eastern Nigeria. Information on SES, demographic characteristics, and barriers and coping mechanisms for accessing ART were elicited from the respondents. The high cost of transportation, HIV stigma, and long waiting hours were found to be key barriers to the use of ART services. On average, ART clients spent just under four hours at the clinic during their monthly appointments. The use of personal savings and financial support from relatives were the main means to access treatment. When the data were analysed according to clients’ SES, transportation costs were a chief concern among the poorest while those who were better off were more likely to be concerned about stigma and discrimination. These findings should be borne in mind when designing and locating services to maximise ongoing accessibility to ART. Keywords: accessibility, equity, sub-Saharan Africa, utilisation patterns
Introduction With approximately 3 million people living with HIV, Nigeria has about 8% of the global burden of HIV cases (National Agency for the Control of AIDS [NACA] & UNAIDS, 2010). Officially selected public-sector facilities and faith-based organisations (FBOs) in the country provide antiretroviral treatment (ART) free at the point of use (Kombe, Galaty & Nwagbara, 2004; Amanyeiwe, Hatt, Arur, Taye, Mehta-Steffen, De Valdenebro et al., 2008). While Nigeria has progressively increased the provision of ART, only 34% of those with advanced HIV infection received ART in 2009 (NACA & UNAIDS, 2010). The limited number of ART facilities in urban areas also raises questions about accessibility, particularly for the poor. The United Nations General Assembly (2006) resolution titled ‘Political Declaration on HIV/AIDS’ outlines over 50 different HIV-related commitments, including progress towards the goal of achieving ‘universal access’ to ART by 2010 — specified as providing treatment to at least 80% of those in need of ART as defined by clinical guidelines (WHO/ UNAIDS/UNICEF, 2010). However, given that this goal is linked to the overall numbers of people starting ART, there is no commitment to ensuring that treatment availability extends to the poor. It is also likely that the poor will face greater barriers to remaining in care once treatment is initiated. The inverse-equity hypothesis suggests that the introduction of new interventions might lead to a worsening of health equity
as those in urban areas and those of higher socioeconomic status (SES) might initially have better accessibility to ART services than rural dwellers and the poor. Because of this, some have called for the specific inclusion of health-equity targets within overall targets for ART coverage so that progress on this front can be monitored (Hanefeld, 2008), especially since universal access by 2010 was unlikely to be achieved by the majority of low- and middle-income countries with a high burden of HIV. While access to healthcare is a frequently identified goal of health policy, there is still debate about the precise meaning of the term. In earlier literature, ‘access’ was primarily viewed in terms of two factors: monetary fees at the point of use, and distance travelled to use healthcare. Others have defined access to healthcare in terms of service use or coverage (e.g. WHO/UNAIDS within their definition of universal access), perhaps because this is easier to quantify (Mooney, 2009). More recently, access has been defined as the empowerment of individuals to use the available healthcare, which is a multidimensional concept based on the degree of fit between healthcare systems, individuals, households and communities. In this regard, three dimensions of access to healthcare are availability (or physical access), affordability (or financial access), and acceptability (or cultural access) (McIntyre, Thiede & Birch, 2009). These dimensions may act as a starting point for an empirical investigation of access to healthcare and for developing heath-policy strategies that address barriers
African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
Downloaded by [Korea University] at 21:56 31 December 2014
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to accessibility (Thiede, Akweongo & McIntyre, 2007), including with reference to socioeconomic dimensions. Despite the importance of equitable accessibility to ART, little research has been conducted regarding the barriers facing people needing access to treatment. A recent literature review (Posse, Meheus, Van Asten, Van Der Ven & Baltussen, 2008) found only six studies on this topic in developing countries; the review concluded that more research is needed to help policymakers differentiate between context-specific factors and findings that show important barriers across many settings. In addition, none of the studies assessed whether these factors differed according to clients’ SES. This study aims to describe the barriers to accessibility and the coping strategies employed to overcome these barriers among the users of free ART services at two sites in Nigeria through the application of a comprehensive ‘conceptual framework of access.’ A further objective is to examine the distribution of these elements and coping strategies according to SES. The findings may provide evidence to assist in developing policies to mitigate barriers to ART accessibility. Methods Setting The study was conducted in Enugu State in south-eastern Nigeria. The state has a population of 3.2 million and had an estimated HIV prevalence of 5.8% in 2008 (Ministry of Health, 2008; NACA & UNAIDS, 2010). Most urban dwellers are civil servants, traders, transporters or artisans (Onwujekwe, Onoka, Uzochukwu, Obikeze & Ezumah, 2009), while rural dwellers are largely subsistence farmers or petty traders (Ichoku & Fonta, 2006). As of 2008, five public hospitals and four private mission hospitals in Enugu State were providing free ART. From these, one public and one private site were purposively chosen for the study. The public facility was the ART centre within the University of Nigeria Teaching Hospital (UNTH), located in a peri-urban area on the outskirts of Enugu city (the administrative capital of the state). The chosen private facility was the ART centre within the Mother of Christ Specialist Hospital and Maternity (MCSH&M) — a private, not-for-profit facility located in the centre of Enugu city. Both sites administered ART free at the point of use to HIV-positive patients who met clinical eligibility criteria. Study design and conceptual framework of access An exit-interview-style, interviewer-administered questionnaire was designed to gather socioeconomic and demographic data as well as information regarding key barriers to ART accessibility, from the perspective of ART users, as well as any means employed by the respondents to overcome these barriers. This study draws on a comprehensive conceptual framework of access wherein accessibility to ART is viewed in terms of the availability, affordability, and acceptability of the services. Each of these dimensions can be represented by several clearly defined and measurable variables, as outlined in Table 1. Thus, availability is concerned with whether services are available when and where they are needed, as assessed
Okoli and Cleary
through documenting the clients’ transportation options and travelling time and the availability of key resources (e.g. medicines) at the facilities. Affordability includes the costs incurred in seeking healthcare (in terms of transportation, waiting time, and lost income) as well as the ability to cope with these costs (such as through salary income, savings, or loans). Acceptability includes the nature or form of the service provision and how this is perceived by clients and communities, as measured through the clients’ satisfaction with the services and their perceptions about the attitudes of doctors and nurses (cf. Thiede et al., 2007). The questionnaire was piloted and refined prior to implementation. A sample of 240 individuals was interviewed (120 individuals per facility) in a language of the respondent’s choice. To ensure consistency, the questionnaire was administered by the first author. The participants were recruited to the study after they had completed their clinical consultations. All respondents were provided with a brief introduction to the study and a written information sheet, and each gave written informed consent. Ethical approval for the study was obtained from the research ethics committees at the University of Cape Town and the University of Nigeria, Enugu, and permission to conduct the study was obtained from both hospital facilities. Measuring socioeconomic status (SES) While some argue that SES is best measured by household income, consumption or expenditure, such data are often difficult to collect in developing countries (Montgomery, Gragnolati, Burke & Paredes, 2000). In addition, measures of household monetary income and consumption may not capture seasonal variations, may suffer from reporting and recall bias, and are not sensitive to non-cash transfers and income in-kind (Vyas & Kumaranayake, 2006). As an alternative, researchers are increasingly using the characteristics of households and individuals as a measure of SES, such as the ownership of assets and access to amenities (e.g. potable water) (Vyas & Kumaranayake, 2006). Following this approach, SES was measured by performing a principal components analysis (PCA) on pooled individual/household data from both sites. Variables in the PCA included ownership of assets (radio, TV, phone, fridge, gas cooker, iron, fan, motorcycle, car and lantern), type of toilet (flush toilet, pit toilet, bush or no toilet) and water supply (safe water, stream, or well). After prediction, SES was categorised as two groups of clients: poorest and least poor. The factors constraining accessibility to ART and the coping mechanisms employed by users of free ART services were then assessed relative to SES using summary statistics and cross tabulations. Bivariate logistic regression was used to summarise differences in variables according to SES, where a value greater than zero on the odds ratio indicates that the poorest were more likely to answer the question in the affirmative. All analyses were conducted in Stata version 11.0. Results Of the 240 respondents, 67.5% were females (Table 2), the mean age was 36 years, and 50.4% were married.
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Table 1: Three dimensions of access to antiretroviral treatment Availability The relationship between the location of healthcare facilities and the location of those who need these services, as measured through: • Transportation options; • Travelling time.
Affordability The direct and indirect costs of seeking healthcare, as measured through: • Transportation costs; • Waiting-time costs; • Employment-related barriers to healthcare use (e.g. permission to leave work).
The relationship between the type, range, quantity and quality of the health services provided, as measured through: • Availability of medicines; • Availability of patient records; • Length of queues and the availability of sufficient health personnel.
Ability to incur these costs, as measured through: • Access to personal savings; • Receipt of salaried income; • Access to loans; • Availability of household assets or property that can be sold; • Financial support from relatives or an employer.
Acceptability The nature of service provision and how this is perceived by clients, as measured through: • Clients’ satisfaction with the services; • Clients’ perceptions of the attitudes of doctors, nurses and other healthcare staff; • Clients’ perceptions about whether key information (e.g. HIV status) is kept confidential.
Adapted from Thiede et al. (2007)
Table 2: Demographic and socioeconomic characteristics of the users of free antiretroviral treatment (n = 240)
Males Females Age group (years): 18–29 30–41 42–53 54–65 Marital status: Married Never married/single Widowed Divorced Highest education level: No formal education Primary school Secondary school University Occupation: Subsistence farmer Employed in private sector Big business Government worker Artisan Petty trader Unemployed
n (%) 78 (32.5) 162 (67.5) mean age 36 (±9.2) 62 (25.8) 112 (46.7) 55 (22.9) 11 (4.6) 121 (50.4) 66 (27.5) 47 (19.6) 6 (2.5) 9 (3.8) 65 (27.1) 106 (44.2) 60 (25) 14 (5.8) 16 (6.7) 25 (10.4) 46 (19.2) 48 (20) 51 (21.3) 40 (16.7)
The majority of respondents (44.2%) had a secondary school education, followed by 27.1% with a primary school education, 25% with some university education, and 3.8% with no formal education. The main occupations were petty trader (21.3%), artisan (20%) and government worker (19.2%). Using an asset index computed by pooling data from both sites, we were able to compare the SES of the users of free ART at the different facilities. The resulting index
achieved equally spaced groupings, indicating no problems with clumping or truncation which can occur if insufficient assets are used in the index or when the chosen assets are not able to distinguish between the poor and the rich (for example, ownership of a cellphone will not be a useful variable if this is owned by most respondents) (cf. McKenzie, 2005; Vyas & Kumaranayake, 2006). The first component of the final index explained 30% of the common variation in SES, which is similar to other studies of SES in the literature (Vyas & Kumaranayake, 2006). Our key findings regarding accessibility to ART, overall and by SES, are summarised in Table 3. While there were no significant differences in SES between the clients at the two ART facilities included in this research, there were noteworthy differences in SES according to the respondents’ place of residence. Clients living in Enugu city were far less likely to be poor, with 74% of these individuals categorised in the ‘least poor’ group (p < 0.001). The reverse was the case for respondents living in Enugu State but outside Enugu city, where the odds of being in the ‘poorest’ group were 5.24-times higher relative to the least poor group (p < 0.001). It is noteworthy that 45 patients (19% of the total sample) were not living in Enugu State. In terms of availability, the vast majority of the respondents took public transportation to the ART facility, and there was no significant association between the mode of transportation used and SES. However, the poorest were more likely to have spent longer at the clinic during their previous appointment than the least poor (3h52 versus 3h26 on average) and this difference was significant. The poorest were also more likely to agree that the queues to see doctors or nurses were too long (p = 0.05) and that the services could be improved by employing more doctors and nurses (p = 0.04) (Table 3). Only four respondents indicated that drug stock-outs were a problem at the facility they attended. In terms of affordability, the poorest incurred higher transportation costs than did the least poor (significant at
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Table 3: Access to antiretroviral treatment (ART) according to availability, affordability and acceptability, by socioeconomic status and overall; bold font denotes statistical significance (n = 240)
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Variable
‘Poorest’ n (%)
Place of residence: Enugu metropolis 25 (21) Enugu State 71 (59) Other state 24 (20) ART facility: University of Nigeria Teaching Hospital 62 (52) Mother of Christ Specialist Hospital and Maternity 58 (48) Availability Mode of transportation: Public transportation 107 (89) Personal car 0 Friend/relative’s car 1 (1) Motorcycle 8 (7) By foot 4 (3) Mean (and median) time spent at the facility (hours:minutes) 3h52 (4h00) ‘The queues to see the doctor or nurse are too long at this 95 hospital’ (% agree) ‘Services could be improved if more doctors or nurses were 85.8 employed’ (% agree) Affordability Transportation costs (mean US$) $2.33 Coping mechanisms: Use personal savings to cope with the costs of accessing ART (%) 44.2 Use salary income to cope with the costs of accessing ART (%) 11.7 Borrow money to cope with the costs of accessing ART (%) 5 Rely on relatives to assist with the costs of accessing ART (%) 36.7 Acceptability ‘Patient information is kept confidential in this hospital’ (% agree) 95.8 ‘Some staff do not treat patients with sufficient respect’ (% agree) 10.8 Service satisfaction (% ‘very satisfied’ or ‘satisfied’) 97.5 *Significant at the 5% level **Significant at the 10% level
the 10% level). The majority of respondents used personal savings to cope with the costs incurred (44.2% overall), while 25% of the least-poor group relied on a salary income, and 37% of the poorest relied on their relatives. Only 3.75% of the total sample said they resorted to borrowing money (Table 3). In terms of acceptability, most respondents (93%) believed that their private information was kept confidential at the ART facility, but the least poor were far more likely to argue that staff did not treat them with sufficient respect (odds ratio [OR] 0.38; p = 0.008) (Table 3). Similarly, the poorest reported higher levels of satisfaction with the services (98% ‘satisfied’ or ‘very satisfied’ versus 89% in the least poor group). No respondents indicated that they thought that the doctors or nurses were rude to patients, while only one respondent thought that the hospital workers were unfriendly (data not shown). Finally, the respondents were asked for their views on the most important barrier to their ongoing use of ART services. There were clear differences in the answers provided by respondents according to their SES (as shown in Table 4), with the poorest far more likely to be concerned about the high cost of transportation (OR 4.27; p < 0.001), while the least poor were more concerned about stigma (OR 0.49; p
‘Least poor’ n (%)
Total sample n (%)
Odds ratio
p-value
73 (61) 26 (22) 21 (18)
98 (41) 97 (40) 45 (19)
0.17 5.24 1.18
African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20
Socioeconomic status and barriers to the use of free antiretroviral treatment for HIV/AIDS in Enugu State, south-eastern Nigeria a
Chijioke I Okoli & Susan M Cleary
b
a
Health Policy Research Group, University of Nigeria, College of Medicine , Enugu Campus, PMB, 01129, Enugu, Nigeria b
University of Cape Town, Health Economics Unit , Observatory 7925, Cape Town, South Africa Published online: 22 Jun 2011.
To cite this article: Chijioke I Okoli & Susan M Cleary (2011) Socioeconomic status and barriers to the use of free antiretroviral treatment for HIV/AIDS in Enugu State, south-eastern Nigeria, African Journal of AIDS Research, 10:2, 149-155, DOI: 10.2989/16085906.2011.593377 To link to this article: http://dx.doi.org/10.2989/16085906.2011.593377
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Copyright © NISC (Pty) Ltd
African Journal of AIDS Research 2011, 10(2): 149–155 Printed in South Africa — All rights reserved
AJAR
ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2011.593377
Socioeconomic status and barriers to the use of free antiretroviral treatment for HIV/AIDS in Enugu State, south-eastern Nigeria Chijioke I Okoli1* and Susan M Cleary2 Health Policy Research Group, University of Nigeria, College of Medicine, Enugu Campus, PMB 01129, Enugu, Nigeria University of Cape Town, Health Economics Unit, Observatory 7925, Cape Town, South Africa *Corresponding author, e-mail: [email protected]
1
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2
With about 3 million people living with HIV, Nigeria has approximately 8% of the global burden of HIV cases. In 2009, only about 34% of those in need of antiretroviral treatment (ART) were able to access care, which means that Nigeria was far from achieving the United Nations target of ‘universal access’ by 2010. This study aimed to describe the barriers to accessibility and the coping strategies employed to overcome these barriers among users of free ART services overall and by socioeconomic status (SES). Data were collected from 240 people receiving ART at one urban and one peri-urban health facility in Enugu State, south-eastern Nigeria. Information on SES, demographic characteristics, and barriers and coping mechanisms for accessing ART were elicited from the respondents. The high cost of transportation, HIV stigma, and long waiting hours were found to be key barriers to the use of ART services. On average, ART clients spent just under four hours at the clinic during their monthly appointments. The use of personal savings and financial support from relatives were the main means to access treatment. When the data were analysed according to clients’ SES, transportation costs were a chief concern among the poorest while those who were better off were more likely to be concerned about stigma and discrimination. These findings should be borne in mind when designing and locating services to maximise ongoing accessibility to ART. Keywords: accessibility, equity, sub-Saharan Africa, utilisation patterns
Introduction With approximately 3 million people living with HIV, Nigeria has about 8% of the global burden of HIV cases (National Agency for the Control of AIDS [NACA] & UNAIDS, 2010). Officially selected public-sector facilities and faith-based organisations (FBOs) in the country provide antiretroviral treatment (ART) free at the point of use (Kombe, Galaty & Nwagbara, 2004; Amanyeiwe, Hatt, Arur, Taye, Mehta-Steffen, De Valdenebro et al., 2008). While Nigeria has progressively increased the provision of ART, only 34% of those with advanced HIV infection received ART in 2009 (NACA & UNAIDS, 2010). The limited number of ART facilities in urban areas also raises questions about accessibility, particularly for the poor. The United Nations General Assembly (2006) resolution titled ‘Political Declaration on HIV/AIDS’ outlines over 50 different HIV-related commitments, including progress towards the goal of achieving ‘universal access’ to ART by 2010 — specified as providing treatment to at least 80% of those in need of ART as defined by clinical guidelines (WHO/ UNAIDS/UNICEF, 2010). However, given that this goal is linked to the overall numbers of people starting ART, there is no commitment to ensuring that treatment availability extends to the poor. It is also likely that the poor will face greater barriers to remaining in care once treatment is initiated. The inverse-equity hypothesis suggests that the introduction of new interventions might lead to a worsening of health equity
as those in urban areas and those of higher socioeconomic status (SES) might initially have better accessibility to ART services than rural dwellers and the poor. Because of this, some have called for the specific inclusion of health-equity targets within overall targets for ART coverage so that progress on this front can be monitored (Hanefeld, 2008), especially since universal access by 2010 was unlikely to be achieved by the majority of low- and middle-income countries with a high burden of HIV. While access to healthcare is a frequently identified goal of health policy, there is still debate about the precise meaning of the term. In earlier literature, ‘access’ was primarily viewed in terms of two factors: monetary fees at the point of use, and distance travelled to use healthcare. Others have defined access to healthcare in terms of service use or coverage (e.g. WHO/UNAIDS within their definition of universal access), perhaps because this is easier to quantify (Mooney, 2009). More recently, access has been defined as the empowerment of individuals to use the available healthcare, which is a multidimensional concept based on the degree of fit between healthcare systems, individuals, households and communities. In this regard, three dimensions of access to healthcare are availability (or physical access), affordability (or financial access), and acceptability (or cultural access) (McIntyre, Thiede & Birch, 2009). These dimensions may act as a starting point for an empirical investigation of access to healthcare and for developing heath-policy strategies that address barriers
African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
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to accessibility (Thiede, Akweongo & McIntyre, 2007), including with reference to socioeconomic dimensions. Despite the importance of equitable accessibility to ART, little research has been conducted regarding the barriers facing people needing access to treatment. A recent literature review (Posse, Meheus, Van Asten, Van Der Ven & Baltussen, 2008) found only six studies on this topic in developing countries; the review concluded that more research is needed to help policymakers differentiate between context-specific factors and findings that show important barriers across many settings. In addition, none of the studies assessed whether these factors differed according to clients’ SES. This study aims to describe the barriers to accessibility and the coping strategies employed to overcome these barriers among the users of free ART services at two sites in Nigeria through the application of a comprehensive ‘conceptual framework of access.’ A further objective is to examine the distribution of these elements and coping strategies according to SES. The findings may provide evidence to assist in developing policies to mitigate barriers to ART accessibility. Methods Setting The study was conducted in Enugu State in south-eastern Nigeria. The state has a population of 3.2 million and had an estimated HIV prevalence of 5.8% in 2008 (Ministry of Health, 2008; NACA & UNAIDS, 2010). Most urban dwellers are civil servants, traders, transporters or artisans (Onwujekwe, Onoka, Uzochukwu, Obikeze & Ezumah, 2009), while rural dwellers are largely subsistence farmers or petty traders (Ichoku & Fonta, 2006). As of 2008, five public hospitals and four private mission hospitals in Enugu State were providing free ART. From these, one public and one private site were purposively chosen for the study. The public facility was the ART centre within the University of Nigeria Teaching Hospital (UNTH), located in a peri-urban area on the outskirts of Enugu city (the administrative capital of the state). The chosen private facility was the ART centre within the Mother of Christ Specialist Hospital and Maternity (MCSH&M) — a private, not-for-profit facility located in the centre of Enugu city. Both sites administered ART free at the point of use to HIV-positive patients who met clinical eligibility criteria. Study design and conceptual framework of access An exit-interview-style, interviewer-administered questionnaire was designed to gather socioeconomic and demographic data as well as information regarding key barriers to ART accessibility, from the perspective of ART users, as well as any means employed by the respondents to overcome these barriers. This study draws on a comprehensive conceptual framework of access wherein accessibility to ART is viewed in terms of the availability, affordability, and acceptability of the services. Each of these dimensions can be represented by several clearly defined and measurable variables, as outlined in Table 1. Thus, availability is concerned with whether services are available when and where they are needed, as assessed
Okoli and Cleary
through documenting the clients’ transportation options and travelling time and the availability of key resources (e.g. medicines) at the facilities. Affordability includes the costs incurred in seeking healthcare (in terms of transportation, waiting time, and lost income) as well as the ability to cope with these costs (such as through salary income, savings, or loans). Acceptability includes the nature or form of the service provision and how this is perceived by clients and communities, as measured through the clients’ satisfaction with the services and their perceptions about the attitudes of doctors and nurses (cf. Thiede et al., 2007). The questionnaire was piloted and refined prior to implementation. A sample of 240 individuals was interviewed (120 individuals per facility) in a language of the respondent’s choice. To ensure consistency, the questionnaire was administered by the first author. The participants were recruited to the study after they had completed their clinical consultations. All respondents were provided with a brief introduction to the study and a written information sheet, and each gave written informed consent. Ethical approval for the study was obtained from the research ethics committees at the University of Cape Town and the University of Nigeria, Enugu, and permission to conduct the study was obtained from both hospital facilities. Measuring socioeconomic status (SES) While some argue that SES is best measured by household income, consumption or expenditure, such data are often difficult to collect in developing countries (Montgomery, Gragnolati, Burke & Paredes, 2000). In addition, measures of household monetary income and consumption may not capture seasonal variations, may suffer from reporting and recall bias, and are not sensitive to non-cash transfers and income in-kind (Vyas & Kumaranayake, 2006). As an alternative, researchers are increasingly using the characteristics of households and individuals as a measure of SES, such as the ownership of assets and access to amenities (e.g. potable water) (Vyas & Kumaranayake, 2006). Following this approach, SES was measured by performing a principal components analysis (PCA) on pooled individual/household data from both sites. Variables in the PCA included ownership of assets (radio, TV, phone, fridge, gas cooker, iron, fan, motorcycle, car and lantern), type of toilet (flush toilet, pit toilet, bush or no toilet) and water supply (safe water, stream, or well). After prediction, SES was categorised as two groups of clients: poorest and least poor. The factors constraining accessibility to ART and the coping mechanisms employed by users of free ART services were then assessed relative to SES using summary statistics and cross tabulations. Bivariate logistic regression was used to summarise differences in variables according to SES, where a value greater than zero on the odds ratio indicates that the poorest were more likely to answer the question in the affirmative. All analyses were conducted in Stata version 11.0. Results Of the 240 respondents, 67.5% were females (Table 2), the mean age was 36 years, and 50.4% were married.
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Table 1: Three dimensions of access to antiretroviral treatment Availability The relationship between the location of healthcare facilities and the location of those who need these services, as measured through: • Transportation options; • Travelling time.
Affordability The direct and indirect costs of seeking healthcare, as measured through: • Transportation costs; • Waiting-time costs; • Employment-related barriers to healthcare use (e.g. permission to leave work).
The relationship between the type, range, quantity and quality of the health services provided, as measured through: • Availability of medicines; • Availability of patient records; • Length of queues and the availability of sufficient health personnel.
Ability to incur these costs, as measured through: • Access to personal savings; • Receipt of salaried income; • Access to loans; • Availability of household assets or property that can be sold; • Financial support from relatives or an employer.
Acceptability The nature of service provision and how this is perceived by clients, as measured through: • Clients’ satisfaction with the services; • Clients’ perceptions of the attitudes of doctors, nurses and other healthcare staff; • Clients’ perceptions about whether key information (e.g. HIV status) is kept confidential.
Adapted from Thiede et al. (2007)
Table 2: Demographic and socioeconomic characteristics of the users of free antiretroviral treatment (n = 240)
Males Females Age group (years): 18–29 30–41 42–53 54–65 Marital status: Married Never married/single Widowed Divorced Highest education level: No formal education Primary school Secondary school University Occupation: Subsistence farmer Employed in private sector Big business Government worker Artisan Petty trader Unemployed
n (%) 78 (32.5) 162 (67.5) mean age 36 (±9.2) 62 (25.8) 112 (46.7) 55 (22.9) 11 (4.6) 121 (50.4) 66 (27.5) 47 (19.6) 6 (2.5) 9 (3.8) 65 (27.1) 106 (44.2) 60 (25) 14 (5.8) 16 (6.7) 25 (10.4) 46 (19.2) 48 (20) 51 (21.3) 40 (16.7)
The majority of respondents (44.2%) had a secondary school education, followed by 27.1% with a primary school education, 25% with some university education, and 3.8% with no formal education. The main occupations were petty trader (21.3%), artisan (20%) and government worker (19.2%). Using an asset index computed by pooling data from both sites, we were able to compare the SES of the users of free ART at the different facilities. The resulting index
achieved equally spaced groupings, indicating no problems with clumping or truncation which can occur if insufficient assets are used in the index or when the chosen assets are not able to distinguish between the poor and the rich (for example, ownership of a cellphone will not be a useful variable if this is owned by most respondents) (cf. McKenzie, 2005; Vyas & Kumaranayake, 2006). The first component of the final index explained 30% of the common variation in SES, which is similar to other studies of SES in the literature (Vyas & Kumaranayake, 2006). Our key findings regarding accessibility to ART, overall and by SES, are summarised in Table 3. While there were no significant differences in SES between the clients at the two ART facilities included in this research, there were noteworthy differences in SES according to the respondents’ place of residence. Clients living in Enugu city were far less likely to be poor, with 74% of these individuals categorised in the ‘least poor’ group (p < 0.001). The reverse was the case for respondents living in Enugu State but outside Enugu city, where the odds of being in the ‘poorest’ group were 5.24-times higher relative to the least poor group (p < 0.001). It is noteworthy that 45 patients (19% of the total sample) were not living in Enugu State. In terms of availability, the vast majority of the respondents took public transportation to the ART facility, and there was no significant association between the mode of transportation used and SES. However, the poorest were more likely to have spent longer at the clinic during their previous appointment than the least poor (3h52 versus 3h26 on average) and this difference was significant. The poorest were also more likely to agree that the queues to see doctors or nurses were too long (p = 0.05) and that the services could be improved by employing more doctors and nurses (p = 0.04) (Table 3). Only four respondents indicated that drug stock-outs were a problem at the facility they attended. In terms of affordability, the poorest incurred higher transportation costs than did the least poor (significant at
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Table 3: Access to antiretroviral treatment (ART) according to availability, affordability and acceptability, by socioeconomic status and overall; bold font denotes statistical significance (n = 240)
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Variable
‘Poorest’ n (%)
Place of residence: Enugu metropolis 25 (21) Enugu State 71 (59) Other state 24 (20) ART facility: University of Nigeria Teaching Hospital 62 (52) Mother of Christ Specialist Hospital and Maternity 58 (48) Availability Mode of transportation: Public transportation 107 (89) Personal car 0 Friend/relative’s car 1 (1) Motorcycle 8 (7) By foot 4 (3) Mean (and median) time spent at the facility (hours:minutes) 3h52 (4h00) ‘The queues to see the doctor or nurse are too long at this 95 hospital’ (% agree) ‘Services could be improved if more doctors or nurses were 85.8 employed’ (% agree) Affordability Transportation costs (mean US$) $2.33 Coping mechanisms: Use personal savings to cope with the costs of accessing ART (%) 44.2 Use salary income to cope with the costs of accessing ART (%) 11.7 Borrow money to cope with the costs of accessing ART (%) 5 Rely on relatives to assist with the costs of accessing ART (%) 36.7 Acceptability ‘Patient information is kept confidential in this hospital’ (% agree) 95.8 ‘Some staff do not treat patients with sufficient respect’ (% agree) 10.8 Service satisfaction (% ‘very satisfied’ or ‘satisfied’) 97.5 *Significant at the 5% level **Significant at the 10% level
the 10% level). The majority of respondents used personal savings to cope with the costs incurred (44.2% overall), while 25% of the least-poor group relied on a salary income, and 37% of the poorest relied on their relatives. Only 3.75% of the total sample said they resorted to borrowing money (Table 3). In terms of acceptability, most respondents (93%) believed that their private information was kept confidential at the ART facility, but the least poor were far more likely to argue that staff did not treat them with sufficient respect (odds ratio [OR] 0.38; p = 0.008) (Table 3). Similarly, the poorest reported higher levels of satisfaction with the services (98% ‘satisfied’ or ‘very satisfied’ versus 89% in the least poor group). No respondents indicated that they thought that the doctors or nurses were rude to patients, while only one respondent thought that the hospital workers were unfriendly (data not shown). Finally, the respondents were asked for their views on the most important barrier to their ongoing use of ART services. There were clear differences in the answers provided by respondents according to their SES (as shown in Table 4), with the poorest far more likely to be concerned about the high cost of transportation (OR 4.27; p < 0.001), while the least poor were more concerned about stigma (OR 0.49; p
‘Least poor’ n (%)
Total sample n (%)
Odds ratio
p-value
73 (61) 26 (22) 21 (18)
98 (41) 97 (40) 45 (19)
0.17 5.24 1.18
