Demand Creation and Service Utilization: Understanding the Behavioral Dimensions of Delayed Care Seeking

Summary:

Seeking care from trained health workers is critical to preventing and treating a variety of health conditions. Despite advances in quality of care and efforts to educate and inform individuals, delays in care-seeking remain a persistent problem across many health areas. Through qualitative research in three distinct contexts, we investigated behavioral dimensions of care-seeking: how environment, past experiences, and interactions with others trigger universal human tendencies that may hold an individual back from seeking timely, appropriate care. These tendencies include, for example, biases that may lead a person to incorrectly weigh risks and an overweighting of immediate costs and inconveniences that may lead to procrastination. Through qualitative research, we identified barriers to care-seeking for symptoms suggestive of tuberculosis (Breakthrough RESEARCH Philippines), common childhood illnesses (Breakthrough ACTION Zambia), and routine maternal and child health services (Breakthrough RESEARCH Nigeria). This research included interviews with those who have faced (or might in the future face) a decision about whether or when to seek care, interviews with others who might influence the care-seeking choice, and observations of interactions in health facilities. Shared barriers to care-seeking across health areas relate to the perceived severity of health care needs, fear of confronting frightening information, flawed heuristics for when professional care is necessary, expectations and uncertainty about the care-seeking experience, and anticipated health and social consequences of care-seeking. Insights from this work can inform new approaches to social and behavior change programming to increase acceptance of and use of services.

Background/Objectives:

A variety of health conditions can be prevented and treated through timely care-seeking from trained health workers. But delay and avoidance of care-seeking remain persistent problems despite advances in quality of care and expanding efforts to educate and inform people on the importance of seeking care. Through qualitative research informed by behavioral sciences, we investigated the behavioral dimensions of care-seeking for symptoms suggestive of tuberculosis (Breakthrough RESEARCH Philippines), common childhood illnesses (Breakthrough ACTION Zambia), and routine maternal and child health services (Breakthrough RESEARCH Nigeria). Insights from this work can inform programming which seeks to increase service utilization.

Description of Intervention and/or Methods/Design:

Research from the behavioral sciences sheds light on how a person's environment, past experiences, and interactions with others can trigger universal human tendencies leading to biased decisions or failure to follow through on intentions. Informed by this research, we conducted qualitative research investigating behavioral dimensions of health care-seeking in three unique contexts: TB testing and treatment by symptomatic individuals, treatment for routine childhood illnesses by caregivers, and routine preventive and curative maternal and child health services by women who are pregnant or have recently given birth. The research includes interviews (n=194) with those who have faced (or might in the future face) a decision about whether or when to seek care, health workers, family members, and other community members. It also includes observations of interactions in health facilities (n=16). Data were analyzed using inductive and deductive thematic analysis to identify behavioral barriers to care-seeking in each context.

Results/Lessons Learned:

Several common themes about the behavioral dimensions of care-seeking arise across the three health areas. The choice about whether to seek care at a particular moment is influenced by perceived severity of the health care need; this assessment is in turn influenced by the tendency to avoid confronting the prospect of potentially negative or frightening information (active information avoidance). Individuals also frequently use rational but flawed heuristics, or rules of thumb, for when care is necessary. Expectations about care-seeking experiences (including how one may be treated by health workers and anticipated inconveniences and costs) can also influence the decision, and ambiguity around this experience contributes to fear and avoidance. Finally, care-seeking can be influenced by anticipated health and social consequences. Social consequences may be positive (as when care-seeking signals that one is a responsible mother) or negative (as when it may reveal a stigmatized health condition).

Discussion/Implications for the Field:

These shared barriers to care-seeking can inform approaches to social and behavior change programming that go beyond educating and informing people on the necessity of care-seeking, such as: prompting plan-making for future care-seeking grounded in more accurate heuristics for when to seek care, implementation intention prompts which help clients to envision and plan for how to overcome potential obstacles to care seeking, reshaping narratives about who might need to seek care, reducing anticipated stigma connected to a health condition to make the prospect of seeking care less frightening, or connecting care-seeking to a positive identity.

Abstract submitted by: 

Emily Zimmerman - ideas42
Lydia Trupe - Breakthrough ACTION Zambia
Peter Chabwela - Breakthrough ACTION Zambia
Rachel Banay - ideas42
Jana Smith - ideas42
Rahin Khandker - ideas42
Madeline Kau - ideas42