Health seeking for chronic lung disease in central Malawi: Adapting existing models using insights from a qualitative study

Background
Chronic lung diseases contribute to the growing non-communicable disease (NCD) burden and are increasing, particularly in many low and middle-income countries (LMIC) in sub-Saharan African. Early engagement with health systems in chronic lung disease management is critical to maintain quality of life and prevent further damage. Our study sought to understand health seeking behaviour in relation to chronic lung disease and TB in a rural district in Malawi.
Methods
Qualitative data was collected between March-May 2015, exploring patterns of health seeking for lung disease amongst residents of two districts in rural Malawi. Participants included those with and without lung disease, health workers and village leaders. Participants with a history of TB were included in the sample due to similarities in clinical presentation and in view of potential to cause long-term damage to lung tissue.
Results
Our findings are ordered around a specific model of health seeking devised by adapting previous models. The model and findings span three broad areas that were found to influence health seeking: understandings of health and disease which shaped whether, when and where to seek care; the care seeking decision which was influenced by social and structural factors; and the care seeking experience which impacted future care decisions creating ‘feedback loops’.
Discussion
Efforts to improve effective and accessible healthcare provision for chronic lung disease need to address all the determinants of health seeking behaviour identified. This may include: enhancing the structural and financial accessibility of health services, through the strengthening of community linkages; improving communication between formal health providers, patients and communities around symptoms, diagnosis and management of chronic lung diseases; and improving the quality of diagnostic and management services through the strengthening of health systems ‘hardware’ (equipment availability) and ‘software’ (development of trusting and respectful relationships between providers and patients).

背景
慢性肺部疾病正在加剧非传染性疾病（non-communicable disease, NCD）的负担，且患病率持续攀升，在撒哈拉以南非洲的众多低收入和中等收入国家（low and middle-income countries, LMIC）中尤为显著。在慢性肺部疾病管理中尽早对接医疗体系，对维持患者生活质量、阻止病情进一步恶化至关重要。本研究旨在探究马拉维某农村地区居民针对慢性肺部疾病与肺结核（Tuberculosis, TB）的就医行为。

方法
本研究于2015年3月至5月期间收集定性数据，旨在探究马拉维农村地区两个区县居民针对肺部疾病的就医行为模式。研究对象涵盖肺部疾病患者、健康个体、医疗卫生工作者以及村社领袖。鉴于肺结核（TB）与肺部疾病临床表现相似，且肺结核可对肺组织造成长期损伤，因此有肺结核病史的人群也被纳入研究样本。

结果
本研究结果围绕经改良既往模型构建的专属就医行为模型展开阐述。该模型及研究结果涵盖了三大影响就医行为的核心维度：一是对健康与疾病的认知，这决定了患者是否就医、何时就医以及前往何处就医；二是就医决策过程，该过程受社会与结构因素的影响；三是就医体验，其会对后续就医决策产生影响并形成“反馈循环”。

讨论
若要改善慢性肺部疾病的高效可及医疗服务供给，需针对已明确的所有就医行为影响因素采取干预措施。具体举措可包括：通过强化社区联动，提升医疗服务的结构可及性与经济可及性；优化正规医疗卫生服务提供者、患者与社区之间关于慢性肺部疾病症状、诊断及管理的沟通交流；并通过强化医疗体系的“硬件”（设备配置）与“软件”（构建医护人员与患者之间互信尊重的医患关系），提升诊断与治疗服务的质量。