Inpatient healthcare provider bypassing by women and their children in urban Bo, Sierra Leone

Introduction Bypassing refers to a person's decision to seek care at a healthcare facility that is not the nearest one of its type to the person's home. Methods This study examined inpatient care facility bypassing in urban Bo, Sierra Leone using data from 1,980 women with children 15 years of age and younger who were interviewed in 2010-2011. The locations of residential structures and hospitals were identified using a geographic information system (GIS), and the road distances from participating households to the nearest and preferred inpatient care facilities were measured. Results Nine inpatient care facilities serve Bo residents, but more than 70% of the participating women reported that the city's main public hospital (Bo Government Hospital), located in the city center, was their preferred inpatient care provider. Participants resided within a median distance of 0.9 km (Interquartile range (IQR): 0.6, 1.8) from their closest inpatient facility, but they would travel a median distance of 2.4 km (IQR: 1.0, 3.3) to reach their preferred providers. About 87% of the women would bypass their nearest inpatient care facility to access care at a preferred provider. Bypassing rates were similar for various demographic and socioeconomic groups, but higher for women living farther from the city center. Conclusion Although Bo has a diverse healthcare marketplace, access to affordable advanced care options is limited. Most women in Bo would choose to bypass facilities nearer to their homes to seek the low-cost and comprehensive care offered by Bo Government Hospital.


Introduction
Healthcare Bypassing refers to a person's choice to seek care from health facilities that are located farther from their homes rather than nearby options [1,2]. The healthcare facility bypassing literature seeks to understand the reasons behind this choice. The considerations involved in a decision to bypass may include: the perceived severity of illness [2][3][4]; the number of beds at the healthcare facility nearest to a person's home [1,5,6]; the range of services provided at the facility [7,8]; satisfaction with the care provided by the facility during previous visits [1,9]; as well as individual characteristics such as age [1,9], education [1,5], marital status [1], income [9, 10], and insurance status [3,4,10].
Studies examining the factors associated with bypassing have been conducted almost exclusively in high-income countries or in rural areas of low-and middle-income countries (LMICs) [11]. Few studies have focused on bypassing behaviors in urban areas of LMICs. A study from Chad found significant differences in bypassing of primary care services in rural versus urban areas [10]. In urban areas, the search for high quality services was a key factor in bypassing, and individuals with high socioeconomic status were most likely to bypass [10]. A study from Sri Lanka examined the bypassing phenomenon in both rural and urban areas, but only reported results at the aggregate level [2]. Bypassing was common among those who perceived their illness to be severe and were searching for a higher quality of care for their condition [2]. There is a need for more studies on the factors that influence provider selection and bypassing in urban areas of LMICs where there are diverse options for accessing healthcare services from formal and informal providers [12,13]. The city of Bo, the second largest urban center in Sierra Leone, has a diverse healthcare marketplace that serves an estimated population of about 150,000 people who live in an area of about 30 km 2 [14]. Government (public) hospitals and clinics in Bo offer care at low or no cost to the patient. Private nonprofit facilities run by religious organizations (missions) and nongovernmental organizations (NGOs) may offer affordable care [15].
Private for-profit hospitals are also available but may be expensive.
Treatment is also available from traditional healers, herbalists, and pharmacists as well as from nurses and some physicians in private practice who may make house calls (usually as a side business while also being employed by a hospital or clinic). This paper examines bypassing behavior in Bo. The purposes of this study are (1) to determine the preference of inpatient care facility by mothers of children less than 15 years old for themselves and their children in urban Bo, (2)   computer, and at the end of each day the data from the tablets were downloaded to a secure computer and the stored files were removed from the tablet. Two questions were used to examine provider selection for inpatient care. The first question asked "If you were very sick and needed to be treated for several days and nights away from home, where would you go for care?" This same question was also asked about each woman's youngest living child.
A follow-up question asked which specific healthcare facility or provider a mother would choose for inpatient care. Of the 2,735 (76.7%) participating women who had children 15 years of age or younger, 1,980 (72.4%) named a fixed-location inpatient facility for both herself and her child. Women who named a particular doctor or nurse rather than a fixed-location hospital or clinic were excluded from the analysis, as were women who named a facility that provides only outpatient care. (Facilities named less than 20 times across women and children combined were classified as ones that did not routinely offer inpatient care services and excluded from analysis after local residents confirmed that the facilities were not inpatient care providers.) For this study, a mother or child was classified as having bypassed a healthcare facility if the inpatient healthcare facility nearest in road distance to the home was different from her preferred facility. The Network Analyst tool in ArcGIS was used to identify the nearest inpatient care provider and to calculate the road distance measurements from each woman's home to this facility and to her preferred provider for herself and for her youngest child. This tool was also used to measure the road distance from each residence to the city center, which was defined as the place where three main roads in Bo (Old Gerihun Road, Fenton Road, and Bojon Street) intersect ( Figure 1). Geographic data were projected to Universal Transverse Mercator (UTM) coordinate system WGS 84 / UTM Zone 29N. Road segment errors in the geographic data were corrected using a tolerance distance of 3 meters. Residences and facility locations were automatically snapped to the nearest road within 5 meters of the structure.
Four additional questions were used to examine the factors that may influence bypassing: "If cost was not a barrier, would you prefer to go to a different healthcare provider than the one you usually go to when you are sick?" and a three-part pairedcomparison question about "When you are choosing where to go for medical care, which is a more important factor?" Using a circular To create SES tertiles, sums of 0 to 4 were classified as low socioeconomic status (SES), scores of 5 and 6 were classified as middle SES, and scores from 7 to 10 were classified as high SES.
Based on this method, a total of 656 (33.1%) households were classified as low SES, 766 (38.7%) were classified as middle SES, and 558 (28.2%) were classified as high SES households. Statistical analysis was conducted using SPSS (v. 21) with a significance level of α=0.05. Chi-square tests (x 2 ) were used to identify differences in sociodemographic characteristics, SES index, and proximity to the nearest healthcare provider between women who would and would not bypass the nearest inpatient healthcare facility to access the preferred inpatient care provider for herself and her youngest child.

Results
Nine inpatient healthcare facilities were identified as preferred providers of inpatient care ( Figure 1). Eight were located within Bo city limits: Bo Government Hospital (BGH), located in the city's center; two government-run community health clinics; four nonprofit facilities (one hospital and three clinics); and one for-profit private hospital. Additionally, the nonprofit Médicins Sans Frontières (MSF) clinic in Gondama, 12 km south of Bo, was listed as a preferred provider for both women and children. (In Bo, the terms "clinic" and "hospital" are not consistently applied to particular types of facilities. Some "clinics" offer inpatient care, and some "hospitals" do not. All nine of the providers listed as preferred offer inpatient care services.) The majority of participants listed BGH, the city's only public referral hospital, as the preferred inpatient provider for themselves (73.9%) and their children (72.8%). Of the remaining women, 18.6% listed a nonprofit, 6.8% listed another government facility, and 0.7% named the for-profit facility as preferred for themselves. For children, these percentages were 20.0% nonprofit, 6.5% public, and 0.8% for-profit. The median distance from the nearest inpatient facility to a home was 0.9 km (Inter-Quartile Range: 0.6, 1.8). The median distance from home to the preferred inpatient care provider was a much longer 2.4 km (IQR: 1.0, 3.3) one-way. Nonprofit providers were the nearest inpatient care providers to more than 60% of homes, but BGH or another public provider was preferred by nearly 80% of the participants. Because of this strong preference for BGH, most participants-87.0% of women and 87.6% of their children-would need to bypass the nearest facility to access care at the preferred facility. Thus, most bypassing for inpatient care in Bo occurs when an individual living near to a nonprofit provider passes by that facility to access care at BGH, which is a median distance of 2.4 km (IQR: 1.1, 3.1) from women's homes. Women who would bypass to reach their preferred facilities for themselves and their children were more likely than non-bypassers to live nearest to a nonprofit provider rather than a public facility, to say that cost was a primary consideration over reputation, to say that they would select a different provider if cost was not a barrier, and to live far from the city center (Table   2 and Table 3). The women most likely to bypass were those who lived farthest from the city center, especially those who lived too far from their nearest inpatient provider to comfortably walk to it.
Bypassing rates did not significantly vary by SES or demographic characteristics. Distance from BGH was the primary factor associated with bypassing. Most women who would bypass to access a preferred facility listed BGH as the preferred inpatient care provider. Women preferring BGH were significantly more likely than other women to bypass, and they were also significantly more likely to live far from their nearest providers and to rate cost as a high priority in provider selection (Table 4). Preference for BGH over another facility was not associated with the distance of the home from the city center or a preference for a different provider if cost was not a barrier.

Discussion
Bypassing inpatient care facilities is a common occurrence in urban Bo. Previous studies have observed that the decision about where to receive health care services is influenced by the facility's quality and reputation and by whether facilities are government or privately run [15,22]. Most studies suggest that public providers have a poorer reputation than private providers [23-26]. However, in Bo, the main public hospital, BGH, was the strongly preferred option for inpatient care for women and children. The preference for BGH, despite the proximity of many households to other providers, usually private nonprofit facilities, suggests that access to advanced services, such as diagnostic and specialty care, as well as to free or low-cost inpatient care, is a key factor in household-level decision-making about where to access health care. Women from lower SES households may prefer BGH over options nearer to their home because they know the costs of care will be limited. While some private providers offer free or low-cost care, health consumers may not be able to access advanced diagnostic and therapeutic services at those facilities, and they may have to negotiate on prices rather than trusting that prices will be disclosed ahead of time like they are at BGH. Women from higher SES households-the women most likely to say that they would choose a different provider if cost was not a barrier-may consider BGH to be an acceptable and affordable option when compared to the more expensive advanced care options in Freetown, the capital city. However, the paired-comparison questions indicated that reputation was a higher priority for healthcare provider selection than cost or provider location. Thus, the strong preference for BGH expressed by women from both high SES and low SES households may be a sign that, in addition to providing reasonably-priced care, BGH also has a favorable reputation for providing advanced services not available elsewhere   Tables and figures   Table 1: Factor analysis component loadings