摘要：Objectives. We identified barriers to care seeking for pneumonia and diarrhea among rural Guatemalan children. Methods. A population-based survey was conducted twice from 2008 to 2009 among 1605 households with children younger than 5 years. A 14-day calendar recorded episodes of carer-reported pneumonia (n = 364) and diarrhea (n = 481), and formal (health services, public, private) and informal (neighbors, traditional, local shops, pharmacies) care seeking. Results. Formal care was sought for nearly half of severe pneumonias but only for 27% within 2 days of onset, with 31% and 18%, respectively, for severe diarrhea. In multivariable analysis, factors independently associated with formal care seeking were knowing the Community Emergency Plan, mother’s perception of illness severity, recognition of World Health Organization danger signs, distance from the health center, and having someone to care for family in an emergency. Conclusions. Proximal factors associated with recognizing need for care were important in determining formal care, and were strongly linked to social determinants. In addition to specific action by the health system with an enhanced community health worker role, a systems approach can help ensure barriers are addressed among poorer and more remote homes. Globally, some 7.6 million children younger than 5 years die annually, the majority from low-income countries. 1 Two of the most important causes are acute lower respiratory infections, mainly pneumonia and diarrhea (18% and 14% of all deaths in children younger than 5 years, respectively). Adequate access to health care for young children with pneumonia and diarrhea is extremely important in improving survival as there are cheap and effective interventions available. In 2003, the Bellagio Child Survival Study group reviewed child survival interventions feasible for delivery in low-income settings, and concluded that if effective interventions had global coverage, 63% of childhood deaths could be prevented. 2 The power of existing interventions is not matched by the capacity of health systems to deliver them to those in greatest need in a comprehensive way and on an adequate scale. 3 This situation persists, and a recent study of global research priorities for the prevention of deaths from pneumonia among children by 2015 identified barriers to care seeking and access as one of the highest priorities. 4 In Guatemala, the 2006 infant mortality rate was 31 per 1000 live births, and under-5 mortality was 41 per 1000 child-years. 5 In rural areas where the majority of the population resides, the infant mortality rate and under-5 mortality rates are likely considerably higher. On the basis of their investigation, Heuveline and Goldman suggested that improved access to health care could have considerable impact on under-5 mortality in Guatemala. 6 Studies conducted in the 1990s found that health care uptake was very poor, with between 60% and 80% of families not seeking any formal, qualified health care for acute lower respiratory infections and diarrhea. 6,7 In relation to poor uptake, poverty was seen as an important predictor, and education and ethnicity were found to be less important. 8 In addition to informal health care in Guatemala (traditional healers, midwives, neighbors, local stores, pharmacies), formal services are provided by the Ministry of Public Health and Social Assistance (MSPAS). The main health facilities include health posts (usually staffed by an auxiliary nurse), health centers (staffed by at least 1 doctor and qualified nurse), and “national” (general) and specialized hospitals. Recently there has been substantial growth in private services (individual doctors and hospitals), stimulated by rising income in urban areas and dissatisfaction with public services. Other health services are provided by the Social Security Institute and nongovernmental organizations. From 1997, MSPAS has also funded the Programme to Extend Coverage of Basic Health Services ( Extension de Cobertura [EdC]). This program, part of the wider Comprehensive Health Care System ( Sistema Integrado Atencion de Salud ), involves the contracting of nongovernmental organizations to extend basic services to impoverished rural populations. 9 Following a randomized controlled trial investigating the impact of reducing household air pollution on pneumonia among children, 10 and motivated by efforts to develop integration of protection, prevention, and treatment, 11 we carried out a study in the same communities of Comitancillo and San Lorenzo into barriers to health care access. We used mixed methods (population-based surveys and qualitative interviews and focus groups) to understand the key demand and supply-side issues that could inform future interventions to improve access to high-quality care. We report here results from the survey component, and focus on the determinants of formal care seeking for maternal report of an episode in children of pneumonia, diarrhea, or both in the past 14 days, with “formal” care defined as contact with 1 or more MSPAS, private, or EdC services.
