In light of growing interest in ART-related healthcare pluralism, this multisite South African study examined utilization of additional health providers and self-purchased health products concurrently with ART services. The study provides insights into factors associated with these plural healthcare practices among ART patients, and how these factors differ between urban and rural settings. The results suggest increased plural healthcare utilization, inequitably distributed between rural and urban areas, is largely a function of higher SES, better ability to finance healthcare and factors related to poor quality of care in ART clinics. Healthcare expenditure of a catastrophic nature to households remained a persistent consequence associated with plural healthcare utilization. Notably, plural healthcare utilization was neither associated with biological markers of ART success, CD4 count and viral load, nor scheduled visits to the ART clinic.
Provider-related (19%) and self-care (15%) pluralism are conceptually distinct variants in that the former is driven by usage of healthcare providers, and the latter by self-help behavior. However, they both represent the same phenomenon of seeking complementary healthcare to ART. A study by Rosen et al. found self-care to be as high as 60% among HIV/AIDS patients, while 12% paid for other medical care in the preceding week . In our study, provider and self-care pluralism were more common in urban and rural settings respectively, suggesting possible geographic inequities. Horstmann et al. hypothesized that differences in multiple service usage by ART patients between urban and rural settings were much more likely to occur due to inequitable distribution of health providers and resources . Our study found provider pluralism patterns to involve public, private and indigenous sectors, and this concurs with previous qualitative research . The use of self-care practices and traditional healers were more common in rural areas, whereas the private sector was used largely by urban residents, who also had a much higher SES. Several household studies have identified SES as an important determinant of using or choosing health providers [23–25].
Some similarities were identified between provider and self-care pluralism, notwithstanding geographic differences. The direct costs of healthcare were higher among users of traditional healers who were mostly rural patients. Although these costs were high, alternatives to cash payments through payment in kind or on credit renders traditional healthcare affordable . Urban patients spent money largely on private chemists and doctors. Plural healthcare users, both provider-related and self-care, created debts by raising money to finance healthcare, a known practice via social networks . In addition, provider pluralism and self-care practices were associated with possession of medical aid insurance and temporary disability grants respectively, both of which may increase the ability to finance healthcare utilization. Furthermore, geographic disparities in SES may explain high levels of catastrophic household expenditure in rural areas, which may in turn account for the increased need to borrow money so as to finance healthcare. Previous studies have shown that catastrophic expenditure associated with chronic care, as is the case with ART, may result in depletion of household livelihoods with a greater effect among rural residents [23, 25, 27]. Most likely, the higher SES among urban ART users may have provided some resilience against catastrophic household expenditure.
Further implications of provider and self-care pluralism pertain to the direct role of the ART services. Both provider and self-care pluralism increased when patients experienced disrespect by the healthcare team in the ART clinic. A study by Magnus et al. showed that perceived respect at the ART clinic was associated with increased patient retention, a result of perceived good quality healthcare . On the contrary, perceived poor quality of care was identified in other studies as an important reason for poor patient retention or attendance in the ART clinic [29, 30]. Other poor quality of care factors identified in this study included lack of privacy during consultations and having to leave the ART clinic without receiving help. These factors may act as barriers to care, and recourse to different medical systems is known to reduce barriers to HIV care in certain cases . Furthermore, the role of treatment supporters in increasing plural healthcare utilization is worth noting, and this form of social support is also necessary to improve adherence to ART . Social influence, manifesting in the context of cultural networks, may function against the goals of ART services particularly when plural healthcare is discouraged in the ART clinic [32, 33]. However, a collaborative beneficial effect may be seen in a coordinated plural healthcare system .
With regards to healthcare outcomes, only self-care pluralism was associated with low knowledge regarding ART care and reports of missed treatment doses in the preceding 6 months. Poor ART-related knowledge was associated with low level of education in a study by Nachega et al. , while in this study it was associated with the rural context and low SES associated with self-care behavior. However, clinic visits in the preceding 6 months and immunological and virological markers were neither affected by provider nor self-care pluralism. Limiting the study were the low levels of recorded biological markers. Future research needs to explore these outcomes in the context of complete results. Furthermore, this study could not establish the direction of cause and effect due to a cross-sectional design, and longitudinal studies are needed to better describe determinants and consequences of plural healthcare utilization. In addition, studies are needed to establish the clinical, personal and contextual appropriateness of plural healthcare utilization, if effective integrated healthcare interventions are to be designed. Furthermore, plural health care utilization is a complex concept that is used in particular way in this study and challenging to measure by quantitative tools. Some benefits of using a hybrid of health care modalities may have included non-medical or psychological relief not captured by economic or access variables used in this study.