Unveiling the unseen toll: exploring the impact of the Lebanese economic crisis on the health-seeking behaviors in a … – BMC Public Health

The study results explored how the economic crisis has taken its toll on the healthcare using a sample of Lebanese respondents who reported being previously diagnosed with DM, HTN or both. The devaluation of the national currency has led to a surge in medication prices, drug shortage and disruptions in affordable healthcare access. Amidst these challenges, barriers to adequate adherence to treatment regimens, high reported stress levels and unsatisfaction with the current Lebanese healthcare system were reported in participants with DM and HTN.

In our study sample, there is a greater representation of Mount Lebanon and the capital, Beirut, compared to other remote regions, which may point to regional differences in socioeconomic conditions, infrastructure, and access to healthcare that may have an impact on health outcomes [23]. Indeed, the impacts of the economic crisis were shown to be more pronounced in rural areas where people have lower incomes and decreased access to healthcare services [24, 25]. A study conducted in rural Crete showed that most patients, without referring to their physicians and to face the high costs, lowered their medication doses [26]. This was specifically prominent in chronic disease patients where insulin users reduced the quantity used. Moreover, the study sample presents a high prevalence of both married participants and respondents with undergraduate/postgraduate degrees. Marital status and education have been shown to correlate with improved clinical outcomes. Married people were reported to have access to resources and social support that have a positive impact on their health [27]. Education level may have an impact on health literacy, health-seeking behavior, and knowledge of health [28].

The wide range of job situations and income levels reported by the participants reflect the countrys economic inequalities. It is noteworthy that only 34% of the participants reported an income higher than 3, 000, 000 LBP and 32.1% had no medical insurance. Economic hardship makes it difficult for patients to pay for medical treatment and prescription drugs, thus worsening clinical outcomes and leading to health disparities. This association has been cited by different studies [29, 30] where lower income levels and unemployment were associated with poorer health status and less access to healthcare services. The Lebanese economic situation not only affected drug costs and availability but also led to non-adherence to treatment and medical follow-ups, increases in consultation fees and a significant emigration of many physicians. These challenges led a high proportion of the Lebanese respondents suffering from DM and HTN to change their primary care physician or to switch from private to public institutions, which may lead to fragmented care and jeopardize treatment continuity [31]. Overall, most of the participants were unsatisfied with the current Lebanese Healthcare system. Our data are in agreement with results from Greece where the concomitant rise in unemployment and decreases in the purchasing power of the public led to a decrease in utilization of private care as opposed to public care, thus increasing the burden on an already strained public sector [32].

More than 85% of the medications in Lebanon are imported [33]. Disruptions within the pharmaceutical supply chain due to the economic crisis [34] left patients with DM and HTN with a few drugs locally produced. This has contributed to the scarcity of DM and HTN medications, thereby affecting patients treatment continuity [34]. To alleviate the burdens caused by drug shortages, the Lebanese MOPH issued several decrees regarding the import and pricing of drugs, the most important of which was decree 8922021 issued on July 16, 2021, which stated that some drugs are no longer supported by the central bank. As a result, the prices of drugs increased at least four to six times. The effect of these decrees remains questionable as the efforts taken were not to the magnitude of the pre-crisis period and drug shortages, especially of antidiabetics and antihypertensives, continued. Consequently, Lebanese patients adopted several coping mechanisms to navigate the challenges of obtaining medications during economic hardships depending on their different rational. A large proportion of participants with DM and HTN (around 50%) reported challenges to access at least one of their medications with most patients reporting a change in their medication or regimen as an alternative, without referral to medical advice. In turn, this pushed some of the patients to discontinue their medication because of their inability to afford either their cost or the medical consultation fee to address the issue or even because they do not perceive a detrimental effect on health if they stop. Other reduced the dosage, or altered the regimen so that a box of medication can be used for a longer period, hence lengthening the time to buy another box. A proportion of patients sought alternative or generic, usually the available and the cheaper. Conversely, most of the patients (around 70%) employed these adaptive strategies although they were aware of the side effects of such practice on their health outcomes. This scenario is reminiscent of experiences in other nations, where decreases in the use of medications due to economic hardships were also observed with subtle differences between countries. In Greece, pharmaceutical expenditure has long been high mainly due to low use of generics and usage of new expensive medications [17]. Following the Greek economic instability that strained healthcare access, a reduction in pharmaceutical prices was imposed by the government as a corrective measure; however, this created a huge shortage in drugs in the country [35] which led several diabetic patients to refuse the usage of expensive medications and to decrease the frequency of taking their drugs [26, 36]. Needles, even though provided freely, were not of sufficient quantities for multi-injection patients further leading to a decrease in adherence [36]. The same applies to test strips used in self-monitoring of blood sugar [36]. Similarly, in Venezuela, shortage of medications have reduced access to treatment, thus leading to selling antimalarial drugs in black markets for patients at unaffordable costs for many people [19]. Moreover, in Portugal, some patients requested cheaper medications from their physicians as they could no longer afford them, whereas others cut medicine doses on their own [37] or even discontinued their treatment [38]. This was accompanied by financial pressure on pharmacies that have struggled in supplying some medications which led to shortages of medicines [37]. In Italy, patients reported that they choose pharmaceutical items based on the recommendation of a family member or friend, rather than a medical expert [39]. This could be attributed to a lack of trust in health professionals and a desire to find a simpler and less expensive option than what doctors recommend [39]. Also, the decrease in the usage of all types of drugs was prominent in low socioeconomic areas where the unemployment rate was high [38]. Continuing along with this trend, in the United States, chronically ill patients felt the financial upheaval as they were unable to purchase their prescription medications [18]. Taken together, this growing body of literature emphasizes the vulnerability of healthcare systems during economic downturns and sheds lights on the implications for patients managing chronic diseases.

The association between adherence to medications and a decrease in complications and mortality [40] in both DM and HTN [41] is well established. In Lebanon, after the shortage of outpatient as well as inpatient cardiovascular medications, increases in the incidence of decompensated heart failure, myocardial infarction, and unstable arrhythmias requiring emergency intervention were reported [3].

Although Lebanese pharmacies remained the main source of medication, a high proportion of participants straining under the weight of the economic crisis, employed adaptive strategies to ensure the prescribed medications, such as resorting to dispensaries, NGOs, online purchasing from abroad, personal import of medications, seeking alternative treatments and relying on support networks and relatives living abroad. A good proportion of individuals have stocked medications. This practice has further worsened medication shortage and unavailability in pharmacies, because there was a trend that patients with chronic diseases have stocked medications for months, especially with the projections in increased lira inflation and skyrocket increase in medication prices. In other words, people bought excess amount of medication at lower prices and stocked them in anticipation of increased prices and medication shortage. This acted as a factor in furthering the lack of medication availability in pharmacies. Taken together the abovementioned results are in accordance with earlier research done in settings with limited resources, emphasizing the necessity for a variety of strategies to guarantee drug accessibility and affordability under trying conditions [42]. However, many concerns have yet to be addressed. The major question is whether these alternative sources helped maintain an adequate level of adherence to treatment. Another concern is the long-term sustainability of such an alternative method, especially if the economic situation does not stabilize soon. Hence, further studies are needed in this regard.

Despite the Lebanese economic challenges, more than half of the participants were still able to monitor their blood sugar and blood pressure. This provides a sigh of relief, as disease monitoring is a cornerstone of management. Home glucose monitoring has been associated with improved glycemic control and reduced long-term complications from DM. Similarly, home blood pressure levels can predict target organ damage and cardiovascular outcomes better than office values [43]. In essence, discussing these specific aspects within the Lebanese context provides a nuanced understanding of how the economic crisis uniquely affects health-seeking behavior of- and medication availability for DM and HTN patients. Economic recessions were reported to disproportionately affect vulnerable populations, exacerbating health inequalities [44]. In this intricate landscape, patient coping strategies and the support of Lebanese diaspora, discussed above, emerge as a critical area in our study.

Poor lifestyle factors have been discussed in the literature particularly during the pandemic [45]. Consistently with this data, our findings show high prevalence of smoking and low prevalence of exercise.

Our study presents a humanistic dimension by shedding the lights on the mental health of patients with DM and HTN. The stress level reported by the respondents was relatively high and was attributed mainly to the Lebanese economic crisis, medication shortage, the political instability in the country, August 4th Beirut port explosion, COVID-19 pandemic, and the inability to access healthcare. While several countries suffered economic turmoil, the situation in Lebanon is peculiar since its population has witnessed a combination of hardships at the same time. The reported level of stress was further explored by the DASS-21 questionnaire. The challenging times have led to extreme severe levels of anxiety, depression, and stress in all participants. Interestingly, patients with DM and HTN had higher levels of depression, anxiety, and stress, evident by higher means (SD) scores, than individuals having either of the diseases. Moreover, a higher proportion of participants with severe or extremely severe depression, anxiety and stress was noted in patients with DM and HTN compared to individuals having either of the diseases. Additionally, although a higher score was obtained for stress, a higher proportion of patients exhibited anxiety as compared to depression or stress. This can be explained by the many factors experienced by Lebanese people raising anxiety, such as instability, fear of the unknown in a chaotic environment, unclear timeline for improvement of the situation, inability to forecast the future and the probability of sudden disastrous events to be repeated (such as Beirut explosion), lack of access to hospitals (because of their destruction with the explosion), unavailability of physicians and medication shortage, etc. Importantly, a high proportion of individuals agreed that their health can be affected if they stop their medication or cannot have regular checkups or cannot be hospitalized. This could be also aligned with results of severe and extremely severe anxiety, which highlight the participants perception to the impact on their health in the context of lack of access to care and medication shortage. It is worth noting that the large SD that we recorded from the DASS-21 results can be attributed to the small sample size. This also indicates that the data points in our dataset are spread out over a wider range from the mean. In other words, this is suggestive of a significant amount of variability or dispersion in the data, which has led to a less consistent or more variable level of depression, anxiety, and stress with lower values than what the true mean is. Overall, our findings are in accordance with other studies reporting that shortage of medication has negative consequences on the mental and psychological aspects of the patient, including frustrations, anger, feeling like a burden to themselves and caregivers, panic, overthinking, suicide thoughts, and anxiety status.

This research study presents several limitations and strengths. We first acknowledge the small study sample size which is not representative of the entire Lebanese population. However, our exploratory findings about a small group of Lebanese patients with DM and HTN still provide a comprehensive, relevant and insightful report which captured the challenges faced by a vulnerable population in a critical point in time during the economic turmoil in Lebanon. Additionally, this is the first study that delves into the understudied domain of healthcare, specifically examining how the economic downturn in Lebanon has critically influenced the availability and accessibility of medications vital for patients diagnosed with DM and HTN and who are also strained by several other stressors in a critical point in time. As the nation faces unprecedented challenges, the ramifications on the health and well-being of individuals managing chronic conditions underscore the urgent need to comprehend and address the intricate interplay between economic hardships and healthcare outcomes. As an inherent limitation, the surveyed population was recruited through a convenient sample using a snowball method [22], which again may not reflect the general Lebanese population with DM and HTN. Besides, the distribution of the online questionnaire through social media may be limited to those with internet access, which could explain the poor response rate. However, using an online survey and a snowball method made it possible to collect data during hardships in a short time, with limited resources, and to attain a vulnerable population that is somehow difficult to reach in-person during unprecedented times of multiple crises. Our focus on understanding the health-seeking behaviors of patients with DM and HTN and the use of a descriptive methodology provided a comprehensive overview of the healthcare situation and drug availability in Lebanon. Hence, our findings should be considered as exploratory since they did not aim to identify or verify causal statistical relationships. Moreover, this exploratory/descriptive approach highlighted the impact of economic crises on healthcare outcomes, helped identify relevant topics to be explored in future research, and served as a clarion call for evidence-based policies and interventions tailored to the unique challenges faced by Lebanon. Furthermore, we acknowledge the simplicity of the statistical analysis that did not allow us to explore interactions that are more specific; the sample size further reduced the opportunities for subgroup analyses. The emphasis though is on generating insights and understanding patterns rather than on statistical precision. Additionally, the adopted questionnaire might not have assessed all aspects of economic, clinical, and humanistic outcomes of Lebanese patients with DM and HTN. It is also noteworthy that the time interval during which the data was collected plays a crucial role in the interpretation of our findings. In other words, our study describes the situation in Lebanon at a particular point in time where the population was strained by several stressors and hardships. Other factors and different events could have influenced at other times. Finally, this study is based on a survey where the participants are self-reporting data that relies on the memory and recall of the respondents. The latter can be influenced by various factors, such as time, context, emotions, motivation, and social norms.

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