Help Seeking Behaviour

Dr Sunanda Ray
Sept 2010
What is health?
 Causes of ill-health or disease
• Disharmony, violation of taboos, ancestors
warnings, malevolent sorcery [witchcraft] –
African, Papua New Guinea
• Lack of balance of basic body elements: heat,
cold, strong emotions – Aryuvedic, Chinese,
ancient Greek – need for equilibrium
• Biomedical - led to more individualistic
approach, cause and responsibility with
individual rather than family or community
 Holistic approaches
• Homeopathic, faith healing etc more
appealing since approaches ‘’whole person’’
but no evidence yet of clinical effectiveness
other than placebo
• Acupuncture – some evidence of effectiveness
in chronic pain
 Functional approach
• Priority given to being able to work, to
function, to be a useful member of society
[attributed to a capitalist ideology of value]
• Need for a healthy workforce – generated
many social reforms in Europe end 19th/early
20th century – parallel with approach to
treatment for AIDS
 Two agendas
• biomedical (‘disease’) and psychosocial (‘illness’)
• Doctors failed to elicit 54% of patients’ reasons
for consulting and 45% of their worries
• Unvoiced agenda items from patients – worries
about possible diagnosis, what the future holds,
side effects, information relating to the social
context
• May lead to misunderstandings about “what the
patient wants” and poor outcomes – non-
adherence or unwanted prescriptions
• In one UK study average consultation times
were 8 mins; giving pts with psychosocial
problems 1 minute longer was sufficient to
improve quality of care.
• As well as increasing the time spent, more
realistic to improve the way the time is spent
– hence learning consultation skills
• A lot of ill health never comes to the attention
of health professionals, dealt with through
self-care, pharmacies, home remedies
• Often let the illness run its course [lay
understanding of natural history]
• But also “illness behaviour” “sick role” – the
way symptoms are acted on by a person who
associates them with organic malfunction
 Symptom iceberg – Hannay 1979
• Well-being and asymptomatic illness at the broad base of
iceberg, above it the non-consulters who have symptoms but
do not seek medical help, then the ones who do present are
the tip of the iceberg
• Community surveys in UK & US have shown that only about
30% of those with symptoms present for medical advice;
symptom diaries show that 1 in 40 symptoms ever get taken
for medical advice
• some doctors complain about wasting time on unnecessary
cases; some patients get labelled “problem patients” but
these often have interpersonal or social problems that some
doctors find difficult
• Gap between need and utilisation - argued that health
services should seek out unmet need while discouraging
apparently trivial illness [about 10% of consultations], to bring
appropriate use of resources into balance
 Strategies
• Informal advisers and care-givers
• Self-care – based on folklore, media, websites,
pharmacy, etc
• Alternative therapists & traditional healers
• Primary care clinics, emergency departments
• Apex of pyramid – secondary and tertiary care
– highly selected minority of patient
population
• Those who seek treatment are not
representative of the whole who need
treatment; research only on seekers will give
biased results
• To reduce the gap – public education plus
improved consultation skills
Non-physiological “triggers” to decision to seek
medical advice Zola 1973
• Interpersonal crisis: symptoms threaten a
relationship
• Interference with social or personal
relationships, valued activities
• Sanctioning: a significant person [eg employer
or spouse] urges treatment
• Interference with physical activities
• Temporalising: setting of time criteria – “if it
isn’t better in 3 days......then I’ll go...”]
 Intervention rather than prevention
• Belief that one intervenes after disease has
become established, rather than anticipating
and preventing occurrence
• has led to emphasis on allocation of resources
to hospitals, laboratories, diagnostics rather
than behavioural ie prevention
• Monitoring of this relies on good information
systems – less resource investment
• what facilitates the use of health services, and
what influences people to behave differently
in relation to their health
• the ‘end point’ (utilisation of the formal
system, or health care seeking behaviour); or
• Emphasis on the ‘process’ (illness response, or
health seeking behaviour).
• the decision to engage with a particular health
service 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)
 Category Determinant Details

Cultural Status of women Elements of patriarchy

Social Age and sex
Socioeconomic Household Education level, Maternal
resources occupation, Marital status,
Economic status

Economic Costs of care Treatment, Travel, Time

Type and severity

of illness
Geographical Distance and
physical access
Organisational Perceived quality Standard of drugs
Standard of equipment
 Process – illness response
• women follow quite different pathways for
different conditions, relating predominantly to
the role of the husband, social networks and
cultural customs. Bedri in Sudan 2001

• different facilities [and healers] will be

frequented for different needs, according to a
complex interplay of factors, sometimes
regardless of the intended purpose of those
facilities. Rahman (2000)
 Focus on individual behaviour
• factors which enable or prevent people from
making ‘healthy choices’, in either their lifestyle
behaviours or their use of medical care and
treatment
• Links with behaviour change models [eg health
belief model] on what motivates people to seek
health interventions
• those who believe they have control over their
health are more likely to engage in health
promoting behaviours [“locus of control”]
• When an individual makes a decision in relation
to their health, they weigh up the potential risks
or benefits of a particular behaviour.
• But they do so in a way that is mediated by their
immediate practical environment, their social
rootedness and their whole outlook on life more
generally, eg risk perception, self identity.
• Example – perception that cancer of cx is serious,
but do not seek help because belief that there is
no treatment, or an act of God etc
• 40% of those attending a health centre have a
mental health problem as their primary
problem
• Headaches and chronic fatigue common
presentations of depression
• Somatic symptoms especially those related to
heart and head, cultural metaphors for fear or
grief – simple questions can elicit
psychological basis
 212 Batswana with smear-positive
pulmonary TB during 1993/94 -Kweneng
District

• traditional ideas of disease being caused by

pollution (breaking of taboos) vs modern
theories of spread via germs
• Patients who regard TB as a 'Tswana disease'
may use modern medicine for symptom relief
but traditional medicine to treat what they
consider the cause of the disease
 
• 95% of patients visited a modern health
facility as their first step of action
• Before start of specific treatment one or more
alternative treatments was tried by 52% of
patients during the delay period [median 12
weeks].
• After starting modern treatment, 47% of
patients visited, or planned to visit, a
traditional healer or a faith healer.
• Traditional explanations of disease seemed
less prevalent in 1993/94 than in a study
conducted among TB patients in Botswana ten
years earlier, but few patients had a thorough
understanding of TB from a biomedical point
of view.
 Knowledge and attitude of health workers towards
leprosy in north-western Botswana -1994

• Interviews with 99 health workers from various health

institutions.
• Knowledge on causation of leprosy was generally lacking
• Although majority knew that leprosy is curable, less than
half knew the correct duration of treatment
• Attitude of service providers was influenced by poor
knowledge - more than 1/3 claimed that patients should be
isolated
• The pattern of health seeking behaviour, initially
traditional or religious healers and then modern
health facilities, was a significant finding.
• For early case detection and prevent deformities,
it is vital that education of community, patients
and health workers is provided to an extent that
health seeking behaviour is altered.
• Traditional and religious leaders to be included in
training sessions.
 People living with HIV or AIDS
• Study of 83 HIV+ adults registered at Scottish
Livingstone Hospital [Kweneng district]
• 22% had been feeling ill for >1 yr before
getting an HIV test with 65% reporting feeling
sick when they went for testing
• Already most had a CD4 count <150
• Difficulties in accessing services were
transport and waiting times
Cues for action – Health Belief Model
• the majority of people who tested for health reasons -
even those who were seriously ill - only did so when
prompted by a medical professional.  Kabo (26, male,
HIV negative) tested after consulting a neurologist at
the government hospital:
• “I was encouraged to test by my doctor...He didn’t
force me, he just encouraged me to go and do it.  I did
because I was concerned…and because the doctor was
not sure if it was the virus that was causing my
condition or something else.”
• Connie, a 36-year-old unemployed mother of three, was fairly
certain that she was HIV positive when she fell ill because her
symptoms closely matched the HIV symptoms that she had
heard about on the radio.  However, it was not until her
health deteriorated seriously that she consulted healthcare
workers, who advised her to take a test. On testing HIV
positive, Connie was glad for the immediate referral for
further tests, and enrolment in the ARV programme:     
• “I am glad because when I was sick I couldn’t eat and was
always sad even if people tried to cheer me up.  But after
testing the sadness went away and my life went back to
normal.”
 Information about testing
• a 36 year old HIV positive man explained that
he had little difficulty with testing because he
was already familiar with where and how to
get an HIV test as his aunt and mother were
nurses who spoke openly about health issues
including sexual health and HIV testing.
• Victor (36, male, HIV negative), a volunteer in
a home-based care programme was so
distressed by the experiences of the resident
patients that he resolved to take an HIV test
so that he could access treatment in a timely
fashion if he were positive. Several other
respondents noted that seeing their
neighbours, friends and relatives be ill with
and/or die from HIV/AIDS was a motivation to
test, given the accessibility of treatment.