A Sociological Study in Two Villages of Jessore District-Health Seeking Behavior among Married Women in Rural Bangladesh

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Health Seeking Behavior among Married Women in Rural Bangladesh:

A Sociological Study in Two Villages of Jessore District

1.1 Background :

Health seeking behavior in modern society, particularly in the developing countries exhibits medical pluralism. Different options for treatment are available within a for mal structure such as government health centers or in a traditional healers clinic. In the developing societies it could be observed within more informal ways, such as through medicament often purchased with accompanying advises from the owner of the medicine shop or the medicine sellers and the self care by the people themselves. In spite of the fact that modern medicine has achieved a tremendous advancement in curing diseases, it is not necessarily always the option preferred.

A large segment of the treatment seekers uses a variety of health care resources either alternatively for different ailments or simultaneously, serially or intermittently, for an ailment over the time. These different systems and types of health care and option available before the patients, offer them the scope for explaining, diagnosing and treating ill health. The decision on the options for treating ailments is often a complex process. It depends on a number of factors or dimensions. These factors or dimensions are wide in nature and related variables are too large to be addressed easily in any situation. Besides, the influence of these factors and emphasis on the same varies from country to country and from one socio-culture group to another.

These differences in the behaviour pattern of seeking medical care in different socio-cultural set up and countries have been and are continuing to be the subject to extensive investigation in medical sociology. The question, what are the social factors which influence in encouraging or discouraging a person from seeking certain system or types of treatment, has important sociological significance. An understanding of the health seeking behaviour of the of the population at large, can have a tremendous impact on the structuring of health service for maximum utilization by people living in a community. This would help in providing the population better medical care as well making that care more accessible to the people who need the same. Cockerhem viewed “an understanding of the health seeking process in medicine can have a tremendous impact upon the structuring of health service utilization by people living in a community, both in terms of providing better medical care and making that care accessible to the people who need it”. (Cockerham 1982:98)

Health is a dynamic ever changing state that is difficult to define and to measure. The state of a person’s health lies on a continuum between death and complete health in every aspect possible (Scott, Ian et al1995).Individual and public health is highly persuaded by our knowledge and acts. Health and illness are social phenomena as they are socially patterned and an individual’s social position may have an important bearing on their experience. Illness behavior of an individual varies by social group whether it is influenced by class, gender, age or ethnicity. Individuals are inevitably shaped in the social relationships that constitute our every day lives and the wider society (Bury, 1997). Culture is a system of interrelated values which are much active to, fluence and condition perception, judgment, communication and behavior in a society (Airhihenbuwa, 1995).

Health, disease and illness are highly subjective phenomena which are affected by a multitude of individual and social factors (Moon and Gillespie, 1995). Rather than biological and medical aspects of health care, sociological perspectives of health and illness emphasizes the aspects of health care as prevention of illness, social management of illness and rehabitation. It depicts how social processes work to dine illness, understand the causes of illness and promotion of health or to interpret the organizational structures within the health care system (Bond and Bond, 1994).

Understanding of both the individual and society in which they live is the central concern for social science. It helps us to look critically into some of the things which we frequently take for granted (Moon and Gillespie, 1995). Now it has become common practice in the field of public health and in the social and behavioral sciences to give more importance to culture for understanding health behavior. But culture has to be given the priority for health promotion and disease prevention programs in such a manner that legitimates public health praxis (Airhihenbuwa, 1995).

Public health care can be understood in a social context. Using the health care services or working in a health care setting relates social transactions between different types of health professionals and patients/clients. These transactions take place in situations which are closely constrained by political decisions about resources, service management and service innovation (Moon and Gillespie, 1995). In this regard sociology of health care provides an understanding of the social processes involved in the delivery of health care. The practice of health care is now considered as social action and it is developing a sociological understanding of health providers and their practices. It refers to using sociological insights to policy and planning of the health services and the education of the workforce. Therefore, sociology offers various ways of viewing and explaining health care and health problems (Bond and Bond, 1994). So, it is now important to understand of people’s culture, social structure, health beliefs and practices and how this diversity can be addressed in terms of health policy (Helman, 2000).

In Bangladesh many people have harmful health behavior still at present. Here majority of the people suffers from poverty, hunger, malnutrition, illiteracy, ignorance and superstition. Here traditional, native or indigenous methods of healing are exercised, especially in rural areas from ancient times. After the half of 19th century modern scientific medicine has begun to spread in rural areas. During Pakistan period the situation regarding health problems and services were very poor. After independence the situation has improved, but not the desired extent (Mahbullah, 1981). Here socio-economic and cultural obstruction including insufficient information act as a resistance to awareness towards positive changes in health behavior.

1.2 Outline

At the beginning of study the researcher have expressed his acknowledgements to the guideliners of the study and also discussed abstracts, table of contents, list of table , list of figures, and abbreviations which used in this study. In chapter one the researcher has described the background, outline, importance, objectives of this study, research hypothesis and operational definitions of the study. In chapter two, the researcher has made related literature review with sub-sections. In chapter three, theoretical framework of the study, comparative discussion and a conceptual frame work have been made. In chapter four, the description about which method and why is used by the researcher, the study site, study population, sampling, study instrument, pre-test, techniques of data collection, data processing and analysis, reliability and validity and limitations of the study are discussed. In chapter five, the results of the study are represented with subsections including frequency tables and figures. Tested hypothesis are also represented here. In chapter six, the researcher has made general discussion of the result with sub-sections. In chapter seven, the conclusion on the above study has been discussed. At last, the references and appendix are given for completing the research monograph.

1.3 Importance

Bangladesh, being a developed country, suffers from poor rural facilities. The government of Bangladesh has taken some very useful and important measures to improve the overall health condition of the country. Public Health facilities in the country are provided through a hierarchically developed five-tiered delivery system. These are:

1) Home and community level

2) Union level

3) Upazila level

4) District level and

5) National and territory level.

The first two tires are located in rural areas, while the others are in urban locations. All citizens of the country, ideally though, have equal access to all of these facilities. In reality very little is available for the common people, particularly the poor whether they live in rural or urban areas. Inspite of the governmental efforts, the rate utilization of health facilities is very poor due to ignorance of health problems.

People living in the poorer families are generally the victims of malnutrition and diseases, and within these families married women are vulnerable. Health care in Bangladesh is poorly developed and concentrated in the urban areas. The effect of married women’s malnutrition and under nutrition is manifest in the form of anemia, low resistances to diseases and maternal mortality. Despite the facilities provided by private as well as public authorities in various forms for maternity treatment in Bangladesh, a large majority of the rural births still takes place with the help of traditional birth attendants known as Dai. Married women are also treated by the traditional healers and quacks for most other kinds of sickness.

Having understood the importance, I took an initiative to carry on an inquiry on searching health seeking behaviour among married women in rural Bangladesh. I reasonably hope that obtained result of my study will be helpful for professional, family, social, or national life

1.4 objectives

To know better about the health related seeking behaviour among the rural married women is the primer aim of the study since they are the vital portion of the nation. For achieving this aim some significant objectives have been fabricated regarding the issues as follows:

1. To closely observe the rural married women sources of health care services.

2. Identify the role played by health center around rural areas in Bangladesh.

3. To see whether and to what extent the common rural married women from all works

of life have access to these services.

4. To examines the attitude to and level of acceptance family planning services by rural



Review of Literature

A review of literature is an important component in any research process. In any case, the review of literature is basically a critical review of the existing knowledge on the subject. The researcher has reviewed a couple of English literatures, articles, newspapers and various national and international reports from multi-disciplines in order to get an overall insight about the present research subject. In this chapter an attempt will be taken to examine and review those specific issues, which help the researcher to understand Health seeking behaviour among married women in rural Bangladesh.

2.1 Understanding health seeking behaviour:

Health promotion programmes worldwide have long been premised on the idea that providing knowledge about causes of ill health and choices available will go a long way towards promoting a change in individual behaviour, towards more beneficial health seeking behaviour. However, there is growing recognition, in both developed and developing countries, that providing education and knowledge at the individual level is not sufficient in itself to promote a change in behaviour. An abundance of descriptive studies on health seeking behaviour, highlighting similar and unique factors, demonstrate the complexity of influences on an individual’s behaviour at a given time and place. However, they focus almost exclusively on the individual as a purposive and decisive agent, and elsewhere there is a growing concern that factors promoting ‘good’ health seeking behaviours are not rooted solely in the individual, they also have a more dynamic, collective, interactive element. Academics have therefore started to explore the way in which the local dynamics of communities have an influence over the well-being of the inhabitants.

This reflects a growing interest across the social sciences in the contested concept of social capital. Attempts are now being made to develop this, as yet under-utilized idea, to incorporate knowledge about health seeking behaviour into health service delivery strategies in a way which is sensitive to the local dynamics of the community. This may be an extremely positive development. The whole area of knowledge around health seeking behaviour is rendered of little value if not incorporated into management and system developments. The fact that health seeking behaviour is ‘not even mentioned’ in widely used medical textbooks (Steen and Mazonde, 1999), perhaps reflects that many health seeking behaviour studies are presented in a manner which delivers no effective route forward. This results in an unfortunate loss for medical practice and health systems development programmes, as proper understanding of health seeking behaviour could reduce delay to diagnosis, improve treatment compliance and improve health promotion strategies in a variety of contexts.

As part of this research, it begins to explore some of the growing body of literature around local social development, participation and citizenship. This is usually divorced from the sort of one-on-one understanding of actual acts of health seeking behaviour, but the paper highlights a few key studies that begin to make more explicit the importance of the links between the health seeking behaviour of the individual and wider theoretical models of the local dynamics of health systems and social participation. In this review of the literature I work towards an understanding of how this more collective, situational, experiential understanding can be developed in a practical way through this research.

2.2 Health seeking behaviours: two approaches:

Researchers have long been interested in what facilitates the use of health services, and what influences people to behave differently in relation to their health. There has been a plethora of studies addressing particular aspects of this debate, carried out in many different countries. For the sake of this paper they can simplistically be divided into two types, which roughly correspond with a division identified by Tipping and Segall (1995). Firstly there are studies which emphasis the ‘end point’ (utilization of the formal system, or health care seeking behaviour); secondly, there are those which emphasis the ‘process’ (illness response, or health seeking behaviour)

2.3 Health care seeking behaviours: utilization of the system

There is often a tendency for studies to focus specifically on the act of seeking ‘health care’ as defined officially in a particular context. Although data are also gathered on self care, visits to more traditional healers and unofficial medical channels, these are often seen largely as something which should be prevented, with the emphasis on encouraging people to opt first for the official channels (Ahmed, et al, 2001). These studies demonstrate that the decision to engage with a particular medical channel is influenced by a variety of socio-economic variables, sex, age, the social status of women, the type of illness, access to services and perceived quality of the service (Tipping and Segall, 1995). In mapping out the factors behind such patterns, there are two broad trends. Firstly there are studies which categories the types of barriers or determinants which lie between patients and services. In this approach, there are as many categorizations and variations in terminology as there are studies, but they tend to fall under the divisions of geographical, social, economic, cultural and organizational factors

Bedri (2001) develops pathways to care model in her exploration of abnormal vaginal discharge in Sudan. She identifies five stages where decisions are made, and delay may be introduced, towards adoption of ‘modern care’. There are four ‘sub pathways’ that women may follow, from seeking modern medical care immediately, to complete denial and ignoring of symptoms. This approach offers an opportunity to identify key junctions where there may be a delay in seeking competent care, and is therefore of potential practical relevance for policy development. For example, in order to optimize the pathways taken by women, Bedri suggests husbands should be involved in health education programmes about vaginal discharge, and women should be enabled to conduct home vaginal swabs. Bedri’s study is particularly interesting as it compares health care seeking behaviour around vaginal discharge and malaria, revealing, perhaps not surprisingly, that women follow quite different pathways for different conditions, relating predominantly to the role of the husband, social networks and cultural customs. This clearly has implications for health systems development.

The view is often that the desired health care seeking behaviour is for an individual to respond to an illness episode by seeking first and foremost help from a trained allopathic doctor, in a formally recognized health care setting. Yet a consistent finding in many studies is that, for some illnesses, people will chose traditional healers, village homeopaths, or untrained allopathic doctors above formally trained practitioners or government health facilities (Ahmed et al, 2001). There are variations witnessed, and apart from differences according to type of illness, gender is a recurring theme. For example, Yamasaki-Nakagawa et al (2001) found women in Nepal were more likely than men to seek help from traditional healers first. The scale of this may be reflected in findings from a recent study by Rahman (2000) in rural Bangladesh, where 86% of women received health care from non-qualified health care providers. This has implications for diagnosis, and women have been found to have significantly longer delays to diagnosis than men (Needham et al, 2001; Yamasaki-Nakagawa et al, 2001).

Despite the ongoing evidence that people do choose traditional and folk medicine or providers in a variety of contexts which have potentially profound impacts on health, few studies recommend ways to build bridges to enable individual preferences to be incorporated into a more responsive health care system. For example, Ahmed et al (2001, 98) conclude: “efforts should be made to raise community awareness regarding…the importance of seeking care from trained personnel and the availability of services”. Nonetheless there is now growing recognition of the need to be more sensitive to the realities of health care seeking behaviour. For example, in Bangladesh there is a large and growing sector of non-qualified allopathic providers engaged in the traffic of modern pharmaceuticals. They provide an accessible means of reaching Western medicines to a wider range of the population, yet lack formal medical training. There is therefore the accompanying problem of bad, unregulated prescriptive practices. Incorporating these unqualified providers into more formal training may therefore be beneficial (Ahmed et al, 2000).Uzma et al (1999) also suggest incorporating unqualified TBAs into training programmes for maternal health in order to improve the health status of women. Thus increasingly health care seeking behaviour studies are coming to the conclusion that traditional and unqualified practitioners need to be recognized as ‘the main providers of care’ (Rahman, 2000) in relation to some health problems in developing countries.

In acknowledgement of the fact that untrained non-Western practitioners remain a strong favorite, Outwater et al (2001) interviewed traditional healers about their knowledge and relationship with ‘modern’ medicine, and explored in far more depth the preferences of women who attended traditional healers and unofficial sources of health care. Through this they recognized, as have others (Moses et al, 1994) that some groups appear to ‘wander’ between practitioners rather than seek care through one avenue or provider. Similarly, Rahman (2000) found that different facilities will be frequented for different needs, according to a complex interplay of factors, sometimes regardless of the intended purpose of those facilities.

Thus there is growing acknowledgement that health care seeking behaviours and local knowledge’s need to be taken seriously in programmes and interventions to promote health in a variety of contexts (Price, 2001; Runganga, Sundby and Aggleton, 2001). With this broader appreciation of behaviour, some have suggested the need to improve integration of private sector providers with public care (Needham et al, 2001). Calls have been made for explicit recognition of the potential to combine the two worlds by involving unofficial providers in official training and service provision (Green, 1994; Outwater et al, 2001).

However, Ahmed et al concede that whilst extending training to such providers may enhance their services, training in itself will not change practice. For this, managerial and regulatory intervention is needed. Thus the provision of medical services alone in efforts to reduce health inequalities is inadequate (Ahmed et al, 2000). Clearly any research interest in health care seeking behaviour, focusing on end point utilization, needs to address the complex nature of the process involved, cognizant of the fact that the particular ‘end point’ uncovered may be multi-faceted and not correspond to the preferred end points of service providers.

2.4 Health seeking behaviors: the process of illness response

The second body of work, rooted especially in psychology, looks at health seeking behaviours more generally; drawing out the factors which enable or prevent people from making ‘healthy choices’, in either their lifestyle behaviours or their use of medical care and treatment. Thus whilst in the former literature health care seeking behaviour is conceptualized as a ‘sequence of remedial actions’ taken to rectify ‘perceived ill-health’ (Ahmed et al, 2000), in the second approach the latter part of the definition, responding specifically to perceived ill-health, may be dropped, as a wider perspective on affirmative, health promoting behaviours is adopted. A number of ‘social cognition models’ (Conner and Norman, 1996a) have been developed in this tradition, to predict possible behaviour patterns. These are based on a mixture of demographic, social, emotional and cognitive factors, perceived symptoms, access to care and personality (Conner and Norman, 1996b). The underlying assumption is that behaviour is best understood in terms of an individual’s perception of their social environment.

A number of genres of model exist, and variations have been developed around them. One of the most widely applied is the ‘health belief model’. Sheeran and Abraham (1996) categorize the range of behaviours that have been examined using health belief models into three broad areas: preventive health behaviours, sick role behaviours and clinic use. In this type of model, individual beliefs offer the link between socialization and behaviour. One of the earliest examples was Hochbaum’s study of the uptake of screening for TB, where he discovered that a belief that sufferers could be asymptomatic was linked to screening uptake. Health belief models focus on two elements: ‘threat perception’ and ‘behavioural evaluation’ (Sheeran and Abraham, 1996). Threat perception depends upon perceived susceptibility to illness and anticipated severity; behavioural evaluation consists of beliefs concerning the benefits of a particular behaviour and the barriers to it. ‘Cues to action’ and general ‘health motivation’ have also been included (Becker et al, 1977). The health belief model has been criticized for portraying individuals as asocial economic decision makers, and its application to major contemporary health issues, such as sexual behaviour, have failed to offer any insights (Sheeran and Abraham, 1996).

A second genre of model is linked to the general assumption that those who believe they have control over their health are more likely to engage in health promoting behaviours (Normand and Bennett, 1996). The ‘health locus of control’ construct is therefore utilized to assess the relationship between an individual’s actions and experience from previous outcomes. The most popular of these is ‘the multidimensional health locus of control measure’ (Wallston, 1992). However, this approach to social cognition models has been criticized for taking too narrow an approach to health and because the amount of variance explained is low (Norman and Bennett, 1996). Other approaches, including ‘protection motivation theory’ and ‘theory of planned behaviour’ have equally met with mixed reception (Boer and Seydel, 1996; Conner and Sparks, 1996).

If we adopted this sort of approach to health seeking behaviour, it would move beyond the traditional confines of social cognition models and health promotion assumptions, and may therefore be a more fruitful conceptual framework to use when exploring the decisions people make around health seeking behaviour. Lash and Urry (1994) claim all human existence is ‘a movement towards death’, but that individuals recognize there are ways of prolonging or hastening that movement. A whole host of factors come into play in this reflexive process, which we are only just beginning to understand in relation to health seeking behaviours.

Norman and Conner (1996) propose that social cognition models may in future be developed to incorporate other variables such as self identity (‘I am a healthy eater’). I see this as a potentially promising development, as it would open up the field to including the role of ‘reflexive communities’ in decision making. Although work around risk cultures and health has to date concentrated predominantly on contemporary Western society and large-scale environmental risks, a framework developed from such work could bring the idea and relevance of health seeking behaviour into a useful area for health service development in the context of the developing world, and is an idea worth exploring further. If we aim to investigate the way in which people in particular places make decisions regarding their patterns of health seeking behaviour, we could fruitfully adopt a framework that highlights the way in which people identify ‘risks’ attached to particular behaviours. For some it may simply be a matter of cost, for others a particular lifestyle aesthetic or cultural code may underpin any decision they make in a seemingly less ‘rational’ or scientific manner. Thus we need to expose not just people’s perceptions, definitions and legitimations of risks in not seeking health care, but also the mutual constitution of implicit assumptions about behaviours and their translation into risks (Adam, Beck and van Loon 2000), or Lash’s ‘reflexive communities’. It seems therefore that neither of the literatures outlined above adequately address either the nature of how people reach the decisions they do in the context of their daily, socially and culturally embedded lives, or the complexity of health care systems.

Both approaches see health seeking behaviour as a one-off event, following a linear direction, filtered in different ways along its course. If we explore Lash’s reflexive communities we would begin to conceptualize health seeking behaviour much more as a state of being which ebbs and flows around daily life and is brought into sharp focus at particular points of crisis in time and space. Thus it is my belief that we need to move the debate forwards into the messier terrain which remains unmapped around the dynamics of engaging in a complex and ongoing process that can not adequately be conceptualized by measuring dislocated actions aimed at a specific end point. As we are particularly interested in health systems, implications must be drawn out for service utilization and system development, and this necessitates our lens encompass something far broader than the majority of health seeking behaviour studies. Broader both in terms of the channels which the individual may engage with (i.e. not purely official medical ones) and in terms of how we look at the influences on people’s behaviour in particular places. MacPhail and Campbell (2001) begin to explore this broader context of system and policy implications, as they suggest sexual health policy and practice for young South Africans is influenced by simplistic generalized views held by adults, thereby excluding the very groups they wish to target. It is these sorts of ideas that need to be teased out of work on health seeking behaviour more explicitly.

2.5 Health seeking behaviour: global perspective

Health seeking behaviour clearly varies for the same individuals or communities when faced with different illnesses. For example, Bedri (2001) highlights contrasting pathways to care for women when faced with abnormal vaginal discharge, as opposed to malaria. For the former, the woman is bound far more by rituals and obligations, such as shaving prior to examination, and being accompanied to a medical consultation by her husband. There have been a plethora of studies on women’s health seeking behaviour in Bangladesh, some of which are cited in this paper, and alternative suggestions made for improvements to the health system in relation to particular conditions or services. But there have been less explicit attempts to address the social dimensions of health seeking behaviour, as demonstrated for example in the literature around HIV and sexual health, particularly in South Africa.

TB represents a classic public health issue, as effective diagnosis, treatment and control are important for the whole of a society. Hence it is appropriate for the state to play a dominant role in provision of services for TB detection and treatment (Lönnroth et al, 2001). Nonetheless, studies of health seeking behaviour in relation to TB repeatedly demonstrate that patients do not always choose a public health care facility; they delay diagnosis and often do not complete the lengthy course of treatment necessary.

Steen and Mazonde (1999) found 95% of patients in Botswana visited a ‘modern’ health facility as a first step. However, after initiating modern treatment, 47% then went on to visit a traditional or faith healer as well. They emphasize the importance of social and cultural factors in contributing to the outcome of TB control. For these patients TB is seen as a ‘European disease’ that will respond well to Western medicine. Nonetheless a traditional healer is also consulted to explain the ‘meaning’ of the disease for that particular person: “there is an increasing tendency to use modern medicine as a ‘quick fix’ solution, whereas traditional medicine is utilized for providing answers that may be asked about the meaning of the misfortune, and to deal with the ‘real’ causes of the illness” (Steen and Mazonde, 1999. 170).

Steen and Mazonde berate the fact that health seeking behaviour is ‘not even mentioned’ in widely used textbooks, despite the fact that proper understanding of health seeking behaviour can potentially reduce delay to diagnosis, improve treatment compliance and improve health education strategies. They suggest lessons can be learnt from work around HIV and AIDS, regarding in particular greater co-operation between traditional and modern medicine. Similarly in Pronyk et al’s (2001) study, they found TB patients in South Africa attended government facilities more readily than for some other conditions. 72% presented initially to a hospital or clinic, with only 15% presenting to a spiritual or traditional healer, and 13% to a private doctor. Nonetheless the authors recognized a significant failure of official clinical services to diagnose symptomatic individuals. This added to the already substantial problem of late presentation, particularly amongst women.

The picture in the Philippines appears to be different. Here Auer et al (2000) suggest ‘multiple health seeking’ may account for delayed case finding. Only 29% of patients in their study presented first to a health centre, with 53% consulting a private doctor initially. They found 69% of patients had been told by a member of the household to seek medical advice for their symptoms, and that those who felt ostracized because of their TB delayed seeking medical help longer. The authors claim: “effective health seeking and case finding are influenced by the health system, community, family, and other personal issues” (Auer et al, 2000: 648). Indeed the health system appeared to play a large role in the health seeking behaviour of these patients. They chose private doctors over public facilities, as they believed their service to be more polite, more effective, more sympathetic and respectful of privacy.

Auer et al stress that in the case of TB, with its lengthy treatment period, the fostering of a good doctor-patient relationship is crucial. Information is also needed regarding the availability of free drugs. Many patients in their survey continued to purchase privately prescribed drugs and were unaware these were available free of charge at public facilities. This has a potential impact on treatment compliance. They also found fear did not necessarily motivate health seeking and in fact may delay seeking treatment, and recommend it should therefore not be overstated in health education messages.

Maternal health and health seeking behaviour of mothers have a huge impact not only on the lives of women, but also on the lives of their children. Perhaps unsurprisingly therefore there is a substantial body of health seeking behaviour work directed specifically at women. This typically highlights the difficulty women face in many developing countries where they rely on the male head of household to secure access to medical treatment, financially and practically. They may also require support from the wider social network for childcare or household duties that must be undertaken 13 while they travel sometimes great distances for a medical consultation, often with long waiting times at the other end (Bedri, 2001; Manhart et al, 2000; Rahman, 2000).

Thus we have a body of knowledge about the cultural, social and structural difficulties faced by women in a variety of contexts in relation to their health seeking behaviours. Evans and Lambert suggest that too much emphasis has been placed on a biomedical definition of ‘health’ in many studies. Whilst this renders health to be little more than the absence of disease, they argue women have much more subtle interpretations of health which impact upon their health seeking behaviour. Thus their emphasis is to “situate women’s health practices and understandings analytically within the specific political-economic and social context of their every day lives” (Evans and Lambert, 1997. 1993).

Although accessibility is commonly suggested as a factor in health facility use, Bhatia and Cleland (2001) support the findings of many others, that women are quite happy to travel further to attend a private, more expensive service that is perceived to be of ‘good quality’. Complex justifications are also seen for inappropriate use of treatment, over-dosage, under-dosage, stopping a course halfway through or selecting particular drugs from a lengthy prescription (Evans and Lambert, 1997; Manhart et al, 2000; Thera et al, 2000).

The type of health care provider that is sought, or the health seeking behaviour adopted, also differs according to the type of disease. Goldman and Heuveline (2000) found mothers more likely to seek help for diarrhoeal disease than acute respiratory infections, despite the fact that both are leading causes of child mortality in developing countries. In another study, mothers in Uganda were found to be poor at recognising malaria in their children. They interpreted signs of malaria, notably fever, differently according to the general health of that particular child, and adopted varying health seeking behaviours accordingly. If the child was a finger-sucker, fever may have been put down to worms, or if the child had developed a fever following on from, or in conjunction with another illness, the mother was less likely to interpret it as malaria (Lubanga et al, 1997).

Although the focus is often on social and cultural restrictions on women, there are also other enabling and constraining factors. Wallman and Baker (1996) provide a detailed list of ‘elements of livelihood’ that are likely to affect women’s capacity to obtain treatment: actual money income, potential money income, social status, social life, networks, autonomy and liability. These they argue will come into play after a woman has assessed how well, kind, shameful, private, feasible and appropriate options are, within the physical infrastructure of that area. The total resource base will vary in absolute size between women, in relative proportions, geographic scope and according to a particular illness episode. They use the model to study through a range of illness episodes over time, and begin to “transform the respondent from a flat unit of enquiry into a person ‘in the round’, embedded, as real people are, in social relationships and economic obligations which constrain all the decisions they make” (Wallman and Baker, 1996: 678). This allows a picture of the resources to build up as the actor experiences them, and claim the authors, is a crucial step towards understanding why and how people do what they do.

Bedri (2001) in her study of women’s health seeking behaviour around abnormal vaginal discharge highlighted the role of the husband and the availability of knowledgeable social contacts as key factors in securing an early diagnosis and use of health care services. She suggests women could be empowered by policy and health system developments that encourage the creation of ‘expert social networks’ and ‘expert husbands’ in order to ensure the necessary social infrastructure is in place to support women through their health care seeking process.

Ahmed et al (2000) also suggest that efforts are needed to raise community awareness of the immediate and future benefits of improving women’s health, and this also appeals more directly to existing social structures and an opportunity to strengthen them for beneficial health outcomes, rather than a further attempt to change behaviour of individuals.

Evans and Lambert (1997) adopt the word ‘strategy’ rather than ‘behaviour’, to reflect the complexity of the decision making processes that women face on a daily basis, weighing up social, economic, practical, cultural and personal factors, and not simply in response to one-off isolated illness events. This they argue suggests a purposeful action rather than an unreflecting, predetermined behaviour. This idea is salient across the study of health seeking behaviour and mirrors my own interest in theorizing ‘reflexive communities’ to understand health seeking behaviour in a more meaningful way. Thus, there is a lot of work on women and health seeking behaviour that simply portrays women as an unfortunate group caught up in the patriarchal cultures of their society. However, there are also a number of original and interesting studies that start to explore women as intentional individuals mediating the structures around them in order to fit their particular aims at that time and to offer policy solutions to create a more enabling environment for these women to act within.

Some of the most interesting work around health seeking behaviour is carried out in relation to this probe. Because of the very ‘social’ nature of the spread of HIV, and the reflection of cultural beliefs around sexuality, virility and reproduction it is perhaps seen as an area where solutions will only be found through research that reflects this cultural and social element. Health education aimed at using condoms for safer sex, for example, will have minimal impact when directed at individual girls or women who have little or no control over their sexual encounters (MacPhail and Campbell, 2001). Campbell and Williams (1999) have therefore criticized management and policy approaches to HIV and AIDS that have been dominated by biomedical and behavioural approaches, rather than seeing it as a wider social and developmental issue.

Research around sexual behaviour and health seeking behaviour is now beginning to move away from the realm of the private individual, interviewed retrospectively about illness episodes in their house, and into the reality of interaction in the social world. Campbell and Williams (1999) present a pathways model to HIV infection in the context of the Southern African mining industry. This flows through four stages to potential infection: Social factors (economic factors, gender dynamics, working conditions), psychosocial mediators (self-efficacy, competing knowledge’s and beliefs, masculine identities), Behavioural pathways (poor condom use with multiple partners) and/or Physical pathways (other sexually transmitted diseases). Such studies demonstrate clearly that decisions made around sexual behaviour are far more complex than traditional health promotion approaches would acknowledge. “This is because – far from being a matter over which individuals exercise rational control as the KAP [knowledge-attitudes-practices] framework suggests – sexuality is shaped by a complex process of identity formation nested within the dynamic web of cultural, psychological and social factors” (Campbell, 1997. 280).

Campbell suggests changing behaviours will only be witnessed if individuals are allowed to refashion their identities as part of a collective process. At a group level people can then change their ‘recipes for living’ in an active rather than an individualized passive manner. I would suggest the same argument could be applied to any study of health seeking behaviour, not just one focused on behaviour in relation to STDs. Bedri’s (2001) policy suggestions around expert social networks similarly place the potential for changing women’s health seeking behaviour in the evolution of social structures rather than the individual.

Rapley and Fruin (1999) emphasize that conditions such as diabetes often require changes in lifestyle and approach to health behaviours, and the ease with which such changes occur depends on the person’s self-efficacy and expectations about outcomes. Clearly this is linked to health seeking behaviour. A paper on native and immigrant diabetes sufferers in Sweden reiterates the importance of self-efficacy in health related behaviours and compliance, as well as the cultural relativity of beliefs about health and illness (Hjelm et al, 1999). However, Miglani, Sood and Shah (2000) suggest that physicians usually neglect the social or psychological issues associated with diabetes during consultations with diabetic patients. Stenström and Andersson (2000) also raise the interesting point that patients with weaker beliefs in health care professionals may be more likely to engage in risky behaviours in relation to their diabetic status. Thus this doctor-patient dynamic is yet again raised as an important issue.

In Guatemala, Weller and colleagues (1997) have shown that up to 90% of the initial treatment actions take place at home and they may involve use of home remedies or remedies obtained from a pharmacy. Of the remaining 10%, 8% of the initial actions involved seeing a physician or a nurse while about 2% of the people visited a folk healer. The importance of home treatment with a particular emphasis on malaria has been shown in a variety of studies (e.g. Foster, 1995; Hamel et al., 2001; Nyamongo 2002). In developing countries, constrained access to health care facilities reinforces the need to focus on local solutions in the management of illnesses. Particularly in the field of malaria, interventions have been designed to improve access to drugs and treatment compliance.

Abdool Karim et al., (1994:16) asserts that the role played by traditional healers cannot be over-emphasized. In rural Africa, medical doctors are outnumbered by traditional healers. Furthermore, the traditional healers are located in places where the community has easy access. This makes them popular and readily relied on by communities. Similarly, traditional birth attendants (TBAs) are popular with women for whom access to health care facilities is beyond their financial ability.

2.6 Health seeking behaviour: Asian perspective

The World Bank, (2001:10), asserts that Most women lack access to basic maternity care. Only 27 percent of women seek antenatal care once during pregnancy. Of those that seek prenatal care, the average number of ANC visits per pregnancy is 1.8, far short of the minimum of four visits per pregnancy that are required. According to a 1997 survey, a little over a third of surveyed women (34 percent) said that they did not receive ANC because they thought they did not need it. Thirty-one percent said that they did not traditionally receive antenatal care. Twenty four percent of women said they did not know that such services were available. Eleven percent said the health facilities were located too far away and five percent did not have enough money to pay for the services. Two percent of the women did not have time to visit a health facility; two percent said their family members did not allow them to seek care and two percent said they did not seek care because the service was poor. As for childbirth, most deliveries occurred at home in unsafe conditions. Only 8 percent of births take place at health facilities and only 13.4 percent of births are attended by trained health personnel. After childbirth, 9 percent of women seek postnatal care.

G U, xingyan,(1999:39),argues that the major problems in health service provisions in china’s poor rural areas is that peasant , especially poor peasants, can not be certain they will receive basic medical services. He shows that the main reason peasants in poor countries lack access to basic medical care is not a shortage of rural health recourses, but the high costs of health care. A national survey showed that 20 percents who should have sought medical treatment did not do so because they could not afford it. Another 44 percents would gather medicinal herbs or treat themselves with indigenous methods because they could not afford to seek treatment at health facilities.

Saha, A. et.al(2006) asserts that in kolkata reason for choosing one health care provider over another was mostly due to faith in quality of health care (58.8%) followed by accessibility (19.1%). Cost of care, provision of privacy and sympathetic behaviour were also predictor of choice but to a much lesser degree (8.4%, 7.6% and 6.1% respectively). Family structure, socio-economic status and literacy status did not significantly affect the health seeking behaviour in this study same.

The analysis carried out by Govindasamy and Ramesh (1997) for south India as a whole showed that there was no significant difference between rural and urban woman in receiving antenatal check up even without controlling for other important confounding variables(e.g. childhood place of residence).

The World Bank, (2001:15), asserts that in all districts women were recognized to be ill by family members only when they were bed ridden or unable to perform their daily tasks. The women felt that most illnesses would get cured by themselves. Those who sought care for general illnesses first tried home medicine. If this was not successful, they visited traditional healers. If they were still sick, those who were able to access care would then visit the nearest health facility, usually the health post, followed by the hospital, sub-health post, private medical shops and clinics and NGO facilities. When girls under 18 were sick, they informed their mothers about their illness but hesitated to visit health facilities if they needed gynecological or family planning services. They only visited the hospital if they were seriously ill.

The Safe Motherhood Initiative proclaims that all pregnant women must receive basic, professional antenatal care. The package of ANC apart from physical treatment of checking, vaccinations and prescribing medicines also includes dietary advice and counseling on safe motherhood. Women receiving proper ANC are assured of undergoing safe pregnancies without posing much risk to the life of both mother and child. A woman may receive ANC either from a health worker visiting at home or from clinic. The Reproductive and Child Health Programme recommends that as part of antenatal care, women receive two doses of tetanus toxoid vaccine, adequate amounts of iron and folic acid tablets or syrup to prevent and treat anemia, and at least three antenatal check-ups that include blood pressure checks and other procedures to detect pregnancy complications. The health-seeking behaviour varies according to source of ANC and is hence examined separately. In Uttar Pradesh according to NFHS-2 only 34.6 per cent of women receive any type of ANC and this figure is the lowest in the country. (Ministry of Health and Family Welfare, 1997).

Patients are electric in their choice of health care practitioners and services. Over 75 percents of those interviewed by kakar (1988) reported that they routinely sought treatment from various kinds of traditional and local practitioners for at least some kind’s ailments. Dugal and Amin (1999) report similar findings for rural Maharashtra. In general, the more serious and incapacitating an illness is considered, the more likely is that allopathic treatment will be sought. The data also indicate a correlation between patient’s socio-economic status and their use of allopathic medicine, a fact that probably reflects the effects of education. A larger portion of those from wealthier, high-caste families recognizes the symptoms of common diseases and are likely to seek allopathic attention for them. Education is probably also responsible for the finding that relatively young are likely are more than their elders to utilize modern health care (kakar 1998).

2.7 Health seeking behaviour: Bangladesh perspective

Begum, Sharifa (1997:15) asserts that both for acute and major illnesses, rural women currently seem to make lesser use of the public sector facilities than the rural men do. The situation was interestingly distinctly reverse ten years ago. In 1984, rural women used to receive about a quarter (24 per cent) of their treatment from the government health facilities against 15 per cent noted for the rural men (Begum, 1988). Currently, these figures are respectively 13 and 11 per cents. Thus, as it seems, in the process of losing popularity the government facilities have lost it faster with the rural women than with the rural men. This no doubt is a matter of grave concern in view of the fact that the rural maternal health face a dangerously gloomy situation and through appropriate policy measures only the government sector can heal it.

Mahbub & Ahmed, (1997:16.) argues that for their illnesses, including gynecological ones, women tend to ask other women for advice. Usually these women are from their natal home. They rarely asked women from their in-laws side of the family for health related advice, and mothers-in-law were not reported at all for health consultation in this study. For menstrual problems such as menorrhagia (khum jhore) women find it appropriate to ask a kabiraj (traditional healer) for treatment because they feel that, as this illness is caused by humka batas, only a kabiraj can cure them of this spirit. The kabiraj usually gives them an amulet that contains a kind of herbal medicine and the patient is told to eat sweet pumpkin, some selected fish like puti, gojar and taki, kheshari dal, tamarind, etc.

According to a recent estimate for all over Bangladesh, 91 per cent delivery take place at home In the metropolitan and town areas 32 per cent delivery take place in the hospitals or in places with clinical facilities. In the rural areas on the other hand only 7 percent deliveries take place in a clinical facility which may include Upazilla health complex, union health center or the Upazilla family welfare center. Hence the above information strongly indicates how widespread the home delivery practices are in rural Bangladesh. (NIPORT 2003: 51).

Ahmed, Syed Masud, (2006:5), argues that the overall health service consumption (from any source) in Bangladesh is low compared to other developing countries. Also, the number of qualified physicians and nurses in Bangladesh is quite low, compared to other low-income countries. For example, in 1998 Bangladesh had 19 physicians and 11 nurses per 100,000 population compared to 73 and 132 respectively for low-income countries, and 286 and 750 respectively for high income countries. Around 26% of professional posts in rural areas remain vacant and there is high rate of absenteeism (about 40%), particularly among medical doctors in rural areas. Both shortage of trained manpower coupled with “brain drain,” and lack of required investment in health sector are responsible for this.

In their monograph titled Determinants of antenatal care-seeking behaviour in rural Bangladesh, Rahman, MM, says that 41% did not receive prenatal care prior to their most recent delivery. Most who received prenatal advice went to an unqualified person. Only about 14% consulted qualified persons, but over 50% reported consulting someone for prenatal care. 36% consulted unqualified female family planning outreach workers during home-based visits. Only 5% received prenatal care 6 or more times, even though the recommended number of visits are 10. Only 1% of deliveries were at health centers or hospitals, and the rest were at home. Most deliveries were performed by untrained traditional birth attendants. Over 33% reported delivery complications during their most recent pregnancy. 71% reported prolonged labor, 18% reported hemorrhage, 15% reported a retained placenta, 7% reported eclampsia, and 6% reported laceration or tears. 55% went to untrained homeopathic practitioners. 5% consulted trained government health providers. 11% went to qualified private physicians. 33% did not consult anyone. Logistic model findings indicate that poorer women were less likely to seek prenatal care or to consult qualified persons. Younger and more educated women were more likely to seek prenatal care. Younger low-parity women were more likely to use a qualified person for delivery. Findings suggest a strong need to increase use of health care facilities. (Rahman MM, et.al, 1997:85)

Alam, Tauhid.et.al (2008) indicated that Thailand and India have done reasonably well in health sector by decreasing patient and health center ratio by establishing more and more health centers. In India and Thailand, aiurvedic and other indigenous treatment facilities have been given more importance which is always ignored in Bangladesh. Health sector is always ignored by the government of Bangladesh. It is not possible to achieve millennium development goal in health care if present situation continues. Good governance needs immediately to be established in order to make the health sector transparent and accountable. It is the responsibility of the State to make sure that every citizen particularly the poor and the marginalized has access to affordable, equitable and sustainable health care system.

Mashreky Dr. S. R. et.al (2008) says that poor people especially peripheral population do not get proper health service due to unavailability of adequate health service provider. Doctors are very reluctant to stay at the work station if transferred to rural areas. Rural population has limited access to reproductive health facility though they are very concerned about their reproductive health. Sexual and reproductive health service delivery models need to understand the critical importance of incorporating lay understandings of sexual health. On the other hand, this was found from the discussion that maternal and infant mortality has been decreased considerably though primary health care is still not in a right direction to improve maternal health. The main reason of infant mortality is malnutrition. There is lack of knowledge about nutrition even among the population of Bangladesh staying in the higher wealth quintal end. Emphasis should be given on health education program regarding nutrition to create awareness about nutrition related health problem.

ICDDR, B (2004) strongly argues that a major change in rural health service delivery was introduced in Bangladesh under the government’s five-year sector programme (1998 2003). Family planning services previously provided through household visits by fieldworkers and satellite clinics were transferred to new static community clinics. Data on use of services from an ICDDR, B surveillance area in Abhoynagar show that in a period of considerable change in service delivery, women switched to new sources of contraceptive supply and the overall contraceptive prevalence rate was maintained at about 60%. Within two years (2001-2002) community clinics became the source of contraceptives for about one-third of users, and a steady increase in use of shops and pharmacies continued. The data suggest that where community clinics are made operational, women will use them and despite cultural constraints on mobility they have not become dependent on home-delivery of contraceptives.

Recent preliminary findings from the 2004 Bangladesh Demographic and Health Survey (BDHS) show that fertility has declined in Bangladesh after a decade long plateau. Overall, fertility has declined dramatically since the early 1970s from 6.3 children per woman to 3.4 in the early 1990s, remaining stable during most of the 1990s. The recent decline in fertility from 3.3 in 1999 to 3.0 in 2004 is modest but encouraging for policy makers and program managers. Contraceptive use continues to increase in Bangladesh with 58 percent of married couples now using a contraceptive method compared to 54 percent four years ago. There has been a significant increase in use of antenatal care among pregnant women, from 33% in 2000 to 49% in 2004. Now, almost half of pregnant women receive at least one antenatal care visit from a trained health provider. Despite the rise in antenatal care, only one in four women receive three or more antenatal visits during her pregnancy, and a vast majority of women give birth without a trained birth attendant.

In an important article “interventions to promote local level planning services” in written by Mohammad Jasim Uddin says that The health and family planning programmes of Bangladesh have made remarkable progress over the past two decades. Despite the recent overall success, however, there are still significant variations in the coverage and availability of health and family planning services. In some areas, like the district of Chittagong and sylhet divisions, the key indicators of health and family planning services, such as immunization coverage, contraceptive prevalence rate and antenatal care (ANC) contact are considerably lower than the rest of the country. Sixty percent of the married women in Khulna division and 59 percent of those in Rajshahi division are using a family planning method, compared to only 20 percent of the women in sylhet and 37 percent in Chittagong divisions. The health and family planning infrastructure in rural Bangladesh includes doorstep services, regular satellite clinics at the village level, and a health and family welfare center in every union. In practice, however, most services are not linked, especially at the periphery, and therefore, are of limited effectiveness. (Uddin, Mohammad Jasim, et al, 1999:1)

Ala Uddin, Muhammad and Mitu, Mst. Khadija (2008:49) assert that there exit reciprocal relationship between cultural pattern of life ways and health seeking behaviour. Traditional health care which is a part of indigenous culture of the rural Bangladesh. Indigenous medicines are so fit and commonly known to rural people that they often take it without seeking advice of trained healers. There are different types of treatment system in villages. Different indigenous treatment systems as for example, unani, and ayurbedic use these plants as major component in their medicine. According to some respondents because of high cost and having side effect of the allopathic treatment is not seemed suitable, and the provider-receiver interaction is considered to be devoid of humane touch which pushed them to folk medicines.



3.1 Becker and Rosenstock: Health Behaviour and Health Belief Model:

One of the most important models for explaining health seeking behaviour from socio-psychological perspective has been in use for long by researcher is ‘Health belief