Applying the Three Delay Model for Non-communicable diseases: lessons learnt from emergency department admissions in Peru

Applying the Three Delay Model for Non-communicable diseases: lessons learnt from emergency department admissions in Peru | 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 Article Applying the Three Delay Model for Non-communicable diseases: lessons learnt from emergency department admissions in Peru De La Cruz-Saldaña Tania, Portocarrero Jill, Pérez-León Silvana, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7257280/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract In many low- and middle-income countries, people with diabetes and hypertension lack timely, quality healthcare and often turn to overcrowded emergency departments (ED). This study explored experiences and barriers to care among adults with type 2 diabetes mellitus (T2DM) or hypertension (HT) admitted to a public emergency department. We conducted a hospital-based study including questionnaires, 3-month follow-up calls, and semi-structured interviews. Questionnaires collected sociodemographic characteristics, medical history, medication, hospitalization details, and discharge indications. Interviews, analyzed through the Three Delays framework, explored prior healthcare experiences, disease knowledge and perception, and care facilitators and barriers. A total of 189 adults with T2DM and/or HT were surveyed; mean age was 60.8 (SD 13.7), with 50.3% male. Of these, 62.4% did not seek care periodically and 33.7% missed follow-up appointments. Twenty interviews revealed recurring delays due to previous negative experiences, poor disease awareness, excessive costs, time and transportation constraints, and insufficient supplies. People with chronic conditions face repeated delays and difficulties navigating the health system, often reaching care only in emergency situations. These findings call for targeted interventions to improve lower levels of care to break these cycles, reduce ED burden, improve continuity and ensure sustainable management of chronic conditions. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research hypertension diabetes mellitus emergency service mixed methods Figures Figure 1 INTRODUCTION The burden of non-communicable diseases (NCDs) in low- and middle-income countries has increased over the last two decades.(1,2) Beyond biological factors, health systems vulnerabilities and social inequalities significantly impact NCD-related morbidity and mortality.(2–5) Health system associated factors can act as barriers for access to care at all levels, but this is especially true for primary health care.(5–8) Critical problems identified such as, incompatible health information systems, bureaucratic referral processes, limited infrastructure, scarce culturally grounded interventions, frequent out-of-pocket costs, ill-equipped or low-quality services and workforce, have been described as barriers.(4,5,9) These compromise the continuity and delay access to care of people living with chronic conditions. Cardiovascular diseases and hypertension (HT), obesity and type 2 diabetes (T2D) are among the most frequent causes of health seeking behavior at tertiary levels in Peru. (10) This is both due to limited access to periodic care as well as delayed access to the services they need resulting in people with NCDs often arriving late and with complications to the overloaded and under resourced emergency services. (11,12) The delay in care can be understood by breaking down the process in which the patients decide to seek care within the health system. These delays can be due to a variety of population and disease-related factors. These population elements include educational level, income, insurance, geographical distance to the nearest health center. (13) The perception of illness, disease beliefs, attitudes and previous experiences with health systems can also lead to delays. (14–16) The Three Delays Framework, originally developed to explain the varied factors that influence the delay in obstetric care, can be helpful to identify the factors of delayed care for other health conditions. (17) This framework explains the delays from three perspectives: a delay in the decision to seek care, the delay in reaching a medical facility and the delay in receiving adequate treatment. To better understand the three-delays and how they relate to non-communicable diseases a mixed method approach was used to explore the barriers that prevented people with T2D and HT from receiving efficient and timely access to the public health system and ended at the emergency department and their experiences during this admission. We explored their characteristics and perceptions of the health system from the scope of the Three Delay framework. RESULTS We approached 519 potential participants between 2017 and 2018 in the ED of a public hospital, 189 were eligible and agreed to participate. The mean age was 60.8 (SD 13.7) and 50.3% were male. Out of the 189 included, we interviewed twenty participants; twelve had a diagnosis of T2D, four had HT and four had both conditions. Other characteristics are available in Table 1. The information from the surveys and interviews will be presented in together in the following three sections using the Three Delays model. Delay in deciding to seek care Out of all participants, we found that 33.7% did not seek care in the previous year; only 14.1% attended a primary care establishment for HT or T2D control. Also, 62.4% did not seek care periodically even when having a chronic condition. (Table 2) Through the interviews, we recognized that patients were hesitant to seek care for two reasons: poor disease awareness and previous negative experiences with the health system. Their negative experiences included unpleasant interactions with healthcare personnel; the perception of being mistreated, previous experiences that generated distrust in the care received that made them reluctant to visit the ED again. These negative experiences were related to care at the ED; however, they were experienced at different primary care and, less frequently, in private care. Patient (P): (…) that´s why they didn´t want to bring me here because we had a bad experience with one of our sisters, who died here. She came with a problem in her kidneys, some nurse assistants came by the emergency, they said they wanted to take something out of her lungs, but they left her in a coma.” (JRSD14 – hospitalized for 7 days). Most of the interviewed patients knew they had T2D and/or HT for at least two years, some for more than 20 years. Despite living with a chronic condition for a long time most of them lacked a clear knowledge of how to manage it. Questions like ‘why the disease does not have a cure’ or ‘how could they control the disease’ were commonly expressed during the interviews. Only three of the twenty patients expressed having no doubts about their diseases. “Interviewer (I): Is there anything left unclear about diabetes? Any doubts? P: Yes, why is this disease transmitted? Why do we get this disease? I: Have you had any chance to ask this to a doctor in the hospital? P: No” (D5: BLQD07 - hospitalized for 17 days) “P: Doctors don´t tell you anything, nurses tell using words that one doesn´t understand.” (D18: CPVDH09 – hospitalized for 30 days) A third of the patients expressed they received an insufficient explanation or none of the reasons for their admission to the ED or their status. Some patients had trouble distinguishing non-serious situations that did not require going to the ED but that did require visiting a doctor, such as elevated levels of blood glucose, low risk foot lesions or going frequently to urinate. “Before coming to the ED, I would take water, tea or anise and I would immediately need to go urinate (…) I do not know if it was due to the medicines or because I was worried.” (D6:LRAD05- hospitalized for 2 days) For others, going to the ED was the “usual” procedure to get check-ups; they already knew they could get their glucose measured and receive a prescription for their medicine more quickly, partly because their access to ambulatory care services was limited. “Each time I asked for an appointment with the doctor they told me it was not available (…) one gets tired. The months passed by, and I felt bad and would come back to emergency. (…) They would stabilize and would tell me to ask for an appointment, but I never found any appointment available and that is how I let the years go by” (D9:MB5D02- - hospitalized for 2 days) Delay in reaching an adequate health care facility Reaching an appropriate health facility requires participants to navigate several barriers like long distance to healthcare facility, time constraints or high transportation costs. Individual experiences also play a role in this delay. Patients often expressed distrust in the public system because of previous experiences and explored other options like private healthcare providers. However, those who went to private clinics also expressed dissatisfaction with the care received, either because they perceived little or no improvement after the treatment received or because they could not afford it. As a result, some participants were left with the decision to return to the public hospital. One of them remarked that the budget for a heart procedure at the clinic was close to US$ 12,000 (PEN 40,000). This information made him dismiss the procedure and wait for the facilities that the public hospital could provide regardless of the long waiting time. “I went to a clinic, what they see is one´s economic situation. Suddenly, they told me everything cost 40 thousand soles. I mean, they practically let you on the verge of decompensating even more, that is why I did not return there anymore and had to come again to this hospital and keep waiting.” (MVCD1 – hospitalized for 2 days) Additionally, although 86.8% of survey respondents reported having public insurance (Table 1), its use was inconsistent. Survey results reflect what interviewees also described: they do not use their insurance for medications and seek care through a mix of public and private services. Interestingly, they are somewhat more likely to use their insurance for laboratory tests. This may be because such tests are more expensive or because they are often associated with emergency or inpatient care. Transportation presents a challenge as well. Participants reported that getting to the hospital meant an extra expense. In Peru, public transportation is not implemented with facilities for older adults; it is of low quality and high stress. Patients often prefer or need to pay for taxis and prioritize the emergency visit where they can guarantee they will be treated even though they have to wait. Even when some patients wished to attend outpatient services, they could not afford the transportation to their appointments and would prioritize spending – and waiting – only for emergencies. Caregiver(C): “(…) our appointment was for a week ago. It has been 8 days, let´s say, tomorrow. But we haven´t come for financial reasons, taxi fare.” P: It´s just that I have to come in a taxi, I can´t come on a bus.” (CSCh06 – hospitalized for 10 days Another challenge is the time they must invest, 49.7% of the participants takes at least an hour to get to the hospital, even when most participants (93.7% of the total sample) have primary care facilities in less than a 30-minute distance, experiences with primary care were hardly mentioned and going to the hospital seemed to be preferred. Additionally, it was common patients would point out that finding an appointment was an arduous process that sometimes would require several visits to the hospitals or the help of a family member. Some patients would point out that this would discourage them from looking for ambulatory appointments. Delay in receiving adequate care at the facility (ED) Once at the ED, two problems seemed to recur: shortages and overcrowding. Participants explained it was frequent that the ED had insufficient medical supplies. A patient told us that on one occasion the health workers did not assist her to the bathroom because there were no gloves available. P: “(about the difficulties of mobilizing) Oh because there was no one, they told me I had to buy gloves and then they were not in the obligation to take that off. (…) (So), I took it off, I stood up and took everything off (…) and went to the bathroom safely, thank goodness.” (EPCDH16 – hospitalized for 3 days) Along with insufficient supplies, the available health care staff also were insufficient. Getting prompt evaluations, consultations by specialties or timely administration of treatment were challenges mentioned by patients attending the emergency department, posing delays, and risking adequate care. C: “She complained that she wasn´t better because we would leave her prescription medication and they wouldn´t administer it on time. (…) I bought a glove and until Saturday it was there and they didn´t use it.” (VMCD04) P: “Since yesterday at approximately ten in the morning, and they should have made the consult, the traumatologist should have already seen me. Now it is approximately 10:30 in the morning and the traumatologist hasn´t seen me, they haven´t taken me to traumatology.” (ACRD13 – Hospitalized for 2 days) Laboratory testing at the hospital could be troublesome. Some tests are not available, or results may take several days, so some respondents opted to pay for private laboratories services. Being insured (86.8%) does not ensure access to medications and laboratory tests they require for treatment and diagnosis. In both interviews and surveys, they reported out of the pocket expenses for medications (61.4%) or laboratory tests (18.4%). Causing delays and economic and psychological hardships, many expressed concerns of not having enough money to pay these extras and become a burden for their families. P: “what is missing these last months is medication, so then one has to buy it outside.” (D 1: CJBD08 – hospitalized for 22 days) “I feel impotent, money makes everything, they don’t think about our pockets (…), I don´t know how my kids are going to be able to afford this. I don´t show that I´m feeling bad in front of them, but it makes me sad that they have to come every day to buy medicine.” (NCAH18 - hospitalized for 4 days) C: “there are tests that are not here, and you have to look for them outside. (...) Well, there are tests that also take a long time for the national public insurance (SIS) , such as the test they have to do to him; they tell you that they do not know when is going to be ready, (…) I think that the test he needs is important for them to see what part of the heart is not working; (...) they tell us that it will delay, they do not know when it will come out. (TPSDH011 – hospitalized for 5 days) The permanent state of overcrowding in the ED naturally causes limited space for patients. All participants interviewed said they waited a long time – days even – for a stretcher and in the meantime, they were sitting on chairs or benches. P: “A gurney, yes I´ve always had that problem, two or three days and my family has always tried to find it, sitting on a wheelchair or bench… that always happens.” (CJBD08 – hospitalized for 22 days) In reaction to the overcrowding, other non-health related staff would step over and try to contain the flow of patients, often wrongly. A testimony of a patient explains how she was denied entrance to the ED by the security staff that did not recognize a visible emergency. P: “They wouldn´t let me in, If he didn´t see me like this, the security told me ¨the lady is not very ill, let her wait¨ (…) and my brother, since he was upset by what he saw said ¨how are you not going to let me in, let me in, my sister is ill, my sister is ill¨ the lady is not too ill, how do you know? You are not a doctor, but then they let me in and took care of me.” (NCAH18 – hospitalized for 4 days). There is an evident barrier of communication, patients perceive they are often provided with insufficient or unclear information about the procedures they would receive, and they go to one service to another, they feel the information many times could be confusing and unhelpful. In the questionnaires we found that 64.8% knew their diagnosis and indications and 73.8% had a reference to their PHC at discharge. (Table 2) “At the beginning they didn’t want to treat me, they sent me to outpatient services, and from there they would send us back to ED where I did not receive care. I went back and forward several times. (…) Then someone from the security staff saw my foot and saw it was black. It is then that I was treated in ED, a doctor told me I was going to be taken care off.” (EPCDH16 – hospitalized for 3 days) After the ED discharge, patients must go through many bureaucratic procedures to get treated by a medical specialist as an outpatient or wait a long time for an available appointment after being treating in ED. Overall, the lack of appointments and drawn-out bureaucratic procedures leave patients sorting multiple barriers that let them to a sub optimal care or back to the ED. “I: So, is it difficult to follow treatment? P: Sure, well if there is a treatment that will be for my health, I will have to find a way to come, look for someone, however the reality is. What makes me angry is that here they give you appointments from one month to the other, when I’m dead already. C: We came here to the hospital on October 22nd or 23rd; it was to have her gynecology treatment, the test. We go to the admissions office, and they say ¨oh ok, your appointment is for the end of December¨ they tell us, until then the patient is dead (…). That is the problem, they don’t see you and when the appointment comes, the doctor comes back and says you have to take the ultrasound first, or something.” (NCAH18 – hospitalized for 4 days) After the 3-delays: Challenges post-discharge Around 33.8% (Table 3) of participants did not attend follow up control within the three months after discharge. Some participants expressed their willingness to continue follow-up as an outpatient but since they must wait weeks or months for appointments, they often preferred to bypass the system and come directly to the ER again. We found attendance to their appointments at 3 months after discharge was associated to the number of diseases, 52.5% of participants that attend to their appointment have one disease in comparison to 79.2% of participants that have 3 or more diseases. Also, people with previous periodic contact (every three months in the previous year to the hospitalization) with the system had more attendance to their appointment at 3 months after discharge in comparison with those without previous contact but this difference was not significant (74.2% vs. 60.7%, p=0.08) (Supplementary Table S1) During follow-up three months after discharge, 9.9% of the participants did not have health insurance, 66.2% had attended their appointment to the PHC or hospital and most of them went to the public hospital. Also, 9.6% of the participants died during the follow-up period. The Patient Journey The patient’s pathways are not linear; delays interact and repeat in a complex cycle. (Figure 1) Some of the reasons that perpetuate this cycle can be understood also looking at what happens after the discharge. Through the interviews we were also able to recreate the paths that each patient took. Each person interviewed described the previous steps they had to take before reaching the ED. Interviewees reported "bounces" within the system, some paths repeated more frequently and formed loops. We found that fifteen out of the twenty interviewed made at least three trips before receiving adequate care for their present health event. We simplified these patterns in Figure 1. Loop 1 describes the cycle between the emergency room and private consultation. Patients that seek care in private services can bounce between these two, seeking the ER for emergencies or procedures and private services for follow-up. Loop 2 describes the cycle between the public consultation and the ER. These patients are seen often at the ER and once discharged face delays in reaching the public consultation and finally returning to the ER. This is the most frequently referred loop representing those who after discharge to EMG return to EMG repeatedly for the same problem. Loop 3 describes the patients that after been hospitalized in a medicine floor, return to the ER, often because of lack of follow-up. DISCUSSION Using the framework of the Three delays, we were able to classify the barriers reported by the patients in three moments: when deciding to seek care, when arriving at the health care facility, and when receiving adequate care. When exploring the first delay, we found that most participants recall having a bad experience with the health system, especially with the public health system, they also express a lack of knowledge about their diagnosis and its implications. When exploring the second delay, they faced multiple barriers for reaching a care facility including distance and transportation costs that lead them to seek care in the private sector, this often implies higher costs that causes them to return to the public system. There is also the notion that private services are better than public. Finally, on the third delay, participants faced a health system not being ready to respond to their needs. That was evident in the lack of medical supplies or insufficient health care staff. Qualitative and quantitative findings showed these barriers often overlap and strengthen each other creating a vicious cycle that patients must navigate to receive care. Previous studies have illustrated the difficulties that patients face during their search for care in different contexts.(22–24) In our study we focused on the barriers that led patients to the ER. The most prominent finding in our study was the previous bad experiences, which can be an indirect measure of the quality of care in the health care system. (25,26) The chronic patient strongly perceives that the quality of care they receive is low. Previous studies have described that a perceived high quality of care and trust -interpersonal or institutional- are strong drivers for seeking care, maintaining adherence and overall, a more positive patient experience.(27,28) In contrast, some participants seemed satisfied with the emergency care. One explanation may be that in the emergency department many finally “find the solution” to their health problem.(29) It is interesting that most of the bad previous experiences told by the participants are not necessarily related to the ER, which could also explain the apparent preference towards the ER. Other studies describe that in populations where the quality of health is low, the patient’s expectation of quality is also low which could explain a better perceived experience. (25) Reaching the ER was perceived as time consuming, troublesome and costly but often as the only feasible option for accessing health care in certain medical scenarios.(30–32) There is a constant push and pull between getting worse and going to “find a solution” and postponing care to reduce costs and time invested, most often time away from work or family responsibilities. This “dance” inevitably leads to complications of the chronic condition, complicating treatment, extending hospitalizations, and possibly endangering the health of patients. The patient with chronic conditions repeatedly faced the multiple resources shortages of the emergency department. These shortages are mostly caused by overcrowded services, administrative and/or financial problems.(33) As a result, the emergency department experience is perceived as confusing and chaotic, driving patients to seek alternatives in health care subsystems outside the public system, such as the private system or using strategies to compensate for the lack of supplies in the public sector. This search for alternatives carries out-of-pocket (OOP) costs. (32) The final challenge is how to shift the ED discharge to become a patient engagement tool rather than the start of the next loop. Breaking the cycle goes beyond what hospital policies alone can do, this requires the involvement of stakeholders to address, for example, the multiple bureaucratic barriers, operational barriers like supply management, or the overdue and delayed empowerment of primary healthcare facilities as the first point of contact that can respond readily and timely to patient demand and, most importantly promote knowledge and prevention. Although originally developed for maternal health, the Three Delays Model offers valuable insights into the challenges faced by patients with chronic diseases. Like childbirth and obstetric emergencies, chronic conditions can lead to acute complications where timely care is critical. The model allows us to analyze delays in seeking, reaching, and receiving care—key moments that influence health outcomes in both acute and chronic settings. Understanding these delays can help design interventions that break repetitive barriers, enhance continuity of care, and make health systems more proactive rather than reactive. The barriers we expose in this article are well known and have been previously described, meaning they are abundantly prevalent worldwide.(34–36) Because these barriers overlap and reinforce each other, addressing them separately can be challenging. However, their similarity to those seen in other conditions, such as mental health, indicates that progress in these areas could meaningfully improve overall patient care. (37–39) These results are from the pre pandemic context, as for the current situation of the person with chronic diseases can be critical and the aftermath of the pandemic will require intense intervention to rebuild the care of other diseases that have been displaced, this can also be an opportunity to reorganize and strengthen health care systems in the future. Especially since the pandemic has limited the patient's ability to go to health facilities in person, this presents the opportunity to create alternatives so that the health system can go to the patient and offer quality care through patient-centered design health care systems. We used the Three delay model as a way of facilitating the understanding of the complex journey towards care for patients with chronic conditions. The use of the model has limitations because it proposes a more ‘linear’ journey. However, simplifying the delays could serve as a starting point to propose solutions and understand that some factors affecting care of patients with chronic conditions are outside of the scope of just improving health care services (i.e. Distances), delays caused by the bad perception of the public system (first delay), or lack of supplies (third delay). The different challenges can be more readily understood and -possibly- addressed implementing initiatives to improve the experience of patients and improve empathetic care.(40–42) The confusion, miscommunication and lack of knowledge often reported could be improved with effective communication skills training for healthcare providers. A bigger challenge is addressing overflow and the discouragement of the use of emergency services. This is closely linked to the betterment of the primary care, and possibly the implementation of more creative solutions that promote the decentralization of care out of the bigger hospitals like telemedicine or community-based interventions. The limitations of our study were the identification of delays before reaching the ED, the participants focused more on their present experience than on previous ones making it difficult to recall what happened to them at primary care level or in previous attempts to use the ambulatory services at hospitals. We indirectly measured factors related to the system like available medication or tests and did not delve into other critical issues such as health personnel training or information or referral systems; however, we found it evident that the system is not currently responding efficiently in providing timely and quality care. This hospital-based study gives insights into the experiences of patients with chronic conditions that eventually reached the ER after many attempts to access health care, providing us with a thorough view into the failures at different levels of the health care system. Future research can expand on these results by exploring rural settings or critically ill patients, where delays may be even more pronounced. CONCLUSION This study provides valuable insights into the delays to access healthcare for patients with chronic conditions, highlighting the barriers faced by them before eventually reaching emergency care. Using the Three delay framework, our findings provide a basis for understanding how and where these delays in care occur which can be instrumental for designing future interventions. The COVID-19 pandemic offered a view in the critical role of timely access to care and facing increased care demands in times of crisis, lessons learned from that period should be considered for future interventions. Future research could explore rural areas and critically ill patients, where barriers to care may be even greater. METHODS Study design, setting and participants The study was conducted at the ED of a public hospital in Lima, Peru between 2017 and 2018. About 90% of the people who come to this ED come from the northern part of Lima where the poverty belts are located. This ED receives around 6 000 patients a month and gives about 16000 inpatient discharges per year. The last situation analysis from 2023 found that the ED receives 10 000 patients with a similar number of discharges than 2018. (18–20) We considered it important to include people from the ED, where we expected to find the "worst scenarios" from people who lack access to other non-urgent care. Using a mixed methods observational study, we carried a qualitative approach with semi-structured interviews and a quantitative approach with a short questionnaire and a follow-up call at 3 months after discharge. We included adults (> 18 y) with confirmed type 2 diabetes and/or hypertension whose primary reason for ED admission was decompensation or acute complications of T2D or HT. We excluded individuals in critical condition, unresponsive, and those whose primary reason for emergency admission was not related to HT or T2D. Eligibility criteria were the same for both qualitative and quantitative approaches. Interviews Semi-structured interviews were conducted between October 2017 and January 2018 by a trained psychologist with some experience doing interviews, most of them were conducted during hospital stay and some had to be scheduled post-discharge (for the convenience of the participant). The interview guide was designed by one physician, one sociologist and one psychologist with expertise in qualitative methods and the guide was organized to explore previous experiences and interaction with health care services, knowledge and perception of their disease, and facilitators and barriers in the care of their disease. We used purposive sampling methods. We estimated information saturation at a sample of twenty interviews. Questionnaires Interviews were conducted between October 2017 and August 2018. They were administered face-to-face by a researcher during hospitalization at the ED or the medicine ward. The questionnaire included a baseline assessment and a 3-month follow-up. The baseline assessment collected information on sociodemographic characteristics, medical history, medication, cause of hospitalization, hospitalization time, indications to discharge and prognosis at discharge. And follow-up phone call was made 3 months after the discharge to collect data about changes in insurance status, access to post-discharge health services and evolution of the disease and complications. The questionnaires were reviewed by the research team to ensure data quality and then coded without personal identifiers. For sample estimation, we used previous data of the proportion of people with chronic diseases who do not seek medical attention nationwide (21), resulting in a sample size of 185 participants with an accuracy of 7% and a confidence level of 95%. Analysis Qualitative The interviews were audio recorded and transcribed verbatim. Qualitative data from the transcripts were coded using the software Atlas.ti version 8 in an iterative process by one sociologist and one psychologist that participated in the interview guide designed. The interviews were analyzed using the Three Delays model framework proposed by Thaddeus and Maine. (17) The results presented in this manuscript are organized using the three phases of the Three Delays model to understand chronologically the experiences and barriers to seek care and access healthcare services of the patients admitted to the emergency department (ED). The results have been structured in three sections: Delay 1: refers to all the personal or family factors that delay the decision to seek care, including distance, costs, the perceived quality of care, the perception of the illness, economic and educational status. Delay 2: refers to all the factors or situations that delay reaching an adequate health care facility, including the geographical distribution of the facilities, travel distances, transportation availability and cost. Delay 3: refers to relevant factors that delay receiving adequate care at the facility, including ill-staffed or ill-equipped facilities, incorrect management at the facility. Quantitative The initial analysis was descriptive, mean, and standard deviation was estimated for quantitative variables like age whereas frequency and percentages were estimated for categorical variables like access to post-discharge health services. Additionally, the risk ratio was calculated using Poisson regression considering access to post-discharge health services as outcome and number of diseases and periodic contact with the health system as exposures adjusted by age and gender. Ethical issues Study procedures were conducted in full compliance with the Declaration of Helsinki and relevant regulations, and approved by the Institutional Review Board of Hospital Cayetano Heredia, Lima, Peru prior to its execution. The participants were duly informed verbally of the objectives and procedures of the study as well as its risks and benefits. Written informed consent was obtained from all participants prior to their participation. All participants’ personal data, including audio recordings and transcriptions, were anonymized using coded identifiers and handled exclusively by the study researchers. Declarations Acknowledgments We gratefully acknowledge Meryliz Alonso, Korali Santiago and Patricia Busta for their support in data collection. Authors' contributions statement T.D.(first author) contributed with protocol and study design, supervised and coordinated the fieldwork, led the qualitative analyses, interpreted the findings, and drafted the manuscript. S.P. provided qualitative methodological support, led qualitative analyses and interpretations, and contributed to the writing of the results. J.P. assisted with qualitative analyses, interpretation, and results writing. G.M. contributed to study design, protocol development, data interpretation, and final manuscript approval. D.B. provided supervision, contributed to data interpretation, and critically revised the draft. M.L. supported the design and methodology across all stages, participated in analysis and interpretation, and critically revised and approved the final manuscript. All authors approved the manuscript for publication. Additional information Competing interests statement The authors declare no competing interests. Availability of data and material The authors confirm that the data supporting the findings of this study are available within the manuscript and its supplementary materials. Additional data can be requested from the corresponding author. Funding This work received partial support from the Peruvian American Medical Society (PAMS) Medical Education & Research Fund. The funder had no role in study design, data collection, data analysis, decision to publish, or preparation of the manuscript References Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2021 (GBD 2021) Results (2024, Institute for Health Metrics and Evaluation – IHME) [Internet]. [cited 2025 Jan 27]. Available from: https://vizhub.healthdata.org/gbd-results/ Schutte AE, Srinivasapura Venkateshmurthy N, Mohan S, Prabhakaran D. Hypertension in Low- and Middle-Income Countries. Circ Res [Internet]. 2021 Apr 2 [cited 2025 Feb 19];128(7):808–26. Available from: https://www.ahajournals.org/doi/10.1161/CIRCRESAHA.120.318729 The Lancet: Latest global disease estimates reveal perfect storm of rising chronic diseases and public health failures fuelling COVID-19 pandemic | Institute for Health Metrics and Evaluation [Internet]. 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Lima: Ministerio de Salud Centro Nacional de Epidemiología, Prevención y Control de Enfermedades (CDC); 2019. Turner H), Coster JE, Chambers J. Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review. ACADEMIC EMERGENCY MEDICINE [Internet]. 2015 Sep 1 [cited 2021 Apr 5];3(43):1137. Available from: https://doi.org/onlinelibrary.wile Kartschmit N, Beratarrechea A, Gutiérrez L, Cavallo AS, Rubinstein AL, Irazola V. Health care access and health-related quality of life among people with diabetes in the Southern Cone of Latin America—a cross-sectional analysis of data of the CESCAS I study. Quality of Life Research. 2020; Vargas I, Mogollón-Pérez AS, De Paepe P, Ferreira da Silva MR, Unger JP, Vázquez ML. 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Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4100460/ Devi R, Kanitkar K, Narendhar R, Sehmi K, Subramaniam K. A Narrative Review of the Patient Journey Through the Lens of Non-communicable Diseases in Low- and Middle-Income Countries. Adv Ther [Internet]. 2020 Dec 1 [cited 2025 Feb 19];37(12):4808–30. Available from: https://link.springer.com/article/10.1007/s12325-020-01519-3 Hashemi G, Wickenden M, Bright T, Kuper H. Barriers to accessing primary healthcare services for people with disabilities in low and middle-income countries, a Meta-synthesis of qualitative studies. Disabil Rehabil [Internet]. 2022 [cited 2025 Feb 19];44(8):1207–20. Available from: https://www.tandfonline.com/doi/abs/10.1080/09638288.2020.1817984 Gleeson H, Calderon A, Swami V, Deighton J, Wolpert M, Edbrooke-Childs J. Systematic review of approaches to using patient experience data for quality improvement in healthcare settings. BMJ Open [Internet]. 2016 Aug 1 [cited 2025 Feb 19];6(8):e011907. Available from: https://bmjopen.bmj.com/content/6/8/e011907 World Health Organization News. Evolving a people-centred approach to noncommunicable disease (NCD) services in Bhutan [Internet]. 2022 [cited 2025 Feb 19]. Available from: https://www.who.int/southeastasia/news/feature-stories/detail/Evolving-a-people-centred-approach-to-noncommunicable-disease-NCD-services-in-Bhutan Afulani PA, Getahun M, Ongeri L, Aborigo R, Kinyua J, Ogolla BA, et al. A cluster randomized controlled trial to assess the impact of the ‘Caring for Providers to Improve Patient Experience’ (CPIPE) intervention in Kenya and Ghana: study protocol. BMC Public Health [Internet]. 2024 Dec 1 [cited 2025 Feb 19];24(1):1–13. Available from: https://link.springer.com/articles/10.1186/s12889-024-20023-9 Tables Table 1. General Characteristics Surveys Interviews N=189 N=20 Age , mean (SD) 60.8 (13.7) 58.5 (10.8) Gender Male 95 (50.3%) 9 (45.0%) Female 94 (49.7%) 11 (55.0%) Education level (*) None 12 (6.4%) 0 Elementary/middle school 50 (26.6%) 3 (15.0%) High school 95 (50.5%) 13 (65.0%) Further education 31 (16.5%) 4 (20.0%) Source of Income Unemployed 102 (54.0%) 9 (45.0%) Employed/Retiree 87 (46.0%) 11 (55.0%) Comorbidities None 75 (39.7%) 8 (40.0%) One disease 57 (30.2%) 3 (15%) 2 or more 57 (30.1) 9 (45%) Insurance None 23 (12.2%) 3 (15.0%) Public (SIS/ESSALUD) 164 (86.8%) 16 (80.0%) Private 2 (1.0%) 1 (5.0%) (*N=188, one missing data) Table 2. Health care delivery burden (N=189) N (%) Seek healthcare in the previous 12 months Yes 122 (66.3) No 62 (33.7) Have a caregiver Yes 92 (49.2) No 95 (50.8) Place where participant seek care for NCD management Public tertiary care (MINSA/ESSALUD) 80 (43.2) Public primary care 26 (14.1) Private only 20 (10.8) Public and private system 59 (31.9) Seek healthcare in the hospital More than once a month 7 (3.7) Once a month 23 (12.2) Once every two or three months 41 (21.7) Rarely 118 (62.4) Place of medication delivery Public Insurance (SIS/ESSALUD) 29 (15.3) Out-off-pocket (partial or entirely) 160 (84.7) Place of laboratory or another test performed Public tertiary care (MINSA/ESSALUD) 124 (67.0) Public primary care 4 (2.2) Private 23 (12.4) Public and private system 34 (18.4) NCD: Non- communicable disease (HT or T2DM) Time to the nearest PHC Less than 10 minutes 120 (63.5) Less than 30 minutes 57 (30.2) 1 hour 6 (3.2) Did not know the nearest PHC 6 (3.2) Time to arrive to the hospital Less than 10 minutes 10 (5.3) Less than 30 minutes 85 (45.0) 1 hour 77 (40.7) 2 hours or more 17 (9.0) Knowledge of discharge diagnosis Yes 103(64.8) No 56 (35.2) Knowledge of indications at discharge Yes 103 (64.8) No 54 (35.2) Reference to the PHC Yes 116 (73.8) No 41 (26.2) Table 3. Follow-up at 3-months after discharge N (%) Insurance None 15 (9.9) Public Health Insurance (SIS) 130 (86.1) Social security insurance 4 (2.7) Private 2 (1.3) Seek care after discharge Yes 100 (66.2) No 51 (33.8) Seek care for reasons different to NCD Yes 54 (38.9) No 85 (61.1) Place where seek care Public hospital 38 (27.7) Public PHC 2 (1.5) Social security PHC 3 (2.2) Private 12 (8.8) Not applicable/No response 82 (59.9) Death Yes 16 (9.6) No 150 (90.4) NCD: Non- communicable disease (HT or T2DM) Additional Declarations No competing interests reported. Supplementary Files SupplementaryTableS1.docx SupplementaryTableS2.xlsx Cite Share Download PDF Status: Posted Version 1 posted 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. 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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-7257280","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":559594162,"identity":"0ecac6c1-4b7b-47aa-9479-699203288d06","order_by":0,"name":"De La Cruz-Saldaña Tania","email":"","orcid":"","institution":"Cayetano Heredia University","correspondingAuthor":false,"prefix":"","firstName":"De","middleName":"La Cruz-Saldaña","lastName":"Tania","suffix":""},{"id":559594163,"identity":"332f9269-b6d1-4dad-8ac6-ff811428cb6f","order_by":1,"name":"Portocarrero Jill","email":"","orcid":"","institution":"Cayetano Heredia University","correspondingAuthor":false,"prefix":"","firstName":"Portocarrero","middleName":"","lastName":"Jill","suffix":""},{"id":559594164,"identity":"d8ea4005-dd9d-4970-8150-884ca990da32","order_by":2,"name":"Pérez-León Silvana","email":"","orcid":"","institution":"Cayetano Heredia University","correspondingAuthor":false,"prefix":"","firstName":"Pérez-León","middleName":"","lastName":"Silvana","suffix":""},{"id":559594165,"identity":"36aa8535-fa1d-4326-b0a3-a2004cbf61e2","order_by":3,"name":"Malaga German","email":"","orcid":"","institution":"Cayetano Heredia University","correspondingAuthor":false,"prefix":"","firstName":"Malaga","middleName":"","lastName":"German","suffix":""},{"id":559594166,"identity":"174c6b78-e22e-47a3-851b-02b446f71546","order_by":4,"name":"David Beran","email":"","orcid":"","institution":"University Hospital of Geneva","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"","lastName":"Beran","suffix":""},{"id":559594167,"identity":"0c919e2a-2455-44a6-9d61-cb7fa4e338d7","order_by":5,"name":"Lazo-Porras Maria","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYJCCAwwMFkCK+QCETaQWCSDFlkC8FgaIFh4D4rTotp99eOAHg4S8fHvPN+mCmjsM5uwN+LWYnUk3ONjDIGHY2HN2m/SMY88YLHsI2GR2II3hAA+DBGOzRO42ad6GwwwGNxIIaDn/jOHgHwYJ+zaJnGcQLfcfENByI43hMNCWxB6JHDaoLfh1ALU8YzgsYyCRPIPnmLH1jGOHeSx7CDosjfnjmwob2/ntzQ9vF9QcljNnP0DAGjAwgFDMDNDYIR4wI2kfBaNgFIyCUQAHAOXyQmHW+fBYAAAAAElFTkSuQmCC","orcid":"","institution":"Cayetano Heredia University","correspondingAuthor":true,"prefix":"","firstName":"Lazo-Porras","middleName":"","lastName":"Maria","suffix":""}],"badges":[],"createdAt":"2025-07-31 02:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7257280/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7257280/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":98223074,"identity":"9ed4ff9e-ec73-40cd-a763-f29a8523d92e","added_by":"auto","created_at":"2025-12-15 12:00:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":108104,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThe Patient Journey: experiences in healthcare seeking\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFigure 1 was outlined based on the descriptions of the 20 interviewees. Dotted arrows draw to reaching care at the ED for the current episode. Interviewees described numerous intermediate stops (not shown) as well as frequent repeated routes before finally accessing care. Patients were interviewed during their stay in the ED or hospitalization. Frequencies shown come from surveys data (N=189). For detailed interviewees journey refer to Supplementary Table S2.\u003c/p\u003e\n\u003cp\u003eFigure created by authors, images adapted from Servier Medical Art (https://smart.servier.com/), licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7257280/v1/2e6fe6e7fb814106959a435d.png"},{"id":100990111,"identity":"17647a43-90de-4a5f-8829-7e54077eeb5a","added_by":"auto","created_at":"2026-01-23 14:11:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1081209,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7257280/v1/641335fd-b2a9-4962-8a2d-c0088a047c99.pdf"},{"id":98223075,"identity":"9f958ec5-0bb1-41f7-8024-0c7a7a4cbc2f","added_by":"auto","created_at":"2025-12-15 12:00:48","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":16973,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTableS1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7257280/v1/190b78811ec6f04cde17ad4e.docx"},{"id":98223076,"identity":"fcdae758-edd7-4dad-97a0-d06cec55ce6e","added_by":"auto","created_at":"2025-12-15 12:00:48","extension":"xlsx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17116,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTableS2.xlsx","url":"https://assets-eu.researchsquare.com/files/rs-7257280/v1/98c5db8b8eec635cacb5a4f8.xlsx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Applying the Three Delay Model for Non-communicable diseases: lessons learnt from emergency department admissions in Peru","fulltext":[{"header":"INTRODUCTION ","content":"\u003cp\u003eThe burden of non-communicable diseases (NCDs) in low- and middle-income countries has increased over the last two decades.(1,2) Beyond biological factors, health systems vulnerabilities and social inequalities significantly impact NCD-related morbidity and mortality.(2–5) Health system associated factors can act as barriers for access to care at all levels, but this is especially true for primary health care.(5–8) Critical problems identified such as, incompatible health information systems, \u0026nbsp;bureaucratic referral processes, \u0026nbsp;limited infrastructure, scarce culturally grounded interventions, frequent out-of-pocket costs, ill-equipped or low-quality services and workforce, have been described as barriers.(4,5,9) These compromise \u0026nbsp;the continuity and delay access to care of people living with chronic conditions.\u003c/p\u003e\n\u003cp\u003eCardiovascular diseases and hypertension (HT), obesity and type 2 diabetes (T2D) are among the most frequent causes of health seeking behavior at tertiary levels in Peru. (10) This is both due to limited access to periodic care as well as delayed access to the services they need resulting in people with NCDs often arriving late and with complications to the overloaded and under resourced emergency services. \u0026nbsp;(11,12)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe delay in care can be understood by breaking down the process in which the patients decide to seek care within the health system. These delays can be due to a variety of population and disease-related factors. These population elements include educational level, income, insurance, geographical distance to the nearest health center. (13) The perception of illness, disease beliefs, attitudes and previous experiences with health systems can also lead to delays. (14–16) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The Three Delays Framework, originally developed to explain the varied factors that influence the delay in obstetric care, can be helpful to identify the factors of delayed care for other health conditions. (17) This framework explains the delays from three perspectives: a delay in the decision to seek care, the delay in reaching a medical facility and the delay in receiving adequate treatment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo better understand the three-delays and how they relate to non-communicable diseases a mixed method approach was used to explore the barriers that prevented people with T2D and HT from receiving efficient and timely access to the public health system and ended at the emergency department and their experiences during this admission. We explored their characteristics and perceptions of the health system from the scope of the Three Delay framework.\u0026nbsp;\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eWe approached 519 potential participants between 2017 and 2018 in the ED of a public hospital, 189 were eligible and agreed to participate. The mean age was 60.8 (SD 13.7) and 50.3% were male. Out of the 189 included, we interviewed twenty participants; twelve had a diagnosis of T2D, four had HT and four had both conditions. Other characteristics are available in Table 1. The information from the surveys and interviews will be presented in together in the following three sections using the Three Delays model.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eDelay in deciding to seek care\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eOut of all participants, we found that 33.7% did not seek care in the previous year; only 14.1% attended a primary care establishment for HT or T2D control. Also, 62.4% did not seek care periodically even when having a chronic condition. (Table 2) Through the interviews, we recognized that patients were hesitant to seek care for two reasons: poor disease awareness and previous negative experiences with the health system.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTheir negative experiences included unpleasant interactions with healthcare personnel; the perception of being mistreated, previous experiences that generated distrust in the care received that made them reluctant to visit the ED again. These negative experiences were related to care at the ED; however, they were experienced at different primary care and, less frequently, in private care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient (P): (…) that´s why they didn´t want to bring me here because we had a bad experience with one of our sisters, who died here. She came with a problem in her kidneys, some nurse assistants came by the emergency, they said they wanted to take something out of her lungs, but they left her in a coma.” (JRSD14 – hospitalized for 7 days).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMost of the interviewed patients knew they had T2D and/or HT for at least two years, some for more than 20 years. Despite living with a chronic condition for a long time most of them lacked a clear knowledge of how to manage it. Questions like ‘why the disease does not have a cure’ or ‘how could they control the disease’ were commonly expressed during the interviews. Only three of the twenty patients expressed having no doubts about their diseases.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Interviewer (I): Is there anything left unclear about diabetes? Any doubts?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: Yes, why is this disease transmitted? Why do we get this disease?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eI: Have you had any chance to ask this to a doctor in the hospital?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: No” (D5: BLQD07 - hospitalized for 17 days)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“P: Doctors don´t tell you anything, nurses tell using words that one doesn´t understand.” (D18: CPVDH09 – hospitalized for 30 days)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA third of the patients expressed they received an insufficient explanation or none of the reasons for their admission to the ED or their status.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSome patients had trouble distinguishing non-serious situations that did not require going to the ED but that did require visiting a doctor, such as elevated levels of blood glucose, low risk foot lesions or going frequently to urinate.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Before coming to the ED, I would take water, tea or anise and I would immediately need to go urinate (…) I do not know if it was due to the medicines or because I was worried.” (D6:LRAD05- hospitalized for 2 days)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor others, going to the ED was the “usual” procedure to get check-ups; they already knew they could get their glucose measured and receive a prescription for their medicine more quickly, partly because their access to ambulatory care services was limited.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“Each time I asked for an appointment with the doctor they told me it was not available (…) one gets tired. The months passed by, and I felt bad and would come back to emergency. (…) They would stabilize and would tell me to ask for an appointment, but I never found any appointment available and that is how I let the years go by” (D9:MB5D02- - hospitalized for 2 days)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eDelay in reaching an adequate health care facility\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eReaching an appropriate health facility requires participants to navigate several barriers like long distance to healthcare facility, time constraints or high transportation costs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIndividual experiences also play a role in this delay. Patients often expressed distrust in the public system because of previous experiences and explored other options like private healthcare providers. However, those who went to private clinics also expressed dissatisfaction with the care received, either because they perceived little or no improvement after the treatment received or because they could not afford it.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs a result, some participants were left with the decision to return to the public hospital. One of them remarked that the budget for a heart procedure at the clinic was close to US$ 12,000 (PEN 40,000). This information made him dismiss the procedure and wait for the facilities that the public hospital could provide regardless of the long waiting time.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I went to a clinic, what they see is one´s economic situation. Suddenly, they told me everything cost 40 thousand soles. I mean, they practically let you on the verge of decompensating even more, that is why I did not return there anymore and had to come again to this hospital and keep waiting.” (MVCD1 – hospitalized for 2 days)\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAdditionally, although 86.8% of survey respondents reported having public insurance (Table 1), its use was inconsistent. Survey results reflect what interviewees also described: they do not use their insurance for medications and seek care through a mix of public and private services. Interestingly, they are somewhat more likely to use their insurance for laboratory tests. This may be because such tests are more expensive or because they are often associated with emergency or inpatient care.\u003c/p\u003e\n\u003cp\u003eTransportation presents a challenge as well. Participants reported that getting to the hospital meant an extra expense. In Peru, public transportation is not implemented with facilities for older adults; it is of low quality and high stress. Patients often prefer or need to pay for taxis and prioritize the emergency visit where they can guarantee they will be treated even though they have to wait. Even when some patients wished to attend outpatient services, they could not afford the transportation to their appointments and would prioritize spending – and waiting – only for emergencies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCaregiver(C): “(…) our appointment was for a week ago. It has been 8 days, let´s say, tomorrow. But we haven´t come for financial reasons, taxi fare.”\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: It´s just that I have to come in a taxi, I can´t come on a bus.” (CSCh06 – hospitalized for 10 days\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAnother challenge is the time they must invest, 49.7% of the participants takes at least an hour to get to the hospital, even when most participants (93.7% of the total sample) have primary care facilities in less than a 30-minute distance, experiences with primary care were hardly mentioned and going to the hospital seemed to be preferred. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAdditionally, it was common patients would point out that finding an appointment was an arduous process that sometimes would require several visits to the hospitals or the help of a family member. Some patients would point out that this would discourage them from looking for ambulatory appointments.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eDelay in receiving adequate care at the facility (ED)\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eOnce at the ED, two problems seemed to recur: shortages and overcrowding. Participants explained it was frequent that the ED had insufficient medical supplies. A patient told us that on one occasion the health workers did not assist her to the bathroom because there were no gloves available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: “(about the difficulties of mobilizing) Oh because there was no one, they told me I had to buy gloves and then they were not in the obligation to take that off. (…) (So), I took it off, I stood up and took everything off (…) and went to the bathroom safely, thank goodness.” (EPCDH16 – hospitalized for 3 days)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAlong with insufficient supplies, the available health care staff also were insufficient. Getting prompt evaluations, consultations by specialties or timely administration of treatment were challenges mentioned by patients attending the emergency department, posing delays, and risking adequate care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;C: “She complained that she wasn´t better because we would leave her prescription medication and they wouldn´t administer it on time. (…) I bought a glove and until Saturday it was there and they didn´t use it.” (VMCD04)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;P: “Since yesterday at approximately ten in the morning, and they should have made the consult, the traumatologist should have already seen me. Now it is approximately 10:30 in the morning and the traumatologist hasn´t seen me, they haven´t taken me to traumatology.” (ACRD13 – Hospitalized for 2 days)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eLaboratory testing at the hospital could be troublesome. Some tests are not available, or results may take several days, so some respondents opted to pay for private laboratories services. Being insured (86.8%) does not ensure access to medications and laboratory tests they require for treatment and diagnosis. In both interviews and surveys, they reported out of the pocket expenses for medications (61.4%) or laboratory tests (18.4%). Causing delays and economic and psychological hardships, many expressed concerns of not having enough money to pay these extras and become a burden for their families.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: “what is missing these last months is medication, so then one has to buy it outside.” (D 1: CJBD08 – hospitalized for 22 days) \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;“I feel impotent, money makes everything, they don’t think about our pockets (…), I don´t know how my kids are going to be able to afford this. I don´t show that I´m feeling bad in front of them, but it makes me sad that they have to come every day to buy medicine.” (NCAH18 - hospitalized for 4 days) \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eC: “there are tests that are not here, and you have to look for them outside. (...) Well, there are tests that also take a long time for the national public insurance (SIS) , such as the test they have to do to him; they tell you that they do not know when is going to be ready, (…) I think that the test he needs is important for them to see what part of the heart is not working; (...) they tell us that it will delay, they do not know when it will come out. (TPSDH011 – hospitalized for 5 days) \u0026nbsp; \u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe permanent state of overcrowding in the ED naturally causes limited space for patients. All participants interviewed said they waited a long time – days even – for a stretcher and in the meantime, they were sitting on chairs or benches.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eP: “A gurney, yes I´ve always had that problem, two or three days and my family has always tried to find it, sitting on a wheelchair or bench… that always happens.” (CJBD08 – hospitalized for 22 days)\u003c/p\u003e\n\u003cp\u003eIn reaction to the overcrowding, other non-health related staff would step over and try to contain the flow of patients, often wrongly. A testimony of a patient explains how she was denied entrance to the ED by the security staff that did not recognize a visible emergency.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: “They wouldn´t let me in, If he didn´t see me like this, the security told me ¨the lady is not very ill, let her wait¨ (…) and my brother, since he was upset by what he saw said ¨how are you not going to let me in, let me in, my sister is ill, my sister is ill¨ the lady is not too ill, how do you know? You are not a doctor, but then they let me in and took care of me.” (NCAH18 – hospitalized for 4 days).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere is an evident barrier of communication, patients perceive they are often provided with insufficient or unclear information about the procedures they would receive, and they go to one service to another, they feel the information many times could be confusing and unhelpful. In the questionnaires we found that 64.8% knew their diagnosis and indications and 73.8% had a reference to their PHC at discharge. (Table 2)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“At the beginning they didn’t want to treat me, they sent me to outpatient services, and from there they would send us back to ED where I did not receive care. I went back and forward several times. (…) Then someone from the security staff saw my foot and saw it was black. It is then that I was treated in ED, a doctor told me I was going to be taken care off.” (EPCDH16 – hospitalized for 3 days) \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter the ED discharge, patients must go through many bureaucratic procedures to get treated by a medical specialist as an outpatient or wait a long time for an available appointment after being treating in ED. Overall, the lack of appointments and drawn-out bureaucratic procedures leave patients sorting multiple barriers that let them to a sub optimal care or back to the ED.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e“I: So, is it difficult to follow treatment?\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eP: Sure, well if there is a treatment that will be for my health, I will have to find a way to come, look for someone, however the reality is. What makes me angry is that here they give you appointments from one month to the other, when I’m dead already.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eC: We came here to the hospital on October 22nd or 23rd; it was to have her gynecology treatment, the test. We go to the admissions office, and they say ¨oh ok, your appointment is for the end of December¨ they tell us, until then the patient is dead (…). That is the problem, they don’t see you and when the appointment comes, the doctor comes back and says you have to take the ultrasound first, or something.” (NCAH18 – hospitalized for 4 days) \u0026nbsp;\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eAfter the 3-delays: Challenges post-discharge\u0026nbsp;\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eAround 33.8% (Table 3) of participants did not attend follow up control within the three months after discharge. Some participants expressed their willingness to continue follow-up as an outpatient but since they must wait weeks or months for appointments, they often preferred to bypass the system and come directly to the ER again.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe found attendance to their appointments at 3 months after discharge was associated to the number of diseases, 52.5% of participants that attend to their appointment have one disease in comparison to 79.2% of participants that have 3 or more diseases. Also, people with previous periodic contact (every three months in the previous year to the hospitalization) with the system had more attendance to their appointment at 3 months after discharge in comparison with those without previous contact but this difference was not significant (74.2% vs. 60.7%, p=0.08) (Supplementary Table S1)\u003c/p\u003e\n\u003cp\u003eDuring follow-up three months after discharge, 9.9% of the participants did not have health insurance, 66.2% had attended their appointment to the PHC or hospital and most of them went to the public hospital. Also, 9.6% of the participants died during the follow-up period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Patient Journey\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient’s pathways are not linear; delays interact and repeat in a complex cycle. (Figure 1) Some of the reasons that perpetuate this cycle can be understood also looking at what happens after the discharge.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThrough the interviews we were also able to recreate the paths that each patient took. Each person interviewed described the previous steps they had to take before reaching the ED. Interviewees reported \"bounces\" within the system, some paths repeated more frequently and formed loops. We found that fifteen out of the twenty interviewed made at least three trips before receiving adequate care for their present health event. We simplified these patterns in Figure 1. Loop 1 describes the cycle between the emergency room and private consultation. Patients that seek care in private services can bounce between these two, seeking the ER for emergencies or procedures and private services for follow-up. \u0026nbsp;Loop 2 describes the cycle between the public consultation and the ER. These patients are seen often at the ER and once discharged face delays in reaching the public consultation and finally returning to the ER. \u0026nbsp;This is the most frequently referred loop representing those who after discharge to EMG return to EMG repeatedly for the same problem. Loop 3 describes the patients that after been hospitalized in a medicine floor, return to the ER, often because of lack of follow-up. \u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eUsing the framework of the Three delays, we were able to classify the barriers reported by the patients in three moments: when deciding to seek care, when arriving at the health care facility, and when receiving adequate care. When exploring the first delay, we found that most participants recall having a bad experience with the health system, especially with the public health system, they also express a lack of knowledge about their diagnosis and its implications. When exploring the second delay, they faced multiple barriers for reaching a care facility including distance and transportation costs that lead them to seek care in the private sector, this often implies higher costs that causes them to return to the public system. There is also the notion that private services are better than public. Finally, on the third delay, participants faced a health system not being ready to respond to their needs. That was evident in the lack of medical supplies or insufficient health care staff. Qualitative and quantitative findings showed these barriers often overlap and strengthen each other creating a vicious cycle that patients must navigate to receive care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrevious studies have illustrated the difficulties that patients face during their search for care in different contexts.(22\u0026ndash;24) In our study we focused on the barriers that led patients to the ER. The most prominent finding in our study was the previous bad experiences, which can be an indirect measure of the quality of care in the health care system. (25,26) The chronic patient strongly perceives that the quality of care they receive is low. Previous studies have described that a \u0026nbsp; perceived high quality of care and trust -interpersonal or institutional- are strong drivers for seeking care, maintaining adherence and overall, a more positive patient experience.(27,28) \u0026nbsp;In contrast, some participants seemed satisfied with the emergency care. One explanation may be that in the emergency department many finally \u0026ldquo;find the solution\u0026rdquo; to their health problem.(29) It is interesting that most of the bad previous experiences told by the participants are not necessarily related to the ER, which could also explain the apparent preference towards the ER. Other studies describe that in populations where the quality of health is low, the patient\u0026rsquo;s expectation of quality is also low which could explain a better perceived experience. (25)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eReaching the ER was perceived as time consuming, troublesome and costly but often as the only feasible option for accessing health care in certain medical scenarios.(30\u0026ndash;32) There is a constant push and pull between getting worse and going to \u0026ldquo;find a solution\u0026rdquo; and postponing care to reduce costs and time invested, most often time away from work or family responsibilities. This \u0026ldquo;dance\u0026rdquo; inevitably leads to complications of the chronic condition, complicating treatment, extending hospitalizations, and possibly endangering the health of patients. The patient with chronic conditions repeatedly faced the multiple resources shortages of the emergency department. These shortages are mostly caused by overcrowded services, administrative and/or financial problems.(33) As a result, the emergency department experience is perceived as confusing and chaotic, driving patients to seek alternatives in health care subsystems outside the public system, such as the private system or using strategies to compensate for the lack of supplies in the public sector. This search for alternatives carries out-of-pocket (OOP) costs. (32) The final challenge is how to shift the ED discharge to become a patient engagement tool rather than the start of the next loop. Breaking the cycle goes beyond what hospital policies alone can do, this requires the involvement of stakeholders to address, for example, the multiple bureaucratic barriers, operational barriers like supply management, or the overdue and delayed empowerment of primary healthcare facilities as the first point of contact that can respond readily and timely to patient demand and, most importantly promote knowledge and prevention. \u0026nbsp;\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough originally developed for maternal health, the Three Delays Model offers valuable insights into the challenges faced by patients with chronic diseases. Like childbirth and obstetric emergencies, chronic conditions can lead to acute complications where timely care is critical. The model allows us to analyze delays in seeking, reaching, and receiving care\u0026mdash;key moments that influence health outcomes in both acute and chronic settings. Understanding these delays can help design interventions that break repetitive barriers, enhance continuity of care, and make health systems more proactive rather than reactive. \u0026nbsp;The barriers we expose in this article are well known and have been previously described, meaning they are abundantly prevalent worldwide.(34\u0026ndash;36) Because these barriers overlap and reinforce each other, addressing them separately can be challenging. However, their similarity to those seen in other conditions, such as mental health, indicates that progress in these areas could meaningfully improve overall patient care. (37\u0026ndash;39) These results are from the pre pandemic context, as for the current situation of the person with chronic diseases can be critical and the aftermath of the pandemic will require intense intervention to rebuild the care of other diseases that have been displaced, this can also be an opportunity to reorganize and strengthen health care systems in the future. Especially since the pandemic has limited the patient\u0026apos;s ability to go to health facilities in person, this presents the opportunity to create alternatives so that the health system can go to the patient and offer quality care through patient-centered design health care systems.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe used the Three delay model as a way of facilitating the understanding of the complex journey towards care for patients with chronic conditions. The use of the model has limitations because it proposes a more \u0026lsquo;linear\u0026rsquo; journey. \u0026nbsp;However, \u0026nbsp; simplifying the delays \u0026nbsp;could \u0026nbsp;serve as a starting point to propose solutions and understand that some factors affecting care of patients with chronic conditions are outside of the scope of just improving health care services (i.e. Distances), delays caused by the bad perception of the public system (first delay), or lack of supplies (third delay). The different challenges can be more readily understood and -possibly- addressed implementing initiatives to improve the experience of patients and improve empathetic care.(40\u0026ndash;42) The confusion, miscommunication and lack of knowledge often reported could be improved with effective communication skills training for healthcare providers. A bigger challenge is addressing overflow and the discouragement of the use of emergency services. This is closely linked to the betterment of the primary care, and possibly the implementation of more creative solutions that promote the decentralization of care out of the bigger hospitals like telemedicine or community-based interventions. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe limitations of our study were the identification of delays before reaching the ED, the participants focused more on their present experience than on previous ones making it difficult to recall what happened to them at primary care level or in previous attempts to use the ambulatory services at hospitals. We indirectly measured factors related to the system like available medication or tests and did not delve into other critical issues such as health personnel training or information or referral systems; however, we found it evident that the system is not currently responding efficiently in providing timely and quality care. This hospital-based study gives insights into the experiences of patients with chronic conditions that eventually reached the ER after many attempts to access health care, providing us with a thorough view into the failures at different levels of the health care system. \u0026nbsp;Future research can expand on these results by exploring rural settings or critically ill patients, where delays may be even more pronounced. \u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study provides valuable insights into the delays to access healthcare for patients with chronic conditions, highlighting the barriers faced by them before eventually reaching emergency care. Using the Three delay framework, our findings provide a basis for understanding how and where these delays in care occur which can be instrumental for designing future interventions. The COVID-19 pandemic offered a view in the critical role of timely access to care and facing increased care demands in times of crisis, lessons learned from that period should be considered for future interventions. Future research could explore rural areas and critically ill patients, where barriers to care may be even greater.\u003c/p\u003e"},{"header":"METHODS","content":"\u003ch2\u003e\u003cstrong\u003eStudy design, setting and participants\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study was conducted at the ED of a public hospital in Lima, Peru between 2017 and 2018. About 90% of the people who come to this ED come from the northern part of Lima where the poverty belts are located. This ED receives around 6 000 patients a month and gives about 16000 inpatient discharges per year. The last situation analysis from 2023 found that the ED receives 10 000 patients with a similar number of discharges than 2018. (18\u0026ndash;20) We considered it important to include people from the ED, where we expected to find the \u0026quot;worst scenarios\u0026quot; from people who lack access to other non-urgent care. Using a mixed methods observational study, we carried a qualitative approach with semi-structured interviews and a quantitative approach with a short questionnaire and a follow-up call at 3 months after discharge.\u003c/p\u003e\n\u003cp\u003eWe included adults (\u0026gt; 18 y) with confirmed type 2 diabetes and/or hypertension whose primary reason for ED admission was decompensation or acute complications of T2D or HT. We excluded individuals in critical condition, unresponsive, and those whose primary reason for emergency admission was not related to HT or T2D. Eligibility criteria were the same for both qualitative and quantitative approaches.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eInterviews\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eSemi-structured interviews were conducted between October 2017 and January 2018 by a trained psychologist with some experience doing interviews, most of them were conducted during hospital stay and some had to be scheduled post-discharge (for the convenience of the participant). The interview guide was designed by one physician, one sociologist and one psychologist with expertise in qualitative methods and the guide was organized to explore previous experiences and interaction with health care services, knowledge and perception of their disease, and facilitators and barriers in the care of their disease. We used purposive sampling methods. We estimated information saturation at a sample of twenty interviews.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003eQuestionnaires\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eInterviews were conducted between October 2017 and August 2018. They were administered face-to-face by a researcher during hospitalization at the ED or the medicine ward. The questionnaire included a baseline assessment and a 3-month follow-up. The baseline assessment collected information on sociodemographic characteristics, medical history, medication, cause of hospitalization, hospitalization time, indications to discharge and prognosis at discharge. And follow-up phone call was made 3 months after the discharge to collect data about changes in insurance status, access to post-discharge health services and evolution of the disease and complications. The questionnaires were reviewed by the research team to ensure data quality and then coded without personal identifiers. For sample estimation, we used previous data of the proportion of people with chronic diseases who do not seek medical attention nationwide (21), resulting in a sample size of 185 participants with an accuracy of 7% and a confidence level of 95%.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eAnalysis\u003c/strong\u003e\u003c/h2\u003e\n\u003ch3\u003e\u003cstrong\u003e\u003cem\u003eQualitative\u003c/em\u003e\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe interviews were audio recorded and transcribed verbatim. Qualitative data from the transcripts were coded using the software Atlas.ti version 8 in an iterative process by one sociologist and one psychologist that participated in the interview guide designed. The interviews were analyzed using the Three Delays model framework proposed by Thaddeus and Maine. (17)\u003c/p\u003e\n\u003cp\u003eThe results presented in this manuscript are organized using the three phases of the Three Delays model to understand chronologically the experiences and barriers to seek care and access healthcare services of the patients admitted to the emergency department (ED). The results have been structured in three sections:\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eDelay 1: refers to all the personal or family factors that delay the decision to seek care, including distance, costs, the perceived quality of care, the perception of the illness, economic and educational status.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDelay 2: refers to all the factors or situations that delay reaching an adequate health care facility, including the geographical distribution of the facilities, travel distances, transportation availability and cost.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDelay 3: refers to relevant factors that delay receiving adequate care at the facility, including ill-staffed or ill-equipped facilities, incorrect management at the facility.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch3\u003e\u003cstrong\u003e\u003cem\u003eQuantitative\u003c/em\u003e\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eThe initial analysis was descriptive, mean, and standard deviation was estimated for quantitative variables like age whereas frequency and percentages were estimated for categorical variables like access to post-discharge health services. Additionally, the risk ratio was calculated using Poisson regression considering access to post-discharge health services as outcome and number of diseases and periodic contact with the health system as exposures adjusted by age and gender.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eEthical issues\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eStudy procedures were conducted in full compliance with the Declaration of Helsinki and relevant \u0026nbsp;regulations, and approved by the Institutional Review Board of Hospital Cayetano Heredia, Lima, Peru prior to its execution. The participants were duly informed verbally of the objectives and procedures of the study as well as its risks and benefits. Written informed consent was obtained from all \u0026nbsp;participants prior to their participation. All participants\u0026rsquo; personal data, including audio recordings and transcriptions, were anonymized using coded identifiers and handled exclusively by the study researchers.\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe gratefully acknowledge Meryliz Alonso, Korali Santiago and Patricia Busta for their support in data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eT.D.(first author) contributed with protocol and study design, supervised and coordinated the fieldwork, led the qualitative analyses, interpreted the findings, and drafted the manuscript. S.P. provided qualitative methodological support, led qualitative analyses and interpretations, and contributed to the writing of the results. J.P. assisted with qualitative analyses, interpretation, and results writing. G.M. contributed to study design, protocol development, data interpretation, and final manuscript approval. D.B. provided supervision, contributed to data interpretation, and critically revised the draft. M.L. supported the design and methodology across all stages, participated in analysis and interpretation, and critically revised and approved the final manuscript. All authors approved the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAdditional information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests statement\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the manuscript and its supplementary materials. \u0026nbsp;Additional data can be requested from\u0026nbsp;the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis work received partial support from the Peruvian American Medical Society (PAMS) Medical Education \u0026amp; Research Fund. The funder had no role in study design, data collection, data analysis, decision to publish, or preparation of the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGlobal Burden of Disease Collaborative Network. Global Burden of Disease Study 2021 (GBD 2021) Results (2024, Institute for Health Metrics and Evaluation \u0026ndash; IHME) [Internet]. [cited 2025 Jan 27]. Available from: https://vizhub.healthdata.org/gbd-results/\u003c/li\u003e\n\u003cli\u003eSchutte AE, Srinivasapura Venkateshmurthy N, Mohan S, Prabhakaran D. Hypertension in Low- and Middle-Income Countries. Circ Res [Internet]. 2021 Apr 2 [cited 2025 Feb 19];128(7):808\u0026ndash;26. 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An\u0026aacute;lisis de Situaci\u0026oacute;n de Salud del Per\u0026uacute;, 2018. Lima: Ministerio de Salud Centro Nacional de Epidemiolog\u0026iacute;a, Prevenci\u0026oacute;n y Control de Enfermedades (CDC); 2019. \u003c/li\u003e\n\u003cli\u003eTurner H), Coster JE, Chambers J. Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis What evidence is there on the effectiveness of different models of delivering urgent care? A rapid review. ACADEMIC EMERGENCY MEDICINE [Internet]. 2015 Sep 1 [cited 2021 Apr 5];3(43):1137. Available from: https://doi.org/onlinelibrary.wile\u003c/li\u003e\n\u003cli\u003eKartschmit N, Beratarrechea A, Guti\u0026eacute;rrez L, Cavallo AS, Rubinstein AL, Irazola V. Health care access and health-related quality of life among people with diabetes in the Southern Cone of Latin America\u0026mdash;a cross-sectional analysis of data of the CESCAS I study. Quality of Life Research. 2020; \u003c/li\u003e\n\u003cli\u003eVargas I, Mogoll\u0026oacute;n-P\u0026eacute;rez AS, De Paepe P, Ferreira da Silva MR, Unger JP, V\u0026aacute;zquez ML. Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil. Health Policy Plan. 2016 Jul;31(6):736\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eMinisterio de Salud del Per\u0026uacute;. An\u0026aacute;lisis de la demanda y el acceso a los servicios de salud en el Peru. 2012. \u003c/li\u003e\n\u003cli\u003eVargas JJ, Molina GM. Acceso a los servicios de salud en seis ciudades de Colombia: limitaciones y consecuencias. Revista Facultad Nacional de Salud Publica. 2009; \u003c/li\u003e\n\u003cli\u003eVargas-Lorenzo I, Luisa V\u0026aacute;zquez-Navarrete M, Mogoll\u0026oacute;n-P\u0026eacute;rez AS. Acceso a la atenci\u0026oacute;n en salud en Colombia. Vol. 12, Revista de Salud Publica. 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Elsevier Ltd; 2018. p. e1196\u0026ndash;252. \u003c/li\u003e\n\u003cli\u003eDoubova S V., Garc\u0026iacute;a-Saiso S, P\u0026eacute;rez-Cuevas R, Sarabia-Gonz\u0026aacute;lez O, Pacheco-Estrello P, Infante-Casta\u0026ntilde;eda C, et al. Quality governance in a pluralistic health system: Mexican experience and challenges. Vol. 6, The Lancet Global Health. Elsevier Ltd; 2018. p. e1149\u0026ndash;52. \u003c/li\u003e\n\u003cli\u003eBatbaatar E, Dorjdagva J, Luvsannyam A, Savino MM, Amenta P. Determinants of patient satisfaction: a systematic review. https://doi.org/101177/1757913916634136 [Internet]. 2016 Mar 22 [cited 2025 Feb 19];137(2):89\u0026ndash;101. Available from: https://journals.sagepub.com/doi/10.1177/1757913916634136?url_ver=Z39.88-2003\u0026amp;rfr_id=ori%3Arid%3Acrossref.org\u0026amp;rfr_dat=cr_pub++0pubmed\u003c/li\u003e\n\u003cli\u003eArakelyan S, Jailobaeva K, Dakessian A, Diaconu K, Caperon L, Strang A, et al. The role of trust in health-seeking for non-communicable disease services in fragile contexts: A cross-country comparative study. Soc Sci Med. 2021 Dec 1;291:114473. \u003c/li\u003e\n\u003cli\u003eCoster JE, Turner JK, Bradbury D, Cantrell A. Why Do People Choose Emergency and Urgent Care Services? A Rapid Review Utilizing a Systematic Literature Search and Narrative Synthesis. Academic Emergency Medicine [Internet]. 2017 Sep 1 [cited 2025 Feb 19];24(9):1137\u0026ndash;49. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/acem.13220\u003c/li\u003e\n\u003cli\u003eBhojani U, Mishra A, Amruthavalli S, Devadasan N, Kolsteren P, De Henauw S, et al. Constraints faced by urban poor in managing diabetes care: patients\u0026rsquo; perspectives from South India. Glob Health Action [Internet]. 2013 [cited 2025 Feb 19];6(1):22258. 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Intern Emerg Med [Internet]. 2024 Mar 1 [cited 2025 Feb 19];19(2):483\u0026ndash;91. Available from: https://www.researchgate.net/profile/Sabrina-Pearce-2/publication/376173028_Overcrowding_in_emergency_departments_an_overview_of_reviews_describing_global_solutions_and_their_outcomes/links/656c1403b86a1d521b2c6694/Overcrowding-in-emergency-departments-an-overview-of-reviews-describing-global-solutions-and-their-outcomes.pdf\u003c/li\u003e\n\u003cli\u003eStarbird LE, DiMaina C, Sun CA, Han HR. A Systematic Review of Interventions to Minimize Transportation Barriers Among People with Chronic Diseases. J Community Health [Internet]. 2019 Apr 1 [cited 2025 Feb 19];44(2):400\u0026ndash;11. Available from: https://link.springer.com/article/10.1007/s10900-018-0572-3\u003c/li\u003e\n\u003cli\u003eDanhieux K, Martens M, Colman E, Wouters E, Remmen R, van Olmen J, et al. What Makes Integration of Chronic Care so Difficult? A Macro-Level Analysis of Barriers and Facilitators in Belgium. Int J Integr Care [Internet]. 2021 [cited 2025 Feb 19];21(4):8. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8555482/\u003c/li\u003e\n\u003cli\u003eKhatri R, Endalamaw A, Erku D, Wolka E, Nigatu F, Zewdie A, et al. Continuity and care coordination of primary health care: a scoping review. BMC Health Serv Res [Internet]. 2023 Dec 1 [cited 2025 Feb 19];23(1):1\u0026ndash;13. Available from: https://link.springer.com/articles/10.1186/s12913-023-09718-8\u003c/li\u003e\n\u003cli\u003eAndrade LH, Alonso J, Mneimneh Z, Wells JE, Al-Hamzawi A, Borges G, et al. Barriers to Mental Health Treatment: Results from the WHO World Mental Health (WMH) Surveys. Psychol Med [Internet]. 2013 [cited 2025 Feb 19];44(6):1303. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4100460/\u003c/li\u003e\n\u003cli\u003eDevi R, Kanitkar K, Narendhar R, Sehmi K, Subramaniam K. A Narrative Review of the Patient Journey Through the Lens of Non-communicable Diseases in Low- and Middle-Income Countries. Adv Ther [Internet]. 2020 Dec 1 [cited 2025 Feb 19];37(12):4808\u0026ndash;30. Available from: https://link.springer.com/article/10.1007/s12325-020-01519-3\u003c/li\u003e\n\u003cli\u003eHashemi G, Wickenden M, Bright T, Kuper H. Barriers to accessing primary healthcare services for people with disabilities in low and middle-income countries, a Meta-synthesis of qualitative studies. Disabil Rehabil [Internet]. 2022 [cited 2025 Feb 19];44(8):1207\u0026ndash;20. Available from: https://www.tandfonline.com/doi/abs/10.1080/09638288.2020.1817984\u003c/li\u003e\n\u003cli\u003eGleeson H, Calderon A, Swami V, Deighton J, Wolpert M, Edbrooke-Childs J. Systematic review of approaches to using patient experience data for quality improvement in healthcare settings. BMJ Open [Internet]. 2016 Aug 1 [cited 2025 Feb 19];6(8):e011907. Available from: https://bmjopen.bmj.com/content/6/8/e011907\u003c/li\u003e\n\u003cli\u003eWorld Health Organization News. Evolving a people-centred approach to noncommunicable disease (NCD) services in Bhutan [Internet]. 2022 [cited 2025 Feb 19]. Available from: https://www.who.int/southeastasia/news/feature-stories/detail/Evolving-a-people-centred-approach-to-noncommunicable-disease-NCD-services-in-Bhutan\u003c/li\u003e\n\u003cli\u003eAfulani PA, Getahun M, Ongeri L, Aborigo R, Kinyua J, Ogolla BA, et al. A cluster randomized controlled trial to assess the impact of the \u0026lsquo;Caring for Providers to Improve Patient Experience\u0026rsquo; (CPIPE) intervention in Kenya and Ghana: study protocol. BMC Public Health [Internet]. 2024 Dec 1 [cited 2025 Feb 19];24(1):1\u0026ndash;13. Available from: https://link.springer.com/articles/10.1186/s12889-024-20023-9\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"554\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. General Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurveys\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInterviews\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=189\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN=20\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e, mean (SD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e60.8 (13.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e58.5 (10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e95 (50.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e9 (45.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e94 (49.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e11 (55.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation level (*)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e12 (6.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eElementary/middle school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e50 (26.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e3 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eHigh school\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e95 (50.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e13 (65.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eFurther education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e31 (16.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e4 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSource of Income\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eUnemployed\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e102 (54.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e9 (45.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eEmployed/Retiree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e87 (46.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e11 (55.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e75 (39.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e8 (40.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eOne disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e57 (30.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e3 (15%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e2 or more\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e57 (30.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e9 (45%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e23 (12.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e3 (15.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic (SIS/ESSALUD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e164 (86.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e16 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e2 (1.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\n \u003cp\u003e1 (5.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e(*N=188, one missing data)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 96px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"458\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Health care delivery burden (N=189)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 78px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeek healthcare in the previous 12 months\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e122 (66.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e62 (33.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHave a caregiver\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e92 (49.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e95 (50.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace where participant seek care for NCD management\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic tertiary care (MINSA/ESSALUD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e80 (43.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic primary care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e26 (14.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePrivate only\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e20 (10.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic and private system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e59 (31.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeek healthcare in the hospital\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eMore than once a month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e7 (3.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eOnce a month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e23 (12.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eOnce every two or three months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e41 (21.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eRarely\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e118 (62.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of medication delivery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic Insurance (SIS/ESSALUD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e29 (15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eOut-off-pocket (partial or entirely)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e160 (84.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of laboratory or another test performed\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic tertiary care (MINSA/ESSALUD)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e124 (67.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic primary care\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e4 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e23 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic and private system\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e34 (18.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNCD: Non- communicable disease (HT or T2DM)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to the nearest PHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eLess than 10 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e120 (63.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eLess than 30 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e57 (30.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e1 hour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e6 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eDid not know the nearest PHC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e6 (3.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to arrive to the hospital\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eLess than 10 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e10 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eLess than 30 minutes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e85 (45.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e1 hour\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e77 (40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e2 hours or more\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e17 (9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of discharge diagnosis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e103(64.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e56 (35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge of indications at discharge\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e103 (64.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e54 (35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReference to the PHC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e116 (73.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e41 (26.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"458\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Follow-up at 3-months after discharge \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 380px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e15 (9.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic Health Insurance (SIS)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e130 (86.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eSocial security insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e4 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e2 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeek care after discharge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e100 (66.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e51 (33.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 458px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSeek care for reasons different to NCD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e54 (38.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e85 (61.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace where seek care\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic hospital\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e38 (27.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePublic PHC\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e2 (1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eSocial security PHC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e3 (2.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e12 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNot applicable/No response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e82 (59.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDeath\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e16 (9.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 78px;\"\u003e\n \u003cp\u003e150 (90.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 380px;\"\u003e\n \u003cp\u003eNCD: Non- communicable disease (HT or T2DM)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 78px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"hypertension, diabetes mellitus, emergency service, mixed methods","lastPublishedDoi":"10.21203/rs.3.rs-7257280/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7257280/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"In many low- and middle-income countries, people with diabetes and hypertension lack timely, quality healthcare and often turn to overcrowded emergency departments (ED). This study explored experiences and barriers to care among adults with type 2 diabetes mellitus (T2DM) or hypertension (HT) admitted to a public emergency department. We conducted a hospital-based study including questionnaires, 3-month follow-up calls, and semi-structured interviews. Questionnaires collected sociodemographic characteristics, medical history, medication, hospitalization details, and discharge indications. Interviews, analyzed through the Three Delays framework, explored prior healthcare experiences, disease knowledge and perception, and care facilitators and barriers. A total of 189 adults with T2DM and/or HT were surveyed; mean age was 60.8 (SD 13.7), with 50.3% male. Of these, 62.4% did not seek care periodically and 33.7% missed follow-up appointments. Twenty interviews revealed recurring delays due to previous negative experiences, poor disease awareness, excessive costs, time and transportation constraints, and insufficient supplies. People with chronic conditions face repeated delays and difficulties navigating the health system, often reaching care only in emergency situations. These findings call for targeted interventions to improve lower levels of care to break these cycles, reduce ED burden, improve continuity and ensure sustainable management of chronic conditions.","manuscriptTitle":"Applying the Three Delay Model for Non-communicable diseases: lessons learnt from emergency department admissions in Peru","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-15 12:00:43","doi":"10.21203/rs.3.rs-7257280/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"32b6fb46-b80f-4898-82de-27305bf0ea77","owner":[],"postedDate":"December 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":59578833,"name":"Health sciences/Diseases"},{"id":59578834,"name":"Health sciences/Health care"},{"id":59578835,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-01-23T14:10:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-15 12:00:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7257280","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7257280","identity":"rs-7257280","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}