Our analysis of 1447 adults with elevated blood pressure in rural Kenya revealed that women were of poorer socio-economic status, had poorer self-reported health status, and greater healthcare utilization of outpatient visits and medication prescriptions compared to men. Three distinct patterns emerged among the entire study cohort: health care utilizers with high medical costs, health care utilizers with low medical costs, and non-utilizers. Being female and having insurance had the most influence on being in a health-utilizing class. However, across all classes, women experienced worse functional health status than men.
Greater health care-seeking behavior by women, especially outpatient care, is consistent with findings from several parts of the world.(3, 15–19) However, there were some notable differences and patterns that were illuminated by our latent class analysis. First, individuals with no or low utilization of health care services also had lower awareness of their elevated blood pressure, likely reflecting a long-term cycle of low utilization leading to lower awareness of health issues, leading to further under-utilization of health care, and so on. However, one-third to one-half of these individuals did endorse knowing about their elevated blood pressure, yet did not utilize healthcare. It is possible that competing obligations, such as concern about work and employment, constrained health care-seeking behavior. Finally, contrary to what has been reported in other populations,(16, 20, 21) our latent class analysis indicated that the level of healthcare utilization was similar across incomes of those employed. This unexpected finding merits further inquiry, and research is needed to clarify the factors that may impact health care utilization.
Our latent class analysis revealed that one group of individuals faces higher health costs without increased income or employment. This combination of low income and high health costs is clearly concerning and highlights the urgent need for financial risk protection such as health insurance. Notably, the rates of national insurance (NHIF) enrollment among our participants was very low, with only 13% of women and 17% of men reporting current enrollment, in line with national statistics.(22) While we found that those with the highest healthcare costs had the highest rates of enrollment in NHIF, we were not able to determine whether the NHIF enrollment was initiated before or after the high-cost health care experience.
Additionally, it is worth noting that NHIF does not cover the cost of visits to herbalists or spiritual healers, seen by a substantial proportion of participants in our study, thus increasing the out-of-pocket burden for those individuals. In addition, efforts to medically engage this population need to consider collaborating with these practitioners, in order to maximize the reach across different segments of the population. Partnering with nontraditional medical providers in communities has been shown to be beneficial with respect to building trust and improving blood pressure control.(23–25)
Several potential strategies to improve the implementation gap with respect to blood pressure treatment and control arise from our findings. These include the need to improve community awareness of hypertension, address poverty, reduce out-of-pocket health care expenditures, and consider alternative sites of health care delivery. Community health workers can improve awareness and help to serve as a critical link between communities and the health sector.(26) Efforts to combine economic and financial programs with health care delivery are underway and actively being evaluated.(27, 28) Kenya, along with many other countries, is expanding universal health coverage in alignment with population health initiatives.(29) Finally, shifting clinical care out of the clinic and into community settings is gaining popularity and support throughout the world.(24, 25, 30) Across all of these strategies, accounting for sex-specific differences, preferences, and patterns will be critical to ensure population-level success.
We acknowledge the following limitations in our study. The sex of our participants was gathered from clinical data that were linked to the research database instead of being directly reported to the research team. In addition, all data regarding health care utilization, health care costs, and functional status were cross-sectional and self-reported and therefore subject to recall bias. We did not gather information on family income level, and it is quite likely that family members pool financial resources. Similarly, we did not collect data on education level. Lastly, the participants in the study are from rural, agricultural areas, and might not be fully representative of the general population.