Background

Bhaktapur District lies in Bagmati zone. Health units have been established in each ward and VDC to provide preventive, promotive and curative health services. Health behaviour refers to all those things humans do to prevent diseases and to detect diseases in asymptomatic stages. In contrast illness behaviour refers to all those activities designed to recognize and explain symptoms after one feels ill, and sick role behaviour refers to all those activities designed to cure diseases and restore health after a diagnosis has been made (pp 65 K.K. Holmes et al Sexually Transmitted Diseases 1st Edition). Health care seeking behavior is that action taken by an individual in response to a stimulus ( such as preception of a symptoms ) that he or she decides is indicative of condition needind evaluation by a health professional. This behavior is influenced by personal, physical and psychological characteristics and by sociocultural and environmental factors.(Gilliland, Phillips, Raczynski, Smith, Cornell and Bittner, 1999: 95) Infant Mortality Rate in Nepal was 48 per 1000 live births in 2008. Among childhood deaths in developing countries 27% result from ARI and 25% from diarrhoea. Acute diarrhea disease and ARI are the most important cause of morbidity and mortality among the children in Nepal. (Annual Report 2006) More than 10 million children in the developing countries die before the age of five years mostly from preventable illness. The child mortality has declined in every reasons of the world since 1990 but the progress is slow. Only 35 countries are in the tract to meet the Millennium Development Goals(MDGs) of reducing under five mortality rate by two-third between 1990 and 2015. Progress is slow in the Sub Saharan Africa where AIDS, malaria and malnutrition are driving up mortality rate. Improving the maternal health is the powerful instrument for reducing shild mortality rate. More than 500,000 women in the developing countries die in child birth each year and at least 10 million suffer from injuries, infection and disabilities. Many researches have been done regarding morbidity pattern and services seeking behaviors in the various part of the world. However rates researchers have been found on these topics in Nepal. A study in Gutemalla about health seeking behaviors; The parent generally thought help and treatment advice from an older women in the family and did so more often for diarrhoea , fever, cough, and worms. Obtaining advice in the pharmacy or from a drug seller ranked second, depending upon the symptoms, before the procurement of professional help at a medical services. Traditional healer were hardly consulted. Incase of self treatment the women prodominently relied on western drugs around 80% in diarrhoea and fever and above 50% in cough. Herbs and traditional external remedies were little used. Except in cough and worms. None of the mother reported ORS as home treatment for diarrhoea. Problem of geographical or financial accessibility could not explain the utilization of the western health care system. Study on prevalence of childhood illness and care seeking practice in rural ugnada of WHO 30 cluster sampling. Prevalence of childhood illness and care seeking practices wre obtained using a structured quwstionaire supplement by in-depth interviews. The resuls showed that the 300 women interviewds had 1

323 children of whom 37.9% had an episode of fever 2 weeks before surgery, 40.3% had diarrhoea, 37.4% had URTI and 26.8% were fully immunized. However , most children with fever, diarrhoea, and URTI were treatment at home and taken to health unit was complicated by high cost of care and long distance to the health units. Poor attitude of health workers, lack of drugs at health units and involvement of fathers in care of the children. The results of this showed that although the perceptions of childhood disease were high, the care seeking practices were poor. The birth attended by skilled health staff increased from 60% to 70% between 1990 and 2004 in global statistics where as in Nepal the data is only 7% in 1990 to 15 %in 2007(world Development Indicators 2007). In Nepal six out of ten pregnant women do not get modern health services during delivery (World Bank Report 2005) and 95% of the women do not have to access to the emergency obstetrics care due to te complication of the pregnancy(MOH/DFID 2004) and this may even less in the context of minority group of people and the indigenous people. High mortality rate results from malnutrition, frequent pregnancies and inadequate health care during pregnancy and childbirth. Childhood illness (IMCI) strategy, besides improving provider's skill in managing childhood illness also aims to improve families care seeking behavior. The health worker's are trained to teach the mothers about the danger signs and counsel them about the need to seek care promptly if there sign occur. Information on the health seeking behavior helps the policy maker set strategies to decrease the mortality due to common childhood illness. For the best of our knowledge no such studies have been reported in Nepal. Various studies from developing countries have reported that delay in seeking appropriate care and not seeking any care contributes to the large number child death. Existing interventions colud prevent many deaths among children if they are presented for appropriate and timely care. Improving families care seeking behavior could contribute significantly to reducing child morbidity in developing countries. Various researcher have been conducted in what facilitied the use of health services and what influenced people to behave differently in relation to their health. There has been a Plethora of studies addressing particular aspects of these issues, carried out in different countries. The factors associated with the health seeking behavior is determine by various factors like: cultural, socio-economic, political, accessibility/affordability, psychological beliefs, disease pattern, type of health services available, status of the women in the society etc. Information on the health seeking behavior helps to policy maker set strategies to decrease the mortality due to the common childhood illness. Health Belief Model(HBM) given by sheeran and Abraham (1995) sates that the beliefs about the impact of illness and its consequences like perceived susceptabilty and perceived severity of illness, beliefs about the consequence of health practices ( perceived benefits and perceived barriers), the nature and intensity of illness, symptoms experienced, mass media campaigns, advice from relevant other family members, friends health staffs etc determine the seeking health services. Health care model states that the health services utilization determined by predisposing factors: Age, gender, religion, global health assessment, prior experiences with enabling factors , availability of services, financial resources, to purchase services, health insurance, social network support etc. 2

The "four As" model of health seeking behavior emphasis that Availability factors (geographic distribution of health facilites, Pharmaceuticals products etc) Accessibility factors (transport, road), Affordability factors(treatment costs for the individual, household or family) and Acceptable factors (cultural and social distance like the characteristics of the health providers, health workers behaviors, gender aspects, excessive bureaucracy) determine in seeking the health services. The advantages of the four as is the easy identification of the key potential "barriers" for the adequate treatment.

Statement of Problem
Out of 292 mother in Pokhara, health seeking behaviour was found as 46.2% sought pharmacy, 26.4% sought allopathic medical practitioners, 8.9% sought traditional healers, 2.7% no care Source: Care seeking behaviour for childhood illness,a questionnaire survey in western nepal,2006 According to the annual Report of 2008/09 no. Of cases sufferring from ARI and CDD were 1,817,499 and 2,851,111 respectively.

Rationale of study
Child Mortality is a major public problem in the developing countries like Nepal. Infant mortality rate and child mortality rate are 48 and 61 per thousand in Nepal. (2006). y Maternal mortality rate is 281/100000 live birth and total life expectancy rate is 64.4. In the same year 55% people seek health service, while remaining 25% seek dhami, Jhankri, Vaidya and 21% seek to jadibuti. (annual Report 2006) To deliver proper health services actual information ia required. Health authorities are devoted to provide preventive, promotive and curative health services. To identify health seeking pattern during sickness. To utilize health services for the improvement of health status of their children.

y y y

Objectives of Study
y General  To identify health seeking behaviour among the parents having under 5 year children during sickness of their children y Specific  To assess the places seeking for treatment during morbidity  To assess the reason for choosing that particular place

Research Question
y What are the health seeking behaviour among the parents of thier under 5 years children in Bhaktapur.

Study Variables
y Dependent Variable 1. Health seeking behaviour among parents having under 5 years children. y Independent Variables 1. Socio- economic status 2. Cultural Beliefs 3. Education 4. Occupation 5. Sex of the Child 6. Types and Seriousness of disease 7. Availability and accessibility of service

Conceptual Framework

Operational Definition
y y Health Seeking Behaviour : the behaviour of seeking child health care during sickness Parents: childs father or mother taking the care

Limitation of study
y Research finding cannot be generalized to the whole country due to small sample size.

Chapter II

Review of Literature
2.1 Reviewed Literature related to variables Bajracharya Suman et al (2006) revealed that the Health service in our country is top-down approach with multiple levels of operation, which has let to compromise the effectiveness and the quality of the health services. The private service providers, NGOs are the major part of the health service in Nepal. The cost of private sector and users fees models of the public and the NGOs sectors are not friendly to the poor and disadvantaged people. Gartaulla R.P(1998) revealed that despite the health facilities provided by the government, more than 50% of the health problems do not reach the re-service. They are treated through a system of ethno-medicine and plural medicines which are based on home remedies other menthods of unconventional treatment includes commercial sales of over the counter(OTC) drugs self medication varies and the symptoms of the patient, their sex and their lack of knowledge of the rural population in Nepal is still served by traditional practitioners who rely on the local resources for their drugs requirements. Gartaulla, RP(1998) revealed that some of the studies at different rural areas of asian countries show that only between 16-20% health care are provided through governmental health institution. The rest are taken care by self treatment, locally available traditional health care system or even without any treatment. Many families have a system of home remedies and self treatment. The role of the traditional health care system in providing primary health care services is important and unavailable basis. The traditional health care system in the asian countries plays a vital role in the health services. Lawson, David (2004) reported that Drug availability, staffs attitude and performance, equipments range and the effectiveness of the services have recently worsened in republic of Uganda(1999). Utilization of the public services have declined by approximately 20% between 1995 and 2000. Of the other factors that affect the health care demand, gender and education have been found to be important determinants. Gender disparities is assess to the health care services have been studied in number of Contries. Generally time constraints and the opportunity cost faced by women are higher than that of man thus determining them from assessing the health services to a larger extend. As the income increases, the type of health care sought progress from the traditional to the modern one. As for the mild illness the patients do not seek health care. In Nepal, there is a serious problem in assess to the drugs. The drugs are not available to the needy people due to the needy people due to various factors includeing the cost. In the present condition the mushrooming private clinical services are unaffordable to the poor people and the patient have to turn towards untrained indigenous healers often with unfourtunate consequences. (MDJ,2005) Barriers to accessing health care include language barriers, financial handicap, lack of health information, not knowing where to seek help, and poor understanding of how to access health services. (MJA,2006).
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NDHS(2006) reported that 1 in every 21 Nepalese children dies before reaching age one, while in every 16 does not survive to the fifth birthday more than 80% of the deliveries take place at the home, most of the births are assisted by family member and neighbors. Only one fifth of the total deliveries are attended by the health workers. The delivery care from SBA is 19%. The report also shows that ANC visits are 77 % and the planning device is 17 times higher in the urban areas than in rural areas. Pradhan and Shrestha (2005) stated that the health status of the country in determined by its economic status. Nepal is characterized not only by poverty and low HDI, but also by extreme disparities in income and wealth. For example, the bottom 20 percent households receive only 3.7 percent of the national income whereas the top 10 percent receive nearly 50 percent. There is a broad convergence between income, wealth, and HDI on the one hand, and social and cultural identities on the other. Similarly, hill castes, such as Brahmins and Chhetris and Newaris have a higher HDI than most other ethnic groups and Minority groups of people. Sheeran and Abraham(1995) reported that Health Belief Model about the impact of illness and its consequences like perceived barriers), the nature and intensity of illness, symptoms experienced, mass media campaigns, advice from relevant other family members, friends health staffs, etc determine the seeking in health services.

2.2 Summary of literature reviews Various research have been conducted in what facilities the use of health services and what influences people differently in relation to their health. The factors associated with the health seeking behaviour is determined by various factors like cultural, socio-economic, political, accessibility, affordability, Psychological beliefs, disease pattern, type of health services available status of parents in the society etc. Health care utilization model states that health services utilization is determined by predisposing factor age, gender religion, global health assesment, financial resources to purchase services, social network support etc. One in every Nepalese children dies before reaching age one year, while 1 in every 16 does not survive to the fifth birthday more than 80% of the deliveries take place at the home, most of the births are assisted by family member and neighbours only one fifth of the total deliveries are attended by the health workers. The delivery care from SBA is 19%. The planning device is that ANC visits are 44% and the planning device is 17 times higher in the urban areas. Morbidity pattern and services seeking behaviour in the various part of the world.In the case of self-treatment the women preominatly klestern drugs around 80% in diarrhoea and fever and above 50% in cough. Herbs and traditional external remedies were little used except in cough(27%) and worms (58%). None of the mothers reported URS home treatment for diarrohea. In Nepal, the drugs are not available to the needy people due to various factors including the cost. In present the private clinical services are unaffordable to the poor people and poor are avail to this services and patient have to turn towards the untrained indigenous healers often with
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unfortunate consequences. Health facilities provided by teh government more than 50% of the health problems do not reach the reservices. Barriers to accessing health care includes language barriers,financial handicap, lack of health information. For mild illness the parents do not seek health care.

Chapter III Methodology

3.1 Research Design This is descriptive type of research design. 3.2 Selection of Study Area The study was conducted in Bhaktapur ward no.2. 3.3 Sample Population Study population ware under 5 childern. Parents could be father or mother and interview were taken whoever present at the tie of data collection.

3.4 Sample size The sample size was 50 Parents could be father or mother, who have under 5 children.

3.5 Sampling Tecnique Non probability purpose sampling technique used to select the sample.

3.6 Method of data collection The interview was directly asked to the parents of under 5 children. The data were collect by interviewing with parents.

3.7 Instrumentation A semi-structure questionaire were used to collect the data from the parents.

3.8 Validity and Reliability of the Instrument y y y Consultation was done with research guide/subject expert and to read the questionaire and take feedback. Daily editing was done at the end of the day. If any query that was collected to another day. Reliability was maintained by pre-testing of tool 5 (10%) of the total sample in the similar setting.

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3.9 Ethical Consideration y y The purpose of this study was given to the respondent at the time of interview Data was collected with verbal consent not forcefully. There was taken care of full confidentiality.

3.10 Data Analysis Data analysis was done by manually and shows the finding on tables and piechart in frequency and percentage.

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Chapter IV RESULTS 4.1 Demographic finding Table 1 Religion of the Respondents Religion Hindu Buddhist Christian Muslim Other Total Frequency 43 5 2 50 Percentage 86 10 4 100

The above table shows that among 50 respondents 43(86%) were Hindu, 5(10%) were Buddhist and 2(4%) were christian.

Table 2 Caste of the Respondents Caste Brahmin Chhetri Newar Tamang Other Frequency 2 3 39 6 Percentage 4 6 78 12 -

The above shows that among 50 respondent 39(78%) were Newar, 2(4%) were Brahmin, 3(6%) were chhetri and 6(12%) were tamang. Table 3 Educational status of Respondent Educational Status Frequency Percentage
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Primary level Secondary level SLC Pass Higher Secondary & above Illiterate

12 11 15 10 2

24 22 30 20 4

The above table shows that among 50 of respondant 2(4%) wee illiterate, 12(24%) were educated on primary level, 11(22%) were educated on secondary level, 15(30%) were educated on SLC Pass and 10(20%) were educated on higher secondary and above.

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Table 4 Main Occupation of the Respondent Respondent Mother occupation Business Farmer Laborer Housewife Service holder Frequency 10 5 31 4 Percentage 20 10 62 8

Respondant father occupation Business Farmer Laborer Service hoder Other

Frequency 15 10 11 14 -

Percent 30 20 22 28 -

The above 2 table shows that among 50 respondent mothers, the main occupation of 31(62%) were housewife, 10(20%) were farmer, 5(10%) were laborer and 4(8%) were service holder whereas 50 resondant fathers, themain occupation of 15(30%) were business, 14(28%) were service holder, 11(22%) were laborer and 10(20%) were farmer. Table 5 Types of family Family structure Single Joint Frequency 38 12 Percentage 76% 24%

The above table shows that among the total 50 respondents, 38(76%) were single family and 12(24%) were joint family.

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Finding of health seeking behaviour

Table 6 Health worker Modern health worker Traditional health worker Frequency 39 11 Percentage 78% 22%

Findings of Health Seeking Behaviour

Modern health worker traditional health worker

The above figure shows that among 50 respondents, 39(78%) were seeking modern health worker whereas 11(22%) were seeking help from traditional health worker.

Table 7 Reasons of seeking help from traditional healer Reason for seeking help from Traditional healer a. Easily available at any time b. Someone recommended me c. Culturally accepted practice d. There is no harm in child e. Other Frequency (n=11) 1 5 4 1 9.09 45.45 36.36 9.09 Percentage

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The above table shows that among 11 resondents 5(45.45%) said someone recommended me, 4(36.36%) said culturally accepted practice in society, 1(9.09%) said easily available at any time, and 1(9.09 said there is no harm in child. Table 8 Reasons of seeking help from modern health worker at first Resons of seeking help from modern health at first a. Health facilities nearby b. Types & seriousness of disease c. Someone recommended me d. Other Frequency (n=39) 15 19 5 38.46 48.72 12.82 Percentage

The above table shows that among 39 respondent 15(38.46%) said seek help from modern health workers at first because of health facilities nearby, 19(48.72%) said seek at first because of types and seriousness of disease and 5(12.82%) said seek at first because someone recommended to me. Table 9 Recommended you to take your child to modern health at first Recommend you take your child to modern at first Family Friend Relatives Neighbour Others Frequency (n-5) 3 2 60% 40% Percent

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Table 10 Recommended you to take your child to traditional healer at first Recommended you to take your child to traditional healer at first Family Friend Frequency Percent

2 3

40% 60%

Above table shows that among the five respondents 3(60%) were recommended by friends whereas 2(40%) were recommended by family.

Table 11 Types of Health nearby to respondent house Types of health facilities nearby the respondent house Subhealth post/ Health post Clinic hospital Frequency (n=13) 1 10 2 7.69% 76.9% 15.38% Percentage

The above table shows that the health facilties near by the repondants house are 13 in which 10(76.9%) are clinics,2(76.9%) are hospitals and 1(7.69%) is health post.

Table 12 Types of disease respondent may seek help from modern health workers at first Types of diseases Diarrohea Dysentry Pneumonia Frequency(n=39) 6 14 19 percentage 16 36 48

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Above table shows that among 39 respondants, 19(49%) were seek help because of Pneumonia, 14(36%) were seek because of Dysentry and 6(16%) wre seek because of Diarrhoea.

Table 13 Consult modern health workers later on after taking the help from traditional healer at first Consult modern health worker later on Yes No Frequency(n=11) 11 Percentage 100 -

Above table shows that among 11 respondants, 100% were consulted modern health worker later on traditional healer at first. Table 14 Satisfied with the health services provided for child when they get sick Variables Satisfied with health services provided for the child Yes No If yes, do you recommended to use the same health services to other people Recommended Not recommended Frequency (n=50) Percentage

39 11 (n=39)

78 22

29 10

74 26

Above table shows that among the 50 respondants, 39(78%)were satisfied with provided the health services and 11(22%) were not satisfied. Whereas among the satisfied respondants(39), 29 (74%)were recommended to use the same health services and 10(26%) were not recommended.

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Chapter V

Summary of findings, conclusion and recommendation

5.1 Summary of the Findings 5.1.1 Demographic findings Among 50 respondents 43(86%) were Hindu, 5(10%) were Buddhist and 2(4%) were christian whereas 2(4%) wee illiterate, 12(24%) were educated on primary level, 11(22%) were educated on secondary level, 15(30%) were educated on SLC Pass and 10(20%) were educated on higher secondary and above and the main occupation of the respondants of 31(62%) were housewife, 10(20%) were farmer, 5(10%) were laborer and 4(8%) were service holder whereas 50 resondant fathers, themain occupation of 15(30%) were business, 14(28%) were service holder, 11(22%) were laborer and 10(20%) were farmer as well as 38(76%) were single family and 12(24%) were joint family.

5.1.2 Health Seeking Behavior Findings Among 50 respondents, 39(78%) were seeking modern health worker whereas 11(22%) were seeking help from traditional health worker. However 100% respondants were consult to modern health workers later on after taken help from traditional healer at first.

Among 39 respondent 15(38.46%) said seek help from modern health workers at first because of health facilities nearby, 19(48.72%) said seek at first because of types and seriousness of disease and 5(12.82%) said seek at first because someone recommended to me. The health facilties near by the repondants house are 13 in which 10(76.9%) are clinics, 2(76.9%) are hospitals and 1(7.69%) is Public health post. Among 39 respondants, 19(49%) were seek help because of Pneumonia, 14(36%) were seek because of Dysentry and 6(16%) were seek because of Diarrhoea. Among 11 respondants, 100% were consulted modern health worker later on traditional healer at first. Among the 50 respondants, 39(78%)were satisfied with provided the health services and 11(22%) were not satisfied whereas among the satisfied respondants(39), 29 (74%)were recommended to use the same health services and 10(26%) were not recommended.

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5.2 Discussion and Conclusion

5.2.1 Demographic Finding The social characteristics deal with the caste, educational status, family structure and family size taken in the study. The study was done only on 50 respondants thus there is only one type of ethinicity but were Four caste. They were Brahamin, Chhetri, Newar and Tamang. Most of the respondants were Newar which was 39(78%) and 96% were literate and 4% were illiterate.31(62%) wre housewife, 15 (30%) were engaged in bussiness Whereas 43(86%) were belief in Hindu religion. 5.2.2 Health Seeking Behaviour Finding The pattern of disease and health seeking behaviour are varying between different geographical areas as well as different group of the people within the country. Prevention as well as effective treatment of health seeeking behaviour depends on a host of the individual, household and community level behaviour factors. Education was found to have positive co-relation with the health seeking behaviour and also it include maternal education which has the positive co-relation with the child health. Closeness to the health services has a direct association with the demand in the health care. Reasons of seeking help from modern health workers at first 19(48.72%) said seek help from modern health worker at first because of seriousness and types of disease, 15(38.46%)said health faciltiy was nearby, 5(12.82%)said someone recommended me. Recommendation to take child to the traditional healer at first 2(40%) were recommended at first by family, 3(60%)were recommended by friends. Recommendation to take child to modern health healer at first 3(60%) were recommended by family member, 2(40%) were recommended by friends. Recommendation to take child according to types of health facilities nearby respondants house, 1(7.69%) were near from health post, 10(76.9%) were clinic and2(76.9%) hospital. Most of the respondants seeking help to take modern health services sick from pneumonia19(49%), 6(16%) eek help from diarrhoea, 14(36%) were seek help because of Dysentry. Among . 11 respondants, 100%respondants were consult modern health worker later on traditional health healers. Among 50 respondants 39(78%)were satisfied with provided health services but 11(22%) respondants were not satisfied with the provided the health services. Among the respondants who were satisfied 39, 29 (74%) were recommended and 10(26%) were not recopmmended to use the same health services to the other people. In this research, most of the respondants answered that the disease has been caused due to the unhygienic behavior not due to sin. That all information, they have had heard from thier family member which is very good for preventing many communicable disease.

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In next step, if the first line treatment i.e. health seeking behaviour was not productive. Qualitative information was collected for exploring the type of health seeking behavior. Qualitative information explored in case of no different if thecondition was worsen, most people sought treatment in clinic and few resorted in public health post Therefore the utilization of a health care system, public or private formal or non formal may depend on the socio-demographic factors, social structures level of education, cultural beliefs and practices and disease pattern and health care system itself. Finally the result was used to improve health services delivery and better services utilization.

5.3 Recommendation The further should be conducted on such areas to increase the health seeking behavior and minimize morbidity and mortality of under 5 years children. In Bhaktapur ward no. 2 some respondant still accepted traditional practice as their elders did, So bad culture and practice should be changed which is harmful for their health by awaring the respondants through the media or by another way.

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References
1. Annual Report of Department of health services,2060/61 (2005/2006). Government of Nepal, Minister of health Department of Health Services. Kathmandu. 2. Gastrula, RP (1998), Introduction to medical sociology and Anthropology{Ktm,RECID, Nepal) 3. Pradhan, B (2006), Human and Human Development in Nepal Reading in human development (ktm, UNDP), page 149-190) 4. World Bank Report (2005), the World Bank Oxford University press 5. (Author: Sara MacKian Article reviewed by: Dr Nihar Ranjan Ray) http://www.articlesbase.com/vision-articles/a-review-of-health-seeking-behaviorproblems-and-prospects-825835.html#ixzz1LP5R0mjv 6. ([Article in French]Tursz A, Crost M, Kermani S, Reghal M, Grangaud JP) www.ncbi.nlm.nih.gov/pubmed/10575709at may 3 2011

7. (Pavitra Mohan, Sharad D. Iyengar, Jose Martines, Simon Cousens and Kalpana Sen BMJ: British Medical Journal Vol. 329, No. 7460 (Jul. 31, 2004), pp. 266-269 )
www.jstor.org/stable/25468791

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