Table 3.

Emergent themes from patient interviews

Dimension of access	Sub-theme	Excerpt
Approachability/ability to perceive need for care	Lack of knowledge or recognition of symptoms	‘So, it's because of her understanding. At that time, she thought [the ear problem] was not important. She can still go to school, move around, walk, can do everything … It's just smelling and discharge…’ (participant 4)
	Acceptance of traditional health beliefs	‘When he was a young baby, he cried a lot, so the tear is drop into the ear and he got infected in there’ (participant 10)
	Preference for traditional treatments or self-treatment	‘His son has a hearing problem, so he tried to find the treatment somewhere … people gave advice to get treatment from the traditional healer, but most of that treatment [did] not help much’ (caregiver 18)
	Practice of medical pluralism	‘She went to the doctor, but also asked help from the tree [spirit-belief/Kru Khmer], like combined together … she believes more in the doctor, but she likes to combine [treatment] together’ (caregiver 2)
	Transiency of symptoms	‘It [discharge] usually happens every one or two months, maybe five days each time, and then it gets better and then another month it goes away’ (participant 4)
Acceptability/ability to seek care	Fear or lack of trust in provider	‘Initially, she felt very, very, very scared. She felt not too confident with the hospital’ (participant 5)
	Fear of surgery	‘His family worry about after the surgery … Cannot work and affect his life after the surgery’ (participant 17)
	Fear of anaesthesia	‘He's scared about the operation because most Khmer people don't understand about the anaesthesia. They usually hear from other rumours, “the anaesthesia can make people die!”’ (participant 11)
	Stigma	‘She never told anybody. So scared. Scared to let everybody know her disease … She didn't want anybody to know she had the problem because the ear gets smell and dirty. The pus came out, so she tried to clean and keep secret. She doesn't want anybody to know her problem. In family is ok but [not] for everybody around’ (caregiver 8)
	Cultural or family influence on decision making	‘Everyone in her family influence her, like push her, to find treatment. Some people that know the place to go for treatment, they tell her’ (participant 1)
	Collectivism	‘It's still a problem [her mother's ear condition], so that's why her daughter stopped studying and helped her … she need to stop her dream to take care of her mother. Her dream is, she want to have cafe and bakery shop, but she need to stop everything to take care of her… Sometimes [older parents] try to keep this [information] by themselves. They don't tell anybody except husband or wife. They don't want the children to know. Cambodian children worry very much if they heard that their parents have any problem. If she saw her mum was sick, [her daughter would] decide to stop studying, [so] the parents decided to keep things [secret]’ (caregiver 8)
Availability/ability to reach care	Lack of available ear and hearing care services close by	‘The ear service around the commune, it's just simple general medical care, but no specialists’ (participant 7). ‘They said they don't have the ENT Department in their hospital, so they tell her to go to find the treatment outside, like a private clinic’ (caregiver 3)
	Lack of ability to navigate to service	‘His village is far away from the town [Phnom Penh]. He doesn't like to stay there and then it's difficult traffic and roads’ (participant 13)
	Occupational flexibility/seasonal factors	‘Right now [in] his neighbourhood, they plan to come to hospital to check, but you know the farmers have to decide the time. They need to be free from their farm work’ (participant 13)
	Lack of childcare	‘She has many children. It's hard to take time to bring the child with the problem to the hospital. She has a problem with money too. That's why [it's] difficult to bring the child to see the doctor’ (caregiver 15)
Affordability/ability to pay for care	Direct costs too high	‘They have to spend each time at least 40 to 50 USD each consultation and the medication, but her daughter looks not better. So, he decide to bring her to ‘free’ hospital’ (participant 3)
	Indirect (opportunity) costs too high	‘When he cannot hear well, it's difficult; it's hard to work … when he got sick, he difficult to earn money and then not enough money is difficult to find treatment’ (participant 12) ‘In his family, just only him that earn the money… so he is very important in the family. He cannot spend the time to get operation’ (participant 16)
Appropriateness/ability to engage with providers	Lack of patient centred care	‘…some hospital outside when she has a question, they just only shout back. She went many times for medical treatment, and she tried to ask why [is there] no cure for her daughter. They said “It's the disease for follow up! Cannot get cure quick!”, but the answer is not polite’ (caregiver 3)
	Lack of belief in providers	‘Before, he felt they don't believe in medical staff who work at the commune because they don't work with experience about ear care. And then may need to be charged money a lot! So, both problems – the money and the technique or experience to try to make [healthcare] work’ (participant 13)
	Lack of belief in the integrity of the medical system	‘They (hospital providers) don't do the right way. They take the money and they want to take again and again. Not just one way. So that is the way that they are making money into the hospital. So, most of the patients, they don't like to go and see them’ (participant 11)
	Medical paternalism	‘No doctor told him anything about what is the problem that child has … He just got medical treatment, like injection and perfusion, but they didn't know what it is’ (caregiver 18)

USD = US dollars