PATIENTS WITH SEXUALLY TRANSMITTED infections (STIs) seek health care from a variety of sources such as public health units, private health units, drug shops, pharmacies, shops, self-treatment, and from traditional healers.1–11 The reasons influencing choice of health care provider are not systematically studied.12 However, perceived quality of care such as availability of medications at health units, waiting time, and confidentiality have been suggested, as well as the accessibility, affordability, social stigma, beliefs about various health outlets, social influence, and perceived barriers and supports.2,13–18
Health-seeking behavior (HSB) can be defined as any activity undertaken by individuals who perceive themselves to have a health problem or to be ill for the purpose of finding an appropriate remedy. A precondition of most HSBs is recognition of symptoms and how the symptoms are interpreted by the individual and by those around them. The interpretation of symptoms may include their perceived cause and the beliefs held about appropriate and effective treatments.19,20 Many STIs are however, asymptomatic,21–23 and asymptomatic individuals can only seek health care either through screening or through sexual partner notification and referral.24 Thus, the sexual partner becomes an important force in HSB for STIs.
People with STI symptoms may consult a number of health care providers in turn. The availability of multiple sources of care, combined with uncertainty about symptoms, inappropriate treatment of patients and their partners, inadequate doses, drug resistance, lack of sexual partner referral, stigma surrounding STIs, problems of access, and lack of affordability, may lead to considerable delays in diagnosis and treatment.9,16,25–28 This can lead to increased complications and increased transmission for STIs, including high risk for human immunodeficiency virus (HIV) transmission.29 Thus, a better understanding of factors influencing HSB associated with STIs could assist by helping to direct health education initiatives and public health communication programs and to encourage the involvement and collaboration of alternative health care providers (e.g., pharmacists, private health practitioners) in programs aimed at controlling and preventing STIs and HIV/acquired immunodeficiency syndrome (AIDS). Furthermore, such knowledge helps to guide improvement in service delivery for patients with STIs.
Materials and Methods
The study sites included health/treatment outlets in Mbarara district of southwestern Uganda. For the public health unit, patients with STIs were interviewed at the outpatient department of Mbarara university teaching hospital. The hospital doubles as a regional referral centre for southwestern Uganda and the major district hospital for Mbarara district. The population of Mbarara town is about 100,000 people. The town is a junction of major highways and feeder roads, so that transport to and from Mbarara town to neighboring trading centers and rural areas is relatively easy. The population of Mbarara district is about 1,000,000 people, whose main occupation is subsistence agriculture. At the hospital, STI patients are seen as part of the general outpatient population that is generally treated in a walk-in clinic.
The patients from private health units were interviewed at 2 busy walk-in clinics in Mbarara town. Each clinic serves about 50 clients a day, with facilities for outpatients and inpatients, as well as laboratory facilities. These clinics are headed by doctors but use other assistants, e.g., clinical officers, nurses/midwives, and other paramedical staff that help them in running of the clinics.
At public health units, patients do not pay for the services, whereas at private health units, patients pay a user fee for all services. Furthermore, compared to private health units, public health units are often overcrowded, with long waiting time, shortage of staff and of medications.18
Two hundred twenty-five consecutive patients who presented at the study sites during the study period were invited to complete an interviewer-administered questionnaire from October 1998 to February 1999. The questionnaire was developed using previous research results from a qualitative study about possible determinants for HSB among patients with STIs.18 Other possible determinants were from literature.15 After giving informed consent, participants were interviewed by trained research assistants. The interviews were carried out after the patients had received care (exit interviews). All new patients presenting at the study sites were interviewed, except for 5 patients who declined to participate. No further information was collected on patients who declined participation.
Information was collected on current and previous STI symptoms, previous HSB for current and previous STI episode, sociodemographic characteristics, whether the patient was referred by a partner or not, and on attitudinal, normative, and self-efficacy beliefs towards various treatment sites. A person’s attitudinal beliefs towards attendance of a treatment site for STI treatment are a result of the consequences that a person expects from attending that site. Normative beliefs are the social influence as a result of social norms relevant to attendance of a particular site for STI treatment and support from important others to attend or not attend that site and whether important others attend or do not attend the site themselves. Self-efficacy beliefs can be seen as a person’s belief of ease (supports) to attend a particular site for STI treatment and the ability to cope with barriers that may hinder actual attendance.
The computer software version 10.0 of SPSS/PC for Windows (SPSS Inc., Chicago, IL) was used in the analyses. Both univariate and multivariate analyses were performed. Crude odds ratios (CORs) and their 95% confidence intervals (95% CIs) were calculated after the univariate analysis. Adjusted odds ratios (AORs) and the 95% CIs were calculated after multivariate analysis. The multivariate analysis was done by unconditional logistic regression. Only variables that were significant on univariate analysis were included in stepwise multivariate analysis using backward elimination methods. Variables that did not improve the fit of the regression (as measured by log likelihood) were left out. The percentages of cases correctly classified were examined, and the adequacy of the fitted models was assessed by the chi-squared test. For all the analyses, a P level of 5% with Yates’s corrected 2-tailed chi-squared test was used.
Ethical clearance was obtained from the Uganda National Council for Science and Technology. The participants were asked to give informed consent or to refuse to participate in the interviews.
Of the 225 patients enrolled, 101 (45%) were recruited at private health units and 124 (55%) at public health units. More than half of the patients, 132 (59%), had visited another treatment site before seeking care at the site of enrollment, and 109 (48%) of all the clients had had at least another STI episode in the last 5 years. Only 63 (28%) of the patients were referred to their treatment site by a sexual partner, and 64 (62%) had symptoms for less than 30 days. The perceived quality of care at current treatment site as assessed by the patients was low, with only 78 (35%) of the patients rating the quality of care as either good or very good.
The results of the univariate analyses are presented under the headings sociodemographic variables, symptoms of STIs and their duration, previous experiences with STIs and treatment sites, attitudinal beliefs, normative beliefs, and under self-efficacy beliefs towards the treatment sites.
The variables that favor choice of private compared to public health units as seen in Table 1 are being male, rural residence, being older than 25 years, not being married, having at least secondary education, and spouse not being employed.
Symptoms Duration and Previous Experiences With STIs
The analyses for symptoms and for current and previous experiences with STIs are shown in Table 1. Compared to public health units, patients who chose private health units are more likely to have had STI symptoms for less than 30 days, have had an STI in the past, and more likely to say that the quality of care received was either good or very good. On the other hand, patients who chose private health units were less likely to be presenting with a genital ulcer.
The attitudinal beliefs towards public health units and private health units are presented in Table 2. Compared to public health units, patients who chose private health units are less likely to believe that public health units are convenient, are clean, have sympathetic staff, do not use expired drugs, do give adequate drug doses, are not far, do not have corrupt staff, keep patients’ secrets, and do not delay patients (Table 2). On the other hand, compared to public health units, patients who chose private health units were more likely to believe that private health units cure STIs, prevent STIs, are convenient, are not expensive, are clean, do not cause client problems, have sympathetic staff, do not use expired drugs, give adequate drug doses, do not like giving injections, are not far away, do not risk people with SLIM (AIDS), do not have corrupt staff, keep patients’ secrets, do not delay patients, and that private health units do not make STIs chronic (Table 2).
Compared to public health units, patients who choose private health units are more likely to be influenced by friend and drug sellers and less likely to be influenced by spouse or sexual partner (Table 3).
Compared to public health units, patients who choose private health units are less likely to choose a treatment site if sexual partners are treated free, site is near place of work, site is near place of residence, site is recommended by a friend, and site opens in weekends or at night. However, the choice of treatment site for private health units users compared to public health units users is more likely if it had corrupt staff and if it was run by workers of a different sex (Table 3).
Compared to public health units, the independent predictors of choosing private health units, shown in Table 4, are being older than 25 years, believing that private health units cure STIs, believing that private health units prevent STIs, believing that public health units can make STIs chronic, believing that public health units have corrupt staff, believing that private health units give adequate drug doses, not being influenced by a sexual partner in choice of treatment site, being likely to choose a treatment site if sexual partners were not treated free and being likely to choose a treatment site if it was not recommend by a friend. The model with these 9 variables fitted the data very well (−2 log likelihood ratio chi squared = 117, 215 degrees of freedom (df), P = 1.00; model chi-squared = 192, 9 df, P <0.001; goodness of fit chi-squared = 150, 215 df, P = 1.00). Overall, of the 225 patients who chose either public health units or private health units, 214 (95%) were correctly classified by the model. Among the 124 who chose public health units, 119 (96%) were correctly classified, and among the 101 who chose private health units, 95 (94%) were correctly classified.
This study was aimed at identifying those attributes that encourage or discourage patients with STIs from attending public or private health units. The strengths of the research design were that it was based on a theoretical methodology12,30 and that it was built upon previous qualitative research.18 The qualitative research elicited possible determinants of choice of health provider. The main focus of the present quantitative research is on identifying a set of determinants that are associated with the choice of different kinds of health service. Both qualitative and quantitative approaches are needed to better understand health-seeking behavior as they complement each other.12
This study had some limitations. First, the psychosocial variables were measured after the behavior had occurred, with patients being interviewed after they had received care from the sites they visited. This could have changed their beliefs, particularly the attitudinal ones, depending on the quality of service and the way they were attended to at the particular site. Second, there is lag time between time of collecting data and publication. However, the information is still relevant today as the factors influencing choice of health care provider have not changed much over time. There are still shortage of medications, staff, and underfunding of public health units in Uganda and elsewhere in sub-Saharan Africa.31,32 Third, the study was limited to 1 public health unit. It is, however, thought that the results are generalizable to public health units as the questions asked were related to public health units in general rather than the public health unit where the patients were recruited.
These data suggest that patients seeking care at private health units and public health units differed mainly on psychosocial variables (such as attitudinal, normative, or self-efficacy beliefs) rather than sociodemographic characteristics or disease-related variables. That is although sociodemographic and disease-based variables such as age, sex, education, residence, marital status, type and duration of symptoms, and experience with previous STI and place of treatment were important on univariate analysis, most of these variables (except age) did not reach significance in multivariate analysis. This means that the effect of these sociodemographic variables is mediated through the psychosocial variables, as postulated by applied social psychology models.33,34 This is clearly advantageous as psychosocial variables are amenable to manipulation to influence choice of health care provider, whereas sociodemographic, disease-based, or partner-type variables are not. In other words, one, for example, cannot change the sex or marital status of the patient so as to influence choice of health care provider, but the psychosocial variables such as self-efficacy can be increased so as to achieve a higher likelihood of choosing a treatment site. Moreover, the treatment sites may also be modified/improved to make attitudinal normative and self-efficacy beliefs more favorable to patients.
Patients were sampled by study site. It is thus not possible to estimate the proportion of patients with STIs who seek care at particular sites within the population. A previous study in Rakai district of Uganda estimated that less than 20% of adults with symptoms suggestive of STIs sought treatment at public health units.35 These data are comparable to what has been observed elsewhere in Africa,3,7,8,13 Thailand11 and India.36 Findings from this study help to explain these observations. According to patients interviewed, quality of care as defined by ability to get cure for STIs, getting adequate medications, and not being attended by corrupt staff were important in distinguishing where they seek care. Because public units in sub-Saharan Africa are underfunded and characterized by shortage of medications and staff,31,32 these results are not surprising. Another interesting evidence is that actual improvement of quality of care in the public sector such as ensuring that medications are always available and through training of health workers in syndromic management greatly improves HSB in the public sector.13
These results also show that people with STIs get treatment from a variety of sources whose quality of care in all sites was low and characterized by low rates of patients that were referred by sexual partners. Thus, the data suggest that sexual partner referral needs to be promoted at both private health units and public health units.
The reasons for choice of private health units or public health units are related to age of patients; and about attitudinal, normative, and self-efficacy beliefs, about sites. These data also provide information on salient service attributes those patients with STIs hold in high esteem. Thus, attracting patients to either private health units or public health units will need improvements in some of these. However, since some of the attitudinal beliefs may actually take long to change and the sociodemographic variables (such as age) are not changeable, it may be more practicable to promote high-quality syndromic management of STIs at both private health units and public health units. This could be done through training of service providers in syndromic management or promoting social marketing of STI treatment therapies.13,37–40 These measures may actually improve the cure rates, thereby reducing the transmission of pathogens.
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