The burden of chronic diseases and patients' preference for healthcare services among adult patients suffering from chronic diseases in Bangladesh

Abstract Background Low‐ and middle‐income countries (LMICs) have a disproportionately high burden of chronic diseases, with inequalities in health care access and quality services. This study aimed to assess patients' preferences for healthcare services for chronic disease management among adult patients in Bangladesh. Methods The present analysis was conducted among 10,385 patients suffering from chronic diseases, drawn from the latest Household Income and Expenditure Survey 2016–2017. We used the multinomial logistic regression to investigate the association of chronic comorbid conditions and healthcare service‐related factors with patients' preferences for healthcare services. Results The top four dimensions of patient preference for healthcare services in order of magnitude were quality of treatment (30.3%), short distance to health facility (27.6%), affordability of health care (21.7%) and availability of doctors (11.0%). Patients with heart disease had a 29% significantly lower preference for healthcare affordability than the quality of healthcare services (relative risk ratio [RRR] = 0.71; 0.56–0.90). Patients who received healthcare services from pharmacies or dispensaries were more likely to prefer a short distance to a health facility (RRR = 6.99; 4.80–9.86) or affordability of healthcare services (RRR = 3.13; 2.25–4.36). Patients with comorbid conditions were more likely to prefer healthcare affordability (RRR = 1.39; 1.15–1.68). In addition, patients who received health care from a public facility had 2.93 times higher preference for the availability of medical doctors (RRR = 2.93; 1.70–5.04) than the quality of treatment in the health facility, when compared with private service providers. Conclusions Patient preferences for healthcare services in chronic disease management were significantly associated with the type of disease and its magnitude and characteristics of healthcare providers. Therefore, to enhance service provision and equitable distribution and uptake of health services, policymakers and public health practitioners should consider patient preferences in designing national strategic frameworks for chronic disease management. Patient or Public Contribution Our research team includes four researchers (co‐authors) with chronic diseases who have experience of living or working with people suffering from chronic conditions or diseases.


| BACKGROUND
Chronic diseases have become a global challenge, imposing an enormous economic and health burden on society. 1 Chronic diseases are defined as health conditions lasting 12 months or more, which require ongoing medical intervention and may result in the limitation of activities of daily living. 1 The epidemiological burden of chronic diseases 2 and exposure to their risk factors are increasing worldwide, 3 particularly in low-and middle-income countries (LMICs), such as Bangladesh. [4][5][6] Chronic diseases account for around 41 million deaths each year, representing about 71% of all deaths globally. 7 The most common chronic diseases include cardiovascular diseases (e.g., coronary heart diseases, stroke and peripheral vascular diseases), diabetes, cancers, chronic obstructive pulmonary disease, mental illness and arthritis 7 ; approximately 77% of all yearly deaths are related to chronic diseases occur in LMICs, of which 85% occur in the most productive age groups (30-69 years). 7 It has been estimated that chronic diseases will account for an accumulated global economic loss of 47 trillion US dollars by 2030, approximately 75% of the global gross domestic product. 8 In Bangladesh, an LMIC with a substantial social and economic burden, about 886,000 deaths (i.e., 59% of total deaths) occur due to chronic diseases each year. 3,9 The burden due to chronic diseases has increased in Bangladesh from 43.4% in 2000 to 66.9% in 2015. 3 It is anticipated that chronic diseases will exceed the combined burden of communicable, maternal, perinatal and nutrition-related diseases by 2030 globally, including in Bangladesh. 10,11 Despite the high burden of chronic diseases, Bangladesh, like many LMIC countries, does not have a national integrated chronic diseases management policy, strategy or action plan. 9,11 For instance, the prevalence of undiagnosed chronic diseases is high, and the proportion of unmanaged chronic diseases is even higher in many LMICs, 10 including Bangladesh. 12 This highlights the frequent inadequacies in the diagnosis, prevention and management of chronic diseases among the healthcare systems of LMICs. 9,10 Efforts in chronic disease management in Bangladesh continue to be inadequate. Little attention has been given to addressing the contributing behaviours associated with chronic diseases, including unhealthy dietary patterns, lack of physical activity and exposure to factors potentially detrimental to health such as alcohol, drug and tobacco use. 6 However, it is possible to counteract the rising prevalence of the chronic disease by implementing effective prevention strategies, population-based screening, reduction of risk factors, early detection and appropriate treatments. 10,11 If such actions are not taken, the burden of chronic diseases, which is referred to as an emerging prevalence of chronic diseases globally imposing an enormous economic and health burden will likely continue to rise, 10,11 which is alarming especially among the vulnerable and marginalized populations of Bangladesh with limited affordability for health services. 11 In addition, the emerging prevalence of chronic disease may also lead to a health system burden in terms of increasing healthcare utilization, treatment costs and chronic disease management.
It is well established that chronic diseases are increasingly associated with the over-utilization of healthcare services and a higher financial burden. 13 For example, a previous study documented that a higher number of chronic diseases was linked to an increased number of outpatient visits. 14 Therefore, adequate preventative services must be in place to reduce the social-economic burden of chronic disease, thereby ensuring optimal use of health resources.
However, the major challenges to ensure effective prevention and management of chronic diseases include social status, power gradients, racial/ethnic differences, poor accessibility and affordability of healthcare services. 2,6,[15][16][17] Previous research has identified several factors associated with healthcare utilization, such as demographic and socioeconomic characteristics, type of healthcare providers and presence of chronic illnesses. 18 In addition, patients' preference for healthcare services depends on several factors, including personal preference, disease severity, economic capacity, the reputation of healthcare providers 18 as well as affordable costs associated with treatment. 19 Furthermore, short travel time to healthcare facilities, effective interactions with healthcare providers, 19,20 respectful service provider attitudes 21 and short waiting time 22 were positively associated with the patient preference for healthcare services. A recent discrete choice experiment study found that the availability of medicine and transport to the health facility were significant attributes of patient preference for healthcare services. 23 Notably, optimum healthcare utilization among chronically ill patients has a significant role in preventing and managing chronic diseases.
In Bangladesh, a family spends an average of 11% of their total household budget on health care and half of the population spends 7% of their monthly per capita consumption expenditure on illness. 24 Understanding patients' preferences could help medical professionals and healthcare providers restructure the healthcare delivery model and ensure the quality of services. In addition to clinical guidelines, patients' preferences may also provide guidelines for the selection of treatment options. Patient preferences also help to inform clinical decisions where science has not yet been able to provide effective solutions to healthcare problems. 25 Therefore, information on patients' preferences for healthcare utilization in terms of healthcare expenditure is critical; without this knowledge, an effective national healthcare policy cannot be formulated. 26  In the HIES survey, a semistructured questionnaire (Supporting Information: Appendix Table A1: HIES 2016-2017 Questionnaire) was used to collect information from the survey participants (adults aged 18 years or above) under nine modules: (1) household information, (2) education, (3) health-illnesses and injuries, (4) economic activities and wage employment, (5) nonagricultural enterprises, (6) housing, (7) agriculture, (8) other assets and income and (9) consumption (Supporting Information: Appendix Table A1: HIES 2016-2017 Questionnaire). However, our analysis is based on the chronic disease-related questions included in Module-3: Health (Illnesses and Injuries) of the HIES (Supporting Information: Appendix Table A2). Therefore, we only used the indicators pertaining to chronic disease and health service utilization along with the sociodemographic characterizes of the participants (Supporting Information: Appendix Table A2). All health-related information was self-reported in the HIES. Respondents were asked to prioritize the chronic diseases they were suffering from in order of their importance. We selected the primary disease (i.e., principal diagnosis) based on the patients' experience of diseases in order of their importance. For instance, if one patient was diagnosed with three chronic conditions, they reported three diseases in order of importance (i.e., first, second and third importance). Therefore, a patient's first importance of disease was considered as the primary disease in the present study.

| HIES survey sampling and sample size calculation
where, n was the required sample for allocation to each district to achieve a certain level in the accuracy statistic (r Y ( ̅ ) = 10% relative standard error desired for the mean total household expenditure estimated at the district level associated with the targeted

| Study population
All selected household members were included in the survey. The participants were selected based on the HIES 2016-2017 survey protocol and following the same inclusion criteria: (1) an individual who had suffered from any chronic disease for the last 12 months or more and (2) patients who received any treatment due to chronic disease in the last 30 days. Based on these inclusion criteria, a total of 10,385 patients were selected for the present analysis ( Figure 1).

| Outcome measures
Patients' preference for chronic disease healthcare utilization was the primary outcome measure for this study. Participants responded to questions that asked them about their preference for selecting a healthcare provider: 'why did you choose this provider?' Response options were recoded as the quality of healthcare services, availability of medical doctors (e.g., availability of male or female doctors in a health facility), affordable healthcare services (i.e., acceptable costs), short distance to health facility (i.e., nearby) and others (e.g., referred by other providers).

| Chronic diseases and comorbid conditions
Participants were asked about chronic illness, 'have you suffered from any chronic illness/disability in the last 12 months or more?' The prevalence of chronic diseases was assessed based on this question.
Individuals who suffered from chronic disease for the last 12 months (or more) and received any treatment due to chronic diseases were the only population considered in this study. The study population was diagnosed with chronic illnesses and conditions such as chronic heart disease, respiratory diseases, chronic gastric or ulcers, high blood pressure, arthritis or rheumatism, diabetes, chronic fever and other diseases. There is no gold-standard method for measuring comorbidity status among patients with chronic diseases. 28 A previous review study identified that 21 separate approaches were executed to measure comorbidity status. 28 The selection of the approach depends on the study research questions, study design, data availability and population studied. The most straightforward approach to measuring comorbidity status is to investigate the distribution of individual comorbid conditions and to treat them independently and/or to combine them by summing the total number of conditions. 29,30 A single condition count approach was performed to measure comorbidity status in this study. The count of chronic health condition(s) was measured for each patient based on the number of disease exposures and who had been prescribed medication for their illness. It was counted as multiple responses if the patients had multiple chronic conditions. In addition, the principal diagnosis was defined based on patients diagnosed based on their reported first importance. Chronic comorbid conditions (principal diagnosis plus one, two or three or more comorbid conditions) were assessed in this study.

| Covariates
Based on the ongoing literature and the authors' own expertise, we selected variables to address the study objective, including healthcare service-related factors (e.g., type of healthcare service-inpatient or outpatient, type of health facilities, waiting time for receiving healthcare services, out-of-pocket payment and location of consulted healthcare provider) and patients' sociodemographics factors (e.g., gender, age, marital status, education and employment) (Supporting Information: Appendix Table A2).

| STATISTICAL ANALYSIS
The adjusted multinomial logistic regression model was used to identify the potential factors that had an association with the patient's preference for healthcare service. The dependent variable (chronic illness patient's preference for healthcare services) was characterized as a categorical measure in the regression model. An unadjusted analysis was performed using each of the explanatory variables for the following reasons: (1) primary screening of the selection of qualified variables, which were added in the adjusted model, (2) the χ 2 tests (or one-way analysis where appropriate) were used to find the association between outcome and explanatory variables. However, the majority of the explanatory variables were categorical with two or more labels; therefore, an unadjusted analysis was performed to find the association between the outcome variable and different categories of explanatory variables. The explanatory variables were included in the adjusted model only if any label of the predictor was significant at a 5% or less risk level in the unadjusted model, which in turn was used to adjust for the associations of other potential confounders. For the explanatory variables, the category found to be least at risk of having patients' preferences for healthcare services related to chronic illness in the analysis was considered the reference category for constructing the relative risk ratio (RRR).
Statistical significance was considered at a 5% risk level. All data analyses were undertaken using the statistical software Stata/SE 14 (StataCorp). Table 1 shows the participant's characteristics. Of the 10,385 patients with chronic diseases, approximately 50% were female, 51% were married and 70% were unemployed. The majority of the patients were aged between 18 and 45 (81%) years, and around onethird (37%) had no formal education.

| The distribution of chronic disease and utilization of healthcare services
The most prevalent chronic diseases reported by the patients included gastric/ulcer (16%) followed by arthritis/rheumatism (14%) ( Table 1)

| Preferences for healthcare services for chronic illnesses
Approximately 30% of patients reported that they preferred quality healthcare services, whereas 28% preferred a short distance to the health facility. Furthermore, 22% of the patients preferred affordable healthcare costs as the main driver, and 11% expressed a preference for the doctor's availability. However, the scenario varied among different chronic illnesses and healthcare services ( Table 1). For example, among the patients who received healthcare services from a pharmacy or dispensary, 49% preferred short distances to health facilities, and 32% reported their preference for healthcare affordability.
6.3 | Correlates of patient preference for chronic disease-related healthcare services

| DISCUSSION
Chronic diseases among adults are becoming a significant health concern in many LMICs, including Bangladesh. This is the first study to focus on patient preferences for healthcare services for chronic disease management, using a recent nationally representative HIES. This study showed that patients with heart disease were more likely to prefer quality health care than healthcare affordability or a short distance to a health facility. This is in agreement with previous studies, which have also documented that chronic heart disease patients are more likely to prefer quality healthcare services. [31][32][33] Several attributes might influence a patient's preference for quality healthcare services. For instance, heart disease may be associated with both acute episodes and high levels of long-term adverse events (e.g., mortality and disability). 34 In the present study, one of the most influential aspects of a patient's healthcare-seeking behaviour was the healthcare provider's location; the shorter the distance to the healthcare facility the more likely the patient uptake of the healthcare services. It is plausible that patients may be unwilling or unable to travel long distances to access medical expertise or treatment, particularly if the nature of the chronic illness requires frequent appointments.
This finding is supported by previous studies which reported that distance to healthcare facilities was a potential barrier to accessing healthcare services in LMICs. 44 Although this is the first study to investigate patient preference for healthcare services to manage chronic diseases among adults in Bangladesh, the extension and transferability of our findings to contexts beyond the study population should be handled with caution because of our study limitations. For instance, due to the cross-sectional nature of the study, causality cannot be inferred.
Furthermore, these findings may be subjected to some level of bias as data on the main variables of interest were self-reported (i.e., illness, utilization and expenditure), thereby risking recall bias. However, the relatively short recall period (i.e., the last 30 days) of the household income and expenditure survey strives to reduce this potential bias.

| Implications for policy and practice
Our study highlights the significance of patient preferences for healthcare utilization. This study provides timely findings to address health inequities linked to sociocultural and economic factors in Bangladesh. Understanding patients' preferences in chronic disease management is critical to achieving the Sustainable Development Goal (SDG) target 3.4, which focuses solely on reducing premature mortality from noncommunicable diseases by a third by 2030 relative when compared to 2015 as a baseline. Bangladesh is a signatory to the SDGs and the Colombo declaration (strengthening health systems to accelerate delivery of NCD-related services at the primary healthcare level), 48 providing evidence that informs culturally competent NCD prevention and treatment approaches through tailored and responsive health financing, and expenditure policies will contribute significantly to achieving the SDG target 3.4.
However, progress in implementing strategies to meet international targets related to NCDs remains slow. 9,11,49 Additionally, Bangladesh lacks a national surveillance programme focused on chronic diseases and does not have any integrated community public health programme that regularly monitors chronic diseases. 11 An established disease management plan should consider the adequacy, accessibility, affordability and quality of services. 48 Most importantly, the factors influencing patient preferences for healthcare services may not have been considered when developing the chronic disease management policy. 11 Therefore, policymakers and public health practitioners should consider patient preferences regarding healthcare utilization in managing chronic diseases.

| CONCLUSION
Our study findings highlighted that patient preferences for healthcare services in chronic disease management were significantly associated with disease severity and healthcare providers' attributes. Therefore, policymakers and public health practitioners should consider patient preferences for managing chronic conditions within the national strategic frameworks to improve service provision, equitable distribution and uptake of the services.