title: The Relationship between Poverty and Healthcare Seeking among Patients Hospitalized with Acute Febrile Illnesses in Chittagong, Bangladesh.
abstract: Delays in seeking appropriate healthcare can increase the case fatality of acute febrile illnesses, and circuitous routes of care-seeking can have a catastrophic financial impact upon patients in low-income settings. To investigate the relationship between poverty and pre-hospital delays for patients with acute febrile illnesses, we recruited a cross-sectional, convenience sample of 527 acutely ill adults and children aged over 6 months, with a documented fever ≥38.0 °C and symptoms of up to 14 days' duration, presenting to a tertiary referral hospital in Chittagong, Bangladesh, over the course of one year from September 2011 to September 2012. Participants were classified according to the socioeconomic status of their households, defined by the Oxford Poverty and Human Development Initiative's multidimensional poverty index (MPI). 51% of participants were classified as multidimensionally poor (MPI>0.33). Median time from onset of any symptoms to arrival at hospital was 22 hours longer for MPI poor adults compared to non-poor adults (123 vs. 101 hours) rising to a difference of 26 hours with adjustment in a multivariate regression model (95% confidence interval 7 to 46 hours; P = 0.009). There was no difference in delays for children from poor and non-poor households (97 vs. 119 hours; P = 0.394). Case fatality was 5.9% vs. 0.8% in poor and non-poor individuals respectively (P = 0.001)-5.1% vs. 0.0% for poor and non-poor adults (P = 0.010) and 6.4% vs. 1.8% for poor and non-poor children (P = 0.083). Deaths were attributed to central nervous system infection (11), malaria (3), urinary tract infection (2), gastrointestinal infection (1) and undifferentiated sepsis (1). Both poor and non-poor households relied predominantly upon the (often informal) private sector for medical advice before reaching the referral hospital, but MPI poor participants were less likely to have consulted a qualified doctor. Poor participants were more likely to attribute delays in decision-making and travel to a lack of money (P<0.001), and more likely to face catastrophic expenditure of more than 25% of monthly household income (P<0.001). We conclude that multidimensional poverty is associated with greater pre-hospital delays and expenditure in this setting. Closer links between health and development agendas could address these consequences of poverty and streamline access to adequate healthcare.
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.|University College, University of Oxford, Oxford, United Kingdom.
authors.forename: M Trent
authors.initials: MT
authors.lastname: Herdman
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.|Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom.
authors.forename: Richard James
authors.initials: RJ
authors.lastname: Maude
authors.affiliation: Chittagong Medical College Hospital, Chittagong, Bangladesh.
authors.forename: Md Safiqul
authors.initials: MS
authors.lastname: Chowdhury
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.|Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Northern Territory, Australia.
authors.forename: Hugh W F
authors.initials: HW
authors.lastname: Kingston
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
authors.forename: Atthanee
authors.initials: A
authors.lastname: Jeeyapant
authors.affiliation: Chittagong Medical College Hospital, Chittagong, Bangladesh.
authors.forename: Rasheda
authors.initials: R
authors.lastname: Samad
authors.affiliation: Chittagong Medical College Hospital, Chittagong, Bangladesh.
authors.forename: Rezaul
authors.initials: R
authors.lastname: Karim
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.|Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom.
authors.forename: Arjen M
authors.initials: AM
authors.lastname: Dondorp
authors.affiliation: Chittagong Medical College Hospital, Chittagong, Bangladesh.
authors.forename: Md Amir
authors.initials: MA
authors.lastname: Hossain
mesh_terms: D000293:Adolescent; D000328:Adult; D001459:Bangladesh / Q000453:epidemiology; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D005260:Female; D005334:Fever / Q000175:diagnosis* / Q000191:economics / Q000453:epidemiology / Q000523:psychology*; D015438:Health Behavior; D005102:Health Expenditures; D000066505:Help-Seeking Behavior; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care; D011203:Poverty; D012923:Social Class; D012959:Socioeconomic Factors; D055815:Young Adult