For a long time, quantitative and qualitative research methods were largely employed by different researchers and rarely overlapped. More recently, mixed research design, able to offer a greater depth of understanding whilst offsetting the weaknesses inherent to using each approach by itself, has become increasingly popular.I here describe how a mix of quantitative and qualitative research methods provided a valuable insight on the cost associated with Hepatitis C (HCV) in Egypt when writing my Master’s thesis at the London School of Economics (LSE).
BackgroundWhat happens when a nation-wide intravenous vaccination programme goes catastrophically wrong? In the 1960s, in an effort to combat a growing Schistosomiasis epidemic in Egypt, the ministry of health undertook a 20-year long vaccination programme. Through disastrous ill- management, injections were given using unsterile needles which led to rapid transmission of HCV throughout the country. This practice continued until the mid-1980s, when an effective oral drug for Schistosomiasis eradicated the need for injections. As HCV was only discovered as a disease in the early 1990s, the Egyptian government was completely alien to the fact that it had undertaken the most calamitous public health policy in recent human history. To this day, Egypt has the highest HCV incidence in the world with 14% of its population diagnosed with the virus (Mohamoud et al., 2013) – compared to the international average of 3% – with a vast reservoir of yet undiscovered HCV cases (Averhoff et al., 2012) In the early and chronic stages of HCV, there is a complete absence of hepatic symptoms. Since the chronic phase of the disease is the longest – lasting up to 30 years – the disease was previously often mistakenly considered to be asymptomatic and was largely ignored in health economics literature. However, it is now known that, if left untreated, HCV eventually develops into cirrhosis and liver cancer and that, even in the chronic stage, HCV is linked to extrahepatic symptoms which significantly affect patients’ health related quality of life (HRQOL). As such, there is reason to assume that HCV will greatly impact on utilisation of healthcare services and work productivity. However, due to the ambiguity of the disease’s symptoms, efforts to measure its economic impact on its sufferers have been few and far between – with the only reliable estimates being based on data from the United States.
Methodology overviewI used mixed research methods to identify the effect of HCV on individual wealth in Egypt. First, quantitative analysis was used to establish the nature of the causal relationship between HCV and household wealth. A dataset of 16, 002 individuals from Egypt was acquired from the Demographic and Health Surveys (DHS) project. The data contain a range of characteristics of each person such as age, gender, education and a range of relevant health indicators e.g. HCV status. In addition to multi-variate regression – where a proxy for wealth was used as the dependent variable and HCV status was used as the independent variable – a regression discontinuity design (R.D.D.) was also implemented. Thereafter, qualitative methods in the form of 15 in-depth semi-structured interviews with patients in rural and urban Egypt were employed to establish the causal mechanisms that link HCV and individual wealth.
Quantitative findingsUsing the historical setting of the epidemic, I found a clear change in incidence rate at the end of the intravenous vaccination programme. This meant that HCV incidence rate in those born after the termination of the programme was significantly lower (3%, in line with international average) than in those born before or during the programme (up to 25%, 8x times the international average). This cut-off point was used to carry out the R.D.D. analysis. Both, the multi-variate regression and the R.D.D. analysis found a negative relationship between HCV positive patients and their wealth (β=–0.4453, p=0.01 in one estimate).Qualitative findings: I found that HCV affects patients’ wealth mainly through loss in productivity and its crippling medical costs, which in Egypt are mainly paid directly by the patients – out of pocket health expenditure in Egypt stands at 91% (World Bank, 2015). Furthermore, I found that not all patients interviewed were affected uniformly. Instead, HCV had a considerably greater negative economic impact on those at more advanced stages of the disease, who had an increased risk of cirrhosis and liver cancer.
RecommendationsBased on the results and an interview with Moez El Shohdi, founder and CEO of the Egyptian Cure Bank - a non-profit organisation dedicated to tackling the epidemic – a set of recommendations were made:
- Social insurance provision – due to the high OOP rate in Egypt, HCV medical costs can push families into poverty by crippling them financially. Therefore, the government must prioritise these groups by providing them with financial support through social insurance programmes
- Undertaking mass HCV awareness campaigns – in Egypt, over 150, 000 HCV new cases are discovered a year, along with thousands of relapse cases (Waked et al, 2014). Many of these are avoidable and can be prevented through hygiene educational campaigns
- A more even geographical distribution of medical care – the agglomeration of healthcare services in Cairo has forced many family members to move to the capital to receive treatment resulting in detrimental knock on effects on household wealth
ConclusionWhereas in some cases, mixed research has been dismissed as “cumbersome” and “difficult to manage”, the results demonstrated the attractiveness of combining quantitative and qualitative methods. Triangulation provided a much deeper understanding of the research problem at hand. Due to the historical background of the epidemic and the diversity of different causal paths, mixed research design was appropriate to use in this setting. Quantitative analysis was crucial in order to establish a robust causal relationship between HCV and wealth. Qualitative methods were then integral to creating causal mechanisms on how HCV affects its sufferers’ wealth at different stages of the disease. The combination of the two methods therefore produced powerful results which could then be used to design more targeted, succinct and robust policy recommendations.
- Averhoff, Francisco M., Nancy Glass, and Deborah Holtzman. "Global burden of hepatitis C: considerations for healthcare providers in the United States." Clinical Infectious Diseases 55, no. suppl 1 (2012): S10-S15.
- Mohamoud, Yousra A., Ghina R. Mumtaz, Suzanne Riome, DeWolfe Miller, and Laith J. Abu-Raddad. "The epidemiology of hepatitis C virus in Egypt: a systematic review and data synthesis." BMC infectious diseases 13, no. 1 (2013): 1.
- Waked, Imam, Waheed Doss, Manal Hamdy El-Sayed, Chris Estes, Homie Razavi, Gamal Shiha, Ayman Yosry, and Gamal Esmat. "The current and future disease burden of chronic hepatitis C virus infection in Egypt." Arab J Gastroenterol 15, no. 2 (2014): 45-52.
- World Bank Databank - Out of pocket health expenditure (%of private expenditure on health) http://databank.worldbank.org/data/reports.aspx?source=2&series=SH.XPD.OOPC.ZS&country=