A total of 372 participants were surveyed of which 167 (45%) were females. The mean age (standard deviation) was 52 (17) years with age range 18 to 92 years. Table 1 summarizes participant characteristics.
Anatomic region scanned and clinical indications
CT scans of the head and facial bones accounted for 236 out of 372 scans (63% [95%CI: 59%, 68%]) and the top three indications were suspected stroke, transient ischemic attack or hypertensive emergency (27% [95%CI: 22%, 32%]), trauma (14% [95%CI: 10%, 18%]) and persistent headaches, blurred vision or suspected space-occupying lesion (14% [95%CI: 10%, 18%]). Table 2 summarizes the anatomic regions scanned.
Risk of financial hardship after CT utilization
Among study participants, 246 out of 344 (72% [95%CI: 67%, 76%]) declared having “just enough” or “less than enough” money to cater for their bills, food and clothing after paying for the scan, indicating risk of financial hardship. A hundred and two respondents out of 370 (28% [95%CI: 23, 32%]) reported to have negotiated for direct cost reduction, with 44 (43% [95%CI: 34%, 53%]) doing so formally through the hospital Social Services or the administration and 58 (57% [95%CI: 47%, 66%]) informally through healthcare staff directly related with service provision. Table 4 shows the relationship between some selected variables and risk of financial hardship on univariate and multivariable analyses.
Table 5 summarizes the characteristics of the persons interviewed.
Three main themes related to CT utilization were identified: I) coping with CT utilization, II) CT utilization despite reported hardship and III) deterrents to CT utilization and missed opportunities. There were three and two subthemes for themes I and III respectively.
Coping with CT use
Some respondents reported that close family relatives had to be called up for financial assistance. Persons called up were not limited to the nuclear family as they included other relatives and even close friends. In the study context regular use of the word “family” goes beyond blood ties. The excerpts below from three respondents illustrate:
“… my husband is a logger and works for himself … since he has been down with sickness it is not easy so I have to support him financially … I sell pea nuts” (P01; caregiver of 38-year old male patient)
“We had to pay for the scan. She is not working and the doctor had planned to operate her … where was she supposed to get the money from?” (P08; caregiver of 28-year-old female patient)
“… we came prepared … my mother paid for everything” (P09; caregiver of 56-year old male patient)
Despite many respondents’ acknowledgement of receiving help from family, some nevertheless stated they had to “dig deep” into their savings to pay for the cost of CT all by themselves. These persons also claimed in doing so they felt a “vacuum” in their reserves but considered it necessary so that they could be diagnosed and properly treated.
Some respondents declared to have benefitted from some sort of fee-reduction scheme. This happened through mainly two pathways: fee reduction approved by hospital administration or Social Services, and through staff directly involved with the provision of services. The former was reported by persons who either claimed to personally know some members of the administration, belonged to the same ethnic group, attended same church, or upon recommendation from a political or local administrative figure. The benefits ranged from totally free direct cost to reductions of up to 75%. For fee reduction obtained through healthcare staff, beneficiaries hoped economic hardship would predispose them to strive for direct personal gain thus open for a bargain. Some clients would even pose as a staff relative so as to “soften” the negotiations. The accounts below from four respondents illustrates:
“I had to give part of the money for the scan to the “nurse” first … I told him I cannot run away since my patient is admitted in the hospital” (P18; caregiver of 52-year old male patient)
“… pension is how much? The government doesn’t know what the people are going through … as a senior citizen I had to ask the director for a reduction and he cut the cost by two” (P02; 61 years old, female)
“… I know the director personally … so I went to him [director] for consultation and he prescribed the scan himself and asked me to pay 50% of the cost” (P10; 31 years old, male)
“I explained my situation [financial] to the person I met who offered to help me … so I gave him what I had” (P11; 43 years old, female)
Borrowing of money
Having to borrow money from neighbors, friends and small common interest groups was also reported as a means of raising money to pay for CT when the need arose.
“I was pushed to borrow money because I was not feeling fine at all” (P04; 42 years old, female)
“I had to stretch my hands to my neighbors … I am on a loan” (P21; 56 years old, male)
CT utilization despite reported hardship
Despite reporting risk of financial hardship after CT utilization, it is obvious that CT is still being utilized. One of the reasons why CT was promptly done was because of reported pain. Also, some respondents believed appropriate medical care would only be administered after CT scan was performed. Furthermore some CT users had the understanding that CT scanning was necessary to determine the cause of ill health and therefore guide treatment. To others still CT scan was considered to be a kind of “one-stop-shop” test for the entire body and was expected to “reveal any anomaly” besides the present complaint. The excerpts below from two respondents illustrate:
“My patient was feeling some “hot pains” so we had no choice but to run up and down to mobilize the funds to get the scan done” (P01; caregiver of 38-year old male patient).
“… I am feeling very bad … cannot walk right now … I had to do it [CT] so that my entire body could be properly checked” (P06; 66 years old, male)
Deterrents to CT use and missed opportunities
Some respondents reported not showing up for CT scan despite having received a prescription from a healthcare provider (for clients who had to do a repeat CT) because of fear. The reasons were varied: no money as previous experience showed the cost was substantial, resentful attitude of hospital staff as clients feared being ridiculed should they show up with insufficient funds, the scare of the equipment as patients are left alone inside the room, and also the fact that the machine uses x-rays which should have a long term effect in “reducing the lifespan” according to some respondents.
“ … money issues otherwise we were supposed to have done another CT scan following treatment … ” (P01; caregiver of 38-year old male patient)
“If you dare go to hospital without money do you know what the staff can do to you?” (P03; 62 years old, female)
“The machine is scary … didn’t like being left alone in the room … not my first time doing CT scan and I am already afraid of the effect of the rays on my body” (P17; 56 years old, male)
Some respondents would not believe that CT services could be provided in emergency situations before the financial obligations are met. They remained adamant when this was explained and relied heavily on their past experiences with using health care services where pre-payment was mandatory. Also there was no knowledge of the Social Action Service, a department within the hospital facility that identifies paupers within the local community to offer them some fee reduction so that they can use needed healthcare services.