Understanding health seeking behaviors to inform COVID-19 surveillance and detection in resource-scarce settings

Since mass COVID-19 testing may be challenging for resource-scarce settings, effective disease management in developing countries need to resolve to different measures, which can be identified and prioritised by understanding health seeking behavior of a country's population. As the common practice of many developing nations' citizens is contacting local pharmacists and nonofficial health providers firstly when having health problems, these local health gatekeepers should be involved as first point of case detection, while accurate information regarding COVID-19 prevention and control can also be delivered through them in timely manner. Utilising local health gatekeepers has indeed been at the core of current success story of Vietnam in COVID-19 management. One of the examples of how understanding health seeking behavior of population can result in effective strategies for detecting and controlling SARS-COV-2 infections is the case of Vietnam. A low middle income country with health system facing numerous constrains, Vietnam has so far managed to keep the number of SARS-COV-2 confirmed infected cases at 382 and no mortality as of 18 July 2020, through effective utilization of the network of nonofficial, community-based health facilities and pharmacies, based on the knowledge that majority of the Vietnamese population would prefer going to these local, nonofficial health workforce when having health problems. They believe that current success The story will encourage similar resources around the world to pay more attention health-seeking behaviors of their populations and their impact on disease management when developing and implementing measures to monitor and detect COVID-19.

Since mass COVID-19 testing may be challenging for resource-scarce settings, effective disease management in developing countries need to resolve to different measures, which can be identified and prioritized by understanding health seeking behavior of a country's population.
ing of health seeking behaviors among local communities. While most people in Western countries visit health clinics or family doctors when perceiving a health problem, previous studies have described various contextual factors and barriers that shape access and utilization of health care services in resource-scare settings [3,4]. Many residents prefer to purchase un-prescribed medications at pharmacies for self-treatment, or visit traditional healers, private or non-registered clinics, rather than hospitals and official health stations as places of first contact for health issues (for example, people in Pakistan regions (39.1%) and Indonesia regions (42.9%) preferred going to pharmacy first to treat illness; Table 1). This would be a larger obstacle to confirming and monitoring cases, especially in the early stages of COVID-19 epidemics, including cases importation and cluster transmission.
As the common practice of many developing nations' citizens is contacting local pharmacists and non-official health providers firstly when having health problems, these local health gatekeepers should be involved as first point of case detection, while accurate information regarding COVID-19 prevention and control can also be delivered through them in timely manner. Utilizing local health gatekeepers has indeed been at the core of current success story of Vietnam in COVID-19 management. Ref.
-reference *For publication where no indication of percentage (%) of participant using a provider is found, we ranked the providers in terms of time of contact (ie, first contact will be Rank 1) People with mild COVID-19 symptoms that in many cases are similar to a common or seasonal cold, do not thinking that they may have been infected with the virus, and may go to these non-official health facilities for medication, increasing the risk of exposure of others while limiting the chance of tracing back to first infection case (F0). They may be long gone before other positive cases infected by them are detected. In addition, people who believed they might have been infected based on their symptoms may also ask their families and friends to get their medication from health workers in the communities or from the pharmacies, rather than going to hospitals or testing centers. Such behavior is likely to be induced by the fear of stigma towards them, should they be tested positive, as well as fear of having their whole families transferred to quarantine location, or having to disclose their past activities for contact tracing. SARS-COV-2 associated stigma, which can undermine the testing and monitoring efforts, has been one of the major concerns of health experts and organizations globally [19]. The habit and ease of seeking health advice and medication from pharmacies, traditional health providers, and private/non-official clinics in developing countries is likely to exacerbate such problem.
To effectively detect and control the SAR-COV-2 infection in these resource-scarce settings, thus, would require the active and thorough involvement of health facilities other than hospitals and official health centers, especially in more remote regions where accessibility to official health care is limited. Pharmacies, traditional healers, village health collaborators, private clinics, or mobile independent health workers in the commune should be considered as gatekeepers in a closely connected network of COVID-19 surveillance. Ideally, a well-determined mechanism for timely information sharing between these first contact points and higher-level and specialized taskforces should be established. Staff at these facilities should be trained to detect signs and epidemiological history of suspected COVID-19 cases from or relating to their customers while being provided with sufficient equipment for their own disease protection. These local health gatekeepers can also be effective, community-based, and far-reaching channels in which accurate information regarding COVID-19 knowledge and response can be delivered to the individuals. For example, pharmacists can persuade disease-suspecting customers to visit hospital or testing centers. In addition, due to their proximity to the residency and familiarity with local residents, these facilities would also be points via which intervention packages being delivered to the community, in the unfortunate case of prolonged disease.
One of the examples of how understanding health seeking behavior of population can result in effective strategies for detecting and controlling SARS-COV-2 infections is the case of Vietnam. A low middle income country with health system facing numerous constrains, Vietnam has so far managed to keep the number of SARS-COV-2 confirmed infected cases at 382 and no mortality as of 18 July 2020, through effective utilization of the network of non-official, community-based health facilities and pharmacies, based on the knowledge that majority of the Vietnamese population would prefer going to these local, non-official health workforce when having health problems [20]. We believe that this current success story would further encourage similar resource-scarce settings all over the world to pay more attention to health seeking behaviors of their population and effects of such behaviors on disease management when developing and implementing COVID-19 surveillance and detection measures.