Drivers of respiratory healthcare demand in Acre state, Brazilian Amazon: a cross-sectional study


 1.1 BackgroundThe scant knowledge on drivers of demand for respiratory healthcare in Brazilian Amazon, where the gap of human and physical healthcare resources is wide, is expanded with two surveys conducted at the west of the region in Acre state. Potential drivers, informed by a review of twelve recent papers, were classified in seven categories comprising the individual, household, community and macroeconomic dimensions.1.2 MethodsOn-field quantitative structured surveys were conducted in 2017 and 2019 based in coupled conglomerate-quota-randomization sampling, with support of community health agents. Adults responded about their own or their children’s health. Whether physician care was sought to treat the latest episode of respiratory illnesses or of dry cough was analysed statistically with multiple non-linear regressions having as covariates the potential predictors informed by literature.1.3 ResultsThe propensity to seek healthcare and to purchase medication was larger when targeting children rather than adults. Influenza was the most frequent cause of latest episodes of respiratory illnesses and dry cough, what makes the below-40% healthcare seeking rate worrying as it may sustain a considerable local contagion rate. Illnesses’ severity, including the pain experienced, were the main predictors, revealing that subjective perception exerted stronger influence than objective individual’s and households’ characteristics. The insignificance of education indicated that it was not the sole determinant of health literacy, the latter a more important driver, according to literature. Income was insignificant due to respondents relying almost uniquely on free healthcare offered by the Brazilian Health System.1.4 ConclusionsResults suggest that subjective underestimation of respiratory illnesses’ consequences for oneself and for local society could motivate a refusal to seek treatment. This is in line with some previous studies but departs from those overemphasizing the role of objective factors. Social consequences, of, for instance, macroeconomic nature, needs highlighting, based on studies detecting a long-run relationship between healthcare demand, health and economic performance at national level. Microeconomic behavioural policy is needed to change subjective perceptions of symptoms and illnesses with nudges and educational interventions.


Abstract 1.1 Background
The scant knowledge on drivers of demand for respiratory healthcare in Brazilian Amazon, where the gap of human and physical healthcare resources is wide, is expanded with two surveys conducted at the west of the region in Acre state. Potential drivers, informed by a review of twelve recent papers, were classi ed in seven categories comprising the individual, household, community and macroeconomic dimensions.

Methods
On-eld quantitative structured surveys were conducted in 2017 and 2019 based in coupled conglomerate-quota-randomization sampling, with support of community health agents. Adults responded about their own or their children's health. Whether physician care was sought to treat the latest episode of respiratory illnesses or of dry cough was analysed statistically with multiple non-linear regressions having as covariates the potential predictors informed by literature.

Results
The propensity to seek healthcare and to purchase medication was larger when targeting children rather than adults. In uenza was the most frequent cause of latest episodes of respiratory illnesses and dry cough, what makes the below-40% healthcare seeking rate worrying as it may sustain a considerable local contagion rate. Illnesses' severity, including the pain experienced, were the main predictors, revealing that subjective perception exerted stronger in uence than objective individual's and households' characteristics. The insigni cance of education indicated that it was not the sole determinant of health literacy, the latter a more important driver, according to literature. Income was insigni cant due to respondents relying almost uniquely on free healthcare offered by the Brazilian Health System.

Conclusions
Results suggest that subjective underestimation of respiratory illnesses' consequences for oneself and for local society could motivate a refusal to seek treatment. This is in line with some previous studies but departs from those overemphasizing the role of objective factors. Social consequences, of, for instance, macroeconomic nature, needs highlighting, based on studies detecting a long-run relationship between healthcare demand, health and economic performance at national level. Microeconomic behavioural policy is needed to change subjective perceptions of symptoms and illnesses with nudges and educational interventions.  5,196 individuals from seven developed and seven developing countries including Brazil, estimated that only 30% of patients with sore throat, a symptom associated with In uenza-like illnesses and acute respiratory illnesses (Zhang et al., 2020), seek a general practitioner. Similarly high rates of refusal and also delay in seeking care were found in national-level surveys (Datiko et al., 2020, Seid and Metaferia, 2018, Zhang et al., 2020, Suka et al., 2016. These behaviours besides prolonging the impairment of own health and labour productivity (Piabuo and Tieguhong, 2017), and increasing risk of own mortality, which already have social consequences, may also increase contagion locally in case of viral and bacterial diseases (Datiko et al., 2020, Seid andMetaferia, 2018).
Such negative social effects are more probable in less developed regions such as the Brazilian Amazon.
There, the per capita number of families receiving poverty alleviation cash transfers is 1.5 that of the whole country (MC, 2021, IBGE, 2021) and large scale exposure to pollution from agricultural res is seasonal and comparable in its intensity to exposure to urban pollution in megacities such as London and Mexico City (Morello, 2021, Gonçalves et al., 2018. Also, the prevalence of both tuberculosis (TB) and In uenza is 1.3 fold larger than the country's average (of six cases per 10,000 inhabitants; SINAN, 2021, IBGE, 2021). Contradictorily, the greater health challenge coincides with a smaller endowment of health resources. In the Amazon, the number of physicians per capita is thirty fold below the world average and 0.09 hospital beds per 1,000 inhabitants are available as compared with 3.2 in the world (WB, 2021, DATASUS, 2021).
Besides the supply-side gap, previous studies in Brazil have also detected demand-side barriers to healthcare, such as low capacity to recognize, both in oneself and in children cared for, diseases, their severity and contagiousness (Passos et al., 2018, Borges et al., 2018, limited capacity to obtain and use health-relevant information, mainly by the low-educated (Apolinario et al., 2013, Almeida et al., 2019, household income incompatible with transport costs required by visiting a health facility, which is more likely for rural residents (Parry et al., 2018), and reliance on self-medication (Arrais et al., 2016).
Nevertheless, none of these studies are based on patient surveys uncovering factors enabling and disabling care seeking for respiratory illnesses, which are rare in Brazil, and, as far as it could be assessed, unavailable for the Amazonian region. Nevertheless, in order to stimulate healthcare seeking, there is need to detect patients' characteristics predicting whether such course of action would be spontaneously carried out or not. This is required for knowing which social groups should be prioritized by speci c interventions (Diaz et al., 2013), such as behavioural nudges (Schmidt, 2019) and educational campaigns (Suka et al., 2016), and how these should be designed. Seeking to ll such gaps, this study detects predictors of healthcare seeking among respiratory ill individuals of Acre state, western Amazon.

Factors of demand for health care
A total of twelve recently published papers were resorted to in order to identify potential factors in uencing the demand for healthcare, as basis for selecting covariates for quantitative analysis and for discussing and complementing the results. Summaries of all papers are provided in the Additional Information and here a short overall synthesis and taxonomy are presented.
The papers revised highlighted the relevance of multiple factors including characteristics of patients, of social groups (households and communities), social context and macroeconomic features such as development and economic growth level (Table 1). These factors exert effect through multiple mechanisms at individual (e.g., identi cation of illness from symptoms), household (e.g., women autonomy to seek care for children), community (e.g., support for seeking care) and macroeconomic level (e.g., economic growth expanding national health systems). Therefore, the demand for health care is both a multidimensional and multi-level process which can hardly be comprehensively apprehended with only one research method. This is clear from the larger diversity of factors in the literature as compared with the datasets used in this paper (Table 1). Nevertheless it is also clear that a signi cant fraction of factors is captured, with the uncaptured (macroeconomic) factors being left to be accounted for in the results' discussion (Sect. 5). Also, the focus on demand-side variables is coherent with the consulted literature, especially with the nding by Datiko et al. (2020) and Seid and Metaferia (2018) that delay in receiving TB treatment was mostly demand-driven. .Limited knowledge about prevention and treatment (-) .Degree of "health literacy" or capacity to obtain and use information in order to ensure good health [SUK16] (+)  .Household size (-) .Female gender (-/+) .Support from relatives in seeking healthcare and overcoming stigmatization (+) . .Previous contacts (+) and good personal relations with healthcare provider (+), including good patient- .Health facility distance (-) .Treatment cost (-), co-payment or any out-of-pocket disbursement being required (-) .Opportunity cost of treatment (speci cally transport cost) (-) . .Resort to self-made medication (including traditional plant and herb based remedies) (-) and selfmedication with either traditional or ordinary drugs (-) [SEI18]; .Resort to traditional healers and "chemists" (medication vendors) (-) .Relative distance of formal and nonformal care options (e.g., "chemist"/drug vendors are inside the community and health facility is outside) (-) Resort to nonprofessional healthcare (mostly traditional medication) Note participants. The goal was to elicit the willingness to pay (WTP) for avoiding the recurrence of the most recent respiratory illness episode. A hypothetical vaccine was offered as a product capable of yielding full prevention. Since WTP estimates are not directly related with the goal of this paper, only the survey's rst module, on the description of the illness episode, and the third module, on socioeconomic and health covariates are here detailed.
The sample was selected with a mix of conglomerate-quota-randomization with the help of local CHAs (details are found in Morello et al. 2019, SI, Sect. 4). In the rst stage, ten neighbourhoods of Rio Branco urban perimeter were selected, initially randomly, and, afterwards, whether CHA support proved insu cient, new neighbourhoods were introduced as replacements, being selected in order to ensure representativeness of income and respiratory illnesses' prevalence at whole perimeter level. The shares of eight combinations of two genders and four age intervals (0 to 4, 5 to 17, 18 to 65, above 65) in the study region Census population were moderately altered to end with considerable numbers of sampled children and elderly. Such quotas, after multiplied by 18, which was the number of interviews a CHA could support, were informed to such professionals, whom were instructed to write down a patients' list with a size two to fourfold that of each quota. Research assistants then drew randomly, for each age-gender group, a number of individuals matching the quota. The interviews were then conducted in interviewees' houses, and whether selected individuals were not found or refused to participate, the next listed subject of the age-gender group was approached (what was repeated in case of a new failure). Enumerators were accompanied by CHAs in interviews, what both minimized rejection and helped, whenever needed, in rephrasing questions in ways more understandable to respondents.
A total of 519 interviews that were valid for the purposes of this paper were conducted. In 278 interviews, adults responded about illnesses acquired by them and in the remaining 241, about illness acquired by their children. Caregivers, generally mothers or fathers, were interviewed on behalf of children.
Now turning to the questionnaire, its rst module retrieved descriptive data on the most recent illnesses episode, including (i) a sequence of yes/no/can't remember questions on whether 21 symptoms were felt, (ii) a three-point Likert scale on subjective pain experienced, (iii) symptoms beginning date and duration, (iv) whether medical care was sought and (v) diagnosed illness. Children aged above ve years were asked to con rm caregivers' responses. The third module asked about age, household size, years of schooling (according with the Brazilian educational system), and household income, which was asked in a comprehensive way comprising six main income sources. This was complemented by the inquiry on the ownership of durable goods that were highly related with income according with the National Household Survey (IBGE, 2016). Additional questions covered smoking, health insurance, distance to the health unit where treatment for rst module's illness could be found and seven serious lung diseases (asthma, bronchitis, lung cancer, chronic obstructive pulmonary disease, emphysema, pneumonia and TB).

Cough survey
From December 2019 to middle March 2020, a new survey designed as an improvement of the one described in the previous section was run also in Acre state, but this time including also its second most populous municipality, Cruzeiro do Sul. The survey consisted in a discrete choice experiment estimating the WTP for a hypothetical remedy able to reduce the number of days with dry cough. Thus, its main particularity was the focus on one single respiratory symptom, which was selected from medical literature as highly recurrent across respiratory illnesses (Balbani, 2011, Morice, 2002. Dry cough was considered because it is more likely that suppression be sought by treatment in the case of dry rather The same approaches of the respiratory illness survey for sampling and for including children were adopted. The modules used in this paper were near equivalent as in the case of the previous survey, except for focussing on the latest dry cough episode and for having inquired about income in the form of eight intervals, whose medium points were used in analysis, instead of the open-ended format adopted in the previous survey. Before the nal stage of the survey, a pre-pilot comprising 33 interviews was conducted in July 2019 and a pilot with 54 interviews in December 2020. The latter is here included as part of the analysed data due to minor differences with the questionnaire applied in the nal stage.

Data quality and analysis
In the respiratory illness survey, two research assistants were trained by the rst author and monitored oneld during the pilot wave. These last-year undergraduate students were also quali ed to train enumerators. All questionnaires were revised after applied and, if needed, the enumerator returned to respondents' houses, or the questionnaire was discarded. In the two cases, the decision was based both in the missing or ill-lled elds and in the last questionnaire module, the latter lled by the own enumerator alone, which accessed the quality of the responses received. In the cough survey, similar procedures were adopted, with the exception that the whole team was trained by the rst author himself (except for one enumerator that conducted 18 interviews).
Standard central tendency, position and dispersion statistics were applied to describe the data. Proportion difference test, based in the standard normal distribution, was applied to compare adults and children subsamples. Econometric analysis was pursued with standard index multivariate regressions for discrete dependent variables (whether healthcare was sought), whose disturbances followed either the Gaussian cumulative distribution function (probit) or the logistic function (logit). Estimators' standard errors were robust for heteroscedasticity (Cameron and

Surveys' description
In the respiratory illnesses survey, the average respondent had 30 years and an income 2.5 fold the minimum wage, near 30% received poverty alleviation cash transfers, and 62% had the lower secondary educational level or above ( Table 2). The latest respiratory illnesses reported by participants caused 10 symptoms, lasted 10 days and in icted moderate to extreme pain in 95% of cases. Only 14% of the episodes occurred in the dry season (i.e., from June to September, in the case of Acre state). Only 38% of respondents sought healthcare, 32% when the illness was acquired by an adult and 46% when a child was the patient, a statistically signi cant difference (p-value < 5%). A diagnosis was provided in 98% of cases and In uenza (or cold) was the most recurrent disease (50%). All symptoms with high frequency (> 50%) either attacked the nose, throat, caused cough (dry and wet), fever, headache, body aches, shortness of breath and malaise.
In the cough survey, income was smaller, twofold the minimum wage, in consonance with a higher rate of poverty of 47% and age and education were near-equivalent to the respiratory illness survey (Table 3). In average, the most recent dry cough episode lasted 10 days, caused moderate to extreme pain in 78% of cases and occurred in the dry season in 38% of cases. Overall healthcare seeking rate was of 33%, 26% for adults and 39% for children, a signi cant difference at 10% signi cance level and the rate of (pharmacy-purchased) medication was 66%, 57% for adults and 75% for children, a statistically signi cant difference at 5% level. Diagnosis was obtained in 95% of cases with In uenza being again the most recurrent disease (47%).
In summary, most of respondents were of low to medium income, reported a moderately painful In uenza episode during 10 days and were more likely to seek care and purchase medication for children rather than for adults.

Econometric analysis
Three models were estimated for each survey. First, a baseline model with all factors suggested by the literature review that could be retrieved in the surveys (as in Table 1 above). Second, an extended version of the former including a female gender vs household size interaction in order to capture that the more members are in the household, the smaller may be the time female members allocate to domestic tasks and thus the larger the time available to seek healthcare (this captures intra-household effects as in Table  1). Third, a children only model to test whether the kinship tie between child and respondent, supposedly the caregiver, i.e., whether the latter was the mother, father or other relative, in uenced healthcare seeking (which again captures the in uence of intra-household phenomena). Tables 4 and 5 show that healthcare seeking was driven mainly, considering the two surveys, by health condition characteristics, rst of all, subjective pain but also severity as measured by number of symptoms (signi cant only in the respiratory illness survey) or duration. Factors that were signi cant only in one survey corresponded to respondents' health, speci cally whether a lung disease was ever experienced (cough survey) and to individual characteristics, speci cally age (respiratory illness survey), and, at last, household characteristics, in the case, household size (cough survey). In addition, in the cough survey, whether the symptom occurred in the dry season increased care seeking, as expected, due to the better condition of roads and thus the easier access to facilities and also because in the colder dry season, cough could happen together with more or severer symptoms (Silva et al., 2009). Factors whose insigni cance was less expected were education, revealing that schooling may not capture health knowledge or that the latter was not signi cantly related with care seeking in the particular context, income, which was due to respondents resorting to free care offered by the public system (what also explains why poverty was irrelevant), distance to health unit, which could have be caused by most respondents living close to units (75% within 2 km in the illness survey and 94% within 30 min in the cough survey), a consequence of the considerable geographical diffusion of primary care facilities and, probably, of CHAs' priority to patients located nearer to facilities in routine home visits. In the case of waiting time inside health unit (cough survey), its non-signi cance could be also due to insu cient variation (58% waited up to one hour). Resort to non-professional healthcare (cough survey), which mostly captured household-made medication, was non-signi cant probably because it was not a question made to all respondents, but, instead, a spontaneous statement made as part of the choice experiment whenever medication was not opted for, what probably biased the variable's signi cance downwards. Household-level phenomena, captured by the interaction of female gender and household size, and also by the relative that answered in behalf of the child (supposedly the caregiver), did not in uence signi cantly the healthcare seeking decision. Note: standard errors in brackets; "pro" denotes probit and "log" logit models, the rst two columns contain the baseline model, the model with female * household size interaction is indicated with "int" and the children-only model with "chi". Pseudo-R 2 is denoted with "r2_p", the statistic and p-value of the chi-square global signi cance test as "chi2" and "p", and the log-likelihood as "ll". Note: standard errors in brackets; "pro" denotes probit and "log" logit models, the rst two columns contain the baseline model, the model with female * household size interaction is indicated with "int" and the children-only model with "chi". Pseudo-R 2 is denoted with "r2_p", the statistic and p-value of the chi-square global signi cance test as "chi2" and "p", and the log-likelihood as "ll". The signi cance of duration, severity and subjective pain, and the insigni cance of individual, household and facility characteristics, in models explaining whether an episode of respiratory illness or, of dry cough, was addressed with a medical visit, reveals that subjective, rather than objective factors, play a key role in driving healthcare seeking. This is line with the revised literature. In Suka et al. (2016), expecting that relatives and friends would support care seeking was a signi cant predictor of opting for it and also symptoms that were believed to be of a somatic rather than a psychological nature, and thus less stigmatized, were more likely to trigger a stated intention to seek healthcare. In similar fashion, Results also support the conjecture that supply-side policy recommendations, such as performancebased increase of government expenditure on health care (suggested by Abdullah et al., 2017), may bring less-than-expected results due to demand-side barriers. One clear barrier is the subjective underestimation of respiratory illnesses' consequences both for own health and for the broader society suggested both by a rate of care seeking below 40% and by the dominant role of subjective covariates. For this, simultaneous implementation of microeconomic behavioural policies seeking to change subjective perception of symptoms and illnesses, via nudges (Schmidt, 2015) but also through educational health interventions (as proposed by Suka et al. 2016 andSeid andMetaferia, 2018), is advisable. One possibility, suggested by the lower likelihood of adults to seek care for respiratory illnesses, as compared to children, is CHAs' educational actions stressing that adults' illnesses, whether contagious, could be acquired by their children. In uenza vaccination campaigns which achieve over 80% coverage in Acre state (SI-PNI, 2021) could also better inform about symptoms and contagiousness (as recommended for TB by Seid and Metaferia, 2018) and the need to seek care even whether vaccinated or experiencing tolerable pain. A speci c study on alternatives to increase healthcare usage during the wet season is needed, what requires assessing the possibility of temporarily expanding health workers' teams in rural areas when rain is intense enough to prevent rural-urban displacements.

Results in
To nish, the results here achieved are generalizable only to other developing countries that also have a Ethical approval for conducting the two surveys was obtained from the Federal University of ABC's ethical committee, on behalf of the National Council of Research Ethics (CONEP). An informed consent document was signed by all participants before questionnaire was applied, and after detailed explanation of the voluntary nature of participation, of research goals, bene ts, costs, anonymity and con dentiality, and rst author's contact information. Illiterate participants had the document signed by a relative or witness. A copy of the document, signed by the rst author, was handed to participants. All methods were carried out in accordance with the Brazilian standards of ethics in research involving human subjects, which are based in the Helsinki declaration.

Consent for publication
Not applicable, there are no data about individual participants in the manuscript.

Availability of data and materials
The datasets generated and/or analysed during the current study are not publicly available due the con dentiality commitment contained in the informed consent document signed by participants, which forbids public data sharing, but are available from the corresponding author on reasonable request.