Assessment of health-seeking behavior among the households of an urban area, Bengaluru, Karnataka--A cross-sectional study.
"Health is a state of complete physical, mental, and social well-being and not merely an absence of disease or infirmity." In recent years, this statement has been amplified to the ability to lead a "socially and economically productive life.  Health is a fundamental human right. The World Health Assembly in 2005 and the United Nations General Assembly in 2012 have emphasized the concept of universal health coverage to imply human right to health.  According to Alma-Ata Declaration, primary health care is a key to achieve this universal health coverage.  In a country like India, which has diverse culture and socioeconomic status; implementing Health For All is a huge task. It can only be possible by determining the health behavior of this diverse population. Health behavior is a wide concept and refers to series of actions taken to correct the perceived ill-health. These actions which are taken to fight illness depend on the perceptions, interpretations, and behavior pattern and are highly individualized. With limited manpower and resources in field of health, it becomes pertinent to understand the health-care-seeking behavior of the population to formulate health system, policies, and programs. Health system needs to plan their strategies based on the behavior of the population which can be obtained from the findings from such behavioral studies.  One such example of a program is Integrated Management of Neonatal and Childhood Illness strategy, which concentrates not only to improve providers' skills in managing childhood illness but also to improve families' care-seeking behavior.  Knowledge on health-seeking behavior (HSB) of target population is necessary to achieve universal health coverage.  HSB of a person is affected by number of factors acting at various levels such as individual, family, and community. The health-care seeking, public or private, depends on sociodemographic characteristics, literacy, cultural practices, economic conditions, issues of accessibility and quality, gender discrimination, status of women, economic and political systems, environmental conditions, and the disease pattern and health-care system itself.  For example, the individual or community's culture takes them to home remedies and traditional healers. Health-care-seeking patterns, especially those involving non-qualified practitioners and pharmacists, result in inadequate treatment, improper dosing, and over-the-counter purchase of drugs, frequently leading to the development of antimicrobial resistance and other bad outcomes. 
The public sector, to provide quality health care, needs to be reformed taking into account the health-care-seeking behavior of the population under that health center. However, it suffers from a lack of accountability, a poor referral system, and also very poor quality and attitude of staff. These factors are major access barriers for the poor. Recent studies indicate that almost 60-86% of people from rural and urban India turn to private facilities for ambulatory care.  The reasons for such a behaviour may be because the private sector has a different environment that makes patients feel safe and comfortable. However, it is also leads to high health expenditure and also nullifies the concept of health for all. Hence, the only effective solution for this is to improvise the quality of health-care services in public health sector. Hence, this study was conducted in the urban field practice area containing the population of different socioeconomic status to understand the HSB of the population, and the implications from this study were utilized to improve the services at urban health center.
The objectives of this study were to assess the HSB and factors affecting it among the households of urban field practice area, Bengaluru.
MATERIALS AND METHODS
Study Design, Area, and Study Population
This was a descriptive cross-sectional study conducted among the households of H. Siddaiah Road, an urban area in Bengaluru, Karnataka. The study was conducted from July 2015 to March 2016.
Study Sample Size
Based on a previous study by Mani et al.,  65% of the households preferred health care at a government facility, and at 5% significance, sample size was calculated to be 350 households. The households were selected from the study urban area by simple random sampling method.
Ethical Consideration and Data Collection Method
Data collection was started after obtaining ethical clearance from the Institutional Ethical committee. An informed consent was obtained from the households for the study. Data regarding sociodemographic profile, preferred health sector during illness, factors affecting the health seeking, and other details were obtained by interview method using a pre-tested and semi-structured questionnaire.
Data were analyzed using SPSS software Version 23. Descriptive statistics and non-parametric tests were used to analyze and results were presented in the form of Tables and Figures.
Sociodemographic Profile of the Households
Total population enrolled in the study was 1581. 991 (62.68%) of them were adults. Females were higher in our study (811, 51.3%) than the males. 669 (42.31%) were literates. 299 (85.4%) of the households belonged to Hindu religion and 51 (14.6%) were Muslims. Most of the households belonged to upper lower class (194, 55.4%) followed by lower middle (128, 35.71%). Many of the households were below poverty line (75.10%).
HSB of the Households
Majority of households (269, 76.90%) agreed that they were availing services from government health sector. However, still, it was noticed that 81 households (23.10%) did not avail any kind of services from government health sector.
Figure 1 depicts the type of services (preventive/curative) availed by the households who seek health care from government health sector.
Table 1 shows the association between sociodemographic characteristics of the household and health-care seeking at government health sector. A statistically significant association was seen with the characteristic religion. Though not statistically significant but more than 60% of the households under each characteristic availed services from government health sector.
Table 2 shows that the most common reasons for not visiting government health sector for curative services were inconvenient timings (40.96% of responses), overcrowding (28.80%), and unsatisfactory services (21.40%).
Apart from government health-care sector, it was found that the households visit most times to private clinics (66.96%) and also prefer over the counter medicines (16.52%) [Table 3]. Some of them were also satisfied with home remedies.
It was observed that most of the visits to a private health sector were for curative services (82.60%). Table 4 shows that the households preferred to visit private health sector for curative services due to good services (35.12%), convenient timings (32.44%), and its distance from house (16.94%).
The study was done with an aim to understand the HSB of the households. The vulnerable population such as children and the elderly were in good proportion which gives an impression that illness and hence health events also will be in a considerable amount. All kinds of services were availed from government health-care setting by a small part of the study population. Majority of them preferred private health center for the curative type of services. The common reasons for not availing curative services in government health-care setting were inconvenient timings and overcrowding.
Our study observed preference to a private health sector for health-care seeking among the households which is contradictory to observations in a study conducted by Mani et al. where positive preference toward private hospital was expressed by 35% of the study population and 65% of the participants felt that government hospitals are as good as private facilities.  Another study in which observations are similar as our study was conducted by Gopalan et al. who observed that about half of the respondents received care exclusively from various categories of private providers, whereas 20% depended on public health-care facilities for care and remaining 31% approached both public and private providers.  Most of preventive services such as maternal services and immunization services were availed from government hospitals which is in contradiction to a study by Bonu et al., where private providers were preferred over public providers in urban areas for all maternity services--ANC, delivery, and PNC.  In a study conducted by Chandwani et al. among mothers, 56.8% stated dissatisfaction with the health-care services, due to lack of accountability and humaneness of the health-care providers and also inconvenience of transportation (68.3%).  Our study found that inconvenient timing, overcrowding and poor quality care were the most common reasons for unsatisfactory health care services unlike a study by Rehman A et al., where it was found that the local community consulted private doctors due to the proximity (92%), their empathetic attitude (90%), and the satisfaction with the treatment provided by them (64%).  Apart from government, other type of healthcare sectors were also visited predominantly in this study which is in accordance with the observations of the study conducted by Mani et al. where 86% of the study population sought hospitals (government and private), 4% went for over the counter medicines, and 6% took home remedies at the time of illness.  Similarly, in a study conducted by Bhatia et al., it was observed that 80% of the visits were to a private practitioner and self-medication was seen in 26% of the illness episodes. 
The strengths of the study were that it had a large sample size representing the general community, which contained people belonging to different socioeconomic status. The HSB details were obtained from the responsible member of the family. Limitation was that the mixed responses were obtained and multiple responses were considered.
The population in this study chose costly, satisfactory health services at private sector over low-cost unsatisfactory health services at government health center. Hence, the households ended up in high health-care expenses. Since the lower class people are experiencing catastrophic health expenditure by seeking care at private health sector, it becomes pertinent on the part of the Government to provide satisfactory and quality health-care services, 24x7 which will increase the convenience of the people to seek health care at government health center. And also encouraging empanelment of superspecialty hospitals under various schemes which can provide tertiary level health care at an affordable cost. Regulation of health-care cost at the private health sector will have an impact on the high health-care cost experienced by the population.
International Journal of Medical Science and Public Health Online 2018. [C] 2018 Swetha NB, et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.
Source of Support: Nil, Conflict of Interest: None declared.
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Swetha N B (1), Shobha (2), Ramya M S (3), Sriram S (4)
(1) Department of Community Medicine, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India, (2) Department of Community Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India, (3) Department of Community Medicine, East Point College of Medical Sciences and Research Centre, Bengaluru, Karnataka, India, (4) Department of Pharmacology, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
Corresponding to: Swetha NB, E-mail: firstname.lastname@example.org
Received: December 03, 2018; Accepted: December 25, 2018
Table 1: Association between sociodemographic characteristic of the household and health-care seeking at government health sector Characteristics n=350 Health-care seeking X value P at government health sector n (%) Religion Hindu 299 221 (73.9) 3.621 0.05 Muslim 51 44 (86.3) Socioeconomic status Upper middle 28 18 (64.3) 4.059 0.13 Lower middle 128 93 (72.6) Upper lower 194 154 (79.4) Type of family Nuclear 250 186 (74.4) 0.831 0.66 Three generation 23 18 (78.3) Joint 77 61 (79.2) Table 2: Reasons for not availing curative health-care services in government health-care center (n=271) * Reasons Frequency (%) Inconvenient timings 111 (40.96) Overcrowding 78 (28.80) Unsatisfactory services 58 (21.40) Unavailability of drugs 22 (8.12) Others (far away, etc.) 2 (0.74) * Multiple responses were considered Table 3: Other type of health-care center visited by households (n=448) Health center Frequency (%) Private clinic 300 (66.96) Nursing home 70 (15.63) Over the counter medicines 74 (16.52) Alternate system 4 (0.89) * Multiple responses were considered Table 4: Reasons for preferring private sector over government for curative services (n=484) * Reasons Frequency (%) Nearby 82 (16.94) Convenient timings 157 (32.44) Good services 170 (35.12) Quick services 57 (11.78) Less crowded 18 (3.72) * Multiple responses were considered Figure 1: Type of service availed at government health-care center (n = 269) Only Preventive 34.94% Only Curative 8.17% Both 56.88%
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|Title Annotation:||Research Article|
|Author:||N.B., Swetha; Shobha; M.S., Ramya; S., Sriram|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Feb 1, 2019|
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