|ORIGINAL RESEARCH REPORT
|Year : 2015 | Volume
| Issue : 2 | Page : 103-107
Health care-seeking behavior among patients with chronic kidney disease: A cross-sectional study of patients presenting at a single teaching hospital in Lagos
Babawale Taslim Bello1, Christiana Oluwatoyin Amira1, Yemi Raheem Raji2, Ofonime Koko Udoh3
1 Department of Medicine, College of Medicine, University of Lagos, Lagos, Nigeria
2 Department of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria
3 Department of Medicine, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
|Date of Web Publication||17-Nov-2015|
Babawale Taslim Bello
Department of Medicine, College of Medicine, University of Lagos, Lagos
Source of Support: None, Conflict of Interest: None
Introduction: Health care-seeking behavior of individuals determines how early they present for appropriate care. In patients with chronic kidney disease (CKD), late presentation to the nephrologist is associated with poor outcomes. This study aims to describe the health care-seeking behavior of patients with CKD attending the nephrology outpatient clinic of a teaching hospital located in Lagos, Nigeria. Materials and Methods: This was a cross-sectional survey conducted on 104 consecutive adult patients with CKD, presenting for the first time at the nephrology outpatient clinic of a teaching hospital located in Lagos, South West Nigeria. Information was retrieved from the study participants using a structured interviewer-administered questionnaire, entered into an Excel spreadsheet, and analyzed using Epi Info® statistical software version 7.0. Results: Overall, 74 (71.2%) patients sought help, first from a trained health care provider, and their health care-seeking behavior was adjudged to be appropriate. Compared to patients with appropriate health care-seeking behavior, those with inappropriate health care-seeking behavior had a lower mean age (40.4 ± 13.7 years vs 47.3 ± 15.6 years;P = 0.03), were less likely to see their illness as a medical problem (46.7% vs 67.6%;P = 0.04), more likely to have a monthly income less than N25,000 ($150) (80.0% vs 59.5%;P = 0.04), and have received below tertiary level education (20.0% vs 48.6%; P < 0.01). They were also more likely to have consulted more than one health care provider before being referred to our clinic. The factors predicting inappropriate health care-seeking behavior were education below the tertiary level and age less than 45 years. Conclusion: Though health care-seeking behavior was appropriate in majority of our patients with CKD, there remains a need for improved public health awareness.
Keywords: Chronic kidney disease, health care-seeking behavior
|How to cite this article:|
Bello BT, Amira CO, Raji YR, Udoh OK. Health care-seeking behavior among patients with chronic kidney disease: A cross-sectional study of patients presenting at a single teaching hospital in Lagos. J Clin Sci 2015;12:103-7
|How to cite this URL:|
Bello BT, Amira CO, Raji YR, Udoh OK. Health care-seeking behavior among patients with chronic kidney disease: A cross-sectional study of patients presenting at a single teaching hospital in Lagos. J Clin Sci [serial online] 2015 [cited 2020 Feb 19];12:103-7. Available from: http://www.jcsjournal.org/text.asp?2015/12/2/103/169691
| Introduction|| |
Chronic kidney disease (CKD) is associated with its rising incidence and prevalence, high cost of treatment, and poor outcomes.,,, There is evidence to suggest that early in the course of CKD, appropriate interventions may slow down its progression, completely halt the progression of the disease, or even reverse the disease process altogether., Despite this, however, many patients with CKD present late to nephrologists so that at the time of initial patient presentation, all that can be offered is preparation for renal replacement therapy. This is particularly so in resource-poor settings where among several other factors, the lack of awareness, the need to pay out-of-pocket for health care, traditional beliefs about the cause and nature of the disease, and shortage of specialists combine to lead to inappropriate health care-seeking behavior and consequently, late presentation to the nephrologist.
Health care-seeking behavior is the action undertaken by individuals in response to the symptoms experienced. It concerns specific steps taken (sometimes called hierarchy of resort) and involves what is done and why it is done. Studies have shown that the decision about when and where to seek health care is influenced by several factors including the individual's educational and economic status, the extent to which he/she is worried about the symptom, his/her beliefs about the cause and nature of the diseases, past experiences with health-care services as well as perception about the quality and efficiency of health-care services.,,, For an individual, the desired health care-seeking behavior is to respond to an episode of illness by first seeking help from a trained health care provider in a formally recognized health-care setting. Yet, many studies, especially from developing countries, have reported that for some illnesses, people choose traditional healers and spiritualists over formally trained practitioners.,,,,
Inappropriate health care-seeking behavior often leads to delay in presentation to health care facilities where specialized care can be offered. Among patients with CKD, late referral or presentation to nephrologists has been shown to be associated with higher CKD-related morbidity, higher burden of other comorbid disease conditions, longer duration of hospitalization, greater overall cost of care, delay in the institution of renal replacement therapy, and higher all-cause mortality.,, There are, however, limited data on the health care-seeking behavior patterns of patients with CKD in general and in sub-Saharan Africa in particular. The aim of this study is to describe the health care-seeking behavior of patients with CKD attending the nephrology outpatient clinic at our teaching hospital located in Lagos, South West Nigeria.
| Materials and Methods|| |
This was a cross-sectional survey of patients with CKD attending the nephrology outpatient clinic of a teaching hospital located in Lagos, South West Nigeria. All the newly presenting patients diagnosed to have CKD who presented at the clinic over a 6-month period between January 1, 2012 and June 30, 2012 were recruited to participate in this study. A total of 104 patients were eventually recruited for this study. All the patients recruited for the study were at least 18 years old, diagnosed with CKD, and had consented to participate in the study. For the purpose of this study, CKD was defined as an estimated glomerular filtration rate (GFR) <60 mL/min/1.73 m2. GFR was estimated from serum creatinine using the four-variable version of the estimation formula developed from the modification of diet in renal disease (MDRD) study. The study protocol was approved by the Health Research and Ethics Committee of the hospital.
Information was retrieved from the study participants using a structured interviewer-administered questionnaire. It included biodata of the patients, their highest level of education, average monthly income, their perception of the cause of illness, the first point of call when seeking health care intervention, the number of health care providers consulted as well as the duration of their symptoms before presentation at the nephrology outpatient clinic of our hospital.
The patients were considered to have displayed appropriate health care-seeking behavior if their first resort to care following the onset of their symptoms was consultation with a trained health care provider. For the purpose of this study, a trained health care provider was defined as a medical doctor or a trained nurse. Individuals whose first resort to care was a visit to any other care provider were deemed to have displayed inappropriate health care-seeking behavior.
The data obtained were analyzed using Epi InfoTM (United States Centers for Disease Control and Prevention) version 7.0 statistical software. The continuous variables were presented as means and standard deviation or medians while the discrete variables were presented as percentages. Sociodemographic characteristics were compared between patients with appropriate and those with inappropriate health care-seeking behavior. Comparison between the means was carried out using the Student's t-test or analysis of variance, while comparison of the proportions was carried out using Chi-square test. Logistic regression analysis was used to determine the factors that predicted inappropriate health care-seeking behavior. Baseline characteristics included in the logistic regression model were age, gender, marital status, highest level of education achieved, average monthly income, religion, view on the nature of illness, and the number of health care providers consulted before presentation. The age of the patients, their income levels, and the number of health care providers consulted by them before presentation were modeled as the categorical variables, with the mean age set as the cutoff for comparison of age, the median monthly income set as the cutoff for comparison of income levels, and the median number of care providers consulted set as the cutoff for comparison of health care providers consulted before presentation. The level of significance was set at 5%.
| Results|| |
Of the 104 patients who were recruited for this study, 56 (54.4%) were females. The mean age of the study population was 45.3 ± 15.3 years (range: 19-80 years). While 89.4% of the patients were Christians, the remaining 10.6% were Muslims. Of the 104 patients, 42 (40.4%) had received at least tertiary level education while the median monthly income of the study population was N25,000 ($150). [Figure 1] shows the distribution of age range of the study population while [Figure 2] shows the perception of the respondents on the nature of their illness.
|Figure 2: Opinion of the participants of the study about the cause of their illness1|
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Overall, 74 (71.2%) participants of the study were deemed to have displayed appropriate health care-seeking behavior, having first presented to a trained health care provider (a trained nurse or a doctor) at the onset of their symptoms. [Figure 3] shows the first source of health care accessed by the patients. [Table 1] shows a comparison of the baseline characteristics of the patients who displayed appropriate and inappropriate health care-seeking behavior. Compared to patients with appropriate health care-seeking behavior, those with inappropriate health care-seeking behavior had a lower mean age, were more likely to have a monthly income less than N25,000 ($150), more likely to have received education below the tertiary level, and less likely to see their illness as a medical problem. They were also more likely to have consulted more than one health care provider before presenting to our clinic.
|Table 1: Comparison of patients with appropriate and inappropriate health care-seeking behavior|
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[Table 2] shows the results of the logistic regression analysis of factors predicting inappropriate health-seeking behavior in the study population. Patients with CKD who were less than 45 years of age had greater than four-fold increased odds of having inappropriate health care-seeking behavior, while CKD patients who had received education below the tertiary level had a four-fold increased odds of having inappropriate health care-seeking behavior. Also, inappropriate health care-seeking behavior was 12 times more likely to be observed in those who visited more than one health care provider before presenting to our outpatient clinic.
|Table 2: Logistic regression analysis showing factors predicting inappropriate health care-seeking behavior|
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| Discussion|| |
In this population of patients with CKD presenting to the outpatient nephrology clinic, over 70% had sought care from a trained health care provider (a doctor or a trained nurse) at the onset of their illness and as such had appropriate health care-seeking behavior. This high proportion of patients presenting to a trained health care provider at the onset of their symptoms is similar to that reported by Odusanya et al. who, in their study on the patterns of delays among pulmonary tuberculosis patients in Lagos, found that 74% of the patients presented to a private hospital at the onset of their illness. The most common health care facility initially accessed by the patients were private hospitals, a finding that is again similar to that reported by Odusanya et al. Okeke et al., who compared health care-seeking behavior among Nigerians residing in rural and urban areas, similarly reported that 64.7% of urban dwellers patronized private over government health care facilities.
The factors predicting that an individual would initially seek care from an untrained/unqualified health care provider in this study population were education below the tertiary level and age less than 45 years. The individuals who were educated below the tertiary level were four times more likely to seek care from untrained/unqualified health care providers at the onset of their illness. In several studies, the level of education an individual possesses has been shown to influence the choices he/she makes while seeking health care.,,, To the best of our knowledge, the tendency of the younger patients to have inappropriate health care-seeking behavior found in this study has not been previously reported in the literature although, Amaghionyeodiwe, in his study on the determinants of the choice of health care provider(s) in Nigeria, had reported that older patients tended to patronize public and private hospitals rather than unqualified health care providers. One possible explanation for this finding of ours is that the older individuals may have had unpalatable experiences with untrained/unqualified health care providers in the past and on account of this, they subsequently avoid presenting to such individuals. This is further buttressed by the findings of Sule et al. who documented that past experiences with health care providers influence future choices regarding health care. Several studies have shown that patients who had a previous pleasant experience with a particular health care provider are more likely to return to such provider(s) while those who experienced complications of health care interventions or poor/unpleasant outcomes of therapy are less likely to return to such care provider(s).,,
The participants in our study who sought care from untrained/unqualified health care providers at the onset of their illness were more likely to have presented to multiple health care providers before being eventually referred for specialist care. In fact, they were 12 times more likely to have received care from more than one health care provider before presenting to our clinic. This finding is most likely due to the fact that following their presentation to untrained/unqualified health care providers, they experienced non- or incomplete resolution of the symptoms experienced that necessitated them to seek further care from other health care providers.
Although the patients who earned less than N25,000 (approximately $150) per month and those who were of the opinion that their illness was caused by factors other than a medical condition were more likely to have inappropriate health care-seeking behavior; following logistic regression analysis, neither of these two factors remained significant in predicting inappropriate health care-seeking behavior. This finding is at variance with previous studies that found income/poverty to strongly predict health care-seeking behavior., Also, health care-seeking behavior was not influenced by gender, marital status, or religion in this study population.
Our study identified the following two groups of patients with CKD who are more likely to demonstrate inappropriate health care-seeking behavior: Those aged less than 45 years and those educated below the tertiary level. The implication of this finding is that specific interventions targeted at this population of patients, such as health awareness campaigns in secondary schools, may be developed with the aim to improve health care-seeking behavior.
This study was carried out among city dwellers, with an apparently high level of education. It is unlikely that our findings can be generalized to CKD patients residing in rural areas where the degree of literacy is much lower, especially considering the fact that Okeke et al. have previously documented significant differences in health care-seeking behavior between rural and urban dwellers.
| Conclusion|| |
Though health care-seeking behavior was adjudged to be appropriate in the majority of patients with CKD who presented to our clinic, our study identified subpopulation of these patients for whom targeted interventions, such as the improvement of public awareness campaigns, may improve their health care-seeking behavior.
Limitations of the study
The relatively small size of the study population as well as reliance on the patient-reported health care-seeking behavior are some of the limitations of this study.
Financial support and sponsorship
Conflict of interest
There are no conflicts of interest.
| References|| |
Levey AS, Atkins R, Coresh J, Cohen EP, Collins AJ, Eckardt KU, et al
. Chronic kidney disease as a global public health problem: Approaches and initiatives - a position statement from Kidney Disease Improving Global Outcomes. Kidney Int 2007;72:247-59.
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis 2002;39(Suppl 1):S1-266.
Levey AS, Schoolwerth AC, Burrows NR, Williams DE, Stith KR, McClellan W; Centers for Disease Control and Prevention Expert Panel. Comprehensive public health strategies for preventing the development, progression, and complications of CKD: Report of an expert panel convened by the Centers for Disease Control and Prevention. Am J Kidney Dis 2009;53:522-35.
Echouffo-Tcheugui JB, Kengne AP. Risk models to predict chronic kidney disease and its progression: A systematic review. PLoS Med 2012;9:e1001344.
Formica RN Jr. CKD series: Delaying the progression of chronic kidney disease. Hosp Physician 2003;39:24-33, 45.
Gayoso-Diz P, Otero-González A, Rodríguez-Alvarez MX, García F, González-Quintela A, Martin de Francisco AL. Strategy to estimate risk progression of chronic kidney disease, cardiovascular risk, and referral to nephrology: The EPIRCE Study. Nefrologia 2013;33:223-30.
Nugent RA, Fathima SF, Feigl AB, Chyung D. The burden of chronic kidney disease on developing nations: A 21st
century challenge in global health. Nephron Clin Pract 2011;118:c269-77.
Arogundade FA, Barsoum RS. CKD Prevention in Sub-Saharan Africa: A call for governmental, nongovernmental, and community support. Am J Kidney Dis 2008;51:515-23.
Mushtaq MU, Gull S, Shad MA, Akram J. Socio-demographic correlates of the health-seeking behaviours in two districts of Pakistan's Punjab province. J Pak Med Assoc 2011;61:1205-9.
Shaikh BT, Haran D, Hatcher J, Iqbal Azam S. Studying health-seeking behaviours: Collecting reliable data, conducting comprehensive analysis. J Biosoc Sci 2008;40:53-68.
Katung PY. Socio-economic factors responsible for poor utilisation of the primary health care services in a rural community in Nigeria. Niger J Med 2001;10:28-9.
Amaghionyeodiwe LA. Determinants of the choice of health care provider in Nigeria. Health Care Manag Sci 2008;11:215-27.
Sule S, Ijaduola K, Onayade A, Fatusi A, Soetan R, Connell F. A study on the utilization of primary health care facilities in a rural community. Niger J Med 2008;7:96-106.
Kapur RL. The role of traditional healers in mental health care in rural India. Soc Sci Med Med Anthropol 1979;13 B: 27-31.
Kale R. Traditional healers in South Africa: A parallel health care system. BMJ 1995;310:1182-5.
Razali SM, Najib MA. Help-seeking pathways among Malay psychiatric patients. Int J Soc Psychiatry 2000;46:281-9.
Baskind R, Birbeck G. Epilepsy care in Zambia: A study of traditional healers. Epilepsia 2005;46:1121-6.
Chan MR, Dall AT, Fletcher KE, Lu N, Trivedi H. Outcomes in patients with chronic kidney disease referred late to nephrologists: A meta-analysis. Am J Med 2007;120:1063-70.
Kinchen KS, Sadler J, Fink N, Brookmeyer R, Klag MJ, Levey AS, et al
. The timing of specialist evaluation in chronic kidney disease and mortality. Ann Intern Med 2002;137:479-86.
Lameire N, Van Biesen W. The pattern of referral of patients with end-stage renal disease to the nephrologist--a European survey. Nephrol Dial Transplant 1999;14(Suppl 6):16-23.
Sesso R, Belasco AG. Late diagnosis of chronic renal failure and mortality on maintenance dialysis. Nephrol Dial Transplant 1996;11:2417-20.
Odusanya OO, Babafemi JO. Patterns of delays amongst pulmonary tuberculosis patients in Lagos, Nigeria. BMC Public Health 2004;4:18.
Okeke TA, Okeibunor JC. Rural-urban differences in health-seeking for the treatment of childhood malaria in south-east Nigeria. Health Policy 2010;95:62-8.
Victoor A, Delnoij DM, Friele RD, Rademakers JJ. Determinants of patient choice of healthcare providers: A scoping review. BMC Health Serv Res 2012;12:272.
Chandler PJ, Chandler C, Dabbs ML. Provider gender preference in obstetrics and gynecology: A military population. Mil Med 2000;165:938-40.
Marang-van-De Mheen PJ, Dijs-Elsinga J, Otten W, Versluijs M, Smeets HJ, van der Made WJ, et al
. The importance of experienced adverse outcomes on patients' future choice of a hospital for surgery. Qual Saf Health Care 2010;19:e16.
Abdulraheem IS. Health needs assessment and determinants of health-seeking behaviour among elderly Nigerians: A house-hold survey. Ann Afr Med 2007;6:58-63.
Ahmed SM, Tomson G, Petzold M, Kabir ZN. Socioeconomic status overrides age and gender in determining health-seeking behaviour in rural Bangladesh. Bull World Health Organ 2005;83:109-17.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]