Patient Utilization of Primary Healthcare Services for Cardiovascular Disease in Resource-Limited Settings in Nepal: A Mixed Methods Study

Abstract

BACKGROUND: Cardiovascular disease (CVD) is the greatest killer of mankind. In Nepal, a small, landlocked country in South Asia and one of the poorest countries in the world, the burden of cardiovascular disease is high; national CVD monitoring has substantial gaps; and CVD risk factors are poorly controlled. Primary healthcare (PHC) is often at the front lines of prevention and control of CVD. Thus, strengthening local and national primary healthcare systems is an essential step toward prevention and management of CVD in low- and middle-income countries (LMICs). To inform further research and policy development, we conducted an exploratory, mixed-methods study to understand patient-side utilization of CVD services in rural and urban areas in Nepal.

METHODS: We surveyed 114 CVD patients from 10 PHC facilities across two regions of Nepal. Survey contents included sociodemographic information, disease history, and data on accessibility, affordability, availability, and utilization of PHC services. We further completed 20 in-depth interviews within our sample to understand patient-side perceptions of CVD-related PHC care.

RESULTS: In the final cohort, 23% had experienced a stroke, 26% had some form of existing heart disease, 76% presented with hypertension, and 67% had diabetes. For all conditions, hospitals were a more common place of diagnosis than PHC facilities. The mean visitation frequency to PHC facilities in the past year was 10.7 times, with healthier patients having higher visitation rates than those with poorer health. 69% of patients reported difficulty obtaining CVD medicine from their local PHC facility. Qualitative data revealed that PHC facilities lacked resources for diagnosing and managing CVD conditions. Additionally, behavior of physicians and affordability were both considered important components of PHC satisfaction. Patient recommendations included increased diagnostic equipment in PHC facilities, free essential medicines, and community awareness initiatives for cardiovascular disease.

CONCLUSION: There are clear shortcomings between national aims and objectives – such as free essential medicines and universal PHC services – and the reality faced by CVD patients in resource-limited settings in Nepal. Despite PHC facilities generally being close to patients, participants reported inadequate resources when seeking care for CVD and expressed a strong desire that such services could be provided locally. Based on the challenges articulated by CVD patients in our study, mhealth may be a relevant direction of future research for connecting hospital-based specialists to CVD patients in rural areas, improving follow-up, and decreasing expensive visits to far away tertiary care centers. Overall, we recommend increased national CVD monitoring, prioritization of NCDs and CVDs in national policymaking and strategizing, and continued provision of PHC facilities close to patients in their communities.

Keywords: primary care, cardiovascular, utilization, Nepal, public healthcare facilities

DEDICATION