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Worldwide, the issue of adequate access to healthcare services is a policy concern. This is especially the case for those living in rural areas of developing countries, who seem to have limited access to healthcare services.(2) In most African countries, unsatisfactory access to healthcare is as a result of various factors, notably the distance people have to travel and the time they have to spend waiting before they can be served, which have a huge influence on the way people respond to the healthcare system.(3) Another issue of great concern is the attitudes of healthcare workers, which seem to scare patients away, thereby complicating the health problems that already exist in many parts of the developing world.
This paper seeks to highlight the problems caused by distance, time and healthcare workers’ attitudes towards patients as far as access to healthcare is concerned. The paper discusses the profiles and demographics of people who are most affected and examines how these factors impact their lives in relation to healthcare access. The paper concludes by discussing possible ways in which the spatial and temporal problems that hinder access to healthcare can be overcome. In addition, possible ways in which healthcare workers can improve their relationships with patients are explored.
The factors of distance, time and healthcare worker attitudes
The issue of distance as a detriment to people’s access to healthcare services has been well documented. People in the developing world are the main victims of the extreme spatial disparities between people’s homes and healthcare services due to low life standards that make it difficult for many to go to health centres. According to UNICEF“[s]ome regions of the world have more dire situations than others, but even within one country there can be broad disparities – between city and rural children, for example ... Women who must walk long distances to fetch household water may not be able to fully attend to their children, which may affect their health and development.”(4) Many people have lost their lives due to the long distances they have to cover before they reach their nearest health centre. According to Schoeps et al., “[t]he mortality risk clearly increases with increasing distance.”(5) In Sub-Saharan Africa, some heavily pregnant women have died while others have lost their unborn children due to walking long inhospitable roads, unassisted.(6)
The issue of timeliness is critical in ensuring that people develop an appropriate health-seeking behaviour. “Long waiting times to obtain healthcare services can frustrate people and result in negative perceptions of their service providers,” observes Dye.(7) It has been discovered that in many countries in Africa, the nurse-patient ratio is highly uneven, which, in turn, forces nurses to serve unfairly large numbers of patients. Even in rich countries such as the United States of America (USA), the greatest shortages of healthcare workers are found in remote rural communities with fewer than 10,000 people, where the doctor-patient ratio has remained static since the 1940s, while the ratio improved significantly in the urban areas.(8) The uneven ratio compromises the time spent with each patient and the healthcare practitioner’s effectiveness in addressing patients’ needs.
Coupled with the issue of time and distance, many patients are faced with unwelcoming healthcare workers who do very little to make patients feel welcome, fuelling levels of patient dissatisfaction.(9) In a study conducted in Uganda, it was discovered that patients had a negative attitude towards seeking healthcare in public facilities because health workers tend to turn away poor women who cannot afford soap, clothes and simple gloves. The only other option is to seek maternity care at private clinics,(10) which is unaffordable to the majority of people in the developing world. Studies have shown that patient satisfaction is crucial to healthcare as it influences whether a person will seek medical advice, complies with treatments and maintains a relationship with the provider/health facility.(11)
Demographic profiles of people who are at the receiving end
As shown above, people who are poor people and live in the rural areas in most countries in the Sub-Saharan region, walk many kilometres to and from healthcare centres. Numerous studies have shown that the inaccessibility of roads and erratic transport systems contribute tremendously to sidelining poor, rural people who want to access healthcare services. In a study conducted in Burkina Faso, for patients living a distance of about 6 walking hours from their healthcare facility, an approximately doubled mortality risk was found for people of all ages when compared with people who live closer.(12) The widely recommended maximum time to access healthcare is 30 minutes.(13) Within the poor, rural population, in countries such as Lesotho, herd boys spend close to 6 months tending animals away from home, with the nearest hospital or health centre being a minimum of 50 kilometres away - on foot or on horseback.(14) Similarly at risk are long distance truck drivers who spend much of their time on the road and hardly have time for regular medical check-ups.(15)
Walking for several hours on winding, steep and slippery paths is a daunting task to many patients - especially heavily pregnant women who run a high risk of miscarriage.(16) Thousands of children and pregnant women in many Sub-Saharan African countries have succumbed to diseases that are preventable in other countries as a result of the distances they travel to access healthcare services. There are numerous studies that have been conducted in Sub-Saharan Africa showing that there is a clear correlation between high infant mortality rates for under-fives and long distances to healthcare services. In one such study, researchers investigated the relationship between distance to health facilities measured as continuous travel time, and mortality among infants and children younger than five years of age in rural Burkina Faso, an area with low health facility density. Of 24,555 children born between 1993 and 2005 in the Nouna Health and Demographic Surveillance System,(17) it was observed that 3,426 childhood deaths were recorded as a result of increasing travel time, demonstrating that walking distance was significantly related to both infant and child mortality.(18) The situation is even more serious for thousands of orphans and vulnerable children (OVC) who are sick and have no one to make sure that they attend regular medical check-ups.(19) Due to depleted social fabric, more and more OVCs are being exposed to precarious life situations.
People with disability who live in the rural areas are also victims of long distances to healthcare. Restricted movement coupled with slow, erratic or non-existent public transportation systems complicates access for many disabled people.(20) In addition to this, vulnerable people who live in the mountainous parts of a country normally cannot access healthcare due to seasonal disasters, such as heavy snowfall and heavy rains where roads are washed away making movement very difficult.
What needs to be done
There is a dire need for comprehensive primary healthcare services in order to address the issue of patients who are struggling to access healthcare. One such programme for the short term is the introduction of mobile clinics in order to reach the most remote areas. Outreach programmes where doctors and nurses can travel by car to these communities on a regular basis in order to reach patients could allow people to access healthcare in the comfort of their surroundings where familiar people are around. It has been found that independence and familiarity with friends and community are important to consider in the healing process of any patient.(21)
In the long term, there is a need to map and set boundaries with relation to healthcare delivery and outcomes. This will help in the allocation of resources and in formulating health policies.(22) This method should also be used in assessing the redistribution of healthcare workers to the neediest areas of any country. However, redistribution needs to be done bearing in mind the health providers’ welfare and professional needs. In the USA, Medically Underserved Areas (MUAs) and Medically Underserved Populations (MUPs) projects have been created in order to encourage building of community health centres. These MUAs and MUPs receive higher rates of Medicare and Medicaid reimbursable services as a way of incentivising healthcare workers and addressing the uneven distribution of healthcare.(23)
Another strategy that has been used to address issues of health in a quick way is the introduction of telehealth. Telehealth is defined as a resource that relies on technology to provide services, education, and medical consultations.(24) Telehealth is defined as the use of electronic information and telecommunications technologies to support long-distance clinic healthcare, patient and professional health-related education, and public health and health administration. Technologies include video conferencing, the internet, store-and-forward imaging, streaming media and terrestrial and wireless communications.(25) It may be as basic as two health professionals discussing a case over the telephone or as sophisticated as doing robotic surgery between facilities at different ends of the world.
In rich countries with advanced telecommunication systems, telehealth is reported to have gained acceptance as a quick, easy method of offering timely healthcare, “particularly for preventive, public health, and chronic care.”(26) Due to geographic inaccessibility of health services in Lesotho, in May 2010, the Elizabeth Glaser Paediatric Aids Foundation (EGPAF) launched a strategy to reduce HIV test turnaround time, by speeding transfer of test results to health facilities to facilitate early initiation of infants on ART.(27) EGPAF supported Lesotho’s Ministry of Health and Social Welfare at the district level by supplying district clinical coordinators (DCC) with laptops and 3G mobile internet technology. DCCs were trained on the use of the devices and test result confidentiality issues and were provided with printers to print DNA PCR results in their respective districts.(28) As a result of this strategy, the percentage of HIV-positive children initiated on ART increased significantly from 2% in the second quarter of 2010 (when 3G technology was introduced) to 22% in the fourth quarter of 2010.(29) The use of 3G cut down the average test result turnaround time from 12 weeks to 4 weeks.(30)
It has been discovered in various similar studies conducted around the world that one of the ways in which healthcare workers’ negative attitudes towards patients can change is through actively involving the patients in the decision making of the healing process. The traditional role, in which a nurse, nursing assistant or physician exercises absolute power in deciding what is good or bad for the patient, has been found to perpetuate negative attitudes towards patients.(31) According to Longtin et al, “... patients can be persuasive and substantially modify behaviour of healthcare workers.”(32) According to Longtin, in one observational study of more than 500 visits to 45 physicians, patients who requested a prescription were almost three times more likely to be prescribed a new medication compared to those who did not. Similarly, those who requested a specialty referral had more than four times the odds of receiving a referral. In a randomised trial of patients with major depression, 76% of those who requested an antidepressant received a prescription compared with only 31% of those who did not.(33) Thus, it is imperative for patients to be given room to air their views.
High levels of education for healthcare workers have also been found to change negative attitudes of healthcare workers towards patients. In one study conducted in the Republic of Ireland, “...study to a higher level at university appears to mitigate towards holding more positive attitudes...”(34) towards patients by the healthcare workers. In a similar study conducted in Nigeria, it was discovered that respondents' level of knowledge and attitude towards patients was influenced by the level of formal education attained, length of practice, gender and attendance at refresher courses.(35) Of the 254 randomly selected nurses in Nigeria, large percentages of the nurses, held negative attitudes towards HIV-positive patients with over 30% of them believing that the patients deserve to suffer, while 55.9% of the nurses believed that the HIV positive patients brought the disease upon themselves, and these attitudes were attributed to low or moderate levels of education.(36) Healthcare workers can be educated to improve relationships with patients.(37) Longtin (2010: 53) adds, “Medical students,... specialized educators,... and physicians who have completed their training in general medicine, gynecology, oncology, and pediatrics were all able to improve their attitudes with respect to patient participation through structured training sessions.”(38) Furthermore, the benefits of training persisted for up to 10 years.(39)
As seen in the discussion, time and distance barriers to care and negative attitudes of healthcare workers towards patients have adverse implications in the way majority people across the world respond to healthcare, which can lead to considerable health disparities.(40) Thus, there is a need for all-inclusive approaches to be employed by both health policy-makers and healthcare providers when rolling out healthcare programmes. A myriad of healthcare problems facing many people around the world, especially in Africa, can be halved or even eradicated if issues of distance and timeliness, as well as healthcare worker attitudes, are addressed using practical and appealing strategies.
Written by Malefetsane Soai (1)
(1) Contact Malefetsane Soai through Consultancy Africa Intelligence’s Public Health Unit (firstname.lastname@example.org).
(2) Peters, K.E. and Gupta, S., ‘Geographic barriers to healthcare’,Encyclopaedia of Health Services Research, http://www.whatisencyclopedia.com.
(4) ‘Millennium Development Goals: Eradicate extreme poverty and hunger’, UNICEF, http://www.unicef.org.
(5) Schoeps, A., et al., 2011. The effect of distance to health-care facilities on childhood mortality in rural Burkina Faso. American Journal of Epidemiology, 173(5), pp. 492-498, http://aje.oxfordjournals.org.
(6) ‘Bwindi’s waiting mother’s hostel – the story of Turyakira’, Stars Foundation, http://www.starsfoundation.org.uk.
(7) Dye, F., ‘Factors that affect customer satisfaction in healthcare’ eHow,, http://www.ehow.com.
(8) Peters, K.E. and Gupta, S., ‘Geographic barriers to healthcare’,Encyclopaedia of Health Services Research, http://www.whatisencyclopedia.com.
(10) Kiguli, L., et al., 2009. Increasing access to quality health care for the poor: Community perceptions on quality care in Uganda. Patient Preference and Adherence, 3, pp. 77-85, http://www.ncbi.nlm.nih.gov.
(12) Schoeps, A., et al., 2011. The effect of distance to health-care facilities on childhood mortality in rural Burkina Faso. American Journal of Epidemiology, 173(5), pp. 492-498, http://aje.oxfordjournals.org.
(13) Peters, K.E. and Gupta, S., ‘Geographic barriers to healthcare’,Encyclopaedia of Health Services Research, http://www.whatisencyclopedia.com.
(14) Stephen, T., ‘Livelihoods in Lesotho’, Care Lesotho, 5 April 2001, http://sarpn.octoplus.co.za.
(15) Solomon, A.J., et al., 2004. Healthcare and the long haul: Long distance truck drivers - a medically underserved population. American Journal of Industrial Medicine, 46(5), pp. 463-71, http://www.ncbi.nlm.nih.gov.
(16) ‘Bwindi’s waiting mother’s hostel – the story of Turyakira’, Stars Foundation, http://www.starsfoundation.org.uk.
(18) Schoeps, A., et al., 2011. The effect of distance to health-care facilities on childhood mortality in rural Burkina Faso. American Journal of Epidemiology, 173(5), pp.492-498, http://aje.oxfordjournals.org.
(19) ‘Millennium Development Goals: Eradicate extreme poverty and hunger’, UNICEF, http://www.unicef.org.
(20) Peters, K.E. and Gupta, S., ‘Geographic barriers to healthcare’,Encyclopaedia of Health Services Research, http://www.whatisencyclopedia.com.
(21) ‘How to Care: Long-Distance Caregiving’, How to Care, http://www.howtocare.com.
(22) Peters, K.E. and Gupta, S., ‘Geographic barriers to healthcare’,Encyclopaedia of Health Services Research, http://www.whatisencyclopedia.com.
(25) ‘Health resources and services administration - rural health’, Telehealth, US Department of Health and Human Services.
(26) Peters, K.E. and Gupta, S., ‘Geographic barriers to healthcare’,Encyclopaedia of Health Services Research, http://www.whatisencyclopedia.com.
(27) Oyebanyi, O., et al., ‘Using 3G mobile internet technology to enhance early initiation of children on ART in rural settings of Lesotho’, http://www.pedaids.org.
(31) Longtin, Y. et al., 2010. Patient participation: Current knowledge and applicability to patient safety. Mayo Clinic Proceedings, 85 (1), pp 53-62, http://www.ncbi.nlm.nih.gov.
(34) Doherty, M. et al., 2011. Attitudes of Healthcare Workers towards older people in a rural population: A survey using the Kogan Style. Nursing Research and Practice, 2011, http://www.hindawi.com
(35) Adebajo, S.B. et al. 2003. Attitudes of healthcare providers to persons living with HIV/AIDS in Lagos State, Nigeria. African Journal on Reproduction Health, 7, pp. 103-112.
(37) Longtin, Y. et al., 2010. Patient participation: Current knowledge and applicability to patient safety. Mayo Clinic Proceedings, 85 (1), pp 53-62, http://www.ncbi.nlm.nih.gov.
(40) Peters, K.E. and Gupta, S., ‘Geographic barriers to healthcare’,Encyclopaedia of Health Services Research, http://www.whatisencyclopedia.com.