Determinants of health care seeking behavior among rural population of a coastal area in South India

INTRODUCTION

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. The decisions made encompasses all available health care options like visiting a public or private and modern or traditional health facility, self-medication and use of home remedies or not to utilize the available health services etc.

The desired HSB has been related to visiting official channels in a formally recognized health-care. As for health care system, in almost all the developing countries, the public and the private health sector coexist but private care provider are usually preferred all around due to easy accessibility even in the night, quick relief and individual attention.¹ Whereas, Public hospitals in India are known for low quality treatment, long waiting period, long distance, inconvenient location, and inadequate facilities.²

Further, some public hospitals also charges money for free services.³ However, owing to lack of money to access care at private hospitals, many poor people resort to self-treatment and by-pass primary care providers.⁴

HSB is a result of a complex interaction of provider, patient, illness and household characteristics.⁵ HSB is influenced by a variety of socio-economic variables, including sex, age, the social status of women, the type of illness, access to services and perceived quality of the service etc. HSB has been found to be associated with type of illness and gender of ill-person, income group and area of residence.^6,7

Nearly 80% of the health facilities, both public and private are concentrated in the urban areas and are widely utilized by the urban communities.⁸ Further, the indirect costs like those associated with travel to the health facilities act as deterrents for the rural population.

Planning for health care services provision depends on the health needs and HSB of the population. Determining the health care seeking behavior is essential to provide need based health care services to the population. While hospital data remains the main source of information regarding the disease pattern, community based studies well reflects the preferences in seeking health care services.

This study was done to understand the process of decision making and various factors (household, individual, illness and provider characteristics) influencing the health care seeking behavior among rural population of a coastal area in Tamil Nadu.

METHODS

Study design and setting

This community based descriptive study was done in a rural coastal area of Villupuram district of Tamil Nadu state in India. The study area, with a population of approximately 6000 is the field practice area of Department of Community Medicine, Pondicherry Institute of Medical Sciences. For last more than ten years, a Community-Based Health Information and Management System (CHIMS) is being maintained for the resident population. The study area is having both public and private health facilities apart from traditional healers.

Sample size and sampling

The sample size calculation was based on the assumptions that there would be 40% individuals who are visiting private health care facilities in case of any sickness. This resulted in a sample of 576. A village was randomly selected from the list of all villages in the study area and all the households in the selected village were included in the study.

Study tools

A pre-tested structured questionnaire was used to collect data by house to house visits. Interview schedule was administered to the household head and all the available study participants. Data was collected on demographic characteristics, employment, education level, family size, presence of acute and chronic illnesses, health care seeking behavior and reasons for non-utilisation of particular health facilities etc.

Definition: Choice of provider was defined as the place of first contact following an illness (public hospital, private health facility, public health centre/dispensary or traditional healer/self-medication). The alternative of traditional healer or self-medication refers to those who sought treatment outside the home from a traditional healer, drugstore or pharmacy. This differs from individuals who did not seek care but instead used home remedies or those who delayed seeking care and opted to start with home remedies first. Traditional healer and self-medication was later merged as others since both choices represent alternative sources of care.

Data collection: A house to house survey was done during June-August 2014 and trained interviewers visited all selected households. If any of the household was found locked then they were visited again. Two return visits were made to households where eligible members were not available for interview during the first visit. Informed written consent and/or assent were taken from all the participants/guardians before the initiation of interview. All available adult members in the household were interviewed and the information about the health seeking behavior during child’s illness was collected from their mother or primary caregiver.

Statistical analysis: All the data were captured in the Microsoft excel spreadsheet and the analysis was done in SPSS version 17. Means and proportions were calculated for continuous and categorical variables respectively. Chi square test was applied to find the association of health care seeking behavior with various patient characteristics. P value of <0.05 was considered as statistically significant.

RESULTS

Among 559 study participants, majority (51.2%) were male and also most (84.5%) of the households were headed by male. Almost one-third of the participants were illiterate. Most of the study participants were involved in agricultural work and were having monthly income of INR <2000 (Table1).

Majority (56.4%) of study participants reported to visit public health facilities for various illnesses. Almost one-third of the study participants visited the private health facilities and another 11.6% visited other health facilities including pharmacies. Among various causes of health facility visits, febrile illnesses (39.5%) and pain (20.8%) were the most common reasons. Other common morbidities include respiratory causes (8.4%), diarrhea (8.6%) and other gastrointestinal problems (5.2%), non-communicable diseases including diabetes and road traffic accidents (Table 2).

Various factors like education, occupation, morbidity and age were not found to be associated with any particular type of health care seeking behavior but income was significantly associated with the HSB (p value <0.05) (Table 3).

*Children upto 14 years of age were excluded during analysis

*Others include - pharmacy, traditional healer and self-medication

Among various reasons for preferring a particular health facility, ease of access, services free of cost, quality of services were some of the reported reasons. Most common reason for preferring to the public health facility was that the services were free of cost. Private practitioners were preferred due to their availability and quality of care (Table 4).

DISCUSSION

The under-utilization of the health services in public sector has been almost a universal phenomenon in developing countries. On the other hand, private health care sector is growing in low and middle income countries and has flourished everywhere because it focuses mainly on ‘public health goods’ such as antenatal care, immunization, family planning services, treatment for tuberculosis, malaria and sexually transmitted infections.^9-12

The present study, conducted in a coastal rural area of South India found that, in case of illness, majority (56.4%) of the study participants visited public health facilities. Similar finding were observed in other study where participants preferred to visit a health clinic than private practitioners.¹³ This could be related to the available income, since a health clinic provides free care and a medical doctor in private practice does not. But these finding differ to other study done in Bangladesh where majority of the participants were accessing the private doctors for health care.¹⁴

In the present study, one-third of the study participants visited the private health facilities and another 11.6% visited other health facilities including pharmacies. Although, the quality of services provided by the private practitioners is also questionable but many factors like availability and easy accessibility make them as a preferred choice, particularly by those who don’t have any financial constraints.¹⁵

Most of the participants in present study reported to visit the health facilities for febrile illness (39.5%) and pain (20.8%). Other common morbidities for health facility visits include respiratory problems (8.4%), diarrhea (8.6%) and other gastrointestinal problems (5.2%) and other non-communicable disease including diabetes and road traffic accidents.

Among various age-groups, most preference for public health facilities was given for children followed by adults and elderly. Also among all age groups, elderly preferred to take home remedies, self-medications or visited traditional healers. As compared to male adults, females preferred to visiting private health facilities. This could be due to non-availability of female health care provider in most of the public health facilities.^16,17 Contrary to our study, a similar study for health care seeking behavior of children in Puducherry found no gender differences in seeking private or government health care. Income was found to be associated with the preference to the organized health care providers and with higher income lesser participants were taking self-medication or were visiting traditional healers. This paper identifies factors that drive healthcare-seeking behaviour in rural coastal area but does not avoid reporting bias in a self-perceived need. It also examined the healthcare-seeking behaviour for any conditions but no separate assessment for individual disease condition was sought.

CONCLUSION

Health seeking behaviour of people is dependent on the perception of people regarding the quality of health care services in health centers. The perception of the people has to be changed to attract them more to government hospitals and health centers. It can be done through improving the quality of care, proper maintenance of facilities and also by inculcating a caring and sympathetic attitude in health professionals while dealing the patients.

ACKNOWLEDGEMENTS

Authors would like to thank all the participants who consented to participate in the study. Authors also thank those students of nursing sociology who helped in collecting data.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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