Participant characteristics
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.
Table 1. Characteristics of study participants with comparison between those who did/didn’t report risk of financial hardship
|
Variables
|
Frequency (%)
|
P value*
|
Age group (years; N=344)
|
|
0.088
|
18-24
|
21 (5.7)
|
|
25-34
|
51 (13.7)
|
|
35-44
|
55 (14.8)
|
|
45-54
|
76 (20.4)
|
|
55-64
|
55 (14.8)
|
|
>65
|
114 (30.6)
|
|
Sex (N=372)
|
|
0.069
|
|
Female
|
167 (44.9)
|
|
|
Male
|
205 (55.1)
|
|
Marital status (N=372)
|
|
0.277
|
|
Married
|
232 (62.7)
|
|
|
Single
|
83 (22.3)
|
|
|
Widow(er)
|
42 (11.3)
|
|
|
Divorced
|
11 (3.0)
|
|
|
Living in union
|
4 (1.1)
|
|
Educational achievement (N=347)
|
|
<0.001
|
|
<O level
|
158 (45.5)
|
|
|
O level or equivalent
|
61 (17.6)
|
|
|
A level or equivalent
|
64 (18.4)
|
|
|
Degree or equivalent
|
45 (13.0)
|
|
|
Master & above
|
19 (5.5)
|
|
Employment status (N=294)
|
|
0.001
|
|
Employed, with contract
|
82 (27.9)
|
|
|
Employed, with no contract
|
2 (0.7)
|
|
|
Self-employed
|
115 ( 39.1)
|
|
|
Unemployed
|
12 (4.1)
|
|
|
Retired
|
83 (28.2)
|
|
Socioeconomic status quintiles (N=370) from the lowest (1) to the highest (5)
|
|
<0.001
|
|
SES quintile 1
|
74 (20.0)
|
|
|
SES quintile 2
|
75 (20.3)
|
|
|
SES quintile 3
|
75 (20.3)
|
|
|
SES quintile 4
|
79 (21.4)
|
|
|
SES quintile 5
|
67 (18.1)
|
|
Health insurance ownership (N=370)
|
|
<0.001
|
|
Yes
|
38 (10.3)
|
|
|
No
|
332 (89.7)
|
|
Number of deponents (N=272)
|
|
0.425
|
|
0 to 3
|
117 (43.0)
|
|
|
4 to 6
|
97 (35.7)
|
|
|
7 and above
|
58 (21.4)
|
|
Presence of chronic illnesses (N=369)
|
|
0.232
|
|
Yes†
|
130 (35.2)
|
|
|
No
|
239 (64.8)
|
|
*P values obtained using Fisher’s exact and χ² tests
†Included in this category are hypertension, diabetes, peptic ulcer disease, cancer, chronic kidney disease, hyperprolactinemia
|
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.
Table 2. Anatomic regions scanned
|
Anatomic region scanned (N=372)
|
Frequency (%; 95%CI)
|
Head + facial bones
|
236 (63.4; 58.5 - 68.3)
|
Abdomen
|
46 (12.4; 9.0 - 15.7)
|
Spine
|
41 (11.0; 7.8 - 14.2)
|
Chest + abdomen
|
14 (3.8; 1.8 - 5.7)
|
Chest
|
10(2.69; 1.0 - 4.3)
|
Angiograms
|
7 (1.88; 0.5 - 3.3)
|
Neck region
|
4 (1.08; 0.0 - 2.1)
|
Multiple regions
|
14 (3.77; 1.8 - 5.7)
|
Table 3. Indications for scanning per anatomic region
|
Indications for CT scan*
|
Frequency (%; 95% CI)
|
Head & facial bones
|
|
|
Suspected stroke/transient ischemic attack/hypertensive emergency
|
86 (27.0; 22.2 - 31.9)
|
|
Trauma
|
45 (14.1; 10.3 - 18.0)
|
|
Persistent headaches, blurred vision, suspected space-occupying lesion
|
44 (13.8; 10.0 - 17.6)
|
Chest
|
|
|
Suspected pulmonary embolism
|
7 (2.2; 0.6 - 3.8)
|
|
Chronic cough
|
4 (1.2; 0.0 - 2.5)
|
|
Tumor workup
|
2 (0.6; 0.0 - 1.5)
|
Abdomen/Pelvis
|
|
|
Pain, acute abdomen
|
18 (5.7; 3.1 - 8.2)
|
|
Suspected tumor, mass
|
22 (6.9; 4.1 - 9.7)
|
|
Urinary symptoms
|
15 (4.7; 2.4 - 7.0)
|
Spine
|
|
|
Back ache (severe, chronic, persistent)
|
28 (8.8; 5.7 - 11.9)
|
|
Suspected cord compression
|
9 (2.8; 1.0 - 4.6)
|
|
Trauma
|
6 (1.9; 0.4 - 3.4)
|
*Data available for 318 respondents
|
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 CT 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%]) illegally through hospital staff directly related with the provision of care. Table 4 shows the relationship between some selected variables and risk of financial hardship in univariate and multivariable analyses.
Table 4. Risk of financial hardship after CT utilization
|
Variables
|
Univariate
|
Multivariate
|
Odds ratio (95% CI)
|
P value
|
Adjusted Odds ratio (95% CI)
|
P value
|
Age group (years; N=344)
|
|
|
|
|
18-24
|
1.39 (0.42 – 4.64)
|
0.589
|
0.63 (0.10 – 3.97)
|
0.624
|
25-34
|
ref
|
|
ref
|
|
35-44
|
2.47 (1.00 - 6.08)
|
0.049
|
4.22 (1.18 – 15.11)
|
0.027
|
45-54
|
2.26 (1.02 – 5.01)
|
0.046
|
3.10 (0.80 – 10.66)
|
0.073
|
55-64
|
2.47 (1.00 -6.08)
|
0.049
|
0.41 (0.09 – 1.78)
|
0.234
|
>65
|
1.17 (0.58 – 2.34)
|
0.665
|
0.07 (0.01 – 0.48)
|
0.007
|
Sex (N=344)
|
|
|
|
|
|
Female
|
1.55 (0.96 - 2.50)
|
0.070
|
1.25 (0.60 – 2.60)
|
0.553
|
|
Male
|
ref
|
|
Ref
|
|
Marital status (N=344)
|
|
|
|
|
|
Married/living in union
|
ref
|
|
Ref
|
|
|
Single/divorced/widow
|
1.36 (0.83 - 2.24)
|
0.222
|
2.05 (0.80 – 5.23)
|
0.135
|
Educational level (N=319)
|
|
|
|
|
|
≤O level
|
2.42 (1.44 - 4.06)
|
0.001
|
2.07 (0.90 – 4.76)
|
0.087
|
|
>O level or equivalent
|
ref
|
|
Ref
|
|
Employment status (N=266)
|
|
|
|
|
|
Employed (formally, informally, self)
|
ref
|
|
Ref
|
|
|
Unemployed/Retired
|
1.05 (0.60 - 1.86)
|
0.855
|
11.75 (2.59 – 53.18)
|
0.001
|
SES (N=342)
|
0.20 (0.12 - 0.34)
|
<0.001
|
0.15 (0.07 - 0.33)
|
<0.001
|
Health insurance ownership (N=342)
|
|
|
|
|
|
Yes
|
Ref
|
|
ref
|
|
|
No
|
6.28 (2.73 - 14.45)
|
<0.001
|
5.56 (1.74 – 17.76)
|
0.004
|
Chronic illnesses (N=369)
|
|
|
|
|
|
Yes
|
1.36 (0.82 - 2.24)
|
0.233
|
2.07 (0.93 – 4.58)
|
0.074
|
|
No
|
ref
|
|
ref
|
|
Model R2 = 0.2685; p<0.001.
|
Qualitative findings
Quantitative phase participants who reported to be at risk of financial hardship were purposively selected for in-depth interviews. None of the selected participants reported any health insurance subscription. The interviews lasted between ten and eighteen minutes. Table 5 summarizes some characteristics of the interviewees.
Table 5. Characteristics of interviewees
|
Number of participants
|
22
|
|
Male
|
9
|
|
Female
|
13
|
Mean age (SD), years
|
49.7 (9.9)
|
Employment status of the patients
|
|
|
Self-employed
|
8
|
|
Retired
|
8
|
|
Unemployed
|
3
|
|
Employed with a formal contract
|
3
|
Interviewee
|
|
|
Patient
|
16
|
|
Caregiver
|
6
|
Three main themes related to CT utilization were identified: I) coping with CT utilization, II) unavoidability of CT utilization and III) deterrents to CT utilization and missed opportunities. There were three and two subthemes for themes I and III respectively.
Coping with CT utilization
Family support
Some participants reported that close family relatives were called to financially assist them. Those called up were not limited to the nuclear family and even included close friends. In the study context regular use of the word “family” goes beyond blood ties. The excerpts below from three participants 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 participants’ 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 participants 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.
Exonerations
Some participants declared they benefitted from some sort of discount. 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 participants who either claimed to personally know some members of the hospital administration, belonged to the same ethnic group, attended same church, or upon recommendation from a political or local administrative authority. The benefits ranged from paying nothing at all to a 75% discount on the direct cost. Concerning the second pathway of fee reduction, participants admitted they paid money directly to hospital staff for services and often at a discount after some negotiations. This practice is illegal but participants believed was a win-win situation; they benefitted from direct cost reduction and some fast-tracking to obtain their results while the healthcare staff had a supplementary income. The accounts below from four participants illustrate:
“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 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)
Unavoidability of CT utilization
Despite reporting to be at risk of financial hardship after CT utilization, CT is still being utilized. One of the reasons why CT was promptly done was because of reported pain. Also, some participants 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 participants 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
Fear
Some participants 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 participants.
“ … 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)
Ignorance
Some participants were not aware that CT services could be provided in emergency situations before the financial obligations were met. They refused to believe when this fact was explained and relied on anecdotes and past experiences with using healthcare 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.