Comparing Patient Related Factors Associated With Choice Of Cancer Treatment Centre, Locally In Kenya Or Abroad: A Case Control Study

Abstract

Background Medical tourism is an emerging and growing industry globally. In Kenya, medical tourism is characterized by patients seeking treatment abroad for non-communicable diseases, such as cancer. Further, it is associated with significant loss of foreign exchange and introduction of multidrug resistant microorganisms by the returning patients. The factors that influence patients to choose treatment centres locally or abroad and their perceptions on quality of care (QOC) they receive have not been adequately researched and documented. There is need to determine these factors and contribute to the body of knowledge that will assist the health sector become responsive to the increasing burden of noncommunicable diseases. Further, the additional knowledge may be used to position the Country to be a regional hub for medical tourism as is envisioned in the Vision 2030 goals. This study will use the case of cancer to generate the required information. Study Objective: To compare the patient related factors and perceptions on quality of care experienced associated with choice of cancer treatment centre, in Kenya or abroad. Methods A case control study on randomly sampled 254 cancer patients. The cases were patients who chose to receive treatment abroad while controls were those who received treatment at the Kenyatta National Hospital Cancer Treatment Centre (KNH) or Texas Cancer treatment Centre (TCC). A researcher administered questionnaires were populated with quantitative data elements focusing on sociodemographic, probable influencing factors and components of QOC. Data collection was conducted using face-to-face and phone interviews. Thereafter analysis was done using SPSS Software Version 21. Descriptive statistics were obtained using frequency distribution. Bivariate analysis was carried out on independent variables such as socio-demographic characteristics, co-morbidities, potentially influencing factors and perceptions on QOC to determine level of significance. Multiple logistic regression analysis was performed on the variables that demonstrated significance to determine strength of association. Statistical test was performed at 5% (P< 0.05.) level of significance. Results Our study randomly sampled 254 study subjects seeking treatment for various types of cancer in Kenya or abroad; 174 (68.5%) were treated in KNH and TCC, while 80 (31.5%) abroad. The latter respondents all received cancer care in India. The mean age of the patients was 50 years, 65.7% were female. The commonest cancers were from the reproductive system (49.6%) and gastrointestinal tract (18.1%). Majority of patients received chemotherapy (87.0%), while others underwent radiotherapy (28%) and surgery (21.0%). The study WANGAI M.W W61/88242/2016 xi

revealed that treatment was financed from the National Hospital Insurance Fund (NHIF) (57.3%) or out-of-pocket household finances (42.7%), with was no significant difference between the cases and controls. Logistic regression models revealed that when controlling for other factors, the odds for seeking treatment abroad was 39 times higher for respondents with monthly incomes of higher than KES 25,000/= (p <0.0001, 95% Confidence Interval (CI) 7.5-201.3). Further, every additional month from diagnosis was associated with increased likelihood of seeking treatment in India by 1.16 times; p= 0.005, 95% CI 1.046- 1.28. Other key significant factors that influenced treatment in India were advice from health care providers (p<0.0001, OR 66.2, 95% CI 8-553), opinion of friends or relatives (p=0.008, OR 42, 95% CI 7-249) and anticipation for better quality of care at chosen facility (p=0.009, OR 22.5, 95% CI 2.2-230.6). On the other hand independent predictors for not selecting India were inadequate cancer services at initial health facilities (OR=99%, 95% CI 88.4- 99.9%), and general perception that the country’s reputation (OR=93.5%, 95% CI 51.6-99.1%). Perception of quality of health care respondents received at their chosen treatment centre was generally rated as ‘good’or ‘very good’ irrespective of their country of choice. When we adjusted for other components of QOC we found that respondents were more likely to prefer Indian health facilities with respect to the caring attitude of health workers, OR 8.3 times (95% CI 2.3-30.3). Conversely, with regard to timeliness of service and cleanliness of the health facilities respondents were less likely to have chosen India; OR 27.8% (95% CI 0.13-0.59) and 34.8% (95% CI 0.16-0.77) respectively. Conclusion The reason cancer patients seek treatment abroad are multifactorial. The commonest destination is India. Key factors include access to finances, inadequate treatment facilities, perception of quality of care and advice from friends, relatives and healthcare providers. These influencing factors are similar to those demonstrated in other studies, however unlike other studies online information, opportunity for sightseeing and marketing were not found to influence our respondents. Interestingly although cost of treatment was an important factor for respondents treated in both countries, it was not a signifant influencing factor for outward bound medical tourism. This too was unlike other studies based in developed countries. The Kenyan health sector will need to address these influencing factors to reverse outward bound medical tourism and develop the country into a regional hub for medical tourism for patients suffering from cancer.