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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 18-24

Utilization of noncommunicable disease services provided by public health facilities in Kasaragod, Kerala


Department of Public Health and Community Medicine, Central University of Kerala, Kasaragod, Kerala, India

Date of Web Publication12-Jun-2019

Correspondence Address:
Dr. Prakash Babu Kodali
Department of Public Health and Community Medicine, Bramhaputra Block, Central University of Kerala, Tejaswini Hills, Periya, Kasaragod - 671 316, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_132_18

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  Abstract 


Background: The burden of noncommunicable diseases (NCDs) is high with significant impact on households in the form of out-of-pocket expenditure. Provision of NCD services through public health facilities is considered as cost-effective and efficient means. Aim: The study aimed to assess the proportion of individuals using NCD services provided through public health facilities and identify the factors associated with its use in Kasaragod district of Indian state of Kerala. Materials and Methods: A cross-sectional survey of 375 individuals was conducted in Kasaragod District of Kerala state. The data obtained were analyzed using descriptive and analytical statistical methods using Statistical Package for the Social Sciences version 20. Results: About 56.28% of individuals with NCD, received NCD services from public health facilities; these services were primarily comprised screening services. In addition, 40.69% of total individuals with NCDs received treatment services from government health facilities. Insurance coverage, perception about quality, perceived barriers in accessing health services, health worker visit, knowledge about NCD services, and information provided by frontline health workers were significantly influencing NCD service utilization in public health facilities. Conclusion: Individual's usage of screening services provided by government facilities is higher than that of treatment services. Overall, the utilization of NCD services provided through the public health system could be said to be less than satisfactory. It could be improved by addressing the perceived barriers with respect to the quality of services provided in public health facilities. In addition, employing the frontline health workers to bridge the awareness gap in NCD service provision could help in improving NCD service utilization.

Keywords: Health-care delivery, health-care utilization, noncommunicable diseases


How to cite this article:
Bhagyalakshmi C K, Kodali PB. Utilization of noncommunicable disease services provided by public health facilities in Kasaragod, Kerala. Arch Med Health Sci 2019;7:18-24

How to cite this URL:
Bhagyalakshmi C K, Kodali PB. Utilization of noncommunicable disease services provided by public health facilities in Kasaragod, Kerala. Arch Med Health Sci [serial online] 2019 [cited 2019 Sep 16];7:18-24. Available from: http://www.amhsjournal.org/text.asp?2019/7/1/18/260002




  Introduction Top


“Noncommunicable diseases (NCDs),” characterized by their nature of nontransmissibility and chronicity, account for majority of disease burden and disability worldwide. NCDs are the most common causes of premature death and morbidity worldwide and have a major impact on health-care costs, productivity, and growth of nation.[1],[2] Due to their chronic nature and associated multimorbidity, health-care cost for NCDs is usually high.[3],[4] According to 2017 estimates, NCDs kill 40 million people each year, equivalent to 70% of all deaths globally.[4] Each year, 15 million people die prematurely (i.e., between the ages of 30 and 69 years) due to NCDs with over 80% of these premature deaths occurring in low- and middle-income countries.[4] Within NCDs, cardiovascular diseases account for most NCD deaths, of 17.7 million annually, followed by cancers (8.8 million), respiratory diseases (3.9 million), and diabetes (1.6 million). These four groups of diseases account for over 80% of all premature NCD deaths.[5] Once developed, NCDs reduce the productivity, cause premature deaths, and the individual may become lifelong consumer of medicines. As a result of the multidimensional effect at individual, household, health system, and macroeconomic level, NCDs are labeled as global chronic emergency.[5]

In India, NCDs contribute to around 5.87 million deaths that account for 60% of all deaths marking country's share to over two-thirds of the total deaths due to NCDs in the Southeast Asian region.[6] The major chronic diseases of cardiovascular diseases, cancer, chronic respiratory diseases, diabetes, injuries, and mental illness account for an estimated 62% of the total age-standardized burden of forgone disability-adjusted life years.[7]

The NSSO's 71st round survey conducted in 2014 has identified that close to 70% of health expenditure in India is often paid out of pocket by household.[8] Considering that the nature of NCDs is often chronic, they require treatment of long time duration, for which payment is often out of pocket. This chronic nature of noncommunicable diseases could often be costly pushing the individuals into impoverishment. Recognizing the impact of NCDs on health, productivity, and economy of individual households and the country, the government of India launched national program for cancer, diabetes, cardiovascular disease, and stroke (NPCDCS) in the year 2008. NPCDCS aims to prevent and control NCDs by means of behavioral change communication, community participation, opportunistic screening of NCDs, and provision of NCD services through public health facilities.[9] The National Health Policy 2017 gave a special emphasis toward the provision of NCD-specific health services through health and wellness centers. In 2018, the Government of India launched its ambitious Ayushman Bharat program with a component of health and wellness centers to provide comprehensive health care including that for NCDs.[10]

While there is a growing emphasis toward provision of all the NCD-related health services through public health facilities, the utilization of health services provided by public health institutions is traditionally low in the Indian context. The recent district level household survey reported a lower rate of institutional deliveries in public health facilities, particularly from Southern states of India which traditionally had high percentage of institutional deliveries.[11] The NSSO's 71st round survey reported low utilization of public health facilities compared to their private counterparts.[8]

Given the context, understanding the utilization of services provided by public health facilities is of key importance. The study aimed at estimating the proportion of individuals utilizing NCD services provided by public health facilities under NPCDCS. In addition, it also intended to identify what facilitates the individuals utilize NCD services provided by public health facilities in Kerala.

Objectives

The objectives of this study are as follows:

  1. To identify the prevalence of NCDs and NCD multimorbidity among individuals above 30 years of age in Kasaragod district, Kerala
  2. To estimate the proportion of individuals utilizing NCD services (screening and treatment) provided by public health facilities in Kasaragod district, Kerala
  3. To assess the factors influencing utilization of NCD services (screening and treatment) provided by public health facilities in Kasaragod district, Kerala.



  Materials and Methods Top


Study design

Considering the aim and objectives of the study, the cross-sectional study design which helps to identify the proportion/prevalence of disease/health behavior, and which facilitates the capture of multiple variables at the sample point of time was adopted for the current study.

Study setting

The study was set in the Kasaragod, the Northern most district in the Indian state of Kerala. The district is considered underdeveloped in the state owing to low human development index and poor health indicators. The district is known to have a weak public health system, particularly with respect to tertiary care.[12] The district was chosen as the study site considering the backwardness of the district and logistic feasibility.

Sampling

Sample size

The current study adopted the following formula for sample size calculation n = 3.84 pq/d2 3.84 was the value used in the place of z2, considering the 95% confidence level where P is the prevalence/proportion, q = 1−p. For the sample size calculation for the current study, the value of “p,” that is, the proportion of public health service utilization is taken as 33%.[13] The other values are substituted as q = 67%, d (precision) = 5%; the sample size was estimated to be 339.6 (340). Considering the nonresponse rate of 10%, the sample size is calculated to 374 which was finally rounded off to 375.

Sample selection procedure

The study adopted a multistage random sampling method for selecting the sample for the study. From a total of four taluks in Kasaragod district, Vellarikkundu taluk was randomly selected through lottery method. From all the seven panchayats of taluk, three wards from each panchayat were randomly selected. From each ward, 18 households were randomly selected through lottery method. From each household, one individual as per the inclusion criteria (individual above 30 years of age and the resident of the district at least for the last 6 months) was randomly selected. In addition, exclusion criteria (individuals with serious illness/disability; migrants; who developed disease in early stages of life; individuals with a history of pregnancy-induced hypertension and preeclampsia; and recorded victims of endosulfan exposure) were applied for respondent selection into the sample.

Data collection tools and techniques

A structured questionnaire was designed as a tool for collecting the data. The tool consisted of closed-ended questions and was designed by adopting questions from prevalidated questionnaires from earlier surveys on the utilization of NCD services from government health facilities conducted in the context of India and Kerala.[14],[15] In addition, certain key variables identified through the literature review but were not present in the earlier questionnaires were added to the tool. The tool was translated from English to Malayalam and then back-translated to check for consistency. The data collection was carried out by the method of structured interview. For each individual respondent, it took around 45–50 min for completion of the structured interview.

Data analysis

The collected quantitative data were entered into spreadsheets which were later transferred to International Business Machine (IBM)'s Statistical Package for the Social Sciences version 20 for analysis (IBM, Armonk, NY, USA). The data were checked for missing variables and none were found. Some continuous variables (such as age and distance to the nearest public health facility) were converted into categorical variables. The data analysis was conducted by descriptive (mean, frequencies, and percentage) and analytical (binary logistic regression) statistical methods.

Ethical considerations

Measures were taken to ensure highest ethical standards at all the stages of the study. The study was approved by the Institutional Human Ethics Committee (IHEC) of Central University of Kerala with reference no CUK/IHEC/2017-006. All the participants were given adequate information about the study, their participation, possible benefits, and risks involved in addition to the participant information sheet. The participants were provided all the information in Malayalam (the local language of the study site). Informed consent was obtained in written from all the participants who were willing to participate in the study. The participants were categorically informed that by signing informed consent the participants will not lose any of their rights and can withdraw from the study with short notice. All the structured interviews were conducted at the participant's home to ensure his/her privacy. The details of the participants were kept confidential and the data entry, analysis, and presentation of the results commenced postidentifier removal. The data security was ensured by protecting the data as encrypted files in the password-protected computers. The data were accessible only to the members of research team (authors).


  Results Top


Descriptive statistics

The total sample size was 375. Among them, 49.3% (185) people were female and 50.7% (190) were male. Mean age of the sample is 52.7 years, ranging from 33 years to 83 years. Over 39.5% of the sample reported currently unemployed and close to 35% of the respondents reported belonging to below poverty line. The mean income of the respondents was rupees 10,808.76 with standard deviation ± 13342.55.

The median distance to the nearest public health facility is 6 km. Only 57.86% of the respondents reported availability of the transportation facility to the health center at the convenient time. Over 86.9% (326) of the respondents reported health-care visit in the last 12 months. Around 59.2% of the respondents were covered by health insurance, of which 46.9% were covered under government health insurance scheme. About 74% of the respondents reported that the quality of health services provided by government facilities was adequate.

Prevalence of noncommunicable diseases and utilization of noncommunicable disease services from public hospitals

Considering the NCD status of the individuals, over 61.5% were reported to be diagnosed with any NCD. Within the sample, over 22% of the respondents were having multimorbidity (i.e., at least two if the identified NCDs). Over 15.2% of the sample reported being diagnosed with hypertension, followed by diabetes standing at 12%. [Figure 1] provides a detailed insight into the NCD status of the respondents in the sample.
Figure 1: Noncommunicable disease status of the individuals in the sample

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Over 62% (233) of the respondents attended NCD screening, of which over 54% (128) of them attended NCD screening programs conducted in government facilities. Within the respondents who attended screening at the government health facilities, 89.84% (115) reported referral to the higher level health facilities. The detailed insights of the utilization of NCD screening services by the respondents are provided in [Table 1].
Table 1: Table providing information on utilization of screening services

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With respect to treatment-related services, within the 102 respondents who reported visiting hospital, 92% (94) reported to be informed to undergo treatment for NCDs. Around 70% (70) of the individuals referred received treatment from government facilities. The details of the utilization of NCD-related treatment services are provided in [Table 2].
Table 2: Table providing detailed outline of utilization of treatment services for NCDs

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Factors influencing noncommunicable disease service utilization

Adjusted odds ratio was calculated for utilization of NCD services in public health facilities as the outcome variable and sociodemographic, individual-specific factors, NCD-specific, and health system-specific factors as predictor variables. The variables which were identified to be significantly associated in the Chi-square test were selected to perform binary logistic regression to calculated adjusted odds ratio (OR). The sociodemographic factors of age, education, economic status, etc., did not show a significant association with utilization of NCD services. The individual specific factors of perception about the quality of government health services perceived barriers for accessing government health services and knowledge about NPCDCS, and insurance coverage had significant odds of OR = 17.244 (95% confidence interval [CI] = 5.103–58.132. P < 0.01); OR = 2.466 (95% CI = 1.312–4.636. P < 0.01); OR = 40.615 (95% CI = 9.538–172.748. P < 0.01); and OR = 2.017 (95% CI = 1.179–3.449. P < 0.01), respectively. The NCD-specific factors, that is, NCD status of the individual, self-reported knowledge of NCDs, and knowledge about control measures showed no significant association. Health system factors, that is, health worker visit in the last 6 months and information provision by frontline health workers showed significant odds of OR = 2.398 (95% CI = 1.312–4.636. P < 0.01) and OR = 19.516 (95% CI = 8.670–43.932. P < 0.01), respectively. The detailed outline of the bivariate analysis is provided in [Table 3].
Table 3: Table providing a detailed outline of factors influencing utilization of NCD services from public health facilities

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  Discussion Top


NCDs are of public health priority nationally and internationally. The World Health Assembly's resolution of achieving the 25 × 25 target (i.e., 25% reduction in NCD mortality by 2025) reaffirms the commitment of WHO member states including India toward NCD mortality reduction. One of the important means to achieve said target is early diagnosis and treatment of NCDs. Within the Indian context, the public health system with over 5363CHCs, 25,020 PHCs, and 152,326 subcenters[16] holds potential for sustainable provision of NCD services. The NPCDCS aims to use these existing resources to improve the provision of NCD services by providing essential screening and treatment services through public health facilities (i.e., PHCs, CHCs, and Referral Hospitals).[9]

Prevalence of noncommunicable diseases

Within the sample of 375, 61.6% reported to be suffering with one or other NCD (including diabetes, cardiovascular disease, stroke, cancer, chronic respiratory disease, chronic kidney diseases, and arthritis). Such a prevalence is not surprising as the mean age of the sample was 52.7 years with more than half of the study sample aged over 50 years, an age group with high risk of developing noncommunicable diseases.[17] The study identified the prevalence of the key noncommunicable diseases of diabetes, hypertension, cardiovascular diseases, and cancers to be standing at 30.1%, 34.3%, 8.2%, and 3.2%, respectively. Such a high burden of NCDs was also particularly reported from other studies in Kerala where the prevalence of diabetes was identified to be between 17% and 32.9%[18],[19] and the prevalence of hypertension was between 25.7% and 41.5%.[11],[20] In addition, one of the specific insights obtained was the high prevalence of NCD multimorbidity standing at 22.9% of the respondents with NCDs. Such a high burden was even reported in other studies with NCD multimorbidity ranging from 10.3% to 30.7%.[5],[20] In the above aspects, while the deviation of the observations of the current study toward lower or higher values could be because of individual study-specific variations, the high burden of NCD multimorbidity warrants need for the provision of accessible and affordable NCD care services owing to their higher need for health-care utilization and subsequent health-care costs.

Utilization of noncommunicable disease survives in public health facilities

In India, public health services are provided under a three-tier hierarchy with subcenters at the village level, primary health-care centers at the block level, and community health centers and district hospitals at the higher levels. In case of inpatient treatment in Kerala, public health services contribute to 34.7% in rural and 33.3% in urban areas.[21] While conventionally, public health facilities in India were predominantly focused on providing MCH care including immunization, in the last decade after the launch of NPCDCS, the provision of NCD services through public health facilities gained prominence.

The current study identified that over 34.67% (130) of respondents received NCD services from government facilities. Specifically, the services could be split into screening services and treatment services. The screening services provided through government health facilities which are for the general population above 30 years of age were used by 34.13% (128) of total sample. The treatment services through government facilities which are specifically for the individuals suffering with NCDs were used by 40.69% (94) of total individuals with NCDs.

The utilization of the NCD services provided through public health facilities (i.e., NPCDCS services) is slightly higher than that of the utilization for other services provided through the public health system of Kerala.[21] The study reports a lesser utilization of NPCDCS services for general population. However, among the individuals with NCDs, the NPCDCS service usage was similar to the findings of other studies such as the study by Shammy which identified the utilization of screening services to be 53.1% and treatment services to be 40.9%.[15] As per NSSO's 71st round survey, outpatient utilization of public health facilities for major NCDs is found to be 46%.[22] NPCDCS interventions aim to reach the whole population for early detection and provision of better management strategies at a low cost. The current study reveals the utilization of both screening and treatments, services are still stagnated at comparatively lower level. In addition, the utilization of NCD screening services, compliance of referral to higher centers, utilization of treatment services, and attendance to counseling services were influenced by multiple factors discussed below.

Factors influencing utilization of noncommunicable disease services in government facilities

The utilization of health facilities (though public/private) is not spontaneous with the illness and is guided by several factors with come in decision-making pathway to utilize a particular facility. The same could be said with respect to NCDs which in contrary to their counterparts (i.e., acute communicable diseases) are chronic requiring a repeated engagement between patient and the health system. The individual's inclination toward utilization of a particular kind of a health service is explained by multiple factors. This study identified that the aspects such as insurance coverage, perception about quality of government services, perceived barriers in accessing health services, health worker visit, knowledge about NPCDCS services, and information provided by frontline health workers (Accredited Social Health Activists [ASHAs] or other community health workers [CHWs]) significantly influenced the utilization of NCD services in the government facilities.

The individuals having any type of insurance coverage had two times higher odds of accessing health services through government health facilities. While the individuals with a health insurance coverage traditionally are inclined toward utilizing private health-care services, the large-scale coverage of the state-funded comprehensive health insurance scheme in Kerala[23] and comparatively lesser availability of private health facilities in the local geography of Kasaragod might have impacted the NCD service utilization in public health facilities.

The individual's perception of the quality of the government provided health services is one of the key factors determining their utilization. Literature from low- and middle-income countries reiterate that the utilization of state-funded health facilities is traditionally poor owing to the poor quality of the services provided.[24],[25] The quality of health services along with the perceived barriers to access the government provided health services was pointed out to be primary determinants of low utilization of health services in government facilities in the Indian context.[24]

In addition to the above, a key factor strongly impacting the health service utilization of NCD services is the knowledge of NPCDCS services. NPCDCS envisions to prevent and control NCDs by utilizing public health facilities (subcenters, PHCs, CHCs, and district hospitals) as point-of-care centers for provision of services. The knowledge of the services provided in public health facilities is the key factor in enabling their utilization. This idea was recurrent in majority of the state-funded health programs providing maternal, neonatal and child health-care services, communicable disease prevention services, and insurance coverage.[26],[27]

Moreover, health worker visit (particularly the CHW visit) was one of the strongest enabling factors in utilization of NCD services provided through public health facilities. These results enable us to put forward the argument that the knowledge of NPCDCS services and health worker visits are the two most important predisposing factors enabling the individuals to utilize NCD services provided in government facilities. Most importantly, considering the roles mandated for frontline health workers (i.e., ASHAs and Auxiliary Nurse Midwives) in National Health Mission and NPCDCS,[9] it could be said that the community level health worker is acting as a gateway enabling health service utilization. A qualitative analysis of ASHA worker's functions under NPCDCS identified that ASHAs play a prominent role in the provision of behavioral change communication, community education, informing the community members about the NCD camps, and following up the individuals with NCDs.[28] Evidence from low- and middle-income countries has identified that CHW visit improves the utilization of health services, improve adherence to the treatment regimen, and strengthen referral and follow-up.[29],[30] Moreover, considering that CHWs are usually selected from the community they work in, they elicit a greater response from the beneficiaries in terms of utilization services provided. Evidence of CHWs improving institutional deliveries and immunization rates, particularly in the empowered action group states of India support the findings of the current study that frontline health worker's visits improve NCD service utilization.

Overall, it can be said that the utilization of NCD services provided under NPCDCS is predominantly dependent on the activities of health system strengthening (to improve the quality of the services provided and reduce the barriers to access health care), community awareness (to make the community members knowledgeable about the services provided under NPCDCS), and health worker involvement (to provide health education, awareness, and follow-up). In addition to the above, priority to NCD care and management has to be sustained through better health-care financing and acceptable innovations in health-care delivery.

This study has a few limitations. Given the study is cross-sectional in nature, the aspect of temporality cannot be justified with respect to the factors influencing utilization of NPCDCS services. Limited time duration and logistic feasibility limited the possibility of conducting a larger representative study of Kerala limiting the generalizability of the study.


  Conclusion Top


The burden of NCDs is consistently high with NCD multimorbidity being a predominant challenge. The public health systems should be equipped to tackle the growing NCD burden with special focus on NCD multimorbidity. While the burden of individual NCDs and NCD multimorbidity is high, the utilization of NCD services provided through public health facilities is less than satisfactory. Health system strengthening measures (including infrastructural, human resource, and health financing) to improve the adequacy and quality of NCD services provided and health promotion to improve the awareness of beneficiaries is essential. The CHWs acting as a bridge between the community and health system could be a key player in taking the NCD services to the community and improving their utilization.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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