In this section, we discuss the analytical approach, definitions and measurements of outcome variables and relate the study findings to existing studies on the same or similar associations. Therefore, our discussions centre on the use of health literacy profiles, the meaning, and implications of desirable use of healthcare, then, the association between health literacy and use of healthcare. We follow up with discussions on our cost estimates and the associations between health literacy and costs. Finally, we present strengths and limitations of this study.
We generated seven health literacy profiles which mapped out the combined strengths and weaknesses of caregivers in terms of the nine health literacy dimensions (27-29). The profile descriptions coupled with respondents’ socio-demographic characteristics may provide useful information for policies and intervention design(30) . For example, almost all health literacy profiles in our study had challenges with health provider support, so this dimension could generally be addressed. On the other hand, some profiles scored low on almost all dimensions. While it is difficult to target interventions based on intangible characteristics such as health literacy, the identification of socio-demographic characteristics of the least scoring profile, improves the ability to reach the group with the greatest need(30). Thus, the use of this multi-dimensional health literacy questionnaire (HLQ) is essential in identification of health literacy needs, still, the use of the profiling approach could contribute to equitable health literacy interventions(30).
In this study, use of health care was categorized into desirable and undesirable healthcare. Use of health care is usually defined as either use of formal healthcare (public or private health facilities) or informal healthcare which includes drug stores, herbal and traditional medicine or other therapies acquired outside the hospital for the treatment of a particular disease(14, 31-33). We found that 42% of caregivers used an undesirable treatment pathway, either not seeking formal care or doing so only as 3rd or 4th choice. Other studies in Ghana also suggest a high use of informal care for malaria treatment(15, 21, 34), with a recent study reporting 28% choosing informal over formal care among caregivers of children under 5 years in Upper West Region(15). This is in line with our finding of a high percentage of undesirable practices as we include late use of formal care. Based on the recommendations by WHO and Ghana’s Ministry of Health’s malaria treatment guidelines(10, 25) which encourages seeking early treatment for malaria from health facilities, we defined desirable healthcare as timely use (at least second treatment option) of health facilities in treatment of malaria in children under five years.
However, in malaria prone areas, presumptive malaria is mostly defined by the presence of fever(35), and in children, several illnesses could present with fever(36) which may or may not necessarily require a visit to the hospital. Thus, in this study, some caregivers may have used informal treatment as the first or second option and did not seek further treatments because the child recovered. Such caregivers were categorized as using an undesirable approach, which could be questionable if the child recovered from the illness. Although, our definition is in line with appropriate and accurate timely diagnosis and treatment of malaria(10), the desirable use as defined may also result in an influx of patients at health facilities which yields unnecessary pressure on the limited resources in the Ghanaian health system. In other words, there may be scope for management of some of these presumptive malaria cases at lower level than the health facilities; indeed, this was the basis for programmes like the community case management of malaria in Ghana(35). For countries with limited resources, the proliferated use of informal sources of healthcare in the treatment of malaria could be channelled into an advantage by training and equipping such sources to promote test prior to treatment(37, 38). This could serve as a form of screening of mild and severe cases for treatment, thereby making it a desirable treatment option which would likely imply less cost to the individual as well as the health system.
Although health literacy is associated with proper management of health conditions and engagement in healthy behaviours(1, 3, 4, 39), the associations between health literacy levels of caregivers and the use of health care for their children has been mixed(31, 40, 41). For example, a study conducted in Wisconsin USA, by May et al reports that, certain capabilities including good assessment of severity of illness, navigating the health system, relationship between caregiver and health providers as well as perception of care, could positively influence the behaviour of caregivers in managing their child’s health in mild or acute illnesses with possibilities of waiting for longer appointments(42). Thus, such caregivers are less frequent users of formal health facilities. In a similar study setting in the United States, Sanders et al reported that there was no statistically significant association in health care use and costs for children of caregivers with low health literacy or otherwise(31).
In the present study, we found that caregivers in both Profile 1 (high scores) and Profile 7 (low scores) were associated with reduced odds of using desirable healthcare. This could be driven by different factors. Given the high health literacy scores and high level of education, caregivers in Profile 1 may assume to have better judgement of health conditions and only use formal healthcare when necessary as reported in the study by May et al (42). Again, with over 80% of caregivers in Profile 1 employed, the high indirect costs which in this study comprises value of time spent in care, could possibly also influence their decisions. However, characterized with low health literacy scores coupled with low education and socio-economic status, cost could be a more influential determinant in the decisions of caregivers in Profile 7 in their choice of informal treatments. Other studies also show that caregivers with low socio-economic status use more informal healthcare due to the low cost of care(43, 44). However, none of the associations in our study were statistically significant as Sanders et al(31) also reported. As we find high total costs associated with the desirable use of health care, much effort will be needed to stimulate the practice of desirable healthcare by such groups.
With cost being a barrier as mentioned above, we could expect National Health Insurance Scheme (NHIS) membership to be a mediating factor. The mediating effect was evident as we observed a reduction in the differences in the odds ratios after we adjusted for NHIS covariate. Caregivers in Profile 3 subscribed (94%) to the NHIS more often than all other profiles including Profile 1 (82%). Thus, it seems that high subscription to NHIS emphasizes the strength of caregivers in Profile 3 in the active management of health and in their high (57%) use of public health facilities as compared to the 47% use by caregivers in Profile 1. Agbanyo et al. reports that among expectant mothers’ subscribers of the NHIS have 29.4% higher likelihood to use public health facilities and clinics with 2.3% higher likelihood of using private facilities(45). It is also reported that the positive effect of the NHIS is predominant in lower-educated than otherwise(46). Several other factors could also account for the differences in the use of healthcare and cost among the Profiles. These could include, but not be limited to, trust in healthcare providers, the perceptions on various curative measures, birth parity, and the perception of the disease of interest(43, 47).
In the present study, household costs per an episode of malaria on the average amounted to $20.29 of which $9.54 in direct treatment costs and $11.10 due to lost income. This appears to be slightly above estimates in other studies that also measured costs for malaria in children under five. Using a model-based analysis Sicuri et. al, report an expected average direct treatment cost per case of US$7.85 in 2013(18) and two studies report direct and indirect costs in 2011 around US$14.00 (US$ 13.90, US$14.6) (21, 34). In comparison with costs reported from other studies in Ghana, (18, 21), the differences in costs estimates could be attributable to the differences in study population, increasing costs over the years, inclusion of expenditures for informal care in our study, valuation of indirect costs and differences in recall period. Out of the identified studies on costs estimates on malaria, some focus on estimates for malaria in children (15, 18) while others report on cost estimates for the general population(21, 34, 48). In terms of differences in years of cost estimates, most studies were based on almost 10 years old data (18, 34).
Comparison of cost estimates across studies is also challenged by different cost components included in the studies, for example one study reports on only direct costs (15), others report on both direct and indirect costs (18, 21, 34); some studies report on both informal and formal treatment costs (15, 21, 34), and others report on only formal treatment costs (18). However, where possible, we compared relevant sub-results from the studies. Generally, compared to the other cost studies with 2 weeks (21) and 1 month recall period(15), our study had a longer recall period of 6 months and this could have influenced the cost reported by respondents. The cost level apart, our study reports the indirect cost as a greater share of the total costs which is in line with other studies which reports 71% (48), 80% (21) and 74% (34) of costs as indirect expenditure in management of Malaria.
With respect to associations between health literacy and cost of healthcare, the direction did not follow previously reported associations between health literacy and cost of health care (8, 9). We found that costs tended to be higher among caregivers within profiles with relatively good health literacy compared to those with relatively poor health literacy. This could reflect that caregivers with high health literacy value health and health care and thus are willing to pay more for appropriate care, but it could of course also reflect a higher ability to pay. Another possible reason could be a difference in the type of undesirable healthcare used between Profiles 1 and 7. Although both high and low scoring caregivers were associated with reduced odds of using desirable healthcare, the use of undesirable healthcare differs between the two extreme profiles. Caregivers in Profile 1 were dominant in the late use of formal healthcare, which was the most costly use of healthcare, while caregivers in Profile 7 dominated in sole use of informal healthcare, the least costly use of healthcare.
We found that resorting to an undesirable treatment pathway, on average, costs less than seeking early treatment from a formal source of healthcare. This is because caregivers who chose an undesirable pathway (highly informal), were likely to incur lower direct cost due to the absence of consultation costs and other possible informal payments, including motivations for health staff at health facilities (15). However, the lower cost should be assessed against health outcomes forgone. According to Sumba et al(33), on an episode of malaria in Kenya, children who are sent to health facilities as first source of treatment are significantly more likely to recover and would not need further treatment as compared to those who use informal treatments(33). Thus, resorting to informal treatments could likely lead to failed treatments, hence require further treatment possibly from formal sources of health care, which could in sum result in higher costs of treatment.
Strengths and Limitations
This study used a standardised health literacy questionnaire(24) in measuring health literacy levels. The translation and cultural adaptation of the Health Literacy Questionnaire reports of an acceptable fit for the overall nine factor model with less model fit for the ninth scale on understanding of health information(24). However, the less model fit had no influence on the profile groups. This is the first study to use this tool validated for use in a local language in Ghana and thus assesses the usefulness of the questionnaire.
The cross-sectional design is a limitation as it does not permit close monitoring on costs from the onset of malaria till the child recovered. It also does not allow firm conclusions on causal inference. Our study values work time loss based on self-reported income and a detailed measure of income could have improved this estimate. Due to long time recall period of six months, it is likely that some caregivers did not report the accurate costs they incurred when their child had malaria. This study used six-months recall period because, it has been reported that children are likely to have an episode of malaria within a six months period (33). However, the recall bias may have influenced the results in this study. We, however, have no reason to believe that this inaccuracy would differ by health literacy level. In terms of the overall relationship between health literacy, incidence of malaria, use of healthcare, and costs, malaria may not have been the best health condition for the assessment considering the familiarity of the disease in this context. A more complex health issue like a non-communicable disease may have shown different associations.