"It's just a fever": Gender based barriers to care-seeking for visceral leishmaniasis in highly endemic districts of India: A qualitative study

• Published in: PLoS neglected tropical diseases 2019-06, Vol.13 (6), p.e0007457-e0007457
• Main Authors: Jayakumar, Beulah, Murthy, Nirmala, Misra, Kingsuk, Burza, Sakib
• Format: Article
• Language: English
• Subjects: Adult; Aged; Aged, 80 and over; Analysis; Care and treatment; Computer and Information Sciences; Demographic aspects; Diagnosis; Disease control; Facilities and Services Utilization - statistics & numerical data; Female; Females; Fever; Gender; Health aspects; Health care facilities; Health care services accessibility; Health services; Health Services Accessibility - statistics & numerical data; Humans; India; Interviews as Topic; Leishmaniasis; Leishmaniasis, Visceral - diagnosis; Leishmaniasis, Visceral - drug therapy; Male; Males; Medical personnel; Medical treatment; Medicine and Health Sciences; Messages; Middle Aged; Older people; Parasitic diseases; Patient Acceptance of Health Care - statistics & numerical data; People and Places; Public health; Qualitative research; Sex Factors; Shopping; Signs and symptoms; Symptoms; Therapeutics; Tropical diseases; Vector-borne diseases; Vectors (Biology); Visceral leishmaniasis; Women; Women's health services; Womens health; Young Adult
• ISSN: 1935-2735; 1935-2727; 1935-2735
• DOI: 10.1371/journal.pntd.0007457

Diagnosis and treatment for visceral leishmaniasis (VL) is considered to be delayed amongst poor, rural women in highly endemic districts of Bihar and Jharkhand. The objective of this study was to assess and understand barriers to VL diagnosis and treatment for women in endemic districts with a high burden of VL. The study used a stratified and purposive sample of 33 female patients with VL, 11 health staff, 11 local (unqualified) health providers and 12 groups of community elders drawn from ten districts in Bihar and four in Jharkhand with high burdens of VL. The study was conducted within an exploratory and inductive framework, using semi-structured in-depth interviews and discussions. Women accessing treatment more quickly tended to move faster from treating their symptoms on their own to seeking care from local providers. Perception among female patients of the illness being not serious (owing to initially non-specific and mild symptoms), lack of money, prioritisation of household chores over their need to seek care and the absence of a male guardian to accompany them in seeking care at facilities worked together to drive these choices. Most patients and their families did not suspect VL as the cause for their non-specific symptoms, but when VL was suspected, treatment shopping ended. Lack of prioritization of women's health issues appears to be a pervasive underlying factor. Public health facilities were not an early treatment choice for the majority, but where it was, the diagnosis of VL was often not considered when presenting with under 2 weeks of symptoms, nor were appropriate follow-up plans instituted. The insidious presentation of VL and the low prioritisation of women's health need to be jointly addressed through messages that emphasise the importance of early diagnosis and treatment of disease, which is low-cost in time and money when managed in public health facilities. Clear messages that project prioritising women's care-seeking over household work as a smart choice and the need for rallying male support are needed. Additionally, efforts to reduce missed opportunities through early case suspicion and engaging private providers to better counsel women with suspected VL could close critical gaps in the continuum of care.