Health care seeking behaviour among rural women in Telangana: A cross sectional study.

BACKGROUND: The health of women is of particular concern because, in many societies, they are disadvantaged by discrimination rooted in sociocultural factors. Women need to breach many social barriers to empower and to get access for quality health care services. Health seeking behavior is one of the important determinants of women health.
OBJECTIVES: To assess healthcare seeking behavior among rural women in Telangana.
METHODS: Cross-sectional study with sample size of 200 was conducted in three villages attached to a medical college. Women of aged 20 years and above were included in the study. Data was collected by predesigned pretested semi-structured questionnaire. Data was presented in proportions with confidence interval and Chi-square test was applied to find the association between variables by using SPSS ver. 23.
RESULTS: Only 34.5% [95% CI: 27.9, 41.5] of the subjects seek medical care as soon as symptoms appear and 69% [95% CI: 62.1, 75.3] of the participants were aware of nearby functioning health centres. Majority (60.5%) of the subjects Visits qualified medical practitioner during illness.
CONCLUSIONS: The present study found that there is still a need to create awareness about the importance of healthcare and available health centers as significant proportion of women population approached unqualified medical practitioners and seeking home remedies as first consultancy source for their health remedies. Copyright:

Introduction

Healthcare seeking behavior has been defined as “any action or inaction undertaken by individuals who perceive themselves to have a health problem or to be ill for the purpose of finding an appropriate remedy.[1] It is very essential to identify and understand health seeking behavior in order to provide basic healthcare services and develop strategies for improving utilization of health services by the community particularly women. The health of women is of particular concern because, in many societies, they are disadvantaged by discrimination rooted in sociocultural factors. Some of the sociocultural factors that prevent women to benefit from quality health services and attaining the best possible level of health include unequal power relationships between men and women, social norms that decrease education and paid employment opportunities, an exclusive focus on women's reproductive roles and potential or actual experience of physical, sexual, and emotional violence.[2]

Women's health in India has assumed importance particularly after the International Conference on Population and Development held at Cairo, Egypt in September 1994 and the fourth World Conference on Women, held in Beijing in September 1995.[3] Both these conferences placed immense importance on women's health, empowerment, and reproductive rights. Women need to breach many social barriers to empower and to get access for quality healthcare services in our country. Women should be educated regarding common health issues encountered and should improve the access to healthcare services by not only establishing health centers but also sensitize them to identify health related felt needs and improving health seeking behavior. Health seeking behavior is one of the important determinants of women health and will be influenced by the individual knowledge, disease perception, sociodemographic factors, and the availability and accessibility of health services. Depending on these determinants and their interactions, healthcare seeking behavior is a complex outcome of many factors operating at individual, family, and community level.[4]

Under primary healthcare approach, promotive, preventive, and curative services were provided by health team which also includes field level health workers like auxillary nurse midwife (ANM), Anganwadi worker, Accredited social health activist (ASHA) to all the rural women during different phases of life with much attention towards improving health seeking behavior. The rationale of this study is to assess the health seeking behavior of women which helps to evaluate the quality of services provided by healthcare team at ground level and emphasize the need to address the barriers and take necessary measures for improving health seeking behavior of rural women. Not much literature is available on this aspect and hence this study was undertaken to assess healthcare seeking behavior among rural women in Telangana state.

Subjects and Methods

Study design, setting, and subjects

The study was a descriptive, community-based cross-sectional study conducted from 1st June 2019–31st August 2019 in three randomly selected villages out of 11 villages attached to a medical college in Nalgonda district of Telangana state. Study participants were women aged 20 years and above. Ill and moribund patients, participants of pilot study and women who were not willing to participate in the study were excluded.

Sample size and sampling technique

Sample size was estimated using formula of n = 4 pq/d2 where P = 72.6%[5] (P was taken from findings of previous study), q = 27.4, precision (d) = 7.26 (10% of P). The calculated n = 150.9. Taking non-response rate as 10%, total will be 165.9 which is rounded off to 200 and hence final sample size was 200. Based on proportionate sampling method, it was decided to collect data of 89 subjects from Cherlapally village, 60 subjects from Marrigudem village, 51 from Anaparthy village. Houses were selected by systematic random sampling method. After visiting the selected house, younger eligible subject among the available was included in the study.

Study tool and data collection

Pre-designed and pretested semi-structured questionnaire was used as a study tool and pilot study was conducted on 50 rural women initially and questionnaire was translated into local language as a part of standardization of the questionnaire. The questionnaire consists of sociodemographic variables such as age, religion, education, occupation, socioeconomic status, and marital status. It also consists of questions regarding healthcare seeking behavior and preference of health care centers. Data was collected by face-to-face interview method.

Ethical considerations

The study participants were briefed about the purpose and nature of the study, and informed consent was obtained before data collection. Study was approved by Institutional ethics committee on 25.04.2019.

Statistical analysis

Data were analyzed using IBM SPSS Statistics for Windows Version 23.0. Data was expressed in proportions with confidence interval (95% CI) and mean with standard deviation (SD), respectively. Pearson's Chi-square test was applied as test of significance for assessing association between marital Status and education status with health care seeking behavior. P < 0.05 was considered as statistically significant.

Results

The mean age of study participants was 39.2 years (SD ± 12.3). Majority of participants were of age group 20–30 years (30.5%), Hindu (69%), literates (51.5%), unemployed (64.5%), middle class (38.5%), and married women (58%). [Table 1].

Table 1

Demographic profile of study participants (n=200)

Age group	Frequency (%)
20-30	61 (30.5)
30-40	49 (24.5)
40-50	45 (22.5)
50-60	35 (17.5)
60-70	10 (5)
Religion	Frequency (%)
Hindu	138 (69)
Muslim	45 (22.5)
Christian	17 (8.5)
Education	Frequency (%)
Illiterate	97 (48.5)
Literate	103 (51.5)
Occupation	Frequency (%)
Working	71 (35.5)
Not working	129 (64.5)
Socioeconomic status	Frequency (%)
Upper class	13 (6.5)
Upper middle class	35 (17.5)
Middle class	77 (38.5)
Lower middle class	59 (29.5)
Lower class	16 (8)
Marital status	Frequency (%)
Married	116 (58)
Unmarried	62 (31)
Widow	22 (11)

The study showed that 42% (95% CI: 35.1, 49.2) out of 200 participants required permission from any of the family members to access healthcare services. Only 34.5% (95% CI: 27.9, 41.5) of the subjects seek medical care as soon as symptoms appear and 69% (95% CI: 62.1, 75.3) of the participants were aware of nearby functioning health centers [Table 2].

Table 2

Health care seeking behavior among study subjects (n=200)

Health care seeking behaviour	No. of subjects answered Yes (%)	95% CI
Do you have inhibitions in discussing your health issues with family members	70 (35)	28.4, 42
Do you require permission from any of the family members to access health care services	84 (42)	35.1, 49.2
Can you make own decisions regarding health care	131 (65.5)	58.5, 72.1
Do you seek medical care as soon as symptoms appear	69 (34.5)	27.9, 41.5
Treating doctor will be choosed based on his consultation fees	123 (61.5)	54.4, 68.3
Distance from your place will decide the health centre to be visited	61 (30.5)	24.2, 37.4
Are you aware of nearby functioning health centres	138 (69)	62.1, 75.3

Majority (60.5%) of the subjects visits qualified medical practitioner during illness followed by visiting RMP (19.5%) and following home remedies (15.5%) [Table 3].

Table 3

Distribution of study subjects according to first preferred health care practices during illness (n=200)

Health care practice during illness	Frequency (%)
Visits qualified medical practioner	121 (60.5)
Visits RMP	39 (19.5)
Home remedies	31 (15.5)
Spiritual healers	7 (3.5)
Over the counter medication	2 (1)

The present study found statistically significant association between marital Status (P = 0.04) and education status (P = 0.01) with health care seeking behavior. [Table 4].

Table 4

Association between marital Status and education status with health care seeking behavior (n=200)

Marital status	Own decision making		Total (%)	Chi square P
	Yes (%)	No (%)
Married	83 (71.6)	33 (28.4)	116 (100)	0.04
Unmarried	33 (53.2)	29 (46.8)	62 (100)
Widow	15 (68.2)	7 (31.8)	22 (100)
Total	131 (65.5)	69 (34.5)	200 (100)
Education status	Knowledge about available health centres		Total (%)
	Yes (%)	No (%)
Literate	83 (80.6)	20 (19.4)	103 (100	0.01
Illiterate	55 (56.7)	42 (43.3)	97 (100)
Total	138 (69)	62 (31)	200 (100)

Discussion

In the present study, 200 rural women were included with the mean age of 39.2 ± 12.3. The present study found that 35% of the women have inhibitions in discussing their health issues with family members and 42% of the subjects required permission from any of the family members to access healthcare services. These findings reflect the hurdles to overcome among the women in order to seek healthcare services. In a study conducted by Khan A, et al., in Pakistan, it was observed that 29% of the women doesn't want to discuss with their husband if they are hit with tuberculosis.[6] Current study observed that 65.5% of the rural women can make their own decisions regarding health care. In a study conducted by Gopalakrishnan S, et al., among antenatal and postnatal rural women in Tamil Nadu, it was observed that only 3.3% of the subjects could take a final decision regarding the place of delivery which projects the status of the women in the society.[7] Lassi ZS, et al., in their systematic review study observed that decision-making power is less likely to be with women and mostly rests with their partners and mothers-in-law.[8] In another study conducted by Sikder SS, et al. in rural Bangladesh, it was observed that more than one-third of women identified their husbands as the main healthcare decision maker.[9] Mainuddin AKM et al. found that only 12% women were empowered to decide on their own about seeking healthcare and 8.5% in healthcare seeking for their children in a study done on rural Bangladesh women.[10] Considering all these barriers, women often postpone seeking help, with the hope that the problem will subside on its own. This clearly states that women empowerment is a key issue in healthcare seeking behavior of women, on which targeted strategies should be implemented.

It was observed in the present study that 34.5% of the subjects seek medical care as soon as symptoms appear where as in the study conducted by Khajeh A, et al., in Iran found that 13.5% of the study subjects visited health centers when they had mild symptoms.[11] Older females were 0.41 times more likely to go for treatment in contrast to males according to the findings of Srivastava S et al. study.[12] This emphasizes the need to sensitize the women regarding her health and provide them essential health education. The current study also observed that 61.5% of the study participants opted treating doctor based on his consultation fees whereas Omotoso et al., in their study conducted in Nigeria observed that 32.9% of rural dwellers claimed that they patronized a particular medical establishment because they could afford the medical charge.[13] Distance from home is the deciding factor to opt a particular health center among 30.5% of rural women in the present study which is similar to the findings of Chauhan RC, et al., study conducted in Tamil Nadu where most (31.12%) common reason for visiting particular health facility was easy accessibility.[14] Omotoso et al., reported that 24.3% subjects indicated that visiting a particular center was due to the closeness of such medical establishment.[13] Chandana KR et al. study conducted on tribal women of Telangana state found an association between preference choices of health service with the distance from home to health facilities and in another study conducted by Nakovics MI, et al., in rural Malawi, it was observed that increasing distance to the health facility significantly decreased the likelihood of utilizing formal care.[1516] These observations indicate the need to improve the accessibility to essential health services in rural areas. Though majority (69%) of the study participants in the current study were aware of nearby functioning health centers, it is not an encouraging finding this, it is essential to take necessary measures in order to identify the felt needs of the rural women and sensitization them regarding the available health centers.

Utilization of health services is as important as availability of health services in order to step forward to achieve sustainable development goals. The current study observed that 60.5% of the participants preferred qualified medical practitioner for getting treatment during illness and 3.5% subjects approach spiritual healers. Similar results were observed in Awasthi S et al. study conducted on urban poor of Lucknow, where 48% of the subjects sought care from qualified health personnel and it is only 42% in the study done by Khan MDSI, et al., in Bangladesh rural community.[1718] In the studies conducted by Vijayalakshmi S, et al., in rural Pondicherry and Hoeven MVD, et al., in South Africa, 83.6% and 71.8% of the subjects visited hospitals for treatment.[1920] In a study conducted by Nusrat K, et al., in Karachi observed that 82.05% pregnant women would like to seek healthcare services from hospital or clinics and 13.67% opted self-medication.[21] The first approach of seeking health for the reported illness among 51% of the women subjects was the traditional healer according to Shrestha MV, et al., study conducted in Nepal, however, 1% of the rural Bangladesh community visited spiritual healers according to Khan MDSI, et al., study.[2218] Quacks and unqualified persons providing health care was most commonly seen in rural areas and in the current study 19.5% subjects visits RMP doctors. In Kanungo S, et al., study conducted in West Bengal found that 53.5% of the subjects visited non-qualified person for medical care, whereas in Koenig MA, et al., study in Bangladesh, 29% subjects opted unqualified care provider.[2324] The preferred place to seek healthcare when ill by 91.9% of the respondents was patent medicine stores according to Adam VY, et al., study conducted in Nigeria rural community.[25] Paul AV, et al., study from Tamil Nadu observed that 12.7% of the subjects preferred pharmacies, home remedies, traditional healing and alternative medicine.[5]

Current study found that majority of the married women were able to make their own decision regarding health problems when compared to unmarried and widow and this association was found to be statistically significant (P = 0.04). Majority (80.6%) of the literates were aware of available health centers when compared to illiterates and this association was found to be statistically significant (P = 0.01). Ravi RP et al. study conducted in Tamil Nadu found positive relationship between women education and treatment seeking behavior.[26] Barman B et al. study in India observed that women's education was positively and significantly associated with utilization of maternal and child health services.[27]

Relevance to the practice of primary care physicians

Health of the women in all stages of life must be given utmost importance because it is one of the determinants of child's health and family health. However, it is often neglected because many social factors. Though government had introduced many schemes and programmes, still significant number of women couldn't utilize those services. Reducing the maternal mortality ratio, neonatal mortality, Under-5 mortality rates and ensuring universal access to sexual and reproductive healthcare services are the targets of Sustainable Development Goals (SDGs), which can be achieved by delivering services through primary health care system and improving health care seeking behavior of women.[28] Primary care physicians play a key role in sensitizing and improving health care seeking behavior. The current study may be useful for primary care physicians as it highlights the healthcare practices and extent of health care seeking behavior of women. The present study may also be useful in identifying determinants of healthcare seeking behavior of women and planning appropriate interventions to breach the barriers and for promoting women's health in the community.

Conclusion

Nearly half of the women require permission of family members to access health services and only one-third of the subjects seek medical care as soon as symptoms appear and aware of nearby health centers. The present study found that there is a need to create awareness about the importance of health care and available health centers as significant proportion of women population approached unqualified medical practitioners and seeking home remedies as first consultancy source for their health remedies. This study strongly emphasizes that healthcare seeking behavior of rural women depends on socioeconomic conditions and geographical factors as their decision of choice of doctor depended on consultation fee and location of health care service rather than on the qualification of health care professionals and quality of service provided. Ignorance of Women about health issues, social stigma, socioeconomic conditions, communication barriers in family and availability of necessary health care played a major role in inappropriate health care seeking behavior among rural women. An integrated and structural approach is strongly suggested to create awareness about commonly encountered health issues and improve health seeking behavior among rural women.

Strengths and limitations

Exploring the health seeking behavior of rural women and its determinants which is very essential in identifying the barriers and thus improving women health is the strength of the current study. However, few limitations could not be avoided, particularly restricting to only 3 villages with relatively small sample size which limits the generalization of the results.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Funded by Indian Council of Medical Research (ICMR) for this STS project.

Conflicts of interest

There are no conflicts of interest.