The variation of health seeking behaviour in urban households: an assessment on two selected residential areas in Sylhet

INTRODUCTION

The government of Bangladesh has a constitutional obligation to ensure the minimum health opportunity to all citizens which is also considered as fundamental right of human being.¹ Health, like education, is among the basic capabilities that gives value to human life.² However, a large number of the people in Bangladesh, particularly in rural areas, remain with little access to health care facilities.³ Health seeking behavior refers to decision or an action taken by an individual to maintain, attain, or regain good health and to prevent illness. Health seeking behavior determines how different classes of people use health services from the health professionals and the health service organizations. A number of factors that determine health seeking behavior are: physical, socio-economic, cultural and political.^4,5

Empirical studies from Bangladesh and few other developing countries found that socio-economic condition is highly considerable factors in health seeking behavior.⁶ Socio-demographic factors, such as age is a factor which varies the health care seeking behavior from person to person. A study found that age was significantly associated with visiting modern health care facility.⁷ Another study on the health-seeking behaviour of the people in Chakaria, a rural area in Bangladesh shows that half of the people (47.1%) reporting any sickness during the 14 days preceding the survey had sought treatment for their illnesses.⁸ However, treatment seeking was not equitable throughout the community. Socioeconomic indicators were the single most pervasive determinant of health-seeking behavior among the study population, overriding age and sex, and in case of health-care expenditure, types of illness as well.⁹

In low-income countries such as Bangladesh, the less than optimum use of services could be due to low levels of health literacy where health literacy helps individuals to make effective use of available health services. The quality of medical treatment was associated with urbanity and type of disease.¹⁰ A study shows that seeking medical treatment from any provider in the last one year was higher in the rural than urban patients.¹⁰ The major finding of a study conducted in three divisions of Bangladesh was that a household’s relative poverty status, as reflected by wealth quintiles, was a major determinant in health-seeking behavior.¹¹ Mothers in the highest wealth quintile were significantly more likely to use modern trained providers for antenatal care, birth attendance, post natal care and child health care than those in the poorest quintile.¹¹ Study also found that both formal education and relative wealth were positively associated with the utilization of maternal and child health services.¹¹

The effectiveness of a health system depends on the availability and accessibility of services in a form which the people are able to understand, accept and utilize.¹² However, a large number of the people in Bangladesh, particularly in rural areas, remain with little access to health care facilities.¹² Urban area has private health facilities, therefore urban population get relatively quality health care which is completely absent for rural population. The factors that contribute to poor accessibility of health care in developing countries are illiteracy, poverty, poor funding of the health sector, inadequate water and poor sanitation facilities.¹³ Within rural areas of Bangladesh, where overall poverty is greater and access to health care more difficult, wealth differentials in utilization remain pronounced.¹¹ There were others barriers such as lack of access to quality service and information regarding quality service which deters the use of service.¹¹ This study examines some significant health service determinants such as socio-economic, socio-cultural and demographic factors which are correlated with health seeking behavior of households. Some examples include gender, age, education, access to health, income, social taboos, traditional beliefs and modern health care system.¹⁴

METHODS

This study has used mixed research approach because both qualitative and quantitative data have been collected from September to October 2018 and analyzed for understanding the various factors such as socio-demographic, socio-economic, health systems and their relationships with health seeking behavior of Sylhet city dwellers. This study selects two residential areas purposively e.g., Uposhohor under ward 22 and Nabab road under ward 10 located in Sylhet City Corporation on the basis of socio-economic status of city dwellers. Data from two different socio-economic areas enables this research to get new insights on health seeking behaviors which may meets the objectives of this study.

Sampling and selection criteria

The multistage cluster sampling method has been chosen to collect primary data from the large population with different socio-economic background. Data have been collected from different clusters. As sampling, the population of the Sylhet city will be divided into 27 clusters according to the geographical locations (wards). The specific number of sample has been selected randomly from two randomly selected clusters. From the above mentioned two residential areas of Sylhet City, 150 respondents from 150 households have been selected using multistage cluster sampling using the following formula-

Instruments

A survey questionnaire has been used for collecting data on socio-economic factors and health seeking behavior. This study has been collected data from the respondents on socio-economic background and health seeking patterns and preferences, and the causes of inequalities in health service delivery in the Sylhet city dwellers.

Data analysis

Survey data have been analyzed using SPSS Version 20. Descriptive statistics are used to describe the characteristics of sample data by using SPSS program and inferential statistics allow the researchers to examine casual relationships. Inferential statistical tools including chi-square and univariate analysis have been applied in this study using SPSS software.

RESULTS

The health seeking behavior is varies from area to area. It totally depends on the health care facilities and different kinds of factors.

Socio-demographic information by residential areas

The Table 1 shows that the education levels of the households in the Uposohor area shows higher percentage compared to the Nababroad. For example, the educational levels of households under this study were degree or above (18.7%) and HSC (11.3%) in the Uposohor area where the education levels of households in Nababroad were degree or above (12%) and HSC (4%) respectively. Both residential areas have more or less healthy sanitary system. The association between socio-economic status and the status of residential area has a significant relationship. Most of the household’s head employed in the private sectors in both residential areas. The p-value indicates most of the socio-demographic factors except sanitary system associated with the status of residential households (Table 1).

Economic factors and health seeking behavior according to the residential areas

In the Uposohor area (Table 2), most of the respondents, 27.3% households belong to income range (30,000-60,000 BDT taka) while the most of the respondents (22%) among the households of Nababroad under the study belong to income range (18,000-30,000 BDT). Likely the income range, the expenditure for maximum number of both residential households fall into 30,000-60,000 BDT taka (27.3%) and 18,000-30,000 BDT (22%) in the Uposohor and Nababroad respectively. In the Uposohor, the maximum number of households under this study spent the amount of above 30.000 BDT (37.2%) while only 10.7 % of the respondents in Nababroad area spent same amount of taka for their monthly expense.

Source: Field data, collected from Uposohor and Nababroad, September-October 2018, Sylhet City.

Source: Field data, collected from Uposohor and Nababroad, September-October 2018, Sylhet City.

It is noticeable in Table 2 that the most of households in the Uposohor area under this study spent the amount between 2000 to 5000 (15.3%) and between 5000 to 10,000 BDT taka (13.3%) where the maximum number of households in the Nababroad spent the amount 500-1000 (14%) and 2000-5000 (21.3%) for their medical expense. Although the average income is higher in the Uposohor area, the respondents (33.3%) of that area said the income level was insufficient while 16.7% respondent’s income was insufficient and interfered their seeking health care. In both residential areas, only a few 6.7 % had the health insurance scheme under this study. In the Uposohor area, the main source of health service was private clinic (43.3%) among the respondents while majority of the respondents (30.7%) used the public hospital as their main source of health care in the Nababroad area. The reason for choosing specific source health care was better service in both residential areas among the respondents of the households in the Sylhet city, 26% in the Uposohor and 31.3% in the Nababroad. The association among income range, total expenditure, medical expense, income interfere by perceiving illness, health insurance, main source of health care, reason for choosing specific source of health care and the pattern of health seeking behavior of the residential areas are statistically significant which is shown in the Table 2.

Socio-cultural factors according to residential areas under study

Both in the two residential areas shown in Table 3, the majority of the respondents choose alternative health care as their priority in Uposhor (37.3%) and Nababroad (46.7%). The barriers mostly visible in health care reported by respondents are feel shyness to express (9.3%) and mistreatment the health problem by physician (9.3%).

It is surprising that most of the respondents (more than half of the households) in both residential areas did not face any barrier for seeking treatment from health centres. Maximum number of respondents of the respondents (39.3%) said the attitude of health service providers affect the health seeking behavior in the Uposohor area while the 35.3% of the households in the Nababroad under this study said that the attitude of heath service providers did not affect their health seeking behavior.

The association among the priority in choosing health care, perception of bio-medical treatment, barriers facing in seeking treatment, patient’s dignity, the health provider’s attitude and the patterns of the seeking behavior of the residential area are statistically significant (Table 3).

Source: Field data, collected from Uposohor and Nababroad, September-October 2018, Sylhet City.

Source: Field data, collected from Uposohor and Nababroad, September-October 2018, Sylhet City.

Health service system according to the residential areas

From the field survey (Table 4), it is found that 44.7 % of the households under this study claimed that the distance of health service providers or facilities from their home is less than 1 kilometer in Nababroad while the second highest number of the respondents (42.7%) said that the distance of the health service providers or facilities is 1-2 kilometer. The association between the effect of distance on client's attendance and the health seeking behavior of the residential areas is statistically significant at the level of p=0.000. Most of the respondents (32%) in the Uposohor area said that transport availability affects the choice of health care while 45.3 % of the respondents in the Nababroad area under this study reported that the transport availability did not affect their choice of health care. The p value=0.000 indicates that the transport availability has a significant relationship with the health seeking behavior of the residential areas. In the Uposohor area, 42% of the respondents said that private Hospital/ clinic/doctor’s chamber are available within the 10-15 minutes walking distance while the maximum number of the respondents (48%) among the households of the Nababroad said that the government hospital/clinics are available within 10-15 minutes walking distance. Most of the respondents (30%) and (45.3%) respectively in Uposohor and Nababroad reported that the skilled health worker are available in their locality of health facility. 26% of the respondents in the Uposohor area reported that the medical resources are little in the health facility during their treatment where most of the respondents (40.7%) of the households of Nababroad stated that the medical resources are sufficient in their health facility during their treatment. The association among skilled health worker and medical resources and the health seeking behavior of the residential areas are statistically significant at the level p=0.000. Most of respondents (34%) of the Uposhor area in Sylhet city said that they had easy access to the physician during their treatment while 36% respondents among households of Nababroad stated that they had easy access to physician during their treatment. At the same time, 40% of the households of the Uposohor area in Sylhet city under this study said that the proximity of health centre have huge effects to make easy the access to their health care while 38.7% of the respondents among the households of Nababroad said that the proximity of health centre have a number of effects to make easy the access to their health centre.

Source: Field data, collected from Uposohor and Nababroad, September-October 2018, Sylhet City.

Source: Field data, collected from Uposohor and Nababroad, September-October 2018, Sylhet City.

Factors affecting health seeking behavior according to the residential areas

According to the Table 5, the households of two residential areas went to MBBS doctor for their last health problem in Nababroad (42.3%) and Uposohor (44.3%) under this study. In the Uposohor area, the households under this study choose this provider/facility are provider friendly (12.7%), low cost/free (12.7%), medicines available (12%) where in the Nababroad, the respondents reported that the reasons they choose this provider/facility are qualified doctors (MBBS or specialist) (26%) and close to home (12.7%). The association between reason of choosing this provider/facility and the health seeking behavior of the residential areas has a significant relationship. The maximum number of households (15.3%) in the Uposohor area spent between 1000-2000 taka only for the last visit including transport costs, medical expenses, registration fees etc. while the maximum number of respondents (14%) among the households in the Nababroad spent less than 500 taka for the last visit. The last expenditure has a relationship with the pattern of seeking behavior of the residential areas (Table 5).

Univariate analysis

A two-way ANOVA is used to understand whether there is an interaction between residence and reason for choosing specific health care on main source of health care among the households of the residential areas under this study, where residential area and reason for choosing specific source of health care are the independent variables, and main source of health care is an dependent variable.

The particular rows this study is interested in are the “Reason for choosing specific source of Health care” and “Residential area” rows in the Table 6. The two-way ANOVA was conducted that examined the effect of residential area and reason for choosing specific source of health care on main source of health service. There was a statistically significant interaction between the effects of residential area and reason of choosing specific source of health care on main source of health service, F=5.55, p=0.001.

DISCUSSION

The study findings showed that the education levels of the households in the Uposohor area shows higher percentage compared to Nababroad. Both residential areas have more or less healthy sanitary system. But the p value indicates most of the socio-demographic factors except sanitary system associated with the status of residential households. This findings are in agreement with a study by Engeda et al which reported socio-demographic such as age varies the health seeking behavior from person to person and significantly associated with health seeking behavior.⁷

In the Uposohor area, most of the respondents, 27.3% households belong to income range (30,000-60,000) while the most of the respondents (22%) among the households of Nababroad under the study belong to income range (18,000-30,000 BDT). Although the average income is higher in the Uposohor area, the respondents (33.3%) of that area said the income level was insufficient while 16.7% respondent’s income was insufficient and interfered their seeking health care. This findings agreed with a study by Ahmed et al which reported that socio-economic indicators were the most pervasive determinants of health seeking behavior among the study population.⁹

This study observed that most of the respondents (more than half of the households) in both residential areas did not face any barrier for seeking treatment from health centres. In addition, majority of the respondents said the attitude of the health service providers affect the health seeking behavior in the Uposohor area while the majority of the households in the Nababroad under this study said that the attitude of health service providers did not affect their health seeking behavior. This is in an agreement with the study of Uddin et al who found that the quality of medical treatment was associated with urbanity. The association among the priority in choosing health care, perception of bio-medical treatment, barriers facing in seeking treatment, patient’s dignity, the health provider’s attitude and patterns of the seeking behavior of the residential are statistically significant.^11,12 The association between distance affect and health seeking behavior of the residential area have a significant relationship at the level p=0.000.¹² Majority of the respondents in the Uposohor areas said that transport availability affect the choice of health care while 45.3% of the respondents in the Nababroad area under this study reported that the transport availability did not affect their choice of health care. The value p=0.000 indicates that the transport availability has a significant relationship with the health seeking behavior of the residential areas. These findings are supported by the study of Islam and Biswas which reported the effectiveness of a health system depends on the availability and accessibility of services in a form which the people are able to understand, accept and utilize.¹² The association among skilled health worker and medical resources and the health seeking behavior of the residential areas are statistically significant at the level p=0.000.^12,13

This study found that the maximum number of households in the Uposohor area spent between 1000-2000 taka only for the last visit including transport costs, medical expenses, registration fees etc. while the maximum number of respondents among the households in Nababroad spent less than 500 taka for the last visit. This finding is an agreement with the study of Osman who reported that major factors contribute to poor accessibility of health care is poor funding of the health sector. The last expenditure has a significant relationship with the pattern of seeking behavior of the residential areas.⁹

The study also found that there was a statistically significant interaction between the effects of residential area and reason of choosing specific source of health care on main source of health services, p=0.001.¹⁰

CONCLUSION

Health care seeking behavior (HCSB) refers to decision or an action taken by an individual to maintain, attain, or regain good health and to prevent illness. Understanding of health seeking behavior (HSB) is essential to provide need based health care services to the population. Many factors like gender, age, type of illness, access to services and perceived quality of the services, influences the health seeking behavior. After all, health seeking behavior totally depends on the perception of the study population. The following recommendation extracted from the field data and feedback from the respondents-

As socio-economic factors is the main determinant in seeking health care, the culture of health insurance system should be established and Government should coverage this system in the health policy of Bangladesh to reduce the inequalities in health service and the access of poor communities to minimum standard of quality health care.

Health facilities for poor communities should be modernized and accessible. Besides this, the government should create income generating sources for the poor people so that they can access and afford the quality health care as income is the major restraint and determinant in health seeking behaviour.

The Sylhet city corporation should take initiative or propose government to establish urban health centre with modern equipment and resources and specialized hospital for ensuring participation of the poor people with minimum cost in quality health service and ensure health equality.

ACKNOWLEDGEMENTS

Authors would like to thank Councilor of the City Corporation, Sylhet and the households under the study for providing valuable information for this research.

Funding: Department of Public Administration

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Ministry of Health and Family Welfare. Local health bulletin 2016 for Sylhet Civil Surgeon office, 2016. Mohakhali, Dhaka, Bangladesh.
2. 2. Sen AK. Health in Development. Bulletin of the World Health Organization. 1999;77:619-23
3. 3. Islam A, Biswas T. Health system in Bangladesh: challenges and opportunities. Am J Health Res. 2014;2(6):366-74.
4. 4. Musoke D, Boynton P, Butler C, Musoke MB. Health seeking behavior and challenges in utilizing health facilities in Wakiso district, Uganda. African Health Sci. 2015;14(4):1046-55.
5. 5. Kroeger A. Anthropological and socio-medical health care research in developing countries. Social Sci Med. 1983;17:147-61.
6. 6. Biswas P, Kabir ZN, Nilsson J, Zaman S. Dynamics of health care seeking behavior of elderly people in rural Bangladesh. Int J Ageing Later Life. 2006;1(1):69-89.
7. 7. Engeda EH, Dachew BA, Woreta HK. Health seeking behaviour and associated factors among pulmonary tuberculosis suspects in Lay Armachiho District, Northwest Ethiopia: A Community-based study. Tuberc Res Treat. 2016;2016:7892701.
8. 8. Mahmood, SS, Iqbal M, Hanifi SMA. Health-seeking behavior. In A. Bhuiya (Ed.), Health for the rural masses insights from Chakaria.2009;67-96.
9. 9. Ahmed MS, Tomson G, Petzold M, Kabir NK. Socio-economic status overrides age and gender in determining health seeking behavior in rural Bangladesh. 2005;83(2):109-17.
10. 10. Uddin MJ, Alam N, Koehlmoos TP, Sarma H. Consequences of hypertension and chronic obstructive pulmonary disease, healthcare-seeking behaviors of patients, and responses of the health system: a population-based cross-sectional study in Bangladesh. BMC Public Health. 2014;14:547.
11. 11. Amin R, Shah MN, Becker S. Socioeconomic factors differentiating maternal and child health-seeking behavior in rural Bangladesh: a cross-sectional analysis. Int J Equity Health. 2010;9:3-11.
12. 12. Islam A, Biswas T. Health system in Bangladesh: challenges and opportunities. Am J Health Res. 2014;2(6):366-74.
13. 13. Osman AF. Health policy, programmes and system in Bangladesh: achievements and challenges. South Asian Survey. 2008;15(2):263-88.
14. 14. Islam N, Angeles G, Lance P. Slums of urban Bangladesh, Mapping and Census, 2005. Centre for urban studies, measure, emulation. National Institution of Population Research and Training, Dhaka. 2006.
15. 15. Qasim M, Bashir A, Anees MM, Khalid M, Ghan, UM. Socio economic effect on health seeking behavior of women (review paper). Adv Agricult Sci Engineer Res. 2014;4(6):1646-50.