Health Science Journal

Keywords

Elderly people; Health care seeking behaviour; Wolaita zone; Southern Ethiopia

Introduction

According to the UN definition, elderly people are those people whose age is 60 years and above [1]. This also corresponds with Ethiopia's official retirement age [2]. According to the estimate of the UN in 1980, there were 378 million people in the world aged 60 years or above. That figure has risen to 759 million over the past three decades and is projected to jump to 2 billion by 2050 which will constitute 16 per cent of the global population [3,4]. Among 15 countries that currently have more than 10 million elderly people; seven are developing countries [5,6]. The elderly people over age of sixty make up around five per cent (3.6 million in the 2007 census) of total population in Ethiopian [7]. The rise in the number increases the burden of providing social services, including health care services [4]. However, policies that support people in later life such as pensions, free healthcare and treatment of chronic conditions have been slow to evolve in developing countries compared with the fast rise in the numbers of elderly people [8]. The situation in Ethiopia is not any different [2]. Most have no reliable income sources, no adequate public sector pension for employed [2] and absence/ lack of social security system among unemployed rural elderly people [9-11]. This affects not only their income and wealth but also contributes to poor housing, ill health and personal insecurity [12,13]. It might also hamper appropriate health care seeking behaviour of elderly people such that they could be obliged to visit traditional medicine or healers than seeking modern health care [14]. Despite the above challenges, with regard to the health care service provision and caring for the elderly people, the need to give attention to this group of people is overlooked [15] and as per the authors’ knowledge health care seeking behaviour of elderly people was not well known in the study area. Therefore, the objective of this study was to assess health care seeking behaviour and its determinant factors among elderly people in rural part of Wolaita zone, Southern Ethiopia.

Methods and Materials

Study design and setting

We conducted community based cross-sectional study in January 2015, in Wolaita zone, Southern Ethiopia. Wolaita zone is administratively divided in to twelve districts and three town administrations. The zone has five hospitals, 69 health centers, 372 health posts and 98 private clinics. Based on the projection of the 2007 Population and Housing Census, the population of Wolaita zone is about 1,888,390 in 2014, out of which 50.73% is female and 49.27% is male [7].

Sample size and sampling technique

Sample size was calculated using Open-EPI software by using the following parameters: proportion of appropriate health care seeking behaviour by elderly people 50%, 95% confidence interval, 5% margin of error, a design effect of 2, and a nonresponse rate of 10%. By taking the total elderly population (aged ≥ 60 years) of 11,7951 the final calculated sample size was 820; however, 795 were actually participated in the study. Multistage sampling technique was employed. Two rural districts (Ofa and Damot Pulasa) and then six kebele2 (three from each district) were selected randomly. Census was conducted to identify the number of elderly people in selected kebele and the sample size was allocated proportionally to size of study population. Households with at least one member of age 60 and above were framed and systematic random sampling technique was used to select study subjects until the final sample size was obtained. Elderly people of both sexes of age 60 and above who have been encountered to any health problem within one month before the survey were included; however, those people with communication problems, such as those with severe hearing impairment, a previous diagnosis of dementia and those who did not encounter any health problem within one month prior to survey were excluded from the study. If selected household did not meet inclusion criteria the next nearby household was considered. In households if there were more than one individual who met the inclusion criteria, lottery method was used to select study participants for interview.

Data collection

After identifying the study subject data was collected from elderly (if they can respond) or from care giver during serious illness. In our case, due to severe illness and/or hearing problem, 49 (6.9%) of data was collected form care givers. Six data collectors and three supervisors were involved during data collection process. Pre-tested, interviewer administered structured questionnaire were used to collect data. The questionnaire addressed socio demographic characteristics, knowledge on available health facility and feeding during illness, health care seeking behaviour of elderly people during illnesses, distance to health facility and family support during illness.

Data management

Data was checked for completeness, edited, coded and entered into Epi Info statistical software version 3.5.1 and exported to SPSS 20 statistical software for analysis. Descriptive statistics, such as frequency distribution, mean, and percentage were used for some variables. Bivariate analysis was done and all explanatory variables which have association with the outcome variable (appropriate health care seeking behaviour) with p value less than 0.2 were included in multivariate analysis. Then multivariate analysis using backward stepwise selection method was employed to assess the relative importance of the explanatory variables on the dependent variable. The odds ratio (OR) with a 95% confidence interval (CI) were used to test the statistical significance association of variables.

Ethical consideration

Ethical approval and clearance was obtained from institutional review committee of Wolaita Sodo University. Letter of cooperation was obtained from concerned administrative body at various levels to respective district and kebele. Verbal informed consent was obtained from the respondents; however, during disabilities and other chronic morbidities it was obtained from family/caregivers. The elderly people in such critical cases were referred to and linked with the nearby health institutions so that they can be supported to get treatment.

Operational definitions

Adequate food supply - Availability of food at household for elderly people to be consumed at least three times within 24 hours.

Appropriate health care seeking behaviour: The intention to seek treatment at health facilities (hospital, health centers and health posts) in the event of sickness.

Health care seeking behaviour: Any action undertaken by individuals who perceive themselves to have health problems or to be ill for the purpose of finding an appropriate remedy.

Inappropriate health care seeking behaviour: Those who decide to visit Holy water, traditional healers, and other sources in the event of sickness.

Results

Out of the total 820 elderly people approached for the interview, 795 were included in our study, making the response rate of 97.03%. Among those interviewed data collected form care givers were 49 (6.9%) due to severe illness and hearing problem.

Socio-demographic characteristics of respondents

Among total respondents 333 (41.9%) belongs to the age group of 60-65, 433 (54.5%) were women, 416 (52.3%) were married, 652 (82%) were protestant by religion, 754 (94.8%) belongs to Wolaita ethnicity group, 669 (84.2%) were unable to read and write. The income category of the respondents puts 301 (37.9%) at lower category and 407 (51.2%) of study participants reported that they did not have adequate food at their home to feed themselves three times a day. Regarding occupation, 693 (87.2%) of elderly were farmers and 363 (45.7%) have a family size greater than 5.8 (Table 1).

Knowledge on available health facility and feeding during illness

Regarding the participant’s knowledge about the available health facility in their vicinity; majority of study participants, 707 (88.9%) knew the availability of health center followed by health post 582 (73.3%). The mean single trip traveling time on foot to reach health post was 26.6 minutes and that of health center was 46.3 minutes; however, those who were travelling above half an hour for single trip to reach one of primary health care unit (district hospital, health center and health post) were 209 (26.3%). Four hundred seventy four (59.6%) of elderly people have support from family members during illness and 526 (66.2%) of study participants have knowledge to consume supplementary food during illness; however, only 283 (53.8%) of them actually consumed it (Table 2).

Health care seeking behaviour of elderly during illnesses

About 636 (80%) of study participants reported that they knew when to visit the health facility for health care and 460 (72.3%) of them actually visited health facility during the last episode of illness while the rest did not visit health facilities for different reasons. Among the health facility visited during illness, majority of clients got treatment from health center, 205 (44.6%); however only 32 (6.9%) of ill participants got health service from hospital. Among those who visited health facility during illness, only 161 (35%) took health care within 24 hours of illness. The common reasons that hindered the potential visit to health facilities was shortage of money, 114 (64.8%) followed by lack of family support 46 (26.1%) (Table 3).

Factors affecting appropriate health care seeking behaviour

When computing different independent variables in binary logistic regression age, educational status, marital status, availability of food in house hold, knowledge when to visit health facility, family support during illness, and distance to health facility was statistically associated with health care seeking behaviours of elderly people. However, after controlling for possible confounders on multivariate analysis, those elderly people in age group between 60-65, who attended formal education, who knew when to visit the health facility for health care, who had family support during illness and who lived nearer to the primary health care unit had statistically significant association with health care seeking behaviour (Table 4).

Discussion

This study measured proportion of appropriate health care seeking behaviour and identified multiple factors that affecting elderly peoples’ health care seeking behaviour in rural parts of Wolaita zone. In the study area about 636 (80%) had knowledge when to visit the health facility for health care. Among the study participants, 460 (57.9%) of elderly people had visited health facility during illness and 161 (35%) of them visited health facility within 24 hours of illness. This result was higher than a study conducted in southwest Ethiopia [16] and household survey carried out in Nigeria [17] where only 45.6% and 31.2% visited the health facility during illness respectively. Thus, efforts should be strengthened to improve health care seeking behaviour in the study area.

Characteristic(n=795)	Frequency	Percent
Age(n=795)
60-65	333	41.9
66-70	198	24.9
Above 70	264	33.2
Sex(n=795)
Male	362	45.5
Female	433	54.5
Marital status(n=795)
Married	416	52.3
Widowed	342	43
Others*	37	4.7
Religion(n=795)
Protestant	652	82
Others**	143	18
Ethnicity(n=795)
Wolaita	754	94.8
Others***	41	5.2
Education(n=795)
Unable to read and write	669	84.2
Primary and above	126	15.8
Occupation (n=795)
Farmer	693	87.2
House wife	85	10.7
Others****	17	2.1
Income (n=795)
Low income	301	37.9
Middle income	232	29.2
Higher income	262	33
Food Availability(Eating three times a day) (n=795)
Yes	388	48.8
No	407	51.2
Family size (n=795)
<5.8	432	54.3
>5.8	363	45.7

  *Divorced, Separated                      ** Orthodox, Catholic, Muslim, Apostolic, Jehovah Witness and Traditional
*** Hadiya, Amhara, Kucha       **** Carpentry, poetry, blacksmithing, petty trade

Table 1: Socio-demographic characteristics of elderly people in rural part of Wolaita zone, Southern Ethiopia, January 2015

Characteristics	Frequency	Percent
Knowledge about the available health facility
Health post	582	73.2
Health center	707	88.9
Hospital	27	3.4
Private clinic	130	16.4
Minimum distance to PHCU* (n=795)
< 30 minutes	586	73.7
> 30 minutes	209	26.3
Has family support during illness(n=795)
Yes	474	59.6
No	321	40.4
Knowledge  to eat supplementary food during illness(n=795)
Yes	526	66.2
No	269	33.8
Consumed supplementary food ** during illness (n=526)
Yes	283	53.8
No	243	46.2

*PHCU= Primary Heath Care Unit and District hospital, health center and health post are considered to be primary health care unit **Supplementary food = extra meal or medically advised food item during illness to improve their health status

Table 2: Knowledge on available health facility and feeding during illness by elderly people in rural part of Wolaita zone, Southern Ethiopia, January 2015.

Characteristics	Frequency	Percent
Know when to visit the health facility for health care (n=795)
Yes	636	80
No	159	20
Visited Health facility during illness(n=636)
Yes	460	72.3
No	176	27.7
Type of health facility  visited during illness (n=460)
Hospital	32	6.9
Health center	205	44.6
Health post	115	25
Private clinic	108	23.5
Duration until go for treatment (n=460)
Within  24 hours	161	35
After 24 hours	299	65
Reasons not to visit health facility (n=176)
Shortage of money	114	64.8
Lack of family Support	46	26.1
Distance from health facility	10	5.7
Others	6	3.4

Table 3: Health care seeking behavior of elderly people during illness in rural part of Wolaita zone, Southern Ethiopia, January 2015.

Among the factors associated with health care seeking behaviours, those elderly people whose age group were between 60-65 were 1.51 times were more likely visited health facility during illness than those elders whose age were above 70 years [AOR= 1.51 (1.06, 2.14)].This finding was consistent with the study done in Nigeria [17] in which younger age positively associated with health care seeking behaviour.

Those elderly people who attended formal education have more likely health care seeking behaviour than those who did not attend formal education [AOR = 2.28, (95% CI = 1.45, 3.61)]. This finding was in line with study conducted in Zambia, Myanmar and India [18-20] in which elderly with lower educational status were more likely to skip treatment than that of middle and higher education status. Since education is key tool to develop good awareness on utilization of modern health care service government and other stalk holders should address it to all citizens especially to vulnerable elderly people.

Those elderly people who knew when to visit health facility for health care were more likely visited health facility than those who didn’t know when to visit it [AOR = 1.95, (95% CI = 1.43, 2.67)]. This finding pointed that knowledge was the major contributing factor for practical dimension of health care seeking behaviours among elderly people. Therefore, disseminating health information on appropriate health care service is suitable strategy to address health need of elderly people in the study area.

Our study also revealed that the elderly people who had family support during illness were about three times more likely visited health facility during illness than those elderly people who had no support [AOR= 3.06, (95% CI = 2.25, 4.15)]. This finding was consistent with the study conducted in southern part of Ethiopia [21] and Cross River State of Nigeria [22] in which elderly people who were living with family members and their spouses were more likely utilized health services than those who were staying alone. This showed direction for concerned stalk holders so that family members and relatives, community members, government institutions and NGOs to strengthen care and support to elderly people.

Our study also showed that study participants who were travelling short distance (less than or equals to half an hour) to got primary health care unit were more likely visited health facility than those who were travelling beyond half an hour [AOR= 1.58, (95% CI = 1.11, 2.25)]. This finding was consistent with the study done in Nigeria and Amhara region of Ethiopia [22,23]. Since physical access to health facility were determinant factor for appropriate health care seeking behaviour of elderly people, expansion of health facility, mainly to the rural part of country, should be augmented.

Characteristics (n=795)	Visited health facilities	COR(95%CI)	AOR(95%CI)
Age of respondents (ref.= above 70 years)
60-65	215(64.6)	1.74(1.25-2.42)*	1.51(1.06-2.14)**
66-70	110(55.6)	1.19(0.83-1.73)	1.13(0.76-1.68)
Attended formal education (ref.= not attended)	95(75.4)	2.55(1.66-3.94)*	2.28((1.45-3.61)**
Knew when to visit health facility (ref = didn’t know)	322(64.7)	2.11(1.57-2.83)*	1.95(1.43-2.67)**
Family support during illness (ref = no support)	327(69)	3.14(2.34-4.23)*	3.06(2.25- 4.15)**
Minimum distance to PHCU (ref.  > 30 minutes)	235(64.4)	1.64(1.26-2.12)*	1.58(1.11- 2.25)**

*Significant in crude odds ratio (COR)                   ** Significant in adjusted odds ratio (AOR)

Table 4: Determinants of health care seeking behaviors among elderly people in rural part of Wolaita zone, Southern Ethiopia, January 2015.

Strength and limitation of the study

This study addressed different factors which were affecting elderly peoples’ health seeking behaviours of rural community in Wolaita zone; usually their health care status was neglected. We used adequately large sample size for generalizability of the findings. However, in addition to recall bias, there might be social desirability bias since many people might be afraid to admit that they visited a traditional practitioner which possibly over estimate modern health service utilization rate.

Conclusion

Elderly people health care seeking behaviour was unsatisfactory in Wolaita zone; nearly half of study participants did not visit the health facility during their illness. Early age (60-65), attending formal education, family support during illness, knowledge when to visit health facility and accessibility to health facility were major predictors of health care seeking behaviours of elderly people in the study area. Therefore, health care and support should be strengthened from government and stake holders working on elderly people to overcome barriers of appropriate health care seeking behaviour.

Competing interests

The authors declare that there is no competing interest.

Authors’ contributions

TF: Conceived the study, involved proposal development, supervision, and data analysis and manuscript preparation. WF: Took lead in preparing the manuscript. He also participated in designing, data management, analysis and manuscript writing. MM: Participated in the proposal development, study design, analysis and manuscript preparation. AW: Guided overall stage of the study, data analysis and interpretation. All authors read and approved the final manuscript.

Acknowledgements

The authors would like to thank Wolaita zone health department, data collectors and supervisors for their unreserved effort throughout the study.

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