Influence of health institution related factors on health seeking behaviors among men suffering from lower urinary tract symptoms attending surgical outpatient clinic at a county referral hospital Meru Kenya

INTRODUCTION

Lower urinary tract symptoms (LUTS) describe a distinct phenotype of a group of disorders affecting bladder and prostate that share common clinical manifestations to include frequency, urgency, nocturia, difficult in initiating urination, sense of incomplete bladder emptying, decreased force of stream and interrupted stream.¹ Benign prostate hyperplasia (BPH) and prostate cancer (Pca) mostly accounts for LUTS.²

According to United States of America, census bureau international data base, it was projected that 1.9 billion persons of the world population (45.2%) were affected by LUTS in 2008.³ Correspondingly, a population-based study done on Nigerian men who were above the age of 40 years showed that, the overall prevalence of LUTS was 59.1%.⁴ A study done in Kenya in a tertiary health facility in western Kenya revealed that the health seeking behaviors of male patients with LUTS was low.⁵ Another study done in Singapore, showed that only 28.3% of males who aged 40 years and above with moderate-to-severe LUTS sought medical help.⁶ While in Nigeria, 78.4% of respondents who had mild LUTS didn’t seek medical care.⁷ Study In Nyamira County in Kenya, showed 87.9% of respondents had never sought medical help.⁸ The objective of this study was determine influence of health institution related factors influencing health seeking behaviors among male patients suffering from LUTS attending surgical outpatient clinic at Meru county referral hospital Kenya.

METHODS

Study design

Research design utilized analytical cross-sectional. Both qualitative and quantitative data collection methods were used in study. These included the use of questionnaires, focused group discussion and key informant interviews.

Study area

The study was carried out at Meru county referral hospital surgical outpatient clinic.

Study population

The total population comprised of 124 respondents, 120 men suffering from LUTS, 2 physicians and 2 nurses. The study population was 120 LUTS patients, 2 physician and 2 nurses working at this clinic (Table 1).

Inclusion criteria

The study included male patients who were above 40 years of age suffering from LUTS were included.

Exclusion criteria

Patients who had mental illness or neurological diseases which affect bladder emptying, and patients with other chronic conditions like diabetes were excluded.

Sampling procedure

The study used the census thus sample size was 120 LUTS patients, 2 physicians and 2 nurses.

Study period

The study was carried out august 2018 to march 2020

Data analysis and presentation techniques

Qualitative and quantitative data analysis was used. The responses were analyzed using statistical package for social sciences (SPSS) version 22. Descriptive analysis was used to generate the mean, standard deviation and frequencies. Logistic regressions were used whereby p values were used to determine statistical significance of results with cut off set at p≤0.05). The results were then presented using frequency distribution tables and charts. Qualitative data was analyzed using qualitative techniques mainly developing and applying codes, identifying themes, patterns and relationships and summarizing the data from direct quotes and selected comments from key informant interviews, and focused group discussion.

Ethical issues

The researcher obtained an introductory letter from Jomo Kenyatta university of agriculture and technology (JKUAT) school of nursing, after which ethical clearance was obtained from Kenya methodist university (KEMU) ethical review committee, national commission for science, technology and innovation (NACOSTI), Meru teaching and referral hospital management and Meru level five surgical outpatient clinic in charge. The researcher ensured that the respondents were informed of the research goals and objectives to minimize suspicion.

RESULTS

The sample for the study was 124 respondents who participated in the study. The respondents who filled the questionnaires were 112 the remaining 8 respondents participated in the focused group discussion. Four (4) key informants who were health workers participated in the study.

Socio-demographic characteristics of men with LUTS

A larger proportion of the respondents (42; 37.5%) aged between 61-70 years, while (34; 30.3) where aged above 70 years, (19; 17%) of the respondents aged between 40-50 years whereas (17; 15.2%) of the respondents aged between 51-60 years. Most of the respondents reported to be Catholics (64; 57.1%), protestants were (30; 26.8%) whereas a small proportion reported to be Muslims (10; 8.9%) as well as Hindu (8; 7.1%). Majority (70; 62.5%) of the respondents indicated that they were married. More than half (68; 60.7%) of the respondents indicated that they lived in urban areas. With respect to education level of the respondents, more than half of the respondents (75; 67%) indicated to have primary school education. A greater majority of the respondents (95; 84.8%) indicated to have informal employment. With respect to income, majority (81; 72.3%) of respondents revealed to earn less than Kshs 20,000 while a smaller proportion (31; 27.7%) of respondents revealed that they were earning Kshs 20,000 and above (Table 2).

Association between socio-demographic characteristics and high health seeking behavior

A greater majority of men having a high health seeking behavior was observed among men who were aged above 70 years (31; 91.2%) compared to men who were aged between 40-50 years (9; 47.4%). Men who were aged above 70 years were 11.48 [95% CI=2.59-50.86, p=0.001] times more likely to have high health seeking behavior compared to men who were aged between 40-50 years. A smaller proportion of men having a high health seeking behavior was observed among men who were aged between 61-70 years (8; 19.0%) compared to men who were aged between 40-50 years (9; 47.4%). Men who were aged between 61-70 years were 0.26 [95% CI=0.08-0.86, p=0.026] times more likely to have high health seeking behavior compared to men who were aged between 40-50 years. Similarly, a smaller proportion of men having a high health seeking behavior was observed among men who were aged between 51-60 years (1; 5.9%) compared to men who were aged between 40 – 50 years (9; 47.4%). Men who were aged between 51-60 years were 0.07 [95% CI=0.01-0.63, p=0.018] times more likely to have high health seeking behavior compared to men who were aged between 40-50 years.

A greater majority of men having a high health seeking behavior was observed among men who were married (44; 62.9%) compared to men who were single (2; 5.9%). Men who were married were 27.08 [95% CI=5.99-122.40, p<0.001] times more likely to have high health seeking behavior compared to men who were single. Similarly, a high proportion of men having a high health seeking behavior was observed among men who were widowed (2; 50%) compared to men who were single (2; 5.9%). Men who were widowed were 16.00 [95% CI=1.42-180.90, p=0.025] times more likely to have high health seeking behavior compared to men who were single.

Significantly a higher proportion of men having a high health seeking behavior was observed among men who resided in urban areas (25; 56.8%) compared to men who resided in rural areas (24; 35.3%). Men who resided in urban areas were 2.41 [95% CI=1.11-5.24, p=0.026] times more likely to have had high health seeking behavior compared to men who were residing in rural areas.

A greater majority of men having a high health seeking behavior was observed among men who had tertiary education (16; 88.9%) compared to men who were not educated (1; 10.0%). Men who had tertiary education were 72.00 [95% CI=5.70-908.90, p=0.001] times more likely to have high health seeking behavior compared to men who were not educated. Similarly a high proportion of men having a high health seeking behavior were observed among men who had secondary education (6; 66.7%) compared to men who were not educated (1; 10.0%). Men who had secondary education were 18.00 [95% CI=1.50-216.62, p=0.023] times more likely to have high health seeking behavior compared to men who were not educated (Table 3).

Health Institution-related factors influencing health seeking behaviors among men suffering from LUTS

More than half (71; 63.4%) of the respondents indicated that there were adequate drugs. Majority of the respondents (81; 72.3%) indicated they were treated well by the health care workers. Almost half of the respondents (55; 49.1%) indicated that there was short duration time taken to be served in the hospital. Slightly less than half of the respondents (53; 47.3%), indicated there were adequate screening/testing resources. High proportion of the respondents (77; 68.8%), indicated there were adequate personnel. More than a quarter (35; 31.3%) of the respondents indicated that screening/testing methods for LUTS were tedious. Majority (79; 70.5%) of the respondents indicated that treatment was expensive. More than half of the respondents (71; 63.4%) indicated that there was a long distance to the health care facility (Table 4).

Association between institutional-related factors and high health seeking behavior

Binary logistic regression was used to model influence of health institution related factors and health seeking behavior among men suffering from LUTS. Risk factors identified to be significant at p<0.05 during bivariate analysis were adjusted in multivariable logistic regression model. Backward conditional stepwise method was specified with removal of variables set at p<0.05.

A high proportion of men having a high health seeking behavior was observed among men who indicated that there was adequate drugs (38; 53.5%), compared to men who indicated that there was no adequate drugs (11; 26.8%). Men who indicated that there was adequate drugs were 3.14 [95% CI=1.36-7.23, p=0.007] times, more likely to have high health seeking behavior compared to men who indicated that there was no adequate drugs at the hospital.

Significantly a high proportion of men having a high health seeking behavior was observed among men who indicated that they had been treated well by the health care workers (41; 50.6%), compared to men who indicated that they had not been treated well by the health care workers (8; 25.8%). Men who indicated that they had been treated well by the health care workers were 2.95 [95% CI=1.18-7.36, p=0.021] times, more likely to have high health seeking behavior compared to men who indicated that they had not been treated well by the health care workers.

A high proportion of men having a high health seeking behavior was observed among men who indicated that there were adequate personnel (39; 50.6%), compared to men who indicated that there no adequate personnel (10; 28.6%). Men who indicated that there were adequate personnel were 2.57 [95% CI=1.09-6.06, p=0.032] times, more likely to have high health seeking behavior compared to men who indicated that there were no adequate personnel.

Higher proportion of men having a high health seeking behavior was observed among men who indicated that there was short duration time taken to be served in the hospital (30; 54.5%), compared to men who indicated that there wasn’t short duration time taken to be served in the hospital (19; 33.3%). Men who indicated that there was short duration time taken to be served in the hospital were 2.40 [95% CI=1.12-5.16, p=0.025] times, more likely to have high health seeking behavior compared to men who indicated that there wasn’t short duration time taken to be served in the hospital.

Significantly a high proportion of men having a high health seeking behavior was observed among men who indicated that treatment was not expensive (20; 83.3%), compared to men who indicated that treatment was not expensive (29; 16.7%). Men who indicated that treatment was not expensive were 10.17 [95% CI=3.18-32.51, p<0.001] times more likely to have high health seeking behavior compared to men who indicated that treatment was not expensive.

A high proportion of men having a high health seeking behavior was observed among men who indicated that there was no long distance to health care facility (23; 56.1%), compared to men who indicated that there was long distance to health care facility (26; 36.6%). Men who indicated that there was no long distance to the health care facility were 2.21 [95% CI=1.01-4.84, p=0.047] times more likely to have high health seeking behavior compared to men who indicated that there was long distance to the health care facility (Table 5).

Responses from the key informants and participants during focused group discussion

Health institution related factors that were identified by the key informants and participants during the focused group discussions, two subthemes emerged namely cost of health care and human resource.

Sub-theme 1: Cost of health care.

It came out clearly that the cost of health care influenced health seeking behaviors among male patients with LUTS. This was reported by 48 participants. Specifically, one respondent noted that: “Hospitals require a lot of money before being treated and getting that money is a problem in these difficult times” Respondent 3 FGD 4.

Key informants seconded the above sentiments by stating that health care services were expensive and that majority of patients could not afford unless those with medical insurance covers. One of them noted that:

“Health care services in Kenya are expensive therefore most patients can’t afford them” KI 3.

Sub-theme 2: health personnel

The respondents in the FGDs reported inadequate health personnel as a barrier for them to seek health care at the health facilities. This was reported by 30 participants. One of the respondents noted that:

“Hospitals do not have enough doctors and nurses to treat us; sometimes you stay the whole day before you are treated” Respondent 3 FGD 1.

DISCUSSION

Men who indicated that there was adequate drugs were 3.14 [95% CI=1.36-7.23, p=0.007] times, more likely to have high health seeking behavior compared to men who indicated that there was no adequate drugs at the hospital. Men who indicated that there were adequate personnel were 2.57 [95% CI=1.09-6.06, p=0.032] times, more likely to have high health seeking behavior compared to men who indicated that there were no adequate personnel. This was congruent to a study done in Nigeria which showed that 34.5% and 7.1% of respondents reported adequate staffing and availability of drugs respectively were necessary and this had a significant influence on their health seeking behavior.⁹

Men who indicated that they had been treated well by the health care workers were 2.95 [95% CI=1.18-7.36, p=0.021] times, more likely to have high health seeking behavior compared to men who indicated that they had not been treated well by the health care workers. Similarly, those who indicated that there was short duration time taken to be served in the hospital were 2.40 [95% CI=1.12-5.16, p=0.025] times, more likely to have high health seeking behavior compared to men who indicated that there wasn’t short duration time taken to be served in the hospital. This was congruent to a study done in primary health care center in Dubai, which showed that waiting time had significant influence on health seeking behavior.¹⁰ The main causes of prolonged waiting time were high workload, insufficient work procedure, employees-supervisor interaction problems and lack of adequate health resources.¹⁰

Men who indicated that treatment was not expensive were 10.17 [95% CI=3.18-32.51, p<0.001] times more likely to have high health seeking behavior compared to men who indicated that treatment was expensive. This was similar to study done in Meru Kenya on patient related factors influencing health seeking behavior among men suffering from LUTS which revealed that 78.6% (p<0.001) of the respondents agreed that lack of funds to cater for health care bill impended them from seeking health care.¹¹ This was also congruent to a study done on clinical care for patients with LUTS, which showed that high health care cost was associated with the low health seeking behavior.¹²

Men who indicated that distance from their home to health care facility was not long were 2.21 [95% CI=1.01-4.84, p=0.047] times more likely to have high health seeking behavior compared to men who indicated that there was long distance to health care facility. Long distance leads to reduced accessibility of health facilities, as patients need to walk for a longer duration of time or use a lot of money to cater for transport cost.¹³ This was similar, to a study done in Meru Kenya on Social cultural factors influencing health seeking practices among men suffering from LUTS attending surgical outpatient clinic at a county referral hospital in Kenya which showed that 58.9% (p<(0.001) of them were living within 10-15km from the health care facility and this had negative influence on health seeking behaviour.Also congruent to a study done in Denmark on cancer, which showed that distance had significance influence on health seeking behavior (p=0.02,OR=1). ¹⁴

Therefore, the null hypothesis “there was no significant relationship between health institution related factors and health seeking behaviors among men suffering from LUTS attending surgical outpatient clinic at Meru county referral hospital”, was rejected in favor of its alternative hypothesis which stated that “there was a significant relationship between institution-related factors and health seeking behaviors among men suffering from LUTS attending surgical outpatient clinic at Meru county referral hospital ”.

Limitation

This study was limited by the fact that it was carried on men with LUTS who attended surgical outpatient clinic but it didn’t address those who remained at home without seeking help and those that visited private hospitals for treatment of LUTS.

COCLUSSION

On the influence of health institution-related factors on health seeking behavior among men suffering from LUTS, adequate personnel 2.57 [95% CI=1.09-6.06, p=0.032], adequate drugs were 3.14 [95% CI=1.36-7.23,

p=0.007], treated well by the health care workers 2.95 [95% CI=1.18-7.36, p=0.021], short duration time taken to be served in the hospital were 2.40 [95% CI=1.12-5.16, p=0.025] and distance to the health facility 2.21 [95% CI=1.01-4.84, p=0.047],were significant parameters associated with health seeking behavior

Funding: No funding sources

Conflict of interest: None declared

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

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