Understanding Interpersonal Influences on the Use of Formal Health Services among a Population of Iranian Women in Reproductive Age: A Qualitative Study.

BACKGROUND: One of the most important factors contributing to using formal health care services by women is people who are involved in the social network around them. AIM: This study aimed to understand the interpersonal influences on the use of formal health services among Iranian women of reproductive age.
METHODS: This study is a deductive content analysis approach based on the Health Promotion Model. Twenty-two semi-structured interviews were done with women of reproductive age and health care staffs in Qom, Iran. Transcripts were analysed by a deductive content analysis approach based on the Health Promotion Model (HPM).
RESULTS: Three main categories and eight subcategories were drawn consisting of (1) social support with 4 subcategories including "Family support and influence", "support of religious people", "support of health care providers" and "negative social support"; (2) social pressure and expectations with 2 subcategories including "feeling pressure due to role-playing" and "society's expectations regarding women's health", and (3) healthy role models with 2 subcategories including "family role models" and "modeling friends and peers in taking action for treatment".
CONCLUSION: A positive interpersonal influence in women acts as a strong incentive to seek health care when they are suffering from a disease, and prevents the chronicity of the disease by timely treatment.

Introduction

Health research on health care in different populations shows that gender differences lead to different patterns in the use of formal health service resources [1], [2]. Some studies have shown that women more frequently refer to formal health services due to gynaecological problems and maternity-related issues, but there is no clear pattern of the use of health services for the physical symptoms shared by men and women [3]. Although women pay more attention to the symptoms of illness than men and tend to assess their health status [1], when deciding on the use of health services, a group of external factors affects their decision. In addition to the gender roles of women such as child care and providing and maintaining of households, which may lead them into making use of more available, informal networks, interpersonal factors can also affect the selection of treatment resources [4].

As Pender in Health Promotion Model (HPM) points out, interpersonal factors affecting health issues include social support (instrumental or emotional incentives), norms (others’ expectations), and modelling, and can include family, peers and health care staff [5]. The patient’s perception of the social support of people around him/her has a positive effect on referring to health care centres [6]. In contrast, patients who do not have adequate social support are twice as likely to delay receiving health care as others who do [7]. Social norms may also hinder or facilitate people’s decision making because they are pressured by being socially approved by the environment [8]. Finally, a healthy role model can positively effect on patient’s attitude and lifestyles [9].

The literature review showed there are few studies about the role of interpersonal influences in seeking care among Iranian women. Also, this issue has not yet been addressed in terms of the qualitative approach. The purpose of this article is to investigate the interpersonal influences in performing health care seeking behaviour (HCSB) in Iranian women of reproductive age.

Methods

Study design and Participants

The study was a deductive content analysis approach and done from May 2016 to January 2017. Participants included 17 reproductive-aged women and 5 health care staffs from Qom, Iran. Inclusion criteria were Iranian married women 15-49 years, with the ability to communicate appropriately. For health staffs having at least 1 year of work experience was considered. Purposive and maximum variation sampling was used to identify participants.

Data Collection

Data was collected using semi-structured; in-depth interviews lasted on average 35 to 65 minutes. With interviewee’s agreement, interviews were performed at the health centres near their homes in any meeting time they chose. The objective of the study before starting the interview clarified to women. All interviews tape-recorded and the process of interviewing continued until data saturation was achieved through interviews.

Interview tool

A predefined guide question was developed based on interpersonal influences construct described in the HPM. The information of Table 1 represents the key questions that extracted responses experiences in this study.

Table 1

Interview guide questions

Social Support

- Who will encourage you to seek formal health care, when you get sick? - Does your husband support you using health services? - What kind of support you have for your clients? (health care provider’s question)

Social Norms

- Do any of your family members or friends expect you to use modern medicine? - What do you think about social pressures surrounded women’s health?

Role models

- Is anyone in your family or any of your friends just visit a health professional for disease treatment?

Data analysis

All interviews were transcribed to verbatim and coded using unstructured categorisation matrix which reflected the categories of triple interpersonal influences construct. A deductive content analysis approach was applied to analyse the qualitative data of interviews. In this way, theories are the basis for creating categories, and initial coding is made using previous research findings [10]. The result of qualitative interviews is reported as an exploration of women’s interpersonal influences about HCSB, as per standards for reporting qualitative approach [11].

Ethical considerations

Ethical approval for this study was obtained from the Ethics Committee of Public Health School, Shahid Sadoughi University of Medical Sciences (with Ethics Committee Code of IR.SSU.SPH.REC.1394.89). Written informed consent was acquired from the participant before each interview. Participation in this study was voluntary, and women could exit at any time of the study without affecting their use of free health care services.

Results

The age range of participants was about 17-47 years. Only 5.88% of women were illiterate. In addition to being housewives, 25.3% of women also worked outside the house, and 88.2% were covered by health insurance. Three main categories and eight subcategories were drawn from qualitative data (Table 2).

Table 2

Categories and subcategories of interpersonal influences on the use of formal health services among a population of Iranian women in reproductive age (n = 22)

Main Construct	Categories	Subcategories
Interpersonal influences	Social support	Family support and influence
		Support of religious people
		Support of health care providers
		Negative social support
	Social pressure and expectations	Feeling pressure due to role-playing
		Society’s expectations regarding women’s health
	Healthy role models	Family role models
		Modelling friends and peers in taking action for treatment

Social support

Family support and influence

Most participants recognised the family as the most important source of HCSB support. Support from the spouse was mainly instrumental; in contrast, the mother’s or sister’s support was mainly emotional. Insisting on and leading women into doing HCSB was mainly done by a person other than the spouse.

“When I get sick, my husband will help me so much. He takes leave from work to take and return me to the doctor, or keep the children up. He says as much as you want, pay for going to the doctor, but be healthy” (Participant 7).

“Sometimes, I don’t wanna go to the doctor for [taking care of] kids, my sisters tell [me] to get up and go [to the doctor], the children will grow up and leave [you]. If you’re not healthy, then there’s nobody to give a glass of water to you. Even, when I feel too lazy to go to the doctor, my sisters books an appointment with a doctor for me and I’ll have to go to” (Participant 5).

Support of religious people

Religious people such as clerics and other religious entities can be a good source of support for women in the community.

“When I went to the mosque for prayers, the mosque’s cleric advised men to give more importance to the physical and psychological health of their wives, especially in the period of pregnancy or lactation. He quoted the hadiths that show in Islam, woman and mothers have been given much attention” (Participant 15).

“When I was going to undergo an operation for my womb problem, I could get help from a charity group. They are women that hold a religious meeting every month, and the end of the meeting, everyone offers as much as money she affords, it is only for the purchase of medical care for a female who can’t afford their expenses. Many women who are custodians of [their] households or their husbands are unemployed or addicted use this money to treat their illnesses” (Participant 17).

Support of health care providers

Health care staff reported helping women mainly by giving informational support. They eliminated the ambiguities that participants had about the stages of treatment and trained self-care to them.

“When mothers come to health centres for taking care of their little children, we also deliver necessary care to them. We answer their questions. We ask them what did you do when you were sick? In emergency cases, we will perform follow-up call until the end of treatment” (a health care provider).

Negative social support

Unfortunately, some of the participants in responding to the question of what source of support they had during illness or during the treatment process, talked of the lack of support received from their spouse.

“My husband, who is opposed to going to the doctor, says why women are constantly looking for this pain and that pain? If I go to my doctor, he won’t accompany me, even for my delivery I went alone. There they said where your husband is? I spuriously said he’s abroad” (Participant 4).

There was also a lack of verbal and emotional support even in women whose husbands disagreed with their referral to the doctor. “When I get sick, my husband doesn’t ask anything about it; he hasn’t yet told me “How are you? Do you need to go to the doctor or not?” even once. I think emotional support is essential for a woman, even it works better than medications and doctors, but he says nothing” (Participant 2).

Social pressure and expectations

Feeling due pressure to role-playing

Most participants, as housewives, were under pressure to be healthy and able to perform their duties. The constant expectations of the children and the spouse were reported to preclude conduction of HCSB.

“You know that the mummies are not allowed to get sick. When a mother becomes ill, all the work of the house is disturbed, the mother should be on the legs so that she can care about the rest. When I’m sick, I have to treat it in some way” (Participant 11). Some participants who worked outside the home expressed their experiences of work-related pressures and expectations for maintaining health and treating illness.

“My job was contractual. I can’t stay at home because of illness. I would have to go to the doctor, because if I don’t, my disease may be elongated [and] our manager may replace me with another one” (Participant 5).

Society’s expectations regarding women’s health

From some women’s perspectives, the atmosphere of society has created a climate that induces women’s health and makes them choose a healthier life.

“Now, in our society, it’s so that normally women are given less value than men, now you suppose that this woman is disabled or sick, then no one accepts her, so you can’t be indifferent to your health” (Participant 16).

Healthy role models

Family role models

The family is a source of behaviour formation from childhood to adulthood. These behaviours may be to improve one’s health or vice versa.

“I’ve always tried to go to the doctor when I became ill because all in our home did so. My mom recommends us to go to the doctor quickly. She too has neither medications in the home nor herbal medicine. I learned from her to consult with the doctor first” (Participant 7).

Modelling friends and peers in taking action for treatment

Some participants reported that they sometimes conducted the HCSB due to the influence of their friends.

“I have an intimate friend who cares so much about his health and seeks treatment for the slightest problem in his body. Even though she is my peer, she seems to be much younger. When I see her, I tell myself I too need to protect my health” (Participant 3).

Another group of role models for the patients is those relatives who have a history of suffering from the same ailment. “I ask more than my friends who were sick and went to the doctor and became well. Anything that they have done I’ll do or any doctor who they have gone to, I’ll go to become well” (Participant 14).

Discussion

In this study, social support, social pressures and expectations and healthy role models were drawn as interpersonal influences of HCSB. The role of social support in HCSB has been studied in some qualitative and quantitative studies. Ohashi et al. stated that husbands played an important role in encouraging Egyptian women to maintain their health, while the role of mothers-in-law was not remarkable [12]. The study of Schooley et al., in Guatemala showed that in addition to the support of the family, the support of friends, healthcare staff and women’s advocacy groups influence the decisions on HCSB and increases the self-esteem and sense-value among women [13]. Some studies have also pointed to the social support of religious leaders in increasing the use of health services [14].

The other side of social support can be lacking it. The lack of social support from the spouse and other family members in the women of the study of Snell-Rood et al., led to resisting against seeking the assistance of others to resolve psychological problems [15]. Also, there is evidence of insufficient emotional support of women as they are conducting HCSB [16].

Healthcare staffs are also likely not to provide social support. The study of Roost et al. indicated that most women who used alternative therapies found themselves apart from those who use health care. They stated that because of the mistreatment of health care staff (such as lack of giving information about their health conditions or process of treatment), their sense of being isolated is strengthened [17]. Since social support is a significant dimension in addressing health issues, the family and health stuff should create an environment in which women can easily talk about their health concerns.

Social pressures and expectations from family members, health care providers, or the atmosphere of the community can act as a powerful trigger for HCSB. The pressure from the woman’s family for HCBS depends on who has more power in making decisions for her [18]. In developing countries where women have lower liberty to decide on their health, then HCBS develops if the spouse or household custodian expects more to maintain family members’ health. Other social influences also depend on the atmosphere of the community in which women live. If a community is influenced by the traditional medicine, family members and friends force the individual to choose inappropriate treatments [19].

Another category drawn in the interpersonal influences construct was the influence of healthy role models. Women acknowledged that, in addition to selecting family members, they also chose friends and peers, as well as other patients as role models. The study of Low et al., on HCSB in diabetic patients has shown that because peers have similar experiences and undergo different types of treatments, they can serve as suitable patterns for other patients. Friends and peers offered the necessary treatments and shared information with patients [18]. In the study of Modi et al., in India, health workers introduced as healthy role models to women. They point out that the role models are different in different societies, and their desperate performance in using public health services, may have a negative impact on women and reduce their credibility [20].

In conclusion, these findings reveal family members, healthcare staff, religious people, friends and community atmosphere are involved in supporting and making pressure for HCSB in women. To improve the quality of care, family members should be educated about their potential supporting roles. Married men must understand the importance of emotional support to start and continue the treatment process in their wives. Healthcare staff, in addition to providing informational and emotional support for women, can introduce patients who use appropriate therapies as a role model for them. As a social responsibility, all members of the community should also attempt to encourage women to use formal health services.