Age, sex and primary care setting differences in patients' perception of community healthcare seeking behaviour towards health services.

INTRODUCTION: Understanding the potential determinants of community healthcare seeking behaviour helps in improving healthcare utilisation and health outcomes within different populations. This in turn will aid the development of healthcare policies and planning for prevention, early diagnosis and management of health conditions.
OBJECTIVE: To evaluate patients' perception of community healthcare seeking behaviour towards both acute and preventive physical and psychosocial health concerns by sex, age and type of primary care setting (as a proxy for affordability of healthcare).
METHODS: A total of 3979 patients from 221 public and 239 private clinics in Malaysia were interviewed between June 2015 and February 2016 using a patient experience survey questionnaire from the Quality and Cost of Primary Care cross-sectional study. Multivariable logistic regression analysis adjusted for the complex survey design was used.
RESULTS: After adjusting for covariates, more women than men perceived that most people would see their general practitioners for commonly consulted acute and preventive physical and some psychosocial health concerns such as stomach pain (adjusted odds ratio (AOR), 1.64; 95% confidence interval (CI), 1.22-2.21), sprained ankle (AOR, 1.29; 95% CI, 1.06-1.56), anxiety (AOR, 1.32; 95% CI, 1.12-1.55), domestic violence (AOR, 1.35; 95% CI, 1.13-1.62) and relationship problems (AOR, 1.24; 95% CI, 1.02-1.51). There were no significant differences in perceived healthcare seeking behaviour by age groups except for the removal of a wart (AOR, 1.41; 95% CI, 1.12-1.76). Patients who visited the public clinics had generally higher perception of community healthcare seeking behaviour for both acute and preventive physical and psychosocial health concerns compared to those who went to private clinics.
CONCLUSIONS: Our findings showed that sex and healthcare affordability differences were present in perceived community healthcare seeking behaviour towards primary care services. Also perceived healthcare seeking behaviour were consistently lower for psychosocial health concerns compared to physical health concerns.

Introduction

Healthcare seeking behaviour involves decision-making or actions taken for any health-related problems at the community or household level [1]. These decisions take into consideration all available healthcare options within public or private sectors as well as formal and informal healthcare services [1]. Studies have shown that various determinants such as sex, age, social status, type of illness, access to services and perceived quality of the service [1, 2] affect an individual’s healthcare seeking behaviour but findings have been inconsistent. As such, it is necessary to understand these potential determinants in improving healthcare utilisation and health outcomes within different populations. Information on healthcare seeking behaviour and patterns of healthcare utilisation in turn will aid the development of healthcare policies and planning for prevention, early diagnosis and management of health conditions [3]. In addition, early healthcare utilisation and appropriate interventions allow reduction of healthcare costs, disability and death from diseases [4].

In this study, we focus on perceived community healthcare seeking behaviour in primary care as primary care is often patients’ first point of contact with the healthcare system for most medical problems. It offers a wide spectrum of clinical services spanning from prevention, screening, treatment and rehabilitation of all major health conditions, particularly non-communicable diseases [5, 6]. Thus far, patient surveys on healthcare seeking behaviour have often focused on disease specific areas such as tuberculosis [7] or depression [8], while less attention has been given to primary care in general. Understanding this is important because the community perception provides another indicator of primary care utilisation. We aim to bridge this gap in knowledge on healthcare seeking behaviour which will not only reflect the patterns of perceived healthcare seeking behaviour at the different stages of utilisation, access and barriers to healthcare services in a given community but also the potential determinants to community perceptions [9]. Hence, perceived healthcare seeking behaviour can serve as a tool to understand how healthcare services are used and also to gauge future demand for healthcare services.

It was found that age, sex and accessibility or affordability to healthcare are some of the main determinants which significantly influence healthcare seeking behaviour among different population segments [1, 10]. However, reviews showed lack of consistency in the associations between these determinants and healthcare utilization [10, 11]. Few have investigated how people generally perceive the community’s intention to seek primary care consultations and it is known that help seeking patterns amongst people are influenced by community norms [2].

We hypothesise that sex, age and health insurance or affordability of care are key determinants for perceived community healthcare seeking behaviour for a range of physical and psychosocial health problems in Malaysia. Therefore, the aim of this study is to determine the perceived community healthcare seeking behaviour for acute and preventive physical and psychosocial health concerns in Malaysian primary care clinics with a focus on differences in age, sex and type of primary setting (as a proxy for affordability of healthcare).

Materials and methods

Study design

The data for this study was extracted from the International Quality and Cost of Primary Care (QUALICOPC) study conducted in the primary care setting in Malaysia [12, 13]. Data collection was conducted between July 2015 and February 2016 across five states (Wilayah Persekutuan Kuala Lumpur, Selangor, Sabah, Sarawak, and Kelantan), which were representative of the primary care population in Malaysia in terms of patient demographics and disease patterns. The QUALICOPC study aimed to collect information from patients on their experiences on the coordination, continuity, quality and equity in primary care. A total of 221 and 239 clinics were randomly sampled from the public and private sector respectively. We stratified the clinics by state and geographical location (urban or rural) and sampled clinics proportionately to the size of each stratum. Further details on the methods including study design, sampling frame, sampling methods, questionnaires and eligibility criteria are described elsewhere [12, 13].

Study population

Ten patients aged 18 years old and above from each clinic were invited to participate in the survey. One patient will be administered the patient values questionnaire while nine others will be administered the patient experience questionnaire [14]. They were informed that participation was voluntary and would not affect the provision of medical care. They were also assured that their responses will be treated with strict confidentiality and no identifiers were collected. A total of 4983 patients were invited and the overall response rate for both patient questionnaires was 91.1%. A non-response analysis was not necessary as it is usually conducted only when response rates fall below 80% [15]. One hundred and three respondents were excluded because of incomplete data. Of the two types of questionnaires administered, we used data from only the patient experience survey in this analysis.

Ethical approval was granted by the Medical Research and Ethics Committee, Ministry of Health Malaysia (NMRR-15-607-25769).

Survey tool

The QUALICOPC study comprised four sets of questionnaires namely (i) practice, (ii) doctor, (iii) patient experience and (iv) patient values questionnaires [14]. We adapted the original QUALICOPC questionnaire to the local primary care setting but kept as close possible to the original versions. The patient questionnaires were translated into Malay and Chinese languages using the forward-backward translation process [12, 13] as they were sets that answered by general public. Only the sub-section on the community healthcare seeking behaviour perception (12 items) from the patient experience questionnaire was presented in this analysis and all patients who responsed to this questionnaire were included.

The outcome measures were based on 8 acute and preventive physical and 4 psychosocial health concerns, which begins with the following question: “Would most people visit a clinic doctor for:”. The 12 items were divided into two groups as shown below:

Acute and preventive physical health concerns

A cut finger that needs to be stitched

Removal of a wart

Routine health checks

Deteriorated vision

Stomach pain

Blood in stool

Sprained ankle

Help to quit smoking

Psychosocial health concerns

Anxiety

Domestic violence

Sexual problems

Relationship problems

The response options were on a 4-point scale (1 = no, 2 = probably not, 3 = probably yes and 4 = yes), with higher scores indicating greater inclination to visit a primary care clinic doctor. Individuals with a score of 3 and 4 were assigned to perceived high inclination and score of 1 and 2 were assigned to perceived low inclination. There was also a “don’t know” option for patients who were unable to select one of the 4-scale responses and these were treated as missing in the analysis. The prevalence of “don’t know” responses were reported to illustrate the extent to which patients’ were unable to express an opinion on perceived community healthcare seeking behaviour for each of the health concerns evaluated.

The covariates of interest are patients’ age, sex and the type of primary care setting (public or private clinics) where the interviews were conducted. The influence of age was first explored by dividing age into quartiles and plotting the coefficients on a quartile plot to observe the effect of age on each outcome. The relationship between age and the outcome measures were shown to be non-linear and change in the estimates mainly occur between the ages of 45 and 50 years. Hence, we chose to dichotomize the age covariate to two groups: one between 18 and 49 years and another with those aged 50 years and older.

Type of primary care setting serves as a proxy measure for affordability of medical care and health financing categories. Primary care in Malaysia is mainly provided by a public sector of about 1060 health clinics with daily attendances ranging between 50 and 1000 attendances and about 7400 private general practitioner clinics, which were largely solo practices [16-18]. Healthcare in the public sector is virtually free of charge and financed almost entirely by government funds while payment in private clinics is borne out-of-pocket or via private insurance [19].

The final models were adjusted for patients’ characteristics including sex, age, ethnicity, educational level, employment status, household monthly income, self-reported health status, self-reported presence of chronic condition, whether the respondent has a family/own doctor and frequency of primary care visits in the past 6 months. Clinic-related characteristics that were included in the model were travelling time from home to clinic, waiting time between arriving at the clinic and consultation, willingness of doctor to discuss patients’ dissatisfaction of treatment received and whether patients’ trust doctors in general. The missing data rates for covariates ranged from 0.5% to 17.8%.

Statistical analysis

Continuous variables were presented as mean and standard deviation while categorical variables were reported in frequencies and percentages. Chi-square test was used for univariable comparisons between groups. Multivariable logistic regression using complex survey design to account for clustering within clinics was used to estimate adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association sex, age and the type of primary care setting for each of the acute and preventive physical health concerns and psychosocial health concerns. All models were adjusted for the patient and clinic-related variables described above. Multicollinearity of the covariates was checked and linearity of continuous variables was assessed using quartile plots [20]. Also, interactions between age, sex and type of primary care setting were also checked for and no significant interactions were found for each outcome. Complete case analysis was used and Forest plots were used to display the OR and 95% CI for each outcome measure. A p-value <0.05 was considered statistically significant. For the age comparison of perceived community healthcare seeking behaviour, sensitivity analyses were conducted based an age cut-off of 45 years (18–44 years and ≥ 45 years) and these estimates were compared with estimates for the cut-off of 50 years old in the results section. Data analyses were performed using Stata statistical software version 14.3 (StataCorp LP, College Station, TX) [21].

Results

A total of 3979 patients completed the patient experience questionnaire. The mean age of patients was 41.9 years (SD,15.5) with more women (61.6%) and adults below the age of 50 years (67.2%) being surveyed. Table 1 showed the socio-demographic and clinic characteristics of the study sample. Majority of the patients were of Malay ethnicity (52.3%), under employment (65.3%), do not have any chronic conditions (61.3%) and reported either good or very good health status (68.5%). Almost a third (30.0%) had education up to tertiary level and 60% came from the lower household income group (

Table 1

Baseline characteristics of participants.

Characteristic	n	%
Sex
Men	1527	38.4
Women	2452	61.6
Age (years)
<50	2675	67.2
≥ 50	1304	32.8
Ethnicity
Malay	2082	52.3
Chinese	593	14.9
Indian	301	7.6
Others	1003	25.2
Educational level
No formal education till lower secondary	1249	31.4
Upper secondary	1537	38.6
Post secondary and higher	1193	30.0
Household income
< MYR5000	2395	60.2
≥ MYR5000	1584	39.8
Employment status
Unemployed	1379	34.7
Employed	2600	65.3
General health
Poor	162	4.1
Fair	1090	27.4
Good	2277	57.2
Very good	450	11.3
Longstanding condition (Yes)	1541	38.7
Have own doctor (Yes)	824	20.7
Number of GP visits in the past 6 months
≤3 visits	2920	73.4
>3 visits	1059	26.6
Type of primary care setting visited
Public	1927	48.4
Private	2052	51.6
Location of clinic visited
Rural	1156	29.1
Urban	2823	70.9
Time to travel from home to practice
≤15minutes	2844	71.5
>15 minutes	1135	28.5
Waiting time between arrival at practice and consultation (N = 3968)
<15 minutes	1615	40.7
15–30 minutes	1016	25.6
30–45 minutes	339	8.5
45–60 minutes	237	6.0
>60 minutes	761	19.2
If you are unhappy with the treatment you received, do you think this doctor would be prepared to discuss it with you? (N = 3363) (Yes)	3089	91.9
In general, doctors can be trusted
Strongly disagree	4	0.1
Disagree	103	2.6
Agree	2003	50.3
Strongly agree	1869	47.0

If N is not stated, the total patients included for analysis was 3979.

SD, standard deviation; MYR, Malaysian Ringgit; GP, general practitioner.

About 80% of patients claimed that they do not have their own general practitioners to first consult on a health problem. However, almost all the patients reported they trusted doctors in general and believed that the doctors they were seeing on the day of visit were prepared to discuss, should they be unhappy with the treatment received. About 30% had at least four GP visits in the last 6 months while 72% claimed they took less than 15 minutes to travel from home to the clinic. About two third (66.3%) reported the waiting time between arriving at the clinics and the consultation was within 30 minutes.

In general, the perceived community healthcare seeking behavior for primary care was higher for acute and preventive health concerns than those for psychosocial concerns, with the percentage who reported high perceived healthcare seeking behavior ranging between 48% to 93% and 21% to 52%, respectively (Table 2). Almost all the patients perceived high community utilisation of primary care services for acute and preventive physical health concerns, particularly for stomach pain (92.3%), blood in the stool (86.9%) and routine health checks (87.7%). In contrast, the perceived community primary health care utilisation was lower for psychosocial concerns, where 51.9% believe the community would consult for anxiety, followed by sexual problems (48.0%), domestic violence (30.1%) and relationship problems (21.5%). The don’t know responses were lowest for stomach pain (0.9%) and highest for help to quit smoking (17.8%). The ‘don’t know’ responses were on average more prevalent for psychosocial health concerns (14.7%) compared to acute and preventive ones (7.2%).

Table 2

Perception of community healthcare seeking behavior to utilisation of primary care services.

	Perceived healthcare seeking behaviorcategory
Would most people visit a clinic doctor for:	Low		High		Don’t know
	n	%	n	%	n	%
Acute and preventive physical health concerns
Stomach pain	268	6.8	3674	92.3	37	0.9
Blood in the stool	312	7.8	3458	86.9	209	5.3
Routine health checks	385	9.7	3489	87.7	105	2.6
Cut finger that needs to be stitched	565	14.2	3170	79.7	244	6.1
Deteriorated vision	758	19.1	3042	76.4	179	4.5
Sprained ankle	891	22.4	2957	74.3	131	3.3
Help to quit smoking	1277	32.1	1993	50.1	709	17.8
Removal of a wart	1365	34.3	1931	48.5	683	17.2
Psychosocial health concerns
Anxiety	1466	36.8	2063	51.9	450	11.3
Sexual problems	1404	35.3	1909	48.0	666	16.7
Domestic violence	2162	54.3	1196	30.1	621	15.6
Relationship problems	2517	63.3	855	21.5	607	15.2

Table 3 showed that more women than men perceived high healthcare seeking behavior to utilisation of primary care across all health concerns surveyed. Univariable comparisons found sex differences of perceived healthcare seeking behavior were significant for health concerns such as stomach pain, blood in the stool, sprained ankle, help to quit smoking, removal of wart, anxiety, domestic violence and relationship problems. However, after adjustment for patient and clinic covariates (Fig 1), only 6 health concerns, i.e. stomach pain, sprained ankle, removal of a wart, anxiety, domestic violence and relationship problems were significantly different between men and women. Another noteworthy finding is, while perceived healthcare seeking behavior is generally higher in women, perceived healthcare seeking behavior for psychosocial health concerns were consistently lower than those for acute and preventive health concerns across both men and women, especially pertaining to domestic violence (31.5% and 38.2%) and relationship problems (22.1% and 27.4%) (Table 3).

Table 3

Perception of healthcare seeking behaviour in acute and preventive physical and psychosocial health concerns by sex.

Health concern	Sex	Perceived healthcare seeking behaviour				p-value†
		Low		High
		n	%	n	%
Acute and preventive physical health
Stomach pain	Men	123	8.1	1391	91.9	0.01
	Women	145	6.0	2283	94.0
Blood in the stool	Men	141	9.7	1307	90.3	0.01
	Women	171	7.4	2151	92.6
Routine health checks	Men	160	10.7	1331	89.3	0.19
	Women	225	9.4	2158	90.6
Cut finger that needs to be stitched	Men	232	16.2	1202	83.8	0.16
	Women	333	14.5	1968	85.5
Deteriorated vision	Men	301	20.7	1152	79.3	0.35
	Women	457	19.5	1890	80.5
Sprained ankle	Men	380	25.6	1102	74.4	0.004
	Women	511	21.6	1855	78.4
Help to quit smoking	Men	549	42.2	751	57.8	0.002
	Women	728	37.0	1242	63.0
Removal of a wart	Men	566	44.2	716	55.9	0.01
	Women	799	39.7	1215	60.3
Psychosocial health
Anxiety	Men	624	45.4	752	54.6	<0.001
	Women	842	39.1	1311	60.9
Sexual problems	Men	556	43.0	738	57.0	0.58
	Women	848	42.0	1171	58.0
Domestic violence	Men	895	68.5	412	31.5	<0.001
	Women	1267	61.8	784	38.2
Relationship problems	Men	1023	77.9	290	22.1	<0.001
	Women	1494	72.6	565	27.4

† chi-square test between groups.

Fig 1

Adjusted ORs with corresponding 95% CI for perceived high healthcare seeking behaviour for acute and preventive physical and psychosocial health concerns by sex.

Models were adjusted for age, ethnicity, educational level, employment status, household monthly income, self-reported general health status, self-reported presence of chronic condition, whether the patient has a family doctor and frequency of clinic visits in past 6 months, travel time from home to clinic, waiting time between arriving at the clinic and consultation, perceived willingness of the doctor to discuss if patient is unhappy with treatment received, whether patients trust doctors in general, type of primary care setting (public/private), geographical location of clinic (urban/rural). OR, odds ratio; CI, confidence interval; * statistical significant p-value <0.05.

For the univariable analysis on age, differences were observed for routine health checks, a cut finger that needs to be stitched, deteriorated vision, removal of a wart, and sexual problems (Table 4). However, after adjusting for other patient and clinic covariates, these age differences in perceived healthcare seeking behavior becomes diminished except for the removal of warts, where older participants were more likely to perceive high healthcare seeking behavior in most people (Fig 2).

Table 4

Perception of healthcare seeking behaviour in acute and preventive physical and psychosocial health concerns stratified by age.

Health concern	Age (years)	Perceived healthcare seeking behaviour				p-value†
		Low		High
		n	%	n	%
Acute and preventive physical health
Stomach pain	< 50	179	6.7	2481	93.3	0.80
	≥ 50	89	6.9	1193	93.1
Blood in the stool	< 50	211	8.3	2344	91.7	0.95
	≥ 50	101	8.3	2344	91.7
Routine health checks	< 50	281	10.8	2331	89.2	0.01
	≥ 50	104	8.2	1158	91.8
Cut finger that needs to be stitched	< 50	415	16.3	2124	83.7	0.002
	≥ 50	150	12.5	1046	87.5
Deteriorated vision	< 50	564	22.0	1998	78.0	<0.001
	≥ 50	194	15.7	1044	84.3
Sprained ankle	< 50	594	22.8	2011	77.2	0.45
	≥ 50	297	23.9	946	76.1
Help to quit smoking	< 50	920	40.0	1379	60.0	0.08
	≥ 50	357	36.8	614	62.2
Removal of a wart	< 50	981	43.9	1256	56.1	<0.001
	≥ 50	384	36.3	675	63.7
Psychosocial health
Anxiety	< 50	1017	42.3	1387	57.7	0.18
	≥ 50	449	39.9	676	60.1
Sexual problems	< 50	926	40.5	1362	59.5	0.001
	≥ 50	478	46.6	547	53.4
Domestic violence	< 50	1505	65.3	800	34.7	0.10
	≥ 50	657	62.4	396	37.6
Relationship problems	< 50	1752	75.2	577	24.8	0.25
	≥ 50	765	73.4	278	26.6

† chi-square test between groups.

Fig 2

Adjusted ORs with corresponding 95% CI for perceived high healthcare seeking behaviour for acute and preventive physical and psychosocial health concerns by age.

† Models were adjusted for sex, ethnicity, educational level, employment status, household monthly income, self-reported general health status, self-reported presence of chronic condition, whether the patient has a family doctor and frequency of clinic visits in past 6 months, travel time from home to clinic, waiting time between arriving at the clinic and consultation, perceived willingness of the doctor to discuss if patient is unhappy with treatment received, whether patients trust doctors in general, type of primary care setting (public/private), geographical location of clinic (urban/rural). OR, odds ratio; CI, confidence interval; * statistical significant p-value <0.05.

Table 5 showed that patients who visited the public clinics perceived higher healthcare seeking behavior for all acute and preventive physical and psychosocial health concerns (except stomach pain) compared to those who visited the private clinics. After adjustment for covariates, these differences in perceived healthcare seeking behavior between patients for public and private clinics remained for four acute and preventive physical health concerns and all psychosocial health concerns (Fig 3). The adjusted odds ratios with corresponding 95% CI were displayed for age, sex and type of primary care setting using Forest plots in Figs 1–3 respectively.

Table 5

Perception of healthcare seeking behaviour in acute and preventive physical and psychosocial health concerns stratified by type of primary care setting.

Health concern	Setting	Perceived healthcare seeking behaviour				p-value†
		Low		High
		n	%	n	%
Acute and preventive physical health
Stomach pain	Public	127	6.7	1775	93.3	0.77
	Private	141	6.9	1899	93.1
Blood in the stool	Public	98	5.4	1713	94.6	<0.001
	Private	214	10.9	1745	89.1
Routine health checks	Public	156	8.4	1704	91.6	0.002
	Private	229	11.4	1785	88.6
Cut finger that needs to be stitched	Public	198	11.0	1603	89.0	<0.001
	Private	367	19.0	1567	81.0
Deteriorated vision	Public	173	9.4	1677	90.7	<0.001
	Private	585	30.0	1365	70.0
Sprained ankle	Public	389	21.2	1450	78.8	0.005
	Private	502	25.0	1507	75.0
Help to quit smoking	Public	458	29.2	1109	70.8	<0.001
	Private	819	48.1	884	51.9
Removal of a wart	Public	599	39.1	932	60.9	0.013
	Private	766	43.4	999	56.6
Psychosocial health
Anxiety	Public	606	36.4	1060	63.6	<0.001
	Private	860	46.2	1003	53.8
Sexual problems	Public	634	40.2	941	59.8	0.02
	Private	770	44.3	968	55.7
Domestic violence	Public	941	59.4	643	40.6	<0.001
	Private	1221	68.8	553	31.2
Relationship problems	Public	1088	69.3	481	30.7	<0.001
	Private	1429	79.3	374	20.7

† chi-square test between group.

Fig 3

Adjusted ORs with corresponding 95% CI for perceived high healthcare seeking behavior for acute and preventive physical and psychosocial health concerns by type of primary care setting.

† Models were adjusted for sex, age, ethnicity, educational level, employment status, household monthly income, self-reported general health status, self-reported presence of chronic condition, whether the patient has a family doctor and frequency of clinic visits in past 6 months, travel time from home to clinic, waiting time between arriving at the clinic and consultation, perceived willingness of the doctor to discuss if patient is unhappy with treatment received, whether patients trust doctors in general, geographical location of clinic (urban/rural). OR, odds ratio; CI, confidence interval; * statistical significant p-value <0.05.

A sensitivity analysis was done to check for differences in estimates when different age cutoffs (at 45 years and 50 years) were used for age comparisons. The results showed estimates were of similar direction and magnitude across all health concerns with the two different age cut-off points. We opted to present the results using the age categories with 50 year cut-off to allow comparisons of findings with other studies.

Discussion

This study found that sex and type of primary care setting were significant determinants of perceived community healthcare seeking behaviour, for both acute and preventive physical health concerns and psychosocial health concerns. For health concerns which sex differences were found, higher odds of perceived community healthcare seeking were consistently in one direction, i.e. women reporting higher perceived healthcare seeking behaviour than men. This finding upholds those from previous studies, where women were known to consult their general practitioners more often than men and were more proactive in health seeking [22, 23]. We found that women were more likely to perceive healthcare seeking for pain-related complaints such as stomach pain and sprained ankle and this is consistent with studies showing that women utilise health services more for pain than men [24, 25]. Possible explanations are that men could have higher threshold to pain, were less willing to report pain and could possibly have waited longer before seeking care than women [26, 27]. Besides that, we have shown that women were also more likely to perceive higher community healthcare seeking for psychosocial concerns compared to men and this confirms previous literature that women were more inclined to report on consultations for mental health issues [22, 23]. The lower likelihood of men to perceive community healthcare seeking for psychosocial concerns may be related to a lack of psychological openness among men [23]. Statistically, about a third of adults in Malaysia were shown to be facing mental health issues and prevalences did not differ between the males and females [28].Therefore, in this age where mental illness rates are rising, there is a pressing need to address the low perceived healthcare seeking behaviour among men especially for psychosocial concerns.

Differences in perceived healthcare seeking tendencies were observed between those who seeked treatment at the two major types of primary care clinics in Malaysia. Compared to the private clinics, those who received care at public clinics were more likely to perceive high community healthcare seeking behaviour for eight of the 12 health concerns investigated. The primary difference between public and private clinics in Malaysia is the health financing mechanism; one that is publicly funded versus another that charges fee-for-service. Hence, the type of primary care setting serves as a proxy for differences in healthcare financing methods. Higher perception of community healthcare seeking behaviour is occurring among public clinic patients. This observation is attributable to reasons such as lack of financial barriers and affordability of care, which is consistent with results by Chomi et al. where people who had health insurance were more likely to seek healthcare compared to those who were not insured [29]. This notion is also supported by another study which showed that, the lower income group gained better access to care in communities which had more government funded health facilities [30]. Another explanation for the tendency to perceive higher community healthcare seeking behaviour among public primary care attendees is the availability of a more comprehensive range of services at public clinics compared to private clinics [18].

Age was not a predictor for perceived community healthcare seeking behaviour except for the removal of warts, where people aged 50 years and above perceived higher community healthcare seeking than the lower age group. This could be partially explained by concerns among the elderly on the risks between genital warts or skin lesions and malignancies with increasing age [31, 32]. Contrary to other studies which demonstrated that older persons were less likely to use or report use of mental health services, we found no difference in perceived community healthcare seeking behaviour between age groups [22, 33]. Our results also showed no difference in perceived community health seeking for routine health examinations between the older and younger age groups and this is in contrast with findings by Deeks and colleagues, where screening behaviours were more prevalent among men and women above 50 years old [34].

We have shown that primary care clinics were not generally perceived as the first point of contact for psychosocial concerns and tobacco addiction. Unsurprisingly, primary care patients’ perceived a higher tendency for the community to seek care for physical complaints than psychosocial or mental health complaints and this is in agreement with health-seeking and utilisation patterns reported by other researchers [22, 35]. However, the prevalence of perceived community health seeking for psychosocial concerns is lower compared to results from another Malaysian study which surveyed patterns of help-seeking for common mental disorders within an urban population [36]. Similar finding was also observed in a comparative study where rural residents with mental health problems were less likely to seek help than their urban counterparts [37].

The authors did note a potential over-reporting of socially desirable behaviour because the number of subjects which reported use of complementary and alternative medicine is far too small for a setting where complementary and alternative medicine is known to play a strong influence when it comes to mental health issues [36]. Low perception of community healthcare seeking behaviour found in our study for psychosocial concerns could be attributable to belief that mental disorders were caused by supernatural occurrences and fear of stigmatization or discrimination [38]. Besides, low perception for community healthcare seeking for mental health issues at clinics may also stem from poor public awareness of the availability of mental health services at primary care clinics and insufficient knowledge and training for primary care providers to screen and manage mental disorders [39].

It is worth noting that the proportion of patients who chose the ‘don’t know’ option was about twice higher for psychosocial issues, raising concern that the participants were either indifferent or unaware that those were potential health issues or did not know that primary care clinics were appropriate facilities to seek care from. This is in line with surveys which found low mental health literacy rates in this country [40].

This study has several strengths. While majority of studies on primary healthcare seeking behaviour have investigated utilisation patterns or individual health behaviours, few have looked at the perceived community healthcare seeking behaviour [10]. Despite difficulties in performing direct comparisons with literature, we have shown that these perceptions are broadly in line with findings on health utilisation and intention to seek primary care consultations. Another strength is the large sample size which allowed sufficient statistical power to explore sex, age and type of primary care setting differences of the study population’s perspective with regard to the perception towards healthcare seeking behaviour in primary care. Also, this study had a good response rate and was conducted in a sample of clinics which are representative of both public and private primary care clinics in the country [12, 13]. One limitation of this study is that the proportion of don’t knows reponses coded as missing data for the regression analysis was as high as 18%; this could potentially introduce bias to the study findings. However, this missing information could not be dealt with using methods such as imputation because the don’t know responses do constitute a form of response and it is the intention of this paper to determine a specific direction for perceived healthcare seeking behaviour; i.e. whether high or low. Another limitation is that the true reason for healthcare utilisation patterns was not captured to enable triangulation of whether perceived healthcare seeking behaviour truly translates into actual utilisation.

Implications to policy, practice and research

Steps to increase awareness of preventive and mental health services in primary care come from two main approaches; first from educating and informing the community about the availability of services and second, through direct patient engagement by primary care providers.

Despite integration of mental health services into primary care since the 1990s, the overall perceived community psychosocial health-seeking tendency is still low. Policies need to be put in place to complement the Malaysian 2012 National Mental Health Policy to actively inform and engage the community to understand the fundamentals of mental health, reduce society stigma and discrimination on mental illness and know when and where to seek help. Public education campaigns and mental health literacy programs have been shown to be effective in reducing stigma, a main barrier to seeking health services [41]. Education on mental disorders should begin early at schools and teachers play pertinent roles in promoting mental health among children and adolescents. Another approach to promote awareness on mental health services is to provide professional, reliable and easily accessible health resources on the web makes full use of the broad reach of the internet and counters misinformation that circulate on social media [41].

Perceived community healthcare seeking behaviour for preventive services in primary care were high in general and similar between sexes and age groups. The major difference noted was in the lower perceived community healthcare seeking tendency in men for psychosocial health services. Hence, there is a need to emphasize public education on engaging men and encouraging them to come forward to seek help for mental health concerns at primary care settings as it was revealed in the Asian Men's Health Report that there was a higher mortality rate due to suicide for men compared to women [42]. Screening rate for mental illness are being conducted by public primary care clinics but the screening rates are still below 10% [43]. Among the reasons to this are the high workload in public clinic which limits meaningful interactions between provider and patient as well as the lack of confidence in providers to detect and manage mental disorders. Therefore, it is very important to strengthen the clinical skills for early detection, diagnosis, management and counselling among primary care providers through formal training at both the undergraduate and postgraduate level [36]. Further, it is equally important for private general practitioners to be equipped with the skills to engage patients when it comes to promoting screening for mental disorders in primary care. It is also highly important that implementation of all policy and practice changes are scientifically and systematically evaluated through research to determine effectiveness of these efforts.

Conclusions

We found that there were sex and type of primary care setting differences when it comes to acute and preventive physical health concerns as well as psychosocial health concerns. Differences in perceived healthcare seeking tendencies were however, not observed between those aged below 50 years and 50 years and above. Overall, perceived community healthcare seeking for primary care services was low for psychosocial or mental health concerns and there was still a substantial proportion of patients who were unaware that they could seek primary care services for mental health complaints.

23 Aug 2019

PONE-D-19-17088

Age, sex and primary care setting differences in patients’ perception of community healthcare seeking behaviour to health services

PLOS ONE

Dear Ms Lim,

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Comments to the Author

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Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

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Reviewer #2: Yes

Reviewer #3: No

**********

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The scientific value of this manuscript is questionable and I don't think that it will have positive impact in the field

Reviewer #2: Dear Authors,

The publication is a good one with much variability's taken and can be accepted from my point of view, but there are some points which must be taken into consideration:

1. Try to avoid repetition of the same sentences as in the abstract (Healthcare seeking ...) within the same paragraph.

2. In some paragraphs you left spaces at the beginning in others not. Please unify

3. In the tables, they are very long. It is advisable to separate them each for a criteria, so that you would have precise characters within one table to avoid long tables for the reader.

Reviewer #3: Congratulations to the authors for this interesting manuscript regarding the perceived community healthcare seeking behavior for acute and preventive physical and psychosocial health concerns in Malaysian primary care clinics. The authors took into consideration sex, age and affordability of care (health insurance) as key elements of healthcare seeking behaviors in Malaysian community. This is a continuation of the efforts in the previous publications, Quality and Costs of Primary Care(QUALICOPC) study in Malaysia: Phase I –Public Clinics, and Quality and Costs of Primary Care (QUALICOPC) Malaysia: Phase II – Private Clinics (cited as references 12, 13) in understanding potential determinants of community healthcare seeking behaviors in Malaysia.

Comments:

1) Line 116: The data for this study was extracted from the International Quality and Cost of Primary Care (QUALICOPC) study: Can you please add a citation for this statement? you may cite the data used in the study if previously published, alongside with references 12 and 13.

2) Lines 124-125: Further details on the methods of this study are described elsewhere: can you please explain more what these details are for the reader? Did you mean sampling frame, sampling methods, and eligibility of participants?

3) Lines 128-134: Ten patients aged 18 years old and above from each clinic were invited to participate in the survey:

The sample size is 3979 patients. Total number of clinics is 221+239= 460 clinics.

Overall response rate for both patient questionnaires was 91.1%.

One patient will be administered the patient values questionnaire while nine will be administered the patient experience questionnaire.

Since the overall sample size was 3979, can you please clarify if there were any excluded patients for incomplete data or because of the exclusion criteria?

4) Lines 129-130: the patient values questionnaire and patient experience questionnaire were mentioned before the appearance of reference 15 in Survey Tool part (which can be considered as a reference for them too).

5) 337-339: please add references to this statement (you can use one of those mentioned later on in this paragraph).

6) Lines 385- 388: A comparison between urban and rural clinics visitors in seeking medical attention for psychosocial or mental health complaints, in addition to acute and preventive physical health concerns, can be considered.

7) Some minor writing errors within the text are present. It is suggested to carefully review the manuscript towards spelling and/or grammatical errors. Some examples are given below:

Lines 55-56: lower than for physical health concerns.

Line 92: [8] while > [8], while

Line 145: were presented > was presented (since the verb is for the sub-section, not the 12 items)

Line 225: they do not their have own general practitioners > do not have their own

Line 406: behaviour [10. > behaviour [10].

**********

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Reviewer #1: No

Reviewer #2: Yes: Adnan Al Lahham

Reviewer #3: Yes: Isam Bsisu

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

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11 Sep 2019

Responses to comments from Reviewer #1

Have the authors made all data underlying the findings in their manuscript fully available?

Q1) No

R1) Yes, we have consulted the principal investigator of the data source and agreed to include our de-identified dataset with relevant variables. As such our data availability statement will be amended to

All relevant data are within the manuscript and its Supporting Information files.

Review Comments to the Author

Q2) The scientific value of this manuscript is questionable and I don't think that it will have positive impact in the field

R2) We appreciate the reviewer’s concern.

We would like to reassure the reviewer that our findings in this paper would help in the understanding of healthcare utilisation pattern by type of health concerns developing of healthcare policy and planning for effective treatment and appropriate interventions for management of health concerns. Furthermore, early recognition presentation to health care facilities and compliance with effective treatment have shown to reduce morbidity and thereby mortality [1-3].

1. Van der Hoeven M, Kruger A, Greeff M. Differences in health care seeking behaviour between rural and urban communities in South Africa. International Journal for Equity in Health 2012; 11: 31.

2. Hausmann-Mueala S, Muela Ribera J, Nyamongo I: Health-seeking behaviour and the health system response. Disease Control Priorities Project (DCPP). Working Paper no.14;. 2003

3. World Health Organization: Rapid assessment of health seeking behaviour in relation to sexual transmitted disease: draft protocol.1995

___________________________________________________________________________________________________________________________

Responses to comments from Reviewer #2

Review Comments to the Author

The publication is a good one with much variability's taken and can be accepted from my point of view, but there are some points which must be taken into consideration:

Q1) Try to avoid repetition of the same sentences as in the abstract (Healthcare seeking ...) within the same paragraph.

R1) We thank the reviewer for his comments and suggestions.

We rephrased the following paragraph to avoid repetitions of same sentence as in the introduction section which read previously

“Healthcare seeking behaviour is also influenced by various determinants such as sex, age, social status, type of illness, access to services and perceived quality of the service [1, 2]. Understanding these potential determinants of healthcare seeking behaviour will be necessary in improving healthcare utilisation and health outcomes within different populations.”

to

Introduction , page 4, line 78-82

Studies have shown that various determinants such as sex, age, social status, type of illness, access to services and perceived quality of the service [1, 2] affect an individual’s healthcare seeking behaviour but findings have been inconsistent. As such, it is necessary to understand these potential determinants in improving healthcare utilisation and health outcomes within different populations.

Q2) In some paragraphs you left spaces at the beginning in others not. Please unify

R2) We have removed the space at the beginning of every paragraph. To differentiate between paragraphs, we inserted an empty line between paragraphs.

Q3) In the tables, they are very long. It is advisable to separate them each for a criteria, so that you would have precise characters within one table to avoid long tables for the reader.

R3) We acknowledge the concerns raised by the reviewer. However, we believe that the characteristics listed within Table 1 would all complement each other to provide baseline characteristics of our study participants.

We agree that the table is rather long and have amended it. We rephrased the question into more concise phrase.

Kindly refer to Table 1 within the manuscript.

Results, page 11-13, line 247-249

___________________________________________________________________________________________________________________________

Response to comments from Reviewer #3

Have the authors made all data underlying the findings in their manuscript fully available?

Q1) No

R1) Yes, we have consulted the principal investigator of the data source and agreed to include our de-identified dataset with relevant variables. As such our data availability statement will be amended to

All relevant data are within the manuscript and its Supporting Information files.

Review Comments to the Author

Congratulations to the authors for this interesting manuscript regarding the perceived community healthcare seeking behavior for acute and preventive physical and psychosocial health concerns in Malaysian primary care clinics. The authors took into consideration sex, age and affordability of care (health insurance) as key elements of healthcare seeking behaviors in Malaysian community. This is a continuation of the efforts in the previous publications, Quality and Costs of Primary Care(QUALICOPC) study in Malaysia: Phase I –Public Clinics, and Quality and Costs of Primary Care (QUALICOPC) Malaysia: Phase II – Private Clinics (cited as references 12, 13) in understanding potential determinants of community healthcare seeking behaviors in Malaysia.

Comments:

Q1) Line 116: The data for this study was extracted from the International Quality and Cost of Primary Care (QUALICOPC) study: Can you please add a citation for this statement? you may cite the data used in the study if previously published, alongside with references 12 and 13.

R1) We thank the reviewer for his comments and suggestions.

We have added the references as follows:

Materials and methods, page 5, line 118-119.

The data for this study was extracted from the International Quality and Cost of Primary Care (QUALICOPC) study conducted in the primary care setting in Malaysia [12, 13].

Q2) Lines 124-125: Further details on the methods of this study are described elsewhere: can you please explain more what these details are for the reader? Did you mean sampling frame, sampling methods, and eligibility of participants?

R2) Yes, and we have amended the sentence. It now reads:

Materials and methods, page 6, line 127-129

Further details on the methods including study design, sampling methods, questionnaires and eligibility criteria are described elsewhere [12, 13].

Q3) Lines 128-134: Ten patients aged 18 years old and above from each clinic were invited to participate in the survey:

The sample size is 3979 patients. Total number of clinics is 221+239= 460 clinics.

Overall response rate for both patient questionnaires was 91.1%.

One patient will be administered the patient values questionnaire while nine will be administered the patient experience questionnaire.

Since the overall sample size was 3979, can you please clarify if there were any excluded patients for incomplete data or because of the exclusion criteria?

R3) We added the following statements and hope that it would provide better clarity on the number of respondents.

Materials and methods, page 6, line 137-141

A total of 4983 patients were invited and the overall response rate for both patient questionnaires was 91.1%. A non-response analysis was not necessary as it is usually conducted only when response rates fall below 80% [15]. One hundred and three respondents were excluded because of incomplete data. Of the two types of questionnaires administered, we used data from only the patient experience survey in this analysis.

Q4) Lines 129-130: the patient values questionnaire and patient experience questionnaire were mentioned before the appearance of reference 15 in Survey Tool part (which can be considered as a reference for them too).

R4) We inserted the required reference as suggested as follows:

Materials and methods, page 6, line 133-134

One patient will be administered the patient values questionnaire while nine will be administered the patient experience questionnaire [14].

Q5) 337-339: please add references to this statement (you can use one of those mentioned later on in this paragraph).

R5) We inserted the required references as suggested as follows:

Discussion, page 22, line 350-352

This finding upholds those from previous studies, where women were known to consult their general practitioners more often than men and were more proactive in health seeking [22-23].

22) Thompson AE, Anisimowicz Y, Miedema B,Hogg W, Wodchis WP, Bassler KA. The influence of gender and other patient characteristics on health care-seeking behaviour: a QUALICOPC study. BMC Family Practice 2016; 17: 38.

23) Mackenzie CS, Gekoski WL, Knox VJ. Age, gender, and the underutilization of mental health services: the influence of help-seeking attitudes. Aging Ment Health 2006; 10: 574–582.

Q6) Lines 385- 388: A comparison between urban and rural clinics visitors in seeking medical attention for psychosocial or mental health complaints, in addition to acute and preventive physical health concerns, can be considered.

R6) We included a comparative study to support our finding on help-seeking behaviour for mental health problem between rural and urban population.

Discussion, page 24, line 401-406

However, the prevalence of perceived community health seeking for psychosocial concerns is lower compared to results from another Malaysian study which surveyed patterns of help-seeking for common mental disorders within an urban population [36]. Similar finding was also observed in a comparative study where rural residents with mental health problems were less likely to seek help than their urban counterparts [37].

36) Ismail SIF. Patterns and risk factors with help- seeking for common mental disorders in an urban Malaysian community. London School of Hygiene and Tropical Medicine, 2011

37) Caldwell TM, Jorm AF, Dear KBG. Suicide and mental health in rural, remote and metropolitan areas in Australia. The Medical Journal of Australia 2004; 181: S10.

Q7) Some minor writing errors within the text are present. It is suggested to carefully review the manuscript towards spelling and/or grammatical errors. Some examples are given below:

R7) Thank you for highlighting the spelling and/or grammatical errors. We have corrected those mistakes as follow:

Q7a) Lines 55-56: lower than for physical health concerns.

R7a) Abstract, page 3, line 53-56

Our findings showed that sex and healthcare affordability differences were present in perceived community healthcare seeking behaviour towards primary care services. Also, perceived healthcare seeking behaviour was consistently lower for psychosocial health concerns compared to physical health concerns.

Q7b) Line 92: [8] while > [8], while

R7b) Introduction, page 4, line 92-94

Thus far, patient surveys on healthcare seeking behaviour have often focused on disease specific areas such as tuberculosis [7] or depression [8], while less attention has been given to primary care in general.

Q7c) Line 145: were presented > was presented (since the verb is for the sub-section, not the 12 items)

R7c) Introduction, page 7, line 152-154

Only the sub-section on the community healthcare seeking behaviour perception (12 items) from the patient experience questionnaire was presented in this analysis and all patients who responded to this questionnaire were included.

Q7d) Line 225: they do not their have own general practitioners > do not have their own

R7d) Results, page 10, line 239-240

About 80% of patients claimed that they do not have their own general practitioners to first consult on a health problem.

Q7e) Line 406: behaviour [10. > behaviour [10].

R7e) Discussion, page 25, line 424-426

While majority of studies on primary healthcare seeking behaviour have investigated utilisation patterns or individual health behaviours, few have looked at the perceived community healthcare seeking behaviour [10].

___________________________________________________________________________________________________________________________

Additional information (From Ms Michelle Ellis)

Q1) Please include a copy of the interview guide used in the study, in both the original language and English, as Supporting Information, or include a citation if it has been published previously

R1) The copy of patient questionnaires in English, Malay and Mandarin languages are available at the citation as mentioned in following section of the manuscript

Materials and methods, page 6, line 127-129

Further details on the methods including study design, sampling methods, questionnaires and eligibility criteria are described elsewhere [12, 13].

Submitted filename: Response to reviewers.docx

Click here for additional data file.

23 Sep 2019

PONE-D-19-17088R1

Age, sex and primary care setting differences in patients’ perception of community healthcare seeking behaviour towards health services

PLOS ONE

Dear Ms Lim,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

We would appreciate receiving your revised manuscript by Nov 07 2019 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Wen-Jun Tu

Academic Editor

PLOS ONE

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[Note: HTML markup is below. Please do not edit.]

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Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: I want to thank the authors for their effort in this manuscript entitled "Age, sex and primary care setting differences in patients’ perception of community healthcare seeking behaviour towards health services'.

With all my respect to the authors, again the scientific value of this manuscript is questionable and I don't think that it will have a positive impact in the field.

My comments:

First: I think the sub-section (12 items) of the main tool of QUALICOPC only can’t measure the community health seeking behavior.

Second: The main question is “Would most people visit a clinic doctor for?”. In my opinion, the question is asking the patients what other people expected to do. I can talk for myself, not about what others think.

Reviewer #2: I have read carefully the authors answers to my points of view regarding the manuscript. I do accept his or their points. The current paper satisfies my review points and can be accepted in this form

Reviewer #3: Reviewer comments have been adequately addressed and the manuscript adapted accordingly. I would like to take this opportunity to congratulate the authors for their interesting article, and encourage them to work on increasing the awareness of preventive and mental health services in primary care through educating and informing the community about the availability of these services, in addition to direct patient engagement by primary care provider, as recommended by their article.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Adnan Al Lahham

Reviewer #3: Yes: Isam Bsisu

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

25 Sep 2019

Responses to comments from Reviewer #1

Q1) I want to thank the authors for their effort in this manuscript entitled "Age, sex and primary care setting differences in patients’ perception of community healthcare seeking behaviour towards health services'.

With all my respect to the authors, again the scientific value of this manuscript is questionable and I don't think that it will have a positive impact in the field.

My comments:

First: I think the sub-section (12 items) of the main tool of QUALICOPC only can’t measure the community health seeking behavior.

Second: The main question is “Would most people visit a clinic doctor for?”. In my opinion, the question is asking the patients what other people expected to do. I can talk for myself, not about what others think.

R1) We appreciate the reviewer’s comments. We agree that evaluating patient’s health seeking would necessitate a direct evaluation of the patient. We also agree with the reviewer that we were not directly measuring the community healthcare seeking behaviour. Nevertheless, we are taking a different angle. We apologise for not being sufficiently clear enough. We were evaluating our primary health care responsiveness to community needs. Thus, the focus is on community perception rather than patient direct health seeking behaviour.

The objective of the survey question for the perceived health seeking behaviour is regarding the perceptions of patients about conditions warranting a visit to our primary care services. As such, the main question is designed as “Would most people visit a clinic doctor for?”. This refers to what a person perceives the community would seek in terms of healthcare.

Therefore, we have revised some of sentences in the introduction section of our manuscript and hope that it would provide better clarity on our objective which is to describe community perception of healthcare seeking behaviour.

Introduction, page 4, line 88-90

In this study, we focus on perceived community healthcare seeking behaviour in primary care as primary care is often patients’ first point of contact with the healthcare system for most medical problems.

Introduction, page 4-5, Line 94-101:

Understanding this is important because the community perception provides another indicator of primary care utilisation. We aim to bridge this gap in knowledge on healthcare seeking behaviour which will not only reflect the patterns of perceived healthcare seeking behaviour at the different stages of utilisation, access and barriers to healthcare services in a given community but also the potential determinants to community perceptions. [9]. Hence, perceived healthcare seeking behaviour can serve as a tool to understand how healthcare services are used and also to gauge future demand for healthcare services.

We believe this patients’ perception of community of healthcare seeking behaviour study is important as it reflects the ‘Comprehensiveness of services’ where patients’ views on the breadth of the clinical task profile of services offered by the GP are taken into consideration.

Our findings of this study would hopefully have direct implications to practice and healthcare policy maker such as efforts to increase awareness of available healthcare services especially in psychosocial health concerns should be made to address this gap in healthcare, to improve barriers to health care access by identifying those who are more likely to engage in health care-seeking behaviours and the variables predicting health care-seeking and consequently, those who are not accessing primary care can be targeted and policies can be developed and put in place to promote their health care-seeking behaviour.

In addition, previous studies have demonstrated that information gathered on health care seeking behaviour would not only help in the understanding of healthcare utilisation pattern by type of health concerns but also crucial for developing health care policies and planning for early diagnosis, effective treatment and appropriate interventions [1-3].

References

1.Van der Hoeven M, Kruger A, Greeff M. Differences in health care seeking behaviour between rural and urban communities in South Africa. International Journal for Equity in Health 2012; 11: 31.

2.Hausmann-Mueala S, Muela Ribera J, Nyamongo I: Health-seeking behaviour and the health system response. Disease Control Priorities Project (DCPP). Working Paper no.14; 2003.

3.World Health Organization: Rapid assessment of health seeking behaviour in relation to sexual transmitted disease: draft protocol 1995.

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10 Oct 2019

Age, sex and primary care setting differences in patients’ perception of community healthcare seeking behaviour towards health services

PONE-D-19-17088R2

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14 Oct 2019

PONE-D-19-17088R2

Age, sex and primary care setting differences in patients’ perception of community healthcare seeking behaviour towards health services

Dear Dr. Lim:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

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