Assessing Healthcare Pathway through patient experience with Completing Cancer Treatment Incentive (CCTI) Program for Low-Income Populations in Malaysia

Assessing Healthcare Pathway through patient experience with Completing Cancer Treatment Incentive (CCTI) Program for Low-Income Populations in Malaysia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessing Healthcare Pathway through patient experience with Completing Cancer Treatment Incentive (CCTI) Program for Low-Income Populations in Malaysia Nur Hidayati Abdul Halim, Nur Azmiah Zainuddin, Farhana Aminuddin, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4580048/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 26 Mar, 2025 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Background Cancer diagnosis imposes a significant economic burden on healthcare systems, patients, and their families. Technological advancements in cancer detection and treatment, leading to improved cancer detection rates and increased treatment uptake, have intensified this burden particularly among the economically disadvantaged. Despite efforts like universal health coverage and financial assistance programs, challenges persist in addressing the financial impact of cancer on patients. Methods Using qualitative methods, the study explores cancer patients’ experiences with the Completing Cancer Treatment Incentive (CCTI) in Malaysia. Interviews were conducted with both CCTI recipients and non-applicants from eight public hospitals. The RE-AIM framework was employed to evaluate dimensions such as reach, adoption, and implementation. Results Patients’ awareness of CCTI varied, with recipients mostly informed through acquaintances, media, or healthcare providers. Non-recipients lacked awareness, with limited information provided by healthcare personnel. CCTI was viewed positively by recipients, particularly for easing transportation costs, but challenges in the application process were evident. Patients faced difficulties navigating complex procedures, redundant health screenings, and limited communication about application progress. Conclusions The study highlights the need for improved implementation of CCTI to mitigate financial burdens on low-income cancer patients. Simplifying application processes, enhancing information dissemination, and addressing challenges such as redundant health screenings are crucial. The findings underscore the importance of proactive measures in policy implementation to improve CCTI effectiveness and accessibility for low-income cancer patients. Cancer policy evaluation RE-AIM framework Completing Cancer Treatment Incentive (CCTI) financial incentive policy implementation Figures Figure 1 Figure 2 Background Cancer diagnosis is associated with a high economic burden both to the healthcare system and the patients and their families or caregivers ( 1 , 2 ). Furthermore, advancements in technology leading to improved cancer detection rates and increased treatment uptake have intensified this burden. As a result, financial difficulties, particularly among those who are economically disadvantaged or lack insurance coverage, have become more pronounced ( 2 ). Even with universal health coverage, out-of-pocket expenses, or non-medical costs related to cancer treatment can still pose financial challenges. Thus, cancer patients and their families may still experience significant economic impact that affects their income, employment, and the risk of going into poverty ( 3 – 6 ); which in turn may affect the quality of life, adherence to treatment, survival rate, and the future of the affected families ( 3 , 7 ). Financial hardship is common among cancer survivors with a significant percentage (ranging from 12–62%) of them reported being in debt due to their treatment, while a substantial number (4–45%) could not afford the recommended prescription ( 2 ). Furthermore, research has found that the mean annual productivity loss for survivors was found to range from USD380 to USD8236 ( 2 ). These figures highlight the considerable economic impact that cancer can have on survivors, underscoring the need for comprehensive support and assistance to mitigate financial challenges in this population ( 2 , 3 ). Governmental policies such as lowering copayment rate of insured services, and financial assistance program for cancer patients has been introduced in some countries to alleviate the financial burden of cancer patients ( 7 , 8 ). The Financial Aid Program for Cancer Patient (FAPCP) introduced by the Korean government is an example of a public financial assistance program for low-income cancer patients ( 8 ). Other forms of financial assistance such as the provision of healthcare services free at the point of use in UK ( 9 ), and government-funded programs and charitable organizations that offer financial assistance and support to cancer patients for out-of-pocket expenses (Australia) ( 10 ). The PeKa B40 scheme ( Skim Peduli Kesihatan – healthcare scheme for low-income group), with the focus to reduce the burden of non-communicable diseases (NCDs), to strengthen the public-private partnerships, and to prioritise primary healthcare. There are four benefits of PeKa B40; 1) screening for selected NCDs including hypertension, diabetes mellitus and dyslipidaemia; 2) subsidies for selected health aids; 3) Completing Cancer Treatment Incentive (CCTI); and 4) subsidies for travelling expenses, the transport incentive (TI), related to benefits ( 2 ) and ( 3 ) ( 11 ). CCTI is a form of government financial incentive aimed to provide financial support to low-income cancer patients. Introduced in April 2019, whose eligibility for CCTI includes; cancer patients receiving treatment at public hospitals, PeKa B40 beneficiaries, and have undergone a health screening. CCTI comprises of cash benefits disbursed twice (once upon approval of application, and once after treatment completion) as well as transport incentives for each hospital visit (Fig. 1 ) ( 11 ). The CCTI process flow stipulates that all PeKa B40 beneficiaries diagnosed with cancer and receiving treatment at public hospitals are eligible to apply for CCTI incentives. To commence the application process, the attending physician must first ascertain the patient’s eligibility for PeKa B40. Furthermore, it is imperative that the patient has undergone a health screening prior to application submission, as this serves as a prerequisite for approval. Despite being launched at the beginning of 2019, the CCTI program’s adoption by the end of the year was underwhelming. This may be attributed to various issues similar to those faced by PeKa B40 (NCD screening), which includes lengthy screening processes, providers’ lack of awareness regarding procedures, unclear and cumbersome processes, absence of feedback mechanisms, and inadequate compensation for comprehensive screening, which involved lengthy multi-page reports. ( 12 ). The then Health Minister Khairy Jamaluddin reported that 90% of six million Malaysians eligible for free health screenings under PeKa B40 do not make use of the service ( 13 ). Reach or uptake, is the extent to which the intervention has been taken up, and has been described as the most important factor in determining the success of any cancer screening program ( 14 , 15 ). The challenges faced by CCTI and PeKa B40 are common occurrences where there are gaps between what was planned and what occurs as a result of policy implementation ( 16 , 17 ). Effective public policy formulation necessitates a thorough understanding and consideration of the prevailing realities on the ground. It has been suggested that there should be a clear link and communication between policy formulators and implementers to improve clarity of policy intention and implementation goals ( 18 ). These implementation challenges are often due to lack of understanding of the factors that influence the policy’s uptake and effectiveness ( 19 ). Understanding of the factors that shape and influence policy implementation can provide crucial information for a more robust, context specific, design and delivery of public policies. An evaluation of CCTI was conducted from October 2020 to June 2022, using the RE-AIM framework to elucidate all pertinent program aspects within real-world environments, to yield crucial insights into their impact, including barriers and facilitators ( 11 ). The RE-AIM framework, comprising five dimensions – Reach, Effectiveness, Adoption, Implementation, and Maintenance, serves as a valuable tool for evaluating program efficacy and effectiveness in real-world contexts ( 20 ). The study found that the overall uptake of CCTI was only 6.7%, despite being recognised as a good incentive to encourage patients to comply and complete their cancer treatment ( 11 ). It was also noted that the burden was mainly on the hospitals to assist with patient applications ( 11 ). This paper describes the experience of patients in navigating the system to receive the benefits of CCTI, which is part of the overall study evaluating the implementation of CCTI in Malaysia. Methods Study design and setting Utilising qualitative methods, insights from cancer patients, regarding their experiences with CCTI were obtained. Eligible patients receiving cancer treatment at public hospitals in Malaysia, including both CCTI recipients and non-applicants, were purposely selected from eight public hospitals with highest or lowest uptake of CCTI, allowing us to compare patient perspectives on their experience across the different sites as well as on why they did or not apply for the incentive. The institutional review board for National Institutes of Health (NIH), Malaysia, approved this study [NMRR-20-279-53249; MREC: KKM/NIHSEC/P20-1558( 12 )]. Table 1 illustrates each focus dimensions, indicators assessed and outcome measures in this process evaluation. Each indicator corresponds to an RAI dimension of the RE-AIM framework. Table 1 The RAI domains, indicators, and outcome measures. RE-AIM dimension Indicators Outcome measures Reach Information or knowledge regarding the incentive program • Patients’ awareness of CCTI Adoption Acceptability* of CCTI by cancer patients • Patient’s perception of the incentive, barriers, and facilitators Implementation Delivery of the CCTI (overall process) • Patient experience with the application process • Barriers and facilitators to apply or participate in the incentive program * Acceptability as an antecedent assessment of adoption (i.e. organizational staff and stakeholder perceptions of acceptability) ( 21 ). Data collection Due to challenges imposed by the COVID-19 pandemic, interviews were conducted remotely via phone calls between June 2021 to June 2022. We recruited interview participants until we reached data saturation. Data saturation was realized when no new information emerged from the interviews. An interview guide, structured in accordance with the RE-AIM framework, was developed to facilitate question development for assessments, with a particular emphasis on the REI dimensions. Before the interview commenced, the question guide underwent a pilot phase and subsequent refinements. Patients provided verbal consent prior to the interview. The interviews varied in length, lasting between 20–30 minutes. Interviews were conducted in either Malay or English language, or both; by 3 researchers, i) the second author (NA), ii) the third author (FA), and iii) another team member (AN). Data analysis Audio of all interviews were digitally captured, transcribed, and anonymised before being analysed in Microsoft Excel. Coding was led by the second author, a researcher with experience in qualitative analysis. It was done under supervision of an experienced consultant in qualitative research methods; and with the assistance of 2 other master’s- and bachelor’s-level research assistants. The research team members that conducted the interview were also involved in the coding of the transcriptions. Transcripts were coded based on a codebook with deductive RE-AIM constructs as well as inductive codes not captured in the RE-AIM that were relevant to the analysis. Confidentiality was maintained throughout data collection, analysis, and storage. All identifiable information was removed from final records after data collection to ensure participant anonymity, and only the core research team and the principal investigator had access to the original data. Results Participant characteristics A total of 23 participants were interviewed. The demographic and types of cancer of the interview participants are shown in Table 2 . Table 2 Characteristics of interview participants (N = 23). Characteristics Frequency (%) Gender Male 5 (21.7) Female 18 (78.3) Age group (years) 40–49 5 (21.7) 50–59 10 (43.5) ≥ 60 8 (34.8) Cancer site Breast 11 (47.8) Digestive tract 2 (8.7) Ear, nose, and throat 4 (17.4) Cervix 2 (8.7) Respiratory system 3 (13.0) Lymphoid system 1 (4.3) Results by RAI dimension of the RE-AIM framework Reach (R) From the patient interviews, it was evident that awareness among those who did not receive CCTI was lacking. Remarkably, despite undergoing active treatment, they were not adequately informed about the availability of this incentive. Seven out of eight non-CCTI recipients have neither heard of nor were informed by the healthcare personnel managing their illness, about CCTI and its benefit. “It feels like I’ve never heard of [CCTI], don’t really know much about it either.” – H3P04 “I’ve never heard of it, and the doctor has never told me about this [CCTI] thing either.” – H2P05 For CCTI recipients, information was obtained mainly from friends or fellow cancer patient, the media such as television and internet, and from private general practitioners or healthcare practitioners who were treating them. While they received information about the availability of the incentive itself, the exact details regarding the application process and the patients would be receiving were not clear. “I knew about it from TV. After that, I searched on Google too. But first, we saw it on TV because we always watch the news.” – H3P01 “At that time, I was receiving treatment at the hospital for radiotherapy. A Malay friend of mine, he told me about this for B40, can make a claim.” – H4P01 Adoption (A) For CCTI recipients, CCTI was recognised as a good incentive that helps to ease some of their financial burden, especially in terms of transportation cost. “You have it [CCTI]… I need, I want it. No matter, if you guys think can support me then that’s okay. You know I need to buy something to eat and pay electricity and sort of things I need to pay” – H2P02 “Of course, it really helps. It’s like for transportation, Grab, and such.” – H3P02 These patients also believe that even if they did not receive the financial aid conferred by CCTI, they would still seek treatment. “I can [continue treatment without assistance], but if there’s assistance, it’s even better.” – H7P02 “Even if I don’t receive any assistance... I will still go to the hospital.” – H5P04 Implementation (I) The application process for CCTI is dependent on the knowledge of both patient and healthcare practitioners on the availability of CCTI. Application is done by the treating doctor and its progress, and whether the application is successful, is unknown to the patient. Successful application is only confirmed when the incentive money is deposited into the beneficiaries’ account. “I know, the doctor applied for me.” – H6P02 “Doctor not tell me. Okay, you apply, okay, I submit. That’s it. And later on, they do not tell me, nothing about the incentive.” – H2P02 “I didn’t receive any messages or emails either. There was no notification. Just check [the account].” – H3P02 “So after I did everything, I sent it back, that’s what I waited for, how the response would be, whether I would get it or not.” – H7P01 To apply for CCTI, patients faced the arduous task of shuttling between hospitals and primary care facilities while undergoing cancer therapy and grappling with its side effects. Since only the attending doctor can submit the CCTI application, some patients found themselves shuffled between multiple doctors in search of the right one to initiate the process. Additionally, patients lamented on the cumbersome and bureaucratic nature of the CCTI application and approval process. They particularly highlighted the mandatory health screening, which proved burdensome given their health condition and financially taxing for some individuals. “But at that time (during the application process), I wasn’t feeling well, so I didn’t ask for anything. I didn’t say anything. I was undergoing chemotherapy, vomiting, feeling dizzy, so I just kept quiet.” – H2P01 “Actually, if you already know, the process is easy for you. But since we don’t know, you know, it’s like being ignorant, meaning you go to one clinic, then another. First, I asked at the radiotherapy centre, how to apply for PeKa B40? They said I had to go to a clinic nearby. Going there, going here. So, if you don’t know, it becomes complicated, it’s stressful, you know.” – H6P01 Discussion This paper describes the use of RE-AIM to understand the experience of patients navigating the system to obtain the benefits of CCTI. Understand their experience can provide crucial information on how implementation of CCTI could be enhanced in the future. It contributes to the body of knowledge on the influence a policy design on its intended beneficiaries, as well as the complex relationship between policy design and its impact on targeted beneficiaries. While monitoring performance delivery is critical in determining the effectiveness of a policy, particularly for complex and long-term efforts, monitoring alone without an evaluation may not be sufficient to assure optimal outcomes ( 22 ). Information about CCTI, the recruitment process, health screening, CCTI amount and payment process, and transportation incentives were some of the issues highlighted by our respondents. Patients lack knowledge about CCTI and its procedure; mainly gets the information about CCTI from their acquaintances and media such as television and the internet, and occasionally from their healthcare providers. Even though information of the availability of such incentive is known, the details of the application process and what benefits the patients will receive varies. Lack of knowledge about an intervention is an important barrier to participation; and the knowledge about the benefits and harms of the intervention is essential for informed uptake ( 23 ). Conducting refresher training for service providers can improve continuous collaboration, motivation, and education. Frequent follow-ups with feedback; and initial training and awareness campaigns can all help to reinforce new routines and appropriate behaviour, which are the cornerstones of successful interventions ( 24 ). Another issue highlighted by the patients were the need to undergo health screening despite having been diagnosed with cancer and is actively on treatment. This redundant process, discourages patients from completing the application, and incurs additional cost to both patients and healthcare providers. Patients undergoing cancer treatment often experiences side effects such as nausea, vomiting, and lethargy. The disease and its treatment itself are already stressful enough even without the added stress of needing to do additional health screening to be eligible for CCTI. Figure 2 illustrates the patient journey as they experienced it to obtain the benefits of CCTI. The mandatory health screening also incurs cost to both healthcare providers and patients, and uses precious healthcare resources that could be allocated elsewhere. Apart from cost, the system’s efficiency may be compromised due to lack of streamlined processes, resulting in delays in delivering the benefits of CCTI to patients. Disjointed workflow, and inefficient processes can significantly impact the effectiveness of any program; resulting in bottlenecks and delays; resource wastage; and administrative burden that diverts attention from core responsibilities. Since CCTI beneficiaries are patients already receiving treatment for cancer, the health screening is a redundant step that should be eliminated to streamline the process. Financial incentives are increasingly utilised to change the behaviour of both healthcare providers and patients. Economic theory suggests that such incentives work by improving the value associated with the target behaviour. However, success of such incentives is influenced by the complexity of both the behaviours incentivized and the way financial incentives are used ( 25 – 27 ). Additionally, these policies can also create administrative burdens, particularly for vulnerable groups, and are influenced by political and administrative choices ( 28 ). Minimising administrative burdens through streamlining of application processes; eliminating duplicate and redundant processes; and utilising digital solutions that are user-friendly and accessible to individuals with limited digital literacy or internet access; can help to increase the uptake rate of CCTI ( 29 – 31 ). By doing so, the patients’ focus will not be shifted from their treatment and recovery. Some of the issues addressed in this paper resonates with the challenges observed in policy implementation. Frequently, policies intended to address diverse social and economic concerns may falter in reaching their intended beneficiaries for a multitude of reasons. Hudson et. al. described four broad categories of contributors to policy shortcomings: overly optimistic expectations; implementations in dispersed governance; inadequate collaborative policymaking; and the vagaries of the political cycle ( 32 ). These factors shape and influence policy implementation, and are seen to be complex, multifaceted, multileveled, and are resistant to change. Limitations This study yields a unique opportunity to evaluate the implementation of policies in real-world context. The main limitation of this study is that we conducted phone interviews with the respondents, which limits observation of pertinent non-verbal cues during the conversation. The experiences of the respondents with regards to CCTI too were limited as during the study period, the nation was under movement control order due to the COVID-19 pandemic. We also described the reach, adoption and implementation dimensions of the RE-AIM framework using qualitative methods alone. Mixed methods would be more informative for all RE-AIM domains. Conclusions This paper illustrated the use of RE-AIM dimensions; reach, adoption, and implementation; to evaluate the CCTI policy in the real-world setting. Findings of this study highlights the importance of addressing implementation challenges to ensure the success of CCTI in supporting low-income cancer patients. To achieve this, it is recommended that the government take proactive measures, including streamlining the CCTI application process to reduce bureaucratic hurdles for patients. Additionally, enhancing information dissemination about CCTI through targeted awareness campaigns and educational initiatives can improve patients’ understanding of the program’s benefits and eligibility criteria. Furthermore, efforts should be made to eliminate redundant health screenings for patients already undergoing cancer treatment, reducing both financial and physical burdens. By implementing these targeted strategies, policymakers can enhance the effectiveness and accessibility of CCTI, thus improving cancer patients’ overall treatment experience and alleviating some the financial hardships faced by low-income cancer patients. Abbreviations FAPCP Financial Aid Program for Cancer Patient CCTI Completing Cancer Treatment Incentive PeKa B40 Skim Peduli Kesihatan for low–income group RE AIM framework–Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework Declarations Ethical approval and consent to participate All the data obtained are restricted to the principal investigators only and solely used for research purposes. Study was conducted in compliance with ethical principles outlined in the Declaration of Helsinki and Malaysian Good Clinical Practice Guideline. This study was registered with the National Medical Research Register (study registration number: NMRR-20-279-53249) and Ethics Committee (MREC), National Institutes of Health Malaysia prior to the actual study with approval number KKM/NIHSEC/P20-1558(12), dated 15 November 2020. Verbal informed consent was obtained prior to data collection. Consent for publication We thank Director General of Health, Ministry of Health, Malaysia for permission to publish this study. Availability of data and materials No datasets were generated or analysed during the current study. Competing interest All other authors declare that they have no conflict of interest. Notwithstanding, the principal investigator will take the responsibility to report any conflict of interest emerges during the study. Funding We thank the National Institute of Health, Ministry of Health Malaysia for the provision of grant to conduct this research. Authors’ contribution FA and NZAMH were involved in the study design and preparation of the study protocol. NAZ, FA, and NZAMH were involved in the data collection and analysis. NHAH, NAZ, FA, and NAN contributed to the writing of the manuscript and NHAH prepared Figure 2. All authors critically revised the paper and approved the manuscript. 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Camillo CA. Understanding the mechanisms of administrative burden through a within-case study of Medicaid expansion implementation. Journal of Behavioral Public Administration. 2021 Feb 1;4(1). Martin L, Delaney L, Doyle O. The distributive effects of administrative burdens on decision-making. Journal of Behavioural Public Administration. 2023;6. Hudson B, Hunter D, Peckham S. Policy failure and the policy-implementation gap: can policy support programs help? Policy Design and Practice. 2019;2(1):1–14. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 26 Mar, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 19 Jun, 2024 Editor assigned by journal 19 Jun, 2024 Submission checks completed at journal 19 Jun, 2024 First submitted to journal 14 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4580048","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":316291773,"identity":"eac62dd2-30dd-403f-90a5-f57c8b746e3c","order_by":0,"name":"Nur Hidayati Abdul Halim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYHACNoYENhDN2ABENgwMEkRrYQNrSSNSCwMbhAJqOUxYi7lE7rMHD8rsEvvnNzcw/NxxPppfuoH5xcc2hmiDA9i1WM5INzdIOJecOOMYYwNj75nbuTPnHGCznNnGkLsBhxaDG2lsEoltzIkNQC0MvG23czfcSGAz5jlDUEt94nyQLX/bzhGt5XDiBqAWZt62AyAtzI95KvBoOfOMTSLh3HHjjccSGw7LtiXnzpyR2MY4o0IidyYuLcfT2CR/lFXLzjt8/OHDt212uf0SyYc/fDCwye3DoQUGHBuABFQNY5sEKHYUCGixR+YwfwCR8g34tYyCUTAKRsGIAQBnDWbgHCPU0wAAAABJRU5ErkJggg==","orcid":"","institution":"National Institutes of Health (NIH), Ministry of Health","correspondingAuthor":true,"prefix":"","firstName":"Nur","middleName":"Hidayati Abdul","lastName":"Halim","suffix":""},{"id":316291774,"identity":"9263131c-7219-4d8c-9ce9-f76f766f1999","order_by":1,"name":"Nur Azmiah Zainuddin","email":"","orcid":"","institution":"National Institutes of Health (NIH), Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Nur","middleName":"Azmiah","lastName":"Zainuddin","suffix":""},{"id":316291775,"identity":"980a7a60-b85c-477a-8e2e-57e304e75222","order_by":2,"name":"Farhana Aminuddin","email":"","orcid":"","institution":"National Institutes of Health (NIH), Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Farhana","middleName":"","lastName":"Aminuddin","suffix":""},{"id":316291776,"identity":"f2f29f7a-5cf8-4b51-b4fe-5ddf16f6d412","order_by":3,"name":"Nurul Athirah Naserruddin","email":"","orcid":"","institution":"National Institutes of Health (NIH), Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Nurul","middleName":"Athirah","lastName":"Naserruddin","suffix":""},{"id":316291777,"identity":"6a528b2c-3def-4d13-ad9a-a1a42b83bbcc","order_by":4,"name":"Nor Zam Azihan Mohd Hassan","email":"","orcid":"","institution":"National Institutes of Health (NIH), Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Nor","middleName":"Zam Azihan Mohd","lastName":"Hassan","suffix":""}],"badges":[],"createdAt":"2024-06-14 06:57:38","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4580048/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4580048/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-12544-9","type":"published","date":"2025-03-26T15:56:54+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60447599,"identity":"375870d3-7dd3-47ad-9a70-4fb583e5eb57","added_by":"auto","created_at":"2024-07-16 22:05:21","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":198609,"visible":true,"origin":"","legend":"\u003cp\u003eCCTI application process\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4580048/v1/7a04b7fe9e686650f420e558.jpeg"},{"id":60446823,"identity":"cf3ebb10-fe43-4da3-84c8-b0b3e613a492","added_by":"auto","created_at":"2024-07-16 21:57:21","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":67631,"visible":true,"origin":"","legend":"\u003cp\u003eCCTI application, as experienced by applicants\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4580048/v1/99a83c4157b7ae7e9333fb63.jpeg"},{"id":79605198,"identity":"4bdb2052-36fd-4d3b-b771-66564d538881","added_by":"auto","created_at":"2025-03-31 16:10:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":815498,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4580048/v1/548f7192-0adf-4894-aaca-846fe69bf2ab.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessing Healthcare Pathway through patient experience with Completing Cancer Treatment Incentive (CCTI) Program for Low-Income Populations in Malaysia","fulltext":[{"header":"Background","content":"\u003cp\u003eCancer diagnosis is associated with a high economic burden both to the healthcare system and the patients and their families or caregivers (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Furthermore, advancements in technology leading to improved cancer detection rates and increased treatment uptake have intensified this burden. As a result, financial difficulties, particularly among those who are economically disadvantaged or lack insurance coverage, have become more pronounced (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Even with universal health coverage, out-of-pocket expenses, or non-medical costs related to cancer treatment can still pose financial challenges. Thus, cancer patients and their families may still experience significant economic impact that affects their income, employment, and the risk of going into poverty (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e); which in turn may affect the quality of life, adherence to treatment, survival rate, and the future of the affected families (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFinancial hardship is common among cancer survivors with a significant percentage (ranging from 12\u0026ndash;62%) of them reported being in debt due to their treatment, while a substantial number (4\u0026ndash;45%) could not afford the recommended prescription (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Furthermore, research has found that the mean annual productivity loss for survivors was found to range from USD380 to USD8236 (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). These figures highlight the considerable economic impact that cancer can have on survivors, underscoring the need for comprehensive support and assistance to mitigate financial challenges in this population (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGovernmental policies such as lowering copayment rate of insured services, and financial assistance program for cancer patients has been introduced in some countries to alleviate the financial burden of cancer patients (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). The Financial Aid Program for Cancer Patient (FAPCP) introduced by the Korean government is an example of a public financial assistance program for low-income cancer patients (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Other forms of financial assistance such as the provision of healthcare services free at the point of use in UK (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), and government-funded programs and charitable organizations that offer financial assistance and support to cancer patients for out-of-pocket expenses (Australia) (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe PeKa B40 scheme (\u003cem\u003eSkim Peduli Kesihatan\u003c/em\u003e \u0026ndash; healthcare scheme for low-income group), with the focus to reduce the burden of non-communicable diseases (NCDs), to strengthen the public-private partnerships, and to prioritise primary healthcare. There are four benefits of PeKa B40; 1) screening for selected NCDs including hypertension, diabetes mellitus and dyslipidaemia; 2) subsidies for selected health aids; 3) Completing Cancer Treatment Incentive (CCTI); and 4) subsidies for travelling expenses, the transport incentive (TI), related to benefits (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCCTI is a form of government financial incentive aimed to provide financial support to low-income cancer patients. Introduced in April 2019, whose eligibility for CCTI includes; cancer patients receiving treatment at public hospitals, PeKa B40 beneficiaries, and have undergone a health screening. CCTI comprises of cash benefits disbursed twice (once upon approval of application, and once after treatment completion) as well as transport incentives for each hospital visit (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe CCTI process flow stipulates that all PeKa B40 beneficiaries diagnosed with cancer and receiving treatment at public hospitals are eligible to apply for CCTI incentives. To commence the application process, the attending physician must first ascertain the patient\u0026rsquo;s eligibility for PeKa B40. Furthermore, it is imperative that the patient has undergone a health screening prior to application submission, as this serves as a prerequisite for approval.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eDespite being launched at the beginning of 2019, the CCTI program\u0026rsquo;s adoption by the end of the year was underwhelming. This may be attributed to various issues similar to those faced by PeKa B40 (NCD screening), which includes lengthy screening processes, providers\u0026rsquo; lack of awareness regarding procedures, unclear and cumbersome processes, absence of feedback mechanisms, and inadequate compensation for comprehensive screening, which involved lengthy multi-page reports. (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The then Health Minister Khairy Jamaluddin reported that 90% of six million Malaysians eligible for free health screenings under PeKa B40 do not make use of the service (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Reach or uptake, is the extent to which the intervention has been taken up, and has been described as the most important factor in determining the success of any cancer screening program (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe challenges faced by CCTI and PeKa B40 are common occurrences where there are gaps between what was planned and what occurs as a result of policy implementation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Effective public policy formulation necessitates a thorough understanding and consideration of the prevailing realities on the ground. It has been suggested that there should be a clear link and communication between policy formulators and implementers to improve clarity of policy intention and implementation goals (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). These implementation challenges are often due to lack of understanding of the factors that influence the policy\u0026rsquo;s uptake and effectiveness (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Understanding of the factors that shape and influence policy implementation can provide crucial information for a more robust, context specific, design and delivery of public policies.\u003c/p\u003e \u003cp\u003eAn evaluation of CCTI was conducted from October 2020 to June 2022, using the RE-AIM framework to elucidate all pertinent program aspects within real-world environments, to yield crucial insights into their impact, including barriers and facilitators (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The RE-AIM framework, comprising five dimensions \u0026ndash; Reach, Effectiveness, Adoption, Implementation, and Maintenance, serves as a valuable tool for evaluating program efficacy and effectiveness in real-world contexts (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The study found that the overall uptake of CCTI was only 6.7%, despite being recognised as a good incentive to encourage patients to comply and complete their cancer treatment (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). It was also noted that the burden was mainly on the hospitals to assist with patient applications (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This paper describes the experience of patients in navigating the system to receive the benefits of CCTI, which is part of the overall study evaluating the implementation of CCTI in Malaysia.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eUtilising qualitative methods, insights from cancer patients, regarding their experiences with CCTI were obtained. Eligible patients receiving cancer treatment at public hospitals in Malaysia, including both CCTI recipients and non-applicants, were purposely selected from eight public hospitals with highest or lowest uptake of CCTI, allowing us to compare patient perspectives on their experience across the different sites as well as on why they did or not apply for the incentive. The institutional review board for National Institutes of Health (NIH), Malaysia, approved this study [NMRR-20-279-53249; MREC: KKM/NIHSEC/P20-1558(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)]. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates each focus dimensions, indicators assessed and outcome measures in this process evaluation. Each indicator corresponds to an RAI dimension of the RE-AIM framework.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe RAI domains, indicators, and outcome measures.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRE-AIM dimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndicators\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOutcome measures\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReach\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInformation or knowledge regarding the incentive program\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Patients\u0026rsquo; awareness of CCTI\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAdoption\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcceptability* of CCTI by cancer patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Patient\u0026rsquo;s perception of the incentive, barriers, and facilitators\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eImplementation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDelivery of the CCTI (overall process)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026bull; Patient experience with the application process\u003c/p\u003e \u003cp\u003e\u0026bull; Barriers and facilitators to apply or participate in the incentive program\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e* Acceptability as an antecedent assessment of adoption (i.e. organizational staff and stakeholder perceptions of acceptability) (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eDue to challenges imposed by the COVID-19 pandemic, interviews were conducted remotely via phone calls between June 2021 to June 2022. We recruited interview participants until we reached data saturation. Data saturation was realized when no new information emerged from the interviews. An interview guide, structured in accordance with the RE-AIM framework, was developed to facilitate question development for assessments, with a particular emphasis on the REI dimensions. Before the interview commenced, the question guide underwent a pilot phase and subsequent refinements. Patients provided verbal consent prior to the interview. The interviews varied in length, lasting between 20\u0026ndash;30 minutes. Interviews were conducted in either Malay or English language, or both; by 3 researchers, i) the second author (NA), ii) the third author (FA), and iii) another team member (AN).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAudio of all interviews were digitally captured, transcribed, and anonymised before being analysed in Microsoft Excel. Coding was led by the second author, a researcher with experience in qualitative analysis. It was done under supervision of an experienced consultant in qualitative research methods; and with the assistance of 2 other master\u0026rsquo;s- and bachelor\u0026rsquo;s-level research assistants. The research team members that conducted the interview were also involved in the coding of the transcriptions. Transcripts were coded based on a codebook with deductive RE-AIM constructs as well as inductive codes not captured in the RE-AIM that were relevant to the analysis. Confidentiality was maintained throughout data collection, analysis, and storage. All identifiable information was removed from final records after data collection to ensure participant anonymity, and only the core research team and the principal investigator had access to the original data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eA total of 23 participants were interviewed. The demographic and types of cancer of the interview participants are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of interview participants (N\u0026thinsp;=\u0026thinsp;23).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (78.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eAge group (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (43.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (34.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eCancer site\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBreast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (47.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDigestive tract\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEar, nose, and throat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (17.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCervix\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRespiratory system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (13.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLymphoid system\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eResults by RAI dimension of the RE-AIM framework\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eReach (R)\u003c/h2\u003e \u003cp\u003eFrom the patient interviews, it was evident that awareness among those who did not receive CCTI was lacking. Remarkably, despite undergoing active treatment, they were not adequately informed about the availability of this incentive. Seven out of eight non-CCTI recipients have neither heard of nor were informed by the healthcare personnel managing their illness, about CCTI and its benefit.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It feels like I\u0026rsquo;ve never heard of [CCTI], don\u0026rsquo;t really know much about it either.\u0026rdquo; \u0026ndash; H3P04\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;ve never heard of it, and the doctor has never told me about this [CCTI] thing either.\u0026rdquo; \u0026ndash; H2P05\u003c/em\u003e \u003c/p\u003e \u003cp\u003eFor CCTI recipients, information was obtained mainly from friends or fellow cancer patient, the media such as television and internet, and from private general practitioners or healthcare practitioners who were treating them. While they received information about the availability of the incentive itself, the exact details regarding the application process and the patients would be receiving were not clear.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I knew about it from TV. After that, I searched on Google too. But first, we saw it on TV because we always watch the news.\u0026rdquo; \u0026ndash; H3P01\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;At that time, I was receiving treatment at the hospital for radiotherapy. A Malay friend of mine, he told me about this for B40, can make a claim.\u0026rdquo; \u0026ndash; H4P01\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eAdoption (A)\u003c/h2\u003e \u003cp\u003eFor CCTI recipients, CCTI was recognised as a good incentive that helps to ease some of their financial burden, especially in terms of transportation cost.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You have it [CCTI]\u0026hellip; I need, I want it. No matter, if you guys think can support me then that\u0026rsquo;s okay. You know I need to buy something to eat and pay electricity and sort of things I need to pay\u0026rdquo; \u0026ndash; H2P02\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Of course, it really helps. It\u0026rsquo;s like for transportation, Grab, and such.\u0026rdquo; \u0026ndash; H3P02\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThese patients also believe that even if they did not receive the financial aid conferred by CCTI, they would still seek treatment.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I can [continue treatment without assistance], but if there\u0026rsquo;s assistance, it\u0026rsquo;s even better.\u0026rdquo; \u0026ndash; H7P02\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Even if I don\u0026rsquo;t receive any assistance... I will still go to the hospital.\u0026rdquo; \u0026ndash; H5P04\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eImplementation (I)\u003c/h2\u003e \u003cp\u003eThe application process for CCTI is dependent on the knowledge of both patient and healthcare practitioners on the availability of CCTI. Application is done by the treating doctor and its progress, and whether the application is successful, is unknown to the patient. Successful application is only confirmed when the incentive money is deposited into the beneficiaries\u0026rsquo; account.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I know, the doctor applied for me.\u0026rdquo; \u0026ndash; H6P02\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Doctor not tell me. Okay, you apply, okay, I submit. That\u0026rsquo;s it. And later on, they do not tell me, nothing about the incentive.\u0026rdquo; \u0026ndash; H2P02\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I didn\u0026rsquo;t receive any messages or emails either. There was no notification. Just check [the account].\u0026rdquo; \u0026ndash; H3P02\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So after I did everything, I sent it back, that\u0026rsquo;s what I waited for, how the response would be, whether I would get it or not.\u0026rdquo; \u0026ndash; H7P01\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTo apply for CCTI, patients faced the arduous task of shuttling between hospitals and primary care facilities while undergoing cancer therapy and grappling with its side effects. Since only the attending doctor can submit the CCTI application, some patients found themselves shuffled between multiple doctors in search of the right one to initiate the process. Additionally, patients lamented on the cumbersome and bureaucratic nature of the CCTI application and approval process. They particularly highlighted the mandatory health screening, which proved burdensome given their health condition and financially taxing for some individuals.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;But at that time (during the application process), I wasn\u0026rsquo;t feeling well, so I didn\u0026rsquo;t ask for anything. I didn\u0026rsquo;t say anything. I was undergoing chemotherapy, vomiting, feeling dizzy, so I just kept quiet.\u0026rdquo; \u0026ndash; H2P01\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Actually, if you already know, the process is easy for you. But since we don\u0026rsquo;t know, you know, it\u0026rsquo;s like being ignorant, meaning you go to one clinic, then another. First, I asked at the radiotherapy centre, how to apply for PeKa B40? They said I had to go to a clinic nearby. Going there, going here. So, if you don\u0026rsquo;t know, it becomes complicated, it\u0026rsquo;s stressful, you know.\u0026rdquo; \u0026ndash; H6P01\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis paper describes the use of RE-AIM to understand the experience of patients navigating the system to obtain the benefits of CCTI. Understand their experience can provide crucial information on how implementation of CCTI could be enhanced in the future. It contributes to the body of knowledge on the influence a policy design on its intended beneficiaries, as well as the complex relationship between policy design and its impact on targeted beneficiaries. While monitoring performance delivery is critical in determining the effectiveness of a policy, particularly for complex and long-term efforts, monitoring alone without an evaluation may not be sufficient to assure optimal outcomes (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInformation about CCTI, the recruitment process, health screening, CCTI amount and payment process, and transportation incentives were some of the issues highlighted by our respondents. Patients lack knowledge about CCTI and its procedure; mainly gets the information about CCTI from their acquaintances and media such as television and the internet, and occasionally from their healthcare providers. Even though information of the availability of such incentive is known, the details of the application process and what benefits the patients will receive varies. Lack of knowledge about an intervention is an important barrier to participation; and the knowledge about the benefits and harms of the intervention is essential for informed uptake (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Conducting refresher training for service providers can improve continuous collaboration, motivation, and education. Frequent follow-ups with feedback; and initial training and awareness campaigns can all help to reinforce new routines and appropriate behaviour, which are the cornerstones of successful interventions (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother issue highlighted by the patients were the need to undergo health screening despite having been diagnosed with cancer and is actively on treatment. This redundant process, discourages patients from completing the application, and incurs additional cost to both patients and healthcare providers. Patients undergoing cancer treatment often experiences side effects such as nausea, vomiting, and lethargy. The disease and its treatment itself are already stressful enough even without the added stress of needing to do additional health screening to be eligible for CCTI. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the patient journey as they experienced it to obtain the benefits of CCTI.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe mandatory health screening also incurs cost to both healthcare providers and patients, and uses precious healthcare resources that could be allocated elsewhere. Apart from cost, the system\u0026rsquo;s efficiency may be compromised due to lack of streamlined processes, resulting in delays in delivering the benefits of CCTI to patients. Disjointed workflow, and inefficient processes can significantly impact the effectiveness of any program; resulting in bottlenecks and delays; resource wastage; and administrative burden that diverts attention from core responsibilities. Since CCTI beneficiaries are patients already receiving treatment for cancer, the health screening is a redundant step that should be eliminated to streamline the process.\u003c/p\u003e \u003cp\u003eFinancial incentives are increasingly utilised to change the behaviour of both healthcare providers and patients. Economic theory suggests that such incentives work by improving the value associated with the target behaviour. However, success of such incentives is influenced by the complexity of both the behaviours incentivized and the way financial incentives are used (\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Additionally, these policies can also create administrative burdens, particularly for vulnerable groups, and are influenced by political and administrative choices (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Minimising administrative burdens through streamlining of application processes; eliminating duplicate and redundant processes; and utilising digital solutions that are user-friendly and accessible to individuals with limited digital literacy or internet access; can help to increase the uptake rate of CCTI (\u003cspan additionalcitationids=\"CR30\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). By doing so, the patients\u0026rsquo; focus will not be shifted from their treatment and recovery.\u003c/p\u003e \u003cp\u003eSome of the issues addressed in this paper resonates with the challenges observed in policy implementation. Frequently, policies intended to address diverse social and economic concerns may falter in reaching their intended beneficiaries for a multitude of reasons. Hudson et. al. described four broad categories of contributors to policy shortcomings: overly optimistic expectations; implementations in dispersed governance; inadequate collaborative policymaking; and the vagaries of the political cycle (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). These factors shape and influence policy implementation, and are seen to be complex, multifaceted, multileveled, and are resistant to change.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study yields a unique opportunity to evaluate the implementation of policies in real-world context. The main limitation of this study is that we conducted phone interviews with the respondents, which limits observation of pertinent non-verbal cues during the conversation. The experiences of the respondents with regards to CCTI too were limited as during the study period, the nation was under movement control order due to the COVID-19 pandemic. We also described the reach, adoption and implementation dimensions of the RE-AIM framework using qualitative methods alone. Mixed methods would be more informative for all RE-AIM domains.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis paper illustrated the use of RE-AIM dimensions; reach, adoption, and implementation; to evaluate the CCTI policy in the real-world setting. Findings of this study highlights the importance of addressing implementation challenges to ensure the success of CCTI in supporting low-income cancer patients. To achieve this, it is recommended that the government take proactive measures, including streamlining the CCTI application process to reduce bureaucratic hurdles for patients. Additionally, enhancing information dissemination about CCTI through targeted awareness campaigns and educational initiatives can improve patients\u0026rsquo; understanding of the program\u0026rsquo;s benefits and eligibility criteria. Furthermore, efforts should be made to eliminate redundant health screenings for patients already undergoing cancer treatment, reducing both financial and physical burdens. By implementing these targeted strategies, policymakers can enhance the effectiveness and accessibility of CCTI, thus improving cancer patients\u0026rsquo; overall treatment experience and alleviating some the financial hardships faced by low-income cancer patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFAPCP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eFinancial Aid Program for Cancer Patient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCCTI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCompleting Cancer Treatment Incentive\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePeKa B40\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eSkim Peduli Kesihatan\u003c/em\u003e for low\u0026ndash;income group\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAIM framework\u0026ndash;Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical approval and consent to participate\u003c/p\u003e\n\u003cp\u003eAll the data obtained are restricted to the principal investigators only and solely used for research purposes. Study was conducted in compliance with ethical principles outlined in the Declaration of Helsinki and Malaysian Good Clinical Practice Guideline. This study was registered with the National Medical Research Register (study registration number: NMRR-20-279-53249)\u0026nbsp;and Ethics Committee (MREC), National Institutes of Health Malaysia prior to the actual study with approval number\u0026nbsp;KKM/NIHSEC/P20-1558(12), dated 15 November 2020. Verbal informed consent was obtained prior to data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eWe thank Director General of Health, Ministry of Health, Malaysia for permission to publish this study.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interest\u003c/p\u003e\n\u003cp\u003eAll other authors declare that they have no conflict of interest. Notwithstanding, the principal investigator will take the responsibility to report any conflict of interest emerges during the study.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eWe thank the National Institute of Health, Ministry of Health Malaysia for the provision of grant to conduct this research.\u003c/p\u003e\n\u003cp\u003eAuthors\u0026rsquo; contribution\u003c/p\u003e\n\u003cp\u003eFA and NZAMH were involved in the study design and preparation of the study protocol. NAZ, FA, and NZAMH were involved in the data collection and analysis. NHAH, NAZ, FA, and NAN contributed to the writing of the manuscript and NHAH prepared Figure 2. All authors critically revised the paper and approved the manuscript.\u003c/p\u003e\n\u003cp\u003eAcknowledgements\u003c/p\u003e\n\u003cp\u003eWe thank the Director General of Health, Ministry of Health, Malaysia for permission to publish this study. We thank as well all individuals who participated in this study. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRitter J, Allen S, Cohen PD, Fajardo AF, Marx K, Loggetto P, et al. Financial hardship in families of children or adolescents with cancer: a systematic literature review. Vol. 24, The Lancet Oncology. 2023. \u003c/li\u003e\n\u003cli\u003eAltice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial hardships experienced by cancer survivors: A systematic review. J Natl Cancer Inst. 2017;109(2):1\u0026ndash;17. \u003c/li\u003e\n\u003cli\u003eBhoo-Pathy N, Ng CW, Lim GCC, Tamin NSI, Sullivan R, Bhoo-Pathy NT, et al. Financial Toxicity After Cancer in a Setting With Universal Health Coverage: A Call for Urgent Action. J Oncol Pract. 2019;15(6):e537\u0026ndash;46. \u003c/li\u003e\n\u003cli\u003eOdahowski CL, Zahnd WE, Zgodic A, Edward JS, Hill LN, Davis MM, et al. Financial hardship among rural cancer survivors: An analysis of the Medical Expenditure Panel Survey. Prev Med (Baltim). 2019;129. \u003c/li\u003e\n\u003cli\u003eRitter J, Allen S, Cohen PD, Fajardo AF, Marx K, Loggetto P, et al. Financial hardship in families of children or adolescents with cancer: a systematic literature review. Vol. 24, The Lancet Oncology. 2023. \u003c/li\u003e\n\u003cli\u003eAlzehr A, Hulme C, Spencer A, Morgan-Trimmer S. The economic impact of cancer diagnosis to individuals and their families: a systematic review. Vol. 30, Supportive Care in Cancer. Springer Science and Business Media Deutschland GmbH; 2022. p. 6385\u0026ndash;404. \u003c/li\u003e\n\u003cli\u003eLentz R, Benson AB, Kircher S. Financial toxicity in cancer care: Prevalence, causes, consequences, and reduction strategies. Vol. 120, Journal of Surgical Oncology. John Wiley and Sons Inc.; 2019. p. 85\u0026ndash;92. \u003c/li\u003e\n\u003cli\u003eMin HS, Yang HK, Park K. 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Policy Design and Practice. 2019;2(1):1\u0026ndash;14. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cancer, policy evaluation, RE-AIM framework, Completing Cancer Treatment Incentive (CCTI), financial incentive, policy implementation","lastPublishedDoi":"10.21203/rs.3.rs-4580048/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4580048/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eCancer diagnosis imposes a significant economic burden on healthcare systems, patients, and their families. Technological advancements in cancer detection and treatment, leading to improved cancer detection rates and increased treatment uptake, have intensified this burden particularly among the economically disadvantaged. Despite efforts like universal health coverage and financial assistance programs, challenges persist in addressing the financial impact of cancer on patients.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eUsing qualitative methods, the study explores cancer patients\u0026rsquo; experiences with the Completing Cancer Treatment Incentive (CCTI) in Malaysia. Interviews were conducted with both CCTI recipients and non-applicants from eight public hospitals. The RE-AIM framework was employed to evaluate dimensions such as reach, adoption, and implementation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003ePatients\u0026rsquo; awareness of CCTI varied, with recipients mostly informed through acquaintances, media, or healthcare providers. Non-recipients lacked awareness, with limited information provided by healthcare personnel. CCTI was viewed positively by recipients, particularly for easing transportation costs, but challenges in the application process were evident. Patients faced difficulties navigating complex procedures, redundant health screenings, and limited communication about application progress.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe study highlights the need for improved implementation of CCTI to mitigate financial burdens on low-income cancer patients. Simplifying application processes, enhancing information dissemination, and addressing challenges such as redundant health screenings are crucial. The findings underscore the importance of proactive measures in policy implementation to improve CCTI effectiveness and accessibility for low-income cancer patients.\u003c/p\u003e","manuscriptTitle":"Assessing Healthcare Pathway through patient experience with Completing Cancer Treatment Incentive (CCTI) Program for Low-Income Populations in Malaysia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-16 21:57:17","doi":"10.21203/rs.3.rs-4580048/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-19T08:36:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-19T04:56:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-19T04:55:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-06-14T06:56:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1615cb35-de31-42ff-9670-1e837105bf58","owner":[],"postedDate":"July 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T16:07:43+00:00","versionOfRecord":{"articleIdentity":"rs-4580048","link":"https://doi.org/10.1186/s12913-025-12544-9","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-03-26 15:56:54","publishedOnDateReadable":"March 26th, 2025"},"versionCreatedAt":"2024-07-16 21:57:17","video":"","vorDoi":"10.1186/s12913-025-12544-9","vorDoiUrl":"https://doi.org/10.1186/s12913-025-12544-9","workflowStages":[]},"version":"v1","identity":"rs-4580048","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4580048","identity":"rs-4580048","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}